Policy Statement: Billing Health First Colorado Members for Services

Purpose

To outline the Department’s policy on billing Health First Colorado (Colorado's Medicaid Program) members for covered and non-covered services.

Background

Health First Colorado expansion in Colorado means that thousands of Coloradans now have health insurance, some for the first time.  While this is positive overall, it has also created pressure on the Health First Colorado provider network. Health First Colorado members may sometimes seek services from non-Health First Colorado providers, who may not know or understand Colorado law regarding billing Health First Colorado members.

Policy

It is important that all health care providers know that Health First Colorado members cannot be billed for services covered by Health First Colorado.

Federal statutes and regulations provide that state Health First Colorado agencies must limit provider participation to those who will accept Health First Colorado reimbursement as “payment in full” (42 C.F.R. §447.15). Providers must participate in Health First Colorado to be reimbursed for covered services. Further, Health First Colorado member payments are limited to state-defined cost sharing arrangements (42 U.S.C. §1396a (a)(14)). Colorado Medical Assistance Program cost sharing arrangements are limited to established co-pays for services received.

At the state level, Colorado law (C.R.S. 25.5-4-301(II)), provides that no Health First Colorado member shall be liable for the cost, or the cost remaining after payment by Health First Colorado, Medicare, or a private insurer, of medical benefits authorized under Title XIX of the Social Security Act. This law applies whether or not Health First Colorado has reimbursed the provider, whether claims are rejected or denied by Health First Colorado due to provider error, and whether or not the provider is enrolled in the Colorado Medical Assistance Program. This law applies even if a Health First Colorado member agrees to pay for part or all of a covered service.

These federal and state regulations are designed to protect Health First Colorado members who, by definition, are low income and/or disabled, from paying for services that are provided by Health First Colorado.  Providers are responsible for determining if a patient has Health First Colorado coverage before services are rendered.

Payment may be collected from or billed to a Health First Colorado member only if the service rendered is not covered by Health First Colorado. In this situation, the Department strongly recommends that providers obtain a statement signed by the Health First Colorado member acknowledging that the specific service is not a Health First Colorado-covered benefit and agreeing to pay.  Questions regarding whether or not a service is covered by Health First Colorado may be referred to Hewlett Packard Enterprises Provider Services at
1-844-235-2387.

Please note that providers should not send overdue Health First Colorado member accounts to collection agencies, unless the billing is for a non-covered service and the member has reneged on a written payment agreement.

Health First Colorado’s policy on billing members for services is clearly articulated on pages 4-5 of the Department’s April 2015 Provider Bulletin (B1500365).

Co-Payments and Deductibles Required By Private Insurance Or Third Party Plans - Medicaid Recipients With Dual Coverage

Under the Colorado Medical Assistance Act, non-enrolled providers can collect co-payments and/or deductibles required by private insurance or a third party plan from a Medicaid recipient with dual coverage (i.e., Medicaid and private insurance or a third party plan) but only where the Medicaid recipient enters into a voluntary and informed documented agreement with the provider to do so. Without a documented agreement, non-enrolled providers would be violating the Colorado Medical Assistance Act if they were to try to collect a co-payments and/or deductibles required by private insurance or a third party plan from a Medicaid recipient with dual coverage for Medicaid covered services. Please contact Paul R. Ritzma, HCPF’s Legal Director at paul.ritzma@state.co.us if you have any questions.

Health First Colorado Provider Relations

Health First Colorado’s Provider Relations Unit was developed to ensure that Health First Colorado has an adequate and comprehensive network of quality providers that meet high standards for physical, behavioral, dental and long-term services.

For more information about the Provider Relations Unit or this policy, please contact:

Marceil Case, Provider Relations Manager
Marceil.Case@state.co.us
303-866-3054