The CHI Weekly Legislative Update: March 3

In this weekly legislative update, we’re focusing on SB 12-127, a bill that addresses a complex but important subject - Coloradans who are eligible for both Medicaid and Medicare coverage (“dual eligibles”) - and how to best provide medical care for them within new health delivery systems in our state.

The Colorado Department of Health Care Policy and Financing (HCPF) has developed a new Accountable Care Collaborative (ACC) delivery model that aims to increase quality and contain costs in the federal-state Medicaid program. The model focuses on coordinating a patient’s care across a variety of medical settings and ensuring that each patient receives necessary preventive care from a primary care provider within a medical home.

In Colorado, seven Regional Care Collaborative Organizations (RCCOs) have been created to organize the model by geographical regions. Children and parents covered by Medicaid began enrolling in the ACCs last year.

This is where the dual eligibles come in.

HCPF – with a federal grant to develop a program specifically for dual eligibles – plans to include them in the ACCs. If the plan is approved, Colorado would be able to in share any cost savings achieved by being more efficient and providing the dual eligible clients with better care.

Dual eligibles present a number of challenges. About two-thirds of them are over 65 and many have cognitive, mental and physical impairments. As many as one in four may be institutionalized. Still others may have less debilitating conditions but qualify for Medicaid because they have very low incomes.

Generally, a dual eligible client is more likely to have multiple chronic conditions that require more complex services than an average Medicaid enrollee.  Many dual eligibles require Long-Term Services and Supports (LTSS) and behavioral health services as well as medical care.

Coordinating their medical care is so complicated because they have three sets of benefits - Medicare, Medicaid and prescription drugs.

About 71,000 Medicaid enrollees in Colorado are dual eligibles. They make up 13 percent of all Medicaid enrollees in the state, but consume 43 percent of the Medicaid budget.

Throughout the planning process, concerns have been raised that enrolling dual eligibles in the ACC would not make full use of the care-coordination services provided by their current LTSS providers. LTSS providers currently coordinate most of the care for their patients.

The Senate Health and Human Services committee on Thursday passed SB 12-127, which attempts to ensure that dual eligibles enrolled in an ACC are provided a range of options so they can choose the setting that best suits their preferences and needs.

The law would allow LTSS providers to contract with the RCCOs as health homes or as part of a health home to provide services such as care coordination and health promotion, assistance with transitional care, and patient and family support.  A key provision in this legislation is an expanded definition of health home which includes a “group of providers” that coordinate with a primary care provider selected by the individual.

The legislation extends the same “health home” options for Medicaid enrollees with a chronic condition. States that provide health homes for persons with chronic conditions are able to receive 90 percent federal matching funds for two years under the federal health reform law. The normal federal matching rate in Colorado is 50 percent.

The first section of SB 12-127 states the “drastic” increase in Coloradans over the age of 65 drives the need to create long-term care that is integrated, person-centered and that efficiently uses limited state resources.  The legislation aims to strike a balance between providing more coordinated, efficient care and maintaining choice in and flexibility in services for the dual eligibles.

The bill was voted out of committee by a unanimous vote on February 29. It will be sent to the Senate for a vote on Monday, March 5.  The bill sponsors are Senators Linda Newell (D) and Representative Ken Summers (R).

Allison Summerton is a legislative liaison and research analyst at CHI.