Colorado agency: most 2026 rural health clinic rates loaded; reconciliations nearly complete

The Colorado Department of Health Care Policy & Financing told attendees at its March 2026 rural health clinic engagement meeting that it has loaded most 2026 encounter rates into its claims processing system and completed retroactive claims adjustments, while reconciliations tied to audited Medicare cost reports remain in final clearance.

Andrew Obalos, facility rate section manager at the department, said the agency loaded updated rates into its MMIS and completed claims corrections in the Feb. 6 financial cycle so 2026 service dates should now be paying at the appropriate rates. “For any of those 2026 claims that have come through for service dates within 2026, they should now be paying on the appropriate rate and we should have had all the claims adjusted,” Obalos said.

Why it matters: encounter rates determine how much rural health clinics (RHCs) are reimbursed by Medicaid and by managed care entities; timely loading and reconciliation affect clinic revenue and cash flow. Obalos said the department relies on audited Medicare cost reports and an external auditor to calculate alternative payment methodology (APM) rates and perform reconciliations that compare interim rates to finalized, audited rates.

How the rates are set: for freestanding RHCs the department uses the higher of the PPS rate established by BIPA (2000) or the Medicare upper payment limit as the APM. Obalos summarized the hospital‑based (provider‑based) methodology as similarly taking the higher of PPS or an APM that reflects audited Medicare cost‑report cost‑per‑visit data; after a cost report is finalized the department performs reconciliations that may result in one‑time lump‑sum payments or recoveries.

Auditing and data sources: Obalos said the department contracts with an auditor (identified in the meeting as Myers and Stafer) that uses CMS’s health care cost report information database to obtain finalized cost‑report data, typically after a year‑end data load. He described the internal workflow: auditors provide finalized rates, the department loads the higher of PPS or finalized rates into MMIS, performs calculations, clears payments through leadership, and issues reconciliation letters.

Timing and status: Obalos acknowledged prior‑year reconciliations were delayed by staffing shortages and said those were aggregated into the 2026 workload. He said rate letters for calendar year 2026 were distributed in late January and early February and that reconciliation letters are “currently undergoing their final clearance steps with our leadership,” with staff close to issuing them.

Managed care validation and transparency steps: the department is updating its managed‑care validation systems so managed care entities can verify the rates they are using; Obalos said most RHC rates were shared with managed care entities on Feb. 6 but a small number of facilities still lack finalized rates. The department also intends to publish a broader RHC rates posting on its website to increase transparency and provide a verification mechanism for regional accountable entities.

Participation and scope changes: Obalos reviewed the scope‑of‑service rate adjustment process for RHCs, saying clinics may request a PPS rate change when a valid change in scope occurs and directing clinics to the website for instructions and application materials. He said the managed care accuracy audit allows facilities to participate by submitting quarterly data, notifying the department if paid in full, or submitting data showing additional payment is due.

Staffing and contacts: Obalos announced the department has filled a vacant RHC rate analyst position and introduced Marcela Kousniaak as the new point of contact for RHC rate matters. He listed himself and Marcela for rate questions and named Morgan and Janelle as policy contacts; he also noted a staff member named Kennedy as a contact for the managed care accuracy audit.

Next steps: clinics should review posted materials and, if they see payment discrepancies, contact Marcela Kousniaak or Andrew Obalos. The department said it will correct the posted meeting date where necessary and expects to issue reconciliation letters soon. The next bimonthly engagement meeting is scheduled for April 30.

Sources: Meeting presentation and remarks by Andrew Obalos at the Colorado Department of Health Care Policy & Financing rural health clinic engagement meeting (March 2026).