(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.
Managed care plans participating in the plan shall not discriminate against any potential or current enrollee based upon health status, disability, sex, sexual orientation, marital status, race, creed, color, national origin, ancestry, ethnicity, or religion.
Managed care plans that contract with the department to provide the plan to enrolleesshall also be willing to contract with the medicaid managed care program, as administered by the department.
(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.
The managed care organization shall seek proposals from each essential communityprovider in a county in which the managed care organization is enrolling recipients 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 such proposals in good faith and shall, when deemed reasonable by the managed care organization based on the needs of its enrollees, contract with essential community providers. Each essential community provider shall be willing to negotiate on reasonably equitable terms with each managed care organization. Essential community providers making proposals under this subsection (4) shall be able to meet the contractual requirements of the managed care organization. The requirement of this subsection (4) shall not apply to a managed care organization in areas in which the managed care organization operates entirely as a group model health maintenance organization.
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.
In selecting managed care organizations through competitive bidding, the departmentshall 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 costbased reimbursement to federally qualified health centers as defined in the federal "Social Security Act".
The department may receive and act upon complaints from enrollees regarding failure to provide covered services or efforts to obtain payment, other than authorized copayments, for covered services directly from eligible recipients.
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.
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.
The department may contract with essential community providers or other providersor 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.
The department shall allow, at least annually, an opportunity for enrollees to transferamong participating managed care plans serving their respective geographic regions. The department shall establish a period of at least twenty days annually when this opportunity is afforded eligible recipients. In geographic regions served by more than one participating managed care plan, the department shall endeavor to establish a uniform period for such opportunity.
(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.
Source: L. 2006: Entire article added with relocations, p. 1982, § 7, effective July 1. L. 2008: (2) amended, p. 1603, § 32, effective May 29. L. 2009: (10) amended, (SB 09-265), ch. 205, p. 936, § 7, effective May 1. L. 2010: (10)(b) repealed, (HB 10-1382), ch. 217, p. 940, § 6, effective May 6. L. 2013: (1) amended, (HB 13-1266), ch. 217, p. 993, § 65, effective May 13.
Editor's note: This section is similar to former § 26-19-110 as it existed prior to 2006.
Cross references: (1) For the legislative declaration contained in the 2008 act amending subsection (2), see section 1 of chapter 341, Session Laws of Colorado 2008.
(2) For the definition of "federally qualified health centers" in the federal Social Security Act, see 42 U.S.C. sec. 1395x.