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Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600543 - 10/2026)
Act
by Jan 1, 2027
Effective date
Not stated in the notice
Identified
Oct 2, 2026
Summary
Several Health First Colorado changes take effect January 1, 2027, including the statewide NEMT broker transition to MediDrive, an Individual NPI requirement for behavioral health providers, and Phase 2 of the Weekly Caregiver Limit. Other changes took effect October 1 and October 13, 2026, including new prior authorization requirements for certain physician-administered drugs, licensure date mismatches that can cause claim denials, and new gender-affirming care rules for members under 18. Historical deadlines include the DRA Declaration due November 2, 2026.
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What to do
by Jan 1, 2027 · 23 steps
01Transportation providers must schedule and get approval for all NEMT trips through MediDrive, and reimbursement is processed through MediDrive.
02Enroll with MediDrive using the exact business name and NPI or Medicaid ID used for Health First Colorado enrollment, with no doing-business-as names, and keep driver, vehicle, insurance and credential rosters current in ProCredEx.
03Trips performed before that date can still be billed directly to the Department within the 365-day timely filing period.
04By January 1, 2027: Behavioral health providers, including pre-licensed clinicians and unlicensed professionals, must list an Individual National Provider Identifier on the claim, obtained through NPPES.
05By January 1, 2027: Outpatient hospital claims that report a vaccine acquired through the Vaccines for Children program require an SL modifier on the claim detail line, for members under 19.
06Providers are encouraged to make sure the IRS 1099 mailing address is accurate by January 1, 2027, through Provider Maintenance in the Provider Web Portal.
07Phase 2 of the Weekly Caregiver Limit sets 70 hours per week per caregiver, per member, for Community First Choice homemaker, personal care and health maintenance activities, and Long-Term Home Health nursing and home health aide services.
08Agencies with caregivers above 70 hours should plan now to comply or submit an exception request, which can begin November 1, 2026.
09Already effective October 1, 2026: Update license dates in the Provider Web Portal through a Provider Maintenance Request, because claims may deny for dates of service on or after October 1, 2026 when license dates on file do not match, and resubmit previously denied claims once license updates are complete.
10Already effective October 1, 2026: Submit a member-specific prior authorization request to Acentra and get approval before administering Yartemlea (J1289), which now requires prior authorization.
11Criteria for Omvoh (J2267), Kisunla (J0175) and Benlysta (J0490) were updated.
12Already effective October 1, 2026: Hospice rates below the CMS Medicaid hospice minimums are increased to the published CMS rates.
13Already effective October 1, 2026: Behavioral health providers that hold an Ohio Recovery Housing certification and contract with RAEs must sign and submit the Health First Colorado Behavioral Health Recovery Residence Policy Attestation to their RAEs, stating they will not submit claims for behavioral health services delivered in a recovery residence.
14Already effective October 13, 2026: For members under 18, gender-affirming surgery is no longer covered and prior authorization requests for it will be denied beginning October 13, 2026.
15Estrogen, testosterone and LHRH/GnRH agents require prior authorization for gender-affirming care, and claims for GnRH/LHRH agents for that care will not be allowed.
16Already effective August 28, 2026: Claims for QRTP, PRTF or OHIRT treatment with dates of service on or after December 15, 2025 suspend for prior authorization verification.
17Prior authorization is required for periods of treatment longer than 30 days, and claims without the required prior authorization will deny.
18For DMEPOS, a PAR is needed only when a member needs more than the monthly or yearly limit allows.
19Oxygen and respiratory codes A7027 through A7045 are limited to 6 units per year, and E0465 through E0467 are limited to 2 units per month.
20Already effective for dates of service on or after July 1, 2026: Hemodiafiltration may be reported with revenue code 0829 and procedure code 90999.
21K0739 with U1 modifier rates were realigned, and claims with dates of service on or after October 1, 2025 are reprocessed to the correct rate.
22Historical deadline: the DRA Declaration for federal fiscal year 25-26 was due by email to hcpf_draact2005@state.co.us Previously due November 2, 2026 (date passed; verify current applicability).
23Check current applicability before relying on it.
Codes mentioned
K0739A7027A7028A7029A7030A7032A7033A7034A7035A7036A7044A7045E0465E0466E0467J1289J2267J0175J049090999
Original notice
Health First Colorado (Colorado's Medicaid Program) News and Updates (B2600543 - 10/2026)
hcpf.colorado.gov · Always check the source before changing claims.
Related changes
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