Accountable Care Collaborative Client Selection Methodology
The Statewide Data and Analytics Contractor (SDAC), Treo Solutions, is responsible for enrolling clients into the ACC program. This information addresses frequently asked provider questions about how the SDAC enrolls clients into the ACC program and connects them to a primary care medical provider (PCMP).
Which clients are not currently able to enroll in the ACC program?
Only clients currently eligible for Medicaid are able to enroll in the ACC program. Clients may gain and lose eligibility many times in a given year; a person who is part of your patient panel may have been Medicaid-eligible three months ago but is no longer eligible for Medicaid.
Certain clients are not being enrolled into the ACC program at this time. These include:
- Clients already enrolled in a Medicaid managed care program
- Clients enrolled in a Medicare Advantage Plan
- Clients residing in an institutional setting (for example, a nursing facility) within the last 3 months, unless the client is participating in the Colorado Demonstration to Integrate Care for Medicare-Medicaid Enrollees (FBMME Demonstration Project).
- Clients whose provider is not a participating ACC provider
How does the SDAC enroll eligible clients into the ACC program?
The remaining pool of Medicaid clients (who have not been excluded from enrollment based on the factors described above) are eligible for selection to the ACC program. Enrollment is tied to a client’s existing PCMP relationship because the PCMP is an essential part of the program.
The Department’s objective is to maintain existing client-provider relationships. To meet this objective, the SDAC analyzes a client’s past 12 months of Medicaid claims (24 months if no 12-month claim history is found) for Evaluation & Management (physician) codes to determine the medical provider the client has seen most frequently. This process has one of four outcomes:
- The client has a clear pattern of using one primary care provider and the provider is participating in the ACC. In this scenario, the client is enrolled into the program with the identified provider as the client’s PCMP.
- The client has a clear pattern of using one primary care provider but the provider is not participating in the ACC. In this scenario, the client is not enrolled into the ACC program. ,
- The client has a clear pattern of using two or more providers equally. In this case, the client is connected to the provider visited most recently. If this provider is participating in the ACC program, the client will be enrolled into the ACC program with that provider as the PCMP.
- The client has no clear pattern of using any primary care provider. In this case, if the client has a family member with an identified PCMP, the client is enrolled into the ACC program with that PCMP. If the client does not have a family member with a PCMP, he or she is enrolled in the ACC without a PCMP and given the opportunity to select a PCMP by contacting HealthColorado, the Department’s enrollment broker.
Is enrollment mandatory? Do clients have to stay in the program once the SDAC has selected them for enrollment?
For ACC eligible clients, enrollment is automatic, but clients may choose to “opt out” of the program. Clients selected for enrollment receive a letter informing them they will be enrolled into the ACC program in 30 days and may opt out of participation during this time. The letter also states that, once enrolled, clients have an additional 90 days to opt out of the program, and that the client will be able to change Medicaid programs within 60 days of their month of birth.
This letter includes the name and contact information for the RCCO in which the client is enrolled (based on where the client lives), and the name of the provider (group practice, clinic, Federally Qualified Health Center, etc.) that will be the client’s PCMP.
Clients are allowed to choose a different PCMP if they wish. If a client was not attributed to a PCMP, it is the RCCO’s responsibility to reach out to the client to help them identify a PCMP and then connect the client with HealthColorado to make the selection.