Colorado – EPSDT
In Colorado:
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As of July 1, 2011, there were 583,618 beneficiaries enrolled in Colorado’s Medicaid program. Of these, 551,972 were enrolled in some form of managed care.
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While the state has a contract with a single comprehensive Medicaid-only managed care organization serving 46,962 beneficiaries, Colorado Medicaid has relied more heavily on primary care case management (PCCM). Since 2011, Colorado Medicaid has been transitioning Medicaid beneficiaries into a new program known as the Accountable Care Collaborative.
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A significant portion of managed care enrollment (572,491 beneficiaries) through the state is through Prepaid Inpatient Health Plans covering mental health benefits. Behavioral benefits are provided through five Behavioral Health Organizations in the state.
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Medicaid Home and Community-Based Services (HCBS) are provided through waivers, including:
- Children’s HCBS Waiver, for disabled children who would otherwise be ineligible for Medicaid due to excess parental income and/or resources;
- Children with Autism Waiver;
- Children’s Extensive Support Waiver, providing services to children with developmental disabilities or delays that are most in need due to the severity of their disability;
- Children’s Habilitation Residential Program Waiver for children and youth in foster care who have a developmental disability and extraordinary needs; and
- Waiver for Children with Life-Limiting Illness.
As of 2012, 475,671 individuals were eligible for the Medicaid benefit for children and adolescents in Colorado (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to CMS data from 2012, Colorado achieved an EPSDT screening ratio of 66% and a participation ratio of 51%. 233,244 children received dental services of any kind, with 215,317 receiving preventive dental services.
Last updated May 2014.
| Medical Necessity |
According to regulations (10 CCR 2505-10, Section 8.076.1.8) in Colorado:
“Medical necessity means a Medical Assistance program good or service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, injury, or disability. It may also include a course of treatment that includes mere observation or no treatment at all. The good or service must be: Code of Colorado Regulations 53
The state also has an EPSDT-specific definition (10 CCR 2505-10 8.280.1):
“Medical Necessity means that a covered service shall be deemed a medical necessity or medically necessary if, in a manner consistent with accepted standards of medical practice, it:
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| Initiatives to Improve Access |
Colorado offers Family Health Coordinators through its Healthy Communities initiative. The coordinators offer outreach and case management to help children and their families access coordinated health care services. In addition to helping families apply for Medicaid coverage and educating them on how to access benefits (including preventive services) in appropriate settings, the coordinators also work to connect families to a medical home and provider information and referrals to other community programs and resources.
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| Reporting & Data Collection |
In 2013, Colorado added a well child visit “key performance indicator” to its Accountable Care Collaborative program. Providers and the entities administering the program will be able to earn incentive payments based on performance on this indicator.
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| Behavioral Health |
Behavioral health benefits are provided by Behavioral Health Organizations, which are contractually obligated to provide or arrange all medically necessary services covered under EPSDT.
Under the state’s Child Mental Health Treatment Act, children (both Medicaid-eligible and non-Medicaid eligible children) with a mental illness and under age 18 have access to a variety of community, residential, and transitional treatment services. Transitional services provided include case management and post-discharge services provided by community mental health centers, while covered community-based services include:
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| Support to Providers and Families |
The Colorado Department of Health Care Policy and Financing hosts an EPSDT website for families and health care providers.
For providers, the site offers information on referral processes and the periodicity schedule. A dedicated provider section of the website offers additional information, including a fact sheet on EPSDT and links to state and national resources.
For families, the site offers information on benefits available under Medicaid and CHIP, Frequently Asked Questions about the programs.
Colorado has also launched a School-Based Health Center Improvement Project in partnership with New Mexico Medicaid and with support from a CHIPRA Quality Demonstration Grant. The project is working with a set of school-based health centers to engage Medicaid-eligible adolescents in their own health care and its goals include increasing the percentage of children and adolescents who have up-to-date immunization records; who receive screens for sexually transmitted disease; who receive screenings for depression; and who receive appropriate follow-up after depression screens. The project is also working to improve care coordination of health care between primary care providers and other providers.
Under the project, the state is offering school-based health centers training in:
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| Care Coordination |
Through the Colorado Medical Home Initiative, the state supported a “systems-building effort to promote quality health care for all children in Colorado.” Medical home standards for providers serving children in Medicaid or CHIP were developed through a partnership between state agencies in Colorado.
The state has since transitioned its Accountable Care Collaborative model. Seven Regional Care Coordination Organizations are now responsible for providing medical management, care coordination among providers and services, and support to providers, and are accountable for quality and cost through utilization-based incentive payments and a shared savings program.
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| Oral Health |
Colorado Medicaid’s Dental Manual contains information on covered services for children under the EPSDT benefit. The state allows physicians, nurse practitioners, and physician assistants to bill for administering fluoride varnish to children under age 5 during a well-child visit. Dental providers may also provide the service.
Medical personnel offering oral health services to young children enrolled in Medicaid must either receive on-site training from a Colorado initiative that trains health care providers on providing oral health services to children (“Cavity Free at Three”) or they must complete modules of the national Smiles for Life curriculum.
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