C.R.S. § 25.5-8-103 — CO Code / Title 25.5 / Article 8 / Section 25.5-8-103
25.5-8-103. Definitions - rules
Status: repealed

25.5-8-103. Definitions - rules. As used in this article 8, unless the context otherwise requires:

(1) "Child" means a person who is less than nineteen years of age.

(2) "Children's basic health plan" or "plan" means the subsidized health insurance product designed by the department of health care policy and financing and provided to enrollees, as defined in this section.

(3) "Department" means the department of health care policy and financing created in section 25.5-1-104.

(4) "Eligible person" means:

(a) (I) A person who is less than nineteen years of age, who is a citizen or meets the immigration status requirements set forth in section 25.5-8-109 (6) or 25.5-8-109 (7), whose family income does not exceed two hundred sixty percent of the federal poverty line, adjusted for family size, and who is not eligible for medical assistance pursuant to articles 4, 5, and 6 of this title 25.5.

(II) Notwithstanding the provisions of subsection (4)(a)(I) of this section, if the money in the healthcare affordability and sustainability fee cash fund established pursuant to section 25.5-4-402.4 (5), together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), for persons less than nineteen years of age, the state board may by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) reduce the percentage of the federal poverty line to below two hundred sixty percent, but the percentage shall not be reduced to below two hundred thirteen percent.

(III) Repealed.

(b) (I) A pregnant person who is a citizen or meets the immigration status requirements set forth in section 25.5-8-109 (6) or 25.5-8-109 (7), whose family income does not exceed two hundred sixty percent of the federal poverty line, adjusted for family size, and who is not eligible for medical assistance pursuant to articles 4, 5, and 6 of this title 25.5.

(II) Notwithstanding the provisions of subsection (4)(b)(I) of this section, if the money in the healthcare affordability and sustainability fee cash fund established pursuant to section 25.5-4-402.4 (5), together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), for pregnant women, the state board by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) may reduce the percentage of the federal poverty line to below two hundred sixty percent, but the percentage shall not be reduced to below two hundred thirteen percent.

(III) Repealed.

(5) "Enrollee" means any eligible person that has enrolled in the plan.

(6) "Essential community provider" means a health-care provider that:

(a) Has historically served medically needy or medically indigent patients and demonstrates a commitment to serve low-income and medically indigent populations who make up a significant portion of its patient population, or in the case of a sole community provider, serves the medically indigent patients within its medical capability; and

(b) Waives charges or charges for services on a sliding scale based on income and does not restrict access or services because of a member's financial limitations.

(7) "Health-care program" means any health-care program in the state that is supported with state general fund or federal dollars.

(8) "Master settlement agreement" means the master settlement agreement, the smokeless tobacco master settlement agreement, and the consent decree approved and entered by the court in the case denominated State of Colorado, ex rel. Gale A. Norton, Attorney General v. R.J. Reynolds Tobacco Co.; American Tobacco Co., Inc.; Brown & Williamson Tobacco Corp.; Liggett & Myers, Inc.; Lorillard Tobacco Co., Inc.; Philip Morris, Inc.; United States Tobacco Co.; B.A.T. Industries, P.L.C.; The Council For Tobacco Research--U.S.A., Inc.; and Tobacco Institute, Inc., Case No. 97 CV 3432, in the district court for the city and county of Denver.

(9) "Medical services board" means the medical services board created in section 25.5-1-301.

(10) "Subsidized enrollee" means an eligible person who receives a subsidy from the department to purchase coverage under the plan or a comparable health insurance.

(11) "Subsidy" means the amount paid by the department to assist an eligible person in purchasing coverage under the plan or a comparable health insurance product available to the eligible person through another coverage entity.

(12) "Trust" means the children's basic health plan trust created in section 25.5-8-105.
C.R.S. § 25.5-6-1603 — CO Code / Title 25.5 / Article 6 / Part 16 / Section 25.5-6-1603
25.5-6-1603. Minimum wage - wage pass-through requirement for certain home care agencies - ap
Status: in_force

25.5-6-1603. Minimum wage - wage pass-through requirement for certain home care agencies - applicability - reports - recovery. (1) This section applies to each home care agency that receives reimbursement pursuant to the "Colorado Medical Assistance Act" for the provision of personal care services, homemaker services, or in-home support services.

(2) On and after July 1, 2020, the hourly minimum wage for persons who provide personal care services, homemaker services, or in-home support services for which a home care agency may receive reimbursement pursuant to the "Colorado Medical Assistance Act" is twelve dollars and forty-one cents per hour.

(3) For any increase to the reimbursement rates for personal care services, homemaker services, or in-home support services that takes effect during the 2020-21 fiscal year, home care agencies shall use eighty-five percent of the funding resulting from the increase to increase compensation for nonadministrative employees above the rate of compensation that nonadministrative employees are receiving as of June 30, 2020. Home care agencies may use any remaining funding resulting from the reimbursement rate increase for general and administrative expenses, such as chief executive officer salaries, human resources, information technology, oversight, business management, general record keeping, budgeting and finance, and other activities not identifiable to a single program.

(4) (a) Each home care agency shall track and report how it used any funding resulting from the increase in the reimbursement rate pursuant to this section or section 25.5-6-1602 using a reporting tool developed by the state department. On or before December 31, 2020, each home care agency shall submit the report to the state department demonstrating how the funding was used to increase compensation for the 2019-20 fiscal year. On or before December 31, 2021, each home care agency shall report to the state department how the funding was used to increase or, in the event that there is no reimbursement rate increase, maintain each employee's compensation for the 2020-21 fiscal year. The state department has ongoing discretion to request information from a home care agency demonstrating how it maintained increases in compensation for nonadministrative employees beyond the reporting period.

(b) Each home care agency shall maintain all books, documents, papers, accounting records, and other evidence required to support the reporting of payroll information for increased compensation to nonadministrative employees pursuant to subsection (4)(a) of this section for at least three years from the reporting deadlines described in subsection (4)(a) of this section for each respective fiscal year. Each home care agency shall make the information and materials available for inspection by the state department or its designees at all reasonable times.

(5) (a) The state department may recoup part or all of the funding resulting from the increase in the reimbursement rate described in this section or section 25.5-6-1602 if the state department determines that a home care agency:

(I) Did not use one hundred percent of any funding resulting from the rate increase to increase compensation for nonadministrative employees, as required by section 25.5-6-1602 (2);

(II) Did not use eighty-five percent of the funding resulting from the rate increase to increase compensation for nonadministrative employees, as required by subsection (3) of this section; or

(III) Failed to track and report how it used any funds resulting from the increase in the reimbursement rate as required by subsection (4) of this section.

(b) If the state department makes a determination described in subsection (5)(a) of this section, the state department shall notify the home care agency in writing of the state department's intention to recoup funds pursuant to subsection (5)(a) of this section. A home care agency has forty-five days after receiving such notice to:

(I) Challenge the determination of the state department;

(II) Provide additional information to the state department demonstrating compliance; or

(III) Submit a plan of correction to the state department.

(c) The state department shall notify a home care agency in writing of its final determination after affording the home care agency the opportunity to take one of the actions specified in subsection (5)(b) of this section.

(d) The state department shall recoup from a home care agency any funding resulting from the increase in the reimbursement rate pursuant to this section or section 25.5-6-1602 that the home care agency received but did not use for compensation for nonadministrative employees if:

(I) The home care agency fails to respond to a notice of determination of the state department within the time provided in subsection (5)(b) of this section;

(II) The home care agency is unable to provide documentation of compliance; or

(III) The state department does not accept the plan of correction submitted by the home care agency pursuant to subsection (5)(b)(III) of this section.
C.R.S. § 25.5-6-1206 — CO Code / Title 25.5 / Article 6 / Part 12 / Section 25.5-6-1206
25.5-6-1206. Report - repeal
Status: repealed

25.5-6-1206. Report - repeal. (1) The state department shall report annually to the joint budget committee of the general assembly and the health and human services committee of the senate, or any successor committee, and the health and environment committee of the house of representatives, or any successor committee, on the implementation of in-home support services. At a minimum the report shall include the cost-effectiveness of providing in-home support services to the elderly, blind, and disabled and to eligible disabled children, the number of persons receiving such services, and any strategies and resources that are available or that are necessary to assist more persons in staying in their homes through the use of in-home support services.

(2) This section is repealed, effective July 1, 2025.
C.R.S. § 25.5-4-402.5 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-402.5
25.5-4-402.5. Providers - state university teaching hospitals
Status: in_force

25.5-4-402.5. Providers - state university teaching hospitals. Subject to appropriations by the general assembly, the state department shall make payments to state university teaching hospitals for providing care under the state's medical assistance program established pursuant to this article and articles 5 and 6 of this title.
C.R.S. § 25.5-8-101 — CO Code / Title 25.5 / Article 8 / Section 25.5-8-101
25.5-8-101. Short title
Status: in_force

25.5-8-101. Short title. This article shall be known and may be cited as the "Children's Basic Health Plan Act".
C.R.S. § 25.5-6-1203 — CO Code / Title 25.5 / Article 6 / Part 12 / Section 25.5-6-1203
25.5-6-1203. In-home support services - eligibility - licensure exclusion - in-home support s
Status: repealed

25.5-6-1203. In-home support services - eligibility - licensure exclusion - in-home support service agency responsibilities - rules - repeal. (1) [Editor's note: This version of subsection (1) is effective until July 1, 2025.] The state department shall offer in-home support services as an option for eligible persons who receive home- and community-based services. In-home support services shall be provided to eligible persons. The state department shall seek any federal authorization that may be necessary to implement this part 12. The state department shall design and implement in-home support services with input from consumers of home- and community-based services and independent living centers and home- and community-based service providers.

(1) [Editor's note: This version of subsection (1) is effective July 1, 2025.] The state department shall offer in-home support services as an option for eligible persons who receive community first choice services. In-home support services must be provided to eligible persons. The state department shall seek any federal authorization that may be necessary to implement this part 12. The state department shall design and implement in-home support services with input from consumers of community first choice services and independent living centers.

(1.5) Repealed.

(2) An eligible person receiving in-home support services or the eligible person's authorized representative or parent or guardian shall be allowed to:

(a) Choose the eligible person's in-home support service agency or the eligible person's attendant; and

(b) Direct the eligible person's care, including directly scheduling, managing, and supervising the attendant, and determine the level of in-home support services agency support.

(3) Sections 12-255-104 (7), (8.5), and (11), 12-255-125 (1), and 12-255-214 (1)(b) shall not apply to a person who is directly employed by an in-home support service agency to provide in-home support services and who is acting within the scope and course of such employment or is a family member providing in-home support services pursuant to this part 12. However, such person may not represent himself or herself to the public as a licensed nurse, a certified nurse aide, a licensed practical or professional nurse, a registered nurse, or a registered professional nurse. This exclusion shall not apply to any person who has had his or her license as a nurse or certification as a nurse aide suspended or revoked or his or her application for such license or certification denied.

(4) (a) In-home support service agencies providing in-home support services shall provide twenty-four-hour back-up services to the agencies' members. In-home support service agencies shall either contract with or have on staff a state licensed health-care professional, as defined by state board by rule, acting within the scope of the person's profession. The state board shall promulgate rules setting forth the training requirements for attendants providing in-home support services and the oversight and monitoring responsibilities of the state licensed health-care professional that is either contracting with or is on staff with the in-home support service agency. The state board rules must allow the eligible person or the eligible person's authorized representative, parent of a minor, or guardian to determine, in conjunction with the in-home support services agency, the amount of oversight needed in connection with the eligible person's in-home support services.

(b) The state board shall promulgate rules that establish how an in-home support service agency can discontinue a member under this part 12. The rules must establish that a member can only be involuntarily discontinued when equivalent care in the community has been secured or that a member can be discontinued after exhibiting documented prohibited behavior involving attendants, including abuse of attendants, and that dispute resolution has failed. The state department shall determine whether an in-home support service agency has made adequate attempts at resolution.

(5) The case management agencies established in section 25.5-6-1703 are responsible for determining a person's eligibility for in-home support services; except that for eligible disabled children, the state department shall designate the entity that will determine the child's eligibility. The state board shall promulgate rules specifying the case management agencies' responsibilities pursuant to this part 12. At a minimum, the rules must require that case managers discuss the option and potential benefits of in-home support services with all eligible long-term care members.

(6) (a) Section 25.5-6-310 does not apply to a family member of an eligible person who provides in-home support services to the eligible person pursuant to this part 12. The state board shall promulgate rules, as necessary, to establish limits on reimbursement to family members.

(b) This subsection (6) is repealed, effective July 1, 2025.

(7) In administering the provision of in-home support services pursuant to this part 12, the state department shall:

(a) Implement a system for the routine and accurate monitoring of the number of persons receiving in-home support services; and

(b) Provide comprehensive, periodic training for all case management agencies in the state, which training shall include, at a minimum:

(I) The current eligibility requirements for the receipt of in-home support services; and

(II) The location of, and contact information for, the in-home support service agencies providing in-home support services in the state.
C.R.S. § 25.5-1-112 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-112
25.5-1-112. Drug-purchasing pool - report - repeal
Status: repealed

25.5-1-112. Drug-purchasing pool - report - repeal. (Repealed)
C.R.S. § 25.5-3-304 — CO Code / Title 25.5 / Article 3 / Part 3 / Section 25.5-3-304
25.5-3-304. Primary care fund report
Status: in_force

25.5-3-304. Primary care fund report. [Editor's note: This section is effective July 1, 2025.] (1) Beginning February 1, 2026, and each February 1 thereafter, the executive director shall prepare and submit an annual report to the house of representatives health and human services committee and the senate health and human services committee, or their successor committees; the joint budget committee; the governor; and the state board concerning the status of the primary care fund, created in section 24-22-117 (2)(b). At a minimum, the report must include:

(a) The number of uninsured or medically indigent patients served who have an annual household income at or below two hundred percent of the federal poverty guideline;

(b) The allocation of money to qualified providers;

(c) The state department's recommendations concerning the primary care fund; and

(d) The information presented by the state department to the general assembly pursuant to section 25.5-3-505 (6).
C.R.S. § 25.5-6-311 — CO Code / Title 25.5 / Article 6 / Part 3 / Section 25.5-6-311
25.5-6-311. Duties of state department
Status: in_force

25.5-6-311. Duties of state department. (1) The state department shall:

(a) Seek and utilize any available federal, state, or private funds which are available for carrying out the purposes of this part 3, including but not limited to medicaid funds, pursuant to Title XIX of the federal "Social Security Act", as amended;

(b) Provide a system for reimbursement for services provided pursuant to this part 3, which system shall encourage cost containment.
C.R.S. § 25.5-6-210 — CO Code / Title 25.5 / Article 6 / Part 2 / Section 25.5-6-210
25.5-6-210. Additional supplemental payments - nursing facilities - funding methodology - re
Status: repealed

25.5-6-210. Additional supplemental payments - nursing facilities - funding methodology - reporting requirement - rules - repeal. (1) Notwithstanding any other provision of law to the contrary and subject to available appropriations, for the purposes of reimbursing a medicaid-certified class I nursing facility provider, the state department shall issue additional supplemental payments to nursing facility providers that meet the requirements outlined in this section and the state department's subsequent regulation as follows:

(a) and (b) Repealed.

(c) A payment to a nursing facility with disproportionately high medicaid utilization or geographically critical to ensuring access to care. In determining qualifying facilities for this payment, the state department shall consider any access to care impacts to individuals not covered by medicaid, including, but not limited to, veterans administration beneficiaries, individuals without health-care coverage, and individuals pending medicaid coverage.

(d) A payment to a nursing facility admitting compassionate release individuals from the department of corrections who need additional services to ensure access to care.

(2) The state department shall establish reporting and result tracking requirements necessary to administer the funding outlined in this section. The state department may deny or recoup funding from nursing facility providers that are noncompliant with reporting requirements or if funding is used for purposes outside the intent of supporting and stabilizing nursing facility providers that are medicaid providers.

(3) The state department shall evaluate provider outcomes, including changes in capacity, associated with the payment of supplemental money to nursing facility providers. The state department shall utilize nursing facility providers' financial statements and labor and wage records to evaluate the results of payments.

(4) (a) The state department shall pursue federal matching funds. If federal matching funds are unavailable for any reason, payments outlined in this section may be reduced or restricted, subject to available funding.

(b) For the purposes of federal upper payment limit calculations, the state department shall pursue federal matching funds for payments made pursuant to this section but only after securing federal matching funds for payments outlined in sections 25.5-6-203 (2) and 25.5-6-208.

(5) (a) Supplemental payments made to nursing facility providers pursuant to this section must be determined based on the most recent available data.

(b) Pursuant to rules promulgated by the state department, payments received pursuant to this section must be reported as revenue on the annual cost report when calculating nursing facility provider per diem reimbursement as directed by the state department.

(6) to (9) Repealed.

(10) This section is repealed, effective July 1, 2026.
C.R.S. § 25.5-4-418 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-418
25.5-4-418. Integration of physical and behavioral health services - department review - rep
Status: repealed

25.5-4-418. Integration of physical and behavioral health services - department review - report - repeal. (Repealed)
C.R.S. § 25.5-6-1703 — CO Code / Title 25.5 / Article 6 / Part 17 / Section 25.5-6-1703
25.5-6-1703. Case management system - defined service areas - case management services - only
Status: in_force

25.5-6-1703. Case management system - defined service areas - case management services - only willing and qualified provider exemption - rules. (1) No later than July 1, 2024, the state board shall adopt rules providing for the establishment of a case management system that consists of case management agencies throughout the state for the purpose of enabling individuals in need of long-term care to access appropriate long-term services and supports. Members in need of specialized assistance may be referred to other services outside of long-term services and supports, as necessary for additional care coordination.

(2) No later than December 31, 2021, the state department shall work with stakeholders to develop a timeline for the implementation of this part 17.

(3) (a) No later than December 31, 2022, the state department shall issue a competitive solicitation in order to select case management agencies pursuant to subsection (1) of this section. The competitive solicitation must include a reimbursement structure developed through a fiscal analysis.

(b) No later than January 31, 2023, the state department shall provide an update on the status of the implementation of this part 17 to the joint budget committee of the general assembly as part of its annual presentation to that committee.

(4) The state department shall utilize a stakeholder process to identify defined service areas for case management agencies across the state.

(5) A case management agency may provide case management services to private paying individuals on a fee-for-service basis and shall provide case management services to members of publicly funded long-term services and supports programs, including but not limited to programs created pursuant to this article 6 and article 10 of this title 25.5.

(6) Where applicable, the state department is authorized to seek a federal exemption from conflict-free case management requirements for defined service areas within the state where the only willing and qualified entity to provide case management services is also the only willing and qualified entity to provide home- and community-based services in that defined service area.

(7) The state board shall utilize a stakeholder process when promulgating rules to implement this section.
C.R.S. § 25.5-4-205 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-205
25.5-4-205. Application - verification of eligibility - demonstration project - rules
Status: repealed

25.5-4-205. Application - verification of eligibility - demonstration project - rules. (1) (a) Determination of eligibility for medical benefits shall be made by the county department in which the applicant resides, except as otherwise specified in this section. Local social security offices also determine eligibility for medicaid benefits at the same time the local social security office determines eligibility for supplemental security income. The state department may accept medical assistance applications and determine medical assistance eligibility and may designate the private service contractor that administers the children's basic health plan, Denver health and hospital authority, created in section 25-29-103, a hospital that is designated as a regional pediatric trauma center, as defined in section 25-3.5-703 (4)(f), and other medical assistance sites determined necessary by the state department to accept medical assistance applications, to determine medical assistance eligibility, and to determine presumptive eligibility. A hospital licensed pursuant to part 1 of article 3 of title 25 or certified pursuant to section 25-1.5-103 (1)(a)(II) is authorized to determine presumptive eligibility for medical assistance pursuant to 42 U.S.C. sec. 1396a (a)(47)(B). When the state department determines that it is necessary to designate an additional medical assistance site, the state department shall notify the county in which the medical assistance site is located that an additional medical assistance site has been designated. A person who is determined to be eligible pursuant to the requirements of this article 4 and articles 5 and 6 of this title 25.5 is eligible for benefits until the person is determined to be ineligible. Upon determination that a person is ineligible for medical benefits, the county department, the state department, or other entity designated by the state department shall notify the applicant in writing of its decision and the reason. When an applicant is found ineligible for medical assistance eligibility programs, the applicant's application data and verifications must be automatically shared with the state insurance marketplace through a system interface. Separate determination of eligibility and formal application for benefits pursuant to this article 4 and articles 5 and 6 of this title 25.5 for persons eligible pursuant to sections 25.5-5-101 and 25.5-5-201 must be made in accordance with the rules of the state department.

(a.5) Repealed.

(a.7) As part of the medicaid eligibility modernization, the department is authorized to create a universal application for case management agencies for home- and community-based services waivers for children.

(b) The state department shall develop training safeguards to prevent actions taken by staff of medical assistance sites from affecting food and cash assistance eligibility.

(2) (a) Any married couple, at the beginning of a continuous period of institutionalization of one spouse, may request the county department to assess and document the total value of the resources of the couple, if the couple supplies to the county department the necessary information and documentation which is needed to make such an assessment.

(b) Any assessment prepared by the county department and provided to a couple shall contain a procedure for appealing any determinations which have been made.

(c) If a request for assessment and documentation is not part of an application for medical assistance, the county department may establish a fee not exceeding the reasonable expenses of the county department of providing and documenting such assessment.

(3) (a) The state department shall promulgate rules to simplify the processing of applications in order that medical benefits are furnished to members as soon as possible, including rules that:

(I) Provide for initial processing of applications and determination of eligibility for medical assistance only at locations other than the county departments, at locations used for processing applications for the Colorado works program, or at the location used by the private service contractor that administers the children's basic health plan for determining eligibility of children for the plan; and

(II) May make provision for the payment of medical benefits for a period not to exceed three months prior to the date of application in cases where the applicant did not make application prior to his or her need for said medical benefits.

(b) (I) The state department shall promulgate rules that:

(A) To the extent authorized under federal law, require an applicant to state only the applicant's income and require the state department to verify the applicant's income through federally approved electronic data sources; except that, if electronic data is not available, or the information obtained from an electronic data source is not reasonably compatible with information provided by or on behalf of an applicant, the rules shall require an individual to provide documentation in order to verify the applicant's income; and

(B) Require the state department at least annually to verify a member's income eligibility at reenrollment through federally approved electronic data sources and, if the member meets all eligibility requirements, permit the member to remain enrolled in the medical assistance program. The rules must only require an individual to provide documentation verifying income if electronic data is not available or the information obtained from electronic data sources is not reasonably compatible with information provided by or on behalf of an applicant.

(C) and (D) (Deleted by amendment, L. 2009, (SB 09-292), ch. 369, p. 1974, § 96, effective August 5, 2009.)

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

(B) Notwithstanding any other provision in this subsection (3)(b), for applications that contain self-employment income, the state department shall not implement this subsection (3)(b) until the state department can verify self-employment income through federally approved electronic data sources as authorized by rules of the state department and federal law.

(C) The state department may seek federal authorization to not require additional verification during a member's eligibility reenrollment process if information about the member's income is not verified through a federally approved electronic data source. The state department may use the information on file or the information that was originally collected during the application process to determine whether the member is eligible for reenrollment. Notwithstanding this subsection (3)(b)(I.5)(C) to the contrary, the state department shall require additional income verification if information about a member's income is not verified through a federally approved electronic data source for two or more consecutive years or as specified through federal authorization.

(D) The state department may seek federal authorization to not require additional verification during a member's eligibility reenrollment process if information about the member's assets is not verified through a federally approved electronic data source in a reasonable time, as determined by the state department. The state department may complete the member's eligibility reenrollment process without any additional verification of the member's assets if there has been no change in the member's assets since the initial verification during the application process or as specified through federal authorization.

(E) The state department may seek federal authorization to delay a member's procedural termination during the reenrollment process to allow the member to continue receiving necessary services during the reenrollment process. The state department may apply this delay in procedural termination to a specific population or as specified through federal authorization.

(F) The state department may seek federal authorization to allow an applicant's or member's eligibility for reenrollment to be based on financial findings from the supplemental nutrition assistance program established pursuant to part 3 of article 2 of title 26, the temporary assistance for needy families program established pursuant to part 7 of article 2 of title 26, and other means-tested benefit programs administered through the Colorado benefits management system. The state department may apply financial eligibility for medicaid to individuals whose gross income program and assets for applicable means-tested benefit programs are below applicable medicaid limits, regardless of differences in household composition and income-counting rules between programs or as specified through federal authorization.

(G) Subject to available appropriations and upon receiving necessary federal authorization, the state department may implement subsections (3)(b)(I.5)(C), (3)(b)(I.5)(D), (3)(b)(I.5)(E), and (3)(b)(I.5)(F) of this section.

(II) Repealed.

(c) Adequate safeguards shall be established by the state department to ensure that only eligible persons receive benefits under this article and articles 5 and 6 of this title.

(d) (I) In addition, an applicant who is eighteen years of age or older shall be required to supply a form of personal photographic identification either by providing a valid Colorado driver's license or a valid identification card issued by the department of revenue pursuant to section 42-2-302, C.R.S. The state department may adopt rules that exempt applicants from the requirement of supplying a form of personal photographic identification if the requirement causes an unreasonable hardship or if the requirement is in conflict with federal law.

(II) The state department shall also adopt rules that allow for assistance to be provided until the applicant is able to obtain or qualify for a driver's license or identification card; however, a county department or an entity designated by the state department pursuant to subsection (1) of this section is not required to pursue recovery of assistance from an applicant who fails, upon recertification, to meet the photographic identification requirement.

(e) (I) In collaboration with and to augment the state department's efforts to simplify eligibility determinations for benefits under the state medical assistance program and the children's basic health plan, the state department shall establish a process so that a member, or the parent or guardian of a member, may apply for reenrollment either over the telephone or through the internet.

(II) (A) Subject to receipt of federal authorization and spending authority, the state department may implement a pilot program that allows a limited number of members to apply for reenrollment either over the telephone or through the internet during a transition to a process that will serve members statewide. The pilot program is not a replacement for a statewide process.

(B) Notwithstanding any other provision in this subsection (3)(e), the state department shall not implement this subsection (3)(e) until the state department can verify the eligibility of a member over the telephone or through the internet as authorized by rules of the state department and federal law.

(C) Notwithstanding any other provision in this paragraph (e), the state department shall not implement or administer any portion of this paragraph (e) until spending authority has been received in the general appropriation act or any supplemental appropriation and shall only implement and administer this paragraph (e) to the extent of such spending authority.

(III) The state department may solicit and accept gifts, grants, and donations from public or private sources for the development or implementation of reenrollment either over the telephone or through the internet process described in this paragraph (e); except that the state department may not accept a gift, grant, or donation that is subject to conditions that are inconsistent with this paragraph (e) or any other law. Any gifts, grants, or donations received by the state department shall be transmitted to the state treasurer, who shall credit the same to the department of health care policy and financing cash fund created pursuant to section 25.5-1-109.

(f) (I) To ensure that the state department maintains access to state and federal funding provided by the federal "Families First Coronavirus Response Act", Pub.L. 116-127, and the federal "Consolidated Appropriations Act, 2023", subsections (3)(b)(I) and (3)(d) of this section requiring the collection or verification of any information related to medical assistance eligibility factors, including citizenship, household size, income, or assets for those individuals already enrolled in the medical assistance program, are suspended until January 1, 2025.

(II) The state board may adopt rules to implement this subsection (3)(f) to ensure that the state department can resume routine operations that follow guidance issued by the federal centers for medicare and medicaid services, including terminations of eligibility, the processing of eligibility renewals, and the transition between medical assistance and children's basic health plan eligibility categories.

(III) This subsection (3)(f) is repealed, effective January 1, 2025.

(4) (a) By signing an application for medical assistance, a person assigns to the state department, by operation of law, all rights the applicant may have to medical support or payments for medical expenses from any other person on the applicant's own behalf or on behalf of any other member of the applicant's family for whom application is made. For purposes of this subsection (4), an assignment takes effect upon the determination that the applicant is eligible for medical assistance and up to three months prior to the date of application if the applicant meets the requirements of subsection (3) of this section and shall remain in effect so long as an individual is eligible for and receives medical assistance benefits. The application shall contain a statement explaining this assignment.

(b) An applicant for medical benefits upon initial application and each redetermination shall disclose any third party who may be responsible for the payment of medical expenses on behalf of the applicant or any other member of the applicant's family for whom application is made. As part of its medicaid eligibility modernization, the state department shall require the county department or other entity designated to accept applications for medical benefits to enter the third-party information into the automated system developed pursuant to section 25.5-4-204.

(5) (a) The state department shall not pursue recovery from a county for the cost of medical services provided to a person who has been incorrectly determined eligible for medical assistance by that county or any other entity.

(b) (Deleted by amendment, L. 2008, p. 2024, § 1, effective June 3, 2008.)
C.R.S. § 25.5-4-402.4 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-402.4
25.5-4-402.4. Hospitals - healthcare affordability and sustainability fee - Colorado healthcar
Status: repealed

25.5-4-402.4. Hospitals - healthcare affordability and sustainability fee - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - reports - rules - legislative declaration - repeal. (1) Short title. The short title of this section is the "Colorado Healthcare Affordability and Sustainability Enterprise Act of 2017".

(2) Legislative declaration. The general assembly hereby finds and declares that:

(a) The state and the providers of publicly funded medical services, and hospitals in particular, share a common commitment to comprehensive health-care reform;

(b) Hospitals within the state incur significant costs by providing uncompensated emergency department care and other uncompensated medical services to low-income and uninsured populations;

(c) This section is enacted as part of a comprehensive health-care reform and is intended to provide the following services and benefits to hospitals and individuals:

(I) Providing a payer source for some low-income and uninsured populations who may otherwise be cared for in emergency departments and other settings in which uncompensated care is provided;

(II) Reducing the underpayment to Colorado hospitals participating in publicly funded health insurance programs;

(III) Reducing the number of persons in Colorado who are without health-care benefits;

(IV) Reducing the need of hospitals and other health-care providers to shift the cost of providing uncompensated care to other payers;

(V) Expanding access to high-quality, affordable health care for low-income and uninsured populations; and

(VI) Providing the additional business services specified in subsection (4)(a)(IV) of this section to hospitals that pay the healthcare affordability and sustainability fee charged and collected as authorized by subsection (4) of this section by the Colorado healthcare affordability and sustainability enterprise created in subsection (3)(a) of this section;

(d) The Colorado healthcare affordability and sustainability enterprise provides business services to hospitals when, in exchange for payment of healthcare affordability and sustainability fees by hospitals, it:

(I) [Editor's note: This version of subsection (2)(d)(I) is effective until July 1, 2025.] Obtains federal matching money and returns both the healthcare affordability and sustainability fee and the federal matching money to hospitals to increase reimbursement rates to hospitals for providing medical care under the state medical assistance program and the Colorado indigent care program and to increase the number of individuals covered by public medical assistance; and

(I) [Editor's note: This version of subsection (2)(d)(I) is effective July 1, 2025.] Obtains federal matching money and returns both the healthcare affordability and sustainability fee and the federal matching money to hospitals to increase reimbursement rates to hospitals for providing medical care under the state medical assistance program, including disproportionate share hospital payments pursuant to 42 U.S.C. sec. 1396r-4, and to increase the number of individuals covered by public medical assistance; and

(II) Provides additional business services to hospitals as specified in subsection (4)(a)(IV) of this section;

(e) It is necessary, appropriate, and in the best interest of the state to acknowledge that by providing the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section, the Colorado healthcare affordability and sustainability enterprise engages in an activity conducted in the pursuit of a benefit, gain, or livelihood and therefore operates as a business;

(f) Consistent with the determination of the Colorado supreme court in Nicholl v. E-470 Public Highway Authority, 896 P.2d 859 (Colo. 1995), that the power to impose taxes is inconsistent with enterprise status under section 20 of article X of the state constitution, it is the conclusion of the general assembly that the healthcare affordability and sustainability fee charged and collected by the Colorado healthcare affordability and sustainability enterprise is a fee, not a tax, because the fee is imposed for the specific purposes of allowing the enterprise to defray the costs of providing the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section to hospitals that pay the fee and is collected at rates that are reasonably calculated based on the benefits received by those hospitals; and

(g) So long as the Colorado healthcare affordability and sustainability enterprise qualifies as an enterprise for purposes of section 20 of article X of the state constitution, the revenues from the healthcare affordability and sustainability fee charged and collected by the enterprise are not state fiscal year spending, as defined in section 24-77-102 (17), or state revenues, as defined in section 24-77-103.6 (6)(c), and do not count against either the state fiscal year spending limit imposed by section 20 of article X of the state constitution or the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I).

(3) Colorado healthcare affordability and sustainability enterprise. (a) The Colorado healthcare affordability and sustainability enterprise, referred to in this section as the "enterprise", is created. The enterprise is and operates as a government-owned business within the state department for the purpose of charging and collecting the healthcare affordability and sustainability fee, leveraging healthcare affordability and sustainability fee revenue to obtain federal matching money, and utilizing and deploying the healthcare affordability and sustainability fee revenue and federal matching money to provide the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section to hospitals that pay the healthcare affordability and sustainability fee.

(b) The enterprise constitutes an enterprise for purposes of section 20 of article X of the state constitution so long as it retains the authority to issue revenue bonds and receives less than ten percent of its total revenues in grants from all Colorado state and local governments combined. So long as it constitutes an enterprise pursuant to this subsection (3)(b), the enterprise is not subject to any provisions of section 20 of article X of the state constitution.

(c) (I) The repeal of the hospital provider fee program, as it existed pursuant to section 25.5-4-402.3 before its repeal, effective July 1, 2017, by Senate Bill 17-267, enacted in 2017, and the creation of the Colorado healthcare affordability and sustainability enterprise as a new enterprise to charge and collect a new healthcare affordability and sustainability fee as authorized by subsection (4) of this section and provide healthcare affordability and sustainability fee-funded business services to hospitals that replace and supplement services previously funded by hospital provider fees is the creation of a new government-owned business that provides business services to hospitals as a new enterprise for purposes of section 20 of article X of the state constitution, does not constitute the qualification of an existing government-owned business as an enterprise for purposes of section 20 of article X of the state constitution or section 24-77-103.6 (6)(b)(II), and, therefore, does not require or authorize adjustment of the state fiscal year spending limit calculated pursuant to section 20 of article X of the state constitution or the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I).

(II) Notwithstanding subsection (3)(c)(I) of this section, because the repeal of the hospital provider fee program, as it existed pursuant to section 25.5-4-402.3 before its repeal by Senate Bill 17-267, enacted in 2017, will allow the state to spend more general fund money for general governmental purposes than it would otherwise be able to spend below the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I), it is appropriate to restrain the growth of government by lowering the base amount used to calculate the excess state revenues cap for the 2017-18 state fiscal year by two hundred million dollars.

(d) The enterprise's primary powers and duties are:

(I) To charge and collect the healthcare affordability and sustainability fee as specified in subsection (4) of this section;

(II) To leverage healthcare affordability and sustainability fee revenue collected to obtain federal matching money, working with or through the state department and the state board to the extent required by federal law or otherwise necessary;

(III) To expend healthcare affordability and sustainability fee revenue, matching federal money, and any other money from the healthcare affordability and sustainability fee cash fund as specified in subsections (4) and (5) of this section;

(IV) To issue revenue bonds payable from the revenues of the enterprise;

(V) To enter into agreements with the state department to the extent necessary to collect and expend healthcare affordability and sustainability fee revenue;

(VI) To engage the services of private persons or entities serving as contractors, consultants, and legal counsel for professional and technical assistance and advice and to supply other services related to the conduct of the affairs of the enterprise, including the provision of additional business services to hospitals as specified in subsection (4)(a)(IV) of this section; and

(VII) To adopt and amend or repeal policies for the regulation of its affairs and the conduct of its business consistent with the provisions of this section.

(e) The enterprise is a type 2 entity, as defined in section 24-1-105, and exercises its powers and performs its duties and functions under the department.

(4) Healthcare affordability and sustainability fee. (a) [Editor's note: This version of the introductory portion to subsection (4)(a) is effective until July 1, 2025.] For the fiscal year commencing July 1, 2017, and for each fiscal year thereafter, the enterprise is authorized to charge and collect a healthcare affordability and sustainability fee, as described in 42 CFR 433.68 (b), on outpatient and inpatient services provided by all licensed or certified hospitals, referred to in this section as "hospitals", for the purpose of obtaining federal financial participation under the state medical assistance program as described in this article 4 and articles 5 and 6 of this title 25.5, referred to in this section as the "state medical assistance program", and the Colorado indigent care program described in part 1 of article 3 of this title 25.5, referred to in this section as the "Colorado indigent care program". If the amount of healthcare affordability and sustainability fee revenue collected exceeds the federal net patient revenue-based limit on the amount of such fee revenue that may be collected, requiring repayment to the federal government of excess federal matching money received, hospitals that received such excess federal matching money shall be responsible for repaying the excess federal money and any associated federal penalties to the federal government. The enterprise shall use the healthcare affordability and sustainability fee revenue to:

(4) Healthcare affordability and sustainability fee. (a) [Editor's note: This version of the introductory portion to subsection (4)(a) is effective July 1, 2025.] For the fiscal year commencing July 1, 2017, and for each fiscal year thereafter, the enterprise is authorized to charge and collect a healthcare affordability and sustainability fee, as described in 42 CFR 433.68 (b), on outpatient and inpatient services provided by all licensed or certified hospitals, referred to in this section as "hospitals", for the purpose of obtaining federal financial participation under the state medical assistance program as described in this article 4 and articles 5 and 6 of this title 25.5, referred to in this section as the "state medical assistance program", including disproportionate share hospital payments pursuant to 42 U.S.C. sec. 1396r-4. If the amount of healthcare affordability and sustainability fee revenue collected exceeds the federal net patient revenue-based limit on the amount of such fee revenue that may be collected, requiring repayment to the federal government of excess federal matching money received, hospitals that received such excess federal matching money are responsible for repaying the excess federal money and any associated federal penalties to the federal government. The enterprise shall use the healthcare affordability and sustainability fee revenue to:

(I) [Editor's note: This version of subsection (4)(a)(I) is effective until July 1, 2025.] Provide a business service to hospitals by increasing reimbursement to hospitals for providing medical care under:

(A) The state medical assistance program; and

(B) The Colorado indigent care program;

(I) [Editor's note: This version of subsection (4)(a)(I) is effective July 1, 2025.] Provide a business service to hospitals by increasing reimbursement to hospitals for providing:

(A) Medical care under the state medical assistance program; and

(B) Hospital financial assistance programs for care provided to uninsured patients;

(II) Provide a business service to hospitals by increasing the number of individuals covered by public medical assistance and thereby reducing the amount of uncompensated care that the hospitals must provide;

(II.3) (A) For state fiscal years 2019-20, 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, and the "American Rescue Plan Act of 2021", Pub.L. 116-260, are still available only, offset general fund expenditures for the state medical assistance program.

(B) This subsection (4)(a)(II.3) is repealed, effective December 31, 2024.

(II.5) Repealed.

(III) Pay the administrative costs to the enterprise in implementing and administering this section subject to the limitation that administrative costs of the enterprise are limited to three percent of the enterprise's expenditures based on a methodology approved by the office of state planning and budgeting and the staff of the joint budget committee of the general assembly; and

(IV) Provide or contract for or arrange the provision of additional business services to hospitals by:

(A) Consulting with hospitals to help them improve both cost efficiency and patient safety in providing medical services and the clinical effectiveness of those services;

(B) Advising hospitals regarding potential changes to federal and state laws and regulations that govern the provision of and reimbursement paid for medical services under the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5;

(C) Providing coordinated services to hospitals to help them adapt and transition to any new or modified performance tracking and payment systems for the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5, which may include data sharing, telehealth coordination and support, establishment of performance metrics, benchmarking to such metrics, and clinical and administrative process consulting and other appropriate services;

(D) Providing any other services to hospitals that aid them in efficiently and effectively participating in the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5; and

(E) Providing funding for, and in cooperation with the state department and hospitals supporting the implementation of, a health-care delivery system reform incentive payments program as described in subsection (8) of this section.

(b) The enterprise shall recommend for approval and establishment by the state board the amount of the healthcare affordability and sustainability fee that it intends to charge and collect. The state board must establish the final amount of the fee by rules promulgated in accordance with article 4 of title 24. The state board shall not establish any amount that exceeds the federal limit for such fees. The state board may deviate from the recommendations of the enterprise, but shall express in writing the reasons for any deviations. In establishing the amount of the fee and in promulgating the rules governing the fee, the state board shall:

(I) Consider recommendations of the enterprise;

(II) Establish the amount of the healthcare affordability and sustainability fee so that the amount collected from the fee and federal matching funds associated with the fee are sufficient to pay for the items described in subsection (4)(a) of this section, but nothing in this subsection (4)(b)(II) requires the state board to increase the fee above the amount recommended by the enterprise; and

(III) For the 2017-18 fiscal year, establish the amount of the healthcare affordability and sustainability fee so that the amount collected from the fee is approximately equal to the sum of the amounts of the appropriations specified for the fee in the general appropriation act, Senate Bill 17-254, enacted in 2017, and any other supplemental appropriation act.

(c) (I) In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1) and (e)(2), the enterprise, acting in concert with or through an agreement with the state department if required by federal law, may seek a waiver from the broad-based healthcare affordability and sustainability fee requirement or the uniform healthcare affordability and sustainability fee requirement, or both. In addition, the enterprise, acting in concert with or through an agreement with the state department if required by federal law, shall seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health-care delivery system reform incentive payments program as described in subsection (8) of this section. Subject to federal approval and to minimize the financial impact on certain hospitals, the enterprise may exempt from payment of the healthcare affordability and sustainability fee certain types of hospitals, including but not limited to:

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

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

(C) [Editor's note: This version of subsection (4)(c)(I)(C) 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 under 42 CFR part 485, subpart F;

(C) [Editor's note: This version of subsection (4)(c)(I)(C) is effective July 1, 2026.] Critical access hospitals that are licensed and certified by the department of public health and environment under 42 CFR 485, subpart F;

(D) Inpatient rehabilitation facilities; or

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

(II) In determining whether a hospital may be excluded, the enterprise shall use one or more of the following criteria:

(A) A hospital that is located in a rural area;

(B) A hospital with which the state department does not contract to provide services under the state medical assistance program;

(C) A hospital whose inclusion or exclusion would not significantly affect the net benefit to hospitals paying the healthcare affordability and sustainability fee; or

(D) A hospital that must be included to receive federal approval.

(III) The enterprise may reduce the amount of the healthcare affordability and sustainability fee for certain hospitals to obtain federal approval and to minimize the financial impact on certain hospitals. In determining for which hospitals the enterprise may reduce the amount of the healthcare affordability and sustainability fee, the enterprise shall use one or more of the following criteria:

(A) The hospital is a type of hospital described in subsection (4)(c)(I) of this section;

(B) The hospital is located in a rural area;

(C) The hospital serves a higher percentage than the average hospital of persons covered by the state medical assistance program, medicare, or commercial insurance or persons enrolled in a managed care organization;

(D) The hospital does not contract with the state department to provide services under the state medical assistance program;

(E) If the hospital paid a reduced healthcare affordability and sustainability fee, the reduced fee would not significantly affect the net benefit to hospitals paying the healthcare affordability and sustainability fee; or

(F) The hospital is required not to pay a reduced healthcare affordability and sustainability fee as a condition of federal approval.

(IV) The enterprise may change how it pays hospital reimbursement or quality incentive payments, or both, in whole or in part, under the authority of a federal waiver if the total reimbursement to hospitals is equal to or above the federal upper payment limit calculation under the waiver.

(d) The enterprise may alter the process prescribed in this subsection (4) to the extent necessary to meet the federal requirements and to obtain federal approval.

(e) (I) The enterprise shall establish policies on the calculation, assessment, and timing of the healthcare affordability and sustainability fee. The enterprise shall assess the healthcare affordability and sustainability fee on a schedule to be set by the enterprise board as provided in subsection (7)(d) of this section. The periodic healthcare affordability and sustainability fee payments from a hospital and the enterprise's reimbursement to the hospital under subsections (5)(b)(I) and (5)(b)(II) of this section are due as nearly simultaneously as feasible; except that the enterprise's reimbursement to the hospital is due no more than two days after the periodic healthcare affordability and sustainability fee payment is received from the hospital. The healthcare affordability and sustainability fee must be imposed on each hospital even if more than one hospital is owned by the same entity. The fee must be prorated and adjusted for the expected volume of service for any year in which a hospital opens or closes.

(II) The enterprise is authorized to refund any unused portion of the healthcare affordability and sustainability fee. For any portion of the healthcare affordability and sustainability fee that has been collected by the enterprise but for which the enterprise has not received federal matching funds, the enterprise shall refund back to the hospital that paid the fee the amount of that portion of the fee within five business days after the fee is collected.

(III) The enterprise shall establish requirements for the reports that hospitals must submit to the enterprise to allow the enterprise to calculate the amount of the healthcare affordability and sustainability fee. Notwithstanding the provisions of part 2 of article 72 of title 24 or subsection (7)(f) of this section, information provided to the enterprise pursuant to this section is confidential and is not a public record. Nonetheless, the enterprise may prepare and release summaries of the reports to the public.

(f) A hospital shall not include any amount of the healthcare affordability and sustainability fee as a separate line item in its billing statements.

(g) [Editor's note: This version of subsection (4)(g) is effective until July 1, 2025.] The state board shall promulgate any rules pursuant to the "State Administrative Procedure Act", article 4 of title 24, necessary for the administration and implementation of this section. Prior to submitting any proposed rules concerning the administration or implementation of the healthcare affordability and sustainability fee to the state board, the enterprise shall consult with the state board on the proposed rules as specified in subsection (7)(d) of this section.

(g) [Editor's note: This version of subsection (4)(g) is effective July 1, 2025.] (I) The state board shall promulgate any rules pursuant to the "State Administrative Procedure Act", article 4 of title 24, necessary for the administration and implementation of this section. Prior to submitting any proposed rules concerning the administration or implementation of the healthcare affordability and sustainability fee to the state board, the enterprise shall consult with the state board on the proposed rules as specified in subsection (7)(d) of this section.

(II) No later than July 1, 2025, the state board, in consultation with the enterprise, shall promulgate rules concerning the policy for qualification for disproportionate share hospital payments. Subject to the requirements under federal law, the disproportionate share hospital payment policy must direct funding to hospitals serving a greater proportion of medicaid and uninsured patients compared to other hospitals and offering financial assistance to lower-income Coloradans.

(5) Healthcare affordability and sustainability fee cash fund. (a) Any healthcare affordability and sustainability fee collected pursuant to this section by the enterprise must be transmitted to the state treasurer, who shall credit the fee to the healthcare affordability and sustainability fee cash fund, which fund is hereby created and referred to in this section as the "fund". The state treasurer shall credit all interest and income derived from the deposit and investment of money in the fund to the fund. The state treasurer shall invest any money in the fund not expended for the purposes specified in subsection (5)(b) of this section as provided by law. Money in the fund shall not be transferred to any other fund and shall not be used for any purpose other than the purposes specified in this subsection (5) and in subsection (4) of this section.

(b) All money in the fund is subject to federal matching as authorized under federal law and, subject to annual appropriation by the general assembly, shall be expended by the enterprise for the following purposes:

(I) To maximize the inpatient and outpatient hospital reimbursements to up to the upper payment limits as defined in 42 CFR 447.272 and 42 CFR 447.321;

(II) [Editor's note: This version of subsection (5)(b)(II) is effective until July 1, 2025.] To increase hospital reimbursements under the Colorado indigent care program to up to one hundred percent of the hospital's costs of providing medical care under the program;

(II) [Editor's note: This version of subsection (5)(b)(II) is effective July 1, 2025.] To increase hospital reimbursements through disproportionate share hospital payments to up to one hundred percent of the hospital's hospital-specific disproportionate share hospital limit;

(III) To pay the quality incentive payments provided in section 25.5-4-402 (3);

(IV) Subject to available revenue from the healthcare affordability and sustainability fee and federal matching funds, to expand eligibility for public medical assistance by:

(A) Increasing the eligibility level for parents and caretaker relatives of children who are eligible for medical assistance, pursuant to section 25.5-5-201 (1)(m), from sixty-one percent to one hundred thirty-three percent of the federal poverty line;

(B) Increasing the eligibility level for children and pregnant women under the children's basic health plan to up to two hundred sixty percent of the federal poverty line;

(C) Providing eligibility under the state medical assistance program for a childless adult or an adult without a dependent child in the home, pursuant to section 25.5-5-201 (1)(p), who earns up to one hundred thirty-three percent of the federal poverty line; and

(D) Providing a buy-in program in the state medical assistance program for disabled adults and children whose families have income of up to four hundred fifty percent of the federal poverty line;

(V) To provide continuous eligibility for twelve months for children enrolled in the state medical assistance program;

(VI) To pay the enterprise's actual administrative costs of implementing and administering this section, including but not limited to the following costs:

(A) Administrative expenses of the enterprise;

(B) The enterprise's actual costs related to implementing and maintaining the healthcare affordability and sustainability fee, including personal services, operating, and consulting expenses;

(C) The enterprise's actual costs for the changes and updates to the medicaid management information system for the implementation of subsections (5)(b)(I) to (5)(b)(III) of this section;

(D) [Editor's note: This version of subsection (5)(b)(VI)(D) is effective until July 1, 2025.] The enterprise's personal services and operating costs related to personnel, consulting services, and for review of hospital costs necessary to implement and administer the increases in inpatient and outpatient hospital payments made pursuant to subsection (5)(b)(I) of this section, increases in the Colorado indigent care program payments made pursuant to subsection (5)(b)(II) of this section, and quality incentive payments made pursuant to subsection (5)(b)(III) of this section;

(D) [Editor's note: This version of subsection (5)(b)(VI)(D) is effective July 1, 2025.] The enterprise's personal services and operating costs related to personnel, consulting services, and for review of hospital costs necessary to implement and administer the increases in inpatient and outpatient hospital payments made pursuant to subsection (5)(b)(I) of this section, disproportionate share hospital payments made pursuant to subsection (5)(b)(II) of this section, and quality incentive payments made pursuant to subsection (5)(b)(III) of this section;

(E) The enterprise's actual costs for the changes and updates to the Colorado benefits management system and medicaid management information system to implement and maintain the expanded eligibility provided for in subsections (5)(b)(IV) and (5)(b)(V) of this section;

(F) The enterprise's personal services and operating costs related to personnel necessary to implement and administer the expanded eligibility for public medical assistance provided for in subsections (5)(b)(IV) and (5)(b)(V) of this section, including but not limited to administrative costs associated with the determination of eligibility for public medical assistance by county departments; and

(G) The enterprise's personal services, operating, and systems costs related to expanding the opportunity for individuals to apply for public medical assistance directly at hospitals or through another entity outside the county departments, in connection with section 25.5-4-205, that would increase access to public medical assistance and reduce the number of uninsured served by hospitals;

(VII) To offset the loss of any federal matching money due to a decrease in the certification of the public expenditure process for outpatient hospital services for medical services premiums that were in effect as of July 1, 2008;

(VIII) Subject to any necessary federal waivers being obtained, to provide funding for a health-care delivery system reform incentive payments program as described in subsection (8) of this section;

(VIII.3) (A) For state fiscal years 2019-20, 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, and the "American Rescue Plan Act of 2021", Pub.L. 116-260, are still available only, and regardless of when this federal money is made available, the amount in excess of the fifty percent federal financial participation generated by increased reimbursements and payments appropriated for use in subsections (5)(b)(I) to (5)(b)(III) of this section pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto, to offset general fund expenditures for the state medical assistance program.

(B) This subsection (5)(b)(VIII.3) is repealed, effective December 31, 2024.

(VIII.5) and (VIII.7) Repealed.

(IX) To provide additional business services to hospitals as specified in subsection (4)(a)(IV) of this section.

(c) ARPA home- and community-based services account. (I) (A) There is created the "ARPA home- and community-based services account" within the fund, referred to in this subsection (5)(c) as the "ARPA account". Notwithstanding any other provision of this section to the contrary, money in the ARPA account as a result of fund savings and federal matching dollars must be used in accordance with section 9817 of the federal "American Rescue Plan Act of 2021", Pub.L. 117-2, as amended, referred to in this section as "ARPA", to implement or supplement the implementation of home- and community-based services under the medical assistance program pursuant to the provisions of part 18 of article 6 of this title 25.5.

(B) Notwithstanding subsection (5)(c)(I)(A) or any other provision of this section, money in the ARPA account may be used for a purpose that is ineligible for a federal match but otherwise authorized pursuant to the ARPA if the general assembly appropriates the money for that purpose.

(II) (A) On June 30, 2021, the state treasurer shall transfer nineteen million eight hundred thirty thousand nine hundred eighteen dollars from the fund to the ARPA account.

(B) If the fund savings due to the enhanced federal match under ARPA is greater than the amount transferred to the ARPA account under subsection (5)(c)(II)(A) of this section, then the state department shall notify the state treasurer of the amount by which the savings exceeds the transfer. The state treasurer shall transfer this amount from the fund to the ARPA account.

(C) If the fund savings due to the enhanced federal match under ARPA is less than the amount transferred to the ARPA account under subsection (5)(c)(II)(A) of this section, then the state department shall notify the state treasurer of the amount by which the transfer exceeds the savings. The state treasurer shall transfer this amount from the ARPA account to the fund.

(III) The state treasurer shall credit all interest and income derived from the money in the ARPA account to the fund.

(IV) Money in the ARPA account is subject to annual appropriation by the general assembly consistent with the purposes specified in this section and ARPA, and pursuant to part 18 of article 6 of this title 25.5.

(V) Money in the ARPA account remains in the ARPA account until the end of the spending period authorized under ARPA, at which time money remaining in the ARPA account becomes part of the fund.

(VI) This subsection (5)(c) is repealed, effective July 1, 2025.

(6) Appropriations. (a) (I) Except as otherwise provided in subsection (6)(b)(I.5) or (6)(b)(I.7) of this section, the healthcare affordability and sustainability fee is to supplement, not supplant, general fund appropriations to support hospital reimbursements. General fund appropriations for hospital reimbursements shall be maintained at the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008; except that general fund appropriations for hospital reimbursements may be reduced if an index of appropriations to other providers shows that general fund appropriations are reduced for other providers. If the index shows that general fund appropriations are reduced for other providers, the general fund appropriations for hospital reimbursements shall not be reduced by a greater percentage than the reductions of appropriations for the other providers as shown by the index.

(II) If general fund appropriations for hospital reimbursements are reduced below the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008, the general fund appropriations will be increased back to the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008, at the same percentage as the appropriations for other providers as shown by the index. The general assembly is not obligated to increase the general fund appropriations back to the level of appropriations in the medical services premium line item in a single fiscal year, and such increases may occur over nonconsecutive fiscal years.

(III) For purposes of this subsection (6)(a), the "index of appropriations to other providers" or "index" means the average percent change in reimbursement rates through appropriations or legislation enacted by the general assembly to home health providers, physician services, and outpatient pharmacies, excluding dispensing fees. The state board, after consultation with the enterprise board, is authorized to clarify this definition as necessary by rule.

(b) If the revenue from the healthcare affordability and sustainability fee is insufficient to fully fund all of the purposes described in subsection (5)(b) of this section:

(I) The general assembly is not obligated to appropriate general fund revenues to fund such purposes;

(I.3) Repealed.

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

(B) This subsection (6)(b)(I.5) is repealed, effective December 31, 2024.

(I.7) Repealed.

(II) The hospital provider reimbursement and quality incentive payment increases described in subsections (5)(b)(I) to (5)(b)(III) of this section and the costs described in subsection (5)(b)(VI) of this section shall be fully funded using revenue from the healthcare affordability and sustainability fee and federal matching funds before any eligibility expansion is funded; and

(III) (A) If the state board promulgates rules that expand eligibility for medical assistance to be paid for pursuant to subsection (5)(b)(IV) of this section, and the state department thereafter notifies the enterprise board that the revenue available from the healthcare affordability and sustainability fee and the federal matching funds will not be sufficient to pay for all or part of the expanded eligibility, the enterprise board shall recommend to the state board reductions in medical benefits or eligibility so that the revenue will be sufficient to pay for all of the reduced benefits or eligibility. After receiving the recommendations of the enterprise board, the state board shall adopt rules providing for reduced benefits or reduced eligibility for which the revenue will be sufficient and shall forward any adopted rules to the joint budget committee. Notwithstanding the provisions of section 24-4-103 (8) and (12), following the adoption of rules pursuant to this subsection (6)(b)(III)(A), the state board shall not submit the rules to the attorney general and shall not file the rules with the secretary of state until the joint budget committee approves the rules pursuant to subsection (6)(b)(III)(B) of this section.

(B) The joint budget committee shall promptly consider any rules adopted by the state board pursuant to subsection (6)(b)(III)(A) of this section. The joint budget committee shall promptly notify the state department, the state board, and the enterprise board of any action on the rules. If the joint budget committee does not approve the rules, the joint budget committee shall recommend a reduction in benefits or eligibility so that the revenue from the healthcare affordability and sustainability fee and the matching federal funds will be sufficient to pay for the reduced benefits or eligibility. After approving the rules pursuant to this subsection (6)(b)(III)(B), the joint budget committee shall request that the committee on legal services, created pursuant to section 2-3-501, extend the rules as provided for in section 24-4-103 (8) unless the committee on legal services finds after review that the rules do not conform with section 24-4-103 (8)(a).

(C) After the state board has received notification of the approval of rules adopted pursuant to subsection (6)(b)(III)(A) of this section, the state board shall submit the rules to the attorney general pursuant to section 24-4-103 (8)(b) and shall file the rules and the opinion of the attorney general with the secretary of state pursuant to section 24-4-103 (12) and with the office of legislative legal services. Pursuant to section 24-4-103 (5), the rules are effective twenty days after publication of the rules and are only effective until the following May 15 unless the rules are extended pursuant to a bill enacted pursuant to section 24-4-103 (8).

(c) Notwithstanding any other provision of this section, if, after receipt of authorization to receive federal matching funds for money in the fund, the authorization is withdrawn or changed so that federal matching funds are no longer available, the enterprise shall cease collecting the healthcare affordability and sustainability fee and shall repay to the hospitals any money received by the fund that is not subject to federal matching funds.

(7) Colorado healthcare affordability and sustainability enterprise board. (a) (I) Except as otherwise provided in subsection (7)(a)(II) of this section, the enterprise board consists of thirteen members appointed by the governor, with the advice and consent of the senate, as follows:

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

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

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

(D) One member of the health-care industry who does not represent a hospital or a health insurance carrier;

(E) One member who is a consumer of health care and who is not a representative or an employee of a hospital, health insurance carrier, or other health-care industry entity;

(F) One member who is a representative of persons with disabilities, who is living with a disability, and who is not a representative or an employee of a hospital, health insurance carrier, or other health-care industry entity;

(G) One member who is a representative of a business that purchases or otherwise provides health insurance for its employees; and

(H) Two employees of the state department.

(II) The initial members of the enterprise board are the members of the hospital provider fee oversight and advisory board that was created and existed pursuant to section 25.5-4-402.3 (6), prior to July 1, 2017, and such members shall serve on and after July 1, 2017, for the remainder of the terms for which they were appointed as members of the advisory board. The powers, duties, and functions of the enterprise board include the powers, duties, and functions of the former hospital provider fee oversight and advisory board, and the hospital provider fee oversight and advisory board is abolished.

(III) The governor shall consult with representatives of a statewide organization of hospitals in making the appointments pursuant to subsections (7)(a)(I)(A) and (7)(a)(I)(B) of this section. No more than six members of the enterprise board may be members of the same political party.

(IV) Members of the enterprise board serve at the pleasure of the governor. All terms are for four years. A member who is appointed to fill a vacancy shall serve the remainder of the unexpired term of the former member.

(V) The governor shall designate a chair from among the members of the enterprise board appointed pursuant to subsections (7)(a)(I)(A) to (7)(a)(I)(G) of this section. The enterprise board shall elect a vice-chair from among its members.

(b) Members of the enterprise board serve without compensation but must be reimbursed from money in the fund for actual and necessary expenses incurred in the performance of their duties pursuant to this section.

(c) The enterprise board may contract for a group facilitator to assist the members of the enterprise board in performing their required duties.

(d) The enterprise board has, at a minimum, the following duties:

(I) To determine the timing and method by which the enterprise assesses the healthcare affordability and sustainability fee and the amount of the fee;

(II) If requested by the health and human services committee of the senate or the public health care and human services committee of the house of representatives, or any successor committees, to consult with the committees on any legislation that may impact the healthcare affordability and sustainability fee or hospital reimbursements established pursuant to this section;

(III) To determine changes in the healthcare affordability and sustainability fee that increase the number of hospitals benefitting from the uses of the healthcare affordability and sustainability fee described in subsections (5)(b)(I) to (5)(b)(IV) of this section or that minimize the number of hospitals that suffer losses as a result of paying the healthcare affordability and sustainability fee;

(IV) To recommend to the state department reforms or changes to the inpatient hospital and outpatient hospital reimbursements and quality incentive payments made under the state medical assistance program to increase provider accountability, performance, and reporting;

(V) To direct and oversee the enterprise in seeking, in concert with or through an agreement with the state department if required by federal law, any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health-care delivery system reform incentive payments program as described in subsection (8) of this section;

(VI) To recommend to the state department the schedule and approach to the implementation of subsections (5)(b)(IV) and (5)(b)(V) of this section;

(VII) If money in the fund is insufficient to fully fund all of the purposes specified in subsection (5)(b) of this section, to recommend to the state board changes to the expanded eligibility provisions described in subsection (5)(b)(IV) of this section;

(VIII) To prepare the reports specified in subsection (7)(e) of this section;

(IX) To monitor the impact of the healthcare affordability and sustainability fee on the broader health-care marketplace;

(X) To establish requirements for the reports that hospitals must submit to the enterprise to allow the enterprise to calculate the amount of the healthcare affordability and sustainability fee; and

(XI) To perform any other duties required to fulfill the enterprise board's charge or those assigned to it by the state board or the executive director.

(e) On or before January 15, 2018, and on or before January 15 each year thereafter, the enterprise board shall submit a written report to the health and human services committee of the senate and the public health care and human services committee of the house of representatives, or any successor committees, the joint budget committee of the general assembly, the governor, and the state board. The report shall include, but need not be limited to:

(I) The recommendations made to the state board pursuant to this section;

(II) A description of the formula for how the healthcare affordability and sustainability fee is calculated and the process by which the healthcare affordability and sustainability fee is assessed and collected;

(III) An itemization of the total amount of the healthcare affordability and sustainability fee paid by each hospital and any projected revenue that each hospital is expected to receive due to:

(A) The increased reimbursements made pursuant to subsections (5)(b)(I) and (5)(b)(II) of this section and the quality incentive payments made pursuant to subsection (5)(b)(III) of this section; and

(B) The increased eligibility described in subsections (5)(b)(IV) and (5)(b)(V) of this section;

(IV) An itemization of the costs incurred by the enterprise in implementing and administering the healthcare affordability and sustainability fee;

(V) Estimates of the differences between the cost of care provided and the payment received by hospitals on a per-patient basis, aggregated for all hospitals, for patients covered by each of the following:

(A) Medicaid;

(B) Medicare; and

(C) All other payers; and

(VI) A summary of:

(A) The efforts made by the enterprise, acting in concert with or through an agreement with the state department if required by federal law, to seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health-care delivery system reform incentive payments program as described in subsection (8) of this section; and

(B) The progress actually made by the enterprise, in cooperation with the state department and hospitals, towards the goal of implementing such a program.

(e.5) The enterprise board shall calculate the estimates described in subsection (7)(e)(V) of this section by using appropriate information provided to the state department by hospitals and any state department analysis of that information.

(f) (I) The enterprise is subject to the open meetings provisions of the "Colorado Sunshine Act of 1972", contained in part 4 of article 6 of title 24, and the "Colorado Open Records Act", part 2 of article 72 of title 24.

(II) For purposes of the "Colorado Open Records Act", part 2 of article 72 of title 24, and except as may otherwise be provided by federal law or regulation or state law, the records of the enterprise are public records, as defined in section 24-72-202 (6), regardless of whether the enterprise receives less than ten percent of its total annual revenues in grants, as defined in section 24-77-102 (7), from all Colorado state and local governments combined.

(III) The enterprise is a public entity for purposes of part 2 of article 57 of title 11.

(8) Health-care delivery system reform incentive payments program - funding and implementation. The enterprise, acting in concert with or through an agreement with the state department if required by federal law, shall seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation, no earlier than October 1, 2019, of a health-care delivery system reform incentive payments program that will improve health-care access and outcomes for individuals served by the state department while efficiently utilizing available financial resources. Such a program must, at a minimum:

(a) Include an initial planning phase to:

(I) Assess needs; and

(II) Develop achievable outcome-based metrics to be used to measure progress towards program goals, including the goals of health-care delivery system integration, improved patient outcomes, and more efficient provision of care; and

(b) Address the following focus areas:

(I) Care coordination and care transition management;

(II) Integration of physical and behavioral health-care services;

(III) Chronic condition management;

(IV) Targeted population health; and

(V) Data-driven accountability and outcome measurement.
C.R.S. § 25.5-3-101 — CO Code / Title 25.5 / Article 3 / Part 1 / Section 25.5-3-101
25.5-3-101. Short title
Status: in_force

25.5-3-101. Short title. This part 1 shall be known and may be cited as the "Colorado Indigent Care Program".
C.R.S. § 25.5-8-104 — CO Code / Title 25.5 / Article 8 / Section 25.5-8-104
25.5-8-104. Children's basic health plan - rules
Status: repealed

25.5-8-104. Children's basic health plan - rules. The medical services board is authorized to adopt rules to implement the children's basic health plan to provide health insurance coverage to eligible persons on a statewide basis pursuant to the provisions of this article. Any rules adopted by the children's basic health plan policy board in accordance with the requirements of the "State Administrative Procedure Act", article 4 of title 24, C.R.S., shall be enforceable and shall be valid until amended or repealed by the medical services board.
C.R.S. § 25.5-2.5-207 — CO Code / Title 25.5 / Article 2.5 / Part 2 / Section 25.5-2.5-207
25.5-2.5-207. Importation program authorized - rules
Status: in_force

25.5-2.5-207. Importation program authorized - rules. (1) Upon approval by the United States secretary of health and human services, in accordance with section 25.5-2.5-205, the state department shall administer an importation program.

(2) The state department shall approve a method of financing the administrative costs of the importation program, which method may include imposing a fee on each prescription pharmaceutical product sold through the importation program or any other appropriate method determined by the state department to finance administrative costs. The state department shall not require a fee in an amount that the state department determines would significantly reduce consumer savings.

(3) The executive director shall promulgate rules, in accordance with article 4 of title 24 and section 25.5-1-108, as necessary for the administration of this part 2.
C.R.S. § 25.5-6-206 — CO Code / Title 25.5 / Article 6 / Part 2 / Section 25.5-6-206
25.5-6-206. Personal needs benefits - amount - patient personal needs trust fund required -
Status: in_force

25.5-6-206. Personal needs benefits - amount - patient personal needs trust fund required - funeral and final disposition expenses - penalty for illegal retention and use. (1) The state department, pursuant to its rules, may include in medical care benefits provided under this article 6 and articles 4 and 5 of this title 25.5 reasonable amounts for the personal needs of any member receiving nursing facility services or intermediate care facilities for individuals with intellectual disabilities, if the member is not otherwise eligible for the amounts from other categories of public assistance, but the amounts for personal needs must not be less than the minimum amount provided for in subsection (2) of this section. Payments for funeral and final disposition expenses upon the death of a member may be provided under rules of the state department in the same manner as provided to members of public assistance as defined by section 26-2-103 (8).

(2) (a) The basic minimum amount payable pursuant to subsection (1) of this section for personal needs to any member admitted to a nursing facility or intermediate care facility for individuals with intellectual disabilities is seventy-five dollars monthly; except that, commencing January 1, 2015, and each January 1 thereafter, the basic minimum amount must increase annually by the same percentage applied to the general fund share of the aggregate statewide average of the per diem net of patient payment pursuant to section 25.5-6-202 (9)(b)(I). Commencing with the fiscal year beginning July 1, 2014, and each fiscal year thereafter, the reduction to patient payments received by nursing facilities resulting from an increase in the basic minimum amount is funded in full by general fund and applicable federal funds.

(b) On and after October 1, 1992, the basic minimum amount payable pursuant to subsection (1) of this section for personal needs is ninety dollars for the following persons:

(I) A medical assistance member who receives a non-service connected disability pension from the United States veterans administration, has no spouse or dependent child, and is admitted to or is residing in a nursing facility; and

(II) A medical assistance member who is a surviving spouse of a person who received a non-service connected disability pension from the United States veterans administration, has no dependent child, and is admitted to or is residing in a nursing facility.

(3) (a) All personal needs funds shall be held in trust by the nursing facility or intermediate care facility for individuals with intellectual disabilities, or its designated trustee, separate and apart from any other funds of the facility. The facility shall deposit any personal needs funds of a resident in an amount of fifty or more dollars in an interest-bearing checking account or accounts or savings account or any combination thereof established to protect and separate the personal needs funds of the patients. Any interest earned on a resident's personal needs funds shall be credited to such account or accounts. In the event residents' personal needs funds are maintained in a pooled account, separate accountings shall be made for each resident's share of the pooled account. Any personal needs funds of a resident in an amount less than fifty dollars shall be maintained in a non-interest-bearing account, an interest-bearing account, or a petty cash fund.

(b) At all times, the principal and all income derived from said principal in the patient personal needs trust fund shall remain the property of the participating patients, and the facility or its designated trustee is bound by all of the duties imposed by law upon fiduciaries in the handling of such fund. Those duties include but are not limited to providing notice to a resident when the resident's personal needs account accumulates two hundred dollars less than the federal supplemental security income resource limit for one person.

(c) The facility or its designated trustee shall post a surety bond in an amount to assure the security of all personal needs funds deposited in the patient personal needs trust fund or shall otherwise demonstrate to the satisfaction of the state department that the security of residents' personal needs funds is assured.

(d) Within sixty days after a resident's death, the facility shall transfer the resident's personal needs funds and a final accounting of the funds to the person responsible for settling the resident's estate or, if there is none, to the resident's heirs in accordance with the provisions of title 15, C.R.S. Within fifteen days after receiving the funds, the executor, administrator, or other appropriate representative of the resident's estate shall provide written notice to the state department regarding the receipt of the funds. Upon receipt of the notice, the state department may bring an action to recover the funds pursuant to the provisions of this article and articles 4 and 5 of this title.

(4) The state department shall establish rules concerning the establishment of a patient personal needs trust fund and procedures for the maintenance of a system of accounting for expenditures of each patient's personal needs funds. The facility shall use an accounting system that assures a complete and separate accounting of residents' personal needs funds based on generally accepted accounting principles and that precludes the commingling of a resident's personal needs funds with the facility's funds or the funds of any other person other than the personal needs funds of another resident. These rules shall provide that the nursing facility or intermediate care facility for individuals with intellectual disabilities shall maintain complete records of all receipts and expenditures involving the patient personal needs trust fund, that all expenditures shall be approved by the patient, legal custodian, guardian, or conservator prior to an expenditure, and that each patient or such patient's legal custodian, guardian, or conservator shall be given at least a quarterly accounting of the receipts and expenditures of such funds. In addition, the rules shall require that the person who maintains the patient personal needs trust fund for the facility and who is responsible for the deposit of moneys into such trust fund shall deposit any personal needs funds received from a patient or from the state department no later than sixty days after the receipt of such moneys.

(5) All patient personal needs trust funds shall be subject to audit by the state department. A record of a patient's personal needs trust fund shall be kept by the facility for a period of three years from the date of the patient's discharge from the facility or until such records have been audited by the state department, whichever occurs later.

(6) Any overpayment of personal needs funds to a nursing facility or an intermediate care facility for individuals with intellectual disabilities by the state department due to the omission, error, fraud, or defalcation of the nursing facility or intermediate care facility for individuals with intellectual disabilities or any shortage in an audited patient personal needs trust fund is recoverable by the state on behalf of the member in the same manner and following the same procedures as specified in section 25.5-4-301 (2) for an overpayment to a provider.

(7) Nothing in this section shall prevent a nursing facility or intermediate care facility for individuals with intellectual disabilities patient from excluding himself or herself from participation in the patient personal needs trust fund.

(8) (a) It is unlawful for any person to knowingly fail to deposit personal needs funds received from a patient or from the state department for a patient's personal needs into the patients' personal needs trust fund within sixty days after the receipt of such moneys or to knowingly apply, spend, commit, pledge, or otherwise use a patient personal needs trust fund, or any other moneys paid by a patient or the state department for patient personal needs, for any purpose other than the personal needs of the patient to purchase necessary clothing, incidentals, or other items of personal needs that are not reimbursed by any federal or state program. Deposit or use of personal needs funds, including the use of a petty cash fund for personal needs purposes, is not a violation of this section if such deposit or use is in substantial compliance with applicable rules of the state department. Sums later ordered repaid to the patients' personal needs trust fund as a result of an audit adjustment related to simple accounting errors such as data entry errors, mathematical errors, or posting errors or a dispute related to a proration of patient payment is not a violation of this section.

(b) Any person who knowingly violates any of the provisions of this subsection (8) by failing to deposit personal needs funds within sixty days after the receipt of such moneys commits the crime of unlawful retention of patient personal needs funds. Any person who violates any of the provisions of this subsection (8) by applying, spending, committing, pledging, or otherwise using a patient personal needs trust fund for any purpose other than the purposes permitted by this subsection (8) commits the crime of unlawful use of a patient personal needs trust fund.

(c) Unlawful retention of patient personal needs funds is:

(I) A petty offense if the amount is less than three hundred dollars;

(II) A class 2 misdemeanor if the amount is three hundred dollars or more but less than one thousand dollars;

(III) A class 1 misdemeanor if the amount is one thousand dollars or more but less than two thousand dollars;

(IV) A class 6 felony if the amount is two thousand dollars or more but less than five thousand dollars;

(V) A class 5 felony if the amount is five thousand dollars or more but less than twenty thousand dollars;

(VI) A class 4 felony if the amount is twenty thousand dollars or more but less than one hundred thousand dollars;

(VII) A class 3 felony if the amount is one hundred thousand dollars or more but less than one million dollars; and

(VIII) A class 2 felony if the amount is one million dollars or more.

(d) Unlawful use of a patient personal needs trust fund is:

(I) A petty offense if the amount is less than three hundred dollars;

(II) A class 2 misdemeanor if the amount is three hundred dollars or more but less than one thousand dollars;

(III) A class 1 misdemeanor if the amount is one thousand dollars or more but less than two thousand dollars;

(IV) A class 6 felony if the amount is two thousand dollars or more but less than five thousand dollars;

(V) A class 5 felony if the amount is five thousand dollars or more but less than twenty thousand dollars;

(VI) A class 4 felony if the amount is twenty thousand dollars or more but less than one hundred thousand dollars;

(VII) A class 3 felony if the amount is one hundred thousand dollars or more but less than one million dollars; and

(VIII) A class 2 felony if the amount is one million dollars or more.

(e) Any person who is convicted of violating this subsection (8) may not own or operate a nursing facility that receives medical assistance pursuant to this article or article 4 or 5 of this title. For the purposes of this paragraph (e), "convicted" means the entry of a plea of guilty, including a plea of guilty entered pursuant to a deferred sentence under section 18-1.3-102, C.R.S., the entry of a plea of no contest accepted by the court, or the entry of a verdict of guilty by a judge or jury.
C.R.S. § 25.5-5-307 — CO Code / Title 25.5 / Article 5 / Part 3 / Section 25.5-5-307
25.5-5-307. Child mental health treatment and family support program
Status: in_force

25.5-5-307. Child mental health treatment and family support program. (1) The general assembly finds that many parents in Colorado who have experienced challenging circumstances because their children have significant mental health needs and who have attempted to care for their children or seek services on their behalf often are burdened with the excessive financial and personal costs of providing such care. Private insurance companies may not cover mental health services and rarely cover residential mental health treatment services; those that do seldom cover a sufficient percentage of the expense to make such mental health treatment a viable option for many families in need. The result is that many families do not have the ability to obtain the mental health services that they feel their children desperately need. The general assembly finds that it is in the best interests of these families and the citizens of the state to encourage the preservation of family units by making mental health treatment available to these children pursuant to article 67 of title 27, C.R.S.

(2) In order to make mental health treatment available, it is the intent of the general assembly that each medicaid-eligible child who is diagnosed as a person with a mental health disorder, as that term is defined in section 27-65-102 (11.5), must receive mental health treatment, which may include in-home family mental health treatment, other family preservation services, residential treatment, or any post-residential follow-up services, that must be paid for through federal medicaid funding.
C.R.S. § 25.5-5-802 — CO Code / Title 25.5 / Article 5 / Part 8 / Section 25.5-5-802
25.5-5-802. Definitions
Status: in_force

25.5-5-802. Definitions. As used in this part 8, unless the context otherwise requires:

(1) "At risk of out-of-home placement" means a child or youth who is eligible for medical assistance pursuant to articles 4, 5, and 6 of this title 25.5 and the child or youth:

(a) Has been diagnosed as having a mental health disorder, as defined in section 27-65-102 (11.5), or a behavioral health disorder; and

(b) May require a level of care that is provided in a residential child care facility, inpatient psychiatric hospital, or other intensive care setting outside of the child's or youth's home. "At risk of out-of-home placement" includes a child or youth who:

(I) Is entering the division of youth services; or

(II) Is at risk of child welfare involvement.

(2) "Behavioral health disorder" means a substance use disorder, mental health disorder, or one or more substantial disorders of the cognitive, volitional, or emotional processes that grossly impair judgment or capacity to recognize reality or to control behavior, including serious emotional disturbances. "Behavioral health disorder" also includes those mental health disorders listed in the most recent versions of the diagnostic statistical manual of mental health disorders, the diagnostic classification of mental health and developmental disorders of infancy and early childhood, and the international statistical classification of diseases and related health problems.

(3) "Behavioral health services" or "behavioral health system" means the child and youth service system that encompasses prevention and promotion of emotional health, prevention and treatment services for mental health and substance use conditions, and recovery support.

(4) "Child and youth" means a person who is twenty-six years of age or younger.

(5) "Managed care entity" means an entity that enters into a contract to provide services in the statewide managed care system pursuant to articles 4, 5, and 6 of this title 25.5.

(6) "Mental health professional" means an individual licensed as a mental health professional pursuant to article 245 of title 12 or a professional person as defined in section 27-65-102 (17).

(7) "Out-of-home placement" means a child or youth who is eligible for medical assistance pursuant to articles 4, 5, and 6 of this title 25.5 and the child or youth:

(a) Has been diagnosed as having a mental health disorder, as defined in section 27-65-102 (11.5), or a behavioral health disorder; and

(b) May require a level of care that is provided in a residential child care facility, inpatient psychiatric hospital, or other intensive care setting outside of the child's or youth's home. "Out-of-home placement" includes a child or youth who:

(I) Has entered the division of youth services; or

(II) Is at risk of child welfare involvement.

(8) "Wraparound" means a high-fidelity, individualized, family-centered, strengths-based, and intensive care planning and management process used in the delivery of behavioral health services for a child or youth with a behavioral health disorder, commonly utilized as part of the system of care framework.
C.R.S. § 25.5-1-126 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-126
25.5-1-126. Discounted prices for durable medical equipment and supplies
Status: in_force

25.5-1-126. Discounted prices for durable medical equipment and supplies. (1) The state department shall work with one or more nonprofit organizations to develop a link of approved vendors who are willing to sell durable medical equipment and medical supplies at discounted prices to persons who have applied for, but are not yet receiving, benefits under the "Colorado Medical Assistance Act". The state department shall provide the exclusive criteria for a nonprofit organization to use to approve a vendor for placement on the approved vendor list.

(2) The state department shall maintain a link of approved vendors developed pursuant to this section and shall:

(a) Make the link available on the state department's website; and

(b) Provide copies of the list to county departments and to sites authorized to accept medical assistance applications pursuant to section 25.5-4-205 (1), through the survey given to applicants.
C.R.S. § 25.5-5-402 — CO Code / Title 25.5 / Article 5 / Part 4 / Section 25.5-5-402
25.5-5-402. Statewide managed care system - rules - definitions
Status: repealed

25.5-5-402. Statewide managed care system - rules - definitions. (1) The state board shall adopt rules to implement a statewide managed care system for Colorado medical assistance members pursuant to the provisions of this article 5 and articles 4 and 6 of this title 25.5. The statewide managed care system shall be implemented to the extent possible.

(2) The statewide managed care system implemented pursuant to this article 5 does not include:

(a) The services delivered under the residential child health-care program described in section 25.5-6-903, except in those counties in which there is a written agreement between the county department of human or social services, the designated and contracted MCE responsible for community behavioral health care, and the state department;

(b) Long-term care services and the program of all-inclusive care for the elderly, as described in section 25.5-5-412. For purposes of this subsection (2), "long-term care services" means nursing facilities and home- and community-based services provided to eligible members who have been determined to be in need of such services pursuant to the "Colorado Medical Assistance Act" and the state board's rules.

(3) The statewide managed care system must include a statewide system of community behavioral health care that must:

(a) Address the economic, social, and personal costs to the state of Colorado and its citizens of untreated behavioral health disorders, including mental health and substance use disorders;

(b) Approach behavioral health disorders as treatable conditions not unlike other chronic health issues that require a combination of behavioral change and medication or other treatment;

(c) Offer timely access through multiple points of entry to a full continuum of culturally responsive behavioral health services, including prevention, early intervention, crisis response, treatment, and recovery services, that support individuals living full, productive lives;

(c.5) Provide coordination of care for the full continuum of substance use disorder and mental health treatment and recovery, including support for individuals transitioning between levels of care;

(d) Feature a comprehensive and integrated system of quality behavioral health care that is individualized and coordinated to meet individuals' changing needs;

(e) Be paid for by the state department establishing capitated rates specifically for behavioral health services that account for a comprehensive continuum of needed services such as those provided by licensed behavioral health providers, including essential and comprehensive community behavioral health providers, as defined in section 27-50-101;

(f) Make the behavioral health system's administrative processes, service delivery, and funding more effective and efficient to improve outcomes for Colorado citizens;

(g) In addition to network adequacy requirements determined by the state department, require each MCE to offer an enrollee an initial or subsequent nonurgent care visit within a reasonable period where medically necessary and at appropriate therapeutic intervals, as determined by state board rule;

(h) Specify that the diagnosis of an intellectual or developmental disability, a neurological or neurocognitive disorder, or a traumatic brain injury does not preclude an individual from receiving a covered behavioral health service; and

(i) Require an MCE to cover all medically necessary covered treatments for covered behavioral health diagnoses, regardless of any co-occurring conditions.

(3.5) (a) No later than July 1, 2023, the state department, in collaboration with the behavioral health administration in the department of human services and other state agencies, shall develop the universal contract as described in section 27-50-203.

(b) Repealed.

(4) The statewide managed care system must promote the utilization of the medical home model of care for all enrolled members. The medical home model of care establishes a focal point of care for comprehensive primary care and efficient coordination with specialty care providers and other health-care systems. The medical home model has proven effective in promoting early intervention and prevention, improving individuals' health, and reducing health-care costs.

(5) The statewide managed care system builds upon the lessons learned from previous managed care and community behavioral health-care programs in the state in order to reduce barriers that may negatively impact medicaid member experience, medicaid member health, and efficient use of state resources. The statewide managed care system is authorized to provide services under a single MCE type or a combination of MCE types.

(6) (a) The state department is authorized to assign a medicaid member to a particular MCE, consistent with federal requirements and rules promulgated by the state board.

(b) For a child or youth who obtains eligibility for services under the state's medicaid program through a dependency and neglect action resulting in out-of-home placement pursuant to article 3 of title 19 or a juvenile delinquency action resulting in out-of-home placement pursuant to article 2.5 of title 19, the state department shall assign the child or youth to the MCE covering the county with jurisdiction over the action. The state department shall only change the assignment if the change is requested by the county with jurisdiction over the action or by the child's or youth's legal guardian.

(7) The state department is authorized to enter into a contract with MCOs, PCCM Entities, prepaid ambulatory health plans, and prepaid inpatient health plans, subject to the receipt of any required federal authorizations and pursuant to the requirements of this section.

(7.5) (a) The state department shall offer to enter into a direct contract for physical health-care services with the MCO operated by or under the control of Denver health and hospital authority, created pursuant to article 29 of title 25, from July 1, 2025, until June 30, 2032, as long as the MCO meets all MCO criteria required by the state department. If the state department designates an MCE other than the MCO operated by or under the control of Denver health and hospital authority to manage behavioral health-care services pursuant to this article 5, Denver health and hospital authority, or any subsidiary, shall collaborate with the MCE during the term of contract.

(b) The MCO operated by or under the control of Denver health and hospital authority shall:

(I) Maintain adequate financials to ensure proper solvency as a risk manager;

(II) Accept rates determined by the state department, through standard methodologies, to cover the population it is serving. Rates paid by the MCO to contracted providers must not be higher than the state department's medicaid fee-for-service rates unless the provider enters into a quality incentive agreement with the MCO.

(III) Maintain service and quality metrics, as determined by the state department; and

(IV) Meet statewide managed care system standards and operate as part of the overall managed care system.

(8) Waivers. The implementation of this part 4 is conditioned, to the extent applicable, on the issuance of necessary waivers by the federal government. The provisions of this part 4 must be implemented to the extent authorized by federal waiver, if so required by federal law.

(9) Bidding. (a) The state department is authorized to institute a program for competitive bidding pursuant to section 24-103-202 or 24-103-203 for MCEs seeking to provide, arrange for, or otherwise be responsible for the provision of services to its members. The state department is authorized to award contracts to more than one offeror. The state department shall use competitive bidding procedures to encourage competition and improve the quality of care available to medicaid members over the long term that meets the requirements of this section and section 25.5-5-406.1.

(b) (I) On or before January 1, 2023, in order to promote transparency and accountability, the state department shall require each MCE that has twenty-five percent or more ownership by providers of behavioral health services to comply with the following conflict of interest policies:

(A) Providers who have ownership or board membership in an MCE shall not have control, influence, or decision-making authority in the establishment of provider networks.

(B) Each MCE shall report quarterly the number of providers who applied to join the network and were denied and a comparison of rate ranges for providers who have ownership or board membership versus providers who do not.

(C) An employee of a contracted provider of an MCE shall not also be an employee of the MCE unless the employee is a clinical officer or utilization management director of the MCE. If the individual is also an employee of a provider that has board membership or ownership in the MCE, the MCE shall develop policies, approved by the executive director of the state department, to mitigate any conflict of interest the employee may have.

(D) An MCE's board shall not have more than fifty percent of contracted providers as board members, and the MCE is encouraged to have a community member on the MCE's board.

(II) No later than July 1, 2025, the state department shall appropriately address perceived or actual provider ownership and control of MCEs participating in the statewide managed care system in the interest of transparency and accountability. In designing a competitive bidding process, the state department shall incorporate community feedback and have a public process related to governing requirements, including how to address conflicts of interest.

(III) As used in this subsection (9)(b):

(A) "Clinical officer" means a physician who provides the clinical vision for the MCE or provides clinical direction to network management, quality improvement, utilization management, or credentialing divisions.

(B) "MCE" means a managed care entity responsible for the statewide system of community behavioral health care, as described in section 25.5-5-402 (3), and is not owned, operated by, or affiliated with an instrumentality, municipality, or political subdivision of the state.

(C) "Ownership" means an individual who is a legal proprietor of an organization, including a provider or individual who owns assets of an organization, or has a financial stake, interest, or governance role in the MCE.

(D) "Utilization management director" means a licensed health-care professional with behavioral health clinical experience who leads and develops the utilization management program or manages the medical review and authorization process.

(10) An MCE that is contracting for a defined scope of services under a risk contract shall certify the financial stability of the MCE pursuant to criteria established by the division of insurance.

(11) The state department shall conduct a review of each MCE, in accordance with federal requirements, prior to the implementation of a contract to assess the ability and capacity of the MCE to satisfactorily perform the operational requirements of the contract.

(12) Graduate medical education. The state department shall continue the graduate medical education, referred to in this subsection (12) as "GME", funding to teaching hospitals that have graduate medical education expenses in their medicare cost report and are participating as providers under one or more MCEs with a contract with the state department under this part 4. GME funding for members enrolled in an MCE is excluded from the premiums paid to the MCE and must be paid directly to the teaching hospital. The state board shall adopt rules to implement this subsection (12) and establish the rate and method of reimbursement.

(13) Nothing in this part 4 creates an exemption from the applicable provisions of title 10.

(14) Nothing in this part 4 creates an entitlement to an MCE to contract with the state department.

(15) On or before July 1, 2020, the state department shall include utilization management guidelines for the MCEs in the state board's managed care rules.

(16) The state department shall provide information on its website specifying how the public may request the network adequacy plan and quarterly network reports for an MCE. The plan must include actions taken by the MCE to ensure that all necessary and covered primary care, care coordination, and behavioral health services are provided to enrollees with reasonable promptness. Such actions include, without limitation:

(a) Utilizing single case agreements with out-of-network providers when necessary; and

(b) Using financial incentives to increase network participation.

(17) If the state department receives a complaint from the office of the ombudsman for behavioral health access to care established pursuant to part 3 of article 80 of title 27 that relates to possible violations of subsection (3) of this section or the MHPAEA, the state department shall examine the complaint, as requested by the office, and shall report to the office in a timely manner any actions taken related to the complaint.
C.R.S. § 25.5-3-402 — CO Code / Title 25.5 / Article 3 / Part 4 / Section 25.5-3-402
25.5-3-402. Legislative declaration
Status: in_force

25.5-3-402. Legislative declaration. (1) The general assembly hereby finds and declares that:

(a) The purpose of this part 4 is to promote the health and welfare of Colorado low-income seniors by providing access to patient-centered dental care and services to individuals sixty years of age or older whose income and resources are insufficient to meet the costs of such care and thereby support individuals and families to live independently with a good quality of life;

(b) By relocating and reorganizing the "Colorado Dental Care Act of 1977", which provided dental services to certain eligible seniors, the state department can align those dental health-care services with adult dental benefits provided through other dental health-care programs for seniors and thereby target the resources effectively to low-income seniors who may not qualify for those programs;

(c) The state department shall implement this part 4 through collaboration among various executive departments, agencies, and political subdivisions of the state; private individuals; and organizations, including but not limited to:

(I) The local area agencies on aging;

(II) Community health centers;

(III) Safety-net clinics;

(IV) Private practice dental providers; and

(V) Foundations; and

(d) The state department shall implement this part 4 as a grant program throughout all geographic regions of the state using best practices and experience from other grant programs operated by the state department to provide maximum flexibility to safety-net and private-practice dental providers in order to promote the health and welfare of low-income seniors.
C.R.S. § 25.5-4-105 — CO Code / Title 25.5 / Article 4 / Part 1 / Section 25.5-4-105
25.5-4-105. Federal requirements under Title XIX
Status: in_force

25.5-4-105. Federal requirements under Title XIX. Nothing in this article or articles 5 and 6 of this title shall prevent the state department from complying with federal requirements for a program of medical assistance in order for the state of Colorado to qualify for federal funds under Title XIX of the social security act and to maintain a program within the limits of available appropriations.
C.R.S. § 25.5-4-301 — CO Code / Title 25.5 / Article 4 / Part 3 / Section 25.5-4-301
25.5-4-301. Recoveries - overpayments - penalties - interest - adjustments - liens - review
Status: repealed

25.5-4-301. Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - definitions - repeal. (1) (a) (I) Except as provided in section 25.5-4-302 and subsection (1)(a)(III) of this section, a member or estate of the member is not liable for the cost or the cost remaining after payment by medicaid, medicare, or a private insurer of medical benefits authorized by Title XIX of the federal "Social Security Act", by this title 25.5, or by rules promulgated by the state board, which benefits are rendered to the member by a provider of medical services authorized to render the service in the state of Colorado, except those contributions required pursuant to section 25.5-4-209 (1). However, a member may enter into a documented agreement with a provider under which the member agrees to pay for items or services that are nonreimbursable under the medical assistance program. Under these circumstances, a member is liable for the cost of the services and items.

(II) The provisions of subsection (1)(a)(I) of this section apply regardless of whether medicaid has actually reimbursed the provider and regardless of whether the provider is enrolled in the Colorado medical assistance program.

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

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

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

(C) The provisions of this subsection (1)(a)(II.5) do not apply to a long-term care facility licensed pursuant to section 25-3-101.

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

(III) (A) When a third party is primarily liable for the payment of the costs of a member's medical benefits, prior to receiving nonemergency medical care, the member shall comply with the protocols of the third party, including using providers within the third party's network or receiving a referral from the member's primary care physician. Any member failing to follow the third party's protocols is liable for the payment or cost of any care or services that the third party would have been liable to pay; except that, if the third party or the service provider substantively fails to communicate the protocols to the member, the items or services are nonreimbursable under this article 4 and articles 5 and 6 of this title 25.5 and the member is not liable to the provider.

(B) A member may enter into a written agreement with a third party or provider under which the member agrees to pay for items provided or services rendered that are outside of the network or plan protocols. The member's agreement to be personally liable for nonemergency, nonreimbursable items must be recorded on forms approved by the state board and signed and dated by both the member and the provider in advance of the services being rendered.

(b) Member income applied pursuant to section 25.5-4-209 (1) does not disqualify any member, as defined in section 26-2-103 (8), from receiving benefits pursuant to this article 4, article 5 or 6 of this title 25.5, or public assistance pursuant to article 2 of title 26, and does not disqualify an individual from receiving child care assistance pursuant to part 1 of article 4 of title 26.5. If, at any time during the continuance of medical benefits, the member gains possession of property having a value in excess of that amount set by law or by the rules of the state department or receives any increase in income, the member shall notify the county department and the county department may, after investigation, either revoke the medical benefits or alter the amount of medical benefits, as the circumstances may require.

(c) Any medical assistance paid to which a member was not lawfully entitled is recoverable from the member or the estate of the member by the county as a debt due the state pursuant to section 25.5-1-115, but no lien may be imposed against the property of a member on account of medical assistance paid or to be paid on the member's behalf under this article 4 or article 5 or 6 of this title 25.5, except pursuant to the judgment of a court of competent jurisdiction or as provided by section 25.5-4-302.

(d) If any medical assistance was obtained fraudulently, interest must be charged and paid to the county department on the amount of the medical assistance calculated at the legal rate and calculated from the date that payment for medical services rendered on behalf of the member is made to the date the amount is recovered.

(2) Any overpayment to a provider, including those of personal needs funds made pursuant to section 25.5-6-206, are recoverable regardless of whether the overpayment is the result of an error by the state department, a county department of human or social services, an entity acting on behalf of either department, or by the provider or any agent of the provider as follows:

(a) (I) If the state department makes a determination that such overpayment has been made as a result of the provider's false representation, the state department may collect the overpayment, plus a civil monetary penalty equal to one-half the amount of the overpayment, and interest on the sum of the two amounts accruing at the statutory rate from the date the overpayment is identified, by the means specified in this subsection (2). Such sum may be collected for up to the amount of time prescribed in section 13-80-103.5, C.R.S., after the overpayment is identified. Amounts remaining uncollected for more than the time period prescribed in section 13-80-103.5, C.R.S., after the last repayment was made may be considered uncollectible. For the purposes of this subparagraph (I), "false representation" means an inaccurate statement that is relevant to a claim for reimbursement and is made by a provider who has actual knowledge of the truth of false nature of the statement or by a provider acting in deliberate ignorance of or with reckless disregard for the truth of the statement. A provider acts with reckless disregard for truth if the provider fails to maintain records required by the department or if the provider fails to become familiar with rules, manuals, and bulletins issued by the department, board, or the department's fiscal agent.

(II) If the state department makes a determination that the overpayment has been made for some other reason than a false representation by the provider specified in subsection (2)(a)(I) of this section, the state department may collect the amount of overpayment, plus interest accruing at the statutory rate from the date the provider is notified of the overpayment, by the means specified in this subsection (2). Pursuant to the criteria established in rules promulgated by the state board, the state department may waive the recovery or adjustment of all or part of the overpayment and accrued interest specified in this subsection (2)(a)(II) if it would be inequitable, uncollectible, or administratively impracticable; except that no action shall be taken against a member of medical services initially determined to be eligible pursuant to section 25.5-4-205 if the overpayment occurred through no fault of the member. Amounts remaining uncollected for more than five years after the last repayment was made may be considered uncollectible.

(b) In order to collect the amounts specified in paragraph (a) of this subsection (2), the state department may withhold subsequent payments to which the provider is or becomes entitled and apply the amount withheld as an offset. The state board shall establish in rules the rate at which an overpayment may be offset, with provision for a reduction of such rate upon a good cause shown by the provider that the rate at which payment will be withheld will result in an undue hardship for the provider. In determining whether to grant a good cause reduction, the state department shall consider the impact of collecting the amount provided by state board rules on the quality of patient care and the financial viability of the provider. The state department may also take such other steps administratively as are available for the collection of the amounts specified in paragraph (a) of this subsection (2).

(c) If a provider defaults on repayment of the amounts specified in paragraph (a) of this subsection (2), the state department may bring a suit against the provider in the appropriate court. Court costs shall not be assessed against the state department but shall be assessed against the provider if the court finds in favor of the state department. Any costs collected by the state department shall be paid into the registry of the court. Once the amount has been reduced to judgment, the state department may proceed with all available postjudgment remedies.

(d) Repealed.

(e) Any provider adversely affected by actions taken pursuant to this subsection (2), except when a suit is filed against the provider pursuant to paragraph (c) of this subsection (2), may appeal the determination of the state department pursuant to the provisions in section 24-4-105, C.R.S.

(f) If the state department, either directly or through a contracting agent, undertakes a review or an audit of a provider to determine whether an overpayment has been made to that provider, the review or audit shall be subject to the procedures required in subsection (3) of this section.

(3) (a) A review or audit of a provider is subject to the following procedures:

(I) The reviewer or auditor shall conduct a review or audit in accordance with applicable state and federal law.

(II) The reviewer or auditor shall apply uniform standards and procedures to each class of providers subject to a review or an audit to determine an overpayment.

(III) The reviewer or auditor shall prepare findings for the entire period under review or audit, and a provider shall be subject to only one demand for repayment in connection with the review or audit.

(IV) Prior to a review or audit requiring an inspection of a provider's records, the reviewer or auditor, or a qualified agent contracted with the state department pursuant to subsection (3)(b) of this section, shall confirm the provider's contact information with the provider. After confirming the provider's contact information, the reviewer or auditor, or qualified agent, shall notify the provider of additional information concerning the review or audit, including instructions, correspondence timelines, and a state department contact for the provider to notify if the provider does not receive the written request for records. The reviewer or auditor shall initiate each review or audit requiring an inspection of the provider's records by delivering to the provider not less than ten business days prior to the commencement of the audit a written request through both e-mail and certified mail describing in detail such records and offering the provider the option of providing either a reproduction of such records or inspection by the reviewer or auditor at the provider's site. The request must also clearly define milestone dates pertaining to records' requested due dates, permissible extensions of dates, the timelines for informal reconsideration, and deadlines for requesting a formal appeal. The records subject to the request must be limited to records directly related to claims for reimbursement submitted by the provider. Prior to a qualified agent commencing any review or audit, the state department shall ensure providers understand the relationship between the state department and the qualified agent and how to contact the qualified agent. In the event such records are available from a county department of human or social services or another agency, subdivision, or contractor of the state, the reviewer or auditor shall request such records from such other agencies as may be appropriate prior to making a request to the provider. The reviewer or auditor shall conduct on-site inspections at reasonable times during regular business hours, and the reviewer or auditor shall make arrangements necessary for the reproduction of such records on site. If the provider chooses to provide a reproduction of the records requested by the reviewer or auditor instead of on-site inspection, the reviewer or auditor shall give the provider a reasonable period of time, not less than forty-five days, to provide such records, taking into account the scope of the request, the time frame covered, and the reproduction arrangements available to the provider.

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

(A) The findings of the reviewer or auditor;

(B) Any documentation useful for the provider to refute the findings of the reviewer or auditor; and

(C) The next steps in the review or audit process.

(V) A physician's record or other order for health-care services, drugs, or medicinal supplies in a form transmitted electronically shall be sufficient to validate the provider's records regarding the ordering of the health-care services, drugs, or medicinal supplies.

(VI) Whenever possible, the reviewer or auditor shall base a determination of an overpayment to a provider upon a review of actual records of the department, its agents, or the provider. In the event sufficient records are not available to the reviewer or auditor, an overpayment determination may be based upon a sampling of records so long as the sampling and any extrapolation therefrom is reasonably valid from a statistical standpoint and is in accordance with generally accepted auditing standards.

(VII) If a reviewer or auditor determines that there has been an overpayment to the provider, then, at the time demand for repayment is made, the state department shall offer the provider an informal reconsideration of the review or audit findings. The state department shall notify the provider in writing of the right to an informal reconsideration prior to implementing any recovery of an overpayment and give the provider an opportunity to request an informal reconsideration. In the event informal reconsideration is requested or a formal appeal is filed pursuant to subparagraph (VIII) of this paragraph (a), the state department shall not implement recovery of the overpayment until such informal reconsideration or formal appeal has been completed. Within forty-five days after the request for an informal reconsideration, the state department shall render a decision on the request and notify the provider of the decision. The notification shall include information concerning requesting a formal appeal, including informing the provider that the request must be filed within thirty days after the date of the state department's decision on the request for an informal reconsideration. If the state department is unable to render a decision on the request for informal reconsideration within forty-five days after the request, within forty-five days after the request, the state department shall notify the provider of its inability to complete the decision and shall include information concerning requesting a formal appeal, including informing the provider that the request must be filed within thirty days after the receipt of the notification that the state department is unable to render a decision. For purposes of this subparagraph (VII), an informal reconsideration shall be considered final thirty days after the earlier of the date on which the provider withdraws its request or the date on which the state department issues a written decision on the request.

(VIII) In accordance with paragraph (e) of subsection (2) of this section, any provider adversely affected by the actions of the state department or its contracting agent in connection with a review or an audit, including whether the state department or its contracting agent adhered to the provisions of this subsection (3) in making an overpayment determination, may appeal such actions pursuant to the provisions of section 24-4-105, C.R.S.

(IX) For audits conducted pursuant to 42 CFR 455.506, at least quarterly, the state department shall publish on its website an audit activity report detailing current and recently completed audits and reviews and summaries of the findings of such audits and reviews, including the number and amounts of overpayments and underpayments found, the number and results of appeals, the amounts collected, and the error rates identified. At least quarterly, the state department shall conduct trainings for providers and hold stakeholder meetings regarding audits and reviews. In addition, when the state department enters into contracts pursuant to this subsection (3)(a), the state department shall publish on its website a copy of the contract, scope of work, and information regarding supervision of contractor deliverables.

(a.5) Any additional review or audit procedures shall be adopted by rule of the state board and shall be specifically referenced in any contract with a provider.

(b) The state department is authorized to engage the services of a qualified agent through a competitive contract issued pursuant to the state's procurement code for the purpose of conducting a review or audit of a provider to assist in determining whether there has been an overpayment to a provider and the amount of that overpayment. In addition to such terms and conditions as the state department may deem necessary, any contract shall be subject to the requirements for conducting a review or an audit in accordance with paragraph (a) of this subsection (3). The state department is further authorized to enter into a contract with a qualified agent for the purpose of conducting a review or an audit of a provider that provides that the compensation of the contracting agent shall be contingent and based upon a percentage of the amount of the recovery collected from the provider. A contract issued by the state department for the purpose of conducting a review or an audit of a provider to determine whether the provider has received an overpayment shall also be subject to the following conditions:

(I) The compensation paid to the contracting agent under a contingency-based contract shall not exceed eighteen percent of the amount finally collected from the provider overpayment, and the state department may establish a limit on the amount of annual compensation that may be paid to a contracting agent under a contingency-based contract and may further establish a limit on the amount that may be paid to a contracting agent under a contingency-based contract for recovery from any one provider.

(II) Reimbursement of the contracting agent's costs in performing the review or audit under a contingency-based contract shall be deemed included in the percentage compensation due the agent under the contract.

(III) No employee or agent of the contracting agent involved in the performance of a contingency-based contract shall be compensated by the contracting agent based upon the amount recovered under the contract.

(IV) The state department shall retain all authority for providing notice and otherwise making demand upon a provider for recovery of an overpayment, and the state department shall review and approve any written demand, request, or determination by the contracting agent regarding a review or an audit of a provider under this subsection (3).

(V) In any contingency-based contract authorized pursuant to this paragraph (b), the state of Colorado shall not be obligated to pay the contracting agent for amounts not actually collected from the provider.

(3.5) (a) Prior to the start of a contract to review or audit providers, the state department is encouraged to meet with organizations or associations of providers to educate providers on the review or audit process and the responsibilities of both the providers and the state department throughout the review or audit process. The state department is also encouraged to prepare an annual report on common findings following a contract to review or audit providers and distribute the report to organizations or associations of providers. The annual report should include information to prevent similar findings in future reviews or audits and should direct providers to resource information.

(b) Repealed.

(c) The state department shall create a provider advisory group for recovery audits consisting of employees of the state department and members from different provider groups, including physicians, hospitals, and any other provider types directly impacted by audits conducted pursuant to this section, appointed by the executive director. The provider advisory group shall meet at least quarterly to review quarterly activity reports required by subsection (3)(a)(IX) of this section and advise the state department on issues providers experience with audits of the recovery audit contractors program.

(3.7) (a) During the 2023-24 state fiscal year, the office of the state auditor shall conduct an independent review of the state department's recovery audit contractor program pursuant to 42 CFR 455.506 for compliance with requirements of the federal centers for medicare and medicaid services medicaid recovery audit program, compliance with coding practice standards, and state law. To the extent possible, the audit shall examine and issue policy recommendations to the joint budget committee of the general assembly, the health and human services committee of the senate, and the public and behavioral health and human services committee of the house of representatives, or their successor committees, regarding:

(I) The effectiveness and level of the payment model used for the state department's recovery audit contractor, including the level of payments sufficient to maintain a contractor, the scope of the contract and deliverables, and impacts on providers related to a contingency fee-based system significantly above the federal standard;

(II) The methods and effectiveness of the state department's current approach to addressing provider concerns regarding the medicaid recovery audit contractor program;

(III) The design, effectiveness, and methods used by other states in meeting the federal standard, including:

(A) An assessment of requirements imposed by other states in regard to overall recovery audit contractor staffing and qualifications of reviewers to ensure alignment of specialty and subspecialty expertise for conducting initial audits and final determinations;

(B) An assessment of other states' lookback periods and the states' relative financing mechanisms;

(C) Best practices employed by other states or recommended by Colorado providers to help improve billing practices and compliance and to provide support throughout the recovery audit contractor process; and

(D) Models from other states used to incentivize identification of underpayments, along with a feasibility assessment for the use of such models in Colorado;

(IV) Implications for providers and the state's general fund of adjusting the lookback period used for the recovery audit contractor audits. The office of the state auditor shall examine, compare to other states, and, to the extent feasible, disaggregated by dates of service, audit finding date, and provider type:

(A) The number, proportion, and value of claims reviewed, relative to total potential claims subject to the recovery audit contractor program;

(B) The number and proportion of providers impacted by claim reviews and contested payments;

(C) The number, proportion, and value of contested payments, including underpayments, overpayments, and recoupments; and

(D) The number, proportion, value, and result of contested payments by disposition status, including those resolved through interview requests pursuant to subsection (3)(a)(IV.5) of this section, informal reconsiderations, and appeals;

(V) Provider administrative burdens associated with the recovery audit contractor program;

(VI) The feasibility of incentives for underpayment identification, including models from other states and methods for identifying underpayments;

(VII) The impact of audits on provider participation and access to care, and opportunities to increase meaningful provider participation and access to care; and

(VIII) An assessment of the duplication of utilization management reviews and approvals, such as prior authorization, with post-payment and audit reviews.

(b) (I) The office of the state auditor shall contract with an entity that reviews state plans and amendments submitted to the federal centers for medicare and medicaid services on behalf of states for the entity to assess federal flexibilities pursuant to 42 CFR 455.516 that Colorado can utilize in order to improve the recovery audit contractor program and assist in pursuing those flexibilities, when already authorized. The contracted entity must not be a contractor under the recovery audit contractor program, nor a competitor of such a contractor, nor a provider of similar program integrity products.

(II) The contracted entity shall consider the following issues:

(A) What are the impacts on providers and medicaid beneficiaries of contractor contingency fees and a lookback period that exceeds federal standards for medicaid recovery audit contractor programs?

(B) Using information from other states or similar audit programs in the public and private sectors, how can Colorado optimize staffing to balance potential overpayment claims and medical necessity reviews?

(C) What is the level of federal flexibility for adjusting the timing and procedure when assessing when a potential overpayment is "identified" or "determined", and how could modifications to that timing or procedure improve the recovery audit contractor program?

(D) How should the state evaluate the cost benefit analysis to determine whether the medicaid recovery audit contractor program is striking the right balance between accountability and access to care?

(E) What are other states' best practices in exercising federal flexibilities in the recovery audit contractor program to improve provider education, training, and error rates?

(c) This subsection (3.7) is repealed, effective July 1, 2025.

(4) If medical assistance is furnished to or on behalf of a member pursuant to the provisions of this article 4 and articles 5 and 6 of this title 25.5 for which a third party is liable, the state department has an enforceable right against the third party for the amount of medical assistance, including the lien right specified in subsection (5) of this section. Whenever the member has brought or may bring an action in court to determine the liability of the third party, the state department, without any other name, title, or authority to enforce the state department's right, may enter into appropriate agreements and assignments of rights with the member and the member's attorney, if any. Any agreement must be filed with the court in which the action is pending. The attorney named in the agreement upon designation as a special assistant attorney general by the attorney general shall prove both the member's claim and the state department's claim. The state department, without any other name, title, or authority, may take any necessary action to determine the existence and amount of the state department's claims under this section, whether the claims are founded on judgment, contract, lien, or otherwise, and take any other action that is appropriate to recover from third parties. To enforce the right, the attorney general, pursuant to section 24-31-101, on behalf of the state department, may institute and prosecute, or intervene of right in legal proceedings against the third party having legal liability, either in the name of the state department or in the name of the member or the member's assignee, guardian, personal representative, estate, or survivors. When the state department intervenes in legal proceedings against the third party, the state department is not liable for any portion of the attorney fees or costs of the member.

(5) (a) When the state department has furnished medical assistance to or on behalf of a member pursuant to the provisions of this article 4 or articles 5 and 6 of this title 25.5 for which a third party is liable, the state department has an automatic statutory lien for all medical assistance. The state department's lien is against any judgment, award, or settlement in a suit or claim against the third party and is in an amount that is the fullest extent allowed by federal law as applicable in this state, but not to exceed the amount of the medical assistance provided.

(b) No judgment, award, or settlement in any action or claim by a member to recover damages for injuries in which the state department has a lien is satisfied without first satisfying the state department's lien. Failure by any party to the judgment, award, or settlement to comply with this section makes each party liable for the full amount of medical assistance furnished to or on behalf of the member for the injuries that are the subject of the judgment, award, or settlement.

(c) Except as otherwise provided in this article 4, the entire amount of any judgment, award, or settlement of the member's action or claim, with or without suit, regardless of how characterized by the parties, is subject to the state department's lien.

(d) When the action or claim is brought by the member alone and the member incurs a personal liability to pay attorney fees, the state department shall pay the state department's reasonable share of attorney fees not to exceed twenty-five percent of the state department's lien. The state department is not liable for costs.

(e) The state department's right to recover under this section is independent of the member's right.

(6) When the applicant or member, or the applicant's or member's guardian, executor, administrator, or other appropriate representative, brings an action or asserts a claim against any third party, the person shall give the state department written notice of the action or claim by personal service or certified mail within fifteen days after filing the action or asserting the claim. Failure to comply with this subsection (6) makes the member, legal guardian, executor, administrator, attorney, or other representative liable for the entire amount of medical assistance furnished to or on behalf of the member for the injuries that gave rise to the action or claim. The state department may, after thirty days' written notice to the person, enforce the state department's rights under subsection (5) of this section and this subsection (6) in the district court of the city and county of Denver; except that liability of a person other than the member exists only if the person had knowledge that the member had received medical assistance or if excusable neglect is found by the court. The court shall award the state department its costs and attorney fees incurred in the prosecution of any such action.

(7) When a legally responsible relative of the member agrees or is ordered to provide medical support or health insurance coverage for the member's dependents or other persons, and the dependents are applicants for, members of, or otherwise entitled to receive medical assistance pursuant to this article 4 and articles 5 and 6 of this title 25.5, the state department is subrogated to any rights that the responsible persons may have to obtain reimbursement from a third party or insurance carrier for the cost of medical assistance provided for such dependents or persons. When the state department gives written notice of subrogation, any third party or insurance carrier liable for reimbursement for the cost of medical care shall accord to the state department all rights and benefits available to the responsible relative that pertain to the provision of medical care to any persons entitled to medical assistance pursuant to this article 4 and articles 5 and 6 of this title 25.5 for whom the relative is legally responsible.

(8) All members of medical assistance under the medicaid program are deemed to have authorized the member's attorneys, all third parties, including but not limited to insurance companies, and providers of medical care to release to the state department all information needed by the state department to secure and enforce its rights under subsections (4) and (5) of this section.

(9) Nothing in part 6 of article 4 of title 10 limits the right of the state department to recover the medical assistance furnished to or on behalf of a member as the result of the negligence of a third party.

(10) No action taken by the state department pursuant to subsection (4) of this section or any judgment rendered in the action bars any action upon the claim or cause of action of the applicant or member or the member's guardian, personal representative, estate, dependent, or survivors against the third party having legal liability, nor shall any action or judgment operate to deny the applicant or member the recovery for that portion of the member's medical costs or other damages not provided as medical assistance under this article 4 or article 5 or 6 of this title 25.5.

(11) (a) The state department may recover any amount of medical assistance paid on behalf of a member because:

(I) The trustee of a trust for the benefit of the member has used the trust property in a manner contrary to the terms of the trust; or

(II) A person holding the member's power of attorney has used the power for purposes other than the benefit of the member.

(b) To enforce the right under this subsection (11), the county or state department may institute or intervene in legal proceedings against the trustee or person holding the power of attorney. Any amount of medical assistance recovered pursuant to this subsection (11) shall be distributed between the state and county in proportion to the amount of medical assistance paid by each respectively, if any.

(c) No action taken by the county or state department pursuant to this subsection (11) or any judgment rendered in an action or proceeding bars any action upon the claim or cause of action of the member or the member's guardian, personal representative, estate, dependent, or survivors against the trustee or person holding the power of attorney.

(12) (a) An entity that provides managed care, as defined in section 25.5-5-403, that has entered into a risk contract with the state department shall have the same rights of the department set forth in this section except with respect to the rights described in subsections (5) and (6) of this section. In addition, the attorney general may not enforce the rights set forth in this subsection (12). Venue for an action brought by or on behalf of an entity pursuant to this subsection (12) shall be governed by the Colorado rules of civil procedure.

(b) Within fifteen days after filing an action or asserting a claim against a third party, a member under a managed care plan or a guardian, executor, administrator, or other appropriate representative of the member shall provide to the entity that administers the managed care plan written notice of the action or claim. Notice must be by personal service or certified mail.

(c) In cases where the state department has recovery rights against a third party pursuant to subsections (4) and (5) of this section and an entity that provides managed care has subrogation rights against the same party pursuant to paragraph (a) of this subsection (12), the recovery rights of the state department shall take precedence over the rights of the managed care plan.

(13) To the extent allowable under federal law, the state department shall recover from the sponsor of a lawfully residing individual all medical assistance paid on behalf of the sponsored lawfully residing individual who is enrolled in the medical assistance program.

(14) Notwithstanding any provision of this section to the contrary:

(a) (I) The state department, or the state department's designated agent, shall conduct pre-enrollment and post-enrollment site visits of providers who are designated as moderate or high categorical risks to the medicaid program. The purpose of the site visit is to verify that the information submitted to the state department is accurate and to determine compliance with federal and state enrollment requirements.

(II) As established in rules promulgated by the state board, the state department may waive pre-enrollment and post-enrollment site visits of providers if the site visits are conducted by medicare or other federally designated entities.

(III) A provider is designated as a limited, moderate, or high categorical risk pursuant to the medicare program and federal regulations. If a provider is not designated in a risk category pursuant to the medicare program and federal regulations, the provider's risk category shall be established pursuant to rules promulgated by the state board.

(b) A provider enrolled in the medicaid program shall permit the federal centers for medicare and medicaid services or its agent or designated contractors and the state department or its agent to conduct unannounced, on-site inspections of any and all provider locations. Payment for any agent designated by the state department to perform on-site inspections shall not be based on any recoveries paid to the state department by a provider for violations discovered as a result of the on-site inspection.

(15) (a) The state department may request a written response from any provider who fails to comply with the rules, manuals, or bulletins issued by the state department, state board, or the state department's fiscal agent, or from any provider whose activities endanger the health, safety, or welfare of medicaid members. The written response must describe how the provider will come into and ensure future compliance. If a written response is requested, a provider has thirty days, or longer if approved by the state department, to submit the written response.

(b) If the provider does not agree with the state department's findings that resulted in the request issued pursuant to subsection (15)(a) of this section, then the provider's written response must include an explanation and specific reasons for the provider's disagreement.

(16) (a) The state department may suspend the enrollment of a provider, including a children's basic health plan provider, only if:

(I) The state department identifies that the provider is participating in an alleged and ongoing organized crime or organized fraud scheme that impacts the state medical assistance program, this article 4 and articles 5 and 6 of this title 25.5, or the children's basic health plan, article 8 of this title 25.5; and

(II) The state department documents in writing that at least three of the following factors are met:

(A) The provider has been enrolled in the state medical assistance program or children's basic health plan for less than three years;

(B) At least three providers are involved in the organized crime or organized fraud scheme;

(C) The collective billing amount identified in the organized crime or organized fraud scheme exceeds one million dollars;

(D) The provider's billing indicates a pattern of abuse or noncompliance;

(E) The volume of claims or billing amount has increased at a significant rate and there is no other reasonable explanation for the increase;

(F) The federal centers for medicare and medicaid services has approved a provider enrollment moratorium for the provider type involved in the organized crime or organized fraud scheme; or

(G) The state department has notified law enforcement of the organized crime or organized fraud scheme.

(b) The state department shall notify the provider of the suspension in writing and include the reasons for the suspension.

(c) The state department may suspend a provider's enrollment pursuant to subsection (16)(a) of this section for an initial period of six months while the state department conducts a review of the organized crime or organized fraud scheme. After the state department's review is complete, regardless of whether the six-month period has ended, the state department must reinstate the provider's enrollment if the state department determines the provider did not engage in an organized crime or organized fraud scheme. If the state department's review cannot be completed during the initial six-month period, the state department may extend the review period in additional six-month increments if the state department documents in writing the necessity for extending the review.

(d) As used in this subsection (16):

(I) "Organized crime or organized fraud scheme" means a provider is allegedly participating in a coercive, fraudulent, extortionary, criminal, or otherwise illegal coordinated scheme or operation that repeatedly or consistently defrauds the state medical assistance program or children's basic health plan that may put members' health, safety, or welfare at immediate risk.

(II) "Suspend" means temporarily prohibiting a provider from participating in the state medical assistance program or children's basic health plan, from rendering services or supplies to a member, and from submitting claims to the state department for any services or supplies rendered to a member.

(e) This section does not apply to a provider that has been enrolled in the state medical assistance program, including the children's basic health plan, for three years or more and that has consistently rendered services and received payment for those services during the provider's enrollment.
C.R.S. § 25.5-1-109 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-109
25.5-1-109. Department of health care policy and financing cash fund
Status: in_force

25.5-1-109. Department of health care policy and financing cash fund. All moneys collected by the state department as fees or otherwise shall be transmitted to the state treasurer, who shall credit the same to the department of health care policy and financing cash fund, which fund is hereby created in the state treasury. Moneys in the fund shall be subject to annual appropriation by the general assembly for the direct and indirect costs of the state department's duties as provided by law.
C.R.S. § 25.5-4-302 — CO Code / Title 25.5 / Article 4 / Part 3 / Section 25.5-4-302
25.5-4-302. Recovery of assets
Status: in_force

25.5-4-302. Recovery of assets. (1) The general assembly finds, determines, and declares that the cost of providing medical assistance to qualified members throughout the state has increased significantly in recent years; that such increasing costs have created an increased burden on state revenues while reducing the amount of revenues available for other state programs; that recovering some of the medical assistance from the estates of medical assistance members would be a viable mechanism for members to share in the cost of assistance; and that an estate recovery program would be a cost-efficient method of offsetting medical assistance costs in an equitable manner. The general assembly also declares that, in order to ensure that medicaid is available for low-income individuals, reasonable restrictions consistent with federal law should be placed on the ability of persons to become eligible for medicaid by means of making transfers of property without fair and valuable consideration.

(2) (a) Medical assistance paid on behalf of any individual who was fifty-five years of age or older when the individual received such assistance may be recovered by the state department from the estate of such individual in accordance with paragraph (c) of this subsection (2).

(b) Medical assistance paid on behalf of any individual who is institutionalized may be recovered by the state department from the estate of such individual in accordance with paragraph (c) of this subsection (2).

(c) The state department shall establish an estate recovery program only insofar as such program is in accordance with Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended, and shall not take any action to recover medical assistance when the amount of assistance to be recovered is economically inappropriate in relation to expenses of recovery.

(3) The state department is authorized to file liens against any property of an individual who is institutionalized and from whom the state department may recover medical assistance pursuant to paragraph (b) of subsection (2) of this section.

(4) The state department may compromise, settle, or waive any recovery of medical assistance authorized pursuant to subsection (2) of this section upon good cause shown.

(5) Subject to any limitation concerning estate recovery in Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended, the amount of any medical assistance paid pursuant to the provisions of this article and articles 5 and 6 of this title is a claim against the estate pursuant to the provisions of section 15-12-805 (1), C.R.S.

(6) The state board shall promulgate rules to implement the provisions of this section, including rules limiting the eligibility for medical assistance if the person made a voluntary assignment or transfer of property without fair and valuable consideration prior to applying for medical assistance. A contract for an exempt burial fund for an individual shall include a provision restricting the full amount to the cost of the burial and stating that any portion not expended for the burial costs shall be refunded to the state department by the mortuary as reimbursement for the cost of medical assistance provided to the individual. Said rules shall be in accordance with Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended.

(7) Effective upon the implementation of a private-public partnership program for financing long-term care pursuant to section 25.5-6-110, this section shall apply to participants of such program only after excluding from the amount that may otherwise be recovered from such person's estate an amount allowed by rules adopted by the state board in accordance with section 25.5-6-110.
C.R.S. § 25.5-6-108.5 — CO Code / Title 25.5 / Article 6 / Part 1 / Section 25.5-6-108.5
25.5-6-108.5. Community long-term care studies - authority to implement - alternative care fac
Status: in_force

25.5-6-108.5. Community long-term care studies - authority to implement - alternative care facility report. (1) (a) Subject to the receipt of sufficient funding pursuant to subsection (1)(c) of this section, the state department shall contract for one or more studies of the population of members receiving services under the home- and community-based waivers authorized pursuant to this article 6. The state department shall make necessary data available to the contractor, including but not limited to data on activities of daily living. In selecting a contractor to perform any study conducted pursuant to this subsection (1), the state department is not required to follow the competitive bidding requirements of the "Procurement Code", articles 101 to 112 of title 24. The state department shall provide copies of all studies conducted pursuant to this subsection (1) to members of the health and human services committees of the general assembly, or any successor committees, and to the members of the joint budget committee.

(b) If a study conducted pursuant to this subsection (1) concludes that a program of home- and community-based services would result in cost savings, the state department shall seek any necessary federal authorization to implement the program. If federal authorization to implement the program is obtained, the state department shall request, through the state budget process, that the program be implemented. The state department shall report to the joint budget committee annually concerning the amount of any savings realized from the program.

(c) The state department is authorized to seek and accept gifts, grants, or donations from private and public sources for the purposes of this subsection (1); except that the state department may not accept a gift, grant, or donation that is subject to conditions that are inconsistent with this subsection (1) or any other law of the state. The state department shall transmit all private and public moneys received through gifts, grants, or donations to the state treasurer, who shall credit the same to the department of health care policy and financing cash fund created in section 25.5-1-109.

(2) (a) Subject to the receipt of sufficient funding, one of the studies contracted for pursuant to subsection (1) of this section must include research and analysis of:

(I) The number of members with incontinence, Alzheimer's disease, dementia, or other diagnoses of a chronic incapacitating condition that severely limit the member's activities of daily living who would benefit from receiving additional services through an alternative care facility to avoid nursing home placement;

(II) The actuarially sound rate for providing services for the members at an alternative care facility;

(III) The amount of savings associated with providing services at an alternative care facility;

(IV) Recommendations for utilization controls or program controls for a program to provide services at an alternative care facility;

(V) The experiences of the program of all-inclusive care for the elderly, created pursuant to section 25.5-5-412, with tiered rates for alternative care facilities, including cost savings or cost avoidance;

(VI) Other states' experiences with tiered rates for alternative care facilities, including cost savings or cost avoidance; and

(VII) Recommendations for maintaining or improving quality of care.

(b) The study conducted pursuant to this subsection (2) shall be completed by January 1, 2012, and, if federal approval is obtained prior to final figure-setting for the fiscal year commencing July 1, 2012, the state department shall submit a request through the budget process for implementation of the approved changes for that fiscal year.
C.R.S. § 25.5-4-209 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-209
25.5-4-209. Payments by third parties - copayments by members - review - appeal - children's
Status: repealed

25.5-4-209. Payments by third parties - copayments by members - review - appeal - children's waiting list reduction fund - rules. (1) (a) Any member receiving benefits pursuant to this article 4 or article 5 or 6 of this title 25.5 who receives any supplemental income, available for medical purposes under rules of the state department, or who receives proceeds from sickness, accident, health, or casualty insurance, must apply the supplemental income or insurance proceeds to the cost of the benefits rendered, and the state department rules may require reports from providers of other payments received from or on behalf of members.

(b) Subject to any limitations imposed by Title XIX of the federal "Social Security Act", a member shall pay at the time of service a portion of the cost of any medical benefit rendered to the member or to the member's dependents pursuant to this article 4 or article 5 or 6 of this title 25.5, as determined by rules of the state department.

(c) to (e) Repealed.

(2) (a) Notwithstanding the provisions of section 26-1-114, C.R.S., the state department is authorized to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services available, including the collection of sufficient information from individuals who are eligible for medical assistance to pursue claims against the third parties. The state department shall collect the information at the time of any determination or redetermination of eligibility for medical assistance. A knowing or willful failure of an individual to provide the information may result in the termination of the individual's eligibility for medical assistance.

(b) A third party, as a condition of doing business in the state, shall:

(I) (A) Provide on a monthly basis to the state department or its business associate eligibility records identifying all persons covered by the third party in a manner prescribed by rule to allow the state department or its business associate to perform an analysis and determine which persons are eligible for medical assistance;

(B) The eligibility record data elements provided by the third party shall be the minimum necessary to achieve a satisfactory data match. The third party shall provide, upon request of the state department or its business associate, additional data elements as needed to confirm eligibility matches as determined by the initial analysis, including, but not limited to, the name, address, and identifying number of the third party's plan.

(II) Accept the state's right of recovery and the assignment to the state of any right of an individual or other entity to payment from the third party for an item or service for which payment has been made under the medical assistance plan to the extent that such service is covered by the third party;

(III) Respond to any inquiry by the state regarding a claim for payment for any health-care item or service that is submitted not later than three years after the date of the provision of the health-care item or service; and

(IV) Agree not to deny a claim submitted by the state solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim, if:

(A) The claim is submitted by the state within the three-year period beginning on the date that the item or service is furnished; and

(B) Any action by the state to enforce its rights with respect to the claim is commenced within six years after the state's submission of the claim.

(c) The cost to a third party of providing data, including eligibility records, shall be borne by the state department.

(d) A third party that provides data required by the state department, whether confidential or not, shall not be held liable for the provision of such data to the state department or for any use made thereof.

(e) (I) The state department's business associate shall not use, transfer, extract, copy, revise, or store any data required to be provided to the state department and its business associate, including the eligibility records, social security numbers, coverage, nature of coverage, period provided, or any other data elements, for purposes other than:

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

(B) Cost avoidance;

(C) The remuneration of the state department for services provided or paid for;

(D) Any record retention requirements;

(E) Audit requirements; and

(F) Purposes related to litigation and testimony.

(II) The state department's business associate shall destroy all data once the functions specified in subparagraph (I) of this paragraph (e) have been accomplished.

(f) (I) A Colorado resident shall have a private right of action against the state department's business associate if the business associate negligently uses the data specified in paragraph (e) of this subsection (2) for purposes other than those stated in paragraph (e) of this subsection (2). The right of action shall be enforceable in the courts of Colorado and limited to the actual damages incurred by the individual bringing the action.

(II) A third party may bring an action on behalf of a Colorado resident for injunctive relief against the state department's business associate to prevent the business associate from intentionally using the data for purposes other than those specified in paragraph (e) of this subsection (2).

(g) As used in this section:

(I) "Business associate" shall have the same meaning as provided in 45 CFR 160.103.

(II) "Third party" means a health insurer, self-insured plan, group health plan as defined in 29 U.S.C. sec. 1167 (1), service benefit plan, managed care organization, pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health-care item or service.

(3) (a) The rights assigned by a member of medical assistance to the state department pursuant to section 25.5-4-205 (4) must include the right to appeal an adverse coverage decision by a third party for which the medical assistance program may be responsible for payment, including but not limited to the internal and external reviews described in sections 10-16-113 and 10-16-113.5 and a third party's reasonable appeal procedure under state and federal law. The state department or the independent contractor retained pursuant to subsection (3)(b) of this section shall review and, if necessary, may appeal at any level an adverse coverage decision, except an adverse coverage decision relating to medicare, Title XVIII of the federal "Social Security Act", as amended.

(b) The state department shall enter into one or more agreements with an independent contractor to pursue recoveries from third parties pursuant to paragraph (a) of this subsection (3). Any such agreement shall provide that the independent contractor's only compensation shall be a prudent and reasonable percentage of the amount recovered on behalf of the state department as determined by the state department.

(c) (I) An independent contractor retained pursuant to paragraph (b) of this subsection (3) shall maintain a contemporaneous record of the hours of services provided and any costs incurred. When the matter is resolved, the independent contractor shall provide to the state department a statement of the hours of services provided, the amount of costs incurred, the total amount of the contingent fee, and the hourly rate for the services provided. The hourly rate for the services provided shall be determined by dividing the amount of the contingent fee, less the amount of costs incurred, by the number of hours of services provided by the independent contractor. The statement required by this subparagraph (I) shall be available for inspection and copying at reasonable times at the state department.

(II) Compliance with this paragraph (c) does not relieve a contracting attorney of any obligation or legal responsibility imposed by the Colorado rules of professional conduct or any provision of law.

(d) Nothing in this subsection (3) authorizes the denial of or delay of payment to a provider by the state department or the delay or interference with the provision of services to a medical assistance member.

(e) Repealed.

(4) With respect to programs administered by the state department, the state department shall access available data from the public assistance reporting information system for the purpose of identifying persons who are receiving certain public benefits from other states. The state department shall ensure that duplicate benefits are not being paid improperly to persons identified pursuant to the public assistance reporting information system.
C.R.S. § 25.5-1-111 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-111
25.5-1-111. Waiver applications - authorization
Status: in_force

25.5-1-111. Waiver applications - authorization. (Deleted by amendment)
C.R.S. § 25.5-1-303 — CO Code / Title 25.5 / Article 1 / Part 3 / Section 25.5-1-303
25.5-1-303. Powers and duties of the board - scope of authority - rules - repeal
Status: repealed

25.5-1-303. Powers and duties of the board - scope of authority - rules - repeal. (1) The board shall have the authority set forth in subsection (3) of this section over the following programs administered by the state department:

(a) The "Colorado Medical Assistance Act", as specified in articles 4, 5, and 6 of this title;

(b) (I) The "Colorado indigent care program", as specified in part 1 of article 3 of this title;

(II) This subsection (1)(b) is repealed, effective July 1, 2025.

(c) Repealed.

(d) The "Children's Basic Health Plan Act", as specified in article 8 of this title;

(e) The old age pension health and medical care program, as specified in section 25.5-2-101;

(f) Programs, services, and supports for persons with intellectual and developmental disabilities, as specified in article 10 of this title.

(2) Nothing in this section shall be construed to affect any specific statutory provision granting rule-making authority to the board in relation to a specific program.

(3) The board shall adopt rules in connection with the programs set forth in subsection (1) of this section governing the following:

(a) The implementation of legislative and departmental policies and procedures for such programs; except that no rules shall be promulgated for any policy or procedure which governs the administration of the state department as specified in section 25.5-1-108 (1);

(b) The establishment of eligibility requirements for members receiving services from the state department;

(c) The establishment of the type of benefits that are available to an applicant if eligibility requirements are met, subject to the authorization, requirements, and availability of the benefits;

(d) The requirements, obligations, and rights of members and applicants;

(e) The establishment of a procedure to resolve disputes that may arise between members and the state department or members and providers;

(f) The requirements, obligations, and rights of providers, including policies and procedures related to provider payments that may affect member benefits;

(g) The establishment of a procedure to resolve disputes that may arise between providers and between the state department and providers.

(4) At the request of the executive director, the board shall advise the executive director as to any proposed policies or rules governing programs administered by the state department that are not set forth in subsection (1) of this section.

(5) The board shall have no authority over the revenue of the state department.

(6) All rules and orders of the department of human services in connection with the old age pension health and medical care program shall continue to be effective until revised, amended, repealed, or nullified pursuant to law.

(7) The rules issued by the state board shall be binding upon the county departments. At any public hearing relating to a proposed rule-making, interested persons shall have the right to present their data, views, or arguments orally. Proposed rules of the state board shall be subject to the provisions of section 24-4-103, C.R.S.

(8) To the extent that rules are promulgated by the state board of human services for programs or providers that receive either medicaid only or both medicaid and nonmedicaid funding, the rules shall be developed in cooperation with the state department and shall not conflict with state statutes or federal statutes or regulations.

(9) The rules and orders of the department of human services and the state board of human services in connection with the programs, services, and supports specified in paragraph (f) of subsection (1) of this section shall continue to be effective until revised, amended, repealed, or nullified pursuant to law.
C.R.S. § 25.5-4-206 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-206
25.5-4-206. Reimbursement to counties - costs of administration
Status: in_force

25.5-4-206. Reimbursement to counties - costs of administration. The state department shall reimburse the county departments for costs of administration incurred by the counties under this article and articles 5 and 6 of this title in accordance with the provisions of section 26-1-122 (5), C.R.S.
C.R.S. § 25.5-6-1701 — CO Code / Title 25.5 / Article 6 / Part 17 / Section 25.5-6-1701
25.5-6-1701. Legislative declaration
Status: in_force

25.5-6-1701. Legislative declaration. The general assembly finds and declares that there is a need to ensure a high-performing statewide case management system exists that serves all populations of people who qualify for long-term services and supports. The case management system includes, but is not limited to, intake and eligibility screening and determination, outreach, and other administrative activities and case management services. The five key outcomes of the statewide case management system must include federal compliance, quality, simplicity, stability, and accountability.