USE CASE: Claims Data for a New Health Plan

Colorado HealthOP (CO-OP) was a nonprofit, consumer-directed health plan formed under provisions of the Affordable Care Act. The CO-OP offered health plan products on the Colorado Health Insurance Exchange. Their mission was to offer lower cost products while improving health outcomes for Colorado residents by contracting with providers who share this mission and enrolling members in plan designs that promote healthy living.


Project Summary: Prior to implementation, the CO-OP needed historical data on populations it intended to serve, and relied on the CO APCD along with other data sources to model financial outcomes deriving from innovations in provider contracting and plan design. The CO-OP hoped to target previously underserved populations including, newly insured low-income people who didn’t qualify for Medicaid, along with others who were attracted to the CO-OP’s value-based benefit designs and activated patient philosophy. The CO-OP engaged providers with contracts designed to migrate away from fee-for-service to innovative, aligned models that promoted improved population health outcomes, care delivery and patient experience consistent with the principles of the Triple Aim. On the consumer side, the CO-OP intended to offer products that were simple and affordable, while implementing incentive-driven plan designs that encouraged enrollees to take control of their health, seek preventive services and self-manage their chronic conditions.

Benefit to Colorado: By using APCD data, Colorado HealthOP was able to better understand patterns of care in rural/Western Slope areas, plus the percentage of care types that stay local vs. traveling to other areas. “Deeper dive” geographic analysis was influential in development of health plans to serve the underserved and uninsured in the high-cost rural resort/Western slope regions. Additionally, the creation of a nonprofit insurance company in the Colorado market allowed residents to choose plans that lower their costs and improved their care.