C.R.S.
Section 25.5-5-402
Statewide managed care system
- rules
- definitions
- repeal
(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:(a)
The services delivered under the residential child health-care program described in section 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;(b)
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:(a)
Address the economic, social, and personal costs to the state of Colorado and its citizens of untreated behavioral health disorders, including mental health and substance use disorders;(b)
Approach behavioral health disorders as treatable conditions not unlike other chronic health issues that require a combination of behavioral change and medication or other treatment;(c)
Offer timely access through multiple points of entry to a full continuum of culturally responsive 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;(d)
Feature a comprehensive and integrated system of quality behavioral health care that is individualized and coordinated to meet individuals’ changing needs;(e)
[Editor’s note:(e)
[Editor’s note:(f)
Make the behavioral health system’s administrative processes, service delivery, and funding more effective and efficient to improve outcomes for Colorado citizens;(g)
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;(h)
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(i)
Require an MCE to cover all medically necessary covered treatments for covered behavioral health diagnoses, regardless of any co-occurring conditions.(3.5)
Intentionally left blank —Ed.(a)
No later than July 1, 2023, the state department, in collaboration with the behavioral health administration in the department of human services and other state agencies, shall develop the universal contract as described in section 27-50-203.(b)
Intentionally left blank —Ed.(I)
For the 2022-23 state fiscal year, the general assembly shall appropriate three million dollars from the behavioral and mental health cash fund, created in section 24-75-230, to the state department for the development, implementation, and administration of the universal contract.(II)
This subsection (3.5)(b) is repealed, effective July 1, 2024.(4)
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.(5)
The statewide managed care system builds upon the lessons learned from previous managed 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.(6)
Intentionally left blank —Ed.(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 2.5 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.(7)
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)
Intentionally left blank —Ed.(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:(I)
Maintain adequate financials to ensure proper solvency as a risk manager;(II)
Accept rates determined by the state department, through standard methodologies, to cover the population it is serving;(III)
Maintain service and quality metrics, as determined by the state department; and(IV)
Meet statewide managed care system standards and operate as part of the overall managed care system.(8)
Waivers.(9)
Bidding.(a)
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.(b)
Intentionally left blank —Ed.(I)
On or before January 1, 2023, in order to promote transparency and accountability, the state department shall require each MCE that has twenty-five percent or more ownership by providers of behavioral health services to comply with the following conflict of interest policies:(A)
Providers who have ownership or board membership in an MCE shall not have control, influence, or decision-making authority in the establishment of provider networks.(B)
Each MCE shall report quarterly the number of providers who applied to join the network and were denied and a comparison of rate ranges for providers who have ownership or board membership versus providers who do not.(C)
An employee of a contracted provider of an MCE shall not also be an employee of the MCE unless the employee is a clinical officer or utilization management director of the MCE. If the individual is also an employee of a provider that has board membership or ownership in the MCE, the MCE shall develop policies, approved by the executive director of the state department, to mitigate any conflict of interest the employee may have.(D)
An MCE’s board shall not have more than fifty percent of contracted providers as board members, and the MCE is encouraged to have a community member on the MCE’s board.(II)
No later than July 1, 2025, the state department shall appropriately address perceived or actual provider ownership and control of MCEs participating in the statewide managed care system in the interest of transparency and accountability. In designing a competitive bidding process, the state department shall incorporate community feedback and have a public process related to governing requirements, including how to address conflicts of interest.(III)
As used in this subsection (9)(b):(A)
“Clinical officer” means a physician who provides the clinical vision for the MCE or provides clinical direction to network management, quality improvement, utilization management, or credentialing divisions.(B)
“MCE” means a managed care entity responsible for the statewide system of community behavioral health care, as described in section 25.5-5-402 (3), and is not owned, operated by, or affiliated with an instrumentality, municipality, or political subdivision of the state.(C)
“Ownership” means an individual who is a legal proprietor of an organization, including a provider or individual who owns assets of an organization, or has a financial stake, interest, or governance role in the MCE.(D)
“Utilization management director” means a licensed health-care professional with behavioral health clinical experience who leads and develops the utilization management program or manages the medical review and authorization process.(10)
An MCE that is contracting for a defined scope of services under a risk contract shall certify the financial stability of the MCE pursuant to criteria established by the division of insurance.(11)
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.(12)
Graduate medical education.(13)
Nothing in this part 4 creates an exemption from the applicable provisions of title 10.(14)
Nothing in this part 4 creates an entitlement to an MCE to contract with the state department.(15)
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.(16)
The state department shall provide information on its website specifying how the public 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:
Section 25.5-5-402 — Statewide managed care system - rules - definitions - repeal, https://leg.colorado.gov/sites/default/files/images/olls/crs2023-title-25.5.pdf (accessed Oct. 20, 2023).
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