Purpose
Health First Colorado (Colorado's Medicaid program) is the payer of last resort when a member has other insurance or Medicare. Federal regulations require that all available resources be used before Health First Colorado considers payment. This means that if a member is able to provide for their care, the member must pay for medical benefits first. If there is a responsible third-party who should be paying for the member's health benefits -- for example, a health insurance provider -- that responsible third-party should be paying first. Coordinating benefits makes sure that the correct party pays first by, 1) cost-avoiding claims where a known other party should be paying, or 2) cost-recovering from a claim Health First Colorado paid that should have been paid by someone else.
Cost Avoidance
The Department is responsible for identifying all instances where a Medicaid member has commercial insurance or Medicare as their primary payor. The Department utilizes many sources of other coverage such as members, providers, and federal data feeds. The Department has also contracted with a third-party cost avoidance vendor to supply primary payor coverage. The Department utilizes the data it sources to ensure that claims submitted by providers are properly coordinated prior to Medicaid paying.
Email the Third Party Liability team about member-specific coverage questions
Carrier Recoveries
The Department is responsible for identifying all instances where a Medicaid member has commercial insurance or Medicare as their primary payor. If Medicaid is unable to identify the primary payor and erroneously pays a claim, recovery can be initiated directly from commercial insurance carriers.
Estate Recoveries
The Colorado Medical Assistance Estate Recovery Program is a federally mandated program that requires the State of Colorado to recover Health First Colorado expenditures correctly paid on behalf of certain Health First Colorado members. After the death of a person who has received medical assistance, the law requires that certain individual's assets be used to repay the Colorado Department of Health Care Policy and Financing (Department) for these benefits. The Department utilizes a vendor, Health Management Systems (HMS), to administer the estate recovery program.
Health Care Policy & Financing and HMS Third Party Liability webpage
Health Insurance Buy-In (HIBI)
When cost effective, the Department pays a member’s commercial insurance premium to assist in retaining the policy of the primary payor. The commercial insurance is billed as primary for services prior to Medicaid issuing payment.
Medicare Buy-In
Medicare Buy-In is designed to help keep low-income Medicare recipients from having to pay Medicare costs that are continuing to rise, so that these particular Medicaid beneficiaries do not lose their Medicare benefits. The Department pays the Medicare premium for certain clients, allowing them to retain Medicare as their primary payor.
Sources for additional Medicare Buy-In Information:
Public Assistance Reporting Information System (PARIS)
PARIS is a data matching service that helps to determine whether Medicaid members are receiving duplicate benefits in two or more states. The program verifies Colorado residency, client-reported income, veteran benefits, and works to identify third party insurance coverage. PARIS matches help identify improper payments and minimize fraud, waste, and abuse.
| ACF PARIS website | PARIS Email inbox |
Provider Recoveries
Erroneous payments to the provider made by Medicaid can be recovered directly from the provider when commercial insurance or Medicare should have been billed as the primary coverage. The Department conducts two types of recovery cycles - Medicare Part A and Part B cycles every other month, Commercial Insurance cycles every quarter.
The Department has hired a vendor, Health Management Systems (HMS), to initiate and manage provider recoveries. You can reach out to the Provider Relations team using the contact information below:
| Fax | phone | ||
|---|---|---|---|
| 877-256-1226 | 877-262-7396 | prdoc@gainwelltechnologies.com | Colorado Provider Relations Department – HMS Provider Relations, P.O Box 168528, Irving, TX 75016-8528 |
Tort & Casualty
The Tort and Casualty Unit in the Third Party Liability & Recoveries section of the Department recovers money from a legally responsible third party when the Department has paid claims on behalf of a Health First Colorado (Colorado's Medicaid Program) member. These circumstances commonly include payments, awards, or settlements from auto, homeowners' and malpractice insurance carriers intended to compensate the members for their injuries. Health First Colorado has an automatic lien by statute in these circumstances.
Trusts
The Trust Policy & Recoveries Section reviews trusts created by or benefiting individuals applying for or receiving medical assistance and then issues formal guidance to eligibility sites and other stakeholders on how these trusts impact eligibility. This Section also recovers funds from trusts that require repayment to the Department under federal and state law and collects funds from other post-death recoveries not subject to estate recovery (i.e., annuity closures, etc.). Any submissions or inquiries concerning trusts or these recoveries should be sent to medicaid.trusts@state.co.us