SENATE BILL 97005
BY SENATORS Hopper, Bishop, Hernandez, Johnson, Matsunaka, Norton, Reeves, Rizzuto, Weddig, and Wham;
also REPRESENTATIVES Owen, Clarke, Dyer, Grampsas,
Hagedorn, Keller, Lawrence, Leyba, and Saliman.
CONCERNING MEDICAID MANAGED CARE, AND MAKING AN APPROPRIATION
IN CONNECTION THEREWITH.
Be it enacted by the General Assembly of the State
of Colorado:
SECTION 1. Part
1 of article 4 of title 26, Colorado Revised Statutes, 1989 Repl.
Vol., as amended, is amended BY THE ADDITION OF A NEW SECTION
to read:
264101.5. Short title
citation. THIS SUBPART 1 CONSISTS OF SECTIONS
264101 TO 264110 AND MAY BE CITED AS SUBPART
1. THE TITLE OF THIS SUBPART 1 SHALL BE KNOWN AND MAY BE CITED
AS "GENERAL PROVISIONS".
SECTION 2. 264104,
Colorado Revised Statutes, 1989 Repl. Vol., as amended, is amended
to read:
264104. Program of medical
assistance single state agency.
(1) The
state department, by rules and regulations, shall establish a
program of medical assistance to provide necessary medical care
for the categorically needy. The state department is hereby designated
as the single state agency to administer such program in accordance
with Title XIX and this article. Such program shall not be required
to furnish recipients under sixtyfive years of age the benefits
that are provided to recipients sixtyfive years of age and
over under Title XVIII of the social security act; but said program
shall otherwise be uniform to the extent required by Title XIX
of the social security act.
(2) The state department shall
promulgate rules and regulations which establish a managed care
system for the provision of medical services under this article.
Said rules may include, but are not limited to, the establishment
of programs which require the selection of one physician or organization
to provide primary care and consultation to a recipient of assistance
under this article, standards for selection of a primary care
provider, utilization review and quality assurance programs, and
financial incentives for the operation of a program.
SECTION 3. Part
1 of article 4 of title 26, Colorado Revised Statutes, 1989 Repl.
Vol., as amended, is amended BY THE ADDITION OF A NEW SUBPART
CONTAINING RELOCATED PROVISIONS, WITH AMENDMENTS, to read:
SUBPART 2
STATEWIDE MANAGED CARE SYSTEM
264111. Short title
citation. THIS SUBPART 2 CONSISTS OF SECTIONS
264111 TO 264130 AND MAY BE CITED AS SUBPART
2. THE TITLE OF THIS SUBPART 2 SHALL BE KNOWN AND MAY BE CITED
AS THE "STATEWIDE MANAGED CARE SYSTEM".
264112. Legislative declaration.
(1) THE GENERAL ASSEMBLY HEREBY FINDS THAT:
(a) COLORADO'S BUDGET, LIKE THE BUDGETS
OF MANY STATES, HAS BEEN CONSTRAINED BY THE INCREASING COSTS ASSOCIATED
WITH FEDERAL PROGRAMS. FEDERAL MANDATES CAUSE STATE BUDGETARY
STRAIN WHEN IMPOSED WITHOUT CORRESPONDING ADJUSTMENTS TO THE FINANCING
FORMULA FOR DETERMINING THE FEDERALSTATE SHARE. THIS PHENOMENON
HAS BEEN PARTICULARLY EVIDENT IN THE IMPLEMENTATION OF THE FEDERAL
MEDICAID PROGRAM.
(b) THE FEDERAL MEDICAID PROGRAM DOES
NOT ADEQUATELY ADDRESS THE NEEDS OF ALL IMPOVERISHED COLORADO
CITIZENS AND, AS A RESULT, THIS STATE FINDS IT NECESSARY TO ADDRESS
THE MEDICAL NEEDS OF ITS POOR THROUGH STATEFUNDED PROGRAMS,
INCLUDING BUT NOT LIMITED TO THE "CHILDREN'S HEALTH PLAN
ACT", ARTICLE 17 OF THIS TITLE, AND THE "REFORM ACT
FOR THE PROVISION OF HEALTH CARE FOR THE MEDICALLY INDIGENT",
ARTICLE 15 OF THIS TITLE;
(c) (I) THE FEDERAL GOVERNMENT MAY
CHOOSE TO PROVIDE FUNDING FOR MEDICAL ASSISTANCE PROGRAMS THROUGH
FEDERAL BLOCK GRANTS. IF STATES ARE GIVEN MAXIMUM FLEXIBILITY
FOR THE IMPLEMENTATION OF MEDICAL ASSISTANCE PROGRAMS USING THE
BLOCK GRANTS, THIS STATE MAY BE IN A POSITION TO BALANCE THE STATE'S
TOTAL BUDGETARY NEEDS WITH THE NEEDS OF THE STATE'S POOR WITHOUT
ADHERENCE TO RESTRICTIVE FEDERAL REQUIREMENTS THAT MAY BE IMPRACTICAL
FOR COLORADO.
(II) IF THE FEDERAL GOVERNMENT REDUCES
ITS FEDERAL FINANCIAL PARTICIPATION WITHOUT MAKING ANY CORRESPONDING
CHANGES TO FEDERAL REQUIREMENTS, THIS STATE WILL NEED TO DETERMINE
WHICH POPULATIONS CAN BE SERVED IN THE MOST COSTEFFICIENT
MANNER;
(d) WHETHER THE FEDERAL GOVERNMENT FUNDS
MEDICAL ASSISTANCE PROGRAMS THROUGH BLOCK GRANTS OR REDUCES ITS
FINANCIAL PARTICIPATION WITHOUT CHANGING ANY FEDERAL REQUIREMENTS,
COLORADO HAS AN OPPORTUNITY TO ADOPT INNOVATIVE AND COSTEFFICIENT
STATE MEDICAL ASSISTANCE STRATEGIES FOR MEETING THE MEDICAL NEEDS
OF ITS IMPOVERISHED CITIZENS;
(e) THE EXPERIENCE OF OTHER STATES INDICATES
THAT REACTIVE, RAPID, AND COMPREHENSIVE CHANGES TO A STATE'S MEDICAL
ASSISTANCE PROGRAM CAN BE COSTLY AND INEFFICIENT;
(f) COLORADO HAS ADOPTED MANAGED CARE
ON A SMALL SCALE BASIS FOR SPECIFIC POPULATIONS AND IS CONDUCTING
PILOT PROGRAMS FOR OTHER POPULATIONS, INCLUDING BUT NOT LIMITED
TO MANAGED CARE, CAPITATED MANAGED CARE, THE USE OF PRIMARY CARE
PHYSICIANS, COPAYMENTS, AND MANAGED CARE PROGRAMS FOR THE ELDERLY
SUCH AS THE PACE PROGRAM;
(g) IT IS IN THE STATE'S BEST INTEREST
TO ENSURE THAT ALL MEDICAL ASSISTANCE PROGRAMS PROMOTE INDEPENDENT
LIVING AND THAT ALL REGULATIONS FOR SUCH PROGRAMS ARE DEVELOPED
WITH MAXIMUM RECIPIENT INVOLVEMENT; AND
(h) TO THE EXTENT IT IS NECESSARY FOR
THE STATE DEPARTMENT TO ASSIGN A RECIPIENT TO A MANAGED CARE PROVIDER,
THE STATE DEPARTMENT SHALL TO THE EXTENT POSSIBLE CONSIDER THE
CONTINUUM OF THE RECIPIENT'S CARE.
(2) THE GENERAL ASSEMBLY FURTHER FINDS
THAT, WITH RECOMMENDATIONS FROM THE MEDICAL ASSISTANCE REFORM
ADVISORY COMMITTEE CREATED IN SECTION 264704, THE
OFFICE OF STATE PLANNING AND BUDGETING HAS STUDIED THE ALTERNATIVE
METHODS OF PROVIDING MEDICAL ASSISTANCE TAKING INTO ACCOUNT COSTEFFICIENCY,
CONTINUED RECEIPT OF FEDERAL MONEYS, AND MINIMAL IMPACT ON THE
QUALITY OF MEDICAL ASSISTANCE FOR POOR PERSONS IN THIS STATE.
(3) (a) THE GENERAL ASSEMBLY DECLARES
THAT IT IS IN THE STATE'S BEST INTEREST TO USE SAVINGS IN MEDICAID
PER CAPITA COSTS FROM THE IMPLEMENTATION OF THIS SUBPART 2 AND
FROM THE IMPLEMENTATION OF SECTION 264404 (1) (b)
TO COVER THE ADMINISTRATIVE COSTS OF IMPLEMENTING MANAGED CARE
PURSUANT TO THE PROVISIONS OF THIS SUBPART 2.
(b) REMAINING SAVINGS IN MEDICAID PER
CAPITA COSTS FROM THE IMPLEMENTATION OF THIS SUBPART 2 SHALL BE
USED TO ESTABLISH PROGRAMS TO INSURE ADDITIONAL LOWINCOME
COLORADANS AND TO SUPPORT ESSENTIAL COMMUNITY PROVIDERS AS LONG
AS SUCH NEW PROGRAMS DO NOT CREATE AN ENTITLEMENT TO SERVICES
AND MINIMIZE ANY SUBSTITUTION OF SUBSIDIZED COVERAGE FOR EMPLOYERBASED
COVERAGE.
(c) REMAINING SAVINGS IN MEDICAID PER
CAPITA COSTS FROM THE IMPLEMENTATION OF SECTION 264404
(1) (b) MAY BE USED FOR THE EXPANSION OF THE INCENTIVE PROGRAM
TO PROVIDERS OF DENTAL SERVICES FOR CHILDREN UNDER THE EARLY PERIODIC
SCREENING, DIAGNOSIS, AND TREATMENT PROGRAM.
(4) THE GENERAL ASSEMBLY THEREFORE DECLARES
THAT IT IS IN THE STATE'S BEST INTEREST TO ADOPT THIS SUBPART
2.
264113. Statewide managed
care system implementation required.
(1) Rules. (a) EXCEPT AS PROVIDED
IN SUBSECTION (5) OF THIS SECTION, THE STATE DEPARTMENT SHALL
ADOPT RULES TO IMPLEMENT A MANAGED CARE SYSTEM FOR SEVENTYFIVE
PERCENT OF THE COLORADO MEDICAL ASSISTANCE POPULATION ON A STATEWIDE
BASIS PURSUANT TO THE PROVISIONS OF THIS ARTICLE. THE MANAGED
CARE SYSTEM IMPLEMENTED PURSUANT TO THIS ARTICLE SHALL NOT INCLUDE
THE SERVICES DELIVERED UNDER THE RESIDENTIAL CHILD HEALTH CARE
PROGRAM DESCRIBED IN SECTION 264527. THE RULES SHALL
INCLUDE A PLAN TO IMPLEMENT THE STATEWIDE MANAGED CARE SYSTEM
OVER A THREEYEAR PERIOD PURSUANT TO THE PROVISIONS OF SUBSECTION
(2) OF THIS SECTION.
(b) IT IS THE GENERAL ASSEMBLY'S INTENT
THAT THE STATE DEPARTMENT ELIMINATE ADMINISTRATIVE RULES AND FUNCTIONS
THAT ARE UNNECESSARY AND UNRELATED TO THE IMPLEMENTATION OF THE
STATEWIDE MANAGED CARE SYSTEM. THE RULES AND FUNCTIONS SHALL BE
REDUCED ACCORDING TO THE SCHEDULE FOR IMPLEMENTING THE STATEWIDE
MANAGED CARE SYSTEM IN SUBSECTION (2) OF THIS SECTION. THE STATE
DEPARTMENT SHALL TAKE INTO CONSIDERATION RECOMMENDATIONS FROM
MANAGED CARE PROVIDERS, RECIPIENTS OR THEIR ADVOCATES, HEALTH
CARE COVERAGE COOPERATIVES, AND THE MEDICAL ASSISTANCE REFORM
ADVISORY COMMITTEE IN ELIMINATING UNNECESSARY AND UNRELATED RULES
AND FUNCTIONS.
(2) Statewide managed care implementation. (a) SUBJECT
TO THE PROVISIONS OF SUBSECTION (5) OF THIS SECTION AND SECTION
264121 (2), IF THE EXECUTIVE DIRECTOR DETERMINES THAT
THEY HAVE BEEN EFFECTIVE, ALL MANAGED CARE CONTRACTS AND PILOT
PROJECTS IN EFFECT OR WITH APPROVED FEDERAL WAIVERS AS OF JULY
1, 1997, MAY BE IMPLEMENTED ON A STATEWIDE BASIS NO LATER THAN
JULY 1, 2000, UNLESS OTHERWISE REPEALED BY THE GENERAL ASSEMBLY
BEFORE THAT DATE.
(b) MANAGED CARE PILOT PROJECTS THAT SHALL
BE IN EFFECT OR AUTHORIZED AS OF JULY 1, 1997, ARE THE FOLLOWING:
(I) Acute and longterm care. THE
INTEGRATED CARE AND FINANCING PROJECT TO STUDY THE INTEGRATION
OF ACUTE AND LONGTERM CARE, AS DESCRIBED IN SECTION 264122;
(II) Managed care contracts. LIMITED
ENROLLMENT IN CAPITATED MANAGED CARE FOR MEDICAL ASSISTANCE RECIPIENTS.
(III) Mental health. MANAGED
MENTAL HEALTH SERVICES, AS DESCRIBED IN SECTION 264123
[FORMERLY 264528];
(IV) Elderly. PROGRAM OF ALLINCLUSIVE CARE FOR THE ELDERLY, AS DESCRIBED IN SECTION 264124 [FORMERLY 264519];
(3) Bidding. THE STATE DEPARTMENT
IS AUTHORIZED TO INSTITUTE A PROGRAM FOR COMPETITIVE BIDDING PURSUANT
TO SECTION 24103202 OR 24103203, C.R.S.,
FOR PROVIDING MEDICAL SERVICES ON A MANAGED CARE BASIS FOR PERSONS
ELIGIBLE TO BE ENROLLED IN MANAGED CARE. THE STATE DEPARTMENT
IS AUTHORIZED TO AWARD CONTRACTS TO MORE THAN ONE OFFEROR. THE
STATE DEPARTMENT PROCEDURES SHALL SEEK TO USE COMPETITIVE BIDDING
PROCEDURES TO MAXIMIZE THE NUMBER OF MANAGED CARE CHOICES AVAILABLE
TO MEDICAID CLIENTS OVER THE LONG TERM THAT MEET THE REQUIREMENTS
OF SECTIONS 264115 AND 264117.
(4) Waivers. THE IMPLEMENTATION
OF THIS SUBPART 2 IS CONDITIONED, TO THE EXTENT APPLICABLE, ON
THE ISSUANCE OF NECESSARY WAIVERS BY THE FEDERAL GOVERNMENT. THE
PROVISIONS OF THIS SUBPART 2 SHALL BE IMPLEMENTED TO THE EXTENT
AUTHORIZED BY FEDERAL WAIVER, IF SO REQUIRED BY FEDERAL LAW.
(5) Longterm care assessment. (a) WITH
THE EXCEPTION OF THE PILOT PROGRAMS DESCRIBED IN SUBSECTION (2)
OF THIS SECTION, THE STATE DEPARTMENT SHALL NOT CONTRACT FOR LONGTERM
CARE SERVICES AS PART OF THE STATEWIDE MANAGED CARE SYSTEM UNTIL
FURTHER AUTHORIZATION BY THE JOINT BUDGET COMMITTEE, THE COMMITTEE
ON HEALTH, ENVIRONMENT, WELFARE, AND INSTITUTIONS IN THE SENATE,
AND THE COMMITTEE ON HEALTH, ENVIRONMENT, WELFARE, AND INSTITUTIONS
IN THE HOUSE OF REPRESENTATIVES FOLLOWING THE STATE DEPARTMENT'S
ASSESSMENT REQUIRED BY PARAGRAPH (b) OF THIS SUBSECTION (5). FOR
PURPOSES OF THIS SUBSECTION (5), "LONGTERM CARE SERVICES"
MEANS NURSING FACILITY AND HOME AND COMMUNITYBASED SERVICES
PROVIDED TO ELIGIBLE RECIPIENTS WHO HAVE BEEN DETERMINED TO BE
IN NEED OF SUCH SERVICES BY A SINGLE ENTRY POINT AGENCY OR PROFESSIONAL
REVIEW ORGANIZATION AS REQUIRED BY TITLE XIX OF THE SOCIAL SECURITY
ACT.
(b) DURING THE THREEYEAR PERIOD
FOR IMPLEMENTATION OF STATEWIDE MANAGED CARE PURSUANT TO SUBSECTION
(2) OF THIS SECTION, THE STATE DEPARTMENT SHALL ASSESS THE RESULTS
OF THE INTEGRATED CARE AND FINANCING PROJECT DESCRIBED IN SECTION
264122, THE PROGRAM OF ALLINCLUSIVE CARE FOR
THE ELDERLY DESCRIBED IN SECTION 264124, AND, IF SENATE
BILL 9742 BECOMES LAW, THE SYSTEM OF CASEMIX REIMBURSEMENT
FOR NURSING FACILITIES, INCLUDING PAYMENT FOR ANCILLARY SERVICES
SUCH AS PHARMACEUTICAL SERVICES, PRESCRIPTION DRUGS, AND OXYGEN
AS PART OF THAT SYSTEM. THE STATE DEPARTMENT'S ASSESSMENT SHALL
INCLUDE CONSIDERATION OF COMMENTS AND INPUT FROM LONGTERM
CARE PROVIDERS, RECIPIENTS OR THEIR ADVOCATES, AND FAMILIES. THE
STATE DEPARTMENT SHALL INCLUDE IN ITS ANNUAL REPORT REQUIRED PURSUANT
TO SECTION 264118 A SUMMARY OF ITS ONGOING ANALYSIS
OF THE RESULTS OF THESE PROGRAMS AND SYSTEMS.
(6) Graduate medical education. (a) THE
GENERAL ASSEMBLY DECLARES THAT GRADUATE MEDICAL EDUCATION, REFERRED
TO IN THIS SUBSECTION (6) AS "GME" IS OF VALUE TO THE
STATE AND THE PEOPLE OF COLORADO. THE GENERAL ASSEMBLY RECOGNIZES
THAT MEDICAID MONEYS HAVE HISTORICALLY CONTRIBUTED TO THE FUNDING
OF GME BY BEING INCLUDED IN THE RATE PAID TO TEACHING HOSPITALS
UNDER THE MEDICAID FEEFORSERVICE PROGRAM. THE GENERAL
ASSEMBLY INTENDS THAT FISCAL SUPPORT FOR GME CONTINUE, BUT FINDS
THAT UNDER A MANAGED CARE ENVIRONMENT, MCO'S WOULD HAVE NO OBLIGATION
OR INCENTIVE TO CONTINUE THIS SUPPORT FOR GME.
(b) THE STATE DEPARTMENT SHALL CONTINUE
THE 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 MCO WITH A CONTRACT WITH THE STATE
DEPARTMENT UNDER THIS SUBPART 2. GME FUNDING FOR RECIPIENTS ENROLLED
IN AN MCO SHALL BE EXCLUDED FROM THE PREMIUMS PAID TO THE MCO
AND SHALL BE PAID DIRECTLY TO THE TEACHING HOSPITAL. THE MEDICAL
SERVICES BOARD SHALL ADOPT RULES TO IMPLEMENT THIS SUBSECTION
(6) AND ESTABLISH THE RATE AND METHOD OF REIMBURSEMENT.
(c) THIS SUBSECTION (6) SHALL BE IMPLEMENTED
AS SOON AS PRACTICAL, BUT NOT LATER THAN JANUARY 1, 1998.
(7) Annual savings report and use of
savings. (a) BY SEPTEMBER 1 OF EACH YEAR, THE STATE
DEPARTMENT SHALL SUBMIT TO THE JOINT BUDGET COMMITTEE, THE HEALTH,
ENVIRONMENT, WELFARE, AND INSTITUTIONS COMMITTEE OF THE SENATE,
THE HEALTH, ENVIRONMENT, WELFARE, AND INSTITUTIONS COMMITTEE OF
THE HOUSE OF REPRESENTATIVES, AND TO THE OFFICE OF STATE PLANNING
AND BUDGETING A SAVINGS REPORT STATING THE COST SAVINGS REALIZED
OR ANTICIPATED IN THE PREVIOUS, CURRENT, AND SUBSEQUENT STATE
FISCAL YEARS FROM ENROLLMENT OF RECIPIENTS IN MANAGED CARE PROGRAMS
PURSUANT TO THE PROVISIONS OF THIS SUBPART 2. THE REPORT SHALL
INCLUDE AN ASSESSMENT OF THE EXTENT TO WHICH THE PROGRAM DESCRIBED
IN SUBSECTION (8) OF THIS SECTION HAS REDUCED PROVIDERS' UNCOMPENSATED
BURDENS AND AN ASSESSMENT OF CHANGES ON THE FINANCIAL VIABILITY
OF ESSENTIAL COMMUNITY PROVIDERS. THE REPORT SHALL ALSO INCLUDE
A RECOMMENDATION FOR PRIORITIZING BETWEEN THE SUBSIDIZED INSURANCE
PROGRAM DESCRIBED IN SUBSECTION (8) OF THIS SECTION AND THE GRANTS
PROGRAMS DESCRIBED IN SUBSECTION (9) OF THIS SECTION, AND FOR
PRIORITIZING RESOURCES WITHIN EACH OF THOSE PROGRAMS TO DIFFERENT
POPULATIONS AND REGIONS OF THE STATE. THESE RECOMMENDATIONS SHALL
BE BASED UPON QUANTITATIVE AND QUALITATIVE ASSESSMENTS OF NEEDS
AND ON THE RELATIVE COSTEFFECTIVENESS OF DIFFERENT RESOURCE
ALLOCATIONS.
(b) IN CALCULATING COST SAVINGS FROM ENROLLMENT
OF RECIPIENTS IN MANAGED CARE PROGRAMS, THE STATE DEPARTMENT SHALL
CALCULATE THE TOTAL ANNUAL COST SAVINGS FROM GROWTH IN MANAGED
CARE ENROLLMENT SUBSEQUENT TO JULY 1, 1997, AND TOTAL ANNUAL COST
SAVINGS FROM ACTUAL REDUCTIONS IN ADMINISTRATIVE AND PROGRAMMATIC
COSTS ASSOCIATED WITH THE IMPLEMENTATION OF THIS SUBPART 2. COST
SAVINGS FOR EACH ADDITIONAL ENROLLEE SHALL BE CALCULATED AS THE
DIFFERENCE IN PER CAPITA COST BETWEEN AN ENROLLEE IN FEEFORSERVICE
MEDICAID AND A SIMILAR ENROLLEE IN MANAGED CARE.
(c) THE GENERAL ASSEMBLY SHALL ANNUALLY
APPROPRIATE ALL SAVINGS ACHIEVED THROUGH IMPLEMENTATION OF THIS
SUBPART 2 AND DESCRIBED IN THIS SUBSECTION (7) TO COVER THE ADMINISTRATIVE
COSTS OF IMPLEMENTING MANAGED CARE PURSUANT TO THE PROVISIONS
OF THIS SUBPART 2 AND THE COSTS OF PROGRAMS PROVIDED IN SUBSECTIONS
(8) AND (9) OF THIS SECTION AND ANY OTHER COSTEFFECTIVE
OPTIONS TO EXPAND ACCESS TO SERVICES FOR THE MEDICALLY INDIGENT
POPULATION. IT IS THE INTENT OF THE GENERAL ASSEMBLY THAT THE
MANDATORY AND OPTIONAL POPULATIONS AND BENEFITS PROVIDED BY THE
"COLORADO MEDICAL ASSISTANCE ACT" AS OF JUNE 30, 1997,
ARE A HIGHER PRIORITY FOR FUNDING THAN THE WAIVERED OPTIONAL PROGRAMS
DESCRIBED IN SUBSECTIONS (8) AND (9) OF THIS SECTION. SUCH APPROPRIATIONS
SHALL INCLUDE ALL ANTICIPATED COST SAVINGS SUBSEQUENT TO JULY
1, 1997, THAT ARE ACHIEVED THROUGH THE IMPLEMENTATION OF THIS
SUBPART 2 AND DESCRIBED IN THIS SUBSECTION (7). BEGINNING WITH
AND SUBSEQUENT TO STATE FISCAL YEAR 19992000, SUCH APPROPRIATIONS
SHALL INCLUDE ALL OF THE SAVINGS DESCRIBED IN THE ANNUAL SAVINGS
REPORT DESCRIBED IN PARAGRAPH (a) OF THIS SUBSECTION (7).
(d) THE STATE DEPARTMENT SHALL MONITOR
ACTUAL MANAGED CARE SAVINGS REALIZED DURING A PARTICULAR FISCAL
YEAR BASED UPON THE METHODOLOGY DESCRIBED IN PARAGRAPH (b) OF
THIS SUBSECTION (7). TO THE EXTENT THAT THE GENERAL ASSEMBLY HAS
APPROPRIATED MANAGED CARE SAVINGS PURSUANT TO PARAGRAPH (c) OF
THIS SUBSECTION (7) AND THE STATE DEPARTMENT DETERMINES THAT IT
WILL NOT REALIZE ALL OF SUCH MANAGED CARE SAVINGS DURING A PARTICULAR
FISCAL YEAR, THE STATE DEPARTMENT SHALL RESTRICT ITS SPENDING
UNDER SUBSECTIONS (8) AND (9) OF THIS SECTION.
(e) TO IMPLEMENT THE PROVISIONS OF PARAGRAPH
(d) OF THIS SUBSECTION (7), THE STATE DEPARTMENT SHALL SUBMIT
SUPPLEMENTAL APPROPRIATION REQUESTS DURING A PARTICULAR FISCAL
YEAR TO MODIFY APPROPRIATIONS FOR THE PROGRAMS DESCRIBED IN SUBSECTIONS
(8) AND (9) OF THIS SECTION.
(f) THE STATE DEPARTMENT SHALL NOT SPEND
MONEYS FROM MANAGED CARE SAVINGS ON THE PROGRAMS DESCRIBED IN
SUBSECTIONS (8) AND (9) OF THIS SECTION DURING THE FISCAL YEAR
BEGINNING JULY 1, 1997.
(8) Subsidized insurance coverage. (a) THERE
IS HEREBY CREATED A SUBSIDIZED INSURANCE PROGRAM, REFERRED TO
IN THIS SUBSECTION (8) AS THE "PROGRAM", THAT SHALL
PROVIDE SUBSIDIZED INSURANCE COVERAGE FOR UNINSURED CHILDREN UNDER
AGE NINETEEN. SUCH PROGRAM SHALL BE LIMITED TO PERSONS WITH FAMILIES
WITH INCOMES LESS THAN OR EQUAL TO ONE HUNDRED EIGHTYFIVE
PERCENT OF THE FEDERAL POVERTY LEVEL. THE STATE DEPARTMENT IS
HEREBY AUTHORIZED TO SEEK THE NECESSARY FEDERAL WAIVERS TO IMPLEMENT
THE PROGRAM.
(b) NOTHING IN THIS SUBSECTION (8) OR
ANY RULES PROMULGATED PURSUANT TO THE PROGRAM SHALL BE INTERPRETED
TO CREATE A LEGAL ENTITLEMENT IN ANY PERSON TO SUBSIDIZED INSURANCE
COVERAGE.
(c) ENROLLMENT IN THE PROGRAM SHALL BE
LIMITED BASED UPON ANNUAL APPROPRIATIONS BY THE GENERAL ASSEMBLY
AS DESCRIBED IN PARAGRAPH (c) OF SUBSECTION (7) OF THIS SECTION.
THE GENERAL ASSEMBLY SHALL ANNUALLY ESTABLISH MAXIMUM ENROLLMENT
FIGURES FOR CHILDREN.
(d) TO BE ELIGIBLE FOR A SUBSIDY UNDER THE PROGRAM, A CHILD MUST NOT HAVE CURRENTLY NOR IN THE THREE MONTHS PRIOR TO APPLICATION FOR THE PROGRAM HAVE BEEN INSURED BY A COMPARABLE HEALTH PLAN THROUGH AN EMPLOYER, WITH THE EMPLOYER CONTRIBUTING AT LEAST FIFTY PERCENT OF THE PREMIUM COST; EXCEPT THAT A CHILD WHO HAS LOST INSURANCE COVERAGE DUE TO A CHANGE IN OR LOSS OF EMPLOYMENT SHALL NOT BE SUBJECT TO THE THREEMONTH WAITING PERIOD.
(e) IN IMPLEMENTING THIS PROGRAM, THE
STATE DEPARTMENT SHALL CONTRACT FOR MANAGED CARE SERVICES WITH
THE SAME GOALS AND UNDER THE SAME CONDITIONS AS THOSE DESCRIBED
IN THIS SUBPART 2 AND SHALL SEEK TO PRIVATIZE ADMINISTRATIVE FUNCTIONS
IN THE SAME MANNER AS DESCRIBED IN SECTION 264120.
(f) THE STATE DEPARTMENT SHALL DEFINE
BENEFITS FOR THIS PROGRAM BASED UPON THE STANDARD AND BASIC HEALTH
BENEFITS PLANS DESCRIBED IN ARTICLE 16 OF TITLE 10, C.R.S.
(g) THE STATE DEPARTMENT MAY REQUIRE ENROLLEES
IN THE PROGRAM TO PAY A PORTION OF THE PREMIUM COSTS FOR THE PROGRAM
AND PAY FOR A PORTION OF THE COST OF SERVICES DELIVERED UNDER
THE PROGRAM. ON OR BEFORE JANUARY 1 OF EACH YEAR, THE STATE DEPARTMENT
SHALL SUBMIT TO THE JOINT BUDGET COMMITTEE ITS PROPOSAL FOR A
SCALE FOR INCREASING PREMIUMS OR SERVICE COST SHARING FOR THE
PROGRAM BASED UPON A FAMILY'S INCOME.
(h) THE STATE DEPARTMENT SHALL ESTABLISH
PROCEDURES FOR RECEIVING PART OR ALL OF THE REQUIRED PREMIUM PAYMENTS
UNDER THE PROGRAM FROM OTHER HEALTH CARE PURCHASERS AND SHALL
ESTABLISH PROCEDURES FOR BUYING HEALTH CARE INSURANCE WITH SUBSTANTIALLY
SIMILAR BENEFITS TO THOSE UNDER THE PROGRAM THROUGH OTHER HEALTH
CARE PURCHASERS.
(i) THE STATE DEPARTMENT MAY ESTABLISH
RULES UNDER THE PROGRAM FOR DETERMINING ELIGIBILITY AND FOR ENROLLING
ELIGIBLE PERSONS IN MANAGED CARE PLANS THAT ARE DIFFERENT FROM
THE MEDICAL ASSISTANCE PROGRAM.
(j) IN IMPLEMENTING THE PROGRAM, THE STATE
DEPARTMENT SHALL SEEK TO ACHIEVE A DISTRIBUTION OF ENROLLMENT
IN THE PROGRAM BY COUNTY THAT IS AS SIMILAR AS POSSIBLE TO THE
DISTRIBUTION OF ENROLLMENT IN CAPITATED MEDICAID MANAGED CARE
PROGRAMS BY COUNTY.
(9) Grants programs. (a) SUBJECT
TO APPROPRIATIONS AS DESCRIBED IN PARAGRAPH (c) OF SUBSECTION
(7) OF THIS SECTION, THERE IS HEREBY CREATED A GRANT PROGRAM THAT
SHALL BE ADMINISTERED BY THE STATE DEPARTMENT. THE PURPOSE OF
THE GRANT PROGRAM IS TO ASSIST ESSENTIAL COMMUNITY PROVIDERS TO
SERVE THE MEDICALLY INDIGENT POPULATION AND TO IDENTIFY AND IMPLEMENT
ADDITIONAL COSTEFFECTIVE OPTIONS TO EXPAND ACCESS TO SERVICES
FOR SAID POPULATION.
(b) THE STATE DEPARTMENT SHALL PROMULGATE
RULES FOR THE IMPLEMENTATION OF THE GRANT PROGRAM THAT SHALL INCLUDE
BUT NOT BE LIMITED TO:
(I) PROCEDURES FOR APPLYING FOR A GRANT
UNDER THIS SECTION;
(II) METHODS FOR THE EVALUATION OF APPLICATIONS
FOR GRANTS UNDER THIS SECTION AND AWARD OF GRANTS UNDER THIS SUBSECTION
(9); AND
(III) METHODS FOR EVALUATING THE GRANT
PROGRAM.
(10) (a) BY NOVEMBER 1, 1997, THE
STATE DEPARTMENT SHALL SUBMIT TO THE JOINT BUDGET COMMITTEE, THE
HEALTH, ENVIRONMENT, WELFARE, AND INSTITUTIONS COMMITTEE OF THE
SENATE, AND THE HEALTH, ENVIRONMENT, WELFARE, AND INSTITUTIONS
COMMITTEE OF THE HOUSE OF REPRESENTATIVES A REPORT ON A PLAN TO
DEVELOP A DENTAL SERVICES PROGRAM THAT ASSURES ACCESS TO DENTAL
SERVICES FOR CHILDREN IN THE MEDICAID PROGRAM. ANY DENTAL RATE
INCREASE MAY BE EFFECTIVE ON OR AFTER JULY 1, 1998.
(b) THIS SUBSECTION (10) IS REPEALED,
EFFECTIVE JULY 1, 1998.
264114. Managed care organizations
definitions. (1) (a) Managed
care. AS USED IN THIS SUBPART 2, "MANAGED
CARE" MEANS:
(I) THE DELIVERY BY A MANAGED CARE ORGANIZATION,
AS DEFINED IN SUBSECTION (2) OF THIS SECTION, OF A PREDEFINED
SET OF SERVICES TO RECIPIENTS; OR
(II) THE DELIVERY OF SERVICES PROVIDED
BY THE PRIMARY CARE PHYSICIAN PROGRAM ESTABLISHED IN SECTION 264118.
(b) NOTHING IN THIS SECTION SHALL BE DEEMED
TO AFFECT THE BENEFITS AUTHORIZED FOR RECIPIENTS OF THE STATE
MEDICAL ASSISTANCE PROGRAM.
(2) Managed care organization.
AS USED IN THIS SUBPART 2, "MANAGED CARE ORGANIZATION"
MEANS AN ENTITY CONTRACTING WITH THE STATE DEPARTMENT THAT PROVIDES,
DELIVERS, ARRANGES FOR, PAYS FOR, OR REIMBURSES ANY OF THE COSTS
OF HEALTH CARE SERVICES THROUGH THE RECIPIENT'S USE OF HEALTH
CARE PROVIDERS MANAGED BY, OWNED BY, UNDER CONTRACT WITH, OR EMPLOYED
BY THE ENTITY BECAUSE THE ENTITY OR THE STATE DEPARTMENT EITHER
REQUIRES THE RECIPIENT'S USE OF THOSE PROVIDERS OR CREATES INCENTIVES,
INCLUDING FINANCIAL INCENTIVES, FOR THE RECIPIENT'S USE OF THOSE
PROVIDERS.
(3) Essential community provider.
"ESSENTIAL COMMUNITY PROVIDER" OR "ECP" MEANS
A HEALTH CARE PROVIDER THAT:
(a) HAS HISTORICALLY SERVED MEDICALLY
NEEDY OR MEDICALLY INDIGENT PATIENTS AND DEMONSTRATES A COMMITMENT
TO SERVE LOWINCOME AND MEDICALLY INDIGENT POPULATIONS WHO
MAKE UP 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 CLIENT'S FINANCIAL LIMITATIONS.
264115. Selection of managed
care organizations. (1) THE
MEDICAL SERVICES BOARD AFTER PUBLIC HEARING AND INPUT FROM RECIPIENTS,
THEIR ADVOCATES, AND PROVIDERS SHALL ESTABLISH CRITERIA FOR THE
SELECTION OF RISKASSUMING MCO'S.
(2) MCO'S SHALL BE SELECTED BY THE STATE
DEPARTMENT TO PARTICIPATE IN THE STATEWIDE MANAGED CARE SYSTEM
BASED UPON THE MCO'S ASSURANCE AND THE STATE DEPARTMENT'S VERIFICATION
OF COMPLIANCE WITH SPECIFIC CRITERIA SET BY THE MEDICAL SERVICES
BOARD PURSUANT TO THIS SUBSECTION (2) THAT INCLUDE BUT ARE NOT
LIMITED TO THE FOLLOWING:
(a) THE MCO WILL NOT INTERFERE WITH APPROPRIATE
MEDICAL CARE DECISIONS RENDERED BY THE PROVIDER NOR PENALIZE THE
PROVIDER FOR REQUESTING MEDICAL SERVICES OUTSIDE THE STANDARD
TREATMENT PROTOCOLS DEVELOPED BY THE MCO OR ITS CONTRACTORS;
(b) THE MCO WILL MAKE OR ASSURE PAYMENTS
TO PROVIDERS WITHIN THE TIME ALLOWED FOR THE STATE TO MAKE PAYMENTS
ON STATE LIABILITIES UNDER THE RULES ADOPTED BY THE DEPARTMENT
OF PERSONNEL PURSUANT TO SECTION 2430202 (13), C.R.S.;
(c) AN EDUCATIONAL COMPONENT IN THE MCO'S
PLAN THAT TAKES INTO CONSIDERATION RECIPIENT INPUT AND THAT INFORMS
RECIPIENTS AS TO AVAILABILITY OF PLANS AND USE OF THE MEDICAL
SERVICES SYSTEM, APPROPRIATE PREVENTIVE HEALTH CARE PROCEDURES,
SELFCARE, AND APPROPRIATE HEALTH CARE UTILIZATION;
(d) MINIMUM BENEFIT REQUIREMENTS AS ESTABLISHED
BY THE MEDICAL SERVICES BOARD;
(e) PROVISION OF NECESSARY AND APPROPRIATE
SERVICES TO RECIPIENTS THAT SHALL INCLUDE BUT NOT BE LIMITED TO
THE FOLLOWING:
(I) WITH RESPECT TO RECIPIENTS WHO ARE
UNABLE TO MAKE DECISIONS FOR THEMSELVES, COLLABORATION BY THE
MCO AND ALL RELEVANT PROVIDERS IN THE MCO=S
NETWORK SERVING THE RECIPIENTS WITH THE DESIGNATED ADVOCATE OR
FAMILY MEMBER IN ALL DECISIONMAKING INCLUDING ENROLLMENT
AND DISENROLLMENT;
(II) DELIVERY OF SERVICES THAT ARE COVERED
BENEFITS IN A MANNER THAT ACCOMMODATES OR IS COMPATIBLE WITH THE
RECIPIENT=S
ABILITY TO FULFILL DUTIES AND RESPONSIBILITIES IN WORK AND COMMUNITY
ACTIVITIES.
(f) APPROPRIATE USE OF ANCILLARY HEALTH
CARE PROVIDERS BY APPROPRIATE QUALIFIED HEALTH CARE PROFESSIONALS;
(g) DATA COLLECTION AND REPORTING REQUIREMENTS
ESTABLISHED BY THE MEDICAL SERVICES BOARD;
(h) TO THE EXTENT PROVIDED BY LAW OR WAIVER,
PROVISION OF RECIPIENT BENEFITS THAT THE MEDICAL SERVICES BOARD
SHALL DEVELOP AND THE STATE DEPARTMENT SHALL IMPLEMENT IN PARTNERSHIP
WITH LOCAL GOVERNMENT AND THE PRIVATE SECTOR, INCLUDING BUT NOT
LIMITED TO:
(I) RECIPIENT OPTIONS TO RENT, PURCHASE,
OR OWN DURABLE MEDICAL EQUIPMENT;
(II) RECOGNITION FOR IMPROVED HEALTH STATUS
OUTCOMES; OR
(III) RECEIPT OF MEDICAL DISPOSABLE SUPPLIES
WITHOUT CHARGE;
(i) UTILIZATION REQUIREMENTS ESTABLISHED
BY THE STATE DEPARTMENT;
(j) A FORM OR PROCESS FOR MEASURING GROUP
AND INDIVIDUAL RECIPIENT HEALTH OUTCOMES, INCLUDING BUT NOT LIMITED
TO THE USE OF TOOLS OR METHODS THAT IDENTIFY INCREASED HEALTH
STATUS OR MAINTENANCE OF THE INDIVIDUAL'S HIGHEST LEVEL OF FUNCTIONING,
DETERMINE THE DEGREE OF MEDICAL ACCESS, AND REVEAL RECIPIENT SATISFACTION
AND HABITS. SUCH TOOLS SHALL INCLUDE THE USE OF CLIENT SURVEYS,
ANECDOTAL INFORMATION, COMPLAINT AND GRIEVANCE DATA, AND DISENROLLMENT
INFORMATION. THE MCO SHALL ANNUALLY SUBMIT A CARE MANAGEMENT REPORT
TO THE STATE DEPARTMENT THAT DESCRIBES TECHNIQUES USED BY THE
MCO TO PROVIDE MORE EFFICIENT USE OF HEALTH CARE SERVICES, BETTER
HEALTH STATUS FOR POPULATIONS SERVED, AND BETTER HEALTH OUTCOMES
FOR INDIVIDUALS.
(k) FINANCIAL STABILITY OF THE MCO;
(l) ASSURANCE THAT THE MCO HAS NOT PROVIDED
TO A RECIPIENT ANY PREMIUMS OR OTHER INDUCEMENTS IN EXCHANGE FOR
THE RECIPIENT SELECTING THE MCO FOR COVERAGE;
(m) A GRIEVANCE PROCEDURE PURSUANT TO
THE PROVISIONS IN SECTION 264117 (1) (b) THAT ALLOWS
FOR THE TIMELY RESOLUTION OF DISPUTES REGARDING THE QUALITY OF
CARE, SERVICES TO BE PROVIDED, AND OTHER ISSUES RAISED BY THE
RECIPIENT. MATTERS SHALL BE RESOLVED IN A MANNER CONSISTENT WITH
THE MEDICAL NEEDS OF THE INDIVIDUAL RECIPIENT. PURSUANT TO SECTION
25.51107, C.R.S., A RECIPIENT MAY SEEK AN ADMINISTRATIVE
REVIEW OF AN ADVERSE DECISION MADE BY THE MCO.
(n) WITH RESPECT TO PREGNANT WOMEN AND
INFANTS, THE FOLLOWING:
(I) ENROLLMENT OF PREGNANT WOMEN WITHOUT
RESTRICTIONS AND INCLUDING AN ASSURANCE THAT THE HEALTH CARE PROVIDER
SHALL PROVIDE TIMELY ACCESS TO INITIATION OF PRENATAL CARE IN
ACCORDANCE WITH PRACTICE STANDARDS;
(II) COVERAGE WITHOUT RESTRICTIONS FOR
NEWBORNS, INCLUDING SERVICES SUCH AS, BUT NOT LIMITED TO, PREVENTIVE
CARE, SCREENING, AND WELLBABY EXAMINATIONS DURING THE FIRST
MONTH OF LIFE;
(III) THE IMPOSITION OF PERFORMANCE STANDARDS
AND THE USE OF QUALITY INDICATORS WITH RESPECT TO PERINATAL, PRENATAL,
AND POSTPARTUM CARE FOR WOMEN AND BIRTHING AND NEONATAL CARE FOR
INFANTS. THE STANDARDS AND INDICATORS SHALL BE BASED ON NATIONALLY
APPROVED GUIDELINES.
(IV) FOLLOWUP BASIC HEALTH MAINTENANCE
SERVICES FOR WOMEN AND CHILDREN, INCLUDING IMMUNIZATIONS AND EARLY
PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT SERVICES FOR CHILDREN
AND APPROPRIATE PREVENTIVE CARE SERVICES FOR WOMEN;
(o) THE MCO WILL ACCEPT ALL ENROLLEES
REGARDLESS OF HEALTH STATUS CONSISTENT WITH THE PROVISIONS OF
SECTION 264118;
(p) DISCLOSURE REQUIREMENTS AS ESTABLISHED
BY THE STATE DEPARTMENT AND MEDICAL SERVICES BOARD;
(q) PROVIDE A MECHANISM WHEREBY A PRESCRIBING
PHYSICIAN CAN REQUEST TO OVERRIDE RESTRICTIONS TO OBTAIN MEDICALLY
NECESSARY OFFFORMULARY PRESCRIPTION DRUGS, SUPPLIES, EQUIPMENT,
OR SERVICES FOR HIS OR HER PATIENT;
(r) MAINTENANCE OF A NETWORK OF PROVIDERS
SUFFICIENT TO ASSURE THAT ALL SERVICES TO RECIPIENTS WILL BE ACCESSIBLE
WITHOUT UNREASONABLE DELAY. THE STATE DEPARTMENT SHALL DEVELOP
EXPLICIT CONTRACT STANDARDS, IN CONSULTATION WITH STAKEHOLDERS,
TO ASSESS AND MONITOR THE MCO'S CRITERIA. SUFFICIENCY SHALL BE
DETERMINED IN ACCORDANCE WITH THE REQUIREMENTS OF THIS PARAGRAPH
(r) AND MAY BE ESTABLISHED BY REFERENCE TO ANY REASONABLE CRITERIA
USED BY THE MCO INCLUDING BUT NOT LIMITED TO THE FOLLOWING:
(I) GEOGRAPHIC ACCESSIBILITY IN REGARD
TO THE SPECIAL NEEDS OF RECIPIENTS;
(II) WAITING TIMES FOR APPOINTMENTS WITH
PARTICIPATING PROVIDERS;
(III) HOURS OF OPERATION;
(IV) VOLUME OF TECHNOLOGICAL AND SPECIALTY
SERVICES AVAILABLE TO SERVE THE NEEDS OF RECIPIENTS REQUIRING
TECHNOLOGICALLY ADVANCED OR SPECIALTY CARE.
(s) (I) FOR THE DELIVERY OF PRESCRIPTION
DRUG BENEFITS TO RECIPIENTS ENROLLED IN AN MCO WHO ARE RESIDENTS
OF A NURSING FACILITY, MCO'S SHALL USE PHARMACIES WITH A DEMONSTRATED
CAPABILITY OF PROVIDING PRESCRIPTION DRUGS IN A MANNER CONSISTENT
WITH THE NEEDS OF CLIENTS IN INSTITUTIONAL SETTINGS SUCH AS NURSING
FACILITIES. IN CASES WHERE A NURSING FACILITY AND A PHARMACY HAVE
A CONTRACT FOR A SINGLE PHARMACY DELIVERY SYSTEM FOR RESIDENTS
OF THE NURSING FACILITY:
(A) AN MCO PROVIDING PRESCRIPTION DRUG
BENEFITS FOR RESIDENTS OF THE NURSING FACILITY SHALL AGREE TO
CONTRACT WITH THAT PHARMACY UNDER REASONABLE CONTRACT TERMS; AND
(B) THE PHARMACY SHALL AGREE TO CONTRACT
WITH EACH MCO THAT PROVIDES PRESCRIPTION DRUG BENEFITS FOR RESIDENTS
OF THE NURSING FACILITY UNDER REASONABLE CONTRACT TERMS.
(II) ANY DISPUTES CONCERNING PROVIDING
PRESCRIPTION DRUG BENEFITS BETWEEN NURSING FACILITIES, PHARMACIES,
AND MCO'S THAT CANNOT BE RESOLVED THROUGH GOOD FAITH NEGOTIATIONS
MAY BE RESOLVED THROUGH A PARTY REQUESTING AN INFORMAL REVIEW
BY THE STATE DEPARTMENT OR, IF REQUESTED, A HEARING THROUGH THE
STATE DEPARTMENT'S AGGRIEVED PROVIDER APPEAL PROCEDURES IN ACCORDANCE
WITH SECTION 25.51107 (2), C.R.S.
(III) THE MEDICAL SERVICES BOARD SHALL
ADOPT RULES REQUIRING MCO'S TO CONTRACT WITH QUALIFIED PHARMACY
PROVIDERS IN A MANNER PERMITTING A NURSING FACILITY TO CONTINUE
TO COMPLY WITH FEDERAL MEDICAID REQUIREMENTS OF PARTICIPATION
FOR NURSING FACILITIES. SUCH RULES SHALL DEFINE "QUALIFIED
PHARMACY PROVIDERS" AND SHALL BE BASED UPON CONSULTATIONS
WITH NURSING FACILITIES, MCO'S, PHARMACIES, AND MEDICAID CLIENTS.
THE STATE DEPARTMENT SHALL PROVIDE MCO'S WITH A LIST OF PHARMACIES
THAT HAVE A CONTRACT WITH NURSING FACILITIES SERVING RECIPIENTS
IN NURSING FACILITIES IN EACH COUNTY IN WHICH THE MCO IS CONTRACTING
WITH THE STATE DEPARTMENT.
(3) (a) THE MCO SHALL SEEK PROPOSALS
FROM EACH ECP IN A COUNTY IN WHICH THE MCO IS ENROLLING RECIPIENTS
FOR THOSE SERVICES THAT THE MCO PROVIDES OR INTENDS TO PROVIDE
AND THAT AN ECP PROVIDES OR IS CAPABLE OF PROVIDING. TO ASSIST
MCO'S IN SEEKING PROPOSALS, THE STATE DEPARTMENT SHALL PROVIDE
MCO'S WITH A LIST OF ECP'S IN EACH COUNTY. THE MCO SHALL CONSIDER
SUCH PROPOSALS IN GOOD FAITH AND SHALL, WHEN DEEMED REASONABLE
BY THE MCO BASED ON THE NEEDS OF ITS ENROLLEES, CONTRACT WITH
ECP'S. EACH ECP SHALL BE WILLING TO NEGOTIATE ON REASONABLY EQUITABLE
TERMS WITH EACH MCO. ECP'S MAKING PROPOSALS UNDER THIS SUBSECTION
(3) MUST BE ABLE TO MEET THE CONTRACTUAL REQUIREMENTS OF THE MCO.
THE REQUIREMENTS OF THIS SUBSECTION (3) SHALL NOT APPLY TO AN
MCO IN AREAS IN WHICH THE MCO OPERATES ENTIRELY AS A GROUP MODEL
HEALTH MAINTENANCE ORGANIZATION.
(b) ANY DISPUTES BETWEEN AN MCO AND AN
ECP THAT CANNOT BE RESOLVED THROUGH GOOD FAITH NEGOTIATIONS MAY
BE RESOLVED THROUGH A PARTY REQUESTING AN INFORMAL REVIEW BY THE
STATE DEPARTMENT, OR, IF REQUESTED, A HEARING THROUGH THE STATE
DEPARTMENT'S AGGRIEVED PROVIDER APPEAL PROCESS IN ACCORDANCE WITH
SECTION 25.51107 (2), C.R.S.
(4) IN SELECTING MCO'S THROUGH COMPETITIVE
BIDDING, THE STATE DEPARTMENT SHALL GIVE PREFERENCE TO THOSE MCO'S
THAT HAVE EXECUTED CONTRACTS FOR SERVICES WITH ONE OR MORE ECP.
IN SELECTING MCO'S, THE STATE DEPARTMENT SHALL NOT PENALIZE AN
MCO FOR PAYING COSTBASED REIMBURSEMENT TO FEDERALLY QUALIFIED
HEALTH CENTERS AS DEFINED IN THE "SOCIAL SECURITY ACT".
(5) (a) NOTWITHSTANDING ANY WAIVERS
AUTHORIZED BY THE FEDERAL DEPARTMENT OF HEALTH AND HUMAN SERVICES,
EACH CONTRACT BETWEEN THE STATE DEPARTMENT AND AN MCO SELECTED
TO PARTICIPATE IN THE STATEWIDE MANAGED CARE SYSTEM UNDER THIS
SUBPART 2 SHALL COMPLY WITH THE REQUIREMENTS OF 42 U.S.C. SEC.
1396a (a) (23) (B).
(b) EACH MCO SHALL ADVISE ITS ENROLLEES
OF THE SERVICES AVAILABLE PURSUANT TO THIS SUBSECTION (5).
(6) NOTHING IN THIS SUBPART 2 SHALL BE
CONSTRUED TO CREATE AN EXEMPTION FROM THE APPLICABLE PROVISIONS
OF TITLE 10, C.R.S.
264116. Quality measurements.
(1) THE STATE DEPARTMENT SHALL MEASURE QUALITY PURSUANT
TO THE FOLLOWING CRITERIA:
(a) QUALITY SHALL BE MEASURED AND CONSIDERED
BASED UPON INDIVIDUALS AND GROUPS WITH THE SATISFACTION OF THE
SERVICE RECEIVED ANALYZED AND COMPARED TO NONRECIPIENT POPULATIONS
FOR THE SAME OR SIMILAR SERVICES WHEN AVAILABLE.
(b) QUALITY SHALL FOCUS ON HEALTH STATUS
OR MAINTENANCE OF THE INDIVIDUAL'S HIGHEST LEVEL OF FUNCTIONING,
WITHOUT STRICT ADHERENCE TO STATISTICAL NORMS.
(2) THE STATE DEPARTMENT SHALL PROMULGATE
RULES AND REGULATIONS TO CLARIFY AND ADMINISTER QUALITY MEASUREMENTS.
264117. Required features
of managed care system. (1) General
features. ALL MEDICAID MANAGED CARE PROGRAMS SHALL
CONTAIN THE FOLLOWING GENERAL FEATURES, IN ADDITION TO OTHERS
THAT THE STATE DEPARTMENT AND THE MEDICAL SERVICES BOARD CONSIDER
NECESSARY FOR THE EFFECTIVE AND COSTEFFICIENT OPERATION
OF THOSE PROGRAMS:
(a) Recipient selection of MCO's. (I) THE
GENERAL ASSEMBLY FINDS THAT THE ABILITY OF RECIPIENTS TO CHOOSE
AMONG COMPETING HEALTH PLANS OR HEALTH DELIVERY SYSTEMS IS AN
IMPORTANT TOOL IN ENCOURAGING SUCH PLANS AND DELIVERY SYSTEMS
TO COMPETE FOR ENROLLEES ON THE BASIS OF QUALITY AND ACCESS. THE
STATE DEPARTMENT SHALL, TO THE EXTENT IT DETERMINES FEASIBLE,
PROVIDE MEDICAIDELIGIBLE RECIPIENTS A CHOICE AMONG COMPETING
MCO'S AND A CHOICE AMONG PROVIDERS WITHIN AN MCO. CONSISTENT WITH
FEDERAL REQUIREMENTS AND RULES PROMULGATED BY THE MEDICAL SERVICES
BOARD, THE STATE DEPARTMENT IS AUTHORIZED TO ASSIGN A MEDICAID
RECIPIENT TO A PARTICULAR MCO OR PRIMARY CARE PHYSICIAN IF:
(A) NO OTHER MCO OR PRIMARY CARE PHYSICIAN
HAS THE CAPACITY OR EXPERTISE NECESSARY TO SERVE THE RECIPIENT;
OR
(B) A RECIPIENT DOES NOT RESPOND WITHIN
TWENTY DAYS AFTER THE DATE OF A SECOND NOTIFICATION OF A REQUEST
FOR SELECTION OF AN MCO OR PRIMARY CARE PHYSICIAN SENT NOT LESS
THAN FORTYFIVE DAYS AFTER DELIVERY OF A FIRST NOTIFICATION.
(II) CONSUMERS SHALL BE INFORMED OF THE
CHOICES AVAILABLE IN THEIR AREA BY APPROPRIATE SOURCES OF INFORMATION
AND COUNSELING. THIS SHALL INCLUDE AN INDEPENDENT, OBJECTIVE FACILITATOR
ACTING UNDER THE SUPERVISION OF THE STATE DEPARTMENT. THE STATE
DEPARTMENT SHALL CONTRACT FOR THE FACILITATOR THROUGH A COMPETITIVE
BIDDING PROCESS. THIS FUNCTION SHALL ENSURE THAT CONSUMERS HAVE
INFORMED CHOICE AMONG AVAILABLE OPTIONS TO ASSURE THE FULLEST
POSSIBLE VOLUNTARY PARTICIPATION IN MANAGED CARE. THE FACILITATOR
SHALL ATTEMPT TO COLLECT AND CONSIDER, AT A MINIMUM, A CONSUMER'S
USUAL AND HISTORIC SOURCES OF CARE, LINGUISTIC NEEDS, SPECIAL
MEDICAL NEEDS, AND TRANSPORTATION NEEDS. THE FACILITATOR SHALL,
IF THE ENROLLEE REQUESTS, ACT AS THE ENROLLEE'S REPRESENTATIVE
IN RESOLVING COMPLAINTS AND GRIEVANCES WITH THE MCO. THE DEPARTMENT,
IN CONJUNCTION WITH THE MEDICAL SERVICES BOARD, SHALL ADOPT REGULATIONS
SETTING FORTH MINIMUM DISCLOSURE REQUIREMENTS FOR ALL MCO'S. ONCE
A RECIPIENT IS ENROLLED IN AN MCO, THE RECIPIENT MAY NOT CHANGE
TO A DIFFERENT MCO FOR A PERIOD OF SIX MONTHS EXCEPT FOR GOOD
CAUSE AS DETERMINED BY THE STATE DEPARTMENT. GOOD CAUSE SHALL
INCLUDE BUT NEED NOT BE LIMITED TO ADMINISTRATIVE ERROR AND AN
MCO'S INABILITY TO PROVIDE ITS COVERED SERVICES TO A RECIPIENT
AFTER REASONABLE EFFORTS ON THE PART OF THE MCO AND THE RECIPIENT,
AS DEFINED BY THE MEDICAL SERVICES BOARD. BASED UPON ITS ASSESSMENT
OF ANY SPECIAL NEEDS OF RECIPIENTS WITH COGNITIVE DISABILITIES,
THE MEDICAL SERVICES BOARD MAY ADOPT RULES RELATING TO ANY NECESSARY
GOOD CAUSE PROVISIONS FOR RECIPIENTS WITH COGNITIVE DISABILITIES
WHO ARE ASSIGNED TO A PARTICULAR MCO PURSUANT TO SUBPARAGRAPH
(I) OF THIS PARAGRAPH (a).
(III) WHEN ELIGIBLE CONSUMERS CHOOSE TO
CHANGE OR DISENROLL FROM THEIR SELECTED MCO, THE STATE DEPARTMENT
SHALL MONITOR AND GATHER DATA ABOUT THE REASONS FOR DISENROLLING,
INCLUDING DENIAL OF ENROLLMENT OR DISENROLLMENT DUE TO AN ACT
OR OMISSION OF AN MCO. THE STATE DEPARTMENT SHALL ANALYZE THIS
DATA AND PROVIDE FEEDBACK TO THE PLANS OR PROVIDERS AND SHALL
USE THE INFORMATION IN THE STATE DEPARTMENT'S CONTRACTING AND
QUALITY ASSURANCE EFFORTS. PERSONS WHO HAVE BEEN DENIED ENROLLMENT
OR HAVE DISENROLLED DUE TO AN ACT OR OMISSION OF AN MCO MAY SEEK
REVIEW BY AN INDEPENDENT HEARING OFFICER, AS PROVIDED FOR AND
REQUIRED UNDER FEDERAL LAW AND ANY STATE STATUTE OR REGULATION.
(b) Complaints and grievances. EACH
MCO SHALL UTILIZE A COMPLAINT AND GRIEVANCE PROCEDURE AND A PROCESS
FOR EXPEDITED REVIEWS THAT COMPLY WITH REGULATIONS ESTABLISHED
BY THE STATE DEPARTMENT IN CONFORMITY WITH FEDERAL LAW. THE COMPLAINT
AND GRIEVANCE PROCEDURE SHALL PROVIDE A MEANS BY WHICH ENROLLEES
MAY COMPLAIN ABOUT OR GRIEVE ANY ACTION OR FAILURE TO ACT THAT
IMPACTS AN ENROLLEE'S ACCESS TO, SATISFACTION WITH, OR THE QUALITY
OF HEALTH CARE SERVICES, TREATMENTS, OR PROVIDERS. THE PROCESS
FOR EXPEDITED REVIEWS SHALL 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. AN ENROLLEE SHALL BE ENTITLED TO DESIGNATE A REPRESENTATIVE,
INCLUDING BUT NOT LIMITED TO AN ATTORNEY, A FACILITATOR DESCRIBED
IN PARAGRAPH (a) OF THIS SUBSECTION (1), A LAY ADVOCATE, OR THE
ENROLLEE'S PHYSICIAN, TO FILE AND PURSUE A GRIEVANCE OR EXPEDITED
REVIEW ON BEHALF OF THE ENROLLEE. THE PROCEDURE SHALL ALLOW FOR
THE UNENCUMBERED PARTICIPATION OF PHYSICIANS. AN ENROLLEE WHOSE
COMPLAINT OR GRIEVANCE IS NOT RESOLVED TO HIS OR HER SATISFACTION
BY A PROCEDURE DESCRIBED IN THIS PARAGRAPH (b) OR WHO CHOOSES
TO FOREGO A PROCEDURE DESCRIBED IN THIS PARAGRAPH (b) SHALL BE
ENTITLED TO REQUEST A SECONDLEVEL REVIEW BY AN INDEPENDENT
HEARING OFFICER, FURTHER JUDICIAL REVIEW, OR BOTH, AS PROVIDED
FOR BY FEDERAL LAW AND ANY STATE STATUTE OR REGULATION. THE STATE
DEPARTMENT MAY ALSO PROVIDE BY REGULATION FOR ARBITRATION AS AN
OPTIONAL ALTERNATIVE TO THE COMPLAINT AND GRIEVANCE PROCEDURE
SET FORTH IS THIS PARAGRAPH (b) TO THE EXTENT THAT SUCH REGULATIONS
DO NOT VIOLATE ANY OTHER STATE OR FEDERAL STATUTORY OR CONSTITUTIONAL
REQUIREMENTS.
(c) Billing medicaid recipients. NOTWITHSTANDING
ANY FEDERAL REGULATIONS OR THE GENERAL PROHIBITION OF SECTION
264403 AGAINST PROVIDERS BILLING MEDICAID RECIPIENTS,
A PROVIDER MAY BILL A MEDICAID RECIPIENT WHO IS ENROLLED WITH
A SPECIFIC MEDICAID PRIMARY CARE PHYSICIAN OR MCO AND, IN CIRCUMSTANCES
DEFINED BY THE REGULATIONS OF THE MEDICAL SERVICES BOARD, RECEIVES
CARE FROM A MEDICAL PROVIDER OUTSIDE THAT ORGANIZATION'S NETWORK
OR WITHOUT REFERRAL BY THE RECIPIENT'S PRIMARY CARE PHYSICIAN.
(d) Marketing. IN MARKETING
COVERAGE TO MEDICAID RECIPIENTS, ALL MCO'S SHALL COMPLY WITH ALL
APPLICABLE PROVISIONS OF TITLE 10, C.R.S., REGARDING HEALTH PLAN
MARKETING. THE MEDICAL SERVICES BOARD IS AUTHORIZED TO PROMULGATE
RULES CONCERNING THE PERMISSIBLE MARKETING OF MEDICAID MANAGED
CARE. THE PURPOSES OF SUCH RULES SHALL INCLUDE BUT NOT BE LIMITED
TO THE AVOIDANCE OF BIASED SELECTION AMONG THE CHOICES AVAILABLE
TO MEDICAID RECIPIENTS.
(e) Prescription drugs. ALL
MCO'S SHALL PROVIDE PRESCRIPTION DRUG COVERAGE AS PART OF A COMPREHENSIVE
HEALTH BENEFIT AND WITH RESPECT TO ANY FORMULARY OR OTHER ACCESS
RESTRICTIONS:
(I) THE MCO SHALL SUPPLY PARTICIPATING
PROVIDERS WHO MAY PRESCRIBE PRESCRIPTION DRUGS FOR MCO ENROLLEES
WITH A CURRENT COPY OF SUCH FORMULARY OR OTHER ACCESS RESTRICTIONS,
INCLUDING INFORMATION ABOUT COVERAGE, PAYMENT, OR ANY REQUIREMENT
FOR PRIOR AUTHORIZATION; AND
(II) THE MCO SHALL PROVIDE TO ALL MEDICAID
RECIPIENTS 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 RECIPIENTS,
INCLUDING INFORMATION ABOUT SUCH FORMULARY OR OTHER ACCESS RESTRICTIONS
AND PROCEDURES FOR GAINING ACCESS TO PRESCRIPTION DRUGS, INCLUDING
OFFFORMULARY PRODUCTS.
(f) Access to prescription drugs.
(I) THE STATE DEPARTMENT SHALL ENCOURAGE AN MCO TO
SOLICIT COMPETITIVE BIDS FOR THE PRESCRIPTION DRUG BENEFIT AND
DISCOURAGE AN MCO FROM CONTRACTING FOR THE PRESCRIPTION DRUG BENEFIT
WITH A SOLE SOURCE PROVIDER AS MUCH AS POSSIBLE. THE STATE DEPARTMENT'S
REPORTS REQUIRED BY SECTION 264121 SHALL INCLUDE A
SUMMARY OF EACH MCO'S PHARMACY NETWORK BY GEOGRAPHIC CATCHMENT
AREA.
(II) IF AN MCO SOLICITS COMPETITIVE BIDS
FOR THE PRESCRIPTION DRUG BENEFIT, THE MCO SHALL REQUEST BIDS
FROM EACH PHARMACY PROVIDER LOCATED IN THE GEOGRAPHIC AREAS IN
WHICH THE MCO IS SOLICITING BIDS. ALL MCO'S SHALL FOLLOW A REASONABLE
STANDARD FOR RECIPIENT ACCESS TO PRESCRIPTION DRUGS. AT A MINIMUM,
THE STATE DEPARTMENT SHALL VERIFY COMPLIANCE WITH THESE REQUIREMENTS
BY REVIEWING EVIDENCE PROVIDED BY THE COMMISSIONER OF INSURANCE
CONCERNING COMPLIANCE WITH ANY STANDARDS OR GUIDANCE ESTABLISHED
BY THE COMMISSIONER OF INSURANCE FOR CONSUMER ACCESS TO PRESCRIPTION
DRUGS.
(III) THE STANDARDS AND GUIDANCE FROM
THE INSURANCE COMMISSIONER SHALL BE BASED ON THE FOLLOWING:
(A) PROCEDURES THAT AN MCO SHALL FOLLOW
TO ENSURE THAT PHARMACIES IN RURAL COMMUNITIES WITH FEWER THAN
TWENTYFIVE THOUSAND PERSONS HAVE THE OPPORTUNITY TO JOIN
RETAIL PRESCRIPTION DRUG NETWORKS IF THEY AGREE TO REASONABLE
CONTRACT TERMS;
(B) PROCEDURES THAT AN MCO SHALL FOLLOW
TO NOTIFY THE PHARMACY COMMUNITY OF COMPETITIVELY BID PRESCRIPTION
DRUG CONTRACTS;
(C) PROCEDURES THAT AN MCO SHALL FOLLOW
TO GIVE ALL PHARMACIES AND PHARMACY NETWORKS A FAIR OPPORTUNITY
TO PARTICIPATE IN PRESCRIPTION DRUG CONTRACTS;
(D) ANY RELATED MATTERS THAT ARE DESIGNED
TO EXPAND CONSUMER ACCESS TO PHARMACY SERVICES; AND
(E) ANY RELATED MATTERS THAT WILL ENHANCE
THE FUNCTIONING OF THE FREE MARKET SYSTEM WITH RESPECT TO PHARMACIES.
(IV) NOTHING IN THIS PARAGRAPH (f) SHALL
APPLY TO THE DELIVERY OF PRESCRIPTION DRUG BENEFITS TO RECIPIENTS
ENROLLED IN AN MCO WHO ARE RESIDENTS OF A NURSING FACILITY.
(g) Continuity of care. (I) NEW
ENROLLEES, WITH SPECIAL NEEDS AS DEFINED BY THE MEDICAL SERVICES
BOARD AND AS CERTIFIED BY A NONPLAN PHYSICIAN, MAY CONTINUE
TO SEE A NONPLAN PROVIDER FOR SIXTY DAYS FROM THE DATE OF
ENROLLMENT IN AN MCO, IF THE ENROLLEE IS IN AN ONGOING COURSE
OF TREATMENT WITH THE PREVIOUS PROVIDER AND ONLY IF THE PREVIOUS
PROVIDER AGREES:
(A) TO ACCEPT REIMBURSEMENT FROM THE MCO
AS PAYMENT IN FULL AT RATES ESTABLISHED BY THE MCO THAT SHALL
BE NO MORE THAN THE LEVEL OF REIMBURSEMENT APPLICABLE TO SIMILAR
PROVIDERS WITHIN THE MCO'S GROUP OR NETWORK FOR SUCH SERVICES;
(B) TO ADHERE TO THE MCO'S QUALITY ASSURANCE
REQUIREMENTS AND TO PROVIDE TO THE MCO NECESSARY MEDICAL INFORMATION
RELATED TO SUCH CARE; AND
(C) TO OTHERWISE ADHERE TO THE MCO'S POLICIES
AND PROCEDURES INCLUDING BUT NOT LIMITED TO PROCEDURES REGARDING
REFERRALS, OBTAINING PREAUTHORIZATIONS, AND MCOAPPROVED
TREATMENT PLANS.
(II) NEW ENROLLEES WHO ARE IN THEIR SECOND
OR THIRD TRIMESTER OF PREGNANCY MAY CONTINUE TO SEE THEIR PRACTITIONER
UNTIL THE COMPLETION OF POSTPARTUM CARE DIRECTLY RELATED
TO THE DELIVERY ONLY IF THE PRACTITIONER AGREES:
(A) TO ACCEPT REIMBURSEMENT FROM THE MCO AS PAYMENT IN FULL AT RATES ESTABLISHED BY THE MCO THAT SHALL BE NO MORE THAN THE LEVEL OF REIMBURSEMENT APPLICABLE TO SIMILAR PROVIDERS WITHIN THE MCO'S GROUP OR NETWORK FOR SUCH SERVICES;
(B) TO ADHERE TO THE MCO'S QUALITY ASSURANCE
REQUIREMENTS AND TO PROVIDE TO THE MCO NECESSARY MEDICAL INFORMATION
RELATED TO SUCH CARE; AND
(C) TO OTHERWISE ADHERE TO THE MCO'S POLICIES
AND PROCEDURES INCLUDING BUT NOT LIMITED TO PROCEDURES REGARDING
REFERRALS, OBTAINING PREAUTHORIZATIONS, AND MCOAPPROVED
TREATMENT PLANS.
(III) NEW ENROLLEES WITH SPECIAL NEEDS
AS DEFINED BY THE STATE DEPARTMENT MAY CONTINUE TO SEE ANCILLARY
PROVIDERS AT THE LEVEL OF CARE RECEIVED PRIOR TO ENROLLMENT FOR
A PERIOD OF UP TO SEVENTYFIVE DAYS. THE TERMS AND CONDITIONS,
INCLUDING REIMBURSEMENT RATES, SHALL REMAIN THE SAME AS PRIOR
TO ENROLLMENT IF THE PROVIDER AND ENROLLEE AGREE TO WORK IN GOOD
FAITH WITH THE MCO TOWARD A TRANSITION.
(IV) THIS PARAGRAPH (g) SHALL NOT BE CONSTRUED
TO REQUIRE AN MCO TO PROVIDE COVERAGE FOR BENEFITS NOT OTHERWISE
COVERED.
264118. State department
recommendations primary care physician program special
needs annual report. (1) (a) IT
IS THE GENERAL ASSEMBLY'S INTENT THAT THE STATE OF COLORADO HAVE
A STATEWIDE MANAGED CARE SYSTEM FOR MEDICAL ASSISTANCE RECIPIENTS
WITH AT LEAST SEVENTYFIVE PERCENT ENROLLMENT. THE GENERAL
ASSEMBLY, HOWEVER, RECOGNIZES THE NEED FOR THE STATE DEPARTMENT
TO EXPLORE VARIOUS METHODS OF PROVIDING MANAGED CARE FOR CERTAIN
MEDICAL ASSISTANCE POPULATIONS. THE METHODS MAY RANGE FROM UNIQUE
MANAGED CARE CONTRACTS WITH SPECIAL REIMBURSEMENT ARRANGEMENTS
TO SPECIFIC PROVIDERS OR SERVICES. NO LATER THAN THE FIRST DAY
OF DECEMBER OF EACH FISCAL YEAR OF THE IMPLEMENTATION PERIOD PROVIDED
IN SECTION 264113 (2), THE STATE DEPARTMENT SHALL
MAKE RECOMMENDATIONS IN A WRITTEN REPORT TO THE GENERAL ASSEMBLY
WITH RESPECT TO NECESSARY EXEMPTIONS FROM THE REQUIREMENT THAT
MANAGED CARE BE IMPLEMENTED FOR SEVENTYFIVE PERCENT OF THE
MEDICAL ASSISTANCE POPULATION ON A STATEWIDE BASIS NO LATER THAN
JULY 1, 2000.
(b) THE GENERAL ASSEMBLY RECOGNIZES THAT
CAPITATED MANAGED CARE PROGRAMS MAY NOT BE APPROPRIATE FOR SOME
SEGMENTS OF THE MEDICAID POPULATION. FOR EXAMPLE, RURAL MEDICAID
RECIPIENTS MAY NOT HAVE A CHOICE OF CAPITATED MCO'S AND SPECIAL
NEEDS POPULATIONS MAY NOT BE ABLE TO RECEIVE NECESSARY SERVICES
FROM CAPITATED MCO'S.
(2) (a) THE PRIMARY CARE PHYSICIAN
PROGRAM REQUIRES MEDICAID RECIPIENTS TO SELECT A PRIMARY CARE
PHYSICIAN WHO IS SOLELY AUTHORIZED TO PROVIDE PRIMARY CARE AND
REFERRAL TO ALL NECESSARY SPECIALTY SERVICES. TO ENCOURAGE LOWCOST
AND ACCESSIBLE CARE, THE STATE DEPARTMENT IS AUTHORIZED TO UTILIZE
THE PRIMARY CARE PHYSICIAN PROGRAM TO DELIVER SERVICES TO APPROPRIATE
MEDICAID RECIPIENTS.
(b) THE STATE DEPARTMENT SHALL ESTABLISH
PROCEDURES AND CRITERIA FOR THE COSTEFFECTIVE OPERATION
OF THE PRIMARY CARE PHYSICIAN PROGRAM, INCLUDING BUT NOT LIMITED
TO SUCH MATTERS AS APPROPRIATE ELIGIBILITY CRITERIA AND GEOGRAPHIC
AREAS SERVED BY THE PROGRAMS.
264119. Capitation rates
risk adjustments. (1) THE
STATE DEPARTMENT SHALL MAKE PREPAID CAPITATION PAYMENT TO MANAGED
CARE ORGANIZATIONS BASED UPON A DEFINED SCOPE OF SERVICES. PAYMENTS
SHALL BE BASED UPON THE FOLLOWING UPPER AND LOWER LIMITS:
(a) THE UPPER LIMIT SHALL NOT EXCEED NINETYFIVE
PERCENT OF THE COST OF PROVIDING THESE SAME SERVICES ON AN ACTUARIALLY
EQUIVALENT NONMANAGED CARE ENROLLED COLORADO MEDICAID POPULATION
GROUP. THIS LIMIT MAY BE MODIFIED BASED UPON ANY FEDERAL REQUIREMENTS
FOR REIMBURSEMENT TO FEDERALLY QUALIFIED HEALTH CLINICS AS DEFINED
IN THE FEDERAL "SOCIAL SECURITY ACT".
(b) THE LOWER LIMIT SHALL BE A MARKET
RATE SET THROUGH THE COMPETITIVE BID PROCESS FOR A SET OF DEFINED
SERVICES. THE STATE DEPARTMENT SHALL ONLY USE MARKET RATE BIDS
THAT DO NOT DISCRIMINATE AND ARE ADEQUATE TO ASSURE QUALITY, NETWORK
SUFFICIENCY, AND LONGTERM COMPETITIVENESS IN THE MEDICAID
MANAGED CARE MARKET. A CERTIFICATION OF A QUALIFIED ACTUARY, RETAINED
BY THE STATE DEPARTMENT, TO THE APPROPRIATE LOWER LIMIT SHALL
BE CONCLUSIVE EVIDENCE OF THE STATE DEPARTMENT'S COMPLIANCE WITH
THE REQUIREMENTS OF THIS PARAGRAPH (b). FOR THE PURPOSES OF THIS
PARAGRAPH (b), A "QUALIFIED ACTUARY" SHALL BE A PERSON
DEEMED AS SUCH UNDER REGULATIONS PROMULGATED BY THE COMMISSIONER
OF INSURANCE.
(2) THE STATE DEPARTMENT SHALL DEVELOP
CAPITATION RATES FOR MCO'S THAT INCLUDE RISK ADJUSTMENTS, REINSURANCE,
OR STOPLOSS FUNDING METHODS. PAYMENTS TO PLANS MAY VARY
WHEN IT IS SHOWN THROUGH DIAGNOSES OR OTHER RELEVANT DATA THAT
CERTAIN POPULATIONS ARE EXPECTED TO COST MORE OR LESS THAN THE
CAPITATED POPULATION AS A WHOLE.
(3) THE MEDICAL SERVICES BOARD, IN CONSULTATION
WITH RECOGNIZED MEDICAL AUTHORITIES, SHALL DEVELOP A DEFINITION
OF SPECIAL NEEDS POPULATIONS THAT INCLUDES EVIDENCE OF DIAGNOSED
OR MEDICALLY CONFIRMED HEALTH CONDITIONS. THE STATE DEPARTMENT
SHALL DEVELOP A METHOD FOR ADJUSTING PAYMENTS TO PLANS FOR SUCH
SPECIAL NEEDS POPULATIONS WHEN DIAGNOSES OR OTHER RELEVANT DATA
INDICATES THESE SPECIAL NEEDS POPULATIONS WOULD COST SIGNIFICANTLY
MORE THAN SIMILARLY CAPITATED POPULATIONS.
(4) THE RISK ADJUSTMENT, REINSURANCE,
OR STOPLOSS FUNDING METHODS DEVELOPED BY THE STATE DEPARTMENT
PURSUANT TO SUBSECTION (2) OF THIS SECTION SHALL BE IMPLEMENTED
NO LATER THAN JULY 1, 1998, ON THE CONDITION THAT THE DIAGNOSES
AND RELEVANT DATA ARE MADE AVAILABLE TO THE STATE DEPARTMENT IN
SUFFICIENT TIME TO ALLOW THE RATES TO BE SET BY JULY 1, 1998.
(5) UNDER NO CIRCUMSTANCES SHALL THE RISK
ADJUSTMENTS, REINSURANCE, OR STOPLOSS METHODS DEVELOPED
BY THE STATE DEPARTMENT PURSUANT TO SUBSECTION (2) OF THIS SECTION
CAUSE THE AVERAGE PER CAPITA MEDICAID PAYMENT TO A PLAN TO BE
GREATER THAN THE PROJECTED MEDICAID EXPENDITURES FOR TREATING
MEDICAID ENROLLEES OF THAT PLAN UNDER FEEFORSERVICE
MEDICAID.
(6) THE STATE DEPARTMENT MAY DEVELOP QUALITY
INCENTIVE PAYMENTS TO RECOGNIZE SUPERIOR QUALITY OF CARE OR SERVICE
PROVIDED BY A MANAGED CARE PLAN.
264120. State department
privatization. (1) THE
GENERAL ASSEMBLY FINDS THAT THE STATEWIDE MANAGED CARE SYSTEM
IS A PROGRAM UNDER WHICH THE PRIVATE SECTOR HAS A GREAT DEAL OF
EXPERIENCE IN MAKING VARIOUS HEALTH CARE PLANS AVAILABLE TO THE
PRIVATE SECTOR AND SERVING AS THE LIAISON BETWEEN LARGE EMPLOYERS
AND HEALTH CARE PROVIDERS, INCLUDING BUT NOT LIMITED TO HEALTH
MAINTENANCE ORGANIZATIONS. THE GENERAL ASSEMBLY THEREFORE DETERMINES
THAT A STATEWIDE MANAGED CARE SYSTEM INVOLVES DUTIES SIMILAR TO
DUTIES CURRENTLY OR PREVIOUSLY PERFORMED BY STATE EMPLOYEES BUT
IS DIFFERENT IN SCOPE AND POLICY OBJECTIVES FROM THE STATE MEDICAL
ASSISTANCE PROGRAM.
(2) TO THAT END, PURSUANT TO SECTION 2450504
(2) (a), C.R.S., THE STATE DEPARTMENT SHALL ENTER INTO PERSONAL
SERVICES CONTRACTS THAT CREATE AN INDEPENDENT CONTRACTOR RELATIONSHIP
FOR THE ADMINISTRATION OF NOT LESS THAN TWENTY PERCENT OF THE
STATEWIDE MANAGED CARE SYSTEM. THE STATE DEPARTMENT SHALL ENTER
INTO PERSONAL SERVICE CONTRACTS FOR THE ADMINISTRATION OF THE
MANAGED CARE SYSTEM ACCORDING TO THE IMPLEMENTATION OF THE STATEWIDE
MANAGED CARE SYSTEM IN ACCORDANCE WITH SECTION 264113
(2).
(3) IN CONNECTION WITH THE REQUIREMENT
SET FORTH IN SUBSECTION (2) OF THIS SECTION, THE STATE DEPARTMENT
SHALL INCLUDE RECOMMENDATIONS CONCERNING PRIVATIZATION OF THE
ADMINISTRATION OF THE MANAGED CARE SYSTEM IN ITS ANNUAL REPORT
REQUIRED BY SECTION 264118.
(4) THE IMPLEMENTATION OF THIS SECTION
IS CONTINGENT UPON:
(a) LEGISLATIVE REVIEW OF THE COSTEFFECTIVENESS
OF PRIVATIZATION AND THE EXTENT TO WHICH SUCH PRIVATIZATION ENHANCES
THE QUALITY OF CARE TO RECIPIENTS; AND
(b) A FINDING BY THE STATE PERSONNEL DIRECTOR
THAT ANY OF THE CONDITIONS OF SECTION 2450504 (2),
C.R.S., HAVE BEEN MET OR THAT THE CONDITIONS OF SECTION 2450503
(1), C.R.S., HAVE BEEN MET.
264121. Data collection
for managed care programs reports.
(1) IN ADDITION TO ANY OTHER DATA COLLECTION OR REPORTING
REQUIREMENTS SET FORTH IN THIS ARTICLE, THE STATE DEPARTMENT SHALL
ACCESS AND COMPILE DATA CONCERNING HEALTH DATA AND OUTCOMES. IN
ADDITION, NO LATER THAN JULY 1, 1998, THE STATE DEPARTMENT SHALL
CONDUCT OR SHALL CONTRACT WITH AN INDEPENDENT EVALUATOR TO CONDUCT
A QUALITY ASSURANCE ANALYSIS OF EACH MANAGED CARE PROGRAM IN THE
STATE FOR MEDICAL ASSISTANCE RECIPIENTS. NO LATER THAN JULY 1,
1999, AND EACH FISCAL YEAR THEREAFTER, THE STATE DEPARTMENT, USING
THE COMPILED DATA AND RESULTS FROM THE QUALITY ASSURANCE ANALYSIS,
SHALL SUBMIT A REPORT TO THE HOUSE AND SENATE COMMITTEES ON HEALTH,
ENVIRONMENT, WELFARE, AND INSTITUTIONS ON THE COSTEFFICIENCY
OF EACH MANAGED CARE PROGRAM OR COMPONENT THEREOF, WITH RECOMMENDATIONS
CONCERNING STATEWIDE IMPLEMENTATION OF THE RESPECTIVE PROGRAMS
OR COMPONENTS. FOR THE PURPOSES OF THIS SUBSECTION (1), "QUALITY
ASSURANCE" MEANS COSTS WEIGHED AGAINST BENEFITS PROVIDED
TO CONSUMERS, HEALTH OUTCOMES OR MAINTENANCE OF THE INDIVIDUAL'S
HIGHEST LEVEL OF FUNCTIONING, AND THE OVERALL CHANGE IN THE HEALTH
STATUS OF THE POPULATION SERVED. THE STATE DEPARTMENT'S REPORT
SHALL ADDRESS CAPITATION, INCLUDING METHODS FOR ADJUSTING RATES
BASED ON RISK ALLOCATIONS, FEESFORSERVICES, COPAYMENTS,
CHRONICALLY ILL POPULATIONS, LONGTERM CARE, COMMUNITYSUPPORTED
SERVICES, AND THE ENTITLEMENT STATUS OF MEDICAL ASSISTANCE. THE
STATE DEPARTMENT'S REPORT SHALL INCLUDE A COMPARISON OF THE EFFECTIVENESS
OF THE MCO PROGRAM AND THE PRIMARY CARE PHYSICIAN PROGRAM BASED
UPON COMMON PERFORMANCE STANDARDS THAT SHALL INCLUDE BUT NOT BE
LIMITED TO RECIPIENT SATISFACTION.
(2) IN ADDITION, THE STATE DEPARTMENT
OF HUMAN SERVICES, IN CONJUNCTION WITH THE STATE DEPARTMENT, SHALL
CONTINUE ITS EXISTING EFFORTS, WHICH INCLUDE OBTAINING AND CONSIDERING
CONSUMER INPUT, TO DEVELOP MANAGED CARE SYSTEMS FOR THE DEVELOPMENTALLY
DISABLED POPULATION AND TO CONSIDER A PILOT PROGRAM FOR A CERTIFICATE
SYSTEM TO ENABLE THE DEVELOPMENTALLY DISABLED POPULATION TO PURCHASE
MANAGED CARE SERVICES OR FEEFORSERVICE CARE, INCLUDING
LONGTERM CARE COMMUNITY SERVICES. THE DEPARTMENT OF HUMAN
SERVICES SHALL NOT IMPLEMENT ANY MANAGED CARE SYSTEM FOR DEVELOPMENTALLY
DISABLED SERVICES WITHOUT THE EXPRESS APPROVAL OF THE JOINT BUDGET
COMMITTEE. ANY PROPOSED IMPLEMENTATION OF FULLY CAPITATED MANAGED
CARE IN THE DEVELOPMENTAL DISABILITIES COMMUNITY SERVICE SYSTEM
SHALL REQUIRE LEGISLATIVE REVIEW.
(3) IN ADDITION TO ANY OTHER DATA COLLECTION
AND REPORTING REQUIREMENTS, EACH MANAGED CARE ORGANIZATION SHALL
SUBMIT THE FOLLOWING TYPES OF DATA TO THE STATE DEPARTMENT OR
ITS AGENT:
(a) MEDICAL ACCESS;
(b) CONSUMER OUTCOMES BASED ON STATISTICS
MAINTAINED ON INDIVIDUAL CONSUMERS AS WELL AS THE TOTAL CONSUMER
POPULATIONS SERVED;
(c) CONSUMER SATISFACTION;
(d) CONSUMER UTILIZATION;
(e) HEALTH STATUS OF CONSUMERS; AND
(f) UNCOMPENSATED CARE DELIVERED.
264122. Integrated
care and financing project. (1) THE STATE DEPARTMENT
IS AUTHORIZED TO OVERSEE AND ADMINISTER THE INTEGRATED CARE AND
FINANCING PROJECT TO STUDY THE INTEGRATION OF ACUTE AND LONGTERM
CARE WITHIN THE FOLLOWING GUIDELINES:
(a) THE PROJECT SHALL BE CONDUCTED IN
A COUNTY OR COUNTIES SELECTED BY THE STATE DEPARTMENT THAT HAVE
AT LEAST ONE YEAR'S EXPERIENCE IN PROVIDING MANAGED CARE FOR THE
MEDICAL ASSISTANCE POPULATION AND HAS A SYSTEM FOR MANAGING LONGTERM
CARE, INCLUDING REFERRAL TO APPROPRIATE SERVICES, CASE PLANNING,
AND BROKERING AND MONITORING OF SERVICES.
(b) THE STATE DEPARTMENT SHALL COMBINE
ACUTE AND LONGTERM CARE IN A MANAGED CARE ENVIRONMENT FOR
THE PURPOSE OF CREATING COSTEFFICIENT AND ECONOMICAL CLINICAL
APPROACHES TO SERVING THE MEDICAL ASSISTANCE POPULATION IN NEED
OF BOTH TYPES OF CARE.
(c) THE STATE DEPARTMENT SHALL MAINTAIN
APPLICABLE FEDERAL OR STATE ELIGIBILITY REQUIREMENTS.
(d) IN NO EVENT SHALL THE STATE DEPARTMENT
REQUIRE ANY PERSON WHO IS ELIGIBLE FOR BOTH MEDICAL ASSISTANCE
UNDER THE PROVISIONS OF THIS ARTICLE AND FOR ANOTHER THIRDPARTY
COVERAGE TO ENROLL IN AN MCO BEFORE JULY 1, 2000. NOTHING IN THIS
PARAGRAPH (d) SHALL PREVENT THE STATE DEPARTMENT FROM PURCHASING
THIRDPARTY COVERAGE ON BEHALF OF A MEDICAID RECIPIENT.
(e) THE PROJECT SHALL BE FOR PERSONS ELIGIBLE
FOR MEDICAL ASSISTANCE.
(f) PARTICIPANTS SHALL BE MEDICAL ASSISTANCE
RECIPIENTS ENROLLED IN A HEALTH MAINTENANCE ORGANIZATION; EXCEPT
THAT THE PROJECT SHALL NOT INCLUDE THE DELIVERY OF MENTAL HEALTH
SERVICES AND DEVELOPMENTALLY DISABLED SERVICES, WHICH SERVICES
SHALL CONTINUE TO BE PROVIDED THROUGH THE MENTAL HEALTH CAPITATION
PROJECT AND THE DEVELOPMENTAL DISABILITIES SERVICES SYSTEM. PERSONS
WITH DEVELOPMENTAL DISABILITIES AND MENTAL HEALTH NEEDS MAY PARTICIPATE
IN THIS PROJECT FOR ALL THE SERVICES OFFERED BY THE PROJECT.
(g) THE PROJECT SHALL ADOPT GOALS THAT
ENSURE: INTEGRATED ACUTE AND LONGTERM MANAGED CARE RESULTS
IN ADEQUATE ACCESS TO AND QUALITY OF HEALTH CARE; PARTICIPANT
SATISFACTION AND IMPROVED PARTICIPANT HEALTH STATUS OR MAINTENANCE
OF THE INDIVIDUAL'S HIGHEST LEVEL OF FUNCTIONING; AND SUFFICIENT
COLLECTION OF HEALTH DATA AND PARTICIPANT OUTCOMES.
(h) THE STATE DEPARTMENT SHALL CONSULT
WITH KNOWLEDGEABLE AND CONCERNED PERSONS IN THE STATE, INCLUDING
CONSUMER ADVOCACY GROUPS, RECIPIENTS, AND CAREGIVERS.
(i) THE STATE MEDICAL SERVICES BOARD SHALL
ADOPT RULES REQUIRING THE HEALTH MAINTENANCE ORGANIZATION TO ESTABLISH
A COMPLAINT PROCESS FOR PARTICIPANTS DISSATISFIED WITH THE CARE
PROVIDED UNDER THE PROJECT. IF A PARTICIPANT DISAGREES WITH THE
ACTION TAKEN BY THE HEALTH MAINTENANCE ORGANIZATION, THE PARTICIPANT
MAY SEEK REVIEW OF THE ACTION PURSUANT TO SECTION 25.51107,
C.R.S. IN ADDITION, THE STATE MEDICAL SERVICES BOARD SHALL ADOPT
A PROCEDURE UNDER WHICH A PARTICIPANT MAY DISENROLL FROM THE PROJECT
AND CONTINUE ELIGIBILITY UNDER THE MEDICAL ASSISTANCE PROGRAM.
(j) IN ADDITION TO USING OTHER METHODS
OF MEASURING PARTICIPANT SATISFACTION AND OUTCOMES, THE STATE
DEPARTMENT SHALL CONDUCT RANDOM SURVEYS TO ASSESS PARTICIPANT
SATISFACTION AND MEET WITH RECIPIENT GROUPS BEING SERVED BY THE
PROJECT.
(2) THE PROJECT MAY BE EXPANDED TO OTHER
DEMONSTRATION SITES AND MAY BE MODIFIED IN ACCORDANCE WITH THE
PROVISIONS OF THIS SECTION BASED UPON EXPERIENCE IN INITIAL DEMONSTRATION
SITES, AS PERMITTED BY ANY NECESSARY FEDERAL WAIVERS, IN CONSULTATION
WITH RELEVANT STAKEHOLDERS. THE STATE DEPARTMENT IS AUTHORIZED
TO IMPLEMENT THIS PROJECT STATEWIDE ONLY AFTER FULL REVIEW BY
THE GENERAL ASSEMBLY AND ONLY TO THE EXTENT THAT FEDERAL WAIVERS
ARE RECEIVED.
264123. Managed mental
health services feasibility study waiver pilot program.
[Formerly 264528.] (1) (a) The
STATE department of health care policy
and financing and the department
of human services shall jointly conduct a feasibility study concerning
management of mental health services under the "Colorado
Medical Assistance Act", which study shall consider a prepaid
capitated system for providing comprehensive mental health services.
In conducting the study, the STATE department of
health care policy and financing
and the department of human services shall:
(I) (a) Consult
with knowledgeable and concerned persons in the state, including
lowincome persons who are recipients of mental health services
and providers of mental health services under the "Colorado
Medical Assistance Act"; and
(II) (b) Consider
the effect of any program on the provider or community mental
health centers and clinics. Any prepaid capitated program shall,
as much as possible, avoid exposing providers or community mental
health centers and clinics to undue financial risk or reliance
on supplemental revenues from state general funds, local revenues,
or feeforservice funds.
(b) Repealed.
(c) CONSIDER THE EFFECT OF ANY PROGRAM
ON THE COORDINATION OF PATIENTS' MEDICAL CARE AND MENTAL HEALTH
CARE AND ON PATIENTS' ACCESS TO PRESCRIPTION MEDICINES, INCLUDING
MEDICINES FOR THE TREATMENT OF MENTAL DISORDERS.
(2) The state department is authorized
to seek a waiver of the requirements of Title XIX of the social
security act to allow the state department to limit a recipient's
freedom of choice of providers and to restrict reimbursement for
mental health services to designated and contracted agencies.
(3) (a) If a determination is made
by the STATE department of health
care policy and financing and the
department of human services, based on the feasibility study required
in subsection (1) of this section, that the implementation of
one or more model or proposed program modifications would be costeffective,
and if all necessary federal waivers are obtained, the STATE department
of health care policy and financing
shall establish a pilot prepaid capitated system for providing
comprehensive mental health services. The STATE department of
health care policy and financing
shall promulgate rules as necessary for the implementation and
administration of the pilot program. The pilot program shall terminate
on July 1, 1997. If the pilot program is implemented, the STATE
department of health care policy and
financing and the department of human
services shall submit to the house and senate committees on health,
environment, welfare, and institutions on or before July 1, 1996,
a preliminary status report on the pilot program.
(b) In addition to the preliminary report
described in paragraph (a) of this subsection (3), the STATE department
of health care policy and financing
and the department of human services shall submit a final report
to the house and senate committees on health, environment, welfare,
and institutions no later than January 1, 1997, addressing the
following:
(I) An assessment of the pilot program
costs, estimated costsavings, benefits to recipients, recipient
access to mental health services, and the impact of the program
on recipients, providers, and the state mental health system;
(II) Recommendations concerning the feasibility
of proceeding with a prepaid capitated system of comprehensive
mental health services on a statewide basis;
(III) Recommendations resulting from consultation
with local consumers, family members of recipients, providers
of mental health services, and local human services agencies;
(IV) Recommendations concerning the role
of community mental health centers under the prepaid capitated
system, including plans to protect the integrity of the state
mental health system and to ensure that community mental health
providers are not exposed to undue financial risks under the prepaid
capitated system. This subparagraph (IV) is based on the unique
and historical role that community mental health centers have
assumed in meeting the mental health needs of communities throughout
the state.
(4) (Deleted by amendment, L.
95, p. 917, '
16, effective May 25, 1995.)
(5) (4) The
general assembly finds that preliminary indications from other
states show that prepaid capitated systems for providing mental
health services to medical assistance recipients result in costsavings
to the state. The general assembly therefore declares it appropriate
to amend subsections (1), (3), and
(4) (1) AND (3) of this section and
to enact this subsection (5)
(4) and subsections (6) to (9)
(5) TO (8) of this section.
(6) (5) On
or before January 1, 1997, the STATE department of
health care policy and financing
shall seek the necessary waivers to implement the system statewide.
No later than July 1, 1997, or ninety days after receipt of the
necessary federal waivers, whichever occurs later, the department
of human services, in cooperation with the STATE department, of
health care policy and financing,
shall begin to implement on a statewide basis a prepaid capitated
system for providing comprehensive mental health services to recipients
under the state medical assistance program. The prepaid capitated
system shall be fully implemented no later than January 1, 1998,
or six months after receipt of the necessary waivers, whichever
occurs later. The waiver request shall be consistent with the
report submitted to the general assembly in accordance with subsection
(3) of this section.
(7) (6) The
STATE department, of health care policy
and financing, in cooperation with
the department of human services, shall revise the waiver request
obtained pursuant to subsection (2) of this section or, if necessary,
shall submit a new waiver request that allows the STATE department
of health care policy and financing
to limit a recipient's freedom of choice with respect to a provider
of mental health services and to restrict reimbursements to mental
health services providers. This waiver request or amendment shall
be consolidated with the waiver described in subsection (6)
(5) of this section.
(8) (7) No
later than May 1, 1997, or sixty days after receipt of the necessary
federal waivers described in subsections (6)
and (7) (5) AND (6) of this section,
whichever occurs later, the executive director of the STATE department
of health care policy and financing
shall propose rules to the medical services board for the implementation
of the prepaid capitated single entry point system for mental
health services.
(9) (8) The
implementation of this subsection (9)
(8) and subsections (5) to (8)
(4) TO (7) of this section is conditioned upon the receipt of
necessary federal waivers. The implementation of the statewide
system shall conform to the provisions of the federal waiver;
except that, no later than ninety days after receipt of the federal
waivers, the STATE department of health
care policy and financing shall submit
to the general assembly a report that outlines the provisions
of the waiver and makes recommendations for legislation during
the next legislative session that assures state conformance to
the federal waivers.
264124. Program of allinclusive
care for the elderly services eligibility. [Formerly
264519.] (1) The
general assembly hereby finds and declares that it is the intent
of this section to replicate the ON LOK program in San Francisco,
California, that has proven to be costeffective at both
the state and federal levels. The PACE program is part of a national
replication project authorized in section 9412(b)(2) of the federal
"Omnibus Budget Reconciliation Act of 1986", as amended,
which instructs the secretary of the federal department of health
and human services to grant medicare and medicaid waivers to permit
not more than ten public or nonprofit private communitybased
organizations in the country to provide comprehensive health care
services on a capitated basis to frail elderly who are at risk
of institutionalization. The general assembly finds that, by coordinating
an extensive array of medical and nonmedical services, the needs
of the participants will be met primarily in an outpatient environment
in an adult day health center, in their homes, or in an institutional
setting. The general assembly finds that such a service delivery
system will enhance the quality of life for the participant and
offers the potential to reduce and cap the costs to Colorado of
the medical needs of the participants, including hospital and
nursing home admissions.
(1.5) (2) The
general assembly has determined on the recommendation of the state
department of health care policy and
financing that the PACE program is
costeffective. As a result of such determination and after
consultation with the joint budget committee of the general assembly,
application has been made to and waivers have been obtained from
the federal health care financing administration to implement
the PACE program as provided in this section. The general assembly,
therefore, authorizes the state department to implement the PACE
program in accordance with this section. In connection with the
implementation of the program, the state department shall:
(a) Provide a system for reimbursement
for services to the PACE program pursuant to this section;
(b) Develop and implement a contract with
the nonprofit organization providing the PACE program that sets
forth contractual obligations for the PACE program, including
but not limited to reporting and monitoring of utilization of
services and of the costs of the program as required by the state
department;
(c) Acknowledge that it is participating
in the national PACE project as initiated by congress;
(d) Be responsible for certifying the
eligibility for services of all PACE program participants.
(2) (3) The
general assembly declares that the purpose of this section is
to provide services which
THAT would foster the following goals:
(a) To maintain eligible persons at home
as an alternative to longterm institutionalization;
(b) To provide optimum accessibility to
various important social and health resources that are available
to assist eligible persons in maintaining independent living;
(c) To provide that eligible persons who
are frail elderly but who have the capacity to remain in an independent
living situation have access to the appropriate social and health
services without which independent living would not be possible;
(d) To coordinate, integrate, and link
such social and health services by removing obstacles which
THAT impede or limit improvements in delivery of these services;
(e) To provide the most efficient and
effective use of capitated funds in the delivery of such social
and health services;
(f) To assure that capitation payments
amount to no more than ninetyfive percent of the amount
paid under the medicaid feeforservice structure for
an actuarially similar population.
(3) (4) Within
the context of the PACE program, the state department may include
any or all of the services listed in sections 264202,
264203, 264302, and 264303,
as applicable.
(4) (5) An
eligible person may elect to receive services from the PACE program
as described in subsection (3)
(4) of this section. If such an election is made, the eligible
person shall not remain eligible for services or payment through
the regular medicare or medicaid programs. All services provided
by said programs shall be provided through the PACE program in
accordance with this section. An eligible person may elect to
disenroll from the PACE program at any time.
(5) (6) For
purposes of this section, "eligible person" means a
frail elderly individual who voluntarily enrolls in the PACE program
and whose gross income does not exceed three hundred percent of
the current federal supplemental security income benefit level,
whose resources do not exceed the limit established by the state
department of human services for individuals receiving a mandatory
minimum state supplementation of SSI benefits pursuant to section
262204, and for whom a physician licensed pursuant
to article 36 of title 12, C.R.S., certifies that such a program
provides an appropriate alternative to institutionalized care.
The term "frail elderly" means an individual who meets
functional eligibility requirements, as established by the state
department, for nursing home care and who is sixtyfive years
of age or older.
(6) (7) Using
a riskbased financing model, the nonprofit organization
providing the PACE program shall assume responsibility for all
costs generated by PACE program participants, and it shall create
and maintain a risk reserve fund that will cover any cost overages
for any participant. The PACE program is responsible for the entire
range of services in the consolidated service model, including
hospital and nursing home care, according to participant need
as determined by the multidisciplinary team. The nonprofit organization
providing the PACE program is responsible for the full financial
risk at the conclusion of the demonstration period and when permanent
waivers from the federal health care financing administration
are granted. Specific arrangements of the riskbased financing
model shall be adopted and negotiated by the federal health care
financing administration, the nonprofit organization providing
the PACE program, and the state department.
(7) (Deleted by amendment, L.
95, p. 912, '
10, effective May 25, 1995.)
(8) Any person who accepts and receives
services authorized under this section shall pay to the state
department or to an agent or provider designated by the state
department an amount that shall be the lesser of such person's
gross income minus the current federal aid to needy disabled supplemental
security income benefit level and cost of dependents and minus
any amounts paid for private health or medical insurance, or the
projected cost of services to be rendered to the person under
the plan of care. Such amount shall be reviewed and revised as
necessary each time the plan of care is reviewed. The state department
shall establish a standard amount to be allowed for the costs
of dependents. In determining a person's gross income, the state
department shall establish, by rule, a deduction schedule to be
allowed and applied in the case of any person who has incurred
excessive medical expenses or other outstanding liabilities that
require payments.
(9) (Deleted by amendment, L.
95, p. 912, '
10, effective May 25, 1995.)
(10) (9) The
medical services board shall promulgate such rules and regulations,
pursuant to article 4 of title 24, C.R.S., as are necessary to
implement this section.
(11) (10) The
general assembly shall make appropriations to the state department
of health care policy and financing
to fund services under this section provided at a monthly capitated
rate. The state department of health
care policy and financing shall annually
renegotiate a monthly capitated rate for the contracted services
based on the ninetyfive percent of the medicaid feeforservice
costs of an actuarially similar population.
(12) (11) The
state department may accept grants and donations from private
sources for the purpose of implementing this section.
(13) (Deleted by amendment, L.
95, p. 912, '
10, effective May 25, 1995.)
264125. Study of certificate
program providersponsored organizations.
(1) NO LATER THAN JANUARY 1, 1998, THE STATE DEPARTMENT
SHALL SUBMIT TO THE GENERAL ASSEMBLY A LIST OF OPTIONS FOR THE
STATE AND THE STATE DEPARTMENT'S RECOMMENDATIONS FOR THE IMPLEMENTATION
OF A CONSUMER CERTIFICATE CHOICE PROGRAM. IN CONNECTION WITH THIS
SUBMISSION, THE STATE DEPARTMENT SHALL CONSIDER PROCEDURES FOR
THE FOLLOWING ACTIVITIES:
(a) SETTING THE VALUE OF A CERTIFICATE;
(b) CONTROLLING THE USE OF A CERTIFICATE;
(c) ESTABLISHING A COMPETITIVE BIDDING
PROCESS FOR MCO'S AND HEALTH BENEFIT PLANS THAT WILL PARTICIPATE
IN A CONSUMER CERTIFICATE CHOICE PROGRAM;
(d) ESTABLISHING WHERE THE RISK IS ASSUMED
IN THE EVENT THAT A CONSUMER EXHAUSTS THE TOTAL VALUE OF A CERTIFICATE
ALLOWANCE AND IS STILL IN NEED OF SERVICES;
(e) ASSESSING QUALITY OUTCOMES FOR A CONSUMER
CERTIFICATE CHOICE PROGRAM;
(f) COLLECTING DATA AND OUTCOME MEASUREMENTS;
(g) EDUCATING CLIENTS ABOUT CHOICE AND
USE OF CERTIFICATES.
(2) THE STATE DEPARTMENT SHALL ALSO INCLUDE
RECOMMENDATIONS AS TO INCLUSION OF THE MEDICALLY INDIGENT POPULATION
IN THE CONSUMER CERTIFICATE CHOICE PROGRAM. EXPANDED COVERAGE
TO IMPOVERISHED COLORADANS SHOULD BE DEVELOPED BASED UPON AN ASSESSMENT
OF HOW THE STATE CAN MAKE THE MOST EFFICIENT USE OF ALL PUBLIC
MONEYS INCLUDING, BUT NOT LIMITED TO, MEDICAID, MEDICALLY INDIGENT,
AND DISPROPORTIONATE SHARE FUNDS. THE STATE DEPARTMENT SHALL ALSO
EXAMINE ALTERNATIVE SUBSIDY STRUCTURES AND FUNDING RESOURCES FOR
THE CONSUMER CERTIFICATE CHOICE PROGRAM.
(3) FOR PURPOSES OF THIS SECTION, "HEALTH
BENEFIT PLAN" MEANS ANY HOSPITAL OR MEDICAL EXPENSE POLICY
OR CERTIFICATE, HOSPITAL OR MEDICAL SERVICE CORPORATION CONTRACT,
OR HEALTH MAINTENANCE ORGANIZATION SUBSCRIBER CONTRACT.
(4) THE STATE DEPARTMENT, IN CONSULTATION
WITH THE COMMISSIONER OF INSURANCE, IS ENCOURAGED TO REVIEW THE
POTENTIAL FOR MEDICAID SAVINGS THROUGH DIRECT CONTRACTING WITH
PROVIDERSPONSORED ORGANIZATIONS.
264126 to 264130. (Reserved)
SECTION 4. 25.51401,
Colorado Revised Statutes, 1989 Repl. Vol., as amended, is amended
to read:
25.51401. Health care coverage
cooperatives rulemaking authority.
The executive director may promulgate rules and regulations consistent
with the provisions of sections 618204, 618206,
618207, 618207.5, and 618207.7,
C.R.S., for purposes of carrying out the executive director's
duties under said sections. The executive director may promulgate
rules and regulations to carry out the executive director's duties
under section 618202, C.R.S., so long as such rules
and regulations add no additional requirements other than those
specifically enumerated in said section 618202, C.R.S.;
EXCEPT THAT THE EXECUTIVE DIRECTOR MAY ADOPT ADDITIONAL RULES
AND REGULATIONS PURSUANT TO SUBPART 2 OF PART 1 OF ARTICLE 4 OF
TITLE 26, C.R.S.
SECTION 5. 264404
(4) (c), Colorado Revised Statutes, 1989 Repl. Vol., as amended,
is amended to read:
264404. Providers
payments rules. (4) (c) The
state department shall ensure the following:
(I) A managed
care provider shall allow a recipient to disenroll at any time;
(II) A managed care provider shall establish
and implement consumer friendly procedures and instructions for
disenrollment and shall have adequate staff to explain issues
concerning service delivery and disenrollment procedures to recipients,
including staff to address the communications needs and requirements
of recipients with disabilities.
(III) All recipients shall be adequately
informed about service delivery options available to them consistent
with the provisions of this subparagraph (III). If a recipient
does not respond to a state department request for selection of
a delivery option within fortyfive calendar days, the state
department shall send a second notification to the recipient.
If the recipient does not respond within twenty days of the date
of the second notification, the state department shall ensure
that the recipient remains with the recipient's primary care physician,
regardless of whether said primary care physician is enrolled
in a health maintenance organization.
SECTION 6. 264303
(1) (h), Colorado Revised Statutes, 1989 Repl. Vol., as amended,
is amended to read:
264303. Optional programs
with special state provisions. (1) This
section specifies programs developed by Colorado to increase federal
financial participation through selecting optional services or
optional eligible groups. These programs include but are not limited
to:
(h) The program of allinclusive
care for the elderly, as specified in section 264519
264124;
SECTION 7. 264404
(1) (b) (II), Colorado Revised Statutes, 1989 Repl. Vol., as amended,
is amended to read:
264404. Providers
payments rules. (1) (b) (II) The
general assembly shall annually appropriate to the state department
of health care policy and financing onehalf of the amount
that would have been paid to providers if the services described
in subparagraph (I) of this paragraph (b) were compensated under
both Title XIX and Title XVIII of the social security act, which
shall be applied to the costs and
expenses of any primary care provider incentive program established
as a part of any managed care system established pursuant to section
264104 (2) MAINTENANCE
OF A FIXED MARKET RATE PRIMARY CARE PROVIDER INCENTIVE PAYMENT.
ANY BALANCE IN THE SAVINGS MAY BE USED TO COVER THE ADMINISTRATIVE
COSTS OF IMPLEMENTING MANAGED CARE PURSUANT TO THE PROVISIONS
OF SUBPART 2 OF PART 1 OF THIS ARTICLE AND THE COSTS OF THE EXPANSION
OF THE INCENTIVE PROGRAM TO PROVIDERS OF DENTAL SERVICES FOR CHILDREN
UNDER THE EARLY PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT PROGRAM.
SECTION 8. 264301.3
(1), Colorado Revised Statutes, 1989 Repl. Vol., as amended, is
amended to read:
264301.3. Managed care
programs guaranteed minimum enrollment for recipients who
become ineligible for benefits optional program.
(1) Beginning January 1, 1995, any recipient who becomes
ineligible to receive benefits under this article and
who has been enrolled in a managed care program for less than
six months shall continue to be eligible
for enrollment in such program for the minimum enrollment period
IF THE RECIPIENT:
(a) HAS SELECTED OR BEEN ASSIGNED TO A
FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATION OR PREPAID
HEALTH PLAN WITHIN NINETY DAYS OF BECOMING ELIGIBLE FOR MEDICAID;
AND
(b) HAS BEEN ENROLLED IN THE MANAGED CARE
PROGRAM FOR LESS THAN SIX MONTHS.
SECTION 9. Repeal of provisions
being relocated in this act. Sections
264519 and 264528, Colorado Revised Statutes,
1989 Repl. Vol., as amended, are repealed.
SECTION 10. Appropriations in
long bill to be adjusted. For the implementation
of this act, appropriations made in the annual general appropriation
act for the fiscal year beginning July 1, 1997, to the department
of health care policy and financing, shall be adjusted as follows:
(1) The appropriation to medical programs,
administration is increased by three hundred thirtyeight
thousand five hundred thirtyfour dollars ($338,534), and
4.0 FTE. Of said sum, one hundred sixtynine thousand two
hundred sixtyseven dollars ($169,267) shall be from the
general fund and one hundred sixtynine thousand two hundred
sixtyseven dollars ($169,267) shall be from matching federal
funds. Said sum shall be for managed care plan oversight pursuant
to section 264113, Colorado Revised Statutes.
(2) The appropriation to medical programs,
administration is increased by one million eighteen thousand one
hundred twentyfour dollars ($1,018,124), and 3.0 FTE. Of
said sum, three hundred eightyfive thousand eight hundred
sixty dollars ($385,860) shall be from the general fund and subject
to the "(M)" notation as defined in the general appropriation
act and six hundred thirtytwo thousand two hundred sixtyfour
dollars ($632,264) shall be from matching federal funds. Said
sum shall be for quality assurance and client grievance procedures
pursuant to sections 264115, 264116 (1),
264120 (3), and 264117 (1) (b), Colorado
Revised Statutes.
(3) The appropriation to medical programs,
administration is increased by one million eight hundred eighty
thousand eightyeight dollars ($1,880,088), and 1.0 FTE.
Of said sum, nine hundred forty thousand fortyfour dollars
($940,044) shall be from the general fund and subject to the "(M)"
notation as defined in the general appropriation act and nine
hundred forty thousand fortyfour dollars ($940,044) shall
be from matching federal funds. Said sum shall be for the enrollment
broker function pursuant to section 264117 (1) (a)
(II), Colorado Revised Statutes.
(4) The appropriation to medical programs,
medical services is decreased by two million four hundred seventyone
thousand seven hundred eight dollars ($2,471,708). Of said sum,
one million one hundred eightyfive thousand six hundred
seventyeight dollars ($1,185,678) shall be from the general
fund and one million two hundred eightysix thousand thirty
dollars ($1,286,030) shall be from matching federal funds. Said
sum shall be from net savings associated with moving clients into
managed care, pursuant to section 264113, Colorado
Revised Statutes.
(5) The appropriation to medical programs,
other medical services, physician incentive pool is decreased
by one million four hundred thirtyone thousand two hundred
thirtysix dollars ($1,431,236). Of said sum, six hundred
seventyeight thousand four hundred fortythree dollars
($678,443) shall be from the general fund and seven hundred fiftytwo
thousand seven hundred ninetythree dollars ($752,793) shall
be from federal funds. Said sum shall be from savings associated
with the movement to a fixed market rate primary care provider
incentive payment, pursuant to section 264404 (1)
(b) (II), Colorado Revised Statutes.
SECTION 11. Safety
clause. The general assembly hereby finds, determines, and
declares that this act is necessary for the immediate preservation
of the public peace, health, and safety.
____________________________ ____________________________
Tom Norton Charles E. Berry
PRESIDENT OF SPEAKER OF THE HOUSE
THE SENATE OF REPRESENTATIVES
____________________________ ____________________________
Joan M. Albi Judith M. Rodrigue
SECRETARY OF CHIEF CLERK OF THE HOUSE
THE SENATE OF REPRESENTATIVES
APPROVED________________________________________
_________________________________________
Roy Romer
GOVERNOR OF THE STATE OF COLORADO