November 2023

COMBINE represents the mental health care workforce that offers outpatient care through contracts with RAEs for Medicaid.  Medicaid serves over a million Coloradans. The population is pressed and estimates suggest upwards of 30% of these folks are clinical for anxiety, depression, and PTSD, which are all treatable in the outpatient context. 

Our mission is for a diverse, sustainable, and competent Medicaid mental health care workforce.  Mental health care needs real support.

We try very hard to recruit experienced providers to pick up a few Medicaid clients and there's little hope at this point.  "No $ for no-shows, reimbursement too low, too much paperwork, too long to wait for a claim to be paid, no provider support, no help to sign up, too much fear of audits."  Our answer is to provide all the assistance we can to new providers so they learn the ropes and to train and deploy university interns and pre-licensure externs operating under supervision. 

Current concerns:

• The state has no idea how many clinicians are seeing Medicaid clients.  Neither HCPF nor the RAEs ask us about work that is provided under supervision.  This statistic is masked because the claims form asks for the supervisor's info but not the actual rendering provider.  
• The state puts forth inaccurate numbers about the number of mental health care providers contracted with RAEs, and how many are actually available.
• The program is $1 billion (+) and HCPF reported around 110,000 people receiving care.  This figure is curious and surprising.  The numbers are profoundly weird and suggest there are some clients that are very very expensive to treat or that the RAEs are simply throttling care.  
• Beacon(administrator for RAE 2,4, owned now by Anthem/Carelon/Elevance/Wellpoint) charges the state 11% "processing fee" on every claim.  This is profit that reduces care.  Beacon OWNS 19% of RAE 4. The other owners are the Centers that the RAE (owned by the Centers) pays.  
• The situation of HCPF dividing Medical and Mental Healthcare into two entirely different systems has created many MHPAEA Parity violations, notably
• • contracting times (Medical can work immediately after HCPF "validation", Mental Health has to wait for RAEs to contract, and they drag their feet)
  • and the rate setting process.  MHPAEA Parity mandates a "similar" process for rate setting b/w medical and mental, and this is absolutely not the case in Colorado, where RAEs do whatever they want. 
• In fall of 2023,for the third year, the Legislative Audit Committee, which has a bill, has taken no action to expand the OSA authority so that the RAEs could be audited.
• We have no right to organize for collective bargaining, we are never offered employment by the RAEs or the state, and exist as contractors. 
• We have no access to the courts as Scalia in Armstrong 2015 ruled that providers do not have standing ("because CMS has a remedy for inadequate networks, which is to punish the state by reducing federal support"). 
• We do not have lawyer money.  We barely have lobby money. Donate here.
• We get no conferences, PTO, health insurance.  No benefits.  Just the contracted rates.  There is no COLA, there were no inflation adjustments.
• Our RAE contracts, that we must sign to provide care, mandate that we must accept that "rates are variable" and "may change at any time."
• The manager for RAE 6, 7 (Colorado Springs, Golden, Boulder) Anthem/CCHA cut our rates out of the blue by 20% in Jan 2020, we are still not back to where we were in 2018. Providers bailed from the system (364 providers dropped to 240 providers, a 1/3 drop)
• There is no support for MHPAEA Parity enforcement currently through HCPF, or Attorney General, or Legislature.  HCPF produces an annual report mandated by HB19-1269 and it only covers what HCPF wants to discuss.  The HCPF SMART Act hearing was about 20 minutes in 2022 with D leaders restricting the number of questions reps could ask. 
• • (DOI will hear Parity complaints and sometimes act, but only for commercial plans, never for Medicaid)
• Master Level clinicians, the bulk of the workforce, and 80% women, are penalized by a "tiered rate" system where reimbursement is reduced 20% b/c of school credential.  MA clinicians do everything and more (except for drugs and testing) in outpatient care than MDs, NPs, PAs, and PhD psychologists do. All those professions can provide services that we can't.  Paying by credential is credentialism, unrelated to the actual work, and reinforces historical inequities. 
• The Behavioral Health Ombudsman office is about to lay off all except for 1 worker in December 2023.  This is a crucial office when parents cannot accept a kid back into their home. Insurance companies push these kids to the street. 
• Polis' BHA has not, is not, and will not regulate the massive $1 billion Medicaid mental health program. "[It's the RAEs problem, we're not going to deal with it.]"
• The BHA is requiring more and more smaller outpatient clinics to achieve "clinic" facility licensure, which was never necessary before.  This means thousands of $ in fees, compliance with fire codes which could close existing clinics, and time spent producing policy and procedures. 
• Allowing the RAEs to set rates however they wish, with no regard for the Parity law, has created huge disparities in rates.  RAE 2,5 (Denver Aurora) pays 20-30% more than the other RAEs, which is siphoning off providers from the other RAEs, as clinicians attempt to make enough money to stay in business. 

Colorado dithers while the federal government backs Medicaid care 90% for the expansion population.   The federal money could be pouring in and instead HCPF through regulatory capture by the for profit RAEs (RAE 3,5/ Colorado Access is a non-profit veneer over Access Management,  RAE 1/ United Healthcare is for-profit, RAE 2,4,6,7/Anthem/Beacon/Carelon/Elevance/Wellpoint is for-profit) gives RAEs full power and control over rates, contracting, provider support, billing, etc. which leaves us vulnerable to their profit seeking, for example charging us 2% if we want direct deposit instead of paper checks.  It's death by 1000 cuts. 

We need a process independent of HCPF to accept, investigate, substantiate, and consequence MHPAEA Parity violations by the RAEs and by HCPF. 

We need the BHOCO ombuds office to have 10 FTE and access to administrative law court to substantiate the Parity violations, unless the AG is going to act, as other state AG's have acted. 

For MHPAEA compliance, our rate setting process must look identical or similar to how rates are set for Medical, which sets transparent, statewide rates. 

HD-49 2022 Rep. Judy Amabile offered an orientation for legislative action, "well, it's not so much about how much we're paying them as long as we're getting our money's worth."  Colorado is not getting its money's worth. And not enough questions are being directed at these politically powerful corporations who are netting $billions in profit per quarter. 

See a timeline of 4 years of action versus this RAE system at https://combinebh.org/Timeline