C.R.S. § 25.5-5-313 — CO Code / Title 25.5 / Article 5 / Part 3 / Section 25.5-5-313
25.5-5-313. Outpatient substance abuse treatment - report of state auditor - amendment to st
Status: repealed

25.5-5-313. Outpatient substance abuse treatment - report of state auditor - amendment to state plan - repeal. (Repealed)
C.R.S. § 25.5-4-216 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-216
25.5-4-216. Report on impact of hospital facility fees in Colorado - definitions - steering
Status: repealed

25.5-4-216. Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal. (1) As used in this section:

(a) "Affiliated with" has the meaning set forth in section 6-20-102 (1)(a).

(b) "Campus" has the same meaning set forth in section 6-20-102 (1)(b).

(c) "CPT code" has the meaning set forth in section 25.5-1-204.7 (1)(d).

(d) "Facility fee" has the meaning set forth in section 6-20-102 (1)(d).

(e) "Health-care provider" has the meaning set forth in section 6-20-102 (1)(f).

(f) "Health system" has the meaning set forth in section 10-16-1303 (9).

(g) "Hospital" has the meaning set forth in section 6-20-102 (1)(j).

(h) "Owned by" has the meaning set forth in section 6-20-102 (1)(m).

(i) "Payer type" has the meaning set forth in section 6-20-102 (1)(n).

(j) "Steering committee" means the steering committee created in subsection (2) of this section.

(2) There is created in the state department a steering committee to research and report on the impact of outpatient facility fees. The steering committee consists of the following seven members appointed by the governor with relevant expertise in health-care billing and payment policy:

(a) Two members representing health-care consumers, with at least one of the members representing a health-care consumer advocacy organization;

(b) One member representing a health-care payer or payers;

(c) One member representing health-care providers not affiliated with or owned by a hospital or health system or who has independent physician billing expertise;

(d) One member representing a statewide association of hospitals;

(e) One member representing a rural, critical access, or independent hospital; and

(f) The executive director of the department of health care policy and financing, or the executive director's designee.

(3) (a) The steering committee shall facilitate the development of a report detailing the impact of outpatient facility fees on the Colorado health-care system, including the impact on consumers, employers, health-care providers, and hospitals. In developing various aspects of the report required in this section, the steering committee shall work with independent third parties to conduct related research and analysis necessary to identify and evaluate the impact of outpatient facility fees.

(b) The steering committee shall prepare a preliminary version of the report on or before August 1, 2024, unless more time is required, and a final report on or before October 1, 2024, that must be submitted to the house of representatives health and insurance committee and the senate health and human services committee, or their successor committees.

(4) (a) For purposes of developing the report, the steering committee, with administrative support from the state department, may:

(I) Select third-party contractors to assist in researching and creating the report, with an appropriation made to the state department for such purpose;

(II) Develop the format, scope, and templates for requests for information;

(III) Review drafts, provide feedback, and finalize the report;

(IV) Answer technical questions from third-party contractors; and

(V) Consult with external stakeholders.

(b) The steering committee, state department, and any third-party contractors engaged in the development of the report are encouraged to use both primary and secondary sources and research, where possible, and, to the extent feasible, ensure the report is well-informed by the perspectives of diverse stakeholders. The steering committee shall work only with third-party contractors that are already approved as one of the state department's project-based contracts.

(c) To the extent practicable, evaluation and analysis performed for the report must attempt to leverage Colorado-specific data sources and publicly available national data and research.

(5) The report must identify and evaluate:

(a) Payer reimbursement and payment policies for outpatient facility fees across payer types, including insights, where available, into changes over time, as well as provider billing guidelines and practices for outpatient facility fees across provider types, including insights, where available, into changes made over time;

(b) Payments for outpatient facility fees, including insights into the associated care across payer types;

(c) Coverage and cost-sharing provisions for outpatient care services associated with facility fees across payers and payer types;

(d) Denied facility fee claims by payer type and provider type;

(e) The impact of facility fees and payer coverage policies on consumers, small and large employers, and the medical assistance program;

(f) The impact of facility fees and payer coverage policies on the charges for health-care services rendered by independent health-care providers, including a comparison of professional fee charges and facility fee charges; and

(g) The charges for health-care services rendered by health-care providers affiliated with or owned by a hospital or health system, and including a comparison of professional fee and facility fee charges.

(6) The report must include an analysis of:

(a) Data from the Colorado all-payer health claims database as reported under DSG14, including, at a minimum:

(I) The number of patient visits for which facility fees were charged, including, to the extent possible, a breakdown of which visits were in network and which were out of network;

(II) To the extent possible, the number of patient visits for which the facility fees were charged out of network and the professional fees were charged in network for the same outpatient service;

(III) The total allowed facility fee amounts billed and denied;

(IV) The top ten most frequent CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which facility fees were charged;

(V) The top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, with the highest total allowed amounts from facility fees;

(VI) The top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which facility fees are charged with the highest member cost sharing; and

(VII) The total number of facility fee claim denials, by site of service;

(b) Data from hospitals and health systems, which data shall be provided to the steering committee, including:

(I) The number of patient visits for which facility fees were charged;

(II) The total revenue collected in facility fees;

(III) A description of the most frequent health-care services for which facility fees were charged and net revenue received for each such service;

(IV) A description of health-care services that generated the greatest amount of gross facility fee revenue and net revenue received for each such service; and

(V) Data from off-campus health-care providers that are affiliated with or owned by a hospital or health system, including:

(A) Historic and current business names and addresses;

(B) Historic and current tax identification numbers and national provider identifiers;

(C) Health-care provider acquisition or affiliation date;

(D) Facility fee billing policies, including whether any changes were made to such policies before or after the acquisition or affiliation date; and

(E) The top ten CPT codes, revenue codes, or combination thereof, at the state department's discretion, for which a facility fee is billed and the professional fee amount for the same service;

(c) Data, if available, from the state department, the division of insurance, and commercial payers, including:

(I) The payment policy each payer uses for payment of facility fees for network products, including any changes that were made to such policies within the last five years;

(II) A list of common procedures associated with facility fees;

(III) Each payer's network product names;

(IV) Paid aggregate facility fee billings from outpatient providers and the associated number of facility fee claims, broken down by hospital or health system; and

(V) A description of the estimated impact of facility fees on premium rates, out-of-network claims, member cost sharing, and employer costs;

(d) Data from independent health-care providers that are not affiliated with or owned by a hospital or health system, including:

(I) Historic and current business names and addresses;

(II) Historic and current tax identification numbers and national provider identifiers;

(III) Facility fee billing policies, including whether any changes were made to such policies in the past five years; and

(IV) Where applicable, the top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which a facility fee is billed and the professional fee amount for the same service;

(e) The impact of facility fees and payer coverage policies on the Colorado healthcare affordability and sustainability enterprise, created in section 25.5-4-402.4, the medicaid expansion, uncompensated care, and undercompensated care;

(f) The impact of facility fees on access to care, including specialty care, primary care, and behavioral health care; integrated care systems; health equity; and the health-care workforce; and

(g) A description of the way in which health-care providers may be paid or reimbursed by payers for outpatient health-care services, with or without facility fees, that explores any legal and historical reasons for split billing between professional and facility fees at:

(I) On-campus locations;

(II) Off-campus locations by health-care providers affiliated with or owned by a hospital or health system; and

(III) Locations by independent health-care providers not affiliated with or owned by a hospital system.

(7) To the extent feasible, data analyzed for purposes of subsection (6) of this section must be sourced from 2014 through 2022, as determined by the steering committee and third-party contractors, and shall be disaggregated by:

(a) Year;

(b) Hospital or health system, where applicable;

(c) Type of service;

(d) Facility site type, including on- or off-campus; and

(e) Payer.

(8) The steering committee may include in the report information received in accordance with this section; except that the steering committee shall not share publicly any information submitted to the steering committee that is confidential, is proprietary, contains trade secrets, or is not a public record pursuant to part 2 of article 72 of title 24 except in aggregated and de-identified form.

(9) The data described in this section must be sought in a form and manner determined by the steering committee, state department, or third-party contractors to facilitate submission of information. The steering committee shall seek to exhaust existing data sources before making additional requests for information for purposes of the report, and every effort must be made to minimize the number of data requests. The report must include a description of which entities were contacted for information and the outcome of each request.

(10) A statewide association of hospitals may also provide data specified in subsection (6)(b) of this section to the steering committee.

(11) This section is repealed, effective January 1, 2025.
C.R.S. § 25.5-8-111 — CO Code / Title 25.5 / Article 8 / Section 25.5-8-111
25.5-8-111. Department - administration - outsourcing
Status: in_force

25.5-8-111. Department - administration - outsourcing. (1) (a) The department may:

(I) Pursuant to section 24-50-504 (2)(a), C.R.S., enter into personal services contracts for the administration of the children's basic health plan. Any contracts established pursuant to this section shall contain performance measures that shall be monitored by the department.

(II) Use county departments of human or social services to perform functions relating to the administration of the children's basic health plan;

(III) Perform administrative functions at the department, including consolidation of functions with other administrative functions handled by the department.

(b) In deciding how to allocate functions relating to the administration of the children's basic health plan as allowed under paragraph (a) of this subsection (1), the department shall determine and base its decisions upon what is the most cost-effective method to handle the particular function and to deliver the services.

(2) The implementation of subparagraph (I) of paragraph (a) of subsection (1) of this section is contingent upon a finding by the state personnel director that any of the conditions of section 24-50-504 (2), C.R.S., have been met or that the conditions of section 24-50-503 (1), C.R.S., have been met.

(3) If the state department uses county departments of human or social services to perform functions relating to the administration of the children's basic health plan pursuant to subsection (1)(a)(II) of this section and allocates money to a county for that purpose, the state department shall make the allocation in accordance with the results of the public assistance programs funding model described in section 26-1-121.5.
C.R.S. § 25.5-5-515 — CO Code / Title 25.5 / Article 5 / Part 5 / Section 25.5-5-515
25.5-5-515. Pharmacy reimbursement - vaccine administration to children - legislative declar
Status: in_force

25.5-5-515. Pharmacy reimbursement - vaccine administration to children - legislative declaration. (1) (a) The general assembly finds and declares that:

(I) Pharmacists are highly trained and educated, doctorate-level health-care professionals specializing in the effective use of medications and their outcomes;

(II) Pharmacists provide health care throughout the entire health-care system, practicing in community pharmacies, hospitals, provider clinic offices, and specialty areas;

(III) With ninety percent of Americans living within five miles of a pharmacy, pharmacists are able to provide valuable public health services to communities and to provide those services in novel ways, including during nontraditional hours and without appointments; and

(IV) Convenient access to vaccines through a neighborhood pharmacy can help ensure that more children receive their childhood vaccinations according to federal recommended guidelines.

(b) Therefore, the general assembly declares that allowing reimbursement under the medical assistance program to a pharmacist or pharmacy that dispenses or administers childhood vaccinations is an important tool in ensuring the health of Colorado children through immunization.

(2) Pursuant to the requirements set forth in subsection (3) of this section, a pharmacist or pharmacy that dispenses or administers vaccinations to children under nineteen years of age pursuant to the federal centers for disease control and prevention's guidelines pertaining to the childhood immunization schedule may seek reimbursement for the dispensing or administration of vaccines under the medical assistance program either as a pharmacy benefit or as a medical benefit, as applicable.

(3) (a) To be eligible to receive reimbursement pursuant to subsection (2) of this section for administering vaccines to children, a pharmacy or pharmacist must be enrolled in good standing with the vaccines for children program administered by the department of public health and environment.

(b) Until the department of public health and environment determines a framework for participation by pharmacies and pharmacists in the vaccines for children program, nothing in this section requires the department of public health and environment to enroll pharmacies receiving reimbursement for the administration of vaccines through the medical assistance program as vaccines for children providers.

(c) As used in this subsection (3), "vaccines for children program" means the federal centers for disease control and prevention "vaccines for children program" administered by the department of public health and environment, or any successor program.
C.R.S. § 25.5-4-306 — CO Code / Title 25.5 / Article 4 / Part 3 / Section 25.5-4-306
25.5-4-306. Civil actions for false medicaid claims
Status: in_force

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. (a) 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.

(b) 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.

(c) 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.

(d) 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:

(I) Proceed with the action, in which case the state shall conduct the action; or

(II) Notify the court that it declines to take over the action, in which case the relator shall have the right to conduct the action.

(e) 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. (a) 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).

(b) (I) 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.

(II) 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.

(III) 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:

(A) Limiting the number of witnesses the relator may call;

(B) Limiting the length of the testimony of the witnesses;

(C) Limiting the relator's cross-examination of witnesses; or

(D) Otherwise limiting the participation by the relator in the litigation.

(IV) 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.

(c) 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.

(d) 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.

(e) 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. (a) (I) 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.

(II) 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.

(III) 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.

(b) 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.

(c) 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.

(d) 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. (a) 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.

(b) 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.

(c) (I) 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.

(II) 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. (a) 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.

(b) (I) 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:

(A) 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

(B) Compensation for any special damages sustained as a result of the discrimination or retaliation, including litigation costs and reasonable attorney fees.

(II) An employee, contractor, or agent may bring an action in the appropriate court of the state for the relief provided in this subsection (7).
C.R.S. § 25.5-1-1001 — CO Code / Title 25.5 / Article 1 / Part 10 / Section 25.5-1-1001
25.5-1-1001. Hospital collaborative agreements - review of proposed collaborative agreements
Status: in_force

25.5-1-1001. Hospital collaborative agreements - review of proposed collaborative agreements - immunity - legislative declaration - definitions - rules. (1) The general assembly finds and declares that:

(a) (I) Frontier and rural hospitals continue to struggle to deliver high-quality, accessible, low-cost care due to the rising costs of medications, supplies, medical equipment, and contract labor;

(II) Frontier and rural hospitals are largely independent governmental facilities that are governed by local community boards;

(III) Frontier and rural hospitals are generally separated by large distances and are challenged by the need to provide essential services to local communities due to the sparse population in rural areas;

(IV) Frontier and rural hospitals are increasingly challenged by complex requirements imposed by government and private payers that disproportionately negatively impact these providers and unnecessarily drive up administrative costs; and

(V) In cases where the state department, the division of insurance, if applicable, and the attorney general approve collaborative arrangements, it is the general assembly's intent to provide protection to frontier and rural hospitals from certain antitrust scrutiny that impedes frontier and rural hospitals from working collaboratively to improve quality, increase access, and reduce costs of care to the communities they serve;

(b) (I) Forty-seven of Colorado's sixty-four counties include rural and frontier communities yet contain only twelve percent of Colorado's population;

(II) Thirty-two counties are served by critical access hospitals that have twenty-five or fewer beds and are generally located more than thirty-five miles from the next closest hospital; eleven counties lack any hospital;

(III) The scarcity of nearby hospitals causes many residents to struggle to find quality, affordable health care near their homes;

(IV) Further, many residents in Colorado's rural and frontier communities forgo preventive and behavioral health care and lack comprehensive or specialized care or choice in health-care services, and twenty-four counties in Colorado are considered maternal care "deserts";

(V) Where hospitals do exist in rural and frontier areas, those hospitals receive low reimbursement rates due to a preponderance of government payers and declining local tax dollars, which results in a reduced amount of money available to invest in expanding or upgrading facilities or to purchase necessary, new, or innovative medical supplies, equipment, or technology;

(VI) Many hospitals in rural and frontier communities have difficulty recruiting and retaining qualified health-care professionals and making available needed services; and

(VII) County public hospitals, health service districts, and hospital affiliates perform essential public functions on behalf of the state;

(c) As part of the government's interest in providing needed health-care services in Colorado's rural and frontier communities, it is important for the government to support efforts to find collaborative, innovative solutions to the many problems confronting rural health care, including collaborative or coordinated activities that offer the opportunity to expand health-care options through joint purchasing and staffing, shared services, and joint acquisition of new and expensive diagnostic and treatment solutions;

(d) It is the general assembly's intent to exempt from state antitrust laws, and to provide state action immunity from federal antitrust laws for, certain activities that might be characterized as anticompetitive or that might result in the displacement of competition in the provision of hospital, physician, or other health-care-related services or administrative or general business services; and

(e) In order to promote improved quality of, increase access to, and reduce costs of health-care services in rural and frontier communities through collaborative agreements authorized by this section, the general assembly further intends to provide a system of review of relevant collaborative agreements by the state department, the division of insurance, if applicable, and the attorney general to ensure that any potential benefits of such collaborative agreements are not outweighed by the harm to competition in rural and frontier communities.

(2) As used in this section, unless the context otherwise requires:

(a) "Collaborative agreement" means an agreement or similar arrangement between two or more hospitals or hospital affiliates that complies with the requirements set forth in this section.

(b) "County public hospital" means a public hospital established pursuant to section 25-3-301.

(c) "Division of insurance" means the division of insurance in the department of regulatory agencies.

(d) "Health service district" has the same meaning as set forth in section 32-1-103 (9).

(e) "Hospital" means a facility with fewer than fifty beds that is:

(I) A county public hospital;

(II) A hospital established, maintained, or operated directly or indirectly by a health service district; or

(III) A hospital affiliate.

(f) "Hospital affiliate" means an affiliate of a county public hospital or health service district that is under the sole control of the county public hospital or health service district.

(3) Except as provided in subsection (4) of this section, and subject to the requirements in subsections (5), (6), and (7) of this section, a hospital is authorized to enter into collaborative agreements with one or more hospitals or hospital affiliates to engage in the following activities:

(a) Ancillary clinical services, acquisition of equipment, clinic management, or health-care provider recruitment;

(b) Joint purchasing or leasing arrangements, including the joint purchasing or leasing of:

(I) Medical and general supplies;

(II) Medical and general equipment;

(III) Pharmaceuticals; or

(IV) Temporary staffing through a staffing agency;

(c) Consulting services with a focus on public health in rural or frontier communities and non-hospital-specific innovations in health-care delivery in those communities;

(d) Purchasing joint professional, general liability, or property insurance;

(e) Sharing back-office services, such as sharing a business office, accounting and finance services, human resources, and risk management and compliance services, but not including sharing service charging expenses or rates among hospitals;

(f) Sharing data services, including shared services for electronic health records and data extraction and analysis services, charge management, and population health analysis; and

(g) Negotiating with health insurance or government payers, which negotiations are limited to:

(I) Shared care protocols intended to improve patient management and outcomes, including implementation of evidence-based protocols, clinical pathways, and recognized best practices in the care and treatment of patients, including clinical therapies, nutrition, exercise, diagnostic testing, and medication management;

(II) Collaborative efforts with payers to promote appropriate and essential services to be provided in the local community;

(III) Management of prior authorization requests; and

(IV) Analysis of aggregate data to compare costs of procedures and to analyze patient outcomes.

(4) Notwithstanding any collaborative agreements described in subsection (3) of this section, the immunity and protections granted to hospitals and hospital affiliates entering into collaborative agreements pursuant to this section do not extend to collaborative agreements with another hospital or hospital affiliate that have the effect of:

(a) Setting reimbursement rates or other compensation from any commercial self-insured or commercial health insurance or government payer;

(b) Dividing or allocating among hospitals or hospital affiliates specific markets for the delivery of any general acute care or specialty lines of health-care services; or

(c) Negotiating or agreeing to compensation under health-care staffing arrangements for hospital employees that results in a reduction of wages of hospital staff, whether employed by the hospital, a staffing agency, or other employer.

(5) Prior to engaging in any joint activity described by a proposed collaborative agreement executed pursuant to subsection (3) of this section, the hospitals or hospital affiliates shall jointly submit the proposed collaborative agreement to the state department and to the division of insurance, if the proposed collaborative agreement includes negotiating with health insurance payers as described in subsection (3)(g) of this section, pursuant to rules that may be promulgated for the submission and review of proposals by the state department and by the division of insurance, if applicable. The state department and the division of insurance, if applicable, may request additional information necessary to review the proposal.

(6) Within fifteen days after receipt of a proposed collaborative agreement and the receipt of additional information requested by the state department and by the division of insurance, if applicable, if the state department and the division of insurance, if applicable, conclude that a proposed collaborative activity will result in cost savings or other efficiencies that will improve or expand the delivery of health-care services in rural and frontier communities in Colorado, the state department and the division of insurance, if applicable, shall refer the proposal to the attorney general to determine, pursuant to rules that may be promulgated for such purpose, that the benefits of the collaborative activity are not outweighed by any anticompetitive harm that may arise from the collaborative activity.

(7) Within forty-five days after receiving a referral and review from the state department and the division of insurance, if applicable, the attorney general shall review the proposed collaborative agreement and either approve or deny the proposed collaborative agreement or request additional information related to the proposal. If a request for additional information is made, the attorney general has an additional forty-five days to complete the review following receipt of the requested information.

(8) (a) A collaborative agreement is approved if:

(I) The state department and the division of insurance, if applicable, conclude that the proposed collaborative agreement will result in improved quality, increased access or cost savings, or other efficiencies that will improve or expand the delivery of health-care services in rural and frontier communities in Colorado; and

(II) The attorney general concludes that the benefits identified by the state department and by the division of insurance, if applicable, are outweighed by any competitive concerns identified by the attorney general, or the attorney general does not respond within the time frames specified in subsection (7) of this section.

(b) (I) Except as provided in subsection (8)(b)(III) of this section, if a proposed collaborative agreement is denied, the hospitals or hospital affiliates may request reconsideration by resubmitting the proposed agreement to the attorney general within thirty days after the denial along with additional materials, information, or other evidence that was not previously submitted relating to the determination of the benefits or anticompetitive harm associated with the proposed collaborative agreement.

(II) The attorney general has forty-five days from the date of the request to reconsider the denial and may consult with the state department and the division of insurance as part of the reconsideration. The proposed collaborative agreement is not deemed approved if the attorney general fails to respond within the forty-five-day reconsideration period.

(III) A request for reconsideration of a proposed collaborative agreement may be made only once within the thirty-day period following the denial of the proposed collaborative agreement. The attorney general's decision on a proposed collaborative agreement that is not submitted for reconsideration within thirty days or that is denied upon reconsideration is final and non-appealable.

(c) The state department, the division of insurance, if applicable, or the attorney general may review a collaborative agreement annually to ensure the outcomes related to the collaborative agreement are consistent with this section.
C.R.S. § 25.5-6-1402 — CO Code / Title 25.5 / Article 6 / Part 14 / Section 25.5-6-1402
25.5-6-1402. Definitions
Status: in_force

25.5-6-1402. Definitions. As used in this part 14, unless the context otherwise requires:

(1) "Basic coverage group" means the category of eligibility under the federal "Ticket to Work and Work Incentives Improvement Act of 1999", Pub.L. 106-170, that provides an opportunity to buy into medicaid consistent with the federal "Social Security Act", 42 U.S.C. sec. 1396a (a)(10)(A)(ii)(XV), as amended, for each worker with disabilities who is at least sixteen years of age but less than sixty-five years of age and who, except for earnings, would be eligible for the supplemental security income program. A person who is eligible under the basic coverage group may also be a home- and community-based services waiver member.

(2) "Family" means an individual, the individual's spouse, and any dependent child of the individual.

(3) "Health insurance" means surgical, medical, hospital, major medical, or other health service coverage, including a self-insured health plan, but does not include hospital indemnity policies or ancillary coverages such as income continuation, loss of time, or accident benefits.

(4) "Medicaid buy-in program" means a program that gives each person with disabilities the opportunity to buy into medicaid if the person meets the eligibility criteria specified in section 25.5-6-1404.

(5) "Medical improvement group" means the category of eligibility under the federal "Ticket to Work and Work Incentives Improvement Act of 1999", Pub.L. 106-170, that provides an opportunity to buy into medicaid consistent with the federal "Social Security Act", 42 U.S.C. sec. 1496a (a)(10)(A)(ii)(XV), as amended, for each worker with a medically improved disability who is at least sixteen years of age but less than sixty-five years of age and who was previously in the basic coverage group and is no longer eligible for the basic coverage group due to medical improvement. A person who is eligible under the medical improvement group may also be a home- and community-based services waiver member.

(6) "Work incentives eligibility group" means the category of eligibility under the federal "Balanced Budget Act of 1997", Pub.L. 105-33, 111, as amended, for individuals with a disability who, except for assets or income, would be eligible for the supplemental security income program. This eligibility applies to individuals who are sixty-five years of age or older.
C.R.S. § 25.5-4-428 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-428
25.5-4-428. Prior authorization for a step-therapy exception - rules - definition
Status: in_force

25.5-4-428. Prior authorization for a step-therapy exception - rules - definition. (1) As used in this section, unless the context otherwise requires, "step therapy" means a protocol that requires a member to use a prescription drug or sequence of prescription drugs, other than the drug that the member's health-care provider recommends for the member's treatment, before the state department provides coverage for the recommended prescription drug.

(2) (a) The state department shall review and determine if an exception to step therapy is granted if the prescribing provider submits a prior authorization request with justification and supporting clinical documentation for treatment of a serious or complex medical condition, if required, that states:

(I) The provider attests that the required prescription drug is contraindicated, or will likely cause intolerable side effects, a significant drug-drug interaction, or an allergic reaction to the member;

(II) The required prescription drug lacks efficacy based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen;

(III) The member has tried the required prescription drug, and the use of the prescription drug by the member was discontinued due to intolerable side effects, a significant drug-drug interaction, or an allergic reaction; or

(IV) The member is stable on a prescription drug selected by the prescribing provider for the medical condition.

(b) (I) Except as provided in subsection (2)(b)(II) of this section, the state department shall provide a response to a prior authorization request for a step-therapy exception within twenty-four hours after receipt of the request.

(II) If a prior authorization request for a step-therapy exception is incomplete or if additional clinically relevant information is required, the state department shall notify the prescribing provider within twenty-four hours after the submission of the request that the request is incomplete or that additional clinically relevant information is required. The state department shall specify the additional information that is required in order to consider the prior authorization request. If the state department does not receive a response within seventy-two hours after the state department's request for additional information, the prior authorization request is denied. If the state department receives a timely response from the provider, the state department shall provide a response within twenty-four hours after receiving the response.

(c) If the prior authorization request for a step-therapy exception is denied, the state department shall inform the member in writing that the member has the right to appeal the adverse determination pursuant to state department rules.

(3) If the prior authorization request for a step-therapy exception request is granted, the state department shall authorize coverage for the prescription drug prescribed by the member's prescribing provider.

(4) The state department shall make the prior authorization requirements for coverage of prescription drugs and a description of the step-therapy exemption process available on the state department's website.

(5) This section does not prohibit:

(a) The state department from requiring a member to try a generic equivalent of a brand name drug, a biosimilar drug as defined in 42 U.S.C. sec. 262 (i)(2), or an interchangeable biological product as defined in 42 U.S.C. sec. 262 (i)(3), unless such a requirement meets any of the criteria set forth in subsection (2)(a) of this section for an exception to step therapy and a prior authorization request is granted for the requested drug;

(b) The state department from denying a prior authorization request for a step-therapy exception when the request does not meet one of the criteria set forth in subsection (2)(a) of this section based on the justification and supporting clinical documentation submitted by the provider, if applicable; or

(c) A provider from prescribing a drug that, in the provider's clinical judgment, is determined to be medically appropriate.

(6) The state board may promulgate rules to implement this section.
C.R.S. § 25.5-5-312 — CO Code / Title 25.5 / Article 5 / Part 3 / Section 25.5-5-312
25.5-5-312. Treatment program for high-risk pregnant and parenting women - extended coverage
Status: in_force

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 and recovery 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).
C.R.S. § 25.5-5-512.5 — CO Code / Title 25.5 / Article 5 / Part 5 / Section 25.5-5-512.5
25.5-5-512.5. Medications for opioid use disorder - pharmacists - reimbursement - definition
Status: in_force

25.5-5-512.5. Medications for opioid use disorder - pharmacists - reimbursement - definition. (1) As used in this section, unless the context otherwise requires, "medications for opioid use disorder" or "MOUD" has the meaning as set forth in section 12-280-103 (27.5).

(2) The state department shall reimburse a licensed pharmacist for prescribing or administering medications for opioid use disorder, if the pharmacist is authorized pursuant to article 280 of title 12, at a rate equal to the reimbursement provided to a physician, physician assistant, or advanced practice registered nurse for the same services.

(3) The state department shall seek any federal authorization necessary to implement this section.
C.R.S. § 25.5-6-903 — CO Code / Title 25.5 / Article 6 / Part 9 / Section 25.5-6-903
25.5-6-903. Residential child health-care program - waiver - home- and community-based servi
Status: in_force

25.5-6-903. Residential child health-care program - waiver - home- and community-based services - rules. (1) Subject to federal authorization, the state department shall implement a program for medicaid-eligible children with intellectual and developmental disabilities, as defined in section 25.5-10-202, with significant behavioral support needs who are at risk of institutionalization. The state board shall establish, by rule, the type of services provided pursuant to the program, to the extent the services are cost-efficient, and the member eligibility criteria that may include, but are not limited to, a medical necessity determination and a financial eligibility determination.

(2) The state department may limit the number of participants in the program in accordance with any federal waiver obtained by the state department to implement this section.

(3) The state board shall promulgate rules as necessary for the implementation and administration of the program, including but not limited to rules regarding program services; eligibility criteria, including financial eligibility criteria; and reimbursement of providers.

(4) This section will take effect if the federal department of health and human services approves a redesigned children's habilitation residential program waiver for medicaid-eligible children with intellectual and developmental disabilities, as defined in section 25.5-10-202, who have complex behavioral support needs, pursuant to House Bill 18-1328, as enacted in 2018. The executive director of the state department shall notify the revisor of statutes in writing of the date on which the condition specified in this section has occurred by e-mailing the notice to revisorofstatutes.ga@coleg.gov. This section takes effect, effective upon the date identified in the notice that the federal department of health and human services approved the waiver or, if the notice does not specify that date, upon the date of the notice to the revisor of statutes.
C.R.S. § 25.5-2-101 — CO Code / Title 25.5 / Article 2 / Section 25.5-2-101
25.5-2-101. Old age pension health and medical care fund - supplemental old age pension heal
Status: repealed

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 members, and after establishment and maintenance of the old age pension stabilization fund in the amount of five million dollars, must be transferred to a fund to be known as the old age pension health and medical care fund, which is 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 the 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.
C.R.S. § 25.5-4-401 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-401
25.5-4-401. Providers - payments - rules
Status: repealed

25.5-4-401. Providers - payments - rules. (1) (a) The state department shall establish rules for the payment of providers under this article 4 and articles 5 and 6 of this title 25.5. Within the limits of available funds, the rules must provide reasonable compensation to providers, but no provider, by this section or any other provision of this article 4 or article 5 or 6 of this title 25.5, has any vested right to act as a provider under this article 4 and articles 5 and 6 of this title 25.5 or to receive any payment in addition to or different from that which is currently payable on behalf of a member at the time the medical benefits are provided by the provider.

(b) (I) 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.

(II) 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.

(c) 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.

(d) 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) (a) 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 member.

(b) (I) 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.

(II) 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.

(III) The state department may define groups of members 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) (a) The general assembly finds, determines, and declares that access to health-care services would be improved and costs of health care would be restrained if the members 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.

(b) Subject to the provisions of subsection (4)(c) of this section, the executive director of the state department has the authority to require a member of the medicaid program to select a managed care provider and to assign a member to a managed care provider if the member has failed to make a selection within a reasonable time. To the extent possible, this requirement must be implemented on a statewide basis.

(c) The state department shall ensure the following:

(I) A managed care provider shall establish and implement member-friendly procedures and instructions for disenrollment and shall have adequate staff to explain issues concerning service delivery and disenrollment procedures to members, including staff to address the communications needs and requirements of members with disabilities.

(II) All members shall be adequately informed about available service delivery options consistent with the provisions of this subsection (4)(c)(II). If a member does not respond to a state department request for selection of a delivery option after forty-five calendar days, the state department shall send a second notification to the member. If the member does not respond after twenty days of the date of the second notification, the state department shall ensure that the member remains with the member's primary care physician, regardless of whether the 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.
C.R.S. § 25.5-4-402.8 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-402.8
25.5-4-402.8. Hospital transparency report and requirements - definitions
Status: repealed

25.5-4-402.8. Hospital transparency report and requirements - definitions. (1) As used in this section, unless the context otherwise requires:

(a) "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.

(b) "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:

(I) Another hospital;

(II) An entity owned by or under common ownership and control with another hospital; or

(III) A physician group practice.

(c) "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.

(d) [Editor's note: This version of subsection (1)(d) is effective until July 1, 2025.] "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.

(d) [Editor's note: This version of subsection (1)(d) is effective July 1, 2025.] "Major payer group" includes commercial insurers, medicare, medicaid, individuals who self-pay, and a financial assistance plan.

(2) (a) The state department shall annually prepare a written hospital transparency report detailing hospital costs, including uncompensated care costs, and the different categories of expenditures, by major payer group, made by hospitals in the state. The state department shall coordinate the analysis, review, and release of the hospital transparency report and the reports required pursuant to sections 25.5-1-703 (3) and 25.5-4-402.4 (7)(e), including the opportunity to review and consult on the reports made by 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". The state department may share any information and analytics of information that 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 transparency report and share such information with the enterprise board; except that information the state department receives from hospitals in accordance with subsections (2)(b)(II)(D), (2)(b)(III)(N), (2)(b)(III)(O), (2)(b.5)(I), and (2)(b.5)(II) 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 transparency report, share with the enterprise board, or otherwise publish or distribute information derived from reports pursuant to subsections (2)(b)(II)(D), (2)(b)(III)(N), (2)(b)(III)(O), (2)(b.5)(I), and (2)(b.5)(II) 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.

(b) 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 transparency report. The state board shall establish the format of the information provided by each hospital on an annual basis. Each hospital shall provide the following information to the state department:

(I) 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;

(II) (A) Annual audited financial statements, prepared in accordance with generally accepted accounting principles. Each hospital shall submit the statements 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.

(B) 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.

(C) 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.

(D) An annual summary of the hospital's transfers of cash, equity, investments, or other assets to and from related parties, including but not limited to the hospital's parent organization. The summary must include the purpose of the transfers and whether the transfers were made within or outside of Colorado. A hospital may aggregate the transfers for each entity receiving or making the transfer.

(E) A hospital-specific statement of cash flow within a time frame specified annually by the state department, but not less than one hundred twenty days after the hospital's fiscal year end.

(F) Changes to no more than twenty-five categories of specific major service lines, as requested by the state department.

(G) A narrative report of major planned and completed projects and capital investments greater than twenty-five million dollars; except that the information the state department receives from hospitals regarding planned activities is confidential, proprietary, contains trade secrets, and is not a public record pursuant to part 2 of article 72 of title 24.

(III) A report that contains the following information:

(A) The total number of available beds and licensed beds;

(B) Inpatient statistics in total and by major payer group and by care setting, including but not limited to inpatient discharges and patient days;

(C) 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;

(D) 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;

(E) Gross charges in total, by major payer group, and by care setting, including but not limited to inpatient care and outpatient care;

(F) Contractual allowances in total and by major payer group;

(G) Bad debt write-offs in total and by major payer group;

(H) Charity write-offs in total and by major payer group;

(I) 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;

(J) Other operating revenue, operating margin, nonoperating gains and losses, gross revenue, net profit, and total margin;

(K) 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;

(L) Staffing information, including but not limited to full-time equivalents, staff turnover, and staff vacancy rates;

(M) 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;

(N) 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;

(O) Information on current affiliations and a report of physician practice acquisitions;

(P) Salary and total compensation data of the top five highest paid administrative positions of each nonprofit hospital, including the title, a brief description of duties, base compensation, incentive or bonus compensation, and other compensation. The compensation reported must indicate what performance measures were included in the chief executive officer's performance evaluation generated by the hospital's governing board, including, at a minimum, quality of care outcomes performance, patient satisfaction performance, community benefit performance, consumer and employer affordability performance, market share performance, profits or margins, revenue growth, change in days cash on hand or cash reserves, and workforce. The state department may include information it receives from public hospitals pursuant to this subsection (2)(b)(III)(P) that is not otherwise publicly available in the hospital transparency report; except that information the state department receives from a nonprofit hospital is not a public record pursuant to part 2 of article 72 of title 24. The state department may only report information received pursuant to this subsection (2)(b)(III)(P) in an aggregated format that does not name individual hospitals or administrators.

(Q) In a form and manner specified by the state department, details of significant other revenue that would otherwise be reported in the medicare cost report; and

(IV) (A) A quarterly financial report that includes an income statement and balance sheet. If a hospital is owned or affiliated with a health system that is comprised of three or more hospitals or that has more than one billion dollars in reserves, the health system may submit a consolidated quarterly financial report.

(B) Any quarterly financial report made publicly available must clearly state that the quarterly financial report is unaudited, if applicable. The state department shall provide any analysis, report, or presentation based on the quarterly financial report to each hospital at least fifteen days prior to the public release of the analysis, report, or presentation.

(b.5) No later than July 1, 2024, each hospital shall provide the following information to the state department:

(I) For each fiscal year 2014-15 through 2019-20, a summary of the hospital's transfers of cash, equity, investments, or other assets to and from related parties, including but not limited to the hospital's parent organization. The summary must include the purpose of the transfers and whether the transfers were made within or outside of Colorado. A hospital may aggregate the transfers for each entity receiving or making the transfer.

(II) For each fiscal year from 2014-15 through 2019-20, information on affiliations and a report of physician practice acquisitions; and

(III) For each fiscal year from 2019-20 through 2022-23, in a form and manner specified by the state department, details of significant other revenue that would otherwise be reported in the medicare cost report.

(c) The state department may exempt from certain reporting requirements described in subsections (2)(b) and (2)(b.5) of this section certain types of hospitals, including but not limited to:

(I) Psychiatric hospitals, as licensed by the department of public health and environment;

(II) Hospitals that are licensed as general hospitals and certified as long-term care hospitals by the department of public health and environment;

(III) [Editor's note: This version of subsection (2)(c)(III) is effective until July 1, 2026.] 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 subpart F;

(III) [Editor's note: This version of subsection (2)(c)(III) is effective July 1, 2026.] Critical access hospitals that are licensed and certified by the department of public health and environment pursuant to 42 CFR 485 subpart F;

(IV) Inpatient rehabilitation facilities; and

(V) Hospitals specified for exemption under 42 CFR 433.68 (e).

(d) Repealed.

(e) Prior to issuing the hospital transparency report, the state department shall provide any hospital referenced in the hospital transparency report a copy of the report. Each hospital must have a minimum of fifteen days to review the hospital transparency report and any underlying data and submit corrections or clarifications to the state department.

(f) 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.

(g) (I) If a hospital does not provide all of the information required pursuant to subsection (2)(b) of this section, the state department shall inform the hospital of its noncompliance within sixty days and identify the information that needs to be provided. If a hospital does not comply, the state department shall issue a corrective action plan with a timeline of sixty days required for compliance. If a hospital continues to not comply, the state department may create a mandatory pay-for-reporting compliance measure within the hospital transformation program that is tied to the healthcare affordability and sustainability fee supplemental payment and is based on compliance with subsection (2)(b) of this section.

(II) If the state department determines a hospital's noncompliance with this section is knowing or willful or there is a repeated pattern of noncompliance, the state department shall consider the size of the hospital and the seriousness of the violation in setting a fine amount which, for hospitals owned or affiliated with a hospital system comprised of three or more hospitals, must not exceed twenty thousand dollars per violation per week until the hospital takes corrective action and, for all other hospitals, must not exceed five thousand dollars per week until the hospital takes corrective action.

(3) The hospital transparency report must include, but not be limited to:

(a) A description of the methods of analysis and definitions of report components;

(b) Uncompensated care costs by major payer group; and

(c) The percentage that each of the following categories contributes to overall expenses of hospitals:

(I) Delivery of inpatient health care and services by major payer group;

(II) Delivery of outpatient health care and services by major payer group and site location;

(III) Administrative costs;

(IV) Capital construction costs and associated bond liabilities;

(V) Maintenance;

(VI) Capital expenditures;

(VII) Personnel services;

(VIII) Uncompensated care by major payer group; and

(IX) Other expenditure categories, as determined by the state department.

(4) (a) On or before January 15, 2020, and on or before January 15 each year thereafter, the state department shall submit the annual hospital transparency report to:

(I) The house of representatives health and insurance committee and the house of representatives public and behavioral health and human services committee, 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.

(b) The state department may request that the enterprise board combine the hospital transparency 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.

(c) Notwithstanding section 24-1-136 (11)(a)(I), the report required in this section continues indefinitely.

(4.5) The state department shall report on the annual hospital transparency report during the state department's "SMART Act" hearing.

(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.
C.R.S. § 25.5-1-123 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-123
25.5-1-123. Medical homes for children - legislative declaration - duties of the department
Status: repealed

25.5-1-123. Medical homes for children - legislative declaration - duties of the department. (1) The general assembly hereby finds and declares that:

(a) 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.

(b) 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;

(c) 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

(d) 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.
C.R.S. § 25.5-5-406 — CO Code / Title 25.5 / Article 5 / Part 4 / Section 25.5-5-406
25.5-5-406. Required features of managed care system
Status: repealed

25.5-5-406. Required features of managed care system. (Repealed)
C.R.S. § 25.5-6-404 — CO Code / Title 25.5 / Article 6 / Part 4 / Section 25.5-6-404
25.5-6-404. Duties of the department of health care policy and financing and the department
Status: in_force

25.5-6-404. Duties of the department of health care policy and financing and the department of human services. (1) The state department and the department of human services shall provide a system of reimbursement for services provided pursuant to this part 4 that encourages the most cost-effective provision of services.

(2) The state department and the department of human services shall, subject to appropriation, utilize any available federal, state, local, or private funds, including but not limited to, medicaid funds available under Title XIX of the federal "Social Security Act", as amended, such as medicaid home- and community-based waivers, to carry out the purposes of this part 4.

(3) The state department may contract with the department of human services to certify agencies providing services under this part 4 as eligible medicaid providers, to adopt fiscal and administrative procedures, to review plans of care, to set rates, and to make and implement recommendations regarding the scope, duration, and content of programs and the eligibility of persons for specific services provided pursuant to this part 4, and to fulfill any other responsibilities necessary to implement this part 4 that are consistent with the single state agency designation set out in section 25.5-4-104.

(4) The executive director and the state board shall promulgate rules regarding this part 4 as necessary to fulfill the obligations of the state department as the single state agency to administer medical assistance programs in accordance with Title XIX of the federal "Social Security Act", as amended. The rules may include, but are not limited to, determination of the level of care requirements for long-term care, patient payment requirements, members' rights, medicaid eligibility, and appeal rights associated with these requirements.

(5) The state board of human services, created in section 26-1-107, C.R.S., shall promulgate such rules as are necessary to implement the provisions of this part 4 and to fulfill the responsibilities and duties set out in article 10.5 of title 27, C.R.S. Such rules shall be promulgated pursuant to section 24-4-103, C.R.S.

(6) In the event that a direct conflict arises between the rules of the state department promulgated pursuant to subsection (4) of this section and the rules of the department of human services promulgated pursuant to subsection (5) of this section, regarding implementation of this part 4, the rules of the state department shall control.
C.R.S. § 25.5-5-516 — CO Code / Title 25.5 / Article 5 / Part 5 / Section 25.5-5-516
25.5-5-516. Serious mental illness - prescribed drugs
Status: in_force

25.5-5-516. Serious mental illness - prescribed drugs. Notwithstanding any provisions of this part 5 to the contrary, and subject to any necessary federal authorization, the state board shall require a review for coverage of a new drug approved by the federal food and drug administration for a serious mental illness within ninety days after the approval of the drug.
C.R.S. § 25.5-1-113.5 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-113.5
25.5-1-113.5. Children's access to health care - reports
Status: repealed

25.5-1-113.5. Children's access to health care - reports. (Repealed)
C.R.S. § 25.5-4-412 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-412
25.5-4-412. Family planning services - family-planning-related services - rules - definition
Status: in_force

25.5-4-412. Family planning services - family-planning-related services - rules - definitions. (1) When family planning services or family-planning-related services 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 the services, subject to section 50 of article V of the state constitution. The state department, any intermediary, or any managed care organization shall reimburse the provider of those services. Family planning services and family-planning-related services are not subject to policy deductibles, copayments, or coinsurance.

(2) As used in this section, unless the context otherwise requires:

(a) "Family-planning-related services" means services provided in a family planning setting as part of or as a follow-up to a family planning visit, including:

(I) Medically necessary evaluations or preventive services, such as tobacco utilization screening, counseling, testing, and cessation services;

(II) Cervical cancer screening and prevention;

(III) Diagnosis or treatment of a sexually transmitted infection or sexually transmitted disease, and medication and supplies to prevent a sexually transmitted infection or sexually transmitted disease; and

(IV) Any other medical diagnosis, treatment, or preventive service that is routinely provided pursuant to a family planning visit.

(b) "Family planning services" means all services covered by the federal Title X family planning program, regardless of an individual's age, sex, or gender identity, or the age, sex, or gender identity of the individual's partner, including but not limited to:

(I) All contraception, as defined in section 2-4-401 (1.5);

(II) Health-care and counseling services focused on preventing, delaying, or planning for a pregnancy;

(III) Follow-up visits to evaluate or manage problems associated with contraceptive methods;

(IV) Sterilization services, regardless of an individual's sex; and

(V) Basic fertility services.

(3) (Deleted by amendment, L. 2021.)

(4) For purposes of making payments to providers, the state board shall establish rules implementing this section.

(5) Any member may obtain family planning services or family-planning-related services from any licensed health-care provider, including a doctor of medicine, doctor of osteopathy, physician assistant, advanced practice registered nurse, or certified midwife who provides such services. The enrollment of a member in a managed care organization, or a similar entity, does not restrict a member's choice of the licensed provider from whom the member may receive those services.

(6) The state board shall promulgate rules establishing the specific family-planning-related services and family planning services identified in subsections (2)(a) and (2)(b) of this section. Prior to promulgating the rules, the state department shall engage in a stakeholder process that attempts to include individuals who have received family planning services through the state's medical assistance program or the children's basic health plan, representatives of consumer advocacy organizations, and family planning providers. The stakeholders must be diverse with regard to race, ethnicity, immigration status, age, ability, sexual orientation, gender identity, or geographic region of the state.
C.R.S. § 25.5-6-1103 — CO Code / Title 25.5 / Article 6 / Part 11 / Section 25.5-6-1103
25.5-6-1103. Reporting
Status: in_force

25.5-6-1103. Reporting. (1) The state department shall provide a report to the joint budget committee of the general assembly and the health and human services committees of the house of representatives and the senate, or any successor committees, by October 1, 2006, that includes, but is not limited to, the following:

(a) The number of elderly persons participating in the consumer-directed care program;

(b) The cost-effectiveness of the consumer-directed care program;

(c) Feedback from consumers and the state department concerning the progress and success of the consumer-directed care program; and

(d) Any changes to the health status or health outcomes of the program participants.
C.R.S. § 25.5-4-213 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-213
25.5-4-213. Audit of medicaid member correspondence - definition
Status: in_force

25.5-4-213. Audit of medicaid member correspondence - definition. (1) As used in this section, unless the context otherwise requires, "member 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 member correspondence. Thereafter, the state auditor, in the exercise of the state auditor's discretion, may conduct or cause to be conducted additional performance audits of member correspondence pursuant to this section. The audit must 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 must include:

(a) A review of available data from counties, from the state 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 member or applicant confusion regarding correspondence received by medicaid members or applicants;

(b) A review of the accuracy of member correspondence at the time the correspondence is generated;

(c) A review of whether member correspondence satisfies the requirements of any state or federal law, rule, or regulation relating to the sufficiency of any notice;

(d) A review of any member correspondence testing process conducted by the state department and whether testing is done prior to implementing new or significantly revised member correspondence;

(e) A review of the results of any member correspondence testing, including member comprehension of the intended purpose or purposes of the correspondence; and

(f) A review of the accuracy of member income and household composition information that is communicated electronically, if applicable.

(4) If audit findings include findings that information contained in member correspondence is inaccurate at the time the correspondence was generated, the audit must 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 member 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 reviewing the report. The report must 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.
C.R.S. § 25.5-1-701 — CO Code / Title 25.5 / Article 1 / Part 7 / Section 25.5-1-701
25.5-1-701. Definitions
Status: in_force

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) (a) "Reporting hospital" means:

(I) 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;

(II) A hospital established pursuant to section 25-29-103; or

(III) A hospital established pursuant to section 23-21-503.

(b) 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:

(I) Federally certified or undergoing federal certification as a long-term care hospital pursuant to 42 CFR 412.23 (e); or

(II) Federally certified or undergoing federal certification as a critical access hospital pursuant to 42 CFR 485 subpart F.
C.R.S. § 25.5-5-202 — CO Code / Title 25.5 / Article 5 / Part 2 / Section 25.5-5-202
25.5-5-202. Basic services for the categorically needy - optional services
Status: repealed

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:

(a) (I) Prescribed drugs.

(II) Notwithstanding subsection (1)(a)(I) of this section, pursuant to section 25.5-5-503, prescribed drugs are not a covered benefit under the medical assistance program for a member 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.

(a.5) Over-the-counter medications, as specified in section 25.5-5-322;

(b) Clinic services, as defined in sections 25.5-5-301 and 25.5-5-302;

(c) Home- and community-based services, as specified in article 6 of this title 25.5, which include:

(I) 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;

(II) Home- and community-based services for persons with intellectual and developmental disabilities, as specified in part 4 of article 6 of this title;

(III) Repealed.

(IV) 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;

(V) Home- and community-based services for persons with brain injury, as specified in part 7 of article 6 of this title;

(d) Optometrist services;

(e) Eyeglasses when necessary after surgery;

(f) 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;

(g) Rehabilitation services as appropriate to behavioral health safety net providers as defined in section 27-50-101;

(h) Intermediate care facilities for individuals with intellectual disabilities;

(i) Inpatient psychiatric services for persons under twenty-one years of age;

(j) Inpatient psychiatric services for persons over the age of sixty-five;

(k) Case management;

(l) Therapies under home health services, including:

(I) Speech and audiology;

(II) Physical;

(III) Occupational;

(m) Services of a licensed psychologist;

(n) Private duty nursing services;

(o) Podiatry services;

(p) Hospice care;

(q) The program of all-inclusive care for the elderly;

(r) 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;

(s) (I) Outpatient substance use disorder treatment.

(II) Repealed.

(t) Cervical cancer immunization for all females under twenty years of age;

(u) (I) Screening, brief intervention, and referral to treatment for individuals at risk of substance abuse, including referral to the appropriate level of intervention and treatment.

(II) 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.

(v) (I) 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.

(II) 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.

(w) Dental services for adults.

(x) (I) Residential and inpatient substance use disorder treatment and medical detoxification services pursuant to section 25.5-5-325.

(II) 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.

(y) For any perinatal person, comprehensive lactation support services, lactation supplies and equipment, and maintenance of multi-user loaned equipment. An individual trained in advanced lactation support shall provide the lactation support services. Lactation equipment must include a single-user double electric breast pump, pump parts and pump collection kit, and access to a loaned multi-user hospital grade electric breast pump along with a compatible individual collection kit. Individuals must have access to single-user lactation supplies and equipment prior to delivery. Access to multi-user loaned breast pumps shall be authorized by a health-care provider. Access to multi-user loaned breast pumps is prioritized for individuals with premature, medically fragile, low birth weight infants, and with lactation complications. Individuals cannot be required to enroll in separate or additional programs in order to receive covered lactation equipment or lactation support 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 behavioral health administration 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.
C.R.S. § 25.5-5-423 — CO Code / Title 25.5 / Article 5 / Part 4 / Section 25.5-5-423
25.5-5-423. Independent review organization - review denial of residential and inpatient sub
Status: in_force

25.5-5-423. Independent review organization - review denial of residential and inpatient substance use disorder treatment claims - contract. No later than July 1, 2023, the state department shall contract with one or more independent review organizations to conduct external medical reviews requested for review by a medicaid provider when there is a denial or reduction for residential or inpatient substance use disorder treatment and medicaid appeals processes have been exhausted.
C.R.S. § 25.5-3-108 — CO Code / Title 25.5 / Article 3 / Part 1 / Section 25.5-3-108
25.5-3-108. Responsibility of the department of health care policy and financing - provider
Status: repealed

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:

(a) 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;

(b) Promulgation of such reasonable rules as are necessary for the program;

(c) Submission of the report required in section 25.5-3-107; and

(d) 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) (a) The responsibilities of providers who provide medical care through the program for the medically indigent are as follows:

(I) 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.

(II) (A) 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.

(B) 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.

(b) Any two or more providers awarded contracts may, with the approval of the state department, redistribute their respective populations and associated funds.

(c) 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) (a) 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.

(b) Such medical services shall be prioritized in the following order:

(I) Emergency care for the full year;

(II) Any additional medical care for those conditions the state department determines to be the most serious threat to the health of medically indigent persons;

(III) 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) (a) 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.

(b) A medically indigent person requesting assistance under this part 1 specifically authorizes the state department or provider to:

(I) Use any information required by the eligibility requirements set by the state department for the purpose of verifying eligibility; and

(II) 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.

(c) 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) and (19) Repealed.

(20) (a) Notwithstanding any other provision of law, for the state fiscal year starting July 1, 2021, and any subsequent fiscal years, 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; except that the state department shall only retain the federal money based on the date of service as long as the increased reimbursements and payments pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, are still available. The state treasurer shall transfer such money to the general fund created in section 24-75-201 for appropriation to the state medical assistance program.

(b) This subsection (20) is repealed, effective December 31, 2024.
C.R.S. § 25.5-4-403.2 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-403.2
25.5-4-403.2. Certified community behavioral health clinic - application - repeal
Status: repealed

25.5-4-403.2. Certified community behavioral health clinic - application - repeal. (1) (a) No later than February 1, 2025, the state department, in collaboration with the behavioral health administration in the department of human services, shall:

(I) Submit an application to the federal substance abuse and mental health services administration for a certified community behavioral health clinic demonstration planning grant. The grant application must:

(A) Address the feedback the state department received from the federal substance abuse and mental health services administration after the state department's previous grant application, including how the state will establish a prospective payment system rate for behavioral health services provided by certified community behavioral health clinics in accordance with the federal centers for medicare and medicaid guidance;

(B) Be structured in accordance with the demonstration program established by section 223 of the federal "Protecting Access to Medicare Act of 2014", 42 U.S.C. sec. 1396a; and

(C) Be developed in collaboration with stakeholders, including providers, consumer advocates, county representatives, state agencies, and other interested parties identified by the state department; and

(II) Submit a report to the joint budget committee on the status of the grant application described in subsection (1)(a)(I) of this section.

(b) In developing the grant application, the state department and the behavioral health administration shall conduct a robust stakeholder engagement process with community partners and demonstrate that the demonstration planning grant is in the best interest of the state by ensuring the following items are addressed in the demonstration planning grant:

(I) The requirement to serve priority populations, as defined in section 27-50-101;

(II) The provision of behavioral health safety net services, as defined in section 27-50-101;

(III) The requirement for a certified community behavioral health clinic to serve all populations, regardless of an individual's condition or ability to pay for services, as described in section 27-50-301;

(IV) Peer supports and peer counseling;

(V) The requirement for incorporating meaningful participation from individuals with lived experience of a mental health disorder or substance use disorder and the individual's family members, including youth, in all aspects of the decision-making process;

(VI) Quality and reporting requirements, including ensuring the state is not limited to certified community behavioral health clinic outcome or reporting requirements alone;

(VII) The availability of certified community behavioral health clinic certification for any behavioral health entity that is designated by the behavioral health administration as a comprehensive community behavioral health provider or essential community behavioral health provider and which meets the federal requirements;

(VIII) A lack of geographic limitation on the number of certified community behavioral health clinics in a region;

(IX) Assurance that certified community behavioral health clinic crisis services are delivered within the parameter of Colorado's statewide crisis response system, that any crisis services delivered by the certified community behavioral health clinic are aligned with the services provided through the statewide crisis response system, and that services do not duplicate or impede services provided through the statewide crisis response system;

(X) No negative impact on rural access, as well as ensuring certified community behavioral health clinics will not reduce other agencies' ability to provide behavioral health safety net services in the state; and

(XI) That the state department has the ability to implement financial accountability standards for providers.

(c) The state department and behavioral health administration shall work with the joint budget committee to determine how to proceed with the grant if, during the grant application process, there are substantial changes to federal funding that would negatively affect the state of Colorado.

(2) If the state department is awarded the certified community behavioral health clinic demonstration planning grant after applying pursuant to this section, the state department shall comply with all necessary guidelines established by the federal substance abuse and mental health services administration for a certified community behavioral health clinic grant awardee.

(3) This section is repealed, effective January 1, 2026.
C.R.S. § 25.5-6-1708 — CO Code / Title 25.5 / Article 6 / Part 17 / Section 25.5-6-1708
25.5-6-1708. Performance audits - Colorado local government audit law - public disclosure of
Status: in_force

25.5-6-1708. Performance audits - Colorado local government audit law - public disclosure of board administration and operations. (1) The state auditor may conduct or cause to be conducted a performance audit that includes each case management agency or each entity that receives more than seventy-five percent of its funding on an annual basis from the federal, the state, or a local government or from any combination of governmental entities to determine whether the board of directors or the governing body is effectively and efficiently fulfilling its statutory obligations. A case management agency or an entity becomes subject to the audit requirement under this subsection (1) at the time the case management agency or the entity initially satisfies the seventy-five percent funding requirement for any one year regardless of whether or not the funding level decreases below seventy-five percent in any subsequent year. The state auditor shall submit a written report and recommendations on each audit conducted pursuant to this subsection (1) and shall present the report and recommendations to the legislative audit committee created in section 2-3-101 (1). The state auditor shall pay the costs of any performance audit conducted pursuant to this section.

(2) Each case management agency and each entity is subject to the requirements of the "Colorado Local Government Audit Law", part 6 of article 1 of title 29.

(3) In connection with the board of directors or the governing body of each case management agency or each entity, in addition to any other requirements applicable to the operation of the board of directors or the governing body pursuant to this section or as required elsewhere by law:

(a) The case management agency or the entity shall post the date, time, and location of each regularly scheduled meeting of the board of directors or the governing body on the website of the case management agency or the entity not less than fourteen business days before the meeting. The case management agency or the entity shall post the date, time, and location of any special or emergency meeting of the board of directors or the governing body on the website of the case management agency or the entity not less than twenty-four hours before the meeting.

(b) Each case management agency or each entity shall post the agenda for each meeting of the board of directors or the governing body on the website of the case management agency or the entity not less than seven business days before the meeting. The case management agency or the entity shall post the agenda of any special or emergency meeting of the board of directors or the governing body on the website of the case management agency or the entity not less than twenty-four hours before the meeting. Each meeting of the board of directors or the governing body must allow for public comment, and the agenda must reflect this requirement. Public comment must be reasonably permitted during the board's or the governing body's meeting to accommodate community needs. Any documents related to functions of the case management agency or the entity to be distributed at a meeting of the board of directors or the governing body that are available for public dissemination at the time the agenda is posted must also be posted on the website of the case management agency or the entity at the time the agenda is posted. Written copies of the documents must be made available for public dissemination at the board of directors' or the governing body's meeting; except that the posting requirement specified in this subsection (3)(b) does not apply to any document, or any portion of a document, the disclosure of which requires the approval of the board of directors or the governing body and which approval has not been obtained at the time the agenda is posted or any other document, or any portion of a document, containing any information that is legally prohibited from being disclosed to the public pursuant to the privacy requirements specified in the federal "Health Insurance Portability and Accountability Act of 1996", 42 U.S.C. sec. 1320d, any document that has been or will be discussed by the board of directors or the governing body meeting in executive session, or any other document the disclosure of which is otherwise prohibited by law.

(c) Each case management agency and each entity shall provide a direct e-mail address to each member of the board of directors or the governing body on the website of the case management agency or the entity. The e-mail address selected must specify the name of the individual board or governing body member and make reference to the particular case management agency or entity for which the board or governing body member serves as a member of the board of directors or the governing body. An e-mail that is sent to a member of the board of directors or the governing body of a case management agency or an entity must not be filtered by the case management agency or the entity through an employee of the case management agency or the entity before it is sent to the board or governing body member.

(d) The board of directors or the governing body of each case management agency or each entity shall present the financial statements of the organization for the approval of the board of directors or the governing body at each regularly scheduled meeting of the board of directors or the governing body. The financial statements must reflect accurate and current financial information and be prepared using generally accepted accounting principles. Where exigent circumstances are present that materially affect the preparation of the financial statements on a monthly basis, the statements may be presented for the approval of the board of directors or the governing body at the next regularly scheduled meeting of the board of directors or the governing body but not less than at least once each quarter of the calendar year.

(e) Each case management agency and each entity shall require the person or organization that performs financial audits of the case management agency or the entity to present and discuss the results of the audit to the board of directors or the governing body not less than once each year at a regularly scheduled meeting of the board of directors or the governing body;

(f) Each case management agency and each entity shall provide to the incoming members of the board of directors or the governing body training in such topics as the duties of a board or governing body member, the financial and fiduciary responsibilities assumed by board or governing body members, the intellectual and developmental disability and long-term services and supports system in the state, the overall business functions of the case management agency or the entity, and any other matters that will, in the determination of the case management agency or the entity, allow the board or governing body member to better understand and fulfill the board or governing body member's obligations to the board of directors or the governing body and the case management agency or the entity and the role played by the case management agency or the entity in the state in connection with the delivery of services for members receiving services pursuant to this article 6 and article 10 of this title 25.5; and

(g) Each case management agency and each entity shall post on the website of the case management agency or the entity the minutes of each meeting of its board of directors or its governing body as the minutes are approved by the board of directors or the governing body. Each case management agency and each entity shall also post on the website of the case management agency or the entity any additional documents that were distributed to the board or governing body at the meeting that were not, as of that date, already posted on the website of the case management agency or the entity unless the public distribution of the documents, or any portion of the documents, is otherwise prohibited pursuant to the privacy requirements specified in the federal "Health Insurance Portability and Accountability Act of 1996", 42 U.S.C. sec. 1320d, or as otherwise prohibited by law. Minutes of special meetings of the board of directors or the governing body must be posted on the website of the case management agency or the entity after approval by the board of directors or the governing body at the board's or governing body's next regular meeting.

(4) With respect to financial information concerning the case management agency or the entity, each case management agency or each entity shall:

(a) Post the following on the website of the case management agency or the entity in a place that allows access to the public in a clear, accessible, easily operated, and uncomplicated manner:

(I) Each completed financial audit undertaken of the case management agency or the entity not later than thirty days following acceptance by the organization's board of directors or governing body of the audit. Any case management agency or any entity that is not required to have an annual audit of financial statements shall post a detailed account of the agency's or entity's assets, liabilities, revenue, losses and gains, expenses, investing activities, property and equipment, and any other relevant financial disclosures required by the state department.

(II) The most current form 990 the case management agency or the entity has filed with the federal internal revenue service not later than thirty days following filing of the form with the federal internal revenue service. Any case management agency or any entity that is not required to prepare and file a form 990 shall disclose and post the for-profit equivalent federal internal revenue services tax form that includes the total number of individuals employed, all executive-level employee salaries and other compensation, and employee benefits, as required by the state department.

(b) Make the following information available upon reasonable request not later than five business days after the request is made:

(I) The annual budget of the case management agency or the entity for each calendar or fiscal year, as applicable, not later than thirty days after final approval of the budget by the board of directors or the governing body of the case management agency or the entity;

(II) An annual summary of all revenues and expenditures of the case management agency or the entity that have been appropriated by the state department that is calculated by September 30 of each year for the prior year, as applicable; and

(III) A description of the policies and procedures the case management agency or the entity follows to track, manage, and report its financial resources and transactions, which policies and procedures are also known and may be referred to as its "financial controls".

(5) Any contract that each case management agency or each entity enters into with either the state department or the department of human services, created in section 26-1-105, must be posted on the website of the case management agency or the entity in a place that allows access to the public in a clear, accessible, easily operated, and uncomplicated manner not later than thirty days following approval of the contract by the board of directors or the governing body of the case management agency or the entity.

(6) This section does not apply to a county agency, including a county department of human or social services, a county nursing service, an area agency on aging, or a multicounty agency acting as a case management agency that already has existing or duplicative audit and transparency requirements.
C.R.S. § 25.5-3-405 — CO Code / Title 25.5 / Article 3 / Part 4 / Section 25.5-3-405
25.5-3-405. Program reporting
Status: repealed

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) (a) 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.

(b) Repealed.
C.R.S. § 25.5-4-305 — CO Code / Title 25.5 / Article 4 / Part 3 / Section 25.5-4-305
25.5-4-305. False medicaid claims - liability for certain acts
Status: in_force

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:

(a) Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;

(b) Knowingly makes, uses, or causes to be made or used a false record or statement material to a false or fraudulent claim;

(c) 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;

(d) 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;

(e) 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;

(f) 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";

(g) 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:

(a) 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;

(b) 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

(c) 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.
C.R.S. § 25.5-4-204 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-204
25.5-4-204. Automated medical assistance administration
Status: in_force

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:

(a) Electronic claim submittals;

(b) Online eligibility determinations;

(c) Electronic remittance statements;

(d) Electronic fund transfers; and

(e) 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:

(a) Technology is available and proven to perform satisfactorily in a production environment;

(b) 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.

(c) The system has been successfully installed and fully tested; and

(d) Adequate provider training has been provided for an orderly implementation.
C.R.S. § 25.5-4-103 — CO Code / Title 25.5 / Article 4 / Part 1 / Section 25.5-4-103
25.5-4-103. Definitions
Status: repealed

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.

(2.5) "Case management agency" has the same meaning as set forth in section 25.5-6-1702 (2).

(3) "Case management services" means services provided by case management agencies and comprehensive community behavioral health providers, as defined in section 27-50-101, to assist persons 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:

(a) Nursing services;

(b) Home health aide services;

(c) Provision of medical supplies, equipment, and appliances suitable for use in the home;

(d) 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:

(a) 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

(b) 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) "Lawfully residing" 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 member 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 members eligible for and enrolled in the state medical assistance program established pursuant to this article 4 and articles 5 and 6 of this title 25.5, which is funded through Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396u-1, to providers enrolled in the state medical assistance program who render or provide medical care, services, goods, and devices to members pursuant to this article 4 and articles 5 and 6 of this title 25.5, and other related payments, pursuant to this article 4 and articles 5 and 6 of this title 25.5 and the rules of the state department.

(13.2) "Member" means a person who has been determined eligible to receive benefits under this article 4 and articles 5 and 6 of this title 25.5.

(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) (a) "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.

(b) "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 26-6-903, 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) Repealed.

(22) "Recovery" or "amount recovered" means the amount payable to the applicant or member or the applicant's or member's 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.

(24.5) "Serious mental illness" means the following psychiatric illnesses, as defined by the American Psychiatric Association in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders:

(a) Bipolar disorders (hypomanic, manic, depressive, and mixed);

(b) Depression in childhood and adolescence;

(c) Major depressive disorders (single episode or recurrent);

(d) Obsessive-compulsive disorders;

(e) Paranoid and other psychotic disorders;

(f) Schizoaffective disorders (bipolar or depressive); and

(g) Schizophrenia.

(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.:

(a) 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

(b) 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.

(25.7) "Telemedicine" means the delivery of medical and health-care services and any diagnosis, consultation, or treatment using interactive audio, interactive video, or interactive data communication.

(26) "Third party" means an individual, institution, corporation, or public or private agency that 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 member 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 members eligible pursuant to section 25.5-5-101 (1)(b).
C.R.S. § 25.5-6-1903 — CO Code / Title 25.5 / Article 6 / Part 19 / Section 25.5-6-1903
25.5-6-1903. Permissible services and supports
Status: in_force

25.5-6-1903. Permissible services and supports. (1) The state department may provide permissible services and supports that are linked to an assessed need or goal in the individual's person-centered service plan. Permissible services and supports may include, but are not limited to, the following:

(a) Expenditures for transition costs, such as rent and utility deposits, first month's rent and utilities, bedding, basic kitchen supplies, and other necessities linked to an assessed need for an individual to transition from a nursing facility, institution for behavioral or mental health disorders, or intermediate care facility for individuals with intellectual disabilities, to a home- and community-based setting where the individual resides; and

(b) Expenditures relating to a need identified in an individual's person-centered service plan that increases an individual's independence or substitutes for human assistance, to the extent that would otherwise be made for human assistance.
C.R.S. § 25.5-1-116 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-116
25.5-1-116. Records confidential - authorization to obtain records of assets - release of lo
Status: in_force

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, members, and former and potential members of medical assistance for purposes directly connected with the administration of medical assistance and related state department activities, including the custody, use, and preservation of the state's and the county departments' records, papers, files, and communications. Whenever, as required by law, the names and addresses of applicants for, members of, or former and potential members of medical assistance are furnished to or held by another agency or department of government, the agency or department shall prevent the publication of lists of the names and addresses and prevent using the names and addresses for purposes not directly connected with the administration of medical assistance.

(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.

(II) 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.

(III) (A) 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).

(B) 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.

(b) 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.

(c) (I) In order to determine if applicants for or members of medical assistance have assets within eligibility limits, the state department may provide a list of information identifying the applicants or members to any financial institution, as defined in section 15-15-201 (4), or to any insurance company. The information provided may include identification numbers or social security numbers. The state department may require a 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 member, 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 member and inform the member of the apparent results of the computer match and give the member the opportunity to explain or correct any erroneous information secured by the match. The requirement to run a computerized match applies 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 does not require any financial institution or insurance company to change its data or make new entries for the purpose of comparing identifying information. The state department shall pay for the cost of providing a computerized match.

(II) 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.

(III) The state department may expend funds appropriated pursuant to subsection (2)(c)(II) of this section in an amount not to exceed the amount of annualized general fund savings that result from the termination of members from medical assistance specifically due to disclosure of assets pursuant to this subsection (2).

(d) An applicant must not be denied or any member must not be discontinued due to the disclosure of assets unless and until the county department or medical assistance site has assured that the 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 the applicant's or member's eligibility for other medical assistance is affected.

(3) The applicant for or member of medical assistance, or the applicant's or member's representative, has an opportunity to examine all applications and pertinent records concerning the applicant or member that constitute a basis for denial, modification, or termination of medical assistance or to examine the records in case of a fair hearing.

(4) Any person who violates subsection (1) or (2) of this section commits a petty offense.
C.R.S. § 25.5-4-426 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-426
25.5-4-426. Supplemental state payment to urban Indian organizations - definition - repeal
Status: repealed

25.5-4-426. Supplemental state payment to urban Indian organizations - definition - repeal. (Repealed)
C.R.S. § 25.5-1-120 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-120
25.5-1-120. Appropriations
Status: in_force

25.5-1-120. Appropriations. (1) (a) 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.

(b) 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.

(c) 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.
C.R.S. § 25.5-8-107 — CO Code / Title 25.5 / Article 8 / Section 25.5-8-107
25.5-8-107. Duties of the department - schedule of services - premiums - copayments - subsid
Status: repealed

25.5-8-107. Duties of the department - schedule of services - premiums - copayments - subsidies - purchase of childhood immunizations. (1) In addition to any other duties pursuant to this article 8, the department has the following duties:

(a) (I) To design, and from time to time revise, a schedule of health-care services included in the plan and to propose said schedule to the medical services board for approval or modification. The schedule of health-care services as proposed by the department and approved by the medical services board shall include, but shall not be limited to, preventive care, physician services, prenatal care and postpartum care, inpatient and outpatient hospital services, prescription drugs and medications, and other services that may be medically necessary for the health of enrollees; except that the department may modify the schedule of health-care services to meet specific federal requirements or to accommodate those changes necessary for a program designed specifically for children.

(II) In addition to the items specified in subsection (1)(a)(I) of this section and any additional items approved by the medical services board, on and after January 1, 2001, the medical services board shall include dental services for all enrolled children, and on and after October 1, 2019, for all enrolled pregnant women, in the schedule of health-care services.

(III) In addition to the items specified in subsections (1)(a)(I) and (1)(a)(II) of this section and any additional items approved by the medical services board, the medical services board shall include mental health services that are at least as comprehensive as the mental health services provided to medicaid members in the schedule of health-care services.

(IV) The schedule of health-care services included in the plan shall not include coverage pursuant to the mandatory coverage provisions of section 10-16-104 (1.4), C.R.S.

(V) In addition to the items specified in subsections (1)(a)(I), (1)(a)(II), and (1)(a)(III) of this section, and any additional items approved by the medical services board, the medical services board shall include, for all perinatal people, comprehensive lactation support services, lactation supplies and equipment, and maintenance of multi-user loaned equipment. An individual trained in advanced lactation support shall provide the lactation support services. Lactation equipment must include a single-user double electric breast pump, pump parts and pump collection kit, and access to a loaned multi-user hospital grade electric breast pump along with a compatible individual collection kit. Individuals must have access to single-user lactation supplies and equipment prior to delivery. Access to multi-user loaned breast pumps shall be authorized by a health-care provider. Access to multi-user loaned breast pumps is prioritized for individuals with premature, medically fragile, low birth weight infants, and with lactation complications. Individuals cannot be required to enroll in separate or additional programs in order to receive covered lactation equipment or lactation support services.

(b) Repealed.

(c) To design and implement a structure of copayments due to providers of managed health-care plans from enrollees. Enrollees in the plan may use funds from a medical savings account to pay copayments.

(d) To design and propose to the medical services board for adoption detailed rules of eligibility and enrollment processes for the plan;

(e) To design a procedure whereby a financial sponsor may pay the annual enrollment fee or some portion thereof on behalf of a subsidized or nonsubsidized enrollee; except that the payment made on behalf of said enrollee shall not exceed the total enrollment fee due from the enrollee;

(f) To design a procedure whereby the plan may pay subsidies for eligible persons to purchase coverage under the plan or a comparable health insurance product;

(g) To establish criteria to allow a managed care plan, the department, or some other entity to verify eligibility pursuant to section 25.5-8-109;

(h) To conduct pilot projects including, but not limited to, testing models of marketing, enrollment, eligibility determination, and premium structures, to be implemented where appropriate and as approved by the joint budget committee.

(i) (I) The department shall develop and implement an outreach strategy for Coloradans who become eligible for health coverage pursuant to section 25.5-2-104, 25.5-2-105, 25.5-5-201 (6), or 25.5-8-109 (7). The state department shall work with stakeholders to develop an outreach strategy that includes:

(A) Funding for community-based organizations to partner with the department on outreach;

(B) A method for providing information related to eligibility and enrollment that can be provided to nonprofit partners, school districts, and charter schools for outreach purposes; and

(C) At a minimum, providing information related to eligibility and coverage in English, Spanish, and in each language spoken by at least two-and-one-half percent of the population of any county who speak English less than very well, as defined by the United States bureau of the census American community survey, and who speak the minority language at home;

(II) Approximately twelve and twenty-four months after implementation of the strategy required pursuant to subsection (1)(i)(I) of this section, the department shall convene stakeholders, including directly impacted individuals, service providers, and advocacy organizations that are diverse with regard to race, ethnicity, immigration status, sexual orientation, and gender identity and who are affected by higher rates of health disparities and inequities. The department shall report on the outreach and enrollment strategy outcomes, including enrollment of eligible persons into these programs compared to those persons who are eligible for coverage, but not enrolled.

(2) The department is authorized to institute a program for competitive bidding pursuant to section 24-103-202 or 24-103-203, C.R.S., for providing medical services on a managed care basis for children under this article. The department shall select more than one managed care contractor to serve counties in which there are providers contracting with more than one managed care plan. In counties where there is only one operational managed care plan, the department may contract with that managed care plan to serve children enrolled in the plan. The department shall assure the utilization of essential community providers for the provision of services including eligibility determination, enrollment, and outreach when reasonable. The department shall contract with managed care organizations for the delivery of health services pursuant to this article. The department may contract with essential community providers for health-care services in areas of the state that are not adequately served by managed care organizations.

(3) The department may contract for billing and premium collection functions for the children's basic health plan with vendors who provide billing and premium collection functions for other state insurance programs in order to consolidate billing and premium collection functions among multiple state programs. Such contracts may be entered into if the department determines that the scope of work provided by the vendor is similar to the work requirements for the children's basic health plan and that it would be more efficient and cost-effective to contract with the same vendor on multiple programs.

(4) Commencing with fiscal year 2001-02, the annual administrative costs for the children's basic health plan shall not exceed ten percent of the total annual program costs.

(5) The department may purchase vaccines recommended by the advisory committee on immunization practices to the centers for disease control and prevention in the federal department of health and human services, or its successor entity, through a vaccine purchasing system, if such a system is developed pursuant to section 25-4-2403 (1), C.R.S., for children enrolled in the children's basic health plan.
C.R.S. § 25.5-5-401 — CO Code / Title 25.5 / Article 5 / Part 4 / Section 25.5-5-401
25.5-5-401. Short title
Status: in_force

25.5-5-401. Short title. This part 4 shall be known and may be cited as the "Statewide Managed Care System".
C.R.S. § 25.5-10-302 — CO Code / Title 25.5 / Article 10 / Part 3 / Section 25.5-10-302
25.5-10-302. Purpose
Status: in_force

25.5-10-302. Purpose. The purpose of the family support services program created in this part 3 is to provide support to families in their role as primary care givers for a family member with an intellectual and developmental disability.
C.R.S. § 25.5-5-314 — CO Code / Title 25.5 / Article 5 / Part 3 / Section 25.5-5-314
25.5-5-314. Substance use disorder treatment for Native Americans - federal approval
Status: repealed

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.
C.R.S. § 25.5-1-114 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-114
25.5-1-114. Grants-in-aid - county supervision
Status: in_force

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:

(a) 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;

(b) 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;

(c) 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);

(d) 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;

(e) 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.
C.R.S. § 25.5-4-202 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-202
25.5-4-202. Comprehensive plan for other services and benefits
Status: repealed

25.5-4-202. Comprehensive plan for other services and benefits. (Repealed)
C.R.S. § 25.5-4-212 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-212
25.5-4-212. Medicaid member correspondence improvement process - legislative declaration - d
Status: in_force

25.5-4-212. Medicaid member correspondence improvement process - legislative declaration - definition. (1) (a) The general assembly finds and declares that:

(I) Accurate, understandable, timely, informative, and clear correspondence from the state department is critical to the life and health of medicaid members and applicants and, in some cases, is a matter of life and death for our most vulnerable populations;

(II) 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 applicants and members; and

(III) Government should be a good steward of taxpayers' money, ensuring that it is spent in the most cost-effective manner.

(b) Therefore, the general assembly finds that improving medicaid member correspondence is critical to the health and safety of medicaid members and will reduce unnecessary confusion that requires members to call counties and the state department or file appeals.

(2) As used in this section, unless the context otherwise requires, "member correspondence" means any communication 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. "Member 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 member correspondence by ensuring that member correspondence revised or created after January 1, 2018:

(a) Is written using person-first, plain language;

(b) Is written in a format that includes the date of the correspondence and a member greeting;

(c) Is consistent, using the same terms throughout to the extent practicable, including commonly used program names;

(d) Is accurately translated into the second most commonly spoken language in the state if a member indicates that the language is the member's written language of preference or as required by law;

(e) Includes a statement translated into the top fifteen languages most commonly spoken by individuals in Colorado with limited English proficiency informing an applicant or member how to seek further assistance in understanding the content of the correspondence;

(f) Clearly conveys the purpose of the applicant or member correspondence, the action or actions being taken by the state department or the state department's designated entity, if any, and the specific action or actions that the applicant or member shall or may take in response to the correspondence;

(g) Includes a specific description of any necessary information or documents requested from the applicant or member;

(h) Includes contact information for applicant or member questions; and

(i) 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 member specific and detailed information concerning the member's household composition, assets, income sources, and income amounts, if relevant to a determination for which member correspondence was issued. If implemented, the state department shall notify members in the written correspondence of the option to access this information.

(5) The state department is encouraged to promote the receipt of member correspondence electronically or through mobile applications for members who choose those methods of delivery as allowed by law.

(6) As part of its ongoing process to create and improve member correspondence, the state department may engage with experts in written communication and plain language to test member correspondence against the criteria set forth in subsection (3) of this section with a geographically diverse and representative sample of medicaid members relevant to the member correspondence being revised. The state department shall also develop a process to review and consider feedback from stakeholders, including consumer advocates and counties, prior to implementing significant changes to correspondence.

(7) The state department shall ensure that applicant or member correspondence that may only affect a small number of applicants or members, but may, nonetheless, have a significant impact on the lives of those applicants or members, 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:

(a) The state department's process for ongoing improvement of member correspondence;

(b) Member correspondence revised pursuant to criteria set forth in subsection (3) of this section during the prior year and member correspondence improvements that are planned for the upcoming year; and

(c) A description of the results of testing of new or significantly revised member correspondence pursuant to subsection (6) of this section, including a description of the stakeholder feedback.
C.R.S. § 25.5-4-407 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-407
25.5-4-407. Services by licensed psychologists without a doctor's referral
Status: in_force

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.
C.R.S. § 25.5-5-502 — CO Code / Title 25.5 / Article 5 / Part 5 / Section 25.5-5-502
25.5-5-502. Unused medications - reuse - rules - definition
Status: in_force

25.5-5-502. Unused medications - reuse - rules - definition. (1) As used in this section, unless the context otherwise requires, "medication" means prescription medication that is not a controlled substance.

(2) A pharmacist participating in the medical assistance program may accept unused medication from a licensed facility, as defined in section 12-280-135 (1)(b), or a licensed health-care provider for the purpose of dispensing the medication to another person. A pharmacist shall reimburse the state department for the cost of medications that the state department has paid to the pharmacist if medications are returned to a pharmacist and the medications are available to be dispensed to another person. Medications shall only be available to be dispensed to another person under this section if the medications are:

(a) Liquid and the vial is still sealed and properly stored;

(b) Individually packaged and the packaging has not been damaged; or

(c) In the original, unopened, sealed, and tamper-evident unit dose packaging.

(3) Medication dispensed pursuant to this section shall bear an expiration date that is later than six months after the date the drug was donated.

(4) Any savings realized through reimbursements received pursuant to subsection (2) of this section shall fund the administration of this section.

(5) The state board, in consultation with the state board of pharmacy, shall adopt rules for the implementation of this section.
C.R.S. § 25.5-4-413 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-413
25.5-4-413. Certain providers to inform patients of rights concerning advance medical direct
Status: in_force

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.
C.R.S. § 25.5-3-105 — CO Code / Title 25.5 / Article 3 / Part 1 / Section 25.5-3-105
25.5-3-105. Eligibility of legal immigrants for services
Status: in_force

25.5-3-105. Eligibility of legal immigrants for services. The county departments responsible for administering benefits programs under the department of health care policy and financing and the department of human services shall identify and review all current county guidance materials, including forms, training materials, websites, and any other materials that reference a prohibition on sponsorship as a condition of eligibility for benefits and shall remove all such references from verbal and digital communications and from all physical materials currently provided to applicants or beneficiaries.
C.R.S. § 25.5-3-207 — CO Code / Title 25.5 / Article 3 / Part 2 / Section 25.5-3-207
25.5-3-207. Program funding - comprehensive primary and preventive care fund - creation - re
Status: repealed

25.5-3-207. Program funding - comprehensive primary and preventive care fund - creation - repeal. (Repealed)
C.R.S. § 25.5-6-203 — CO Code / Title 25.5 / Article 6 / Part 2 / Section 25.5-6-203
25.5-6-203. Nursing facilities - provider fees - federal waiver - fund created - rules - rep
Status: repealed

25.5-6-203. Nursing facilities - provider fees - federal waiver - fund created - rules - repeal. (1) (a) (I) Beginning with the fiscal year commencing July 1, 2008, and each fiscal year thereafter, the state department shall charge and collect provider fees on health-care items or services provided by nursing facility providers for the purpose of obtaining federal financial participation under the state's medical assistance program as described in articles 4 to 6 of this title. As specified by the priority of the uses of the provider fee in paragraph (b) of subsection (2) of this section, the provider fees shall be used to sustain or increase reimbursement for providing medical care under the state's medical assistance program for nursing facility providers.

(II) For the fiscal years commencing July 1, 2009, and July 1, 2010, the provider fee shall not exceed seven dollars and fifty cents per nonmedicare-resident day. For the fiscal year commencing July 1, 2011, and each fiscal year thereafter, the provider fee shall not exceed twelve dollars per nonmedicare-resident day plus inflation based on the national skilled nursing facility market basket index as determined by the secretary of the department of health and human services pursuant to 42 U.S.C. sec. 1395yy (e)(5) or any successor index.

(III) In calculating the amount of the provider fee portion of the supplemental medicaid payments established under section 25.5-6-202 (5), the state department may include an additional amount of up to five percent of the provider fee portion of said supplemental medicaid payments to initiate the payment to any provider who complies with the established performance measures during the state fiscal year.

(b) The provider fees shall be charged on a nonmedicare-resident day basis and shall be based upon the aggregate gross or net revenue, as prescribed by the state department, of all nursing facility providers subject to the provider fee. The state department may exempt revenue categories from the gross or net revenue calculation and the collection of the provider fee from nursing facility providers, as authorized by federal law.

(c) (I) In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1) and (e)(2), the state department shall seek a waiver from the broad-based provider fees requirement or the uniform provider fees requirement, or both, to exclude nursing facility providers from the provider fee. The state department shall exempt the following nursing facility providers to obtain federal approval and minimize the financial impact on nursing facility providers:

(A) A facility operated as a continuing care retirement community that provides a continuum of services by one operational entity providing independent living services, assisted living services, and skilled nursing care on a single, contiguous campus. Assisted living services include an assisted living residence as defined in section 25-27-102 or that provides assisted living services on-site, twenty-four hours per day, seven days per week.

(B) A skilled nursing facility owned and operated by the state;

(C) A nursing facility that is a distinct part of a facility that is licensed as a general acute care hospital; and

(D) A facility that has forty-five or fewer licensed beds.

(II) No later than July 1, 2026, the state department shall promulgate rules maintaining the exemptions identified in this subsection (1)(c) in order to minimize the financial impact on nursing facility providers.

(III) This subsection (1)(c) is repealed, effective July 1, 2028.

(d) The state department may lower the amount of the provider fee charged to certain nursing facility providers to meet the requirements of 42 CFR 433.68 (e) and to obtain federal approval.

(e) The imposition and collection of a provider fee shall be prohibited without the federal government's approval of a state medicaid plan amendment authorizing federal financial participation for the provider fees. The state department may alter the method prescribed in this section to the extent necessary to meet the federal requirements and to obtain federal approval.

(f) If the provider fee required by this subsection (1) is not approved by the federal government, notwithstanding any other provision of this section, the state department shall not implement the assessment or collection of the provider fee from nursing facility providers.

(g) The state department shall establish a schedule to assess and collect the provider fee on a monthly basis. The state board shall establish rules so that provider fee payments from a nursing facility provider and the state department's supplemental medicaid payments to the nursing facility are due as nearly simultaneously as feasible; except that the state department's supplemental medicaid payments to the nursing facility shall be due no more than fifteen days after the provider fee payment is received from the nursing facility. The state department shall require each nursing facility provider to report annually its total number of days of care provided to nonmedicare residents.

(h) The state department shall not assess or collect the provider fee until state medicaid plan amendments adopting the medicaid reimbursement system for the state's class I nursing facility providers, pursuant to section 25.5-6-202, including the waiver with respect to the provider fees pursuant to this section, have been approved by the federal government.

(i) The state board shall promulgate any rules pursuant to the "State Administrative Procedure Act", article 4 of title 24, C.R.S., necessary for the administration and implementation of this section.

(j) A nursing facility provider shall not include any amount of the provider fee as a separate line item in its billing statements.

(2) (a) All provider fees collected pursuant to this section by the state department shall be transmitted to the state treasurer, who shall credit the same to the medicaid nursing facility cash fund, which fund is hereby created and referred to in this section as the "fund".

(b) (I) All moneys in the fund shall be subject to federal matching as authorized under federal law and subject to annual appropriation by the general assembly for the purpose of paying the administrative costs of implementing section 25.5-6-202 and this section, to satisfy settlements or judgments resulting from nursing facility provider reimbursement appeals, and to pay the supplemental medicaid payments to offset payment of the provider fee established under section 25.5-6-202 (7).

(II) Following the payment of the amounts described in subparagraph (I) of this paragraph (b), the moneys remaining in the fund shall be subject to federal matching as authorized under federal law and subject to annual appropriation by the general assembly for the purpose of paying the supplemental medicaid payments for acuity or case-mix of residents established under section 25.5-6-202 (2).

(III) (A) Except as provided in sub-subparagraph (B) of this subparagraph (III), after the payment of the amounts described in subparagraphs (I) and (II) of this paragraph (b), the moneys remaining in the fund shall be subject to federal matching as authorized under federal law and subject to annual appropriation by the general assembly for the purpose of paying the supplemental medicaid payments for higher quality performance established under section 25.5-6-202 (5).

(B) Notwithstanding any other provision of this paragraph (b), the supplemental medicaid payments established pursuant to section 25.5-6-202 (5) shall not be less than ten percent of the supplemental medicaid payments established under section 25.5-6-202 (7) in the prior state fiscal year.

(IV) Following the payment of the amounts described in subsections (2)(b)(I) to (2)(b)(III) of this section, the money remaining in the fund shall be subject to federal matching as authorized under federal law and subject to annual appropriation by the general assembly for the purpose of paying the supplemental medicaid payments established under section 25.5-6-202 (6) for residents who have moderately to very severe mental health conditions, dementia diseases and related disabilities, or acquired brain injury.

(V) Following the payment of the amounts described in subparagraphs (I) to (IV) of this paragraph (b), the moneys remaining in the fund shall be subject to federal matching as authorized under federal law and subject to annual appropriation by the general assembly for the purpose of paying the supplemental medicaid payments for the amount by which the average statewide per diem rate exceeds the general fund share established under section 25.5-6-202 (9)(b)(II).

(VI) Any moneys in the fund not expended for the purposes specified in 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 any fiscal year shall remain in the fund and shall not be credited or transferred to the general fund or any other fund but may be appropriated by the general assembly to pay nursing facility providers in future fiscal years.

(VII) (A) Notwithstanding any other provision of this subsection (2)(b), for state medicaid expenditures for state fiscal years 2019-20, 2020-21, and any subsequent fiscal years, as long as the increased reimbursements and payments pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, are still available only, and regardless of when this federal money is made available, money in the fund may be used to offset general fund expenditures in the medicaid program in an equivalent amount that would have been in excess of the fifty percent federal financial participation generated by increased reimbursements and payments appropriated for use in subsections (2)(b)(I) to (2)(b)(V) of this section pursuant to the federal"Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto, or any other federal law that increases federal financial participation above the federal financial participation percentage in effect prior to the increase in federal financial participation provided through the federal"Families First Coronavirus Response Act". The state treasurer shall transfer such amount to the general fund for the state medicaid program.

(B) This subsection (2)(b)(VII) is repealed, effective December 31, 2024.
C.R.S. § 25.5-6-1802 — CO Code / Title 25.5 / Article 6 / Part 18 / Section 25.5-6-1802
25.5-6-1802. Definitions
Status: in_force

25.5-6-1802. Definitions. As used in this part 18, unless the context otherwise requires:

(1) "American Rescue Plan Act" means the federal "American Rescue Plan Act of 2021", Pub.L. 117-2, as amended.

(2) "Home- and community-based services" means any of the following:

(a) Home health-care services authorized pursuant to paragraph (7) of section 1905(a) of the "Social Security Act", 42 U.S.C. 1396d(a);

(b) Personal care services authorized pursuant to paragraph (24) of section 1905(a) of the "Social Security Act", 42 U.S.C. 1396d(a);

(c) PACE services authorized pursuant to paragraph (26) of section 1905(a) of the "Social Security Act", 42 U.S.C. 1396d(a);

(d) Home- and community-based services authorized pursuant to subsections (b), (c), (i), (j), and (k) of section 1915 of the "Social Security Act", 42 U.S.C. 1396n; services authorized pursuant to a waiver under section 1115 of the "Social Security Act", 42 U.S.C. 1315; and services through coverage authorized under section 1937 of the "Social Security Act", 42 U.S.C. 1396u-7;

(e) Case management services authorized under section 1905(a)(19) of the "Social Security Act", 42 U.S.C. 1396d(a)(19), and section 1915(g) of the "Social Security Act", 42 U.S.C. 1396n(g);

(f) Rehabilitative services, including those related to behavioral health, described in section 1905(a)(13) of the "Social Security Act", 42 U.S.C. 1396d(a)(13); and

(g) Such other services specified by the United States secretary of health and human services.

(3) "Social Security Act" means the federal "Social Security Act", as amended.