Policy Statement: Billing Health First Colorado Members for Services

Purpose

To outline the Department's policy on billing Health First Colorado (Colorado\'s Medicaid Program) members for covered and non-covered services.

Background

Health First Colorado expansion in Colorado means that thousands of Coloradans now have health insurance, some for the first time. While this is positive overall, it has also created pressure on the Health First Colorado provider network. Health First Colorado members may sometimes seek services from non-Health First Colorado providers, who may not know or understand Colorado law regarding billing Health First Colorado members.

Policy

It is important that all health care providers know that Health First Colorado members cannot be billed for services covered by Health First Colorado.

Federal statutes and regulations provide that state Medicaid agencies must limit provider participation to those who will accept Medicaid reimbursement as payment in full (42 C.F.R. § 447.15). Providers must participate in Medicaid to be reimbursed for covered services. Further, Medicaid member payments are limited to state-defined cost-sharing arrangements (42 U.S.C. § 1396a (a)(14)). Medicaid cost-sharing arrangements are limited to established co-pays for services received.

At the state level, Colorado law (C.R.S. § 25.5-4-301(I)), provides that no Health First Colorado member shall be liable for the cost, or the cost remaining after payment by Health First Colorado, Medicare, or a private insurer, of medical benefits authorized under Title XIX of the Social Security Act. This law applies whether or not Health First Colorado has reimbursed the provider, whether claims are rejected or denied by Health First Colorado due to provider error, and whether or not the provider is enrolled in the Colorado Medical Assistance Program (C.R.S. § 25.5-4-301(II). This law applies even if a Health First Colorado member agrees to pay for part or all of a covered service.

These federal and state regulations are designed to protect Health First Colorado members who, by definition, are low income and/or disabled, from paying for services that are provided by Health First Colorado. Providers are responsible for determining if a patient has Health First Colorado coverage before services are rendered.

Payment may be collected from or billed to a Health First Colorado member only if the service rendered is not covered by Health First Colorado. In this situation, a provider must enter into a documented and written agreement with the member under which the member agrees to pay for items and services that are non-reimbursable under the medical assistance program (C.R.S. § 25.5-4-301(1)(a)(I)). Under these circumstances, a recipient is liable for the cost of such services and items. Questions regarding whether or not a service is covered by Health First Colorado may be referred to the Provider Services Call Center (1-844-235-2387)

Providers shall not send overdue Health First Colorado member accounts to collection agencies, unless the billing is for a non-covered service and the member has reneged on a written payment agreement (C.R.S. § 25.5-4-301(1)(a)(II.5)(A)).

Please note that Health First Colorado is the payor of last resort. If a member has primary health coverage through a third party, such as a commercial or individual policy, the member must utilize that primary third-party coverage prior to utilizing Medicaid services (10 CCR § 2505-10:8.061.4). If a member fails to comply with the primary health coverage requirements, the member will be liable to the provider for the health services and Medicaid will not be liable (§ 8.061.5, C.R.S. § 25.5-4-301(1)(a)(III)(A)).

If a provider who is not enrolled into the member's primary health coverage knowingly provides health services to a Medicaid member, neither the member nor Medicaid will be liable for the costs of services unless the member and the provider entered into a written agreement in which the member agrees to pay for items provided or services rendered that are outside of the network or plan protocols (C.R.S. § 25.5-4-301(1)(a)(III)(B)).

Health First Colorado's policy on billing members for services is clearly articulated on pages 4-5 of the Department's April 2015 Provider Bulletin (B1500365).

Co-Pays and Deductibles Required By Private Insurance Or Third Party Plans - Health First Colorado Members With Dual Coverage

Under the Colorado Medical Assistance Act, non-enrolled providers can collect co-pays and/or deductibles required by private insurance or a third party plan from a Health First Colorado member with dual coverage (i.e., Health First Colorado and private insurance or a third party plan) but only where the Health First Colorado member enters into a voluntary and informed documented agreement with the provider to do so. Without a documented agreement, non-enrolled providers would be violating the Colorado Medical Assistance Act if they were to try to collect co-pays and/or deductibles required by private insurance or a third party plan from a Health First Colorado member with dual coverage for Health First Colorado covered services.

Please also note that providers enrolled in Health First Colorado may only collect established co-payments from members with primary Medicaid coverage (§ 8.754.1).

Direct Primary Care (DPC) Models

The American Academy of Family Physicians defines a Direct Primary Care Model (DPC) as an alternative to fee-for-service insurance billing, typically by charging patients a monthly, quarterly or annual fee (i.e. a retainer) that covers all or most primary care services including clinical, laboratory, and consultative services, and care coordination and comprehensive care management. Because some services are not covered by a retainer, DPC practices often suggest that patients acquire a high deductible wraparound policy to cover emergencies.

As noted above, providers enrolled in Health First Colorado may collect only the established co-pay (if applicable) from Health First Colorado members for services covered by Health First Colorado. Non-enrolled providers are prohibited from collecting any reimbursement for services covered by Health First Colorado. By definition, the majority of services offered under a DPC model are covered by Health First Colorado, but some practices may also offer non-covered services, e.g. massage therapy, acupuncture, chiropractic, etc. Providers may bill Health First Colorado members for non-covered services if the parties enter into a written agreement as described above. DPC practices may choose to offer a limited package of services, those not covered by Health First Colorado, to Health First Colorado members, for an agreed-upon fee. DPC providers should be aware, however, that services offered to a subscribing Health First Colorado member that are determined to be covered by Health First Colorado may not be billed to Health First Colorado or to the Health First Colorado member.

Health First Colorado Provider Relations

Health First Colorado's Provider Relations Unit was developed to ensure that Health First Colorado has an adequate and comprehensive network of quality providers that meet high standards for physical, behavioral, dental and long-term services.

Providers seeking additional information about this policy should contact:

The Provider Services Call Center

Health First Colorado Members

Health First Colorado Members seeking additional information about provider billing practices may contact the Department's Member Contact Center:

Toll Free: 1-800-221-3943 | State Relay: 711| Fax: 303-866-4411