(1) The state board shall adopt rules to implement a statewide managed care system for Colorado medical assistance recipients 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:
The services delivered under the residential child health care program described insection 25.5-6-903, except in those counties in which there is a written agreement between the county department of human or social services, the designated and contracted MCE responsible for community behavioral health care, and the state department;
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 clients who have been determined to be in need of such services pursuant to the "Colorado Medical Assistance Act" and the state board's rules.
(3) The statewide managed care system must include a statewide system of community behavioral health care that must:
Address the economic, social, and personal costs to the state of Colorado and itscitizens of untreated behavioral health disorders, including mental health and substance use disorders;
Approach behavioral health disorders as treatable conditions not unlike other chronichealth issues that require a combination of behavioral change and medication or other treatment;
Offer timely access through multiple points of entry to a full continuum of culturallyresponsive 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;
Feature a comprehensive and integrated system of quality behavioral health care thatis individualized and coordinated to meet individuals' changing needs;
Be paid for by the state department establishing capitated rates specifically for community mental health services that account for a comprehensive continuum of needed services such as those provided by community mental health centers as defined in section 27-66101;
Make the behavioral health system's administrative processes, service delivery, andfunding more effective and efficient to improve outcomes for Colorado citizens;
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;
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
Require an MCE to cover all medically necessary covered treatments for coveredbehavioral health diagnoses, regardless of any co-occurring conditions.
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.
The statewide managed care system builds upon the lessons learned from previousmanaged care and community behavioral health care programs in the state in order to reduce barriers that may negatively impact medicaid recipient experience, medicaid recipient 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.
(a) The state department is authorized to assign a medicaid recipient 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 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.
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.
(7.5) (a) The state department shall offer to enter into a direct contract with the MCO operated by or under the control of Denver health and hospital authority, created pursuant to article 29 of title 25, until the MCO ceases to operate a medicaid managed care program or until June 30, 2025, unless sooner reprocured. If the state department designates an MCO to manage behavioral health services pursuant to this article 5, Denver health and hospital authority, or any subsidiary thereof, shall collaborate with the MCO during the term of contract.
(b) The MCO operated by or under the control of Denver health and hospital authority shall:
Maintain adequate financials to ensure proper solvency as a risk manager;
Accept rates determined by the state department, through standard methodologies, tocover the population it is serving;
Maintain service and quality metrics, as determined by the state department; and
Meet statewide managed care system standards and operate as part of the overallmanaged care system.
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.
Bidding. 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 enrollees. 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 recipients over the long term that meets the requirements of this section and section 25.5-5-406.1.
An MCE that is contracting for a defined scope of services under a risk contractshall certify the financial stability of the MCE pursuant to criteria established by the division of insurance.
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.
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 recipients 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.
Nothing in this part 4 creates an exemption from the applicable provisions of title10.
Nothing in this part 4 creates an entitlement to an MCE to contract with the statedepartment.
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.
The state department shall provide information on its website specifying how thepublic 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.
Source: L. 2006: Entire article added with relocations, p. 1883, § 7, effective July 1. L. 2008: (3) and (5) amended, p. 390, § 1, effective August 5. L. 2012: (6) added, (HB 12-1281), ch. 246, p. 1187, § 3, effective June 4. L. 2018: Entire section amended with relocations, (HB 18-1431), ch. 313, p. 1877, § 1, effective August 8; IP(2) and (2)(a) amended, (HB 18-1328), ch. 184, p. 1244, § 6, effective June 7, 2019. L. 2019: (3)(e) amended and (3)(g), (3)(h), (3)(i), (15), (16), and (17) added, (HB 19-1269), ch. 195, p. 2133, § 12, effective May 16; (7.5) added, (HB 19-1285), ch. 392, p. 3501, § 1, effective August 2. L. 2020: (6) amended, (HB 20-1237), ch.
271, p. 1319, § 1, effective July 11; (3)(c.5) added, (SB 20-007), ch. 286, p. 1391, § 7, effective July 13.
Editor's note: (1) This section is similar to former § 26-4-113 as it existed prior to 2006.
Section 10 of chapter 184 (HB 18-1328), Session Laws of Colorado 2018, providesthat section 6 of the act changing this section takes effect upon notice to the revisor of statutes pursuant to § 25.5-5-306 (6) as enacted in section 2 of the act. For more information, see HB 181328. (L. 2018, p. 1247.) On August 14, 2019, the revisor of statutes received the notice referred to in § 25.5-5-306 (6) that the federal department of health and human services approved the waiver on June 7, 2019.
Amendments to subsections IP(2) and (2)(a) by HB 18-1328 and HB 18-1431 wereharmonized, effective June 7, 2019.
Provisions of this section are similar to provisions of former §§ 25.5-5-402, 25.5-5404, 25.5-5-406, and 25.5-5-411, as they existed prior to 2018. For a detailed comparison of this section, see the comparative tables located at the back of the index.
Cross references: (1) For the legislative declaration in HB 18-1328, see section 1 of chapter 184, Session Laws of Colorado 2018.
(2) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 191269, see section 1 of chapter 195, Session Laws of Colorado 2019.