Commission on Medicaid [Jul 28, 2026]

Yeah, it's Kyle's fault. It's my fault.

Mr. Shadoon. Mr. Shadoon.

Representatives and Senators Bravone.

Bridges.

Brazell.

Are you saying Brazell?

Apologies.

Excused.

Mullica. Here.

Tiger. Here.

Okay. So I'm wondering out loud if maybe some people are waiting in the wrong room. Is that possible?

Okay. So maybe we'll send out a text.

Okay. All right. Okay, so we have a big agenda for today, and I'm going to turn it right over to our facilitator, Ms. Gathercole, and we will get started unless there's any questions.

It's full of really good public servants. So what the book is about is there's always federal

We're only going to call you Summer if we can call Senator Bridges Jeffy.

That's not what we call them at the JBC.

Yes.

Can you hear me?

Excellent. Thank you so much. I am really glad to be here and I wish that I could be in the room because this is obviously awkward setup, but I hope that this could be as conversational as possible and I am really happy to be interrupted and answer questions as we go along I do have a slide deck so I didn get the memo that we were short on trying to limit slides but like I said I'm feel free to jump in. I can't see folks, so I think that someone will just flag when someone has a question, but I will get started. So, there was a quick overview of KFF, but I will I will elaborate a tiny bit. We used to go by Kaiser Family Foundation, but we now, our name officially is KFF, and that's because we are not affiliated with Kaiser Permanente in any way. We have no family members on our board, and we are actually not even a foundation. We're a public charity, so we just go by KFF. As was mentioned, we are a nonprofit, nonpartisan organization that's focused on both policy polling and we also have a news service. And our goals are really to help inform policy debates that you are engaged in right now. We do not take positions and we don't make any policy recommendations. We also do our best to provide as much state level information as we can, and we have a wealth of state level information on our state health facts, and we also try to have those on our website as well. So I will jump in. So just as a reminder, I'm going to do like just a few minutes of overview level setting. You probably already know this since you're on the commission and have been doing this for a while. But just from a national picture, Medicaid has a number of different roles in the health care system and many complicated roles. Next slide. It's the next slide. So before we get into the recent changes, just a quick overview that Medicaid turned or was about to turn 61 years this year was enacted at the same time as the Medicare program in 1965. Over the course of the program, there have been incremental coverage gains that Congress and states have enacted, expanding coverage for children, pregnant women, people with disabilities, and then coverage for more adults with the passage of the Affordable Care Act. Right now, Medicaid covers one in five people in the country. It provides coverage for about four in 10 births in the country and a higher share of births in rural areas. It's an important piece that helps the Medicare program work for low-income people who are duly eligible for Medicare and Medicaid. So it helps pay premiums and cost sharing for individuals who are eligible for Medicare. And also is the primary payer and provider for long-term services and supports in this country. A lot of people think that Medicare provides that, but it does not provide comprehensive long-term care. So Medicaid does that. The program, of course, is shared financing between the federal government and the states, so provides a lot of financing for states as well as providers. And many states have used flexibility in the Medicaid program to help address complicated and challenges in the overall healthcare system. So next slide. So in Colorado and across the country, there's a disproportionate effect of enrollees and expenditures. So there are fewer people who qualify for the program based on age, so over 65, or on the basis of having a disability. But of course, those groups of individuals account for a large share of the expenditures on the program. So the large majority of people on the program are really kids and adults, but the expenditures are the reverse. And there's a lot of variation, next slide, in the Medicaid program across the country. So states administer their programs within these broad federal rules so all states make different decisions and that results in variation in spending per enrollee across the country. When we look at Colorado, there's lower than average spending overall, higher than average spending on people who qualify through the disability pathway, but lower spending overall on people who are children or adults on the program. And of course, why we're all here today and why you're here is because Medicaid is a big piece of state budgets. So it's hard to have budget discussions without thinking about the Medicaid program. So just nationally in Colorado is pretty representative of the national picture. Medicaid accounts for three and $10 of overall state budgets, but also accounts for the largest share of federal revenue that comes to states. So obviously the changes that we're going to get into have a large effect on state budgets. And when we look at the national picture of what's been happening with spending and enrollment. So next slide. We see that over time, typically spending patterns follow what's happening with enrollment. So we see spikes in enrollment during economic downturns and major policy changes. So in 2000 and 2002, there were increases due to the economic downturn. And then there were similar increases after the implementation of the Affordable Care Act. I think more recently, we looked at the pandemic and the policies to prohibit disenrollment of people from the Medicaid program as increasing coverage and then lower enrollment as the unwinding happened. And often spending follows those patterns. I would say across the country, even though enrollment was declining, Colorado is not unique in that there were a number of factors that were putting upward pressure on Medicaid spending. So provider rate increases. There's been analyses of higher acuity. So of the people who remained on the program, these people were tend to be higher cost. and more expensive. There have been, with the aging population and challenges in workforce, increased pressure on long-term care spending and behavioral health. Pharmacy spending, particularly around specialty drugs, was also cited. And then, of course, just healthcare is expensive and growing in cost, and Medicaid is purchasing services in the overall healthcare market. So Medicaid is facing those costs as well.

Thank you Robin Just real quick from the title or the words up in bold it says states project flat enrollment post unwinding Can you kind of explain that a little bit more Because that's maybe not necessarily the narrative or the messaging that we're receiving with. And I guess maybe it's unwinding. I don't know. H.R. 1. Yeah. Can you just explain that a little bit? Because we're being told that people are going to be falling off, that we're going to lose a number of enrollees. Sure. So this was the picture, and we're in the field now actually collecting data. So this was what states reported to us last year. So this was at the start, really, of, so there were the projections for state fiscal year 2026. So from 2025 to 2026, enrollment was pretty flat. We are in the field right now trying to get that national picture of what's happening as states are now into or just at the beginning of fiscal 2027. and what that picture is. And again, we've seen some declines, some flattening of enrollment. And to your point, in the future, we are looking at reductions in Medicaid enrollment due to a number of the provisions in the reconciliation law that was passed. Thanks, Robin.

Summer and Robin, I wonder a couple things. One, some of these slides really do need the color, and both of us, both what was handed out today and what we got earlier are all black and white, and it's hard with the different tones of black and gray to pick up on some of these. So that's one. Secondly, it would be really nice, and this isn't a criticism of Robin's presentation, but some of these slides, it would be really helpful if the department could overlay the Colorado data so we could see it against national trends. Great.

So, yeah, so that's been sort of the picture that was leading up to the major changes that were enacted last year. So I'm going to go over some of those. And where I was able to, I did put in some of our estimates of implications for Colorado, so I will highlight those. But, you know, the states may have more updated or better information, but I tried to put some of the estimates in the national picture. So last year, last July, obviously there was the passage of this reconciliation law. It included many provisions that would affect federal spending and coverage for the Medicaid program They really the most historic restrictions in federal support for spending and enrollment in the history of the program And they really the estimates from the Congressional Budget Office at the time that the law was enacted was that the Medicaid changes would result in $911 billion. Oh, it's the next slide, the pie, over the next 10 years. And I think that there were, again, a lot of provisions, but the biggest pieces were really related to eligibility changes, and those include the new work requirements or work and community engagement requirements that states that have adopted the expansion are required to implement by January 2027, as well as pretty complicated financing changes that really restrict how states are able to gather their state share to pay for the Medicaid services and also changes in how states are able to pay providers. So I'll walk through some of those in a little bit more detail. I think there was a question about the timeline so next slide um of when the provisions were going to go into effect and there are a lot of um different implementation deadlines for different provisions um i highlighted a few of them um in this slide um but you know so i think there's been a lot of attention on the work requirements and those go into effect january 2027 but even though that's when they go into effect. There's a lot of work that states need to be doing now to be ready for that implementation. I would also note that, of course, there was a moratorium put on provider taxes that was effective immediately. So basically, sometimes when states have felt pressure, and I know that this is a topic that's come up, it's been a response to try to access additional federal dollars and adopt additional provider taxes. And the law said states can't adopt new or increase current provider taxes. And then starting later, so October 1st, 2027, there will be restrictions put in place for provider taxes. And then the following year, restrictions on these state directed payments. And again, I'll talk a little bit more about those in a bit. Robin, can I interrupt? We've got another question from Senator Amabile.

And my understanding was that for Colorado, this seems inverted, like the work requirements were less impactful than the provider taxes. But is this because nationally not everybody did expansion? Like, that just doesn't jive with what I thought was the reality for Colorado. And again, I think states may have certainly better estimates of the implications. And I do

Thanks, Robin. We have another question from Rep. Brown.

And I have to pull it up exactly when that goes into effect. I thought that was also 2027, but I need to double check. There is, again, another requirement in the law for states to impose cost sharing on individuals in the expansion group with incomes between 100 and 133 or 138 percent of the poverty level. So, we have that information, so I will check it as soon as I get it to you, the exact implementation deadline. But it's a select group of individuals in the expansion group that states are going to be required to charge cost sharing for that group. Thanks, Robin.

Great. Thanks. So if we are on the work requirements, is there anything else with regard to the work requirements that we should be aware of? Like, for example, is there a percentage of the expansion population? Because it is only the expansion population that has to meet work requirements. That would be the first question. And then is there a percentage that has to meet work requirements? And if we don't meet that percentage, is it or is there a timeline, you know, by which they have to meet it? I mean, I'm just thinking back to the days of TANF when that came in. And if there isn't, is there a penalty to the states if we don't meet the work participation rate?

So on the timeline, yeah, so these number of provisions get phased in. And the next slide just really shows, again, at the national level, and this is likely true at the state level as well, because provisions are getting phased in over time and because, you know, the effects compound over time,

Robin, we've got a question from Senator Kirkmeyer.

And that's for the expansion population. They're at 138 percent of federal poverty level. Thanks. Yes, that is the max. Yeah. And then again, similarly, the Congressional Budget Office does national projections on coverage and participation in different programs and those projections over time, not state-by-state estimates. Again, the Congressional Budget Office did estimate that the bill or changes in the law would reduce coverage by about 10 million people by the year 2034. The vast majority of that change was from the Medicaid changes, so 7.5 million people were estimated to lose coverage. and we did try to look at this on a state-by-state basis using our allocation formula. And again, this was the best we could do from sitting where we are at the federal level, but the estimates can vary across states depending upon expansion status, share people in the expansion status, and share people in marketplace coverage as well.

Senator Kirkmeyer? Thank you. I'm wondering if you did any studies or did any projections with regard to how many of those approximate people that you said would be not receiving Medicaid coverage, but actually would be receiving coverage because they have a job and they're getting it through their employer?

Thanks, Robin. We can keep going, I think.

Okay, I'm going to jump into work requirements unless there are other questions because it seems like there were a lot of questions on the work requirements as well.

Yes. Thank you. So, do states have any flexibility or opportunity to change the

basically the expansion became effectively an option for states. So that's why we still have, you know, 10 states that have not adopted the expansion. But if you adopt the expansion and if you are, you know, as a group and accessing those enhanced federal matching dollars, so the 90% for that coverage, then you can't lower the eligibility thresholds. It has to be the group that goes to the 138% of poverty. I guess that's part of the question. But for example, if a state wishes to, because as funding starts dropping, they're not able to fund able-bodied individuals without dependents in the expansion population. Do they have the flexibility to move them off or no? So you'd have to unexpand the whole thing. I mean, Representative Brown said we can unexpand. We can take the option not to have the expansion population. I get that. I want to know if there's any way to make modification as the percentage keeps going down. Right. So, again, it's you adopt or states adopt. the expansion as a group. So you can't, there is not the flexibility to say, oh, we want to have parents up to 138%, but adults without dependent children up to, you know, 50% of the poverty level. Okay. Is that the, yeah. Yep. That was it. Thanks. You have another question? Yeah. Thank you,

I appreciate it. As we're going through this presentation on work requirements, I know that there have been a couple of states that prior to the ACA had, or sorry, prior to HR1, excuse me, had implemented work requirements. Arkansas, I think Georgia, and then Montana probably about 10 years ago had sort of a workforce supports program which wasn't strictly a requirement. I wonder if you might be able to tell us a little bit about how those programs impacted work participation rates and coverage rates in those particular states. Yeah, I mean, you know, we can.

Next slide.

Another question from Senator Mobley.

Thanks, Robin. I think those are all the questions for now.

show that you qualify in the expansion population through your income. So you do have to tell whoever it is on the application that you're working or you're not working. I don't understand why that particular piece would be so hard, since there is this already a pretty intense qualifying thing that involves disclosing if you're making money or not. Right. So you have to be income eligible, but that doesn't, there are ways that they're going to be able to use the data match to calculate if that income qualifies as potential work but it not always linked up to hours of work So there are pieces that states will have to adopt newly to make sure that the income data is related to being able to verify this work piece as well. I think we had another question from Senator Mullica.

Yeah, so I think that was something that states had hoped to do longer exemptions and hoped to be able to use more self-attestation for individuals to say that they couldn't work for X, Y, and Z. The new rules were more restrictive, I think, than states had requested and were planning for. So there's very limited now self-attestation. So it's really only one time that you're allowed to self-attest. And you can't, the determinations are not, they have to be done every year. So even though, right, your status for meeting some of these exemptions may be more permanent, they still need to be verified. not every six months, but every year. We have another question from Rep Brown.

There has been no, like at the national level and in research done in Arkansas, data from research that supports the increase in overall employment for individuals who are subject to work requirements. So that was something that the Congressional Budget Office looked at as well as other researchers in Arkansas. There, you, I think you were the one who mentioned the Montana experience. There was a small program in Montana. That was much, it was not a requirement and eligibility was not conditioned on meeting a work requirement in Montana. It was a much more targeted and narrow focus on individuals who may be able to work, but needed much more direct support with workforce programs. It was much more targeted and much more intensive. And there was some indication from that program that individuals were connected to work in a different way. But the broad swath of just conditioning Medicaid eligibility on meeting work requirements has not, the research has not shown that those requirements increase aggregate employment. Okay, thanks, Robin. Let's keep going. Okay, so that was a lot on work requirements, and I know we're sort of running low on time, but the other big piece of changes were related to the financing changes. So there were changes related to provider taxes. So again, no new taxes, but also lowering of the safe harbor for the provider taxes have to meet a number of different requirements. And one of them is that there can't be a hold harmless. So states or providers that are paying into the tax can't be guaranteed that they're going to get all of the money back from that tax. except within this Hold Harmless. The current Hold Harmless Safe Harbor is at 6% of net patient revenues for each provider class. Over time, that is going to get lower to 3.5%, and that will limit how states can raise their state share of funding for the Medicaid program. All states use provider taxes right now, except for Alaska is the one state that does not. And many states have multiple provider taxes. And our data from our surveys of states show that Colorado does have a hospital tax and that is over the three and a half percent. So that will be subject to these new limits that will get phased in over time. The other big change was related to changes in state-directed payments. These are for states that use managed care plans to deliver services to Medicaid. States could direct certain payments through managed care to providers and tie those payments to private insurance rates. There were changes and new limits on how states can use state-directed payments. I would say for Colorado, this is an area of a bit of uncertainty because there was a hospital state-directed payment proposal that had been submitted in late June of 2025 to CMS. And as we have not seen an approval of that, So it's unclear whether that proposal for Colorado will be in place and then subject to new limits or it hasn't been, it's still pending at CMS.

that's just at the federal level, correct? Yes. Yes. So it's actually not going to cut Medicaid spending unless, of course, the states cut Medicaid spending because they can't provide the match. I mean, essentially, it's a cost shift. Yeah, exactly. So, right, these were the estimates that the Congressional Budget Office said this is going to reduce. And I think some of the biggest uncertainty in those estimates was exactly, as you just said, how states will respond to that. So, you know, these estimates could be higher or lower based in aggregate on how states respond. So if states are able to raise additional revenue or replace some of those federal dollars, then they would still be spending money on Medicaid and drawing down federal match. But to the extent that these new limits reduce states' ability to fund their share, exactly, that reduces overall federal spending. So I think this is, and the Congressional Budget Office had said this, one of the areas of highest uncertainty in their estimates.

Well, on the coverage side, and actually that tees up the next slides for the next two minutes. But yes, I would just echo that there's a lot going on and the options for states are not, they're hard options for states. They are, you know, more broadly than Colorado because Colorado has its own limits. But states can, in the context of balancing a budget, you could raise revenue, reduce spending in other areas or reduce Medicaid spending. And the levers to reduce Medicaid spending are lowering provider rates, restricting benefits or limiting enrollment. And, of course, there are challenges, you know, with any of those options. States, of course, pay for their share of the Medicaid program. So if there were easy options, many states would have already, you know, already adopted those. And I think, as was mentioned, there are constraints on how you could, you know, use any of these levers. You know, there are new rules around transparency and tying payments to Medicare for certain services. There's just the overall reality that most optional benefits are and the most expensive optional benefits are really home care. So that's something that I know Colorado and lots of other states are struggling with how to manage. you know, there's, it's sometimes there's optional dental, but that's not a big expenditure item. So again, a lot of the spending in terms of optional benefits are in the home care space And certainly there are anticipated reductions in coverage that have implications for access for people as well as implications for providers I would also just say just to wrap up that I think it particularly challenging as you know, for states because these changes are happening in the context of so many other things that are happening at the same time. So there were the tax changes in the law and other cuts and reductions in SNAP, and that's affecting implementation and workforce. There's other existing issues that are happening with state budgets on top of the changes that were part of the law. And then there are also new focus, really, and requirements around program integrity. So all states are being asked to do provider recertification and look at many, respond to a number of federal inquiries on program integrity. There's just a general challenge with implementation across all of these different provisions, as well as some uncertainty, because it does seem like some of the guidance that states need to implement some of these changes. The guidance that's been coming out from CMS is sometimes a little different interpretation than what states had been planning for. And then, of course, there's implications for people and providers. So, all of these things are happening at the same time. So I know that there is a lot on your plates and on the Medicaid agency in terms of navigating and managing and balancing all of the changes that are happening at the same time. Thanks, Robin. We have a question from Senator Mabley. Yeah,

Yeah, that's a great question. And we, right, the states will need to make decisions. There are these changes, but they have these broader effects. And I think for providers, as you just said, the changes are magnified because it's the Medicaid changes as well as changes from related to ACA coverage So together those two pieces are you know really restricting public coverage. And, you know, we know from when coverage was expanded that the expansion in ACA and Medicaid coverage had helped bolster, reduce uninsurance rates and help bolster access and on the Medicaid side helped reduce uncompensated care. So the reverse is likely to increase uncompensated care for providers. And as you said, individuals' healthcare needs are going away. So hospitals and clinics that are serving people who have healthcare needs. We'll still see those, but they will not have a revenue source to meet those healthcare needs. And we know people will go without care. When you look at individuals who are uninsured, they're much less likely to get the care they need when they need it, less likely to get the prescriptions that they need as well. Thank you. I know we've got Senator Malka has a question, then we'll go to Rep Taggart. Go ahead.

Yeah, I think that's a good question. There are other provisions in the law that actually, and this applies for SNAP as well, that impose new penalties for errors. And that's happening at the same time. There are all these new requirements. And, you know, the rules also talk about doing more audits of states and how they're coming up with how they're doing medical frailty. So, you know, I do think states are working with CMS to try to make sure that they're adopting systems that will be in compliance. so that they don't face these errors. I think it's going to, states often collect their own data, but at the national level, we're still hoping that data is just lagged. So the biggest indication is gonna be what happens with overall enrollment and enrollment in the expansion group. And we don't have that at the national level, certainly very quickly, there's always a lag. So it's hard to have systems in place that try to course correct, you know. So, you know, if you see there's a certain area or a certain group of people that are losing coverage, we just don't see that at the national level until things are, you know, it's a very long delay. But hopefully states and hopefully maybe you'll hear from your state folks about mechanisms that they might have in place to be able to do faster, more real-time spotting of enrollment trends as things roll out to be able to, if they identify problems or specific challenges that may be able to be addressed in the implementation. Thanks, Robin. Senator Mulligoff?

I was on another call this morning here with another state, you know, grappling with the same issues. I would say we are in the field right now of collecting our information across states where we're asking on more basic access operational kind of questions, like what's happening with rates, what's happening with benefits. You know, in the years following the pandemic, I think we saw a lot of attention to increasing rates and expanding benefits, particularly on the long-term care and behavioral health side, as there was a lot more attention on demand for those services that was really highlighted during the pandemic. I think even last year, so before a lot of these things were going into place, we did see, you know, in Colorado and across the country, a slowing. So some states implementing rate restrictions. So rolling back rates that were increased And that was a trend that we saw more broadly and trying to make some more modest changes on benefits and the optional benefit area So I think you know again we're going to see some of that in what we collect this year. I think when states want to do bigger changes like, you know, value-based payment or, you know, delivery and payment reforms. These are things that are just much harder to implement on a short timeframe to generate reductions in states. But I think we will be asking states, you know, about, you know, we're usually asking, you know, what are you doing to control costs in the pharmacy area? So we'll be asking about that, but I think some of these bigger delivery and payment system reforms are not things that help balance a budget in the near term. I think we've got another question from Senator Bridges.

So things like value-based payments, not sure if they reduce overall spending or just increase value for dollars that are getting spent. Follow-up question?

Yeah, I mean, again, I think some of this activity with the pandemic and there's, you know, things that a lot of states were working on bigger reforms that have tailed off. I would say one area, and I'm not like the biggest expert on some of these demos, but are more cross-payer initiatives that some states are working on. There is a demonstration at the federal level on the, you know, it's called the AHEAD program where it's looking at more cross-payer type of, So just not looking for just cost savings in one payer or another across the healthcare system. So I think that is one area that we'll be potentially watching for results. There are only a few states right now that are participating in that program. Thank you. Okay, we've got Robin for three more minutes. Any final burning questions? Senator Kirkmire.

website. We don't always, you know, they're complicated. So they're usually approved for at least, you know, a five-year period. And then the evaluations come at a much, you know, again, lag time. So, and they're usually meeting various metrics, not always cost savings. But we do have some of that information on our website. And I would just say it was great to be with you all. And there were a lot of questions. And I have other colleagues also who are expert in different areas. So please, if there's something, a data need that folks need, I'm happy to, my information is available and we'd be happy to try to, sometimes it's hard to find things on our website, so we'd be happy to direct or try to find the information that you, that you might be looking for, at least as it's relative to other states. Senator Mable, did you have a...

Robin, I want to thank you also for being here today. I really appreciate your time and expertise. I have a couple of things I'll follow up with you on in terms of some of the data requests, and we will go from there. But thank you, again, for sharing your expertise in the national lens. I think it's helpful as we switch now or transition to what's happening specifically here in Colorado around HR1. So thank you, Robin. Okay, thank you. Bye-bye.

Summer, could you also, obviously with this last discussion we had that she raised that she has a dashboard on waivers. My gut tells me we probably tapped all the waivers that there are out there, But if we haven't, it would be great to have a follow-up in terms of are there waivers that we have not taken advantage of because we did not take advantage of state-directed payments until the application last year. So maybe there is something there. Yes, I made a note to make sure that we look into that a little bit deeper in terms of the dashboard, and we can talk with HICPF as well. Rep Serena.

I think we want to transition now to have HICPF come up, but let me check in and see.

is here on the Zoom and I'll also say to Rep Gilchrist I just sent you

in and out of internet service, but I appreciate that. Okay. And I think with that, I will hand it

Thank you, Summer. Thank you, everyone. Nice to be here with you. We did have a plan to do sort of a broader overview of the Colorado Medicaid program, the CHIP program, and the other programs that we administer. But given the depth of information that Robin shared and sort of the heaviness with which we face this challenge around HR1, I think we're going to continue to make that a shorter period of time. One of the other things we want to do at the beginning of these meetings is to help when we do provide written responses to any of your questions to see if there's follow-up questions. I know sometimes we feel like we send them over and we're not exactly sure if they met the mark or not. But in the interest of where we find ourselves today, I just wanted to maybe back us up just to the 10,000-foot level and to 20 years of history of health care policy in the state of Colorado. And I think it's relevant because of where you ended with your comments, Senator Mabale, that this is a systems issue and it is a systems issue that we should tackle. So one of the questions that you all asked earlier was sort of about the department's history. You got in your very first commission meeting that history. And it's really an important component because it is around the middle of the 1990s where there begin to be concerns and cracks in the health care delivery system, right? The increase in managed care writ large, both in public and in private, because of concerns of cost containment. So we find ourselves here many years later continuing to talk about the challenges related to costs and to coverage.

The Colorado Medicaid program did have a comprehensive managed care program in the late 80s, which was met with and ended with a series of lawsuits. And so from that time, the state has been innovating in its delivery of the way we provide Medicaid services. In 1995, we did create the Medicaid Community Mental Health Services, which is really the foundation of the capitated behavioral health system that we have today. That has made its way. through. Interestingly, I will take us back to 2006 now, where the Senate Bill 06-208 established the 208 Commission with the explicit goal to find practical ways to cover the uninsured, control spiraling costs, and improve population health. I think things that we all still aspire to do. However, at the time, the coverage, the rate of uninsured was about 16%. We used to say in Colorado, we had 160,000 children who were uninsured in 2007, 2008, who could fill mile high twice, right? We were trying to sort of figure out how we could understand the challenge of the uninsured. So what came from the 208 commission was really a playbook that ended or began with Governor Owens in his final term, then was picked up by Governor Ritter, advanced by Governor Hickenlooper and continued to be moved on collectively as you all have been policymakers now. Those foundations included things like the Colorado Indigent Care Program, another program that we don't talk a lot about, but that is administered here and provides important financing to hospitals for indigent care that they provide. The Public Health Reauthorization Act, Medicaid expansion, and so we did expand the Medicaid coverage as a foundational piece of that continuum of coverage that was described by the 208 commission? Could we have coverage for individuals for whom private market coverage is unavailable because of their resources or their health care needs? Then could we build an exchange, right? At the time, the only exchange that existed was the state of Massachusetts. So we structured our Connect for Health Colorado at the time called the Colorado Health Benefit Exchange. That bill passed in 2011. We also did ACA aligning protections within our private health insurance market around rate banding and then a massive alignment bill that put us in compliance there. In 2009, the Colorado Health Care Affordability Act, also known as the hospital provider fee originally. Funny story, there's an interesting article in the final edition of the Rocky Mountain News that covered the press conference where Governor Ritter, we all were in the Denver Health lobby, announcing that piece of legislation and the collaboration between the state and the hospitals. So if you ever have an old edition of the Rocky, it is in that edition. And then we've also done things around workforce. And so I take us back to that history in some ways, Senator Mable,

hey, is that Medicaid commission over the summer going to be like the 208 commission? And I said, I don't believe it will be. I think it will be focused specifically on the challenges of the Medicaid program that are faced by the upcoming changes in HR1. But I have had the chance to talk to many groups since I've been back, and I would advocate that we may need another 208 commission, obviously with a different name, but that would allow us to take stock of, you know, 21 years later, given all the things we know about how health care has evolved, how amazing technologies have improved lives and extended lives, how our demographics have shifted in this state, and how our population continues to grow and age, might we sit down again and think about that larger structure? I think this conversation obviously does need to start first because these changes are happening immediately in the Medicaid program. But I wanted to acknowledge what you had thought there, Senator Mabale.

That is $200 million. And we as a group, to my knowledge, Don't know how that is going to be dispersed. I just know I have a bit of frustration and concern from my rural hospitals because they're looking at an August 1st deadline on an application that they're not comfortable with in the least. And I was just with the Alliance for Rural Hospitals for their conference last week, And there's tremendous uncomfort. So my worry is I don't want to see this commission, and I never envisioned this commission to be as a direct result of HR 1. Great. Thanks. And thank you, Representative Taggart. I did not mean to mischaracterize the limited nature of this commission. We are planning, based on the agendas that Summer has outlined, to dig into all components of the Medicaid program, long-term services and supports. As you mentioned, rural health transformation, we have a conversation about that today, just this afternoon, so hopefully those questions. So I think what I meant to say, and perhaps did not well enough, is to say those larger questions around impact of loss of coverage because of reductions in participation in exchange-based coverage or changes from other components of the health care system were not necessarily going to be structured in this conversation. So I certainly, we welcome any conversation you'd like, but I think when people were wondering and asked me explicitly, would this commission be like the 208 commission, I said it would be different. So one of the other things to then bring us back to the conversation of HR1 that I did want to, I tried to take as many notes as I could on areas where you had questions about the national context that Robin shared that perhaps we could provide some state context on. So the first is the number of individuals covered by Medicaid. I think, Senator Mullica, you asked a question around flat enrollment, and indeed we have seen flat enrollment in this last fiscal year in the Colorado Medicaid program. We had a change of about 5,000 Coloradans participating in the program by the end of the year, which is a 1% growth. So in some ways I would agree that with the national perspective that our enrollment over this last fiscal year so July of last year to just June of this year has essentially remained flat Similarly, the question that you had around who we cover, so about 52% of those covered by the Colorado Medicaid program of the 1.3 million are adults aged 19 to 64, and that does include those parents that you were asking about, Senator Mable. In Colorado, prior to the Affordable Care Act, Colorado Medicaid, using Colorado General Fund, financed up to 68% of FPL for parents with enrolled children. The Affordable Care Act allowed that expansion from 69% to the 138, and that is financed by the hospital provider fee and the Chase Fund. So that is the distinction, and it does make the communication around the requirements of participation a little bit complicated, in addition to the notion that individuals who parents with a child under the age of 14 would also not be subject to some of the new eligibility requirements. Importantly, we don't talk about CHIP as much as we should, in my humble opinion, but we've got about 77,000 or in that range young people as well as pregnant people enrolled in the CHIP program. That expansion, also up to 250, is financed using the hospital provider fee or the Chase fees, and that's from $205 to $250. So not subject to the HR1 conversation per se, but an important component of those additional groups for whom eligibility was expanded using that financing mechanism. And then lastly, oh, yes, please.

Did I misunderstand something there when you said $250? The green button right there. Oh, there it is. Sorry. That's right. Can you say your name?

Adela Flores Brennan, Medicaid Director at Healthcare Policy and Financing. So when the Affordable Care Act passed, we had to convert our eligibility from the old way it worked to MAGI-based or modified adjusted gross income-based eligibility. And when we did that conversion, it did increase the $250 to $260, $265 because of income disregards and other technicalities like that in the income calculations. So you're right.

Yes.

Yes. Yes. We are not, but through the legislative process, the state is.

Yes, about 3,000 pregnant members.

Yes, 330, what was the number? 330,000 enrolled when we pulled this data are part of the just low income without dependent children. So you would add the number of parents who would be impacted. And currently all in for parents, there's 175,000 parents enrolled, some of whom would have been enrolled prior to the expansion because they have an income under 68% of the federal poverty level.

No. 377 377 And of that 330 are just low income without dependents Correct Without any dependents not the over 13 or under 14 Correct.

their eligibility determination is through that eligibility category, of which nobody would know that that's their eligibility category, but that is the way in which they have been enrolled in the program. So of our 377,000 in the population, we expect that 47,000 will be exempted out.

No. Senator Kirkman, I'm worried that I'm confusing us with all of these numbers, and so maybe as we get to the HR1 implementation, we can walk through the fact sheets. We tried not to use slides, but we recognize that without some sort of written documentation, it can be challenging to keep track of the numbers.

It would be impacted by the chase fee changes, but not by the new eligibility requirements.

I would have to look at our eligibility and caseload reports because we break that down in our monthly reporting to you all.

I'm sorry, ask the question again, please.

Yes.

No. It is not. The federal Medicaid matching percentage for CHIP is 65% for the state of Colorado, so 35% paid by state. But not all of that paid out of the Chase fee.

Tobacco tax and other general fund funds fund the state share of the CHIP program, or the Child Health Plan Plus.

Okay, so 29,000 kids are between 205% and 260% of the federal poverty level, and those are the ones who are financed by the Chase Fee.

I didn't grab the dollar.

About 29,000 kiddos.

Yes.

Closer to the mic, sorry.

So we have a timeline that we start out with to help outline some of the major provisions and when they've gone into effect. One of the things that went into effect right away when the legislation passed was prohibited entity funding. And so you may have remembered that back during the special session last summer, there was legislation passed to help fund Planned Parenthood for a year while there was a federal prohibition in place. So that went into place. That has now expired. We've dealt with that in the system, and we are able to fund Planned Parenthood again through state funding. The next one that is coming that is big, and I don't know that it gets talked about as much nationally or in the public, is there is a major change to who is deemed a qualified immigrant for purposes of public benefits. So the change is going to impact a lot of lawfully present immigrants, which means that about, we're estimating upwards of 7,000 people will lose coverage on October 1st. Those include refugees, asylees, people who have a humanitarian parole, people who have been granted withholding of removal, and certain survivors of domestic violence and trafficking. trafficking. So there is no real exception to this. We just have to end their coverage. And we have been starting to take a look at who is on those roles, like what category of eligibility they're in. We can see that about 400 or over 400 people have home and community-based services, institutional levels of care, are older adults. So these are folks with high needs who are no longer going to have coverage, and they also do not qualify for subsidized coverage in the exchange. So to the extent that maybe a commercial insurance product may be out there, they would not get that premium tax credit through the exchange either. I can just also say we're doing a lot of work to help communicate this out to the community. We've already sent out notices in May. We have a micro-grant program or community ambassador program that we are using to help support a few geographically diverse community-based organizations who work in immigrant communities. to help get the word out and then formal notices will go out in September.

And this is Adela again for the department. Thanks for that reminder. There is an exception for kids and pregnant people, so they can remain eligible under an option that we took previously as a state under the CHIP program, we can maintain children and pregnant people's eligibility.

So after you've taken all those folks out, we still have about 7,000 people that we estimate are going to lose coverage. So then the next big things that come online are the work requirements that we heard a lot about earlier in the day and six-month renewals. So the same group of people, members generally speaking age 19 to 64, up to 133% of the federal poverty level, will be subject to new community engagement requirements. So that includes work, work training, volunteering, or education, or a combination of all of those things. And they have to have 80 hours a month. Now, there are a lot of people who can be excluded from that. The universe of people to whom this applies we're estimating is about 377,000 people. And then we start excluding people based on things like whether they are blind or have a disability, have a substance use disorder, disabling mental health condition. And then we have the medically frail provision, which I will say is increasingly complicated after the new federal regs came out. We are still trying to figure out how we exclude those individuals based on that two-part test that was discussed earlier. So not only is a person defined as medically frail, but they have to have a significant impairment that prevents them from completing that 80 hours. So that makes it more challenging for us to use data that we have access to to evaluate that medical frailty. There are some situations, some diagnoses that we can imagine and are doing the research on that, of course, would exclude somebody. But now we need to start pairing that with other data sources. and I'll pause.

Yes So one of the things that we can use to deem whether somebody has met their work requirement obligation is we can take 80 hours times the federal minimum wage which is roughly per month And if we can see that somebody is already making $580 a month, then they have met their requirement. So that's where Colorado's minimum wage may advantage us.

It's both, but we can use that $580 as an equivalency. So it's equal to the federal minimum wage times 80 hours. And so if we do that math and we can see in the system using our databases and our connections to the labor department, If we can see that that person has $580 in income, then we can deem that they have met the requirement.

Roughly.

So we're still working on recalculating that number, Representative Brown, because of the new federal regulation that came through, and it has complicated our assessment a little bit. And I misstated something a little bit earlier, so I want to go back. We have the work requirements, universe of people who those are 377,000 on an annualized basis. Then we can exclude people who are parents or caregiving, younger children, veterans, members of tribes, et cetera. And then the medically frail we can exclude as well. And of the medically frail, we can see people who are disabled or have a disability based on that federal determination. And if we don't have that, then we can look at whether they have a diagnosis. For our previous number, for the number of people that we thought would remain after we went through all those exclusions, That previous number was 155,000 people who we still needed to inquire with them about whether they are working or meeting the 80 hours or they have some other kind of exception that we can't see in the system. So that number could go up because of the harder, more difficult definition of medically frail.

So we have been working. The minimum viable product, just to make sure everybody's on the same page, is the thing that we have to have minimally working our systems and operations that have to be ready to go live on January 1st, 2027, to implement some of these bigger provisions like work requirements. We have had to do a lot of reassessing. One of the things that we are taking advantage of in the federal regulation is the ability to take self-attestation for year one. So 2027, we can take self-attestation. We have a form that we tested with members and put through some of our stakeholder engagement processes. It's a long one. It asks a lot of questions, like I have it here. Are you pregnant? Are you a parent? Are you currently pregnant? Or were you pregnant in the last 12 months? And it goes through a lot of questions that can help exclude people. So that we're building into the system, which helps on the verification side. We don't necessarily have to go out and find that verification. We will, though, and to I think it was Rep Taggart's point about auditing, by 2028, we're going to have to have an audit trail for all of that. We're going to have to make sure that we have verifications in place. So to the extent somebody attested to something on this work requirements form, we will have to be able to verify that either manually or through some systems interface. So that in a way has helped with minimum viability, but I don't want to understate the complexity of the thing that we are putting into place because, you know, we're not even talking about all these little nuances about the people who are excluded we can look at in the current month, and the people who are accepted we have to look in the month before they applied. And all these types of nuances that are deep in the eligibility weeds that I can't recite off the top of my head. So, yes, we are working very, very hard, and we're going to be doing our testing and everything that is required to make sure all the systems are ready to go. And we still have a lot of development left to do to help figure out how we're going to do all these verifications on the back end. We're also working right now to connect with new sources of data, the National Student Database. I don't think that's the real name of it. Or Clearinghouse. National Student Clearinghouse. There's the Veterans Administration. There are various other places that we can access that we're working to get connections to through the federal government that will help support us doing as much as we can behind the scenes.

That's correct?

Yeah.

My name is Rachel Ryder with the department, and I'll talk a little bit about Director Flores-Brennan talked about kind of the timeline. I'll talk a little bit about the communications and the operations pieces. To your question about preparation for county workers, we are, we, instead of just assuming we knew what they would want for communications and readiness, we went out and did a survey of frontline workers. About 900 folks responded, and we're building our outreach and education plan based on what they told us. So what we're hearing is they want to see not just your typical, you know, training, but also more inaccessible kind of bite-sized pieces, because this is a lot of complicated policy. So while we're building the system, we're also doing some base education around what will be changing, who will be impacted. We rolled out a basic screener tool that has a series of questions that very much follows the plain language reading of the law. We do have to adjust it slightly because of the regulation that came out. But it is kind of helpful for folks that call in and may ask their county worker, does this apply to me? We have a screener where folks can walk through in about four or five clicks to see if it might apply to them, the work requirement piece. It also walks through some of the exclusions and exemptions. We've rolled that out a few months ago and we've had about 3,000 unique folks a month look at it. We have not pushed it out further yet, but we are working on that to make sure that base education is there. It is a screener tool. It doesn't tell you what you have to do yet to comply, but we did see a need for some immediate kind of education while we develop the more robust training that's needed based on what the system changes look like to those county workers, what the screens will look like, et cetera. So those base education materials are out now. There's some base education, but the training will be developed based on what the system looks like. So we're having some regular engagements with counties around what are you hearing, what more would be helpful. We did thank you very much for your support, General Assembly, in approving our HR1 supplemental last year, it boosted county funding 17 million for the next two years to address some of the workload that we think is coming with these changes. Now, that was based on the information we had at the time, back in January. What Director Flores Brennan mentioned about the complexity with medical frailty and some of the other things that came out in that nearly 400-page rule that was released a few weeks ago might mean we have to reassess some of those impacts a bit. But we are grateful that you all approve that and the counties are working on hiring plans right now. They're due in mid-August to get ready for both the six-month renewals. So every six months this population has to go through a renewal and the other piece, which is the work requirement piece. Now we are at the same time working on automating as much as possible. One of the exclusions that Director Flores Brennan didn't mention but that we are very excited about is folks that already comply with SNAP or TANF we can check the box for Medicaid So we don have to kind of reassess them We can check the box So that is really an advantage to Colorado in that we have that joint eligibility system where we have that information already available within our system. Some states have separate systems, so they're building pathways to get that SNAP and TANF information over. So we are working diligently to get not only our county partners ready, But I'll also mention broader stakeholders. This is going to, Senator Momblé, you mentioned earlier, the complexity of the communications of this, and the Kaiser Family Foundation, Robin mentioned it earlier too. This is not just a mass media, hey, guess what this is changing? You're impacted. It's very nuanced on who is impacted and what they will have to do and how they can comply. So we are working on those targeted communications. We'll be bringing on some help to develop, based on what other states have seen work, targeted digital kind of outreach campaigns for those folks, because we know the expansion population. Most of them use PEAK. Most of them are online. So, you know, a general awareness, you know, kind of broadcast message may not be as impactful. Georgia spent about $10 million. They got, what, 7,000 folks enrolled. We don't have that kind of money. we need to be targeted and smart with the funding that we do have. And so we are working on those targeted education campaigns with providers, with RAISE, to make sure they are armed with information. Nebraska rolled out on May 1st. And we're also learning from what is happening there. They're having reports of confusion that sometimes they're getting mixed information.

Sure. Thank you. So I think related to that, it sounds like there's a lot of work going on and movement forward is strong, but I think we want to make sure we get this right, and it's critical we get this right. So I'd say what support are you not getting right now that you need, And that includes both resources and sort of alignment and work. Because so much of this is like joint eligibility and insane software system, it's county folks saying, yes, it's so many changes, right? So are you getting the support and cooperation that you need from counties? Are you getting the support and cooperation you need from folks on the digital side to make sure this whole thing works? I know this is historically a program that has been an utter disaster in really every single way. And so are there things that you need that we can either provide or that we can help to get you?

For that last, you need to submit, this is Senator Bridges, or Jeffy as I referred to earlier. For that last part, the difference between the plain language and the rules, is that a place where we need to talk to the Attorney General about a lawsuit and that maybe that's something the states should get together on and challenge? Because you said in previous years you've done this with thousands of pages of guidance. Now we have very, very few. Is this a place? Thank you. I would love your opinion on that, on whether this is something we should challenge.

But Rep Taggart.

This is Adela from the department. Yes, it's clear in the reg that it's federal minimum wage. Just to add to the nodding on the mic, since you can hear it.

You're right. That is frightening. And we have put some eligibility teams together, finance teams, and our long-term services and support team together to figure out, at the very least, how can we help with transitions, but we're also looking at what other programs in the state that may be state-only financed that may have availability could support some of these individuals, but this one is sticky. This is so to Senator Bridges' question about what we may need. We may need help with solutions there if there's a will.

Senator Mullica? Thank you. I guess, one, I wanted to plant a flag, because I think we're going to talk about this not only today, but maybe in future conversations in regards to CBMS and the impacts, and I think the correlation even with the World Transformational Health dollars is, one thing I am hearing from my community is around the efficiencies. And obviously with the increased number of redeterminations that we're needing, there's, I think, been a number of years that there's been complaints about CBMS and the lack of efficiency. And so what does that look like? And are those rural transformational health dollars potentially being used there or whatnot? I know there's already conversations around there, but I think there should be further conversations and would like the committee to hear that and would like the committee to hear also around these rural transformational health dollars around what kind of outreach is being done. I know that this first batch went around, and that's another one of the critiques I've heard, is that there really wasn't significant or appropriate outreach to the people who we should have been outreaching to. But I digress. My main question is we're talking about outreach to these populations that are going to be impacted. And I know I got a document talking about your plan. We heard about your plan today. We even, I think in the plan, there's many grants that you all have really worked on and appreciate kind of this grassroots path that you're taking to try to reach some of these folks. But what I haven't heard is what the metric is. How are we figuring out if we're successful? And I'm not hearing that. And I would love to hear on how we're measuring success so that we don't, if what we're doing is not working, that we don't just keep spinning the wheels and that we actually have numbers to show that we're reaching the people that we're intending to reach and not just doing something that maybe sounds good on paper.

Can I ask real quick? And I don't want to interrupt, but, and I feel, I don't want to beat a dead horse because I know Representative Taggart is saying the same thing. What's that timeline? Because I know that time is of the essence. And so what's that timeline? How are we going to know? So thank you for that. When are we going to know?

Yeah. Again, so if you've started that process, how do you start the process and not have the metrics? That's what I'm trying to.

But to me, if the ball is rolling already, we should already have an idea of how we're going to determine what these metrics are that we're being successful in regards to this outreach. And that's what I'm curious about, because I do think it sounds great on paper. I think what you all are planning sounds amazing. that doesn't necessarily mean we're going to be successful at it. And how are we determining success? Thank you.

And, Senator, I'll add to that. When we're thinking about the second phase of the campaign, the take action, what we'd like that vendor to help us with is some regular, is it working? Do we need to tweak? Like, were the social influencers more effective? Some states have used those and had a great kind of engagement rate in getting folks to go to the website and take action. If we have a tool that is working better, we want to make sure we have that information and put it up on our website if it's working or not and share with all of you. So we are, as Adela said, kind of building while we're getting like the ambassadors out. And it's just not because that funding became available in July. It's not all together.

And so that my hope A couple of other things that I add This is Adela from the department The feds are also going to direct us on what types of metrics we need to report out on I wouldn't necessarily characterize those as metrics for success, but rather maybe more process-oriented, how many people stayed enrolled, how many people lost enrollment, those types of things. We're also working on a dashboard that we're stakeholder-ing with various interest groups that we work with to figure out what is going to be helpful and relevant for us to post on our website so that people can check in on our status with implementation. So we've got an implementation dashboard that we're going to work on. And then also the metrics that the feds are handing us that we need to report on, not unlike what we had to do for the unwind. So, you know, how many people lost eligibility for this reason or that reason, that type of thing. But I don't think that's exactly what you're talking about. You're really talking about the outreach metrics. Thank you for that question.

I'm not sure we have. I can start at the top.

Yeah. Thanks, Representative Brown. I think I'll start with just a few comments on the public health unwinding. I was obviously not in this state at the time, and then maybe transition to answering some of the questions that you have been getting at. I think that there's a couple of things to know. So there were certainly coverage losses in the Colorado Medicaid program. We were reviewing data yesterday, though, that reminded us that our CHIP enrollment went from somewhere in the low 40s up to the 90s during that time period So while some people did lose Medicaid coverage we do know that they found coverage in other public programs or exchange coverage So it is hard to tease out all of the but we were reviewing monthly budget numbers yesterday

That said, there is another difference that we're trying to distinguish beyond just lesson learning, which is important. I think, as Rachel has said, we didn't have necessarily as robust of initial stakeholder engagement as we do now. Our webinars have had 2,000 people participating in each of our webinars. We're hopefully having the conversation with you today. We have the screener tool and other things that we're trying to do differently. The other shift that we've been trying to make mentally is that unlike the PHE where it was a 12-month, everybody through a single process, this is a new way that eligibility will be determined in the Medicaid program moving forward. So we are going to have to get better over time.

I understand that, and I asked for that exact briefing when I first started back at the department. What did we learn from that period of time, and how might we approach our work differently? I think that we acknowledge. I want to say, though, two things. Our continued North Star is to maximize coverage retention for individuals for whom they remain eligible for the program. Our second metric would be how many of those can be determined to be eligible because of ex parte or other means in which we don't create a burden for the member to have to respond. I would like to say, though, I think as Robin suggested and I think as Adela has said in other forums, the law is anticipating coverage losses. It anticipates coverage losses. And so I think we just have to see that with eyes wide open and do everything we can to help everyone who should remain eligible to stay enrolled. But the federal law does anticipate and built coverage losses, in particular for federal Medicaid spending. I think the accuracy of those slides were on the federal spending. And so that is the environment in which we find ourselves trying to maximize our North Star, which is coverage.

I will say Rachel has a specific answer. I will say all of those numbers are modeled estimates. I do not think we can predict at that level of specificity. So the modeled estimates, there was a recent revision of those modeled estimates out of Manat and State Health Value Strategies, adding on the new nuance of the two-part test for medical frailty. So even if we were to say an estimate today, I just want to qualify that that estimate will change as federal regulations are made clearer. Yeah, and this is Rachel, Senator Mobley. The Minot did an initial estimate, and they did it by state. It was kind of a 50-state walkthrough, and they combined not only the work requirement but also the impact of that six-month renewal, so kind of more broadly, HR1. They recently revised that up because of the new guidance. with medically frail. And they have in there a range in a couple different scenarios. So in that, they list out Colorado. In the range, I think it's about 140-ish is what they estimate over the next couple fiscal years. So I can get that exact link to you so you can see their analysis and what they looked at.

Yes, I'm sorry.

Those are individuals for whom we won't have other information that will allow us to ensure their continued coverage. And this.

I think, Senator, they assume that some of the compounding impacts of the other provisions of H.R. 1 may increase that coverage loss, And I know we're going to talk about provider fee in a little bit here. Okay.

So 140,000 may lose Medicaid coverage over a 10-year period.

That's it. But that isn't due to the fact that they're doing a cost shift.

Senator Krikmeyer, I can start with the provider piece, and I will mention, I mean, that was one of the areas where during the unwind we didn't have provider-tailored messaging to help them. So we're doing that differently now, and we hope to have and test our toolkits with our provider partners at that point of care. They are really critical partners. So tailored messaging tools that work for them in their offices, so in their place, whether that's flyers, whether that's one of the hospital partners during the Unwind did play a video of ours in their waiting room and that worked for them and their location,

May I add something?

Thank you. I wanted to add, you know, I think you all have asked that we be transparent where we have challenges or hear challenges and concerns. One of the things that I have heard in my meetings with hospitals, in particular University of Colorado earlier this month, is this concern about the new medical frailty provision They are very, providers are communicating, they are very anxious about being held responsible for determining someone is too frail to work. That is something that is just not, and made a distinction between when a provider needs to do that under the construct of workers' compensation versus this. We've also heard that from county workers, that, you know, that is an uncomfortable component of this, and people, I think, are raising concerns. We don't have a solution for this at this point. I mean, I looked, Liz was saying, you know, this is a really big concern, and I was like, yes, and we share it. You know, I don't have any flexibility here that I have found yet. So I think an area of ongoing collaboration across the network of stakeholders and individuals who work with Medicaid members is going to be that component and one we just haven't figured out yet.

Thank you, Madam Chair. I think this, I'm hoping I'm not out of line here, that I'm out of order, but I think this is an appropriate time. So we did ask questions of the department, and one of the questions I had was around benefits, and I'm looking at what was the document around the mandatory benefits and the optional benefits and what Colorado's kind of signed up for and what we haven't. And I appreciate that information. I think what I'm curious about, too, is do you all have the data to show dollar amounts associated with each one of those optional benefits that we can get as well? I think that that valuable information when we having to make decisions or looking at different things Yes so we do in our premium and caseload and expenditure report that we send over a monthly breakdown by acute care services inpatient outpatient and how much we spending each month

lines. Yeah. To me, it would be valuable if it could be, if, if, if that can be associated with kind of the list that was given to us, those dollar amounts. And then also, if you're able to, if anyone's able to kind of compare that to even neighboring states, you know, or, or kind of trends at national level, I think that's one of the things I'm trying to, to sort out is, are we, where are we in line where are we kind of out of whack and and how does that you know i think that's information that is going to be useful going forward can i just clarify this is adela from

expansion comparison yeah so the the we have the the the expansion comparison the dollar amounts and then i think you know what some other neighboring states i mean it's it's tough to compare us to a state like California whose population is much larger, but, you know, a state like Utah or a state like Arizona or something like that, something similar to give us an idea of where we are in line and where maybe we've exploded a little bit. All right.

Thank you, Madam Chair. I'm not one that likes to look back, but a name of a consulting group got mentioned in this discussion, and I'm not going to say it again, the name of that consulting group. I have sat through two presentations of that group that I would describe kindly as less than satisfactory. The first time I had to listen to them, they selected a sample group of states to analyze our provider rates, only to come to the JBC and pull one of them out. Anybody that's ever been involved in market research, when you establish a sample, you've got to go through a lot of hurdles to make sure that sample represents the population. They had not done that. And so they come to us with a recommendation taking one state out. It was ridiculous. We were furious. The second one took place this year where we posed questions on who were the stakeholders involved, and they hadn't even spoken with the Rays. and the comment back to us was well basically we'll get to that but they were making a recommendation without talking to our critical people for partners. I, for one, really never want to hear that name again because what they've done for this state is, and I'm being kind, less than satisfactory. And they're very expensive.

Thank you. I have one question. Not to just ask a question, but one thing that I had on my list here is Director Ryder mentioned appeals, and specifically the downstream impacts of, like, we're adding all of these questions, even if they're self-attestation, or later there'll be, you know, verification or whatever. That's going to trigger more and more appeals. My understanding is that sometime last year, you had already reached, like, over 2,000 appeals that had been waiting for more than 90 days and I understand 90 days is kind of the magic number, the requirement. I'm interested in where you think that number is today. I don't know that I've seen the most recent data. But I also want to know like what are you all doing to try to minimize appeals and are you anticipating asking for more resources related to that?

This is Adela from the department. And I think it's going to be a compounding impact because we've seen, you know, eligibility appeals, of course, around the public health emergency unwind. But every time we make an adjustment to benefits, especially when we're trying to do cost reductions and limit benefits, either, you know, the amount or the duration or the scope of the benefit, then that drives coverage appeals. And so to the extent that we are in this position right now as a state to need to make cost reductions and we're reducing benefits, that is driving appeals. And also we're going to have more appeals likely coming in through the eligibility appeals door as we move forward. And we are understaffed there. And we are also adding staff. And we will be asking likely for more support there.

Director Hammer.

it sounds like.

I'm not asking you to get in front of OSPB. Yes, and I will also say the other, so we have the appeals staff internally. We have the appeals staff over with the ALJs, and then when we have benefit appeals, Oftentimes we need to bring in clinical staff from the utilization management side of the house, so our chief medical officer or nursing staff or whomever. So that starts, it's a kind of snowballing effect throughout various places in the department that you might not think about.

Okay. Afternoon, everybody. Kristen Bates here, Deputy Medicaid Director and Director of our Office of Behavioral Health Initiatives and Coverage. In my role as Deputy Medicaid Director, I am leading as a senior executive sponsor for the Rural Health Transformation Program. Though, of course, like everything, it is an all-department effort to put something like this together. So I just kind of wanted to give an overview, about five minutes, and then I can take some questions. I have a number of anticipated questions that I'm also ready to speak to as needed. So high level, this is $200 million a year for five years, almost a billion dollars that we are receiving from the federal government. I want to be clear, this is 100% federal funds. This is not a Medicaid payment. This does not have federal funding participation. These are federal funds that are flowing directly to health care policy and financing in which we are the grantee. We have a cooperative agreement with the federal government, and these are grant funds that come to the executive branch for implementation for our transformation of rural and frontier areas. On June 18th, we put out our main request for applications. and that was about 160 million dollars annually We go through that request for applications process This is the one that is due August 3rd The timelines on this are very much driven by federal requirements For example, if we do not have all of our funding contracted and obligated by October 30th, then we are at risk for losing those funds not just this year, but every year afterwards. So they have been very clear that if we are not spending the funds and we are not obligating the funds, meaning we have a signed contract with every single grantee, then those funds are at risk to be moved to other states. Our goal of success, if we want to measure success, is that we not lose a single dollar and that we are doing such a great job that we are here to potentially get funding from some of the other states. That is one of our goals. So I can walk through some of those things. We already have a question.

So they have to be obligated October 30th, and they have to be spent by the following September 30th.

The way that we have it is encumbered is obligated. That is a similar term. We had a similar situation with ARPA. So as long as we have it committed. Now, spent, though, the September 30th date, that's not encumbered. That's not obligated. That is the funds have to have been spent, sent out, invoices completed. Invoices completed? Paid. Yes. In September this year? September 30th of 2027. In a year. So what we're looking at is a month to review an award. We have a short period to do some negotiations with awardees, and then we have to start contracting. We're anticipating anywhere from 300 to 400 applications. We have a pretty comprehensive process. So we have – that is the process for this $160 million. That includes about $44 million for telehealth, $39 million for alternative models of care, $40 million for whole person health, and $24 million for workforce. Those are the four largest grant categories. And then there's four fairly small grant categories, one for EMS, one for many hospital grants, one for some advisory boards. And the goal really is, again, transforming rural and frontier health. And really our goal has been to push these monies out specifically to our rural providers. We, in line with the federal statutes and in line with the HRSA, which is the Healthcare Resource Services Administration, the federal administration, they have a grants analyzer that says these are the types of providers that are able to be receiving these grants. It's not just that the provider is serving people who live in rural areas, because then every provider could apply. This is very specific to the providers who are in rural areas providing services in rural areas. So the services provided in the grants have to be provided in rural and frontier areas. That is the definition. Yes, Senator.

So this has been a very, you all were part of, many of you were part of our ARPA process, which was very flexible This is very directed So 44 million the amount was the state decision in partnerships with our provider partners and saying what are our priorities. And telehealth, it's not just telehealth. It's telehealth, telemedicine, and IT innovation. So it can include mobile applications. It can include remote monitoring. It can include...

Yes.

Yes.

So the application was put together with a number of hospitals and providers. But telehealth can mean a lot of things, right? Telehealth can be in our rural hospitals. When we talk to our rural hospitals, they don't always have specialists. Telehealth is when somebody comes to the hospital and there's a specialist. There's a program when we went to Lincoln, and they've got a stroke expert. So that as soon as somebody walks in the door, 20 minutes later, there's a stroke expert on the video, looking at the client, connected with all the telemetry. Those are the types of programs that we're hearing are really important. Specialty care is important. Behavioral health is important. And then you also look at some of the smaller primary care providers and what they're needing, again, on specialty care.

So that's one question.

Yes, Senator, that's exactly correct. Just like ARPA, these are funds that are required to be spent per the federal government for supplanting, not supplementing, not supplanting. It can't be going towards just regular operations. It has to be going towards things that are changing, innovations. This is very clearly the purpose of the funding and why it was developed and what we will be doing with it. The $160 million is going directly to providers. We have another $15 million that's going towards public health infrastructure. Now, while the providers have a number of different places, especially in whole person health and support and alternative care models, that absolutely can be provider-based. There's a lot of population health, public health elements in that, preventative health. There is 15 million that's going to the Department of Public Health and Environment, and that's going for, some of it's going out to food banks, some of it's going out to local public health agencies, and some of it's going to their other kind of centralized public health infrastructure data. That's fine.

20 million is going to training. I'm sorry, 10 million. Well, there's 19.5 going to training and technical assistance for grantees. So this is basically instead of having, and this was a direction from CMS as well as what we heard from providers, workforce challenges are not limited to clinicians. Workforce challenges also include IT experts. They include lawyers. They include financial experts and analysts. And so this is basically a pot of funding that we use for training, support for grantees. These are direct dollars for the grantees to use. And then there's some things like research that we're going to be doing that a single, you know, we can't give a provider funding to do research on statewide impact of the program for example so that would be another place where we have professional services and then we have 2.9 million which is 1.5 percent of our total that's going to state administration that includes 19 staff to operate this program but then it also includes a grant oversight vendor that's health tech solutions and then we also are contracting with Colorado Rural Health Center which is our provider which is doing specialty grant support for the grantees as well and overall support for the program and running our advisory committee as chair. Okay, I must have screwed something up. You said 15 million, first you said

million, I think you might have counted it twice. The 15 million is going to the Colorado Department of Public Health and Environment to do public health infrastructure and other support. So that's a single $15 million, not two. That's 35. So then we're like 5 million short.

So all- the Department of Public Health because they came in with ideas to cut that and continue in cutting it for the last two years. So, yes, we did work with the Department of Public Health on some of the requests. Office of eHealth Innovation also is getting funding there, as well as the Behavioral Health Administration for Rural Health Youth Crisis Services.

Thank you. Thank you so much for the conversation. I appreciate it. and I don't want to piggyback too much on Senator Kirkmeyer's question, but I heard a few things that I found that I really wanted to ask questions about. So you talk about your response to the senator's question of who decides how this money is split up or applied, and you said the state. So I'm assuming that by the state that means HICPF. Is that correct?

Okay, thank you. And I'm just going to ask a couple more questions, if I might. So we've talked a little bit about metrics and accountability. So if you're writing a check to, say, CDPHE as part of this grant or providing grant, I don't know what form it takes, how do you know that they're doing with the money that what you are expecting them to do? Are there metrics around this success? And similarly, when we're talking about 44% of this funding going to telehealth, are you looking, are you at all interested in being agile? If that's not the right percentage, how are you going to determine that it's not the right percentage, and how are you going to pivot with that new information? Thank you, Senator.

So that's not 44%.

So that's of the 160 million.

So not 44% of the whole.

So every single grantee will have goals that they send to us that they will hold themselves to, and then we'll have some pretty general high-level goals that are across all of the grantees. Those are set and required by our federal partners.

You refer to clients. I refer to them as patients because they are patients of health care providers.

Yes, Senator, we're really adhering to the grant guidance on this. I would say that the grant guidance is actually very supportive and directive that we use the funding for some administrative changes. Administrative changes for transformation cost money. These dollars are not going for, only 15% can go to provider payments that are like incentive dollars or dollars that can be spent for, you know, workforce participation. The funding is really supposed to go to infrastructure costs, the cost of partnership, the cost of contracting, the cost of. So this is very directive, and I'm happy to share with you, anybody is interested in a deep dive on the contracts and what's inside the federal requirements, I'm happy to walk you through that process in a more in-depth level. But this is going towards improving care for the people in those communities. It's not just for Medicaid members. It's for everybody in the communities. Medicaid, CMS is the agency that is running it, but it is not specific, and you can use it for services that help people who are uninsured. You can use it for, especially as we are seeing some losses, you can use it for people who are commercially insured. You can use it for prevention programs that aren't covered by insurance. What you can't use it for is paying for services that are already covered by insurance.

Sorry, Representative Brown here. Thank you very much for your presentation, Director Bates. I appreciate that. I wanted to, I was chatting with just on Sunday, I was chatting with some other states about their rural health transformation projects and we were talking about some of the requirements that are built into our various, and Director Hammer just mentioned them, sort of the requirements that are built into our proposal upon which we will be accountable for, and if we do not meet them that they may claw information or claw money back or maybe not give us as much money in the future. And I wonder if you could give us a sense as a committee of the, just review the sort of specific requirements and metrics that we expect to be evaluated upon going, through the Rural Health Transformation Project.

Okay.

Just as a follow-up, I wonder if you could give us a sense of sort of what is the, what are the major risks for us in our, you know, so, well, I mean, before we go to that, I want to ask a little bit more about what are the specific – I'm losing my train of thought. Let's talk about risks. Where are the risks that we won't meet those requirements and that we might get money clawed back or in the future we won't have as much money?

Okay.

I'm sorry, I didn't mean to monopolize the conversation. Three areas on this that I have a concern about. and first would be centered around it would be great to get an executive summary of what this program is and what these buckets are and the dollars associated because to my knowledge we've never received that, either as a JBC or as a commission. Secondly, I will reinforce that I was with the association that represents the rural hospitals on the western slope of Colorado. And for those of you that may not know, the western slope of Colorado is not Grand Junction. It is west of the Continental Divide. there is significant frustration of what this program is and the application process to the degree that a couple of the CEOs as well as the executive director of the association asked me, Rick, can you ask these folks to delay the applications by a couple of weeks so we can get through these points of frustration? And so I put that out to you because I think you are underestimating how frustrated folks are with this program. and these are the people that should be gaining a benefit out of it, yet they're frustrated. Last but not least, I don't know the regulation that HRSA has put out on this, and I understand the focus should be rural hospitals that are, in fact, in rural areas. My problem with just that simple approach is we have hospitals in larger metropolitan, I'm not talking about Denver right now, but in slightly larger metropolitan areas that the vast majority of the people they serve are rural. It not 10 percent It not 20 percent It 60 and 70 and 80 percent And I had one hospital turned down that is almost 100 percent rural other than the small community that they in Now, are they right up against the city of Grand Junction? And they won't want to be called a suburb, so I won't call them that. But I don't know how those, again, because this was never shared with us, how much that regulation is. But in some cases, hospitals can't afford to even survive unless they're in a reasonable size town or city. So if I seem frustrated, I am, because we knew about this program and it hasn't been explained to us. I'm getting frustration from the people that it's supposed to benefit, and I don't even understand the regulation in terms of rural has to be just in a rural place. That to me, quite honestly, is way too simplistic, especially when a hospital is serving a huge rural area and the vast majority. Now, if that's HRSA, and I guess I have to accept that, but nobody's ever explained it to us.

Rep Taggart.

I'll just state I am happy to give you the person to talk with, but the confusion and frustration with our rural hospitals on the western slope of Colorado is significant. And they asked me to ask you for an extension. So I'll put you in touch with them if you want to talk with them, but I appreciate everything you're saying, but there is confusion and frustration, and it's significant.

Thank you. Yeah, and I think, yeah, I'm sure everyone, I think, is frustrated by this, by the process. I think it was really quick, and even as policymakers, we weren't really included all that much. But I wanted to kind of shift the discussion a little bit and try to get some information from you all in regards to how these dollars are spent. Obviously, this is going to be over five years, you know. and this is the first year in the first tranche. I just sent an article from February to the commission members here about what Wyoming is looking at. And I think some other states are looking at this as well of creating a, how do we make these dollars last? How do they go forever? Is it a revolving loan fund? Can you do that? And I think the verdict's still out a little bit on that. Maybe not. I'm getting my head, the heads are shaking. No, but I think what I am concerned about in addition to, I think, just the lack of communication is I'm trying to hear a plan of making sure that we don't maybe make some of the same mistakes that I view that we made with the ARPA dollars. because I do think that there are some things that we did with ARPA dollars that we have nothing to show for today. And potentially some of the things that they are, that they're costing us more dollars to actually run, and they're not helping our state. And so you don't get a billion dollars every single day from the federal government. How do you make sure that these dollars last? What's that plan? And if this idea or this concept of a revolving loan or making these dollars be able to bond against them or whatnot is not viable, is that in these discussions that you're having? because I know this is our first tranche, but there's going to be other tranches. And what is that outreach looking like? And what are those conversations like to try to make sure that we have something tangible long term to show that these dollars didn't just kind of disappear into the ether?

I apologize, but that's the first I'm hearing that there's no changes at all. And so this is news to me. And so basically what was put forward and some of the critique that we're hearing today with the lack of feedback from not only the legislature, but from members of the community, that plan now is stuck.

Senator Krukmaier here. So one of the other things I heard, besides the same situation that Representative Taggart mentioned, with regard to hospitals that aren't being called rural hospitals, even though they are in rural areas of what we all would consider rural areas of the state. But CDPHE, is it accurate that they have a mobile ban project?

Because how does that meet the rural transformation guidelines? And second, how many FTE?

So it's the same for FRUTA?

yet they aren't able, as a critical access hospital, get a grant.

Okay, so the health department's allowed to buy a mobile van and operate it. I would like to know what their sustainability plan is for five years out because they shouldn't be thinking that they're going to come and ask for additional dollars for that.

So they're hiring and creating more infrastructure in state government instead of putting the money into rural Colorado in those rural and frontier areas. Does anybody else see that as an issue? I mean, seriously, a state agency. That's not what I think they meant by a rural transformation grant, that we were going to build a state agency and somewhere between 15 and 20 FTE so they can go drive around the state and serve areas that are being served by rural health care providers that do need the infrastructure built up in their area Yes Senator the program is not a new program

I understand that. I've heard you say that now three times. So the thing is we have rural health districts that actually should be the ones who are providing the vaccine ban and probably providing this ban instead of the Department of Public Health and Environment who's located, what, over on Cherry Creek Drive or something? So seriously. So instead of truly building rural health care infrastructure to be transformational, they're building their own department up.

We cut funding public health districts. Okay.

Senator Kirkmeyer. Yeah, there will be a smaller group that meets about it. It's called the Joint Budget Committee, and I'll be having a meeting with them during the public health department and asking what the hell they were doing. So that's when I'll be getting the rest of my questions answered. Other than that, you'll need to continue working with the rural health care providers to make sure that we do have a transformational grant that it actually providing service to those people who live in frontier and rural areas of the state and not increasing and bloating up more state government for things that I don know our public health departments could have been doing which they came in and cut this year and they wanted to cut last year. So that's how I feel about that.

Thank you, Summer, and thank you, Senator Mable. I'm going to take us back in time for a minute. When we were talking about work requirements, I know I mentioned the Montana program in particular. One of the Montana, the aspects of the Montana program was really about work. It was work supports, right? It was like, how are we connecting people with the kinds of community engagement work opportunities that would allow them to maintain their coverage, right? And I think that I would love to know more from the department about how you all are thinking about implementing something similar to those types of supports in working with the Department of Labor and Employment or our new department that may be coming on workforce or whatever. But basically, like, what are the partnerships that you all are putting together or the ways that these other departments are sort of helping to connect folks with work or with community engagement so that they can maintain their coverage. Does that make sense?

Yes. How is that going to be sent to the committee, that information? So if there's comments or questions or whatnot or concerns?

So we won't be getting any individual questions or comments at all? We just get a summary of everything?

we can do both of that would be the preference. I'll speak for myself. I would like the raw data and specifically I know some of it could be anonymous but some of it may not be anonymous and so hearing that feedback is something I would like to hear not just summarized.

Okay, I think that sounds great. And then the testimony, the targeted testimony, that's not starting today, or is it?

I don't know if you're going to go over this, but are we able to make a request for a future or just how a future meeting is ran or feedback?

want to make this different going forward? If I could, I got the email a couple of days ago with some of the information, but I don't know if I missed this or whatnot. I didn't have these, I didn't get these slides that were presented today, and so I find it beneficial to have the slides beforehand too, rather than just seeing them. I agree with the color stuff being printed off and having the slides beforehand to see the KFF presentation I think would have been valuable just to be able to not have to have questions on the fly.

I think that's good, too. I do think it is helpful to have something that we can refer to about where we are in the conversation. That worked very well, I thought.

You're just talking. Okay.

Which email are you sending mine to? I'm still ticked off at this date over my email system.

Thank you.

Me too. I've been saying it for years too, like six.

Good afternoon. My name is Pamela Bishalia. I'm the executive director of Advocacy Denver. Advocacy Denver is Denver's chapter of the arc. I appreciate having an opportunity to testify, provide comment and recommendations. I remember during the last session there was discussion about the explosion of private entities, applied behavior analysis service clinics, and providers in the state, and the need for provider licensing, clinic licensing, and monitoring and oversight. The catchphrase was, we live in the wild, wild west. I have to say we continue to live in the wild, wild west. As we move to conflict-free case management, we observe private entities moving into Colorado or provider agencies, and those provider agencies collect as little as 5% or as much as 60% overhead servicing children, but in particular adults with intellectual and developmental disabilities. The pro of conflict-free case management is the cost for services would no longer influence what a case manager offers to a client. The conflict, the con of conflict-free case management is that we realized an increase in the number of private entities whose business values are to underpay the people who provide direct support or services so as to increase their overhead profit. Accordingly, advocacy Denver recommends legislation that demands licensure and supervision of said entities and sets a cap on overhead costs. Careful consideration should be made in terms of which government agency issues the license versus how said agencies will be supervised or monitored. We recognize that private entities, it's a difficult discussion. I'm here to plant that seed because we certainly are outraged when an entity provides or takes back 60% of the funding. Thank you.

Good afternoon, Madam Chair and members of the Interim Commission. My name is Betty Lehman. I'm representing Lehman Disability Planning. there was a situation where when people needed home health hours Those were determined by home health agencies, conflict of interest. So the department said, we're going to build a new tool called the nurse assessor tool, and we're going to pay Telogen. And I would like you to ask them how much was spent, because the day it was supposed to go live, after training 92 people, they said, oh, the tool doesn't work, so we're just going to have case managers determine home health hours. The same is true with the ISLA or the interim tool for IDD services. We don't need it. Nineteen states do not use any kind of resource allocation tool. We don't need to use it either. I would love to know how many millions and millions and millions, because what we talk about is how we can do punitive things to both members and providers, But we don't look at what we can cut in our government systems that are useless, that are causing harm, and have been used to commit fraud on those members. So I gave you that idea, and I would like to go to the second idea I have, which is that we don't need to have only a $2,000 asset limit. That's a state choice. That's not determined by the feds. 11 states have a much higher limit, and what it does is it creates churn for our state government because it's nearly impossible. This is 30 years old. $2,000 is all you can ever have. Try to pay first and last month's rent with only $2,000. It cannot be done. And so people are not allowed to save, and they lead a very undignified life with only being allowed $2,000 in assets. So right now, California is at 21,000, New York's at 31,000. We don't need to do this punitive positioning with that. I have a third idea. I'm not going to share it now, but I have the materials with me, and it's also on ABA. If there's another opportunity for me to speak about that, if not today, then I'll come back next time and talk to you about my idea about saving money with ABA. Thank you.

Great. I'm Tyler Chaffee, Senior Vice President with the Colorado Hospital Association. We represent hospitals in nearly every community you serve and are affected by the Medicaid cuts. Nearly 20 years ago, the Colorado Hospital Association worked with the governor and the state legislature and stakeholders to produce the hospital provider fee. And that was a win-win-win for hospitals and the Medicaid program and the administration of the Medicaid program. Basically, hospitals pay a cess fee into the fund, and the federal government matches those fees, and Colorado uses hundreds of millions of federal dollars to help ensure access to Medicaid through supplemental payments that serve Medicaid recipients and funding for Medicaid coverage. What started as a program with $686 million in total expenditures in 2010 and was initially anticipated to finance Medicaid benefits for 100,000 Coloradans has grown to a program of $5.6 billion in total expenditures in 2025, supporting Medicaid coverage for 438,000 Coloradans, more than a third of the Medicaid recipients. As enrollment expenses rose more provider fee revenue went to coverage and operations which left less for hospital supplemental payments that secure access to care These changes distorted the function of the enterprise, which was intended to help bridge the gap between the cost of providing service and the inadequate reimbursement for care. Even with those payments, hospitals are reimbursed at roughly 66 cents on every dollar it costs to treat a Medicaid patient. The program was under strain long before the President signed HR1 into law. HR1 has upended the rules that have governed this model for decades. The fallout will mean less provider fee flexibility, new limits on state-directed payments, new eligibility requirements, and we're especially concerned about the work requirements that you have been talking about. For the past year, CHA has led an internal stakeholder process among our very diverse membership to produce a full Chase report that we would like an opportunity to present to this commission at some point, which will cover a lot of your questions about the Chase Fund and its future. Okay, thank you.

Committee members, do you have questions? Senator Mullica.

these things and so and that is why people are here today too so yes because I do I think there would be a lot of value in this information.

from the state in these Medicaid dollars that we currently have? Yeah.

Yes.

the fund is getting out of balance? Are you referring to the allocations or are you referring to something like the decisions that the board is making itself or something we are doing? Mr. Chafee.

Rep Brown.

We want more coverage. We want as many people covered as possible. So I want to be absolutely clear about that. It's just when you have that big a change from the original intent of an enterprise and a law, you need to revisit it. You need to study it and engage a stakeholder process to make sure that it's still working as it was originally intended. So we want that growth to continue. That's why we joined with CCHN and other consumer groups as well with the Save Our Safety Net Coalition to really talk about the unwind, talk about some of these issues, because we want people to have coverage, because if they don't have coverage, they end up, you know, in our emergency rooms in a much more dire situation, which, of course, we do a little bit more than the Chase Fund administration, so that's why we have a bit higher overhead than the Chase Fund. But in order to, you know, execute all of that, we just need access, And I think for rural partners in particular, those critical access hospitals really need to maintain that access to make sure that that network in the community is there. Because that's where closures are already happening. The lines of service that have disappeared across rural Colorado, whether it's Stextrix units or other services, that's the beginning. That's the canary in the coal mine here. So I think we want to just pay attention to that. And again, the HR1 cuts haven't happened yet, and that's already an issue. And so we want to make sure that this, and that's why we're excited about this commission, because I do think it's a way for us to talk to you about this report, create a partnership, see how we can get this enterprise, even under the conditions of HR1, working at its best for patients and Medicaid.

Thank you, Madam Chair. and I don't know that you can answer this and it may be a stretch

Yes.

Mr. Chaypey.

Okay, Senator Mullica.

Mr. J.P.? We're a consensus-based coalition, so I'd love to raise that idea. I think there'd be a lot of interest in that.

Senator Kirkmeyer Yes Can you send us that report so we can look at it prior to any presentation Of course That would be great And thank you for your comments all of you

But the Save the Safety Net bill was two years ago, and it was only supposed to be for two years to try and stabilize the system. So I'm like Senator Mullica and would like to know where we're at on how we're going to stabilize the safety net. And just to put, you know, everybody's least favorite thing to hear about is the reality with regard to funding. There is a cautious that is going on between the federal government and the state government, and it's going down. So their share is going down. Our share would have to go up. We don't have that money. So we are going to have to look at the expansion populations and eligibility and other things that we've done that we're using our money on to determine how we're going to fund. Those are the most medically fragile, and those are in the lowest income brackets. And that's just the reality. So I hope everybody's brains are there. I know when we were talking about the health on wine, everybody thought, oh, everybody should get to stay on. No, it just doesn't happen that way. They don't get to just stay on. We weren't doing the redeterminations and the reassessments. And we had a whole bunch of people, and we, like, doubled our population or something on there. We grew it substantially. So we were back down to pre-COVID levels, but costs have gone up. And I don't know. Apparently, we're doing really well on certain benefits in certain areas because we have become in a tractor state. So we don't want to do that either. But at the same time, we want to be able to provide as many services as possible to those who are low income and medically fragile. At least from my perspective, that's where I am thinking. So I hope everyone else is thinking there as well. We can't have everyone on Medicaid. We can't afford it. Just can't. So I look forward to hearing your next idea next time.

That's the million dollar question, right? That we're all asking. I didn't think of it myself. Billions of dollars question. I don't have a good answer for that. I do think I know that this is a very might have too many political headwinds to be able to achieve it. But the H.R. 1 bill does allow states to ask for a two year reprieve on implementing work requirements. I think the indications that we've gotten from the federal government is that they're not approving those. But I still think it's worth a shot to ask. And that would not cost money. But besides that, I think those are the things that I think we want to be in conversation on.

Michelle, yeah? Yeah, thank you. With your hands. Yeah, I was trying to do it with my hands, but I had the wrong, I was emphasizing the wrong syllable.

I appreciate you bringing that up.

Thank you, members of the commission and chair, and thank you for the opportunity to testify. I'm Bethany Prey, Chief Legal and Policy Officer at the Colorado Center on Law and Policy. We're an anti-poverty organization with relationships statewide and nationally. We're also a member of Save Our Safety Net, like others who testified today, and I'll be talking about H.R. 1. As you heard from KFF's Robin Rudowitz, all states will struggle to make the eligibility changes required by H.R. 1 between now and January, and Colorado has some unique challenges. Administrative burden on people and on county eligibility staff is going to be a driver of coverage loss. Adults who are working or entitled to an exclusion may lose coverage because they don't understand the requirements or struggle to submit verifications or can't find training opportunities. As we saw during the unwind, others will lose coverage because counties are unable to process on time the additional mountain of documentation. And as Ms. Rudowitz said today, past data suggests that we will not see a related increase in workforce participation, and certainly not with our existing workforce support system. In August 2025, last summer, CCLP established a community-based work requirements work group with participants who have expertise in SNAP, Medicaid, and workforce supports, representatives from health clinics, hospitals, and RAISE, researchers and tech experts, county staff, and HICPF and CDHS staff. The discussions held in these monthly meetings resulted in an initial set of recommendations to the state in November 2025, and as we learn more, we are continuously sharing findings with state partners and with those they work with. During the same period, we worked on legislation, HB 2614-29 and HB 2612-35, to beef up publicly available data and allow us to track impacts. We'd love the chance for folks from our work group to present here, and we welcome more participants in the monthly work group, including legislative staff and legislators themselves as we learn about how HR1 will affect Colorado. So anyone who wants to join that, please email me, and we would look forward to a presentation. Thank you.

Thank you, Commission and Chair, for having me here today. I am the executive director of the Patterson Center for Resiliency a behavioral health clinic in Colorado Springs that has been operating since 2020 We serve hundreds of high multi Medicaid clients statewide. We run the state's only therapeutic after-school program for high-risk youth, as well as an intensive trauma treatment program that has kept some of Colorado's most vulnerable families out of emergency rooms, inpatient psychiatric units, and foster care for six years. Over that time, we have had only 26 total psychiatric hospitalizations and zero completed suicides in a population where those numbers should be statistically 10 times higher. We have proven statistical significance in reducing symptoms in only six months of intensive treatment in our program for the state's most acute and chronic outpatient clients, data which I'm happy to share. From 2022 through 2024, Medicaid and other state partners invested in expanding these programs and designated us an essential safety net provider. That funding has since been eliminated before we ever saw a dollar. This summer, the codes that sustain our intensive programs have been cut so severely that we are now weeks away from dissolving both programs, while also losing our highly trained professional talent, further delaying treatment rehabilitation. I have additional reports I can share on this. This is not a situation where a program has failed. The state invested in us, the outcomes justified the investment, and the reimbursement structure was changed underneath us. When these programs close, the cost does not disappear. It shifts to emergency departments, inpatient units, and child welfare at significantly greater cost to Medicaid and to the state. This specific program saves money and it saves lives. Medicaid Ray case managers have already called us with highly acute clients, stepping down from residential care, and we have had to decline them because we cannot get reimbursed for intensive services. The case managers have said they have nowhere else to send them. We are the place they send them. Treatment programs like us are the reason that we should not be treated like part-time clinicians who are treating worried well patients down the street. We are not the same types of programs. Clinics that provide a menu of empirically supported services intensively train their new providers and serve complex clients should receive different base and value-based payments to prevent costly shifts to higher levels of care to other systems. I have more detailed thoughts on this about the common fraud practices I have observed and have attempted to address my concerns with HICPF, the Rays, and elective officials over the years but hope to collaborate more moving forward. Our programs move people into housing, work, and school and eventually off of Medicaid. It moves people out of foster care, residential, and the revolving door of hospitals and emergency rooms and probation. We cannot return to these costly and effective programs. Thank you for your time, and I'm happy to answer questions.