Denver Health Medicaid Choice – 85,697 members as of October 2019.
This plan is limited to members residing in Denver county and covers the same services as traditional Medicaid.
Rocky Mountain Health Plan – 36,013 members as of October 2019.
This is a limited benefit prepaid health plan for members residing in Garfield, Gunnison, Mesa, Montrose, Pitkin and Rio Blanco counties. RMHP covers most medical services like doctors, hospitals, and preventive care. Excluded services include hospice, non-emergent medical transportation (NEMT), private duty nursing, skills nursing facility services, orthodontia, hearing aids, and certain home health and case management services.
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In a traditional PCCM program, each enrollee is assigned to a designated primary care medical provider (PCMP) who is paid a monthly case management fee to assume responsibility for care management and coordination. Individual providers are not at financial risk and continue to be paid on an FFS basis for covered services
On July 1, 2018, new Regional Accountable Entities (RAEs) began serving as the single entity responsible for coordinating both physical and behavioral health (defined as mental health and substance use disorder) for Health First Colorado (Colorado’s Medicaid Program) members and administering the capitated behavioral health benefit. These are the duties previously contracted by Regional Care Collaborative Organizations (RCCOs) and Behavioral Health Organizations (BHOs).
All full-benefit Health First Colorado members (excluding members enrolled in Program for All-Inclusive Care for the Elderly [PACE]) are mandatorily enrolled in a RAE. There are five (5) RAE organizations serving seven (7) regions covering all of Colorado:
Rocky Mountain Health Plans (region 1); 177,533 members*.
Colorado Access (regions 3 & 5); 470,886 members combined across regions.*
Health Colorado, Inc. (region 4); 122,494 members*
Colorado Community Health Alliance (region 6 & 7); 313,828 members combined across regions.*
United Healthcare Community Plan of Ohio, Inc. 24,892*
Members are assigned to a PCMP in one of the following ways:
- Demonstrated claims history with a PCMP over the past 18 months
- Family member’s claims history with a PCMP if the member has no utilization history
- Closest appropriate PCMP within the member’s region if member has no utilization history
- Member chooses PCMP by calling Health First Colorado Enrollment
Physical health services in Colorado are reimbursed on a fee-for-service basis. However, in an effort to maintain the full continuum of community-based, alternative services that are only available under capitation and a waiver with the federal Centers for Medicare & Medicaid Services (CMS), a capitation payment methodology will be retained for core behavioral health services that will be paid directly to the RAEs.
*RAE enrollment figures above are as of October 2019.
- Colorado supplied HMS with a 3-year refresh file of converted data as part of its MMIS conversion. As a result, the data set summary information for Colorado contains duplicated claims from the state’s former MMIS.
- HMS does not currently receive rendering/treating dentist information for dental claims processed after the state’s MMIS conversion go-live date of 3/1/2017
- “Medicaid & CHIP in Colorado.” Medicaid.gov., https://www.medicaid.gov/state-overviews/stateprofile.html?state=colorado
- “Accountable Care Collaborative Phase II Key Concepts for Providers.” Colorado Department of Health Care Policy and Financing. February 2018, https://www.colorado.gov/pacific/sites/default/files/ACC%20Phase%20II%20Overview%20Fact%20Sheet_February%202018.pdf
- “Top 10 Things Providers Need to Know Beginning July 1, 2018.” Colorado Department of Health Care Policy and Financing. June 2018, https://www.colorado.gov/pacific/sites/default/files/ACC%20Phase%20II%20Top%2010%20for%20Providers%20June%202018_2.pdf
- “Behavioral Health Services Accountable Care Collaborative Phase II.” Colorado Department of Health Care Policy and Financing. July 20, 2018, https://www.colorado.gov/pacific/sites/default/files/BH%20Fact%20Sheet%20%26%20FAQs%2007.20.18.pdf
- “Denver Health Medicaid Choice.” Denver Health Medical Plan Inc. Retrieved November 2019, https://www.denverhealthmedicalplan.org/denver-health-medicaid-choice
- “Learn about RMHP Prime.” Rocky Mountain Health Plans. © 2019, Rocky Mountain Health Plans, https://www.rmhp.org/medicaid-chp-plus/understand-health-first-co/rmhp-prime