Colorado Department of Health Care Policy and Financing

Colorado Department of Health Care Policy and Financing

Section 1915(b) Waiver Proposal for

The Colorado Medicaid Accountable Care Collaborative: Primary Care Case Management and Prepaid Inpatient Health Plan Program; Accountable Care Collaborative: Limited Managed Care

Capitation Initiative and

Special Connections: Postpartum Months Three through Twelve

Submitted March 2, 2018 for

Waiver Period July 1, 2018 to June 30, 2023 Revised May 1, 2018 and May 15, 2018

Table of Contents

Factsheet

4

Section A: Program Description

6

Part I: Program Overview

6

A. Statutory Authority

11

B. Delivery Systems

13

C. Choice of MCOs, PIHPs, PAHPs, and PCCMs

15

D. Geographic Areas Served by the Waiver

17

E. Populations Included in Waiver

19

F. Services

23

Part II: Access

32

A. Timely Access Standards

32

B. Capacity Standards

38

C. Coordination and Continuity of Care Standards

41

Part III: Quality

45

Part IV: Program Operations

51

A. Marketing

51

B. Information to Potential Enrollees and Enrollees

54

C. Enrollment and Disenrollment

57

D. Enrollee Rights

65

E. Grievance System

66

F. Program Integrity

70

Section B: Monitoring Plan

72

Part I: Summary Chart

73

Part II: Monitoring Strategies

78

Section C: Monitoring Results

91

Section D: Cost Effectiveness

92

Part I: State Completion Section

92

A. Assurances

92

B. Expedited or Comprehensive Test

93

C. Type of Capitated Contract

94

D. Reimbursement of PCCM Providers

94

E. Appendix D1 ? Member Months

96

F. Appendix D2.S ? Service in Actual Waiver Cost

97

G. Appendix D2.A ? Administration in Actual Waiver Cost 98

H. Appendix D3 ? Actual Waiver Cost

99

I. Appendix D4 ? Adjustments in the Projection OR

Conversion Waiver for DOS within DOP

105

Colorado Medicaid Accountable Care Collaborative: Primary Care Case Management and

2

Prepaid Inpatient Health Plan Program and

Special Connections: Postpartum Months Three through Twelve

J. Appendix D4 ? Conversion or Renewal Waiver Cost Projection

and Adjustments

120

K. Appendix D5 ? Waiver Cost Projection

126

L. Appendix D6 ? RO Targets

126

M. Appendix D7 ? Summary

126

Part II: Appendices D.1-7

127

Colorado Medicaid Accountable Care Collaborative: Primary Care Case Management and

3

Prepaid Inpatient Health Plan Program and

Special Connections: Postpartum Months Three through Twelve

Proposal for a Section 1915(b) Waiver MCO, PIHP, PAHP, and/or PCCM Program

Factsheet

Please fill in and submit this Factsheet with each waiver proposal, renewal, or amendment request.

The State of Colorado requests a waiver/amendment under the authority of section 1915(b) of the Act. The Medicaid agency will directly operate the waiver.

The name of the waiver programs are the Accountable Care Collaborative: PCCM Entity-PIHP Program, Accountable Care Collaborative: Limited Managed Care Capitation Imitative and Special Connections: Postpartum Months Three through Twelve. (Please list each program name if the waiver authorizes more than one program.).

Type of request. This is a(n): _X__ Initial request for new waiver ___ amendment request for existing waiver, which modifies Section/Part ____

__ Replacement pages are attached for specific Section/Part being amended __ Amendment request for existing waiver. Document is replaced in full, with

changes highlighted. ___ Renewal request

__ This is the first time the State is using this waiver format to renew an existing waiver. The full preprint (i.e. Sections A through D) are filled out.

__ The State has used this waiver format for its previous waiver period. Section A is ___ replaced in full _ carried over from previous waiver period. The State: _ __ assures there are no changes in the Program Description from the previous waiver period. assures the same Program Description from the previous waiver period will be used, with the exception of changes noted in attached replacement pages.

Section B is

_ replaced in full carried over from previous waiver period. The State: ___ assures there are no changes in the Monitoring Plan from the previous waiver period. _ assures the same Monitoring Plan from the previous waiver period will be used, with exceptions noted in attached replacement pages.

Colorado Medicaid Accountable Care Collaborative: Primary Care Case Management and

4

Prepaid Inpatient Health Plan Program and

Special Connections: Postpartum Months Three through Twelve

Effective Dates: This initial request for a new waiver is requested for a period of five (5) years, effective July 1, 2018 and ending June 30, 2023. (For beginning date for an initial or renewal request, please choose first day of a calendar quarter, if possible, or if not, the first day of a month. For an amendment, please identify the implementation date as the beginning date, and end of the waiver period as the end date)

State Contact: The State contract person for the ACC Program under this waiver is Susan Mathieu, and she can be reached at (303) 866-5584 or email at susan.mathieu@state.co.us

The State contact person for the Special Connections Program under this waiver is Susanna Snyder and she can be reached by telephone at (303) 866-3154 or e-mail at susanna.snyder@hcpf.state.co.us

The State contact person for the cost effectiveness portion of this waiver is John Doherty he can be reached by telephone at (303) 866-5180 or e-mail at John.Doherty@state.co.us

Colorado Medicaid Accountable Care Collaborative: Primary Care Case Management and

5

Prepaid Inpatient Health Plan Program and

Special Connections: Postpartum Months Three through Twelve

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