C.R.S. Section 25.5-5-408
Capitation payments

  • availability of base data
  • adjustments
  • rate calculation
  • capitation payment proposal
  • preference
  • assignment of medicaid recipients
  • definition

(1)

Intentionally left blank —Ed.

(a)

The state department shall make capitation payments to MCEs based upon a defined scope of services under a risk contract.

(b)

A certification by a qualified actuary retained by the state department is conclusive evidence that the state department has correctly calculated the direct health-care cost of providing these same services on an actuarially equivalent Colorado medicaid population group.

(c)

Except as otherwise provided in subsection (1)(d) of this section and where the state department has instituted a program of competitive bidding provided in section 25.5-5-402 (9), the state department may utilize 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 and network sufficiency. A certification of a qualified actuary, retained by the state department, to the appropriate lower limit is conclusive evidence of the state department’s compliance with the requirements of this subsection (1)(c). For the purposes of this subsection (1), a “qualified actuary” means a person deemed as such under rules promulgated by the commissioner of insurance.

(d)

The state department shall reimburse a federally qualified health center, as defined in the federal “Social Security Act”, 42 U.S.C. sec. 1395x (aa)(4), for the total reasonable costs incurred by the center in providing health-care services to all recipients of medical assistance.

(e)

An MCE shall certify, as a condition of entering into a contract with the state department, that the capitation payments set forth in the contract between the MCE and the state department are sufficient to ensure the financial stability of the MCE with respect to delivery of services to the medicaid recipients covered in the contract.

(f)

Intentionally left blank —Ed.

(I)

Except as provided in subsection (1)(f)(II) of this section, for capitation payments effective on and after July 1, 2003, an MCE that is contracting for a defined scope of services under a risk contract shall certify, through a qualified actuary retained by the MCE, that the capitation payments set forth in the contract between the MCE and the state department comply with all applicable federal and state requirements that govern the capitation payments. For purposes of this subsection (1)(f)(I), a “qualified actuary” means a person deemed as such by rule promulgated by the commissioner of insurance.

(II)

An MCO providing services under the PACE program as described in section 25.5-5-412 shall certify that the capitation payments are in compliance with applicable federal and state requirements that govern said capitation payments and that the capitation payments are sufficient to ensure the financial viability of the MCO with respect to the delivery of services to the PACE program participants covered in the contract.

(2)

The state department shall develop capitation rates for MCEs contracting for a defined scope of services under a risk contract that include risk adjustments, reinsurance, or stop-loss 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 state 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)

Under no circumstances shall the risk adjustments, reinsurance, or stop-loss 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 fee-for-service medicaid.

(5)

The state department may develop quality incentive payments to recognize superior quality of care or service provided by a managed care plan.

(6)

Within two hundred ten days from the beginning of each fiscal year, the state department, in cooperation with the MCEs, shall set a timeline for the rate-setting process for the following fiscal year’s rates and for the provision of base data to the MCEs that is used in the calculation of the rates, which must include but not be limited to the information included in subsection (7) of this section.

(7)

The state department shall identify and make available to the MCEs the base data used in the calculation of the direct health-care cost of providing these same services on an actuarially equivalent Colorado medicaid population group. The state department shall consult with the MCEs regarding any and all adjustments in the base data made to arrive at the capitation payments.

(8)

For capitation payments effective on and after July 1, 2003, the state department shall recalculate the base calculation every three years. The three-year cycle for the recalculation of the base calculation shall begin with capitation payments effective for fiscal year 2003-04. In the years in which the base calculation is not recalculated, the state department shall annually trend the base calculation after consulting with the MCEs. The state department shall take into consideration when trending the base calculation any public policy changes that affect reimbursement under the “Colorado Medical Assistance Act”.

(9)

The rate-setting process referenced in subsection (6) of this section must include a time period after the MCEs have received the direct health-care cost of providing these same services on an actuarially equivalent Colorado medicaid population group for each MCE to submit to the state department the MCE’s capitation payment proposal, which must not exceed one hundred percent of the direct health-care cost of providing these same services on an actuarially equivalent Colorado medicaid population group. The state department shall provide to the MCEs the MCE’s specific adjustments to be included in the calculation of the MCE’s proposal. Each MCE’s capitation payment proposal must meet the requirements of subsections (1)(e) and (1)(f) of this section and section 25.5-5-402 (10).

(10)

For capitation payments effective on and after July 1, 2003, unless otherwise required by federal law, the state department shall certify, through a qualified actuary retained by the state department, that the capitation payments set forth in the contract between the state department and the MCEs comply with all applicable federal and state requirements that govern said capitation payments.

(11)

Effective on and after July 1, 2003, the capitation payments certified by the qualified actuary under subsection (10) of this section shall not be subject to any dispute resolution process, including any such process set forth in any settlement agreement entered into prior to July 1, 2002.

(12)

Nothing in this section shall prevent, to the extent possible, an MCE that is also a government-owned entity from using certified public expenditure or other federally recognized financing mechanisms to provide the state share for the federal match to enhance capitation payments up to or above the one hundred percent limit contained in subsection (9) of this section. The state shall not be obligated to increase any general fund expenditures because of the use of certified public expenditure or other federally recognized financing mechanism pursuant to this subsection (12).

(13)

A PIHP agreement may include a provision for a quality incentive payment that is distributed to the contractor within a reasonable period of time, as specified in the contract, following the end of each fiscal year if the contractor substantially exceeds predetermined quality indicators. The quality indicators must be based upon broadly accepted measures of performance adopted by rule of the state board and agreed upon at the outset of the contract period, and must include, but need not be limited to, the health plan employers data and information set measures. The quality incentive payment may be made proportional if the state board establishes multiple quality measurements. The quality incentive payments must not exceed the total cost savings created under the PIHP agreement, as determined by comparison of the PIHP members with an actuarially equivalent fee-for-service population, and the quality incentive payment must not exceed five percent of the total medicaid payments received by the contractor during the performance period of the PIHP agreement.

Source: Section 25.5-5-408 — Capitation payments - availability of base data - adjustments - rate calculation - capitation payment proposal - preference - assignment of medicaid recipients - definition, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­5.­pdf (accessed Oct. 20, 2023).

25.5‑5‑101
Mandatory provisions - eligible groups - rules - repeal
25.5‑5‑102
Basic services for the categorically needy - mandated services
25.5‑5‑103
Mandated programs with special state provisions - rules
25.5‑5‑104
Qualified medicare beneficiaries
25.5‑5‑105
Qualified disabled and working individuals
25.5‑5‑201
Optional provisions - optional groups - rules - repeal
25.5‑5‑202
Basic services for the categorically needy - optional services
25.5‑5‑203
Optional programs with special state provisions - repeal
25.5‑5‑204
Presumptive eligibility - pregnant person - children - long-term care - state plan
25.5‑5‑204.5
Continuous eligibility - children
25.5‑5‑206
Medicaid buy-in program - disabled children - disabled adults - federal authorization - rules
25.5‑5‑207
Adult dental benefit - adult dental fund - creation - legislative declaration
25.5‑5‑208
Additional services - training - grants - screening, brief intervention, and referral
25.5‑5‑301
Clinic services
25.5‑5‑302
Clinic services - children and pregnant women - utilization of certain providers
25.5‑5‑303
Private-duty nursing
25.5‑5‑304
Hospice care
25.5‑5‑305
Pediatric hospice care - legislative declaration - federal authorization - rules - fund
25.5‑5‑307
Child mental health treatment and family support program
25.5‑5‑308
Breast and cervical cancer prevention and treatment program - creation - legislative declaration - definitions - funds - repeal
25.5‑5‑309
Pregnant women - needs assessment - referral to treatment program - definition
25.5‑5‑310
Treatment program for high-risk pregnant and parenting women - cooperation with private entities - definition
25.5‑5‑311
Treatment program for high-risk pregnant and parenting women - data collection
25.5‑5‑312
Treatment program for high-risk pregnant and parenting women - extended coverage - federal approval
25.5‑5‑314
Substance use disorder treatment for Native Americans - federal approval
25.5‑5‑315
Acceptance of gifts, grants, and donations - Native American substance abuse treatment cash fund
25.5‑5‑316
Legislative declaration - state department - disease management programs authorization - report
25.5‑5‑318
Health services - provision by school districts - repeal
25.5‑5‑319
Family planning pilot program - rules - federal waiver - repeal
25.5‑5‑320
Telemedicine - reimbursement - disclosure statement - rules - definition
25.5‑5‑321
Telemedicine - home health care - home health telemedicine cash fund - rules - repeal
25.5‑5‑321.5
Telehealth - interim therapeutic restorations - reimbursement - definitions
25.5‑5‑322
Over-the-counter medications - rules
25.5‑5‑323
Complex rehabilitation technology - no prior authorization - metrics - report - rules - legislative declaration - definitions
25.5‑5‑324
Nonemergency medical transportation - urgent and secure transportation need - report - repeal
25.5‑5‑325
Residential and inpatient substance use disorder treatment - medical detoxification services - federal approval - performance review report
25.5‑5‑326
Access to clinical trials - definitions
25.5‑5‑327
Eligible peer support services - reimbursement - definitions
25.5‑5‑328
Secure transportation for behavioral health crises - benefit - funding
25.5‑5‑329
Family planning services - federal authorization - rules - definitions
25.5‑5‑330
Screening for perinatal mood and anxiety disorder
25.5‑5‑331
Federally qualified health center - clinical pharmacy services - reimbursement - rules
25.5‑5‑332
Therapy using equine movement - federal authorization - definition
25.5‑5‑333
Primary care and behavioral health statewide integration grant program - creation - report - definition - repeal
25.5‑5‑334
Community health worker services - federal authorization - reporting - rules - definition
25.5‑5‑335
Continuous medical coverage for children and adults feasibility study - federal authorization - rules - report - definition
25.5‑5‑336
Prohibition on using the body mass index or ideal body weight - medical necessity criteria
25.5‑5‑401
Short title
25.5‑5‑402
Statewide managed care system - rules - definitions - repeal
25.5‑5‑403
Definitions
25.5‑5‑406.1
Required features of statewide managed care system
25.5‑5‑408
Capitation payments - availability of base data - adjustments - rate calculation - capitation payment proposal - preference - assignment of medicaid recipients - definition
25.5‑5‑410
Data collection for managed care programs
25.5‑5‑412
Program of all-inclusive care for the elderly - services - eligibility - legislative declaration - rules - definitions
25.5‑5‑414
Telemedicine - legislative intent
25.5‑5‑415
Medicaid payment reform and innovation pilot program - legislative declaration - creation - selection of payment projects - report - rules
25.5‑5‑418
Primary care provider sustainability fund - creation - use of fund
25.5‑5‑419
Accountable care collaborative - reporting - rules
25.5‑5‑420
Advancing care for exceptional kids
25.5‑5‑421
Parity reporting - state department - public input
25.5‑5‑422
Medication-assisted treatment - limitations on MCEs - definition
25.5‑5‑423
Independent review organization - review denial of residential and inpatient substance use disorder treatment claims - contract
25.5‑5‑424
Residential and inpatient substance use disorder treatment - MCE standardized utilization management process - medical necessity - report
25.5‑5‑425
Audit of MCE denials for residential and inpatient substance use disorder treatment authorization - report
25.5‑5‑500.3
Authorization to bill third party
25.5‑5‑501
Providers - drug reimbursement
25.5‑5‑502
Unused medications - reuse - rules - definition
25.5‑5‑503
Prescription drug benefits - authorization - dual-eligible participation
25.5‑5‑504
Providers of pharmaceutical services
25.5‑5‑505
Prescribed drugs - mail order - rules
25.5‑5‑506
Prescribed drugs - utilization review
25.5‑5‑507
Prescription drug information and technical assistance program - rules
25.5‑5‑509
Substance use disorder - prescription drugs - opiate antagonist
25.5‑5‑510
Pharmacy reimbursement - substance use disorder - injections
25.5‑5‑511
Reimbursement for pharmacists’ services - legislative declaration
25.5‑5‑512
Pharmacy benefit - mental health and substance use disorders - legislative declaration
25.5‑5‑513
Pharmacy benefits - prescription drugs - rebates - analysis
25.5‑5‑514
Prescription drugs used for treatment or prevention of HIV - prohibition on utilization management - definition
25.5‑5‑515
Pharmacy reimbursement - vaccine administration to children - legislative declaration
25.5‑5‑516
Serious mental illness - prescribed drugs
25.5‑5‑801
Legislative declaration
25.5‑5‑802
Definitions
25.5‑5‑803
High-fidelity wraparound services for children and youth - federal approval - reporting
25.5‑5‑804
Integrated funding pilot
Green check means up to date. Up to date

Current through Fall 2024

§ 25.5-5-408’s source at colorado​.gov