Colorado § 25.5-5-403 - Definitions.

§ 25.5-5-403. Definitions.

As used in this part 4, unless the context otherwise requires:

(1) Repealed.

(2) "Essential community provider", referred to in this part 4 as an "ECP", means a health-care provider that:

(a) Has historically served medically needy or medically indigent patients and that demonstrates a commitment to serve low-income and medically indigent populations who comprise a significant portion of its patient population or, in the case of a sole community provider, serves the medically indigent patients within its medical capability; and

(b) Waives charges or charges for services on a sliding scale based on income and does not restrict access or services because of a member's financial limitations.

(2.5) "Global payment" means a population-based payment mechanism that is constructed on a per-member, per-month calculation. Global payments must account for prospective local community or health system cost trends and value, as measured by quality and satisfaction metrics, and incorporate community cost experience and reported encounter data to the greatest extent possible to address regional variation and improve longitudinal performance. Risk adjustments, risk-sharing, and aligned payment incentives may be utilized to achieve performance improvement. The rate calculations for global payment are exempt from the provisions of section 25.5-5-408. An entity that uses global payment pursuant to section 25.5-5-402 shall meet the applicable financial solvency requirements of sections 25.5-5-402 (10) and 25.5-5-408 (1)(f) and the essential community provider requirements of sections 25.5-5-406.1 (1)(f)(II) and 25.5-5-408 (1)(d).

(3) (a) "Managed care" means a health-care delivery system organized to manage costs, utilization, and quality. Medicaid managed care provides for the delivery of medicaid health benefits and additional services through contracted arrangements between state medicaid agencies and MCEs.

(b) Nothing in this section affects the benefits authorized for members of the state medical assistance program.

(4) "Managed care entity", referred to in this part 4 as an "MCE", means an entity that enters into a contract to provide services in the statewide managed care system, including MCOs, prepaid inpatient health plans, prepaid ambulatory health plans, and PCCM Entities.

(5) "Managed care organization", referred to in this part 4 as an "MCO", means an entity contracting with the state department that meets the definition of managed care organization as defined in 42 CFR 438.2.

(5.5) "Medical home" means an appropriately qualified medical health-care practice that verifiably ensures continuous access to comprehensive, accessible, and coordinated community-based primary care. All medical homes may have, but are not limited to, the following:

(a) Health maintenance and preventive care;

(b) Anticipatory guidance and health education;

(c) Acute and chronic illness care;

(d) Coordination of medications, specialists, and therapies;

(e) Provider participation in hospital care; and

(f) Mental health care, oral health care, and other related services, as appropriate.

(5.7) "MHPAEA" means the federal "Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008", Pub.L. 110-343, as amended, and all of its implementing and related regulations.

(6) "Prepaid ambulatory health plan", referred to in this part 4 as a "PAHP", means an entity contracting with the state department that meets the definition of prepaid ambulatory health plan as defined in 42 CFR 438.2.

(7) "Prepaid inpatient health plan", referred to in this part 4 as "PIHP", means an entity contracting with the state department that meets the definition of prepaid inpatient health plan as defined in 42 CFR 438.2.

(7.5) "Primary care case management entity", referred to in this part 4 as a "PCCM Entity", means an entity contracting with the state department that meets the definition of primary care case management entity as defined in 42 CFR 438.2.

(8) "Primary care case manager", referred to in this part 4 as a "PCCM", means a physician, a physician group practice, or other practitioner as identified by the state that meets the definition of primary care case manager as defined in 42 CFR 438.2.

Source: L. 2006: Entire article added with relocations, p. 1884, § 7, effective July 1. L. 2007: (1)(a) amended, p. 1354, § 3, effective May 29. L. 2008: Entire section amended, p. 390, § 2, effective August 5. L. 2012: (2.5) added, (HB 12-1281), ch. 246, p. 1187, § 4, effective June 4. L. 2018: (1) repealed, (2.5), (3)(a), (4), and (8) amended, and (5.5) and (7.5) added (HB 18-1431), ch. 313, p. 1881, § 2, effective August 8. L. 2019: (5.7) added, (HB 19-1269), ch. 195, p. 2134, § 13, effective May 16. L. 2024: (2)(b) and (3) amended, (SB 24-176), ch. 152, p. 653, § 57, effective August 7.

Editor's note: This section is similar to former § 26-4-114 as it existed prior to 2006.

Cross references: (1) For additional definitions applicable to this part 4, see § 25.5-4-103.

(2) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.