Last Updated: January 23, 2026
The Colorado Medicaid fee schedule for 2026 includes new CPT codes effective January 1 and reimbursement rates valid through June 30, 2026.
Providers should verify current rates on the HCPF portal to avoid claim denials.
Quick Summary:
- New 2026 CPT and HCPCS codes took effect January 1, 2026
- Current rates reflect a 1.6% increase from July 2025 through June 2026
- Claims with new codes may face temporary suspense periods (EOB 0000)
- Rate changes for July 1, 2026 are under legislative review
- Understanding Colorado Medicaid eligibility 2026 helps determine patient coverage
- Fee schedules vary by provider type and service category
Understanding Colorado’s Dual Timeline System
Colorado Medicaid operates on two different schedules. This can confuse providers who are new to the system.
State Fiscal Year vs. Calendar Year
The state fiscal year runs July 1 through June 30. Reimbursement rate changes typically happen on July 1 each year.
The calendar year runs January 1 through December 31. CPT and HCPCS coding updates follow this schedule to match Medicare.
Why This Matters:
- New codes launch January 1 but rates stay the same
- Rate increases or cuts happen July 1
- Your billing system needs both updates at different times
January 2026 Coding Updates
Health First Colorado updated its system on January 1, 2026 to include new CPT and HCPCS codes from CMS. These are procedure codes used for billing.
The January Suspense Period
Claims with new 2026 codes may temporarily suspend with EOB 0000. This code means “This claim/service is pending for program review.”
What Providers Should Know:
- You can bill immediately using new 2026 codes
- Payment may delay until HCPF finishes system updates
- This typically resolves by February
- Old claims are not affected by this suspense period
Prior Authorization Requirements
Some new codes require prior authorization even if they’re on the fee schedule. The January 2026 provider bulletin lists updated PAR requirements for specific DME and surgical codes.
Always check authorization requirements before providing services. A valid fee schedule rate doesn’t guarantee automatic approval.
Current Reimbursement Rates (FY 2025-26)
The Colorado Department of Health Care Policy and Financing sets rates each fiscal year. Current rates remain valid until June 30, 2026.
Base Rate Methodology
A 1.6% across-the-board increase took effect July 1, 2025. This applies to most Fee-For-Service benefits including physician services, dental care, and behavioral health.
Rate Calculation Methods:
- RBRVS (Physician Services): Based on Medicare’s Resource-Based Relative Value Scale, often paid as a percentage of Medicare rates
- Fee-for-Service (HCBS/Behavioral Health): Flat dollar amount per unit of service
- Hospital DRG: Diagnosis-related group weights determine inpatient payments
Provider Type Rate Variations
| Provider Category | Payment Method | Key Details |
|---|---|---|
| Physician & Lab | RBRVS percentage of Medicare | Follows Medicare fee schedule methodology |
| Behavioral Health | Flat fee per service | Distinct fee schedule with crisis intervention codes |
| DME & Supplies | Capped rental or purchase | Based on equipment type and duration |
| HCBS Waivers | Per 15-minute unit | Includes base wage requirements for workers |
Behavioral Health Rates (2026)
Behavioral health providers have specific rates for October 1, 2025 through June 30, 2026. The Department updated these rates to support mental health access.
Common Therapy Service Rates
| CPT Code | Service Description | Rate (Oct ’25 – June ’26) |
|---|---|---|
| 90791 | Psychiatric diagnostic evaluation | $159.67 |
| 90837 | Psychotherapy, 60 minutes | $134.51 |
| 90834 | Psychotherapy, 45 minutes | $91.09 |
| 90785 | Interactive complexity (Add-on) | $4.54 |
These rates emphasize value-based payments and crisis intervention services. Always verify telehealth modifier requirements when billing remote services.
Home and Community Based Services Updates
HCBS waiver rates saw targeted increases to support direct care workers. The state implemented base wage requirements to address workforce shortages.
January 2026 HCBS Changes
A State Plan Amendment approved in January 2026 modified Personal Care Services fee schedules. Long Term Personal Care providers now follow specific wage floor requirements.
Important HCBS Updates:
- New wage pass-through requirements for home care workers
- Rates set per 15-minute service unit
- Modified billing procedures for personal care services
- Base wage requirements influence overall rate structure
Geographic and Service Variations
Not all providers receive the same rates. Location and facility type affect reimbursement amounts.
Rural vs. Urban Rate Differences
Some rates vary based on geographic designation. This especially affects hospitals and Federally Qualified Health Centers (FQHCs).
Provider Types with Geographic Adjustments:
- Hospital facilities in rural areas
- FQHCs serving underserved communities
- Critical Access Hospitals
- Rural Health Clinics
Understanding Colorado Medicaid income limits 2026 helps you serve patients across different regions of the state.
How to Access Official Fee Schedules
There is no single master PDF for all services. Fee schedules are organized by provider type and service category.
Interactive Online Database
HCPF offers a searchable database where you enter a CPT or HCPCS code to see the current rate.
Step 1: Visit the Health First Colorado website
Go to hcpf.colorado.gov for official rate information
Step 2: Navigate to Provider Resources
Click “For Providers” then select “Provider Rates & Fee Schedule”
Step 3: Choose Your Search Method
Use the interactive code lookup or download static PDF/Excel files for your specialty
Available Fee Schedule Categories
- Physician and laboratory services
- Behavioral health and substance use
- Durable Medical Equipment (DME)
- Dental services and oral surgery
- Home and Community Based Services
- Dialysis and specialty treatments
Important Billing Rules for 2026
Understanding billing requirements prevents claim denials. Colorado Medicaid has specific rules about modifiers, copayments, and balance billing.
Modifier Requirements
Incorrect modifiers cause claims to deny regardless of valid fee schedule rates. Always check the billing manual for your specialty.
Common Modifier Issues:
- GT modifier for telehealth services
- Location modifiers for facility vs. office
- Time-based modifiers for therapy services
- Multiple procedure reductions
Copayment and Balance Billing Rules
Most Colorado Medicaid services have $0 copayments for members. Providers cannot charge patients for covered services.
Strict Prohibitions:
- No balance billing for Medicaid-covered services
- No additional fees beyond Medicaid reimbursement
- Violations result in provider sanctions or removal from network
Medicare Crossover Claims
For dual-eligible patients with Medicare and Medicaid, coordination of benefits applies. Medicaid pays as secondary payer after Medicare processes the claim.
Crossover Billing Process:
- Medicare pays first as primary insurance
- Medicaid covers remaining allowed costs
- 2026 Medicare fee schedule changes affect calculations
- Check the Medicaid fee schedule 2026 for comparison with other states
Proposed Rate Changes for July 2026
The next fiscal year begins July 1, 2026. Rate changes for this period are currently under legislative debate.
Governor’s Budget Proposal
Governor Polis proposed budget adjustments to manage the state budget deficit. These may limit provider rates to 85% of Medicare benchmarks.
Potential Impact:
- Rates could decrease from current levels
- Certain specialties may see larger cuts
- Rural access concerns have been raised
- Final decisions depend on General Assembly action
Advisory Committee Recommendations
The Medicaid Provider Rate Review Advisory Committee (MPRRAC) recommended maintaining rates at 80-100% of Medicare benchmarks. This aims to prevent provider shortages, especially in rural Colorado.
Committee Concerns:
- Provider participation rates may drop with cuts
- Access to specialists could decrease
- Rural areas face particular risk
- Workforce retention requires competitive rates
What Providers Should Do Now
Monitor the Colorado General Assembly sessions in early 2026. Legislative decisions will determine rates for services delivered after July 1, 2026.
Action Steps:
- Subscribe to HCPF provider bulletins
- Attend legislative hearings if affected
- Plan practice finances for potential rate changes
- Review Colorado Medicaid eligibility 2026 to understand patient populations
Patient Eligibility and Coverage
Verifying patient eligibility prevents billing problems. Always check coverage before providing services.
2026 Income Limits
For a single individual, the income limit is approximately $21,597 annually. This represents 138% of the Federal Poverty Level and determines Medicaid eligibility.
Eligibility Verification:
- Use HCPF provider portal for real-time checks
- Income limits vary by household size
- Different categories have different thresholds
- Limits update annually based on federal guidelines
Frequently Asked Questions
What is the current Colorado Medicaid reimbursement rate for 2026?
Colorado Medicaid rates include a 1.6% across-the-board increase effective July 1, 2025 through June 30, 2026. New CPT codes took effect January 1, 2026, but reimbursement rates stay the same until July.
Why are my claims suspended with EOB 0000 in January 2026?
Claims with new 2026 CPT/HCPCS codes may temporarily suspend while HCPF updates the Colorado interChange system. You can bill immediately, but payment typically delays until February when system updates finish.
Where can I find the official Colorado Medicaid fee schedule?
Visit hcpf.colorado.gov and navigate to “Provider Rates & Fee Schedule.” There’s no single master PDF—schedules are organized by provider type. Use the interactive code lookup or download files for your specialty.
What are the 2026 behavioral health therapy rates for Colorado Medicaid?
For October 2025 through June 2026, rates are: 60-minute therapy (90837) pays $134.51, 45-minute therapy (90834) pays $91.09, and psychiatric diagnostic evaluation (90791) pays $159.67 per session.
Will Colorado Medicaid rates decrease in July 2026?
Possibly. Governor Polis proposed limiting rates to 85% of Medicare benchmarks to address budget deficits. The Provider Rate Review Committee recommends maintaining 80-100% of Medicare rates. Final decisions come from the General Assembly.
Can I charge Colorado Medicaid patients copayments or balance bill them?
No. Most services have $0 copayments, and providers are strictly prohibited from balance billing members for covered services. Violations can result in sanctions or removal from the Medicaid provider network.
Official Sources
- Colorado Department of Health Care Policy and Financing (HCPF): hcpf.colorado.gov
- HCPF Provider Bulletin B2600533 (January 2026 Updates): Official guidance on coding changes
- Centers for Medicare & Medicaid Services (CMS): medicaid.gov
This article provides general information about Colorado Medicaid fee schedules. Always verify current rates, coding requirements, and eligibility through official HCPF resources before billing or providing services. Consult the billing manual specific to your provider type for detailed modifier and documentation requirements.
