(1)Managed care plans,
as defined in section 10-16-102 (43), C.R.S., that participate in the plan shall do so by
contract with the department and shall provide the health-care services covered by
the plan to each enrollee.
(2)Managed care plans participating in the plan shall not discriminate
against any potential or current enrollee based upon health status, disability, sex,
sexual orientation, gender identity, gender expression, marital status, race, creed,
color, national origin, ancestry, ethnicity, or religion.
(3)Managed care plans that contract with the department to provide the
plan to enrollees shall also be willing to contract with the medicaid managed care
program, as administered by the department.
(4)(a) Managed care plans shall be selected by the department to
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(1) Managed care plans,
as defined in section 10-16-102 (43), C.R.S., that participate in the plan shall do so by
contract with the department and shall provide the health-care services covered by
the plan to each enrollee.
(2) Managed care plans participating in the plan shall not discriminate
against any potential or current enrollee based upon health status, disability, sex,
sexual orientation, gender identity, gender expression, marital status, race, creed,
color, national origin, ancestry, ethnicity, or religion.
(3) Managed care plans that contract with the department to provide the
plan to enrollees shall also be willing to contract with the medicaid managed care
program, as administered by the department.
(4) (a) Managed care plans shall be selected by the department to
participate in the children's basic health plan based upon the managed care plans'
assurances and the department's verification that the managed care plan is
utilizing within its network essential community providers to the extent that this
action does not result in a net increase in the cost for providing services to the
managed care plan.
(b) The managed care organization shall seek proposals from each essential
community provider in a county in which the managed care organization is enrolling
members for those services that the managed care organization provides or intends
to provide and that an essential community provider provides or is capable of
providing. To assist managed care organizations in seeking proposals, the
department shall provide managed care organizations with a list of essential
community providers in each county. The managed care organization shall consider
the proposals in good faith and shall, when deemed reasonable by the managed
care organization based on the needs of its members, contract with essential
community providers. Each essential community provider must be willing to
negotiate on reasonably equitable terms with each managed care organization.
Essential community providers making proposals pursuant to this subsection (4)
must be able to meet the contractual requirements of the managed care
organization. The requirement of this subsection (4) does not apply to a managed
care organization in areas in which the managed care organization operates entirely
as a group model health maintenance organization.
(c) Any disputes between a managed care organization and an essential
community provider that cannot be resolved through good faith negotiations may
be resolved through an informal review by the department at the request of one of
the parties, or through the department's aggrieved provider appeal process in
accordance with section 25.5-1-107 (2), if requested by one of the parties.
(d) In selecting managed care organizations through competitive bidding, the
department shall give preference to those managed care organizations that have
executed contracts for services with one or more essential community providers. In
selecting managed care organizations, the department shall not penalize a
managed care organization for paying cost-based reimbursement to federally
qualified health centers as defined in the federal Social Security Act.
(5) The department may receive and act upon complaints from members
regarding failure to provide covered services or efforts to obtain payment, other
than authorized copayments, for covered services directly from eligible members.
(6) Parents or guardians of children shall choose a participating health
maintenance organization before enrolling in the plan in areas of the state where a
participating health maintenance organization is available. The department will
assign children who are currently enrolled in the plan and whose parents or
guardians have not selected a health maintenance organization within a time period
determined by the department to a participating health maintenance organization
with the child's primary care physician in the network. The department shall seek to
maintain continuity of the health plan between medicaid and the children's basic
health plan.
(7) In areas of the state in which a participating managed care plan does not
have providers, the department may contract with essential community providers
and other health-care providers to provide health-care services under the children's
basic health plan using a managed care model.
(8) The department may contract with essential community providers or
other providers or develop other administrative arrangements to provide health-care services under the children's basic health plan to enrollees prior to the
effective date of enrollment in the selected managed care plan.
(9) The department shall allow, at least annually, an opportunity for
members to transfer among participating managed care plans serving their
respective geographic regions. The department shall establish a period of at least
twenty days annually when the opportunity to transfer is afforded to eligible
members. In geographic regions served by more than one participating managed
care plan, the department shall endeavor to establish a uniform period for the
opportunity to transfer.
(10) (a) The department shall make a capitation payment to managed care
plans based upon a defined scope of services at an agreed upon rate. The
department shall only use market rate bids that do not discriminate and are
adequate to assure quality, network sufficiency, and long-term competitiveness in
the children's basic health plan managed care market. The department shall retain
a qualified actuary to establish a lower limit for such bids. A certification by such
actuary to the appropriate lower limit shall be conclusive evidence of the
department's compliance with the requirements of this subsection (10). For the
purposes of this subsection (10), a qualified actuary shall be a person deemed as
such under rules promulgated by the commissioner of insurance.
(b) Repealed.
(11) All managed care plans participating in the plan shall meet standards
regarding the quality of services to be provided, financial integrity, and
responsiveness to the unmet health-care needs of eligible persons that may be
served.