COLORADO DEPARTMENT OF HEALTH CARE POLICY & FINANCING

1570 Grant Street, Denver, CO 80203-1818 (303) 866-2993 (303) 866-4411 Fax (303) 866-3883 TTY

Bill Ritter, Jr., Governor Joan Henneberry, Executive Director

Health Care Policy and Financing’s

2008 Legislative Agenda

The Department received approval from the Governor’s Office to submit 12 legislative proposals for the 2008 session. Included in the package are a variety of proposals that range from ensuring that Medicaid is the payer of last resort to authorizing over expenditure authority for CHP+:

1. Mail Order Pharmacy (Sen. Hagedorn and Rep. McGihon): The Department has experienced that clients with third party insurance are being required to go to a mail order pharmacy to receive their maintenance drugs. Some mail order pharmacies do not accept Medicaid and in these instances the client is unable to pay the copayments and goes without medication. In the short term, the Department’s third party specialist has allowed clients to go to a retail pharmacy and bill Medicaid as primary insurance. However, this requires the Department to pay the full cost of the prescription rather than just the Medicaid portion. This legislation intends to require the mail order pharmacy to not charge a Medicaid client more than the Medicaid copayment. The mail order pharmacy would be allowed to bill Medicaid for the remaining portion of the claim.

2. Trusts (sponsors pending): This legislation intends to address the issue whereby individuals have sufficient resources to pay for their own care, yet they become eligible for Medicaid by using a variety of strategies such as shielding assets, transferring property etc. The goal of the legislation would be to cap the amount that a person could put into a pooled trust, and by restoring the limitation on the source of funding of these trusts to personal injury settlements and certain retroactive Social Security payments.

3. Estate Recovery (sponsors pending): This legislation intends to address several aspects of the Medical Assistance Recovery Program. A few aspects that the proposal intends to include are allowing the Department to foreclose on TEFRA liens after the death of a Medicaid recipient; Specifying that the capitation payments made on behalf of Medicaid recipients are considered medical assistance and are recoverable; and allowing the Department, through the county human service departments, to file for a request for notice of transfer of real property of a Medicaid recipient.

4. Third Party (sponsors pending): This legislation intends to clarify who participtes in data matching to allow discovery of potential third party insurance obligations and requires third party insurers to accept claims for recovery under certain guidelines.

5. Family Planning Pilot (sponsors pending): this legislation intends to allow the Department to pursue a family planning pilot program by removing the current 150% FPL and age limitations. If the legislation passes, family planning services would be extended to low income men and women of child bearing age who have no other insurance, and would otherwise not be eligible for Medicaid.

6. Mental Health Audit proposal (sponsors pending): this legislation proposes to reform statutory language to allow for modernization of the mental health capitation rate methodology. This includes establishing a cost-effective capitated community mental health services rates in a manner that includes cost-containment mechanisms. The cost containment mechanisms may include restricting average per member per month utilization growth, restricting on unit cost growth, limiting allowable administrative cost, establishing minimum medical loss ratios, or establishing other cost containment mechanisms that the Department determines appropriate.

7. Over Expenditure Authority for CHP+ (Sen. Sandoval): The proposed legislation authorizes over-expenditure authority in the Children's Basic Health Plan. The purpose is to provide needed flexibility in budgeting for this program to address the impacts of dramatic and ongoing fluctuations in caseload. Being granted this authority would prevent the need to consider establishing an enrollment cap as a potential alternative to expenditures exceeding appropriated funds. It would also prevent recurring fiscal impact to future year budgets which, under current statute, must pay for any over-expenditures that occur during the previous fiscal year.

8. Modify Definition of Managed Care Entity (sponsors pending): this proposal intends to modify language to specify the type of managed care program. The proposed legislation would clarify sections of statute as to whether it applies to physical health or behavioral health programs, Managed Care Organizatons (MCO), Prepaid Inpatient Health Plans (PHIP), or Primary Care Case Management programs (PCCM) As currently written, the statute contains requirements that are not applicable and do not apply to all of these programs.

9. Consolidate Authority for the Home and Community Based Services (HCBS) waivers that serve the Elderly, Blind and Disabled (EBD), and Mental Illness (MI) populations (sponsors pending): This proposal intends to consolidate legislative authority for the HCBS EBD and MI waivers to allow the Department to combine the two waivers. The waivers use the same Single Entry Point (SEP) agencies for case management, the same level of care tool, and the majority of waiver services are the same. HCBS-EBD includes one service (Community Transition Services) that is not in the MI waiver but the advocates would like it to be.

10. Broaden Definition of Licensed Provider Network (sponsors pending): This legislation proposes revisions to the Division of Insurance regulations regarding Limited Services Licensed Provider Network (LSLPN). Specifically request that the definition of “Licensed Provider Network” be expanded to include entities that are formed to transact health care insurance business and to contract with individual or groups of providers. Currently, only entities formed by providers or a group of providers may be licensed as LSLPN’s.

11.  Non Custodial Cash Medical Payments (sponsors pending): This legislation intends to clarify third-party liability regulations to assist the Department of Health Care Policy and Financing in coordinating with Department of Human Service (Title IV-D agency) to collect medical support payments from noncustodial parents with medical support orders, and seek legislation that would allow the Department to accumulate medical support payments to offset Medicaid costs. Noncustodial parent’s medical support orders are not enforceable when the noncustodial parent’s employer does not provide health insurance or it is too costly, consequently many of these children are enrolled in Medicaid. The Department can reduce State and Federal Medicaid costs by increasing the number of noncustodial parents who provide medical support payments for their children.

12. Inclusion of long-term care programs in managed care efforts: This legislation intends to include long-term care programs in managed care efforts. The proposed legislation removes the exclusions for services delivered under the residential child health care program, and long term care services” found at 25.5-5-402(2)(a)&(b) of the managed care statute. This would allow the Department to include long term care programs in the Department’s managed care efforts or residential services for youth in the mental health capitation program.