Colorado HCPF outlines RHC rate changes, reconciliation schedule and plans to post rates online
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Summary
At a rural health clinic engagement webinar, HCPF said some Medicaid encounter rates will rise from $152 to $165 per visit starting Jan. 1, 2026, described reconciliation timing for audited cost reports and said it will post clinic-specific rates online, while reminding clinics about scope-of-service adjustments and managed-care audit options.
The Colorado Department of Health Care Policy and Financing (HCPF) used a bimonthly rural health clinic engagement webinar to walk clinics through how Medicaid rural health clinic (RHC) encounter rates are set, the timing for reconciliations of audited Medicare cost reports and the department’s plan to post clinic-specific rates to its website.
Andrew Abelos, facility rate section manager at HCPF, said the department pays RHCs the higher of a prospective payment system (PPS) rate or an alternative payment methodology (APM) rate. "So right now, we are currently paying at $152, per visit rate," Abelos said. "That will be a $165 for those RHCs whose APM is higher than the PPS," he added, specifying that the Jan. 1, 2026, implementation date applies where the APM/UPL exceeds the PPS.
Abelos described differences between freestanding and hospital-based RHCs: freestanding clinics receive the higher of the PPS (established under the cited BIPA reference) or an APM tied to the Medicare upper payment limit (UPL), while hospital-based RHC APMs are based on audited Medicare cost-report cost-per-visit figures. After a Medicare cost report is audited and finalized, HCPF performs reconciliations comparing reported visits and interim versus finalized rates, which can result in additional payments to clinics or recoupments.
On timing, Abelos said the department sent reconciliation letters in June tied to 2024 finalized rates and has received finalized 2025 rates; HCPF is "still finalizing our calculations and internal clearance" and aims to send 2025 reconciliation letters in November so payments could be made in December or early January. He said the department works with auditor Myers and Stauffer, which uses CMS's Healthcare Cost Report Information System (HCRIS) data, and that HCPF then loads the higher of PPS or finalized rates into its MMIS claims system for the applicable calendar year.
To add transparency, HCPF plans to post rates for all RHCs enrolled in Colorado Medicaid on its website. Abelos said the department solicited feedback on that posting after a September meeting and received none; HCPF is "intending to move forward with creating this rates posting" and is targeting a January availability, with links to be included in the next RHC meeting materials if ready.
Abelos also reminded clinics about two operational processes: a scope-of-service rate-adjustment process (the application and guidance are posted on HCPF’s website) that allows PPS adjustments when a valid change in scope occurs, and the managed-care accuracy audit process. He said managed-care organizations must reimburse RHCs at no less than the HCPF encounter rate, and clinics may submit quarterly data to claim payments still due, notify HCPF they were paid in full, or allow HCPF to determine payment status; Abelos encouraged reconciling data with MCOs prior to submission.
Abelos noted a Colorado Rural Health Transformation program application had been submitted to CMS and that HCPF posted stakeholder materials and a documentation site for clinics seeking more information. He closed by inviting questions and offering contact emails for follow-up; Kennedy (staff contact listed on slides) was noted as a dedicated contact for managed-care audit questions.
Next procedural steps: HCPF aims to finalize 2025 reconciliation calculations and distribute letters (targeting November), implement 2026 rates in early January after Myers and Stauffer finalizes calculations, and post clinic-by-clinic RHC rate data to its website in January. The department scheduled the next RHC engagement meeting for Jan. 8, 2026.
