ARTICLE 1 DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

Section

PART 1 GENERAL PROVISIONS

PART 2 PROGRAMS TO BE ADMINISTERED BY THE DEPARTMENT

PART 3 MEDICAL SERVICES BOARD

PART 4 HEALTH CARE COVERAGE COOPERATIVE RULE-MAKING AUTHORITY

PART 5 COOPERATIVE HEALTH CARE AGREEMENTS INVOLVING HOSPITALS

PART 6 COMMISSION ON FAMILY MEDICINE

PART 7 HEALTH CARE PROVIDERS' ACCOUNTABILITY TO COMMUNITIES

25.5-1-101. Short title.

This title shall be known and may be cited as the "State Health Care Policy and Financing Act".

Source: L. 93: Entire title added, p. 1097, § 15, effective July 1, 1994. L. 2006: Entire part amended, p. 1781, § 1, effective July 1.

25.5-1-102. Legislative declaration.

1. The general assembly declares that state and local policymakers and health and human services administrators recognize that the management of and the delivery system for health and human services have become complex, fragmented, and costly and that the health and human services delivery system in this state should be restructured to adequately address the needs of Colorado citizens.
2. The general assembly further finds and declares that a continuing budget crisis makes it unlikely that funding sources will keep pace with the increasing demands of health and human services.
3. Therefore, the general assembly finds that it is appropriate to restructure principal departments responsible for overseeing the delivery of health and human services and to reform the state's health and human services administration and delivery system, using guiding principles and within the time frames set forth in article 1.7 of title 24, C.R.S., as said article existed prior to July 1, 1997. It is the general assembly's intent that the departments of public health and environment, health care policy and financing, and human services be operational, effective July 1, 1994.

Source: L. 93: Entire title added, p. 1097, § 15, effective July 1, 1994. L. 2006: Entire part amended, p. 1781, § 1, effective July 1.

25.5-1-103. Definitions.

As used in this title 25.5, unless the context otherwise requires:

1. "County board" means the county or district board of human or social services; except that, in the city and county of Denver, "county board" means the department or agency with the responsibility for public assistance and welfare activities, and, in the city and county of Broomfield, "county board" means the city council or a board or commission with the responsibility for public assistance and welfare activities appointed by the city and county of Broomfield.
2. "County department" means the county or district department of human or social services.
3. "County director" means the director of the county or district department of human or social services.
4. "Executive director" means the executive director of the department of health care policy and financing.
5. "Medical assistance" means any program administered by the state department, including but not limited to the "Colorado Medical Assistance Act", as specified in articles 4, 5, and 6 of this title, the "Children's Basic Health Plan Act", article 8 of this title, the old age pension health and medical care program, and the supplemental old age pension health and medical care program; except that "medical assistance" for purposes of articles 4, 5, and 6 of this title shall have the meaning as defined in section 25.5-4-103 (13).

   (5.5) "Medical home" means an appropriately qualified medical specialty, developmental, therapeutic, or mental health care practice that verifiably ensures continuous, accessible, and comprehensive access to and coordination of community-based medical care, mental health care, oral health care, and related services for a child. A medical home may also be referred to as a health care home. If a child's medical home is not a primary medical care provider, the child must have a primary medical care provider to ensure that a child's primary medical care needs are appropriately addressed. All medical homes shall ensure, at a minimum, the following:

   1. Health maintenance and preventive care;
   2. Anticipatory guidance and health education;
   3. Acute and chronic illness care;
   4. Coordination of medications, specialists, and therapies;
   5. Provider participation in hospital care; and
   6. Twenty-four-hour telephone care.
6. "Recipient" means any person who has been determined eligible to receive benefits or services under this title.
7. "State board" or "board" means the medical services board created pursuant to section 25.5-1-301.
8. "State department" means the department of health care policy and financing.
9. "State designated agency" means an agency designated to perform specified functions that would otherwise be performed by the county departments, including the single entry point agencies and medical assistance sites.

Source: L. 93: Entire title added, p. 1098, § 15, effective July 1, 1994. L. 95: (2.5) added, p. 903, § 2, effective May 25. L. 96: (1) repealed, p. 1473, § 25, effective June 1. L. 2006: Entire part amended, p. 1782, § 1, effective July 1. L. 2007: (5.5) added, p. 1487, § 1, effective May 31. L. 2018: IP and (1) to (3) amended, (SB 18-092), ch. 38, p. 443, § 106, effective August 8.

Cross references: For the legislative declaration in SB 18-092, see section 1 of chapter 38, Session Laws of Colorado 2018.

25.5-1-104. Department of health care policy and financing created - executive director - powers, duties, and functions.

1. There is hereby created the department of health care policy and financing, the head of which shall be the executive director of the department of health care policy and financing, which office is hereby created. The executive director shall be appointed by the governor, with the consent of the senate, and shall serve at the pleasure of the governor. The reappointment of an executive director after an initial election of a governor shall be subject to the provisions of section 24-20-109, C.R.S. The executive director has those powers, duties, and functions prescribed for the heads of principal departments in the "Administrative Organization Act of 1968", article 1 of title 24, C.R.S., and any powers, duties, and functions set forth in this title.
2. The department of health care policy and financing shall consist of an executive director of the department of health care policy and financing, the medical services board, and such divisions, sections, and other units as shall be established by the executive director pursuant to the provisions of subsection (3) of this section.
3. The executive director may establish such divisions, sections, and other units within the state department as are necessary for the proper and efficient discharge of the powers, duties, and functions of the state department; except that such action by the executive director shall not conflict with the implementation requirements for the plan for restructuring the delivery of health and human services in this state, as set forth in article 1.7 of title 24, C.R.S.
4. The department of health care policy and financing shall be responsible for the administration of the functions and programs as set forth in this title.
5. 1. The executive director of the state department shall appoint an internal auditor who shall have the status of a division director and, as such, shall have the authority to appoint such personnel as may be necessary to carry out the duties of the internal auditor.
   2. The internal auditor appointed by the executive director pursuant to paragraph (a) of this subsection (5) shall:
      1. Conduct and supervise internal audits of the state department;
      2. Coordinate and facilitate external audits that are performed on the state department by state and federal entities;
      3. Conduct and supervise performance audits for the purpose of determining the efficiency and effectiveness of the state department's operation and administration of programs; and
      4. Conduct such other audits and perform such other duties as may be specified by the executive director.

Source: L. 93: Entire title added, p. 1098, § 15, effective July 1, 1994. L. 94: (2) amended, p. 1559, § 4, effective July 1. L. 96: (2) amended, p. 1474, § 26, effective June 1. L. 2006: Entire part amended, p. 1783, § 1, effective July 1. L. 2010: (5) added, (SB 10-167), ch. 296, p. 1376, § 2, effective May 26.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-1-105. Transfer of functions.

1. The state department shall, on and after July 1, 1994, execute, administer, perform, and enforce the rights, powers, duties, functions, and obligations vested prior to July 1, 1994, in the Colorado health data commission within the department of local affairs, the department of social services concerning the "Colorado Medical Assistance Act", and the university of Colorado health sciences center concerning health care for the medically indigent.
2. All rules, regulations, and orders of the department of local affairs, the state department of social services, the state board of social services, the department of regulatory agencies, and the university of Colorado health sciences center adopted prior to July 1, 1994, in connection with the powers, duties, and functions transferred to the state department shall continue to be effective until revised, amended, repealed, or nullified pursuant to law. On and after July 1, 1994, the state board or the executive director, whichever is appropriate, shall adopt rules necessary for the administration of the state department and the administration of the programs set forth in this title.
3. No suit, action, or other judicial or administrative proceeding lawfully commenced prior to July 1, 1994, or which could have been commenced prior to such date, by or against the department of local affairs, the state department of social services, the department of regulatory agencies, or the university of Colorado health sciences center, or any officer thereof in such officer's official capacity or in relation to the discharge of the official's duties, shall abate by reason of the transfer of duties and functions from said departments to the state department.
4. The executive director, or a designee of the executive director, may accept, on behalf of and in the name of the state, gifts, donations, and grants for any purpose connected with the work and programs of the state department. Any property so given shall be held by the state treasurer, but the executive director, or the designee therefor, shall have the power to direct the disposition of any property so given for any purpose consistent with the terms and conditions under which such gift was created.
5. The revisor of statutes is hereby authorized to change all references in the Colorado Revised Statutes to the department of local affairs, the state department of social services, the department of regulatory agencies, and the university of Colorado health sciences center from said references to the state department, as appropriate and with respect to the powers, duties, and functions transferred to the state department. In connection with such authority, the revisor of statutes is hereby authorized to amend or delete provisions of the Colorado Revised Statutes so as to make the statutes consistent with the powers, duties, and functions transferred pursuant to this section.
6. On and after July 1, 2003, the powers, duties, and functions relating to the old age pension health and medical care program, as specified in section 25.5-2-101, are transferred by a type 2 transfer to the department of health care policy and financing.

Source: L. 93: Entire title added, p. 1099, § 15, effective July 1, 1994. L. 94: (2) amended, p. 2610, § 12, effective July 1; (6) amended, p. 1559, § 5, effective July 1. L. 2003: (10) added, p. 2583, § 1, effective July 1. L. 2005: (1) amended, p. 772, § 50, effective June 1. L. 2006: Entire part amended, p. 1783, § 1, effective July 1. L. 2011: (6) amended, (SB 11-210), ch. 187, p. 721, § 6, effective July 15, 2012.

25.5-1-105.5. Chief medical officer - qualifications.

1. The executive director shall appoint a chief medical officer who shall:
   1. Have a degree of doctor of medicine or doctor of osteopathy and be licensed to practice medicine in the state of Colorado;
   2. Have at least two years of postgraduate experience in primary care; and
   3. Have at least two years of experience in an administrative capacity in a health care organization.
2. The chief medical officer shall, with the assistance of advisory committees of the state department, provide medical judgment and advice regarding all medical issues involving programs administered by the state department.
3. The chief medical officer shall receive a salary within the limits of moneys made available to the state department by appropriation of the general assembly or otherwise.

Source: L. 2007: Entire section added, p. 1492, § 3, effective July 1. L. 2010: (1) amended and (3) added, (SB 10-167), ch. 296, p. 1377, § 3, effective May 26.

Cross references: For the legislative declaration contained in the 2007 act enacting this section, see section 1 of chapter 347, Session Laws of Colorado 2007. For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-1-106. Restructure of health and human services - development of plan - participation of department required. (Deleted by amendment)

Source: L. 93: Entire title added, p. 1101, § 15, effective July 1, 1994. L. 2006: Entire part amended, p. 1785, § 1, effective July 1.

25.5-1-107. Final agency action - administrative law judge - authority of executive director.

1. The executive director may appoint one or more persons to serve as administrative law judges for the state department pursuant to section 24-4-105 and pursuant to part 10 of article 30 of title 24 subject to appropriations made to the department of personnel. Except as provided in subsection (2) of this section, hearings conducted by the administrative law judge are considered initial decisions of the state department and shall be reviewed by the executive director or a designee of the executive director. In the event exceptions to the initial decision are filed pursuant to section 24-4-105 (14)(a)(I), the review must be in accordance with section 24-4-105 (15). In the absence of any exception filed pursuant to section 24-4-105 (14)(a)(I), the executive director shall review the initial decision in accordance with a procedure adopted by the state board. The procedure must be consistent with federal mandates concerning the single state agency requirement. Review by the executive director in accordance with section 24-4-105 (15) or the procedure adopted by the state board pursuant to this section constitutes final agency action. The administrative law judge may conduct hearings on appeals from decisions of county departments of human or social services brought by recipients of and applicants for medical assistance and welfare that are required by law in order for the state to qualify for federal funds, and the administrative law judge may conduct other hearings for the state department. Notice of any such hearing must be served at least ten days prior to such hearing.
2. Hearings initiated by a licensed or certified provider of services shall be conducted by an administrative law judge for the state department and shall be considered final agency action and subject to judicial review in accordance with the provisions of section 24-4-106, C.R.S., for any party, including the state department, which shall be considered a person for such purposes.

Source: L. 93: Entire title added, p. 1101, § 15, effective July 1, 1994. L. 95: (1)(a) and (2) amended, p. 903, § 3, effective May 25; (1)(a) and (1)(c) amended, p. 664, § 101, effective July 1. L. 97: (1)(b) amended, p. 1190, § 10, effective July 1. L. 2005: (1)(c) amended, p. 859, § 25, effective June 1. L. 2006: Entire part amended, p. 1785, § 1, effective July 1. L. 2018: (1) amended, (SB 18-092), ch. 38, p. 443, § 107, effective August 8.

Editor's note: Amendments to subsection (1)(a) by Senate Bill 95-78 and House Bill 95-1362 were harmonized.

Cross references: For the legislative declaration contained in the 1995 act amending subsections (1)(a) and (1)(c), see section 112 of chapter 167, Session Laws of Colorado 1995. For the legislative declaration in SB 18-092, see section 1 of chapter 38, Session Laws of Colorado 2018.

25.5-1-108. Executive director - rules.

1. The executive director shall have authority to promulgate rules in connection with the policies and procedures governing the administration of the department including, but not limited to, rules concerning the following:
   1. Matters of internal administration of the department, including organization, staffing, records, reports, systems, and procedures;
   2. Fiscal and personnel administration for the department;
   3. Accounting and fiscal reporting policies and procedures for disbursement of federal funds, contingency funds, and distribution of available appropriations;
   4. Such other rules relating to those functions the executive director is required to carry out pursuant to the provisions of this title.
2. Nothing in this section shall be construed to affect any specific statutory provision granting rule-making authority in relation to a specific program to the executive director.

Source: L. 94: Entire section added, p. 1556, § 1, effective July 1. L. 95: (4) amended, p.1105, § 43, effective May 31. L. 2006: Entire part amended, p. 1786, § 1, effective July 1.

25.5-1-109. Department of health care policy and financing cash fund.

All moneys collected by the state department as fees or otherwise shall be transmitted to the state treasurer, who shall credit the same to the department of health care policy and financing cash fund, which fund is hereby created in the state treasury. Moneys in the fund shall be subject to annual appropriation by the general assembly for the direct and indirect costs of the state department's duties as provided by law.

Source: L. 94: Entire section added, p. 1941, § 3, effective July 1. L. 2006: Entire part amended, p. 1787, § 1, effective July 1.

25.5-1-109.5. Clinical standards - development.

1. The general assembly finds that:
   1. It is important to collect and analyze objective clinical standards to maximize the scarce dollars available for medical care; and
   2. The development of an ongoing, transparent measurement of health outcomes is essential to ensure quality health care for Coloradans.
2. 1. The state department, following consultation with external clinical advisors, shall develop clinical standards and methods for collecting, analyzing, and disclosing information regarding clinical performance, including but not limited to immunization rates, medical home standards, clinical care guidelines, care coordination, case management, disease management, and coordination and integration of mental health services. The standards and methods shall be consistent with national guidelines and standards regarding the collection and analysis of health data, where feasible, and shall meet the federal reporting requirements established under Titles XIX and XXI of the federal "Social Security Act", 42 U.S.C. secs. 1396 and 1397.
   2. Repealed.

Source: L. 2007: Entire section added, p. 1495, § 9, effective July 1. L. 2016: (2)(b) repealed, (HB 16-1081), ch. 22, p. 50, § 1, effective August 10.

Cross references: For the legislative declaration contained in the 2007 act enacting this section, see section 1 of chapter 347, Session Laws of Colorado 2007.

25.5-1-110. Study of children's access to health care coverage - acceptance of donations - repeal. (Repealed)

Source: L. 2002: Entire section added, p. 1612, § 1, effective June 7. L. 2003: (4) amended, p. 2009, § 89, effective May 22. L. 2006: Entire part amended, p. 1787, § 1, effective July 1.

Editor's note: Subsection (6) provided for the repeal of this section, effective July 1, 2005. (See L. 2002, p. 1612 .)

25.5-1-111. Waiver applications - authorization. (Deleted by amendment)

Source: L. 2002: Entire section added, p. 1308, § 27, effective June 7. L. 2006: Entire part amended, p. 1787, § 1, effective July 1.

25.5-1-112. Drug-purchasing pool - report - repeal. (Repealed)

Source: L. 2004: Entire section added, p. 1995, § 9, effective June 5. L. 2006: Entire part amended, p. 1787, § 1, effective July 1.

Editor's note: Subsection (3) provided for the repeal of this section, effective July 1, 2005. (See L. 2004, p. 1995 .)

25.5-1-113. Federal authorization - repeal. (Deleted by amendment)

Source: L. 2005: Entire section added, p. 1230, § 9, effective June 3. L. 2006: Entire part amended, p. 1787, § 1, effective July 1.

25.5-1-113.5. Children's access to health care - reports. (Repealed)

Source: L. 2007: Entire section added, p. 1494, § 8, effective July 1. L. 2017: Entire section repealed, (HB 17-1060), ch. 6, p. 14, § 1, effective March 1.

25.5-1-114. Grants-in-aid - county supervision.

1. The state department shall consult with and coordinate with the counties before making any changes that affect county operations in the implementation of this section, when possible under state statutes and federal statutes and regulations.
2. In administering any funds appropriated or made available to the state department for medical assistance administration, the state department has the power to:
   1. Require as a condition for receiving grants-in-aid that each county in this state shall bear the proportion of the total expense of furnishing medical assistance administration as is fixed by law relating to such assistance;
   2. Terminate any grants-in-aid to any county of this state if the laws and regulations providing such grants-in-aid and the minimum standards prescribed by rules of the state department thereunder are not complied with;
   3. Undertake forthwith the administration of any or all medical assistance within any county of this state which has had any or all of its grants-in-aid terminated pursuant to paragraph (b) of this subsection (2); but the county shall continue to meet the requirements of paragraph (a) of this subsection (2);
   4. Recover any moneys owed by a county to the state by reducing the amount of any payments due from the state in connection with the administration of medical assistance;
   5. Take any other action which may be necessary or desirable for carrying out the provisions of this title.
3. The state department, under the supervision of the executive director, shall provide supervision of county departments for the effective administration of medical assistance as set out in the rules of the executive director and the rules of the state board pursuant to section 25.5-1-301; except that nothing in this subsection (3) shall be construed to allow counties to continue to receive an amount equal to the increased funding in the event the said funding is no longer available from the federal government.

Source: L. 2006: Entire part amended, p. 1787, § 1, effective July 1.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

25.5-1-114.5. Medicaid fraud detection - request for information.

1. In enacting this section, the general assembly intends to:
   1. Implement waste, fraud, and abuse detection, prevention, and recovery solutions to improve program integrity in the state's medicaid program and create efficiency and cost savings through a shift from a retrospective "pay and chase" model to a prospective prepayment model; and
   2. Invest in the most cost-effective technologies or strategies that yield the highest return on investment.
2. By September 30, 2013, the state department shall issue a request for information to seek input from potential contractors on capabilities that the state department does not currently possess, functions that the state department is not currently performing, and the cost structures associated with implementing:
   1. Advanced predictive modeling and analytics technologies to provide a comprehensive and accurate view across all providers, recipients, and geographic locations within the medicaid program in order to:
      1. Identify and analyze those billing and utilization patterns that represent a high risk of fraudulent activity;
      2. Be easily integrated into the existing medicaid program claims operations;
      3. Undertake and automate such analysis before payment is made to minimize disruptions to state department operations and speed claim resolution;
      4. Prioritize the identified transactions for additional review before payment is made based upon the likelihood of potential waste, fraud, or abuse;
      5. Obtain outcome information from adjudicated claims to allow for refinement and enhancement of the predictive analytics technologies based on historical data and algorithms with the system; and
      6. Prevent the payment of claims for reimbursement that have been identified as potentially wasteful, fraudulent, or abusive until the claims have been automatically verified as valid;
   2. Provider and recipient data verification and screening technology solutions, which may use publicly available records, for the purposes of automating reviews and identifying and preventing inappropriate payments by:
      1. Identifying associations between providers, practitioners, and beneficiaries that indicate rings of collusive fraudulent activity; and
      2. Discovering recipient attributes that indicate improper eligibility, including but not limited to death, out-of-state residency, inappropriate asset ownership, or incarceration; and
   3. Fraud investigation services that combine retrospective claims analysis and prospective waste, fraud, or abuse detection techniques. These services must include analysis of historical claims data, medical records, suspect provider databases, and high-risk identification lists, as well as direct recipient and provider interviews. Emphasis must be placed on the state department providing education to providers and allowing them the opportunity to review and correct any problems identified prior to administrative proceedings.
3. In addition to the information provided pursuant to subsection (2) of this section, a potential contractor responding to the request for information shall include information concerning:
   1. The extent to which the potential contractor will seek clinical and technical expertise from Colorado providers concerning the design and implementation of the medicaid fraud detection system described in this section and the method or methods for seeking that expertise; and
   2. The potential contractor's ability to create an education and outreach program that is widely available and easily accessible to Colorado providers for purposes of educating providers on issues relating to coverage and coding.
4. 1. The state department is encouraged to use the results of the request for information to create formal requests for proposals to carry out the work identified in this section if the following conditions are met:
      1. The state department expects to generate state savings by preventing fraud, waste, and abuse;
      2. This work can be integrated into the state department's current medicaid operations without creating additional costs to the state; and
      3. The reviews or audits are not anticipated to delay or improperly deny the payment of legitimate claims to providers.
   2. Prior to awarding any contract pursuant to this section, the state department shall establish an appeal process for providers that minimizes the administrative burden placed on providers, limits the number of medical records requests, and provides adequate time for providers to respond to inquiries.
5. It is the intent of the general assembly that the savings achieved through this section must more than cover the cost of implementation and administration. Therefore, to the extent possible, technology services used in carrying out this section must be secured using the savings generated by the program, with the state's direct cost funded through the actual savings achieved.

Source: L. 2013: Entire section added, (SB 13-137), ch. 285, p. 1501, § 1, effective August 7.

25.5-1-115. Locating violators - recoveries.

1. The executive director of the state department, or district attorneys may request and shall receive from departments, boards, bureaus, or other agencies of the state or any of its political subdivisions, and the same are authorized to provide, such assistance and data as will enable the state department and county departments properly to carry out their powers and duties to locate and prosecute any person who has fraudulently obtained medical assistance under this title. Any records established pursuant to the provisions of this section shall be available only to the state department, the department of human services, the county departments, the attorney general, and the district attorneys, county attorneys, and courts having jurisdiction in fraud or recovery proceedings or actions.
2. 1. All departments and agencies of the state and local governments shall cooperate in the location and prosecution of any person who has fraudulently obtained medical assistance under this title, and, on request of the county board, the county director, the state department, or the district attorney of any judicial district in this state, shall supply all information on hand relative to the location, employment, income, and property of such persons, notwithstanding any other provision of law making such information confidential, except the laws pertaining to confidentiality of any tax returns filed pursuant to law with the department of revenue. The department of revenue shall furnish at no cost to inquiring departments and agencies such information as may be necessary to effectuate the purposes of this article. The procedures whereby this information will be requested and provided shall be established by rule of the state department. The state department or county departments shall use such information only for the purposes of administering medical assistance under this title, and the district attorney shall use it only for the prosecution of persons who have fraudulently obtained medical assistance under this title, and shall not use the information, or disclose it, for any other purpose.
   2. 1. Whenever the state department, or a district attorney for the state department, or the state department on behalf of a county department, recovers any amount of fraudulently obtained medical assistance funds, the federal government shall be entitled to a share proportionate to the amount of federal funds paid unless a different amount is otherwise provided by federal law, the state shall be entitled to a share proportionate to the amount of state funds paid and such additional amounts of federal funds recovered as provided by federal law, and the county department shall be entitled to a share proportionate to the amount of county funds paid unless a different amount is provided pursuant to federal law or this section.
      2. 1. Whenever a county department, a county board, a district attorney, or a state department on behalf of a county department recovers any amount of fraudulently obtained public assistance funds in the form of assistance payments, it shall be deposited in the county social services fund, and the federal government is entitled to a share proportionate to the amount of federal funds paid, unless a different amount is provided for by federal law, the state is entitled to a share proportionate to one-half the amount of state funds paid, and the county is entitled to a share proportionate to the amount of county funds paid and, in addition, a share proportionate to one-half the amount of state funds paid.
         2. Whenever a county department, a county board, a district attorney, or a state department on behalf of a county department recovers any amount of fraudulently obtained medical assistance, it shall be deposited in the county social services fund, and the federal government is entitled to a share proportionate to the amount of federal funds paid, unless a different amount is provided for by federal law, and the county is entitled to the remaining funds.
3. Whenever a county department, a county board, a district attorney, or the state department on behalf of the county recovers any amount of medical assistance payments that were obtained through unintentional client error, the federal government shall be entitled to a share proportionate to the amount of federal funds paid, unless a different amount is provided for by federal law, the state shall be entitled to a share proportionate to seventy-five percent of the amount of state funds paid, the county shall be entitled to a share proportionate to the amount of county funds paid, if any, and, in addition, a share proportionate to twenty-five percent of the amount of state funds paid.
4. Actual costs and expenses incurred by the district attorney's office in carrying out the provisions of subsection (2) of this section shall be billed to counties or a county within the judicial district in the proportions specified in section 20-1-302, C.R.S. Each county shall make an annual accounting to the state department on all amounts recovered.

Source: L. 2006: Entire part amended, p. 1788, § 1, effective July 1. L. 2012: (2)(b)(II) amended, (SB 12-060), ch. 166, p. 578, § 3, effective August 8.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

25.5-1-115.5. Medical assistance fraud - report.

1. Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or before November 1, 2017, and on or before November 1 each year thereafter, the state department shall submit a written report to the joint budget committee; the judiciary committee and the public health care and human services committee of the house of representatives, or their successor committees; and to the judiciary committee and the health and human services committee of the senate, or their successor committees, concerning fraud in the medicaid program. The state department shall compile a single, comprehensive report that includes the information described in this subsection (1), as well as information that the attorney general provides to the state department pursuant to section 25.5-4-303.3. The state department shall report to the general assembly concerning the fraudulent receipt of medicaid benefits, including, at a minimum:
   1. Investigations of client fraud during the year;
   2. Termination of client medicaid benefits due to fraud;
   3. District attorney action, including, at a minimum, criminal complaints requested, cases dismissed, cases acquitted, convictions, and confessions of judgment;
   4. Recoveries, including fines and penalties, restitution ordered, and restitution collected;
   5. Trends in methods used to commit client fraud, excluding law enforcement-sensitive information; and
   6. An estimate of the total savings, total cost, and net cost-effectiveness of fraud detection and recovery efforts.

Source: L. 2012: Entire section added, (SB 12-060), ch. 166, p. 577, § 1, effective August 8. L. 2017: IP(1) amended, (HB 17-1060), ch. 6, p. 14, § 2, effective March 1; IP(1), (1)(d), and (1)(e) amended and (1)(f) added, (SB 17-295), ch. 298, p. 1636, § 1, effective August 9.

Editor's note: Amendments to the introductory portion of subsection (1) by HB 17-1060 and SB 17-295 were harmonized.

25.5-1-116. Records confidential - authorization to obtain records of assets - release of location information to law enforcement agencies - outstanding felony arrest warrants.

1. The state department may establish reasonable rules to provide safeguards restricting the use or disclosure of information concerning applicants, recipients, and former and potential recipients of medical assistance to purposes directly connected with the administration of such medical assistance and related state department activities and covering the custody, use, and preservation of the records, papers, files, and communications of the state and county departments. Whenever, under provisions of law, names and addresses of applicants for, recipients of, or former and potential recipients of medical assistance are furnished to or held by another agency or department of government, such agency or department shall be required to prevent the publication of lists thereof and their uses for purposes not directly connected with the administration of such medical assistance.
2. 1. 1. Except as provided in subparagraphs (II) and (III) of this paragraph (a), it is unlawful for any person to solicit, disclose, or make use of or to authorize, knowingly permit, participate in, or acquiesce in the use of any lists or names of or any information concerning persons applying for or receiving public assistance and welfare directly or indirectly derived from the records, papers, files, or communications of the state or county departments or subdivisions or agencies thereof or acquired in the course of the performance of official duties. No financial institution or insurance company that provides the data, whether confidential or not, required by the state department, in accordance with the provisions of this subsection (2), shall be liable for the provision of the data to the state department nor for any use made thereof by the state department. (2) (a) (I) Except as provided in subparagraphs (II) and (III) of this paragraph (a), it is unlawful for any person to solicit, disclose, or make use of or to authorize, knowingly permit, participate in, or acquiesce in the use of any lists or names of or any information concerning persons applying for or receiving public assistance and welfare directly or indirectly derived from the records, papers, files, or communications of the state or county departments or subdivisions or agencies thereof or acquired in the course of the performance of official duties. No financial institution or insurance company that provides the data, whether confidential or not, required by the state department, in accordance with the provisions of this subsection (2), shall be liable for the provision of the data to the state department nor for any use made thereof by the state department.
      2. The information described in subparagraph (I) of this paragraph (a) may be disclosed for purposes directly connected with the administration of medical assistance and in accordance with this paragraph (a) and paragraphs (b) and (c) of this subsection (2) and with the rules of the state department.
      3. 1. Notwithstanding any provision of state law to the contrary and to the extent allowable under federal law, at the request of the Colorado bureau of investigation, the state department shall provide the bureau with information concerning the location of any person whose name appears in the department's records who is the subject of an outstanding felony arrest warrant. Upon receipt of such information, it shall be the responsibility of the bureau to provide appropriate law enforcement agencies with location information obtained from the state department. Location information provided pursuant to this section shall be used solely for law enforcement purposes. The state department and the bureau shall determine and employ the most cost-effective method for obtaining and providing location information pursuant to this section. Neither the state department nor its employees or agents shall be liable in civil action for providing information in accordance with the provisions of this sub-subparagraph (A).
         2. As used in sub-subparagraph (A) of this subparagraph (III), "law enforcement agency" means any agency of the state or its political subdivisions that is responsible for enforcing the laws of this state. "Law enforcement agency" includes but is not limited to any police department, sheriff's department, district attorney's office, the office of the state attorney general, and the Colorado bureau of investigation.
   2. By signing an application or redetermination of eligibility form for medical assistance, an applicant authorizes the state department to obtain records pertaining to information provided in that application or redetermination of eligibility form from a financial institution, as defined in section 15-15-201 (4), C.R.S., or from any insurance company. The application or redetermination of eligibility form shall contain language clearly indicating that signing constitutes such an authorization.
   3. 1. In order to determine if applicants for or recipients of medical assistance have assets within eligibility limits, the state department may provide a list of information identifying these applicants or recipients to any financial institution, as defined in section 15-15-201 (4), C.R.S., or to any insurance company. This information may include identification numbers or social security numbers. The state department may require any such financial institution or insurance company to provide a written statement disclosing any assets held on behalf of individuals adequately identified on the list provided. Before a termination notice is sent to the recipient, the county department or the medical assistance site in verifying the accuracy of the information obtained as a result of the match shall contact the recipient and inform the recipient of the apparent results of the computer match and give the recipient the opportunity to explain or correct any erroneous information secured by the match. The requirement to run a computerized match shall apply only to information that is entered in the financial institution's or insurance company's data processing system on the date the match is run and shall not be deemed to require any such institution or company to change its data or make new entries for the purpose of comparing identifying information. The cost of providing such computerized match shall be borne by the state department.
      2. For the fiscal year beginning July 1, 1984, and thereafter, all funds expended by the state department to pay the cost of providing such computerized matches shall be subject to an annual appropriation by the general assembly.
      3. The state department may expend funds appropriated pursuant to subparagraph (II) of this paragraph (c) in an amount not to exceed the amount of annualized general fund savings that result from the termination of recipients from medical assistance specifically due to disclosure of assets pursuant to this subsection (2).
   4. No applicant shall be denied nor any recipient discontinued due to the disclosure of their assets unless and until the county department or medical assistance site has assured that such assets taken together with other assets exceed the limit for eligibility of countable assets. Any information concerning assets found may be used to determine if such applicant's or recipient's eligibility for other medical assistance is affected.
3. The applicant for or recipient of medical assistance, or his or her representative, shall have an opportunity to examine all applications and pertinent records concerning said applicant or recipient which constitute a basis for denial, modification, or termination of such medical assistance or to examine such records in case of a fair hearing.
4. Any person who violates subsection (1) or (2) of this section is guilty of a misdemeanor and, upon conviction thereof, shall be punished by a fine of not more than five hundred dollars, or by imprisonment in the county jail for not more than three months, or by both such fine and imprisonment.

Source: L. 2006: Entire part amended, p. 1790, § 1, effective July 1.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

25.5-1-117. County departments - district departments.

1. Except as provided in subsection (2) of this section, there is established in each county of the state a county department of human or social services that consists of a county board of human or social services, a county director of human or social services, and any additional employees as may be necessary for the efficient performance of public assistance, as defined in section 26-2-103 (7), and medical assistance.
2. Single entry point agencies established pursuant to part 1 of article 6 of this title 25.5, other than county departments of human or social services acting as single entry point agencies, may act as state designated agencies and are authorized to carry out functions as specified in part 1 of article 6 of this title 25.5 that are otherwise performed by county departments of human or social services.
3. With the approval of the state department of human services, two or more counties may jointly establish a district department of human or social services. All duties and responsibilities for county departments of human or social services set forth in this title 25.5 also apply to district departments of human or social services.

Source: L. 2006: Entire part amended, p. 1792, § 1, effective July 1. L. 2018: Entire section amended, (SB 18-092), ch. 38, p. 444, § 108, effective August 8.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

Cross references: For the legislative declaration in SB 18-092, see section 1 of chapter 38, Session Laws of Colorado 2018.

25.5-1-118. Duties of county departments.

1. The county departments or other state designated agencies, where applicable, shall serve as agents of the state department and shall be charged with the administration of medical assistance and related activities in the respective counties in accordance with the rules of the state department.
2. The county departments or other state designated agencies, where applicable, shall report to the state department at such times and in such manner and form as the state department may from time to time direct.
3. The county department or other state designated agencies, where applicable, in each county shall submit quarterly and annually to the board of county commissioners a budget containing an estimate and supporting data setting forth the amount of money needed to carry out the provisions of this title.

Source: L. 2006: Entire part amended, p. 1793, § 1, effective July 1.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

25.5-1-119. County staff.

The county director, with the approval of the county board, shall appoint such staff as may be necessary as determined by the state department rules to administer medical assistance within the county. The staff shall be appointed and shall serve in accordance with a merit system for the selection, retention, and promotion of county department employees as described in section 26-1-120, C.R.S. The salaries of the staff members shall be fixed in accordance with the rules and salary schedules prescribed by the state department or the department of human services, whichever is appropriate; except that, once a county transfers its county employees to a successor merit system as provided in section 26-1-120, C.R.S., the salaries shall be fixed by the county commissioners.

Source: L. 2006: Entire part amended, p. 1793, § 1, effective July 1.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

25.5-1-120. Appropriations.

1. 1. For carrying out the duties and obligations of the state department and county departments under the provisions of this title and for matching such federal funds or meeting maintenance of effort requirements as may be available for public assistance and welfare activities in the state, including medical assistance administration and related activities, the general assembly, in accordance with the constitution and laws of the state of Colorado, shall make adequate appropriations for the payment of such costs, pursuant to the budget prepared by the executive director.
   2. If the federal law shall provide federal funds, in cash or in another form such as medical assistance, not otherwise provided for in this title, the state department is authorized to make such payments or offer such services in accordance with the requirements accompanying said federal funds within the limits of available state appropriations.
   3. When the executive director determines that adequate appropriations for the payment of the costs described in paragraph (a) of this subsection (1) have not been made and that an overexpenditure of an appropriation will occur based upon the state department's estimates, the state board may take actions consistent with state and federal law to bring the rate of expenditure into line with available funds. The general assembly declares that case load and utilization based on medical necessity are legitimate reasons for supplemental funding.
2. The general assembly shall appropriate from the general fund to the state department moneys for the costs of administering medical assistance programs and the state's share of the costs of administering such functions by the county departments amounts sufficient for the proper and efficient performance of the duties imposed upon them by law, including a legal advisor appointed by the attorney general. The general assembly shall make two separate appropriations, one for the administrative costs of the state department and another for the administrative costs of the county departments. Any applicable matching federal funds shall be apportioned in accordance with the federal regulations accompanying such funds. Any unobligated and unexpended balances of appropriated state general funds remaining at the end of each fiscal year shall be credited to the state general fund.
3. The expenses of training personnel for special skills relating to medical assistance, as such expenses shall be determined and approved by the state department, may be paid from state and federal funds available for such training purposes.

Source: L. 2006: Entire part amended, p. 1793, § 1, effective July 1.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

25.5-1-121. County expenditures - advancements - procedures.

1. For purposes of this article, under rules of the state department, administrative costs shall include: Salaries of the county director and employees of the county department staff engaged in the performance of medical assistance activities; the county's payments on behalf of such employees for old age and survivors' insurance or pursuant to a county officers' and employees' retirement plan and for any health insurance plan, if approved by the state department; the necessary travel expenses of the county board and the administrative staff of the county department in the performance of their duties; necessary telephone and other electronic means of communication; necessary equipment and supplies; necessary payments for postage and printing, including the printing and preparation of county warrants required for the administration of the county department; and such other administrative costs as may be approved by the state department; but advancements for office space, utilities, and fixtures may be made from state funds only if federal matching funds are available.
2. Notwithstanding any other provision of this article, the county department may spend in excess of twenty percent of actual costs for the purpose of matching federal funds for the administration of the child support enforcement program or for the administrative costs of activities involving food stamp, public assistance, or medical assistance fraud investigations or prosecutions.
3. 1. Notwithstanding any other provision of this article, the county department may receive and spend federal funds to which it is entitled based on the county's certification of public expenditures for administrative costs made by other entities within the county, which expenditures:
      1. Are from sources other than the county social services fund;
      2. Are in excess of the county department's portion, as required pursuant to section 25.5-1-114 (2)(a), of the administrative costs; and
      3. Are for an administrative activity that has been approved by the state department as an activity that is eligible for reimbursement under a federal program.
   2. Acceptance and expenditure of federal funds pursuant to paragraph (a) of this subsection (3) shall not affect the state's share of and contribution to the administrative costs. The county shall be solely responsible for certifying the nonfederal share that is in excess of the county's required portion of the administrative costs. The state department may retain up to five percent of any federal funds received by a county department pursuant to this subsection (3). In addition, the state, in accordance with the provisions of section 26-1-109 (4)(d), C.R.S., shall recover any federal funds received by the county through the certification of public expenditures that are subsequently determined to be ineligible for federal reimbursement.

Source: L. 2006: Entire part amended, p. 1794, § 1, effective July 1. L. 2011: (3) added, (HB 11-1196), ch. 160, p. 555, § 6, effective August 10.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

25.5-1-122. County appropriation increases - limitations.

1. Beginning in calendar fiscal year 1994 and for each calendar fiscal year thereafter to and including calendar fiscal year 1997, the board of county commissioners in each county of this state shall annually appropriate funds for the county share of the administrative costs of medical assistance in the county in an amount equal to the actual county share for the previous fiscal year adjusted by an amount equal to the actual county share for the previous fiscal year multiplied by the percentage of change in property tax revenue.
2. For the purposes of this section:
   1. "County share" means the actual amount of the county share for the previous fiscal year. "County share" shall not include:
      1. The amount expended by the county from the county contingency fund or the county tax base relief fund pursuant to section 26-1-126, C.R.S.;
      2. The amount expended by the county for general assistance pursuant to part 1 of article 17 of title 30, C.R.S.; and
      3. The amount expended by the county for programs or services provided by the county on its own, without requirements or funding from any other governmental agency.
   2. "Percentage of change in property tax revenue" means the difference between the total property tax levied for the previous fiscal year less the amount levied for debt service for the previous fiscal year and the total property tax levied for the year for which the percentage of change in tax revenue is being calculated less the amount levied for debt service for the year in which the percentage of change in tax revenue is being calculated divided by the total property tax levied for the previous fiscal year less the amount levied for debt service for the previous fiscal year.
3. Notwithstanding the provisions of section 25.5-1-121, a county in the state shall not be required to contribute more than the amount set forth in subsection (1) of this section in any fiscal year. Nothing in this section shall be construed to limit the ability of a county to establish programs or services provided by the county on its own, without requirements or funding from any other governmental agency.
4. (Deleted by amendment, L. 2008, p. 1812 , § 3, effective June 2, 2008.)
5. Any amounts remaining in the county social services fund created in section 26-1-123, C.R.S., at the end of any fiscal year shall remain in the county fund for expenditure as determined by the board of county commissioners for administrative costs of public assistance, medical assistance, and food stamps, and program costs of public assistance and food stamps.
6. The limitation set forth in this section on the increase in the county share of the administrative costs of medical assistance will result in increased costs to the state. By making state funds available, the state is encouraging counties not to exercise any right a county may have pursuant to section 20 (9) of article X of the Colorado constitution to reduce or end its share of the costs of medical assistance administration for the county for three fiscal years following the fiscal year in which the state funds are received. If a county accepts funds from the state based on the limitation provided in this section for any fiscal year, the county agrees not to exercise any rights the county may have to reduce or end its share of the costs of medical assistance administration for the fiscal year in which the funds are accepted. Nothing in this subsection (6) or any agreement pursuant to this subsection (6) shall be construed to affect the existence or status of any rights accruing to the state or any county pursuant to section 20 (9) of article X of the Colorado constitution.

Source: L. 2006: Entire part amended, p. 1795, § 1, effective July 1. L. 2008: (2)(a)(I) and (4) amended, p. 1812, § 3, effective June 2.

Editor's note: This section was contained in a 2006 act that amended this part, resulting in the addition of this section.

25.5-1-123. Medical homes for children - legislative declaration - duties of the department.

1. The general assembly hereby finds and declares that:
   1. The best medical care for infants, children, and adolescents is provided through a medical home, as defined in section 25.5-1-103, and that is consistent with the joint principles of a patient-centered medical home. Those principles shall include a whole-person orientation, care that is coordinated and integrated across all elements of the complex health care system and the patient's community, and care that provides for quality and safety of the patient where qualified health care practitioners provide primary care and help manage and facilitate all aspects of medical care.
   2. Infants, children, and adolescents and their families work best with a health care practitioner who knows the family and who develops a partnership of mutual responsibility and trust;
   3. Medical care provided through emergency departments, walk-in clinics, and other urgent-care facilities is often more costly and less effective than care given by a physician with prior knowledge of the child and his or her family; and
   4. The state department should strive to find a medical home for each child receiving services through the state medical assistance program, articles 4, 5, and 6 of this title, or the children's basic health plan, article 8 of this title.
2. On or before July 1, 2008, the state department, in conjunction with the Colorado medical home initiative in the department of public health and environment, shall develop systems and standards to maximize the number of children enrolled in the state medical assistance program or the children's basic health plan who have a medical home. The systems and standards developed shall include, but need not be limited to, ways to ensure that a medical home shall offer family-centered, compassionate, culturally effective care and sensitive, respectful communication to a child and his or her family.
3. Repealed.

Source: L. 2007: Entire section added, p. 1488, § 2, effective May 31. L. 2017: (3) repealed, (HB 17-1060), ch. 6, p. 15, § 3, effective March 1.

25.5-1-124. Early intervention payment system - participation by state department - rules.

1. The state department shall participate in the development and implementation of the coordinated system of payment for early intervention services authorized pursuant to part 7 of article 10.5 of title 27, C.R.S., and Part C of the federal "Individuals with Disabilities Education Act", 20 U.S.C. sec. 1400 et seq., as amended.
2. The state department shall ensure that the early intervention services and payments for recipients of medical assistance under this title are integrated into the coordinated early intervention payment system developed pursuant to part 7 of article 10.5 of title 27, C.R.S. To the extent necessary to achieve the coordinated payment system and coverage of those early intervention services under this title, the state department shall amend the state plan for medical assistance or seek the necessary federal authorization, promulgate rules, and modify the billing system for medical assistance to facilitate the coordinated payment system.
3. The state department shall also make any modifications necessary to the "Children's Basic Health Plan Act", article 8 of this title, including promulgating rules, to ensure that the children's basic health plan is integrated into the coordinated early intervention payment system developed pursuant to part 7 of article 10.5 of title 27, C.R.S.
4. Repealed.
5. 1. As used in this section, unless the context otherwise requires, "early intervention services" means those services defined as early intervention services by the department of human services in accordance with section 27-10.5-702 (7), C.R.S., that are determined, through negotiation between the state department and the department of human services, to be medically necessary under medical assistance and cost-effective. After negotiating the scope of early intervention services to be covered under medical assistance, the state department and the department of human services shall submit to the joint budget committee of the general assembly, as part of each department's annual budget request, a proposal for the scope of coverage of early intervention services under medical assistance, including the anticipated costs of such coverage and whether the payment of such costs through medical assistance is cost-effective.
   2. "Early intervention services" shall not include the following:
      1. Nonemergency medical transportation;
      2. Respite care;
      3. Service coordination, as defined in 34 CFR 303.12 (d)(11); and
      4. 1. Assistive technology.
         2. The exclusion of assistive technology shall not apply to durable medical equipment that is otherwise covered under the children's basic health plan, as defined in section 25.5-8-103 (2).

Source: L. 2007: Entire section added, p. 888, § 2, effective July 1. L. 2008: (5)(a) amended, p. 1468, § 14, effective August 5. L. 2012: (4) repealed, (HB 12-1247), ch. 53, p. 196, § 6, effective March 22.

25.5-1-125. Centennial care choices - value benefit plans - request for information - request for proposals - report to general assembly - definitions - legislative declaration. (Repealed)

Source: L. 2008: Entire section added, p. 2057, § 1, effective June 3. L. 2010: (2)(b)(VI) amended, (HB 10-1422), ch. 419, p. 2109, § 137, effective August 11. L. 2013: Entire section repealed, (HB 13-1139), ch. 120, p. 407, § 1, effective August 7.

25.5-1-126. Discounted prices for durable medical equipment and supplies.

1. The state department shall work with one or more nonprofit organizations to develop a link of approved vendors who are willing to sell durable medical equipment and medical supplies at discounted prices to persons who have applied for, but are not yet receiving, benefits under the "Colorado Medical Assistance Act". The state department shall provide the exclusive criteria for a nonprofit organization to use to approve a vendor for placement on the approved vendor list.
2. The state department shall maintain a link of approved vendors developed pursuant to this section and shall:
   1. Make the link available on the state department's website; and
   2. Provide copies of the list to county departments and to sites authorized to accept medical assistance applications pursuant to section 25.5-4-205 (1), through the survey given to applicants.

Source: L. 2010: Entire section added, (HB 10-1029), ch. 219, p. 958, § 1, effective May 10.

25.5-1-127. Third-party benefit denials information.

The state department shall provide information to recipients of benefits under this title concerning their right to appeal a denial of benefits by a third party and shall post information on the state department's website concerning recipients' abilities to appeal a third party's denial of benefits, including but not limited to providing a link to information on the insurance commissioner's website regarding such appeals.

Source: L. 2010: Entire section added, (SB 10-002), ch. 366, p. 1727, § 2, effective June 7.

Cross references: For the legislative declaration in the 2010 act adding this section, see section 1 of chapter 366, Session Laws of Colorado 2010.

25.5-1-128. Provider payments - compliance with state fiscal requirements - definitions - rules.

1. 1. Notwithstanding any provision of law to the contrary, when the state department has regulatory authority over a program and when the provider has already signed a state department-approved provider application to provide a service or to bill the state department or its authorized contractor for a service, the state department-approved provider application shall serve to fulfill the requirements of a commitment voucher and the fiscal requirements of section 24-30-202 (1), C.R.S.
   2. The executive director may promulgate rules to exempt a provider who provides services through a program as described in paragraph (a) of this subsection (1) for any program the state department is authorized by law to administer, including but not limited to:
      1. The "Colorado Medical Assistance Act", articles 4 to 6 of this title;
      2. The "Children's Basic Health Plan Act", article 8 of this title;
      3. The "Colorado Indigent Care Program", part 1 of article 3 of this title;
      4. The school health services program authorized by section 25.5-5-318;
      5. Programs that are funded through the primary care fund, created in section 24-22-117 (2)(b), C.R.S.; and
      6. The state-funded old age pension health and medical care program pursuant to article 2 of this title.
2. As used in this section, unless the context otherwise provides, "provider" means a health care provider, a mental health care provider, a pharmacist, a home health agency, a general provider as defined in section 25.5-3-103 (3), school district as defined in section 25.5-5-318 (1)(a), or any other entity that provides health care, health care coordination, outreach, enrollment, or administrative support services to recipients through fee-for-service, the primary care physician program, a managed care entity, a behavioral health organization, a medical home, or any system of care that coordinates health care or services as defined and authorized through rules promulgated by the state board or by the executive director.

Source: L. 2012: Entire section added, (HB 12-1054), ch. 14, p. 36, § 1, effective March 15.

25.5-1-129. State department proposal - state option for health care coverage - report to general assembly - waiver authorization - legislative declaration.

1. 1. The general assembly finds that:
      1. Every Coloradan deserves access to high-quality, affordable health care to help support his or her well-being and economic security;
      2. To achieve these goals, Colorado has successfully implemented provisions of the federal "Patient Protection and Affordable Care Act" that have helped expand access and increase affordability to thousands of Coloradans, including expanding medicaid coverage to more low-income adults and creating the Colorado health benefit exchange;
      3. Despite this success, in several regions of the state, health insurance is not affordable due to high health care costs and limited or no competition among insurance carriers as well as other marketplace factors, and Coloradans cannot afford the health insurance premiums and out-of-pocket expenses;
      4. Specifically, Coloradans in fourteen counties have access to only a single health insurance carrier participating in the Colorado health benefit exchange, and the number of uninsured Coloradans in those counties is rising;
      5. Colorado has historically been a national leader in health care innovation;
      6. Uncertainty at the federal level requires Colorado to be proactive and explore and implement its own innovative solutions to provide greater access to affordable, high-quality health care coverage for Colorado residents; and
      7. A state option for health care coverage that uses existing state health care infrastructure may decrease costs for Coloradans, increase competition, and improve access to high-quality, affordable, and efficient health care.
   2. Therefore, the general assembly declares that tasking the state department and the division of insurance in the department of regulatory agencies, referred to in this section as "the division", with developing a proposal that considers the feasibility and cost of implementing a state option for health care coverage that leverages existing state health care infrastructure, increases competition, improves quality, and provides stable access to affordable health insurance will enable policymakers to consider and create an innovative state option for health insurance coverage to benefit Colorado.
2. 1. On or before November 15, 2019, the state department and the division shall develop and submit a proposal to the joint budget committee; the public health care and human services and health and insurance committees of the house of representatives; and the health and human services committee of the senate, or any successor committees, for a state option for health care coverage that leverages existing state infrastructure.
   2. In addition to submitting the proposal to the committees of the general assembly listed in subsection (2)(a) of this section, the state department and the division shall present a summary of the proposal at the annual joint meeting of the house and senate committees conducted during the legislative interim prior to the 2020 legislative session pursuant to section 2-7-203.
3. The proposal must describe a state option for health care coverage. The proposal must identify the most effective implementation of a state option based on affordability to consumers at different income levels, administrative and financial burden to the state, ease of implementation, and likelihood of success in meeting the objectives described in subsection (1) of this section.
4. In developing the proposal, the state department and the division shall:
   1. Conduct actuarial research to identify the potential cost of premiums and cost-sharing to pay claims in a plan that is, at a minimum, an essential health-benefit-compliant plan, as defined in section 10-16-102 (22);
   2. Evaluate provider rates necessary to incentivize participation and encourage network adequacy and high-quality health care delivery;
   3. Evaluate eligibility criteria for individuals and small businesses to participate;
   4. Determine the impact, if any, on the state budget;
   5. Determine the impact on the stability of the individual market, the small group market, and the Colorado health benefit exchange created in article 22 of title 10;
   6. Evaluate the impact on consumers eligible for financial assistance for plans purchased on the exchange;
   7. Determine whether a state option plan should be offered on or off the exchange;
   8. Determine whether the state option plan should be a fully at-risk, managed care, fee-for-service, or accountable care collaborative plan, or a combination thereof;
   9. Determine whether the state option should be offered through the state department, and identify the expected impact, if any, to the Colorado medical assistance program established in articles 4, 5, and 6 of this title 25.5;
   10. Identify the expected impact, if any, to the children's basic health plan established in article 8 of this title 25.5;
   11. Investigate funding options, including but not limited to state funds and federal funds secured through available waivers;
   12. Evaluate the feasibility, legality, and scope of any necessary federal waivers;
   13. Review information relating to any pilot program that may be operated by the state personnel director pursuant to section 24-50-620, as enacted in Senate Bill 19-004; and
   14. Create a statewide definition of affordability for consumers.
5. In developing the proposal, the state department and the division shall consult with the Colorado health benefit exchange and shall engage in a stakeholder process that includes public and private health insurance experts, as well as consumers, consumer advocates, employers, providers, and carriers.
6. The proposal submitted to the committees of the general assembly pursuant to this section must include detailed analysis of the proposed state option and the various methods for implementing the proposed state option, as well as any identified statutory or rule changes necessary to implement the proposed state option.
7. 1. 1. After the proposal created pursuant to this section is submitted and presented to the committees of the general assembly, the state department and the division shall prepare and submit any federal waivers or state plan amendments necessary to fund and implement the state option for health care coverage as described in the proposal created pursuant to subsection (2)(a) of this section. (7) (a) (I) After the proposal created pursuant to this section is submitted and presented to the committees of the general assembly, the state department and the division shall prepare and submit any federal waivers or state plan amendments necessary to fund and implement the state option for health care coverage as described in the proposal created pursuant to subsection (2)(a) of this section.
      2. The state department's and the division's requests for federal authorization must seek to obtain the maximum amount of federal money available to the state and to persons participating in the state option for health care coverage.
   2. Notwithstanding the provisions of subsection (7)(a)(I) of this section to the contrary, the preparation and submission of federal waivers or amendments must be delayed if a member of the general assembly files a bill during the 2020 legislative session by the regular bill filing deadline of the house of representatives, as set forth in rule 23 of the joint rules of the senate and house of representatives, that substantially alters the federal authorization required pursuant to the proposal to implement the state option for health care coverage, and such bill is not postponed indefinitely in the first committee of reference. The department's and the division's waiver preparation process shall resume after the bill is postponed indefinitely or, if passed by the general assembly, the requested waivers or state plan amendments must reflect the requirements in the passed legislation.
   3. Subject to the conditions described in subsection (7)(b) of this section, the state department and the division may promulgate rules, as necessary, for the preparation and submission of federal waivers or state plan amendments necessary to fund and implement the proposal.

Source: L. 2019: Entire section added, (HB 19-1004), ch. 206, p. 2199, § 1, effective May 17.

25.5-1-130. Improving access to behavioral health services for individuals at risk of entering the criminal or juvenile justice system - duties of the state department.

1. On or before March 1, 2020, the state department shall develop measurable outcomes to monitor efforts to prevent medicaid recipients from becoming involved in the criminal or juvenile justice system.
2. On or before July 1, 2021, the state department shall work collaboratively with managed care entities to create incentives for behavioral health providers to accept medicaid recipients with severe behavioral health disorders. The incentives may include, but need not be limited to, higher reimbursement rates, quality payments to managed care entities for adequate networks, establishing performance measures and performance improvement plans related to network expansion, transportation solutions to incentivize medicaid recipients to attend health care appointments, and incentivizing providers to conduct outreach to medicaid recipients to ensure that they are engaged in needed behavioral health services, including technical assistance with billing procedures. The state department may seek any federal authorization necessary to create the incentives described in this subsection (2).

Source: L. 2019: Entire section added, (SB 19-222), ch. 226, p. 2265, § 2, effective May 20. L. 2020: (2) amended, (SB 20-136), ch. 70, p. 300, § 56, effective September 14.

Cross references: For the legislative declaration in SB 19-222, see section 1 of chapter 226, Session Laws of Colorado 2019. For the legislative declaration in SB 20-136, see section 1 of chapter 70, Session Laws of Colorado 2020.

25.5-1-201. Programs to be administered by the department of health care policy and financing.

1. The department of health care policy and financing shall administer the following programs and perform the following functions:
   1. The "Colorado Medical Assistance Act", as specified in articles 4, 5, and 6 of this title;
   2. The "Colorado Indigent Care Program", as specified in part 1 of article 3 of this title;
   3. Effective July 1, 1996, school entry immunization, as specified in part 9 of article 4 of title 25, C.R.S. Commencing on and after the fiscal year beginning July 1, 1996, the state department is authorized to contract with the department of public health and environment for the purpose of enforcing the school entry immunization requirements.
   4. Repealed.
   5. The "Children's Basic Health Plan Act", as specified in article 8 of this title;
   6. The old age pension health and medical care program, as specified in section 25.5-2-101;
   7. Programs, services, and supports for persons with intellectual and developmental disabilities, as specified in article 10 of this title 25.5; and
   8. Any program concerning the wholesale importation of prescription drugs pursuant to part 2 of article 2.5 of this title 25.5.

Source: L. 93: Entire title added, p. 1102, § 15, effective July 1, 1994. L. 94: (1)(f) and (1)(g) amended and (1)(h) added, p. 1669, § 4, effective July 1. L. 95: (1)(g) and (1)(h)(II) amended and (1)(j) added, p. 511, § 4, effective May 16; (1)(j) added, p. 916, § 15, effective May 25. L. 96: (1)(b) and (1)(h)(I) repealed, p. 1474, § 27, effective June 1; (1)(i) and (1)(j) amended and (1)(k) added, p. 1437, § 7, effective July 1. L. 99: (1)(l) added, p. 700, § 6, effective July 1. L. 2001: (1)(m) added, p. 916, § 11, effective August 8. L. 2002: (1)(h) repealed, p. 427, § 5, effective July 1. L. 2003: (1)(l) and (1)(m) amended and (1)(n) added, p. 2583, § 3, effective July 1. L. 2005: (1)(a) repealed, p. 772, § 51, effective June 1. L. 2006: Entire part amended, p. 1796, § 2, effective July 1. L. 2007: (1)(d) repealed, p. 2042, § 70, effective June 1. L. 2011: (1)(f) amended, (SB 11-210), ch. 187, p. 721, § 7, effective July 15, 2012. L. 2013: (1)(e) and (1)(f) amended and (1)(g) added, (HB 13-1314), ch. 323, p. 1808, § 42, effective March 1, 2014. L. 2019: IP(1), (1)(f), and (1)(g) amended and (1)(h) added, (SB 19-005), ch. 184, p. 2065, § 2, effective August 2.

Cross references: For the legislative declaration in SB 19-005, see section 1 of chapter 184, Session Laws of Colorado 2019.

25.5-1-202. Advisory committee on covering all children in Colorado - reports - definitions - repeal. (Repealed)

Source: L. 2007: Entire section added, p. 1491, § 2, effective July 1. L. 2008: (3)(b)(IV.5) added, p. 2027, § 3, effective June 3. L. 2012: Entire section repealed, (HB 12-1207), ch. 65, p. 229, § 1, effective March 24.

25.5-1-203. Prescription drug information and technical assistance program - expansion.

The state department may expand the prescription drug information and technical assistance program created in section 25.5-5-507 to include persons receiving drug benefits pursuant to any program that is administered by the state department.

Source: L. 2008: Entire section added, p. 231, § 1, effective August 5.

25.5-1-204. Advisory committee to oversee the all-payer health claims database - creation - members - duties - legislative declaration - rules - report.

1. The general assembly hereby finds and declares that an advisory committee for the all-payer health claims database would support the database in its established mission of facilitating the reporting of health care and health quality data that results in transparent and public reporting of safety, quality, cost, and efficiency information; and analysis of health care spending and utilization patterns for purposes that improve the population's health, improve the care experience, and control costs.
2. 1. No later than August 1, 2013, the executive director shall appoint an advisory committee to oversee the Colorado all-payer health claims database. The advisory committee shall include the following members:
      1. A member of academia with experience in health care data and cost efficiency research;
      2. A representative of:
         1. A statewide association of hospitals;
         2. An integrated multi-specialty organization;
         3. Physicians and surgeons;
         4. An organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity;
         5. A nonprofit organization that demonstrates experience working with employers to enhance value and affordability in health insurance;
         6. Dental insurers;
         7. Pharmacists or an affiliate society;
         8. Pharmacy benefit managers;
         9. A statewide association of ambulatory surgical centers;
      3. A representative, who is not a supplier or broker of health insurance, of:
         1. Small employers that purchase group health insurance for employees;
         2. Large employers that purchase health insurance for employees;
         3. Self-insured employers;
      4. A representative from a community mental health center who has experience in behavioral health data collection;
      5. Three representatives with a demonstrated record of advocating health care issues on behalf of consumers;
      6. Two representatives of health insurers, one who represents nonprofit insurers and one who represents for-profit insurers;
      7. Two representatives of nonprofit organizations that facilitate health information exchange to improve health care for all Coloradans;
      8. The executive director or his or her designee, serving as an ex officio member;
      9. The commissioner of insurance or his or her designee, serving as an ex officio member;
      10. A representative of the department of personnel, serving as an ex officio member;
      11. The director of the office of information and technology or his or her designee, serving as an ex officio member; and
      12. Two members of the general assembly, one appointed by the majority leader of the senate and one appointed by the majority leader of the house of representatives; except that, if the majority leaders are from the same political party, the minority leader of the house of representatives shall appoint the second member. The two members of the general assembly shall serve as ex officio members.
   2. The advisory committee shall make recommendations to the executive director and the Colorado all-payer health claims database administrator related to the Colorado all-payer health claims database. The recommendations include the following:
      1. Procedures for the collection, retention, use, and disclosure of data from the Colorado all-payer health claims database, including procedures and safeguards to protect the privacy, integrity, confidentiality, and availability of any data;
      2. Guidelines for charging for custom reports from the Colorado all-payer health claims database;
      3. Procedures to ensure compliance with the "Health Insurance Portability and Accountability Act of 1996", Pub.L. 104-191, as amended, and implementing federal regulations;
      4. Procedures to ensure compliance with other state and federal privacy laws; and
      5. Procedures for data confidentiality and data disposal if the Colorado all-payer health claims database ceases to exist.
   3. The members of the advisory committee appointed pursuant to subparagraph (XII) of paragraph (a) of this subsection (2) are entitled to receive compensation and reimbursement of expenses as provided in section 2-2-326, C.R.S.
3. 1. The administrator shall prepare and file annual reports to the legislature by March 1 of each year. The annual report must contain:
      1. The uses of the data in the all-payer health claims database;
      2. Public studies produced by the administrator;
      3. The cost of administering the Colorado all-payer health claims database, the sources of the funding, and the total revenue taken in by the database;
      4. The recipients of the data, the purposes for the data requests, and whether a fee was charged for the data;
      5. A fee schedule displaying the fees for providing custom data reports from the Colorado all-payer health claims database.
   2. The executive director shall require an evaluation of the Colorado all-payer health claims database initiative every five years beginning in 2018, to ensure that the database accomplishes the goals of this section. The report must contain metrics that document and demonstrate the achievements or challenges of the program goals.
   3. 1. By August 31, 2019, and by each August 31 thereafter, the administrator shall provide a primary care spending report to the commissioner of insurance for use by the primary care payment reform collaborative established in section 10-16-150 regarding primary care spending:
         1. By carriers, as defined in sections 10-16-102 (8) and 24-50-603 (2);
         2. Under the "Colorado Medical Assistance Act", articles 4, 5, and 6 of this title 25.5; and
         3. Under the "Children's Basic Health Plan Act", article 8 of this title 25.5.
      2. The report prepared in accordance with this subsection (3)(c) must include the percentage of the medical expenses allocated to primary care, the share of payments that are made through nationally recognized alternative payment models, and the share of payments that are not paid on a fee-for-service or per-claim basis.
4. 1. The administrator shall seek funding for the creation of the all-payer health claims database and develop a plan for the financial stability of the database. If sufficient funding is received through gifts, grants, and donations on or before January 1, 2012, as determined by the executive director, the administrator shall, in consultation with the advisory committee, create the Colorado all-payer claims database.
   2. The general assembly may annually appropriate general fund money to the state department to pay for expenses related to the all-payer health claims database.
5. If sufficient funding is received, the executive director shall direct the administrator to create the database and the administrator shall:
   1. Determine the data to be collected from payers and the method of collection, including mandatory and voluntary reporting of health care and health quality data;
   2. Seek to establish agreements for voluntary reporting of health care claims data from health care payers that are not subject to mandatory reporting requirements in order to ensure availability of the most comprehensive and systemwide data on health care costs and quality;
   3. Seek to establish agreements or requests with the federal centers for medicare and medicaid services to obtain medicare health claims data;
   4. Determine the measures necessary to implement the reporting requirements in a manner that is cost-effective and reasonable for data sources and timely, relevant, and reliable for consumers, public and private purchasers, providers, and policymakers;
   5. Determine the reports and data to be made available to the public with recommendations from the advisory committee in order to accomplish the purposes of this section, including conducting studies and reporting the results of the studies;
   6. Collect, aggregate, distribute, and publicly report performance data on quality, health outcomes, health disparities, cost, utilization, and pricing in a manner accessible for consumers, public and private purchasers, providers, and policymakers;
   7. Protect patient privacy in compliance with state and federal medical privacy laws while preserving the ability to analyze data and share with providers and payers to ensure accuracy prior to the public release of information;
   8. Repealed.
   9. Provide leadership and coordination of public and private health care quality and performance measurements to ensure efficiency, cost-effectiveness, transparency, and informed choice by consumers and public and private purchasers.
6. The administrator, with input from the advisory committee:
   1. Shall incorporate and utilize publicly available data other than administrative claims data if necessary to measure and analyze a significant health care quality, safety, or cost issue that cannot be adequately measured with administrative claims data alone;
   2. Shall require payer data sources to submit data necessary to implement the all-payer claims database;
   3. Shall determine the data elements to be collected, the reporting formats for data submitted, and the use and reporting of any data submitted. Data collection shall align with national, regional, and other uniform all-payer claims databases' standards where possible.
   4. May audit the accuracy of all data submitted;
   5. May contract with third parties to collect and process the health care data collected pursuant to this section. The contract shall prohibit the collection of unencrypted social security numbers and the use of the data for any purpose other than those specifically authorized by the contract. The contract shall require the third party to transmit the data collected and processed under the contract to the administrator or other designated entity.
   6. May share data regionally or help develop a multistate effort if recommended by the advisory committee.
7. The all-payer health claims database shall:
   1. Be available to the public when disclosed in a form and manner that ensures the privacy and security of personal health information as required by state and federal law, as a resource to insurers, consumers, employers, providers, purchasers of health care, and state agencies to allow for continuous review of health care utilization, expenditures, and quality and safety performance in Colorado;
   2. Be available to state agencies and private entities in Colorado engaged in efforts to improve health care, subject to rules promulgated by the executive director;
   3. Be presented to allow for comparisons of geographic, demographic, and economic factors and institutional size;
   4. Present data in a consumer-friendly manner.
8. The collection, storage, and release of health care data and other information pursuant to this section is subject to the federal "Health Insurance Portability and Accountability Act of 1996", Pub.L. 104-191, as amended.
9. The executive director shall promulgate rules as necessary to implement this section, which rules shall include the assessment of a fine for a payer required to submit data that does not comply with this section. Any fines collected shall be deposited in the all-payer health claims database cash fund, which is hereby created in the state treasury. The moneys in the fund shall be appropriated to the department of health care policy and financing for the purpose of maintaining the all-payer health claims database. The moneys in the fund shall remain in the fund and not revert to the general fund or any other fund at the end of any fiscal year.
10. Repealed.
11. If at any time, there is not sufficient funding to finance the ongoing operations of the database, the database shall cease operating and the advisory committee and administrator shall no longer have the duty to carry out the functions required pursuant to this section. If the database ceases to operate, the data submitted shall be destroyed or returned to its original source.

Source: L. 2010: Entire section added, (HB 10-1330), ch. 299, p. 1406, § 1, effective August 11. L. 2013: (1), (2), and (3) R&RE, (SB 13-149), ch. 152, p. 495, § 1, effective July 1; (10) repealed, (HB 13-1300), ch. 316, p. 1689, § 80, effective August 7; (5)(a) amended, (HB 13-1115), ch. 338, p. 1973, § 16, effective March 31, 2015. L. 2014: (2)(a)(X) amended, (HB 14-1363), ch. 302, p. 1269, § 29, effective May 31; (2)(c) amended, (SB 14-153), ch. 390, p. 1965, § 24, effective June 6. L. 2017: (4) amended and (5)(h) repealed, (HB 17-1060), ch. 6, p. 15, § 4, effective March 1. L. 2018: (4) amended, (HB 18-1327), ch. 150, p. 942, § 1, effective April 23. L. 2019: (3)(c) added, (HB 19-1233), ch. 194, p. 2122, § 6, effective May 16.

Cross references: For the legislative declaration in HB 19-1233, see section 1 of chapter 194, Session Laws of Colorado 2019.

25.5-1-204.5. All-payer health claims database scholarship grant program - creation - definitions.

1. As used in this section, unless the context otherwise requires:
   1. "Advisory committee" means the advisory committee to oversee the all-payer health claims database created pursuant to section 25.5-1-204.
   2. "Governmental entity" means a state or local governmental entity, including a state-supported institution of higher education, but does not include the state department.
   3. "Program" means the all-payer health claims database scholarship grant program established pursuant to this section.
2. There is created in the state department the all-payer health claims database scholarship grant program to defray the costs of nonprofit and governmental entities in accessing the all-payer health claims database to conduct research.
3. The state department shall:
   1. In consultation with the advisory committee, develop a grant application under the program consistent with the rules of the executive director;
   2. Accept applications for scholarship grants from any nonprofit or governmental entity needing access to the all-payer health claims database to conduct research;
   3. After considering the recommendations of the advisory committee, determine which grant applications to approve and the amount of each grant; and
   4. Distribute approved scholarship grants to nonprofit or governmental entities.
4. The executive director shall, following recommendations of the state department and the advisory committee, adopt rules pursuant to section 24-4-103 governing the program, including procedures, criteria, and standards for awarding scholarship grants.
5. The advisory committee shall:
   1. Consult with the state department on the development of a grant application form; and
   2. Review applications for scholarship grants and recommend which scholarship grants to approve and the amount of each recommended grant.

Source: L. 2018: Entire section added, (HB 18-1327), ch. 150, p. 942, § 2, effective April 23.

25.5-1-205. Providing for the efficient provision of health care through state-supervised cooperative action - rules.

1. Cooperation among health care payors, including both private sector entities and federal and state-administered health care programs, has the potential to eliminate needless and costly complexity in the administration of the programs and to benefit patients, payors, and the government. Further, alignment of financial incentives among private and public entities may accelerate and reinforce improvements in health care quality and patient outcomes.
2. The executive director shall facilitate departmental oversight of collaboration among providers, medicaid clients and advocates, and payors that is designed to improve health outcomes and patient satisfaction and support the financial sustainability of the medicaid program.
3. The executive director may promulgate rules relating to the collaborative process set forth in this section.

Source: L. 2012: Entire section added, (HB 12-1281), ch. 246, p. 1182, § 1, effective June 4.

25.5-1-206. School-based substance abuse prevention and intervention program - creation - reporting - legislative declaration - definitions.

1. 1. The general assembly finds and declares that:
      1. The 2011 healthy kids Colorado survey indicates that the top three substances that high school students report they use are alcohol, marijuana, and prescription drugs;
      2. With the legalization of marijuana by citizen initiative in Colorado, there is an increased availability of marijuana in the community and, at the same time, a decreased perception of harm related to marijuana use;
      3. Evidence-based prevention and intervention programs and education awareness programs targeted to school children who are twelve to nineteen years of age are needed to:
         1. Increase the perceived risk of harm associated with marijuana and alcohol use and prescription drug misuse;
         2. Decrease the rates of youth marijuana and alcohol use and prescription drug misuse and delay the age of first-time use; and
         3. Decrease the number of drug- and alcohol-related violations, suspensions, and expulsions reported by schools.
   2. Therefore, the general assembly declares that it is appropriate to award grants to schools, community-based organizations, and health organizations to provide school-based prevention and intervention programs that use evidence-based strategies, practices, and approaches to reduce the risk of marijuana and alcohol use and prescription drug misuse by school-aged children. Successful school-based programs will lead to increased overall health, behavioral health, and educational outcomes for Colorado's youth.
2. As used in this section, unless the context otherwise requires:
   1. "Entity" means a school, school district, board of cooperative services, a nonprofit or not-for-profit community-based organization, or a community-based behavioral health organization.
   2. "Grant program" means the school-based substance abuse prevention and intervention grant program created in subsection (3) of this section.
3. 1. The school-based substance abuse prevention and intervention grant program is created within the state department. The purpose of the grant program is to award competitive grants to entities to provide school-based prevention and intervention programs for youth twelve to nineteen years of age primarily focused on reducing marijuana use, but including strategies and efforts to reduce alcohol use and prescription drug misuse.
   2. To be considered for a competitive grant, the entity must demonstrate in the grant proposal that:
      1. The grant will be used to implement evidence-based programs and strategies delivered in the school setting that are designed to improve overall health, behavioral health, and educational outcomes for youth who are twelve to nineteen years of age;
      2. The entity is delivering the program and strategies to at-risk youth, regardless of the youths' eligibility for Colorado's medical assistance program; and
      3. The evidence-based programs and strategies are designed to achieve the following outcomes:
         1. An increase in the perceived risk of harm associated with marijuana use, prescription drug misuse, and underage alcohol use among youth who are twelve to nineteen years of age;
         2. A decrease in the rates of youth marijuana use, alcohol use, and prescription drug misuse;
         3. A delay in the age of first use of marijuana, alcohol, or prescription drug misuse;
         4. A decrease in the rates of youth who have ever used marijuana or alcohol or misused prescription drugs in their lifetime; and
         5. A decrease in the number of drug- and alcohol-related violations on school property, suspensions, and expulsions reported by schools.
4. On or before September 1, 2014, the state department shall establish procedures and timelines for grant applications, criteria for determining grant amounts and grantee reporting requirements, and any other grant program policies. The state department may amend these policies at any time.
5. Subject to available appropriations, the state department shall award grants for the 2014-15 academic year and for each academic year thereafter. There is no limit on the number of grants that the state department may award, and the same entity may receive more than one grant if the state department considers the needs of at-risk students in communities throughout the state for school-based substance abuse prevention and intervention programs.
6. Repealed.

Source: L. 2014: Entire section added, (SB 14-215), ch. 352, p. 1612, § 6, effective July 1. L. 2017: (6) amended, (HB 17-1060), ch. 6, p. 15, § 5, effective March 1.

Editor's note: Subsection (6)(b) provided for the repeal of subsection (6), effective November 2, 2017. (See L. 2017, p. 15 .)

25.5-1-301. Medical services board - creation.

1. There is created in the state department a medical services board, referred to in this part 3 as the "board". The board consists of eleven members appointed by the governor with the consent of the senate. The governor shall appoint persons to the board who have knowledge of medical assistance programs, and one or more of the appointments may include a person or persons who have received services through programs administered by the department within two years of the date of appointment. No more than six members of the board shall be members of the same political party. Of the eleven members appointed to the board, at least one must be appointed from each congressional district. In making appointments to the board, the governor shall include representation by at least one member who is a person with a disability, as defined in section 24-34-301 (2.5), a family member of a person with a disability, or a member of an advocacy group for persons with disabilities, provided that the other requirements of this subsection (1) are met.
2. Members shall serve at the pleasure of the governor for a term of four years; except that, of the members first appointed, three shall serve for a term of two years and three shall serve for a term of three years. On July 1, 2001, the governor shall appoint one member from the private sector to the board who shall have experience with the delivery of health care, who shall be appointed for a term of two years, and one member who shall have experience or expertise in caring for medically underserved children, who shall be appointed for a term of three years.
3. Members shall receive no compensation but shall be reimbursed for reasonable and necessary actual expenses incurred in the performance of their official duties as members of the board.
4. Vacancies on the board shall be filled by appointment of the governor for the remainder of any unexpired term.

Source: L. 94: Entire part added, p. 1557, § 2, effective July 1. L. 2001: (1) and (2) amended, p. 916, § 12, effective August 8. L. 2006: Entire part amended, p. 1797, § 3, effective July 1. L. 2009: (1) amended, (HB 09-1281), ch. 399, p. 2154, § 4, effective August 5. L. 2011: (1) amended, (SB 11-183), ch. 132, p. 465, § 2, effective August 10. L. 2018: (1) amended, (HB 18-1364), ch. 351, p. 2082, § 7, effective July 1.

25.5-1-302. Medical services board - organization.

1. The board shall elect from its members a president, a vice-president, and such other board officers as it shall determine. All board officers shall hold their offices at the pleasure of the board.
2. Regular meetings of the board shall be held not less than once every three months at such times as may be fixed by resolution of the board. All meetings of the board, in every suit and proceeding, shall be considered to have been duly called and regularly held and all orders and proceedings of the board to have been authorized, unless the contrary is proven.
3. The board shall adopt, and at any time may amend, bylaws in relation to its meetings and the transaction of its business. A majority shall constitute a quorum of the board. The vote of a majority of a quorum of the board shall constitute the action of the board. The board shall act only by resolution adopted at a duly called meeting of the board, and no individual of the board shall exercise any individual administrative authority with respect to the department.

Source: L. 94: Entire part added, p. 1557, § 2, effective July 1. L. 2006: Entire part amended, p. 1798, § 3, effective July 1.

25.5-1-303. Powers and duties of the board - scope of authority - rules.

1. The board shall have the authority set forth in subsection (3) of this section over the following programs administered by the state department:
   1. The "Colorado Medical Assistance Act", as specified in articles 4, 5, and 6 of this title;
   2. The "Colorado indigent care program", as specified in part 1 of article 3 of this title;
   3. Repealed.
   4. The "Children's Basic Health Plan Act", as specified in article 8 of this title;
   5. The old age pension health and medical care program, as specified in section 25.5-2-101;
   6. Programs, services, and supports for persons with intellectual and developmental disabilities, as specified in article 10 of this title.
2. Nothing in this section shall be construed to affect any specific statutory provision granting rule-making authority to the board in relation to a specific program.
3. The board shall adopt rules in connection with the programs set forth in subsection (1) of this section governing the following:
   1. The implementation of legislative and departmental policies and procedures for such programs; except that no rules shall be promulgated for any policy or procedure which governs the administration of the state department as specified in section 25.5-1-108 (1);
   2. The establishment of eligibility requirements for persons receiving services from the state department;
   3. The establishment of the type of benefits that a recipient of services may obtain if eligibility requirements are met, subject to the authorization, requirements, and availability of such benefits;
   4. The requirements, obligations, and rights of clients and recipients;
   5. The establishment of a procedure to resolve disputes that may arise between clients and the state department or clients and providers;
   6. The requirements, obligations, and rights of providers, including policies and procedures related to provider payments that may affect client benefits;
   7. The establishment of a procedure to resolve disputes that may arise between providers and between the state department and providers.
4. At the request of the executive director, the board shall advise the executive director as to any proposed policies or rules governing programs administered by the state department that are not set forth in subsection (1) of this section.
5. The board shall have no authority over the revenue of the state department.
6. All rules and orders of the department of human services in connection with the old age pension health and medical care program shall continue to be effective until revised, amended, repealed, or nullified pursuant to law.
7. The rules issued by the state board shall be binding upon the county departments. At any public hearing relating to a proposed rule-making, interested persons shall have the right to present their data, views, or arguments orally. Proposed rules of the state board shall be subject to the provisions of section 24-4-103, C.R.S.
8. To the extent that rules are promulgated by the state board of human services for programs or providers that receive either medicaid only or both medicaid and nonmedicaid funding, the rules shall be developed in cooperation with the state department and shall not conflict with state statutes or federal statutes or regulations.
9. The rules and orders of the department of human services and the state board of human services in connection with the programs, services, and supports specified in paragraph (f) of subsection (1) of this section shall continue to be effective until revised, amended, repealed, or nullified pursuant to law.

Source: L. 94: Entire part added, p. 1558, § 2, effective July 1. L. 95: (3)(e) to (3)(g) amended, p. 928, § 32, effective May 25. L. 99: (1)(c) amended and (1)(e) added, p. 701, § 7, effective July 1. L. 2001: (1)(f) and (7) added, pp. 916, 917, §§ 13, 14, effective August 8. L. 2003: (7) amended, p. 2009, § 90, effective May 22; (4) amended and (8) added, p. 2584, § 4, effective July 1. L. 2006: Entire part amended, p. 1798, § 3, effective July 1. L. 2007: (1)(c) repealed, p. 2042, § 71, effective June 1. L. 2011: (1)(e) and (6) amended, (SB 11-210), ch. 187, p. 722, § 8, effective July 15, 2012. L. 2013: (1)(f) and (9) added, (HB 13-1314), ch. 323, p. 1808, § 43, effective March 1, 2014.

Cross references: For the legislative declaration contained in the 1999 act amending subsection (1)(c) and enacting subsection (1)(e), see section 1 of chapter 203, Session Laws of Colorado 1999.

25.5-1-304. Repeal of part. (Deleted by amendment)

Source: L. 94: Entire part added, p. 1559, § 2, effective July 1. L. 2000: Entire section amended, p. 410, § 9, effective April 13. L. 2006: Entire part amended, p. 1800, § 3, effective July 1.

25.5-1-401. (Repealed)

Source: L. 2004: Entire part repealed, p. 1011, § 23, effective August 4.

Editor's note: This part 4 was added in 1994. For amendments to this part 4 prior to its repeal in 2004, consult the Colorado statutory research explanatory note and the table itemizing the replacement volumes and supplements to the original volume of C.R.S. 1973 beginning on page vii in the front of this volume.

25.5-1-501 to 25.5-1-516. (Repealed)

Source: L. 2006: Entire part repealed, p. 1800, § 4, effective July 1.

Editor's note: This part 5 was added in 1995. For amendments to this part 5 prior to its repeal in 2006, consult the Colorado statutory research explanatory note and the table itemizing the replacement volumes and supplements to the original volume of C.R.S. 1973 beginning on page vii in the front of this volume.

25.5-1-601. Legislative declaration.

1. The general assembly hereby finds and declares that:
   1. Physicians engaged in family medicine are in critically short supply in this state;
   2. Because of the distribution of such physicians, many rural and urban areas of the state are underserved;
   3. A significant portion of the state population is medically underserved because of indigency;
   4. Family physicians provide health care to all segments of the population;
   5. The provision of more competent family physicians is a public purpose of great importance; and
   6. The creation of the commission on family medicine is a desirable, necessary, and cost-effective means of addressing the needs described in this subsection (1).

Source: L. 2017: Entire part added, (HB 17-1024), ch. 7, p. 19, § 1, effective August 9.

Editor's note: This section is similar to former § 25-1-901 as it existed prior to 2017.

25.5-1-602. Commission created - composition - terms of office.

1. There is hereby created, in the department of health care policy and financing, the commission on family medicine, referred to in this part 6 as the "commission". No more than four members of the commission appointed by the governor pursuant to subsection (1)(d) of this section may be members of the same major political party. A vacancy on the commission occurs whenever any health care consumer member moves out of the congressional district from which he or she was appointed. A health care consumer member who moves out of the congressional district shall promptly notify the governor of the date of the move, but notice is not a condition precedent to the occurrence of the vacancy. The governor shall fill the vacancy by appointment for the unexpired term. The commission consists of the following members:
   1. The deans of accredited allopathic and osteopathic schools of medicine in the state or their designated representatives;
   2. The director of all family medicine programs in the state accredited by the accreditation council on graduate medical education of the American medical association or the American osteopathic association;
   3. A representative of the Colorado academy of family physicians; and
   4. A health care consumer to be appointed by the governor from each congressional district in the state.
2. The members appointed under subsection (1)(d) of this section serve three-year terms. All members serve at the pleasure of the governor.
3. The commission shall elect a chairperson and a vice-chairperson from among its members. Members of the commission serve without compensation, but members described in subsections (1)(b), (1)(c), and (1)(d) of this section are entitled to their actual and necessary expenses incurred in the performance of their duties. The commission shall meet on call of the chairperson, but not less than once every three months. A majority of the members of the commission constitutes a quorum for the transaction of business.

Source: L. 2017: Entire part added, (HB 17-1024), ch. 7, p. 20, § 1, effective August 9.

Editor's note: This section is similar to former § 25-1-902 as it existed prior to 2017.

25.5-1-603. Duties of commission - reporting.

1. The commission shall:
   1. Assure that family medicine residency program standards are equal to or more stringent than the standards established by the accreditation council on graduate medical education of the American medical association or the American osteopathic association for residency training in family medicine;
   2. In cooperation with the dean of the school of medicine, approve and recommend allocation of any funds which are identified and appropriated in the general appropriation bill as a line item for any community family medicine residency training program;
   3. Monitor the state's family medicine residency programs and recommend from time to time that the general assembly appropriate funds for said programs;
   4. Locate specific areas of the state which are underserved by family physicians and determine the priority of need among such areas;
   5. Offer to the general assembly alternative ideas on providing medical care to the medically indigent in the state; and
   6. 1. Support the development and maintenance of family medicine residency programs in rural and other underserved areas of the state for purposes of cultivating family medicine practitioners who are likely to continue practicing in rural and underserved areas of the state at the conclusion of their residency programs.
      2. On or before each November 1, the commission shall report to the office of state planning and budgeting and to the department of health care policy and financing concerning rural family medicine residency programs in the state and the role of the commission with respect to supporting the development and maintenance of those programs. In addition, notwithstanding section 24-1-136 (11), the commission shall present the report to the joint budget committee as part of its annual presentation to that committee.

Source: L. 2017: Entire part added, (HB 17-1024), ch. 7, p. 20, § 1, effective August 9.

Editor's note: This section is similar to former § 25-1-903 as it existed prior to 2017.

25.5-1-701. Definitions.

As used in this part 7, unless the context otherwise requires:

1. "Community" means the community that a hospital has defined as the community that it serves pursuant to 26 CFR 1.501(r)-3 (b)(3).
2. "Community benefit implementation plan" means a plan that satisfies the requirements of an implementation strategy, as set forth in 26 CFR 1.501(r)-3 (c).
3. "Community health needs assessment" means a community health needs assessment that satisfies the requirements of 26 CFR 1.501(r)-3.
4. "Community-identified health need" means a health need of a community that is identified in a community health needs assessment.
5. 1. "Reporting hospital" means:
      1. A hospital licensed as a general hospital pursuant to part 1 of article 3 of title 25 and exempt from federal taxation pursuant to section 501 (c)(3) of the federal internal revenue code;
      2. A hospital established pursuant to section 25-29-103; or
      3. A hospital established pursuant to section 23-21-503.
   2. Notwithstanding subsection (5)(a) of this section, "reporting hospital" does not include a hospital that is licensed as a general hospital with the department of public health and environment and that is:
      1. Federally certified or undergoing federal certification as a long-term care hospital pursuant to 42 CFR 412.23 (e); or
      2. Federally certified or undergoing federal certification as a critical access hospital pursuant to 42 CFR 485 subpart F.

Source: L. 2019: Entire part added, (HB 19-1320), ch. 191, p. 2106, § 1, effective August 2.

25.5-1-702. Hospitals - public community meeting requirement.

1. At least once each year, each hospital shall convene a public meeting to seek feedback regarding the hospital's community benefit activities during the previous year and the hospital's community benefit implementation plan for the following year.
2. 1. Each hospital shall invite, at a minimum, representatives from the following entities to participate in the meeting described in subsection (1) of this section, if any such entities operate in the hospital's community:
      1. Local public health agencies;
      2. Local chambers of commerce and economic development organizations;
      3. Local health care consumer organizations;
      4. School districts;
      5. County governments;
      6. City and town governments;
      7. Community health centers;
      8. Certified rural health clinics or primary care clinics located in a county that has been designated by the federal office of management and budget as a rural or frontier county;
      9. Area agencies on aging; and
      10. Health care consumer advocacy organizations.
   2. In addition to the entities described in subsection (2)(a) of this section, each hospital shall invite, at a minimum, representatives from the following state agencies to participate in the meeting described in subsection (1) of this section:
      1. The state department;
      2. The department of public health and environment;
      3. The department of human services;
      4. The Colorado commission on higher education; and
      5. The office of saving people money on healthcare in the lieutenant governor's office.
   3. In addition to the entities described in subsections (2)(a) and (2)(b) of this section, each hospital shall invite the general public to the annual meeting described in subsection (1) of this section. The hospital shall issue such invitation in an advertisement placed in any major newspaper published in the hospital's community.
3. To satisfy the requirements of this section, a hospital may convene a joint public meeting with one or more other hospitals that share some or all of the hospital's community.

Source: L. 2019: Entire part added, (HB 19-1320), ch. 191, p. 2107, § 1, effective August 2.

25.5-1-703. Hospitals - community health needs assessments - community benefit implementation plans - reports - rules.

1. On or before a date to be determined by rules promulgated by the state board, and on or before such date every three years thereafter, each reporting hospital shall complete a community health needs assessment.
2. On or before a date to be determined by rules promulgated by the state board, and on or before such date each year thereafter, each reporting hospital shall complete a community benefit implementation plan that addresses the needs described by the reporting hospital's community health needs assessment.
3. On or before a date to be determined by rules promulgated by the state board, and on or before such date each year thereafter, each reporting hospital shall prepare and submit to the state department a report on certain community benefits, costs, and shortfalls. The report must include:
   1. The reporting hospital's most recent community health needs assessment completed pursuant to subsection (1) of this section;
   2. The reporting hospital's community benefit implementation plan for the coming year completed pursuant to subsection (2) of this section;
   3. A copy of the reporting hospital's most recent form 990 submitted to the federal internal revenue service; and
   4. A description of certain spending and investments made by the reporting hospital during the preceding year, including:
      1. A list of the investments made by the reporting hospital that were included in part I, part II, and part III of schedule H of the reporting hospital's form 990. For each such investment, the reporting hospital shall:
         1. Indicate the cost of the investment;
         2. Indicate whether the investment addressed a community-identified health need;
         3. For any investment that addressed a community-identified health need, identify any of the following categories, which may be further defined by rules promulgated by the state board, that are applicable: Free or discounted health care services, programs that address health behaviors or risks, programs that address the social determinants of health, and such other categories as may be defined in rules promulgated by the state board; and
         4. For any investment that addressed a community-identified health need, describe available evidence that shows how the investment improves community health outcomes.
      2. The reporting hospital's total expenses included in line 18 of section 1 of the form 990 submitted by the reporting hospital or by the reporting hospital's ownership entity; and
      3. The reporting hospital's revenue less expenses included in line 19 of section 1 of the form 990 submitted by the reporting hospital or by the reporting hospital's ownership entity.
4. A reporting hospital that prepares and submits a report pursuant to subsection (3) of this section shall post the report to the reporting hospital's public website.
5. 1. The state board shall promulgate rules establishing reporting requirements for reporting hospitals that are not required to complete schedule H of the form 990. The rules must promote uniformity with the requirements set forth in subsection (3) of this section.
   2. A general hospital that is licensed as a general hospital pursuant to part 1 of article 3 of title 25 and that is not a reporting hospital may submit a report on certain community benefits, costs, and shortfalls that is consistent with this section.
6. To facilitate the submission of the reports described in subsection (3) of this section, the state department shall develop and provide a website at which each reporting hospital shall submit the reports. The state department shall ensure that the website and the reports remain available to the public.
7. As part of the report authorized in section 25.5-4-402.8, the state department shall include a summary of the reports submitted to the state department pursuant to subsection (3) of this section during the preceding year. The summary must include:
   1. The amount that each reporting hospital invested in:
      1. Free or reduced-cost health care services that addressed community-identified health needs;
      2. Programs that addressed health behaviors or risks;
      3. Programs that addressed social determinants of health; and
      4. All services and programs that addressed community-identified health needs;
   2. A summary of the reporting hospitals' investments that have been effective in improving community health outcomes; and
   3. Any legislative recommendations the state department has for the general assembly.
8. The state department shall post the reports completed pursuant to subsection (7) of this section to a public web page that the state department creates for this sole purpose.

Source: L. 2019: Entire part added, (HB 19-1320), ch. 191, p. 2108, § 1, effective August 2.

25.5-2-101. Old age pension health and medical care fund - supplemental old age pension health and medical care fund - cash system of accounting - legislative declaration - rules.

1. (Deleted by amendment, L. 2011, (SB 11-210), ch. 187, p. 719, § 2, effective July 15, 2012.)
2. Any money remaining in the state old age pension fund after full payment of basic minimum awards to qualified old age pension recipients and after establishment and maintenance of the old age pension stabilization fund in the amount of five million dollars shall be transferred to a fund to be known as the old age pension health and medical care fund, which is hereby created. The state board shall establish and promulgate rules for administration of a program to provide health and medical care to persons who qualify to receive old age pensions and who are not patients in an institution for tuberculosis or behavioral or mental health disorders. The costs of such program, not to exceed ten million dollars in any fiscal year, are defrayed from the health and medical care fund, but all money available, accrued or accruing, received or receivable, in said health and medical care fund in excess of ten million dollars in any fiscal year is transferred to the general fund of the state to be used pursuant to law. Money in the old age pension health and medical care fund is subject to annual appropriation by the general assembly.
3. Repealed.
4. The state department shall utilize the cash system of accounting, as enunciated by the governmental accounting standards board, regardless of the source of revenues involved, for all activities of the state department relating to the financial administration of any nonadministrative expenditure for the health and medical care programs described in subsection (2) of this section.

Source: L. 2006: Entire article amended with relocations, p. 1800, § 5, effective July 1. L. 2007: (4) added, p. 465, § 1, effective July 1. L. 2009: (3) amended, (SB 09-261), ch. 201, p. 905, § 1, effective May 1. L. 2010: (3)(b)(III) amended and (3)(b)(IV) and (3)(b)(V) added, (HB 10-1380), ch. 215, p. 932, § 1, effective May 6. L. 2011: (3)(b)(VI) added, (SB 11-164), ch. 33, p. 93, § 5, effective March 18; (3) amended, (SB 11-210), ch. 187, p. 718, § 1, effective July 1; (1) and (4) amended, (SB 11-210), ch. 187, p. 719, § 2, effective July 15, 2012. L. 2017: (2) amended, (SB 17-242), ch. 263, p. 1326, § 197, effective May 25.

25.5-2-102. Health and medical care program - aid to the needy disabled. (Repealed)

Source: L. 2006: Entire article amended with relocations, p. 1801, § 5, effective July 1. L. 2007: Entire section repealed, p. 2043, § 72, effective June 1.

Editor's note: This section was similar to former § 26-2-119.5 as it existed prior to 2006.

ARTICLE 2.5 PRESCRIPTION DRUGS

Section

PART 1 COLORADO CARES RX ACT

PART 2 CANADIAN PRESCRIPTION DRUG IMPORTATION PROGRAM

25.5-2.5-101. Short title.

The short title of this part 1 is the "Colorado Cares Rx Act".

Source: L. 2007: Entire article added, p. 1, § 1, effective February 5. L. 2019: Entire section amended, (SB 19-005), ch. 184, p. 2073, § 4, effective August 2.

Cross references: For the legislative declaration in SB 19-005, see section 1 of chapter 184, Session Laws of Colorado 2019.

25.5-2.5-102. Legislative declaration.

1. The general assembly finds that:
   1. Uninsured, underinsured, and older Coloradans pay a disproportionately greater share of their income for prescription drugs. In many cases, current drug prices have the effect of denying residents access to necessary medical care, thereby threatening their health and safety.
   2. Prescription drugs play an increasingly important role in improving or stabilizing a person's health and in reducing overall health care costs;
   3. Additionally, the new medicare prescription drug benefit restricts persons from purchasing insurance in order to fully cover their prescription drug needs. This restriction on a person's ability to purchase adequate coverage may threaten the person's health and safety.
   4. Currently, there is no limit on the amount that a pharmacy may charge for a generic or nonpatented drug, and, although some retail pharmacies are offering some generic and nonpatented drugs at discounted prices, there are no guarantees that the pharmacies will continue to do so.
2. The general assembly, therefore, declares that it is important to make information available to the public concerning ways to purchase lower-cost generic and nonpatented prescription drugs through the "Colorado Cares Rx Act" in order to protect the health of uninsured, underinsured, and older Coloradans. The general assembly further declares that the state should continue to actively research cost-effective mechanisms or programs that may provide additional options to address this need in Colorado.

Source: L. 2007: Entire article added, p. 1, § 1, effective February 5. L. 2009: Entire section amended, (SB 09-132), ch. 224, p. 1011, § 1, effective May 4.

25.5-2.5-103. Lower-cost prescription drugs - information - research - reporting.

1. The state department shall make information available to the public concerning lower-cost prescription drug programs. The information shall include, but need not be limited to:
   1. Ways in which low-income, uninsured persons can obtain lower-cost prescription drugs; and
   2. Contact information concerning programs for lower-cost prescription drugs.
2. The state department shall research cost-effective programs or mechanisms by which low-income, uninsured persons may purchase lower-cost prescription drugs.
3. The state department shall report annually to the health and human services committees of the house of representatives and the senate, or any successor committees, concerning the provisions of this article.

Source: L. 2007: Entire article added, p. 2, § 1, effective February 5. L. 2009: Entire section R&RE, (SB 09-132), ch. 224, p. 1012, § 2, effective May 4.

25.5-2.5-104. Program - rules - repeal. (Repealed)

Source: L. 2007: Entire article added, p. 2, § 1, effective February 5. L. 2009: Entire section repealed, (SB 09-132), ch. 224, p. 1012, § 3, effective May 4.

25.5-2.5-105. Cash fund. (Repealed)

Source: L. 2007: Entire article added, p. 4, § 1, effective February 5. L. 2009: Entire section repealed, (SB 09-132), ch. 224, p. 1012, § 3, effective May 4.

25.5-2.5-106. Repeal of article. (Repealed)

Source: L. 2007: Entire article added, p. 4, § 1, effective February 5. L. 2009: Entire section repealed, (SB 09-132), ch. 224, p. 1012, § 3, effective May 4.

25.5-2.5-201. Short title.

The short title of this part 2 is the "Dr. Irene Aguilar Canadian Prescription Drug Importation Act".

Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2065, § 3, effective August 2.

25.5-2.5-202. Definitions.

As used in this part 2, unless the context otherwise requires:

1. "Canadian supplier" means a manufacturer, wholesale distributor, or pharmacy that is appropriately licensed or permitted under Canadian federal and provincial laws and regulations to manufacture, distribute, or dispense prescription drugs.
2. "Eligible importer" means an importer that is described in section 25.5-2.5-204 (3).
3. "Federal act" means the "Federal Food, Drug, and Cosmetic Act", 21 U.S.C. sec. 301 et seq.
4. "Medicaid pharmacy" means a pharmacy registered pursuant to section 12-280-119 that has a provider agreement in effect with the state department and is in good standing with the state department.
5. "Pharmacist" means a person who holds an active and unencumbered license to practice pharmacy pursuant to section 12-280-114.
6. "Prescription drug" has the same meaning set forth in section 12-280-103 (42); except that the term includes only drugs that are intended for human use.
7. "Program" means the Canadian prescription drug importation program created in section 25.5-2.5-203.
8. "Vendor" means a vendor with which the state department contracts for the provision of services under the program pursuant to section 25.5-2.5-203 (1).

Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2065, § 3, effective August 2.

25.5-2.5-203. Canadian prescription drug importation program - created - importation process - contract with vendor - vendor duties.

1. The Canadian prescription drug importation program is created in the state department. Upon receiving approval of the program as described in section 25.5-2.5-205 (1), the state department shall contract with one or more vendors to provide services under the program. For three years following August 2, 2019, the selection of any vendor pursuant to this subsection (1) is exempt from the requirements of the procurement code, articles 101 to 112 of title 24.
2. 1. Each vendor, in consultation with the state department and any other vendors, shall establish a wholesale prescription drug importation list that identifies the prescription drugs that have the highest potential for cost savings to the state. In developing the list, each vendor shall consider, at a minimum, which prescription drugs will provide the greatest cost savings to the state, including prescription drugs for which there are shortages, specialty prescription drugs, and high-volume prescription drugs. Each vendor shall revise the list at least annually and at the direction of the state department pursuant to subsection (2)(b) of this section.
   2. The state department shall review the wholesale prescription drug importation list at least every three months to ensure that it continues to meet the requirements of the program. The state department may direct a vendor to revise the list, as necessary.
   3. Each vendor, in consultation with the state department, shall identify Canadian suppliers that are in full compliance with relevant Canadian federal and provincial laws and regulations and that have agreed to export prescription drugs identified on the wholesale prescription drug importation list. Each vendor shall verify that such Canadian suppliers meet all of the requirements of the program and will export prescription drugs at prices that will provide cost savings to the state. Each vendor shall contract with such eligible Canadian suppliers, or facilitate contracts between eligible importers and Canadian suppliers, to import prescription drugs under the program.
   4. Each vendor shall assist the state department in developing and administering a distribution program within the program.
   5. Each vendor shall assist the state department with the annual report described in section 25.5-2.5-206 and provide any information requested by the state department for the report.
   6. Each vendor shall ensure the safety and quality of drugs imported under the program, as follows:
      1. 1. For an initial imported shipment, ensure that each batch of the drug in the shipment is statistically sampled and tested for authenticity and degradation in a manner consistent with the federal act; and
         2. For any subsequent imported shipment, ensure that a statistically valid sample of the shipment is tested for authenticity and degradation in a manner consistent with the federal act;
      2. Certify that each drug:
         1. Is approved for marketing in the United States and is not adulterated or misbranded; and
         2. Meets all of the labeling requirements under 21 U.S.C. sec. 352;
      3. Maintain qualified laboratory records, including complete data derived from all tests necessary to ensure that the drug is in compliance with the requirements of this section; and
      4. Maintain documentation demonstrating that the testing required by this section was conducted at a qualified laboratory in accordance with the federal act and any other applicable federal and state laws and regulations governing laboratory qualifications.
3. All testing required by this section must be conducted in a qualified laboratory that meets the standards under the federal act and any other applicable federal and state laws and regulations governing laboratory qualifications for drug testing.
4. Each vendor shall maintain a list of all eligible importers that participate in the program.
5. Each vendor shall ensure compliance with Title II of the federal "Drug Quality and Security Act", Pub.L. 113-54, by all Canadian suppliers, eligible importers, distributors, and other participants in the program.
6. Each vendor shall provide an annual financial audit of its operations to the state department. Each vendor shall also provide quarterly financial reports specific to the program and shall include information concerning the performance of its subcontractors and vendors. The state department shall determine the format and contents of the reports.
7. Each vendor shall submit evidence of a surety bond with any bid or initial contract negotiation documents and shall maintain documentation of evidence of such a bond with the state department throughout the contract term. The surety bond may be from this state or any other state in the United States and must be in an amount of at least twenty-five thousand dollars. The surety bond or comparable security arrangement must include the state of Colorado as a beneficiary. In lieu of the surety bond, a vendor may provide a comparable security agreement, such as an irrevocable letter of credit or a deposit into a trust account or financial institution that includes the state of Colorado as a beneficiary, payable to the state of Colorado. The purposes of the bond or other security arrangement are to:
   1. Ensure participation of the vendor in any civil or criminal legal action by the state department, any other state agency, or private individuals or entities against the vendor because of the vendor's failure to perform under the contract, including but not limited to causes of actions for personal injury, negligence, and wrongful death;
   2. Ensure payment by the vendor through the use of a bond or other comparable security arrangement of any legal judgments and claims that are awarded to the state, other entities acting on behalf of the state, individuals, or organizations if the vendor is assessed a final judgment or other monetary penalty in a court of law for a civil or criminal action under the program. The bond or comparable security arrangement may be accessed if the vendor fails to pay any judgment or claim within sixty days after final judgment.
   3. Allow for civil and criminal litigation claims to be made against the bond or other comparable security arrangements for up to one year after the vendor's contract under the program has ended with the state department, the vendor's license is no longer valid, or the program has ended, whichever occurs last.
8. Each vendor shall maintain information and documentation submitted under this section for a period of at least seven years.
9. The state department may require each vendor to collect any other information necessary to ensure the protection of the public health.

Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2066, § 3, effective August 2.

25.5-2.5-204. Eligible prescription drugs - eligible Canadian suppliers - eligible importers - distribution requirements.

1. An eligible importer may import a prescription drug from a Canadian supplier if:
   1. The drug that is to be imported meets the federal food and drug administration's standards related to safety, effectiveness, misbranding, and adulteration;
   2. Importing the drug would not violate federal patent laws;
   3. Importing the drug is expected to generate cost savings; and
   4. The drug is not:
      1. A controlled substance as defined in 21 U.S.C. sec. 802 (6);
      2. A biological product as defined in 42 U.S.C. sec. 262 (i);
      3. An infused drug;
      4. An intravenously injected drug;
      5. A drug that is inhaled during surgery; or
      6. A drug that is a parenteral drug, the importation of which is determined by the federal secretary of health and human services to pose a threat to public health.
2. A Canadian supplier may export prescription drugs into the state under the program if the supplier:
   1. Is in full compliance with relevant Canadian federal and provincial laws and regulations;
   2. Is identified by the vendor as eligible to participate in the program pursuant to section 25.5-2.5-203 (2)(c); and
   3. Submits an attestation that the supplier has a registered agent in the United States, which attestation includes the name and United States address of the registered agent.
3. The following entities are eligible importers and may obtain imported prescription drugs:
   1. A pharmacist or wholesaler employed by or under contract with a medicaid pharmacy, for dispensing to the pharmacy's medicaid recipients;
   2. A pharmacist or wholesaler employed by or under contract with the department of corrections, for dispensing to inmates in the custody of the department of corrections;
   3. Commercial plans, as defined by rules promulgated by the state board and as approved by the federal government; and
   4. A licensed Colorado pharmacist or wholesaler approved by the state department.
4. 1. The state department shall designate an office or division that must be a licensed pharmaceutical wholesaler or that shall contract with a licensed pharmaceutical wholesaler licensed pursuant to part 3 of article 280 of title 12.
   2. The office or division designated by the state department pursuant to subsection (4)(a) of this section shall:
      1. Set a maximum profit margin so that a wholesaler, distributor, pharmacy, or other licensed provider participating in the program maintains a profit margin that is no greater than the profit margin that the wholesaler, distributor, pharmacy, or other licensed provider would have earned on the equivalent nonimported drug;
      2. Exclude generic products if the importation of the products would violate United States patent laws applicable to United States-branded products;
      3. Comply with the requirements of 21 U.S.C. sec. 360eee to 360eee-4 as enacted in Title II of the federal "Drug Quality and Security Act"; and
      4. Determine a method for covering the administrative costs of the program, which method may include a fee imposed on each prescription pharmaceutical product sold through the program or any other appropriate method as determined by the state department, but the state department shall not require a fee in an amount the state department determines would significantly reduce consumer savings.
5. Canadian suppliers and eligible importers participating under the program:
   1. Shall comply with the tracking and tracing requirements of 21 U.S.C. sec. 360eee et seq.; and
   2. Shall not distribute, dispense, or sell prescription drugs imported under the program outside of the state.
6. A participating eligible importer shall submit to the vendor all of following information about each drug to be acquired by the importer under the program:
   1. The name and quantity of the active ingredient of the drug;
   2. A description of the dosage form of the drug;
   3. The date on which the drug is received;
   4. The quantity of the drug that is received;
   5. The point of origin and destination of the drug; and
   6. The price paid by the importer for the drug.
7. A participating Canadian supplier shall submit to the vendor the following information about each drug to be supplied by the Canadian supplier under the program:
   1. The original source of the drug, including:
      1. The name of the manufacturer of the drug;
      2. The date on which the drug was manufactured; and
      3. The country, state or province, and city where the drug was manufactured;
   2. The date on which the drug is shipped;
   3. The quantity of the drug that is shipped;
   4. The quantity of each lot of the drug originally received and the source of the lot; and
   5. The lot or control number and the batch number assigned to the drug by the manufacturer.
8. The state department shall immediately suspend the importation of a specific drug or the importation of drugs by a specific eligible importer if it discovers that any drug or activity is in violation of this section or any federal or state law or regulation. The state department may revoke the suspension if, after conducting an investigation, it determines that the public is adequately protected from counterfeit or unsafe drugs being imported into this state.

Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2068, § 3, effective August 2.

25.5-2.5-205. Federal approval.

1. On or before September 1, 2020, the state department shall submit a request to the United States secretary of health and human services for approval of the program under 21 U.S.C. sec. 384. The state department shall begin operating the program not later than six months after receiving such approval. The request must, at a minimum:
   1. Describe the state department's plan for operating the program;
   2. Demonstrate how the prescription drugs imported into the state under the program will meet the applicable federal and state standards for safety, effectiveness, misbranding, and adulteration;
   3. Include a list of prescription drugs that have the highest potential for cost savings to the state through importation at the time that the request is submitted;
   4. Estimate the total cost savings attributable to the program; and
   5. Include a list of potential Canadian suppliers from which the state would import prescription drugs and demonstrate that the suppliers are in full compliance with relevant Canadian federal and provincial laws and regulations.
2. Notwithstanding any provision of this part 2 to the contrary, the state department may expend money for the purpose of requesting approval of the program as described in subsection (1) of this section but the state department shall not spend any other money to implement the program until the state department receives approval of the program as described in said subsection (1).
3. Upon receipt of federal approval of the program, the state department shall notify the president of the senate and the speaker of the house of representatives, as well as the health and human services committee of the senate and the health and insurance committee of the house of representatives, or any successor committees. After approval is received and before the start of the next regular session of the general assembly in which the proposal could be funded, the state department shall submit to all parties specified in this subsection (3) a proposal for program implementation and program funding.

Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2071, § 3, effective August 2.

25.5-2.5-206. Reports.

1. Notwithstanding section 24-1-136 (11)(a)(I), on or before December 1, 2021, and on or before December 1 each year thereafter, the state department shall submit a report to the governor, the president of the senate, and the speaker of the house of representatives concerning the operation of the program during the previous fiscal year. The report must include, at a minimum:
   1. A list of the prescription drugs that were imported under the program;
   2. The number of participating Canadian suppliers and eligible importers;
   3. The number of prescriptions dispensed through the program;
   4. The estimated cost savings during the previous fiscal year and to date;
   5. A description of the methodology used to determine which prescription drugs should be included on the wholesale prescription drug importation list established pursuant to section 25.5-2.5-203 (2)(a); and
   6. Documentation demonstrating how the program ensures that:
      1. The vendor verifies that Canadian suppliers participating in the program are in full compliance with relevant Canadian federal and provincial laws and regulations;
      2. Prescription drugs imported under the program are not shipped, sold, or dispensed outside of the state once in the possession of the eligible importer;
      3. Prescription drugs imported under the program are pure, unadulterated, potent, and safe;
      4. The program does not put consumers at a higher health and safety risk than if the program did not exist; and
      5. The program provides cost savings to the state on imported prescription drugs.

Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2072, § 3, effective August 2.

25.5-2.5-207. Importation program authorized - rules.

1. Upon approval by the secretary, in accordance with section 25.5-2.5-206, the state department shall administer an importation program.
2. The state department shall approve a method of financing the administrative costs of the importation program, which method may include imposing a fee on each prescription pharmaceutical product sold through the importation program or any other appropriate method determined by the state department to finance administrative costs. The state department shall not require a fee in an amount that the state department determines would significantly reduce consumer savings.
3. The executive director shall promulgate rules, in accordance with article 4 of title 24 and section 25.5-1-108, as necessary for the administration of this part 2.

Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2073, § 3, effective August 2.

ARTICLE 3 INDIGENT CARE

Editor's note: This article was added in 2005. This article was amended in 2006, resulting in the relocation of provisions. For the text of this article prior to 2006, consult the 2005 Colorado Revised Statutes. Former C.R.S. section numbers are shown in editor's notes following those sections that were relocated. For a detailed comparison of this article, see the comparative tables located in the back of the index.

Section

PART 1 COLORADO INDIGENT CARE PROGRAM

PART 2 COMPREHENSIVE PRIMARY AND PREVENTIVE CARE GRANT PROGRAM

PART 3 COMPREHENSIVE PRIMARY CARE SERVICES

PART 4 COLORADO DENTAL HEALTH CARE PROGRAM FOR LOW-INCOME SENIORS

25.5-3-101. Short title.

This part 1 shall be known and may be cited as the "Colorado Indigent Care Program".

Source: L. 2006: Entire article amended with relocations, p. 1802, § 6, effective July 1.

Editor's note: This section is similar to former § 26-15-101 as it existed prior to 2006.

25.5-3-102. Legislative declaration.

1. The general assembly hereby determines, finds, and declares that:
   1. The state has insufficient resources to pay for all medical services for persons who are indigent and must therefore allocate available resources in a manner that will provide treatment of those conditions constituting the most serious threats to the health of such medically indigent persons, as well as increase access to primary medical care to prevent deterioration of the health conditions among medically indigent people; and
   2. Such allocation of resources will require the prioritization of medical services by providers and the coordination of administration and delivery of medical services.
2. The general assembly further determines, finds, and declares that the eligibility of medically indigent persons to receive medical services rendered under the conditions specified in subsection (1) of this section exists only to the extent of available appropriations, as well as to the extent of the individual provider facility's physical, staff, and financial capabilities. The general assembly also recognizes that the program for the medically indigent is a partial solution to the health care needs of Colorado's medically indigent citizens. Therefore, medically indigent persons accepting medical services from such program shall be subject to the limitations and requirements imposed in this part 1.

Source: L. 2006: Entire article amended with relocations, p. 1802, § 6, effective July 1.

Editor's note: This section is similar to former § 26-15-102 as it existed prior to 2006.

25.5-3-103. Definitions.

As used in this part 1, unless the context otherwise requires:

1. "Emergency care" means treatment for conditions of an acute, severe nature which are life, limb, or disability threats requiring immediate attention, where any delay in treatment would, in the judgment of the responsible physician, threaten life or loss of function of a patient or viable fetus.
2. "Executive director" means the executive director of the state department.
3. "General provider" means a general hospital, birth center, or community health clinic licensed or certified by the department of public health and environment pursuant to section 25-1.5-103 (1)(a)(I) or (1)(a)(II); a federally qualified health center, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(4); a rural health clinic, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(2); a health maintenance organization issued a certificate of authority pursuant to section 10-16-402; and the health sciences center when acting pursuant to section 25.5-3-108 (5)(a)(I) or (5)(a)(II)(A). For the purposes of the program, "general provider" includes associated physicians.
4. "Health sciences center" means the schools of medicine, dentistry, nursing, and pharmacy established by the regents of the university of Colorado under section 5 of article VIII of the Colorado constitution.
5. "Program" means the program for the medically indigent established by section 25.5-3-104.
6. "University hospital" means the university hospital operated pursuant to article 21 of title 23, C.R.S.

Source: L. 2006: Entire article amended with relocations, p. 1803, § 6, effective July 1. L. 2011: (3) amended, (HB 11-1101), ch. 94, p. 278, § 3, effective April 8; (3) amended, (HB 11-1323), ch. 265, p. 1199, § 3, effective June 2. L. 2020: (3) amended, (SB 20-136), ch. 70, p. 288, § 26, effective September 14.

Editor's note: This section is similar to former § 26-15-103 as it existed prior to 2006.

Cross references: For the legislative declaration in SB 20-136, see section 1 of chapter 70, Session Laws of Colorado 2020.

25.5-3-104. Program for the medically indigent established - eligibility - rules.

1. A program for the medically indigent is hereby established, to commence July 1, 1983, which shall be administered by the state department, to provide payment to providers for the provision of medical services to eligible persons who are medically indigent. The state board may promulgate rules as are necessary for the implementation of this part 1 in accordance with article 4 of title 24, C.R.S.
2. A client's eligibility to receive discounted services under the program for the medically indigent shall be determined by rule of the state board based on a specified percentage of the federal poverty line, adjusted for family size, which percentage shall not be less than two hundred fifty percent.

Source: L. 2006: Entire section amended, p. 1606, § 2, effective June 2; entire article amended with relocations, p. 1803, § 6, effective July 1. L. 2010: (2) amended, (HB 10-1422), ch. 419, p. 2109, § 138, effective August 11.

25.5-3-105. Eligibility of legal immigrants for services.

A legal immigrant who is a resident of the state of Colorado shall be eligible to receive services under this part 1 so long as he or she meets the eligibility requirements. As used in this section, "legal immigrant" has the same meaning as described in section 25.5-4-103 (10). As a condition of eligibility for services under this part 1, a legal immigrant shall agree to refrain from executing an affidavit of support for the purpose of sponsoring an alien on or after July 1, 1997, under rules promulgated by the immigration and naturalization service, or any successor agency, during the pendency of such legal immigrant's receipt of services under this part 1. Nothing in this section shall be construed to affect a legal immigrant's eligibility for services under this part 1 based upon such legal immigrant's responsibilities under an affidavit of support entered into before July 1, 1997.

Source: L. 2006: Entire article amended with relocations, p. 1804, § 6, effective July 1.

Editor's note: This section is similar to former § 26-15-104.3 as it existed prior to 2006.

25.5-3-106. No public funds for abortion - exception - definitions - repeal.

1. It is the purpose of this section to implement the provisions of amendment 3 to article V of the Colorado constitution, adopted by the registered electors of the state of Colorado at the general election November 6, 1984, which prohibits the use of public funds by the state of Colorado or its agencies or political subdivisions to pay or otherwise reimburse, directly or indirectly, any person, agency, or facility for any induced abortion.
2. If every reasonable effort has been made to preserve the lives of a pregnant woman and her unborn child, then public funds may be used pursuant to this section to pay or reimburse for necessary medical services, not otherwise provided for by law.
3. 1. Except as provided in paragraph (b) of this subsection (3), any necessary medical services performed pursuant to this section shall be performed only in a licensed health care facility by a provider who is a licensed physician.
   2. However, such services may be performed in other than a licensed health care facility if, in the medical judgment of the attending physician, the life of the pregnant woman or her unborn child is substantially threatened and a transfer to a licensed health care facility would further endanger the life of the pregnant woman or her unborn child. Such medical services may be performed in other than a licensed health care facility if the medical services are necessitated by a life-endangering circumstance described in subparagraph (II) of paragraph (b) of subsection (6) of this section and if there is no licensed health care facility within a thirty-mile radius of the place where such medical services are performed.
4. 1. Any physician who renders necessary medical services pursuant to subsection (2) of this section shall report the following information to the state department:
      1. The age of the pregnant woman and the gestational age of the unborn child at the time the necessary medical services were performed;
      2. The necessary medical services which were performed;
      3. The medical condition which necessitated the performance of necessary medical services;
      4. The date such necessary medical services were performed and the name of the facility in which such services were performed.
   2. The information required to be reported pursuant to paragraph (a) of this subsection (4) shall be compiled by the state department and such compilation shall be an ongoing public record; except that the privacy of the pregnant woman and the attending physician shall be preserved.
5. For purposes of this section, pregnancy is a medically diagnosable condition.
6. For the purposes of this section:
   1. 1. "Death" means:
         1. The irreversible cessation of circulatory and respiratory functions; or
         2. The irreversible cessation of all functions of the entire brain, including the brain stem.
      2. A determination of death under this section shall be in accordance with accepted medical standards.
   2. "Life-endangering circumstance" means:
      1. The presence of a medical condition, other than a psychiatric condition, as determined by the attending physician, which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term;
      2. The presence of a lethal medical condition in the unborn child, as determined by the attending physician and one other physician, which would result in the impending death of the unborn child during the term of pregnancy or at birth; or
      3. The presence of a psychiatric condition which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term. In such case, unless the pregnant woman has been receiving prolonged psychiatric care, the attending licensed physician shall obtain consultation from a licensed physician specializing in psychiatry confirming the presence of such a psychiatric condition. The attending physician shall report the findings of such consultation to the state department.
   3. "Necessary medical services" means any medical procedures deemed necessary to prevent the death of a pregnant woman or her unborn child due to life-endangering circumstances.
7. If any provision of this section or application thereof is held invalid, such invalidity shall not affect other provisions or applications of this section which can be given effect without the invalid provision or application and, to this end, provisions of this section are declared severable.
8. Use of the term "unborn child" in this section is solely for the purposes of facilitating the implementation of section 50 of article V of the state constitution and its use shall not affect any other law or statute nor shall it create any presumptions relating to the legal status of an unborn child or create or affect any distinction between the legal status of an unborn child and the legal status of a fetus.
9. This section shall be repealed if section 50 of article V of the Colorado constitution is repealed.

Source: L. 2006: Entire article amended with relocations, p. 1804, § 6, effective July 1.

Editor's note: This section is similar to former § 26-15-104.5 as it existed prior to 2006.

Cross references: For the text of "amendment 3 to article V of the Colorado constitution" referenced in subsection (1) of this section, see section 50 of article V of the state constitution.

25.5-3-107. Report concerning the program.

Notwithstanding the provisions of section 24-1-136 (11)(a)(I), the executive director shall prepare an annual report concerning the status of the medically indigent program to be submitted to the health and human services committees of the senate and the house of representatives, or any successor committees, no later than February 1 of each year. The report shall be prepared following consultation with providers in the program, state department personnel, and other agencies, organizations, or individuals as the executive director deems appropriate in order to obtain comprehensive and objective information about the program.

Source: L. 2006: Entire article amended with relocations, p. 1806, § 6, effective July 1. L. 2017: Entire section amended, (HB 17-1060), ch. 6, p. 16, § 6, effective March 1.

Editor's note: This section is similar to former § 26-15-105 as it existed prior to 2006.

25.5-3-108. Responsibility of the department of health care policy and financing - provider reimbursement - repeal.

1. The state department shall be responsible for:
   1. Execution of such contracts with providers for partial reimbursement of costs for medical services rendered to the medically indigent as the state department shall determine are necessary for the program;
   2. Promulgation of such reasonable rules as are necessary for the program;
   3. Submission of the report required in section 25.5-3-107; and
   4. Application for federal financial participation under the program.
2. The contracts required by paragraph (a) of subsection (1) of this section shall be negotiated between the state department and the various general providers, as defined in section 25.5-3-103 (3), and shall include contracts with providers to provide tertiary or specialized services. The state department may award such contracts upon a determination that it would not be cost effective nor result in adequate quality of care for such services to be developed by the contract providers, or upon a determination that the contract providers are unable or unwilling to provide such services.
3. The state department shall establish procedures requiring the provider to provide for proof of indigency to be submitted by the person seeking assistance, but the provider shall be responsible for the determination of eligibility.
4. The state department shall establish procedures so that the providers of medical services rendered to the medically indigent cover geographic regions of the state.
5. 1. The responsibilities of providers who provide medical care through the program for the medically indigent are as follows:
      1. Denver health and hospitals, including associated physicians, shall, up to its physical, staff, and financial capabilities as provided for under this program, be the primary providers of medical services to the medically indigent for the city and county of Denver.
      2. 1. University hospital and the physicians and other faculty members of the health sciences center shall, up to their physical, staff, and financial capabilities as provided for under this program, be the primary provider of medical services to the medically indigent for the Denver primary metropolitan statistical area.
         2. University hospital and the physicians and other faculty members of the health sciences center shall be the primary provider of such complex care as is not available or is not contracted for in the remaining areas of the state up to their physical, staff, and financial capabilities as provided for under this program.
   2. Any two or more providers awarded contracts may, with the approval of the state department, redistribute their respective populations and associated funds.
   3. Every provider who provides medical care through the program for the medically indigent shall comply with all procedures established by the state department.
6. The state department shall establish procedures that allocate funds to providers based on the anticipated utilization of services.
7. A provider receiving reimbursement pursuant to this section shall transfer a medically indigent patient to another provider only with the prior agreement of the provider.
8. 1. Every provider receiving reimbursement pursuant to this section shall prioritize for each fiscal year the medical services which it will be able to render, within the limits of the funds which will be made available by the state department.
   2. Such medical services shall be prioritized in the following order:
      1. Emergency care for the full year;
      2. Any additional medical care for those conditions the state department determines to be the most serious threat to the health of medically indigent persons;
      3. Any other additional medical care.
9. A provider receiving reimbursement pursuant to this section shall not be liable in civil damages for refusing to admit for treatment or for refusing to treat any medically indigent person for a condition which the state department or the provider has determined to be outside of the scope of the program.
10. 1. A medically indigent person who wishes to be determined eligible for assistance under this part 1 shall comply with the eligibility requirements set by the state department.
    2. A medically indigent person requesting assistance under this part 1 specifically authorizes the state department or provider to:
       1. Use any information required by the eligibility requirements set by the state department for the purpose of verifying eligibility; and
       2. Obtain records pertaining to eligibility from a financial institution, as defined in section 15-15-201 (4), C.R.S., or from any insurance company.
    3. A medically indigent person requesting assistance under this part 1 shall be provided language clearly explaining the provisions of this subsection (10).
11. With the approval of the state department, any provider awarded a contract may enter into subcontracts or other agreements for services related to the program.
12. Providers awarded contracts shall not be paid from funds made available for this program up to the extent, if any, of their annual financial obligation under the Hill-Burton act.
13. When adopting or modifying procedures under this part 1, the state department shall notify each provider, who is contracted to provide medical care through the program for the medically indigent, at least thirty days prior to implementation of a new procedure. The state department shall hold a meeting for all providers at least thirty days prior to the implementation of a new procedure.
14. The state department shall require any hospital provider who may receive payment under the program to annually submit data relating to the hospital's number of medicaid-eligible in-patient days and the hospital's total in-patient days in a form specified by the state department. The hospital provider shall verify the data to the state department through the program audit procedures required by the state department. The state department shall include this information by hospital in the department's annual budget request to the joint budget committee of the general assembly and in the report required by section 25.5-3-107.
15. To qualify for the program's payment formula disproportionate share hospital factor, as described in rule by the state board consistent with the provisions of this part 1, a hospital provider's percent of medicaid-eligible in-patient days relative to total in-patient days shall be equal to or exceed one standard deviation above the mean.
16. After receiving approval by the state department, a community health clinic may utilize moneys received pursuant to this article, and any gifts, grants, and donations, for the development and implementation of demonstration projects that may include but need not be limited to coordination of care and disease management.
17. Subject to adequate funding being made available under section 25.5-4-402.4, the Colorado healthcare affordability and sustainability enterprise created in section 25.5-4-402.4 (3) shall increase hospital reimbursements up to one hundred percent of hospital costs for providing medical care under the program.
18. Repealed.
19. 1. Notwithstanding any other provision of law, for the state fiscal years commencing July 1, 2019, and July 1, 2020, if a provider submits a certification of public expenditures pursuant to 42 CFR 433.51 (b), the state department shall retain any federal money payable as reimbursement for the expenditure in excess of fifty percent of the expenditure amount. The state treasurer shall transfer such money to the general fund created in section 24-75-201 for appropriation for the state medical assistance program.
    2. This subsection (19) is repealed, effective December 31, 2021.

Source: L. 2006: (1) amended and (16) added, p. 1606, § 3, effective June 2; entire article amended with relocations, p. 1806, § 6, effective July 1. L. 2009: (18) added, (SB 09-264), ch. 204, p. 928, § 4, effective May 1; (17) added, (HB 09-1293), ch. 152, p. 644, § 3, effective July 1. L. 2017: (17) amended, (SB 17-267), ch. 267, p. 1447, § 13, effective July 1. L. 2020: (19) added, (HB 20-1385), ch. 173, p. 795, § 1, effective June 29.

25.5-3-109. Appropriations.

The general assembly shall make annual appropriations to the state department to accomplish the purposes of this part 1.

Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1.

Editor's note: This section is similar to former § 26-15-110 as it existed prior to 2006.

25.5-3-110. Effect of part 1.

This part 1 shall not affect the department of human services' responsibilities for the provision of mental health care in accordance with article 66 of title 27, C.R.S., and this part 1 shall not affect any provisions of article 22 of title 23, C.R.S., or any other provisions of law relating to the university of Colorado psychiatric hospital.

Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1. L. 2010: Entire section amended, (SB 10-175), ch. 188, p. 800, § 64, effective April 29.

Editor's note: This section is similar to former § 26-15-111 as it existed prior to 2006.

25.5-3-111. Penalties.

Any person who represents that any medical service is reimbursable or subject to payment under this part 1 when he or she knows that it is not and any person who represents that he or she is eligible for assistance under this part 1 when he or she knows that he or she is not commits a class 2 misdemeanor and shall be punished as provided in section 18-1.3-501, C.R.S.

Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1.

Editor's note: This section is similar to former § 26-15-112 as it existed prior to 2006.

25.5-3-112. Health care services fund - creation - state plan amendment - primary care special distribution fund.

1. 1. There is hereby created in the state treasury the Colorado health care services fund, referred to in this section as the "fund". The fund shall consist of moneys credited thereto pursuant to this section.
   2. In fiscal year 2005-06, the general assembly shall appropriate fourteen million nine hundred sixty-two thousand four hundred eight dollars from the general fund to the fund. Of the moneys in the general fund exempt account created in section 24-77-103.6 (2), C.R.S., the following amounts shall be appropriated by the general assembly to the fund:
      1. In fiscal year 2007-08, fifteen million dollars; and
      2. In fiscal year 2008-09, twelve million nine hundred eighteen thousand seven hundred fifty dollars.
      3. (Deleted by amendment, L. 2010, (HB 10-1321), ch. 48, p. 179, § 1, effective March 29, 2010.)
   3. In fiscal year 2009-10, the general assembly shall appropriate ten million three hundred ninety thousand dollars from the general fund to the fund.
   4. In fiscal year 2011-12, the treasurer shall transfer one million dollars from the general fund to the fund.
   5. All moneys appropriated to the fund shall be used as provided in this section and shall not be deposited in or transferred to the general fund of this state or to any other fund. Notwithstanding any provision of section 24-36-114, C.R.S., to the contrary, all interest derived from the deposit and investment of moneys in the fund shall be credited to the fund.

   (1.5) Notwithstanding any provision of subsection (1) of this section to the contrary, on April 20, 2009, the state treasurer shall deduct five hundred thousand dollars from the fund and transfer such sum to the general fund.

2. In fiscal year 2006-07, and each of the two fiscal years thereafter, notwithstanding the requirements of section 25.5-3-108 (8)(b), the moneys deposited into the fund shall be appropriated as follows:
   1. Of the moneys appropriated pursuant to this subsection (2), eighteen percent of the moneys annually appropriated shall be to Denver health and hospitals as the community health clinic provider for the city and county of Denver.
   2. 1. For fiscal year 2006-07, eighty-two percent of the moneys remaining after the appropriation pursuant to paragraph (a) of this subsection (2) shall be appropriated to community health clinics to provide primary care services pursuant to this article.
      2. For fiscal year 2006-07, eighteen percent of the moneys remaining after the appropriation pursuant to paragraph (a) of this subsection (2) shall be appropriated to primary care clinics operated by a licensed or certified health care facility to provide primary care services pursuant to this article.
      3. For fiscal years 2007-08 and 2008-09, the allocation of the moneys remaining after the appropriation pursuant to paragraph (a) of this subsection (2) shall be determined based on prior utilization as specified in rule by the state board.

   (2.5) In fiscal year 2009-10, notwithstanding the requirements of section 25.5-3-108 (8)(b), the moneys deposited into the fund shall be appropriated as follows:

   1. Twenty percent of the moneys shall be appropriated to the state department for distribution to Denver health and hospitals as the community health clinic provider for the city and county of Denver;
   2. Eighty percent of the moneys shall be appropriated to the state department for distribution to community health clinics based upon prior utilizations as determined by the state department to mitigate reductions the clinics experience due to reductions in moneys available from the primary care fund created pursuant to section 24-22-117 (2)(b), C.R.S.

   (2.7) In the 2010-11 fiscal year, notwithstanding the requirements of section 25.5-3-108 (8)(b), the moneys deposited into the fund shall be appropriated to the state department for distribution to Denver health and hospitals, as the community health clinic for the city and county of Denver, and to community health clinics. The state department shall develop a distribution formula specifying the distributions based upon prior utilizations and, to the extent possible, mitigation of the reductions in funding that the clinics experience due to reductions in moneys available from the primary care fund established pursuant to section 24-22-117 (2)(b), C.R.S.

   (2.8) In the 2011-12 fiscal year, notwithstanding the requirements of section 25.5-3-108 (8)(b), the moneys deposited into the fund shall be appropriated to the state department for distribution to Denver health and hospitals, as the community health clinic for the city and county of Denver, to community health clinics, and to federally qualified health centers. The state department shall develop a distribution formula specifying the distributions based upon prior utilizations and, to the extent possible, mitigation of the reductions in funding that the clinics experience due to reductions in moneys available from the primary care fund established pursuant to section 24-22-117 (2)(b), C.R.S.

3. 1. The state department shall submit a state plan amendment for federal financial participation for moneys appropriated to primary care clinics operated by a licensed or certified health care facility. Upon approval of the state plan amendment, the state department is authorized to receive and expend all available federal moneys without a corresponding reduction in spending authority from the fund.
   2. To the extent possible under federal law, the state department shall pursue available federal financial participation for moneys appropriated to community health clinics.
4. Repealed.

Source: L. 2006: Entire section added, p. 1606, § 4, effective June 2. L. 2007: (2) and (3) amended, p. 559, § 1, effective April 16; (2)(b)(III) amended, p. 2043, § 73, effective June 1. L. 2008: (3)(a) amended, p. 276, § 6, effective March 31. L. 2009: (1.5) added , (SB 09-208), ch. 149, p. 627, § 31, effective April 20; (1)(b) amended, (SB 09-264), ch. 204, p. 928, § 5, effective May 1. L. 2010: (1)(b), IP(2), and (2)(b)(III) amended and (1)(b.5), (2.5), and (4) added, (HB 10-1321), ch. 48, p. 179, §§ 1, 2, effective March 29; (4) amended and (2.7) added, (HB 10-1378), ch. 213, p. 927, § 3, effective May 27. L. 2011: (1)(b.6) and (2.8) added and (4) amended, (SB 11-219), ch. 188, p. 725, §§ 3, 4, 5, effective June 3.

25.5-3-201. Short title. (Repealed)

Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1. L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.

25.5-3-202. Legislative declaration. (Repealed)

Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1. L. 2010: (3) amended, (HB 10-1422), ch. 419, p. 2109, § 139, effective August 11. L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.

25.5-3-203. Definitions. (Repealed)

Source: L. 2006: Entire article amended with relocations, p. 1810, § 6, effective July 1. L. 2010: (7)(a) amended, (HB 10-1422), ch. 419, p. 2109, § 140, effective August 11. L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.

25.5-3-204. Comprehensive primary and preventive care grant program - creation. (Repealed)

Source: L. 2006: Entire article amended with relocations, p. 1811, § 6, effective July 1. L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.

25.5-3-205. Grant-making process. (Repealed)

Source: L. 2006: Entire article amended with relocations, p. 1811, § 6, effective July 1. L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.

25.5-3-206. Reports. (Repealed)

Source: L. 2006: Entire article amended with relocations, p. 1812, § 6, effective July 1. L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.

25.5-3-207. Program funding - comprehensive primary and preventive care fund - creation - repeal. (Repealed)

Source: L. 2006: (1) and (3) amended, p. 1039, § 9, effective May 25; entire article amended with relocations, p. 1813, § 6, effective July 1. L. 2007: (4) added, p. 149, § 9, effective March 22. L. 2008: (4)(b) amended, p. 276, § 7, effective March 31. L. 2009: (3) amended, (SB 09-269), ch. 333, p. 1768, § 8, effective June 1. L. 2010: (4)(c) added, (HB 10-1323), ch. 35, p. 131, § 4, effective March 22. L. 2011: Entire section amended, (SB 11-216), ch. 149, p. 520, § 5, effective May 5.

Editor's note: Subsection (5) provided for the repeal of this section, effective September 15, 2011. (See L. 2011, p. 520 .)

25.5-3-301. Definitions.

As used in this part 3, unless the context otherwise requires:

1. "Comprehensive primary care" means the basic, entry-level health care provided by health care practitioners or non-physician health care practitioners that is generally provided in an outpatient setting. "Comprehensive primary care", at a minimum, includes providing or arranging for the provision of the following services on a year-round basis: Primary health care; maternity care, including prenatal care; preventive, developmental, and diagnostic services for infants and children; adult preventive services; diagnostic laboratory and radiology services; emergency care for minor trauma; pharmaceutical services; and coordination and follow-up for hospital care. "Comprehensive primary care" may also include optional services based on a patient's needs. For the purposes of this subsection (1) and subsection (2) of this section, "arranging for the provision" means demonstrating established referral relationships with health care providers for any of the comprehensive primary care services not directly provided by an entity. An entity in a rural area may be exempt from this requirement if it can demonstrate that there are no providers in the community to provide one or more of the comprehensive primary care services.
2. "Qualified provider" means an entity that provides comprehensive primary care services and that:
   1. Accepts all patients regardless of their ability to pay and uses a sliding fee schedule for payments or that provides comprehensive primary care services free of charge;
   2. Serves a designated medically underserved area or population, as provided in section 330(b) of the federal "Public Health Service Act", 42 U.S.C. sec. 254b, or demonstrates to the state department that the entity serves a population or area that lacks adequate health care services for low-income, uninsured persons;
   3. Has a demonstrated track record of providing cost-effective care;
   4. Provides or arranges for the provision of comprehensive primary care services to persons of all ages; and
   5. Completes initial screening for eligibility for the state medical assistance program, the children's basic health plan, and any other relevant government health care program and referral to the appropriate agency for eligibility determination.
3. "Uninsured or medically indigent patient" means a patient receiving services from a qualified provider:
   1. Whose yearly family income is below two hundred percent of the federal poverty line; and
   2. Who is not eligible for medicaid, medicare, or any other type of governmental reimbursement for health care costs; and
   3. Who is not receiving third-party payments.

Source: L. 2012: Entire part RC&RE, (HB 12-1203), ch. 5, p. 15, § 1, effective March 1.

25.5-3-302. Annual allocation - primary care services - qualified provider - rules.

1. The state department shall annually allocate the moneys appropriated by the general assembly to the primary care fund created in section 24-22-117 (2)(b), C.R.S., to all eligible qualified providers in the state who comply with the requirements of subsection (2) of this section. The state department shall allocate the moneys in amounts proportionate to the number of uninsured or medically indigent patients served by the qualified provider. For a qualified provider to be eligible for an allocation pursuant to this section, the qualified provider shall meet either of the following criteria:
   1. The qualified provider is a community health center, as defined in section 330 of the federal "Public Health Service Act", 42 U.S.C. sec. 254b; or
   2. At least fifty percent of the patients served by the qualified provider are uninsured or medically indigent patients, or patients who are enrolled in the medical assistance program, articles 4, 5, and 6 of this title, or the children's basic health plan, article 8 of this title, or any combination thereof.
2. A qualified provider shall annually submit to the state department information sufficient to establish the provider's eligibility status. A qualified provider, except for a provider specified in paragraph (a) of subsection (1) of this section, shall provide an annual report that includes the total number of patients served, the number of uninsured or medically indigent patients served, and the number of patients served who are enrolled in the medical assistance program, articles 4, 5, and 6 of this title, or the children's basic health plan, article 8 of this title. A community health center specified in paragraph (a) of subsection (1) of this section shall annually provide to the state department the number of uninsured or medically indigent patients served. Each eligible qualified provider shall annually develop and submit to the state department documentation regarding the quality assurance program in place at the provider's facility to ensure that quality comprehensive primary care services are being provided. All qualified providers shall submit to the state department the information required under this section, as specified in rule by the state board. The data regarding the number of patients served shall be verified by an outside entity. For purposes of this part 3, the number of patients served is the number of unduplicated users of health care services and is not the number of visits by a patient.
3. The state department shall make annual direct allocations of the total amount of money annually appropriated by the general assembly to the primary care fund pursuant to section 24-22-117 (2)(b), C.R.S., minus three percent for the administrative costs of the program, to all eligible qualified providers. An eligible qualified provider's allocation shall be based on the number of uninsured or medically indigent patients served by the provider in proportion to the total number of uninsured or medically indigent patients served by all eligible qualified providers in the previous calendar year. The state department shall establish a schedule for allocating the moneys in the primary care fund for eligible qualified providers. The disbursement of moneys in the primary care fund to eligible qualified providers under this part 3 are exempt from the provisions of the "Procurement Code", articles 101 to 112 of title 24, C.R.S.
4. The state board shall adopt any rules necessary for the administration and implementation of this part 3.

Source: L. 2012: Entire part RC&RE, (HB 12-1203), ch. 5, p. 16, § 1, effective March 1.

25.5-3-303. Consultation.

At least annually, the state department shall consult with representatives of federally qualified health centers, school-based health centers, family residency directors, certified rural health clinics, other qualified providers, and consumer advocates regarding the implementation and administration of the allocation of moneys to qualified providers under this part 3.

Source: L. 2012: Entire part RC&RE, (HB 12-1203), ch. 5, p. 17, § 1, effective March 1.

Cross references: For the definition of "federally qualified health centers" in the federal "Social Security Act", see 42 U.S.C. sec. 1395x.

25.5-3-401. Short title.

This part 4 is known as and may be cited as the "Colorado Dental Health Care Program for Low-income Seniors".

Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1358, § 1, effective May 31.

25.5-3-402. Legislative declaration.

1. The general assembly hereby finds and declares that:
   1. The purpose of this part 4 is to promote the health and welfare of Colorado low-income seniors by providing access to patient-centered dental care and services to individuals sixty years of age or older whose income and resources are insufficient to meet the costs of such care and thereby support individuals and families to live independently with a good quality of life;
   2. By relocating and reorganizing the "Colorado Dental Care Act of 1977", which provided dental services to certain eligible seniors, the state department can align those dental health care services with adult dental benefits provided through other dental health care programs for seniors and thereby target the resources effectively to low-income seniors who may not qualify for those programs;
   3. The state department shall implement this part 4 through collaboration among various executive departments, agencies, and political subdivisions of the state; private individuals; and organizations, including but not limited to:
      1. The local area agencies on aging;
      2. Community health centers;
      3. Safety-net clinics;
      4. Private practice dental providers; and
      5. Foundations; and
   4. The state department shall implement this part 4 as a grant program throughout all geographic regions of the state using best practices and experience from other grant programs operated by the state department to provide maximum flexibility to safety-net and private-practice dental providers in order to promote the health and welfare of low-income seniors.

Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1358, § 1, effective May 31.

25.5-3-403. Definitions.

As used in this part 4, unless the context otherwise requires:

1. "Advisory committee" means the senior dental advisory committee created in section 25.5-3-406.
2. "Covered dental care services" are to be defined by rules of the medical services board pursuant to section 25.5-3-404 and include but are not limited to diagnostic, preventive, and restorative care.
3. "Dental health care services grant" means a grant awarded to a qualified grantee pursuant to section 25.5-3-404.
4. "Eligible senior" means an adult who is sixty years of age or older and who is economically disadvantaged as specified by rule of the medical services board.
5. "Program" means the Colorado dental health care program for low-income seniors created pursuant to section 25.5-3-404.
6. "Qualified grantee" means an entity that can demonstrate that it can provide or arrange for the provision of comprehensive dental and oral care services and may include but is not limited to:
   1. An area agency on aging, as defined in section 26-11-203, C.R.S.;
   2. A community-based organization or foundation;
   3. A federally qualified health center, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(4); safety-net clinic; or health district;
   4. A local public health agency; or
   5. A private dental practice.
7. "Qualified provider" means any person who is licensed to practice dentistry in Colorado or who employs a dentist licensed in Colorado and who is willing to accept reimbursement for covered dental services pursuant to this program.

Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1359, § 1, effective May 31. L. 2020: (6)(c) amended, (SB 20-136), ch. 70, p. 289, § 27, effective September 14.

Cross references: For the legislative declaration in SB 20-136, see section 1 of chapter 70, Session Laws of Colorado 2020.

25.5-3-404. Colorado dental health care program for low-income seniors - rules.

1. 1. There is created in the state department the Colorado dental health care program for low-income seniors to provide covered dental care services for eligible seniors who are not eligible for dental services under medicaid, the old age pension health and medical care program, or private insurance.
   2. To ensure the continuity of dental health care to low-income seniors, the state department and the department of public health and environment shall ensure that any individual who meets, on June 30, 2014, the eligibility requirements for dental services under the "Colorado Dental Care Act of 1977", article 21 of title 25, C.R.S., prior to its repeal, remains eligible for dental services after June 30, 2014, through the "Colorado Dental Care Act of 1977", medicaid, the old age pension health and medical care fund, or the program.
2. The state department shall:
   1. In consultation with the advisory committee, review the operation and effectiveness of the program and develop a grant application under the program consistent with rules of the medical services board;
   2. Accept applications for dental health care services grants from any qualified grantee;
   3. On and after July 1, 2015, award dental health care services grants to qualified grantees to provide covered dental care services to eligible seniors;
   4. Pay dental health care services grants within thirty days after approval by the state department;
   5. Ensure that all eligible seniors have access to services through the program; and
   6. Consider geographic distribution of funds among urban and rural areas in the state when making funding decisions.
3. 1. Qualified grantees shall:
      1. Submit an application for a dental health care services grant to the state department on the form developed by the state department;
      2. Provide outreach to targeted eligible seniors and dental care providers;
      3. Identify eligible seniors and qualified providers;
      4. Demonstrate collaboration with community organizations;
      5. Ensure that eligible seniors receive covered dental care services efficiently without duplication of services;
      6. Maintain records of eligible seniors served, dental care services provided, and moneys spent for a minimum of six years; and
      7. Distribute grant funds to qualified providers in their service area or directly provide covered dental care services to eligible seniors in their service area.
   2. A qualified grantee may expend no more than seven percent of the amount of its grant for administrative purposes.
   3. A qualified grantee may also be a qualified provider if the person meets the qualifications of a qualified provider.
4. Following recommendations of the state department and the advisory committee, the medical services board shall adopt rules pursuant to section 24-4-103, C.R.S., governing the program, including but not limited to:
   1. A definition of "economically disadvantaged" for purposes of eligibility;
   2. A description of dental services that may be provided to eligible seniors under the program; except that such services must include but not be limited to oral examination, diagnosis, treatment planning, emergency treatment, prophylaxis, X rays, partial and full dentures, replacement or repair of permanent teeth, removal of permanent teeth, fillings, periodontal treatment, and soft tissue treatment;
   3. Whether to require eligible seniors to make a co-payment and, if so, the circumstances and amount of the co-payment;
   4. A distribution formula for the availability of moneys to each area of the state; and
   5. Procedures, criteria, and standards for awarding dental health care services grants.

Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1360, § 1, effective May 31. L. 2019: (2)(a) amended, (HB 19-1326), ch. 172, p. 2000, § 1, effective May 14.

25.5-3-405. Program reporting.

1. On or before September 1, 2015, and each September 1 thereafter, each qualified grantee receiving a dental health care services grant shall report to the state department concerning the number of eligible seniors served, the types of dental and oral health services provided, recommendations regarding the operation and effectiveness of the program, and any other information deemed relevant by the state department.
2. 1. Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or before November 1, 2016, and each November 1 thereafter, the state department shall submit a report to the joint budget committee of the general assembly and to the health and human services committee of the senate and the public health care and human services committee of the house of representatives, or any successor committees, on the operation and effectiveness of the program, including an itemization of the department's administrative expenditures in implementing and administering the program and any recommendations for legislative changes to the program.
   2. Repealed.

Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1362, § 1, effective May 31. L. 2017: (2) amended, (HB 17-1060), ch. 6, p. 16, § 7, effective March 1. L. 2019: Entire section amended, (HB 19-1326), ch. 172, p. 2000, § 2, effective May 14.

Editor's note: Subsection (2)(b)(II) provided for the repeal of subsection (2)(b), effective January 1, 2020. (See L. 2019, p. 2000 .)

25.5-3-406. Senior dental advisory committee - creation - duties - repeal.

1. 1. There is created in the state department a senior dental advisory committee comprised of eleven members appointed by the executive director as follows:
      1. A member representing the state department;
      2. A dentist in private practice providing dental care to the senior population who represents a statewide organization of dentists;
      3. A dental hygienist providing dental care to seniors;
      4. A representative of either an agency that coordinates services for low-income seniors or the office in the department of human services responsible for overseeing services to the elderly;
      5. A representative of an organization of Colorado community health centers, as defined in the federal "Public Health Service Act", 42 U.S.C. sec. 254b;
      6. A representative of an organization of safety-net health providers that are not community health centers;
      7. A representative of the university of Colorado school of dental medicine;
      8. Two consumer advocates;
      9. A senior who is eligible for services under the program; and
      10. A representative of a foundation with experience in making dental care grants.
   2. Members of the committee shall serve three-year terms. Of the members initially appointed to the advisory committee, the executive director shall appoint six for two-year terms and five for three-year terms. In the event of a vacancy on the advisory committee, the executive director shall appoint a successor to fill the unexpired portion of the term of such member.
   3. 1. The executive director shall designate a member to serve as the chair of the advisory committee. The advisory committee shall meet as necessary at the call of the chair.
      2. Members of the advisory committee serve without compensation or reimbursement of expenses.
      3. Pursuant to section 24-18-108.5, C.R.S., a member of the advisory committee shall not perform an official act that may have a direct economic benefit on a business or other undertaking in which the member has a direct or substantial financial interest.
   4. Repealed.
   5. The state department shall provide staff assistance to the advisory committee.
2. The advisory committee shall:
   1. Advise the state department on the operation of the program;
   2. Make recommendations to the medical services board regarding rules to be promulgated pursuant to section 25.5-3-404, including but not limited to:
      1. Defining covered dental care services;
      2. Whether to require eligible seniors to make a co-payment and, if so, the circumstances and amount of the co-payment;
      3. The distribution formula for the availability of funds to each area of the state;
      4. Dental health care services grant procedures, criteria, and standards, including preference for qualified grantees who demonstrate collaboration with community organizations such as a local area agency on aging; and
      5. A maximum amount per procedure that can be spent by qualified grantees and qualified providers that must not be less than the reimbursement schedule for fee-for-service dental fees under the medical assistance program established in articles 4, 5, and 6 of this title 25.5.
3. 1. This section is repealed, effective September 1, 2024.
   2. Prior to said repeal, the advisory committee must be reviewed as provided for in section 2-3-1203, C.R.S.

Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1362, § 1, effective May 31. L. 2016: IP(2)(b) amended, (SB 16-189), ch. 210, p. 773, § 66, effective June 6. L. 2019: (2)(b)(V) amended, (HB 19-1326), ch. 172, p. 2001, § 3, effective May 14.

Editor's note: Subsection (1)(d)(II) provided for the repeal of subsection (1)(d), effective July 1, 2016. (See L. 2014, p. 1362 .)

ARTICLE 4 COLORADO MEDICAL ASSISTANCE ACT - GENERAL MEDICAL ASSISTANCE

Editor's note: This article was added with relocations in 2006 containing provisions of some sections formerly located in article 4 of title 26 or in article 1 of this title. Former C.R.S. section numbers are shown in editor's notes following those sections that were relocated. For a detailed comparison of this article, see the comparative tables located in the back of the index.

Section

PART 1 GENERAL PROVISIONS

PART 2 ADMINISTRATION

PART 3 RECOVERY

PART 4 PROVIDERS - REIMBURSEMENT

PART 5 STATE PLAN AMENDMENTS - WAIVER AUTHORITY

25.5-4-101. Short title.

This article and articles 5 and 6 of this title shall be known and may be cited as the "Colorado Medical Assistance Act".

Source: L. 2006: Entire article added with relocations, p. 1815, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-101 as it existed prior to 2006.

25.5-4-102. Legislative declaration.

It is the purpose of the "Colorado Medical Assistance Act" to promote the public health and welfare of the people of Colorado by providing, in cooperation with the federal government, medical and remedial care and services for individuals and families whose income and resources are insufficient to meet the costs of such necessary services and to assist such individuals and families to attain or retain their capabilities for independence and self-care, as contemplated by the provisions of Title XIX of the social security act. The state of Colorado and its various departments, agencies, and political subdivisions are authorized to promote and achieve these ends by any appropriate lawful means, through cooperation with and the utilization of available resources of the federal government and private individuals and organizations.

Source: L. 2006: Entire article added with relocations, p. 1815, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-102 as it existed prior to 2006.

25.5-4-103. Definitions.

As used in this article 4 and articles 5 and 6 of this title 25.5, unless the context otherwise requires:

1. Repealed.

   (1.5) "Accountable care collaborative" means a medicaid care delivery system established pursuant to section 25.5-5-419.

2. "Applicant" means an individual who is seeking an eligibility determination for himself or herself under this article and articles 5 and 6 of this title through an application submission or a transfer from another agency or insurance affordability program.
3. "Case management services" means services provided by community-centered boards, as defined by section 25.5-10-202, and community mental health centers and community mental health clinics, as defined by section 27-66-101, to assist persons with intellectual and developmental disabilities, as defined by section 25.5-10-202, and persons with mental health disorders, as defined by section 27-65-102 (11.5), by case management agencies, as defined in section 25.5-6-303 (5), providing case management services, as defined in sections 25.5-6-104 (2)(b) and 25.5-6-303 (6), to persons with a disability, persons who are elderly or blind, and long-term care clients, in gaining access to needed medical, social, educational, and other services.
4. "Categorically needy" means those persons who are eligible for medical assistance under this article and articles 5 and 6 of this title due to their eligibility for one or more of the federal categories of public assistance. A person may be categorically needy and eligible for medical assistance under mandatory provisions as provided under section 25.5-5-101 or may be categorically needy under optional provisions as provided under section 25.5-5-201.
5. "Clinic services" means those services as defined in section 25.5-5-301.

   (5.5) "Dementia diseases and related disabilities" has the same meaning set forth in section 25-1-502 (2.5).

6. "Essential person" means a person who meets the requirements of section 26-2-103 (5), C.R.S.
7. "Home health services" is synonymous with "home health care" and includes the following services provided to an eligible person through a certified home health agency, pursuant to a home health plan of care:
   1. Nursing services;
   2. Home health aide services;
   3. Provision of medical supplies, equipment, and appliances suitable for use in the home;
   4. Physical therapy, occupational therapy, or speech and hearing therapy.
8. "Hospice care" means services provided by a public agency or private organization, or any subdivision thereof, which entity shall be known as a hospice and shall be primarily engaged in providing care to an individual for whom a certified medical prognosis has been made indicating a life expectancy of six months or less and who has elected to receive such care in lieu of other medical benefits available under this article and articles 5 and 6 of this title.
9. "Intermediate nursing facility for persons with intellectual and developmental disabilities" means a tax-supported, state-administered intermediate nursing facility, or a distinct part of such facility, which meets the state nursing home licensing standards set forth in section 25-1.5-103 (1)(a)(I), C.R.S., and the requirements in 42 U.S.C. sec. 1396d and which:
   1. Is maintained primarily to provide health-related care on a regular basis for persons with intellectual and developmental disabilities, as defined in section 27-10.5-102 (11), C.R.S., and section 25.5-10-202, C.R.S., who do not require the degree of services and supports that a hospital or skilled nursing facility can provide but who, because of their mental or physical condition, require care and services above the level of room and board, which can be made available only through institutional facilities; and
   2. May provide care which includes but is not limited to moderate assistance or therapy functions; occasional direction, supervision, or therapy; moderate assistance or therapy for loss of mobility; routine, nonskilled nursing services; and monitoring of the drug regimen.
10. "Legal immigrant" means an individual who is not a citizen or national of the United States and who was lawfully admitted to the United States by the immigration and naturalization service, or any successor agency, as an actual or prospective permanent resident or whose extended physical presence in the United States is known to and allowed by the immigration and naturalization service, or any successor agency.
11. "Liable" or "liability" means the legal liability of a third party, either by reason of judgment, settlement, compromise, or contract, as the result of negligent acts or other wrongful acts or otherwise for all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or recipient of medical assistance.
12. "Managed care system" means a health care system organized to manage costs, utilization, and quality. The statewide managed care system provides for the delivery of health benefits and additional services through contracted arrangements between state medicaid agencies and MCEs.
13. "Medical assistance" means payment on behalf of recipients eligible for and enrolled in the program established in articles 4, 5, and 6 of this title, which is funded through Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396u-1, to enrolled providers under the state medical assistance program of medical care, services, goods, and devices rendered or provided to recipients under this article and articles 5 and 6 of this title, and other related payments, pursuant to this article and articles 5 and 6 of this title and the rules of the state department.

    (13.5) "Modified adjusted gross income" or "MAGI" means an amount of income, as determined pursuant to section 1902 (e)(14) of the federal "Social Security Act", that is used to establish eligibility for medical assistance.

14. "Nursing facility" means a facility, or a distinct part of a facility, that meets the state nursing home licensing standards in section 25-1.5-103 (1)(a)(I), is maintained primarily for the care and treatment of inpatients under the direction of a physician, and meets the requirements in 42 U.S.C. sec. 1396r for certification as a qualified provider of nursing facility services. The patients in such a facility require supportive, therapeutic, or compensating services and the availability of a licensed nurse for observation or treatment on a twenty-four-hour basis. Nursing care may include terminal care; extensive assistance or therapy in the activities of daily living; continual direction, supervision, or therapy; extensive assistance or therapy for loss of mobility; nursing assessment and services that involve assessment of the total needs of the patient, planning of patient care, and observing, monitoring, and recording the patient's response to treatment; and monitoring, observing, and evaluating the drug regimen. "Nursing facility" includes private, nonprofit, or proprietary intermediate nursing facilities for persons with intellectual and developmental disabilities.
15. "Overpayment" means the amount paid by an agency administering the medical assistance program to an enrolled provider under the state medical assistance program participating in the program, which amount is in excess of the amount that is allowable for services furnished and which is required by Title XIX of the social security act to be refunded to the appropriate medicaid agencies.
16. "Patient personal needs trust fund" means any fund or account established by the nursing care facility or intermediate care facility or its agents, employees, or designees to manage the personal needs funds of the facility's patients.
17. "Personal needs funds" means moneys received by any person admitted to a nursing care facility or intermediate care facility, which moneys are received by said person to purchase necessary clothing, incidentals, or other personal needs items which are not reimbursed by any federal or state program, or items of value, which moneys or items of value are in any way surrendered to the management or control of said facility, its agents, employees, or designees.
18. "Pilot program", as used in section 25.5-5-319, means the family planning pilot program established in section 25.5-5-319, which is carried out by all medicaid providers who provide family planning services and which shall be repealed, effective July 1 five years after the issuance of the federal waiver or July 1 in the year in which the waiver is terminated, whichever occurs first.
19. 1. "Provider" means any person, public or private institution, agency, or business concern providing medical care, services, or goods authorized under this article and articles 5 and 6 of this title and holding, where applicable, a current valid license or certificate to provide such services or to dispense such goods and enrolled under the state medical assistance program. These services must be provided and goods must be dispensed only if performed, referred, or ordered by a doctor of medicine or a doctor of osteopathy. Services of dentists, podiatrists, and optometrists or services provided by a school district under section 25.5-5-318 need not be referred or ordered by a doctor of medicine or a doctor of osteopathy.
    2. "Provider" includes a laboratory certified under the federal "Clinical Laboratories Improvement Act of 1967", as amended, 42 U.S.C. sec. 263a, to perform high complexity testing.

    (19.5) "Psychiatric residential treatment facility" means a facility that is licensed as a residential child care facility, as defined in section 26-6-102 (33), that is not a hospital, and that provides inpatient psychiatric services for individuals who are less than twenty-one years of age under the direction of a physician licensed pursuant to article 240 of title 12, and that meets any other requirement established in rule by the state board.

20. "Qualified alien" shall have the meaning ascribed to that term in section 431 (b) of the federal "Personal Responsibility and Work Opportunity Reconciliation Act of 1996", Public Law 104-193, as amended.
21. "Recipient" means any person who has been determined eligible to receive benefits under this article and articles 5 and 6 of this title, whose need for medical care has been professionally established, and for whose care less than full payment is available through the legal obligation of a contractor, public or private, to pay for or provide such care.
22. "Recovery" or "amount recovered" means the amount payable to the applicant or recipient or his heirs, assigns, or legal representatives as the result of any liability of a third party.
23. "Rehabilitative services" means any medical or remedial services recommended by a physician which may reduce physical or mental disability and which may improve functional level.
24. "Resident" means any individual who is living, other than temporarily, within the state. "Resident" includes any unemancipated child whose parent, or other person entitled to custody, lives within the state. The state board shall adopt rules for making this determination. Temporary absences from the state shall not cause an individual to lose his status as a resident of this state.
25. "Social security act" means the federal "Social Security Act" and amendments thereto.

    (25.5) "State university teaching hospital" means a hospital licensed or certified pursuant to section 25-1.5-103 (1)(a), C.R.S.:

    1. That provides supervised teaching experiences to graduate medical school interns and residents enrolled in a state institution of higher education as defined in section 23-18-102 (10), C.R.S.; and
    2. In which more than fifty percent of its credentialed physicians are members of the faculty at a state institution of higher education as defined in section 23-18-102 (10), C.R.S.
26. "Third party" means an individual, institution, corporation, or public or private agency which is or may be liable to pay all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or recipient of medical assistance.
27. "Title XIX" means Title XIX of the social security act, as amended, administered by the federal department of health and human services, or any successor agency, and includes amendments thereto and other federal social security laws replacing said title, in whole or in part.
28. "Transitional medicaid" means the medical assistance provided to recipients eligible pursuant to section 25.5-5-101 (1)(b).

Source: L. 2006: (19.5) added, p. 1202, § 1, effective May 26; entire article added with relocations, p. 1815, § 7, effective July 1; (3) amended, p. 1389, § 18, effective August 7. L. 2007: (19.5) amended, p. 2043, § 74, effective June 1. L. 2008: (25.5) added, p. 1184, § 2, effective May 22. L. 2010: (3) amended, (SB 10-175), ch. 188, p. 800, § 65, effective April 29. L. 2011: (10) amended, (HB 11-1303), ch. 264, p. 1168, § 65, effective August 10. L. 2013: (3), IP(9), and (9)(a) amended, (HB 13-1314), ch. 323, p. 1808, § 44, effective March 1. L. 2014: (1) repealed, (2) amended, and (13.5) added, (SB 14-067), ch. 12, p. 109, § 1, effective February 27. L. 2016: (19.5) amended, (SB 16-189), ch. 210, p. 773, § 67, effective June 6. L. 2017: IP(1) and (14) amended, (HB 17-1046), ch. 50, p. 159, § 13, effective March 16; IP amended and (1.5) added, (HB 17-1353), ch. 231, p. 895, § 1, effective May 23; IP and (3) amended, (SB 17-242), ch. 263, p. 1327, § 198, effective May 25; IP and IP(7) amended, (SB 17-091), ch. 321, p. 1731, § 1, effective June 5. L. 2018: (5.5) added, (HB 18-1091), ch. 74, p. 642, § 2, effective August 8; (12) amended, (HB 18-1431), ch. 313, p. 1892, § 9, effective August 8. L. 2019: (19.5) amended, (HB 19-1172), ch. 136, p. 1707, § 177, effective October 1.

25.5-4-104. Program of medical assistance - single state agency.

1. The state department, by rules, shall establish a program of medical assistance to provide necessary medical care for the categorically needy. The state department is hereby designated as the single state agency to administer such program in accordance with Title XIX and this article and articles 5 and 6 of this title. Such program shall not be required to furnish recipients under sixty-five years of age the benefits that are provided to recipients sixty-five years of age and over under Title XVIII of the social security act; but said program shall otherwise be uniform to the extent required by Title XIX of the social security act.
2. The state department may review any decision of a county department and may consider any application upon which a decision has not been made by the county department within a reasonable time to determine the propriety of the action or failure to take timely action on an application for medical assistance. The state department shall make such additional investigation as it deems necessary and shall, after giving the county department an opportunity to rebut any findings or conclusions of the state department that the action or delay in taking action was a violation of or contrary to state department rules, make such decision as to the granting of medical benefits and the amount thereof as in its opinion is justifiable pursuant to the provisions of this article and articles 5 and 6 of this title and the rules of the state department. Applicants or recipients affected by such decisions of the state department, upon request, shall be given reasonable notice and opportunity for a fair hearing by the state department.

Source: L. 2006: Entire article added with relocations, p. 1819, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-104 as it existed prior to 2006.

25.5-4-105. Federal requirements under Title XIX.

Nothing in this article or articles 5 and 6 of this title shall prevent the state department from complying with federal requirements for a program of medical assistance in order for the state of Colorado to qualify for federal funds under Title XIX of the social security act and to maintain a program within the limits of available appropriations.

Source: L. 2006: Entire article added with relocations, p. 1820, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-105 as it existed prior to 2006.

25.5-4-106. Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services.

1. The state department shall be the sole state agency for administering the state plans for health and medical assistance pursuant to this title, and any other state plan relating to medical assistance that requires state action which is not specifically the responsibility of some other state department, division, section, board, commission, or committee under the provisions of federal or state law.
2. 1. The state department may accept on behalf of the state of Colorado the provisions and benefits of acts of congress designed to provide funds or other property for particular medical assistance within the state, which funds or other property are designated for such purposes within the function of the state department, and may accept on behalf of the state any offers which have been or may from time to time be made of funds or other property by any persons, agencies, or entities for particular medical assistance activities within the state, which funds or other property are designated for such purposes within the function of the state department; but, unless otherwise expressly provided by law, such acceptance shall not be manifested unless and until the state department has recommended such acceptance to and received the written approval of the governor and the attorney general. Such approval shall authorize the acceptance of the funds or property in accordance with the restrictions and conditions for the purpose for which funds or property are intended.
   2. The state treasurer is designated as ex officio custodian of all medical assistance funds received by the state from the federal government and from any other source, if the approval provided for in paragraph (a) of this subsection (2) has been obtained.
   3. The state treasurer shall hold each such fund separate and distinct from state funds and is authorized to make disbursements from such funds for the designated purpose or for administrative costs, which may be provided in such grants upon warrants issued by the state controller upon the voucher of the state department.
3. The state department shall cooperate with the federal department of health and human services and other federal agencies in any reasonable manner, in conformity with the laws of this state, which may be necessary to qualify for federal financial participation, including the preparation of state plans, the making of reports in such form and containing such information as any federal agency may from time to time require, and the compliance with such provisions as the federal government may from time to time find necessary to assure the correctness and verification of the reports.
4. The rules of the state department may include provisions to accommodate requirements of contracts entered into between the state department and the federal department of health and human services, or any successor agency, for studies of guaranteed annual income or other forms of income maintenance research projects; and for such purpose, the requirements of this title as to eligibility for medical assistance shall not apply for the term of and in accordance with the contract for such purpose.
5. The state department is responsible for administering the delivery of medical assistance by county departments of human or social services or any other public or private entities participating in the delivery of medical assistance pursuant to this article 4 and articles 5 and 6 of this title 25.5.

Source: L. 2006: Entire article added with relocations, p. 1820, § 7, effective July 1. L. 2018: (5) amended, (SB 18-092), ch. 38, p. 444, § 109, effective August 8.

Editor's note: This section is similar to former § 26-4-110 as it existed prior to 2006.

Cross references: For the legislative declaration in SB 18-092, see section 1 of chapter 38, Session Laws of Colorado 2018.

25.5-4-107. Retaliation definition.

1. For purposes of any rules promulgated by the state department or state board and any action taken by the state department against any person, "retaliation" means taking any of the following actions against a recipient or someone acting on behalf of a recipient after the recipient or someone acting on behalf of the recipient files a complaint concerning services provided or not provided to the recipient:
   1. Indicating to a recipient that the recipient cannot have an advocate, family member, or other authorized representative assist the recipient; or
   2. 1. An adverse action that negatively affects a recipient's level of eligibility for or receipt of services received at the time of the complaint without verification of a change in the recipient's income, resources, or health care needs that justifies the adverse action.
      2. No adverse action shall be taken against a recipient after a complaint has been filed until the recipient is notified of the proposed action, informed of the reason for the proposed action, and provided an opportunity to appeal the proposed action.
2. "Retaliation" shall not include instances where a recipient is not eligible for a service or program or where a provider documents a problem with a recipient and shares the documentation with the recipient or a third party prior to the recipient filing a complaint.

Source: L. 2006: Entire section added, p. 1019, § 1, effective May 25.

Editor's note: This section was originally numbered as § 26-4-402.5 in House Bill 06-1211. Section 2 of the act provided for the renumbering and relocation of § 26-4-402.5 to this section. (See L. 2006, p. 1020 .)

25.5-4-201. Cash system of accounting - financial administration of medical services premiums - medical programs administered by department of human services - federal contributions - rules.

1. The state department shall utilize the cash system of accounting, as enunciated by the governmental accounting standards board, regardless of the source of revenues involved, for all activities of the state department relating to the financial administration of any nonadministrative expenditure that qualifies for federal financial participation under Title XIX of the federal "Social Security Act", except for expenditures under the program for the medically indigent, article 3 of this title.
   1. (1.5) (a) The state department shall utilize the cash system of accounting, as enunciated by the governmental accounting standards board, for the contributions required by 42 U.S.C. sec. 1396u-5 (c).
   2. The contributions required by 42 U.S.C. sec. 1396u-5 (c) shall be made in the manner required by the federal centers for medicare and medicaid services, or any successor agency. Nothing in this paragraph (b) shall require the state department to make the contribution before the contribution is due.
2. The executive director shall promulgate rules to identify the programs utilizing the cash system of accounting.

Source: L. 2006: Entire section amended, p. 917, § 1, effective May 11; entire article added with relocations, p. 1821, § 7, effective July 1. L. 2007: (1.5) added, p. 465, § 2, effective July 1. L. 2009: (1.5) amended, (SB 09-265), ch. 205, p. 935, § 1, effective May 1.

25.5-4-202. Comprehensive plan for other services and benefits. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1821, § 7, effective July 1. L. 2016: Entire section repealed, (HB 16-1081), ch. 22, p. 52, § 6, effective August 10.

Editor's note: This section was similar to former § 26-4-107 as it existed prior to 2006.

25.5-4-203. Advisory council established.

There is hereby created a state medical assistance and services advisory council, referred to in this article as the "advisory council", consisting of sixteen members. Ex officio members of the advisory council shall be the executive directors of the state department and the department of health or their successors in function. The remaining members of the advisory council shall be appointed by the governor and shall be chosen by him to represent the various areas of medical services and the public. Specifically included shall be two members who are doctors of medicine licensed in this state, one doctor of osteopathy licensed in this state, one dentist licensed in this state, one optometrist licensed in this state, one owner or operator of a licensed nursing facility in this state, one member who shall represent licensed hospitals in this state, one pharmacist licensed in this state, one professional nurse licensed in this state, one member who has provided home health care services for three years, and three members who are not directly associated with the areas of medical services to represent the public. The remaining member may represent any other area of medical services not specifically enumerated but shall not be limited thereto. Members shall serve at the pleasure of the governor and shall receive no compensation but shall be reimbursed for their actual and necessary expenses. The advisory council shall advise the state department on the provision of health and medical care services to recipients.

Source: L. 2006: Entire article added with relocations, p. 1822, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-108 as it existed prior to 2006.

25.5-4-204. Automated medical assistance administration.

1. The general assembly hereby finds and declares that the agency responsible for the administration of the state's medical assistance program would be more effective in its ability to streamline administrative functions of program administrators and providers under the program through the implementation of an automated system that will provide for the following:
   1. Electronic claim submittals;
   2. Online eligibility determinations;
   3. Electronic remittance statements;
   4. Electronic fund transfers; and
   5. Automation of other administrative functions associated with the medical assistance program.
2. Therefore, the general assembly declares that it is appropriate to enact legislation, as set forth in subsection (3) of this section, that authorizes the state department to develop and implement an automated system for processing claims and payments under the medical assistance program, as well as for other administrative functions associated with the program.
3. The executive director of the state department shall develop and implement an automated system through which medical assistance claims and payments and eligibility determinations or other related transactions may be processed. The system shall provide for the use of automated electronic technologies. The automated system may be implemented in phases if deemed necessary by the executive director. The automated system shall be implemented only after the executive director determines that:
   1. Technology is available and proven to perform satisfactorily in a production environment;
   2. Adequate financing is available to facilitate the implementation and maintenance of the system. Financing may include, but is not limited to, federal funds, appropriations from the general fund, provider transaction fees, or any other financing mechanisms which the state department may impose, and grants or contributions from public or private entities.
   3. The system has been successfully installed and fully tested; and
   4. Adequate provider training has been provided for an orderly implementation.

Source: L. 2006: Entire article added with relocations, p. 1822, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-403.7 as it existed prior to 2006.

25.5-4-205. Application - verification of eligibility - demonstration project - rules.

1. 1. Determination of eligibility for medical benefits shall be made by the county department in which the applicant resides, except as otherwise specified in this section. Local social security offices also determine eligibility for medicaid benefits at the same time they determine eligibility for supplemental security income. The state department may accept medical assistance applications and determine medical assistance eligibility and may designate the private service contractor that administers the children's basic health plan, Denver health and hospitals, a hospital that is designated as a regional pediatric trauma center, as defined in section 25-3.5-703 (4)(f), C.R.S., and other medical assistance sites determined necessary by the state department to accept medical assistance applications, to determine medical assistance eligibility, and to determine presumptive eligibility. When the state department determines that it is necessary to designate an additional medical assistance site, the state department shall notify the county in which the medical assistance site is located that an additional medical assistance site has been designated. Any person who is determined to be eligible pursuant to the requirements of this article and articles 5 and 6 of this title shall be eligible for benefits until such person is determined to be ineligible. Upon determination that any person is ineligible for medical benefits, the county department, the state department, or other entity designated by the state department shall notify the applicant in writing of its decision and the reason therefor. When an applicant is found ineligible for medical assistance eligibility programs, the applicant's application data and verifications shall be automatically shared with the state insurance marketplace through a system interface. Separate determination of eligibility and formal application for benefits under this article and articles 5 and 6 of this title for persons eligible as provided in sections 25.5-5-101 and 25.5-5-201 shall be made in accordance with the rules of the state department.
   2. Repealed.
   3. As part of the medicaid eligibility modernization, the department is authorized to create a universal application for single point of entry for home- and community-based services waivers for children.
   4. The state department shall develop training safeguards to prevent actions taken by staff of medical assistance sites from affecting food and cash assistance eligibility.
2. 1. Any married couple, at the beginning of a continuous period of institutionalization of one spouse, may request the county department to assess and document the total value of the resources of the couple, if the couple supplies to the county department the necessary information and documentation which is needed to make such an assessment.
   2. Any assessment prepared by the county department and provided to a couple shall contain a procedure for appealing any determinations which have been made.
   3. If a request for assessment and documentation is not part of an application for medical assistance, the county department may establish a fee not exceeding the reasonable expenses of the county department of providing and documenting such assessment.
3. 1. The state department shall promulgate rules to simplify the processing of applications in order that medical benefits are furnished to recipients as soon as possible, including rules that:
      1. Provide for initial processing of applications and determination of eligibility for medical assistance only at locations other than the county departments, at locations used for processing applications for the Colorado works program, or at the location used by the private service contractor that administers the children's basic health plan for determining eligibility of children for the plan; and
      2. May make provision for the payment of medical benefits for a period not to exceed three months prior to the date of application in cases where the applicant did not make application prior to his or her need for said medical benefits.
   2. 1. The state department shall promulgate rules that:
         1. To the extent authorized under federal law, require an applicant to state only the applicant's income and require the state department to verify the applicant's income through federally approved electronic data sources; except that, if electronic data is not available, or the information obtained from an electronic data source is not reasonably compatible with information provided by or on behalf of an applicant, the rules shall require an individual to provide documentation in order to verify the applicant's income; and
         2. Require the state department at least annually to verify a recipient's income eligibility at reenrollment through federally approved electronic data sources and, if the recipient meets all eligibility requirements, permit the recipient to remain enrolled in the program. The rules shall only require an individual to provide documentation verifying income if electronic data is not available, or the information obtained from electronic data sources is not reasonably compatible with information provided by or on behalf of an applicant.
         4. (Deleted by amendment, L. 2009, (SB 09-292), ch. 369, p. 1974, § 96, effective August 5, 2009.)

            (I.5) (A) If the state department determines that a recipient was not eligible for medical benefits solely based upon the recipient's income after the recipient had been determined to be eligible based upon electronic data obtained through a federally approved electronic data source, the state department shall not pursue recovery from a county department for the cost of medical services provided to the recipient, and the county department is not responsible for any federal error rate sanctions resulting from such determination.

            (B) Notwithstanding any other provision in this paragraph (b), for applications that contain self-employment income, the state department shall not implement this paragraph (b) until it can verify self-employment income through federally approved electronic data sources as authorized by rules of the state department and federal law.

      2. Repealed.
   3. Adequate safeguards shall be established by the state department to ensure that only eligible persons receive benefits under this article and articles 5 and 6 of this title.
   4. 1. In addition, an applicant who is eighteen years of age or older shall be required to supply a form of personal photographic identification either by providing a valid Colorado driver's license or a valid identification card issued by the department of revenue pursuant to section 42-2-302, C.R.S. The state department may adopt rules that exempt applicants from the requirement of supplying a form of personal photographic identification if the requirement causes an unreasonable hardship or if the requirement is in conflict with federal law.
      2. The state department shall also adopt rules that allow for assistance to be provided until the applicant is able to obtain or qualify for a driver's license or identification card; however, a county department or an entity designated by the state department pursuant to subsection (1) of this section is not required to pursue recovery of assistance from an applicant who fails, upon recertification, to meet the photographic identification requirement.
   5. 1. In collaboration with and to augment the state department's efforts to simplify eligibility determinations for benefits under the state medical assistance program and the children's basic health plan, the state department shall establish a process so that a recipient, enrollee, or the parent or guardian of a recipient or enrollee may apply for reenrollment either over the telephone or through the internet.
      2. 1. Subject to receipt of federal authorization and spending authority, the state department may implement a pilot program that allows a limited number of recipients or enrollees to apply for reenrollment either over the telephone or through the internet during a transition to a process that will serve recipients and enrollees statewide. The pilot program shall not serve as a replacement for a statewide process.
         2. Notwithstanding any other provision in this paragraph (e), the state department shall not implement this paragraph (e) until it can verify the eligibility of a recipient or enrollee over the telephone or through the internet as authorized by rules of the state department and federal law.
         3. Notwithstanding any other provision in this paragraph (e), the state department shall not implement or administer any portion of this paragraph (e) until spending authority has been received in the general appropriation act or any supplemental appropriation and shall only implement and administer this paragraph (e) to the extent of such spending authority.
      3. The state department may solicit and accept gifts, grants, and donations from public or private sources for the development or implementation of reenrollment either over the telephone or through the internet process described in this paragraph (e); except that the state department may not accept a gift, grant, or donation that is subject to conditions that are inconsistent with this paragraph (e) or any other law. Any gifts, grants, or donations received by the state department shall be transmitted to the state treasurer, who shall credit the same to the department of health care policy and financing cash fund created pursuant to section 25.5-1-109.
4. 1. By signing an application for medical assistance, a person assigns to the state department, by operation of law, all rights the applicant may have to medical support or payments for medical expenses from any other person on the applicant's own behalf or on behalf of any other member of the applicant's family for whom application is made. For purposes of this subsection (4), an assignment takes effect upon the determination that the applicant is eligible for medical assistance and up to three months prior to the date of application if the applicant meets the requirements of subsection (3) of this section and shall remain in effect so long as an individual is eligible for and receives medical assistance benefits. The application shall contain a statement explaining this assignment.
   2. An applicant for medical benefits upon initial application and each redetermination shall disclose any third party who may be responsible for the payment of medical expenses on behalf of the applicant or any other member of the applicant's family for whom application is made. As part of its medicaid eligibility modernization, the state department shall require the county department or other entity designated to accept applications for medical benefits to enter the third-party information into the automated system developed pursuant to section 25.5-4-204.
5. 1. The state department shall not pursue recovery from a county for the cost of medical services provided to a person who has been incorrectly determined eligible for medical assistance by that county or any other entity.
   2. (Deleted by amendment, L. 2008, p. 2024 , § 1, effective June 3, 2008.)

Source: L. 2006: (1)(a.5) added, p. 1592, § 2, effective June 2; entire article added with relocations, p. 1823, § 7, effective July 1. L. 2008: (3) and (5)(b) amended, p. 2024, § 1, effective June 3. L. 2009: (3)(e) added, (HB 09-1020), ch. 298, p. 1595, § 1, effective May 21; (3)(b)(I)(C) and (3)(B)(I)(D) amended and (3)(b)(I.5) added, (SB 09-292), ch. 369, p. 1974, § 96, effective August 5. L. 2010: (4) amended, (SB 10-002), ch. 366, p. 1727, § 3, effective June 7; (1)(a.7) added, (HB 10-1041), ch. 25, p. 100, § 1, effective August 11. L. 2012: (3)(b)(I)(A), (3)(b)(I)(B), and (3)(b)(I.5)(A) amended, (HB 12-1120), ch. 27, p. 108, § 25, effective June 1. L. 2014: (1)(a), (3)(b)(I)(A), (3)(b)(I)(B), (3)(b)(I.5), and (3)(d)(II) amended, (SB 14-067), ch. 12, p. 109, § 2, effective February 27.

25.5-4-205.5. Confined persons - suspension of benefits.

1. For purposes of this section, unless the context otherwise requires, "confined person" means a person who is:
   1. An inmate confined to a correctional institution operated by or under contract with the department of corrections;
   2. Confined in a jail;
   3. Committed to a juvenile commitment facility;
   4. Committed to a department of human services facility pursuant to part 1 of article 8 of title 16, C.R.S.; or
   5. A patient placed in a department of human services facility pursuant to court order or certification.
2. Notwithstanding any other provision of law, a person who, immediately prior to becoming a confined person, was a recipient of medical assistance pursuant to this article 4 or article 5 or 6 of this title 25.5 remains eligible for medical assistance while a confined person; except that no medical assistance may be furnished pursuant to this article 4 or article 5 or 6 of this title 25.5 while the person is a confined person unless federal financial participation is available for the cost of the assistance, including but not limited to juveniles held in a facility operated by or under contract to the division of youth services established pursuant to section 19-2-203 or the department of human services. Once a person is no longer a confined person, the person continues to be eligible for receipt of medical benefits pursuant to this article 4 or article 5 or 6 of this title 25.5 until the person is determined to be ineligible for the receipt of the assistance. To the extent permitted by federal law, the time during which a person is a confined person is not included in any calculation of when the person must recertify his or her eligibility for medical assistance pursuant to this article 4 or article 5 or 6 of this title 25.5.

Source: L. 2008: Entire section added, p. 903, § 1, effective May 20. L. 2017: (2) amended, (HB 17-1329), ch. 381, p. 1983, § 59, effective June 6.

25.5-4-206. Reimbursement to counties - costs of administration.

The state department shall reimburse the county departments for costs of administration incurred by the counties under this article and articles 5 and 6 of this title in accordance with the provisions of section 26-1-122 (5), C.R.S.

Source: L. 2006: Entire article added with relocations, p. 1825, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-411 as it existed prior to 2006.

25.5-4-207. Appeals - rules - applicability.

1. 1. 1. If an application for medical assistance is not acted upon within a reasonable time after filing of the same, or if an application is denied in whole or in part, or if medical assistance benefits are suspended, terminated, or modified, the applicant or recipient, as the case may be, may appeal to the state department in the manner and form prescribed by the rules of the state department. Except as permitted under federal law, state department rules must provide for at least a ten-day advance notice before the effective date of any suspension, termination, or modification of medical assistance. The county or designated service agency shall notify the applicant or recipient in writing of the basis for the county's decision or action and shall inform the applicant or recipient of the right to a county or service agency conference under the dispute resolution process described in paragraph (b) of this subsection (1) and of the right to a state-level appeal and the process for appeal. (1) (a) (I) If an application for medical assistance is not acted upon within a reasonable time after filing of the same, or if an application is denied in whole or in part, or if medical assistance benefits are suspended, terminated, or modified, the applicant or recipient, as the case may be, may appeal to the state department in the manner and form prescribed by the rules of the state department. Except as permitted under federal law, state department rules must provide for at least a ten-day advance notice before the effective date of any suspension, termination, or modification of medical assistance. The county or designated service agency shall notify the applicant or recipient in writing of the basis for the county's decision or action and shall inform the applicant or recipient of the right to a county or service agency conference under the dispute resolution process described in paragraph (b) of this subsection (1) and of the right to a state-level appeal and the process for appeal.
      2. The applicant or recipient has sixty days after the date of the notice to file an appeal. If the recipient files an appeal prior to the effective date of the intended action, existing medical assistance benefits must automatically continue unchanged until the appeal process is completed, unless the recipient requests in writing that medical assistance benefits not continue during the appeal process; except that, to the extent authorized by federal law, the state department rules may permit existing medical assistance benefits to continue until the appeal process is completed even if the recipient's appeal is filed after the effective date of the intended action. The state department shall promulgate rules consistent with federal law that prescribe the circumstances under which the county or designated service agency may continue benefits if an appeal is filed after the effective date of the intended action. At a minimum, the rules must allow for continuing benefits when the recipient's health or safety is impacted, the recipient was not able to timely respond due to the recipient's disability or employment, the recipient's caregiver was unavailable due to the caregiver's health or employment, or the recipient did not receive the county's or designated service agency's notice prior to the effective date of the intended action.
      3. Either prior to appeal or as part of the filing of an appeal, the applicant or recipient may request the dispute resolution process described in paragraph (b) of this subsection (1) through the county department or service delivery agency.
   2. Every county department or service delivery agency shall adopt procedures for the resolution of disputes arising between the county department or the service delivery agency and any applicant for or recipient of medical assistance. Such procedures are referred to in this section as the "dispute resolution process". Two or more counties may jointly establish the dispute resolution process. The dispute resolution process must be consistent with rules promulgated by the state board pursuant to article 4 of title 24, C.R.S. The dispute resolution process shall include an opportunity for all clients to have a county conference, upon the client's request, and such requirement may be met through a telephonic conference upon the agreement of the client and the county department. The dispute resolution process need not conform to the requirements of section 24-4-105, C.R.S., as long as the rules adopted by the state board include provisions specifically setting forth expeditious time frames, notice, and an opportunity to be heard and to present information. If the dispute is resolved through the county or service delivery agency's dispute resolution process and the applicant or recipient has already filed an appeal, the county shall inform the applicant or recipient of the process for dismissing the appeal.
   3. The state board shall adopt rules setting forth what other issues, if any, may be appealed by an applicant or recipient to the state department. A hearing need not be granted when either state or federal law requires or results in a reduction or deletion of a medical assistance benefit unless the applicant or recipient is arguing that his or her case does not fit within the parameters set forth by the change in the law. In notifying the applicant or recipient that an appeal is being denied because of a change in state or federal law, the state's notice must inform the applicant or recipient that further appeal should be directed to the appropriate state or federal court.
   4. Upon receipt of an appeal, the office of administrative courts shall give the appellant at least ten days' notice of the hearing date and an opportunity for a fair hearing in accordance with the rules of the state department. The fair hearing must comply with section 24-4-105, C.R.S., and the state department's administrative law judge shall preside.
   5. 1. At the commencement of a hearing that concerns the termination or reduction of an existing benefit, the state department's administrative law judge shall review the legal sufficiency of the notice of action from which the recipient is appealing. If the administrative law judge determines that the notice is legally insufficient, the administrative law judge shall inform the appellant that the termination or reduction may be set aside on the basis of insufficient notice without proceeding to a hearing on the merits. The appellant may affirmatively waive the defense of insufficient notice and agree to proceed with a hearing on the merits or may ask the administrative law judge to decide the appeal on the basis of his or her finding that the notice is legally insufficient. The administrative law judge shall also inform the appellant that the state department may issue legally sufficient notice in the future and that the state department may seek recoupment of benefits if a basis for denial or reduction of benefits is subsequently determined.
      2. This subsection (1)(d.5) applies to hearings conducted on and after January 1, 2018.
   6. The appellant shall have an opportunity to examine all applications and pertinent records concerning the appellant that constitute a basis for the denial, suspension, termination, or modification of medical assistance benefits. The person or persons involved in the decision denying, suspending, terminating, or modifying medical assistance benefits or, if the person or persons are not reasonably available, a person familiar with the facts underlying the basis for the decision, shall be available for cross-examination if requested by the appellant.
2. All decisions of the state department shall be binding upon the county department involved and shall be complied with by such county department.

Source: L. 2006: Entire article added with relocations, p. 1825, § 7, effective July 1. L. 2016: (1) amended, (HB 16-1277), ch. 198, p. 698, § 1, effective September 1. L. 2017: (1)(d.5) added, (HB 17-1126), ch. 123, p. 427, § 1, effective April 6.

Editor's note: This section is similar to former § 26-4-402 as it existed prior to 2006.

25.5-4-208. County duties - transitional medicaid.

County departments shall assist families in completing the reporting requirements for transitional medicaid. This shall include informing families of the transitional medicaid eligibility requirements and the required reporting calendar.

Source: L. 2006: Entire article added with relocations, p. 1826, § 7, effective July 1. L. 2014: Entire section amended, (SB 14-067), ch. 12, p. 116, § 11, effective February 27.

Editor's note: This section is similar to former § 26-4-106.5 as it existed prior to 2006.

25.5-4-209. Payments by third parties - copayments by recipients - review - appeal - children's waiting list reduction fund.

1. 1. Any recipient receiving benefits under this article or article 5 or 6 of this title who receives any supplemental income, available for medical purposes under rules of the state department, or who receives proceeds from sickness, accident, health, or casualty insurance shall apply the supplemental income or insurance proceeds to the cost of the benefits rendered, and the rules may require reports from providers of other payments received by them from or on behalf of recipients.
   2. Subject to any limitations imposed by Title XIX and the requirements set forth in subsection (1)(c) of this section, a recipient must pay at the time of service a portion of the cost of any medical benefit rendered to the recipient or to the recipient's dependents pursuant to this article 4 or article 5 or 6 of this title 25.5, as determined by rules of the state department.
   3. 1. Except as otherwise provided in subsection (1)(c)(II) of this section, on and after January 1, 2018, for pharmacy and for hospital outpatient services, including urgent care centers and facilities and emergency services, the rules of the state department required by subsection (1)(b) of this section must require the recipient to pay:
         1. For pharmacy, at least double the average amount paid by recipients in state fiscal year 2015-16; or
         2. For hospital outpatient services, at least double the amount required to be paid as specified in the rules as of January 1, 2017.
      2. For both pharmacy and hospital outpatient services, the amount required to be paid by the recipient shall not exceed any specified maximum dollar amount allowed by federal law or regulations as of January 1, 2017.
   4. The state department shall evaluate options to exempt individuals who are qualified for institutional care but are instead enrolled in home- and community-based service waivers from the increased payment requirements specified in subsection (1)(c) of this section.
2. 1. Notwithstanding the provisions of section 26-1-114, C.R.S., the state department is authorized to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services available, including the collection of sufficient information from individuals who are eligible for medical assistance to pursue claims against the third parties. The state department shall collect the information at the time of any determination or redetermination of eligibility for medical assistance. A knowing or willful failure of an individual to provide the information may result in the termination of the individual's eligibility for medical assistance.
   2. A third party, as a condition of doing business in the state, shall:
      1. 1. Provide on a monthly basis to the state department or its business associate eligibility records identifying all persons covered by the third party in a manner prescribed by rule to allow the state department or its business associate to perform an analysis and determine which persons are eligible for medical assistance;
         2. The eligibility record data elements provided by the third party shall be the minimum necessary to achieve a satisfactory data match. The third party shall provide, upon request of the state department or its business associate, additional data elements as needed to confirm eligibility matches as determined by the initial analysis, including, but not limited to, the name, address, and identifying number of the third party's plan.
      2. Accept the state's right of recovery and the assignment to the state of any right of an individual or other entity to payment from the third party for an item or service for which payment has been made under the medical assistance plan to the extent that such service is covered by the third party;
      3. Respond to any inquiry by the state regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of the health care item or service; and
      4. Agree not to deny a claim submitted by the state solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim, if:
         1. The claim is submitted by the state within the three-year period beginning on the date that the item or service is furnished; and
         2. Any action by the state to enforce its rights with respect to the claim is commenced within six years after the state's submission of the claim.
         3. The remuneration of the state department for services provided or paid for;
         4. Any record retention requirements;
         5. Audit requirements; and
         6. Purposes related to litigation and testimony.
   3. The cost to a third party of providing data, including eligibility records, shall be borne by the state department.
   4. A third party that provides data required by the state department, whether confidential or not, shall not be held liable for the provision of such data to the state department or for any use made thereof.
   5. 1. The state department's business associate shall not use, transfer, extract, copy, revise, or store any data required to be provided to the state department and its business associate, including the eligibility records, social security numbers, coverage, nature of coverage, period provided, or any other data elements, for purposes other than:
      2. The state department's business associate shall destroy all data once the functions specified in subparagraph (I) of this paragraph (e) have been accomplished.

      (A) The identification of persons eligible to receive medical assistance, as defined by section 25.5-1-103 (5);

      (B) Cost avoidance;

   6. 1. A Colorado resident shall have a private right of action against the state department's business associate if the business associate negligently uses the data specified in paragraph (e) of this subsection (2) for purposes other than those stated in paragraph (e) of this subsection (2). The right of action shall be enforceable in the courts of Colorado and limited to the actual damages incurred by the individual bringing the action.
      2. A third party may bring an action on behalf of a Colorado resident for injunctive relief against the state department's business associate to prevent the business associate from intentionally using the data for purposes other than those specified in paragraph (e) of this subsection (2).
   7. As used in this section:
      1. "Business associate" shall have the same meaning as provided in 45 CFR 160.103.
      2. "Third party" means a health insurer, self-insured plan, group health plan as defined in 29 U.S.C. sec. 1167 (1), service benefit plan, managed care organization, pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.
3. 1. The rights assigned by a recipient of medical assistance to the state department pursuant to section 25.5-4-205 (4) shall include the right to appeal an adverse coverage decision by a third party for which the medical assistance program may be responsible for payment, including but not limited to the internal and external reviews provided for in sections 10-16-113 and 10-16-113.5, C.R.S., and a third party's reasonable appeal procedure under state and federal law. The state department or the independent contractor retained pursuant to paragraph (b) of this subsection (3) shall review and, if necessary, may appeal at any level an adverse coverage decision, except an adverse coverage decision relating to medicare, Title XVIII of the federal "Social Security Act", as amended.
   2. The state department shall enter into one or more agreements with an independent contractor to pursue recoveries from third parties pursuant to paragraph (a) of this subsection (3). Any such agreement shall provide that the independent contractor's only compensation shall be a prudent and reasonable percentage of the amount recovered on behalf of the state department as determined by the state department.
   3. 1. An independent contractor retained pursuant to paragraph (b) of this subsection (3) shall maintain a contemporaneous record of the hours of services provided and any costs incurred. When the matter is resolved, the independent contractor shall provide to the state department a statement of the hours of services provided, the amount of costs incurred, the total amount of the contingent fee, and the hourly rate for the services provided. The hourly rate for the services provided shall be determined by dividing the amount of the contingent fee, less the amount of costs incurred, by the number of hours of services provided by the independent contractor. The statement required by this subparagraph (I) shall be available for inspection and copying at reasonable times at the state department.
      2. Compliance with this paragraph (c) does not relieve a contracting attorney of any obligation or legal responsibility imposed by the Colorado rules of professional conduct or any provision of law.
   4. Nothing in this subsection (3) shall be construed to authorize the denial of or delay of payment to a provider by the state department or the delay or interference with the provision of services to a medical assistance recipient.
   5. Repealed.
4. With respect to programs administered by the state department, the state department shall access available data from the public assistance reporting information system for the purpose of identifying persons who are receiving certain public benefits from other states. The state department shall ensure that duplicate benefits are not being paid improperly to persons identified pursuant to the public assistance reporting information system.

Source: L. 2006: Entire article added with relocations, p. 1826, § 7, effective July 1. L. 2008: (1)(a), (2), and (3)(a) amended, p. 1768, § 1, effective June 2. L. 2010: (4) added, (SB 10-167), ch. 296, p. 1378, § 5, effective May 26; (3)(a) amended and (3)(e) added, (SB 10-002), ch. 366, p. 1727, § 4, effective June 7. L. 2017: (1)(b) amended and (1)(c) and (1)(d) added, (SB 17-267), ch. 267, p. 1447, § 14, effective May 30.

25.5-4-210. Purchase of health insurance for recipients.

1. 1. The state department shall purchase group health insurance for a medical assistance recipient who is eligible to enroll for such coverage if enrollment of such recipient in the group plan would be cost-effective. In addition, the state department may purchase individual health insurance for a medical assistance recipient who is eligible to enroll in a health insurance plan if enrollment of such recipient would be cost-effective to this state. A determination of cost-effectiveness shall be in accordance with federal guidelines established by the secretary of the United States department of health and human services.
   2. Notwithstanding any provision of paragraph (a) of this subsection (1) to the contrary, the state department, in purchasing health insurance for medical assistance recipients who are eligible to enroll for private coverage, shall not purchase such health insurance for more than two thousand individuals.
2. Enrollment in a group health insurance plan shall be required of recipients for whom enrollment has been determined to be cost-effective as a condition of obtaining or retaining medical assistance. A parent shall be required to enroll a dependent child recipient, but medical assistance for such child shall not be discontinued if a parent fails to enroll the child.
3. The state department shall pay any premium, deductible, coinsurance, or other cost-sharing obligation required under the group plan for services covered under the state medical assistance plan. In addition, the state department shall pay any premium, deductible, coinsurance, or other cost-sharing obligation required under an individual plan purchased by the state department for a medical assistance recipient pursuant to subsection (1) of this section. Payment of said services shall be treated as payment for medical assistance. Coverage provided by the purchased health insurance plan shall be considered as third-party liability for the purposes of section 25.5-4-209.
4. Services not available to a recipient under the purchased plan shall be provided to the recipient if such services would otherwise be provided as medical assistance services pursuant to this article or article 5 or 6 of this title. Nothing in this section shall be construed to require that services provided under a group health insurance plan for medical assistance recipients shall be made available to recipients not enrolled in the plan. Enrollment in a group health insurance plan pursuant to this section shall not affect the eligibility of a recipient who otherwise qualifies for medical assistance pursuant to this article or article 5 or 6 of this title.

Source: L. 2006: Entire article added with relocations, p. 1828, § 7, effective July 1. L. 2010: (1) amended, (SB 10-167), ch. 296, p. 1378, § 6, effective May 26.

Editor's note: This section is similar to former § 26-4-518.5 as it existed prior to 2006.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-211. Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year.

1. Subject to the limitation in subsection (2) of this section, unexpended and unencumbered moneys from an appropriation in the annual general appropriation act to the state department for the medicaid management information system remain available for expenditure by the state department in the next fiscal year without further appropriation. This section applies to appropriations made by the general assembly for fiscal years beginning on and after July 1, 2013.
2. On or before June 30, 2014, and on or before June 30 of each year thereafter, the state department shall notify the state controller of the amount of the appropriation from the annual general appropriation act for the medicaid management information system for the current fiscal year that the state department needs to remain available for expenditure in the next fiscal year. The state department may not expend more than the amount notified under the authority granted in this section.
3. Repealed.

Source: L. 2013: Entire section added, (HB 13-1281), ch. 205, p. 851, § 1, effective May 11. L. 2017: (3) amended, (HB 17-1060), ch. 6, p. 16, § 8, effective March 1.

Editor's note: Subsection (3)(b) provided for the repeal of subsection (3), effective January 3, 2018. (See L. 2017, p. 16 .)

25.5-4-212. Medicaid client correspondence improvement process - legislative declaration - definition.

1. 1. The general assembly finds and declares that:
      1. Accurate, understandable, timely, informative, and clear correspondence from the state department is critical to the life and health of medicaid recipients, and, in some cases, is a matter of life and death for our most vulnerable populations;
      2. Unclear, confusing, and late correspondence from the state department causes an increased workload for the state, counties administering the medicaid program, and nonprofit advocacy groups assisting clients; and
      3. Government should be a good steward of taxpayers' money, ensuring that it is spent in the most cost-effective manner.
   2. Therefore, the general assembly finds that improving medicaid client correspondence is critical to the health and safety of medicaid clients and will reduce unnecessary confusion that requires clients to call counties and the state department or file appeals.
2. As used in this section, unless the context otherwise requires, "client correspondence" means any communication, the purpose of which is to provide notice of an approval, denial, termination, or change to an individual's medicaid eligibility; to provide notice of the approval, denial, reduction, suspension, or termination of a medicaid benefit; or to request additional information that is relevant to determining an individual's medicaid eligibility or benefits. "Client correspondence" does not include communications regarding the state department's review of trusts or review of documents or records relating to trusts.
3. The state department shall improve medicaid client correspondence by ensuring that client correspondence revised or created after January 1, 2018:
   1. Is written using person-first, plain language;
   2. Is written in a format that includes the date of the correspondence and a client greeting;
   3. Is consistent, using the same terms throughout to the extent practicable including commonly used program names;
   4. Is accurately translated into the second most commonly spoken language in the state if a client indicates that this is the client's written language of preference or as required by law;
   5. Includes a statement translated into the top fifteen languages most commonly spoken by individuals in Colorado with limited English proficiency informing an applicant or client how to seek further assistance in understanding the content of the correspondence;
   6. Clearly conveys the purpose of the client correspondence, the action or actions being taken by the state department or its designated entity, if any, and the specific action or actions that the client must or may take in response to the correspondence;
   7. Includes a specific description of any necessary information or documents requested from the applicant or client;
   8. Includes contact information for client questions; and
   9. Includes a specific and plain language explanation of the basis for the denial, reduction, suspension, or termination of the benefit if applicable.
4. Subject to the availability of sufficient appropriations and receipt of federal financial participation, on and after July 1, 2018, the state department shall make electronically available to a client specific and detailed information concerning the client's household composition, assets, income sources, and income amounts, if relevant to a determination for which client correspondence was issued. If implemented, the state department shall notify clients in the written correspondence of the option to access this information.
5. The state department is encouraged to promote the receipt of client correspondence electronically or through mobile applications for clients who choose those methods of delivery as allowed by law.
6. As part of its ongoing process to create and improve client correspondence, the state department may engage with experts in written communication and plain language to test client correspondence against the criteria set forth in subsection (3) of this section with a geographically diverse and representative sample of medicaid clients relevant to the client correspondence being revised. The state department shall also develop a process to review and consider feedback from stakeholders including client advocates and counties prior to implementing significant changes to correspondence.
7. The state department shall ensure that client correspondence that may only affect a small number of clients, but may, nonetheless, have a significant impact on the lives of those clients, is appropriately prioritized for revision.
8. As part of its annual presentation made to its legislative committee of reference pursuant to section 2-7-203, the state department shall present information concerning:
   1. Its process for ongoing improvement of client correspondence;
   2. Client correspondence revised pursuant to criteria set forth in subsection (3) of this section during the prior year and client correspondence improvements that are planned for the upcoming year; and
   3. A description of the results of testing of new or significantly revised client correspondence pursuant to subsection (6) of this section, including a description of the stakeholder feedback.

Source: L. 2017: Entire section added, (SB 17-121), ch. 303, p. 1651, § 1, effective August 9.

25.5-4-213. Audit of medicaid client correspondence - definition.

1. As used in this section, unless the context otherwise requires, "client correspondence" has the same meaning as defined in section 25.5-4-212.
2. During the 2020 calendar year and the 2023 calendar year, the office of the state auditor shall conduct or cause to be conducted a performance audit of client correspondence. Thereafter, the state auditor, in the exercise of his or her discretion, may conduct or cause to be conducted additional performance audits of client correspondence pursuant to this section. The audit shall include correspondence generated through the Colorado benefits management system, as well as correspondence that is not generated through the Colorado benefits management system.
3. The performance audit conducted pursuant to this section shall include:
   1. A review of available data from counties, the department's customer service contract center, and from assistors within the health benefit exchange, created in article 22 of title 10, regarding customer service contacts that are related to client confusion regarding correspondence received by medicaid clients or applicants;
   2. A review of the accuracy of client correspondence at the time it is generated;
   3. A review of whether client correspondence satisfies the requirements of any state or federal law, rule, or regulation relating to the sufficiency of any notice;
   4. A review of any client correspondence testing process conducted by the department and whether testing is done prior to implementing new or significantly revised client communications;
   5. A review of the results of any client correspondence testing, including client comprehension of the intended purpose or purposes of the correspondence; and
   6. A review of the accuracy of client income and household composition information that is communicated electronically, if applicable.
4. If audit findings include findings that information contained in client correspondence is inaccurate at the time the correspondence was generated, the audit shall identify, if possible, the source of the inaccurate information, which may include but is not limited to computer system or interface issues, county input error, or applicant error.
5. Based on the findings and conclusions identified during the performance audit conducted pursuant to this section, the office of the state auditor shall make recommendations to the state department for improving client correspondence. On or before December 30, 2020, December 30, 2023, and December 30 in any calendar year in which an audit is conducted pursuant to this section, the office of the state auditor shall submit the findings, conclusions, and recommendations from the performance audit in the form of a written report to the legislative audit committee, which shall hold a public hearing for the purposes of a review of the report. The report shall also be submitted to the joint budget committee, the public health care and human services committee of the house of representatives, the health and human services committee of the senate, and the joint technology committee, or any successor committees.

Source: L. 2017: Entire section added, (HB 17-1143), ch. 67, p. 211, § 1, effective August 9; (1) amended, (SB 17-121), ch. 303, p. 1653, § 2, effective August 9.

25.5-4-214. Feasibility study - residential and inpatient substance use disorder treatment - report - repeal. (Repealed)

Source: L. 2017: Entire section added, (HB 17-1351), ch. 288, p. 1600, § 2, effective June 2.

Editor's note: Subsection (5) provided for the repeal of this section, effective July 1, 2019. (See L. 2017, p. 1600 .)

25.5-4-300.4. Last resort for payment - legislative intent.

It is the intent of the general assembly that medicaid be the last resort for payment for medically necessary goods and services furnished to recipients and that all other sources of payment are primary to medical assistance provided by medicaid.

Source: L. 2008: Entire section added, p. 1771, § 2, effective June 2.

25.5-4-300.7. Prevention of coding errors - prepayment review of claims.

1. The state department shall implement and maintain a system for reducing medical services coding errors in medicaid claims submitted to the state department for reimbursement. The system shall include automatic, prepayment review of medicaid claims through the use of nationally recognized correct coding methods in the medicaid management information system, in accordance with 42 U.S.C. sec. 1396b (r) and regulations thereunder, as amended by Pub.L. 111-148, and any other subsequent acts of congress. The state department shall acquire and maintain any information technology necessary to implement the automated, prepayment review of medicaid claims.
2. Repealed.

Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1379, § 8, effective May 26. L. 2016: (2) repealed, (HB 16-1081), ch. 22, p. 50, § 2, effective August 10.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-300.9. Explanation of benefits - medicaid recipients - legislative declaration.

1. 1. The general assembly finds and declares that:
      1. Colorado's medicaid program provides critical medical services to the state's poorest and most vulnerable residents;
      2. Funding for these services is provided through a financial partnership between Colorado and the federal government;
      3. For the 2015-16 state budget year, the general assembly appropriated $8,891,000,000 for Colorado's medicaid program, of which $2,508,000,000 is from the general fund and $677,000,000 is from the hospital provider fee, with the remainder from federal money;
      4. It is in the best interest of Colorado to do everything possible to minimize error, inefficiency, and fraud in providing medicaid services to ensure the long-term viability of this safety net program;
      5. In the private sector, as well as the medicare program, insurers routinely provide an explanation of benefits to their clients, listing claims submitted by providers for services rendered to the client even when the insurer is not seeking a co-payment for the service and the provider is not claiming an amount due from the client;
      6. While creating an explanation of benefits is not without cost to the health care system, only the client receiving medical services or his or her authorized representative is in the position to verify whether the claimed medical services were actually provided and for whom they were provided, which is a necessary first step in containing health care costs;
      7. While medicaid clients may not appear to be affected financially by billing errors or fraudulent claims, medicaid clients who rely on these services for survival and independence are most severely affected by the inappropriate use of scarce resources; and
      8. Further, medicaid clients and medicaid advocates for low-income and vulnerable Coloradans want the opportunity to partner with the state department and providers to ensure a well-run and fraud-free medicaid program in Colorado.
   2. Therefore, the general assembly declares that creating an explanation of benefits for recipients of medicaid-funded services is a necessary step in managing the state's medicaid program and in safeguarding the significant public investment, both state and federal, in meeting the health care needs of low-income and vulnerable Coloradans.
2. By or before July 1, 2017, the state department shall develop and implement an explanation of benefits for recipients of medical services pursuant to articles 4 to 6 of this title. The purpose of the explanation of benefits is to inform a medicaid client of a claim for reimbursement made for services provided to the client or on his or her behalf, so that the client may discover and report administrative or provider errors or fraudulent claims for reimbursement.
3. The explanation of benefits is required for all acute and long-term care services for which a provider is seeking reimbursement under a fee-for-service model.
4. The explanation of benefits must include, at a minimum:
   1. The name of the medicaid client receiving the service;
   2. The name of the service provider;
   3. A description of the service provided;
   4. The billing code for the service;
   5. The date of service, or range of dates for services, if multiple services are provided in a set period of time, such as personal care services;
   6. A clear statement to the medicaid client that the explanation of benefits is not a bill, but is only provided for the client's information and to make sure that a provider is being reimbursed only for services actually provided;
   7. Information regarding at least one verbal and one written method for the medicaid client to report errors in the explanation of benefits that are relevant to provider reimbursement; and
   8. Any other information that the state department determines is useful to the medicaid client or for purposes of discovering administrative or provider error or fraud.
5. The state department shall develop the form and content of the explanation of benefits in conjunction with medicaid clients and medicaid advocates to ensure that medicaid clients understand the information provided and the purpose of the explanation of benefits. The state department shall also work with medicaid clients and medicaid advocates to develop educational materials for the state department's website and for distribution by advocacy and nonprofit organizations that explain the process for reporting errors and encourage clients to take responsibility for reporting errors.
6. The state department shall provide the explanation of benefits to a medicaid client not less frequently than once every two months, if services have been provided to or on behalf of the client during that time period. The state department shall determine the most cost-effective means for producing and distributing the explanation of benefits to medicaid clients, which may include e-mail or web-based distribution, with mailed copies by request only. Further, the state department may include the explanation of benefits with an existing mailing or existing electronic or web-based communication to medicaid clients.
7. Nothing in this section requires the state department to produce an explanation of benefits form if the information required to be included in the explanation of benefits pursuant to subsection (4) of this section is already included in another format that is understandable to the medicaid client.

Source: L. 2016: Entire section added, (SB 16-120), ch. 254, p. 1044, § 1, effective August 10.

25.5-4-301. Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures.

1. 1. 1. Except as provided in section 25.5-4-302 and subparagraph (III) of this paragraph (a), no recipient or estate of the recipient shall be liable for the cost or the cost remaining after payment by medicaid, medicare, or a private insurer of medical benefits authorized by Title XIX of the social security act, by this title, or by rules promulgated by the state board, which benefits are rendered to the recipient by a provider of medical services authorized to render such service in the state of Colorado, except those contributions required pursuant to section 25.5-4-209 (1). However, a recipient may enter into a documented agreement with a provider under which the recipient agrees to pay for items or services that are nonreimbursable under the medical assistance program. Under these circumstances, a recipient is liable for the cost of such services and items. (1) (a) (I) Except as provided in section 25.5-4-302 and subparagraph (III) of this paragraph (a), no recipient or estate of the recipient shall be liable for the cost or the cost remaining after payment by medicaid, medicare, or a private insurer of medical benefits authorized by Title XIX of the social security act, by this title, or by rules promulgated by the state board, which benefits are rendered to the recipient by a provider of medical services authorized to render such service in the state of Colorado, except those contributions required pursuant to section 25.5-4-209 (1). However, a recipient may enter into a documented agreement with a provider under which the recipient agrees to pay for items or services that are nonreimbursable under the medical assistance program. Under these circumstances, a recipient is liable for the cost of such services and items.
      2. The provisions of subparagraph (I) of this paragraph (a) shall apply regardless of whether medicaid has actually reimbursed the provider and regardless of whether the provider is enrolled in the Colorado medical assistance program.

         (II.5) (A) A provider of medical services who bills or seeks collection through a third party from a recipient or the estate of a recipient for medical services authorized by Title XIX of the social security act in an amount in violation of subsection (1)(a)(I) of this section is liable for and subject to the following: A refund to the recipient of any amount unlawfully received from the recipient, plus statutory interest from the date of the receipt until the date of repayment; a civil monetary penalty of one hundred dollars for each violation of subsection (1)(a)(I) of this section; and all amounts submitted to a collection agency in the name of the medicaid recipient. When determining income or resources for purposes of determining eligibility or benefit amounts for any state-funded program under this title 25.5, the state department shall exclude from consideration any money received by a recipient pursuant to this subsection (1)(a)(II.5). The imposition of a civil monetary penalty by the state department may be appealed administratively.

         (A.5) A provider of medical services who, within thirty days of notification by the state department, or longer if approved by the state department, voids the bill, returns any amount unlawfully received, and makes every reasonable effort to resolve any collection actions so that the recipient or the estate of the recipient has no adverse financial consequences is not subject to the provisions of subsection (1)(a)(II.5)(A) of this section.

         (B) In order to establish a claim for the civil monetary penalty established by subsection (1)(a)(II.5)(A) of this section, a recipient or the estate of a recipient, or a person acting on behalf of a recipient or the estate of a recipient, shall notify the state department.

         (C) The provisions of this subparagraph (II.5) shall not apply to a long-term care facility licensed pursuant to section 25-3-101, C.R.S.

         (D) The provisions of subsection (1)(a)(II.5)(A) of this section shall not apply if a recipient knowingly misrepresents his or her medicaid coverage status to a provider of medical services and the provider submits documentation to the state department that the recipient knowingly misrepresented his or her medicaid coverage status and the documentation clearly establishes a good cause basis for granting an exception to the provider.

      3. 1. When a third party is primarily liable for the payment of the costs of a recipient's medical benefits, prior to receiving nonemergency medical care, the recipient shall comply with the protocols of the third party, including using providers within the third party's network or receiving a referral from the recipient's primary care physician. Any recipient failing to follow the third party's protocols is liable for the payment or cost of any care or services that the third party would have been liable to pay; except that, if the third party or the service provider substantively fails to communicate the protocols to the recipient, the items or services are nonreimbursable under this article and articles 5 and 6 of this title and the recipient is not liable to the provider.
         2. A recipient may enter into a written agreement with a third party or provider under which the recipient agrees to pay for items provided or services rendered that are outside of the network or plan protocols. The recipient's agreement to be personally liable for such nonemergency, nonreimbursable items shall be recorded on forms approved by the state board and signed and dated by both the recipient and the provider in advance of the services being rendered.
   2. Recipient income applied pursuant to section 25.5-4-209 (1) shall not disqualify any recipient, as defined in section 26-2-103 (8), C.R.S., from receiving benefits under this article, article 5 or 6 of this title, or public assistance under article 2 of title 26, C.R.S. If, at any time during the continuance of medical benefits, the recipient becomes possessed of property having a value in excess of that amount set by law or by the rules of the state department or receives any increase in income, it is the duty of the recipient to notify the county department thereof, and the county department may, after investigation, either revoke such medical benefits or alter the amount thereof, as the circumstances may require.
   3. Any medical assistance paid to which a recipient was not lawfully entitled shall be recoverable from the recipient or the estate of the recipient by the county as a debt due the state pursuant to section 25.5-1-115, but no lien may be imposed against the property of a recipient on account of medical assistance paid or to be paid on the recipient's behalf under this article or article 5 or 6 of this title, except pursuant to the judgment of a court of competent jurisdiction or as provided by section 25.5-4-302.
   4. If any such medical assistance was obtained fraudulently, interest shall be charged and paid to the county department on the amount of such medical assistance calculated at the legal rate and calculated from the date that payment for medical services rendered on behalf of the recipient is made to the date such amount is recovered.
2. Any overpayment to a provider, including those of personal needs funds made pursuant to section 25.5-6-206, are recoverable regardless of whether the overpayment is the result of an error by the state department, a county department of human or social services, an entity acting on behalf of either department, or by the provider or any agent of the provider as follows:
   1. 1. If the state department makes a determination that such overpayment has been made as a result of the provider's false representation, the state department may collect the overpayment, plus a civil monetary penalty equal to one-half the amount of the overpayment, and interest on the sum of the two amounts accruing at the statutory rate from the date the overpayment is identified, by the means specified in this subsection (2). Such sum may be collected for up to the amount of time prescribed in section 13-80-103.5, C.R.S., after the overpayment is identified. Amounts remaining uncollected for more than the time period prescribed in section 13-80-103.5, C.R.S., after the last repayment was made may be considered uncollectible. For the purposes of this subparagraph (I), "false representation" means an inaccurate statement that is relevant to a claim for reimbursement and is made by a provider who has actual knowledge of the truth of false nature of the statement or by a provider acting in deliberate ignorance of or with reckless disregard for the truth of the statement. A provider acts with reckless disregard for truth if the provider fails to maintain records required by the department or if the provider fails to become familiar with rules, manuals, and bulletins issued by the department, board, or the department's fiscal agent.
      2. If the state department makes a determination that such overpayment has been made for some other reason than a false representation by the provider specified in subparagraph (I) of this paragraph (a), the state department may collect the amount of overpayment, plus interest accruing at the statutory rate from the date the provider is notified of such overpayment, by the means specified in this subsection (2). Pursuant to the criteria established in rules promulgated by the state board, the state department may waive the recovery or adjustment of all or part of the overpayment and accrued interest specified in this subparagraph (II) if it would be inequitable, uncollectible or administratively impracticable; except that no action shall be taken against a recipient of medical services initially determined to be eligible pursuant to section 25.5-4-205 if the overpayment occurred through no fault of the recipient. Amounts remaining uncollected for more than five years after the last repayment was made may be considered uncollectible.
   2. In order to collect the amounts specified in paragraph (a) of this subsection (2), the state department may withhold subsequent payments to which the provider is or becomes entitled and apply the amount withheld as an offset. The state board shall establish in rules the rate at which an overpayment may be offset, with provision for a reduction of such rate upon a good cause shown by the provider that the rate at which payment will be withheld will result in an undue hardship for the provider. In determining whether to grant a good cause reduction, the state department shall consider the impact of collecting the amount provided by state board rules on the quality of patient care and the financial viability of the provider. The state department may also take such other steps administratively as are available for the collection of the amounts specified in paragraph (a) of this subsection (2).
   3. If a provider defaults on repayment of the amounts specified in paragraph (a) of this subsection (2), the state department may bring a suit against the provider in the appropriate court. Court costs shall not be assessed against the state department but shall be assessed against the provider if the court finds in favor of the state department. Any costs collected by the state department shall be paid into the registry of the court. Once the amount has been reduced to judgment, the state department may proceed with all available postjudgment remedies.
   4. Notwithstanding the provisions of section 24-30-202.4, C.R.S., an amount specified in paragraph (a) of this subsection (2) that the state department has determined to be uncollectible may be referred to the controller for collection. Net proceeds of debts collected by the controller pursuant to this paragraph (d) shall be paid into the fund from which the overpayment was made.
   5. Any provider adversely affected by actions taken pursuant to this subsection (2), except when a suit is filed against the provider pursuant to paragraph (c) of this subsection (2), may appeal the determination of the state department pursuant to the provisions in section 24-4-105, C.R.S.
   6. If the state department, either directly or through a contracting agent, undertakes a review or an audit of a provider to determine whether an overpayment has been made to that provider, the review or audit shall be subject to the procedures required in subsection (3) of this section.
3. 1. A review or audit of a provider is subject to the following procedures:
      1. The reviewer or auditor shall conduct a review or audit in accordance with applicable state and federal law.
      2. The reviewer or auditor shall apply uniform standards and procedures to each class of providers subject to a review or an audit to determine an overpayment.
      3. The reviewer or auditor shall prepare findings for the entire period under review or audit, and a provider shall be subject to only one demand for repayment in connection with the review or audit.
      4. The reviewer or auditor shall initiate each review or audit requiring an inspection of the provider's records by delivering to the provider not less than ten business days prior to the commencement of the audit a written request describing in detail such records and offering the provider the option of providing either a reproduction of such records or inspection by the reviewer or auditor at the provider's site. The request must also clearly define milestone dates pertaining to records' requested due dates, permissible extensions of dates, the timelines for informal reconsideration, and deadlines for requesting a formal appeal. The records subject to the request must be limited to records directly related to claims for reimbursement submitted by the provider. In the event such records are available from a county department of human or social services or another agency, subdivision, or contractor of the state, the reviewer or auditor shall request such records from such other agencies as may be appropriate prior to making a request to the provider. The reviewer or auditor shall conduct on-site inspections at reasonable times during regular business hours, and the reviewer or auditor shall make arrangements necessary for the reproduction of such records on site. If the provider chooses to provide a reproduction of the records requested by the reviewer or auditor instead of on-site inspection, the reviewer or auditor shall give the provider a reasonable period of time, not less than forty-five days, to provide such records, taking into account the scope of the request, the time frame covered, and the reproduction arrangements available to the provider.

         (IV.5) At the request of the provider, the reviewer or auditor shall conduct an in-person or telephonic interview with the provider prior to the preparation of a preliminary draft of the report of the reviewer or auditor at which the reviewer or auditor and the provider shall discuss:

         1. The findings of the reviewer or auditor;
         2. Any documentation useful for the provider to refute the findings of the reviewer or auditor; and
         3. The next steps in the review or audit process.
      5. A physician's record or other order for health care services, drugs, or medicinal supplies in a form transmitted electronically shall be sufficient to validate the provider's records regarding the ordering of the health care services, drugs, or medicinal supplies.
      6. Whenever possible, the reviewer or auditor shall base a determination of an overpayment to a provider upon a review of actual records of the department, its agents, or the provider. In the event sufficient records are not available to the reviewer or auditor, an overpayment determination may be based upon a sampling of records so long as the sampling and any extrapolation therefrom is reasonably valid from a statistical standpoint and is in accordance with generally accepted auditing standards.
      7. If a reviewer or auditor determines that there has been an overpayment to the provider, then, at the time demand for repayment is made, the state department shall offer the provider an informal reconsideration of the review or audit findings. The state department shall notify the provider in writing of the right to an informal reconsideration prior to implementing any recovery of an overpayment and give the provider an opportunity to request an informal reconsideration. In the event informal reconsideration is requested or a formal appeal is filed pursuant to subparagraph (VIII) of this paragraph (a), the state department shall not implement recovery of the overpayment until such informal reconsideration or formal appeal has been completed. Within forty-five days after the request for an informal reconsideration, the state department shall render a decision on the request and notify the provider of the decision. The notification shall include information concerning requesting a formal appeal, including informing the provider that the request must be filed within thirty days after the date of the state department's decision on the request for an informal reconsideration. If the state department is unable to render a decision on the request for informal reconsideration within forty-five days after the request, within forty-five days after the request, the state department shall notify the provider of its inability to complete the decision and shall include information concerning requesting a formal appeal, including informing the provider that the request must be filed within thirty days after the receipt of the notification that the state department is unable to render a decision. For purposes of this subparagraph (VII), an informal reconsideration shall be considered final thirty days after the earlier of the date on which the provider withdraws its request or the date on which the state department issues a written decision on the request.
      8. In accordance with paragraph (e) of subsection (2) of this section, any provider adversely affected by the actions of the state department or its contracting agent in connection with a review or an audit, including whether the state department or its contracting agent adhered to the provisions of this subsection (3) in making an overpayment determination, may appeal such actions pursuant to the provisions of section 24-4-105, C.R.S.
   2. Any additional review or audit procedures shall be adopted by rule of the state board and shall be specifically referenced in any contract with a provider.
   3. The state department is authorized to engage the services of a qualified agent through a competitive contract issued pursuant to the state's procurement code for the purpose of conducting a review or audit of a provider to assist in determining whether there has been an overpayment to a provider and the amount of that overpayment. In addition to such terms and conditions as the state department may deem necessary, any contract shall be subject to the requirements for conducting a review or an audit in accordance with paragraph (a) of this subsection (3). The state department is further authorized to enter into a contract with a qualified agent for the purpose of conducting a review or an audit of a provider that provides that the compensation of the contracting agent shall be contingent and based upon a percentage of the amount of the recovery collected from the provider. A contract issued by the state department for the purpose of conducting a review or an audit of a provider to determine whether the provider has received an overpayment shall also be subject to the following conditions:
      1. The compensation paid to the contracting agent under a contingency-based contract shall not exceed eighteen percent of the amount finally collected from the provider overpayment, and the state department may establish a limit on the amount of annual compensation that may be paid to a contracting agent under a contingency-based contract and may further establish a limit on the amount that may be paid to a contracting agent under a contingency-based contract for recovery from any one provider.
      2. Reimbursement of the contracting agent's costs in performing the review or audit under a contingency-based contract shall be deemed included in the percentage compensation due the agent under the contract.
      3. No employee or agent of the contracting agent involved in the performance of a contingency-based contract shall be compensated by the contracting agent based upon the amount recovered under the contract.
      4. The state department shall retain all authority for providing notice and otherwise making demand upon a provider for recovery of an overpayment, and the state department shall review and approve any written demand, request, or determination by the contracting agent regarding a review or an audit of a provider under this subsection (3).
      5. In any contingency-based contract authorized pursuant to this paragraph (b), the state of Colorado shall not be obligated to pay the contracting agent for amounts not actually collected from the provider.
   1. (3.5) (a) Prior to the start of a contract to review or audit providers, the state department is encouraged to meet with organizations or associations of providers to educate providers on the review or audit process and the responsibilities of both the providers and the state department throughout the review or audit process. The state department is also encouraged to prepare an annual report on common findings following a contract to review or audit providers and distribute the report to organizations or associations of providers. The annual report should include information to prevent similar findings in future reviews or audits and should direct providers to resource information.
   2. Repealed.
4. If medical assistance is furnished to or on behalf of a recipient pursuant to the provisions of this article and articles 5 and 6 of this title for which a third party is liable, the state department has an enforceable right against such third party for the amount of such medical assistance, including the lien right specified in subsection (5) of this section. Whenever the recipient has brought or may bring an action in court to determine the liability of the third party, the state department, without any other name, title, or authority to enforce the state department's right, may enter into appropriate agreements and assignments of rights with the recipient and the recipient's attorney, if any. Any such agreement shall be filed with the court in which such an action is pending. The attorney named in such an agreement upon designation as a special assistant attorney general by the attorney general shall have the right to prove both the recipient's claim and the state department's claim. The state department, without any other name, title, or authority, may take any necessary action to determine the existence and amount of the state department's claims under this section, whether such claims are founded on judgment, contract, lien, or otherwise, and take any other action that is appropriate to recover from such third parties. To enforce such right, the attorney general, pursuant to section 24-31-101, C.R.S., on behalf of the state department may institute and prosecute, or intervene of right in legal proceedings against the third party having legal liability, either in the name of the state department or in the name of the recipient or his or her assignee, guardian, personal representative, estate, or survivors. When the state department intervenes in legal proceedings against the third party, it shall not be liable for any portion of the attorney fees or costs of the recipient.
5. 1. When the state department has furnished medical assistance to or on behalf of a recipient pursuant to the provisions of this article, and articles 5 and 6 of this title, for which a third party is liable, the state department shall have an automatic statutory lien for all such medical assistance. The state department's lien shall be against any judgment, award, or settlement in a suit or claim against such third party and shall be in an amount that shall be the fullest extent allowed by federal law as applicable in this state, but not to exceed the amount of the medical assistance provided.
   2. No judgment, award, or settlement in any action or claim by a recipient to recover damages for injuries, where the state department has a lien, shall be satisfied without first satisfying the state department's lien. Failure by any party to the judgment, award, or settlement to comply with this section shall make each such party liable for the full amount of medical assistance furnished to or on behalf of the recipient for the injuries that are the subject of the judgment, award, or settlement.
   3. Except as otherwise provided in this article, the entire amount of any judgment, award, or settlement of the recipient's action or claim, with or without suit, regardless of how characterized by the parties, shall be subject to the state department's lien.
   4. Where the action or claim is brought by the recipient alone and the recipient incurs a personal liability to pay attorney fees, the state department will pay its reasonable share of attorney fees not to exceed twenty-five percent of the state department's lien. The state department shall not be liable for costs.
   5. The state department's right to recover under this section is independent of the recipient's right.
6. When the applicant or recipient, or his or her guardian, executor, administrator, or other appropriate representative, brings an action or asserts a claim against any third party, such person shall give to the state department written notice of the action or claim by personal service or certified mail within fifteen days after filing the action or asserting the claim. Failure to comply with this subsection (6) shall make the recipient, legal guardian, executor, administrator, attorney, or other representative liable for the entire amount of medical assistance furnished to or on behalf of the recipient for the injuries that gave rise to the action or claim. The state department may, after thirty days' written notice to such person, enforce its rights under subsection (5) of this section and this subsection (6) in the district court of the city and county of Denver; except that liability of a person other than the recipient shall exist only if such person had knowledge that the recipient had received medical assistance or if excusable neglect is found by the court. The court shall award the state department its costs and attorney fees incurred in the prosecution of any such action.
7. When a legally responsible relative of the recipient agrees or is ordered to provide medical support or health insurance coverage for his or her dependents or other persons, and such dependents are applicants for, recipients of, or otherwise entitled to receive medical assistance pursuant to this article and articles 5 and 6 of this title, the state department shall be subrogated to any rights that the responsible persons may have to obtain reimbursement from a third party or insurance carrier for the cost of medical assistance provided for such dependents or persons. Where the state department gives written notice of subrogation, any third party or insurance carrier liable for reimbursement for the cost of medical care shall accord to the state department all rights and benefits available to the responsible relative that pertain to the provision of medical care to any persons entitled to medical assistance pursuant to this article and articles 5 and 6 of this title for whom the relative is legally responsible.
8. All recipients of medical assistance under the medicaid program shall be deemed to have authorized their attorneys, all third parties, including but not limited to insurance companies, and providers of medical care to release to the state department all information needed by the state department to secure and enforce its rights under subsections (4) and (5) of this section.
9. Nothing in part 6 of article 4 of title 10, C.R.S., shall be construed to limit the right of the state department to recover the medical assistance furnished to or on behalf of a recipient as the result of the negligence of a third party.
10. No action taken by the state department pursuant to subsection (4) of this section or any judgment rendered in such action shall be a bar to any action upon the claim or cause of action of the applicant or recipient or his or her guardian, personal representative, estate, dependent, or survivors against the third party having legal liability, nor shall any such action or judgment operate to deny the applicant or recipient the recovery for that portion of his or her medical costs or other damages not provided as medical assistance under this article or article 5 or 6 of this title.
11. 1. The state department shall have a right to recover any amount of medical assistance paid on behalf of a recipient because:
       1. The trustee of a trust for the benefit of the recipient has used the trust property in a manner contrary to the terms of the trust;
       2. A person holding the recipient's power of attorney has used the power for purposes other than the benefit of the recipient.
    2. To enforce the right under this subsection (11), the county or state department may institute or intervene in legal proceedings against the trustee or person holding the power of attorney. Any amount of medical assistance recovered pursuant to this subsection (11) shall be distributed between the state and county in proportion to the amount of medical assistance paid by each respectively, if any.
    3. No action taken by the county or state department pursuant to this subsection (11) or any judgment rendered in such action or proceeding shall be a bar to any action upon the claim or cause of action of the recipient or his or her guardian, personal representative, estate, dependent, or survivors against the trustee or person holding the power of attorney.
12. 1. An entity that provides managed care, as defined in section 25.5-5-403, that has entered into a risk contract with the state department shall have the same rights of the department set forth in this section except with respect to the rights described in subsections (5) and (6) of this section. In addition, the attorney general may not enforce the rights set forth in this subsection (12). Venue for an action brought by or on behalf of an entity pursuant to this subsection (12) shall be governed by the Colorado rules of civil procedure.
    2. Within fifteen days after filing an action or asserting a claim against a third party, a recipient under a managed care plan or a guardian, executor, administrator, or other appropriate representative of the recipient shall provide to the entity that administers the managed care plan written notice of the action or claim. Notice shall be by personal service or certified mail.
    3. In cases where the state department has recovery rights against a third party pursuant to subsections (4) and (5) of this section and an entity that provides managed care has subrogation rights against the same party pursuant to paragraph (a) of this subsection (12), the recovery rights of the state department shall take precedence over the rights of the managed care plan.
13. To the extent allowable under federal law, the state department shall recover from a legal immigrant's sponsor all medical assistance paid on behalf of a sponsored legal immigrant who is enrolled in the medical assistance program.
14. Notwithstanding any provision of this section to the contrary:
    1. 1. The state department, or the state department's designated agent, shall conduct pre-enrollment and post-enrollment site visits of providers who are designated as moderate or high categorical risks to the medicaid program. The purpose of the site visit is to verify that the information submitted to the state department is accurate and to determine compliance with federal and state enrollment requirements.
       2. As established in rules promulgated by the state board, the state department may waive pre-enrollment and post-enrollment site visits of providers if the site visits are conducted by medicare or other federally designated entities.
       3. A provider is designated as a limited, moderate, or high categorical risk pursuant to the medicare program and federal regulations. If a provider is not designated in a risk category pursuant to the medicare program and federal regulations, the provider's risk category shall be established pursuant to rules promulgated by the state board.
    2. A provider enrolled in the medicaid program shall permit the centers for medicare and medicaid services or its agent or designated contractors and the state department or its agent to conduct unannounced, on-site inspections of any and all provider locations. Payment for any agent designated by the state department to perform on-site inspections shall not be based on any recoveries paid to the state department by a provider for violations discovered as a result of the on-site inspection.
15. 1. The state department may request a written response from any provider who fails to comply with the rules, manuals, or bulletins issued by the state department, state board, or the state department's fiscal agent, or from any provider whose activities endanger the health, safety, or welfare of medicaid recipients. The written response must describe how the provider will come into and ensure future compliance. If a written response is requested, a provider has thirty days, or longer if approved by the state department, to submit the written response.
    2. If the provider does not agree with the state department's findings that resulted in the request issued pursuant to subsection (15)(a) of this section, then the provider's written response must include an explanation and specific reasons for the provider's disagreement.

Source: L. 2006: Entire article added with relocations, p. 1829, § 7, effective July 1; (1)(a)(II.5) added, p. 107, § 1, effective January 1, 2007. L. 2007: (3)(a)(IV) and (3)(a)(VII) amended and (3)(a)(IV.5), (3)(a.5), and (3.5) added, pp. 1467, 1469, 1468, §§ 1, 3, 2, effective May 30. L. 2009: (5)(a) and (5)(c) amended, (HB 09-1191), ch. 100, p. 372, § 1, effective August 5. L. 2010: (2)(a)(II) amended, (SB 10-167), ch. 296, p. 1378, § 7, effective May 26. L. 2013: (14) added, (HB 13-1068), ch. 119, p. 405, § 1, effective April 8. L. 2017: (1)(a)(II.5)(A) and (1)(a)(II.5)(B) amended and (1)(a)(II.5)(A.5), (1)(a)(II.5)(D), and (15) added, (HB 17-1139), ch. 376, p. 1942, § 2, effective June 6. L. 2018: IP(2), IP(3)(a), and (3)(a)(IV) amended, (SB 18-092), ch. 38, p. 444, § 110, effective August 8.

25.5-4-302. Recovery of assets.

1. The general assembly hereby finds, determines, and declares that the cost of providing medical assistance to qualified recipients throughout the state has increased significantly in recent years; that such increasing costs have created an increased burden on state revenues while reducing the amount of such revenues available for other state programs; that recovering some of the medical assistance from the estates of medical assistance recipients would be a viable mechanism for such recipients to share in the cost of such assistance; and that such an estate recovery program would be a cost-efficient method of offsetting medical assistance costs in an equitable manner. The general assembly also declares that in order to ensure that medicaid is available for low-income individuals reasonable restrictions consistent with federal law should be placed on the ability of persons to become eligible for medicaid by means of making transfers of property without fair and valuable consideration.
2. 1. Medical assistance paid on behalf of any individual who was fifty-five years of age or older when the individual received such assistance may be recovered by the state department from the estate of such individual in accordance with paragraph (c) of this subsection (2).
   2. Medical assistance paid on behalf of any individual who is institutionalized may be recovered by the state department from the estate of such individual in accordance with paragraph (c) of this subsection (2).
   3. The state department shall establish an estate recovery program only insofar as such program is in accordance with Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended, and shall not take any action to recover medical assistance when the amount of assistance to be recovered is economically inappropriate in relation to expenses of recovery.
3. The state department is authorized to file liens against any property of an individual who is institutionalized and from whom the state department may recover medical assistance pursuant to paragraph (b) of subsection (2) of this section.
4. The state department may compromise, settle, or waive any recovery of medical assistance authorized pursuant to subsection (2) of this section upon good cause shown.
5. Subject to any limitation concerning estate recovery in Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended, the amount of any medical assistance paid pursuant to the provisions of this article and articles 5 and 6 of this title is a claim against the estate pursuant to the provisions of section 15-12-805 (1), C.R.S.
6. The state board shall promulgate rules to implement the provisions of this section, including rules limiting the eligibility for medical assistance if the person made a voluntary assignment or transfer of property without fair and valuable consideration prior to applying for medical assistance. A contract for an exempt burial fund for an individual shall include a provision restricting the full amount to the cost of the burial and stating that any portion not expended for the burial costs shall be refunded to the state department by the mortuary as reimbursement for the cost of medical assistance provided to the individual. Said rules shall be in accordance with Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended.
7. Effective upon the implementation of a private-public partnership program for financing long-term care pursuant to section 25.5-6-110, this section shall apply to participants of such program only after excluding from the amount that may otherwise be recovered from such person's estate an amount allowed by rules adopted by the state board in accordance with section 25.5-6-110.

Source: L. 2006: Entire article added with relocations, p. 1836, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-403.3 as it existed prior to 2006.

25.5-4-303. State income tax refund intercept - garnishment of earning - failure to provide medical support for child.

1. 1. At any time prescribed by the department of revenue, but not less frequently than annually, the state department may certify to the department of revenue information regarding any person who:
      1. Is obligated to the state agency responsible for administering medical assistance in this state for medical support based on medical assistance provided to the obligor's dependent child; and
      2. Has received payment from a third party to cover the health care costs of the child but has neither applied such payment to cover the child's health care costs nor to reimburse the state department, the custodial parent of the child, or the provider of medical care.
   2. The information provided to the department of revenue shall include the name and the social security number of the person described in paragraph (a) of this subsection (1), the amount of medical assistance provided to the child during the period for which medical support was ordered but not provided as described in subparagraph (II) of paragraph (a) of this subsection (1), and any other identifying information required by the department of revenue.
2. Prior to a final certification of the information described in subsection (1) of this section to the department of revenue, the state department shall notify the obligated person, in writing, that the state intends to refer the person's name to the department of revenue in an attempt to offset the person's medical support obligation against the person's state income tax refund. Such notification shall include information on the parent's right to object to the offset.
3. Upon notification by the department of revenue of amounts deposited with the state treasurer pursuant to section 39-21-108 (3), C.R.S., the state department may recover the amount of the medical assistance described in paragraph (b) of subsection (1) of this section.
4. The state department may garnish the wages and other earnings of a person described in paragraph (a) of subsection (1) of this section. The garnishment of wages and earning shall be in accordance with articles 54 and 54.5 of title 13, C.R.S.
5. The state board shall adopt rules as are necessary for the implementation of this section.

Source: L. 2006: Entire article added with relocations, p. 1838, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-403.4 as it existed prior to 2006.

25.5-4-303.3. Provider fraud - attorney general report.

1. No later than October 1, 2017, and no later than October 1 each year thereafter, the attorney general shall submit a written report to the state department for inclusion in a single, comprehensive report to the general assembly concerning medicaid fraud pursuant to section 25.5-1-115.5. The attorney general shall provide information relating to medicaid provider fraud including, at a minimum:
   1. Investigations of provider fraud during the year;
   2. Criminal complaints requested, cases dismissed, cases acquitted, convictions, and confessions of judgment;
   3. Recoveries, including fines and penalties, restitution ordered, and restitution collected;
   4. Civil claims;
   5. Trends in methods used to commit provider fraud, excluding law enforcement-sensitive information; and
   6. An estimate of the total savings, total cost, and net cost-effectiveness of fraud detection and recovery efforts.

Source: L. 2012: Entire section added, (SB 12-060), ch. 166, p. 578, § 2, effective August 8. L. 2017: IP(1), (1)(d), and (1)(e) amended and (1)(f) added, (SB 17-295), ch. 298, p. 1637, § 2, effective August 9.

25.5-4-303.5. Short title.

This section and sections 25.5-4-304 to 25.5-4-310 shall be known and may be cited as the "Colorado Medicaid False Claims Act".

Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1379, § 10, effective May 26.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-304. Definitions.

As used in sections 25.5-4-303.5 to 25.5-4-309, unless the context otherwise requires:

1. 1. "Claim" means a request or demand for money or property, whether under a contract or otherwise, and regardless of whether the state has title to the money or property, under the "Colorado Medical Assistance Act" that is:
      1. Presented to an officer, employee, or agent of the state; or
      2. Made to a contractor, grantee, or other recipient if the money or property is to be spent or used on the state's behalf or to advance a program or interest of the state and if the state:
         1. Provides or has provided any portion of the money or property requested or demanded; or
         2. Will reimburse the contractor, grantee, or other recipient for any portion of the money or property that is requested or demanded.
   2. "Claim" does not include a request or demand for money or property that the state has paid to an individual as compensation for employment by the state or as an income subsidy with no restriction on that individual's use of the money or property.
2. "Colorado Medical Assistance Act" means this article and articles 5 and 6 of this title.
3. 1. "Knowing" or "knowingly" means that a person, with respect to information:
      1. Has actual knowledge of the information;
      2. Acts in deliberate ignorance of the truth or falsity of the information; or
      3. Acts in reckless disregard of the truth or falsity of the information.
   2. "Knowing" or "knowingly" does not require proof of specific intent to defraud.
4. "Material" means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.
5. "Obligation" means a fixed or contingent duty arising from an express or implied contractual, quasi-contractual, grantor-grantee, licensor-licensee, statutory, fee-based, or similar relationship, or the retention of overpayment.

Source: L. 2006: Entire article added with relocations, p. 1838, § 7, effective July 1. L. 2010: Entire section R&RE, (SB 10-167), ch. 296, p. 1379, § 11, effective May 26. L. 2013: (5) amended, (SB 13-205), ch. 276, p. 1441, § 3, effective August 7.

Editor's note: This section is similar to former §§ 26-4-1102 and 26-4-1103 (3) as they existed prior to 2006.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-305. False medicaid claims - liability for certain acts.

1. Except as otherwise provided in subsection (2) of this section, a person is liable to the state for a civil penalty of not less than five thousand five hundred dollars and not more than eleven thousand dollars; except that these upper and lower limits on liability shall automatically increase to equal the civil penalty allowed under the federal "False Claims Act", 31 U.S.C. sec. 3729, et seq., if and as the penalties in such federal act may be adjusted for inflation as described in said act in accordance with the federal "Civil Penalties Inflation Adjustment Act of 1990", Pub. L. No. 101-410, plus three times the amount of damages that the state sustains because of the act of that person, if the person:
   1. Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;
   2. Knowingly makes, uses, or causes to be made or used a false record or statement material to a false or fraudulent claim;
   3. Has possession, custody, or control of property or money used, or to be used, by the state in connection with the "Colorado Medical Assistance Act"and knowingly delivers, or causes to be delivered, less than all of the money or property;
   4. Authorizes the making or delivery of a document certifying receipt of property used, or to be used, by the state in connection with the "Colorado Medical Assistance Act" and, intending to defraud the state, makes or delivers the receipt without completely knowing that the information on the receipt is true;
   5. Knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the state in connection with the "Colorado Medical Assistance Act" who lawfully may not sell or pledge the property;
   6. Knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the state in connection with the "Colorado Medical Assistance Act", or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the state in connection with the "Colorado Medical Assistance Act";
   7. Conspires to commit a violation of paragraphs (a) to (f) of this subsection (1).
2. Notwithstanding the amount of damages authorized in subsection (1) of this section, for a person who violates subsection (1) of this section, the court may assess not less than twice the amount of damages that the state sustains because of the act of the person if the court finds that:
   1. The person who committed the violation of subsection (1) of this section furnished to the officials of the state responsible for investigating false claims violations all information about the violation known to the person and furnished said information within thirty days after the date on which the person first obtained the information;
   2. At the time the person furnished the information about the violation to the state, a criminal prosecution, civil action, or administrative action had not commenced with respect to the violation and the person did not have actual knowledge of the existence of an investigation into the violation; and
   3. The person fully cooperated with any investigation of the violation by the state.
3. A person violating this section shall also be liable to the state for the costs of a civil action brought to recover any penalty or damages.
4. Any information furnished pursuant to subsection (2) of this section shall be exempt from disclosure under part 2 of article 72 of this title.

Source: L. 2006: Entire article added with relocations, p. 1839, § 7, effective July 1. L. 2010: Entire section R&RE, (SB 10-167), ch. 296, p. 1380, § 12, effective May 26. L. 2011: IP(1) amended, (HB 11-1303), ch. 264, p. 1168, § 66, effective August 10. L. 2013: IP(1) and (1)(a) amended, (SB 13-205), ch. 276, p. 1441, § 4, effective August 7.

Editor's note: This section is similar to former § 26-4-1103 (1) and (2) as they existed prior to 2006.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-306. Civil actions for false medicaid claims.

1. Responsibility of attorney general. The attorney general shall diligently investigate a violation under section 25.5-4-305. If the attorney general finds that a person has violated or is violating section 25.5-4-305, the attorney general may bring a civil action under this section against the person.
2. Actions by private persons.
   1. A relator may bring a civil action for a violation of section 25.5-4-305 on behalf of the relator and the state. The action shall be brought in the name of the state. The action may be dismissed only if the court and the attorney general give written consent to the dismissal and their reasons for consenting.
   2. A copy of the complaint and written disclosure of substantially all material evidence and information the relator possesses shall be served on the state pursuant to rule 4 of the Colorado rules of civil procedure. The complaint shall be filed in camera, shall remain under seal for at least sixty days, and shall not be served on the defendant until the court so orders. The state may elect to intervene and proceed with the action within sixty days after it receives both the complaint and the material evidence and information.
   3. The state may, for good cause shown, move the court for extensions of the time during which the complaint remains under seal under paragraph (b) of this subsection (2). Any such motion may be supported by affidavits or other submissions in camera. The defendant shall not be required to respond to a complaint filed under this section until twenty days after the complaint is unsealed and served upon the defendant pursuant to rule 4 of the Colorado rules of civil procedure.
   4. Before the expiration of the sixty-day period pursuant to paragraph (b) of this subsection (2) or any extensions obtained under paragraph (c) of this subsection (2), the state shall:
      1. Proceed with the action, in which case the state shall conduct the action; or
      2. Notify the court that it declines to take over the action, in which case the relator shall have the right to conduct the action.
   5. When a relator brings an action under this subsection (2), no person other than the state may intervene or bring a related action based on the facts underlying the pending action.
3. Rights of parties to private actions.
   1. If the state proceeds with an action brought under subsection (2) of this section, it shall have the primary responsibility for prosecuting the action and shall not be bound by an act of the relator. The relator shall have the right to continue as a party to the action, subject to the limitations set forth in paragraph (b) of this subsection (3).
   2. 1. The state may dismiss the action notwithstanding the objections of the relator if the relator has been notified by the state of the filing of the motion and the court has provided the relator with an opportunity for a hearing on the motion.
      2. The state may settle the action with the defendant notwithstanding the objections of the relator if the court determines, after a hearing, that the proposed settlement is fair, adequate, and reasonable under all the circumstances. Upon a showing of good cause, the hearing may be held in camera.
      3. Upon a showing by the state that unrestricted participation during the course of the litigation by the relator would interfere with or unduly delay the state's prosecution of the case, or would be repetitious, irrelevant, or for purposes of harassment, the court may, in its discretion, impose limitations on the relator's participation, including but not limited to:
         1. Limiting the number of witnesses the relator may call;
         2. Limiting the length of the testimony of the witnesses;
         3. Limiting the relator's cross-examination of witnesses; or
         4. Otherwise limiting the participation by the relator in the litigation.
      4. Upon a showing by the defendant that unrestricted participation during the course of the litigation by the relator would be for purposes of harassment or would cause the defendant undue burden or unnecessary expense, the court may limit the participation by the relator in the litigation.
   3. If the state elects not to proceed with the action, the relator who initiated the action shall have the right to conduct the action. If the state so requests, it shall be served with copies of all pleadings filed in the action and, at the state's expense, shall be supplied with copies of all deposition transcripts. When a relator proceeds with the action, the court, without limiting the status and rights of the relator, may nevertheless permit the state to intervene at a later date upon a showing of good cause.
   4. Regardless of whether the state proceeds with the action, upon a showing by the state that certain actions of discovery by the relator would interfere with the state's investigation or prosecution of a criminal or civil matter arising out of the same facts, the court may stay the discovery for a period of not more than sixty days. The showing shall be conducted in camera. The court may extend the sixty-day period upon a further showing in camera that the state has pursued the criminal or civil investigation or proceedings with reasonable diligence and that any proposed discovery in the civil action will interfere with the ongoing criminal or civil investigation or proceedings.
   5. Notwithstanding the provisions of subsection (2) of this section, the state may elect to pursue its claim through any alternate remedy available to the state, including any administrative proceeding to determine a civil money penalty. If an alternate remedy is pursued in another proceeding, the relator shall have the same rights in the proceeding as the relator would have had if the action had continued under this section. Any finding of fact or conclusion of law made in another proceeding that has become final shall be conclusive on all parties to an action under this section. For purposes of this paragraph (e), a finding or conclusion is final if it has been finally determined on appeal to the appropriate court of the state, if all time for filing such an appeal with respect to the finding or conclusion has expired, or if the finding or conclusion is not subject to judicial review.
4. Award to private persons.
   1. 1. If the state proceeds with an action brought by a relator under subsection (2) of this section, the relator shall, subject to subparagraph (II) of this paragraph (a), receive at least fifteen percent but not more than twenty-five percent of the proceeds of the action or settlement of the claim, depending upon the extent to which the relator substantially contributed to the prosecution of the action.
      2. If the court finds the action to be based primarily on disclosures of specific information, other than information provided by the relator, relating to allegations or transactions in a criminal, civil, or administrative hearing, in a legislative, administrative, or state auditor's report, hearing, audit, or investigation, or from the news media, the court may award to the relator such sums as it considers appropriate, but in no case more than ten percent of the proceeds, taking into account the significance of the information and the role of the relator in advancing the case to litigation.
      3. Any payment to a relator under subparagraph (I) or (II) of this paragraph (a) shall be made from the proceeds. The relator shall also receive an amount for reasonable expenses that the court finds to have been necessarily incurred plus reasonable attorney fees and costs. All such expenses, fees, and costs shall be awarded against the defendant.
   2. If the state does not proceed with an action brought under subsection (2) of this section, the relator bringing the action or settling the claim shall receive an amount that the court decides is reasonable for collecting the civil penalty and damages. The amount shall be not less than twenty-five percent and not more than thirty percent of the proceeds of the action or settlement and shall be paid out of the proceeds. The relator shall also receive an amount for reasonable expenses that the court finds to have been necessarily incurred, plus reasonable attorney fees and costs. All such expenses, fees, and costs shall be awarded against the defendant.
   3. Regardless of whether the state proceeds with an action brought under subsection (2) of this section, if the court finds that the action was brought by a relator who planned and initiated the violation of section 25.5-4-305 upon which the action was brought, then the court may, to the extent the court considers appropriate, reduce the share of the proceeds of the action that the relator would otherwise receive under paragraph (a) or (b) of this subsection (4), taking into account the role of the relator in advancing the case to litigation and any relevant circumstances pertaining to the violation. If the relator is convicted of criminal conduct arising from his or her role in the violation of section 25.5-4-305, the relator shall be dismissed from the civil action and shall not receive any share of the proceeds of the action. Such dismissal shall not prejudice the right of the state to continue the action.
   4. If the state does not proceed with an action brought under subsection (2) of this section and the relator bringing the action conducts the action, the court may award to the defendant its reasonable attorney fees and expenses if the defendant prevails in the action and the court finds that the claim of the relator was clearly frivolous, clearly vexatious, or brought primarily for purposes of harassment.
5. Certain actions barred.
   1. A court shall not have jurisdiction over an action brought under this section against a member of the general assembly, a member of the state judiciary, or an elected official in the executive branch of the state of Colorado if the action is based on evidence or information known to the state when the action was brought.
   2. A relator shall not bring an action under subsection (2) of this section that is based upon allegations or transactions that are the subject of a civil suit or an administrative civil money penalty proceeding in which the state is already a party.
   3. 1. A court shall dismiss an action or claim brought under subsection (2) of this section unless opposed by the state, if substantially the same allegations or transactions as alleged in the action or claim were publicly disclosed in a state criminal, civil, or administrative hearing in which the state or its agent is a party, in a legislative, administrative, or state auditor's report, hearing, audit, or investigation, or by the news media, unless the action is brought by the state or the relator is an original source of the information.
      2. For purposes of this paragraph (c), "original source" means an individual who, prior to a public disclosure under subparagraph (I) of this paragraph (c), has voluntarily disclosed to the state the information on which the allegations or transactions in a claim are based, or who has knowledge that is independent of and materially adds to the publicly disclosed allegations or transactions, and has voluntarily provided the information to the state before filing an action under subsection (2) of this section.
6. State not liable for certain expenses. The state is not liable for expenses that a relator incurs in bringing an action under this section.
7. Private action for retaliation.
   1. An employee, contractor, or agent shall be entitled to all relief necessary to make the employee, contractor, or agent whole, if the employee, contractor, or agent is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by the defendant or by any other person because of lawful acts done by the employee, contractor, or agent, or associated others in furtherance of an action under this section or in furtherance of an effort to stop any violations of section 25.5-4-305.
   2. 1. An employee, contractor, or agent who seeks relief pursuant to this subsection (7) shall be entitled to all relief necessary to make the employee, contractor, or agent whole. Such relief shall include:
         1. Reinstatement with the same seniority status the employee, contractor, or agent would have had but for the discrimination, twice the amount of back pay, and interest on the back pay; and
         2. Compensation for any special damages sustained as a result of the discrimination or retaliation, including litigation costs and reasonable attorney fees.
      2. An employee, contractor, or agent may bring an action in the appropriate court of the state for the relief provided in this subsection (7).

Source: L. 2006: Entire article added with relocations, p. 1840, § 7, effective July 1. L. 2009: IP(1)(b), IP(1)(c), and (4) amended, (SB 09-292), ch. 369, p. 1974, § 97, effective August 5. L. 2010: Entire section R&RE, (SB 10-167), ch. 296, p. 1382, § 13, effective May 26. L. 2013: (2)(e), (5), and (7) amended, (SB 13-205), ch. 276, p. 1441, § 5, effective August 7.

Editor's note: This section is similar to former § 26-4-1104 as it existed prior to 2006.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-307. False medicaid claims procedures - statute of limitations.

1. A civil action under section 25.5-4-306 (1) or (2) may not be brought after the later of:
   1. More than six years after the date on which the violation of section 25.5-4-305 is committed; or
   2. More than three years after the date when facts material to the right of action are known or reasonably should have been known by the official of the state charged with responsibility to act in the circumstances, but in no event more than ten years after the date on which the violation of section 25.5-4-305 is committed.
2. If the state elects to intervene and proceed with an action brought under section 25.5-4-306, the state may file its own complaint or amend the relator's complaint to clarify or add detail to the claims in which the state is intervening and to add any additional claims with respect to which the state contends it is entitled to relief. For statute of limitations purposes, any such pleadings by the state shall relate back to the filing date of the relator's complaint, to the extent that the state's claim arises out of the conduct, transactions, or occurrences set forth, or attempted to be set forth, in the prior complaint of the relator.
3. In an action brought under section 25.5-4-306, the state or relator must prove all essential elements of the cause of action, including damages, by a preponderance of the evidence.
4. Notwithstanding any other provision of law, the Colorado rules of criminal procedure, or the Colorado rules of evidence, a final judgment rendered in favor of the state in a criminal proceeding charging fraud or false statements, whether upon a verdict after trial or upon a plea of guilty or nolo contendere, shall estop the defendant from denying the essential elements of the offense in any action that involves the same transaction as in the criminal proceeding and that is brought under section 25.5-4-306.
5. A private action for retaliation under section 25.5-4-306 (7) may not be brought more than three years after the date when the retaliation occurred.

Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1386, § 14, effective May 26. L. 2013: (5) added, (SB 13-205), ch. 276, p. 1442, § 6, effective August 7.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-308. False medicaid claims jurisdiction.

An action under section 25.5-4-306 may be brought in any judicial district in which the defendant or, in the case of multiple defendants, any one defendant can be found, resides, or transacts business or in which an act proscribed by section 25.5-4-305 occurred. A summons as required by the Colorado rules of civil procedure shall be issued by the appropriate district court and served at any place.

Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1387, § 14, effective May 26.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-309. False medicaid claims civil investigation demands.

1. General.
   1. 1. Whenever the attorney general has reason to believe that a person may be in possession, custody, or control of documentary material or information relevant to a false medicaid claims law investigation, the attorney general may, before commencing a civil proceeding under section 25.5-4-306 or other false medicaid claims law or making an election under section 25.5-4-306 (2)(d), issue in writing and cause to be served upon the person a civil investigative demand requiring the person to:
         1. Produce the documentary material for inspection and copying;
         2. Answer in writing written interrogatories with respect to the documentary material or information;
         3. Give oral testimony concerning the documentary material or information; or
         4. Furnish any combination of such material, answers, or testimony.
      2. The attorney general may not delegate the authority to issue civil investigative demands under this subsection (1). Whenever a civil investigative demand is an express demand for any product of discovery, the attorney general, the deputy attorney general, or an assistant attorney general shall cause to be served, in any manner authorized by this section, a copy of the demand upon the person from whom the discovery was obtained and shall notify the person to whom the demand is issued of the date on which the copy was served.
   2. 1. Each civil investigative demand issued under this subsection (1) shall state the nature of the conduct constituting the alleged violation of a false medicaid claims law that is under investigation and the applicable provision of law alleged to be violated.
      2. If the demand is for the production of documentary material, the demand shall:
         1. Describe each class of documentary material to be produced with such definiteness and certainty as to permit the material to be fairly identified;
         2. Prescribe a return date for each such class that will provide a reasonable period of time within which the material so demanded may be assembled and made available for inspection and copying; and
         3. Identify the false medicaid claims law investigator to whom the material shall be made available.
      3. If the demand is for answers to written interrogatories, the demand shall:
         1. Specify the written interrogatories to be answered;
         2. Prescribe dates on which answers to written interrogatories shall be submitted; and
         3. Identify the false medicaid claims law investigator to whom the answers shall be submitted.
      4. If the demand is for the giving of oral testimony, the demand shall:
         1. Prescribe a date, time, and place at which oral testimony shall be commenced and notify the deponent if the oral testimony is to be video or audio recorded;
         2. Identify a false medicaid claims law investigator who shall conduct the examination and the custodian to whom the transcript of the examination shall be submitted;
         3. Specify that such attendance and testimony are necessary to the conduct of the investigation;
         4. Notify the person receiving the demand of the right to be accompanied by an attorney and any other representative; and
         5. Describe the general purpose for which the demand is being issued and the general nature of the testimony, including the primary areas of inquiry, that will be taken pursuant to the demand.
      5. A civil investigative demand issued under this section that is an express demand for any product of discovery shall not be returned or returnable until twenty days after a copy of the demand has been served upon the person from whom the discovery was obtained.
      6. The date prescribed for the commencement of oral testimony pursuant to a civil investigative demand issued under this section shall be a date that is not less than seven days after the date on which the demand is received, unless the attorney general or an assistant attorney general designated by the attorney general determines that exceptional circumstances are present that warrant the commencement of the testimony within a lesser period of time.
      7. The attorney general shall not authorize the issuance under this section of more than one civil investigative demand for oral testimony by the same person unless the person requests otherwise or unless the attorney general, after investigation, notifies that person in writing that an additional demand for oral testimony is necessary. Notwithstanding section 24-31-103, C.R.S., the attorney general shall not authorize the performance, by any other officer, employee, or agency, of any function vested in the attorney general under this subparagraph (VII).
2. Protected material or information.
   1. A civil investigative demand issued under subsection (1) of this section shall not require the production of documentary material, the submission of answers to written interrogatories, or the giving of oral testimony if the material, answers, or testimony would be protected from disclosure under:
      1. The standards applicable to subpoenas or subpoenas duces tecum issued by a court of this state to aid in a grand jury investigation; or
      2. The standards applicable to discovery requests under the Colorado rules of civil procedure, to the extent that the application of the standards to any such demand is appropriate and consistent with the provisions and purposes of this section.
   2. A demand that is an express demand for a product of discovery supersedes any inconsistent order, rule, or provision of law, other than this section, preventing or restraining disclosure of the product of discovery to a person. Disclosure of a product of discovery pursuant to an express demand does not constitute a waiver of any right or privilege that the person making the disclosure may be entitled to invoke to resist discovery of trial preparation materials.
3. Service and jurisdiction.
   1. A civil investigative demand issued under subsection (1) of this section or a petition brought pursuant to subsection (10) of this section may be served by a false medicaid claims law investigator, a sheriff, or a deputy sheriff at any place within the state.
   2. A civil investigative demand issued under subsection (1) of this section or a petition filed under subsection (10) of this section may be served upon a person who is not found within the state in the manner prescribed by the Colorado rules of civil procedure for service in another state or a foreign country. To the extent that the courts of this state can assert jurisdiction over any such person consistent with due process, the district court for the city and county of Denver shall have the same jurisdiction to take an action respecting compliance with this section by any such person that the court would have if the person were personally within the jurisdiction of the court.
4. Service on legal entities and natural persons.
   1. Service of a civil investigative demand issued under subsection (1) of this section or of a petition filed under subsection (10) of this section may be made upon a partnership, corporation, association, or other legal entity by:
      1. Delivering an executed copy of the demand or petition to a partner, executive officer, managing agent, or general agent of the partnership, corporation, association, or entity, or to an agent authorized by appointment or by law to receive service of process on behalf of the partnership, corporation, association, or entity;
      2. Delivering an executed copy of the demand or petition to the principal office or place of business of the partnership, corporation, association, or entity; or
      3. Depositing an executed copy of the demand or petition in the United States mail by registered or certified mail, with a return receipt requested, addressed to the partnership, corporation, association, or entity at its principal office or place of business.
   2. Service of a civil investigative demand issued under subsection (1) of this section or of a petition filed under subsection (10) of this section may be made upon a natural person by:
      1. Delivering an executed copy of the demand or petition to the person; or
      2. Depositing an executed copy of the demand or petition in the United States mail by registered or certified mail, with a return receipt requested, addressed to the person at the person's residence, principal office, or place of business.
5. Proof of service. A verified return by the individual serving a civil investigative demand issued under subsection (1) of this section or a petition filed under subsection (10) of this section setting forth the manner of the service shall be proof of the service. In the case of service by registered or certified mail, the return shall be accompanied by the return post office receipt of delivery of the demand.
6. Documentary material.
   1. 1. The production of documentary material in response to a civil investigative demand issued under subsection (1) of this section shall be made under a sworn certificate, in the form as the demand designates, by:
         1. In the case of a natural person, the person to whom the demand is directed; or
         2. In the case of a person other than a natural person, a person having knowledge of the facts and circumstances relating to the production and authorized to act on behalf of the person.
      2. The certificate shall state that all of the documentary material required by the demand and in the possession, custody, or control of the person to whom the demand is directed has been produced and made available to the false medicaid claims law investigator identified in the demand.
   2. A person upon whom a civil investigative demand for the production of documentary material has been served under this section shall make the material available for inspection and copying to the false medicaid claims law investigator identified in the demand at the principal place of business of the person, or at such other place as the false medicaid claims law investigator and the person thereafter may agree and prescribe in writing, or as the court may direct under subsection (10) of this section. The material shall be made so available on the return date specified in the demand, or on such later date as the false medicaid claims law investigator may prescribe in writing. The person may, upon written agreement between the person and the false medicaid claims law investigator, substitute copies for originals of all or any part of the material.
7. Interrogatories.
   1. Each interrogatory in a civil investigative demand issued under subsection (1) of this section shall be answered separately and fully in writing under oath and shall be submitted under a sworn certificate, in the form the demand designates, by:
      1. In the case of a natural person, the person to whom the demand is directed; or
      2. In the case of a person other than a natural person, the person or persons responsible for answering each interrogatory.
   2. If an interrogatory is objected to, the reasons for the objection shall be stated in the certificate instead of an answer. The certificate shall state that all information required by the demand and in the possession, custody, control, or knowledge of the person to whom the demand is directed has been submitted. To the extent that any information is not furnished, the information shall be identified and reasons set forth with particularity regarding the reasons why the information was not furnished.
8. Oral examinations.
   1. The examination of a person pursuant to a civil investigative demand for oral testimony issued under subsection (1) of this section shall be taken before an officer authorized to administer oaths and affirmations by the laws of the United States, the state of Colorado, or the place where the examination is held. The officer before whom the testimony is to be taken shall put the witness on oath or affirmation and shall, personally or with the assistance of someone acting under the direction of the officer and in the officer's presence, record the testimony of the witness. The testimony shall be taken stenographically and shall be transcribed. When the testimony is fully transcribed, the officer before whom the testimony is taken shall promptly transmit a copy of the transcript of the testimony to the custodian. This subsection (8) shall not preclude the taking of testimony by any means authorized by, and in a manner consistent with, the Colorado rules of civil procedure.
   2. The false medicaid claims law investigator conducting the examination shall exclude from the place where the examination is held all persons except the person giving the testimony, the attorney for and any other representative of the person giving the testimony, the attorney for the state, any person who may be agreed upon by the attorney for the state and the person giving the testimony, the officer before whom the testimony is to be taken, and the stenographer who is recording the testimony.
   3. The oral testimony of a person taken pursuant to a civil investigative demand served under this section shall be taken in the judicial district of the state within which the person resides, is found, or transacts business, or in another place as may be agreed upon by the false medicaid claims law investigator conducting the examination and the person.
   4. When the testimony is fully transcribed, the false medicaid claims law investigator or the officer before whom the testimony is taken shall afford the witness, who may be accompanied by counsel, a reasonable opportunity to examine and read the transcript, unless the witness waives the examination and reading. Any changes in form or substance that the witness desires to make shall be entered and identified upon the transcript by the officer or the false medicaid claims law investigator, with a statement of the reasons given by the witness for making the changes. The transcript shall then be signed by the witness, unless the witness in writing waives the signing, is ill, cannot be found, or refuses to sign. If the witness does not sign the transcript within thirty days after being afforded a reasonable opportunity to examine it, the officer or the false medicaid claims law investigator shall sign it and state on the record the fact of the waiver, illness, absence of the witness, or refusal to sign, together with the reasons, if any, given therefor.
   5. The officer before whom the testimony is taken shall certify on the transcript that the witness was sworn by the officer and that the transcript is a true record of the testimony given by the witness, and the officer or false medicaid claims law investigator shall promptly deliver the transcript, or send the transcript by registered or certified mail, to the custodian.
   6. Upon payment of reasonable charges therefor, the false medicaid claims law investigator shall furnish a copy of the transcript to the witness only; except that the attorney general, the deputy attorney general, or an assistant attorney general may, for good cause, limit the witness to inspection of the official transcript of the testimony of the witness.
   7. 1. A person compelled to appear for oral testimony under a civil investigative demand issued under subsection (1) of this section may be accompanied, represented, and advised by counsel. Counsel may advise the person, in confidence, with respect to any question asked of the person. The person or counsel may object on the record to any question, in whole or in part, and shall briefly state for the record the reason for the objection. An objection may be made, received, and entered upon the record when it is claimed that the person is entitled to refuse to answer the question on the grounds of any constitutional or other legal right or privilege, including the privilege against self-incrimination. The person may not otherwise object to or refuse to answer any question and may not directly or through counsel otherwise interrupt the oral examination. If the person refuses to answer a question, the false medicaid claims law investigator may file a petition in a district court under paragraph (a) of subsection (10) of this section for an order compelling the person to answer the question.
      2. If the person refuses to answer a question on the grounds of the privilege against self-incrimination, the false medicaid claims law investigator may compel the testimony of the person in accordance with the provisions of section 13-90-118, C.R.S.
      3. A person appearing for oral testimony under a civil investigative demand issued under subsection (1) of this section shall be entitled to the same fees and allowances that are paid to witnesses in the district courts of this state.
9. Custodian of documents, answers, and transcripts.
   1. The attorney general shall designate a false medicaid claims law investigator to serve as custodian of documentary material, answers to interrogatories, and transcripts of oral testimony received under this section and shall designate such additional false medicaid claims law investigators as the attorney general determines from time to time to be necessary to serve as deputies to the custodian.
   2. 1. A false medicaid claims law investigator who receives any documentary material, answers to interrogatories, or transcripts of oral testimony under this section shall transmit them to the custodian. The custodian shall take physical possession of the material, answers, or transcripts and shall be responsible for the use made of them and for the return of documentary material under paragraph (d) of this subsection (9).
      2. The custodian may cause the preparation of copies of the documentary material, answers to interrogatories, or transcripts of oral testimony as may be required for official use by a false medicaid claims law investigator or other officer or employee of the department of law who is authorized for such use under regulations that the attorney general shall issue. The material, answers, and transcripts may be used by any such authorized false medicaid claims law investigator or other officer or employee in connection with the taking of oral testimony under this section.
      3. 1. Except as otherwise provided in this subsection (9), documentary material, answers to interrogatories, or transcripts of oral testimony, or copies thereof, while in the possession of the custodian, shall not be available for examination by an individual other than a false medicaid claims law investigator or other officer or employee of the department of law authorized under subparagraph (II) of this paragraph (b).
         2. Sub-subparagraph (A) of this subparagraph (III) shall not apply if consent is given by the person who produced the material, answers, or transcripts or, in the case of any product of discovery produced pursuant to an express demand for the material, if consent is given by the person from whom the discovery was obtained.
         3. Nothing in this subparagraph (III) is intended to prevent disclosure to the general assembly, including any committee of the general assembly, or to any other agency of the state for use by the agency in furtherance of its statutory responsibilities. Disclosure of information to any such other agency shall be allowed only upon application, made by the attorney general to a district court, showing substantial need for the use of the information by the agency in furtherance of its statutory responsibilities.
      4. While in the possession of the custodian and under such reasonable terms and conditions as the attorney general shall prescribe:
         1. Documentary material and answers to interrogatories shall be available for examination by the person who produced the material or answers, or by a representative of that person authorized by that person to examine the material and answers; and
         2. Transcripts of oral testimony shall be available for examination by the person who produced the testimony or by a representative of that person authorized by that person to examine the transcripts.
   3. Whenever an attorney of the department of law has been designated to appear before a court, grand jury, or state agency in a case or proceeding, the custodian of any documentary material, answers to interrogatories, or transcripts of oral testimony received under this section may deliver to the attorney such material, answers, or transcripts for official use in connection with the case or proceeding as the attorney determines to be required. Upon the completion of the case or proceeding, the attorney shall return to the custodian the material, answers, or transcripts so delivered that are not in the control of the court, grand jury, or agency through introduction into the record of the case or proceeding.
   4. The custodian shall, upon written request of a person who produced any documentary material in the course of any false medicaid claims law investigation pursuant to a civil investigative demand under this section, return to the person any such material, other than copies furnished to the false medicaid claims law investigator under paragraph (b) of subsection (6) of this section or made for the department of law under subparagraph (II) of paragraph (b) of this subsection (9), that is not in the control of a court, grand jury, or agency through introduction into the record of the case or proceeding, if:
      1. A case or proceeding before a court or grand jury arising out of the investigation or any proceeding before a state agency involving the material has been completed; or
      2. A case or proceeding in which the material may be used has not been commenced within a reasonable time after completion of the examination and analysis of all documentary material and other information assembled in the course of the investigation.
   5. 1. In the event of the death, disability, or separation from service in the department of law of the custodian of any documentary material, answers to interrogatories, or transcripts of oral testimony produced pursuant to a civil investigative demand under this section, or in the event of the official relief of the custodian from responsibility for the custody and control of the material, answers, or transcripts, the attorney general shall promptly:
         1. Designate another false medicaid claims law investigator to serve as custodian of the material, answers, or transcripts; and
         2. Transmit in writing to the person who produced the material, answers, or testimony notice of the identity and address of the successor so designated.
      2. A person who is designated to be a successor under this paragraph (e) shall have, with regard to the material, answers, or transcripts, the same duties and responsibilities as were imposed by this section upon that person's predecessor in office; except that the successor shall not be held responsible for any default or dereliction that occurred before that designation.
10. Judicial proceedings.
    1. Whenever a person fails to comply with a civil investigative demand issued under subsection (1) of this section, or whenever satisfactory copying or reproduction of the material requested in a demand cannot be done and the person refuses to surrender the material, the attorney general may file, in a district court for the judicial district in which the person resides, is found, or transacts business, and serve upon the person a petition for an order of the court for the enforcement of the civil investigative demand.
    2. 1. A person who has received a civil investigative demand issued under subsection (1) of this section may file a petition for an order of the court to modify or set aside the demand. The person shall file the petition in a district court for the judicial district within which the person resides, is found, or transacts business and shall serve a copy of the petition upon the false medicaid claims law investigator identified in the demand. In the case of a petition addressed to an express demand for a product of discovery, the person may file a petition to modify or set aside the demand only in the district court for the judicial district in which the proceeding in which the discovery was obtained is or was last pending. The person shall file a petition under this subparagraph (I):
          1. Within twenty days after the date of service of the civil investigative demand or at any time before the return date specified in the demand, whichever date is earlier; or
          2. Within such longer period as may be prescribed in writing by a false medicaid claims law investigator identified in the demand.
       2. The petition shall specify each ground upon which the petitioner relies in seeking relief under subparagraph (I) of this paragraph (b) and may be based upon any failure of the demand to comply with the provisions of this section or upon any constitutional or other legal right or privilege of the person. During the pendency of the petition in the court, the court may stay, as it deems proper, the running of the time allowed for compliance with the demand, in whole or in part; except that the person filing the petition shall comply with any portions of the demand not sought to be modified or set aside.
    3. 1. In the case of a civil investigative demand issued under subsection (1) of this section that is an express demand for a product of discovery, the person from whom the discovery was obtained may file a petition for an order of the court to modify or set aside those portions of the demand requiring production of any product of discovery. The person shall file the petition in the district court for the judicial district in which the proceeding in which the discovery was obtained is or was last pending and shall serve a copy of the petition upon the false medicaid claims law investigator identified in the demand and upon the recipient of the demand. The person shall file a petition under this subparagraph (I):
          1. Within twenty days after the date of service of the civil investigative demand or at any time before the return date specified in the demand, whichever date is earlier; or
          2. Within such longer period as may be prescribed in writing by the false medicaid claims law investigator identified in the demand.
       2. The petition shall specify each ground upon which the petitioner relies in seeking relief under subparagraph (I) of this paragraph (c), and may be based upon any failure of the portions of the demand from which relief is sought to comply with the provisions of this section or upon any constitutional or other legal right or privilege of the petitioner. During the pendency of the petition, the court may stay, as it deems proper, compliance with the demand and the running of the time allowed for compliance with the demand.
    4. At any time during which a custodian is in custody or control of any documentary material or answers to interrogatories produced, or transcripts of oral testimony given, by a person in compliance with a civil investigative demand issued under subsection (1) of this section, the person, and in the case of an express demand for any product of discovery, the person from whom the discovery was obtained, may file a petition for an order of the court to require the performance by the custodian of any duty imposed upon the custodian by this section. The person shall file the petition in the district court for the judicial district within which the office of the custodian is situated and shall serve a copy of the petition upon the custodian.
    5. Whenever a petition is filed in a district court under this subsection (10), the court shall have jurisdiction to hear and determine the matter so presented and to enter such order or orders as may be required to carry out the provisions of this section. A final order so entered shall be subject to appeal under section 13-4-102, C.R.S. Any disobedience of a final order entered by a court under this section shall be punished as a contempt of the court.
    6. The Colorado rules of civil procedure shall apply to a petition under this subsection (10) to the extent that the rules are consistent with the provisions of this section.
11. Disclosure exemption. Any documentary material, answers to written interrogatories, or oral testimony provided under a civil investigative demand issued under subsection (1) of this section shall be exempt from disclosure under section 24-72-203, C.R.S.
12. Definitions. As used in this section, unless the context otherwise requires:
    1. "Custodian" means the custodian, or any deputy custodian, designated by the attorney general under paragraph (a) of subsection (9) of this section.
    2. "Documentary material" means the original or a copy of a book, record, report, memorandum, paper, communication, tabulation, chart, or other document, or data compilations stored in or accessible through computer or other information retrieval systems, together with instructions and all other materials necessary to use or interpret the data compilations, and any product of discovery.
    3. "False medicaid claims law" means:
       1. This section and sections 25.5-4-303.5 to 25.5-4-308; and
       2. Any law enacted before, on, or after May 26, 2010, that prohibits or makes available to the state in a court of the state a civil remedy with respect to a false medicaid claim against, bribery of, or corruption of an officer or employee of the state.
    4. "False medicaid claims law investigation" means an inquiry conducted by a false medicaid claims law investigator for the purpose of ascertaining whether a person is or has been engaged in a violation of a false medicaid claims law.
    5. "False medicaid claims law investigator" means an attorney or investigator employed by the department of law who is charged with the duty of enforcing or carrying into effect a false medicaid claims law or an officer or employee of the state acting under the direction and supervision of the attorney or investigator in connection with a false medicaid claims law investigation.
    6. "Person" means a natural person, partnership, corporation, association, or other legal entity.
    7. "Product of discovery" means:
       1. The original or duplicate of a deposition, interrogatory, document, thing, result of the inspection of land or other property, examination, or admission, any one of which is obtained by a method of discovery in a judicial or administrative proceeding of an adversarial nature;
       2. A digest, analysis, selection, compilation, or derivation of an item listed in subparagraph (I) of this paragraph (g); and
       3. An index or other manner of access to an item listed in subparagraph (I) of this paragraph (g).

Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1387, § 14, effective May 26.

Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-310. Medicaid false claims report.

1. Notwithstanding section 24-1-136 (11)(a)(I), on or before January 15, 2012, and on or before each January 15 thereafter, the attorney general shall submit a written report to the health and human services committees of the senate and the house of representatives, or any successor committees, and to the joint budget committee of the general assembly concerning claims brought under the "Colorado Medicaid False Claims Act" during the previous fiscal year. The report shall include, but not be limited to:
   1. The number of actions filed by the attorney general;
   2. The number of actions filed by the attorney general that were completed;
   3. The amount that was recovered in actions filed by the attorney general through settlement or through a judgment and, if known, the amount recovered for damages, penalties, and litigation costs;
   4. The number of actions filed by a person other than the attorney general;
   5. The number of actions filed by a person other than the attorney general that were completed;
   6. The amount that was recovered in actions filed by a person other than the attorney general through settlement or through a judgment and, if known, the amount recovered for damages, penalties, and litigation costs, and the amount recovered by the state and the person; and
   7. The amount expended by the state for investigation, litigation, and all other costs for claims related to the "Colorado Medicaid False Claims Act".

Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1399, § 14, effective May 26. L. 2017: IP(1) amended, (SB 17-233), ch. 175, p. 637, § 3, effective August 9.

Cross references: (1) For the "Colorado Medicaid False Claims Act", see section 25.5-4-303.5.

(2) For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.

25.5-4-401. Providers - payments - rules.

1. 1. The state department shall establish rules for the payment of providers under this article and articles 5 and 6 of this title. Within the limits of available funds, such rules shall provide reasonable compensation to such providers, but no provider shall, by this section or any other provision of this article or article 5 or 6 of this title, be deemed to have any vested right to act as a provider under this article and articles 5 and 6 of this title or to receive any payment in addition to or different from that which is currently payable on behalf of a recipient at the time the medical benefits are provided by said provider.
   2. 1. On and after July 1, 1992, the state department rules established for the payment of providers under this article and articles 5 and 6 of this title shall provide that services that are compensable under both Title XIX and Title XVIII of the social security act shall be paid at either the rate established under Title XIX or the rate established under Title XVIII, whichever is lower.
      2. If any provision of this paragraph (b) is found to be in conflict with any federal law or regulation, such conflicting portion of this paragraph (b) is declared to be inoperative to the extent of the conflict.
   3. The state department shall exercise its overexpenditure authority under section 24-75-109, C.R.S., and shall not intentionally interrupt the normal provider payment schedule unless notified jointly by the director of the office of state planning and budgeting and the state controller that there is the possibility that adequate cash will not be available to make payments to providers and for other state expenses. If it is determined that adequate cash is not available and the state department does interrupt the normal payment cycle, the state department shall notify the joint budget committee of the general assembly and any affected providers in writing of its decision to interrupt the normal payment schedule. Nothing in this paragraph (c) shall be interpreted to establish a right for any provider to be paid during any specific billing cycle.
   4. Repealed.
2. As to all payments made pursuant to this article and articles 5 and 6 of this title, the state department rules for the payment of providers may include provisions that encourage the highest quality of medical benefits and the provision thereof at the least expense possible.
3. 1. As used in this subsection (3), "capitated" means a method of payment by which a provider directly delivers or arranges for delivery of medical care benefits for a term established by contract with the state department based on a fixed rate of reimbursement per recipient.
   2. 1. In order to provide medical benefits under this article and articles 5 and 6 of this title on a capitated basis and subject to the condition imposed in subparagraph (II) of this paragraph (b), the state department is authorized to solicit negotiated contracts with providers based upon the requirements of this subsection (3). The state department may contract with one or more providers concerning the same medical services in a single geographic area.
      2. The state department may award a contract to one or more providers pursuant to subparagraph (I) of this paragraph (b) when the executive director determines that such contract will reduce the costs of providing medical benefits under this article and articles 5 and 6 of this title.
      3. The state department may define groups of recipients by geographic area or other categories and may require that all members of the defined group obtain medical services through one or more provider contracts entered into pursuant to this subsection (3).
4. 1. The general assembly hereby finds, determines, and declares that access to health care services would be improved and costs of health care would be restrained if the recipients of the medicaid program would choose a primary care physician through a managed care provider. For purposes of this subsection (4), "managed care provider" means either a primary care physician program, a health maintenance organization, or a prepaid health plan.
   2. Subject to the provisions of paragraph (c) of this subsection (4), the executive director of the state department has the authority to require a recipient of the medicaid program to select a managed care provider and to assign a recipient to a managed care provider if the recipient has failed to make a selection within a reasonable time. To the extent possible, this requirement shall be implemented on a statewide basis.
   3. The state department shall ensure the following:
      1. A managed care provider shall establish and implement consumer friendly procedures and instructions for disenrollment and shall have adequate staff to explain issues concerning service delivery and disenrollment procedures to recipients, including staff to address the communications needs and requirements of recipients with disabilities.
      2. All recipients shall be adequately informed about service delivery options available to them consistent with the provisions of this subparagraph (II). If a recipient does not respond to a state department request for selection of a delivery option within forty-five calendar days, the state department shall send a second notification to the recipient. If the recipient does not respond within twenty days of the date of the second notification, the state department shall ensure that the recipient remains with the recipient's primary care physician, regardless of whether said primary care physician is enrolled in a health maintenance organization.
5. The state board may promulgate rules to provide for the implementation and administration of subsections (3) and (4) of this section.
6. The state department shall make good faith efforts to obtain a waiver or waivers from any requirements of Title XIX of the social security act which would prohibit the implementation of subsections (3) and (4) of this section. Such waiver or waivers shall be obtained from the federal department of health and human services, or any successor agency. If such waivers are not granted, the state department shall not act to implement or administer subsections (3) and (4) of this section to the extent that Title XIX prohibits it.

Source: L. 2006: Entire article added with relocations, p. 1841, § 7, effective July 1. L. 2009: (1)(d) added, (SB 09-265), ch. 205, p. 935, § 2, effective May 1. L. 2010: (1)(d) repealed, (HB 10-1382), ch. 217, p. 939, § 1, effective May 6.

Editor's note: This section is similar to former § 26-4-404 as it existed prior to 2006.

25.5-4-401.2. Performance-based payments - reporting.

1. To improve health outcomes and lower health care costs, the state department may develop payments to providers that are based on quantifiable performance or measures of quality of care. These performance-based payments may include, but are not limited to, payments to:
   1. Primary care providers;
   2. Federally qualified health centers;
   3. Providers of long-term care services and supports; and
   4. Behavioral health providers, including, but not limited to:
      1. Community mental health centers, as defined in section 27-66-101; and
      2. Entities contracted with the state department to administer the statewide system of community behavioral health care established in section 25.5-5-402.
      3. A description of the stakeholder engagement process for developing the performance-based payments, including the participants in the process and a summary of the stakeholder feedback, and the state department's response to stakeholder feedback.
2. 1. Prior to implementing performance-based payments in the medicaid program pursuant to this article 4 and articles 5 and 6 of this title 25.5, including performance-based payments set forth in this section, the state department shall submit to the joint budget committee:

      (I) (A) Evidence that the performance-based payments are designed to achieve budget savings; or

      (B) A budget request for costs associated with the performance-based payments;

      (II) The estimated performance-based payments compared to total reimbursements for the affected service; and

   2. The information required pursuant to subsection (2)(a) of this section must be provided on or before November 1 for performance-based payments that will take effect in the following fiscal year unless the state department includes with its submission an explanation of the need for faster implementation of the payment. If faster implementation is requested, the state department shall provide the information at least three months prior to the implementation of the performance-based payments unless compliance with federal law necessitates shorter notice.
3. On or before November 1, 2017, and on or before November 1 each year thereafter, the state department shall submit a report to the joint budget committee, the public health care and human services committee of the house of representatives, and the health and human services committee of the senate, or any successor committees, describing rules adopted by the state board and contract provisions approved by the centers for medicare and medicaid services in the preceding calendar year that authorize payments to providers based on performance. Notwithstanding the provisions of section 24-1-136 (11)(a)(I), the report required pursuant to this subsection (3) continues indefinitely. The report must include, at a minimum:
   1. A description of performance-based payments included in state board rules, including which performance standards are targeted with each performance-based payment;
   2. A description of the goals and objectives of the performance-based payments, and how those goals and objectives align with other quality improvement initiatives;
   3. A summary of the research-based evidence for the performance-based payments, to the extent such evidence is available;
   4. A summary of the anticipated impact and clinical and nonclinical outcomes of implementing the performance-based payments;
   5. A description of how the impact or outcomes will be evaluated;
   6. An explanation of steps taken by the state department to limit the administrative burden on providers;
   7. A summary of the stakeholder engagement process with respect to each performance-based payment, including major concerns raised through the stakeholder process and how those concerns were remediated;
   8. When available, evaluation results for performance-based payments that were implemented in prior years; and
   9. A description of proposed modifications to current performance-based payments.

Source: L. 2017: Entire section added, (HB 17-1353), ch. 231, p. 898, § 3, effective May 23. L. 2018: (1)(d)(II) amended, (HB 18-1431), ch. 313, p. 1892, § 10, effective August 8.

25.5-4-401.5. Review of provider rates - advisory committee - recommendations - repeal.

1. 1. On or before September 1, 2015, the state department shall establish a schedule for an annual review of provider rates paid under the "Colorado Medical Assistance Act" so that each provider rate is reviewed at least every five years and shall provide the schedule to the joint budget committee. If the state department receives any petitions or proposals for provider rates to be reviewed or adjusted, the state department must forward a copy of the petition or proposal to the advisory committee.
   2. The state department shall review each of the provider rates scheduled for review pursuant to the process described in this section. Additionally, the advisory committee established pursuant to subsection (3) of this section, by a majority vote, or the joint budget committee, by a majority vote, may direct that the state department conduct a review of a provider rate that is not scheduled for review during that year. The advisory committee or the joint budget committee shall notify the state department by December 1 of the year prior to the year in which the out-of-cycle review will take place of the request for an out-of-cycle review.
   3. 1. The state department may propose to exclude rates from the schedule established pursuant to paragraph (a) of this subsection (1) if those rates are adjusted on a periodic basis as a result of other state statute or federal law or regulation. The state department shall include the proposed list of exclusions with the schedule established pursuant to paragraph (a) of this subsection (1).
      2. The advisory committee or the joint budget committee may, by a majority vote, direct the state department to include any rate that the state department has proposed to exclude from the schedule.
2. 1. In the first phase of the review process, the state department shall conduct an analysis of the access, service, quality, and utilization of each service subject to a provider rate review. The state department shall compare the rates paid with available benchmarks, including medicare rates and usual and customary rates paid by private pay parties, and use qualitative tools to assess whether payments are sufficient to allow for provider retention and client access and to support appropriate reimbursement of high-value services. Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or before May 1, 2016, and each May 1 thereafter, the state department shall provide a report on the analysis required by this paragraph (a) to the advisory committee, the joint budget committee, and any stakeholder groups identified by the state department whose rates are reviewed.
   2. Following the report required by paragraph (a) of this subsection (2), the state department shall work with the advisory committee and any stakeholders identified by the state department to review the report and develop strategies for responding to the findings, including any nonfiscal approaches or rebalancing of rates.
   3. Following the review required by paragraph (b) of this subsection (2), the state department shall work with the office of state planning and budgeting to determine achievable goals and executive branch priorities within the statewide budget.
   4. Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or before November 1, 2016, and each November 1 thereafter, the state department shall submit a written report to the joint budget committee and the advisory committee containing its recommendations on all of the provider rates reviewed pursuant to this section and all of the data relied upon by the state department in making its recommendations. The joint budget committee shall consider the recommendations in formulating the budget for the state department.
3. 1. There is created in the state department the medicaid provider rate review advisory committee, referred to in this section as the "advisory committee", to assist the state department in the review of the provider rate reimbursements under the "Colorado Medical Assistance Act". The advisory committee shall:
      1. Review the schedule for annual review of provider rates established by the state department pursuant to paragraph (a) of subsection (1) of this section and recommend any changes to the schedule;
      2. Review the reports prepared by the state department on its analysis of provider rates pursuant to paragraph (a) of subsection (2) of this section and provide comments and feedback to the state department on the reports;
      3. With the state department, conduct public meetings to allow providers, recipients, and other interested parties an opportunity to comment on the report required by paragraph (a) of subsection (2) of this section;
      4. Review proposals or petitions for provider rates to be reviewed or adjusted received by the advisory committee;
      5. Determine whether any provider rates not scheduled for review during the next calendar year should be reviewed during that calendar year;
      6. Recommend to the state department and to the joint budget committee any changes to the process of reviewing provider rates, including measures to increase access to the process such as by providing for electronic comments by providers and the public; and
      7. Provide other assistance to the state department as requested by the state department or the joint budget committee.
   2. The advisory committee consists of the following twenty-four members:
      1. The following members appointed by the president of the senate:
         1. A recipient with a disability or a representative of recipients with a disability;
         2. A representative of hospitals providing services to recipients recommended by a statewide association of hospitals;
         3. A representative of providers of transportation;
         4. A representative of rural health centers;
         5. A representative of home health providers recommended by a statewide organization of home health providers; and
         6. A representative of providers of durable medical equipment recommended by a statewide association of durable medical equipment providers;
      2. The following members appointed by the minority leader of the senate:
         1. A representative of providers of behavioral health care services;
         2. A representative of primary care physicians who see recipients recommended by a statewide association of primary care physicians;
         3. A representative of dentists providing services to recipients recommended by a statewide association of dentists;
         4. A representative of federally qualified health centers;
         5. A representative of nonmedical home- and community-based service providers; and
         6. A representative of providers serving recipients with intellectual and developmental disabilities;
      3. The following members appointed by the speaker of the house of representatives:
         1. A representative of child recipients with a disability;
         2. A representative of specialty care physicians not employed by a hospital who see recipients recommended by a statewide association whose members include at least one-third of the doctors of medicine or osteopathy licensed by the state;
         3. A representative of providers of alternative care facilities recommended by a statewide association of alternative care facilities;
         4. A representative of single entry point agencies;
         5. A representative of ambulatory surgical centers;
         6. A representative of hospice providers recommended by a statewide association of hospice and palliative care providers; and
      4. The following members appointed by the minority leader of the house of representatives:
         1. A representative of substance use disorder providers recommended by a statewide association of substance use disorder providers;
         2. A representative of facility-based physicians who see recipients. For purposes of this sub-subparagraph (B), "facility-based physicians" include anesthesiologists, emergency room physicians, neonatologists, pathologists, and radiologists.
         3. A representative of pharmacists providing services to recipients;
         4. A representative of managed care health plans;
         5. A representative of advanced practice nurses recommended by a statewide association of nurses; and
         6. A representative of physical therapists or occupational therapists recommended by a statewide association representing occupational or physical therapists.
   3. The appointing authorities shall make their initial appointments to the advisory committee no later than August 1, 2015. In making appointments to the advisory committee, the appointing authorities shall make a concerted effort to include members of diverse political, racial, cultural, income, and ability groups and members from urban and rural areas.
   4. Each member of the advisory committee serves at the pleasure of the official who appointed the member. Each member of the advisory committee serves a four-year term and may be reappointed.
   5. The members of the advisory committee serve without compensation and without reimbursement for expenses.
   6. At the first meeting of the advisory committee, to be held on or after September 1, 2015, the members shall elect a chair and vice-chair from among the members.
   7. The advisory committee shall meet at least once every quarter. The chair may call such additional meetings as may be necessary for the advisory committee to complete its duties.
   8. The advisory committee shall develop bylaws and procedures to govern its operations.
   9. 1. This subsection (3) is repealed, effective September 1, 2025.
      2. Prior to repeal, the department of regulatory agencies shall conduct a sunset review of the advisory committee pursuant to the provisions of section 2-3-1203, C.R.S.

Source: L. 2015: Entire section added, (SB 15-228), ch. 288, p. 1177, § 1, effective June 5. L. 2017: (2)(a) and (2)(d) amended, (HB 17-1060), ch. 6, p. 17, § 9, effective March 1.

25.5-4-402. Providers - hospital reimbursement - hospital review program - rules.

1. For all licensed or certified hospitals contracting for services under this article and articles 5 and 6 of this title, except those hospitals operated by the department of human services or those hospitals deemed exempt by the state board, the state department shall pay for inpatient hospital services pursuant to a system of prospective payment, generally based on the elements of a diagnosis-related group system. The state department shall develop and administer a system for ensuring appropriate utilization and quality of care provided by those providers who are reimbursed under this section. Subject to available appropriations, the state department may also make supplemental medicaid payments to certain hospitals. The state board shall promulgate rules to provide for the implementation of this section.
2. 1. A hospital that receives payment under this article and articles 5 and 6 of this title for telemedicine services shall employ its existing quality-of-care protocols and patient confidentiality guidelines to ensure that such services meet the requirements of this article and articles 5 and 6 of this title.
   2. The executive director of the state department shall adopt rules in furtherance of this subsection (2), including, without limitation, rules to:
      1. Ensure the provision of appropriate care to patients;
      2. Prevent fraud and abuse; and
      3. Establish methods and procedures to avoid overuse of telemedicine services.
3. 1. In addition to the reimbursement rate process described in subsection (1) of this section and subject to adequate funding being made available pursuant to section 25.5-4-402.4, the Colorado healthcare affordability and sustainability enterprise created in section 25.5-4-402.4 (3) shall pay an additional amount based upon performance to those hospitals that provide services that improve health care outcomes for their patients. The state department shall determine this amount based upon nationally recognized performance measures established in rules adopted by the state board. The state quality standards must be consistent with federal quality standards published by an organization with expertise in health care quality, including but not limited to, the centers for medicare and medicaid services, the agency for healthcare research and quality, or the national quality forum.
   2. The amount of the payments made pursuant to this subsection (3) shall be computed annually. For the first two fiscal years that payments are made pursuant to this subsection (3), the total amount of the payments shall be up to five percent of the total reimbursements made to hospitals in the previous year. For each fiscal year after the first two fiscal years, the total amount of the payments shall be up to seven percent of the total reimbursements made to hospitals in the previous year.
4. 1. Subject to federal approval, and notwithstanding any other provision of the "Colorado Medical Assistance Act", the state department shall design and implement an evidence-based hospital review program to ensure appropriate utilization of hospital services.
   2. Consistent with federal regulations set forth in 42 CFR 456, the hospital review program may include the following:
      1. Preadmission review;
      2. Continued stay review;
      3. Transfer planning;
      4. Discharge planning;
      5. Care coordination; and
      6. Retrospective claims review.
   3. The following factors must be considered in any coverage determinations made pursuant to the hospital review programs:
      1. Information provided, diagnosis determined, and treatment recommended by the treating provider or providers;
      2. Evidence-based clinical coverage criteria and recipient coverage guidelines as established by the state department;
      3. Nationally recognized utilization and technology assessment guidelines; and
      4. Industry standard criteria, as appropriate.
   4. 1. The state department shall consult with affected stakeholders prior to implementation of the hospital review program. At a minimum, the state department shall solicit feedback from recipients, hospitals within Colorado that participate in medicaid, providers participating in the accountable care collaborative pursuant to section 25.5-5-419, and the Colorado healthcare affordability and sustainability enterprise board established in section 25.5-4-402.4 (7). If the state department contracts with a third-party vendor to implement the hospital review program, the state department shall require the vendor to participate in the stakeholder outreach with hospitals required pursuant to this subsection (4)(d)(I).
      2. Prior to implementation of the hospital review program, the state department shall provide an opportunity for hospitals to test connectivity to and workability of any new electronic interface created or implemented as part of this section. The state department shall select a limited group of hospitals to test any new requirements prior to full implementation.
      3. The state department shall provide a report to the joint budget committee by November 1, 2018, on the status of the implementation of the hospital review program. The report must include the comments received as part of the stakeholder process described in subsection (4)(d)(I) of this section and a description of, and any available results from, the testing process described in subsection (4)(d)(II) of this section.
      4. The state department shall provide a report to the joint budget committee on November 1, 2019, and November 1, 2020, detailing the estimates of the cost savings achieved and the impact of the cost-control measures authorized pursuant to this section on recipients and recipients' health outcomes.
      5. Beginning in 2018, and every year thereafter through 2020, the state department shall report on the status of the implementation of the hospital review program, any cost savings estimated or achieved due to the program, and the impact on recipients and recipients' outcomes of any cost-control measures as part of its "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act" hearing required by section 2-7-203.
   5. The state board shall adopt any rules necessary for the administration and implementation of this section.

Source: L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1; entire section amended, p. 1546, § 3, effective July 1. L. 2009: (1) amended and (3) added, (HB 09-1293), ch. 152, p. 645, § 4, effective July 1. L. 2017: (3)(a) amended, (SB 17-267), ch. 267, p. 1448, § 15, effective July 1. L. 2018: (4) added, (SB 18-266), ch. 264, p. 1624, § 2, effective May 29.

25.5-4-402.3. Providers - hospital - provider fees - legislative declaration - federal waiver - fund created - rules - advisory board - repeal. (Repealed)

Source: L. 2009: Entire section added, (HB 09-1293), ch. 152, p. 633, § 1, effective July 1. L. 2010: (4)(b)(VIII) added, (SB 10-169), ch. 307, p. 1445, § 1, effective May 27; (4)(b)(IV) amended, (HB 10-1422), ch. 419, p. 2110, § 141, effective August 11. L. 2011: (3)(a)(II) and (3)(a)(III) amended and (3)(a)(IV), (4)(b)(IX), and (5)(b.5) added, (SB 11-212), ch. 146, pp. 508, 509, §§ 1, 2, 3, effective May 5. L. 2013: (4)(b)(IV)(A) and (4)(b)(IV)(C) amended, (SB 13-200), ch. 216, p. 897, § 1, effective May 13. L. 2017: (5)(b.3) added, (SB 17-256), ch. 198, p. 720, § 1, effective May 8; entire section repealed, (SB 17-267), ch. 267, p. 1448, § 16, effective July 1.

Editor's note: Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017, provides that the section of the act repealing this section does not take effect if the centers for medicare and medicaid services determine that the amendments do not comply with federal law. For more information, see SB 17-267. ( L. 2017, p. 1478 .) The executive director of the department of health care policy and financing did not notify the revisor of statutes by June 1, 2017, of such determination; therefore, the repeal of this section took effect July 1, 2017.

Cross references: For the legislative declaration in SB 17-267, see section 1 of chapter 267, Session Laws of Colorado 2017.

25.5-4-402.4. Hospitals - healthcare affordability and sustainability fee - legislative declaration - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - rules - reports - repeal.

1. Short title. The short title of this section is the "Colorado Healthcare Affordability and Sustainability Enterprise Act of 2017".
2. Legislative declaration. The general assembly hereby finds and declares that:
   1. The state and the providers of publicly funded medical services, and hospitals in particular, share a common commitment to comprehensive health care reform;
   2. Hospitals within the state incur significant costs by providing uncompensated emergency department care and other uncompensated medical services to low-income and uninsured populations;
   3. This section is enacted as part of a comprehensive health care reform and is intended to provide the following services and benefits to hospitals and individuals:
      1. Providing a payer source for some low-income and uninsured populations who may otherwise be cared for in emergency departments and other settings in which uncompensated care is provided;
      2. Reducing the underpayment to Colorado hospitals participating in publicly funded health insurance programs;
      3. Reducing the number of persons in Colorado who are without health care benefits;
      4. Reducing the need of hospitals and other health care providers to shift the cost of providing uncompensated care to other payers;
      5. Expanding access to high-quality, affordable health care for low-income and uninsured populations; and
      6. Providing the additional business services specified in subsection (4)(a)(IV) of this section to hospitals that pay the healthcare affordability and sustainability fee charged and collected as authorized by subsection (4) of this section by the Colorado healthcare affordability and sustainability enterprise created in subsection (3)(a) of this section;
   4. The Colorado healthcare affordability and sustainability enterprise provides business services to hospitals when, in exchange for payment of healthcare affordability and sustainability fees by hospitals, it:
      1. Obtains federal matching money and returns both the healthcare affordability and sustainability fee and the federal matching money to hospitals to increase reimbursement rates to hospitals for providing medical care under the state medical assistance program and the Colorado indigent care program and to increase the number of individuals covered by public medical assistance; and
      2. Provides additional business services to hospitals as specified in subsection (4)(a)(IV) of this section;
   5. It is necessary, appropriate, and in the best interest of the state to acknowledge that by providing the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section, the Colorado healthcare affordability and sustainability enterprise engages in an activity conducted in the pursuit of a benefit, gain, or livelihood and therefore operates as a business;
   6. Consistent with the determination of the Colorado supreme court in Nicholl v. E-470 Public Highway Authority, 896 P.2d 859 ( Colo. 1995 ), that the power to impose taxes is inconsistent with enterprise status under section 20 of article X of the state constitution, it is the conclusion of the general assembly that the healthcare affordability and sustainability fee charged and collected by the Colorado healthcare affordability and sustainability enterprise is a fee, not a tax, because the fee is imposed for the specific purposes of allowing the enterprise to defray the costs of providing the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section to hospitals that pay the fee and is collected at rates that are reasonably calculated based on the benefits received by those hospitals; and
   7. So long as the Colorado healthcare affordability and sustainability enterprise qualifies as an enterprise for purposes of section 20 of article X of the state constitution, the revenues from the healthcare affordability and sustainability fee charged and collected by the enterprise are not state fiscal year spending, as defined in section 24-77-102 (17), or state revenues, as defined in section 24-77-103.6 (6)(c), and do not count against either the state fiscal year spending limit imposed by section 20 of article X of the state constitution or the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I).
3. Colorado healthcare affordability and sustainability enterprise.
   1. The Colorado healthcare affordability and sustainability enterprise, referred to in this section as the "enterprise", is created. The enterprise is and operates as a government-owned business within the state department for the purpose of charging and collecting the healthcare affordability and sustainability fee, leveraging healthcare affordability and sustainability fee revenue to obtain federal matching money, and utilizing and deploying the healthcare affordability and sustainability fee revenue and federal matching money to provide the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section to hospitals that pay the healthcare affordability and sustainability fee.
   2. The enterprise constitutes an enterprise for purposes of section 20 of article X of the state constitution so long as it retains the authority to issue revenue bonds and receives less than ten percent of its total revenues in grants from all Colorado state and local governments combined. So long as it constitutes an enterprise pursuant to this subsection (3)(b), the enterprise is not subject to any provisions of section 20 of article X of the state constitution.
   3. 1. The repeal of the hospital provider fee program, as it existed pursuant to section 25.5-4-402.3 before its repeal, effective July 1, 2017, by Senate Bill 17-267, enacted in 2017, and the creation of the Colorado healthcare affordability and sustainability enterprise as a new enterprise to charge and collect a new healthcare affordability and sustainability fee as authorized by subsection (4) of this section and provide healthcare affordability and sustainability fee-funded business services to hospitals that replace and supplement services previously funded by hospital provider fees is the creation of a new government-owned business that provides business services to hospitals as a new enterprise for purposes of section 20 of article X of the state constitution, does not constitute the qualification of an existing government-owned business as an enterprise for purposes of section 20 of article X of the state constitution or section 24-77-103.6 (6)(b)(II), and, therefore, does not require or authorize adjustment of the state fiscal year spending limit calculated pursuant to section 20 of article X of the state constitution or the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I).
      2. Notwithstanding subsection (3)(c)(I) of this section, because the repeal of the hospital provider fee program, as it existed pursuant to section 25.5-4-402.3 before its repeal by Senate Bill 17-267, enacted in 2017, will allow the state to spend more general fund money for general governmental purposes than it would otherwise be able to spend below the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I), it is appropriate to restrain the growth of government by lowering the base amount used to calculate the excess state revenues cap for the 2017-18 state fiscal year by two hundred million dollars.
   4. The enterprise's primary powers and duties are:
      1. To charge and collect the healthcare affordability and sustainability fee as specified in subsection (4) of this section;
      2. To leverage healthcare affordability and sustainability fee revenue collected to obtain federal matching money, working with or through the state department and the state board to the extent required by federal law or otherwise necessary;
      3. To expend healthcare affordability and sustainability fee revenue, matching federal money, and any other money from the healthcare affordability and sustainability fee cash fund as specified in subsections (4) and (5) of this section;
      4. To issue revenue bonds payable from the revenues of the enterprise;
      5. To enter into agreements with the state department to the extent necessary to collect and expend healthcare affordability and sustainability fee revenue;
      6. To engage the services of private persons or entities serving as contractors, consultants, and legal counsel for professional and technical assistance and advice and to supply other services related to the conduct of the affairs of the enterprise, including the provision of additional business services to hospitals as specified in subsection (4)(a)(IV) of this section; and
      7. To adopt and amend or repeal policies for the regulation of its affairs and the conduct of its business consistent with the provisions of this section.
   5. The enterprise shall exercise its powers and perform its duties as if the same were transferred to the state department by a type 2 transfer, as defined in section 24-1-105.
4. Healthcare affordability and sustainability fee.
   1. For the fiscal year commencing July 1, 2017, and for each fiscal year thereafter, the enterprise is authorized to charge and collect a healthcare affordability and sustainability fee, as described in 42 CFR 433.68 (b), on outpatient and inpatient services provided by all licensed or certified hospitals, referred to in this section as "hospitals", for the purpose of obtaining federal financial participation under the state medical assistance program as described in this article 4 and articles 5 and 6 of this title 25.5, referred to in this section as the "state medical assistance program", and the Colorado indigent care program described in part 1 of article 3 of this title 25.5, referred to in this section as the "Colorado indigent care program". If the amount of healthcare affordability and sustainability fee revenue collected exceeds the federal net patient revenue-based limit on the amount of such fee revenue that may be collected, requiring repayment to the federal government of excess federal matching money received, hospitals that received such excess federal matching money shall be responsible for repaying the excess federal money and any associated federal penalties to the federal government. The enterprise shall use the healthcare affordability and sustainability fee revenue to:
      1. Provide a business service to hospitals by increasing reimbursement to hospitals for providing medical care under:
         1. The state medical assistance program; and
         2. The Colorado indigent care program;
      2. Provide a business service to hospitals by increasing the number of individuals covered by public medical assistance and thereby reducing the amount of uncompensated care that the hospitals must provide;

         (II.3) (A) For state fiscal years 2019-20 and 2020-21 only, offset general fund expenditures for the state medical assistance program.

         (B) This subsection (4)(a)(II.3) is repealed, effective December 31, 2021.

         (II.5) (A) For state fiscal year 2020-21 only, offset general fund expenditures for the state medical assistance program.

         (B) This subsection (4)(a)(II.5) is repealed, effective December 31, 2021.

      3. Pay the administrative costs to the enterprise in implementing and administering this section subject to the limitation that administrative costs of the enterprise are limited to three percent of the enterprise's expenditures based on a methodology approved by the office of state planning and budgeting and the staff of the joint budget committee of the general assembly; and
      4. Provide or contract for or arrange the provision of additional business services to hospitals by:
         1. Consulting with hospitals to help them improve both cost efficiency and patient safety in providing medical services and the clinical effectiveness of those services;
         2. Advising hospitals regarding potential changes to federal and state laws and regulations that govern the provision of and reimbursement paid for medical services under the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5;
         3. Providing coordinated services to hospitals to help them adapt and transition to any new or modified performance tracking and payment systems for the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5, which may include data sharing, telehealth coordination and support, establishment of performance metrics, benchmarking to such metrics, and clinical and administrative process consulting and other appropriate services;
         4. Providing any other services to hospitals that aid them in efficiently and effectively participating in the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5; and
         5. Providing funding for, and in cooperation with the state department and hospitals supporting the implementation of, a health care delivery system reform incentive payments program as described in subsection (8) of this section.
   2. The enterprise shall recommend for approval and establishment by the state board the amount of the healthcare affordability and sustainability fee that it intends to charge and collect. The state board must establish the final amount of the fee by rules promulgated in accordance with article 4 of title 24. The state board shall not establish any amount that exceeds the federal limit for such fees. The state board may deviate from the recommendations of the enterprise, but shall express in writing the reasons for any deviations. In establishing the amount of the fee and in promulgating the rules governing the fee, the state board shall:
      1. Consider recommendations of the enterprise;
      2. Establish the amount of the healthcare affordability and sustainability fee so that the amount collected from the fee and federal matching funds associated with the fee are sufficient to pay for the items described in subsection (4)(a) of this section, but nothing in this subsection (4)(b)(II) requires the state board to increase the fee above the amount recommended by the enterprise; and
      3. For the 2017-18 fiscal year, establish the amount of the healthcare affordability and sustainability fee so that the amount collected from the fee is approximately equal to the sum of the amounts of the appropriations specified for the fee in the general appropriation act, Senate Bill 17-254, enacted in 2017, and any other supplemental appropriation act.
   3. 1. In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1) and (e)(2), the enterprise, acting in concert with or through an agreement with the state department if required by federal law, may seek a waiver from the broad-based healthcare affordability and sustainability fee requirement or the uniform healthcare affordability and sustainability fee requirement, or both. In addition, the enterprise, acting in concert with or through an agreement with the state department if required by federal law, shall seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health care delivery system reform incentive payments program as described in subsection (8) of this section. Subject to federal approval and to minimize the financial impact on certain hospitals, the enterprise may exempt from payment of the healthcare affordability and sustainability fee certain types of hospitals, including but not limited to:
         1. Psychiatric hospitals, as licensed by the department of public health and environment;
         2. Hospitals that are licensed as general hospitals and certified as long-term care hospitals by the department of public health and environment;
         3. Critical access hospitals that are licensed as general hospitals and are certified by the department of public health and environment under 42 CFR part 485, subpart F;
         4. Inpatient rehabilitation facilities; or
         5. Hospitals specified for exemption under 42 CFR 433.68 (e).
      2. In determining whether a hospital may be excluded, the enterprise shall use one or more of the following criteria:
         1. A hospital that is located in a rural area;
         2. A hospital with which the state department does not contract to provide services under the state medical assistance program;
         3. A hospital whose inclusion or exclusion would not significantly affect the net benefit to hospitals paying the healthcare affordability and sustainability fee; or
         4. A hospital that must be included to receive federal approval.
      3. The enterprise may reduce the amount of the healthcare affordability and sustainability fee for certain hospitals to obtain federal approval and to minimize the financial impact on certain hospitals. In determining for which hospitals the enterprise may reduce the amount of the healthcare affordability and sustainability fee, the enterprise shall use one or more of the following criteria:
         1. The hospital is a type of hospital described in subsection (4)(c)(I) of this section;
         2. The hospital is located in a rural area;
         3. The hospital serves a higher percentage than the average hospital of persons covered by the state medical assistance program, medicare, or commercial insurance or persons enrolled in a managed care organization;
         4. The hospital does not contract with the state department to provide services under the state medical assistance program;
         5. If the hospital paid a reduced healthcare affordability and sustainability fee, the reduced fee would not significantly affect the net benefit to hospitals paying the healthcare affordability and sustainability fee; or
         6. The hospital is required not to pay a reduced healthcare affordability and sustainability fee as a condition of federal approval.
      4. The enterprise may change how it pays hospital reimbursement or quality incentive payments, or both, in whole or in part, under the authority of a federal waiver if the total reimbursement to hospitals is equal to or above the federal upper payment limit calculation under the waiver.
   4. The enterprise may alter the process prescribed in this subsection (4) to the extent necessary to meet the federal requirements and to obtain federal approval.
   5. 1. The enterprise shall establish policies on the calculation, assessment, and timing of the healthcare affordability and sustainability fee. The enterprise shall assess the healthcare affordability and sustainability fee on a schedule to be set by the enterprise board as provided in subsection (7)(d) of this section. The periodic healthcare affordability and sustainability fee payments from a hospital and the enterprise's reimbursement to the hospital under subsections (5)(b)(I) and (5)(b)(II) of this section are due as nearly simultaneously as feasible; except that the enterprise's reimbursement to the hospital is due no more than two days after the periodic healthcare affordability and sustainability fee payment is received from the hospital. The healthcare affordability and sustainability fee must be imposed on each hospital even if more than one hospital is owned by the same entity. The fee must be prorated and adjusted for the expected volume of service for any year in which a hospital opens or closes.
      2. The enterprise is authorized to refund any unused portion of the healthcare affordability and sustainability fee. For any portion of the healthcare affordability and sustainability fee that has been collected by the enterprise but for which the enterprise has not received federal matching funds, the enterprise shall refund back to the hospital that paid the fee the amount of that portion of the fee within five business days after the fee is collected.
      3. The enterprise shall establish requirements for the reports that hospitals must submit to the enterprise to allow the enterprise to calculate the amount of the healthcare affordability and sustainability fee. Notwithstanding the provisions of part 2 of article 72 of title 24 or subsection (7)(f) of this section, information provided to the enterprise pursuant to this section is confidential and is not a public record. Nonetheless, the enterprise may prepare and release summaries of the reports to the public.
   6. A hospital shall not include any amount of the healthcare affordability and sustainability fee as a separate line item in its billing statements.
   7. The state board shall promulgate any rules pursuant to the "State Administrative Procedure Act", article 4 of title 24, necessary for the administration and implementation of this section. Prior to submitting any proposed rules concerning the administration or implementation of the healthcare affordability and sustainability fee to the state board, the enterprise shall consult with the state board on the proposed rules as specified in subsection (7)(d) of this section.
5. Healthcare affordability and sustainability fee cash fund.
   1. Any healthcare affordability and sustainability fee collected pursuant to this section by the enterprise must be transmitted to the state treasurer, who shall credit the fee to the healthcare affordability and sustainability fee cash fund, which fund is hereby created and referred to in this section as the "fund". The state treasurer shall credit all interest and income derived from the deposit and investment of money in the fund to the fund. The state treasurer shall invest any money in the fund not expended for the purposes specified in subsection (5)(b) of this section as provided by law. Money in the fund shall not be transferred to any other fund and shall not be used for any purpose other than the purposes specified in this subsection (5) and in subsection (4) of this section.
   2. All money in the fund is subject to federal matching as authorized under federal law and, subject to annual appropriation by the general assembly, shall be expended by the enterprise for the following purposes:
      1. To maximize the inpatient and outpatient hospital reimbursements to up to the upper payment limits as defined in 42 CFR 447.272 and 42 CFR 447.321;
      2. To increase hospital reimbursements under the Colorado indigent care program to up to one hundred percent of the hospital's costs of providing medical care under the program;
      3. To pay the quality incentive payments provided in section 25.5-4-402 (3);
      4. Subject to available revenue from the healthcare affordability and sustainability fee and federal matching funds, to expand eligibility for public medical assistance by:
         1. Increasing the eligibility level for parents and caretaker relatives of children who are eligible for medical assistance, pursuant to section 25.5-5-201 (1)(m), from sixty-one percent to one hundred thirty-three percent of the federal poverty line;
         2. Increasing the eligibility level for children and pregnant women under the children's basic health plan to up to two hundred fifty percent of the federal poverty line;
         3. Providing eligibility under the state medical assistance program for a childless adult or an adult without a dependent child in the home, pursuant to section 25.5-5-201 (1)(p), who earns up to one hundred thirty-three percent of the federal poverty line; and
         4. Providing a buy-in program in the state medical assistance program for disabled adults and children whose families have income of up to four hundred fifty percent of the federal poverty line;
      5. To provide continuous eligibility for twelve months for children enrolled in the state medical assistance program;
      6. To pay the enterprise's actual administrative costs of implementing and administering this section, including but not limited to the following costs:
         1. Administrative expenses of the enterprise;
         2. The enterprise's actual costs related to implementing and maintaining the healthcare affordability and sustainability fee, including personal services, operating, and consulting expenses;
         3. The enterprise's actual costs for the changes and updates to the medicaid management information system for the implementation of subsections (5)(b)(I) to (5)(b)(III) of this section;
         4. The enterprise's personal services and operating costs related to personnel, consulting services, and for review of hospital costs necessary to implement and administer the increases in inpatient and outpatient hospital payments made pursuant to subsection (5)(b)(I) of this section, increases in the Colorado indigent care program payments made pursuant to subsection (5)(b)(II) of this section, and quality incentive payments made pursuant to subsection (5)(b)(III) of this section;
         5. The enterprise's actual costs for the changes and updates to the Colorado benefits management system and medicaid management information system to implement and maintain the expanded eligibility provided for in subsections (5)(b)(IV) and (5)(b)(V) of this section;
         6. The enterprise's personal services and operating costs related to personnel necessary to implement and administer the expanded eligibility for public medical assistance provided for in subsections (5)(b)(IV) and (5)(b)(V) of this section, including but not limited to administrative costs associated with the determination of eligibility for public medical assistance by county departments; and
         7. The enterprise's personal services, operating, and systems costs related to expanding the opportunity for individuals to apply for public medical assistance directly at hospitals or through another entity outside the county departments, in connection with section 25.5-4-205, that would increase access to public medical assistance and reduce the number of uninsured served by hospitals;
      7. To offset the loss of any federal matching money due to a decrease in the certification of the public expenditure process for outpatient hospital services for medical services premiums that were in effect as of July 1, 2008;
      8. Subject to any necessary federal waivers being obtained, to provide funding for a health care delivery system reform incentive payments program as described in subsection (8) of this section;

         (VIII.3) (A) For state fiscal years 2019-20 and 2020-21 only, and regardless of when this federal money is made available, the amount in excess of the fifty percent federal financial participation generated by increased reimbursements and payments appropriated for use in subsections (5)(b)(I) to (5)(b)(III) of this section pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto, to offset general fund expenditures for the state medical assistance program.

         (B) This subsection (5)(b)(VIII.3) is repealed, effective December 31, 2021.

         (VIII.5) (A) For the 2020-21 state fiscal year only, due to reductions in the adult dental benefit pursuant to section 25.5-5-207 (2.5), three hundred thirty-one thousand four hundred sixty-two dollars to offset general fund expenditures for the state medical assistance program.

         (B) This subsection (5)(b)(VIII.5) is repealed, effective December 31, 2021.

         (VIII.7) (A) For state fiscal year 2020-21 only, one hundred sixty-one million dollars shall be appropriated to offset general fund expenditures for the state medical assistance program.

         (B) This subsection (5)(b)(VIII.7) is repealed, effective December 31, 2021.

      9. To provide additional business services to hospitals as specified in subsection (4)(a)(IV) of this section.
6. Appropriations.
   1. 1. Except as otherwise provided in subsection (6)(b)(I.3), (6)(b)(I.5), or (6)(b)(I.7) of this section, the healthcare affordability and sustainability fee is to supplement, not supplant, general fund appropriations to support hospital reimbursements. General fund appropriations for hospital reimbursements shall be maintained at the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008; except that general fund appropriations for hospital reimbursements may be reduced if an index of appropriations to other providers shows that general fund appropriations are reduced for other providers. If the index shows that general fund appropriations are reduced for other providers, the general fund appropriations for hospital reimbursements shall not be reduced by a greater percentage than the reductions of appropriations for the other providers as shown by the index.
      2. If general fund appropriations for hospital reimbursements are reduced below the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008, the general fund appropriations will be increased back to the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008, at the same percentage as the appropriations for other providers as shown by the index. The general assembly is not obligated to increase the general fund appropriations back to the level of appropriations in the medical services premium line item in a single fiscal year, and such increases may occur over nonconsecutive fiscal years.
      3. For purposes of this subsection (6)(a), the "index of appropriations to other providers" or "index" means the average percent change in reimbursement rates through appropriations or legislation enacted by the general assembly to home health providers, physician services, and outpatient pharmacies, excluding dispensing fees. The state board, after consultation with the enterprise board, is authorized to clarify this definition as necessary by rule.
   2. If the revenue from the healthcare affordability and sustainability fee is insufficient to fully fund all of the purposes described in subsection (5)(b) of this section:
      1. The general assembly is not obligated to appropriate general fund revenues to fund such purposes;

         (I.3) (A) For the 2020-21 state fiscal year only, due to reductions in the adult dental benefit pursuant to section 25.5-5-207 (2.5), three hundred thirty-one thousand four hundred sixty-two dollars of revenue shall be used first to offset general fund expenditures for the state medical assistance program.

         (B) This subsection (6)(b)(I.3) is repealed, effective December 31, 2021.

         (I.5) (A) The amount in excess of the fifty percent federal financial participation generated by increased reimbursements and payments appropriated for use in subsections (5)(b)(I) to (5)(b)(III) of this section pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto, shall be appropriated to offset general fund expenditures for the state medical assistance program.

         (B) This subsection (6)(b)(I.5) is repealed, effective December 31, 2021.

         (I.7) (A) One hundred sixty-one million dollars of revenue from the healthcare affordability and sustainability fee shall be used first to offset general fund expenditures for the state medical assistance program.

         (B) This subsection (6)(b)(I.7) is repealed, effective December 31, 2021.

      2. The hospital provider reimbursement and quality incentive payment increases described in subsections (5)(b)(I) to (5)(b)(III) of this section and the costs described in subsection (5)(b)(VI) of this section shall be fully funded using revenue from the healthcare affordability and sustainability fee and federal matching funds before any eligibility expansion is funded; and
      3. 1. If the state board promulgates rules that expand eligibility for medical assistance to be paid for pursuant to subsection (5)(b)(IV) of this section, and the state department thereafter notifies the enterprise board that the revenue available from the healthcare affordability and sustainability fee and the federal matching funds will not be sufficient to pay for all or part of the expanded eligibility, the enterprise board shall recommend to the state board reductions in medical benefits or eligibility so that the revenue will be sufficient to pay for all of the reduced benefits or eligibility. After receiving the recommendations of the enterprise board, the state board shall adopt rules providing for reduced benefits or reduced eligibility for which the revenue will be sufficient and shall forward any adopted rules to the joint budget committee. Notwithstanding the provisions of section 24-4-103 (8) and (12), following the adoption of rules pursuant to this subsection (6)(b)(III)(A), the state board shall not submit the rules to the attorney general and shall not file the rules with the secretary of state until the joint budget committee approves the rules pursuant to subsection (6)(b)(III)(B) of this section.
         2. The joint budget committee shall promptly consider any rules adopted by the state board pursuant to subsection (6)(b)(III)(A) of this section. The joint budget committee shall promptly notify the state department, the state board, and the enterprise board of any action on the rules. If the joint budget committee does not approve the rules, the joint budget committee shall recommend a reduction in benefits or eligibility so that the revenue from the healthcare affordability and sustainability fee and the matching federal funds will be sufficient to pay for the reduced benefits or eligibility. After approving the rules pursuant to this subsection (6)(b)(III)(B), the joint budget committee shall request that the committee on legal services, created pursuant to section 2-3-501, extend the rules as provided for in section 24-4-103 (8) unless the committee on legal services finds after review that the rules do not conform with section 24-4-103 (8)(a).
         3. After the state board has received notification of the approval of rules adopted pursuant to subsection (6)(b)(III)(A) of this section, the state board shall submit the rules to the attorney general pursuant to section 24-4-103 (8)(b) and shall file the rules and the opinion of the attorney general with the secretary of state pursuant to section 24-4-103 (12) and with the office of legislative legal services. Pursuant to section 24-4-103 (5), the rules are effective twenty days after publication of the rules and are only effective until the following May 15 unless the rules are extended pursuant to a bill enacted pursuant to section 24-4-103 (8).
         4. One member of the health care industry who does not represent a hospital or a health insurance carrier;
         5. One member who is a consumer of health care and who is not a representative or an employee of a hospital, health insurance carrier, or other health care industry entity;
         6. One member who is a representative of persons with disabilities, who is living with a disability, and who is not a representative or an employee of a hospital, health insurance carrier, or other health care industry entity;
         7. One member who is a representative of a business that purchases or otherwise provides health insurance for its employees; and
         8. Two employees of the state department.
   3. Notwithstanding any other provision of this section, if, after receipt of authorization to receive federal matching funds for money in the fund, the authorization is withdrawn or changed so that federal matching funds are no longer available, the enterprise shall cease collecting the healthcare affordability and sustainability fee and shall repay to the hospitals any money received by the fund that is not subject to federal matching funds.
7. Colorado healthcare affordability and sustainability enterprise board.
   1. 1. Except as otherwise provided in subsection (7)(a)(II) of this section, the enterprise board consists of thirteen members appointed by the governor, with the advice and consent of the senate, as follows:
      2. The initial members of the enterprise board are the members of the hospital provider fee oversight and advisory board that was created and existed pursuant to section 25.5-4-402.3 (6), prior to July 1, 2017, and such members shall serve on and after July 1, 2017, for the remainder of the terms for which they were appointed as members of the advisory board. The powers, duties, and functions of the hospital provider fee oversight and advisory board are transferred by a type 3 transfer, as defined in section 24-1-105, to the enterprise, and the hospital provider fee oversight and advisory board is abolished.
      3. The governor shall consult with representatives of a statewide organization of hospitals in making the appointments pursuant to subsections (7)(a)(I)(A) and (7)(a)(I)(B) of this section. No more than six members of the enterprise board may be members of the same political party.
      4. Members of the enterprise board serve at the pleasure of the governor. All terms are for four years. A member who is appointed to fill a vacancy shall serve the remainder of the unexpired term of the former member.
      5. The governor shall designate a chair from among the members of the enterprise board appointed pursuant to subsections (7)(a)(I)(A) to (7)(a)(I)(G) of this section. The enterprise board shall elect a vice-chair from among its members.

      (A) Five members who are employed by hospitals in Colorado, including at least one person who is employed by a hospital in a rural area, one person who is employed by a safety-net hospital for which the percent of medicaid-eligible inpatient days relative to its total inpatient days is equal to or greater than one standard deviation above the mean, and one person who is employed by a hospital in an urban area;

      (B) One member who is a representative of a statewide organization of hospitals;

      (C) One member who represents a statewide organization of health insurance carriers or a health insurance carrier licensed pursuant to title 10 and who is not a representative of a hospital;

   2. Members of the enterprise board serve without compensation but must be reimbursed from money in the fund for actual and necessary expenses incurred in the performance of their duties pursuant to this section.
   3. The enterprise board may contract for a group facilitator to assist the members of the enterprise board in performing their required duties.
   4. The enterprise board has, at a minimum, the following duties:
      1. To determine the timing and method by which the enterprise assesses the healthcare affordability and sustainability fee and the amount of the fee;
      2. If requested by the health and human services committee of the senate or the public health care and human services committee of the house of representatives, or any successor committees, to consult with the committees on any legislation that may impact the healthcare affordability and sustainability fee or hospital reimbursements established pursuant to this section;
      3. To determine changes in the healthcare affordability and sustainability fee that increase the number of hospitals benefitting from the uses of the healthcare affordability and sustainability fee described in subsections (5)(b)(I) to (5)(b)(IV) of this section or that minimize the number of hospitals that suffer losses as a result of paying the healthcare affordability and sustainability fee;
      4. To recommend to the state department reforms or changes to the inpatient hospital and outpatient hospital reimbursements and quality incentive payments made under the state medical assistance program to increase provider accountability, performance, and reporting;
      5. To direct and oversee the enterprise in seeking, in concert with or through an agreement with the state department if required by federal law, any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health care delivery system reform incentive payments program as described in subsection (8) of this section;
      6. To recommend to the state department the schedule and approach to the implementation of subsections (5)(b)(IV) and (5)(b)(V) of this section;
      7. If money in the fund is insufficient to fully fund all of the purposes specified in subsection (5)(b) of this section, to recommend to the state board changes to the expanded eligibility provisions described in subsection (5)(b)(IV) of this section;
      8. To prepare the reports specified in subsection (7)(e) of this section;
      9. To monitor the impact of the healthcare affordability and sustainability fee on the broader health care marketplace;
      10. To establish requirements for the reports that hospitals must submit to the enterprise to allow the enterprise to calculate the amount of the healthcare affordability and sustainability fee; and
      11. To perform any other duties required to fulfill the enterprise board's charge or those assigned to it by the state board or the executive director.
   5. On or before January 15, 2018, and on or before January 15 each year thereafter, the enterprise board shall submit a written report to the health and human services committee of the senate and the public health care and human services committee of the house of representatives, or any successor committees, the joint budget committee of the general assembly, the governor, and the state board. The report shall include, but need not be limited to:
      1. The recommendations made to the state board pursuant to this section;
      2. A description of the formula for how the healthcare affordability and sustainability fee is calculated and the process by which the healthcare affordability and sustainability fee is assessed and collected;
      3. An itemization of the total amount of the healthcare affordability and sustainability fee paid by each hospital and any projected revenue that each hospital is expected to receive due to:
         1. The increased reimbursements made pursuant to subsections (5)(b)(I) and (5)(b)(II) of this section and the quality incentive payments made pursuant to subsection (5)(b)(III) of this section; and
         2. The increased eligibility described in subsections (5)(b)(IV) and (5)(b)(V) of this section;
      4. An itemization of the costs incurred by the enterprise in implementing and administering the healthcare affordability and sustainability fee;
      5. Estimates of the differences between the cost of care provided and the payment received by hospitals on a per-patient basis, aggregated for all hospitals, for patients covered by each of the following:
         1. Medicaid;
         2. Medicare; and
         3. All other payers; and
      6. A summary of:
         1. The efforts made by the enterprise, acting in concert with or through an agreement with the state department if required by federal law, to seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health care delivery system reform incentive payments program as described in subsection (8) of this section; and
         2. The progress actually made by the enterprise, in cooperation with the state department and hospitals, towards the goal of implementing such a program.
   6. The enterprise board shall calculate the estimates described in subsection (7)(e)(V) of this section by using appropriate information provided to the state department by hospitals and any state department analysis of that information.
   7. 1. The enterprise is subject to the open meetings provisions of the "Colorado Sunshine Act of 1972", contained in part 4 of article 6 of title 24, and the "Colorado Open Records Act", part 2 of article 72 of title 24.
      2. For purposes of the "Colorado Open Records Act", part 2 of article 72 of title 24, and except as may otherwise be provided by federal law or regulation or state law, the records of the enterprise are public records, as defined in section 24-72-202 (6), regardless of whether the enterprise receives less than ten percent of its total annual revenues in grants, as defined in section 24-77-102 (7), from all Colorado state and local governments combined.
      3. The enterprise is a public entity for purposes of part 2 of article 57 of title 11.
8. Health care delivery system reform incentive payments program - funding and implementation. The enterprise, acting in concert with or through an agreement with the state department if required by federal law, shall seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation, no earlier than October 1, 2019, of a health care delivery system reform incentive payments program that will improve health care access and outcomes for individuals served by the state department while efficiently utilizing available financial resources. Such a program must, at a minimum:
   1. Include an initial planning phase to:
      1. Assess needs; and
      2. Develop achievable outcome-based metrics to be used to measure progress towards program goals, including the goals of health care delivery system integration, improved patient outcomes, and more efficient provision of care; and
   2. Address the following focus areas:
      1. Care coordination and care transition management;
      2. Integration of physical and behavioral health care services;
      3. Chronic condition management;
      4. Targeted population health; and
      5. Data-driven accountability and outcome measurement.

Source: L. 2017: Entire section added, (SB 17-267), ch. 267, p. 1448, § 17, effective July 1. L. 2018: IP(5)(b) amended, (SB 18-195), ch. 173, p. 1205, § 1, effective July 1. L. 2019: (7)(e.5) added, (HB 19-1001), ch. 52, p. 177, § 1, effective August 2. L. 2020: (5)(b)(VIII) and (6)(a)(I) amended and (4)(a)(II.5), (5)(b)(VIII.5), and (6)(b)(I.3) added, (HB 20-1361), ch. 161, p. 756, § 2, effective June 29; (5)(b)(VIII) and (6)(a)(I) amended and (4)(a)(II.3), (5)(b)(VIII.3), and (6)(b)(I.5) added, (HB 20-1385), ch. 173, p. 795, § 2, effective June 29; IP(4)(a), (5)(b)(VIII), and (6)(a)(I) amended and (4)(a)(II.5), (5)(b)(VIII.7), and (6)(b)(I.7) added, (HB 20-1386), ch. 210, p. 1023, § 1, effective June 30.

25.5-4-402.5. Providers - state university teaching hospitals.

Subject to appropriations by the general assembly, the state department shall make payments to state university teaching hospitals for providing care under the state's medical assistance program established pursuant to this article and articles 5 and 6 of this title.

Source: L. 2008: Entire section added, p. 1185, § 3, effective May 22.

25.5-4-402.7. Unexpended hospital provider fee cash fund - creation - transfer from hospital provider fee cash fund - use of fund - repeal. (Repealed)

Source: L. 2017: Entire section added, (SB 17-267), ch. 267, p. 1464, § 18, effective July 1.

Editor's note: Subsection (2) provided for the repeal of this section, effective November 1, 2018. (See L. 2017, p. 1464 .)

25.5-4-402.8. Hospital expenditure report - definitions.

1. As used in this section, unless the context otherwise requires:
   1. "Acquired" means the purchase by a hospital, or entity that is owned by or under common ownership and control with the hospital, of all or substantially all of an organization subject to subsection (1)(b)(I) or (1)(b)(II) of this section through an asset, equity, or similar purchase agreement that is a single transaction or series of transactions.
   2. "Affiliated" or "affiliate" means there is a contractual relationship between a hospital or an entity that is owned by or under common ownership and control with the hospital where the contractual relationship enables the hospital or an entity that is owned by or under common ownership and control with the hospital to exercise control over one of the following entities:
      1. Another hospital;
      2. An entity owned by or under common ownership and control with another hospital; or
      3. A physician group practice.
   3. "Control" means the possession, direct or indirect, of the power to direct or cause the direction of management and policies of an affiliate, whether through the ownership of equity or membership, by contract or otherwise.
   4. "Major payer group" includes commercial insurers, medicare, medicaid, individuals who self-pay, a financial assistance plan, and the "Colorado Indigent Care Program", established in part 1 of article 3 of this title 25.5.
2. 1. The state department shall annually prepare a written hospital expenditure report detailing uncompensated hospital costs and the different categories of expenditures, by major payer group, made by hospitals in the state. The state department shall consult with the Colorado healthcare affordability and sustainability enterprise board, created pursuant to section 25.5-4-402.4 (7) and referred to in this section as the "enterprise board", in developing the hospital expenditure report. The state department may share any information it receives from hospitals with the enterprise board. The state department may include information it receives from hospitals in accordance with subsection (2)(b) of this section and that is not otherwise publicly available in the expenditure report and share such information with the enterprise board; except that information the state department receives from hospitals in accordance with subsection (2)(b)(III)(N) of this section is confidential, proprietary, contains trade secrets, and is not a public record pursuant to part 2 of article 72 of title 24. The state department shall not include in the expenditure report, share with the enterprise board, or otherwise publish or distribute information derived from reports pursuant to subsection (2)(b)(III)(N) of this section, although the state department may share this information if such information has been de-identified and aggregated in a manner to prevent identification of the transaction price of any individual acquisition or affiliation. A hospital shall not be in violation of this section if the hospital makes a good faith effort to comply with the reporting requirements of this section.
   2. Except as provided in subsection (2)(c) of this section, each hospital licensed pursuant to part 1 of article 3 of title 25, or certified pursuant to section 25-1.5-103 (1)(a)(II), shall make information available to the state department for purposes of preparing the annual hospital expenditure report. The state board shall establish the format of the information provided by each hospital on an annual basis. The first submission by each hospital must include the information described in subsections (2)(b)(I) and (2)(b)(II) of this section for fiscal years 2011-12 through 2018-19 and the information described in subsection (2)(b)(III) of this section for those fiscal years if such information is available. For each subsequent submission, each hospital shall provide the following information to the state department:
      1. The hospital cost report submitted to the federal centers for medicare and medicaid services (CMS) pursuant to 42 CFR 413.20, including a copy of the final forms and worksheets submitted to CMS as part of the hospital cost report;
      2. 1. An annual audited financial statement prepared in accordance with generally accepted accounting principles. Each hospital shall submit the statement within one hundred twenty days after the end of its fiscal year unless the state department grants an extension in writing in advance of that date.
         2. Notwithstanding the provisions of subsection (2)(b)(II)(A) of this section, if a hospital is operating within a health system or other corporate structure and is normally included in that health system or other corporate structure's financial statement, the hospital may submit the health system or other corporate structure's financial statement if the statement separately identifies the financial information for each of the health system or other corporate structure's licensed hospitals operating in this state.
         3. In lieu of an audited financial statement, each hospital operating within a health system or other corporate structure that does not produce an annual audited financial statement specific to each individual hospital, but instead produces consolidated financial statements, shall submit a reconciliation of the consolidated financial statement and hospital-specific revenue and expenses reported on the medicare cost report pursuant to the federal centers for medicare and medicaid services provider reimbursement manual form 339.
      3. A report that contains the following information:
         1. The total number of available beds and licensed beds;
         2. Inpatient statistics in total and by major payer group and by care setting, including but not limited to inpatient discharges and patient days;
         3. Other inpatient statistics, including but not limited to the number of inpatient surgeries, number of births, number of newborn patient days, number of admissions from the hospital-based emergency department, and number of admissions from free-standing emergency departments;
         4. Outpatient statistics in total and by type of visit, including but not limited to hospital-based emergency department visits, free-standing emergency department visits, ambulatory surgery visits, home health visits, and all other outpatient visits;
         5. Gross charges in total, by major payer group, and by care setting, including but not limited to inpatient care and outpatient care;
         6. Contractual allowances in total and by major payer group;
         7. Bad debt write-offs in total and by major payer group;
         8. Charity write-offs in total and by major payer group;
         9. Operating expenses in total and by expense classification, including but not limited to nonphysician payroll expenses and associated hours, physician payroll expenses and associated hours, total payroll expenses and associated hours, contract labor expenses and associated hours, employee benefits expenses, business development, marketing and advertising expenses, supply expenses, depreciation expenses, interest expenses, and all other operating expenses;
         10. Other operating revenue, operating margin, nonoperating gains and losses, and total margin;
         11. A balance sheet, including but not limited to details for current assets, restricted assets, long-term assets, other assets, current liabilities, long-term debt, other liabilities, and equity or net assets;
         12. Staffing information, including but not limited to full-time equivalents, staff turnover, and staff vacancy rates;
         13. A roll forward of property, plant, and equipment accounts by asset type from the beginning to the end of the reporting period by asset category, including but not limited to purchases, other acquisitions, sales, disposals, and other changes; and
         14. The names and transaction price of acquired hospitals, affiliated hospitals, newly constructed hospitals, and rehabilitated hospitals; the names and transaction price of acquired or affiliated physician group practices; and the number and transaction price of individual physician practices acquired.
   3. The state department may exempt from the reporting requirements described in subsection (2)(b) of this section certain types of hospitals, including but not limited to:
      1. Psychiatric hospitals, as licensed by the department of public health and environment;
      2. Hospitals that are licensed as general hospitals and certified as long-term care hospitals by the department of public health and environment;
      3. Critical access hospitals that are licensed as general hospitals and are certified by the department of public health and environment pursuant to 42 CFR 485 (f);
      4. Inpatient rehabilitation facilities; and
      5. Hospitals specified for exemption under 42 CFR 433.68 (e).
   4. Prior to developing the first annual hospital expenditure report, the state department shall consult with the enterprise board regarding the development of the report. The state department shall strive for consistency in reporting the components in each annual report with those in the report of the enterprise board required pursuant to section 25.5-4-402.4 (7)(e).
   5. Prior to issuing the hospital expenditure report, the state department shall provide any hospital referenced in the hospital expenditure report a copy of the report. Each hospital shall have a minimum of fifteen days to review the hospital expenditure report and any underlying data and submit corrections or clarifications to the state department.
   6. The state department shall provide a statewide hospital association any information received pursuant to this section in a machine-readable format at no cost to the association.
3. The hospital expenditure report must include, but not be limited to:
   1. A description of the methods of analysis and definitions of report components;
   2. Uncompensated care costs by major payer group; and
   3. The percentage that each of the following categories contributes to overall expenses of hospitals:
      1. Delivery of inpatient health care and services by major payer group;
      2. Delivery of outpatient health care and services by major payer group and site location;
      3. Administrative costs;
      4. Capital construction costs and associated bond liabilities;
      5. Maintenance;
      6. Capital expenditures;
      7. Personnel services;
      8. Uncompensated care by major payer group; and
      9. Other expenditure categories, as determined by the state department.
4. 1. On or before January 15, 2020, and on or before January 15 each year thereafter, the state department shall submit the annual hospital expenditure report to:

      (I) The public health care and human services committee of the house of representatives, or any successor committee;

      (II) The health and human services committee of the senate, or any successor committee;

      (III) The joint budget committee of the general assembly;

      (IV) The governor; and

      (V) The state board.

   2. The state department may request that the enterprise board combine the hospital expenditure report described in this section with the report of the enterprise board specified in section 25.5-4-402.4 (7)(e), so long as the specific requirements of this section are fulfilled, and so long as the enterprise board agrees to the request. The state department shall post the annual report on its website by January 15 of each year.
   3. Notwithstanding section 24-1-136 (11)(a)(I), the report required in this section continues indefinitely.
5. The state department, in consultation with the department of public health and environment and the division of insurance, shall review the hospital report card, created pursuant to section 25-3-703, and the hospital charge report, created pursuant to section 25-3-705, and make recommendations to the general assembly by November 1, 2019. The recommendations must identify any structural or substantive changes that should be made to the hospital report card or hospital charge report to increase the value of those reports, including a consideration of whether the hospital report card or hospital charge report still provides value to consumers and policymakers.

Source: L. 2019: Entire section added, (HB 19-1001), ch. 52, p. 177, § 2, effective August 2.

25.5-4-403. Providers - community mental health center and clinics - reimbursement.

For the purpose of reimbursing community mental health center and clinic providers, the state department shall establish a price schedule annually with the department of human services in order to reimburse each provider for its actual or reasonable cost of services.

Source: L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-409 as it existed prior to 2006.

25.5-4-404. Payments for clinic services - restrictions on use.

All payments received by county or district public health agencies or boards of health for clinic services, as defined in section 25.5-5-301 (3), furnished to patients shall be used only to offset costs incurred for provision of services by such county or district public health agencies or boards of health or to cash fund health care services in the county where the services were provided.

Source: L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1. L. 2010: Entire section amended, (HB 10-1422), ch. 419, p. 2110, § 142, effective August 11.

Editor's note: This section is similar to former § 26-4-515 as it existed prior to 2006.

25.5-4-405. Mental health managed care service providers - requirements.

1. Each contract between the state department and a managed care organization providing mental health services to a recipient under the medical assistance program shall comply with all federal requirements, including but not limited to:
   1. Ensuring that a recipient with complex or multiple needs who requires mental health services shall have access to mental health professionals with appropriate training and credentials and shall provide the recipient with such services in collaboration with the recipient's other providers;
   2. Informing each recipient of his or her right to and the process for appeal upon notification of denial, termination, or reduction of a requested service; and
   3. Administering initial stabilization treatment for a recipient and transferring the recipient for appropriate continued services.

   (1.5) Each contract between the state department and a managed care organization providing mental health services to a recipient under the medical assistance program shall allow for the use of telemedicine pursuant to the provisions of section 25.5-5-320.

2. For mental health managed care recipients, the state department shall have a patient representative program for recipient grievances that complies with all federal requirements and that shall:
   1. Be posted in a conspicuous place at each location at which mental health services are provided;
   2. Allow for a patient representative to serve as a liaison between the recipient and the provider;
   3. Describe the qualifications for a patient representative;
   4. Outline the responsibilities of a patient representative;
   5. Describe the authority of a patient representative; and
   6. Establish a method by which each recipient is informed of the patient representative program and how a patient representative may be contacted.

Source: L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1. L. 2008: (1.5) added, p. 111, § 1, effective August 5.

Editor's note: This section is similar to former § 26-4-409.5 as it existed prior to 2006.

25.5-4-406. Rate setting - medicaid residential treatment service providers - monitoring and auditing - report.

1. The state department shall approve a rate-setting process consistent with medicaid requirements for providers of medicaid residential treatment services in the state of Colorado as developed by the department of human services. The rate-setting process developed pursuant to this section may include, but shall not be limited to:
   1. A range for reimbursement that represents a base-treatment rate for serving a child who is subject to out-of-home placement due to dependency and neglect, a child placed in a residential child care facility pursuant to the "Children and Youth Mental Health Treatment Act", article 67 of title 27, or a child who has been adjudicated a delinquent, which includes a defined service package to meet the needs of the child;
   2. A request for proposal to contract for specialized service needs of a child, including but not limited to: Substance-abuse treatment services; sex offender services; and services for the developmentally disabled; and
   3. Negotiated incentives for achieving outcomes for the child as defined by the state department, counties, and providers.
2. The medicaid rate-setting process approved by the state department shall include a two- or three-year implementation timeline with implementation beginning in state fiscal year 2008-09.
3. The state department and the department of human services, in consultation with the representatives of the counties and the provider community, shall review the rate-setting process every two years and shall submit any changes to the joint budget committee of the general assembly.

Source: L. 2006: Entire article added with relocations, p. 1845, § 7, effective July 1. L. 2007: (1)(a), (2), and (3) amended, p. 618, § 2, effective August 3. L. 2010: (1)(a) amended, (SB 10-175), ch. 188, p. 800, § 66, effective April 29. L. 2018: (1)(a) amended, (HB 18-1094), ch. 343, p. 2044, § 10, effective June 30.

25.5-4-407. Services by licensed psychologists without a doctor's referral.

The executive director of the state department may authorize the providing of services of licensed psychologists without the requirement that the services be referred by a doctor of medicine or a doctor of osteopathy, but such services shall be subject to the cost containment program specified under section 25.5-4-408. The executive director may except from the authorization those services the director determines to be necessary for the purpose of promoting the primary care physician program.

Source: L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-412 as it existed prior to 2006.

25.5-4-408. Services provided by licensed psychologists - cost containment program.

1. Working in conjunction with licensed psychologists in the state, the state board shall promulgate rules to establish and implement mechanisms for containing the costs of services provided by licensed psychologists under the medical assistance programs established pursuant to this article and articles 5 and 6 of this title. The cost containment mechanism shall ensure that the costs to the medical assistance program will result in no increase in the total cost of the program solely as a result of the reimbursement for services of licensed psychologists pursuant to section 25.5-4-407. The cost containment mechanisms may include the following:
   1. Limiting the number of days a licensed psychologist may be reimbursed per patient for inpatient hospitalization, partial hospitalization, and outpatient visits without an order for continued treatment from a doctor of medicine or osteopathy;
   2. Limiting the number of hours a licensed psychologist may be reimbursed for diagnostic testing and evaluation per patient per year;
   3. Provision of group therapy when needed or appropriate;
   4. Provision of licensed psychologists' services from a pool of those licensed psychologists requesting to be included in such pool;
   5. Provision of a licensed psychologist's services through the use of telemedicine pursuant to the provisions of section 25.5-5-320.

Source: L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1. L. 2008: (1)(e) added, p. 111, § 2, effective August 5.

Editor's note: This section is similar to former § 26-4-516 as it existed prior to 2006.

25.5-4-409. Authorization of services - nurse anesthetists - advanced practice nurses.

1. When services by a certified registered nurse anesthetist are provided pursuant to an order by a physician in accordance with this article 4, articles 5 and 6 of this title 25.5, and section 12-255-104 (10), the executive director of the state department shall authorize reimbursement for said services. Payment for such services shall be made directly to the nurse anesthetist, if requested by the nurse anesthetist; except that this section shall not apply to nurse anesthetists when acting within the scope of their employment as salaried employees of public or private institutions or physicians.
2. When services by an advanced practice nurse registered pursuant to section 12-255-111 are provided in accordance with this article 4 and articles 5 and 6 of this title 25.5, the executive director of the state department shall authorize reimbursement for said services. Payment for the services shall be made directly to the advanced practice nurse, if requested by the advanced practice nurse; except that this section shall not apply to advanced practice nurses when acting within the scope of their employment as salaried employees of public or private institutions or physicians.

Source: L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1. L. 2008: (2) amended, p. 138, § 1, effective July 1. L. 2019: Entire section amended, (HB 19-1172), ch. 136, p. 1707, § 178, effective October 1.

Editor's note: This section is similar to former § 26-4-413 as it existed prior to 2006.

25.5-4-410. Services of audiologists and speech pathologists without supervision.

1. When medical or diagnostic services by an audiologist or speech pathologist are provided pursuant to an order by a physician in accordance with this article and articles 5 and 6 of this title, the executive director of the state department shall authorize reimbursement for said services. For the purposes of this section, "audiologist" or "speech pathologist" means an individual who meets the requirements set forth in the federal "Social Security Act", as amended, or any federal regulations adopted pursuant thereto, for participating providers of audiology or speech pathology services.
2. Nothing in this section shall be construed as expanding the provision of services available as a part of the medical assistance program established pursuant to this article and articles 5 and 6 of this title. For the purposes of making payments to audiologists or speech pathologists pursuant to this section, the state board shall establish rules implementing this section. The rules promulgated pursuant to this subsection (2) shall ensure that the costs to the medical assistance program will result in no increase in the total cost of the program solely as a result of the reimbursement for services of an audiologist or speech pathologist pursuant to this section.
3. Payments for services included in this section shall be made directly to the audiologist or speech pathologist, if requested by the audiologist or speech pathologist; except that this section shall not apply to audiologists or speech pathologists when acting within the scope of their employment as salaried employees of public or private institutions or physicians.

Source: L. 2006: Entire article added with relocations, p. 1847, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-414 as it existed prior to 2006.

25.5-4-411. Authorization of services provided by dental hygienists.

1. When dental hygiene services are provided to children by a licensed dental hygienist who is providing dental hygiene services pursuant to section 12-220-503 without the supervision of a licensed dentist, the executive director of the state department shall authorize reimbursement for said services, subject to the requirements of this section. Payment for the services shall be made directly to the licensed dental hygienist, if requested by the licensed dental hygienist; except that this section shall not apply to licensed dental hygienists when acting within the scope of their employment as salaried employees of public or private institutions, physicians, or dentists.
2. For each child provided dental hygiene services pursuant to this section, the dental hygienist shall attempt to identify a dentist participating in medicaid for the child.

Source: L. 2006: Entire article added with relocations, p. 1847, § 7, effective July 1. L. 2019: (1) amended, (HB 19-1172), ch. 136, p. 1707, § 179, effective October 1. L. 2020: (1) amended, (HB 20-1056), ch. 64, p. 263, § 9, effective September 14.

Editor's note: This section is similar to former § 26-4-414.3 as it existed prior to 2006.

25.5-4-412. Medical services provided by certified family planning clinics - definition.

1. When medical or diagnostic services are provided in accordance with this article and articles 5 and 6 of this title by a certified family planning clinic, the executive director of the state department shall authorize reimbursement for the services. The reimbursement shall be made directly to the certified family planning clinic.
2. For purposes of this section, "certified family planning clinic" means a family planning clinic certified by the Colorado department of public health and environment, accredited by a national family planning organization, and staffed by medical professionals licensed to practice in the state of Colorado, including, but not limited to, doctors of medicine, doctors of osteopathy, physician assistants, and advanced practice nurses.
3. For purposes of this section, all medical care services or goods rendered by a certified family planning clinic that are benefits of the Colorado medical assistance program shall be ordered by a physician who need not be physically present on the premises of the certified family planning clinic at the time services are rendered.
4. Nothing in this section shall be construed as expanding the provision of services available as a part of the medical assistance program established pursuant to this article and articles 5 and 6 of this title. For purposes of making payments to certified family planning clinics pursuant to this section, the state board shall establish rules implementing this section. The rules promulgated pursuant to this subsection (4) shall ensure that the reimbursement for services rendered by a certified family planning clinic pursuant to this section shall not be the sole result of an increase in the costs to the state medical assistance program.

Source: L. 2006: Entire article added with relocations, p. 1848, § 7, effective July 1. L. 2016: (2) amended, (SB 16-158), ch. 204, p. 729, § 21, effective August 10.

Editor's note: This section is similar to former § 26-4-414.5 as it existed prior to 2006.

Cross references: For the legislative declaration in SB 16-158, see section 1 of chapter 204, Session Laws of Colorado 2016.

25.5-4-413. Certain providers to inform patients of rights concerning advance medical directives.

1. On and after November 5, 1991, with regard to any service rendered on and after said date, each hospital, nursing care facility, home health agency, hospice program, and health maintenance organization participating in the state medical assistance program or providing medical assistance pursuant to parts 3 to 12 of article 6 of this title shall provide written information to all adult patients of such providers concerning patients' rights under state law to make medical treatment decisions, including the right to accept or refuse any medical or surgical treatment and the right to formulate advance directives regarding said decisions. As used in this section, "advance directives" includes any written or oral instructions recognized under state law concerning the making of medical treatment decisions on behalf of or the provision of medical care for the person who provided the instructions in the event such person becomes incapacitated. Advance directives include, but are not limited to, medical durable powers of attorney, durable powers of attorney, or living wills.
2. Providers listed in subsection (1) of this section shall provide educational programs for staff and the community concerning advance directives and shall maintain written policies detailing methods for safeguarding patients' rights concerning medical treatment decisions, including documenting in the patient's medical or patient record whether the patient has executed, amended, or revoked an advance directive. No provider shall condition the provision of services or otherwise discriminate against a patient on the basis of whether the patient has executed an advance directive.

Source: L. 2006: Entire article added with relocations, p. 1848, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-403.5 as it existed prior to 2006.

25.5-4-414. Providers - physicians - prohibition of certain referrals - definitions.

1. As used in this section, unless the context otherwise requires:
   1. "Designated health services" means any of the following services:
      1. Clinical laboratory services;
      2. Physical therapy services;
      3. Occupational therapy services;
      4. Radiology and other diagnostic services;
      5. Radiation therapy services;
      6. Durable medical equipment;
      7. Parenteral or enteral nutrients, equipment, and supplies;
      8. Prosthetics, orthotics, and prosthetic devices;
      9. Home health services;
      10. Outpatient prescription drugs; and
      11. Inpatient and outpatient hospital services.
   2. "Financial relationship" means an ownership or investment interest in an entity furnishing designated health services or a compensation arrangement between a provider or an immediate family member of the provider and the entity. An ownership or investment interest may be reflected in equity, debt, or other instruments.
   3. "Immediate family member of the provider" means any spouse, natural or adoptive parent, natural or adoptive child, stepparent, stepchild, stepbrother, stepsister, in-law, grandparent, or grandchild of the provider.
   4. "Provider" means:
      1. A doctor of medicine or osteopathy who is licensed to practice medicine pursuant to article 240 of title 12;
      2. A doctor of dental surgery or of dental medicine who is licensed to practice dentistry pursuant to article 220 of title 12;
      3. A doctor of podiatric medicine who is licensed to practice podiatry pursuant to article 290 of title 12;
      4. A doctor of optometry who is licensed to practice optometry pursuant to article 275 of title 12; or
      5. A chiropractor who is licensed to practice chiropractic pursuant to article 215 of title 12.
2. 1. Except as otherwise provided in this subsection (2), a provider participating in the medical assistance program under this article and articles 5 and 6 of this title is prohibited from making a referral to an entity for designated health services for which payment may be made under the state's medical assistance program if the provider or an immediate family member of the provider has a financial relationship with the entity.
   2. Paragraph (a) of this subsection (2) shall not apply to any financial relationship that meets the requirements of an exception to the prohibitions established by 42 U.S.C. sec. 1395nn, as amended, or any regulations promulgated thereunder, as amended.
   3. Paragraph (a) of this subsection (2) shall not apply to a financial relationship or referral for designated health services if the financial relationship or referral for designated health services would not violate 42 U.S.C. sec. 1395nn, as amended, and any regulations promulgated thereunder, as amended, if the designated health services were eligible for payment under medicare rather than the "Colorado Medical Assistance Act".
3. An entity that provides designated health services as a result of a prohibited referral shall not present a claim or bill to any individual, any third-party payor, the state department, or any other entity for the designated health services.
4. An entity that provides designated health services shall provide to the state department, upon its request and in the form specified by the state department, information concerning the entity's ownership arrangements including:
   1. The items and services provided by the entity;
   2. The names and provider identification numbers of all providers with a financial interest in the entity or whose immediate family members have a financial interest in the entity.
5. If a provider refers a patient for designated health services in violation of paragraph (a) of subsection (2) of this section or the entity refuses to provide the information required in subsection (4) of this section, the state department may:
   1. Deny any claims for payment from the provider or entity;
   2. Require the provider or entity to refund payments for services;
   3. Refer the matter to the appropriate agency for medical assistance fraud investigation; or
   4. Terminate the provider's or entity's participation in the medical assistance program.

Source: L. 2006: Entire article added with relocations, p. 1849, § 7, effective July 1. L. 2019: (1)(d) amended, (HB 19-1172), ch. 136, p. 1708, § 180, effective October 1.

Editor's note: This section is similar to former § 26-4-410.5 as it existed prior to 2006.

25.5-4-415. No public funds for abortion - exception - repeal.

1. It is the purpose of this section to implement the provisions of section 50 of article V of the Colorado constitution, adopted by the registered electors of the state of Colorado at the general election November 6, 1984, which prohibits the use of public funds by the state of Colorado or its agencies or political subdivisions to pay or otherwise reimburse, directly or indirectly, any person, agency, or facility for any induced abortion.
2. If every reasonable effort has been made to preserve the lives of a pregnant woman and her unborn child, then public funds may be used pursuant to this section to pay or reimburse for necessary medical services, not otherwise provided for by law.
3. 1. Except as provided in paragraph (b) of this subsection (3), any necessary medical services performed pursuant to this section shall be performed only in a licensed health care facility by a provider who is a licensed physician.
   2. However, such services may be performed in other than a licensed health care facility if, in the medical judgment of the attending physician, the life of the pregnant woman or her unborn child is substantially threatened and a transfer to a licensed health care facility would further endanger the life of the pregnant woman or her unborn child. Such medical services may be performed in other than a licensed health care facility if the medical services are necessitated by a life-endangering circumstance described in subparagraph (II) of paragraph (b) of subsection (6) of this section and if there is no licensed health care facility within a thirty-mile radius of the place where such medical services are performed.
4. 1. Any physician who renders necessary medical services pursuant to subsection (2) of this section shall report the following information to the state department:
      1. The age of the pregnant woman and the gestational age of the unborn child at the time the necessary medical services were performed;
      2. The necessary medical services which were performed;
      3. The medical condition which necessitated the performance of necessary medical services;
      4. The date such necessary medical services were performed and the name of the facility in which such services were performed.
   2. The information required to be reported pursuant to paragraph (a) of this subsection (4) shall be compiled by the state department and such compilation shall be an ongoing public record; except that the privacy of the pregnant woman and the attending physician shall be preserved.
5. For purposes of this section, pregnancy is a medically diagnosable condition.
6. For the purposes of this section:
   1. 1. "Death" means:
         1. The irreversible cessation of circulatory and respiratory functions; or
         2. The irreversible cessation of all functions of the entire brain, including the brain stem.
      2. A determination of death under this section shall be in accordance with accepted medical standards.
   2. "Life-endangering circumstance" means:
      1. The presence of a medical condition, other than a psychiatric condition, as determined by the attending physician, which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term;
      2. The presence of a lethal medical condition in the unborn child, as determined by the attending physician and one other physician, which would result in the impending death of the unborn child during the term of pregnancy or at birth; or
      3. The presence of a psychiatric condition which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term. In such case, unless the pregnant woman has been receiving prolonged psychiatric care, the attending licensed physician shall obtain consultation from a licensed physician specializing in psychiatry confirming the presence of such a psychiatric condition. The attending physician shall report the findings of such consultation to the state department.
   3. "Necessary medical services" means any medical procedures deemed necessary to prevent the death of a pregnant woman or her unborn child due to life-endangering circumstances.
7. If any provision of this section or application thereof is held invalid, such invalidity shall not affect other provisions or applications of this section which can be given effect without the invalid provision or application, and to this end the provisions of this section are declared severable.
8. Use of the term "unborn child" in this section is solely for the purposes of facilitating the implementation of section 50 of article V of the state constitution, and its use shall not affect any other law or statute nor shall it create any presumptions relating to the legal status of an unborn child or create or affect any distinction between the legal status of an unborn child and the legal status of a fetus.
9. This section shall be repealed if section 50 of article V of the Colorado constitution is repealed.

Source: L. 2006: Entire article added with relocations, p. 1851, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-512 as it existed prior to 2006.

25.5-4-416. Providers - medical equipment and supplies - requirements.

1. As used in this section, unless the context otherwise requires, "provider" means a person or entity that delivers disposable medical supplies or durable medical equipment products or services directly to a recipient.
2. On and after January 1, 2007, the state board rules for the payment for disposable medical supplies and durable medical equipment, including but not limited to prosthetic and orthotic devices, shall prohibit a provider from being reimbursed unless the provider:
   1. 1. Has one or more physical locations within the state of Colorado or within fifty miles of a border of Colorado with a street address, a local business telephone number, an inventory, and a sufficient staff to service or repair products; except that the requirements of this paragraph (a) shall not apply to durable medical equipment or disposable medical supplies that are medically necessary and cannot be purchased from a provider meeting the requirements of this paragraph (a);
      2. Complies with all state and local licensing, insurance, and regulatory requirements for operating the provider's business;
      3. Is responsible for the delivery of and instructing the recipient on the proper use of the equipment; and
      4. Provides repairs, replacements, or adjustments to the provider's products pursuant to rules of the state board; or
   2. Contracts with a provider who meets the criteria established in paragraph (a) of this subsection (2).
3. The provisions of this section shall apply to fee-for-service and primary care physician program recipients.

Source: L. 2006: Entire section added, p. 525, § 1, effective August 7.

Editor's note: This section was originally numbered as § 26-4-410.7 in House Bill 06-1299. Section 2 of the act provided for the renumbering and relocation of § 26-4-410.7 to this section. (See L. 2006, p. 526 .)

25.5-4-417. Provider fee - medicaid providers - state plan amendment - rules - definitions.

1. For purposes of this section, unless the context otherwise requires:
   1. "Local government" means a county, home rule county, home rule or statutory city, town, territorial charter city, or city and county.
   2. "Provider fee" means a licensing fee, assessment, or other mandatory payment that is related to health care items or services as specified under 42 CFR 433.55.
   3. "Qualified provider" means a hospital licensed pursuant to section 25-3-101, C.R.S., or a certified home health care agency within the territorial boundaries of the local government.
2. For the purpose of sustaining or increasing reimbursement for providing medical care under the state's medical assistance program and to low-income populations, the state department shall amend the state plan effective July 1, 2006. Implementation of the state plan amendment shall be subject to the approval of the federal government. The imposition and collection of a provider fee by a local government pursuant to article 28 of title 29, C.R.S., shall be prohibited without the federal government's approval of a state plan amendment authorizing federal financial participation for the provider fees.
3. In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1) and (e)(2), the state department may seek a waiver from the broad-based provider fee requirement or the uniform provider fee requirement, or both, to exclude qualified providers from the provider fee.
4. To the extent authorized by federal law, the state department may exclude a governmental qualified provider from payment of the provider fee, benefits from the provider fee, or any federal financial participation due to the fee.
5. To the extent authorized by federal law, the state department shall distribute the provider fee and any associated federal financial participation either to a local government that has certified payment to qualified providers within the local government or directly to the qualified providers. The state department shall establish reimbursement methods to distribute the provider fee and associated federal financial participation to qualified providers. The state department may alter reimbursement methods to qualified providers participating under the state's medical assistance program and Colorado indigent care program to the extent necessary to meet the federal requirements and to obtain federal approval of the provider fee. The state department shall work with a statewide association of hospitals on changes to reimbursement methods or provider fees that impact hospital providers. The state department shall work with a statewide association of home health care agencies on changes to reimbursement methods or provider fees that impact home health care agencies.
6. The state board shall adopt any rules necessary for the administration and implementation of this section.

Source: L. 2006: Entire section added, p. 887, § 2, effective May 5. L. 2008: Entire section amended, p. 927, § 1, effective May 20.

Editor's note: This section was enacted as § 26-4-427 in Senate Bill 06-145 but was relocated due to its harmonization with this article as it appeared in Senate Bill 06-219.

25.5-4-418. Integration of physical and behavioral health services - department review - report - repeal. (Repealed)

Source: L. 2011: Entire section added, (HB 11-1242), ch. 271, p. 1230, § 1, effective July 1.

Editor's note: Subsection (4) provided for the repeal of this section, effective July 1, 2012. (See L. 2011, p. 1230 .)

25.5-4-419. Supplemental state payment to qualified providers - office-administered drugs - no federal financial participation - definition - rules - repeal. (Repealed)

Source: L. 2018: Entire section added, (HB 18-1330), ch. 146, p. 932, § 1, effective April 23.

Editor's note: Subsection (6) provided for the repeal of this section, effective July 1, 2019. (See L. 2018, p. 932 .)

25.5-4-420. Providers to obtain unique NPI - service site - provider type - definitions.

1. As used in this section:
   1. "Health care clearinghouse" has the same meaning as set forth in 45 CFR 160.103.
   2. "NPI" or "national provider identifier" means the standard, unique health identifier for health care providers that is issued by the national provider system in accordance with 45 CFR part 162.
   3. "Off-campus location" means a facility:
      1. Whose operations are directly or indirectly owned or controlled by, in whole or in part, or affiliated with a hospital, regardless of whether the operations are under the same governing body as the hospital;
      2. That is located more than two hundred fifty yards from the hospital's main campus;
      3. That provides services that are organizationally and functionally integrated with the hospital; and
      4. That is an outpatient facility providing preventive, diagnostic, treatment, or emergency services.
   4. "Organization health care provider" means a provider that is not an individual and includes a hospital.
   5. "Subpart" has the same meaning as that term is used in 45 CFR part 162 and means a component or separate physical location of an organization health care provider that may be separately licensed or certified by the state.
2. 1. Each organization health care provider and each subpart that is required or eligible to obtain an NPI pursuant to 45 CFR 162.410 must apply for, obtain, and use, on all claims for payment for medical care, services, or goods authorized under this article 4 and articles 5 and 6 of this title 25.5, a unique NPI for each site at which the organization health care provider or its subparts deliver medical care, services, or goods.
   2. Each organization health care provider and each subpart that is required or eligible to obtain an NPI pursuant to 45 CFR 162.410 must apply for, obtain, and use, on all claims for payment for medical care, services, or goods authorized under this article 4 and articles 5 and 6 of this title 25.5, a unique NPI for each provider type, as specified by the state department, under which the organization health care provider or its subparts deliver medical care, services, or goods.
   3. An organization health care provider or subpart submitting a claim for payment for medical care, services, or goods rendered under this article 4 or article 5 or 6 of this title 25.5 shall include on the claim the unique NPI that identifies both the site where the medical care, services, or goods were provided and the provider type, as specified by the state department, regardless of whether the claim is filed or submitted by or through a central office of the organization health care provider or a health care clearinghouse.
3. 1. For an organization health care provider that is a licensed or certified hospital contracting for services under this article 4 and articles 5 and 6 of this title 25.5, the hospital shall obtain and use a unique, separate, and distinct NPI for:
      1. Its main campus;
      2. Each off-campus location of the hospital; and
      3. Each provider type, if specified by the state department, when the hospital delivers medical care, services, or goods at either the hospital's main campus or at an off-campus location.
   2. A hospital submitting a claim for payment for medical care, services, or goods rendered under this article 4 or article 5 or 6 of this title 25.5 shall include on the claim the unique NPI that identifies both the site where the medical care, services, or goods were provided and the provider type, as specified by the state department, regardless of whether the claim is filed or submitted by or through a central office of the hospital or a health care clearinghouse.
4. 1. Starting January 1, 2020, an organization health care provider applying to enroll as a new provider under this article 4 and articles 5 and 6 of this title 25.5 shall demonstrate that it has obtained one or more NPIs as required by this section, and upon enrollment, shall use its unique NPI on every claim for payment in the manner required by this section.
   2. Starting January 1, 2021, an organization health care provider enrolled and applying for revalidation as a provider under this article 4 and articles 5 and 6 of this title 25.5 shall demonstrate that it has obtained one or more NPIs as required by this section as a condition of receiving revalidation, and upon receiving revalidation as a provider, shall use its unique NPI on every claim for payment in the manner required by this section.

Source: L. 2018: Entire section added, (HB 18-1282), ch. 158, p. 1109, § 3, effective August 8.

Cross references: For the legislative declaration in HB 18-1282, see section 1 of chapter 158, Session Laws of Colorado 2018.

25.5-4-421. Supplemental state payment to qualified durable medical equipment providers - no federal financial participation - definition - rules - repeal. (Repealed)

Source: L. 2018: Entire section added, (HB 18-1329), ch. 206, p. 1323, § 1, effective May 4.

Editor's note: Subsection (6) provided for the repeal of this section, effective July 1, 2019. (See L. 2018, p. 1323 .)

25.5-4-422. Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules.

1. It is the intent of the general assembly that:
   1. The department of health care policy and financing pursue strategies to control costs in the medicaid program authorized in the "Colorado Medical Assistance Act";
   2. The state department dedicate permanent staff and resources to pursue cost-control strategies, value-based payments, and other approaches to reduce the rate of expenditure growth in the medicaid program; and
   3. This section not preclude the state department from pursuing other cost-containment activities that are not specifically described in this section.
2. 1. The state department shall provide information regarding medicaid expenditures and the quality of medical services provided by providers participating in the medicaid program to providers participating in the accountable care collaborative pursuant to section 25.5-5-419.
   2. The state department shall provide information regarding medicaid expenditures and the quality of available pharmaceuticals prescribed by providers participating in the medicaid program to providers participating in the accountable care collaborative pursuant to section 25.5-5-419.
   3. The state department may provide the information described in subsections (2)(a) and (2)(b) of this section to other providers participating in the medicaid program.
3. 1. The state department shall utilize the medicaid management information system to ensure that claims are automatically reviewed prior to payment to identify and correct improper coding that leads to inappropriate payment in medicaid claims.
   2. The state department may procure commercial technology to implement the requirements of subsection (3)(a) of this section.
4. 1. The state department shall pursue cost-control strategies, value-based payments, and other approaches to reduce the rate of expenditure growth in the medicaid program.
   2. Prior to implementing and reporting on any new measures authorized by this section, the state department shall provide an opportunity for affected recipients, providers, and stakeholders to provide feedback and make recommendations on the state department's proposed implementation.
5. By November 1, 2018, the state department shall provide a report to the joint budget committee concerning:
   1. The feedback received pursuant to subsection (4)(b) of this section;
   2. The timelines for implementation of any cost-control measures enacted pursuant to this section; and
   3. A description of the expected impact on recipients and recipients' health outcomes and how the state department plans to measure the effect on recipients.
6. 1. The state department shall contract with a third party to perform an independent evaluation of the cost-control measures authorized pursuant to this section.
   2. The state department shall provide a report to the joint budget committee on November 1, 2019, and November 1, 2020, detailing the results of the independent evaluation, including estimates of the cost savings achieved and the impact of the cost-control measures authorized pursuant to this section on recipients and recipients' health outcomes.
7. The state board shall adopt any rules necessary for the administration and implementation of this section.

Source: L. 2018: Entire section added, (SB 18-266), ch. 264, p. 1622, § 1, effective May 29.

25.5-4-423. Targets for investments in primary care.

The state department shall adopt appropriate targets for investments in primary care to support value-based health care delivery in alignment with the affordability standards developed in accordance with section 10-16-107 (3.5). The state department shall consider the recommendations of the primary care payment reform collaborative created in section 10-16-150. Targets established under this section do not apply in the case of a nonprofit, nongovernmental health maintenance organization with respect to managed care plans that provide a majority of covered professional services through a single contracted medical group.

Source: L. 2019: Entire section added, (HB 19-1233), ch. 194, p. 2123, § 7, effective May 16.

Cross references: For the legislative declaration in HB 19-1233, see section 1 of chapter 194, Session Laws of Colorado 2019.

25.5-4-501. State plan amendment - federal authorization - repeal. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1853, § 7, effective July 1.

25.5-4-502. Federal authorization - repeal. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1853, § 7, effective July 1.

25.5-4-503. Waiver applications - authorization.

The state department is authorized to apply for health insurance flexibility and accountability waivers that will enable the state to add more flexibility to Colorado's medicaid program and that will result in a cost-effective method of providing health care services to Coloradans.

Source: L. 2006: Entire article added with relocations, p. 1853, § 7, effective July 1.

Editor's note: This section is similar to former § 25.5-1-111 as it existed prior to 2006.

25.5-4-504. Federal authorization - repeal. (Repealed)

Source: L. 2019: Entire section added, (SB 19-222), ch. 226, p. 2265, § 3, effective May 20.

Editor's note: Subsection (3) provided for the repeal of this section, effective July 1, 2020. (See L. 2019, p. 2265 .)

Cross references: For the legislative declaration in SB 19-222, see section 1 of chapter 226, Session Laws of Colorado 2019.

25.5-5-101. Mandatory provisions - eligible groups.

1. In order to participate in the medicaid program, the federal government requires the state to provide medical assistance to certain eligible groups. Pursuant to federal law and except as provided in subsection (2) of this section, any person who is eligible for medical assistance under the mandated groups specified in this section shall receive both the mandatory services that are specified in sections 25.5-5-102 and 25.5-5-103 and the optional services that are specified in sections 25.5-5-202 and 25.5-5-203. Subject to the availability of federal financial participation, the following are the individuals or groups that are mandated under federal law to receive benefits under this article and articles 4 and 6 of this title:
   1. Repealed.
   2. Parents and caretaker relatives living with a dependent child who meet the eligibility criteria pursuant to section 1902 (a)(10)(A) of the federal "Social Security Act", including those who subsequently would have become ineligible under such eligibility criteria because of increased earnings or increased hours of employment whose eligibility is specified for a period of time by the federal government;
   3. Pregnant women whose family income does not exceed one hundred thirty-three percent of the federal poverty line, adjusted for family size, who meet the requirements pursuant to section 1902 (a)(10)(A) of the federal "Social Security Act". Once initial eligibility has been established, the pregnant woman is continuously eligible throughout the pregnancy and for the sixty days following the pregnancy, even if the woman's eligibility would otherwise terminate during such period due to an increase in income.
   4. A newborn child born of a woman who is categorically needy. Such child is deemed medicaid-eligible on the date of birth and remains eligible for one year.
   5. Children for whom adoption assistance or foster care maintenance payments are made under Title IV-E of the federal "Social Security Act", as amended, including foster care children, pursuant to section 1902 (a)(10)(A)(i)(IX) of the federal "Social Security Act", who are under twenty-six years of age, who were in foster care under the responsibility of the state or a tribe, and who were enrolled in medicaid under the state medicaid plan when they turned eighteen years of age;
   6. Individuals receiving supplemental security income;
   7. Individuals receiving mandatory state supplement, including but not limited to individuals receiving old age pensions;
   8. Institutionalized individuals who were eligible for medical assistance in December 1973;
   9. Individuals who would be eligible except for the increase in old-age, survivors, and disability insurance under Pub.L. 92-336;
   10. Individuals who become ineligible for cash assistance as a result of old-age, survivors, and disability insurance cost-of-living increases after April 1977;
   11. Disabled widows or widowers fifty through sixty years of age who have become ineligible for federal supplemental security income or state supplementation as a result of becoming eligible for federal social security survivor's benefits, in accordance with the social security act, 42 U.S.C. sec. 1383c;
   12. Individuals with income and resources at a level which qualifies them as medicare-eligible under section 301 of Title III of the federal "Medicare Catastrophic Coverage Act";
   13. Children under the age of nineteen who meet the eligibility criteria pursuant to section 1902 (a)(10)(A) of the federal "Social Security Act".
2. 1. A qualified alien who entered the United States before August 22, 1996, who meets the exceptions described in the federal "Personal Responsibility and Work Opportunity Reconciliation Act of 1996", Public Law 104-193, as amended, shall receive benefits under this article and articles 4 and 6 of this title.
   2. 1. A qualified alien who entered the United States on or after August 22, 1996, shall not be eligible for benefits under this article or article 4 or 6 of this title, except as provided in section 25.5-5-103 (3), for five years after the date of entry into the United States unless he or she meets the exceptions described in the federal "Personal Responsibility and Work Opportunity Reconciliation Act of 1996", Public Law 104-193, as amended.
      2. Notwithstanding the five-year waiting period established in subparagraph (I) of this paragraph (b), but subject to the availability of sufficient appropriations and the receipt of federal financial participation, the state department may provide benefits under this article and articles 4 and 6 of this title to a pregnant woman who is a qualified alien and a child under nineteen years of age who is a qualified alien so long as such woman or child meets eligibility criteria other than citizenship.
3. Notwithstanding any other provision of this article and articles 4 and 6 of this title, as a condition of eligibility for medical assistance under this article and articles 4 and 6 of this title, a legal immigrant shall agree to refrain from executing an affidavit of support for the purpose of sponsoring an alien on or after July 1, 1997, under rules promulgated by the immigration and naturalization service, or any successor agency, during the pendency of such legal immigrant's receipt of medical assistance. Nothing in this subsection (3) shall be construed to affect a legal immigrant's eligibility for medical assistance under this article and articles 4 and 6 of this title based upon such legal immigrant's responsibilities under an affidavit of support entered into before July 1, 1997.
4. An asset test shall not be applied as a condition of eligibility for individuals or families described in paragraphs (b), (c), (d), and (e) of subsection (1) of this section.

Source: L. 2006: Entire article added with relocations, p. 1854, § 7, effective July 1. L. 2009: (2)(b) amended, (HB 09-1353), ch. 360, p. 1869, § 1, effective July 1, 2010. L. 2010: (4)(c) added, (HB 10-1043), ch. 92, p. 312, § 1, effective April 15; (1)(m) amended, (HB 10-1422), ch. 419, p. 2110, § 143, effective August 11. L. 2011: (3) amended, (HB 11-1303), ch. 264, p. 1168, § 67, effective August 10. L. 2014: (1)(a) repealed and (1)(b), (1)(c), (1)(d), (1)(e), (1)(m), and (4) amended, (SB 14-067), ch. 12, p. 111, § 3, effective February 27.

25.5-5-102. Basic services for the categorically needy - mandated services.

1. Subject to the provisions of subsection (2) of this section and section 25.5-4-104 , the program for the categorically needy shall include the following services as mandated and defined by federal law:
   1. Inpatient hospital services;
   2. Outpatient hospital services;
   3. Other laboratory and X-ray services;
   4. Physicians' services, wherever furnished;
   5. Nursing facility services;
   6. Home health services;
   7. Early and periodic screening, diagnosis, and treatment, as required by federal law;
   8. Family planning;
   9. Rural health services;
   10. Advanced practice nurse services;
   12. (Deleted by amendment, L. 2008, p. 138 , § 2, effective July 1, 2008.)
   13. Federally qualified health centers.
2. In order to keep expenditures within approved appropriations, the state board may, by rule, establish limits on a service provided pursuant to this section so long as the service provided is sufficient in the amount, duration, and scope to reasonably achieve the purpose of the service as required by federal law or regulation. When a rule is promulgated pursuant to this subsection (2), the state board shall provide a summary report of the limitations established by the rule and any fiscal impact of the rule to members of the health and human services committees of the senate and house of representatives, or any successor committees, and any other members of the general assembly who request the reports.

Source: L. 2006: Entire article added with relocations, p. 1856, § 7, effective July 1. L. 2008: (1)(j), (1)(k), and (1)(l) amended, p. 138, § 2, effective July 1.

Editor's note: This section is similar to former § 26-4-202 as it existed prior to 2006.

Cross references: For the definition of "federally qualified health centers" in the federal "Social Security Act", see 42 U.S.C. sec. 1395x.

25.5-5-103. Mandated programs with special state provisions - rules.

1. This section specifies programs developed by Colorado to meet federal mandates. These programs include but are not limited to:
   1. Repealed.
   2. Special provisions relating to nursing facilities, as specified in sections 25.5-6-201 to 25.5-6-203, 25.5-6-205, and 25.5-6-206;
   3. The program for qualified medicare beneficiaries, as specified in section 25.5-5-104;
   4. The program for qualified disabled and working individuals, as specified in section 25.5-5-105;
   5. Special provisions for the purchase of group health insurance for recipients, as specified in section 25.5-4-210;
   6. The program to provide health services to students by school districts as specified in section 25.5-5-318.
2. The medical assistance program also is subject to special provisions relating to the use of public funds for abortion which are required by section 50 of article V of the Colorado constitution. Those special provisions are specified in section 25.5-4-415.
3. 1. Emergency medical assistance shall be provided to any person who is not a citizen of the United States, including undocumented aliens, aliens who are not qualified aliens, and qualified aliens who entered the United States on or after August 22, 1996, who has an emergency medical condition and meets one of the categorical requirements set forth in section 25.5-5-101; except that such persons shall not be required to meet any residency requirement other than that required by federal law.
   2. The state board shall adopt rules necessary for the implementation of this subsection (3), including in such rules definitions of "emergency services", "emergency medical condition", "geographic area", and "prenatal care".
4. 1. The state department shall ensure that benefits under the medical assistance program for behavioral, mental health, and substance use disorder services are no less extensive than benefits for any physical illness and are in compliance with the MHPAEA, as defined in section 25.5-5-403 (5.7), including the quantitative and nonquantitative treatment limitation requirements specified in 42 CFR 438.910 (c). On or after January 1, 2020, if an MCE, as defined in section 25.5-5-403 (4), denies coverage for a covered behavioral, mental health, or substance use disorder benefit or service based on diagnosis, the state board shall establish, by rule, a procedure to allow for reimbursement of medically necessary state plan services under the medical assistance program. The state department may use multiple payment modalities to comply with this subsection (4).
   2. The state board shall adopt rules establishing the procedures for reimbursement pursuant to this subsection (4) by January 1, 2020.

Source: L. 2006: Entire article added with relocations, p. 1856, § 7, effective July 1. L. 2014: (1)(a) repealed, (SB 14-067), ch. 12, p. 113, § 4, effective February 27. L. 2019: (4) added, (HB 19-1269), ch. 195, p. 2132, § 11, effective May 16.

Editor's note: This section is similar to former § 26-4-203 as it existed prior to 2006.

Cross references: For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.

25.5-5-104. Qualified medicare beneficiaries.

Qualified medicare beneficiaries are medicare-eligible individuals with income and resources at a level which qualifies them as eligible under section 301 of Title III of the federal "Medicare Catastrophic Coverage Act of 1988", as amended, or subsequent amending federal legislation. For purposes of this article and articles 4 and 6 of this title, such individuals shall be referred to as "qualified medicare beneficiaries". The state department is hereby designated as the single state agency to administer benefits available to qualified medicare beneficiaries in accordance with Title XIX and this article and articles 4 and 6 of this title. Such benefits are limited to medicare cost-sharing expenses as determined by the federal government. Accordingly, the state department shall not be required to provide qualified medicare beneficiaries the entire range of services set forth in section 25.5-5-102.

Source: L. 2006: Entire article added with relocations, p. 1857, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-510 as it existed prior to 2006.

Cross references: For provisions of the federal "Medicare Catastrophic Coverage Act of 1988" referenced in this section, see section 301 of Pub.L. 100-360, codified at 42 U.S.C. sec. 1396a et seq.

25.5-5-105. Qualified disabled and working individuals.

Qualified disabled and working individuals are persons with income and resources and disability status, as determined by the social security administration, which qualify them as "qualified disabled and working individuals" under sections 6012 and 6408 of the federal "Omnibus Budget Reconciliation Act of 1989", or subsequent amending federal legislation. The state department is hereby designated as the single state agency to administer benefits available to qualified disabled and working individuals. Such benefits are limited to medicare cost-sharing expenses as determined by the federal government. Accordingly, the state department shall not be required to provide qualified disabled and working individuals the entire range of services set forth in section 25.5-5-102.

Source: L. 2006: Entire article added with relocations, p. 1858, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-511 as it existed prior to 2006.

Cross references: For provisions of the federal "Omnibus Budget Reconciliation Act of 1989" referenced in this section, see sections 6012 and 6408 of Pub.L. 101-239, codified at 42 U.S.C. secs. 1395i and 1396a.

25.5-5-201. Optional provisions - optional groups.

1. The federal government allows the state to select optional groups to receive medical assistance. Pursuant to federal law, any person who is eligible for medical assistance under the optional groups specified in this section shall receive both the mandatory services specified in sections 25.5-5-102 and 25.5-5-103 and the optional services specified in sections 25.5-5-202 and 25.5-5-203. Subject to the availability of federal financial aid funds, the following are the individuals or groups that Colorado has selected as optional groups to receive medical assistance pursuant to this article and articles 4 and 6 of this title 25.5:
   1. Individuals who would be eligible for but are not receiving cash assistance;
   2. Individuals who would be eligible for cash assistance except for their institutionalized status;
   3. Individuals receiving home- and community-based services as specified in article 6 of this title;
   5. Repealed.
   6. Individuals receiving only optional state supplement;
   7. Individuals in institutions who are eligible under a special income level. Colorado's program for citizens sixty-five years of age or older or physically disabled or blind, whose gross income does not exceed three hundred percent of the current federal supplemental security income benefit level, qualifies for federal funding under this provision.
   8. Persons who are eligible for cash assistance under the works program pursuant to section 26-2-706, C.R.S.;
   9. Persons who are eligible for the breast and cervical cancer prevention and treatment program pursuant to section 25.5-5-308;
   10. Individuals who are qualified aliens and were or would have been eligible for supplemental security income as a result of a disability but are not eligible for such supplemental security income as a result of the passage of the federal "Personal Responsibility and Work Opportunity Reconciliation Act of 1996", Public Law 104-193;
   11. Other qualified aliens who entered or were present in the United States before August 22, 1996;
   12. Children for whom subsidized adoption assistance payments are made by the state pursuant to article 7 of title 26, C.R.S., or foster care maintenance payments are made by the state pursuant to article 5 of title 26, C.R.S., but who do not meet the requirements of Title IV-E of the "Social Security Act", as amended;
   13. Parents and caretaker relatives of children who are eligible for the medical assistance program whose family income does not exceed one hundred thirty-three percent of the federal poverty line, adjusted for family size;
   14. Pregnant women, whose family income does not exceed one hundred eighty-five percent of the federal poverty line, adjusted for family size;
   15. Repealed.
   16. 1. Individuals with disabilities who are participating in the medicaid buy-in program established in part 14 of article 6 of this title.
       2. Notwithstanding the provisions of subsection (1)(o)(I) of this section, if the money in the healthcare affordability and sustainability fee cash fund established pursuant to section 25.5-4-402.4, together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), for individuals with disabilities who are participating in the medicaid buy-in program established in part 14 of article 6 of this title 25.5, the state board by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) may reduce the medical benefits offered or the percentage of the federal poverty line to below four hundred fifty percent or may eliminate this eligibility group.
       3. Repealed.
   17. Subject to federal approval, adults who are childless or without a dependent child in the home, as described in section 1902 (a)(10)(A)(i)(VIII) of the social security act, 42 U.S.C. sec. 1396a, who have attained nineteen years of age but have not attained sixty-five years of age, and whose family income does not exceed one hundred thirty-three percent of the federal poverty line, adjusted for family size;
   18. Children who are continuously eligible for twelve months pursuant to section 25.5-5-204.5;
   19. 1. Persons eligible for a medicaid buy-in program established pursuant to section 25.5-5-206 whose family income does not exceed a specified percentage of the federal poverty line, adjusted for family size and as set by the state board by rule, which percentage shall be not more than four hundred fifty percent.
       2. Notwithstanding the provisions of subsection (1)(r)(I) of this section, if the money in the healthcare affordability and sustainability fee cash fund established pursuant to section 25.5-4-402.4, together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), for persons eligible for a medicaid buy-in program established pursuant to section 25.5-5-206, the state board by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) may reduce the medical benefits offered, or the percentage of the federal poverty line, or may eliminate this eligibility group.
       3. Repealed.
2. 1. A qualified alien, who entered the United States on or after August 22, 1996, shall not be eligible for benefits under this article and articles 4 and 6 of this title, except as provided in section 25.5-5-103 (3), for five years after the date of entry into the United States unless he or she meets the exceptions described in the federal "Personal Responsibility and Work Opportunity Reconciliation Act of 1996", Public Law 104-193, as amended. After five years, such qualified alien shall be eligible for benefits under this article and articles 4 and 6 of this title but shall have sponsor income and resources deemed to the individual or family under rules established by the state board of human services pursuant to section 26-2-137, C.R.S.
   2. Notwithstanding the five-year waiting period established in paragraph (a) of this subsection (2), but subject to the availability of sufficient appropriations and the receipt of federal financial participation, the state department may provide benefits under this article and articles 4 and 6 of this title to a pregnant woman who is a qualified alien and a child under nineteen years of age who is a qualified alien so long as such woman or child meets eligibility criteria other than citizenship.
3. A legal immigrant who is receiving medicaid nursing facility care or home- and community-based services on July 1, 1997, shall continue to receive such services as long as he or she meets the eligibility requirements other than citizen status. State general funds may be used to reimburse such care in the event that federal financial participation is not available.
4. A pregnant legal immigrant shall be eligible to receive prenatal and medical services for labor and delivery as long as she meets eligibility requirements other than citizen status. State general funds may be used to reimburse such care in the event that federal financial participation is not available.
5. An asset test shall not be applied as a condition of eligibility for individuals or families described in paragraphs (a), (h), and (m.5) of subsection (1) of this section.

Source: L. 2006: Entire article added with relocations, p. 1858, § 7, effective July 1. L. 2007: (1)(n) added, p. 897, § 1, effective May 15. L. 2008: (1)(l) and (1)(n) amended and (1)(o) added, pp. 1532, 2200, §§ 1, 2, effective July 1. L. 2009: (1)(m)(I) and (1)(o) amended and (1)(p), (1)(q), and (1)(r) added, (HB 09-1293, ch. 152, p. 645, § 5, effective July 1; (2) amended, (HB 09-1353), ch. 390, p. 1869, § 2, effective July 1, 2010. L. 2010: (5)(c) added, (HB 10-1043), ch. 92, p. 312, § 2, effective April 15; (1)(m)(I), (1)(o)(II), (1)(p)(I), (1)(p)(II), (1)(r)(I), and (1)(r)(II) amended, (HB 10-1422), ch. 419, p. 2111, § 144, effective August 11. L. 2013: (1)(m) and (1)(p) amended, (SB 13-200), ch. 216, p. 898, § 2, effective May 13. L. 2014: (1)(d), (1)(e), and (1)(n) repealed, (1)(m.5) added, and (5) amended, (SB 14-067), ch. 12, p. 113, § 5, effective February 27. L. 2017: IP(1), (1)(o)(II), and (1)(r)(II) amended, (SB 17-267), ch. 267, p. 1465, § 19, effective July 1.

25.5-5-202. Basic services for the categorically needy - optional services.

1. Subject to the provisions of subsection (2) of this section, the following are services for which federal financial participation is available and that Colorado has selected to provide as optional services under the medical assistance program:
   1. 1. Prescribed drugs.
      2. Notwithstanding the provisions of subparagraph (I) of this paragraph (a), pursuant to the provisions of section 25.5-5-503, prescribed drugs shall not be a covered benefit under the medical assistance program for a recipient who is enrolled in a prescription drug benefit program under medicare; except that, if a prescribed drug is not a covered Part D drug as defined in the "Medicare Prescription Drug, Improvement, and Modernization Act of 2003", Pub.L. 108-173, the prescribed drug may be a covered benefit if it is otherwise covered under the medical assistance program and federal financial participation is available.
   2. Over-the-counter medications, as specified in section 25.5-5-322;
   3. Clinic services, as defined in sections 25.5-5-301 and 25.5-5-302;
   4. Home- and community-based services, as specified in article 6 of this title 25.5, which include:
      1. Home- and community-based services for individuals who are elderly or blind and individuals with disabilities, as specified in part 3 of article 6 of this title;
      2. Home- and community-based services for persons with intellectual and developmental disabilities, as specified in part 4 of article 6 of this title;
      3. Repealed.
      4. Home- and community-based services for persons with major mental health disorders, as specified in part 6 of article 6 of this title 25.5;
      5. Home- and community-based services for persons with brain injury, as specified in part 7 of article 6 of this title;
   5. Optometrist services;
   6. Eyeglasses when necessary after surgery;
   7. Prosthetic devices, including medically necessary augmentative communication devices; except that nonsurgically implanted prosthetic devices shall be included only after July 1, 1998, and only if the general assembly approves appropriations for these devices as a new benefit;
   8. Rehabilitation services as appropriate to community mental health centers;
   9. Intermediate care facilities for individuals with intellectual disabilities;
   10. Inpatient psychiatric services for persons under twenty-one years of age;
   11. Inpatient psychiatric services for persons over the age of sixty-five;
   12. Case management;
   13. Therapies under home health services, including:
       1. Speech and audiology;
       2. Physical;
       3. Occupational;
   14. Services of a licensed psychologist;
   15. Private duty nursing services;
   16. Podiatry services;
   17. Hospice care;
   18. The program of all-inclusive care for the elderly;
   19. For any pregnant woman who is enrolled or eligible for services pursuant to section 25.5-5-101 (1)(c), alcohol and substance use disorder counseling and treatment, including outpatient and residential care but not including room and board while receiving residential care;
   20. 1. Outpatient substance use disorder treatment.
       2. Repealed.
   21. Cervical cancer immunization for all females under twenty years of age;
   22. 1. Screening, brief intervention, and referral to treatment for individuals at risk of substance abuse, including referral to the appropriate level of intervention and treatment.
       2. Notwithstanding the provisions of subparagraph (I) of this paragraph (u), services relating to screening, brief intervention, and referral to treatment shall not take effect unless all necessary approvals under federal law and regulation have been obtained to receive federal financial participation for the costs of such services.
   23. 1. Counseling by primary care providers and other specialty providers caring for persons with serious, chronic, or terminal illness relating to medical orders for scope of treatment, which counseling may be reimbursed.
       2. Notwithstanding the provisions of subparagraph (I) of this paragraph (v), counseling relating to medical orders for scope of treatment shall not take effect unless all necessary approvals under federal law and regulation have been obtained to receive federal financial participation for the costs of such services.
   24. Dental services for adults.
   25. 1. Residential and inpatient substance use disorder treatment and medical detoxification services pursuant to section 25.5-5-325.
       2. Notwithstanding the provisions of subsection (1)(x)(I) of this section, residential and inpatient substance use disorder treatment shall not take effect unless all necessary approvals under federal law and regulation have been obtained to receive federal financial participation for the costs of such services.
2. In addition to the services described in subsection (1) of this section and subject to continued federal financial participation, Colorado has selected to provide transportation services as an administrative cost.
3. In order to keep expenditures within approved appropriations, the state board may, by rule, establish limits on a service provided pursuant to this section so long as the service provided is sufficient in the amount, duration, and scope to reasonably achieve the purpose of the service as required by federal law or regulation. When a rule is promulgated pursuant to this subsection (3), the state board shall provide a summary report of the limitations established by the rule and any fiscal impact of the rule to members of the health and human services committees of the senate and house of representatives, or any successor committees, and any other members of the general assembly who request the reports.
4. The state department and the office of behavioral health in the department of human services, in collaboration with community mental health services providers and substance use disorder providers, shall establish rules that standardize utilization management authority timelines for the nonpharmaceutical components of medication-assisted treatment for substance use disorders.

Source: L. 2006: Entire article added with relocations, p. 1860, § 7, effective July 1. L. 2007: (1)(t) added, p. 1348, § 2, effective May 29. L. 2010: (1)(r) amended, (HB 10-1043), ch. 92, p. 313, § 3, effective April 15; (1)(a.5) added, (SB 10-117), ch. 227, p. 985, § 1, effective July 1; (1)(u) added, (HB 10-1033), ch. 346, p. 1601, § 1, effective August 11. L. 2013: (1)(h) amended, (SB 13-167), ch. 394, p. 2290, § 2, effective June 5; (1)(u)(II) amended and (1)(w) added, (SB 13-242), ch. 189, p. 761, § 1, effective August 7; (1)(v) added, (HB 13-1202), ch. 117, p. 401, § 1, effective August 7. L. 2014: (1)(r) amended, (SB 14-067), ch. 12, p. 114, § 6, effective February 27; (1)(c)(I) and (1)(c)(II) amended, (SB 14-118), ch. 250, p. 985, § 20, effective August 6. L. 2017: IP(1), (1)(r), and (1)(s)(I) amended, (SB 17-242), ch. 263, p. 1327, § 199, effective May 25; (1)(s)(II) repealed, (SB 17-294), ch. 264, p. 1409, § 92, effective May 25. L. 2018: (1)(x) added, (HB 18-1136), ch. 373, p. 2269, § 1, effective June 5; IP(1)(c) and (1)(c)(IV) amended, (SB 18-091), ch. 35, p. 388, § 25, effective August 8; (1)(c)(III) repealed, (SB 18-093), ch. 62, p. 610, § 3, effective August 8; (4) added, (HB 18-1431), ch. 313, p. 1893, § 14, effective January 1, 2019.

25.5-5-203. Optional programs with special state provisions.

1. Subject to the provisions of subsection (2) of this section, this section specifies programs developed by Colorado to increase federal financial participation through selecting optional services or optional eligible groups. These programs include but are not limited to:
   1. Pharmaceutical services, as specified in section 25.5-5-504;
   2. The home- and community-based services program for the elderly, blind, and disabled, as specified in part 3 of article 6 of this title;
   3. The home- and community-based services program for the developmentally disabled, as specified in part 4 of article 6 of this title;
   4. Repealed.
   5. The home- and community-based services program for persons with major mental health disorders, as specified in part 6 of article 6 of this title 25.5;
   6. The home- and community-based services program for persons with brain injury, as specified in part 7 of article 6 of this title;
   7. Clinic services, as defined in sections 25.5-5-301 and 25.5-5-302;
   8. The program for private duty nursing, as specified in section 25.5-5-303;
   9. The disabled children care program, as specified in section 25.5-6-901;
   10. The program of all-inclusive care for the elderly, as specified in section 25.5-5-412;
   11. Hospice care, as specified in section 25.5-5-304;
   12. The treatment program for high-risk pregnant women, as specified in section 27-80-112, C.R.S., and sections 25.5-5-309, 25.5-5-310, and 25.5-5-311;
   13. The program for residential child health care, as specified in section 25.5-6-903;
   14. The children's personal assistance services and family support waiver program, as specified in section 25.5-6-902;
   15. Home- and community-based services for children with autism, as specified in part 8 of article 6 of this title.
2. In order to keep expenditures within approved appropriations, the state board may, by rule, establish limits on a service provided pursuant to this section so long as the service provided is sufficient in the amount, duration, and scope to reasonably achieve the purpose of the service as required by federal law or regulation. When a rule is promulgated pursuant to this subsection (2), the state board shall provide a summary report of the limitations established by the rule and any fiscal impact of the rule to members of the health and human services committees of the senate and house of representatives, or any successor committees, and any other members of the general assembly who request the reports.

Source: L. 2006: Entire article added with relocations, p. 1862, § 7, effective July 1. L. 2010: (1)(l) amended, (SB 10-175), ch. 188, p. 801, § 67, effective April 29. L. 2018: (1)(d) repealed, (SB 18-093), ch. 62, p. 610, § 4, effective August 8; (1)(e) amended, (SB 18-091), ch. 35, p. 388, § 26, effective August 8; (1)(m) amended, (HB 18-1328), ch. 184, p. 1244, § 5, effective June 7, 2019.

25.5-5-204. Presumptive eligibility - pregnant women - children - long-term care - state plan.

1. For purposes of this section, "presumptive eligibility" means the self-declaration of income, assets, and status in order to promptly receive medical assistance services prior to the verification of income, assets, and status.
2. 1. A pregnant woman shall be presumptively eligible for the medical assistance program and shall receive services specified by federal law only if the woman declares all pertinent information relating to the criteria of income, assets, and status.
   2. A woman shall declare her immigration status unless the general assembly provides funding for prenatal care services for undocumented residents.

   (2.5) A child under the age of eighteen years shall be presumptively eligible for the medical assistance program and shall receive services specified by federal law only if a parent or legal guardian of the child declares all pertinent information relating to the criteria of income, assets, and status of the child's family.

   1. (2.7) (a) The state department is authorized to seek federal authorization to allow a person who is in need of long-term care, as defined in section 25.5-6-104, to be presumptively eligible for the medical assistance program pursuant to this article and articles 4 and 6 of this title.
   2. If the state department receives federal authorization pursuant to paragraph (a) of this subsection (2.7) and sufficient spending authority, a person in need of long-term care shall be presumptively eligible for the medical assistance program if the person or the person's legal representative declares all pertinent information relating to the criteria of income, assets, and immigration status. Such person shall be assessed for the appropriate level of care pursuant to section 25.5-6-104. If required due to limitations of federal authorization or spending authority, the state department may implement this paragraph (b) as a pilot program rather than statewide.
   3. The state department shall make any necessary changes to the state plan and waivers for home- and community-based service programs authorized pursuant to this article and articles 4 and 6 of this title to comply with this subsection (2.7).
   4. If it is determined that a recipient was not eligible for medical benefits after the recipient had been determined to be eligible based upon presumptive eligibility, the state department shall not pursue recovery from a county department for the cost of medical services provided to the recipient, and the county department shall not be responsible for any federal error rate sanctions resulting from such determination.
3. The state department shall make any necessary changes to the state plan to comply with this section.

Source: L. 2006: Entire article added with relocations, p. 1864, § 7, effective July 1. L. 2007: (2.5) added, p. 1493, § 4, effective January 1, 2008. L. 2009: (2.7) added, (HB 09-1103), ch. 160, p. 694, § 1, effective April 22.

Editor's note: This section is similar to former § 26-4-304 as it existed prior to 2006.

Cross references: For the legislative declaration contained in the 2007 act enacting subsection (2.5), see section 1 of chapter 347, Session Laws of Colorado 2007.

25.5-5-204.5. Continuous eligibility - children.

1. A child who is determined to be eligible for benefits under this article or under article 4 or 6 of this title shall remain eligible for twelve months subsequent to the last day of the month in which the child was enrolled; except that a child shall no longer be eligible and shall be disenrolled from the state medical assistance program if the state department becomes aware of or is notified that the child has moved out of the state or has reached nineteen years of age.
2. Notwithstanding the provisions of subsection (1) of this section, if the money in the healthcare affordability and sustainability fee cash fund established pursuant to section 25.5-4-402.4, together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), the state board by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) may eliminate the continuous enrollment requirement pursuant to this section.
3. Repealed.

Source: L. 2009: Entire section added, (HB 09-1293), ch. 152, p. 648, § 6, effective July 1. L. 2017: (2) amended, (SB 17-267), ch. 267, p. 1466, § 20, effective July 1.

25.5-5-205. Baby and kid care program - creation - eligibility. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1864, § 7, effective July 1. L. 2007: (3)(d) amended, p. 1493, § 5, effective January 1, 2008. L. 2010: (3)(a) and (3)(c)(I) amended, (HB 10-1043), ch. 92, p. 313, § 4, effective April 15. L. 2011: (3)(b) amended, (SB 11-250), ch. 219, p. 950, § 1, effective May 27; (3)(c) amended, (SB 11-008), ch. 100, p. 293, § 2, effective September 1. L. 2014: Entire section repealed, (SB 14-067), ch. 12, p. 114, § 7, effective February 27.

Editor's note: This section was similar to former § 26-4-508 as it existed prior to 2006.

25.5-5-206. Medicaid buy-in program - disabled children - disabled adults - federal authorization - rules.

1. 1. Subject to available appropriations, the state department is authorized to seek federal authorization to and to establish a medicaid buy-in program or programs for:
      1. Disabled children; or
      2. Disabled adults who do not qualify for the medicaid buy-in program established pursuant to part 14 of article 6 of this title.
   2. The medicaid buy-in program or programs established pursuant to paragraph (a) of this subsection (1) may provide for premium and cost-sharing charges on a sliding fee scale based upon a family's income.
2. The state board shall promulgate rules consistent with any federal authorization to implement and administer the medicaid buy-in program or programs established pursuant to paragraph (a) of subsection (1) of this section.

Source: L. 2009: Entire section added, (HB 09-1293), ch. 152, p. 698, § 6, effective July 1.

25.5-5-207. Adult dental benefit - adult dental fund - creation - legislative declaration - repeal.

1. 1. The general assembly finds that:
      1. As of 2011, Colorado was one of only ten states that did not offer basic oral health services to adults under medicaid;
      2. Research has shown that untreated oral health conditions negatively affect a person's overall health and that gum disease has been linked to diabetes, heart disease, strokes, kidney disease, dementia diseases and related disabilities, and even behavioral or mental health disorders;
      3. Regular dental care and prevention are the most cost-effective methods available to prevent minor oral conditions from developing into more complex oral and physical health conditions that would eventually require emergency and palliative care;
      4. Further, one in four adults has untreated tooth decay. Early detection and access to preventive and restorative treatments for oral health conditions can be up to ten times less expensive than treating those same conditions in an emergency setting.
      5. Research has also shown that good oral health improves medicaid beneficiaries' ability to obtain and keep employment. Employed adults lose more than one hundred and sixty-four million hours of work each year due to dental problems.
      6. Children are more likely to receive regular dental services if their parents have access to dental services; and
      7. Pregnant women are one of the most vulnerable adult populations that are without oral health benefits under medicaid. During pregnancy, the physical changes a woman's body undergoes can negatively affect oral health. Untreated decay and periodontal disease are associated with adverse pregnancy outcomes such as increased risk for preeclampsia, pre-term labor, and low birth weight babies.
   2. Therefore, the general assembly declares that in order to improve overall health, promote savings in medicaid programs, and prevent future health conditions caused by oral health problems, it is in the best interest of the state of Colorado to create a limited oral health benefit for adults in the medicaid program.
2. 1. Pursuant to section 25.5-5-202 (1)(w), by April 1, 2014, the state department shall design and implement a limited dental benefit for adults using a collaborative stakeholder process to consider the components of the benefit, including but not limited to the cost, best practices, the effect on health outcomes, client experience, service delivery models, and maximum efficiencies in the administration of the benefit.
   2. The state department shall determine the most cost-effective method for providing the adult dental benefit, including but not limited to a comparison of a capitated or fee-for-service method of payment and the purchase of dental insurance.
   3. The state department shall seek any federal authorization necessary to provide the adult dental benefit.
   4. Subject to federal authorization and federal financial participation, on or after July 1, 2016, the diagnosis, development of a treatment plan, instruction to perform an interim therapeutic restoration procedure, or supervision of a dental hygienist performing an interim therapeutic restoration procedure may be provided through telehealth, including store-and-forward transfer, in accordance with section 25.5-5-321.5.
   1. (2.5) (a) Beginning when the higher federal match afforded through the federal "Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto, expires through June 30, 2022, the adult dental benefit provided by this section must not exceed one thousand dollars per year for each recipient.
   2. This subsection (2.5) is repealed, effective December 31, 2022.
3. If the state department chooses to use an administrative service organization to manage the adult dental benefit:
   1. The contract with the administrative service organization must provide that the contracting entity is prohibited from requiring dental providers to participate in any other public or private program or to accept any other insurance products as a condition of participating as a dental provider; and
   2. The state department shall retain policy-making authority, including but not limited to policies concerning covered benefits and rate setting.
4. 1. There is hereby created in the state treasury the adult dental fund, referred to in this section as the "fund", consisting of money transferred to the fund from the unclaimed property trust fund pursuant to section 38-13-801 (3) and any money that may be appropriated to the fund by the general assembly. The money in the fund is subject to annual appropriation by the general assembly to the state department for the direct and indirect costs associated with implementing the adult dental benefit pursuant to section 25.5-5-202 (1)(w).
   2. The state treasurer may invest any unexpended moneys in the fund as provided by law. The state treasurer shall credit all interest and income derived from the investment and deposit of moneys in the fund to the fund.
   3. Any unexpended and unencumbered moneys remaining in the fund at the end of a fiscal year remain in the fund and shall not be credited or transferred to the general fund or another fund.

Source: L. 2013: Entire section added, (SB 13-242), ch. 189, p. 761, § 2, effective August 7. L. 2015: (2)(d) added, (HB 15-1309), ch. 326, p. 1334, § 7, effective August 5. L. 2017: IP(1)(a) and (1)(a)(II) amended, (SB 17-242), ch. 263, p. 1327, § 200, effective May 25. L. 2018: (1)(a)(II) amended, (HB 18-1091), ch. 74, p. 642, § 3, effective August 8. L. 2019: (4)(a) amended, (SB 19-088), ch. 110, p. 467, § 11, effective July 1, 2020. L. 2020: (2.5) added, (HB 20-1361), ch. 161, p. 765, § 1, effective June 29.

Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter 263, Session Laws of Colorado 2017.

25.5-5-208. Additional services - training - grants - screening, brief intervention, and referral.

1. On or after July 1, 2018, the state department shall grant, through a competitive grant program, one million five hundred thousand dollars to one or more organizations to operate a substance abuse screening, brief intervention, and referral to treatment practice. The grant program must require:
   1. Training for health care professionals statewide, including providers who serve women of childbearing age, that is evidence-based and that may be attended either in person or online. The training must include training for reimbursement and billing codes in the "Colorado Medical Assistance Act", articles 4 to 6 of this title 25.5.
   2. Consultation and technical assistance for health care providers, health care organizations, and stakeholders;
   3. Outreach, communication, and education to providers and patients;
   4. Coordination with primary care, mental health care, integrated health care, and substance use prevention, treatment, and recovery efforts; and
   5. Campaigning to increase public awareness of the risks related to alcohol, marijuana, tobacco, and drug use and to reduce any stigma associated with treatment.
2. 1. The state department contractor shall develop a patient education tool for women of childbearing age to learn about the risks of substance-exposed pregnancies, to be deployed for public use in the state.
   2. Repealed.

Source: L. 2015: Entire section added, (HB 15-1367), ch. 271, p. 1078, § 17, effective January 1, 2016. L. 2018: Entire section amended, (HB 18-1003), ch. 224, p. 1428, § 4, effective May 21.

25.5-5-301. Clinic services.

1. As used in this article and articles 4 and 6 of this title, unless the context otherwise requires, "clinic services" means preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services furnished to outpatients.
2. Under the federal option for clinic services, Colorado has selected clinic services provided by the following:
   1. Community mental health centers or clinics;
   2. Community centered boards;
   3. Birthing centers;
   4. Ambulatory surgery facilities;
   5. Freestanding dialysis clinics.
3. "Clinic services" also means preventive, therapeutic, or palliative items or services that are furnished to patients by county or district public health agencies or county or district boards of health established pursuant to part 5 of article 1 of title 25, C.R.S., that are recommended for certification by the department of public health and environment as qualified to receive payments pursuant to this article and articles 4 and 6 of this title.
4. "Clinic services" also means preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services furnished to a pregnant woman who is enrolled or eligible for services pursuant to section 25.5-5-101 (1)(c) or 25.5-5-201 (1)(m.5) in a facility that is not a part of a hospital but is organized and operated as a freestanding substance use disorder treatment program approved and licensed by the office of behavioral health in the department of human services pursuant to section 27-80-108 (1)(c).
5. "Clinic services" also means preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services that are furnished to children up to age twenty-one or to high-risk pregnant women in a facility which is not a part of a hospital but is organized and operated as a school-based clinic.
6. "Clinic services" also means preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services that are furnished to students by a school district, board of cooperative services, or state educational institution within the scope of the "Colorado Medical Assistance Act" pursuant to the provisions of section 25.5-5-318.

Source: L. 2006: Entire article added with relocations, p. 1866, § 7, effective July 1. L. 2010: (4) amended, (HB 10-1043), ch. 92, p. 314, § 5, effective April 15; (4) amended, (SB 10-175), ch. 188, p. 801, § 68, effective April 29; (3) amended, (HB 10-1422), ch. 419, p. 2113, § 145, effective August 11. L. 2014: (4) amended, (SB 14-067), ch. 12, p. 116, § 12, effective February 27. L. 2017: (4) amended, (SB 17-242), ch. 263, p. 1328, § 201, effective May 25.

25.5-5-302. Clinic services - children and pregnant women - utilization of certain providers.

1. The state department shall utilize, to the extent possible and appropriate, county or district public health agencies or boards of health established pursuant to part 5 of article 1 of title 25, C.R.S., that are certified by the department of public health and environment as qualified to receive payments pursuant to this article and articles 4 and 6 of this title and that meet the requirements and standards set forth in rules promulgated by the state board in the state department pursuant to section 25.5-4-104 to provide clinic services to patients who are children under age seven or patients who are pregnant women.
2. In complying with the provisions of subsection (1) of this section, the state department shall utilize, to the extent possible and appropriate, the county or district public health agencies and boards of health specified in subsection (1) of this section to provide outreach to eligible pregnant women and children and to provide clinic services:
   1. Upon the referral of any physician; or
   2. When there exists no primary care physician who agrees to provide clinic services to such patients.

Source: L. 2006: Entire article added with relocations, p. 1867, § 7, effective July 1. L. 2010: (1) and IP(2) amended, (HB 10-1422), ch. 419, p. 2113, § 146, effective August 11.

Editor's note: This section is similar to former § 26-4-514 as it existed prior to 2006.

25.5-5-303. Private-duty nursing.

1. The medical assistance program in this state shall include private-duty nursing to persons who are technology dependent and otherwise eligible as provided under this section.
2. A recipient is eligible for private-duty nursing services if he or she:
   1. Is dependent on technology at least part of each day;
   2. Requires private-duty nursing care as determined in accordance with state department rules;
   3. Is able to be served safely under the limitations of the private-duty nursing benefit and within the availability of services; and
   4. Is not residing in a nursing facility or hospital at the time of the delivery of the private-duty nursing services.
3. 1. The state board shall establish rules in accordance with this section that identify medical criteria for determining the circumstances under which private-duty nursing services will be delivered to assure that only persons who need the services receive them and only to the extent medically necessary.
   2. Private-duty nursing services shall not be provided as twenty-four-hour care except in special circumstances and for limited time periods as established by the state department pursuant to this section.
   3. The home health agency, in conjunction with the family or in-home caregiver and the attending physician, shall include in a care plan that includes private-duty nursing services a process by which the eligible person may receive necessary care, which may include respite care, if the family or in-home caregiver is unavailable due to an emergency situation or to unforeseen circumstances. The family or in-home caregiver shall be duly informed by the home health agency of these alternative care provisions at the time the care plan is initiated.
4. As used in this section, unless the context otherwise requires, "private-duty nursing" means nursing care that is more individualized and continuous than both the nursing care available under the home health benefit and the nursing care routinely provided in a hospital or nursing facility.

Source: L. 2006: Entire article added with relocations, p. 1867, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-517 as it existed prior to 2006.

25.5-5-304. Hospice care.

1. The medical assistance program in this state shall include hospice care. Except as otherwise provided in subsection (2) of this section, hospice care shall be provided for a period of up to two hundred ten days in accordance with rules adopted by the state board, which rules shall comply with 42 U.S.C. sec. 1396d, and shall include at least the following requirements:
   1. That a person shall obtain a certified medical prognosis indicating a life expectancy of nine months or less, which certification shall comply with rules adopted by the state board;
   2. That a person shall execute a waiver of other medical benefits available under this article and articles 4 and 6 of this title, which election shall be executed in accordance with rules adopted by the state board;
   3. That the service shall be reasonable and necessary for the palliation or management of the terminal illness and related conditions.
2. Hospice care may be provided to a person beyond two hundred ten days if such person is recertified by a physician or hospice medical director as terminally ill in accordance with subsection (1) of this section.
3. 1. Subject to the receipt of any necessary federal authorization, for a person who has executed the waiver described in paragraph (b) of subsection (1) of this section and who is a resident in a class I facility, as defined in section 25.5-6-201 (13), the class I facility shall bill the state department and the state department shall pay the class I facility for the room and board costs of the person.
   2. Subject to the receipt of any necessary federal authorization, the hospice care provided pursuant to this section may include room and board in a hospice inpatient facility licensed pursuant to section 25-3-101, C.R.S. The state department is authorized to establish the reimbursement rate for the costs for room and board at a licensed hospice inpatient facility for patients eligible for the routine level of hospice care.
   3. 1. If required, the state department shall seek the appropriate federal authorization, conditioned on the receipt of gifts, grants, or donations sufficient to provide for the state's administrative costs of preparing and submitting the request, to make the payment described in paragraph (a) of this subsection (3) and to include room and board at a licensed hospice inpatient facility as described in paragraph (b) of this subsection (3). On or before January 15, 2011, the state department shall submit a brief report to the members of the health and human services committees of the senate and house of representatives, or any successor committees, on the status of any request for authorization pursuant to this subparagraph (I). If federal authorization to implement the changes described in paragraphs (a) and (b) of this subsection (3) is obtained, the state department shall request, through the state budget process, that the changes be implemented during the fiscal year following the year in which the approval is obtained.
      2. The state department is authorized to seek and accept gifts, grants, or donations from private or public sources for the purpose of providing for the administrative costs of preparing and submitting the request for federal approval for the payments described in paragraphs (a) and (b) of this subsection (3). All such private and public funds received through gifts, grants, or donations shall be transmitted to the state treasurer, who shall credit the same to the hospice care account in the department of health care policy and financing cash fund created pursuant to section 25.5-1-109, which account is hereby created. Moneys in the account shall be subject to appropriation and shall only be used for the purposes described in this subparagraph (II).
4. Repealed.

Source: L. 2006: Entire article added with relocations, p. 1868, § 7, effective July 1. L. 2010: IP(1) and (1)(a) amended and (4) added, (HB 10-1027), ch. 274, p. 1256, § 1, effective August 11; (3) added, (SB 10-061), ch. 247, p. 1104, § 1, effective August 11.

25.5-5-305. Pediatric hospice care - legislative declaration - federal authorization - rules - fund.

1. Legislative declaration.
   1. The general assembly finds and declares that:
      1. The death of a child has a devastating and enduring impact on the child's family;
      2. Too often, children with fatal conditions and their families fail to receive compassionate and consistent care that meets their physical, emotional, and spiritual needs;
      3. Better care is possible but current methods of organizing and financing palliative, end-of-life, and bereavement care impede the provision of services that are both more appropriate and more cost-efficient;
      4. Current federal medicaid regulations contain inherent barriers to providing appropriate palliative and end-of-life care to pediatric patients. These barriers include requirements that preclude the pursuit of curative treatments, mandate a do-not-resuscitate order, and require physician certification that death is expected within six months.
   2. The general assembly declares that it is in the best interest of the state to investigate and implement hospice guidelines that provide appropriate, compassionate care to dying children and their families while proving to be cost-neutral or cost-saving to the state and federal medicaid programs.
   3. The general assembly further finds and declares that, while this direction immediately concerns federal approval for hospice care that recognizes the distinct circumstances of children facing life-threatening illnesses and their families, it is the intent of the general assembly that the information and data produced as a result of this act shall be used to improve the delivery of palliative and end-of-life services to persons of all ages when such improvements can be made in a manner that is cost-neutral or cost-saving to the state.
2. Definitions. As used in this section, unless the context otherwise requires:
   1. "Eligible child" means a child who:
      1. Is less than nineteen years of age; and
      2. Is eligible for the state's medicaid program pursuant to section 25.5-5-101, 25.5-5-201, or 25.5-5-203;
   2. "Pediatric hospice care" means hospice care for eligible children as authorized in this section.
3. Pediatric hospice care.
   1. 1. The state department shall seek the appropriate federal authorization, conditioned on the receipt of gifts, grants, or donations sufficient to provide for the state's administrative costs of preparing and submitting the request, for pediatric hospice care that shall include but may not be limited to:
         1. Respite care;
         2. Expressive therapies, as defined in rule by the state board;
         3. Palliative care from the time of diagnosis of a potentially life-threatening illness; and
         4. A continuum of care through the coordination of services, which may include skilled, intermittent, and around-the-clock nursing care.
      2. The state department is authorized to seek federal approval for modifications to the provision of hospice care for adults who are eligible for the state's medicaid program.
   2. For the provision of pediatric hospice care, the state department shall seek an exemption from the following federal medicaid requirements for the eligibility of and election for hospice care:
      1. The mandatory do-not-resuscitate order;
      2. A physician's certification that a patient is expected to live less than six months; and
      3. The nonallowance of curative care therapies concurrent with palliative and hospice care.
   3. In any application for federal authorization pursuant to this section, the state department shall retain bereavement services to the extent available under federal law.
   4. Pediatric hospice care, as authorized pursuant to this section, shall meet aggregate federal waiver budget neutrality requirements.
   5. The state department shall implement the provision of pediatric hospice care to the extent authorized by the federal government.
4. Review. The state department shall notify the joint budget committee of the general assembly of the extent to which the state department received federal authorization for pediatric hospice care services pursuant to this section in order for the joint budget committee to review the approved budget neutrality analysis for such services prior to the state department's implementation.
5. Rules. The state department shall develop the service provisions for pediatric hospice care in consultation with medical professionals who have expertise in providing end-of-life and palliative care to pediatric patients and family members who have experienced the death of a child. The state board shall adopt rules necessary to implement and administer the provisions of this section.
6. Fund. The state department is authorized to seek and accept gifts, grants, or donations from private or public sources for the purpose of providing for the administrative costs of preparing and submitting the request for federal approval for the provision of pediatric hospice care. All private and public funds received through gifts, grants, or donations shall be transmitted to the state treasurer, who shall credit the same to the pediatric hospice care cash fund, which fund is hereby created and referred to in this section as the "fund". The moneys in the fund shall be subject to annual appropriation by the general assembly for preparing and submitting the request for federal approval pursuant to this section. Any moneys in the fund not expended for the purpose of this section may be invested by the state treasurer as provided by law. All interest and income derived from the investment and deposit of moneys in the fund shall be credited to the fund. Any unexpended and unencumbered moneys remaining in the fund at the end of a fiscal year shall remain in the fund and shall not be credited or transferred or revert to the general fund or another fund.

Source: L. 2006: Entire article added with relocations, p. 1868, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-533 as it existed prior to 2006.

25.5-5-306. Residential child health care - waiver - program - rules - notice to revisor - repeal. (Repealed)

Source: L. 2006: (1) and (3) amended and (4) added, p. 1202, § 2, effective May 26; entire article added with relocations, p. 1871, § 7, effective July 1. L. 2008: (3) amended, p. 1517, § 1, effective May 28. L. 2010: (1) amended, (SB 10-175), ch. 188, p. 801, § 69, effective April 29. L. 2013: (1) amended, (HB 13-1314), ch. 323, p. 1809, § 45, effective March 1, 2014. L. 2016: (1) amended, (SB 16-189), ch. 210, p. 773, § 68, effective June 6. L. 2018: (5) and (6) added, (HB 18-1328), ch. 184, p. 1242, § 2, effective July 1; (1) amended, (SB 18-092), ch. 38, p. 445, § 111, effective August 8. L. 2019: (3) and (4) amended, (HB 19-1172), ch. 136, p. 1708, § 181, effective October 1.

25.5-5-307. Child mental health treatment and family support program.

1. The general assembly finds that many parents in Colorado who have experienced challenging circumstances because their children have significant mental health needs and who have attempted to care for their children or seek services on their behalf often are burdened with the excessive financial and personal costs of providing such care. Private insurance companies may not cover mental health services and rarely cover residential mental health treatment services; those that do seldom cover a sufficient percentage of the expense to make such mental health treatment a viable option for many families in need. The result is that many families do not have the ability to obtain the mental health services that they feel their children desperately need. The general assembly finds that it is in the best interests of these families and the citizens of the state to encourage the preservation of family units by making mental health treatment available to these children pursuant to article 67 of title 27, C.R.S.
2. In order to make mental health treatment available, it is the intent of the general assembly that each medicaid-eligible child who is diagnosed as a person with a mental health disorder, as that term is defined in section 27-65-102 (11.5), must receive mental health treatment, which may include in-home family mental health treatment, other family preservation services, residential treatment, or any post-residential follow-up services, that must be paid for through federal medicaid funding.

Source: L. 2006: Entire article added with relocations, p. 1872, § 7, effective July 1; (2) amended, p. 1389, § 19, effective August 7. L. 2010: Entire section amended, (SB 10-175), ch. 188, p. 802, § 70, effective April 29. L. 2017: (2) amended, (SB 17-242), ch. 263, p. 1328, § 202, effective May 25.

25.5-5-308. Breast and cervical cancer prevention and treatment program - creation - legislative declaration - definitions - funds - repeal.

1. The general assembly hereby finds and declares that breast and cervical cancer are significant health problems for women in this state. The general assembly further finds and declares that these cancers can and should be prevented and treated whenever possible. It is therefore the intent of the general assembly to enact this section to provide for the prevention and treatment of breast and cervical cancer to women where it is not otherwise available for reasons of cost.
2. As used in this section, unless the context otherwise requires:
   1. "Eligible person" means a person who:
      1. 1. Has been screened for breast or cervical cancer under the centers for disease control and prevention's national breast and cervical cancer early detection program established under Title XV of the federal "Public Health Service Act", 42 U.S.C. sec. 300k et seq., in accordance with the requirements of section 1504 of such act, 42 U.S.C. sec. 300n, on or after July 1, 2002, unless the centers for medicare and medicaid services approves the state department's amendment to the medical assistance plan and the state department is able to implement the breast and cervical cancer prevention and treatment program before such date, then the person must be screened on or after the implementation date of such program; or
         2. Has been screened for breast or cervical cancer by any provider, within the provider's scope of practice, who does not receive funds through the centers for disease control and prevention's national breast and cervical cancer early detection program but whose screening activities are recognized by the department of public health and environment as part of screening activities under the centers for disease control and prevention's national breast and cervical cancer early detection program;
      2. Has been diagnosed with breast or cervical cancer and is in need of breast or cervical cancer treatment;
      3. Has not yet attained sixty-five years of age; and
      4. Does not have any creditable coverage as defined under federal law pursuant to 42 U.S.C. sec. 300gg-3 (c).
   2. "Qualified entity" shall be defined pursuant to 42 U.S.C. sec. 1396r-1b(b)(2).
3. There is hereby created a breast and cervical cancer prevention and treatment program to provide medical benefits to eligible persons under this section.
4. 1. Benefits for medical assistance to an eligible person shall be made available beginning on the day on which a determination is made that the person is eligible for medical assistance and throughout the period in which such person meets the definition of an eligible person.
   2. Benefits for medical assistance to an eligible person shall also be available for the following period of presumptive eligibility:
      1. Such period of presumptive eligibility shall begin when a qualified entity determines that the eligible person is in need of treatment for breast or cervical cancer.
      2. Such period of presumptive eligibility shall end with the earlier of:
         1. The day on which a determination is made that the person is eligible or not eligible for medical assistance; or
         2. If the eligible person does not file a simplified application for medical assistance developed by the state department and approved by the centers for medicare and medicaid services on or before the last day of the month following the month during which the eligible person was found to be qualified for services under this section, then benefits shall end on such last day.
5. The state department shall have the following powers and duties:
   1. To establish, operate, and monitor the breast and cervical cancer prevention and treatment program to provide medical assistance to eligible persons in accordance with the provisions of the federal "Breast and Cervical Cancer Prevention and Treatment Act of 2000", enacted October 24, 2000, Pub.L. 106-354, as amended;
   2. To amend the state's medical assistance plan to incorporate the breast and cervical cancer prevention and treatment program. The state department shall submit such proposed amendment to the centers for medicare and medicaid services regional office for approval.
   3. To accept and expend any grant or award of moneys from the federal government, any moneys appropriated by the general assembly, any moneys received through gifts, grants, or donations from nonprofit or for-profit entities, and any interest and income earned on such moneys for the purposes set forth in this section;
   4. To inform the joint budget committee of the general assembly in writing as soon as practicable about any change in the rate of federal financial participation in the program.
6. The state board shall adopt such rules as are necessary to carry out the provisions of this section.
7. The breast and cervical cancer prevention and treatment program is subject to the annual financial and compliance audit of the "Colorado Medical Assistance Act" performed by the state auditor's office and shall not be considered a tobacco settlement program for purposes of section 2-3-113, C.R.S.
8. 1. 1. There is hereby created in the state treasury the breast and cervical cancer prevention and treatment fund, referred to in this subsection (8) as the "fund". The fund shall consist of any moneys credited thereto pursuant to section 24-22-115 (1), C.R.S., any gifts, grants, and donations, any moneys appropriated thereto by the general assembly, and moneys credited thereto pursuant to section 42-3-217.5 (3)(c), C.R.S. Except as provided for in paragraph (b.5) of this subsection (8), all moneys credited to the fund and all interest and income earned on the moneys in the fund shall remain in the fund for the purposes set forth in this section. Any unexpended and unencumbered moneys remaining in the fund at the end of a fiscal year shall remain in the fund and shall not be credited or transferred to the general fund or another fund. The state department is encouraged to secure private gifts, grants, and donations to fund the state costs of the breast and cervical cancer prevention and treatment program. (8) (a) (I) There is hereby created in the state treasury the breast and cervical cancer prevention and treatment fund, referred to in this subsection (8) as the "fund". The fund shall consist of any moneys credited thereto pursuant to section 24-22-115 (1), C.R.S., any gifts, grants, and donations, any moneys appropriated thereto by the general assembly, and moneys credited thereto pursuant to section 42-3-217.5 (3)(c), C.R.S. Except as provided for in paragraph (b.5) of this subsection (8), all moneys credited to the fund and all interest and income earned on the moneys in the fund shall remain in the fund for the purposes set forth in this section. Any unexpended and unencumbered moneys remaining in the fund at the end of a fiscal year shall remain in the fund and shall not be credited or transferred to the general fund or another fund. The state department is encouraged to secure private gifts, grants, and donations to fund the state costs of the breast and cervical cancer prevention and treatment program.
      2. Moneys in the fund may be used to cover the administrative costs of the department of public health and environment to recognize providers in accordance with sub-subparagraph (B) of subparagraph (I) of paragraph (a) of subsection (2) of this section as providing screening activities under the centers for disease control and prevention's national breast and cervical cancer early detection program.
   2. Repealed.
   3. Until section 24-30-2204.5 is repealed, the state treasurer shall transfer any interest or income earned on moneys in the fund to the disability support fund, created in section 24-30-2205.5.
   4. Repealed.
9. 1. For the fiscal year 2005-06, the general assembly shall appropriate fifty percent of the state costs of the breast and cervical cancer prevention and treatment program from the general fund and fifty percent from the moneys credited to the breast and cervical cancer prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such program.
   2. For the fiscal year 2006-07, the general assembly shall appropriate seventy-five percent of the state costs of the breast and cervical cancer prevention and treatment program from the general fund and twenty-five percent from the moneys credited to the breast and cervical cancer prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such program.
   3. For the fiscal year 2007-08, the general assembly shall appropriate one hundred percent of the state costs of the breast and cervical cancer prevention and treatment program from the moneys credited to the breast and cervical cancer prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such program.
   4. For the fiscal year 2008-09, the general assembly shall appropriate one hundred percent of the state costs of the breast and cervical cancer prevention and treatment program from the moneys credited to the breast and cervical cancer prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such program.
   5. For the fiscal years 2009-10 through 2011-12, the general assembly shall annually appropriate one hundred percent of the state costs of the breast and cervical cancer prevention and treatment program from the moneys credited to the breast and cervical cancer prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such program.
   6. For the fiscal years 2012-13 and 2013-14, the general assembly shall annually appropriate fifty percent of the state costs of the breast and cervical cancer prevention and treatment program from the general fund and fifty percent from the moneys credited to the breast and cervical cancer prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such program.
   7. For the fiscal years 2014-15 through 2028-29, the general assembly shall annually appropriate one hundred percent of the state costs of the breast and cervical cancer prevention and treatment program from the money credited to the breast and cervical cancer prevention and treatment fund to the program; except that, if the money in the breast and cervical cancer prevention and treatment fund is insufficient to fully fund the program, the general assembly shall appropriate sufficient money from the general fund.
10. This section is repealed, effective July 1, 2029, unless, in any fiscal year before such date, money received as federal financial participation provided pursuant to the federal "Breast and Cervical Cancer Prevention and Treatment Act of 2000", enacted October 24, 2000, Pub.L. 106-354, as amended, is no longer available to the fund or the rate of federal financial participation has been decreased, in which case the general assembly may repeal this section at the regular session of the general assembly immediately following such decrease or discontinuation of federal money.

Source: L. 2006: (8) amended, p. 1117, § 2, effective May 25; entire article added with relocations, p. 1872, § 7, effective July 1. L. 2008: (8)(a), (9)(b), (9)(c), and (10) amended and (9)(d) and (9)(e) added, p. 1830, § 1, effective June 2. L. 2009: (9)(e) amended and (9)(f) added, (SB 09-262), ch. 202, p. 912, § 1, effective May 1; (2)(a)(I) and (8)(a) amended and (8)(c) added, (HB 09-1164), ch. 215, p. 973, § 4, effective May 2. L. 2013: (8)(a)(I) and (8)(c)(II) amended, (8)(b) repealed, and (8)(b.5) added, (SB 13-276), ch. 256, p. 1352, § 8, effective May 23. L. 2014: (2)(a)(I)(B), (8)(a)(I), and (10) amended, (8)(c) repealed, and (9)(g) added, (HB 14-1045), ch. 137, p. 468, § 1, effective July 1. L. 2015: (7) amended, (SB 15-189), ch. 104, p. 304, § 5, effective April 16. L. 2018: (2)(a)(IV) and (8)(b.5) amended, (HB 18-1375), ch. 274, p. 1714, § 64, effective May 29. L. 2019: (9)(g) and (10) amended, (HB 19-1302), ch. 193, p. 2115, § 1, effective May 16.

25.5-5-309. Pregnant women - needs assessment - referral to treatment program - definition.

1. The health care practitioner for each pregnant woman who is enrolled or eligible for services pursuant to section 25.5-5-101 (1)(c) or 25.5-5-201 (1)(m.5) is encouraged to identify as soon as possible after the woman is determined to be pregnant whether the woman is at risk of a poor birth outcome due to substance use during the prenatal period and in need of special assistance in order to reduce the risk. If the health care practitioner makes such determination regarding any pregnant woman, the health care practitioner is encouraged to refer the woman to any entity approved and licensed by the department of human services for the performance of a needs assessment. Any county department of human or social services may refer an eligible woman for a needs assessment, or any pregnant woman who is eligible for services pursuant to section 25.5-5-201 (1)(m.5) may refer herself for a needs assessment.
2. For the purposes of this section, unless the context otherwise requires, a "needs assessment" means an assessment that is designed to determine the services that are needed for a pregnant woman to minimize the occurrence of a poor birth outcome due to substance use by the pregnant woman.

Source: L. 2006: Entire article added with relocations, p. 1875, § 7, effective July 1. L. 2010: (1) amended, (HB 10-1043), ch. 92, p. 314, § 6, effective April 15. L. 2014: (1) amended, (SB 14-067), ch. 12, p. 116, § 13, effective February 27. L. 2019: Entire section amended, (HB 19-1193), ch. 272, p. 2568, § 2, effective May 23.

Editor's note: This section is similar to former § 26-4-508.2 as it existed prior to 2006.

Cross references: For the legislative declaration in HB 19-1193, see section 1 of chapter 272, Session Laws of Colorado 2019.

25.5-5-310. Treatment program for high-risk pregnant and parenting women - cooperation with private entities - definition.

1. 1. As used in this section, "parenting woman" means a woman up to one year postpartum who is in need of substance use disorder services.
   2. The state department and the departments of human services and public health and environment shall cooperate with any organizations that desire to assist the departments in the provision of services connected with the treatment program for high-risk pregnant and parenting women. Organizations may provide services that are not provided to persons pursuant to this article 5 or article 4 or 6 of this title 25.5 or article 2 of title 26, which services may include but are not limited to needs assessment services, preventive services, rehabilitative services, care coordination, nutrition assessment, psychosocial counseling, intensive health education, home visits, transportation, development of provider training, child care, child care navigation, and other necessary components of residential or outpatient treatment or care.
2. 1. Health care practitioners and county departments of human or social services are encouraged to identify any pregnant or parenting woman. If a practitioner or county department of human or social services makes such determination regarding any pregnant or parenting woman up to one year postpartum, the practitioner or county department of human or social services is encouraged to refer the woman to any entity approved and licensed by the department of human services for a needs assessment in order to improve outcomes for the pregnant or parenting woman and child and reduce the likelihood of out-of-home placement. Any pregnant or parenting woman up to one year postpartum may also refer herself for a needs assessment.
   2. The department of human services is authorized to use state money to provide services to women, including women enrolled in the medical assistance program established pursuant to this article 5 and articles 4 and 6 of this title 25.5, who enroll, up to one year postpartum, in residential substance use disorder treatment services, until such time as those services are covered by the medical assistance program. The department of human services may continue to use state money to enroll parenting women in residential services who qualify as indigent but who are not eligible for services under the medical assistance program.
   3. Facilities approved and licensed by the office of behavioral health within the department of human services to provide substance use disorder services to high-risk pregnant and parenting women and that offer child care services must allow a woman to begin treatment without first presenting up-to-date health records for her child, including those referenced in section 25-4-902. The parenting woman in treatment must present up-to-date health records for her child, including those referenced in section 25-4-902, within thirty days after commencing treatment.

Source: L. 2006: Entire article added with relocations, p. 1875, § 7, effective July 1. L. 2019: Entire section amended, (HB 19-1193), ch. 272, p. 2568, § 3, effective May 23.

Editor's note: This section is similar to former § 26-4-508.4 as it existed prior to 2006.

Cross references: For the legislative declaration in HB 19-1193, see section 1 of chapter 272, Session Laws of Colorado 2019.

25.5-5-311. Treatment program for high-risk pregnant and parenting women - data collection.

The state department, in cooperation with the department of human services, shall create a data collection mechanism regarding persons receiving services pursuant to the treatment program for high-risk pregnant and parenting women that includes the collection of any data that the departments deem appropriate.

Source: L. 2006: Entire article added with relocations, p. 1875, § 7, effective July 1. L. 2019: Entire section amended, (HB 19-1193), ch. 272, p. 2569, § 4, effective May 23.

Editor's note: This section is similar to former § 26-4-508.5 as it existed prior to 2006.

Cross references: For the legislative declaration in HB 19-1193, see section 1 of chapter 272, Session Laws of Colorado 2019.

25.5-5-312. Treatment program for high-risk pregnant and parenting women - extended coverage - federal approval.

1. The state department shall seek federal approval to continue providing substance use disorder treatment services for twelve months following a pregnancy to women who are eligible to receive services under the medical assistance program, who are receiving services pursuant to the treatment program for high-risk pregnant and parenting women, and who continue to participate in the treatment program. The state department shall implement the continued services to the extent allowed by the federal government.
2. The state department is authorized to request any federal changes necessary to permit high-risk pregnant and parenting women to further access treatment for pregnant and parenting women with substance use disorders. Any changes to federal waiver programs for this population must preserve the family-oriented specialty services needed by pregnant and parenting women and their dependent children, including those services described in section 25.5-5-310 (1).

Source: L. 2006: Entire article added with relocations, p. 1876, § 7, effective July 1. L. 2019: Entire section amended, (HB 19-1193), ch. 272, p. 2570, § 5, effective May 23.

Editor's note: This section is similar to former § 26-4-508.6 as it existed prior to 2006.

Cross references: For the legislative declaration in HB 19-1193, see section 1 of chapter 272, Session Laws of Colorado 2019.

25.5-5-313. Outpatient substance abuse treatment - report of state auditor - amendment to state plan - repeal. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1876, § 7, effective July 1.

25.5-5-314. Substance use disorder treatment for Native Americans - federal approval.

1. The state department shall request federal approval, conditioned on the receipt of gifts, grants, or donations sufficient to provide for the state's administrative costs of preparing and submitting the request, to include any substance use disorder treatment benefits available to Native Americans in which there is one hundred percent federal financial participation.
2. Repealed.

Source: L. 2006: Entire article added with relocations, p. 1876, § 7, effective July 1. L. 2014: (2) repealed, (HB 14-1363), ch. 302, p. 1269, § 30, effective May 31. L. 2017: (1) amended, (SB 17-242), ch. 263, p. 1328, § 203, effective May 25.

Editor's note: This section is similar to former § 26-4-422 as it existed prior to 2006.

Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter 263, Session Laws of Colorado 2017.

25.5-5-315. Acceptance of gifts, grants, and donations - Native American substance abuse treatment cash fund.

1. The executive director may accept and expend money from gifts, grants, and donations for purposes of providing for the administrative costs of preparing and submitting the request for federal approval to provide substance use disorder treatment services to Native Americans as provided for in section 25.5-5-314. All such gifts, grants, and donations shall be transmitted to the state treasurer who shall credit the same to the Native American substance abuse treatment cash fund, which fund is created and referred to in this section as the "fund". The money in the fund is subject to annual appropriation by the general assembly. All investment earnings derived from the deposit and investment of money in the fund remains in the fund and shall not be transferred or revert to the general fund of the state at the end of any fiscal year.
2. Repealed.

Source: L. 2006: Entire article added with relocations, p. 1876, § 7, effective July 1. L. 2014: (2) repealed, (HB 14-1363), ch. 302, p. 1269, § 31, effective May 31. L. 2017: (1) amended, (SB 17-242), ch. 263, p. 1328, § 204, effective May 25.

Editor's note: This section is similar to former § 26-4-423 as it existed prior to 2006.

Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter 263, Session Laws of Colorado 2017.

25.5-5-316. Legislative declaration - state department - disease management programs authorization - report.

1. The general assembly finds that, because Colorado is faced with rising health care costs and limited resources, it is necessary to seek new ways to ensure the availability of high-quality, cost-efficient care for medicaid recipients. The general assembly further finds that disease management is a patient-focused, integrated approach to providing all components of care with attention to both quality of care and total cost. In addition, the general assembly finds that this approach may include coordination of physician care with pharmaceutical and institutional care. The general assembly further finds that disease management also addresses the various aspects of a disease state, including meeting the needs of persons who have multiple chronic illnesses. The general assembly declares that the improved coordination in disease management helps to provide chronically ill patients with access to the latest advances in treatment and teaches them how to be active participants in their health care through health education, thus reducing total health care costs.
2. The state department, in consultation with the department of public health and environment, is authorized to develop and implement disease management programs, for fee-for-service and primary care physician program recipients, that are designed to address over- or under-utilization or the inappropriate use of services or prescription drugs and that may affect the total cost of health care utilization by a particular medicaid recipient with a particular disease or combination of diseases. The disease management programs shall target medicaid recipients who are receiving prescription drugs or services in an amount that exceeds guidelines outlined by the state department. The state department shall not restrict a medicaid recipient's access to the most cost-effective and medically appropriate prescription drugs or services. The state department may contract on a contingency basis for the development or implementation of the disease management programs authorized in this subsection (2).
3. If the state department implements any disease management programs authorized in subsection (2) of this section, the state department shall report to the joint budget committee of the general assembly an estimate of the fiscal implications generated by the implementation of the disease management programs. Such report shall be made on or before February 1 of the year following the implementation of a disease management program and on or before each February 1 thereafter in which such program is in place.

Source: L. 2006: Entire article added with relocations, p. 1877, § 7, effective July 1. L. 2008: (2) amended, p. 800, § 2, effective May 14.

Editor's note: This section is similar to former § 26-4-408.5 as it existed prior to 2006.

25.5-5-317. Obesity treatment pilot program - development and implementation - report - repeal. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1878, § 7, effective July 1.

25.5-5-318. Health services - provision by school districts - repeal.

1. As used in this section:
   1. "School district" means any board of cooperative services established pursuant to article 5 of title 22, C.R.S., any state educational institution that serves students in kindergarten through twelfth grade including, but not limited to, the Colorado school for the deaf and the blind, created in article 80 of title 22, C.R.S., and any public school district organized under the laws of Colorado, except a local college district.
   2. "Underinsured" means a person who has some health insurance, but whose insurance does not adequately cover the types of health services for which a school district may receive federal matching funds under this section.
2. 1. Any school district may contract with the state department under this section to receive federal matching funds for amounts spent in providing health services through the public schools to students who are receiving medicaid benefits pursuant to this article and articles 4 and 6 of this title.
   2. Repealed.
   3. Approval of contracts under this section does not constitute a commitment by the general assembly to continue providing health services to students through the public schools using state general funds if federal matching funds are not available in the future. Any moneys provided to a school district pursuant to a contract entered into under this section shall not supplant state or local moneys provided to school districts pursuant to the provisions of articles 20 to 28 or article 54 of title 22, C.R.S.
   4. Nothing in this section shall be construed as requiring any school district to enter into a contract as provided in this section. Participation in a contract by a school district is voluntary.
   5. The state department may make contracting and reimbursement of moneys under this section contingent upon either:
      1. The contracting school district certifying to the state department, through the department of education, that it has expended local and state moneys in an amount sufficient to meet the nonfederal share of expenditures being claimed for federal financial participation; or
      2. The contracting school district meeting the requirements of the intergovernmental transfer provisions of the federal medicaid law, 42 U.S.C. sec. 1396 et seq.
3. Each year, by a date established by rule of the state board, the department of education shall notify the state department concerning any school district that chooses to enter into a contract as provided in this section and the anticipated level of funding for the school district. Nothing in this section shall be construed to require a school district to maintain the same level of funding or services from year to year.
4. 1. 1. Each school district that chooses to enter into a contract as provided in this section shall develop a services plan with input from the local community that identifies the types of health services needed by students within the school district and the services it anticipates providing. Except for medical emergencies and services related to allegations of child abuse, a student's participation in any psychological, behavioral, social, or emotional services, including counseling or referrals, shall be optional and shall require the prior written and informed consent of a parent or legal guardian of the student. (4) (a) (I) Each school district that chooses to enter into a contract as provided in this section shall develop a services plan with input from the local community that identifies the types of health services needed by students within the school district and the services it anticipates providing. Except for medical emergencies and services related to allegations of child abuse, a student's participation in any psychological, behavioral, social, or emotional services, including counseling or referrals, shall be optional and shall require the prior written and informed consent of a parent or legal guardian of the student.
      2. 1. Any health questionnaire or form related to services funded in part through this section shall only relate to the student's personal health, habits, or conduct and shall not include questions concerning the habits or conduct of any other member of the student's family.
         2. No medical or health data or information identifying the student or the student's family shall be disclosed to any person other than a person specifically authorized to receive the information or data without the prior written and informed consent of a parent or legal guardian of the student.
   2. Each school district that chooses to enter into a contract as provided in this section shall perform an assessment of the health care needs of its uninsured and underinsured students and may spend an appropriate portion, not to exceed thirty percent, of the federal moneys received on health care for low-income students. For purposes of this paragraph (b), "low-income students" means students whose families are below one hundred eighty-five percent of the federal poverty line.
   3. The school district shall submit the services plan to the department of education with a notice of participation for purposes of technical assistance evaluation and to the executive director for approval.
5. Each year not less than ninety days prior to the notification date established pursuant to subsection (3) of this section, the state department shall provide information through the department of education to school districts regarding the amount of available moneys and the administrative activities required to enter into a contract for federal matching funds for that year. To the extent allowed by existing resources, the department of education shall provide technical assistance to school districts in determining levels of funding, meeting administrative requirements, and developing services plans.
6. Following the notification date established pursuant to subsection (3) of this section, each contracting school district, through the department of education, shall enter into a contract with the state department specifying the health services to be provided by the school district, the amount to be expended in providing the services, and the amount of federal matching funds for which the school district is eligible under the contract.
7. The state department is authorized to accept and expend donations, contributions, grants, including federal matching funds, and other moneys that it may receive to finance the costs associated with implementing this section.
8. 1. Under the contract entered into pursuant to this section, a contracting school district shall receive from the state department all of the federal matching funds for which it is eligible under the contract, less the amount of state administrative costs allowed under paragraph (b) of this subsection (8). All moneys received by a school district pursuant to this section shall be used only to offset costs incurred for provision of student health services by the school district or to cash fund student health services in the school district.
   2. Total allowable state administrative costs for contracts entered into under this section for both the state department and the department of education shall not exceed ten percent of the total annual amount of federal funds reflected by the general assembly for such contracts in the annual general appropriations bill. State administrative costs include costs incurred in evaluating the implementation of this section.
9. The state board shall specify by rule the types of health services for which a school district may receive federal matching funds under a contract created under this section, including but not limited to:
   1. Basic primary, physical, dental, and mental health services;
   2. Rehabilitation services;
   3. Early and periodic screening, diagnosis, and treatment services; and
   4. Service coordination, outreach, enrollment, and administrative support.
10. 1. A school district that provides health services under contract pursuant to this section may provide the health services directly or through contractual relationships or agreements with public or private entities, as allowed by applicable federal regulations. However, no moneys shall be expended in any form for abortions, except as provided in section 25.5-4-415 or as required by federal law.
    2. Where possible, the school district shall coordinate the provision of health services to a student with the student's primary health care provider. Except for those services that are required by an individualized educational program developed pursuant to section 22-20-108 (4), C.R.S., or by a section 504 plan developed pursuant to the federal "Rehabilitation Act of 1973", 29 U.S.C. sec. 701 et seq., school districts shall not claim reimbursement under this section for direct services to students enrolled in health maintenance organizations that would normally be provided to students by their health maintenance organization.
11. 1. The executive director shall apply for and secure any federal waivers and state plan amendments required to implement this section.
    2. This section shall remain in effect only for so long as federal financial participation is available for reimbursements to school districts. In the event, as specified in writing by the attorney general to the governor that federal law does not allow or is amended to disallow reimbursements to school districts or otherwise prevent the implementation of this section, this section is repealed, effective on the date of the attorney general's opinion.
12. The state department and the department of education shall work with the office of state planning and budgeting and the joint budget committee in implementing this section.
13. The state department and the department of education shall enter into an interagency agreement to provide for the implementation of this section. The state board and the state board of education are authorized to promulgate rules as may be necessary in accordance with the agreement.
14. The state department shall annually, or more often as necessary, hold a public hearing to receive comments from school districts, state agencies, and interested persons regarding implementation of this section.
15. On or before December 15, 2002, the state department shall submit a formal evaluation of the implementation of this section to the committees on education and the committees on health and human services of the house of representatives and the senate, or any successor committees.

Source: L. 2006: Entire article added with relocations, p. 1878, § 7, effective July 1. L. 2009: (2)(a.5) added, (SB 09-264), ch. 204, p. 928, § 6, effective May 1. L. 2010: (4)(b) amended, (HB 10-1422), ch. 419, p. 2113, § 147, effective August 11.

25.5-5-319. Family planning pilot program - rules - federal waiver - repeal.

1. There is hereby established a family planning pilot program for the provision of family planning services to categorically eligible individuals who are at or below a percentage of the federal poverty line established pursuant to the federal waiver sought pursuant to subsection (2) of this section. The state board shall promulgate rules setting forth the family planning services to be provided under the family planning pilot program.
2. The executive director of the state department, in consultation with the department of public health and environment, shall seek a federal waiver that is cost-neutral to the state general fund for the implementation of the family planning pilot program established pursuant to this section such that ten percent of the family planning services provided to low-income families pursuant to the program as described in subsection (1) of this section would be funded with state general fund moneys and ninety percent would be funded with federal matching funds. In the federal waiver, the executive director shall not seek authority to waive or disregard the provisions of 42 U.S.C. sec. 1396a (a)(23)(B).
3. 1. Upon issuance of the federal waiver sought pursuant to subsection (2) of this section, the departments of health care policy and financing and public health and environment shall seek the necessary appropriation of general funds through the normal budgetary process for the implementation of this act.
   2. The executive director of the state department is authorized to accept and expend on behalf of the state any funds, grants, gifts, and donations from any private or public source for the purpose of implementing the family planning pilot program established in this section; except that no gift, grant, donation, or funds shall be accepted if the conditions attached thereto require the expenditure thereof in a manner contrary to law.
4. The executive director of the state department, or such executive director's designee, shall prepare a written report for the members of the general assembly concerning the findings of the department based upon the family planning pilot program. Such report shall be provided to the members of the general assembly not more than three years after commencement of the program. The report shall address the number of individuals served, the type of services provided, the cost of the program, and such other information as the executive director deems appropriate.
5. The implementation of this section is conditioned upon the issuance of any necessary waiver by the federal government and available appropriations pursuant to paragraph (a) of subsection (3) of this section. The provisions of this section shall be implemented to the extent authorized by federal waiver. The pilot program established by this section shall continue for five years from the receipt of the federal waiver or for so long as specified in the federal waiver. The executive director of the state department shall provide written notice to the revisor of statutes of the final termination date of the waiver, and this section shall be repealed, effective July 1 five years after the issuance of the federal waiver or July 1 in the year in which the waiver is terminated, whichever occurs first.

Source: L. 2006: Entire article added with relocations, p. 1882, § 7, effective July 1. L. 2008: (1) and (2) amended, p. 41, § 1, effective March 13. L. 2010: (1) amended, (HB 10-1422), ch. 419, p. 2113, § 148, effective August 11.

25.5-5-320. Telemedicine - reimbursement - disclosure statement - definition - repeal.

1. On or after July 1, 2006, in-person contact between a health care or mental health care provider and a patient is not required under the state's medical assistance program for health care or mental health care services delivered through telemedicine that are otherwise eligible for reimbursement under the program. Any health care or mental health care service delivered through telemedicine must meet the same standard of care as an in-person visit. Telemedicine may be provided through interactive audio, interactive video, or interactive data communication, including but not limited to telephone, relay calls, interactive audiovisual modalities, and live chat, as long as the technologies are compliant with the federal "Health Insurance Portability and Accountability Act of 1996", Pub.L. 104-191, as amended. The health care or mental health care services are subject to reimbursement policies developed pursuant to the medical assistance program. This section also applies to managed care organizations that contract with the state department pursuant to the statewide managed care system only to the extent that:
   1. Health care or mental health care services delivered through telemedicine are covered by and reimbursed under the medicaid per diem payment program; and
   2. Managed care contracts with managed care organizations are amended to add coverage of health care or mental health care services delivered through telemedicine and any appropriate per diem rate adjustments are incorporated.
2. The reimbursement rate for a telemedicine service shall, as a minimum, be set at the same rate as the medical assistance program rate for a comparable in-person service. The state department may consider setting the reimbursement rate on a monthly basis as well as on a daily or per-visit basis.

   (2.1) For the purposes of reimbursement for services provided by home care agencies, as defined in section 25-27.5-102 (3), the services may be supervised through telemedicine or telehealth.

   1. (2.5) (a) A telemedicine service meets the definition of a face-to-face encounter for a rural health clinic, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(2). The reimbursement rate for a telemedicine service provided by a rural health clinic must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.
   2. A telemedicine service meets the definition of a face-to-face encounter for a medical care program of the federal Indian health service. The reimbursement rate for a telemedicine service provided by a medical care program of the federal Indian health service must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.
   3. A telemedicine service meets the definition of a face-to-face encounter for a federally qualified health center, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(4). The reimbursement rate for a telemedicine service provided by a federally qualified health center must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.
3. The state department shall establish rates for transmission cost reimbursement for telemedicine services, considering, to the extent applicable, reductions in travel costs by health care or mental health care providers and patients to deliver or to access such services and such other factors as the state department deems relevant.
4. A health care or mental health care provider who delivers health care or mental health care services through telemedicine shall provide to each patient, before treating that patient through telemedicine for the first time, the following written statements:
   1. That the patient retains the option to refuse the delivery of the services via telemedicine at any time without affecting the patient's right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled;
   2. That all applicable confidentiality protections shall apply to the services; and
   3. That the patient shall have access to all medical information resulting from the telemedicine services as provided by applicable law for patient access to his or her medical records.
5. Subsection (4) of this section shall not apply in an emergency.
6. 1. The state department shall post telemedicine utilization data to the state department's website no later than thirty days after the effective date of this subsection (6) and shall update the data every other month through state fiscal year 2021-22. For state fiscal years 2020-21 and 2021-22, the state department shall compile, summarize, and report on the utilization data to the public through the annual hearing, pursuant to the "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act", part 2 of article 7 of title 2.
   2. This subsection (6) is repealed, efffective July 1, 2022.
7. As used in this section, "health care or mental health care services" includes speech therapy, physical therapy, occupational therapy, hospice care, home health care, and pediatric behavioral health care.

Source: L. 2006: Entire section added, p. 1548, § 5, effective July 1. L. 2008: (1), (3), IP(4), and (4)(a) amended, p. 112, § 3, effective August 5. L. 2020: IP(1) amended and (2.1), (2.5), (6), and (7) added, (SB 20-212), ch. 235, p. 1141, § 5, effective July 6.

Editor's note: This section was enacted as § 26-4-421.5 in Senate Bill 06-165. Section 9 of the bill provided for the renumbering of that section. (See L. 2006, p. 1552 .)

Cross references: For the legislative declaration contained in the 2006 act enacting this section, see section 1 of chapter 312, Session Laws of Colorado 2006. For the legislative declaration in SB 20-212, see section 1 of chapter 235, Session Laws of Colorado 2020.

25.5-5-321. Telemedicine - home health care - home health telemedicine cash fund - rules.

1. On or after August 11, 2010, at-home telemedicine shall be eligible for reimbursement under the state's medical assistance program. The services delivered through telemedicine shall be subject to reimbursement policies promulgated by rule of the state board after consultation with home health care and home- and community-based services providers. This section also applies to managed care organizations that contract with the state department pursuant to the statewide managed care system, but only to the extent that:
   1. Home health care or home- and community-based services delivered through telemedicine are covered by and reimbursed under the medicaid program; and
   2. Managed care contracts with managed care organizations are amended to add coverage of home health care or home- and community-based services delivered through telemedicine.
2. 1. The reimbursement rate for home health care or home- and community-based services delivered through telemedicine that are otherwise eligible for reimbursement under the medical assistance program shall be set by rule of the state board and shall be:
      1. In the form of a flat fee in one or more levels, depending on acuity.
      2. (Deleted by amendment, L. 2010, (HB 10-1005), ch. 345, p. 1598, § 1, effective August 11, 2010.)
   2. Any cost savings identified pursuant to this section shall be considered for use in paying for home- and community-based services under part 6 of this article, community-based long-term care, and home health services.
   3. For the first two years after August 11, 2010, gifts, grants, and donations shall be used to implement this section. Gifts, grants, and donations made for this purpose shall be transferred to the home health telemedicine cash fund, which is hereby created in the state treasury. Moneys in the home health telemedicine cash fund shall be appropriated to the state board and used to implement this section. Moneys in the fund shall remain in the fund and not be transferred to the general fund at the end of any fiscal year. After two years or if the moneys in the cash fund are depleted, the department is authorized to go through the normal budget process to continue implementation of this section.
3. Reimbursement shall not be provided for purchase or lease of telemedicine equipment.
4. 1. A home health care or home- and community-based services provider who delivers services through telemedicine shall provide to each patient, before treating that patient through telemedicine for the first time, the following written statements:
      1. That the patient retains the option to refuse the delivery of home health care or home- and community-based services via telemedicine at any time without affecting the patient's right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled;
      2. That all applicable confidentiality protections shall apply to the services; and
      3. That the patient shall have access to all medical information resulting from the telemedicine services as provided by applicable law for patient access to his or her medical records.
   2. The provisions of paragraph (a) of this subsection (4) shall not apply in an emergency.
5. Nothing in this section shall be construed to:
   1. Alter the scope of practice of any home health care or home- and community-based services provider; or
   2. Authorize the delivery of home health care or home- and community-based services in a setting or manner not otherwise authorized by law.

Source: L. 2007: Entire section added, p. 1182, § 2, effective January 1, 2008. L. 2010: (1), (2), and (3) amended, (HB 10-1005), ch. 345, p. 1598, § 1, effective August 11.

25.5-5-321.5. Telehealth - interim therapeutic restorations - reimbursement - definitions.

1. Subject to federal authorization and federal financial participation, on or after July 1, 2016, in-person contact between a health care provider and a recipient is not required under the state's medical assistance program for the diagnosis, development of a treatment plan, instruction to perform an interim therapeutic restoration procedure, or supervision of a dental hygienist performing an interim therapeutic restoration procedure. A health care provider may provide these services through telehealth, including store-and-forward transfer, and is entitled to reimbursement for the delivery of those services via telehealth to the extent the services are otherwise eligible for reimbursement under the program when provided in person. The services are subject to the reimbursement policies developed pursuant to the state medical assistance program.
2. As used in this section:
   1. "Interim therapeutic restoration" has the same meaning as set forth in section 12-220-104 (10).
   2. "Store-and-forward transfer" means a telehealth by store-and-forward transfer, as defined in section 12-220-104 (14).

Source: L. 2015: Entire section added, (HB 15-1309), ch. 326, p. 1334, § 8, effective August 5. L. 2019: (2) amended, (HB 19-1172), ch. 136, p. 1709, § 182, effective October 1.

25.5-5-322. Over-the-counter medications - rules.

1. 1. Subject to approval through the state budget process in paragraph (b) of this subsection (1), the state board shall adopt by rule a system to allow pharmacies to be reimbursed for providing certain over-the-counter medications to recipients if prescribed by a licensed practitioner authorized to prescribe prescription drugs or, subject to the limitations contained in subsection (2) of this section, a licensed pharmacist. Over-the-counter medications subject to reimbursement pursuant to this section shall be identified through the drug utilization review process established in section 25.5-5-506, and shall be limited to medications that, if reimbursed, shall result in overall cost savings to the state.
   2. After the list of over-the-counter medications is identified pursuant to paragraph (a) of this subsection (1), the state department shall request, through the state budget process, that the reimbursements be implemented. The state department shall report to the joint budget committee annually concerning the amount of any savings realized from the reimbursements.
2. 1. The state board, in consultation with the state board of pharmacy created pursuant to section 12-280-104, shall establish by rule standards for when a licensed pharmacist may prescribe over-the-counter medications as provided under this section for purposes of receiving reimbursement under the medical assistance program.
   2. When prescribing over-the-counter medications under this section, a licensed pharmacist shall consult with the recipient to determine necessity, provide drug counseling, review drug therapy for potential adverse interactions, and make referrals as needed to other health care professionals.

Source: L. 2010: Entire section added, (SB 10-117), ch. 227, p. 985, § 2, effective July 1. L. 2012: (2)(a) amended, (HB 12-1311), ch. 281, p. 1628, § 75, effective July 1. L. 2019: (2)(a) amended, (HB 19-1172), ch. 136, p. 1709, § 183, effective October 1.

25.5-5-323. Complex rehabilitation technology - legislative declaration - definitions.

1. The general assembly finds and declares it is in the best interests of the people of the state of Colorado to:
   1. Continue to protect access to important technology and supporting services for eligible clients;
   2. Establish and improve current safeguards relating to the delivery, provision, and repair of medically necessary complex rehabilitation technology;
   3. Continue to provide supports for clients accessing complex rehabilitation technology to stay in the home or community setting; engage in basic activities of daily living and instrumental activities of daily living, including employment; prevent institutionalization; and prevent hospitalization and other costly secondary complications; and
   4. Continue adequate pricing for complex rehabilitation technology for the purpose of allowing continued access to appropriate products and related services including maintenance and repair.
2. As used in this section, unless the context otherwise requires:
   1. "Complex rehabilitation technology" means individually configured manual wheelchair systems, power wheelchair systems, adaptive seating systems, alternative positioning systems, standing frames, gait trainers, and specifically designated options and accessories classified as durable medical equipment that:
      1. Are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living, including employment, identified as medically necessary to promote mobility in the home and community or prevent hospitalization or institutionalization of the client;
      2. Are primarily used to serve a medical purpose and generally not useful to a person in the absence of illness or injury; and
      3. Require certain services provided by a qualified complex rehabilitation technology provider to ensure appropriate design, configuration, and use of such items, including patient evaluation or assessment of the client by a health care professional, and that are consistent with the client's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
   2. "Individually configured" means that a device has features, adjustments, or modifications specific to a client that a qualified complex rehabilitation technology supplier provides by measuring, fitting, programming, adjusting, adapting, and maintaining the device so that the device is consistent with an assessment or evaluation of the client by a health care professional and consistent with the client's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
   3. "Qualified complex rehabilitation technology professional" means an individual who is certified by the rehabilitation engineering and assistive technology society of North America or other nationally recognized accrediting organizations as an assistive technology professional.
   4. "Qualified complex rehabilitation technology supplier" means a company or entity that:
      1. Is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology;
      2. Meets the supplier and quality standards established for durable medical equipment suppliers under the medicare or medicaid program;
      3. Employs at least one qualified complex rehabilitation technology professional for each location to:
         1. Analyze the needs and capacities of clients for a complex rehabilitation technology item in consultation with the evaluating clinical professionals;
         2. Assist in selecting appropriate complex rehabilitation technology items for such needs and capacities; and
         3. Provide the client technology-related training in the proper use and maintenance of the selected complex rehabilitation technology items;
      4. Has the qualified complex rehabilitation technology professional directly involved with the assessment, and determination of the appropriate individually configured complex rehabilitation technology for the client, with such involvement to include seeing the client visually either in person or by any other real-time means within a reasonable time frame during the determination process.
      5. Maintains a reasonable supply of parts, adequate physical facilities, and qualified service or repair technicians to provide clients with prompt service and repair of all complex rehabilitation technology it sells or supplies; and
      6. Provides the client written information at the time of sale as to how to access service and repair.
3. The state department shall provide a separate recognition within the state's medicaid program established under articles 4, 5, and 6 of this title for complex rehabilitation technology and shall make other required changes to protect client access to appropriate products and services. Such separate recognition must take into consideration the customized nature of complex rehabilitation technology and the broad range of related services necessary to meet the unique medical and functional needs of clients and include the following:
   1. The state department notifying the qualified rehabilitation technology suppliers concerning the parameters of the complex rehabilitation technology benefit, which benefit must include the use of qualified rehabilitation technology suppliers as well as billing procedures that specify the types of equipment identified and included in the complex rehabilitation technology benefit. The state department shall create complex rehabilitation technology benefit parameters that are easily understood by and accessible to clients and qualified rehabilitation technology suppliers. The state department shall provide public notice no later than thirty days prior to a collaborative process that includes discussion of any proposed changes to the types of equipment identified and included in the complex rehabilitation technology benefit.
   2. Adopting specific supplier standards, as described in paragraph (d) of subsection (2) of this section, for companies or entities that provide complex rehabilitation technology and restricting the provision of complex rehabilitation technology to those companies or entities that are qualified complex rehabilitation suppliers;
   3. Ensuring that clients receiving complex rehabilitation technology are evaluated or assessed, as needed, by:
      1. A qualified health care professional, including but not limited to a licensed physical therapist, a licensed occupational therapist, or other licensed health care professional who has no financial relationship with the qualified complex rehabilitation technology supplier and performs specialty evaluations within his or her scope of practice; and
      2. A qualified complex rehabilitation technology professional employed by the qualified complex rehabilitation technology supplier. The assessment and determination performed by the qualified complex rehabilitation technology professional employed by the qualified complex rehabilitation supplier shall continue to be included in the reimbursement for the purchased or rented complex rehabilitation technology;
   4. Continuing pricing policies for complex rehabilitation technology, unless specifically prohibited by the centers for medicare and medicaid services, including the following:
      1. Continuing to ensure that the reimbursement amounts for complex rehabilitation technology, repairs, and supporting clinical complex rehabilitation technology services are adequate to ensure that qualified clients have access to the items, taking into account the unique needs of the clients and the complexity and customization of complex rehabilitation technology. This includes developing pricing policies that ensure access to adequate and timely repairs.
      2. Exempting complex rehabilitation technology from inclusion in competitive bidding programs or similar processes; and
      3. Preserving the option for complex rehabilitation technology to be billed and paid for as a purchase allowing for lump sum payments for devices with a length of need of one year or greater, excluding approved crossover claims for clients enrolled in medicare and medicaid; and
   5. Making other changes as needed to protect access to complex rehabilitation technology for clients.

Source: L. 2014: Entire section added, (HB 14-1211), ch. 253, p. 1008, § 1, effective January 1, 2015.

25.5-5-324. Nonemergency medical transportation - urgent transportation need - report - repeal.

1. On or before January 1, 2019, the state department shall create and implement an efficient and cost-effective method for meeting urgent transportation needs within the existing nonemergency medical transportation benefit under the medical assistance program. Urgent transportation needs include discharge from inpatient, emergency services, and other urgent but nonemergency services, as determined by the state department.
2. The method created by the state department must include, at a minimum:
   1. Medical service provider or facility access to approved transportation providers for patients with urgent transportation needs;
   2. Access to transportation providers that have obtained the necessary background checks, drug tests, training, and vehicle inspections, as required by the state department; and
   3. An efficient method for obtaining and paying for transportation services for urgent transportation needs.
3. The state department may contract for background checks, drug tests, training, and vehicle inspections that may be required pursuant to subsection (2) of this section.
4. 1. The state department shall annually report on the implementation and effectiveness of the process created in this section for meeting urgent transportation needs within the nonemergency medical transportation benefit. The state department shall present the report as part of its annual presentation to the health and human services committee of the senate and the public health and human services committee of the house of representatives, or any successor committees, as required pursuant to section 2-7-203.
   2. Notwithstanding the provisions of section 24-1-136 (11)(a)(I) to the contrary, the report required pursuant to this section shall continue until the beginning of the 2025 legislative session.
   3. This section is repealed, effective July 1, 2025.

Source: L. 2018: Entire section added, (HB 18-1321), ch. 346, p. 2064, § 1, effective May 30. L. 2019: (4)(a) amended, (SB 19-252), ch. 254, p. 2452, § 5, effective August 2.

25.5-5-325. Residential and inpatient substance use disorder treatment - medical detoxification services - federal approval - performance review report.

1. Subject to available appropriations and to the extent permitted under federal law, the medical assistance program pursuant to this article 5 and articles 4 and 6 of this title 25.5 includes residential and inpatient substance use disorder treatment and medical detoxification services. Participation in the residential and inpatient substance use disorder treatment and medical detoxification services benefit is limited to persons who meet nationally recognized, evidence-based level of care criteria for residential and inpatient substance use disorder treatment and medical detoxification services. The benefit shall serve persons with substance use disorders, including those with co-occurring mental health disorders. All levels of nationally recognized, evidence-based levels of care for residential and inpatient substance use disorder treatment and medical detoxification services must be included in the benefit.
2. 1. No later than October 1, 2018, the state department shall seek federal authorization to provide residential and inpatient substance use disorder treatment and medical detoxification services with full federal financial participation. Residential and inpatient substance use disorder treatment and medical detoxification services shall not take effect until federal approval has been obtained.
   2. Prior to seeking federal approval pursuant to subsection (2)(a) of this section, the state department shall seek input from relevant stakeholders, including existing providers of substance use disorder treatment and medical detoxification services and managed service organizations. The state department shall seek input and involve stakeholders in decisions regarding:
      1. The coordination of benefits with managed service organizations and the office of behavioral health in the department of human services;
      2. The most appropriate entity for administration of the benefit;
      3. The provision of wraparound services needed during treatment and the provision of required services following treatment that may not be covered through the medical assistance program;
      4. The authorization process for approval of services; and
      5. The development of a reimbursement rate methodology to ensure sustainability that considers a provider's cost of providing care, including lower-volume providers in rural areas.
3. 1. No later than January 15, 2022, the state department shall prepare and submit a performance review report to the joint budget committee and to the joint health and human services committee, or any successor committees, concerning the residential and inpatient substance use disorder treatment pursuant to this section, including, at a minimum:

      (I) The number of persons who received services pursuant to this section and the service provided;

      (II) The length of time that services were provided;

      (III) The location where services were provided;

      (IV) The effectiveness of the services provided, including the rate of relapse to substance use disorder following treatment; and

      (V) Any other information as determined by the state department that is relevant to the benefit.

   2. After considering the state department's performance review report, the general assembly may enact legislation modifying or repealing the benefit.

Source: L. 2018: Entire section added, (HB 18-1136), ch. 373, p. 2269, § 2, effective June 5.

25.5-5-326. Access to clinical trials - definitions.

1. As used in this section, unless the context otherwise requires:
   1. "Approved clinical trial" means a phase I, II, III, or IV clinical trial involving the prevention, detection, diagnosis, or treatment of a life-threatening or debilitating disease or condition if any one of the following conditions apply:
      1. The clinical trial is conducted under an investigational new drug application or an investigational device exemption reviewed by the federal food and drug administration, or is exempted from review by the federal food and drug administration; or
      2. The clinical trial is approved or funded by:
         1. The national institutes of health;
         2. The centers for disease control and prevention;
         3. The agency for health care research and quality;
         4. The federal centers for medicare and medicaid services;
         5. A cooperative group or center of any of the entities described in subsections (1)(a)(II)(A) to (1)(a)(II)(D) of this section, the federal department of defense, or the federal department of veterans affairs;
         6. A qualified nongovernmental research entity identified in guidelines issued by the national institutes of health for center support grants; or
         7. The federal department of veterans affairs, the federal department of defense, or the federal department of energy, provided that review and approval of the clinical trial occurs through a system of peer review that is comparable to the peer review of clinical trials performed by the national institutes of health, including an unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
   2. "Life-threatening or debilitating disease or condition" means a disease or condition from which the likelihood of death is probable, or the disease or condition is progressive or significantly debilitating, unless the course of the disease or condition is interrupted.
   3. "Qualified individual" means an individual who is eligible for and enrolled in the state medical assistance program and who a treating physician determines has a life-threatening or debilitating disease or condition and meets the selection criteria for the approved clinical trial.
   4. 1. "Routine costs" means medically necessary items and services that are included under the medical assistance program for a medical assistance recipient, to the extent that the provision of such items or services to the individual outside the course of such participation would otherwise be covered under the medical assistance program, without regard to whether the recipient is enrolled in a clinical trial. For medical assistance recipients participating in an approved clinical trial, "routine costs" include medically necessary items and services that are not otherwise excluded pursuant to subsection (1)(d)(II)(D) of this section, relating to the detection and treatment of complications arising from the medical assistance recipient's medical care, including complications relating to participation in the clinical trial, to the extent that the provision of such items or services to the individual outside the course of such participation would otherwise be included under the medical assistance program.
      2. "Routine costs" do not include:
         1. The investigational item, device, or service itself;
         2. Items and services provided solely to satisfy the data collection and analysis needs of the clinical trial;
         3. Items, drugs, or services customarily provided free of charge to any qualified individual enrolled in the clinical trial; or
         4. Items, drugs, or services that the clinical trial is required to provide.
2. The medical assistance program established pursuant to this article 5 and articles 4 and 6 of this title 25.5 must include coverage and payment for the routine costs associated with participation in an approved clinical trial for a qualified individual.

Source: L. 2020: Entire section added, (HB 20-1232), ch. 266, p. 1277, § 1, effective July 10.

25.5-5-401. Short title.

This part 4 shall be known and may be cited as the "Statewide Managed Care System".

Source: L. 2006: Entire article added with relocations, p. 1883, § 7, effective July 1.

Editor's note: This section is similar to former § 26-4-111 as it existed prior to 2006.

25.5-5-402. Statewide managed care system - definition - rules.

1. The state board shall adopt rules to implement a statewide managed care system for Colorado medical assistance recipients pursuant to the provisions of this article 5 and articles 4 and 6 of this title 25.5. The statewide managed care system shall be implemented to the extent possible.
2. The statewide managed care system implemented pursuant to this article 5 does not include:
   1. The services delivered under the residential child health care program described in section 25.5-6-903, except in those counties in which there is a written agreement between the county department of human or social services, the designated and contracted MCE responsible for community behavioral health care, and the state department;
   2. Long-term care services and the program of all-inclusive care for the elderly, as described in section 25.5-5-412. For purposes of this subsection (2), "long-term care services" means nursing facilities and home- and community-based services provided to eligible clients who have been determined to be in need of such services pursuant to the "Colorado Medical Assistance Act" and the state board's rules.
3. The statewide managed care system must include a statewide system of community behavioral health care that must:
   1. Address the economic, social, and personal costs to the state of Colorado and its citizens of untreated behavioral health disorders, including mental health and substance use disorders;
   2. Approach behavioral health disorders as treatable conditions not unlike other chronic health issues that require a combination of behavioral change and medication or other treatment;
   3. Offer timely access through multiple points of entry to a full continuum of culturally responsive behavioral health services, including prevention, early intervention, crisis response, treatment, and recovery services, that support individuals living full, productive lives;
   4. Provide coordination of care for the full continuum of substance use disorder and mental health treatment and recovery, including support for individuals transitioning between levels of care;
   5. Feature a comprehensive and integrated system of quality behavioral health care that is individualized and coordinated to meet individuals' changing needs;
   6. Be paid for by the state department establishing capitated rates specifically for community mental health services that account for a comprehensive continuum of needed services such as those provided by community mental health centers as defined in section 27-66-101;
   7. Make the behavioral health system's administrative processes, service delivery, and funding more effective and efficient to improve outcomes for Colorado citizens;
   8. In addition to network adequacy requirements determined by the state department, require each MCE to offer an enrollee an initial or subsequent nonurgent care visit within a reasonable period where medically necessary and at appropriate therapeutic intervals, as determined by state board rule;
   9. Specify that the diagnosis of an intellectual or developmental disability, a neurological or neurocognitive disorder, or a traumatic brain injury does not preclude an individual from receiving a covered behavioral health service; and
   10. Require an MCE to cover all medically necessary covered treatments for covered behavioral health diagnoses, regardless of any co-occurring conditions.
4. The statewide managed care system must promote the utilization of the medical home model of care for all enrolled members. The medical home model of care establishes a focal point of care for comprehensive primary care and efficient coordination with specialty care providers and other health care systems. The medical home model has proven effective in promoting early intervention and prevention, improving individuals' health, and reducing health care costs.
5. The statewide managed care system builds upon the lessons learned from previous managed care and community behavioral health care programs in the state in order to reduce barriers that may negatively impact medicaid recipient experience, medicaid recipient health, and efficient use of state resources. The statewide managed care system is authorized to provide services under a single MCE type or a combination of MCE types.
6. 1. The state department is authorized to assign a medicaid recipient to a particular MCE, consistent with federal requirements and rules promulgated by the state board.
   2. For a child or youth who obtains eligibility for services under the state's medicaid program through a dependency and neglect action resulting in out-of-home placement pursuant to article 3 of title 19 or a juvenile delinquency action resulting in out-of-home placement pursuant to article 2 of title 19, the state department shall assign the child or youth to the MCE covering the county with jurisdiction over the action. The state department shall only change the assignment if the change is requested by the county with jurisdiction over the action or by the child's or youth's legal guardian.
7. The state department is authorized to enter into a contract with MCOs, PCCM Entities, prepaid ambulatory health plans, and prepaid inpatient health plans, subject to the receipt of any required federal authorizations and pursuant to the requirements of this section.
   1. (7.5) (a) The state department shall offer to enter into a direct contract with the MCO operated by or under the control of Denver health and hospital authority, created pursuant to article 29 of title 25, until the MCO ceases to operate a medicaid managed care program or until June 30, 2025, unless sooner reprocured. If the state department designates an MCO to manage behavioral health services pursuant to this article 5, Denver health and hospital authority, or any subsidiary thereof, shall collaborate with the MCO during the term of contract.
   2. The MCO operated by or under the control of Denver health and hospital authority shall:
      1. Maintain adequate financials to ensure proper solvency as a risk manager;
      2. Accept rates determined by the state department, through standard methodologies, to cover the population it is serving;
      3. Maintain service and quality metrics, as determined by the state department; and
      4. Meet statewide managed care system standards and operate as part of the overall managed care system.
8. Waivers. The implementation of this part 4 is conditioned, to the extent applicable, on the issuance of necessary waivers by the federal government. The provisions of this part 4 must be implemented to the extent authorized by federal waiver, if so required by federal law.
9. Bidding. The state department is authorized to institute a program for competitive bidding pursuant to section 24-103-202 or 24-103-203 for MCEs seeking to provide, arrange for, or otherwise be responsible for the provision of services to its enrollees. The state department is authorized to award contracts to more than one offeror. The state department shall use competitive bidding procedures to encourage competition and improve the quality of care available to medicaid recipients over the long term that meets the requirements of this section and section 25.5-5-406.1.
10. An MCE that is contracting for a defined scope of services under a risk contract shall certify the financial stability of the MCE pursuant to criteria established by the division of insurance.
11. The state department shall conduct a review of each MCE, in accordance with federal requirements, prior to the implementation of a contract to assess the ability and capacity of the MCE to satisfactorily perform the operational requirements of the contract.
12. Graduate medical education. The state department shall continue the graduate medical education, referred to in this subsection (12) as "GME", funding to teaching hospitals that have graduate medical education expenses in their medicare cost report and are participating as providers under one or more MCEs with a contract with the state department under this part 4. GME funding for recipients enrolled in an MCE is excluded from the premiums paid to the MCE and must be paid directly to the teaching hospital. The state board shall adopt rules to implement this subsection (12) and establish the rate and method of reimbursement.
13. Nothing in this part 4 creates an exemption from the applicable provisions of title 10.
14. Nothing in this part 4 creates an entitlement to an MCE to contract with the state department.
15. On or before July 1, 2020, the state department shall include utilization management guidelines for the MCEs in the state board's managed care rules.
16. The state department shall provide information on its website specifying how the public may request the network adequacy plan and quarterly network reports for an MCE. The plan must include actions taken by the MCE to ensure that all necessary and covered primary care, care coordination, and behavioral health services are provided to enrollees with reasonable promptness. Such actions include, without limitation:
    1. Utilizing single case agreements with out-of-network providers when necessary; and
    2. Using financial incentives to increase network participation.
17. If the state department receives a complaint from the office of the ombudsman for behavioral health access to care established pursuant to part 3 of article 80 of title 27 that relates to possible violations of subsection (3) of this section or the MHPAEA, the state department shall examine the complaint, as requested by the office, and shall report to the office in a timely manner any actions taken related to the complaint.

Source: L. 2006: Entire article added with relocations, p. 1883, § 7, effective July 1. L. 2008: (3) and (5) amended, p. 390, § 1, effective August 5. L. 2012: (6) added, (HB 12-1281), ch. 246, p. 1187, § 3, effective June 4. L. 2018: Entire section amended with relocations, (HB 18-1431), ch. 313, p. 1877, § 1, effective August 8; IP(2) and (2)(a) amended, (HB 18-1328), ch. 184, p. 1244, § 6, effective June 7, 2019. L. 2019: (3)(e) amended and (3)(g), (3)(h), (3)(i), (15), (16), and (17) added, (HB 19-1269), ch. 195, p. 2133, § 12, effective May 16; (7.5) added, (HB 19-1285), ch. 392, p. 3501, § 1, effective August 2. L. 2020: (6) amended, (HB 20-1237), ch. 271, p. 1319, § 1, effective July 11; (3)(c.5) added, (SB 20-007), ch. 286, p. 1391, § 7, effective July 13.

25.5-5-403. Definitions.

As used in this part 4, unless the context otherwise requires:

1. Repealed.
2. "Essential community provider", referred to in this part 4 as an "ECP", means a health care provider that:
   1. Has historically served medically needy or medically indigent patients and that demonstrates a commitment to serve low-income and medically indigent populations who comprise a significant portion of its patient population or, in the case of a sole community provider, serves the medically indigent patients within its medical capability; and
   2. Waives charges or charges for services on a sliding scale based on income and does not restrict access or services because of a client's financial limitations.

   (2.5) "Global payment" means a population-based payment mechanism that is constructed on a per-member, per-month calculation. Global payments must account for prospective local community or health system cost trends and value, as measured by quality and satisfaction metrics, and incorporate community cost experience and reported encounter data to the greatest extent possible to address regional variation and improve longitudinal performance. Risk adjustments, risk-sharing, and aligned payment incentives may be utilized to achieve performance improvement. The rate calculations for global payment are exempt from the provisions of section 25.5-5-408. An entity that uses global payment pursuant to section 25.5-5-402 shall meet the applicable financial solvency requirements of sections 25.5-5-402 (10) and 25.5-5-408 (1)(f) and the essential community provider requirements of sections 25.5-5-406.1 (1)(f)(II) and 25.5-5-408 (1)(d).

3. 1. "Managed care" means a health care delivery system organized to manage costs, utilization, and quality. Medicaid managed care provides for the delivery of medicaid health benefits and additional services through contracted arrangements between state medicaid agencies and MCEs.
   2. Nothing in this section shall be deemed to affect the benefits authorized for recipients of the state medical assistance program.
4. "Managed care entity", referred to in this part 4 as an "MCE", means an entity that enters into a contract to provide services in the statewide managed care system, including MCOs, prepaid inpatient health plans, prepaid ambulatory health plans, and PCCM Entities.
5. "Managed care organization", referred to in this part 4 as an "MCO", means an entity contracting with the state department that meets the definition of managed care organization as defined in 42 CFR 438.2.

   (5.5) "Medical home" means an appropriately qualified medical health care practice that verifiably ensures continuous access to comprehensive, accessible, and coordinated community-based primary care. All medical homes may have, but are not limited to, the following:

   1. Health maintenance and preventive care;
   2. Anticipatory guidance and health education;
   3. Acute and chronic illness care;
   4. Coordination of medications, specialists, and therapies;
   5. Provider participation in hospital care; and
   6. Mental health care, oral health care, and other related services, as appropriate.

   (5.7) "MHPAEA" means the federal "Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008", Pub.L. 110-343, as amended, and all of its implementing and related regulations.

6. "Prepaid ambulatory health plan", referred to in this part 4 as a "PAHP", means an entity contracting with the state department that meets the definition of prepaid ambulatory health plan as defined in 42 CFR 438.2.
7. "Prepaid inpatient health plan", referred to in this part 4 as "PIHP", means an entity contracting with the state department that meets the definition of prepaid inpatient health plan as defined in 42 CFR 438.2.

   (7.5) "Primary care case management entity", referred to in this part 4 as a "PCCM Entity", means an entity contracting with the state department that meets the definition of primary care case management entity as defined in 42 CFR 438.2.

8. "Primary care case manager", referred to in this part 4 as a "PCCM", means a physician, a physician group practice, or other practitioner as identified by the state that meets the definition of primary care case manager as defined in 42 CFR 438.2.

Source: L. 2006: Entire article added with relocations, p. 1884, § 7, effective July 1. L. 2007: (1)(a) amended, p. 1354, § 3, effective May 29. L. 2008: Entire section amended, p. 390, § 2, effective August 5. L. 2012: (2.5) added, (HB 12-1281), ch. 246, p. 1187, § 4, effective June 4. L. 2018: (1) repealed, (2.5), (3)(a), (4), and (8) amended, and (5.5) and (7.5) added (HB 18-1431), ch. 313, p. 1881, § 2, effective August 8. L. 2019: (5.7) added, (HB 19-1269), ch. 195, p. 2134, § 13, effective May 16.

Editor's note: This section is similar to former § 26-4-114 as it existed prior to 2006.

Cross references: (1) For additional definitions applicable to this part 4, see § 25.5-4-103.

(2) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.

25.5-5-404. Selection of managed care entities. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1885, § 7, effective July 1. L. 2008: Entire section amended, p. 392, § 3, effective August 5. L. 2014: (1)(v) added, (HB 14-1211), ch. 253, p. 1011, § 2, effective January 1, 2015. L. 2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, § 7, effective August 8.

25.5-5-405. Quality measurements. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1889, § 7, effective July 1. L. 2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, § 7, effective August 8.

Editor's note: This section was similar to former § 26-4-116 as it existed prior to 2006.

25.5-5-406. Required features of managed care system. (Repealed)

Source: L. 2006: Entire article added with relocations, p. 1889, § 7, effective July 1. L. 2008: Entire section amended, p. 396, § 4, effective August 5. L. 2012: (2) amended, (HB 12-1281), ch. 246, p. 1187, § 5, effective June 4. L. 2016: (1)(f)(I) amended, (HB 16-1081), ch. 22, p. 53, § 9, effective August 10. L. 2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, § 7, effective August 8.

25.5-5-406.1. Required features of statewide managed care system.

1. General features. All medicaid managed care programs must contain the following general features, in addition to others that the federal government, state department, and state board consider necessary for the effective and cost-efficient operation of those programs:
   1. The MCE shall accept all enrollees that the state department assigns to the MCE in the order in which they are assigned, without restriction, regardless of health status or need for health care services;
   2. The MCE shall not discriminate against enrolled members on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, disability, religion, creed, or political beliefs, and shall not use any policy or practice that has the effect of discriminating on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity and expression, disability, religion, creed, or political beliefs;
   3. The MCE shall allow each enrolled member to choose his or her network provider to the extent possible and appropriate;
   4. Notwithstanding any waivers authorized by the federal department of health and human services, or any successor agency, each contract between the state department and an MCE selected to participate in the statewide managed care system under this part 4 shall comply with the requirements of 42 U.S.C. sec. 1396a (a)(23)(B);
   5. The MCE shall ensure access to care for all enrolled members in need of medically necessary services covered in the contract;
   6. The MCE shall create, administer, and maintain a network of providers, building on the current network of medicaid providers, to serve the health care needs of its members. In doing so, the MCE shall:
      1. Support providers in serving the medicaid population and implement value-based payment methodologies for network providers that incentivize and reward providers for the effective and efficient delivery of high-quality services to enrolled members;
      2. 1. Seek proposals from each ECP in a county in which the MCE is enrolling recipients for those services that the MCE provides or intends to provide and that an ECP provides or is capable of providing. The MCE shall consider such proposals in good faith and shall, when deemed reasonable by the MCE based on the needs of its enrollees, contract with ECPs. Each ECP shall be willing to negotiate on reasonably equitable terms with each MCE. ECPs making proposals under this subsection (1)(f)(II) must be able to meet the contractual requirements of the MCE. The requirements of this subsection (1)(f)(II) do not apply to an MCE in areas in which the MCE operates entirely as a group health maintenance organization.
         2. In selecting MCEs, the state department shall not penalize an MCE for paying cost-based reimbursement to federally qualified health centers as defined in the federal "Social Security Act".
      3. Demonstrate that there are sufficient Indian health care providers participating in the provider network to ensure timely access to services available under the contract from such providers for Indian enrollees who are eligible to receive services.
   7. The MCE shall ensure that its contracted network providers are capable of serving all members, including contracting with providers with specialized training and expertise across all ages, levels of ability, gender identities, and cultural identities;
   8. The MCE shall meet the network adequacy standards, as established by the state department, describing the maximum time and distance an enrolled member is expected to travel in order to access the provider types covered under the state contract;
   9. The MCE shall meet, and require its network providers to meet, standards as established by the state department for timely access to care and services, taking into account the urgency of the need for services;
   10. The MCE shall not interfere with appropriate medical care decisions rendered by its contracted network providers;
   11. The MCE shall comply with the state department's transition of care policy to ensure continued access to services during a transition from fee-for-service to an MCE or transition from one MCE to another when an enrollee, in the absence of continued access to services, would suffer serious detriment to his or her health or be at risk of hospitalization or institutionalization;
   12. The MCE shall provide and facilitate the delivery of services in a culturally competent manner to all members, including those with limited English proficiency, diverse cultural and ethnic backgrounds, and disabilities, and regardless of gender, sexual orientation, or gender identity;
   13. The MCE shall provide communications in a manner and format that may be easily understood and is readily accessible by members;
   14. Grievances and appeals. (I) (A) Each MCE shall establish a grievance and appeal system that complies with rules established by the state board and federal government.

       (B) An enrollee is entitled to designate a representative, including but not limited to an attorney, the ombudsman for medicaid managed care, a lay advocate, or the enrollee's physician, to file and pursue a grievance or appeal on behalf of the enrollee. The procedure must allow for the unencumbered participation of physicians.

       (II) The MCE shall have an established grievance system that allows for client expression of dissatisfaction at any time about any matter related to the MCE's contracted services, other than an adverse benefit determination. The grievance system must provide timely resolution of such matters in a manner consistent with the medical needs of the individual recipient.

       (III) (A) The MCE shall have an appeal system for review of any determination by the MCE to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested.

       (B) Each MCE shall utilize an appeal process for expedited reviews that complies with rules established by the state board. The appeal process for expedited reviews must provide a means by which an enrollee may complain and seek resolution concerning any action or failure to act in an emergency situation that immediately impacts the enrollee's access to quality health care services, treatments, or providers.

       (C) The state department shall establish the position of ombudsman for medicaid managed care. The ombudsman shall, if the enrollee requests, act as the enrollee's representative in resolving appeals with the MCE. It is the intent of the general assembly that the ombudsman for medicaid managed care be independent from the state department and selected through a competitive bidding process. In the event the state department is unable to contract with an independent ombudsman, an employee of the state department may serve as the ombudsman for medicaid managed care. An enrollee whose appeal is not resolved to his or her satisfaction by a procedure described in this subsection (1)(n), or whose appeal is deemed exhausted, is entitled to request a state fair hearing by an independent hearing officer, further judicial review, or both, as provided for by federal law and any state statute or rule.

   15. The MCE shall maintain and participate in an ongoing comprehensive quality assessment and performance improvement program that must include but not be limited to the following:
       1. Performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care and nonclinical care areas that are expected to have a favorable effect on health outcomes and member satisfaction;
       2. The collection and submission of performance measurement data as required by the state department;
       3. The implementation and maintenance of mechanisms to detect overutilization and underutilization of services and to assess the quality and appropriateness of care furnished to its members, including members with special health care needs; and
       4. Annual participation in an independent quality review and validation of performance improvement projects, performance measures, and other contract requirements;
   16. The MCE shall administer a program integrity system to ensure compliance with all requirements established by the federal government, state of Colorado, state department, and state board that includes, but is not limited to:
       1. Procedures to detect and prevent fraud, waste, and abuse;
       2. Screening and disclosure processes to prevent relationships with individuals or entities that are debarred, suspended, or otherwise excluded from participating in any federal health care program, procurement activities, or nonprocurement activities; and
       3. Treatment of recoveries of overpayment to providers;
   17. Billing medicaid recipients. Notwithstanding any federal regulations or the general prohibition of section 25.5-4-301 against providers billing medicaid recipients, a provider may bill a medicaid recipient who is enrolled with a specific medicaid PCCM or MCE and, in circumstances defined by the rules of the state board, receives care from a medical provider outside that organization's network or without referral by the recipient's PCCM;
   18. Marketing. In marketing coverage to medicaid recipients, all MCEs shall comply with all applicable provisions of title 10 regarding health plan marketing. The state board is authorized to promulgate rules concerning the permissible marketing of medicaid managed care. The purposes of such rules must include but not be limited to the avoidance of biased selection among the choices available to medicaid recipients.