Learn About the Regional Accountable Entity (RAE)

Learn About the Regional Accountable Entity (RAE)

Beginning July 1, 2018, RMHP is the Regional Accountable Entity, or RAE, for Region 1 of the Health First Colorado Accountable Care Collaborative. As the RAE, RMHP is responsible for connecting Health First Colorado Members with both primary care and behavioral health services for Region 1, which includes Western Colorado and Larimer County. We're here to help you understand more about the RAE. If you want to learn more, we invite you to read our RMHP RAE Orientation Guide.

Read the guide

What is the RAE?

In October 2017, the Colorado Department of Health Care Policy and Financing (Department) awarded RMHP the contract to serve as the RAE for Region 1 of the Health First Colorado Accountable Care Collaborative (ACC). This contract is effective July 1, 2018.

As the RAE, RMHP is responsible for connecting Health First Colorado Members with both primary care and behavioral health services for Region 1, which includes Western Colorado and Larimer County. This builds upon our foundation of our previous services as a Regional Care Collaborative Organization (RCCO), growing our community-oriented approach for Health First Colorado Members as RMHP Community.

The RAE for Region 1 includes:

  • the services previously performed by RMHP as the Regional Care Collaborative Organization (RCCO), including the primary care medical provider network and care coordination services;
  • the services previously performed by the regional Behavioral Health Organization (BHO), including managing covered services under the Medicaid Capitated Behavioral Health Benefit;
  • the Western Colorado payment reform initiative known as RMHP Prime; and
  • additional services to support whole person care, including activities to address social determinants of health.

With the transition to the RAE, the terms RCCO and BHO will no longer be used.

Please note: All providers must be revalidated and enrolled with Health First Colorado in order to participate in RMHP’s RAE network. Information can be found on the website for the Department of Health Care Policy & Financing. Please contact RMHP at support@rmhpcommunity.org to access available resources to assist providers with this process.

Visit the HCPF website

Role of the RAE

Community Health

Support and Promote Whole Person Care

  • Develop a cohesive health neighborhood where care across disparate providers is coordinated and collaborative
  • Establish and improve referral processes, including use of care compacts
  • Encourage collaborations and strategies with a wide range of community partners to address social determinants of health

Promote Population Health

  • Develop a population health management plan to prevent the onset of health conditions and lessen the impact of health conditions on Member’s lives
  • Utilize evidence-based practices and promising local initiatives, including those addressing social determinants of health

Responsibility to Providers

Contract and Engage with Primary Care Medical Providers

  • Develop and maintain a network of participating Primary Care Medical Providers (PCMPs)
  • Provide training and support to primary care practices
  • Reimburse PCMPs through a value-based payment model

Contract and Engage with Behavioral Health Providers

  • Develop and maintain a credentialed and contracted statewide network of behavioral health providers to provide covered behavioral health services
  • Provide utilization management of covered behavioral health services
  • Reimburse behavioral health providers for services covered under the Capitated Behavioral Health Benefit
  • Provide training and support to behavioral health providers

To learn more about behavioral health services and the RMHP RAE, please review the RMHP RAE Behavioral Health Guide.

Read the Guide

Payments & Attribution

RMHP is implementing a value-based payment model for all participating RAE Region 1 PCMPs. This payment model outlines a clear delineation of provider responsibilities as well as resources available for different levels of accountability. The levels of participation and accountability, identified as Tiers 1-4, reflect this effort to align payment with activities that lead to better patient outcomes and mitigate against growing costs and limited resources. Provider payments for RAE Region 1 Members are as follows:

  • RMHP maintains the PCMP network and an advanced payment model. PCMP medical home payments are paid at a minimum $2 per member per month.
  • Physical healthcare claims for RAE Members continue to be paid by the Department.
  • Behavioral healthcare services covered under the behavioral health capitation benefit for RAE Region 1 Members are paid by RMHP.
  • For RAE Members enrolled in the Health First Colorado payment reform initiative known as RMHP Prime, primary care practices continue under an RMHP Prime advanced payment model. Physical healthcare services and behavioral healthcare services are paid by RMHP.

Who pays?

Service Type

RMHP RAE Members without RMHP Prime

RMHP RAE Members with RMHP Prime

Physical Health Services

Bills sent to and paid by Department following Department claims and authorization methodology

Bills sent to and paid by RMHP following Provider-RMHP agreement

Behavioral Health Services

Bills sent to and paid by RMHP

Bills sent to and paid by RMHP

Six Behavioral Health Sessions at PCMP Practice

PCMPs bill up to 6 sessions to the Department following the Department’s methodology on procedure codes and licensure

After 6 sessions, these behavioral health sessions must receive RMHP authorization and then bill to RMHP. Paid by RMHP under the RAE behavioral health benefit following RMHP-provider agreement

All claims are billed to RMHP and paid following RMHP-provider agreement.

PCMPs bill RMHP for the first 6 sessions following the Department’s methodology on procedure codes and licensure

After 6 sessions, these behavioral health sessions must receive RMHP authorization and then bill to RMHP. Paid by RMHP under the RAE behavioral health benefit following RMHP-provider agreement

PCMP Medical Home Payments

Paid by RMHP for RMHP RAE Members attributed by the Department to Region 1 PCMP

Paid by RMHP following RMHP attribution methodology and Provider-RMHP Prime agreement

RMHP’s RAE Value-Based PCMP Payment Model – Payment Beyond the $2 PMPM

RMHP is committed to supporting primary care practices in developing the competencies to show value through delivery of advanced primary care. The RAE Attestation Tree defines each tier of participation and allows practices to attest to the following:

  • Levels of transformation activities completed by the practice (as an indicator of the practice’s capacity and capability around providing advanced primary care);
  • Ability to report and achieve electronic clinical quality measures (eCQMs);
  • Commitment to accepting Medicaid patients;
  • Collaborating with high-volume / critical specialists; and
  • Willingness to engage with RMHP in ongoing progress assessments.

RMHP will target resources to practices that demonstrate value through the delivery of advanced primary care. Providers that demonstrate greater levels of accountability for access for Health First Colorado Members, and that achieve the higher transformation and performance levels will receive higher reimbursement.
Practices have the option to participate at the highest tier for which they qualify or decide to participate at a lower tier. Practices also may opt to identify a higher tier and work towards achieving that tier.

Payments for RAE Members Not Enrolled in RMHP Prime

Payments by the Department for Physical Health Services
Physical health services will continue to be reimbursed at Medicaid fee-for-service rates by the Department. Providers will continue to submit physical health claims to the Department for covered health care benefits for Health First Colorado eligible Members.

Administrative Medical Home Payments
RMHP will pay administrative medical home payments to PCMPs for their attributed RAE Members. PCMPs will have the option to receive at least $2 per member per month (PMPM). RMHP is implementing a value-based payment model for PCMPs for an opportunity to receive higher PMPM. The model includes a clear delineation of provider responsibilities and resources available for different levels of participation and accountability (“Tiers”). Region 1 PCMPs will complete RMHP’s RAE Attestation Tree to initially attest to the appropriate tier.

RAE Attribution by the Department
All RAE Members will be immediately attributed to a PCMP by the Department upon being determined eligible for Health First Colorado.
Attribution by the Department is important because it:

  • Determines the RAE assignment (in which RAE a Member is enrolled)
  • Enables the Department to track provider and RAE performance
  • The RAE may use it to calculate PCMP payments
  • Is utilized for PCMPs participating in the Department's Primary Care Alternative Payment Model.

The Department will attribute Members using the following four methods:

  1. Utilization: Used for Members with claims history with a participating PCMP. The Department will use historical claims data to identify the PCMP that the Member has seen the most often during the past 18 months. Paid Evaluation and Management (E&M) claims will be prioritized over other types of claims. For children up to age 21, a set of 10 preventive service codes will be prioritized. Attribution will be determined by the provider with the majority of claims.
  2. Family Connection: In the absence of a utilization history with a PCMP, the Department will identify whether a family member of the Member has a claims history with a PCMP and determine if the PCMP is appropriate. Members will then be enrolled to the family member’s PCMP.
  3. Proximity: Used for Members with no utilization history in the past 18 months. The Department will look for PCMPs within the region covering the Member’s county of residence and attribute the Member to the closest appropriate PCMP.
  4. Member Contact with the Enrollment Broker: All Members who are initially attributed using utilization, family connection, or proximity can change their PCMP at any time by contacting the Health First Colorado enrollment broker, Health First Colorado Enrollment.

Payments for RAE Members Enrolled in RMHP Prime

For RAE Members enrolled in RMHP Prime, PCMPs participating in RMHP Prime will continue to be paid following RMHP’s existing agreement with the practice. No changes to existing RMHP Prime contracts are anticipated for July 1, 2018. Payment for claims and global payment follow the current contract. Continue to submit RMHP Prime claims to RMHP.

RMHP Prime Attribution
RAE Members enrolling with RMHP as part of the RAE payment reform initiative, RMHP Prime, will be immediately enrolled with RMHP upon eligibility determination for Health First Colorado. RMHP Prime Members will be attributed to RMHP Prime participating PCMPs following RMHP’s attribution methodology. The Department enrolls individuals into RMHP Prime based on the Member’s county of residence and eligibility status. This includes most adults with full Health First Colorado benefits and a few children who qualify based on disability status in RMHP Prime counties.

The Department of Health Care Policy & Financing created a helpful FAQ about Member attribution.

Download the FAQ

 

Resources & Support for Providers of RAE Members

The American Society of Addiction Medicine (ASAM), founded in 1954, is a professional society representing over 3,900 physicians, clinicians and associated professionals in the field of addiction medicine. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addiction.

Phone: 301-656-3920

Visit the website

eQHealth Solutions provides services for the ColoradoPAR (prior authorization request) program. The ColoradoPAR Program reviews PARs for the following categories of services and supplies:

  • Audiology
  • Diagnostic imaging
  • Durable medical equipment (DME)
  • Inpatient out-of-state admissions
  • Medical services, including transplant and bariatric surgery
  • Physical & occupational therapy
  • Pediatric long term home health (LTHH)
  • Private duty nursing
  • Synagis®
  • Vision

For questions and additional assistance, please contact the ColoradoPAR program information line at 888-801-9355 or visit the ColoradoPAR program website.

Visit the website

Community Centered Boards (CCBs) provide case management, care planning, and make referrals to other resources for Health First Colorado Members with the following needs:

  • Adults and children living with developmental disabilities
  • Children with autism.

You can find information about CCBs at colorado.gov.

Learn more

To find a dental provider serving the Health First Colorado Child and Adult Dental programs, visit the State website.

Find a provider

Find more information about Colorado's adult dental benefit here.

DentaQuest serves as the contractor for the Health First Colorado Child and Adult Dental programs. Please call 800-417-7140 for general inquiries, 855-225-1731 for Colorado Medicaid Provider Relations/Services, or visit the website.

Visit the website

 

The Department of Health Care Policy and Financing has launched a series of Disability Competency training videos and materials for primary care providers and staff. 

Better understand the barriers persons with disabilities face when accessing Primary Care, and learn easy, tax-advantaged ways to improve your practice. Hear from Members about the value and practice of delivering Disability Competent Care (DCC).

Providing Disability-Competent Care can benefit your practice in many ways:

  • Listening to patients' needs and building trust can lead to cost savings over time, as patients' health needs are better met.
  • Certain improvements are eligible for tax write-offs and other financial incentives.
  • Providing DCC can reduce the likelihood of litigation, since the American Disability Act (ADA) requires that providers maintain equal access.
  • Learning DCC will help you be a better clinician.

Please visit the Disability Competent Care web site to access these resources.

All children and adolescents age 20 and under who receive care through Health First Colorado (Colorado’s Medicaid program) have a special benefit called EPSDT. EPSDT stands for Early and Periodic Screening, Diagnosis and Treatment (EPSDT).

The goal of EPSDT is to ensure that children and adolescents through age 20 receive age-appropriate screening, preventive services, and treatment services that are medically necessary to correct or ameliorate any identified conditions.

  • Early: Assessing and identifying problems early
  • Periodic: Checking children’s health at periodic, age-appropriate intervals
  • Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems
  • Diagnosis: Performing diagnostic tests to follow up when a risk is identified
  • Treatment: Control, correct or reduce health problems found

EPSDT is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, developmental, and specialty services. Referral and transportation/scheduling services are also available.

Covered Screening Services

  • Comprehensive health and developmental history
  • Comprehensive unclothed physical exam
  • Appropriate vision testing
  • Appropriate hearing testing
  • Appropriate immunizations
  • Laboratory tests (including lead toxicity screening)
  • Dental screening, including an assessment of mouth, oral cavity, and teeth; and referral to a dentist for children by 1 year of age or at the eruption of the first tooth
  • Developmental screening to determine whether a child’s emotional and developmental processes fall within a benchmarked range according to the child’s age group and cultural background. Includes self-care skills, gross and fine motor development, communication skills or language development, social-emotional development, cognitive skills, and appropriate mental/behavioral health screening
  • Health education (anticipatory guidance including child development, healthy lifestyles, and accident and disease prevention)

Periodicity Schedule

Colorado has adopted the American Academy of Pediatrics Bright Futures Periodicity schedule for screening services.

Bright Futures

Bright Futures is a national health promotion initiative dedicated to the principle that every child deserves to be healthy and that optimal health involves a trusting relationship between the health professional, the child, the family and the community as partners in healthy living.

Bright Futures is a comprehensive set of health supervision guidelines developed by multidisciplinary child health experts that provide a framework for well child care from birth through age 20. These guidelines are developed to present a single standard of care based on a model of health promotion and disease prevention. Bright Futures publishes guidelines, toolkits, presentations and more to help providers supervise and promote child health.

Healthy Communities

Health First Colorado-eligible individuals ages 20 and under, and adults who are pregnant can benefit from Colorado’s Healthy Communities program. Healthy Communities helps by:

  • Providing information about EPSDT, well child visits, and immunizations
  • Providing or arranging for the provision of screening services for all children
  • Arranging (through referral) for corrective treatment as determined by child health screenings
  • Conducting missed appointment follow-up
  • Referring for transportation assistance

Lead Screening

Lead screening is a requirement for all Health First Colorado-eligible children at 12 and 24 months, or between the ages of 36 and 72 months if not previously tested.

Vision Services covered

Vision benefits for children include standard eyeglasses, replacement or repair of frames or lenses, contact lenses (if medically necessary and prior approved unless provided for vision correction after surgery), ocular prosthetics (when prior authorized), and eye exams.

More information on the Colorado Medicaid vision benefit

Oral Health and Dental Services covered

Oral health is part of overall health, and healthy teeth are important for life-long health. Health First Colorado partners with DentaQuest to help members find a dentist and to manage dental benefits. DentaQuest helps - increase the number of dentists who accept Health First Colorado and helps eligible individuals find a dentist. Member service hours and contact information is at: DentaQuest.com. Services covered include:

  • Preventive services including exams, cleanings, x-rays, sealants, space maintainers and fluoride treatments
  • Restorative procedures such as amalgam and tooth colored fillings, crowns, root canals, gum and oral surgery. For certain procedures, the dentist must receive approval from Health First Colorado before providing the service.
  • Orthodontic benefits (braces) may be available in the case of a child with a severe bite problem
  • More information on the Colorado Medicaid dental benefit

Hearing Services

At a minimum, diagnosis and treatment of children with hearing loss, including hearing aids for children.

Diagnostic Services

When a screening indicates the need for further evaluation, diagnostic services must be provided and are covered. If the screening provider is not equipped or licensed to provide the additional diagnosis, a referral should be made to the appropriate practitioner or facility or to Healthy Communities for assistance in finding a provider.

Treatment

Necessary health care services must be made available for treatment of all physical and mental illnesses or conditions discovered by any screening and diagnostic procedures. If the treating is not equipped or licensed to provide the additional treatment, a referral should be made to the appropriate practitioner or facility or to Healthy Communities for assistance in finding a provider.

Other Necessary Health Care Services and Medical Necessity

Additional health care services that are described in the Federal Medicaid statute and found to be medically necessary to treat, correct or ameliorate illnesses and conditions, are covered regardless of whether the service is covered under what is known as Colorado’s State Medicaid Plan. For these services, medical necessity is determined on a case-by-case basis.

EPSDT Exceptions to State Plan Benefit Limits and Coverage Standards

Additional resources

Health First Colorado EPSDT website - Includes EPSDT fact sheet and family friendly version of EPSDT regulations

Recommended periodicity schedule – American Academy of Pediatrics Bright Futures Periodicity Schedule

Health First Colorado Exceptions to Health First Colorado’s standard benefit limits

Colorado Healthy Communities

The Health First Colorado Data Analytics Portal is a web portal designed to support Health First Colorado’s Accountable Care Collaborative by providing data to Primary Care Medical Providers and RAEs. The Data Analytics Portal was previously hosted by 3M and was often referred to by users as the SDAC. The portal is now hosted by IBM Watson Health (formerly Truven).

Access the portal

To gain access, please contact Nicole Konkoly or Kendra Peters.

Health First Colorado Enrollment is a State program that helps Health First Colorado Members choose their preferred health plan. Health First Colorado Enrollment sends letters to all newly-enrolled Health First Colorado Members informing them  about their health plan options.

Health First Colorado Members can choose a health plan through the Choose a Health Plan page or by calling Health First Colorado Enrollment at 303-839-2120 (in Denver) or 1-888-367-6557 (outside of Denver). Hours are Monday-Friday, 8:00 a.m. to 5:00 p.m. (closed state holidays). The Health First Colorado Enrollment number is not for information on benefits or eligibility.

For Health First Colorado claims, billing, enrollment, revalidation, and Provider Web Portal technical support questions, contact the Department of Health Care Policy and Financing's fiscal agent DXC Technology (formerly Hewlett Packard Enterprise) at 844-235-2387.

Hours are as follows:
7:00 a.m. – 5:00 p.m. MT Monday, Tuesday & Thursday
10:00 a.m. – 5:00 p.m. MT Wednesday & Friday
The Provider Services Call Center utilizes the time between 7 a.m. and 10 a.m. MT on Wednesdays and Fridays to return calls to providers.

Members can call the Colorado Medicaid Nurse Advice Line, at 800-283-3221, 24 hours a day, 7 days a week. The nurse line can assist Members with most medical issues or advise them if they should seek urgent or emergency care.

 

Healthy Communities focuses on the “life cycle of a client,” which may involve all of the activities necessary for the client to obtain coverage and access to coordinated healthcare services in appropriate settings (a medical home). Family health coordinators perform the following activities:

  • Generate awareness of the existence of the Medicaid and CHP+ programs;
  • Offer information about how to apply for Medicaid and CHP+ and the availability of face-to-face application assistance;
  • Inform families about where to submit applications for processing and eligibility determination;
  • Educate families on the value of preventive health care services and how to access benefits at the appropriate settings;
  • Link clients with information and referrals to other community programs and resources; and
  • Explain the re-enrollment process to families who continue to be eligible for Medicaid and CHP+ to eliminate gaps in coverage.

For more information about Healthy Communities, visit their website or call the Health First Colorado Customer Contact Center at 800-221-3943.  (TDD: 800-659-2656.)

Learn more

SEPs provide case management, care planning and make referrals to other resources for Medicaid clients with the following qualifying needs: 

  • Elderly, blind, disabled
  • Behavioral health 
  • Persons living with AIDS 
  • Brain injury 
  • Spinal cord injury 
  • Children with a life-limiting illness 
  • Children with a physical disability

For more information, or to make a referral, contact the SEP in your county using the contacts below.

Archuleta, La Plata and San Juan Counties
San Juan Basin Health Department
281 Sawyer Drive
Durango, CO  81302
Main Phone:  970-247-5702
Fax:  970-247-9126
Administrator:  Barbara Benson

Delta, Gunnison and Hinsdale Counties
Delta County Dept. of Health and Human Services
560 Dodge Street
Delta, CO  81416
Mailing Address: PO Box 729, Hotchkiss, CO  81419
Main Phone:  970-872-1201
Fax:  970-872-1229
Administrator:  Kelly Roy

Eagle, Garfield, Grand, Jackson, Moffat, Pitkin, Rio Blanco, Routt & Summit Counties
Northwest Options for Long-Term Care (OLTC)
108 8th Street, Suite 300
Glenwood Springs, CO  81601
Mailing Address: 195 W. 14th Street, Rifle, CO  81650
Main Phone:  970-963-1639
Fax:  970-963-1974
Administrator:  Mary Baydarian

Larimer County
Larimer County Dept. of Human Services
1501 Blue Spruce Drive
Fort Collins, CO  80524

Larimer County Options for Long-Term Care (OLTC)
205 E. 6th Street
Loveland, CO  80537
Main Phone:  970-498-6821
Fax:  970-498-6874
Administrator:  Kelly Morrison

Mesa County
Mesa County Department of Human Services
510 29 1/2 Road
Grand Junction, CO  81502
Mailing Address: PO Box 20000, Grand Junction, CO  81502-5035
Main Phone: 970-248-2888
Fax: 970-248-2849
Administrator: Grant Jackson

Montezuma and Dolores Counties
Montezuma County Health Department
106 W. North Street
Cortez, CO 81321-3189
Main Phone: 970-565-3056,  ext. 250
Fax: 970-565-0648
Administrator: Jeanne Garbesi

Montrose, Ouray & San Miguel Counties
Montrose County Department of Health and Human Services
1845 S. Townsend Ave.
Montrose, CO  8140
Main Phone: 970-252-5092
Fax: 970-252-5049
Administrator: Stephanie Holsinger

RMHP has resources and tools to help practices that want to achieve patient-centered medical home recognition.

Resources about the patient-centered medical home for patients:

The Ombudsman is independent from all healthcare plans. If a Member has a problem of concern with the PCMP or  health plan, the Mmbudsman will work with the Member, the provider, and/or the health plan to find a solution. The Ombudsman may be reached at 877-435-7123.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based early intervention to prevent alcohol and drug use problems in adults and adolescents. Find scheduled trainings, resources, clinical tools and more at the SBIRT website:

Visit the website

SBIRT Approved Screening Tools

In September 2017, the CUDIT-R and S2BI screening tools were approved for use when conducting SBIRT. The current approved evidence-based screening tools are:

  • The Alcohol Use Disorders Inventory Test (AUDIT)
  • The Drug Abuse Screening Test (DAST)
  • The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
  • The Car, Relax, Alone, Forget, Friends, Trouble Screening Test (CRAFFT), for adolescents
  • The Problem Oriented Screening Instrument for Teenagers (POSIT)
  • The Cannabis Use Disorders Test-revised (CUDIT-R), for adults and adolescents
  • The Screening to Brief Intervention (S2BI), for adolescents

More information about the SBIRT benefit can be found in the SBIRT Billing Manual under the CMS1500 section. Contact Alex Weichselbaum for more information.

Skilled, trained counselors are available to answer calls 24 hours a day, 7 days a week, at 800-273-8255.

Health First Colorado pays for any FDA-approved tobacco cessation medication for two 90-day sessions each year. To learn more about this benefit, please visit colorado.gov.

Visit the website

Know the Terminology

We understand initiatives like the RAE can mean new acronyms. That's why we've identified some of the common terms you'll need to know to better understand the RAE and all it entails.

The Accountable Care Collaborative is a program of Health First Colorado (Colorado’s Medicaid Program) designed to help Health First Colorado enrollees connect with physical health providers, behavioral health providers, care coordinators, and local services and supports. The Accountable Care Collaborative program works to build a Medical Home for each Member, and enhance Member and provider experience.

ACC Members include Health First Colorado Members enrolled with a RAE, and Health First Colorado Members also enrolled with RMHP in the ACC program payment reform initiative known as RMHP Prime.

ACC Phase II is the next iteration of the ACC that seeks to leverage the proven successes of Health First Colorado programs to enhance the Member and provider experience. Regional RAEs are part of this next phase of the ACC.

This is the Federal agency within the United States Department of Health and Human Services that works in partnership with state governments to administer Medicaid.

This is a frequent reference for Colorado’s Department of Health Care Policy and Financing, which is the single state agency that administers Colorado’s Medicaid program. The Department is also known as HCPF.

Health First Colorado is the name of Colorado’s Medicaid Program.

The principles of a Medical Home Model include care provided in a manner that is: Member/family centered; whole-person oriented and comprehensive; coordinated and integrated; provided in partnership with the Member and promotes Member self-management; outcomes-focused; consistently provided by the same provider as often as possible so a trusting relationship can develop; and provided in a culturally competent and linguistically sensitive manner.

A PCMP is a primary care provider who serves as the Medical Home for attributed Health First Colorado Members and partners with their RAE to coordinate the health needs of their Members. To support the additional responsibilities for serving as a PCMP, the RAEs will distribute value-based administrative payments to contracted PCMPs. Providers must, at a minimum, meet the following criteria to qualify as a PCMP:

  • Enroll as a Health First Colorado provider
  • Hold an MD, DO, or NP provider license in one of the following specialties: pediatrics, internal medicine, family medicine, obstetrics and gynecology, or geriatrics, and able to practice in Colorado

A single brick and mortar physical location where services are delivered to Members under a single Medicaid billing provider identification number.

Colorado has seven Regional Accountable Entities that are part of Accountable Care Collaborative program. Rocky Mountain Health Plans is the RAE for Region 1, which includes Western Colorado and Larimer County.

An individual who qualifies for Health First Colorado and is enrolled with a RAE.

Most RAE Members are not enrolled in RMHP Prime. This term is often used to clarify differences/similarities for RAE Members with and without RMHP Prime.

“Payment Reform Initiative for Medicaid Enrollees”, or Prime, is a payment reform initiative under the ACC Program in which RMHP functions as a payer for Health First Colorado physical health services. Within RMHP Prime, the Department pays a fixed global payment to RMHP for medical services provided to RMHP Prime Members. RMHP Prime operates within RMHP’s RAE contract with the Department. As such, all RMHP Prime Members are also enrolled with RMHP as a RAE Member for behavioral health services and other applicable services provided by the RAE. This aligned administration of behavioral and medical services, along with community social determinant of health activities supports a whole person, community-connected approach to care.

Garfield, Gunnison, Mesa, Montrose, Pitkin, and Rio Blanco counties

An individual who qualifies for Health First Colorado and is enrolled by the Department with RMHP under an ACC program payment reform initiative known as RMHP Prime. Eligible individuals must reside in an RMHP Prime county and includes adults who receive full Health First Colorado benefits, and children with disability status. All RMHP Prime Members are also enrolled with RMHP as the RAE for behavioral health services. RMHP Prime Members also may be referenced as RAE Prime Members.

TCR is a comparison of the total cost of health care services reimbursed by RMHP for attributed RAE Members (for months in which RAE Members are attributed to the PCMP practice site) to the average total cost of care for all attributed RAE Members served by PCMP practices participating under a RAE agreement with RMHP. A risk adjustment will be applied to ensure that the PCMP practice’s total cost is normalized for demographic, diagnostic and other complexities when completing this comparison to the RAE average. The Total Cost Relativity will be equivalent to the average total cost for all RMHP contracted RAE practice sites divided by the normalized average total cost for the PCMP’s practice site. Participating RAE PCMPs with a TCR of more than 1.0 (i.e., with lower total costs than average) will receive a proportionately higher performance based incentive payment from RMHP. Participating RAE practices with a TCR of less than 1.0 (i.e., with higher total costs than average) will receive a proportionately lower performance based incentive payment from RMHP.