Concerning access to direct primary care services for Colorado medicaid members.
Summary
HB26-1096 would prohibit the Colorado Department of Health Care Policy and Financing from blocking Medicaid members from purchasing primary care services through a direct primary care arrangement. The bill allows a Medicaid member to pay a direct primary health-care provider directly for primary care services, while making clear that the provider does not bill Medicaid for those services and that the member cannot seek Medicaid reimbursement for them. It also requires the member to sign an acknowledgment form explaining these limits and confirming that the member still retains access to primary care from a Medicaid-enrolled provider.
The bill further requires a direct primary care provider who serves Medicaid members to enroll in the Colorado Medical Assistance Program as an ordering, prescribing, or referring provider so that orders, prescriptions, and referrals can be processed through Medicaid. The department would also be required to seek any necessary federal authorization to implement the policy and to report data in future years about member use of direct primary care and provider participation. The bill amends existing statutes governing direct primary care agreements and Medicaid payment rules to expressly include these arrangements for Medicaid members.
Impact
The bill would change Colorado law to expressly permit Medicaid members to enter into direct primary care agreements and to pay for primary care outside the Medicaid fee-for-service system, while preserving Medicaid coverage for other covered services. It would amend the direct primary care statute and Medicaid recovery/payment provisions to recognize direct primary care retainers and written agreements, and it would impose a new enrollment requirement for participating providers as ordering, prescribing, or referring providers. The measure also creates reporting obligations for the department and participating providers, and it depends on any needed federal approval before full implementation.
Sentiment
The bill appears to have been framed as a patient-choice and access measure, emphasizing affordability, innovation, and improved access to primary care, especially in rural and frontier areas. The legislative declaration reflects support for allowing Medicaid members to choose direct primary care if it better fits their needs. However, the bill did not advance in the Senate Committee on Health & Human Services and was postponed indefinitely, indicating that there was not sufficient committee support to move it forward.
Contention
The main point of contention is the interaction between direct primary care and the Medicaid program. Supporters appear to view the bill as expanding access and provider choice without requiring Medicaid to pay for the direct primary care services themselves, while the bill’s safeguards are designed to prevent duplicate billing and clarify that members cannot seek reimbursement for those services. Potential concerns likely included administrative complexity, federal authorization issues, and whether allowing Medicaid members to pay separately for primary care could affect program oversight, provider participation, or continuity of care. The Senate committee’s decision to postpone indefinitely suggests unresolved concerns outweighed support at that stage.