Colorado’s Medicaid program, known as Health First Colorado, provides health insurance coverage, including home and community-based support, to low-income residents, older adults, and people with disabilities. For home-based care and home health providers, staying current on reimbursement policies, eligibility rules, waiver programs, and compliance requirements can directly impact agency cash flow and revenue cycle success.
What Is Health First Colorado?
Health First Colorado is Colorado’s Medicaid program administrator, offering comprehensive health care services to eligible members. Providers must be enrolled with the program before submitting claims. Depending on a member’s coverage, services may be reimbursed on a fee-for-service basis, or through managed care organizations (MCOs) under a contract with the state.
Eligibility and Enrollment
Eligibility is based on income, household size, age, disability status, and…for long-term services…functional need. Providers should routinely verify eligibility before services are delivered as coverage can change month-to-month. Most adults and children qualify under Modified Adjusted Gross Income (MAGI) based income standards. Long-term support services such as home and community-based services (HCBS) require additional functional eligibility. Regular eligibility checks are a key billing safeguard as lapsed or inaccurate eligibility is a frequent source of denied claims.
Medicaid Reimbursement Structure and Rates
Colorado’s Medicaid rates are published on its Provider Rates and Fee Schedule page and are updated periodically; typically, with annual or semi-annual schedules based on state budget action. For home and community-based services, Colorado implemented a rate increase effective July 1, 2025, that applies to many HCBS service categories. Providers must pull the current fee schedule for the correct procedure codes and units (often reimbursed in 15-minute increments). Because rate schedules are updated regularly, agencies should ensure they are billing under the correct rate period and using up-to-date fee schedules to avoid payment discrepancies.
Community First Choice (CFC) and Waiver Consolidation
One of the most significant changes in Colorado’s long-term services landscape is the transition to Community First Choice (CFC). The CFC program expands access to HCBS through Colorado’s state plan. It offers support such as:
- Personal care services
- Homemaker services
- Reminders for medication
- Support with activities of daily living
- Live-in care
- Remote support and monitoring
Originally, Colorado administered multiple independent waivers such as Elderly, Blind and Disabled (EBD), Developmental Disabilities (DD), ad Brain Injury (BI). Each waiver had its own set of rules and service definitions. Over time, the state committed to consolidating these service pathways into the singular CFC, streamlining access and ensuring broader eligibility across populations. This consolidation is scheduled to take effect fully by the end of June 2026, at which point most HCBS waiver services will be systematically incorporated under the CFC umbrella. Providers will no longer need to navigate separate waiver structures for many services currently delivered under distinct waiver programs.
Importantly, while CFC consolidates services administratively, it does not impose new unique billing rules. Providers will continue to use existing procedure codes tied to personal care and home support services, seek prior authorization where required, submit claims through Health First Colorado or applicable MCO portals, and adhere to EVV requirements for in-home services.
What does change is the eligibility pathway and simplification of service access. Members who meet functional and financial criteria will have a clearer, unified service entitlement under the CFC state plan. For agencies, this means less administrative complexity in tracking multiple waiver categories, a broader defined member base with entitlement to essential HCBS supports, and potential for increased volume of care under a standardized set of service rules.
Home & Community-Based Services (HCBS) Overview
Under Colorado Medicaid, HCBS services are intended to help members get care in their homes and communities instead of institutions. With the full rollout of CFC, most HCBS services will be governed by a single state plan authority rather than dispersed across multiple waiver programs. Providers should continue to monitor ongoing guidance from Colorado’s Department of Health Care Policy and Financing (HCPF) for instructional memos and updated service definitions related to the CFC transition.
Electronic Visit Verification (EVV) Requirements
Colorado requires EVV for personal care and home health services involving in-home visits (mandated by the 21st Century Cures Act). The EVV must accurately record:
- Type of service performed
- Who provided the service
- Where the service took place
- When the service occurred
Claims without matching EVV data risk denial. Providers should train all staff and caregivers on EVV use and reconciliation before claims submission.
Practical Tips for Providers
- Verify eligibility frequently: Medicaid status can change monthly.
- Track fee schedule changes: Colorado updates reimbursement rates; incorrect rate application can lead to underpayment or denials.
- Understand CFC rollout timing: Know which services are transitioning into CFC and how coverage rules apply.
- Confirm EVV compliance: Especially important for personal care and in-home services.
- Plan for operational impact: Consolidation under CFC simplifies administrative workflows but increases the need for updated internal processes.
Conclusion
Colorado’s Medicaid program is evolving, and the transition to Community First Choice (CFC) represents a major modernization of long-term service access. While billing fundamentals remain steady, the program consolidation under CFC offers providers a more efficient and expansive framework for delivering and billing HCBS services. Staying current on rate schedules, eligibility criteria, EVV compliance, and service definitions will help agencies minimize denials and maximize cashflow.
Paradigm will continue publishing state Medicaid breakdowns like this to help providers nationwide master claim and reimbursement complexities. Stay tuned for future posts on additional states.
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