Managed care · Colorado

Colorado Medicaid managed care: what plans must pay

Managed-care plans don't publish their provider fee schedules. What is public is the rule each plan must follow, set in Colorado's plan contracts, statutes and notices. For 5 of 20 service lines, plans must follow a rule tied to the state's published rates.

Sources: plan contracts, statutes, notices and CMS filings

See the rule on every rate Colorado fee schedule

Lines with a binding rule: 5of 20
Plans on record: 24
Directed payments: 0amounts in the workspace
Capitation cells: 372PMPM rates in the workspace

Plan rules

Who sets the rate, by service line

The main rule Colorado's managed-care plans follow for each service line, in plain language.

Service line	Main rule for plans	Rates	Also applies
Physician & professional	Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network	22,749	Paid by the state, outside plansPlans must pay at least this
Equipment & supplies	Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network	9,737	Paid by the state, outside plans
Radiology	Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network	5,200
Dental	Paid by the state, outside plansPaid directly by the state, outside managed care	2,177	Plans negotiate; applies out of network
Lab & pathology	Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network	2,166
Pharmacy	Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network	1,174
IDD services	Paid by the state, outside plansPaid directly by the state, outside managed care	445
Vision & hearing	Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network	436
Hospice	Paid by the state, outside plansPaid directly by the state, outside managed care	358
Nursing facility	Paid by the state, outside plansPaid directly by the state, outside managed care	335
Behavioral health	Plans must pay at least thisPlans must pay at least the published rate	308	Paid by the state, outside plansPlans negotiate; applies out of network
Other home & community services	Paid by the state, outside plansPaid directly by the state, outside managed care	265	Plans must pay at least thisPlans negotiate; applies out of network
Transportation	Paid by the state, outside plansPaid directly by the state, outside managed care	234
Personal care & attendant	Paid by the state, outside plansPaid directly by the state, outside managed care	170
Other	Paid by the state, outside plansPaid directly by the state, outside managed care	149
Therapy (PT/OT/speech)	Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network	99	Paid by the state, outside plansPlans must pay at least this
Home health	Paid by the state, outside plansPaid directly by the state, outside managed care	42
Clinics (FQHC/RHC)	Plans must pay at least thisPlans must pay at least the published rate	20
Hospital outpatient	Not classified yet	11
ABA / autism services	Plans negotiate; applies out of networkPlans negotiate; the published rate applies out of network	8
Private duty nursing	Paid by the state, outside plansPaid directly by the state, outside managed care	7

The plan rule on every Colorado rate you bill. With the contract citation for each one.

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Plans

Colorado Medicaid managed-care plans

24 plans on record across 6 programs.

Accountable Care Collaborative (Phase III RAE)Colorado Access (RAE 4) · Colorado Community Health Alliance (RAE 3) · Northeast Health Partners (RAE 2) · Rocky Mountain Health Plans (RAE 1)

Accountable Care Collaborative (Phase II RAE)Colorado Access (Region 3, Phase II) · Colorado Access (Region 5, Phase II) · Colorado Community Health Alliance (Region 6, Phase II) · Colorado Community Health Alliance (Region 7, Phase II) · Health Colorado (Region 4, Phase II) · Northeast Health Partners (Region 2, Phase II) · Rocky Mountain Health Plans (Region 1, Phase II)

Child Health Plan PlusColorado Access CHP+ HMO · Denver Health CHP+ HMO · Kaiser Permanente CHP+ HMO · Rocky Mountain HMO CHP+

PACEColorado PACE · HopeWest PACE · InnovAge Colorado PACE · Rocky Mountain PACE · Senior CommUnity Care PACE · TRU PACE

Denver Health Medicaid ChoiceDenver Health Medicaid Choice (Phase II) · Elevate (Denver Health) Medicaid Choice

Rocky Mountain Health Plans PrimeRocky Mountain Health Plans Prime

Directed payments

State-directed payments and capitation

Payments CMS approved under 42 CFR 438.6(c) that plans must make on top of, or as a minimum for, their negotiated rates, and 372 published capitation cells.

Program	Amount	Unit	Effective

See Colorado directed-payment amounts and capitation rates — start free

Every amount with its CMS approval letter or rate certification, effective dates and the providers it applies to.

CMS approval letters
Effective dates
Eligible providers

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FAQ

Frequently asked questions

Do Colorado Medicaid plans have to pay the state fee schedule?

For some services. Plans must follow a rule tied to the state's rates for: Physician & professional, Behavioral health, Other home & community services, Therapy (PT/OT/speech), Clinics (FQHC/RHC). For other lines, plans negotiate rates with providers.

Where do these rules come from?

From Colorado's managed-care plan contracts, state statutes and regulations, provider notices and CMS-approved directed-payment filings. Each rate in the workspace carries its citation.

Can I see what each plan actually pays?

No plan publishes its provider fee schedule. The closest public signals are the binding rules above, state-set rates, directed payments and the state's own payment-level estimates in its directed-payment filings.

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