Medicaid Changes

Karen Lee

There is a lot of talk of all the changes coming with the new accountable care collaborative phase two initiative, but what do you really need to know?

The thing that could most impact you is that Colorado Medicaid will now be managed using a “holistic care” approach. This method is designed to ensure all components of managing patient care are integrated. The patient’s primary care provider will be able and responsible to communicate with the hospital or their behavioral health care provider. There will be more transparency and overall communication between all providers involved in the patient’s care process. While slight aspects of this approach were implemented early in 2017 using “Regional Care Collaborative Organizations (RCCO)” this even more defined holistic care approach has now been termed “Regional Accountable Entity (RAE).”

What is a “Regional Accountable Entity (RAE)?” The New Regional Accountable Entities will be responsible for coordinating the physical and behavioral health for clients in their region, as well as: overseeing behavioral and physical health regional networks, onboarding and activating clients, developing and supporting Health Teams, making value-based payments to Health Teams, and Convening Health Neighborhoods. Health Teams, at minimum, includes the client and Primary Care Medical Provider (PCMP). Health Teams may also include a client’s specialty behavioral health practitioner, long-term services and supports case management agency, and certain specialists.

What this means for Providers: The biggest impact this has for providers is two-fold. First, Primary Care Medical Providers (PCMP) will be auto-assigned new clients as they are enrolled into the Medicaid program. This means that PCMP may have little to no contact with patients prior to being assigned as a patient’s primary care provider. In addition, once a patient is assigned there is no guarantee that they will seek the provider out for primary care. It will be a task for the PCMP and RAE to determine best methods for establishing new relationships while trying to focus on the benefits of using primary care versus emergency services. These coordination efforts will in the end have an impact on value-based incentive care payments.

Secondly, behavioral health providers will need to understand that care is based upon the patient’s enrollment in the RAE. If a patient lives in Denver but has been assigned a PCMP in Colorado Springs that means they have a different RAE than someone would who has been assigned a PCMP in Denver. Medicaid benefits are no longer based on where the patient resides. There are seven (7) RAE’s for the various counties in Colorado, so every provider should verify which RAE a patient is assigned to prior to providing care. In addition, behavioral health providers will need to re-credential with the RAE in which they provide most of their care. At Ponderosa Billing Services, we offer all our providers credentialing assistance and guidance and would be more than happy to help you complete the process. Just reach out to find out how we can get started!

Billing for Medical professionals will remain the same. Billing for behavioral health providers will follow suit in the same way it has in the past with RCCOs. Behavioral health providers will need to bill the actual RAE entity directly to be reimbursed for care. For instance, in El Paso County, as noted below, behavioral health providers will need to bill Colorado Community Health Alliance (CCHA) which is a Anthem company directly to be paid for care.

Effective July 1, 2018: All behavioral health providers will need to be credentialed and bill thru the new RAE contractor. All old contracts for RCCOs and the Behavioral Health Organization (BHO) they represent will be ended. Some companies such as BHI are closing business. Be sure you are credentialed and ready to bill before the change. Medical professionals may notice a change in reimbursement and rate schedules and how incentives are calculated. All other billing remains the same.

Below is a list of the new RAE regions for each county:

  1. Rocky Mountain Health Plans – Moffat, Routt, Jackson, Grand, Larimer, Rio Blanco, Garfield, Eagle, Summit, Mesa, Pitkin, Delta, Montrose, San Miguel, Dolores, Montezuma, Ouray, San Juan, La Plata, Gunnison, Hinsdale, and Archuleta Counties.
  2. Northeast Health Partners -Weld, Morgan, Logan, Sedgwick, Philips, Yuma, Washington, Kit Carson, Lincoln, and Cheyenne Counties.
  3. Colorado Access – Adams, Arapahoe, Douglas, and Elbert Counties
  4. Health Colorado, Inc – Lake, Chaffee, Saguache, Mineral, Rio Grande, Alamosa, Conejos, Costilla, Fremont, Custer, Huerfano, Costilla, Pueblo, Las Animas, Crowley, Otero, Kowa, Bent, Prowers, and Baca Counties
  5. Colorado Access –Denver County
  6. Colorado Community Health Alliance – Boulder, Gilpin, Clear Creek, Jefferson, and Broomfield Counties
  7. Colorado Community Health Alliance – Park, Teller, and El Paso Counties


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