SUPPLEMENTAL BUDGET REQUESTS FY 2020-21 AND FY …supplemental budget requests fy 2020-21 and fy 2019-20 . department of health care policy and financing . jbc working document - subject

SUPPLEMENTAL BUDGET REQUESTS FY 2020-21 AND FY 2019-20

DEPARTMENT OF HEALTH CARE

POLICY AND FINANCING

JBC WORKING DOCUMENT - SUBJECT TO CHANGE STAFF RECOMMENDATION DOES NOT REPRESENT COMMITTEE DECISION

PREPARED BY: ERIC KURTZ, JBC STAFF

ROBIN J. SMART, JBC STAFF JANUARY 20, 2021

JOINT BUDGET COMMITTEE STAFF 200 E. 14TH AVENUE, 3RD FLOOR · DENVER · COLORADO · 80203

TELEPHONE: (303) 866-2061 · TDD: (303) 866-3472 https://leg.colorado.gov/agencies/joint-budget-committee

CONTENTS Department Overview ...................................................................................................................................... 1 Summary: FY 2019-20 Appropriation and Recommendation ................................................................... 1 Summary: FY 2020-21 Appropriation and Recommendation ................................................................... 2 Prioritized Supplementals in Department-assigned Order .......................................................................... 4

S1 Medical Services Premiums ........................................................................................................... 5 S2 Behavioral Health ......................................................................................................................... 14 S3 Children's Basic Health Plan ....................................................................................................... 16 S4 Medicare Modernization Act ...................................................................................................... 18 S5 Office of Community Living [Includes Proposed Legislation] .............................................. 20 S6 Nurse advice line ........................................................................................................................... 24 S7 Medicaid for Connect for Health Colorado ............................................................................. 26 S8 Funding for family medicine residence training program ....................................................... 27 S9 Technical adjustments .................................................................................................................. 30 S10 Public health emergency end resources ................................................................................... 31 S11 Roll forward funding for Single Assessment Tool ................................................................ 31 S12 federal match for non-forecast lines ........................................................................................ 33 S13 Public school health services ..................................................................................................... 33 S14 Overexpenditures........................................................................................................................ 35

Staff-initiated Supplemental Requests ........................................................................................................... 37 Public health emergency extension .................................................................................................. 37

Previously Approved Interim Supplementals .............................................................................................. 39 Nurse Advice Line Continuation ..................................................................................................... 39 Medicaid Funding for Connect for Heatlh Colorado ................................................................... 41

Numbers Pages................................................................................................................................................. 43

S1 Medical Services Premiums ......................................................................................................... 43 S2 Behavioral Health ......................................................................................................................... 44 S3 Children's Basic Health Plan ....................................................................................................... 45 S4 Medicare Modernization Act ...................................................................................................... 46 S5 Office of Community Living ...................................................................................................... 47 S6 Nurse advice line ........................................................................................................................... 49

S7 Medicaid for Connect for Health Colorado ............................................................................. 50 S8 Funding for family medicine residence training program ....................................................... 51 S9 Technical adjustments .................................................................................................................. 52 S10 Public health emergency end resources ................................................................................... 54 S11 Roll forward funding for Single Assessment Tool ............................................................. NA S12 Federal match for non-forecast lines ....................................................................................... 57 S13 Public school health services ..................................................................................................... 61 S14 Overexpenditures..................................................................................................................... NA Staff-Initiated: Public health emergency extension ....................................................................... 62 Nurse Advice Line Continuation .................................................................................................. NA Medicaid Funding for Connect for Heatlh Colorado ................................................................... 69

STAFF WORKING DOCUMENT – DOES NOT REPRESENT COMMITTEE DECISION

20-January-21 1 HCP-sup

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

DEPARTMENT OVERVIEW The Department helps pay medical and long-term care expenses for low-income and vulnerable populations. To assist with these costs the Department receives significant federal matching funds, but must adhere to federal rules regarding program eligibility, benefits, and other features, as a condition of accepting the federal money. The major programs administered by the Department include: • Medicaid – serves people with low income and people needing long-term care • Children's Basic Health Plan – provides a low-cost insurance option for children and pregnant

women with income slightly higher than the Medicaid eligibility criteria • Colorado Indigent Care Program – defrays a portion of the costs to providers of

uncompensated and under-compensated care for people with low income, if the provider agrees to program requirements for discounting charges to patients on a sliding scale based on income

• Old Age Pension Health and Medical Program – serves elderly people with low income who qualify for a state pension but do not qualify for Medicaid or Medicare.

The Department also performs functions related to improving the health care delivery system, including advising the General Assembly and the Governor, distributing tobacco tax funds through the Primary Care and Preventive Care Grant Program, financing Public School Health Services, and housing the Commission on Family Medicine Residency Training Programs.

SUMMARY: FY 2019-20 APPROPRIATION AND RECOMMENDATION

REQUEST/RECOMMENDATION DESCRIPTIONS S11 ROLL FORWARD AUTHORITY FOR SINGLE ASSESSMENT TOOL: The Department requests and JBC staff recommends an extension of roll forward authority on funds appropriated in FY 2019-20 related to the implementation of S.B. 16-192 (Assessment Tool Intellectual and Developmental Disabilities). S14 OVEREXPENDITURE: The Department requests and the JBC staff recommends the release of restrictions on the FY 2020-21 appropriations imposed by the State Controller due to over-expenditures in prior years. Because of the entitlement nature of the Medicaid program, statute (Section 24-75-109, C.R.S.) allows the Department to overexpend Medicaid line items, except administrative line items, as long as the overexpenditures are consistent with the statutory purposes of the Medicaid program. However, the State Controller restricts the current fiscal year’s appropriation until the General Assembly approves a supplemental for the prior year overexpenditures. Releasing



the overexpenditure restriction requires increasing the FY 2019-20 appropriation by $28.9 million total funds, including $26.7 million General Fund.

SUMMARY: FY 2020-21 APPROPRIATION AND RECOMMENDATION

DEPARTMENT OF HEALTH CARE POLICY AND FINANCING: RECOMMENDED CHANGES FOR FY 2020-21

TOTAL FUNDS

GENERAL FUND

CASH FUNDS

REAPPROPRIATED FUNDS

FEDERAL FUNDS

FTE

FY 2020-21 APPROPRIATION HB 20-1360 (Long Bill) $12,048,019,640 $3,370,498,402 $1,582,848,138 $48,000,598 $7,046,672,502 560.6 Other Legislation (14,183,893) (185,792,399) 184,520,266 (2,044,073) (10,867,687) (3.9) CURRENT FY 2020-21 APPROPRIATION: $12,033,835,747 $3,184,706,003 $1,767,368,404 $45,956,525 $7,035,804,815 556.7 RECOMMENDED CHANGES Current FY 2020-21 Appropriation $12,033,835,747 3,184,706,003 $1,767,368,404 $45,956,525 $7,035,804,815 556.7 S1 Medical Services Premiums (17,878,040) (148,915,698) (94,492,763) (49,482) 225,579,903 0.0 S2 Behavioral Health (98,830,828) (42,281,674) 1,731,562 0 (58,280,716) 0.0 S3 Children's Basic Health Plan (52,581,053) (14,035,710) (3,774,937) 0 (34,770,406) 0.0 S4 Medicare Modernization Act (14,430,417) (14,430,417) 0 0 0 0.0 S5 Office of Community Living (4,860,971) (14,512,191) 1,637,257 0 8,013,963 0.0 S6 Nurse advice line 306,929 1,117,028 0 0 (810,099) 0.0 S7 Medicaid for Connect for Health 4,049,364 0 1,827,019 0 2,222,345 0.0 S8 Funding for family medicine residency training program

0 0 0 0 0 0.0

S9 Technical adjustments 0 0 0 0 0 0.0 S10 Public health emergency end resources 8,323,654 784,231 1,087,562 0 6,451,861 1.0 S12 Federal match for non-forecast lines 0 (1,701,861) (3,204,160) 0 4,906,021 0.0 S13 Public school health services 8,806,057 0 (842,607) 0 9,648,664 0.0 Public health emergency extension 238,640,880 (75,122,979) 21,044,102 0 292,719,757 0.0 Interim Supplemental Connect for Health 6,806,208 0 3,145,458 0 3,660,750 0.0 Human Services programs 0 0 0 0 0 0.0 RECOMMENDED FY 2020-21 APPROPRIATION: $12,112,187,530 $2,875,606,732 $1,695,526,897 $45,907,043 $7,495,146,858 557.7

RECOMMENDED INCREASE/(DECREASE) $78,351,783 ($309,099,271) ($71,841,507) ($49,482) $459,342,043 1.0 Percentage Change 0.7% (9.7%) (4.1%) (0.1%) 6.5% 0.2% FY 2020-21 EXECUTIVE REQUEST $11,875,418,690 $2,951,087,367 $1,674,482,795 $46,118,093 $7,203,730,435 557.7 Request Above/(Below) Recommendation ($236,768,840) $75,480,635 ($21,044,102) $211,050 ($291,416,423) 0.0

REQUEST/RECOMMENDATION DESCRIPTIONS S1 MEDICAL SERVICES PREMIUMS: The Department requests and the JBC staff recommends a decrease of $17.9 million total funds, including a decrease of $148.9 million General Fund, for projected changes in caseload, per capita expenditures, and fund sources. S2 BEHAVIORAL HEALTH: The Department requests and the JBC staff recommends a decrease of $98.8 million total funds, including a decrease of $42.3 million General Fund, for projected changes in caseload, per capita expenditures, and fund sources.



S3 CHILDREN’S BASIC HEALTH PLAN: The Department requests and the JBC staff recommends a decrease of $52.6 million total funds, including a decrease of $14.0 million General Fund, for projected changes in caseload, per capita expenditures, and fund sources. S4 MEDICARE MODERNIZATION ACT: The Department requests and the JBC staff recommends a decrease of $14.4 million General Fund for a projected change in the state obligation under the federal Medicare Modernization Act. S5 OFFICE OF COMMUNITY LIVING: The Department requests and JBC staff recommends a net decrease of $4,860,971 total funds, including a decrease of $14,512,191 General, to align appropriations with the estimated number of enrollments in each Medicaid Home and Community Based Services waiver program for people with intellectual and developmental disabilities. In addition, JBC staff recommends that the General Fund be used to provide one-time sustainability payments to providers offering day habilitation services to individuals with intellectual and developmental disabilities. This requires legislation. S6 NURSE ADVICE LINE: The Department requests and the JBC staff recommends an increase of $1.0 million total funds, including $1.1 million General Fund, to: 1) repay federal funds previously drawn to support the Nurse Advice Line; and 2) provide funding to continue operating the nurse advice line without federal funds. S7 MEDICAID FOR CONNECT FOR HEALTH COLORADO: The Department requests and the JBC staff recommends $4.0 million total funds, including $1.8 million cash funds and $2.2 million federal funds, for Connect for Health Colorado Eligibility Determinations. The source of cash funds is certified public expenditures by Connect for Health. S8 FUNDING FOR FAMILY MEDICINE RESIDENCY TRAINING PROGRAM: The JBC staff does not recommend the Department's request for $1.2 million total funds, including $379,468 General Fund, to partially restore the FY 2020-21 elimination of the State University Teaching Hospitals line items that impacted family medicine residencies. S9 TECHNICAL ADJUSTMENTS: The Department requests and JBC staff recommends a net zero technical adjustment to shift funding for the Healthy Communities program from the Customer Outreach line item to the Medical Services Premiums line item in FY 2020-21 and ongoing. S10 PUBLIC HEALTH EMERGENCY END RESOURCES: The JBC staff recommendation is pending on the Department's request for administrative resources, primarily for counties, to address an expected surge in eligibility redeterminations and appeals when the federal public health emergency declaration ends and people who are currently locked-in on Medicaid as a result of the requirements of the public health emergency are no longer locked-in. The amount that appears in the table is based on the Department request. S12 FEDERAL MATCH FOR NON-FORECAST LINES: The Department requests and the JBC staff recommends a net $0 total funds change that includes a $1.7 million decrease in General Fund for line items where the Department does not routinely produce expenditure forecasts. The adjustment is to account for a temporary increase in the federal match authorized by the federal Families First Coronavirus Response Act. The impact for the forecast line items is included in the forecast requests (S1-S5).



S13 PUBLIC SCHOOL HEALTH SERVICES: The Department requests and the JBC staff recommends an increase of $8.8 million total funds based on a projected certified public expenditures by school districts and Boards of Cooperative Education Services (BOCES). PUBLIC HEALTH EMERGENCY EXTENSION: The JBC staff recommends an increase of $238.6 million total funds, including a decrease of $75.1 million General Fund, to account for the impact of an extension of the federal public health emergency. The extension of the public health emergency declaration means that Colorado is eligible for an additional 6.2 percent federal match for at least another quarter, meaning the additional 6.2 percent federal match will be in place for all of FY 2020-21. However, it also means that Colorado cannot implement any reductions in eligibility or benefits and cannot terminate eligibility for anybody enrolled in Medicaid for another three months. HUMAN SERVICES PROGRAMS: The staff recommendation for the Human Services programs is pending Committee action on the corresponding requests submitted by the Department of Human Services. Staff will include the corresponding appropriations in the supplemental bill for the Department of Health Care Policy and Financing based on Committee action on the Department of Human Services. The amounts in the table reflect the Department's request. REQUEST ABOVE/(BELOW) RECOMMENDATION The JBC staff recommendation is lower than the Department's request primarily due to the extension of the public health emergency, which happened after the Department submitted the supplemental request. It also reflects the JBC staff recommendation to deny S8 Funding for family medicine residency training program to partially restore funding for family medicine residencies and a technical modification the JBC staff recommends to S7 MEDICAID FOR CONNECT FOR HEALTH COLORADO.



PRIORITIZED SUPPLEMENTAL REQUESTS S1 MEDICAL SERVICES PREMIUMS

REQUEST RECOMMENDATION TOTAL ($17,878,040) ($17,878,040) General Fund (148,915,698) (148,915,698) Cash Funds (94,492,763) (94,492,763) Reappropriated Funds (49,482) (49,482) Federal Funds 225,579,903 225,579,903

Does JBC staff believe the request meets the Joint Budget Committee's supplemental criteria? [An emergency or act of God; a technical error in calculating the original appropriation; data that was not available when the original appropriation was made; or an unforeseen contingency.]

YES

Explanation: JBC staff and the Department agree that this request is the result of new data that was not available when the original appropriation was made regarding actual enrollment and expenditures. DEPARTMENT REQUEST The Department requests a net decrease of $17.9 million total funds, including a decrease of $148.9 million General Fund, based on a new projection of enrollment and expenditures under current law. The Medical Services Premiums line item pays for physical health care and most long-term services and supports for clients eligible for the Medicaid program. The forecast used for the original FY 2020-21 appropriation incorporated trend data through December 2019 while the latest forecast used for this supplemental request incorporates data through June 2020. The Department will submit a new forecast in February that uses data through December 2020. If that February forecast is significantly different than the forecast used for this supplemental, then the JBC staff may recommend a supplemental add-on to the Long Bill. The chart below summarizes the Department's forecast of enrollment and expenditures.



The projection for FY 20-21 is down a net $17.9 million total funds, including a decrease of $148.9 million General Fund. The graph below shows the major contributors to the General Fund change from the FY 20-21 appropriation to the Department's November 2020 forecast for FY 20-21. It does not show differences from FY 19-20 expenditures. For example, the graph shows that the Department lowered the forecast for nursing homes by $5 million total funds from the assumptions used for the appropriation, but the Department still expects expenditures for nursing homes will increase from the FY 19-20 actual.

3,937 4,619

5,728

6,839 6,330

7,473 7,766

8,099

9,014 9,314

10,032

683

861

1,161

1,297 1,346 1,315

1,261 1,219

1,359 1,407

1,545

12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23

Expenditures$ Millions

EnrollmentThousands

Forecast Period

Medical Services Premiums Enrollment and ExpendituresNovember forecast



As illustrated, most of the General Fund decrease is due to lower enrollment projections and a change in the federal match rate, described in more detail below. The next table shows the same change from the FY 20-21 appropriation to the Department's November 2020 forecast for FY 20-21, but in a format similar to the Department summary table.

FY 2020-21 MEDICAL SERVICES PREMIUMS ENROLLMENT/UTILIZATION TRENDS

TOTAL FUNDS

GENERAL FUND

OTHER STATE

FEDERAL FUNDS

FY 2020-21 Appropriation $9,031,460,335 $2,250,293,584 $1,434,889,860 $5,346,276,891 Acute Care

Enrollment (387,929,402) (165,565,291) (3,251,893) (219,112,218) Per capita 216,339,419 56,758,617 15,033,687 144,547,115 Safer-at-home utilization 54,864,453 20,243,690 1,505,680 33,115,083 COVID-19 Treatment 145,352,172 35,183,409 7,181,984 102,986,779 Other acute (14,830) (12,085,229) 4,077,900 7,992,499 Subtotal - Acute Care 28,611,812 (65,464,804) 24,547,358 69,529,258

Long-term Services and Supports HCBS waivers 7,444,151 3,463,407 27,900 3,952,844 Home Health/PDN 11,541,265 5,611,992 (199,139) 6,128,412 Nursing homes (9,969,128) (4,639,281) (36,240) (5,293,607) PACE 5,461,629 2,561,504 0 2,900,125 Hospice 1,684,872 790,205 0 894,667 Subtotal - LTSS 16,162,789 7,787,827 (207,479) 8,582,441

Medicare insurance premiums (6,133,753) (2,876,730) 0 (3,257,023)



FY 2020-21 MEDICAL SERVICES PREMIUMS ENROLLMENT/UTILIZATION TRENDS

TOTAL FUNDS

GENERAL FUND

OTHER STATE

FEDERAL FUNDS

Service management 1,064,957 499,465 0 565,492 Hospital supplemental payments (32,647,603) 0 (121,768,030) 89,120,427 Federal match rate 0 (79,628,947) (3,311,866) 82,940,813 Other (24,936,603) (9,232,509) 6,197,411 (21,901,505) TOTAL $9,013,581,934 $2,101,377,886 $1,340,347,254 $5,571,856,794 Increase/(Decrease) (17,878,401) (148,915,698) (94,542,606) 225,579,903 Percentage Change -0.2% -6.6% -6.6% 4.2%

ACUTE CARE The acute care category includes expenditures for hospitals, primary care, specialty care, and pharmacy, among others. Enrollment The appropriation overestimated enrollment increases due to COVID-19 and the economic downturn nearly across the board. In particular, the appropriation assumed too large an enrollment increase for the elderly and people with disabilities. Historically, the enrollment of these populations has been less sensitive to changes in the economy than enrollment of adults and children. Because the elderly and people with disabilities are expensive per capita and the state share is financed primarily from the General Fund, the change in enrollment assumptions for these populations accounts for nearly 50 percent of the overall change in the forecast that is attributable to enrollment.

The Department is now projecting total enrollment will grow 11.4 percent from FY 19-20 to FY 20-21, compared to the appropriation assumption of 26.1 percent enrollment growth over the same time period. There are several possible explanations for why enrollment is trending lower than expected. For example, some people losing their jobs may have access to spousal benefits or COBRA (Consolidated Omnibus Budget Reconciliation Act)-mandated access to continuation of their health coverage. Some people negatively impacted by the economy may already be on Medicaid or CHP+. The Department believes the main reason is people are going without insurance. Medicaid is not necessarily the highest priority for people with a loss of income who may have more immediate concerns, such as enrolling for unemployment or food benefits. The newly unemployed may delay enrolling in Medicaid until they are sick and need benefits. Applications for Medicaid are coming in at a steadier pace than both applications for the Supplemental Nutrition Assistance Program (SNAP) and unemployment insurance (UI) initial claims (including Pandemic Unemployment Assistance).



Per Capita FY 2019-20 actual per capita expenditures were higher than expected, causing the Department to increase the projection of FY 2020-21 per capita expenditures.

Safer-at-home utilization The appropriation assumed pandemic concerns would decrease Medicaid utilization, even after the stay-at-home order expired, but utilization has rebounded more quickly than expected, and so the November forecast adds $54.9 million total funds back to the forecast. The Department attributes the rebound in utilization in part to faster adoption of telehealth than originally expected.

SNAPMEDICAID

UI INITIAL CLAIMS

0

20,000

40,000

60,000

80,000

100,000

120,000

1-Feb 1-Mar 1-Apr 1-May 1-Jun 1-Jul 1-Aug 1-Sep 1-Oct 1-Nov

$600/Week Unemployment Stimulus Expires

Stay-at-homeorder

Medicaid applications were less sensitive to COVID-19 and stimulus policies than both Unemployment Insurance (UI) Initial Claims and applications for the Supplemental Nutrition Assistance Program (SNAP)



COVID-19 Treatment costs The forecast includes an increase of $145.4 million total funds, including $35.2 million General Fund, for Medicaid hospital costs above the normal trend due to COVID-related hospitalizations. The Department projected total COVID-related hospitalizations using a model prepared by the Colorado Department of Public Health and Environment as of September 21, 2020, and then estimated the portion of total hospitalizations attributable to Medicaid and multiplied this by the average Medicaid cost per COVID-related hospitalization. Some key assumptions include 65 percent social distancing, but only 40 percent over the holidays, and 70 percent mask wearing. The table below shows the total hospitalizations used for the forecast. It is important to note this was the Department's forecast at a point in time and may not reflect current conditions. For more information on the Department's assumptions, or to see how the model changes with different assumptions, follow this link: https://cucovid19.shinyapps.io/colorado/

$50

$55

$60

$65

$70

$75

$80

$85

$90

$95

$100

5-Jan 5-Feb 5-Mar 5-Apr 5-May 5-Jun 5-Jul 5-Aug 5-Sep 5-Oct

Millions

Stay at homeorder

Acute care expenditures recovered quickly to pre-COVID weekly averageAdjusted for estimated incurred but not reported expenditures

pre-COVID weekly average

https://cucovid19.shinyapps.io/colorado/



The Department did not assume any decrease in elective hospital procedures, which seems likely if COVID-related hospitalizations reach this level, due to staffing shortages, bed capacity, and/or government orders. The Department did not assume any new government restrictions beyond what was in effect in September, or any dramatic voluntary changes in population behavior. This adjustment does not include any increase in Medicaid enrollment, which may occur if people are delaying enrollment until they need it and a COVID-related hospitalization triggers that need. The Department says the impacts on Medicaid enrollment of increased hospitalizations are accounted for in the enrollment trend assumptions used for the forecast.

Other acute The forecast for acute care includes other miscellaneous changes with the largest attributable to a new estimate of the drug rebates that are available to offset General Fund expenditures versus drug rebates that must be paid to the federal government. LONG-TERM SERVICES AND SUPPORTS The forecast for long-term services and supports is somewhat influenced by the lower Medicaid enrollment forecast noted above, but overall reductions for enrollment are offset by increases in the estimated cost per utilizer. HCBS waivers Home- and Community-Based Services (HCBS) assist the elderly and people with disabilities with activities of daily living, so that they can live in the community instead of an institutional setting. The services are either non-medical services or routine and repetitive health maintenance services that do not require clinical judgement or assessment. Examples of the services include assistance with bathing, meals, or cleaning a feeding tube.

As with acute care, the appropriation assumed pandemic concerns would reduce utilization, but the November forecast adds money back to the forecast based on actual costs per utilizer. Overall



utilization of HCBS has not changed significantly in response to the pandemic, although some services have changed. Of the top five services only day habilitation shows a significant decrease. There was a small dip and recovery in personal care.

The HCBS services most impacted by the pandemic have been non-medical transportation, day habilitation, and adult day services.



Home Health/PDN Long-term home health and private duty nursing (PDN) are skilled nursing and therapy services provided in a home setting. People can potentially receive both HCBS services and long-term home health or private duty nursing. The difference between long-term home health and private duty nursing is a matter of degree, with private duty nursing the more intensive service and generally limited to people who are machine-dependent and/or require round-the-clock care. In addition to traditional nursing services, home health includes physical therapy, occupational therapy, and speech therapy.

The Department increased the estimated cost per utilizer by 3 percent for long-term home health and 4 percent for private duty nursing, based on trends in actual expenditures per utilizer.

Nursing homes The Department moderately lowered the estimate bed days.

PACE The Department increased the enrollment forecast 2 percent. OTHER Medicare insurance premiums For people eligible for both Medicaid and Medicare the Department pays the Medicare premiums. The change is due to the lower forecast of enrollment.

Service management The change is due to the lower forecast of enrollment. Hospital supplemental payments The Department lowered the forecast of supplemental payments to hospitals that are financed with the Healthcare Affordability and Sustainability Fee. However, at the same time the Department adjusted assumptions about the federal match rate based on a new decision from the federal Centers for Medicare and Medicaid Services (CMS) that allows a 90 percent federal match for payments attributable to ACA expansion populations. Despite the modest decrease in supplemental payments, the Department estimates hospitals are better off due to the increase in the federal match by $210.9 million compared to what was assumed in the appropriation.

Federal match rate The appropriation assumed Colorado would receive an additional 6.2 percent federal match through December 2020, but with the extension of the federal public health emergency the enhanced federal match will continue through at least March 2021. The November forecast takes into account this additional quarter of enhanced federal match. The public health emergency could be extended further, thereby extending the duration of the enhanced federal match. It is unclear how a new administration may impact the duration of the federal public health emergency. STAFF RECOMMENDATION Staff recommends approval of the request. The new forecast uses more recent data than the forecast used for the original appropriation. All of the expenditures contained in the supplemental are for



programs authorized in current law. If the February forecast is significantly different than the forecast used for this supplemental, then the JBC staff may recommend a supplemental add-on to the Long Bill.

S2 BEHAVIORAL HEALTH

REQUEST RECOMMENDATION TOTAL ($98,830,829) ($98,830,829) General Fund (42,281,674) (42,281,674) Cash Funds 1,731,561 1,731,561 Federal Funds (58,280,716) (58,280,716)


YES

Explanation: JBC staff and the Department agree that this request is the result of new data that was not available when the original appropriation was made regarding actual enrollment and expenditures. DEPARTMENT REQUEST The Department requests a net decrease of $17.9 million total funds, including a decrease of $148.9 million General Fund, based on a new projection of enrollment and expenditures under current law. Behavioral health services, which include both mental health and substance use-related services, are provided to Medicaid clients through a statewide managed care or "capitated" program. The Department contracts with “regional accountable entities” (RAEs) to provide or arrange for behavioral health services for clients enrolled with each RAE1. Each RAE receives a pre-determined monthly amount for each Medicaid client who is eligible for behavioral health services and enrolled with the RAE. The "per-member-per-month" rates paid to each RAE are unique for each Medicaid eligibility category in each geographic region. These rates are periodically adjusted based on clients’ actual utilization of behavioral health services and the associated expenditures. The forecast used for the original FY 2020-21 appropriation incorporated trend data through December 2019 while the latest forecast used for this supplemental request incorporates data through June 2020. The Department will submit a new forecast in February that uses data through December 2020. If that February forecast is significantly different than the forecast used for this supplemental, then the JBC staff may recommend a supplemental add-on to the Long Bill. The chart below summarizes the Department's forecast of enrollment and expenditures.

1 Clients are attributed to RAEs based on the location of their primary care provider, rather than their own address.



The table below shows the major contributors to the change from the FY 20-21 appropriation to the Department's November 2020 forecast for FY 20-21. It does not show differences from FY 19-20 expenditures.

FY 2020-21 BEHAVIORAL HEALTH ENROLLMENT/UTILIZATION TRENDS

TOTAL FUNDS

GENERAL FUND

OTHER STATE

FEDERAL FUNDS

FY 2020-21 Appropriation $959,410,239 $249,860,102 $54,860,438 $654,689,699 Enrollment (105,097,833) (34,483,744) (8,653,855) (61,960,234) Per capita (15,732,996) (8,172,019) 9,847,532 (17,408,509) Risk corridor payments for FY 18-19 22,000,000 6,876,422 1,033,486 14,090,092 Federal match rate 0 (6,502,333) (495,602) 6,997,935 TOTAL $860,579,410 $207,578,428 $56,591,999 $596,408,983 Increase/(Decrease) (98,830,829) (42,281,674) 1,731,561 (58,280,716) Percentage Change -10.3% -16.9% 3.2% -8.9%

The state pays predetermined amounts per member per month to the Regional Accountable Entitites (RAEs) for behavioral health services for Medicaid clients. With the lower enrollment forecast, discussed above under Medical Services Premiums, the number of per member payments decreases. Also, the Department lowered the projected per capita cost based on the final negotiated managed care rates coming in lower than estimated for the appropriation. Federal regulations require the managed care rates to be actuarially sound based on the expected costs and utilization of different services. When there is significant uncertainity about the costs or utilization the Department can establish risk corridors where the Department could make additional payments

$301

$391

$555 $554 $629 $601

$632

$712

$824

$1,022 $1,086

659

835

1,130

1,262 1,310 1,278

1,224 1,183

1,320 1,368

1,504

12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23

ExpendituresMillions

CaseloadThousands

Behavioral Health Capitation Payments and CaseloadNovember forecast, reconciliations adjusted for date of service

Forecast Period



or recover payments from the RAEs because acutal costs or utilization fall outside the risk corridor. In FY 2018-19 the rates included risk corridors because Medicaid enrollment was falling and the demographics of who remianed on Medicaid were changing. The majority of people leaving Medicaid were low utilizers of behavioral health services, causing an increase in costs per capita that exceeded the risk corridor and requiring the Department to make additional payments to the RAEs. The decrease in General Fund and increase in federal funds for the federal match rate is to account for the additional quarter of enhanced federal match as a result of the extension of the federal public health emergency, discussed above under Medical Services Premiums. STAFF RECOMMENDATION Staff recommends approval of the request. The new forecast uses more recent data than the forecast used for the original appropriation. All of the expenditures contained in the supplemental are for programs authorized in current law. If the February forecast is significantly different than the forecast used for this supplemental, then the JBC staff may recommend a supplemental add-on to the Long Bill.

S3 CHILDREN'S BASIC HEALTH PLAN

REQUEST RECOMMENDATION TOTAL ($52,581,053) ($52,581,053) General Fund (14,035,710) (14,035,710) Cash Funds (3,774,937) (3,774,937) Federal Funds (34,770,406) (34,770,406)


YES

Explanation: JBC staff and the Department agree that this request is the result of new data that was not available when the original appropriation was made regarding actual enrollment and expenditures. DEPARTMENT REQUEST The Department requests a net decrease of $52.6 million total funds, including a decrease of $14.0 million General Fund, based on a new projection of enrollment and expenditures under current law. The Children’s Basic Health Plan pays for physical health services for eligible children and pregnant women and for dental services for children. The forecast used for the original FY 2020-21 appropriation incorporated trend data through December 2019 while the latest forecast used for this supplemental request incorporates data through June 2020. The Department will submit a new forecast in February that uses data through December 2020. If that February forecast is significantly different than the forecast used for this supplemental, then the JBC staff may recommend a supplemental add-on to the Long Bill. The chart below summarizes the Department's forecast of enrollment and expenditures.



The table below shows the major contributors to the change from the FY 20-21 appropriation to the Department's November 2020 forecast for FY 20-21. It does not show differences from FY 19-20 expenditures.

FY 2020-21 CHILDREN'S BASIC HEALTH PLAN ENROLLMENT/UTILIZATION TRENDS

TOTAL FUNDS

GENERAL FUND

OTHER STATE

FEDERAL FUNDS

FY 2020-21 Appropriation $239,783,819 $23,311,123 $49,379,242 $167,093,454 Enrollment (46,583,054) (11,324,917) (2,480,385) (32,777,752) Per capita (5,997,999) (1,458,188) (319,373) (4,220,438) Federal match rate 0 (1,252,605) (809,973) 2,062,578 TOTAL $187,202,766 $9,275,413 $45,769,511 $132,157,842 Increase/(Decrease) (52,581,053) (14,035,710) (3,609,731) (34,935,612) Percentage Change -21.9% -60.2% -7.3% -20.9%

The lower-than-expected enrollment sounds counter-intuitive given the downturn in the economy and the Medicaid trend. However, it is not uncommon for CHP+ enrollment to slow during an economic downturn when people become eligible for Medicaid and thereby lose eligibility for CHP+. STAFF RECOMMENDATION Staff recommends approval of the request. The new forecast uses more recent data than the forecast used for the original appropriation. If the February forecast is significantly different than the forecast used for this supplemental, then the JBC staff may recommend a supplemental add-on to the Long Bill.

$192 $183

$136 $123

$150

$194 $189 $188 $187

$209 $219

79,446

62,506

54,391 51,708

64,888

77,730 80,949

77,469 77,322 81,101

84,637

$0.0

$50.0

$100.0

$150.0

$200.0

$250.0

12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23

Enrollment


Children's Basic Health Plan (CHP+) Enrollment and ExpenditURESNovember forecast, without reconciliations

Forecast Period



S4 MEDICARE MODERNIZATION ACT

REQUEST RECOMMENDATION TOTAL ($14,430,417) ($14,430,417) General Fund (14,430,417) (14,430,417)


YES

Explanation: JBC staff and the Department agree that this request is the result of new data that was not available when the original appropriation was made regarding actual enrollment and expenditures. DEPARTMENT REQUEST The Department requests a decrease of $14.4 million General Fund based on a new projection of enrollment and expenditures under current law. The Medicare Modernization Act line item reimburses the federal government for a portion of prescription drug costs for people dually eligible for Medicare and Medicaid. In 2006 Medicare took over responsibility for these drug benefits, but to defray the costs the federal legislation requires states to make an annual payment based on a percentage of what states would have paid for this population in Medicaid, as estimated by a federal formula. This is a 100 percent state obligation and there is no federal match. However, in some prior years the General Assembly applied federal bonus payments received for meeting performance goals of the Children's Health Insurance Program Reauthorization Act (CHIPRA) to offset the need for General Fund in this line item. The forecast used for the original FY 2020-21 appropriation incorporated trend data through December 2019 while the latest forecast used for this supplemental request incorporates data through June 2020. The Department will submit a new forecast in February that uses data through December 2020. If that February forecast is significantly different than the forecast used for this supplemental, then the JBC staff may recommend a supplemental add-on to the Long Bill. When the appropriation was made for FY 2020-21 it was not clear whether the enhanced federal match through the federal Families First Coronavirus Response Act would reduce the state obligation under the Medicare Modernization Act. Since then the Centers for Medicare and Medicaid Services (CMS) issued guidance that the enhanced match does reduce the state obligation and gave states a credit for payments made in state FY 2019-20. As a result, the Department estimates Colorado is saving $27.2 million General Fund in FY 2020-21, including a credit or $6.6 million for payments in FY 2019-20 and an expected $20.6 million for invoices in FY 2020-21.



The Medicare Modernization Act is normally a 100 percent General Fund obligation, but from FY 2012-13 to FY 2014-15, in order to offset General Fund costs, Colorado applied bonus payments

$102 $106 $108 $114

$130 $144 $149

$161 $154

$190 $201

$2762,542 67,734

72,104 73,142 73,562 74,803 76,592 80,004

86,374 87,294 87,149

0.0

50.0

100.0

150.0

200.0

250.0

12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23

Medicare Modernization Act Caseload and ExpendituresNovember forecast

Ave. MonthlyCaseload


Forecast Period

Avoided cost due to enhanced federal match

$1,628

$2,013

$2,302

12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23

Medicare Modernization Act per capita costs are rising based on the federal formula calculation of prescription drug costs

Per Capita Costs

Forecast Period



received from the federal government for meeting performance goals for enrolling children in Medicaid and CHP+ toward this obligation. The federal Centers for Medicare and Medicaid Services (CMS) believes Colorado miscalculated the bonus payments earned and is seeking to recover $38.4 million. The Department is disputing the attempted recovery in court. If Colorado loses it would need to come up with the $38.4 million. There are scenarios where Colorado might be able to allocate some of the costs to sources other than the General Fund and/or spread the repayment out over multiple years. STAFF RECOMMENDATION Staff recommends approval of the request. The new forecast uses more recent data than the forecast used for the original appropriation. The obligation to the federal government is calculated based on a federal formula over which the General Assembly has no control. If the February forecast is significantly different than the forecast used for this supplemental, then the JBC staff may recommend a supplemental add-on to the Long Bill.

S5 OFFICE OF COMMUNITY LIVING [INCLUDES LEGISLATION]

REQUEST RECOMMENDATION TOTAL ($4,860,971) ($4,860,971) FTE 0.0 0.0 General Fund (14,512,191) (14,512,191) Cash Funds 1,637,257 1,637,257 Federal Funds 8,013,963 8,013,963


YES

Explanation: JBC staff and the Department agree that this request is the result of data that was not available when the original appropriation was made. DEPARTMENT REQUEST: The Department requests a net decrease of $4,860,971 total funds, including a decrease of $14,512,191 General Fund, to align appropriations with the estimated number of enrollments in each Medicaid Home and Community Based Services waiver program for people with intellectual and developmental disabilities. STAFF RECOMMENDATION: JBC staff recommends approval of the Department’s request. In addition, JBC staff recommends that the Committee consider sponsoring legislation to provide one-time sustainability payments totaling at least $14.5 million General Fund to providers in the Office of Community Living providing day habilitation program services to individuals with intellectual and developmental disabilities. STAFF ANALYSIS: Pursuant to Section 25.5-10-207.5, C.R.S., the Department of Health Care Policy and Financing submits, as part of its annual budget request, information specifically related to achieving the enrollment goal set forth in the intellectual and developmental disabilities strategic plan required by



state law. Since FY 2013-14, the Department has requested sufficient funding to eliminate the waitlist for the Home and Community Based Services (HCBS) Supported Living Services (SLS), Children’s Extensive Services (CES), and Children’s Habilitation Residential Program (CHRP) waivers. A waitlist continues to exist for the Adult Comprehensive Services (DD) waiver, though each year additional enrollments are funded to provide resources for emergency placements, individuals transitioning from the CHRP or CES waivers, or for Colorado Choice Transition clients transitioning from an institutional setting. The FY 2020-21 adjusted funding request based on the November 2020 forecast covers the cost of all individuals currently enrolled in the CHRP, CES, SLS, and DD waiver programs and in the State SLS and FSSP programs. An updated forecast for the current and upcoming fiscal year will be submitted by the Department in February 2021. The FY 2020-21 request is based on the following: • Full program equivalent (FPE) enrollments in waiver programs that do not have a waiting list

include: 93 CHRP FPE, 1,909 CES FPE, and 4,379 SLS FPE. • The maximum enrollment in the DD waiver program is determined by the funding appropriated

by the General Assembly and is 7,302, including 41 transitions from institutions, 47 aging caregiver enrollments, 189 emergency enrollments, 43 foster care transitions, and 91 youth transitions. FPE served in the DD waiver program is anticipated to be 6,790.

• Services to individuals in the State-only Programs, including State SLS and FSSP are limited by the funding made available in the annual appropriation.

• Based on the November 2020 forecast, the Department requests an adjustment to the FY 2020-21 appropriation to align funding with the forecast and projected utilization of services. This adjustment includes a decrease of $4.9 million total funds, including:

o A decrease of $14.5 million General Fund, including $10.3 million resulting from the increased FMAP rate applied through March 31, 2021,

o An increase of $650,200 cash funds from the Individuals with Intellectual and Development Disabilities (IDD) Services Cash Fund,

o An increase of $1.1 million cash funds from the Healthcare Affordability and Sustainability (HAS) Fee Cash Fund,

o A decrease of $125,193 cash funds from the Family Support Loan Program Fund, and o An increase of $8.0 million federal funds.

The Department’s request includes the following adjustments:



DEPARTMENT OF HEALTH CARE POLICY AND FINANCING S5 OFFICE OF COMMUNITY LIVING COST AND CASELOAD

LINE ITEM TOTAL FUNDS

GENERAL FUND

CASH FUNDS

REAPPROPRIATED FUNDS

FEDERAL FUNDS

Adult Comprehensive Services Initial FY 2020-21 appropriation $525,769,702 $239,180,185 $7,520,047 $0 $279,069,470 Adjusted FY 2020-21 estimate 525,827,447 230,942,700 7,520,047 0 287,364,700

FY 2020-21 Adjustment, Requested $57,745 ($8,237,485) $0 $0 $8,295,230 Adult Supported Living Services Initial FY 2020-21 appropriation $71,889,381 $33,352,698 $389,750 $0 $38,146,933 Adjusted FY 2020-21 estimate 69,031,947 29,702,197 1,603,791 0 37,725,959

FY 2020-21 Adjustment, Requested ($2,857,434) ($3,650,501) $1,214,041 $0 ($420,974) Children's Extensive Support Services Initial FY 2020-21 appropriation $29,961,574 $14,082,730 $0 $0 $15,878,844 Adjusted FY 2020-21 estimate 30,587,543 13,871,451 0 0 16,716,092

FY 2020-21 Adjustment, Requested $625,969 ($211,279) $0 $0 $837,248 Children's Habilitation Residential Program Initial FY 2020-21 appropriation $4,779,680 $2,390,029 $0 $0 $2,389,651 Adjusted FY 2020-21 estimate 6,434,595 2,918,089 0 0 3,516,506

FY 2020-21 Adjustment, Requested $1,654,915 $528,060 $0 $0 $1,126,855 Case Management Initial FY 2020-21 appropriation $40,420,895 $18,862,830 $81,163 $0 $21,476,902 Adjusted FY 2020-21 estimate 35,960,674 15,921,844 386,323 0 19,652,507

FY 2020-21 Adjustment, Requested ($4,460,221) ($2,940,986) $305,160 $0 ($1,824,395) State Supported Living Services Initial FY 2020-21 appropriation $9,893,584 $8,228,509 $1,665,075 $0 $0 Adjusted FY 2020-21 estimate 9,949,675 8,228,509 1,721,166 0 0

FY 2020-21 Adjustment, Requested $56,091 $0 $56,091 $0 $0 State Supported Living Services Case Management Initial FY 2020-21 appropriation $2,416,320 $2,140,088 $276,232 $0 $0 Adjusted FY 2020-21 estimate 2,423,785 2,140,088 283,697 0 0

FY 2020-21 Adjustment, Requested $7,465 $0 $7,465 $0 $0 Family Support Services Initial FY 2020-21 appropriation $7,515,264 $7,136,298 $378,966 $0 $0 Adjusted FY 2020-21 estimate 7,569,764 7,136,298 433,466 0 0

FY 2020-21 Adjustment, Requested $54,500 $0 $54,500 $0 $0 Total, Office of Community Living Initial FY 2020-21 appropriation $692,646,400 $325,373,367 $10,311,233 $0 $356,961,800 Adjusted FY 2020-21 estimate 687,785,430 310,861,176 11,948,490 0 364,975,764

FY 2020-21 Adjustment, Requested ($4,860,970) ($14,512,191) $1,637,257 $0 $8,013,964 JBC Staff recommends approval of the Department’s request. DAY PROGRAMMING SERVICES UPDATE The Department operates ten Home and Community Based Services (HCBS) programs to help members requiring support in performing activities of daily living remain in their home and community. The COVID-19 pandemic significantly impacted services provided to people through HCBS waiver programs, requiring the Department and providers to develop new processes through



which members will receive some services. The Department took several actions to sustain services during the pandemic, including: • Expanding the places where services may be provided (including virtual options), • Permitting payments to family caregivers or legally responsible individuals for services provided, • Authorizing retainer payments for day program providers who needed to suspend services, • Allowing all case management activities to be completed via phone or other technology-based

methods. Retainer payments were made to providers of adult day, day habilitation, supported employment, and prevocational services. These retainer payments were authorized by the Centers for Medicare and Medicaid Services (CMS) and included a federal match. CMS limited retainer payments to services that included personal care and habilitation that were unable to be provided during the COVID-19 public health emergency. The Department identified day services as being both allowed by CMS and most significantly affected by closure and capacity limitations put in place as a result of the pandemic. Of the $29.4 million total funds paid to providers in retainer payments, $26.9 million was paid to intellectual and developmental disabilities (IDD) waiver providers. IDD services that were eligible for retainer payments include day habilitation and supported employment. The Department reports that the Office of Community Living explored the possibility of using state-only funds to continue retainer payments. However, in order to implement the payments, the development of a new system and billing method would be necessary and the Department would be required to review thousands of prior authorization requests to ensure claims were submitted appropriately. The Department opted instead to enhance flexibility for where and how people received services, but any implemented changes to service delivery were required to remain budget neutral. The Department had provided telehealth options for its members, however was informed that while it worked well for some members, other members required additional options. Accordingly, the Department designed a 3-tiered delivery system for all Day Programs. These tiers include new options for how services are delivered, including virtual delivery of services, individualized one-on-one services, and in-person individualized services. With the conclusion of the retainer payments and capacity restrictions still in place, access to day programming services has diminished, resulting in a 50 to 65 percent decrease in billable day programming and transportation services by Community Centered Boards (CCBs). CCBs report that prior to the pandemic, day habilitation typically operated at a loss, but because this programming is a critical support service for IDD individuals and their families, the organizations are committed to the ongoing delivery of these services. The significant decrease in utilization due to the restrictions will result in the closure of day habilitation programs and a substantial loss of system capacity. Subsequent to the JBC staff briefing concerning this issue, a $900 billion COVID-relief and $1.4 trillion government funding package was enacted at the federal level, and while day habilitation programs provide respite for caretakers to be able to go to work and much needed services for individuals with IDD, neither package included additional retainer payments for providers negatively impacted by the ongoing public health emergency. Additionally: • The Department rescinded its original operating memo that had identified funding caps for

individuals receiving day programming services and implemented a more individualized approach to establishing service limitations; and



• On January 8, 2020, the Governor signed Executive Order D 2021 010 ordering the suspension of certain statutes and directing the Department of Health Care Policy and Financing to provide additional funds to nursing homes and other congregate care facilities due to the presence of COVID-19.

The executive order requires the Department to increase rates to Home and Community Based Services providers by 8 to 10 percent for certain services through March 31, 2021. The projected fiscal impact of this executive order is $6.9 million total funds, including $3.0 million General Fund per month. Of this amount, $1.4 million total funds, including $0.7 million General Fund, per month is for services in the Office of Community Living. Compared with the four months of IDD retainer payments, paid from March 13 through July 17, 2020, with a monthly cost of approximately $6.7 million total funds, including $3.4 million General Fund, the increased rates for Office of Community Living providers are significantly lower – with rate increases at approximately 20 percent of the retainer payments. Given that CCBs are reporting a reduction in billable services between 50 and 65 percent, JBC staff does not believe that increasing rates by 10 percent will be enough to ensure the ongoing sustainability of these programs. JBC staff recommends that the Committee consider sponsoring legislation that provides one-time sustainability payments in FY 2020-21 to providers offering day programming services to individuals with IDD in order to further close the gap between the lost billable services and the increased rates provided through Executive Order D 2021 010. JBC staff recommends that the payments be at least equivalent to the $14.5 million General Fund reduction resulting from the cost and caseload adjustment in the Department’s S5 budget request. These payments will not be eligible for federal match and will therefore result in a lesser impact than the retainer payments.

S6 NURSE ADVICE LINE

REQUEST RECOMMENDATION TOTAL $966,896 $306,929 General Fund 1,117,028 1,117,028 Federal Funds (150,132) (810,099)


YES

Explanation: JBC staff and the Department agree that this request is the result of data that was not available when the original appropriation was made. The Department did not anticipate the end of federal financial participation. DEPARTMENT REQUEST The Department requests a net increase of $966,896, including an increase of $1,117,028 General Fund, to: 1) repay federal funds previously drawn to support the Nurse Advice Line; and 2) provide funding to continue operating the nurse advice line without federal funds. The federal Centers for Medicare and Medicaid Services (CMS) recently determined the Nurse Advice Line does not qualify for matching federal funds and required the Department to repay federal funding provided back to July 1, 2019.



Nurse Advice Line

TOTAL FUNDS

GENERAL FUND

FEDERAL FUNDS

Repay federal funds $966,896 $966,896 $0 Continue operations 0 150,132 (150,132) Total $966,896 $1,117,028 ($150,132)

In September the JBC approved an interim supplemental to help the Department continue operating the Nurse Advice Line without federal funds by providing some additional budget flexibility in how the Department spends the appropriation for utilization and quality review contracts. With the new flexibility the Department planned to negotiate temporary reductions in other contracts paid from the same line item to backfill the lost revenue for the Nurse Advice Line. However, the Department indicated it would also need to scale back operations of the Nurse Advice Line, such as data collection requirements and/or staffing levels. The Department now has better information about the renegotiated contracts and the remaining shortfall for the Nurse Advice Line in FY 2020-21 and requests $150,132 General Fund to minimize reductions in the scope of service provided. An associated request for FY 2021-22 would fully backfill the lost revenue from the end of federal financial participation for the Nurse Advice Line by providing $898,265 General Fund with no reductions in other contracts or reductions in scope for the Nurse Advice Line. The portion of the request to repay the federal funds was not included in the September interim supplemental because the Department did not need the money before the General Assembly returned to regular session. However, the Department does need the money in FY 2020-21 to meet the negotiated deadline with the federal government to make the repayment. STAFF RECOMMENDATION Staff recommends approval of the request with a technical correction to the federal funds. The Department accounted for the decrease in federal funds that the Department is proposing to offset with an increase in General Fund, but the Department did not account for the total decrease in federal funds due to the end of federal financial participation. The staff write-up of the interim supplemental request, reproduced at the end of this document, discusses the benefits and performance of the Nurse Advice Line in greater detail but, to summarize, the Nurse Advice Line improves access to care and likely results in overall lower care costs and care that is better suited to member health needs. Although the JBC staff is recommending the supplemental, it would not be overly problematic if the JBC denied it. The Department could manage without the FY 2020-21 funding and the impact on performance would likely be small. For example, the current average speed to answer ranges from a minute to twenty seconds, depending on whether the call requires an RN or a lower level health advisor. If less funding for the Nurse Advice Line resulted in a somewhat longer speed to answer it seems unlikely to alter the client experience and decision making. It would be problematic if the JBC did not approve the FY 2021-22 funding. In that scenario the Department would need to eliminate the Nurse Advice Line. In FY 2019-20 the estimated cost of the recommended level of care from the Nurse Advice Line was lower than the original intent of callers after accounting for both upgrades and downgrades in the recommended level of care compared to



the original intent of the callers. It is also possible that absent the Nurse Advice Line people would instead seek advice from a more costly emergency room, urgent care clinic, or primary care provider.

S7 MEDICAID FUNDING FOR CONNECT FOR HEALTH

REQUEST RECOMMENDATION TOTAL $4,049,364 $4,049,364 Cash Funds 1,827,019 1,827,019 Federal Funds 2,222,345 2,222,345


YES

Explanation: JBC staff and the Department agree that this request is the result of data that was not available when the original appropriation was made. DEPARTMENT REQUEST The Department requests $4.0 million total funds, including $1.8 million cash funds and $2.2 million federal funds, for Connect for Health Colorado Eligibility Determinations. The source of cash funds is certified public expenditures by Connect for Health. STAFF RECOMMENDATION Staff recommends the request. Under an agreement approved by the General Assembly in FY 2016-17, when Connect for Health spends local tax revenues on administrative costs related to eligibility determinations for Medicaid and the Children's Basic Health Plan (CHP+) the Department certifies these public expenditures to draw federal matching funds. The federal funds are then distributed to Connect for Health. No state General Fund is spent, because the state match for the federal Medicaid dollars comes from the local tax revenue collected by Connect for Health. Certifying public expenditures to the federal government is an administratively intensive process that requires significant funds documentation and a random moment time study to allocate customer service center staff time attributable to Medicaid and CHP+. There is typically a delay of several quarters between when costs are incurred and when the reconciliation process is compete to certify the expenditures and make the payments of federal funds. The amount that can be certified as public expenditures depends on the total spending and the allocation of time by Connect for Health, rather than on decisions by the Department. The appropriation is based on the Department's best guess, with imperfect and delayed information, about the certified public expenditures by Connect for Health. In September the JBC approved an interim supplemental for a one-time catch-up payment for certified public expenditures that occurred in FY 2018-19 and FY 2019-20. This supplemental carries the trends from prior years forward and increases the forecast payments for certified public expenditures expected to occur in FY 2020-21 and FY 2021-22.



The JBC staff sees no reason to limit the certified public expenditures by Connect for Health. If Connect for Health spends more resources on activities that are eligible for Medicaid or CHP+ reimbursement, then it makes sense to draw the matching federal funds to help pay for those costs, reducing the burden on local tax revenues.

S8 FAMILY MEDICINE RESIDENCY TRAINING PROGRAM

REQUEST RECOMMENDATION TOTAL $1,204,207 $0 General Fund 353,723 0 Cash Funds 211,050 0 Federal Funds 639,434 0


NO

Explanation: The Department argues this was a technical error and the JBC did not intend to cut the University of Colorado family medicine residency program. As evidence, they cite that footnote 26 regarding intergovernmental transfers between the University of Colorado and the Department of Health Care Policy and Financing still references family medicine placements and was not updated to reflect the elimination of the State University Teaching Hospitals – University of Colorado Hospital Authority line item. The JBC staff notes that it was not just the JBC but the entire General Assembly that voted for the change. Based on a review of what was said and written about the reduction to the line item, the JBC staff admits there is a possibility the General Assembly did not understand that reducing the line item would impact family medicine residencies, but the JBC staff's default assumption is that the General Assembly knew what it was doing. The Department did not present any new information about the family medicine residencies. Therefore, the JBC staff concludes this request does not meet the JBC's supplemental criteria. However, the JBC members are better positioned than the JBC staff to judge whether the reduction to family residencies aligned with their intent or was a "technical error." DEPARTMENT REQUEST The Department requests $1.2 million total funds, including $379,468 General Fund, to partially restore the FY 2020-21 elimination of the State University Teaching Hospitals line items that impacted family medicine residencies. The State University Teaching Hospitals line items paid for graduate medical education at the University of Colorado Hospital Authority and Denver Health, but the funding for the University of Colorado Hospital Authority included $1,293,652 total funds that was used for family medicine residencies. The $1,293,652 total funds for family medicine residencies included reappropriated funds from the University of Colorado. The reappropriated funds were added a couple years ago as part of negotiations that resulted in the University of Colorado (CU) sending money appropriated for the School of Medicine to the Department of Health Care Policy and Financing to receive matching federal funds that are then paid to the physicians of CU. The funding in the State University Teaching Hospitals line paid for 36 family medicine residencies. All of the residencies include rural rotations and 6 were specifically rural track residencies. The reason the University of Colorado Hospital Authority had separate funding from the rest of the family medicine residencies are technical and tie back to federal regulation. The federal Center for



Medicare and Medicaid Services (CMS) was questioning the validity of Colorado's payments for graduate medical education. In FY 2008-09 the General Assembly decided the path of least resistance was to separate the funding into a line item that clarified the status of the University of Colorado Hospital as a "unit of government" in its role as a provider of graduate medical education and this successfully resolved the concerns of CMS. The State University Teaching Hospitals line item for Denver Health did not include any money for family medicine residencies. Denver Health does host family medicine residents, but the University of Colorado Hospital Authority is the sponsoring and organizing entity. Denver Health indirectly benefits from state funds for family medicine residencies through payments from the University of Colorado Hospital Authority. In addition to eliminating the State University Teaching Hospitals line items, the General Assembly reduced funding for the Commission on Family Medicine by $1,066,098 total funds. The staff recommendation was to reduce the Commission on Family Medicine by $4,000,000 total funds (almost 50 percent). Instead, the JBC chose to reduce the $8.2 million total funds appropriation for the Commission on Family Medicine by 13.0 percent. The $8.2 million total funds has historically paid for 228 residencies. When the reductions were made the residencies had already been awarded for 2020-21 and so absorbing the reductions by reducing residency placements was problematic, at least in the short term. The Commission is using reserves and proportional operating reductions to continue funding the residencies. In the longer term the number of family medicine residencies could be reduced to absorb the reductions in funding, or sponsoring hospitals and practices could take on the cost. If residencies are reduced it may impact the recruitment and retention of family medicine doctors to the state, although Colorado continues to experience net in-migration, suggesting it is a place people desire to live. Historically, approximately two thirds of the family medicine residents who train in Colorado remain in Colorado to practice and of those who remain approximately 40 percent practice in rural and underserved communities. The table below summarizes the funding for family medicine residencies from the two line items and the JBC's reductions to the two line items. The net result was a 24.9 percent decrease. The total funds match the historic residency funding and the FY 20-21 reductions, but the fund sources have been restated to reflect the higher federal match offered through the Families First Coronavirus Relief Act.

Family Medicine Residency Funding TOTAL

FUNDS GENERAL

FUND REAPPROPRIATED

FUNDS FEDERAL FUNDS

Historic Residency Funding State University Teaching Hospitals $1,293,652 $369,520 $197,100 $727,032 Commission on Family Medicine 8,196,518 3,590,075 0 4,606,443 Subtotal - Residency Funding $9,490,170 $3,959,595 $197,100 $5,333,475 FY 20-21 Reductions State University Teaching Hospitals ($1,293,652) ($369,520) ($197,100) ($727,032) Commission on Family Medicine (1,066,098) (466,951) 0 (599,147) Subtotal - Reductions ($2,359,750) ($836,471) ($197,100) ($1,326,179) Percent Reductions -24.9% -21.1% -100.0% -24.9%



In the supplemental the Department does not propose restoring all of the money in the State University Teaching Hospitals line items, but does request restoring the portion of the line item devoted to family medicine residencies with a reduction proportional to the reduction made to other family medicine residency programs. The proper way to look at this request is as restoring funds for family medicine residencies in general, rather than specifically for the University of Colorado Hospital Authority. In the request the Department asserts that due to federal regulation the money for the University of Colorado Hospital Authority residencies must flow through State University Teaching Hospitals line item and that without the appropriation the Commission on Family Medicine cannot pay for these residencies. However, the JBC staff believes this is likely an overstatement. The Commission on Family Medicine is currently paying for the University of Colorado Hospital Authority residencies from reserves. Further, it is unclear that current staff at CMS would have the same hyper-technical concerns about Colorado's appropriation structure as the staff at CMS over a decade ago that led to the creation of the State University Teaching Hospitals line items. The Commission on Family Medicine has taken a formal position that they want to allocate the money for family medicine residencies proportionally. If the reduction stays in place, the Commission would attempt to reduce funding for all family medicine residencies, rather than specifically eliminating funding for the University of Colorado Hospital Authority. It is unknown if CMS would object to that approach. STAFF RECOMMENDATION Staff does not recommend the request. The original staff recommendation, which the JBC did not approve, was to reduce the Commission on Family Medicine by $4.0 million total funds plus eliminate the State University Teaching Hospital line items, which included another $1.3 million for family medicine residencies, for a net reduction of $5.3 million total funds for family residencies. The current net reduction of $2.4 million total funds is significantly less. While the Commission on Family Medicine plays an important role in developing the primary care provider network, particularly in rural and underserved areas, the appropriation pays for teaching, rather than direct services and, therefore, the JBC staff considered it a lower priority than preserving eligibility and benefits. It appears there is more money now than was assumed in May, but more money is not one of the JBC's supplemental criteria. If the JBC wants to restore funding for the Commission on Family Medicine, the JBC may also want to consider restoring funding for some of the benefit reductions implemented last year, including the increase in member copays, a $1,000 annual cap on the adult dental benefit, stopping implementation of H.B. 20-1384 for wraparound services for at-risk children, and a $1.0 million reduction in the senior dental program. The member copays and $1,000 annual cap on the adult benefit have not yet been implemented due to the extension of the federal public health emergency, so decisions on restoring funding for these benefits will be made in figure setting for FY 2021-22. The H.B. 20-1384 wraparound services for at-risk children was a new program and thus a lower priority. Therefore, if the JBC wants to restore funding in FY 2020-21, the top priority for the JBC staff would be the $1.0 million General Fund for the senior dental program before the funding for family medicine residencies. If the JBC decides to restore funding for the family medicine residencies, then the dollar amounts need to be updated for the current federal match. To provide the same $1.2 million total funds



requested by the Department now requires $330,343 General Fund, rather than the $353,723 that was requested.

S9 TECHNICAL ADJUSTMENTS

REQUEST RECOMMENDATION TOTAL $0 $0 FTE 0.0 0.0 General Fund 0 0 Cash Funds 0 0 Federal Funds 0 0


YES

Explanation: JBC staff and the Department agree that this request is the result of a technical error in calculating the original appropriation. DEPARTMENT REQUEST: The Department requests a net zero shift of funding for the Healthy Communities program from the Customer Outreach line item to the Medical Services Premiums line item in FY 2020-21 and ongoing. STAFF RECOMMENDATION: Staff recommends approval of the Department’s request. STAFF ANALYSIS: The Healthy Communities program provides outreach and health education to children and pregnant women, including assistance with completion of applications for medical assistance, navigating health care systems, understanding coverage and benefits, referrals to community resources and providers, reenrollment, and preventing gaps in coverage. The FY 2020-21 Long Bill included a reduction to the Healthy Communities funding from $2.6 million to $624,374 total funds to shift the outreach and education responsibilities from local contractors to the Regional Accountable Entities (RAEs), which aligns with their current work and creates efficiencies in the program. The Long Bill reflected a transfer of the funding to the incorrect line item. The Department requests a technical correction to reflect the appropriation in the correct line item. This correction will reduce the appropriation in the Customer Outreach line item by $624,374 total funds, including $312,187 General Fund, and increase the appropriation to the Medical Services Premiums line item for contracts for the RAEs, by the same amount. JBC staff recommends approval of the Department’s request.



S10 PUBLIC HEALTH EMERGENCY END RESOURCES

REQUEST RECOMMENDATION TOTAL $8,323,654 PENDING FTE 1.0 General Fund 784,231 Cash Funds 1,087,562 Federal Funds 6,451,861

The staff analysis and recommendation on this supplemental request is pending and will be presented in a separate memo. The request is for administrative resources, primarily for counties, to address an expected surge in eligibility redeterminations and appeals when the federal public health emergency declaration ends and people who are currently locked-in on Medicaid as a result of the requirements of the public health emergency are no longer locked-in. Shortly after the Department submitted the supplemental request the federal government extended the public health emergency declaration. The Department is still sorting through how and if the extension changes the request. The extension changes the projection of when the surge in redeterminations and appeals will occur, but there are still significant logistical challenges to hire and train staff, and so the change in when the projected surge will occur may not change the request for FY 2020-21. The extension of the public health emergency also increases the projection of the number of people who will be locked in, which may increase the need for administrative resources. Due to the impact of the extension of the public health emergency on this request, the JBC staff decided to wait for additional information from the Department before making a recommendation. A separate memo will be provided with the staff recommendation as soon as possible and no later than staff comebacks.

S11 ROLL FORWARD FUNDING FOR SINGLE ASSESSMENT TOOL



YES

Explanation: JBC staff and the Department agree that this request is the result of an unforeseen contingency. DEPARTMENT REQUEST: The Department requests an extension of roll forward authority on funds appropriated in FY 2019-20 related to the implementation of S.B. 16-192 (Assessment Tool Intellectual and Developmental Disabilities).



STAFF RECOMMENDATION: Staff recommends approval of the Department’s request. STAFF ANALYSIS: Senate Bill 16-192 (Assessment Tool Intellectual and Developmental Disabilities) required the Department to select a new needs assessment tool for persons receiving long-term services and supports. The bill appropriated $21.5 million over five fiscal years for the Department to develop and implement a single assessment tool, fund contractors on an annual basis, develop a new system for implementation, and provide statewide training to all case managers. In 2019, the Department began piloting the new Long Term Services and Supports (LTSS) Assessment and Support Plan with case managers and assessed 650 members. Implementation of the pilot in the spring of 2020 was significantly impacted by the COVID-19 pandemic. Work on the pilot was completely halted for a period of time and then assessments that were intended to be performed in person were performed virtually. This affected the integrity of the results and prevented the validation of the assessment tool. In addition to the LTSS Assessment and Support Plan, the Department is working with a contractor and stakeholders to build an objective resource allocation methodology to be used as a component of the new LTSS Assessment and Support Plan process. This Person-Centered Budget Algorithm (PCBA) is an individualized budget allocation for members that uses scores from the assessment tool and input from case managers to develop an individual budget that meets the member’s needs for services. The PCBA is dependent upon validation of the pilot results, therefore its development and implementation has been delayed. Without the validation of the pilot results, the rates determined for assessments and the resource allocation for Home and Community Based Services waiver participants may be skewed. The Department intends to implement the LTSS Assessment and Support Plan with the Care and Case Management IT platform on July 1, 2021. In order to complete the validation process of the assessment tool pilot and complete work on the PCBA, the Department requests that FY 2019-20 roll forward authority be extended through FY 2021-22 as opposed to FY 2020-21 as identified in the FY 2019-20 Long Bill. This will allow for the pilot to include in-person assessments, validation of the LTSS Assessment and Support Plan, finalization and implementation of the PCBA, and implementation of the associated training. JBC staff recommends approval of the Department’s request. Recommended amendment to the FY 2019-20 Long Bill Footnote: 11 Department of Health Care Policy and Financing, Executive Director's Office, General

Administration, General Professional Services and Special Projects – Of this appropriation $5,288,258 remains available for expenditure on the single assessment tool project through the completion of the project or the close of the 2020-21 2021-22 state fiscal year, whichever comes first.



S12 FEDERAL MATCH FOR NON-FORECAST LINES

REQUEST RECOMMENDATION TOTAL $0 $0 General Fund (1,701,861) (1,701,861) Cash Funds (3,204,160) (3,204,160) Federal Funds 4,906,021 4,906,021


YES

Explanation: JBC staff and the Department agree that this request is the result of data that was not available when the original appropriation was made regarding the applicable federal match rate. DEPARTMENT REQUEST The Department request a net $0 total funds change that includes a $1.7 million decrease in General Fund for line items where the Department does not routinely produce expenditure forecasts. The adjustment is to account for a temporary increase in the federal match authorized by the federal Families First Coronavirus Response Act. The impact for the forecast line items is included in the forecast requests (S1-S5). This request includes the impact on all other line items. The duration of the enhanced federal match is tied to a public health emergency declaration by the federal Secretary of Health and Human Services. During the public health emergency and through the end of the fiscal quarter when the public health emergency expires, states are eligible for an additional 6.2 percent federal match for Medicaid. When the current appropriation was made it was assumed the enhanced federal match would end December 31, 2020, but a subsequent extension of the public health emergency resulted in this supplemental request that assumes the enhanced federal match will end March 31, 2021. STAFF RECOMMENDATION Staff recommends approval of the request. The total funds available for each program and administrative function will not change. The request trues up the appropriations to the correct applicable federal match rate, resulting in a savings to the General Fund.

S13 PUBLIC SCHOOL HEALTH SERVICES

REQUEST RECOMMENDATION TOTAL $8,806,057 $8,806,057 Cash Funds (842,607) (842,607) Federal Funds 9,648,664 9,648,664


YES



Explanation: JBC staff and the Department agree that this request is the result of data that was not available when the original appropriation was made regarding certified public expenditures by local school districts and boards of cooperative education services. DEPARTMENT REQUEST The Department requests an increase of $8.8 million total funds based on a projected certified public expenditures by school districts and Boards of Cooperative Education Services (BOCES). Through the School Health Services Program school districts and BOCES are allowed to identify their expenses in support of Medicaid eligible children with an Individual Education Plan (IEP) or Individualized Family Services Plan (IFSP) and claim federal Medicaid matching funds for these costs. Beginning in FY 20-21 the program expanded, following new federal guidance, to include services outside an IEP or IFSP that are included in other student health plans, such as a 504 disability plan, behavior plan, nursing plan, physician order, or crisis intervention services. Participating school districts and BOCES report their allowable expenses to the Department according to a federally-approved methodology and the Department submits them as certified public expenditures to claim the federal matching funds. The federal matching funds, less administrative expenses, are then disbursed to the school districts and BOCES and may be used to offset their costs of providing services or to expand services for low-income, under or uninsured children and to improve coordination of care between school districts and health providers. The Department's revised forecast for FY 2020-21 projects total allowable expenses for Public School Health Services will be $8.8 million higher than the appropriation. The request also updates the fund sources to account for the enhanced federal match. The Department attributes the increase in expenditures to improvements in identifying the number of students who are Medicaid eligible with an IEP and improved understanding of reporting requirements by providers resulting in more accurate accounting of eligible expenditures. Due to the lag between when services are delivered and when the administratively intensive process of certifying the expenditures is completed and payments and reconciliations are complete, a large portion of the payments in FY 2020-21 are for services provided in FY 2019-20 and the Department has limited data to speculate if there has been a COVID impact on expenditure trends. Pursuant to H.B. 20-1385, the amount of increased federal financial participation above 50 percent for certified public expenditures will be transferred to the General Fund. The school districts will be reimbursed as if the federal match were 50 percent. STAFF RECOMMENDATION Staff recommends approval of the request. The expenses for Public School Health Services are driven by an increase in the amount of expenditures by school districts and BOCES that can be claimed for a federal match. The actual amount of certified public expenditures are not in the direct control of the Department, and the availability of data to forecast the expenditures is limited, so this is a line item that frequently receives mid-year adjustments. The Department needs the increase in spending authority to distribute the federal funds to the school districts.



S14 OVEREXPENDITURES

REQUEST (FY 18-19)

RECOMMENDATION (FY 18-19)

TOTAL $28,697,114 $28,935,853 General Fund 26,728,469 26,728,471 Cash Funds 1,968,646 2,207,382


YES

Explanation: The request is the result of data that was not available when the original appropriation was made regarding actual expenditures for Medicaid. DEPARTMENT REQUEST The Department requests $28.7 million total funds, including $26.7 million General Fund, in FY 2019-20 to release restrictions on the FY 2020-21 appropriations imposed by the State Controller due to over-expenditures in prior years. Because of the entitlement nature of the Medicaid program, statute (Section 24-75-109, C.R.S.) allows the Department to overexpend Medicaid line items, except administrative line items, as long as the overexpenditures are consistent with the statutory purposes of the Medicaid program. However, the State Controller restricts the current fiscal year’s appropriation until the General Assembly approves a supplemental for the prior year overexpenditures. This restriction allows the JBC an opportunity to review the reasons for overexpenditures and to decide if the overexpenditures could have been avoided with better management of the appropriation or if the overexpenditures occurred as a result of an unforeseen event or forecast error. Mechanically, the release of the restrictions on the FY 2020-21 appropriations is accomplished by amending the FY 2019-20 appropriations. STAFF RECOMMENDATION Staff recommends releasing the restrictions. The staff recommendation is slightly higher than the Department's request, because the Department requested cash funds based on the net difference in all cash fund sources. The Department overspent some cash funds and underspent others. When releasing an overexpenditure restriction the General Assembly does not typically reduce appropriations for underspent funds. It only increases appropriations for overspent funds. The table below summarizes the recommended release of overexpenditure restrictions by line item and fund source.

Recommended Changes to FY 19-20 to Release Overexpenditure Restrictions in FY 20-21

TOTAL FUNDS

GENERAL FUND

CASH FUNDS

Medical Services Premiums $24,688,979 $24,688,979 $0 Behavioral Health Capitation Payments 1,298,419 0 1,298,419 Behavioral Health Fee-for-service Payments 346,306 0 346,306 Clinic Based Indigent Care 2,492 2,492 0 Children's Basic Health Plan 562,657 0 562,657 Medicare Modernization Act State Contribution 1,670,660 1,670,660 0 Mental Health Institutes 62,947 62,947 0 Division of Youth Services - Medicaid Funding 303,393 303,393 0 TOTAL $28,935,853 $26,728,471 $2,207,382



The largest overexpenditure occurred in the Medical Services Premiums line item, primarily due to overestimating rebates and outpatient cost settlements that otherwise would have offset the need for General Fund. The next largest overexpenditure was for the Medicare Modernization Act, due to unexpected retroactive enrollment. The overexpenditure for Behavioral Health Capitation Payments occurred primarily due to new federal guidance that the Department could claim only a 50 percent federal match for incentive payments to the Regional Accountable Entities (RAEs), rather than the 90 percent federal match budgeted for incentive payments related to expansion populations. All the other overexpenditures were for forecast errors of less than $1.0 million each.



STAFF-INITIATED SUPPLEMENTAL REQUESTS STAFF-INITIATED – PUBLIC HEALTH EMERGENCY EXTENSION

REQUEST RECOMMENDATION TOTAL $0 $238,640,880 General Fund 0 (75,122,979) Cash Funds 0 21,044,102 Federal Funds 0 292,719,757


YES

Explanation: The recommendation is the result of data that was not available when the original appropriation was made. Department Request Shortly after the Department submitted the supplemental request the federal government extended the public health emergency declaration another three months. There is no official department request related to the fiscal impact, but the Department did assist in providing rough estimates of the fiscal impact. The extension of the public health emergency declaration means that Colorado is eligible for an additional 6.2 percent federal match for at least another quarter, meaning the additional 6.2 percent federal match will be in place for all of FY 2020-21. However, it also means that Colorado cannot implement any reductions in eligibility or benefits and cannot terminate eligibility for anybody enrolled in Medicaid for another three months.

Public Health Emergency Extension

TOTAL FUNDS

GENERAL FUND

CASH FUNDS

FEDERAL FUNDS

Delay budget balancing benefit reductions Increase copays $2,202,466 $449,234 $135,621 $1,617,611 Adult dental benefit $1,000 annual cap 2,782,500 804,550 0 1,977,950 Subtotal - Benefit reductions 4,984,966 1,253,784 135,621 3,595,561

Locked-in enrollment impact (~59k people) Medical Services Premiums 214,069,326 38,714,918 15,153,732 160,200,676 Behavioral Health 29,649,562 3,514,644 2,671,934 23,462,984 Subtotal - Locked-in enrollment 243,718,888 42,229,562 17,825,666 183,663,660

Enhanced federal match Medical Services Premiums (0) (79,628,947) (3,311,866) 82,940,813 Behavioral Health 0 (6,502,333) (495,602) 6,997,935 Children's Basic Health Plan 0 (1,252,605) (809,973) 2,062,578 Medicare Modernization Act (6,858,815) (6,858,815) 0 0 Office of Community Living 0 (10,283,536) (68,020) 10,351,556 Non-forecast line items (3,204,159) (1,713,116) (4,598,697) 3,107,654 Subtotal (10,062,974) (106,239,352) (9,284,158) 105,460,536

HB 20-1385 Use of Increased Medicaid Match 0 (12,366,973) 12,366,973 0 Total FY 2020-21 Incremental Impact $238,640,880 ($75,122,979) $21,044,102 $292,719,757

The federal prohibition on reducing eligibility or benefits during the public health emergency delays the Department's ability to implement two budget balancing initiatives approved by the General



Assembly: (1) an increase in copays; and (2) a $1,000 cap on the adult dental benefit. The Department now assumes these will be implemented July 1, 2021, but they could be further delayed if the federal public health emergency is extended again. This additional three month delay in implementing these budget balancing measures costs $5.0 million total funds, including $1.3 million General Fund, beyond the delay costs already accounted for in the forecast (S1). The Department estimates extending the period where people are locked in to Medicaid will increase enrollment by roughly 59 thousand people and cost $243.7 million total funds, including $42.2 million General Fund. This is a very rough estimate based on the November forecast. The Department is in the process of preparing the February forecast that will incorporate more recent actual enrollment data and provide a much more precise estimate. The General Fund portion of these costs is more than offset by the 6.2 percent federal match for an additional fiscal quarter. The enhanced 6.2 percent federal match for an additional quarter is expected to save $106.3 million General Fund. Finally, the enhanced federal match means that, pursuant to H.B. 20-1385, Colorado will use the portions of the Healthcare Affordability and Sustainability (HAS) Fee and the Medicaid Nursing Facility Cash Fund that are no longer needed to match federal funds to offset the need for General Fund, saving $12.4 million General Fund. Staff Recommendation Staff recommends that the Committee make the adjustments to appropriations identified in the table above to account for the fiscal impact of the federal public health emergency extension. It is important to emphasize that these are rough estimates that will likely be refined in the February forecast, but for planning purposes the JBC staff believes it is worthwhile to make the adjustments in the supplemental bill.



PREVIOUSLY APPROVED INTERIM SUPPLEMENTAL REQUESTS

NURSE ADVICE LINE CONTINUATION


Does JBC staff believe the request satisfies the interim supplemental criteria of Section 24-75-111, C.R.S.? [The Controller may authorize an overexpenditure of the existing appropriation if it: (1) Is approved in whole or in part by the JBC; (2) Is necessary due to unforeseen circumstances arising while the General Assembly is not in session; (3) Is approved by the Office of State Planning and Budgeting (except for State, Law, Treasury, Judicial, and Legislative Departments); (4) Is approved by the Capital Development Committee, if a capital request; (5) Is consistent with all statutory provisions applicable to the program, function or purpose for which the overexpenditure is made; and (6) Does not exceed the unencumbered balance of the fund from which the overexpenditure is to be made.]

YES


YES

Explanation: JBC staff and the Department agree that this request is the result of unforeseen circumstances arising while the General Assembly is not meeting.

DEPARTMENT REQUEST The Department requests removal of an (M) note on a line item for utilization and quality review contracts that includes money for the Nurse Advice Line. The (M) note indicates that the money in a line item is used to match federal funds and the Controller must restrict the General Fund appropriation if the federal funds earned are more or less than the amount indicated in the Long Bill. The Department recently received notice that federal funds will not be available for the Nurse Advice Line. The Department is appealing the decision. In the meantime, the Department hopes to keep the Nurse Advice Line operating using the appropriated General Fund by scaling back operations, such as data collection requirements and/or staffing levels, and negotiating reductions (potentially temporary reductions) in other contracts paid from the same line item. This rebalancing to stay within the appropriated General Fund is only possible if the (M) note is removed. If the (M) note remains, the Department would need to stop expenditures for the Nurse Advice Line, since federal funds are no longer available. The Nurse Advice Line provides 24 hour access to medical information and advice for Medicaid recipients. The primary purpose is to direct callers to the right level of care needed for their condition. The Nurse Advice Line uses standardized triage guidelines that the Departments describes as evidence-based to direct people to an appropriate level of care. A secondary purpose is help members manage chronic medical conditions and connect people to community resources when indicated. COMMITTEE ACTION



Staff recommended, and the Committee approved, the request to continue the Nurse Advice Line with the appropriated level of General Fund. The Nurse Advice Line improves access to care and likely results in overall lower care costs and care that is better suited to member health needs. The Department has been spending $1,080,132 total funds per year on the Nurse Advice Line, including $181,867 General Fund, $88,166 cash funds from the provider fee on hospitals (the Healthcare Affordability and Sustainability Fee, or HAS Fee) and $810,099 federal funds. The federal match was 75 percent. If the Department begins the process of shutting down the Nurse Advice Line now it would save about 7/12ths of the appropriated funds, or roughly $106,000 General Fund. However, if the Nurse Advice Line is shut down there might be increases in care costs that exceed this savings. In FY 2019-20 there were 24,089 calls to the Nurse Advice Line. Of these calls 7,673 (31.8 percent) resulted in a downgrade in the recommended level of care compared to the caller's original intent and 4,332 (18.0 percent) resulted in an updgrade. For the remaining calls there was no change. Using average costs of care the contractor (Denver Health) estimates the net result of the downgrades and upgrades was a savings of $1.2 million total funds. It is also possible that absent the Nurse Advice Line people would instead seek advice from an emergency room, an urgent care clinic, or a primary care provider, either in person or through telemedicine. The average price of a call to the Nurse Advice Line is $58.15 compared to a visit to the: emergency room $343; urgent care clinic $117; or primary care $94. The Department estimated the substitution of alternatives to the Nurse Advice Line could result in increased costs in the range of $500,000 to $3.2 million total funds. It is difficult to predict what people would do absent the Nurse Advice Line. Rather than trying to predict a specific change in utilization, the Department indicates it would wait to see what happens and incorporate the care trends into the next forecast. According to the Department, there is not currently a direct substitute for the Nurse Advice Line for fee-for-service members. Some of the managed care organizations, including Denver Health, have call lines for Medicaid members enrolled in managed care. The Department is not aware of any RAEs or other organizations operating similar services for fee-for-service members. Medicaid primary care providers are required to have an after hours line, but the Department asserts that they do not typically use evidence-based protocols to refer callers and that the creation of the Nurse Advice Line and similar services in other states was a direct result of too many referrals to the emergency room from these after hours lines. Based on this feedback from the Department, the JBC staff wonders if a solution might be greater quality regulation by the Department of primary care after hours lines, but this may pass costs to providers. The Department expressed optimism that ongoing negotiations with the federal Centers for Medicare and Medicaid Services (CMS) will eventually result in some level of federal financial participation. The Department notes that CMS has allowed administrative costs for nurse advice lines in managed care states. However, the Department is unsure when a resolution might occur. The supplemental is intended to get the Department through FY 2020-21. The 24,089 calls in FY 2019-20 may include duplicates and so the number of people impacted by the Nurse Advice Line might be somewhat smaller, if there is a smaller number of people who repeatedly use the service. The current average speed to answer ranges from a minute to twenty seconds, depending on whether the call requires an RN or a lower level health advisor. This may increase with the lower level of federal funds available. According to the Department, outcome



surveys indicate a 98 percent customer satisfaction rate and a 98 percent guideline and disposition accuracy. The Department did not provide details on how these are measured, but the JBC staff could collect more information if needed.

MEDICAID FUNDING FOR CONNECT FOR HEALTH COLORADO

REQUEST RECOMMENDATION TOTAL $6,806,208 $6,806,208 FTE 0.0 0.0 General Fund 0 0 Cash Funds 3,145,458 3,145,458 Federal Funds 3,660,750 3,660,750

Does JBC staff believe the request satisfies the interim supplemental criteria of Section 24-75-111, C.R.S.? [The Controller may authorize an overexpenditure of the existing appropriation if it: (1) Is approved in whole or in part by the JBC; (2) Is necessary due to unforeseen circumstances arising while the General Assembly is not in session; (3) Is approved by the Office of State Planning and Budgeting (except for State, Law, Treasury, Judicial, and Legislative Departments); (4) Is approved by the Capital Development Committee, if a capital request; (5) Is consistent with all statutory provisions applicable to the program, function or purpose for which the overexpenditure is made; and (6) Does not exceed the unencumbered balance of the fund from which the overexpenditure is to be made.]

YES


YES

Explanation: JBC staff and the Department agree that this request is the result of unforeseen circumstances arising while the General Assembly is not meeting.

DEPARTMENT REQUEST The Department requests $6.8 million total funds, including $3.1 million cash funds and $3.7 million federal funds, for Connect for Health Colorado Eligibility Determinations. The source of cash funds is certified public expenditures by Connect for Health. COMMITTEE ACTION Staff recommended, and the Committee approved, the request. Under an agreement approved by the General Assembly in FY 2016-17, when Connect for Health spends local tax revenues on administrative costs related to eligibility determinations for Medicaid and the Children's Basic Health Plan (CHP+) the Department certifies these public expenditures to draw federal matching funds. The federal funds are then distributed to Connect for Health. No state General Fund is spent, because the state match for the federal Medicaid dollars comes from the local tax revenue collected by Connect for Health. Certifying public expenditures to the federal government is an administratively intensive process that requires significant funds documentation and a random moment time study to allocate customer service center staff time attributable to Medicaid and CHP+. There is typically a delay of several quarters between when costs are incurred and when the reconciliation process is compete to



certify the expenditures and make the payments of federal funds. The amount that can be certified as public expenditures depends on the total spending and the allocation of time by Connect for Health, rather than on decisions by the Department. The appropriation is based on the Department's best guess, with imperfect and delayed information, about the certified public expenditures by Connect for Health. Beginning in FY 2018-19 Connect for Health's incurred costs started running higher than the spending authority, but due to the delays in the reconciliation process it was not immediately apparent. In FY 2019-20 the Department was able to make the payments for FY 2018-19 from this existing spending authority, but this meant some costs incurred in FY 2019-20 were pushed into FY 2020-21. The supplemental request is for a one-time catch-up payment. A separate request will be submitted in November to rebalance the line item going forward based on the new information about Connect for Health expenditure patterns. The JBC staff sees no reason to limit the certified public expenditures by Connect for Health. If Connect for Health spends more resources on activities that are eligible for Medicaid or CHP+ reimbursement, then it makes sense to draw the matching federal funds to help pay for those costs, reducing the burden on local tax revenues. The General Assembly frequently has to approve similar forecast adjustments for certified public expenditures by local school districts. The JBC staff is exploring with Legislative Legal Services a longer term solution involving minor changes to the headnotes to the Long Bill that would allow the Department to adjust certified public expenditures without the need for a supplemental appropriation. If this option appears viable, the JBC staff may present it as an alternative for the JBC's consideration in the future. This option would involve delegating some of the General Assembly's current budget authority, but the General Assembly may decide it is not necessary to retain the current level of budget authority over certified public expenditures.

JBC Staff Supplemental Recommendations - FY 2020-21Staff Working Document - Does Not Represent Committee Decision

Appendix A: Numbers Pages

FY 2019-20Actual

FY 2020-21Appropriation

FY 2020-21Requested Change

FY 2020-21Rec'd Change

FY 2020-21 Totalw/Rec'd Change

DEPARTMENT OF HEALTH CARE POLICY AND FINANCINGKim Bimestefer, Executive Director

S1 Medical Services Premiums

(2) MEDICAL SERVICES PREMIUMS

Medical and Long-Term Care Services for MedicaidEligible Individuals 8,099,261,570 9,031,460,335 (17,878,040) (17,878,040) 9,013,582,295

General Fund 1,645,024,128 2,165,802,190 (148,915,698) (148,915,698) 2,016,886,492General Fund Exempt 523,323,333 84,491,394 0 0 84,491,394Cash Funds 933,323,923 1,393,285,900 (94,492,763) (94,492,763) 1,298,793,137Reappropriated Funds 88,963,623 41,603,960 (49,482) (49,482) 41,554,478Federal Funds 4,908,626,563 5,346,276,891 225,579,903 225,579,903 5,571,856,794

Total for S1 Medical Services Premiums 8,099,261,570 9,031,460,335 (17,878,040) (17,878,040) 9,013,582,295FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 1,645,024,128 2,165,802,190 (148,915,698) (148,915,698) 2,016,886,492General Fund Exempt 523,323,333 84,491,394 0 0 84,491,394Cash Funds 933,323,923 1,393,285,900 (94,492,763) (94,492,763) 1,298,793,137Reappropriated Funds 88,963,623 41,603,960 (49,482) (49,482) 41,554,478Federal Funds 4,908,626,563 5,346,276,891 225,579,903 225,579,903 5,571,856,794



FY 2019-20Actual





S2 Behavioral Health

(3) BEHAVIORAL HEALTH COMMUNITY PROGRAMS

Behavioral Health Capitation Payments 662,584,643 945,357,559 (99,148,968) (99,148,968) 846,208,591General Fund 174,001,702 246,481,122 (41,542,290) (41,542,290) 204,938,832Cash Funds 37,151,063 54,045,515 1,600,775 1,600,775 55,646,290Reappropriated Funds 0 0 0 0 0Federal Funds 451,431,878 644,830,922 (59,207,453) (59,207,453) 585,623,469

Behavioral Health Fee-for-service Payments 13,176,139 14,052,680 318,140 318,140 14,370,820General Fund 2,445,911 3,378,980 (739,384) (739,384) 2,639,596Cash Funds 798,999 814,923 130,787 130,787 945,710Reappropriated Funds 0 0 0 0 0Federal Funds 9,931,229 9,858,777 926,737 926,737 10,785,514

Total for S2 Behavioral Health 675,760,782 959,410,239 (98,830,828) (98,830,828) 860,579,411FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 176,447,613 249,860,102 (42,281,674) (42,281,674) 207,578,428Cash Funds 37,950,062 54,860,438 1,731,562 1,731,562 56,592,000Reappropriated Funds 0 0 0 0 0Federal Funds 461,363,107 654,689,699 (58,280,716) (58,280,716) 596,408,983



FY 2019-20Actual





S3 Childrens Basic Health Plan

(4) INDIGENT CARE PROGRAM

Children's Basic Health Plan Administration 1,948,101 5,083,274 0 0 5,083,274General Fund 0 0 0 0 0Cash Funds 386,067 1,632,747 (165,206) (165,206) 1,467,541Reappropriated Funds 0 0 0 0 0Federal Funds 1,562,034 3,450,527 165,206 165,206 3,615,733

Children's Basic Health Plan Medical and Dental Costs 188,339,131 239,783,819 (52,581,053) (52,581,053) 187,202,766General Fund 391,683 22,923,991 (14,035,710) (14,035,710) 8,888,281General Fund Exempt 0 387,132 0 0 387,132Cash Funds 35,542,120 49,379,242 (3,609,731) (3,609,731) 45,769,511Reappropriated Funds 0 0 0 0 0Federal Funds 152,405,328 167,093,454 (34,935,612) (34,935,612) 132,157,842

Total for S3 Childrens Basic Health Plan 190,287,232 244,867,093 (52,581,053) (52,581,053) 192,286,040FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 391,683 22,923,991 (14,035,710) (14,035,710) 8,888,281General Fund Exempt 0 387,132 0 0 387,132Cash Funds 35,928,187 51,011,989 (3,774,937) (3,774,937) 47,237,052Reappropriated Funds 0 0 0 0 0Federal Funds 153,967,362 170,543,981 (34,770,406) (34,770,406) 135,773,575



FY 2019-20Actual





S4 Medicare Modernization Act

(5) OTHER MEDICAL SERVICES

Medicare Modernization Act State ContributionPayment 161,064,826 168,297,340 (14,430,417) (14,430,417) 153,866,923

General Fund 161,064,826 168,297,340 (14,430,417) (14,430,417) 153,866,923Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 0 0 0 0 0

Total for S4 Medicare Modernization Act 161,064,826 168,297,340 (14,430,417) (14,430,417) 153,866,923FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 161,064,826 168,297,340 (14,430,417) (14,430,417) 153,866,923Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 0 0 0 0 0



FY 2019-20Actual





S5 Office of Community Living

(4) OFFICE OF COMMUNITY LIVING(A) Division for Individuals with Intellectual and Developmental DisabilitiesMedicaid Programs

Adult Comprehensive Waiver Services 0 525,769,703 57,744 57,744 525,827,447General Fund 0 239,180,185 (8,237,485) (8,237,485) 230,942,700Cash Funds 0 7,520,047 0 0 7,520,047Reappropriated Funds 0 0 0 0 0Federal Funds 0 279,069,471 8,295,229 8,295,229 287,364,700

Adult Supported Living Waiver Services 0 71,889,381 (2,857,434) (2,857,434) 69,031,947General Fund 0 33,352,698 (3,650,501) (3,650,501) 29,702,197Cash Funds 0 389,750 1,214,041 1,214,041 1,603,791Federal Funds 0 38,146,933 (420,974) (420,974) 37,725,959

Children's Extensive Support Services 0 29,961,574 625,969 625,969 30,587,543General Fund 0 14,082,730 (211,279) (211,279) 13,871,451Cash Funds 0 0 0 0 0Federal Funds 0 15,878,844 837,248 837,248 16,716,092

Children's Habilitation Residential Program 0 4,779,680 1,654,915 1,654,915 6,434,595General Fund 0 2,390,029 528,060 528,060 2,918,089Cash Funds 0 0 0 0 0Federal Funds 0 2,389,651 1,126,855 1,126,855 3,516,506



FY 2019-20Actual





Case Management Services 0 40,420,895 (4,460,221) (4,460,221) 35,960,674General Fund 0 18,862,830 (2,940,986) (2,940,986) 15,921,844Cash Funds 0 81,163 305,160 305,160 386,323Federal Funds 0 21,476,902 (1,824,395) (1,824,395) 19,652,507

Family Support Services Program 0 7,515,264 54,500 54,500 7,569,764General Fund 0 7,136,298 0 0 7,136,298Cash Funds 0 378,966 54,500 54,500 433,466Federal Funds 0 0 0 0 0

State Supported Living Services 0 9,893,584 56,091 56,091 9,949,675General Fund 0 8,228,509 0 0 8,228,509Cash Funds 0 1,665,075 56,091 56,091 1,721,166Federal Funds 0 0 0 0 0

State Supported Living Services Case Management 0 2,416,320 7,465 7,465 2,423,785General Fund 0 2,140,088 0 0 2,140,088Cash Funds 0 276,232 7,465 7,465 283,697

Total for S5 Office of Community Living 0 692,646,401 (4,860,971) (4,860,971) 687,785,430FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 0 325,373,367 (14,512,191) (14,512,191) 310,861,176Cash Funds 0 10,311,233 1,637,257 1,637,257 11,948,490Reappropriated Funds 0 0 0 0 0Federal Funds 0 356,961,801 8,013,963 8,013,963 364,975,764



FY 2019-20Actual





S6 Nurse advice line

(1) EXECUTIVE DIRECTOR'S OFFICE(E) Utilization and Quality Review Contracts

Professional Service Contracts 15,186,368 24,377,498 966,896 306,929 24,684,427General Fund 4,671,282 6,182,153 1,117,028 1,117,028 7,299,181Cash Funds 1,018,383 1,592,103 0 0 1,592,103Reappropriated Funds 0 0 0 0 0Federal Funds 9,496,703 16,603,242 (150,132) (810,099) 15,793,143

Total for S6 Nurse advice line 15,186,368 24,377,498 966,896 306,929 24,684,427FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 4,671,282 6,182,153 1,117,028 1,117,028 7,299,181Cash Funds 1,018,383 1,592,103 0 0 1,592,103Reappropriated Funds 0 0 0 0 0Federal Funds 9,496,703 16,603,242 (150,132) (810,099) 15,793,143



FY 2019-20Actual





S7 Medicaid for Connect for Health Colorado

(1) EXECUTIVE DIRECTOR'S OFFICE(C) Information Technology Contracts and Projects

Connect for Health Colorado Systems 490,760 669,757 (669,757) (669,757) 0General Fund 0 0 0 0 0Cash Funds 122,690 122,690 (122,690) (122,690) 0Reappropriated Funds 0 0 0 0 0Federal Funds 368,070 547,067 (547,067) (547,067) 0

(1) EXECUTIVE DIRECTOR'S OFFICE(D) Eligibility Determinations and Client Services

Connect for Health Colorado Eligibility Determination 4,327,277 4,474,451 4,719,121 4,719,121 9,193,572General Fund 0 0 0 0 0Cash Funds 1,667,767 1,667,767 1,949,709 1,949,709 3,617,476Reappropriated Funds 0 0 0 0 0Federal Funds 2,659,510 2,806,684 2,769,412 2,769,412 5,576,096

Total for S7 Medicaid for Connect for HealthColorado 4,818,037 5,144,208 4,049,364 4,049,364 9,193,572

FTE 0 .0 0 .0 0 .0 0 .0 0 .0General Fund 0 0 0 0 0Cash Funds 1,790,457 1,790,457 1,827,019 1,827,019 3,617,476Reappropriated Funds 0 0 0 0 0Federal Funds 3,027,580 3,353,751 2,222,345 2,222,345 5,576,096



FY 2019-20Actual





S8 Funding for family medicine residency training programs


State University Teaching Hospitals University ofColorado Hospital 1,631,984 0 1,204,207 0 0

General Fund 538,075 0 353,723 0 0Cash Funds 0 0 0 0 0Reappropriated Funds 225,000 0 211,050 0 0Federal Funds 868,909 0 639,434 0 0

Total for S8 Funding for family medicine residencytraining programs 1,631,984 0 1,204,207 0 0

FTE 0 .0 0 .0 0 .0 0 .0 0 .0General Fund 538,075 0 353,723 0 0Cash Funds 0 0 0 0 0Reappropriated Funds 225,000 0 211,050 0 0Federal Funds 868,909 0 639,434 0 0



FY 2019-20Actual





S9 Technical adjustments


Contracts for Special Eligibility Determinations 2,904,179 11,402,297 624,374 0 11,402,297General Fund 900,608 969,756 312,187 0 969,756Cash Funds 429,464 4,343,468 0 0 4,343,468Reappropriated Funds 0 0 0 0 0Federal Funds 1,574,107 6,089,073 312,187 0 6,089,073

Customer Outreach 5,401,245 4,085,445 (624,374) (624,374) 3,461,071General Fund 2,363,978 1,706,102 (312,187) (312,187) 1,393,915Cash Funds 336,621 336,621 0 0 336,621Reappropriated Funds 0 0 0 0 0Federal Funds 2,700,646 2,042,722 (312,187) (312,187) 1,730,535


Medical and Long-Term Care Services for MedicaidEligible Individuals 8,099,261,570 9,031,460,335 0 624,374 9,032,084,709

General Fund 1,645,024,128 2,165,802,190 0 312,187 2,166,114,377General Fund Exempt 523,323,333 84,491,394 0 0 84,491,394Cash Funds 933,323,923 1,393,285,900 0 0 1,393,285,900Reappropriated Funds 88,963,623 41,603,960 0 0 41,603,960Federal Funds 4,908,626,563 5,346,276,891 0 312,187 5,346,589,078



FY 2019-20Actual





Total for S9 Technical adjustments 8,107,566,994 9,046,948,077 0 0 9,046,948,077FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 1,648,288,714 2,168,478,048 0 0 2,168,478,048General Fund Exempt 523,323,333 84,491,394 0 0 84,491,394Cash Funds 934,090,008 1,397,965,989 0 0 1,397,965,989Reappropriated Funds 88,963,623 41,603,960 0 0 41,603,960Federal Funds 4,912,901,316 5,354,408,686 0 0 5,354,408,686



FY 2019-20Actual





S10 Public health emergency end resources

(1) EXECUTIVE DIRECTOR'S OFFICE(A) General Administration

Personal Services 37,379,178 41,276,479 517,248 517,248 41,793,727FTE 0.0 516.5 1.0 1.0 517.5

General Fund 12,514,723 14,487,249 0 0 14,487,249Cash Funds 3,568,550 3,911,124 258,624 258,624 4,169,748Reappropriated Funds 1,802,959 2,305,357 0 0 2,305,357Federal Funds 19,492,946 20,572,749 258,624 258,624 20,831,373

Health, Life, and Dental 4,790,328 5,264,801 50,210 50,210 5,315,011General Fund 1,700,447 1,342,322 0 0 1,342,322Cash Funds 421,237 548,313 25,105 25,105 573,418Reappropriated Funds 126,088 138,532 0 0 138,532Federal Funds 2,542,556 3,235,634 25,105 25,105 3,260,739

Short-term Disability 66,598 72,366 211 211 72,577General Fund 24,002 26,778 0 0 26,778Cash Funds 5,301 5,695 105 105 5,800Reappropriated Funds 2,206 1,607 0 0 1,607Federal Funds 35,089 38,286 106 106 38,392

S.B. 04-257 Amortization Equalization Disbursement 1,984,802 2,188,905 6,214 6,214 2,195,119General Fund 722,807 810,157 0 0 810,157Cash Funds 159,398 172,037 3,107 3,107 175,144Reappropriated Funds 46,310 48,635 0 0 48,635Federal Funds 1,056,287 1,158,076 3,107 3,107 1,161,183



FY 2019-20Actual





S.B. 06-235 Supplemental Amortization EqualizationDisbursement 1,984,802 2,188,905 6,214 6,214 2,195,119

General Fund 722,807 810,157 0 0 810,157Cash Funds 159,398 172,037 3,107 3,107 175,144Reappropriated Funds 46,310 48,635 0 0 48,635Federal Funds 1,056,287 1,158,076 3,107 3,107 1,161,183

Operating Expenses 2,199,237 2,356,365 25,265 25,265 2,381,630General Fund 855,772 954,547 0 0 954,547Cash Funds 243,961 214,413 12,632 12,632 227,045Reappropriated Funds 13,297 13,297 0 0 13,297Federal Funds 1,086,207 1,174,108 12,633 12,633 1,186,741

General Professional Services and Special Projects 13,757,424 20,838,547 3,015,883 3,015,883 23,854,430General Fund 3,843,924 6,423,623 0 0 6,423,623Cash Funds 2,113,981 3,230,464 1,507,942 1,507,942 4,738,406Reappropriated Funds 150,000 150,000 0 0 150,000Federal Funds 7,649,519 11,034,460 1,507,941 1,507,941 12,542,401


Contracts for Special Eligibility Determinations 2,904,179 11,402,297 (6,148,800) (6,148,800) 5,253,497General Fund 900,608 969,756 0 0 969,756Cash Funds 429,464 4,343,468 (3,074,400) (3,074,400) 1,269,068Reappropriated Funds 0 0 0 0 0Federal Funds 1,574,107 6,089,073 (3,074,400) (3,074,400) 3,014,673



FY 2019-20Actual





County Administration 78,231,835 88,174,672 10,851,209 10,851,209 99,025,881General Fund 12,590,592 12,476,154 784,231 784,231 13,260,385Cash Funds 15,314,460 21,228,612 2,351,340 2,351,340 23,579,952Reappropriated Funds 0 0 0 0 0Federal Funds 50,326,783 54,469,906 7,715,638 7,715,638 62,185,544

Total for S10 Public health emergency endresources 143,298,383 173,763,337 8,323,654 8,323,654 182,086,991

FTE 0 .0 516.5 1 .0 1 .0 517.5General Fund 33,875,682 38,300,743 784,231 784,231 39,084,974Cash Funds 22,415,750 33,826,163 1,087,562 1,087,562 34,913,725Reappropriated Funds 2,187,170 2,706,063 0 0 2,706,063Federal Funds 84,819,781 98,930,368 6,451,861 6,451,861 105,382,229



FY 2019-20Actual





S12 Federal match for non-forecast lines


Safety Net Provider Payments 301,481,948 206,719,975 0 0 206,719,975General Fund 0 0 0 0 0Cash Funds 141,663,260 96,951,669 (3,204,160) (3,204,160) 93,747,509Reappropriated Funds 0 0 0 0 0Federal Funds 159,818,688 109,768,306 3,204,160 3,204,160 112,972,466

Clinic Based Indigent Care 6,039,386 6,079,573 0 0 6,079,573General Fund 2,832,472 2,829,981 (72,894) (72,894) 2,757,087Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 3,206,914 3,249,592 72,894 72,894 3,322,486

Pediatric Specialty Hospital 13,455,012 10,764,010 0 0 10,764,010General Fund 6,310,401 5,048,321 (166,842) (166,842) 4,881,479Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 7,144,611 5,715,689 166,842 166,842 5,882,531



FY 2019-20Actual






Commission on Family Medicine Residency TrainingPrograms 8,196,518 7,130,420 0 0 7,130,420

General Fund 3,844,167 3,344,167 (110,521) (110,521) 3,233,646Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 4,352,351 3,786,253 110,521 110,521 3,896,774

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(D) Division of Child Welfare - Medicaid Funding

Child Welfare Services 7,072,566 12,848,155 0 0 12,848,155General Fund 3,318,147 6,025,785 (199,146) (199,146) 5,826,639Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 3,754,419 6,822,370 199,146 199,146 7,021,516

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(D.5) Office of Early Childhood - Medicaid Funding

Division of Community and Family Support, EarlyIntervention Services 3,949,142 7,888,342 0 0 7,888,342

General Fund 1,974,571 3,699,632 (122,268) (122,268) 3,577,364Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 1,974,571 4,188,710 122,268 122,268 4,310,978

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(F) Office of Behavioral Health Services - Medicaid Funding



FY 2019-20Actual





(2) DHS Community-based Mental Health Services

Children and Youth Mental Health Treatment Act 59,802 125,332 0 0 125,332General Fund 59,380 58,781 (1,942) (1,942) 56,839Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 422 66,551 1,942 1,942 68,493

High Risk Pregnant Women Program 1,450,757 1,183,268 0 0 1,183,268General Fund 862,329 554,953 (18,340) (18,340) 536,613Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 588,428 628,315 18,340 18,340 646,655

Operating Expenses 0 1,544 0 0 1,544General Fund 0 724 (127,395) (127,395) (126,671)Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 0 820 127,395 127,395 128,215

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(G) Services for People with Disabilities - Medicaid Funding

Regional Centers 0 10,309,717 0 0 10,309,717General Fund 0 4,835,257 (848,952) (848,952) 3,986,305Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 0 5,474,460 848,952 848,952 6,323,412



FY 2019-20Actual





Regional Center Depreciation 0 323,681 0 0 323,681General Fund 0 151,806 (10,721) (10,721) 141,085Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 0 171,875 10,721 10,721 182,596

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(I) Division of Youth Services - Medicaid Funding

Division of Youth Services 1,734,967 460,754 0 0 460,754General Fund 795,149 216,094 (22,840) (22,840) 193,254Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 939,818 244,660 22,840 22,840 267,500

Total for S12 Federal match for non-forecast lines 343,440,098 263,834,771 0 0 263,834,771FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 19,996,616 26,765,501 (1,701,861) (1,701,861) 25,063,640Cash Funds 141,663,260 96,951,669 (3,204,160) (3,204,160) 93,747,509Reappropriated Funds 0 0 0 0 0Federal Funds 181,780,222 140,117,601 4,906,021 4,906,021 145,023,622



FY 2019-20Actual





S13 Public school health services


Public School Health Services 124,811,816 128,793,149 8,806,057 8,806,057 137,599,206General Fund 0 0 0 0 0Cash Funds 59,889,935 64,396,575 (842,607) (842,607) 63,553,968Reappropriated Funds 0 0 0 0 0Federal Funds 64,921,881 64,396,574 9,648,664 9,648,664 74,045,238

Total for S13 Public school health services 124,811,816 128,793,149 8,806,057 8,806,057 137,599,206FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 0 0 0 0 0Cash Funds 59,889,935 64,396,575 (842,607) (842,607) 63,553,968Reappropriated Funds 0 0 0 0 0Federal Funds 64,921,881 64,396,574 9,648,664 9,648,664 74,045,238



FY 2019-20Actual





Public health emergency extension


Medical and Long-Term Care Services for MedicaidEligible Individuals 8,099,261,570 9,031,460,335 0 219,054,292 9,250,514,627

General Fund 1,645,024,128 2,165,802,190 0 (52,027,218) 2,113,774,972General Fund Exempt 523,323,333 84,491,394 0 0 84,491,394Cash Funds 933,323,923 1,393,285,900 0 24,344,460 1,417,630,360Reappropriated Funds 88,963,623 41,603,960 0 0 41,603,960Federal Funds 4,908,626,563 5,346,276,891 0 246,737,050 5,593,013,941

(3) BEHAVIORAL HEALTH COMMUNITY PROGRAMS

Behavioral Health Capitation Payments 662,584,643 945,357,559 0 29,649,562 975,007,121General Fund 174,001,702 246,481,122 0 (2,905,004) 243,576,118Cash Funds 37,151,063 54,045,515 0 2,182,634 56,228,149Reappropriated Funds 0 0 0 0 0Federal Funds 451,431,878 644,830,922 0 30,371,932 675,202,854

Behavioral Health Fee-for-service Payments 13,176,139 14,052,680 0 0 14,052,680General Fund 2,445,911 3,378,980 0 (82,685) 3,296,295Cash Funds 798,999 814,923 0 (6,302) 808,621Reappropriated Funds 0 0 0 0 0Federal Funds 9,931,229 9,858,777 0 88,987 9,947,764

(4) OFFICE OF COMMUNITY LIVING(A) Division for Individuals with Intellectual and Developmental Disabilities



FY 2019-20Actual





Medicaid Programs

Adult Comprehensive Waiver Services 0 525,769,703 0 0 525,769,703General Fund 0 239,180,185 0 (8,096,771) 231,083,414Cash Funds 0 7,520,047 0 0 7,520,047Reappropriated Funds 0 0 0 0 0Federal Funds 0 279,069,471 0 8,096,771 287,166,242

Adult Supported Living Waiver Services 0 71,889,381 0 0 71,889,381General Fund 0 33,352,698 0 (1,062,964) 32,289,734Cash Funds 0 389,750 0 (54,816) 334,934Federal Funds 0 38,146,933 0 1,117,780 39,264,713

Children's Extensive Support Services 0 29,961,574 0 0 29,961,574General Fund 0 14,082,730 0 (470,992) 13,611,738Cash Funds 0 0 0 0 0Federal Funds 0 15,878,844 0 470,992 16,349,836

Children's Habilitation Residential Program 0 4,779,680 0 0 4,779,680General Fund 0 2,390,029 0 (99,081) 2,290,948Cash Funds 0 0 0 0 0Federal Funds 0 2,389,651 0 99,081 2,488,732

Case Management Services 0 40,420,895 0 0 40,420,895General Fund 0 18,862,830 0 (553,728) 18,309,102Cash Funds 0 81,163 0 (13,204) 67,959Federal Funds 0 21,476,902 0 566,932 22,043,834



FY 2019-20Actual






Safety Net Provider Payments 301,481,948 206,719,975 0 (3,204,159) 203,515,816General Fund 0 0 0 0 NaNCash Funds 141,663,260 96,951,669 0 (3,204,159) 93,747,510Reappropriated Funds 0 0 0 0 0Federal Funds 159,818,688 109,768,306 0 0 109,768,306

Clinic Based Indigent Care 6,039,386 6,079,573 0 0 6,079,573General Fund 2,832,472 2,829,981 0 (94,234) 2,735,747Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 3,206,914 3,249,592 0 94,234 3,343,826

Pediatric Specialty Hospital 13,455,012 10,764,010 0 0 10,764,010General Fund 6,310,401 5,048,321 0 (166,842) 4,881,479Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 7,144,611 5,715,689 0 166,842 5,882,531

Children's Basic Health Plan Medical and Dental Costs 188,339,131 239,783,819 0 0 239,783,819General Fund 391,683 22,923,991 0 (1,252,605) 21,671,386General Fund Exempt 0 387,132 0 0 387,132Cash Funds 35,542,120 49,379,242 0 (809,973) 48,569,269Reappropriated Funds 0 0 0 0 0Federal Funds 152,405,328 167,093,454 0 2,062,578 169,156,032



FY 2019-20Actual






Commission on Family Medicine Residency TrainingPrograms 8,196,518 7,130,420 0 0 7,130,420

General Fund 3,844,167 3,344,167 0 (110,522) 3,233,645Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 4,352,351 3,786,253 0 110,522 3,896,775

Medicare Modernization Act State ContributionPayment 161,064,826 168,297,340 0 (6,858,815) 161,438,525

General Fund 161,064,826 168,297,340 0 (6,858,815) 161,438,525Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 0 0 0 0 NaN

Public School Health Services 124,811,816 128,793,149 0 0 128,793,149General Fund 0 0 0 0 NaNCash Funds 59,889,935 64,396,575 0 (1,394,538) 63,002,037Reappropriated Funds 0 0 0 0 0Federal Funds 64,921,881 64,396,574 0 1,394,538 65,791,112

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS



FY 2019-20Actual





(D) Division of Child Welfare - Medicaid Funding

Child Welfare Services 7,072,566 12,848,155 0 0 12,848,155General Fund 3,318,147 6,025,785 0 (199,147) 5,826,638Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 3,754,419 6,822,370 0 199,147 7,021,517

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(D.5) Office of Early Childhood - Medicaid Funding

Division of Community and Family Support, EarlyIntervention Services 3,949,142 7,888,342 0 0 7,888,342

General Fund 1,974,571 3,699,632 0 (122,270) 3,577,362Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 1,974,571 4,188,710 0 122,270 4,310,980

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(F) Office of Behavioral Health Services - Medicaid Funding(2) DHS Community-based Mental Health Services

Children and Youth Mental Health Treatment Act 59,802 125,332 0 0 125,332General Fund 59,380 58,781 0 (1,943) 56,838Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 422 66,551 0 1,943 68,494



FY 2019-20Actual





High Risk Pregnant Women Program 1,450,757 1,183,268 0 0 1,183,268General Fund 862,329 554,953 0 (18,341) 536,612Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 588,428 628,315 0 18,341 646,656

Personal Services 9,272,079 31,240 0 0 31,240FTE 0.0 0.0 0.0 0.0 0.0

General Fund 3,917,691 14,652 0 (127,396) (112,744)Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 5,354,388 16,588 0 127,396 143,984

(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(G) Services for People with Disabilities - Medicaid Funding

Regional CentersFacility 46,607,792 25,757,017 0 0 25,757,017

General Fund 18,778,008 11,317,731 0 (848,951) 10,468,780Cash Funds 1,888,903 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 25,940,881 14,439,286 0 848,951 15,288,237

Regional Center Depreciation 691,725 180,718 0 0 180,718General Fund 324,419 84,757 0 (10,722) 74,035Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 367,306 95,961 0 10,722 106,683



FY 2019-20Actual





(7) DEPARTMENT OF HUMAN SERVICES MEDICAID-FUNDED PROGRAMS(I) Division of Youth Services - Medicaid Funding

Division of Youth Services 1,734,967 460,754 0 0 460,754General Fund 795,149 216,094 0 (12,748) 203,346Cash Funds 0 0 0 0 0Reappropriated Funds 0 0 0 0 0Federal Funds 939,818 244,660 0 12,748 257,408

Total for Public health emergency extension 9,649,249,819 11,479,734,919 0 238,640,880 11,718,375,799FTE 0 .0 0 .0 0 .0 0 .0 0 .0

General Fund 2,025,944,984 2,947,946,949 0 (75,122,979) 2,872,823,970General Fund Exempt 523,323,333 84,878,526 0 0 84,878,526Cash Funds 1,210,258,203 1,666,864,784 0 21,044,102 1,687,908,886Reappropriated Funds 88,963,623 41,603,960 0 0 41,603,960Federal Funds 5,800,759,676 6,738,440,700 0 292,719,757 7,031,160,457



FY 2019-20Actual





Interim Supplemental Connect for Health Colorado


Connect for Health Colorado Eligibility Determination 4,327,277 4,474,451 6,806,208 6,806,208 11,280,659General Fund 0 0 0 0 0Cash Funds 1,667,767 1,667,767 3,145,458 3,145,458 4,813,225Reappropriated Funds 0 0 0 0 0Federal Funds 2,659,510 2,806,684 3,660,750 3,660,750 6,467,434

Total for Interim Supplemental Connect forHealth Colorado 4,327,277 4,474,451 6,806,208 6,806,208 11,280,659

FTE 0 .0 0 .0 0 .0 0 .0 0 .0General Fund 0 0 0 0 0Cash Funds 1,667,767 1,667,767 3,145,458 3,145,458 4,813,225Reappropriated Funds 0 0 0 0 0Federal Funds 2,659,510 2,806,684 3,660,750 3,660,750 6,467,434

Totals Excluding Pending ItemsHEALTH CARE POLICY AND FINANCINGTOTALS for ALL Departmental line items 10,674,850,341 12,033,835,747 (158,424,923) 78,351,783 12,112,187,530

FTE 40.4 556.7 1 .0 1 .0 557.7General Fund 2,429,777,217 3,099,827,477 (233,622,569) (309,099,271) 2,790,728,206General Fund Exempt 523,323,333 84,878,526 0 0 84,878,526Cash Funds 1,283,647,957 1,767,368,404 (92,885,609) (71,841,507) 1,695,526,897Reappropriated Funds 91,600,494 45,956,525 161,568 (49,482) 45,907,043Federal Funds 6,346,501,340 7,035,804,815 167,921,687 459,342,043 7,495,146,858


Documents

SUPPLEMENTAL BUDGET REQUESTS FY 2020-21 AND FY …supplemental budget requests fy 2020-21 and fy 2019-20 . department of health care policy and financing . jbc working document - subject