Summary of Approved Recommendations

November 19, 2007

The Blue Ribbon Commission for Health Care Reform approved this package
of recommendations for comprehensive health reform on Nov. 19, 2007. We
will elaborate upon the rationale behind of specifics of these
recommendations for the Commission’s final report to the Colorado General
Assembly, due Jan. 31, 2008.
These recommendations are drawn, in large part, from the Commissionʹs 5th
proposal. In addition, many of these elements were included in a number of
the other 31 proposals submitted to the Commission. As such, they seem to
reflect a view shared by many informed participants as to their importance for
comprehensive reform. The recommendations also incorporate suggestions
from the Commissionʹs Task Forces and reflect some of the common themes
that emerged from our three rounds of community meetings around the state.
Reviewed for these recommendations:
◦ Lewin Baseline Reports
◦ Contents of the 23 comprehensive proposals, especially coverage strategies
◦ Lewin’s analysis of the 4 proposals
◦ The specification of the 5th proposal
◦ The initial evaluation results of the 5th proposal
◦ Exit interviews with the 4 key authors
◦ Recommendations of the Report Committee (3 meetings)
◦ All Task Force Recommendations

PART 1

Implementing Recommendations as a Comprehensive Plan

A. Implement these recommendations of the Blue Ribbon Commission on
Health Care Reform as a comprehensive, integrated package.

PART 2

Reducing Health Care Costs, while Enhancing Quality of Care

B. Slow the rate of growth of employer and private health insurance premiums
by covering the uninsured and increasing Medicaid provider reimbursement
rates as a means of minimizing the cost shift.

1. Reduce uncompensated care by covering at least 85% of the uninsured in
Colorado, through the recommendations in Part 2.
2. Reduce cost-shifting by increasing Medicaid provider reimbursements
(See Recommendation W).

C. Reduce employee premiums for health insurance.

1. Require Colorado employers to establish at least a Section 125 premiumonly
plans that allow employees to purchase health insurance with pre-tax
dollars.
2. Provide subsidies for uninsured low-income workers below 300% FPL to
purchase their employer’s plan, or, for workers not offered coverage by
their employer, provide subsidies up to 400% FPL for private coverage.

D. Reduce administrative costs.

1. Require health insurers and encourage all payers in Colorado to use
standard claims attachment requirements, eligibility and coverage
verification systems, standard electronic ID cards, standard prior
authorization procedures and uniform insurance application forms.
2. Combine administrative functions of public health insurance programs
(such as Medicaid, CHP+, premium subsidy program, CoverColorado).
3. Review regulatory requirements on third-party payers and providers with
the goal of reducing administrative burden.

E. Promote consumer choice and direction in the health care system.

1. Increase price and quality transparency (Recommendation M).
2. Create a Connector for individuals and employees (Recommendation S).
3. Provide a choice of Minimum Benefit Plans, including a Health Savings
Account option, for all consumers purchasing in the individual insurance
market (Recommendation V).
4. Provide consumers with evidence-based medical information at the point
of service to aid in decision-making through patient-centered care.

F. Increase use of prevention and chronic care management.

1. Where allowed by HIPAA, allow health insurance premiums to be
reduced for enrollees who engage in healthy behaviors.
2. Eliminate patient copayments for preventive care and reduce patient
copayments for chronic care management services as defined by
nationally-recognized, Colorado-vetted uniform guidelines, such as those
developed by the Colorado Clinical Guidelines Collaborative.
3. Encourage employers to provide workplace wellness programs.
4. Encourage individual responsibility for health, wellness and preventive
behavior.
5. Increase funding for local public health agencies in Colorado to perform
functions such as preventing disease and injury, assessing community
health, and promoting healthy behavior.

G. Provide a medical home for all Coloradans.

1. Enhance the provision, coordination, and integration of patientcentered
care, including “healthy handoffs.”
2. Reimburse providers for care coordination and case management,
particularly in the Medicaid/CHP+ and CoverColorado programs.

H. Improve end-of-life care.

1. Identify a process to develop consensus, by a multi-stakeholder group,
based upon best scientific evidence regarding strategies to foster clinically,
ethically, and culturally appropriate end-of-life care, including palliative
and hospice care.
2. Ask patients, upon entry to a nursing home, home health, or other
critical point of access, to complete an advanced directive. There would be
no requirement to complete an advanced directive, patients would be
fully-informed, there would be no outside pressure to complete the form,
and revocation rights would be clear and simple.

I. Commission an independent study to explore ways to minimize barriers to
physician extenders such as Advanced Practice Nurses from practicing to the
fullest extent of their licensure and training.
J. Support the adoption of health information technology.

1. Support the creation of a statewide health information network,
focusing on interoperability.
2. Support the creation of an electronic health record for every
Coloradoan, with protections for patient privacy.

K. Support the provision of evidence-based medicine1.

1. Adopt population-specific care guidelines and performance measures,
where they exist, based on existing national, evidence-based guidelines
1 Evidence-based medicine is defined as “A set of principles and methods intended to ensure
that, to the greatest extent possible, population-based policies and individual medical decisions
are consistent with the evidence of effectiveness and benefit.”
and measures, recognizing the importance of patient safety and best care
for each patient.

L. Pay providers based on quality.

1. Pay providers based on their use of care guidelines, performance on
quality measures, coordination of patient care, and use of health
information technology.

M. Ensure that information on insurer and provider price and quality is available
to all Coloradans and that it is easily accessible through a single entry point
(e.g. Web site).

1. Require DOI to report annually to the legislature regarding financial
information on licensed carriers and public coverage programs;
information should include medical loss ratios, administrative costs, etc,
by line of business; require Medicaid, CHP+, CoverColorado and other
public coverage programs to provide DOI with this information; and
require brokers to report their compensation to their clients.
2. Develop a statewide system aggregating data from all payer plans, public
and private, building upon regional systems or efforts already taking
place for sharing data among providers

N. Create a multi-stakeholder “Improving Value in Health Care Authority” to:

1. Create this multi-stakeholder group to fundamentally realign incentives to
in the Colorado health care system to reduce costs and improve outcomes.
2. Give the Authority rule-making authority to implement the Commission’s
recommendations regarding administrative simplification
(Recommendation C), health care transparency (Recommendation K), and
the Ombudsman and Advocacy Program.
3. Direct the Authority to study and make recommendations to the
Governor, state legislature, and rule-making agencies regarding
prevention (Recommendation E), medical homes (Recommendation F),
health information technology (Recommendation H), evidence-based
medicine (Recommendation I), provider reimbursement
(Recommendation J). The Authority will also be responsible for assessing
and reporting on the effectiveness of reforms, especially their impact on
vulnerable populations and safety net health care providers.
4. Direct the Authority to develop a statewide system aggregating data from
all payer plans, public and private, building upon regional systems or
efforts already taking place for sharing data among providers (this
recommendation is taken directly from the Provider Task Force
Recommendations).
5. Establish the Authority before embarking on the improvements to
coverage and access described in Part 2.

O. Examine and expand the efforts of Colorado communities which have been
proven over the years to enhance quality and lower cost.
P. Conduct a comprehensive review of current Colorado long-term care
information as a supplement to any review of the Commission reports, such
as the SB 173 report , the report of the Developmental Disability Interim
Committee, the Medicaid Redesign Project (SB 06-128), and the National
Clearinghouse for Long-Term Care Information.

PART 3

Improving Access to Care, with Mechanisms to Provide Choices

Q. Require every legal resident of Colorado to have at least a Minimum Benefit
Plan, with provisions to make the mandate enforceable.

1. Require purchase of a Minimum Benefit plan (average monthly premium
of approximately $200 for an individual).
2. Design and periodically review the Minimum Benefit Plan through the
“Improving Value Authority.” Ensure that the process is process to create
the minimum benefit package is transparent, participatory, equitable,
compassion, sensitive to value, flexible and responsive.
3. Provide an affordability exemption or consider another mechanism for
addressing affordability, such as extending the premium subsidy program
to a higher income level. Assuring affordability should include
consideration of both premium and out-of-pocket costs.
4. Enforce through tax penalty; automatically enroll those who are eligible
into fully-subsidized public coverage programs.

R. Implement measures to encourage employees to participate in employersponsored
coverage.

1. Require Colorado employers to establish premium-only Section 125 plans
that allow employees to purchase health insurance with pre-tax dollars.
2. Provide subsidies for uninsured low-income workers below 400% FPL to
purchase their employer’s plan.
3. Enforce waiting periods (minimum periods of being uninsured) for
eligibility for the premium subsidy program, to discourage employers and
employees from dropping employer coverage to enroll in public
programs; create exceptions for involuntary loss of coverage, COBRA
coverage, or qualifying events, such as marriage or birth.

S. Assist individuals and small businesses and their employees in offering and
enrolling in health coverage through creation of a “Connector.”

1. Offer three to four standard benefit plans.
2. Certify participating health plans.
3. Provide information and education, such as comparative price and quality
information.
4. Use same rating rules as the reformed individual and current small group
market.

T. Maximize access to/enrollment in private coverage for working lower-income
Coloradans who are not offered coverage at the workplace.

1. Provide premium subsidies to workers who are not offered coverage at
the workplace who earn less than 300% of poverty for purchase of private
health insurance equivalent to CHP+ benefit package.
2. Provide premium subsidies to individuals and families who earn between
300-400% of poverty such that their premium cost is no more than 9% of
their income.
3. To facilitate enrollment and reduce fraud, use auto enrollment strategies
that use existing state data to determine subsidy eligibility (e.g. tax, wage,
and nutrition program information).

U. Require all health insurance carriers operating in Colorado to offer a
Minimum Benefit Plan in the individual market, with an emphasis on valuebased
and consumer-directed benefit design.

1. Require all health carriers offering health insurance in Colorado to offer a
Minimum Benefit Plan in the individual market.

V. Guarantee access to affordable coverage for Coloradans with health
conditions (Implement in conjunction with Recommendation Q).

1. Require health insurance companies to issue coverage (guarantee issue) to
any individual or family who applies for individual health insurance and
who is not eligible for the restructured CoverColorado program.
2. Allow health insurance companies to set premiums for these individuals
and families based on their age and geographic location; disallow the
consideration of past and current health conditions.
3. Restructure CoverColorado to cover those who apply for coverage, have
an identifiable, high-cost health condition as defined by the newly
expanded program and are not eligible for Medicaid, CHP+ or a premium
subsidy. Finance CoverColorado to ensure that premiums are equal to the
standard rates in the individual market.

W. Restructure and combine public programs (Medicaid and the Child Health
Plan Plus) for parents, childless adults and children (excluding the aged,
disabled, and foster care eligibles).

1. Merge Medicaid and CHP+ into one program for all parents, childless
adults and children (excluding the aged, disabled, and foster care
eligibles).
2. Pay health plans at actuarially-sound rates and providers at least CHP+
rates in the new program.
3. For all other Medicaid enrollees, ensure that physicians are reimbursed at
least 75% of Medicare.
4. Provide the CHP+ benefit and cost-sharing package to enrollees in the
new program, including dental, with access to a Medicaid supplemental
package, including EPSDT for children, for those who need Medicaid
services.
5. Require enrollment in managed care, where available

X. Improve benefits and case management for the disabled and elderly in
Medicaid.

1. Encourage enrollment of the aged and disabled into integrated delivery
systems that have incentives to manage and coordinate care.
2. Promote care delivery in a consumer-directed, culturally competent
manner to promote cost-efficiency and consumer satisfaction.
3. Provide care coordination and targeted case management services.
4. Provide dental coverage up to $1,000 per year.
5. Explore potential for further reforms to Medicaid, particularly for those
who are disabled (see Appendix X).

Y. Improve delivery of services to vulnerable populations.

1. Create a Medicaid buy-in program for working disabled individuals.
2. Create a medically-correctable fund for those who can return to work or
avoid institutionalization through a one-time expense.
3. Increase number of people served by the home- and community-based
programs equal to the number of people on the current waiting list for
these services.2
4. Provide mental health parity in the Minimum Basic Benefit Plan
(Recommendation R).
5. Establish a Medically-Needy or other catastrophic care program for those
between 300% and 500% of poverty to address the issue of people who
have health insurance but do not have coverage for catastrophic events
(Fund at $18 million in state funds).

Z. Expand eligibility in the combined Medicaid/CHP+ program to cover more
uninsured low-income Coloradans.
2 Including the Children’s HCBS waiver program, the Child Autism waiver program, the Adult
Comprehensive waiver program, the Adult SLS waiver program, the Early Intervention waiver program,
the CES waiver program, and the Family Support waiver program.

1. Expand Medicaid/CHP+ to cover all uninsured legal residents of Colorado
under 205% of poverty.
2. Restrict the expansion to adults with less than $100,000 in assets excluding
car, home, qualified retirement and educational accounts, and disabilityrelated
assets.
3. Work with federal government to ensure federal funding for low-income
childless adults; do not fund expansion through reduction of services to
current Medicaid and CHP+ eligibles.

AA. Ease barriers to enrollment in public programs.

1. Use auto enrollment strategies to increase enrollment, reduce fraud, and
lower administrative costs and pursue presumptive eligibility where
possible.
2. Provide one-year continuous eligibility to childless adults, parents, and
children in the newly merged Medicaid/CHP+ program.

BB. Enhance access to needed medical care, especially in rural Colorado where
provider shortages are common.

1. Continue to pay all qualified safety net providers enhanced
reimbursement for serving Medicaid patients.
2. Explore ways to minimize barriers to physician and dentist extenders such
as advanced practice nurses and dental hygienists and others from
practicing to the fullest extent of their licensure and training.
3. Promote and build upon the existing statewide nurse advice line.
4. Expand telemedicine benefits for Medicaid and CHP+ enrollees, especially
in rural areas.
5. Develop and expand mechanisms to recruit and retain health care workers
who will provide services in underserved areas of Colorado, such as
state-based loan repayment, loan forgiveness programs, tax credits, and
other approaches.

DD. Create an Consumer Advocacy Program

5. Create a program that is independent and consumer-directed

a. Provide system navigators to guide people through the system
b. Resolve problems
c. Provide assistance with eligibility and benefit denials
d. Help qualify people on Medicaid for Medicare
e. Help people qualify for SSI

CC. Continue to explore the feasibility of giving Coloradans the option to enroll
in coverage that will stay with them, regardless of life changes, such as the
Optional Continuous Coverage Portable Plan that the Commission modeled.
EE. Continue to explore the feasibility of allowing employers to offer 24-hour
coverage

PART 4

Increase efficiency and access before expanding coverage

PART 5

Dissolve the Commission once its final report is made to the General

Assembly Jan. 31, 2008
Appendix X: Medicaid reform ideas recommended for study
1. Guarantee prompt (direct) reimbursement to clients and providers for any
eligible expenses incurred during any delays in eligibility or periods in which the
individual met all other periods that the client met all eligibility requirements,
but for submission of an application (with a reasonable time limit), or if the client
was required to self-pay, regardless of whether the service/supply was provided
by a authorized Medicaid provider (e.g. hiring a neighbor for home care v. an
agency).
2. Require all Medicaid recipients to have needed care coordination that includes
prescription coordination and management, including medication review of new
and continuing prescriptions.
3. Provide consumer training and education to allow consumers to identify savings
in their own care and potentially provide incentives for doing so.
4. Pursue strategies for providing more reliable transportation, including funding
strategies for Medicaid recipients that address inter-agency conflicts.
5. Combine waiver programs where appropriate (e.g. waivers with similar benefits
thus saving on admin costs).
6. Support strategies to increase access to home based care in a cost effective way,
so that people currently hospitalized (example vent dependent kids) can go
home- and receive adequate care in the community. Results in long term
savings.
7. Investigate stipend respite care as a benefit for eligible waiver participants.
(Saves money because people can go home from hospital).
8. Look at pooling DME purchasing.
Can we purchase DME more cheaply or use equipment more efficiently? Set
aside funding to help with this- example of potential savings is permitting
recycling of wheelchairs, etc.
9. Create consumer-directed program for supplies. For example, Medicaid
enrollees can buy Depends much more cheaply over the counter in the market
place than through a Medicaid supply company.
10. Create new program for care coordinator to facilitate getting people transitioning
out of corrections or the foster care system on to SSI and Medicaid as
appropriate.
11. Study how to provide health management and care coordination for foster care
children.
12. Facilitate transition to services for those on Medicaid aged 18-21, particularly
across multiple systems.
13. Assist veterans transitioning from VA medical Services to DDS and SSI
14. Simplify and standardize entry into all HCBS programs
15. Integrate systems so that mental health, education, and human services all work
together to get appropriate services to children particularly when a child needs
institutional care. Long term savings in getting appropriate care to kids when
they need it.
16. Integrate mental health reform with health care reform. Look at the other
recommendations for mental health coming from interim committees and
DCCO.
17. Generally eliminate prior authorization requirement for over-the-counter
products costing less than $100, with appropriate utilization review.