Here’s a roundup of some of the top questions we hear around what Medicaid does and does not cover when it comes to behavioral health and addiction treatment in Colorado. Regardless of whether you’re looking for information on residential treatment, sober living homes, peer support services, intensive outpatient or IOP programs, detox or partial hospitalization programs (PHP), you’ll find answers to the ins and outs of medicaid services for Substance Use Disorder patients in Colorado here.
What is Medicaid called in Colorado and how do I help patients apply for addiction treatment services in the state?
Medicaid is called Health First Colorado in Colorado. It’s easy to apply through PEAK Colorado, which you can access here. You can access an itemized list of Medicaid coverage for behavioral health services on the Health First site, here.
Are behavioral health and addiction treatment services covered by Colorado’s Medicaid program?
Yes.
Colorado’s Health First program has a very robust coverage map for behavioral health services, which expanded in January, 2021 under HB 18-1136 to include the entire continuum of care, including inpatient treatment, residential treatment and withdrawal management services.
If Colorado has good addiction treatment coverage under Medicaid why do some patients still struggle to access care?
Colorado has “good” behavioral healthcare coverage under its Medicaid program, but there are still some barriers to care for Medicaid patients in the state. There are many reasons why Coloradoans find it difficult to access care but the main issues with Medicaid patients’ access to behavioral healthcare in Colorado revolve around inconsistent application of rules and long wait times for appointments.
Colorado’s Medicaid system is somewhat complicated, with six different regional organizations administering the program for various areas of the state. This means that coordination is cumbersome and the application of coverage rules can appear to be inconsistent depending on the county in which you live. You’ll note that the Medicaid website for Colorado states that prior authorization is “sometimes” needed for many types of behavioral healthcare coverage. Prior authorization can be a big barrier to care, especially for individuals who need immediate assistance. It’s up to the regional organizations to determine whether or not prior authorization is needed and these decisions can vary widely depending on the coverage area.
Furthermore, like many states in the US, Colorado is experiencing an acute shortage of qualified addiction treatment professionals and behavioral health techs. Demand for services in Colorado is very high but there is simply not enough structural capacity to meet the current level of need. This translates into long wait times for appointments and high competition between patients for a limited number of slots that will accept Medicaid. So while a service may be technically “covered,” in some cases it’s still not available due to high demand.
Does Medicaid in Colorado cover residential addiction treatment services?
Yes.
Residential treatment for SUD is covered under Health First Colorado. There are no copays, limits or exclusions when it comes to residential treatment with the state’s Medicaid program.
Prior authorization, however, is required to access residential treatment services. If parity laws get an update, the federal government may force Colorado to change this requirement for at least some addiction treatment services.
Does Medicaid in Colorado pay for rent at sober living homes?
No.
Sober living is not considered to be a part of the official continuum of care for addiction treatment, according to Health First Colorado. While some Colorado sober living homes are targeted at leveraging Medicaid services for residents, rent at sober living facilities may not be covered under Medicaid in Colorado.
However, room and board is covered by Medicaid in Colorado when it is associated with a residential program or a hospital-based addiction treatment program.
Does Medicaid in Colorado pay for peer support services?
Yes.
According to the Uniform Service Coding Standards Manual created by the Colorado Behavioral Health Administration, Colorado considers “Peer Support/Recovery Services” to be one of the covered service categories for Medicaid patients seeking behavioral healthcare.
Peer Support services can take place in many behavioral healthcare settings, like in mentoring programs, coaching programs, resource connection services, recovery groups and other recovery community settings. Peer Support Specialists staff many types of non-clinical work at inpatient and outpatient treatment centers, as well.
Currently, Peer Support Specialists in Colorado are not subject to any licensing requirements, although they are typically qualified for the work on the basis of their lived experience with mental or behavioral health issues. This may change in the future as Colorado and other states begin to explore certification mechanisms for Peer Support Specialists.
One of the most common CPT codes you’ll see attached to Peer Support Services is H0038, which represents one 15 minute unit of Self-help/peer services. Medicaid in Colorado recognizes this CPT code and considers it a part of their coverage universe.
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