CMS has been at the table for Colorado physicians

The months-long Division of Insurance (DOI) Colorado Option benefit design stakeholder process, which included 15 public meetings, two regulatory comment periods, and feedback from the Colorado Medical Society (CMS) and almost 100 other organizations statewide, is coming to an end. The DOI has released a second draft of the regulation defining the standardized plan and will be finalizing this regulation soon so it can go into effect by the start of 2022. 

Throughout this process, CMS has actively advocated for physicians and patients at all stakeholder meetings and by responding to questionnaires and submitting comments on the design of the standardized plan on Aug. 12, Oct. 7, and Oct. 20. CMS has emphasized the need for evidence-based benefit design to help incentivize high-value care and control costs through additional support for prevention and chronic disease management. 

The DOI has made important changes to the second draft of the regulation that incorporate some CMS suggestions, but outstanding issues remain that CMS believes will need to be addressed in the coming months and years. 

Highlights from the draft regulation include: 

  • The Colorado Option will utilize a mixture of copays and coinsurance, along with a number of pre-deductible services with no cost-sharing. 
  • The plan now includes primary care, mental health, behavioral health, treatment for substance use disorder, prenatal and postnatal services with $0 cost-sharing for all visits in the gold and silver plans and three visits of each kind in the bronze plan.  
    • Win for patients and physicians: The gold and silver plans moved from three visits to unlimited visits with $0 cost-sharing for these services at the urging of CMS. These high-value services are often key to prevention, chronic disease management, and addressing health disparities. 
  • Copays for specialty care visits in the gold and silver plans ($50 and $80, respectively) and 50% coinsurance for these visits in the bronze plan. 
  • $0 cost-sharing for preventive drugs. 
  • The plan targets specific health disparities, including maternal and infant mortality, pre-diabetes and diabetes, and tobacco cessation. 

Throughout this process CMS has repeatedly emphasized a number of major points, including the need for better prevention and chronic disease management, focusing on health disparities and social determinants of health, and operationalizing value-based insurance design (VBID) principles to incentivize high-value care to meet patient needs. These elements are critical to ensuring quality of care and addressing drivers of heath care costs.   

CMS recommendations that have not been incorporated in the regulation include: 

  • Recognizing and facilitating all aspects of chronic disease management (not just primary care), including specialty care, drugs, labs, social supports, etc. 
  • Implementing VBID principles by varying cost-sharing within benefit categories (viewing value at the service level and not the category level). 
  • Encouraging the delivery of care at appropriate, high-value sites of service. 

CMS will continue to advocate for physicians and patients as the DOI completes the current rulemaking process (submitting a final comment letter by Nov. 12), implements the Colorado Option, and engages in ongoing efforts to refine the Colorado Option in the coming years.  

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