C.R.S. § 25.5-6-1303 — CO Code / Title 25.5 / Article 6 / Part 13 / Section 25.5-6-1303
25.5-6-1303. Pilot program - complementary or alternative medicine - rules
Status: repealed

25.5-6-1303. Pilot program - complementary or alternative medicine - rules. (1) (a) The general assembly authorizes the state department to implement a pilot program that would allow an eligible person with a disability to receive complementary or alternative medicine to the extent authorized by federal waiver. The pilot program may begin no later than January 1, 2012. The state department shall design and implement the pilot program with input from an advisory committee that must include, but need not be limited to, persons with spinal cord injuries who are receiving complementary or alternative medicine. The state department may seek any federal waivers that may be necessary to implement this part 13.

(b) Subject to available funds, it is the intent of the general assembly that the state department enroll every eligible person that applies for the waiver and that an eligible person is not placed on a waiting list for services.

(2) (a) The purpose of the pilot program is to expand the choice of therapies available to eligible persons with disabilities, to study the success of complementary and alternative medicine, and to produce an overall cost savings for the state compared to the estimated expenditures that would have otherwise been spent for the same persons with spinal cord injuries absent the pilot program.

(b) In order to qualify and to remain eligible for the pilot program authorized by this section, a person shall:

(I) Be diagnosed with a primary condition of a spinal cord injury, multiple sclerosis, a brain injury, spina bifida, muscular dystrophy, or cerebral palsy, with the total inability for independent ambulation directly resulting from one of these diagnoses;

(II) Be willing to participate in the pilot program;

(III) Demonstrate a current need, as further defined in rule by the state board, for complementary or alternative medicine; and

(IV) Be eligible for medicaid, including but not limited to persons who meet the functional level of care and financial criteria described in rules promulgated by the state board relating to long-term care services.

(c) The state department shall implement subsection (2)(b) of this section no later than July 1, 2022.

(d) The pilot program is available to all eligible individuals in Colorado.

(3) The state department shall develop the accountability requirements for the pilot program necessary to safeguard the use of public moneys and to promote effective and efficient service delivery.

(4) The state board shall adopt rules as necessary for the implementation and administration of the pilot program.

(5) The state department shall cause to be conducted an independent evaluation of the pilot program to be completed no later than January 1, 2025. The state department shall provide a report of the evaluation 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 report on the evaluation must include the following:

(a) The number of eligible persons with disabilities participating in the pilot program;

(b) The cost-effectiveness of the pilot program;

(c) Feedback from members and the state department concerning the progress and success of the pilot program;

(d) Any changes to the health status or health outcomes of the persons participating in the pilot program;

(e) Other information relevant to the success and problems of the pilot program; and

(f) Recommendations concerning the feasibility of continuing the pilot program beyond the pilot stage and changes, if any, that are needed.

(6) Repealed.

(7) Unless the state department receives sufficient appropriations, the state department is not required to seek federal approval or implement the pilot program.

(8) (a) No later than January 2024, the state department shall submit a report to the senate health and human services committee, the house of representatives public and behavioral health and human services committee, and the house of representatives health and insurance committee, or any successor committees, as part of its "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act" presentation required by section 2-7-203. At a minimum, the report must identify:

(I) A reimbursement system with a goal to incentivize and increase transportation provider participation;

(II) How the state department will ensure compliance with applicable federal laws and waiver requirements;

(III) A system of common reporting to ensure a member does not exceed the medicaid benefit in a multi-provider scenario; and

(IV) Best practices based on what other states have done to allow transportation network companies to provide nonmedical transportation services for individuals receiving services, including but not limited to, reimbursement rates; driver compensation; and integration with programs that provide nonmedical transportation services.

(b) In developing the report, the state department shall engage in a stakeholder process that includes individuals with intellectual and developmental disabilities and their families, individuals with disabilities, and transportation network companies. The report may be developed in conjunction with the reporting requirement in sections 25.5-6-307 (6), 25.5-6-409 (6), 25.5-6-606 (9), and 25.5-6-704 (8).

(c) (I) Upon completion of the report described in subsection (8)(a) of this section, the state department shall analyze and review each operational transportation network company, as defined in section 40-10.1-602 (3). The state department shall verify each transportation network company's viability to ensure the health, safety, welfare, cost effectiveness, and capability in expanding nonmedical transportation services for individuals receiving services pursuant to this section and comply with all rules promulgated pursuant to subsection (8)(e)(I) of this section.

(II) No later than July 1, 2024, the state department shall authorize verified transportation network companies to provide nonmedical transportation services if the state department finds the transportation network company viable under federal requirements and within budgetary constraints.

(III) For the purposes of this subsection (8)(c), "verify" means a transportation network company meets all requirements resulting from the report described in subsection (8)(a) of this section.

(d) The state department may seek any necessary federal authorization for the implementation of this subsection (8).

(e) (I) The state department shall promulgate any necessary rules to ensure transportation network companies comply with federal and state oversight requirements and shall include all relevant stakeholders, including medicaid members, transportation network companies, current providers and drivers for nonmedical transportation services, and other parties interested in developing the requirements.

(II) Pursuant to section 40-10.1-105 (1)(l), transportation network companies are not subject to regulation by the public utilities commission when providing nonmedical transportation services pursuant to this section and are instead subject to rules promulgated by the state department pursuant to this subsection (8)(e).

(f) This subsection (8) does not apply to a provider authorized to provide transportation services pursuant to part 8 of article 1 of title 25.5 prior to August 10, 2022.
C.R.S. § 25.5-4-201 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-201
25.5-4-201. Cash system of accounting - financial administration of medical services premium
Status: in_force

25.5-4-201. Cash system of accounting - financial administration of medical services premiums - medical programs administered by department of human services - federal contributions - rules. (1) The state department shall utilize the cash system of accounting, as enunciated by the governmental accounting standards board, regardless of the source of revenues involved, for all activities of the state department relating to the financial administration of any nonadministrative expenditure that qualifies for federal financial participation under Title XIX of the federal "Social Security Act", and for the administration of the state-funded health and medical care program, created pursuant to section 25.5-2-104, and for the state children's basic health plan, created pursuant to section 25.5-2-105, except for expenditures under the program for the medically indigent, article 3 of this title 25.5.

(1.5) (a) The state department shall utilize the cash system of accounting, as enunciated by the governmental accounting standards board, for the contributions required by 42 U.S.C. sec. 1396u-5 (c).

(b) The contributions required by 42 U.S.C. sec. 1396u-5 (c) shall be made in the manner required by the federal centers for medicare and medicaid services, or any successor agency. Nothing in this paragraph (b) shall require the state department to make the contribution before the contribution is due.

(2) The executive director shall promulgate rules to identify the programs utilizing the cash system of accounting.
C.R.S. § 25.5-6-201 — CO Code / Title 25.5 / Article 6 / Part 2 / Section 25.5-6-201
25.5-6-201. Special definitions relating to nursing facility reimbursement
Status: repealed

25.5-6-201. Special definitions relating to nursing facility reimbursement. As used in this part 2, unless the context otherwise requires:

(1) "Acquisition cost" means the actual allowable cost to the owners of a capital-related asset or any improvement thereto as determined in accordance with generally accepted accounting principles.

(2) "Actual cost" or "cost" means the audited cost of providing services.

(3) "Administration and general services costs" means costs in the following categories:

(a) Advertising, recruitment, and public relations, to the extent that such costs are necessary, reasonable, and patient-related;

(b) Travel and training of facility staff, unless the travel includes residents of the facility or the training is for the facility staff described in paragraph (a) of subsection (15) of this section; and

(c) All other costs that are not direct or indirect health-care services, raw food costs, or capital-related assets.

(4) "Appraised value" means the determination by a qualified appraiser who is a member of an institute of real estate appraisers, or its equivalent, of the depreciated cost of replacement of a capital-related asset to its current owner. The depreciated replacement appraisal must be based on a nationally recognized valuation system determined by the state department. The depreciated cost of replacement appraisal must be redetermined at least every four years by new appraisals of the nursing facilities. The new appraisals must be based upon rules promulgated by the state board.

(5) "Array of facility providers" means a listing in order from lowest per diem cost facility to highest for that category of costs or rates, as may be applicable, of all medicaid-participating nursing facility providers in the state.

(6) (a) "Base value" means:

(I) For the fiscal year 1986-87 and every fourth year thereafter, the appraised value of a capital-related asset;

(II) For each year in which an appraisal is not done pursuant to subparagraph (I) of this paragraph (a), the most recent appraisal together with fifty percent of any increase or decrease each year since the last appraisal, as reflected in the index.

(b) For the fiscal year 1985-86, the base value shall not exceed twenty-five thousand dollars per licensed bed at any participating facility, and, for each succeeding fiscal year, the base value shall not exceed the previous year's limitation adjusted by any increase or decrease in the index.

(c) An improvement to a capital-related asset, which is an addition to that asset, as defined by rules adopted by the state board, shall increase the base value by the acquisition cost of the improvement.

(7) "Capital-related asset" means the land, buildings, and fixed equipment of a participating facility.

(8) "Case-mix" means a relative score or weight assigned for a given group of residents based upon their levels of resources, consumption, and needs.

(9) "Case-mix adjusted direct health-care services costs" means those costs comprising the compensation, salaries, bonuses, workers' compensation, employer-contributed taxes, and other employment benefits attributable to a nursing facility provider's direct care nursing staff whether employed directly or as contract employees, including but not limited to registered nurses, licensed practical nurses, and nurses' aides.

(9.5) "Case-mix group" means the system determined by the state department for grouping a nursing facility's residents according to their clinical and functional status as identified from data supplied by the facility's minimum data set as published by the United States department of health and human services.

(10) "Case-mix index" means a numeric score assigned to each nursing facility resident based upon a resident's physical and mental condition that reflects the amount of relative resources required to provide care to that resident.

(11) "Case-mix neutral" means the direct health-care costs of all facilities adjusted to a common case-mix.

(12) "Case-mix reimbursement" means a payment system that reimburses each facility according to the resource consumption in treating its case-mix of medicaid residents, which case-mix may include such factors as the age, health status, resource utilization, and diagnoses of the facility's medicaid residents as further specified in this section.

(13) "Class I facility" means a private for-profit or not-for-profit nursing facility provider or a facility provider operated by the state of Colorado, a county, a city and county, or special district that provides general skilled nursing facility care to residents who require twenty-four-hour nursing care and services due to their ages, infirmity, or health-care conditions, including residents who are behaviorally challenged by virtue of a severe behavioral or mental health disorder.

(14) "Direct health-care services costs" means those costs subject to case-mix adjusted direct health-care services costs.

(15) "Direct or indirect health-care services costs" means the costs incurred for patient support services, including the following:

(a) Salaries, payroll taxes, workers' compensation payments, training, and other employee benefits for registered nurses, licensed practical nurses, aides, medical records librarians, social workers, and activity personnel;

(b) Nonprescription drugs ordered by a physician;

(c) Consultant fees for nursing, medical records, patient activities, social workers, pharmacies, physicians, and therapies;

(d) Purchases, rentals, and costs incurred to operate, maintain, or repair health-care equipment;

(e) Supplies for nurses, medical records personnel, social workers, activity personnel, and therapy personnel;

(f) Medical director fees;

(g) Therapies and other medically related services, including the following:

(I) Utilization review;

(II) Dental care, when required by federal law;

(III) Audiology;

(IV) Psychology;

(V) Physical therapy;

(VI) Recreational therapy;

(VII) Occupational therapy; and

(VIII) Speech therapy;

(h) Other patient support services determined and defined by the state board pursuant to rule;

(i) Raw food costs that do not include the costs of equipment, staff, or other costs associated with meal preparation;

(j) Malpractice insurance;

(k) Depreciation and interest for major health-care equipment, such as equipment purchased for the sole purpose of providing care to facility residents; and

(l) Photocopying related to health-care purposes such as medical records of patients.

(15.5) "Eligible nursing facility provider" means a nursing facility, as defined in section 25.5-4-103.

(16) "Facility population distribution" means the number of Colorado nursing facility residents who are classified into each case-mix group as of a specific point in time.

(17) "Fair rental allowance" means the product obtained by multiplying the base value of a capital-related asset by the rental rate.

(18) "Improvement" means the addition to a capital-related asset of land, buildings, or fixed equipment.

(19) "Index" means the RSMeans construction systems cost index or an equivalent index that is based upon a survey of prices of common building materials and wage rates for nursing home construction.

(20) "Index maximization" means classifying a resident who could be assigned to more than one category to the category with the highest case-mix index.

(20.5) Repealed.

(21) "Median per diem cost" means the average daily cost of care and services per patient for the nursing facility provider that represents the middle of all of the arrayed facilities participating as providers or as the number of arrayed facilities may dictate, the mean of the two middle providers.

(22) "Minimum data set" means a set of screening, clinical, and functional status elements that are used in the assessment of a nursing facility provider's residents under the federal medicare and medicaid programs.

(23) "Normalization ratio" means the statewide average case-mix index divided by the facility's cost report period case-mix index.

(24) "Normalized" means multiplying the nursing facility provider's per diem case-mix adjusted direct health-care services cost by its case-mix index normalization ratio for the purpose of making the per diem cost comparable among facilities based upon a common case-mix in order to determine the maximum allowable reimbursement limitation.

(25) "Nursing facility provider" means a facility provider that meets the state nursing home licensing standards established pursuant to section 25-1.5-103 (1)(a), C.R.S., and is maintained primarily for the care and treatment of inpatients under the direction of a physician.

(26) "Nursing salary ratios" means the relative difference in hourly wages of registered nurses, licensed practical nurses, and nurses' aides.

(27) "Nursing weights" means numeric scores assigned to each category of the case-mix groups that measure the relative amount of resources required to provide nursing care to a nursing facility provider's residents.

(28) "Occupancy-imputed days" means the use of a predetermined number for patient days rather than actual patients days in computing per diem cost.

(29) "Per diem cost" means the daily cost of care and services per patient for a nursing facility provider.

(30) "Per diem rate" means the daily dollar amount of reimbursement that the state department shall pay a nursing facility provider per patient.

(31) "Provider fee" means a licensing fee, assessment, or other mandatory payment that is related to health-care items or services as specified under 42 CFR 433.55.

(32) "Raw food" means the products and substances, including but not limited to nutritional supplements, that are consumed by residents.

(33) "Rental rate" means the average annualized composite rate for United States treasury bonds issued for periods of ten years and longer plus two percent. The rental rate shall not exceed ten and three-quarters percent nor fall below eight and one-quarter percent.

(34) Repealed.

(35) "Statewide average per diem rate" means the average daily dollar amount of the per patient payments to all medicaid-participating facility providers in the state.

(36) "Supplemental medicaid payment" means a lump sum payment that is made in addition to a provider's per diem rate. A supplemental medicaid payment is calculated on an annual basis using historical data and paid as a fixed monthly amount with no retroactive adjustment.

(37) "Wage enhancement supplemental payment" means a supplemental payment to an eligible nursing facility provider that is subject to available appropriations and not a rate enhancement.
C.R.S. § 25.5-10-213 — CO Code / Title 25.5 / Article 10 / Part 2 / Section 25.5-10-213
25.5-10-213. Discharge - repeal
Status: repealed

25.5-10-213. Discharge - repeal. (Repealed)
C.R.S. § 25.5-8-110 — CO Code / Title 25.5 / Article 8 / Section 25.5-8-110
25.5-8-110. Participation by managed care plans
Status: repealed

25.5-8-110. Participation by managed care plans. (1) Managed care plans, as defined in section 10-16-102 (43), C.R.S., that participate in the plan shall do so by contract with the department and shall provide the health-care services covered by the plan to each enrollee.

(2) Managed care plans participating in the plan shall not discriminate against any potential or current enrollee based upon health status, disability, sex, sexual orientation, gender identity, gender expression, marital status, race, creed, color, national origin, ancestry, ethnicity, or religion.

(3) Managed care plans that contract with the department to provide the plan to enrollees shall also be willing to contract with the medicaid managed care program, as administered by the department.

(4) (a) Managed care plans shall be selected by the department to participate in the children's basic health plan based upon the managed care plans' assurances and the department's verification that the managed care plan is utilizing within its network essential community providers to the extent that this action does not result in a net increase in the cost for providing services to the managed care plan.

(b) The managed care organization shall seek proposals from each essential community provider in a county in which the managed care organization is enrolling members for those services that the managed care organization provides or intends to provide and that an essential community provider provides or is capable of providing. To assist managed care organizations in seeking proposals, the department shall provide managed care organizations with a list of essential community providers in each county. The managed care organization shall consider the proposals in good faith and shall, when deemed reasonable by the managed care organization based on the needs of its members, contract with essential community providers. Each essential community provider must be willing to negotiate on reasonably equitable terms with each managed care organization. Essential community providers making proposals pursuant to this subsection (4) must be able to meet the contractual requirements of the managed care organization. The requirement of this subsection (4) does not apply to a managed care organization in areas in which the managed care organization operates entirely as a group model health maintenance organization.

(c) Any disputes between a managed care organization and an essential community provider that cannot be resolved through good faith negotiations may be resolved through an informal review by the department at the request of one of the parties, or through the department's aggrieved provider appeal process in accordance with section 25.5-1-107 (2), if requested by one of the parties.

(d) In selecting managed care organizations through competitive bidding, the department shall give preference to those managed care organizations that have executed contracts for services with one or more essential community providers. In selecting managed care organizations, the department shall not penalize a managed care organization for paying cost-based reimbursement to federally qualified health centers as defined in the federal "Social Security Act".

(5) The department may receive and act upon complaints from members regarding failure to provide covered services or efforts to obtain payment, other than authorized copayments, for covered services directly from eligible members.

(6) Parents or guardians of children shall choose a participating health maintenance organization before enrolling in the plan in areas of the state where a participating health maintenance organization is available. The department will assign children who are currently enrolled in the plan and whose parents or guardians have not selected a health maintenance organization within a time period determined by the department to a participating health maintenance organization with the child's primary care physician in the network. The department shall seek to maintain continuity of the health plan between medicaid and the children's basic health plan.

(7) In areas of the state in which a participating managed care plan does not have providers, the department may contract with essential community providers and other health-care providers to provide health-care services under the children's basic health plan using a managed care model.

(8) The department may contract with essential community providers or other providers or develop other administrative arrangements to provide health-care services under the children's basic health plan to enrollees prior to the effective date of enrollment in the selected managed care plan.

(9) The department shall allow, at least annually, an opportunity for members to transfer among participating managed care plans serving their respective geographic regions. The department shall establish a period of at least twenty days annually when the opportunity to transfer is afforded to eligible members. In geographic regions served by more than one participating managed care plan, the department shall endeavor to establish a uniform period for the opportunity to transfer.

(10) (a) The department shall make a capitation payment to managed care plans based upon a defined scope of services at an agreed upon rate. The department shall only use market rate bids that do not discriminate and are adequate to assure quality, network sufficiency, and long-term competitiveness in the children's basic health plan managed care market. The department shall retain a qualified actuary to establish a lower limit for such bids. A certification by such actuary to the appropriate lower limit shall be conclusive evidence of the department's compliance with the requirements of this subsection (10). For the purposes of this subsection (10), a "qualified actuary" shall be a person deemed as such under rules promulgated by the commissioner of insurance.

(b) Repealed.

(11) All managed care plans participating in the plan shall meet standards regarding the quality of services to be provided, financial integrity, and responsiveness to the unmet health-care needs of eligible persons that may be served.
C.R.S. § 25.5-10-204 — CO Code / Title 25.5 / Article 10 / Part 2 / Section 25.5-10-204
25.5-10-204. Duties of the executive director - state board rules - definitions
Status: repealed

25.5-10-204. Duties of the executive director - state board rules - definitions. (1) In order to implement the provisions of this article 10, the executive director shall, subject to available appropriations, carry out the following duties:

(a) Conduct monitoring and review activities that include case management agencies and service agencies;

(b) Provide or obtain training and technical assistance through case management agencies and service agencies in order to improve the quality of long-term services and supports provided to persons with intellectual and developmental disabilities;

(c) Prepare and transmit annually to the governor and the joint budget committee of the general assembly, in the form and manner prescribed pursuant to section 24-1-136, a report detailing the following information, as available and appropriate, that is broken down into defined service areas as well as provided in an overall statewide format:

(I) The total number of persons receiving services pursuant to this article;

(II) The types of services and supports provided;

(III) The costs of services and supports regardless of funding source;

(IV) An evaluation of the quality of the services and supports rendered;

(V) An evaluation of the effectiveness of the services and supports rendered in implementing the individualized plans of persons receiving services;

(VI) The numbers, types, and resolution of appeals that were heard by the state department arising from disputes specified in section 25.5-10-212; and

(VII) The number of persons determined to be eligible to receive services and supports who are not receiving services or supports pursuant to this article along with an analysis of the reasons they are not receiving services and supports;

(d) Designate a case management agency in each defined service area in the state;

(e) Implement the provision of home- and community-based services to eligible persons with intellectual and developmental disabilities and pursue other medicaid-funded services determined by the state department to be appropriate for persons with intellectual and developmental disabilities, pursuant to part 4 of article 6 of this title and subject to available appropriations;

(f) Promote effective coordination with agencies serving persons with intellectual and developmental disabilities in order to improve continuity of services and supports for persons facing life transitions from toddler to preschool, school to adult life, and work to retirement; and

(g) Facilitate employment first policies and practices by:

(I) Developing practices that reflect a presumption that all persons with disabilities are capable of working in competitive integrated employment if they choose to do so, and ensuring that options for competitive integrated employment with appropriate supports are explored before consideration of segregated activities;

(II) Providing state department input and assistance to the employment first advisory partnership described in section 8-84-303, C.R.S., in carrying out its duties;

(III) Establishing annual reporting of the following data, reported by county, for individuals eligible for supported employment services, including but not limited to home- and community-based waiver services:

(A) The number of individuals employed in group employment, the sector of employment, the mean wage per hour earned, and the mean hours worked per week;

(B) The number of individuals employed in competitive integrated employment, the sector of employment, the mean wage per hour earned, and the mean hours worked per week;

(C) The number of individuals employed and served in prevocational services, the sector of employment, the mean wage per hour earned, the mean hours worked per week, and the mean service hours per week;

(D) The number of individuals served in community-based nonwork and the mean service hours per week;

(E) The number of individuals served in specialized habilitation services and the mean service hours per week;

(F) The number of individuals employed or served, as applicable, in any other employment services or day services model, the sector of employment, and the mean wage per hour worked, mean hours worked per week, or the service hours per week, as applicable;

(G) The number of individuals eligible for employment services, regardless of whether the individual is utilizing employment services; and

(H) The number of individuals served earning less than minimum wage.

(IV) Maintaining Colorado's membership in the state employment leadership network that was founded as a joint partnership between the national association of state directors of developmental disabilities services and the institute for community inclusion at the university of Massachusetts Boston or another similar organization that facilitates collaboration with other states to share effective solutions to increase employment outcomes for persons with disabilities; and

(V) Presenting the reports and recommendations of the employment first advisory partnership to the state department's legislative committee of reference pursuant to section 8-84-303 (7), C.R.S.

(2) The state board shall adopt such rules, in accordance with section 24-4-103, as are necessary to carry out the provisions and purposes of this article 10, including but not limited to the following subjects:

(a) Standards for services and supports, including preparation of individualized plans;

(b) Repealed.

(c) Purchase of services and supports and financial administration;

(d) Procedures for resolving disputes over eligibility determination and the modification, denial, or termination of services;

(e) Eligibility determination, the criteria for determination, and admission to the program;

(f) Systems of quality assurance and data collection;

(g) The rights of a person receiving services;

(h) Confidentiality of records of a person receiving services;

(i) Designation of authorized representatives and delineation of their rights and duties pursuant to this article;

(j) (I) The establishment of guidelines and procedures for authorization of persons for administration of nutrition and fluids through gastrostomy tubes.

(II) The state department shall require that a service agency providing residential or day program services or supports have a staff member qualified pursuant to subparagraph (III) of this paragraph (j) on duty at any time the facility administers said nutrition and fluids through gastrostomy tubes, and that the facility maintain a written record of each nutrient or fluid administered to each person receiving services, including the time and the amount of the nutrient or fluid.

(III) A person who is not otherwise authorized by law to administer nutrition and fluids through gastrostomy tubes is allowed to perform the duties only under the supervision of a licensed nurse, a licensed certified midwife, or a licensed physician. A person who administers nutrition and fluids in compliance with this subsection (2)(j) is exempt from the licensing requirements of the "Colorado Medical Practice Act", article 240 of title 12, and the "Nurse and Nurse Aide Practice Act", article 255 of title 12. Nothing in this subsection (2)(j) shall be deemed to authorize the administration of medications through gastrostomy tubes. A person administering medications through gastrostomy tubes is subject to the requirements of part 3 of article 1.5 of title 25.

(IV) As used in this subsection (2)(j):

(A) "Administration" means assisting a person in the ingestion of nutrition or fluids according to the direction and supervision of a licensed nurse, a licensed certified midwife, or a licensed physician.

(B) "Certified midwife" has the same meaning as set forth in section 12-255-104 (3.2).

(k) (I) No later than July 1, 2019, the state board, in conjunction with the department of labor and employment, shall require a nationally recognized supported employment training certificate or nationally recognized supported employment certification for all vendors of supported employment services, including supported employment professionals who provide individual competitive integrated employment outcomes, and excluding those professionals exclusively providing group or other congregate services. The state board's rules must include time frames for compliance with the training or certification requirement for existing staff and for newly hired staff and requirements for supervision of newly hired staff until the staff member has completed the training or certification. The time frames established in the state board's rules must provide for training to be completed over a five-year period, subject to the availability of appropriations for reimbursement of vendors pursuant to subsection (2)(k)(II) of this section.

(II) The training or certification requirement in subsection (2)(k)(I) of this section is contingent upon appropriations to the department of health care policy and financing for reimbursement to vendors of supported employment services for the cost of training and certification. The state board shall adopt rules for administering the reimbursement to vendors, which reimbursement must be three hundred dollars for each certification exam and twelve hundred dollars for each training program certificate, which includes reimbursement for both the cost of the training and wages paid to employees during training. The state board may increase the fixed reimbursement amount over time based on increases in the cost of the exam and employee wages.
C.R.S. § 25.5-4-300.9 — CO Code / Title 25.5 / Article 4 / Part 3 / Section 25.5-4-300.9
25.5-4-300.9. Explanation of benefits - medicaid members - legislative declaration
Status: in_force

25.5-4-300.9. Explanation of benefits - medicaid members - legislative declaration. (1) (a) The general assembly finds and declares that:

(I) Colorado's medicaid program provides critical medical services to the state's poorest and most vulnerable residents;

(II) Funding for these services is provided through a financial partnership between Colorado and the federal government;

(III) For the 2015-16 state budget year, the general assembly appropriated $8,891,000,000 for Colorado's medicaid program, of which $2,508,000,000 is from the general fund and $677,000,000 is from the hospital provider fee, with the remainder from federal money;

(IV) It is in the best interest of Colorado to do everything possible to minimize error, inefficiency, and fraud in providing medicaid services to ensure the long-term viability of this safety net program;

(V) In the private sector, as well as the medicare program, insurers routinely provide an explanation of benefits to their clients, listing claims submitted by providers for services rendered to the client even when the insurer is not seeking a co-payment for the service and the provider is not claiming an amount due from the client;

(VI) While creating an explanation of benefits is not without cost to the health-care system, only the member receiving medical services or the member's authorized representative is in the position to verify whether the claimed medical services were actually provided and for whom they were provided, which is a necessary first step in containing health-care costs;

(VII) While medicaid members may not appear to be affected financially by billing errors or fraudulent claims, medicaid members who rely on these services for survival and independence are most severely affected by the inappropriate use of scarce resources; and

(VIII) Further, medicaid members and consumer advocates for low-income and vulnerable Coloradans want the opportunity to partner with the state department and providers to ensure a well-run and fraud-free medicaid program in Colorado.

(b) Therefore, the general assembly declares that creating an explanation of benefits for members of medicaid-funded services is a necessary step in managing the state's medicaid program and in safeguarding the significant public investment, both state and federal, in meeting the health-care needs of low-income and vulnerable Coloradans.

(2) On or before July 1, 2017, the state department shall develop and implement an explanation of benefits for members of medical services pursuant to this article 4 and article 5 or 6 of this title 25.5. The purpose of the explanation of benefits is to inform a medicaid member of a claim for reimbursement made for services provided to the member or on the member's behalf, so that the member may discover and report administrative or provider errors or fraudulent claims for reimbursement.

(3) The explanation of benefits is required for all acute and long-term care services for which a provider is seeking reimbursement under a fee-for-service model.

(4) The explanation of benefits must include, at a minimum:

(a) The name of the medicaid member receiving the service;

(b) The name of the service provider;

(c) A description of the service provided;

(d) The billing code for the service;

(e) The date of service, or range of dates for services, if multiple services are provided in a set period of time, such as personal care services;

(f) A clear statement to the medicaid member that the explanation of benefits is not a bill, but is only provided for the member's information and to make sure that a provider is being reimbursed only for services actually provided;

(g) Information regarding at least one verbal and one written method for the medicaid member to report errors in the explanation of benefits that are relevant to provider reimbursement; and

(h) Any other information that the state department determines is useful to the medicaid member or for purposes of discovering administrative or provider error or fraud.

(5) The state department shall develop the form and content of the explanation of benefits in conjunction with medicaid members and consumer advocates to ensure that medicaid members understand the information provided and the purpose of the explanation of benefits. The state department shall also work with medicaid members and consumer advocates to develop educational materials for the state department's website and for distribution by advocacy and nonprofit organizations that explain the process for reporting errors and encourage members to take responsibility for reporting errors.

(6) The state department shall provide the explanation of benefits to a medicaid member not less frequently than once every two months, if services have been provided to or on behalf of the member during that time period. The state department shall determine the most cost-effective means for producing and distributing the explanation of benefits to medicaid members, which may include e-mail or web-based distribution, with mailed copies by request only. Further, the state department may include the explanation of benefits with an existing mailing or existing electronic or web-based communication to medicaid members.

(7) Nothing in this section requires the state department to produce an explanation of benefits form if the information required to be included in the explanation of benefits pursuant to subsection (4) of this section is already included in another format that is understandable to the medicaid member.
C.R.S. § 25.5-4-208 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-208
25.5-4-208. County duties - transitional medicaid
Status: in_force

25.5-4-208. County duties - transitional medicaid. County departments shall assist families in completing the reporting requirements for transitional medicaid. This shall include informing families of the transitional medicaid eligibility requirements and the required reporting calendar.
C.R.S. § 25.5-5-412 — CO Code / Title 25.5 / Article 5 / Part 4 / Section 25.5-5-412
25.5-5-412. Program of all-inclusive care for the elderly - services - eligibility - rules -
Status: repealed

25.5-5-412. Program of all-inclusive care for the elderly - services - eligibility - rules - legislative declaration - definitions. (1) (a) The general assembly hereby finds and declares that it is the intent of this section to replicate the ON LOK program in San Francisco, California, that has proven to be cost-effective at both the state and federal levels. The PACE program is part of a national replication project authorized in section 9412(b)(2) of the federal "Omnibus Budget Reconciliation Act of 1986", as amended. The general assembly finds that, by coordinating an extensive array of medical and nonmedical services, the needs of the participants will be met primarily in an outpatient environment in an adult day health center, in their homes, or in an institutional setting. The general assembly finds that such a service delivery system will enhance the quality of life for the participant and offers the potential to reduce and cap the costs to Colorado of the medical needs of the participants, including hospital and nursing home admissions.

(b) Repealed.

(2) The general assembly has determined on the recommendation of the state department that the PACE program is cost-effective. As a result of such determination and after consultation with the joint budget committee of the general assembly, application has been made to and waivers have been obtained from the federal health care financing administration to implement the PACE program as provided in this section. The general assembly, therefore, authorizes the state department to implement the PACE program in accordance with this section. In connection with the implementation of the program, the state department shall:

(a) Provide a system for reimbursement for services to the PACE program pursuant to this section;

(b) Develop and implement a contract with any public, private, nonprofit, or for-profit entity providing the PACE program, as permitted by federal law, that sets forth contractual obligations for the PACE program as required by the state department, including but not limited to reporting and monitoring of utilization of services and of the costs of the program, quality of care, and a comprehensive assessment of the provider's fiscal soundness;

(c) Acknowledge that it is participating in the national PACE project as initiated by congress;

(d) Be responsible for certifying the eligibility for services of all PACE program participants.

(3) The general assembly declares that the purpose of this section is to provide services that would foster the following goals:

(a) To maintain eligible persons at home as an alternative to long-term institutionalization;

(b) To provide optimum accessibility to various important social and health resources that are available to assist eligible persons in maintaining independent living;

(c) To provide that eligible persons who are frail elderly but who have the capacity to remain in an independent living situation have access to the appropriate social and health services without which independent living would not be possible;

(d) To coordinate, integrate, and link such social and health services by removing obstacles that impede or limit improvements in delivery of these services;

(e) To provide the most efficient and effective use of capitated funds in the delivery of such social and health services.

(f) Repealed.

(4) Within the context of the PACE program, the state department may include any or all of the services listed in sections 25.5-5-102, 25.5-5-103, 25.5-5-202, and 25.5-5-203, as applicable.

(5) An eligible person may elect to receive services from the PACE program as described in subsection (4) of this section. If such an election is made, the eligible person shall not remain eligible for services or payment through the regular medicare or medicaid programs. All services provided by said programs shall be provided through the PACE program in accordance with this section. An eligible person may elect to disenroll from the PACE program at any time.

(6) The state department, in cooperation with the case management agencies established in section 25.5-6-1703, shall develop and implement a coordinated plan to provide education about PACE program site operations under this section. The state board shall adopt rules:

(a) To ensure that case managers and any other appropriate state department staff discuss the option and potential benefits of participating in the PACE program with all eligible long-term care members. These rules must require additional and ongoing training of the case management agency case managers in counties where a PACE program is operating. This training must be provided by a federally approved PACE provider. In addition, each case management agency may designate case managers who have knowledge about the PACE program.

(b) To allow PACE providers to contract with an enrollment broker to include the PACE program in its marketing materials to eligible long-term members.

(6.5) An eligible person who is enrolled in a managed care organization, an organization contracted with the state department pursuant to part 4 of article 5 of this title, or other risk-bearing entity may elect to withdraw from or terminate such enrollment and enroll in and receive services through a PACE program. The state board's rules shall define how such election is made. The effective date of an eligible person's election shall not be more than thirty days after the eligible person's date of election.

(7) For purposes of this section:

(a) "Dually eligible person" means a person who is eligible for assistance or benefits under both medicaid and medicare.

(b) "Eligible person" means a frail elderly individual who voluntarily enrolls in the PACE program and whose gross income does not exceed three hundred percent of the current federal supplemental security income benefit level, whose resources do not exceed the limit established by the state department of human services for individuals receiving a mandatory minimum state supplementation of SSI benefits pursuant to section 26-2-204, or in the case of a person who is married, do not exceed the amount authorized in section 25.5-6-101, and for whom a physician licensed pursuant to article 240 of title 12 certifies that such a program provides an appropriate alternative to institutionalized care. "Eligible person" may also include a dually eligible person.

(c) "Frail elderly" means an individual who meets functional eligibility requirements, as established by the state department, for nursing home care and who is fifty-five years of age or older.

(d) "Upper payment limit" means a federal upper payment limit on the amount of the medicaid payment for which federal financial participation is available for a class of services and a class of health-care providers, as specified in 42 CFR 447.

(8) Using a risk-based financing model, any public, private, nonprofit, or for-profit entity providing the PACE program, as permitted by federal law, shall assume responsibility for all costs generated by PACE program participants, and shall create and maintain a risk reserve fund that will cover any cost overages for any participant. The PACE program is responsible for the entire range of services in the consolidated service model, including hospital and nursing home care, according to participant need as determined by the multidisciplinary team. Any public, private, nonprofit, or for-profit entity providing the PACE program, as permitted by federal law, is responsible for the full financial risk at the conclusion of the demonstration period and when permanent waivers from the federal health care financing administration are granted. Specific arrangements of the risk-based financing model shall be adopted and negotiated by the federal health care financing administration, any public, private, nonprofit, or for-profit entity providing the PACE program, as permitted by federal law, and the state department.

(9) Nothing in this section requires a PACE program site operator to hold a certificate of authority as a health maintenance organization under part 4 of article 16 of title 10, C.R.S., for purposes of the PACE program.

(10) (a) The state department shall perform a feasibility study, conditioned on the receipt of sufficient gifts, grants, and donations, in order to identify viable communities that may support a PACE program site. This study shall be completed on or before May 1, 2003.

(b) The state department, consistent with the results of the feasibility study, shall use its best efforts to have in operation:

(I) One additional PACE program site by July 1, 2004;

(II) A total of four additional PACE program sites by July 1, 2005; and

(III) A total of six additional PACE program sites by July 1, 2006.

(c) (I) No later than May 30, 2003, the executive director of the state department shall submit to the joint budget committee of the general assembly and to the health and human services committees of the house of representatives and the senate, or any successor committees, a written report of the results of the feasibility study conducted under paragraph (a) of this subsection (10).

(II) No later than January 1, 2007, the executive director of the state department shall submit to the joint budget committee of the general assembly and to the health and human services committees of the house of representatives and the senate, or any successor committees, a final written report detailing the expansion of PACE program sites across the state.

(11) The state board shall promulgate such rules, pursuant to article 4 of title 24, C.R.S., as are necessary to implement this section.

(12) (a) The general assembly shall make appropriations to the state department to fund services under this section provided at a monthly capitated rate. For the 2019-20 fiscal year, and each fiscal year thereafter, the state department shall annually renegotiate, pursuant to the provisions set forth in this subsection (12), a monthly capitated rate for the contracted services.

(b) The monthly capitated rate negotiated with the state department must be included in the contract with the PACE organization and must be based upon a prospective monthly capitation payment to a PACE organization for a medicaid participant enrolled in a PACE program that is less than what would otherwise have been paid under the state medicaid plan if the participant were not enrolled in the PACE program.

(c) In determining the monthly capitated rate, the state department, with the participation of Colorado PACE organizations, shall develop an actuarially sound upper payment limit methodology that complies with federal law relating to PACE organizations.

(d) Repealed.

(13) The state department may accept grants and donations from private sources for the purpose of implementing this section.

(14) (a) No later than sixty days prior to the closing or effective date of a conversion of a nonprofit PACE provider to a for-profit PACE provider, the nonprofit PACE provider shall:

(I) Transmit a conversion plan and written notice of the conversion to the attorney general, which conversion plan must include, at a minimum:

(A) A copy of the results of an independent valuation of the fair market value of the business that proposes to convert;

(B) A detailed explanation of the plans for distribution of the proceeds of the conversion, including whether the proceeds will be distributed to a new nonprofit entity or to an existing organization and, if to an existing nonprofit organization, which organization and the reasons for selecting that organization, or, if to a new nonprofit organization, how the initial board of directors will be selected;

(C) Information about any compensation, bonus, or inducement to any officers or directors of the converting entity resulting from the conversion; and

(D) The PACE organization's audited financial statements for its three most recent fiscal years for Colorado, and separately, for those operations outside of Colorado, for any such operations that may be related to the conversion; and

(II) Bear all costs associated with public oversight and review by the attorney general of the conversion, including the retention of outside experts, if any.

(b) Within ten days after the receipt of the conversion plan, the attorney general shall post the complete conversion plan on its website and receive public comments about the plan, which shall also be posted as soon as practicable to the attorney general's website. Public comment shall be received for a minimum of thirty days and available on the website for at least the duration of the comment period.

(c) Nothing in this section shall be construed to affect the common law authority of the attorney general.

(15) (a) No later than June 30, 2023, the state department, in conjunction with the department of public health and environment, shall develop a regulatory plan to establish formal oversight requirements for PACE entities. In developing the plan, the departments shall consider, at a minimum:

(I) Input from executive agencies; any local governments within a PACE service area, including cities and counties; aging and older adult advocacy organizations; PACE participants; family members of PACE participants; disability advocacy organizations; urban PACE entities; rural PACE entities; and PACE trade organizations;

(II) State department demographic data to determine the feasibility of potential or existing PACE entities to establish or expand within a specific geographical area with an established PACE program;

(III) Utilization, quality, and performance data of each PACE entity and associated PACE entities;

(IV) Business continuity and solvency information of each PACE entity or associated PACE entities;

(V) Measurable innovative practices of PACE entities;

(VI) Staffing practices of PACE entities;

(VII) Transportation data of each PACE entity, including the number of trips, travel time, and pick-up and drop-off processes;

(VIII) Satisfaction and exit survey data of each PACE entity;

(IX) Audits, complaints, and grievances of each PACE entity;

(X) Current PACE oversight processes, including home health regulatory requirements and licensure;

(XI) Any duplication of federal oversight processes;

(XII) Due process and appeal rights of PACE entities; and

(XIII) Citations, fines, and suspension remedies to ensure compliance with regulations to protect the health, safety, and welfare of medicaid members.

(b) No later than March 1, 2024, the state department shall establish, administer, and enforce minimum regulatory standards and rules for the PACE program, including for contracted entities of the PACE program. The standards and rules must be sufficient to ensure the health, safety, and welfare of PACE participants.

(c) The state department shall continually analyze the reimbursement methodology for PACE entities and provide an update to the house of representatives public and behavioral health and human services committee, the senate health and human services committee, and the joint budget committee, or their successor committees, of any new methodology requirements that incorporate encounter data and any associated cost to the state department in overseeing PACE entities.
C.R.S. § 25.5-5-409 — CO Code / Title 25.5 / Article 5 / Part 4 / Section 25.5-5-409
25.5-5-409. State department - privatization
Status: repealed

25.5-5-409. State department - privatization. (Repealed)
C.R.S. § 25.5-4-403 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-403
25.5-4-403. Providers - behavioral health safety net providers - reimbursement
Status: in_force

25.5-4-403. Providers - behavioral health safety net providers - reimbursement. (1) For the purpose of reimbursing essential behavioral health safety net and comprehensive community behavioral health providers, as defined in section 27-50-101, except for those that are also federally qualified health centers, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x(aa)(4), which have payment methodology pursuant to section 25.5-5-408, the state department shall establish an appropriate cost accounting methodology annually with the behavioral health administration in the department of human services in order to support sustainable access to behavioral health safety net services, as defined in section 27-50-101. In establishing the payment methodology, the state department shall consider:

(a) Actual costs of services, including services to address language and cultural barriers necessary to serve communities of color and other underserved populations;

(b) Costs that are reasonable, as determined by the state department in collaboration with the behavioral health administration in the department of human services;

(c) Quality and accessibility of behavioral health safety net care provided, as determined by the state department, in collaboration with the behavioral health administration in the department of human services, by rule;

(d) Health equity;

(e) Access by priority populations as determined by the behavioral health administration in the department of human services; and

(f) Value-based payment approaches that incentivize providers to expand access to cost-effective behavioral health services to serve the behavioral health safety net.

(2) The standards and processes for determining the payment methodology will be determined by an auditing and accounting committee. The members of the committee are selected by the state department to include behavioral health administrative service organizations, managed care entities, behavioral health safety net providers as defined in section 27-50-101, independent auditors, actuaries, consumer and family advocates, local government representatives, other state agencies, and other relevant stakeholders.
C.R.S. § 25.5-10-211 — CO Code / Title 25.5 / Article 10 / Part 2 / Section 25.5-10-211
25.5-10-211. Eligibility determination - individualized plan - periodic review - rules - repe
Status: repealed

25.5-10-211. Eligibility determination - individualized plan - periodic review - rules - repeal. (Repealed)
C.R.S. § 25.5-5-320 — CO Code / Title 25.5 / Article 5 / Part 3 / Section 25.5-5-320
25.5-5-320. Telemedicine - reimbursement - disclosure statement - rules - definition
Status: repealed

25.5-5-320. Telemedicine - reimbursement - disclosure statement - rules - definition. (1) On or after July 1, 2006, in-person contact between a health-care or mental health-care provider and a patient is not required under the state's medical assistance program for health-care or mental health-care services delivered through telemedicine that are otherwise eligible for reimbursement under the program. The state department shall promulgate rules specifically relating to entities that deliver health-care or mental health-care services exclusively or predominately through telemedicine. Any health-care or mental health-care service delivered through telemedicine must meet the same standard of care as an in-person visit. Telemedicine may be provided through interactive audio, interactive video, or interactive data communication, including but not limited to telephone, relay calls, interactive audiovisual modalities, and live chat, as long as the technologies are compliant with the federal "Health Insurance Portability and Accountability Act of 1996", Pub.L. 104-191, as amended. The health-care or mental health-care services are subject to reimbursement policies developed pursuant to the medical assistance program. This section also applies to managed care organizations that contract with the state department pursuant to the statewide managed care system only to the extent that:

(a) Health-care or mental health-care services delivered through telemedicine are covered by and reimbursed under the medicaid per diem payment program; and

(b) Managed care contracts with managed care organizations are amended to add coverage of health-care or mental health-care services delivered through telemedicine and any appropriate per diem rate adjustments are incorporated.

(2) The reimbursement rate for a telemedicine service shall, as a minimum, be set at the same rate as the medical assistance program rate for a comparable in-person service. The state department may consider setting the reimbursement rate on a monthly basis as well as on a daily or per-visit basis.

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

(2.5) (a) A telemedicine service meets the definition of a face-to-face encounter for a rural health clinic, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(2). The reimbursement rate for a telemedicine service provided by a rural health clinic must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.

(b) A telemedicine service meets the definition of a face-to-face encounter for a medical care program of the federal Indian health service. The reimbursement rate for a telemedicine service provided by a medical care program of the federal Indian health service must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.

(c) A telemedicine service meets the definition of a face-to-face encounter for a federally qualified health center, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(4). The reimbursement rate for a telemedicine service provided by a federally qualified health center must be set at a rate that is no less than the medical assistance program rate for a comparable face-to-face encounter or visit.

(3) The state department shall establish rates for transmission cost reimbursement for telemedicine services, considering, to the extent applicable, reductions in travel costs by health-care or mental health-care providers and patients to deliver or to access such services and such other factors as the state department deems relevant.

(4) A health-care or mental health-care provider who delivers health-care or mental health-care services through telemedicine shall provide to each patient, before treating that patient through telemedicine for the first time, the following written statements:

(a) That the patient retains the option to refuse the delivery of the services via telemedicine at any time without affecting the patient's right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled;

(b) That all applicable confidentiality protections shall apply to the services; and

(c) That the patient shall have access to all medical information resulting from the telemedicine services as provided by applicable law for patient access to his or her medical records.

(5) Subsection (4) of this section shall not apply in an emergency.

(6) Repealed.

(7) As used in this section, "health-care or mental health-care services" includes speech therapy, physical therapy, occupational therapy, dental care, hospice care, home health care, substance use disorder treatment, and pediatric behavioral health care.
C.R.S. § 25.5-4-211 — CO Code / Title 25.5 / Article 4 / Part 2 / Section 25.5-4-211
25.5-4-211. Medicaid management information system - appropriation in annual general appropr
Status: repealed

25.5-4-211. Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year. (1) Subject to the limitation in subsection (2) of this section, unexpended and unencumbered moneys from an appropriation in the annual general appropriation act to the state department for the medicaid management information system remain available for expenditure by the state department in the next fiscal year without further appropriation. This section applies to appropriations made by the general assembly for fiscal years beginning on and after July 1, 2013.

(2) On or before June 30, 2014, and on or before June 30 of each year thereafter, the state department shall notify the state controller of the amount of the appropriation from the annual general appropriation act for the medicaid management information system for the current fiscal year that the state department needs to remain available for expenditure in the next fiscal year. The state department may not expend more than the amount notified under the authority granted in this section.

(3) Repealed.
C.R.S. § 25.5-6-1101 — CO Code / Title 25.5 / Article 6 / Part 11 / Section 25.5-6-1101
25.5-6-1101. Definitions
Status: in_force

25.5-6-1101. Definitions. As used in this part 11, unless the context otherwise requires:

(1) "Attendant support" means any action to assist an eligible person in accomplishing activities of daily living, instrumental activities of daily living, and habilitative and health-related tasks. Such activities include, but are not limited to, personal care services, household services, cognitive services, mobility services, and health-related tasks.

(2) "Authorized representative" means an individual designated by the eligible person, by the parent of a minor, or by the legal guardian of the eligible person if the eligible person cannot demonstrate sound judgment to his or her primary care physician, who has the judgment and ability to assist the eligible person in acquiring and utilizing services under this part 11. The extent of the authorized representative's involvement shall be determined upon designation.

(3) "Consumer-directed" means that an eligible person receives a direct payment through a voucher and employs, trains, and in other ways manages the person who provides his or her attendant support. The direct payment through a voucher that is received by an eligible person to pay for attendant support shall not be counted as income for purposes of determining eligibility for medicaid and other state programs that use income to determine eligibility.

(4) [Editor's note: This version of subsection (4) is effective until July 1, 2025.] "Eligible person" means a person who is eligible to receive services under parts 3 to 12 of this article or any other home- and community-based service waiver for which the state department has federal waiver authority.

(4) [Editor's note: This version of subsection (4) is effective July 1, 2025.] "Eligible person" means a person who is eligible to receive services pursuant to part 19 of this article 6.

(5) "Primary care physician" means a physician who is the primary provider of physician services to the eligible person or who is familiar with the eligible person's needs and capabilities.

(6) [Editor's note: This version of subsection (6) is effective until July 1, 2025.] "Qualified services" means services provided under the eligible person's applicable waiver program and attendant support.

(6) [Editor's note: This version of subsection (6) is effective July 1, 2025.] "Qualified services" means services provided under the eligible person's community first choice option.
C.R.S. § 25.5-4-415 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-415
25.5-4-415. No public funds for abortion - exception - definitions - repeal
Status: repealed

25.5-4-415. No public funds for abortion - exception - definitions - repeal. (1) It is the purpose of this section to implement the provisions of section 50 of article V of the Colorado constitution, adopted by the registered electors of the state of Colorado at the general election November 6, 1984, which prohibits the use of public funds by the state of Colorado or its agencies or political subdivisions to pay or otherwise reimburse, directly or indirectly, any person, agency, or facility for any induced abortion.

(2) If every reasonable effort has been made to preserve the lives of a pregnant woman and her unborn child, then public funds may be used pursuant to this section to pay or reimburse for necessary medical services, not otherwise provided for by law.

(3) (a) Any medically necessary services performed pursuant to this section shall be performed only by a provider who is licensed by the state and acting within the scope of the provider's license and in accordance with applicable federal regulations.

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

(4) (a) Any physician who renders necessary medical services pursuant to subsection (2) of this section shall report the following information to the state department:

(I) The age of the pregnant woman and the gestational age of the unborn child at the time the necessary medical services were performed;

(II) The necessary medical services which were performed;

(III) The medical condition which necessitated the performance of necessary medical services;

(IV) The date such necessary medical services were performed and the name of the facility in which such services were performed.

(b) The information required to be reported pursuant to paragraph (a) of this subsection (4) shall be compiled by the state department and such compilation shall be an ongoing public record; except that the privacy of the pregnant woman and the attending physician shall be preserved.

(5) For purposes of this section, pregnancy is a medically diagnosable condition.

(6) For the purposes of this section:

(a) (I) "Death" means:

(A) The irreversible cessation of circulatory and respiratory functions; or

(B) The irreversible cessation of all functions of the entire brain, including the brain stem.

(II) A determination of death under this section shall be in accordance with accepted medical standards.

(b) "Life-endangering circumstance" means:

(I) The presence of a medical condition, other than a psychiatric condition, as determined by the attending physician, which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term;

(II) The presence of a lethal medical condition in the unborn child, as determined by the attending physician and one other physician, which would result in the impending death of the unborn child during the term of pregnancy or at birth; or

(III) The presence of a psychiatric condition which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term. In such case, unless the pregnant woman has been receiving prolonged psychiatric care, the attending licensed physician shall obtain consultation from a licensed physician specializing in psychiatry confirming the presence of such a psychiatric condition. The attending physician shall report the findings of such consultation to the state department.

(c) "Necessary medical services" means any medical procedures deemed necessary to prevent the death of a pregnant woman or her unborn child due to life-endangering circumstances.

(7) If any provision of this section or application thereof is held invalid, such invalidity shall not affect other provisions or applications of this section which can be given effect without the invalid provision or application, and to this end the provisions of this section are declared severable.

(8) Use of the term "unborn child" in this section is solely for the purposes of facilitating the implementation of section 50 of article V of the state constitution, and its use shall not affect any other law or statute nor shall it create any presumptions relating to the legal status of an unborn child or create or affect any distinction between the legal status of an unborn child and the legal status of a fetus.

(9) This section shall be repealed if section 50 of article V of the Colorado constitution is repealed.
C.R.S. § 25.5-10-305.5 — CO Code / Title 25.5 / Article 10 / Part 3 / Section 25.5-10-305.5
25.5-10-305.5. Family support services fund - creation
Status: in_force

25.5-10-305.5. Family support services fund - creation. (1) The family support services fund, referred to in this section as the "fund", is hereby created in the state treasury. The fund consists of money transferred to the fund from the Colorado family support loan fund as created in section 25.5-10-402 prior to its repeal, payments relating to outstanding loans made from the Colorado family support loan fund as created in section 25.5-10-402 prior to its repeal, and any other money that the general assembly may appropriate or transfer to the fund.

(2) The state treasurer shall credit all interest and income derived from the deposit and investment of money in the fund to the fund.

(3) Subject to annual appropriation by the general assembly, the state department may expend money from the fund for necessary expenditures relating to the administration of outstanding loans made from the Colorado family support loan fund as created in section 25.5-10-402 prior to its repeal, and to provide family support services pursuant to this part 3.
C.R.S. § 25.5-3-505 — CO Code / Title 25.5 / Article 3 / Part 5 / Section 25.5-3-505
25.5-3-505. Health-care facility reporting requirements - agency enforcement - report - rule
Status: in_force

25.5-3-505. Health-care facility reporting requirements - agency enforcement - report - rules. (1) Beginning September 1, 2023, and each September 1 thereafter, each health-care facility and licensed health-care professional shall report to the state department data that the state department determines is necessary to evaluate compliance across race, ethnicity, age, and primary-language-spoken patient groups with the screening, discounted care, payment plan, and collections practices required pursuant to this part 5. If a health-care facility or licensed health-care professional is not capable of disaggregating the data required pursuant to this subsection (1) by race, ethnicity, age, and primary language spoken, the health-care facility or licensed health-care professional shall report to the state department the steps the facility or licensed health-care professional is taking to improve race, ethnicity, age, and primary-language-spoken data collection and the date by which the facility or licensed health-care professional will be able to disaggregate the reported data.

(2) No later than April 1, 2022, the state board shall promulgate rules necessary for the administration and implementation of this part 5. At a minimum, the rules must:

(a) Outline a process for an insured patient to request a screening pursuant to section 25.5-3-502 (5);

(b) Outline a process for documenting, pursuant to section 25.5-3-502 (4), that a patient has made an informed decision to decline the screening, including procedures for retaining such documentation;

(c) Establish the process for and the maximum number of days that a health-care facility has to:

(I) Initiate a screening after a patient receives services;

(II) Request information from the patient needed for the screening process; and

(III) Complete the screening process;

(d) Outline the requirements for notifying the patient of the results of the screening, including an explanation of the basis for a denial of discounted care and the process for appealing a denial;

(e) Establish guidelines for patient appeals regarding eligibility for discounted care pursuant to section 25.5-3-503;

(f) Establish a methodology that all health-care facilities must use to determine monthly household income. The methodology must not consider a patient's assets.

(g) Identify the documents that may be required to establish income eligibility for discounted care using the minimum amount of information needed to determine eligibility;

(h) Identify the steps a health-care facility and licensed health-care professional must take before sending patient debt to collections;

(i) [Editor's note: This version of subsection (2)(i) is effective until July 1, 2025.] Create a single uniform application that a health-care facility shall use when screening a patient for eligibility for the Colorado indigent care program and discounted care, as described in section 25.5-3-502; and

(i) [Editor's note: This version of subsection (2)(i) is effective July 1, 2025.] Create a uniform application that a health-care facility must use when screening a patient for eligibility for discounted care, as described in section 25.5-3-502; and

(j) Annually establish rates for discounted care pursuant to section 25.5-3-503 (1)(a). The rates should approximate and not be less than one hundred percent of the medicare rate or one hundred percent of the medicaid base rate, whichever is greater. The state department shall publicly post the established rates on the state department's website.

(3) [Editor's note: This version of subsection (3) is effective until July 1, 2025.] In promulgating rules pursuant to this section, the state department shall:

(a) Align the processes of qualifying for and appealing denials of eligibility for the Colorado indigent care program with discounted care, as described in section 25.5-3-502; and

(b) Consider potential limitations relating to the federal "Emergency Medical Treatment and Labor Act", 42 U.S.C. sec. 1395dd.

(3) [Editor's note: This version of subsection (3) is effective July 1, 2025.] In promulgating rules pursuant to this section, the state department shall consider potential limitations relating to the federal "Emergency Medical Treatment and Labor Act", 42 U.S.C. sec. 1395dd.

(4) Prior to promulgating rules pursuant to this section, the state department shall hold at least one stakeholder meeting with hospital representatives, health-care consumers, and health-care consumer advocates that is accessible to individuals whose primary language is not English, if requested.

(5) No later than April 1, 2022, the state department shall:

(a) Using feedback from hospital health-care consumers and health-care consumer advocate stakeholders, develop a written explanation of a patient's rights under this section that is written in plain language at a sixth-grade reading level and translated into all languages spoken by ten percent or more of the population in each county of the state and post the written explanation in all required languages on the state department's website. Each health-care facility shall make the explanation available to the public and each patient as provided in section 25.5-3-504.

(b) (I) Establish a process for patients to submit a complaint relating to noncompliance with this part 5 to the state department by phone, mail, or online. The state department shall conduct a review within thirty days after receiving a complaint.

(II) The state department shall periodically review health-care facilities and licensed health-care professionals to ensure compliance with this section. If the state department finds that a health-care facility or licensed health-care professional is not in compliance with this section, the state department shall notify the health-care facility or licensed health-care professional and the facility or professional has ninety days to file a corrective action plan with the state department that must include measures to inform the patient about the noncompliance and provide a financial correction consistent with this part 5. A health-care facility or licensed health-care professional may request up to one hundred twenty days to submit a corrective action plan. The state department may require a health-care facility or licensed health-care professional that is not in compliance with this part 5 or any state board rules adopted pursuant to this part 5 to develop and operate under a corrective action plan until the state department determines the health-care facility or licensed health-care professional is in compliance.

(III) If a health-care facility's or licensed health-care professional's noncompliance with this section is determined by the state department to be knowing or willful or there is a repeated pattern of noncompliance, the state department may fine the facility or professional no more than five thousand dollars. If the health-care facility or licensed health-care professional fails to take corrective action or fails to file a corrective action plan with the state department pursuant to subsection (5)(b)(II) of this section, the state department may fine the facility or professional no more than five thousand dollars a week until the facility or professional takes corrective action. The state department shall consider the size of the health-care facility and the seriousness of the violation in setting the fine amount.

(6) The state department shall make the information reported pursuant to subsection (1) of this section and any corrective action plans for which fines were imposed pursuant to subsection (5)(b) of this section available to the public and shall annually report the information as a part of its presentation to its committees of reference at a hearing held pursuant to section 2-7-203 (2)(a) of the "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act".
C.R.S. § 25.5-10-235 — CO Code / Title 25.5 / Article 10 / Part 2 / Section 25.5-10-235
25.5-10-235. Limitations on sterilization
Status: in_force

25.5-10-235. Limitations on sterilization. (1) Consent to sterilization shall be made neither a condition for release from any institution nor a condition for the exercise of any right, privilege, or freedom.

(2) Nothing in this article requires any hospital or any person to participate in any sterilization, nor shall any hospital or any person be civilly or criminally liable for refusing to participate in any sterilization.
C.R.S. § 25.5-6-409.5 — CO Code / Title 25.5 / Article 6 / Part 4 / Section 25.5-6-409.5
25.5-6-409.5. Transition plan for youth with intellectual and developmental disabilities to ad
Status: repealed

25.5-6-409.5. Transition plan for youth with intellectual and developmental disabilities to adult services - legislative declaration - report - rules - cash fund. (1) The general assembly finds and declares that:

(a) Youth with intellectual and developmental disabilities who are eighteen to twenty years of age are currently served through the county child welfare system; and

(b) The home- and community-based services program for persons with intellectual and developmental disabilities is better designed to meet the complex needs of these youth.

(2) Therefore, the general assembly declares that, in order to have a person-centered system, youth with intellectual and developmental disabilities who are eighteen years of age and older who are currently being served through child welfare services must be transitioned to the home- and community-based services program for persons with intellectual and developmental disabilities and a plan developed for the ongoing transition of such youth when they turn eighteen years of age, except in extenuating circumstances when the court or interdisciplinary team determines that it is not in the best interest of the youth to transition.

(3) (a) On or before June 30, 2014, each county department of human or social services shall identify youth with intellectual and developmental disabilities who are receiving services through the child welfare system in that county and who:

(I) Are twenty years of age or older as of June 30, 2014;

(II) Are nineteen years of age or older but younger than twenty-one years of age as of June 30, 2014;

(III) Are eighteen years of age or older but younger than twenty years of age as of June 30, 2014; and

(IV) Will become eighteen years of age on or after June 30, 2014, and before January 1, 2015.

(b) On or before October 1, 2014, and as necessary thereafter, each county department of human or social services shall identify youth with intellectual and developmental disabilities who are receiving services through the child welfare system in that county and who will become eighteen years of age within the following six months.

(c) Each county department of human or social services shall develop a plan to transition youth identified pursuant to paragraphs (a) and (b) of this subsection (3) to adult services for persons with intellectual and developmental disabilities. The transition plan must meet the criteria set forth in subsection (4) of this section and any rules promulgated by the state board to implement this section. Each county's plan must provide for:

(I) Youth described in paragraph (a) of this subsection (3) to be transitioned as soon as possible but in no case later than January 1, 2016; and

(II) Youth described in subparagraph (IV) of paragraph (a) of this subsection (3) or paragraph (b) of this subsection (3) to be transitioned as soon as possible based on individual needs but in no case earlier than their eighteenth birthday.

(d) The requirement to transition youth as set forth in subsection (3)(c) of this section does not apply to youth currently serving a sentence in the division of youth services or to youth under a court order in a juvenile delinquency case, unless the court approves the transition by written court order.

(4) For each youth with intellectual and developmental disabilities who is going to be transitioned to adult services for persons with intellectual and developmental disabilities pursuant to subsection (3) of this section, the county department of human or social services that is currently providing services to the youth through its child welfare system shall develop a transition plan for that youth. The transition plan must, at a minimum:

(a) Include the department-prescribed assessment provided by the case management agency, as defined in section 25.5-6-1702 that is performed as soon as possible for those youth who are being transitioned pursuant to subsection (3) of this section and at seventeen and a half years of age for those youth who are being transitioned pursuant to subsection (3)(a)(IV) or (3)(b) of this section. In all instances, the assessment must be completed within six months of a youth's transition to adult services.

(b) Provide for the social, habilitative, remedial, residential, educational, health, and other needs of the youth who is being transitioned; and

(c) Address any legal needs concerning guardianship of the youth who is being transitioned.

(5) In all instances, the involved parties and the county department of human or social services shall consider and place precedence on the best interest of the youth prior to the transition process, as set forth in sections 19-3-205 and 19-3-213, C.R.S.

(6) It is the intent of the general assembly that county child welfare systems and case management agencies, as defined in section 25.5-6-1702, collaborate to ensure minimal disruption for youth during the transition process.

(7) The medical services board and the state board of human services may promulgate rules as necessary and appropriate for the implementation of this section.

(8) The department shall submit a report to the joint budget committee on or before January 1, 2015, and on or before January 1, 2016, on the status of the youth being transitioned. The report must include, at a minimum:

(a) The number of youth transitioned to date by county;

(b) The needs assessment of the youth who have been transitioned; and

(c) The type of adult residential locations of the youth who have been transitioned.

(9) Repealed.
C.R.S. § 25.5-6-705 — CO Code / Title 25.5 / Article 6 / Part 7 / Section 25.5-6-705
25.5-6-705. Implementation of part contingent upon receipt of federal waiver - repeal of par
Status: repealed

25.5-6-705. Implementation of part contingent upon receipt of federal waiver - repeal of part. (1) (a) The implementation of this part 7 is conditioned upon the issuance of necessary waivers by the federal government and available appropriations. The provisions of this part 7 shall be implemented to the extent authorized by federal waiver. The state department shall propose legislation that conforms with the waiver provisions no later than the next regular legislative session following the issuance of the waiver.

(b) The implementation of the provisions of this part 7 relating to services provided on a supportive care campus are conditioned upon the approval of necessary waiver amendments by the federal government. The provisions of this part 7 relating to supported living shall be implemented to the extent authorized by federal waiver and in accordance with applicable federal requirements.

(2) Provisions of this part 7 that are approved by the federal government and are authorized by federal waiver shall remain in effect only for so long as specified in the federal waiver, unless otherwise extended by the federal government. The state department shall provide written notice to the revisor of statutes of the final termination date of the waiver, and this part 7 shall be repealed, effective July 1 of the year in which the waiver is terminated.
C.R.S. § 25.5-6-1805 — CO Code / Title 25.5 / Article 6 / Part 18 / Section 25.5-6-1805
25.5-6-1805. Home- and community-based services improvement fund - creation - transfer - expe
Status: in_force

25.5-6-1805. Home- and community-based services improvement fund - creation - transfer - expenditures. (1) The home- and community-based services improvement fund, referred to in this section as the "fund", is created in the state treasury. The fund consists of money transferred to the fund pursuant to subsection (2) of this section.

(2) (a) On June 30, 2021, the state treasurer shall transfer two hundred sixty million seven hundred thirty thousand ninety-nine dollars from the general fund to the fund.

(b) (I) If the general fund savings due to the enhanced federal match under section 9817 of the "American Rescue Plan Act" is greater than the amount transferred to the fund under subsection (2)(a) of this section, then the state department shall notify the state treasurer of the amount by which the savings exceeded the transfer. The state treasurer shall transfer this amount of money from the general fund to the fund.

(II) If the general fund savings due to the enhanced federal match under section 9817 of the "American Rescue Plan Act" is less than the amount transferred to the fund under subsection (2)(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 of money from to the fund to the general fund.

(3) The state treasurer shall credit all interest and income derived from the deposit and investment of money in the fund to the general fund.

(4) (a) Money in the fund is appropriated to the state department for the fiscal year commencing on July 1, 2021, for the expenditures identified in the spending plan approved by the joint budget committee pursuant to section 25.5-6-1804; except that the spending authority conferred by this subsection (4)(a) expires if a supplemental appropriation bill that appropriates money from the fund to the state department is enacted.

(b) During the next legislative session, the joint budget committee shall introduce a supplemental appropriation bill with the specific expenditures authorized under subsection (4)(a) of this section.

(5) For fiscal years commencing on and after July 1, 2021, money in the fund is subject to annual appropriation to enhance, expand, and strengthen medicaid home- and community-based services pursuant to section 9817 of the "American Rescue Plan Act".

(6) The state department may use the money in the fund for reasonable and necessary administrative costs associated with implementing this part 18.
C.R.S. § 25.5-5-503 — CO Code / Title 25.5 / Article 5 / Part 5 / Section 25.5-5-503
25.5-5-503. Prescription drug benefits - authorization - dual-eligible participation
Status: in_force

25.5-5-503. Prescription drug benefits - authorization - dual-eligible participation. (1) The state department is authorized to ensure the participation of Colorado medical assistance members who are also eligible for medicare in any federal prescription drug benefit enacted for medicare recipients.

(2) Prescribed drugs are not a covered benefit under the medical assistance program for a member who is eligible for a prescription drug benefit program under medicare; except that, if a prescribed drug is not a covered Part D drug as defined in the "Medicare Prescription Drug, Improvement, and Modernization Act of 2003", Pub.L. 108-173, the prescribed drug may be a covered benefit if it is otherwise covered under the medical assistance program and federal financial participation is available.
C.R.S. § 25.5-10-207.5 — CO Code / Title 25.5 / Article 10 / Part 2 / Section 25.5-10-207.5
25.5-10-207.5. Strategic plan for long-term services and supports - joint hearing - appropriati
Status: in_force

25.5-10-207.5. Strategic plan for long-term services and supports - joint hearing - appropriation - reporting - legislative declaration - rules. (1) (a) The general assembly finds that:

(I) Colorado has a long commitment to supporting persons with intellectual and developmental disabilities in communities of their choosing;

(II) Coloradans with intellectual and developmental disabilities who are eligible for state services and supports should be able to access services and supports in a timely manner to allow them to benefit from those services and supports and lead lives that build on their independence;

(III) Providing early and timely access to services and supports for persons with intellectual and developmental disabilities is an excellent and cost-effective investment that results in substantial future savings;

(IV) The presence of a waiting list as long as fifteen years for essential services and supports contradicts Colorado's commitment to supporting persons in the least restrictive environment of their choosing;

(V) Colorado must have accurate data concerning the need for services and supports for persons with intellectual and developmental disabilities and their families and must regularly forecast this data to ensure that effective policy and programs are directed to meet these needs;

(VI) The waiting list includes persons with intellectual and developmental disabilities who are at risk of experiencing a crisis due to the advanced age, reduced capacity, and illness of their caregivers;

(VII) After a lifetime of providing continuous support, these caregivers deserve the comfort of knowing that their loved one will have needed services and supports; and

(VIII) Persons with intellectual and developmental disabilities and their caregivers should not have to experience a crisis before getting needed assistance, as each crisis puts undue hardship and strain on the person and caregiver, and the services system.

(b) Therefore, the general assembly declares that Colorado is committed to developing a strategic plan to ensure that Coloradans with intellectual and developmental disabilities and their families will be able to access the services and supports they need and want at the time that they need and want those services and supports.

(2) During each regular session of the general assembly, the joint budget committee and the health and human services committees of the senate and the house of representatives, or any successor committees, shall hold a joint hearing and take public testimony on the status of the waiting lists for persons with intellectual and developmental disabilities who are waiting for enrollment into a home- and community-based services program or a program provided pursuant to this article 10 and the availability of general fund money to reduce the number of persons on the waiting lists and the amount of time eligible persons wait for such services. Notwithstanding the provisions of section 24-1-136 (11)(a)(I), the state department shall present testimony, including the information provided in the report pursuant to subsection (3) of this section, as well as information concerning the ongoing implementation of the strategic plan required pursuant to subsection (4) of this section, including any revisions to the strategic plan. Additionally, the state department, case management agencies, and providers shall report on the use and effectiveness of any money appropriated in the preceding state fiscal year for increasing system capacity. The goal of the hearing is to propose an appropriation from the general fund to the intellectual and developmental disabilities services cash fund.

(3) (a) Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or before November 1, 2014, and November 1 of each year thereafter, in accordance with section 24-1-136 (9), the state department shall report to the general assembly the total number of persons with intellectual and developmental disabilities who are waiting at the time of the report for enrollment into a home- and community-based services program or a program provided pursuant to this article 10. The report must also include information concerning the ongoing implementation of the strategic plan required pursuant to subsection (4) of this section, including any revisions to the strategic plan.

(b) The information reported pursuant to paragraph (a) of this subsection (3) relating to persons with intellectual and developmental disabilities who are waiting for enrollment into a home- and community-based services program or a program provided pursuant to this article shall be disaggregated by:

(I) The specific medicaid waiver program or other intellectual and developmental disabilities program, service, or support;

(II) The persons who need services immediately but who are not currently receiving services;

(III) The persons who need services immediately who are currently receiving some services; and

(IV) The persons who are eligible for services but who do not need services at this time.

(4) (a) On or before November 1, 2014, the state department shall develop, in consultation with intellectual and developmental disability system stakeholders, a comprehensive strategic plan including administrative procedures and adequate funding to enroll eligible persons with intellectual and developmental disabilities into home- and community-based services programs and programs provided pursuant to this article 10 at the time those persons choose to enroll in the programs or need the services or supports. As part of developing the strategic plan, the state department shall review the statutory definition of "waiting list" set forth in section 25.5-10-202 and make recommendations concerning amendments to the definition. In engaging stakeholders, the state department shall include both persons and families receiving services, as well as persons and families waiting for enrollment into programs, services, or supports. These persons and families must include, at a minimum, persons and families who reside in each defined service area within the state. In developing the strategic plan, the state department shall review relevant recommendations from the community living advisory group created in the office pursuant to the governor's executive order D 2012-027, as well as other relevant information. The strategic plan must include specific recommendations and annual benchmarks for achieving this enrollment goal by July 1, 2020, including recommendations relating to increasing system capacity. The state department shall review the strategic plan annually and revise the plan as needed to meet the enrollment goal. Nothing in this section precludes the state department from considering changes in the structure of the state's intellectual and developmental disabilities programs, including medicaid waiver modification.

(b) The state department shall submit the strategic plan to the general assembly in accordance with section 24-1-136 (9), C.R.S., and shall present the strategic plan to the joint budget committee on or before December 1, 2014.

(5) In its annual submission of the state department's budget request to the joint budget committee, the governor's office of state planning and budgeting shall reference the number of persons who are waiting at the time of the November 1 report for enrollment into a home- and community-based services program or a program provided pursuant to this article and shall indicate to the joint budget committee those budget requests related specifically to achieving the enrollment goal set forth in the strategic plan required pursuant to this section.

(6) (a) Subject to the availability of reserve capacity enrollment, a person with an intellectual and developmental disability who is on the waiting list for services and who is at risk of experiencing an emergency due to any of the criteria included in subsection (6)(b) of this section and who meets other applicable criteria for enrollment established by the state board shall be offered enrollment into the home- and community-based services developmental disabilities waiver using a person-centered transition process.

(b) No later than June 1, 2019, the state board shall promulgate rules regarding the criteria for reserve capacity enrollments for those persons described in subsection (6)(a) of this section, which criteria must include but is not limited to:

(I) The age of the custodial parent or caregiver;

(II) The loss of the custodial parent or caregiver;

(III) Incapacitation of the custodial parent or caregiver;

(IV) Any life-threatening or serious persistent illness of the custodial parent or caregiver; and

(V) A threat to health or safety that the custodial parent or caregiver places on the person with intellectual and developmental disabilities.

(c) As part of the rule-making process for reserve capacity enrollment pursuant to subsection (6)(b) of this section, the state board shall solicit feedback from persons with intellectual and developmental disabilities and family members of persons with intellectual and developmental disabilities.

(7) During the state fiscal year beginning July 1, 2018, the state department shall initiate three hundred nonemergency enrollments from the waiting list for the home- and community-based services developmental disabilities waiver.

(8) Beginning July 2018, and continuing monthly thereafter, the state department shall include in its monthly premiums, expenditures, and caseload report the number of persons who were moved off the developmental disabilities waiting list, specifying the enrollments initiated under the order of selection and the enrollments initiated under the reserve capacity criteria.
C.R.S. § 25.5-6-105 — CO Code / Title 25.5 / Article 6 / Part 1 / Section 25.5-6-105
25.5-6-105. Legislative declaration relating to implementation of single entry point system
Status: repealed

25.5-6-105. Legislative declaration relating to implementation of single entry point system - repeal. (Repealed)
C.R.S. § 25.5-1-204.5 — CO Code / Title 25.5 / Article 1 / Part 2 / Section 25.5-1-204.5
25.5-1-204.5. All-payer health claims database scholarship grant program - creation - definiti
Status: in_force

25.5-1-204.5. All-payer health claims database scholarship grant program - creation - definitions. (1) As used in this section, unless the context otherwise requires:

(a) "Advisory committee" means the advisory committee to oversee the all-payer health claims database created pursuant to section 25.5-1-204.

(b) "Governmental entity" means a state or local governmental entity, including a state-supported institution of higher education, but does not include the state department.

(c) "Program" means the all-payer health claims database scholarship grant program established pursuant to this section.

(2) There is created in the state department the all-payer health claims database scholarship grant program to defray the costs of nonprofit and governmental entities in accessing the all-payer health claims database to conduct research.

(3) The state department shall:

(a) In consultation with the advisory committee, develop a grant application under the program consistent with the rules of the executive director;

(b) Accept applications for scholarship grants from any nonprofit or governmental entity needing access to the all-payer health claims database to conduct research;

(c) After considering the recommendations of the advisory committee, determine which grant applications to approve and the amount of each grant; and

(d) Distribute approved scholarship grants to nonprofit or governmental entities.

(4) The executive director shall, following recommendations of the state department and the advisory committee, adopt rules pursuant to section 24-4-103 governing the program, including procedures, criteria, and standards for awarding scholarship grants.

(5) The advisory committee shall:

(a) Consult with the state department on the development of a grant application form; and

(b) Review applications for scholarship grants and recommend which scholarship grants to approve and the amount of each recommended grant.
C.R.S. § 25.5-4-505.5 — CO Code / Title 25.5 / Article 4 / Part 5 / Section 25.5-4-505.5
25.5-4-505.5. Federal authorization related to persons involved in the criminal justice system
Status: in_force

25.5-4-505.5. Federal authorization related to persons involved in the criminal justice system - report - rules - legislative declaration. (1) (a) The general assembly finds that:

(I) For decades, federal medicaid policy prohibited the use of federal funding for incarcerated medicaid members;

(II) With the emerging opportunity to allow for coverage of incarcerated medicaid members, Colorado is supportive of ensuring these members have access to needed services and treatment; and

(III) Colorado is committed to ensuring medicaid members have access to a civil, community-based system that meets members' needs and ensures Colorado's county jails, juvenile facilities, and prisons do not become primary access points for health-care services for people experiencing behavioral health conditions.

(b) Therefore, the general assembly declares it is in the best interest of all Coloradans, and especially Coloradans living with behavioral health conditions, to require the department of health care policy and financing to seek a federal waiver of the medicaid inmate exclusion policy that includes annual data reporting requirements that:

(I) Inform Coloradans regarding the unmet health needs of individuals involved in the criminal justice system;

(II) Promote the establishment of continuous civil systems of care within communities demonstrably committed to diversion or deflection efforts, including, but not limited to, mobile outreach, co-responder programs, and prosecutor- or judicial-led initiatives; and

(III) Aim to reduce unnecessary involvement with the criminal justice system and increase access to community-based housing, health care, supports, and services.

(2) (a) No later than April 1, 2024, the state department shall seek a federal authorization to provide, through the state medical assistance program, medication-assisted treatment and case management to a member prior to the member's release and a thirty-day supply of prescription medications to a member upon the member's release from a juvenile institutional facility, as defined in section 25-1.5-301 (2)(b), or a department of corrections facility.

(b) Beginning July 1, 2025, and subject to available appropriations, the services described in subsection (2)(a) of this section are available upon receipt of the necessary federal authorization.

(3) (a) (I) No later than April 1, 2025, the state department shall seek a federal authorization to provide, through the state medical assistance program, medication-assisted treatment and case management to a member prior to the member's release from jail and a thirty-day supply of prescription medications to a member upon the member's release from jail.

(II) The state department shall implement subsection (3)(a)(I) of this section only if the state department determines that providing the services described in subsection (3)(a)(I) of this section is budget neutral.

(b) Beginning July 1, 2026, and subject to available appropriations, the services described in subsection (3)(a) of this section are available upon receipt of the necessary federal authorization.

(4) Upon receipt of the necessary federal authorization, the state department shall:

(a) Conduct a rigorous stakeholder process that includes, but is not limited to, receiving feedback from individuals with lived experience in accessing, or the inability to access, behavioral health services in civil settings, county jails, juvenile institutional facilities, and the department of corrections; and

(b) Require each county with a county jail seeking to provide services pursuant to this section to demonstrate a commitment to diversion or deflection efforts, including, but not limited to, mobile outreach, co-responder programs, and prosecutor- or judicial-led initiatives that aim to reduce unnecessary involvement with the criminal justice system and increase access to community-based housing, health care, supports, and services.

(5) (a) The state department shall only reimburse an opioid treatment program, as defined in section 27-80-203, for administering medication-assisted treatment in a jail setting. At a minimum, an opioid treatment program that administers medication-assisted treatment shall:

(I) Employ a physician medical director;

(II) Ensure the individual receiving medication-assisted treatment undergoes a minimum observation period after receiving medication-assisted treatment as determined by behavioral health administration rule pursuant to section 27-80-204; and

(III) Meet all critical incident reporting requirements as determined by behavioral health administration rule pursuant to section 27-80-204.

(b) The state department shall ensure as part of the state department's quality oversight that opioid treatment programs that administer medication-assisted treatment in a jail setting maintain emergency policies and procedures that address adverse outcomes.

(6) The state department may expand services available pursuant to this section as authorized pursuant to federal law and regulations. If the state department seeks to expand services, the state department shall demonstrate how the state department will ensure quality of care and client safety, which must include addressing quality and safety in administering medications in a jail setting.

(7) (a) Beginning July 1, 2025, and each July 1 thereafter, the state department shall annually report to the house of representatives public and behavioral health and human services committee and the senate health and human services committee, or their successor committees, the following information:

(I) De-identified information of individuals who have accessed services, including each individual's demographics, the type of services the individual accessed, the duration of the services offered in a carceral setting compared to the duration of the same services offered in a civil setting, and the individual's experiences before and after incarceration, including but not limited to:

(A) Emergency room or crisis system visits;

(B) Inpatient stays for a primary behavioral health condition; and

(C) Services accessed in a qualified residential treatment program, as defined in section 19-1-103, or a psychiatric residential treatment facility, as defined in section 25.5-4-103;

(II) The total number of medicaid members who were unhoused before or after incarceration, if available;

(III) The total number of unique incarceration stays by medicaid members, as demonstrated by the services accessed;

(IV) The total number of individuals who accessed services in a civil setting prior to arrest or detainment and were subsequently evaluated for competency, ordered to competency restoration, restored to competency, or found incompetent to proceed in a forensic setting; and

(V) Persistent gaps in continuity of care in least-restrictive civil settings.

(b) Notwithstanding section 24-1-136 (11)(a)(I) to the contrary, the state department's report continues indefinitely.

(8) The state department may promulgate rules for the implementation of this section.
C.R.S. § 25.5-6-1501 — CO Code / Title 25.5 / Article 6 / Part 15 / Section 25.5-6-1501
25.5-6-1501. Community transition services and supports - legislative declaration - rules
Status: repealed

25.5-6-1501. Community transition services and supports - legislative declaration - rules. (1) The general assembly finds and declares that:

(a) Federally required assessments indicate that more persons living in institutional settings expressed an interest in transitioning to home- or community-based settings than currently have transitions available to them;

(b) Federally required surveys indicate these persons report a higher quality of life after transitioning to home- and community-based settings, and those successful transitions often result in cost savings to the state;

(c) In order to ensure a successful transition, such persons will need ongoing services and supports after the transition; and

(d) Some persons transitioning out of an institution will need assistance with finding and paying for housing that may be provided by vouchers from the department of local affairs.

(2) (a) The state department shall implement community transition services and supports that allow eligible persons to receive services to support a successful transition from an institutional setting to a home- or community-based setting. The state department may seek any state plan amendments or federal waivers or waiver amendments that may be necessary to implement this part 15.

(b) With input from consumers of home- and community-based services, the state department shall design and implement community transition services and supports for eligible persons who are preparing to transition or have recently transitioned from an institutional setting.

(c) An eligible person is not required to leave an institutional setting if, while exploring the option to transition, the person decides to remain in his or her current living situation. If an eligible person does transition, the person may choose between state plan benefits and waiver services for which he or she is eligible to ensure a successful transition.

(3) In order to qualify and to remain eligible for the community transition services and supports authorized by this part 15, a person shall:

(a) Be eligible for home- and community-based services under parts 3 to 12 of this article 6 or any other home- and community-based service waiver for which the state department has federal waiver authority;

(b) Be willing to participate and have expressed an interest in moving to a home- or community-based setting;

(c) Reside in a nursing home or other institutional setting;

(d) Obtain medicaid eligibility prior to discharging from the institutional setting and prior to accessing community transition services needed to assist the person with planning and preparing for the transition;

(e) Work with a case management agency to determine and enroll in the additional home- and community-based services needed for a successful transition;

(f) Transition to a home- or community-based setting that complies with federal and state rules; and

(g) Meet any other qualifications established by the state board by rule.

(4) The services provided to the eligible person under this part 15 must be based on the eligible person's community living goals, assessed needs, and support plan, or any approved resource allocation process as determined by the state department for the eligible person.

(5) The state department shall develop the accountability requirements necessary to safeguard the use of public dollars, to promote effective and efficient delivery of services, and to monitor the safety and welfare of persons receiving services pursuant to this part 15.

(6) The state board shall adopt rules as necessary for the implementation and administration of the community transition services and supports authorized by this part 15, including establishing limits on the units of service per eligible person to fit within available appropriations.

(7) A person who has been designated as a legal guardian must be involved in the decision-making related to the feasibility of a transition to a home- or community-based setting and the choice of services and supports that may be needed to support a successful transition.

(8) Repealed.
C.R.S. § 25.5-1-129 — CO Code / Title 25.5 / Article 1 / Part 1 / Section 25.5-1-129
25.5-1-129. State department proposal - state option for health-care coverage - report to ge
Status: repealed

25.5-1-129. State department proposal - state option for health-care coverage - report to general assembly - waiver authorization - legislative declaration. (1) (a) The general assembly finds that:

(I) Every Coloradan deserves access to high-quality, affordable health care to help support his or her well-being and economic security;

(II) To achieve these goals, Colorado has successfully implemented provisions of the federal "Patient Protection and Affordable Care Act" that have helped expand access and increase affordability to thousands of Coloradans, including expanding medicaid coverage to more low-income adults and creating the Colorado health benefit exchange;

(III) Despite this success, in several regions of the state, health insurance is not affordable due to high health-care costs and limited or no competition among insurance carriers as well as other marketplace factors, and Coloradans cannot afford the health insurance premiums and out-of-pocket expenses;

(IV) Specifically, Coloradans in fourteen counties have access to only a single health insurance carrier participating in the Colorado health benefit exchange, and the number of uninsured Coloradans in those counties is rising;

(V) Colorado has historically been a national leader in health-care innovation;

(VI) Uncertainty at the federal level requires Colorado to be proactive and explore and implement its own innovative solutions to provide greater access to affordable, high-quality health-care coverage for Colorado residents; and

(VII) A state option for health-care coverage that uses existing state health-care infrastructure may decrease costs for Coloradans, increase competition, and improve access to high-quality, affordable, and efficient health care.

(b) Therefore, the general assembly declares that tasking the state department and the division of insurance in the department of regulatory agencies, referred to in this section as "the division", with developing a proposal that considers the feasibility and cost of implementing a state option for health-care coverage that leverages existing state health-care infrastructure, increases competition, improves quality, and provides stable access to affordable health insurance will enable policymakers to consider and create an innovative state option for health insurance coverage to benefit Colorado.

(2) (a) On or before November 15, 2019, the state department and the division shall develop and submit a proposal to the joint budget committee; the public health care and human services and health and insurance committees of the house of representatives; and the health and human services committee of the senate, or any successor committees, for a state option for health-care coverage that leverages existing state infrastructure.

(b) In addition to submitting the proposal to the committees of the general assembly listed in subsection (2)(a) of this section, the state department and the division shall present a summary of the proposal at the annual joint meeting of the house and senate committees conducted during the legislative interim prior to the 2020 legislative session pursuant to section 2-7-203.

(3) The proposal must describe a state option for health-care coverage. The proposal must identify the most effective implementation of a state option based on affordability to consumers at different income levels, administrative and financial burden to the state, ease of implementation, and likelihood of success in meeting the objectives described in subsection (1) of this section.

(4) In developing the proposal, the state department and the division shall:

(a) Conduct actuarial research to identify the potential cost of premiums and cost sharing to pay claims in a plan that is, at a minimum, an essential health-benefit-compliant plan, as defined in section 10-16-102 (22);

(b) Evaluate provider rates necessary to incentivize participation and encourage network adequacy and high-quality health-care delivery;

(c) Evaluate eligibility criteria for individuals and small businesses to participate;

(d) Determine the impact, if any, on the state budget;

(e) Determine the impact on the stability of the individual market, the small group market, and the Colorado health benefit exchange created in article 22 of title 10;

(f) Evaluate the impact on consumers eligible for financial assistance for plans purchased on the exchange;

(g) Determine whether a state option plan should be offered on or off the exchange;

(h) Determine whether the state option plan should be a fully at-risk, managed care, fee-for-service, or accountable care collaborative plan, or a combination thereof;

(i) Determine whether the state option should be offered through the state department, and identify the expected impact, if any, to the Colorado medical assistance program established in articles 4, 5, and 6 of this title 25.5;

(j) Identify the expected impact, if any, to the children's basic health plan established in article 8 of this title 25.5;

(k) Investigate funding options, including but not limited to state funds and federal funds secured through available waivers;

(l) Evaluate the feasibility, legality, and scope of any necessary federal waivers;

(m) Repealed.

(n) Create a statewide definition of affordability for consumers.

(5) In developing the proposal, the state department and the division shall consult with the Colorado health benefit exchange and shall engage in a stakeholder process that includes public and private health insurance experts, as well as consumers, consumer advocates, employers, providers, and carriers.

(6) The proposal submitted to the committees of the general assembly pursuant to this section must include detailed analysis of the proposed state option and the various methods for implementing the proposed state option, as well as any identified statutory or rule changes necessary to implement the proposed state option.

(7) (a) (I) After the proposal created pursuant to this section is submitted and presented to the committees of the general assembly, the state department and the division shall prepare and submit any federal waivers or state plan amendments necessary to fund and implement the state option for health-care coverage as described in the proposal created pursuant to subsection (2)(a) of this section.

(II) The state department's and the division's requests for federal authorization must seek to obtain the maximum amount of federal money available to the state and to persons participating in the state option for health-care coverage.

(b) Notwithstanding the provisions of subsection (7)(a)(I) of this section to the contrary, the preparation and submission of federal waivers or amendments must be delayed if a member of the general assembly files a bill during the 2020 legislative session by the regular bill filing deadline of the house of representatives, as set forth in rule 23 of the joint rules of the senate and house of representatives, that substantially alters the federal authorization required pursuant to the proposal to implement the state option for health-care coverage, and such bill is not postponed indefinitely in the first committee of reference. The department's and the division's waiver preparation process shall resume after the bill is postponed indefinitely or, if passed by the general assembly, the requested waivers or state plan amendments must reflect the requirements in the passed legislation.

(c) Subject to the conditions described in subsection (7)(b) of this section, the state department and the division may promulgate rules, as necessary, for the preparation and submission of federal waivers or state plan amendments necessary to fund and implement the proposal.
C.R.S. § 25.5-5-408 — CO Code / Title 25.5 / Article 5 / Part 4 / Section 25.5-5-408
25.5-5-408. Capitation payments - availability of base data - adjustments - rate calculation
Status: in_force

25.5-5-408. Capitation payments - availability of base data - adjustments - rate calculation - capitation payment proposal - preference - assignment of medicaid members - definition. (1) (a) The state department shall make capitation payments to MCEs based upon a defined scope of services under a risk contract.

(b) A certification by a qualified actuary retained by the state department is conclusive evidence that the state department has correctly calculated the direct health-care cost of providing these same services on an actuarially equivalent Colorado medicaid population group.

(c) Except as otherwise provided in subsection (1)(d) of this section and where the state department has instituted a program of competitive bidding provided in section 25.5-5-402 (9), the state department may utilize a market rate set through the competitive bid process for a set of defined services. The state department shall only use market rate bids that do not discriminate and are adequate to assure quality and network sufficiency. A certification of a qualified actuary, retained by the state department, to the appropriate lower limit is conclusive evidence of the state department's compliance with the requirements of this subsection (1)(c). For the purposes of this subsection (1), a "qualified actuary" means a person deemed as such under rules promulgated by the commissioner of insurance.

(d) The state department shall reimburse a federally qualified health center, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(4), for the total reasonable costs incurred by the center in providing health-care services to all members of medical assistance.

(e) An MCE shall certify, as a condition of entering into a contract with the state department, that the capitation payments set forth in the contract between the MCE and the state department are sufficient to ensure the financial stability of the MCE with respect to delivery of services to the medicaid members covered in the contract.

(f) (I) Except as provided in subsection (1)(f)(II) of this section, for capitation payments effective on and after July 1, 2003, an MCE that is contracting for a defined scope of services under a risk contract shall certify, through a qualified actuary retained by the MCE, that the capitation payments set forth in the contract between the MCE and the state department comply with all applicable federal and state requirements that govern the capitation payments. For purposes of this subsection (1)(f)(I), a "qualified actuary" means a person deemed as such by rule promulgated by the commissioner of insurance.

(II) An MCO providing services under the PACE program as described in section 25.5-5-412 shall certify that the capitation payments are in compliance with applicable federal and state requirements that govern said capitation payments and that the capitation payments are sufficient to ensure the financial viability of the MCO with respect to the delivery of services to the PACE program participants covered in the contract.

(2) The state department shall develop capitation rates for MCEs contracting for a defined scope of services under a risk contract that include risk adjustments, reinsurance, or stop-loss funding methods. Payments to plans may vary when it is shown through diagnoses or other relevant data that certain populations are expected to cost more or less than the capitated population as a whole.

(3) The state board, in consultation with recognized medical authorities, shall develop a definition of special needs populations that includes evidence of diagnosed or medically confirmed health conditions. The state department shall develop a method for adjusting payments to plans for such special needs populations when diagnoses or other relevant data indicates these special needs populations would cost significantly more than similarly capitated populations.

(4) Under no circumstances shall the risk adjustments, reinsurance, or stop-loss methods developed by the state department pursuant to subsection (2) of this section cause the average per capita medicaid payment to a plan to be greater than the projected medicaid expenditures for treating medicaid enrollees of that plan under fee-for-service medicaid.

(5) The state department may develop quality incentive payments to recognize superior quality of care or service provided by a managed care plan.

(6) Within two hundred ten days from the beginning of each fiscal year, the state department, in cooperation with the MCEs, shall set a timeline for the rate-setting process for the following fiscal year's rates and for the provision of base data to the MCEs that is used in the calculation of the rates, which must include but not be limited to the information included in subsection (7) of this section.

(7) The state department shall identify and make available to the MCEs the base data used in the calculation of the direct health-care cost of providing these same services on an actuarially equivalent Colorado medicaid population group. The state department shall consult with the MCEs regarding any and all adjustments in the base data made to arrive at the capitation payments.

(8) For capitation payments effective on and after July 1, 2003, the state department shall recalculate the base calculation every three years. The three-year cycle for the recalculation of the base calculation shall begin with capitation payments effective for fiscal year 2003-04. In the years in which the base calculation is not recalculated, the state department shall annually trend the base calculation after consulting with the MCEs. The state department shall take into consideration when trending the base calculation any public policy changes that affect reimbursement under the "Colorado Medical Assistance Act".

(9) The rate-setting process referenced in subsection (6) of this section must include a time period after the MCEs have received the direct health-care cost of providing these same services on an actuarially equivalent Colorado medicaid population group for each MCE to submit to the state department the MCE's capitation payment proposal, which must not exceed one hundred percent of the direct health-care cost of providing these same services on an actuarially equivalent Colorado medicaid population group. The state department shall provide to the MCEs the MCE's specific adjustments to be included in the calculation of the MCE's proposal. Each MCE's capitation payment proposal must meet the requirements of subsections (1)(e) and (1)(f) of this section and section 25.5-5-402 (10).

(10) For capitation payments effective on and after July 1, 2003, unless otherwise required by federal law, the state department shall certify, through a qualified actuary retained by the state department, that the capitation payments set forth in the contract between the state department and the MCEs comply with all applicable federal and state requirements that govern said capitation payments.

(11) Effective on and after July 1, 2003, the capitation payments certified by the qualified actuary under subsection (10) of this section shall not be subject to any dispute resolution process, including any such process set forth in any settlement agreement entered into prior to July 1, 2002.

(12) Nothing in this section shall prevent, to the extent possible, an MCE that is also a government-owned entity from using certified public expenditure or other federally recognized financing mechanisms to provide the state share for the federal match to enhance capitation payments up to or above the one hundred percent limit contained in subsection (9) of this section. The state shall not be obligated to increase any general fund expenditures because of the use of certified public expenditure or other federally recognized financing mechanism pursuant to this subsection (12).

(13) A PIHP agreement may include a provision for a quality incentive payment that is distributed to the contractor within a reasonable period of time, as specified in the contract, following the end of each fiscal year if the contractor substantially exceeds predetermined quality indicators. The quality indicators must be based upon broadly accepted measures of performance adopted by rule of the state board and agreed upon at the outset of the contract period, and must include, but need not be limited to, the health plan employers data and information set measures. The quality incentive payment may be made proportional if the state board establishes multiple quality measurements. The quality incentive payments must not exceed the total cost savings created under the PIHP agreement, as determined by comparison of the PIHP members with an actuarially equivalent fee-for-service population, and the quality incentive payment must not exceed five percent of the total medicaid payments received by the contractor during the performance period of the PIHP agreement.
C.R.S. § 25.5-1-301 — CO Code / Title 25.5 / Article 1 / Part 3 / Section 25.5-1-301
25.5-1-301. Medical services board - creation
Status: in_force

25.5-1-301. Medical services board - creation. (1) (a) There is created in the state department the medical services board, referred to in this part 3 as the "board". The board consists of members appointed by the governor with the consent of the senate as follows:

(I) One member from each congressional district in the state; and

(II) Three members from the state at large.

(b) The governor shall appoint persons to the board who have knowledge of medical assistance programs, and one or more of the appointments may include a person or persons who have received services through programs administered by the department within two years of the date of appointment.

(c) No more than a minimum majority of the members of the board may be affiliated with the same political party.

(d) In making appointments to the board, the governor shall include:

(I) One member from the private sector who has experience with the delivery of health care;

(II) One member who has experience or expertise in caring for medically underserved children; and

(III) Representation by at least one member who is a person with a disability, as defined in section 24-34-301, a family member of a person with a disability, or a member of an advocacy group for persons with disabilities, provided that the other requirements of this subsection (1) are met.

(2) Each member serves at the pleasure of the governor for a term of four years; except that the terms shall be staggered so that no more than a minimum majority of members' terms expire in the same year.

(3) Members shall receive no compensation but shall be reimbursed for reasonable and necessary actual expenses incurred in the performance of their official duties as members of the board.

(4) Vacancies on the board shall be filled by appointment of the governor for the remainder of any unexpired term.

(5) The board is a type 1 entity, as defined in section 24-1-105.
C.R.S. § 25.5-4-417 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-417
25.5-4-417. Provider fee - medicaid providers - state plan amendment - rules - definitions
Status: in_force

25.5-4-417. Provider fee - medicaid providers - state plan amendment - rules - definitions. (1) For purposes of this section, unless the context otherwise requires:

(a) "Local government" means a county, home rule county, home rule or statutory city, town, territorial charter city, or city and county.

(b) "Provider fee" means a licensing fee, assessment, or other mandatory payment that is related to health-care items or services as specified under 42 CFR 433.55.

(c) "Qualified provider" means a hospital licensed pursuant to section 25-3-101, C.R.S., or a certified home health-care agency within the territorial boundaries of the local government.

(2) For the purpose of sustaining or increasing reimbursement for providing medical care under the state's medical assistance program and to low-income populations, the state department shall amend the state plan effective July 1, 2006. Implementation of the state plan amendment shall be subject to the approval of the federal government. The imposition and collection of a provider fee by a local government pursuant to article 28 of title 29, C.R.S., shall be prohibited without the federal government's approval of a state plan amendment authorizing federal financial participation for the provider fees.

(3) In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1) and (e)(2), the state department may seek a waiver from the broad-based provider fee requirement or the uniform provider fee requirement, or both, to exclude qualified providers from the provider fee.

(4) To the extent authorized by federal law, the state department may exclude a governmental qualified provider from payment of the provider fee, benefits from the provider fee, or any federal financial participation due to the fee.

(5) [Editor's note: This version of subsection (5) is effective until July 1, 2025.] To the extent authorized by federal law, the state department shall distribute the provider fee and any associated federal financial participation either to a local government that has certified payment to qualified providers within the local government or directly to the qualified providers. The state department shall establish reimbursement methods to distribute the provider fee and associated federal financial participation to qualified providers. The state department may alter reimbursement methods to qualified providers participating under the state's medical assistance program and Colorado indigent care program to the extent necessary to meet the federal requirements and to obtain federal approval of the provider fee. The state department shall work with a statewide association of hospitals on changes to reimbursement methods or provider fees that impact hospital providers. The state department shall work with a statewide association of home health-care agencies on changes to reimbursement methods or provider fees that impact home health-care agencies.

(5) [Editor's note: This version of subsection (5) is effective July 1, 2025.] To the extent authorized by federal law, the state department shall distribute the provider fee and any associated federal financial participation either to a local government that has certified payment to qualified providers within the local government or directly to the qualified providers. The state department shall establish reimbursement methods to distribute the provider fee and associated federal financial participation to qualified providers. The state department may alter reimbursement methods to qualified providers participating under the state's medical assistance program to the extent necessary to meet the federal requirements and to obtain federal approval of the provider fee. The state department shall work with a statewide association of hospitals on changes to reimbursement methods or provider fees that impact hospital providers. The state department shall work with a statewide association of home health-care agencies on changes to reimbursement methods or provider fees that impact home health-care agencies.

(6) The state board shall adopt any rules necessary for the administration and implementation of this section.
C.R.S. § 25.5-5-504 — CO Code / Title 25.5 / Article 5 / Part 5 / Section 25.5-5-504
25.5-5-504. Providers of pharmaceutical services
Status: in_force

25.5-5-504. Providers of pharmaceutical services. (1) Consistent with the provisions of section 25.5-4-401 (1) and subsections (2) and (3) of this section, and subject to available appropriations, no provider of pharmaceutical services who meets the conditions imposed by this article 5 and articles 4 and 6 of this title 25.5 and who complies with the terms and conditions established by the state department and contracting health maintenance organizations and prepaid health plans shall be excluded from contracting for the provision of pharmaceutical services to members authorized in this article 5 and articles 4 and 6 of this title 25.5.

(2) This provision does not apply to a health maintenance organization or prepaid health plan that enrolls less than forty percent of all the resident medicaid members in any county with over one thousand medicaid members.

(3) The state board shall establish specifications in rules in order to provide criteria to health maintenance organizations and prepaid health plans that ensure the accessibility and quality of service to members and the terms and conditions for pharmaceutical contracts.
C.R.S. § 25.5-4-420 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-420
25.5-4-420. Providers to obtain unique NPI - service site - provider type - definitions
Status: in_force

25.5-4-420. Providers to obtain unique NPI - service site - provider type - definitions. (1) As used in this section:

(a) "Health care clearinghouse" has the same meaning as set forth in 45 CFR 160.103.

(b) "NPI" or "national provider identifier" means the standard, unique health identifier for health-care providers that is issued by the national provider system in accordance with 45 CFR part 162.

(c) "Off-campus location" means a facility:

(I) Whose operations are directly or indirectly owned or controlled by, in whole or in part, or affiliated with a hospital, regardless of whether the operations are under the same governing body as the hospital;

(II) That is located more than two hundred fifty yards from the hospital's main campus;

(III) That provides services that are organizationally and functionally integrated with the hospital; and

(IV) That is an outpatient facility providing preventive, diagnostic, treatment, or emergency services.

(d) "Organization health-care provider" means a provider that is not an individual and includes a hospital.

(e) "Subpart" has the same meaning as that term is used in 45 CFR part 162 and means a component or separate physical location of an organization health-care provider that may be separately licensed or certified by the state.

(2) (a) Each organization health-care provider and each subpart that is required or eligible to obtain an NPI pursuant to 45 CFR 162.410 must apply for, obtain, and use, on all claims for payment for medical care, services, or goods authorized under this article 4 and articles 5 and 6 of this title 25.5, a unique NPI for each site at which the organization health-care provider or its subparts deliver medical care, services, or goods.

(b) Each organization health-care provider and each subpart that is required or eligible to obtain an NPI pursuant to 45 CFR 162.410 must apply for, obtain, and use, on all claims for payment for medical care, services, or goods authorized under this article 4 and articles 5 and 6 of this title 25.5, a unique NPI for each provider type, as specified by the state department, under which the organization health-care provider or its subparts deliver medical care, services, or goods.

(c) An organization health-care provider or subpart submitting a claim for payment for medical care, services, or goods rendered under this article 4 or article 5 or 6 of this title 25.5 shall include on the claim the unique NPI that identifies both the site where the medical care, services, or goods were provided and the provider type, as specified by the state department, regardless of whether the claim is filed or submitted by or through a central office of the organization health-care provider or a health care clearinghouse.

(3) (a) For an organization health-care provider that is a licensed or certified hospital contracting for services under this article 4 and articles 5 and 6 of this title 25.5, the hospital shall obtain and use a unique, separate, and distinct NPI for:

(I) Its main campus;

(II) Each off-campus location of the hospital; and

(III) Each provider type, if specified by the state department, when the hospital delivers medical care, services, or goods at either the hospital's main campus or at an off-campus location.

(b) A hospital submitting a claim for payment for medical care, services, or goods rendered under this article 4 or article 5 or 6 of this title 25.5 shall include on the claim the unique NPI that identifies both the site where the medical care, services, or goods were provided and the provider type, as specified by the state department, regardless of whether the claim is filed or submitted by or through a central office of the hospital or a health care clearinghouse.

(4) (a) Starting January 1, 2020, an organization health-care provider applying to enroll as a new provider under this article 4 and articles 5 and 6 of this title 25.5 shall demonstrate that it has obtained one or more NPIs as required by this section, and upon enrollment, shall use its unique NPI on every claim for payment in the manner required by this section.

(b) Starting January 1, 2021, an organization health-care provider enrolled and applying for revalidation as a provider under this article 4 and articles 5 and 6 of this title 25.5 shall demonstrate that it has obtained one or more NPIs as required by this section as a condition of receiving revalidation, and upon receiving revalidation as a provider, shall use its unique NPI on every claim for payment in the manner required by this section.
C.R.S. § 25.5-4-430 — CO Code / Title 25.5 / Article 4 / Part 4 / Section 25.5-4-430
25.5-4-430. Increasing access to behavioral health care for children and youth - directed pa
Status: in_force

25.5-4-430. Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates. (1) (a) The state department shall analyze how directed payment authority can be used as part of a comprehensive plan to facilitate an adequate network of services for children and youth with behavioral health needs who are under twenty-one years of age and receive medicaid benefits by requiring each managed care entity to pay no less than state department-established fee schedule rates to increase access to care for services needed to promote clinical stabilization. The state department shall analyze how directed payment authority may be applied to clinical stabilization services, including, but not limited to, residential treatment services, multisystemic therapy, functional family therapy, and psychotherapy services for children and youth.

(b) In analyzing directed payment authority and establishing fee schedule rates, the state department shall consider whether the rates should increase based on the acuity of the child or youth.

(2) No later than October 1, 2023, the state department shall report to the house of representatives public and behavioral health and human services committee and the senate health and human services committee, or their successor committees, and the joint budget committee whether directed payment authority should be pursued and whether funding should be requested to expand access to residential treatment services, multisystemic therapy, functional family therapy, and psychotherapy services. If the state department determines that directed payments are not appropriate to expand access to such services, the state department shall present an alternative plan to expanding access to the services.
C.R.S. § 25.5-5-322 — CO Code / Title 25.5 / Article 5 / Part 3 / Section 25.5-5-322
25.5-5-322. Over-the-counter medications - rules
Status: in_force

25.5-5-322. Over-the-counter medications - rules. (1) (a) Subject to approval through the state budget process described in subsection (1)(b) of this section, the state board shall adopt by rule a system to allow pharmacies to be reimbursed for providing certain over-the-counter medications to members if prescribed by a licensed practitioner authorized to prescribe prescription drugs or, subject to the limitations contained in subsection (2) of this section, a licensed pharmacist. Over-the-counter medications subject to reimbursement pursuant to this section must be identified through the drug utilization review process established in section 25.5-5-506, and are limited to medications that, if reimbursed, result in overall cost savings to the state.

(b) After the list of over-the-counter medications is identified pursuant to paragraph (a) of this subsection (1), the state department shall request, through the state budget process, that the reimbursements be implemented. The state department shall report to the joint budget committee annually concerning the amount of any savings realized from the reimbursements.

(2) (a) The state board, in consultation with the state board of pharmacy created pursuant to section 12-280-104, shall establish by rule standards for when a licensed pharmacist may prescribe over-the-counter medications as provided under this section for purposes of receiving reimbursement under the medical assistance program.

(b) When prescribing over-the-counter medications under this section, a licensed pharmacist shall consult with the member to determine necessity, provide drug counseling, review drug therapy for potential adverse interactions, and make referrals as needed to other health-care professionals.
C.R.S. § 25.5-6-202 — CO Code / Title 25.5 / Article 6 / Part 2 / Section 25.5-6-202
25.5-6-202. Providers - nursing facility provider reimbursement - exemption - rules - repeal
Status: repealed

25.5-6-202. Providers - nursing facility provider reimbursement - exemption - rules - repeal. (1) (a) (I) Subject to available appropriations, for the purpose of reimbursing a medicaid-certified class I nursing facility provider a per diem rate for the cost of direct and indirect health-care services and raw food, the state department shall establish an annually readjusted schedule to pay each nursing facility provider the actual amount of the costs. The payment shall not exceed one hundred twenty-five percent of the median cost of direct and indirect health-care services and raw food as determined by an array of all facility providers; except that, for state veteran nursing homes, the payment shall not exceed one hundred thirty percent of the median cost.

(II) For the fiscal year commencing July 1, 2009, and for each fiscal year thereafter, any increase in the direct and indirect health-care services and raw food costs shall not exceed eight percent per year. The calculation of the eight percent per year limitation for rates effective on July 1, 2009, shall be based on the direct and indirect health-care services and raw food costs in the as-filed facility's cost reports up to and including June 30, 2009. For the purposes of calculating the eight-percent limitation for rates effective after July 1, 2009, the limitation shall be determined and indexed from the direct and indirect health-care services and raw food costs as reported and audited for the rates effective July 1, 2009.

(b) In computing per diem cost, each nursing facility provider shall annually submit cost reports, and actual days of care shall be counted, not occupancy-imputed days of care. In addition, in determining the median cost, the cost of direct health care shall be case-mix neutral. The cost reports used by the state department to establish the per diem cost shall be those filed with the state department during the period ending December 31 of the prior year following implementation of this subsection (1) and for each succeeding year. The state department shall redetermine the median per diem cost based upon the most recent cost reports filed during the period ending December 31 of the prior year.

(2) The state department shall further adjust and, subject to available appropriations, pay the per diem rate to the nursing facility provider for the cost of direct health-care services based upon the acuity or case-mix of the nursing facility provider residents in order to provide for the resource utilization of its residents. The state department shall determine this adjustment in accordance with each resident's status as identified and reported by the nursing facility provider on its federal medicare and medicaid minimum data set assessment. The state department shall establish a case-mix index for each nursing facility provider according to the case-mix group determined by the state department. The state department shall calculate nursing weights based upon standard nursing time studies and weighted by facility population distribution and Colorado-specific nursing salary ratios. The state department shall determine an average case-mix index for each nursing facility provider's medicaid residents on a quarterly basis.

(3) (a) Subject to available appropriations, for the purpose of reimbursing a medicaid-certified class I nursing facility provider a per diem rate for the cost of its administrative and general services, the state department shall establish an annually readjusted schedule to pay each nursing facility provider a reasonable price for the costs, which reasonable price shall be a percentage of the median per diem cost of administrative and general services as determined by an array of all nursing facility providers. For facilities of sixty licensed beds or fewer, the reasonable price shall be one hundred ten percent of the median per diem cost for all class I facilities. For facilities of sixty-one licensed beds and more, the reasonable price shall be one hundred five percent of the median per diem cost for all class I facilities.

(b) In computing per diem cost, each nursing facility provider shall annually submit cost reports to the state department, and actual days of care shall be counted, not occupancy-imputed days of care. The cost reports used to establish this median per diem cost shall be those filed during the period ending December 31 of the prior year following implementation of this subsection (3), and, for each succeeding fourth year, the state department shall redetermine the median per diem cost based upon the most recent cost reports filed during the period ending December 31 of the prior year.

(c) Repealed.

(4) In addition to the reimbursement components paid pursuant to subsections (1) to (3) of this section, a per diem rate constituting a fair rental allowance for capital-related assets shall be paid to each nursing facility provider as a rental rate based upon the nursing facility's appraised value.

(5) Subject to available appropriations and the priority of the uses of the provider fees as established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid pursuant to subsections (1) to (4) of this section, the state department shall make a supplemental medicaid payment based upon performance to those nursing facility providers that provide services that result in better care and higher quality of life for their residents. The state department shall determine the payment amount based upon performance measures established in rules adopted by the state board in the domains of quality of life, quality of care, and facility management. Beginning July 1, 2024, the payment must not be less than twelve percent of total provider fee payments and must be adjusted for fiscal years 2024-25 and 2025-26. No later than July 1, 2026, the payment must not be less than fifteen percent of total provider fee payments and must be annually adjusted thereafter. During each state fiscal year, the state department may discontinue the supplemental medicaid payment established pursuant to this subsection (5) to any nursing facility provider that fails to comply with the established performance measures during the state fiscal year, and the state department may initiate the supplemental medicaid payment established pursuant to this subsection (5) to any provider that comes into compliance with the established performance measures during the state fiscal year.

(6) Subject to available appropriations and the priority of the uses of the provider fees as established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid pursuant to subsections (1) to (5) of this section, the state department shall make a supplemental medicaid payment to nursing facility providers that serve residents:

(a) Who have severe mental health conditions that are classified at a level II by the medicaid program's preadmission screening and resident review assessment tool. The state department shall compute this payment annually as of July 1, 2009, and each July 1 thereafter, and it must not be less than two percent of the statewide average per diem rate for the combined rate components determined pursuant to subsections (1) to (4) of this section. Beginning July 1, 2023, the state department shall annually adjust the rate to ensure access to care for residents who have severe mental health conditions.

(b) With severe dementia diseases and related disabilities or acquired brain injury. The state department shall calculate the payment based upon the resident's cognitive assessment established in rules adopted by the state board. The state department shall compute this payment annually as of July 1, 2009, and each July 1 thereafter, and it must not be less than one percent of the statewide average per diem rate for the combined rate components determined pursuant to subsections (1) to (4) of this section. Beginning July 1, 2023, the state department shall annually adjust the rate to ensure access to care for residents with severe dementia diseases and related disabilities or acquired brain injury.

(7) Subject to available moneys and the priority of the uses of the provider fees as established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid pursuant to subsections (1) to (6) of this section, the state department shall pay a nursing facility provider a supplemental medicaid payment for care and services rendered to medicaid residents to offset payment of the provider fee assessed under the provisions of section 25.5-6-203. The state department shall compute this payment annually, as of July 1, 2009, and each July 1 thereafter.

(8) (Deleted by amendment, L. 2009, (SB 09-263), ch. 203, p. 912, § 2, effective May 1, 2009.)

(9) (a) The per diem amount paid for direct and indirect health-care services and administrative and general services costs shall include an allowance for inflation in the costs for each category using a nationally recognized service that includes the federal government's forecasts for the prospective medicare reimbursement rates recommended to the United States congress. Amounts contained in cost reports used to determine the per diem amount paid for each category shall be adjusted by the percentage change in this allowance measured from the midpoint of the reporting period of each cost report to the midpoint of the payment-setting period.

(b) (I) Except for changes in the number of patient days, the state department shall establish the general fund share of the aggregate statewide average of the per diem rate net of patient payment pursuant to subsections (1) to (4) of this section. The state's share of the reimbursement rate components pursuant to subsections (1) to (4) of this section may be funded through the provider fee assessed pursuant to section 25.5-6-203 and any associated federal funds. Any provider fee used as the state's share and all federal funds must be excluded from the calculation of the general fund share. For the fiscal year commencing July 1, 2009, and for each fiscal year thereafter, the state department shall calculate the general fund share of the aggregate statewide average per diem rate net of patient payment pursuant to subsections (1) to (4) of this section using the rates that were effective on July 1 of that fiscal year; except that:

(A) For fiscal year 2023-24, the state department shall increase the aggregate statewide average of the per diem rate by at least ten percent;

(B) For fiscal year 2024-25, the state department shall increase the aggregate statewide average of the per diem rate by at least three percent;

(C) For fiscal year 2025-26, the state department shall increase the aggregate statewide average of the per diem rate by at least one and one-half percent; and

(D) Beginning in fiscal year 2026-27, and for each fiscal year thereafter, the state department shall establish the aggregate statewide average of the per diem rate.

(I.5) When increasing the aggregate statewide average of the per diem rate for fiscal years 2023 through 2027, the reimbursement rate for a class I nursing facility that operates efficiently and economically must be reasonable and adequate to meet the nursing home's costs in order to provide care and services in conformity with applicable state and federal laws, regulations, and quality and safety standards, and must be based on the most recent audited and finalized cost and utilization data available.

(II) If the aggregate statewide average per diem rate net of patient payment pursuant to subsections (1) to (4) of this section exceeds the general fund share, the amount of the average statewide per diem rate that exceeds the general fund share shall be paid as a supplemental medicaid payment using the provider fee established under section 25.5-6-203. Subject to the priority of the uses of the provider fee established under section 25.5-6-203 (2)(b), if the provider fee is insufficient to fully fund the supplemental medicaid payment, the supplemental medicaid payment shall be reduced to all providers proportionately.

(III) to (V) Repealed.

(VI) Notwithstanding any other provision of law, for the fiscal year commencing July 1, 2013, and each fiscal year thereafter, the general fund portion of the per diem rate pursuant to subsections (1) to (4) of this section shall be reduced by one and one-half percent. The state department may, but is not required to, increase the supplemental medicaid payment pursuant to subparagraph (II) of this paragraph (b) due to this reduction; except that the provider fee shall not exceed the amount specified in section 25.5-6-203 (1)(a)(II).

(VII) Notwithstanding any other provision of law to the contrary, for the 2020-21 and 2021-22 fiscal years, the general fund portion of the per diem rate pursuant to subsections (1) to (4) of this section is limited to an annual increase of two percent.

(b.3) (I) For the fiscal year commencing July 1, 2009, and for each fiscal year thereafter, if the provider fee established under section 25.5-6-203 is insufficient to fully fund the supplemental medicaid payments established under subsections (5) to (7) of this section, subject to the priority of the uses of the provider fee established pursuant to section 25.5-6-203 (2)(b), the state department may suspend or reduce the supplemental medicaid payment subject to the uses of the provider fee established under section 25.5-6-203.

(II) If it is determined by the state department that the case-mix reimbursement includes a factor for nursing facility providers that serve residents with severe dementia diseases and related disabilities or acquired brain injury, the state department may eliminate the supplemental medicaid payment to those providers that serve residents with severe dementia diseases and related disabilities or acquired brain injury.

(b.5) Notwithstanding any other provision of law or any federal law that temporarily increases the federal matching participation rate for any fiscal year, payments to nursing facility providers from the general fund share of the aggregate statewide average of the per diem rate shall be calculated based on a fifty-percent federal match.

(b.7) Repealed.

(c) (I) The general assembly finds that the historical growth in nursing facility provider rates has significantly exceeded the rate of inflation. These increases have been caused in part by the inclusion of medicare costs in medicaid cost reports. The state of Colorado has an interest in limiting these exceptional increases in medicaid nursing facility provider rates by removing medicare costs from the medicaid nursing facility provider rates and by imposing a ceiling on the medicare part A ancillary costs that are included in calculating medicaid nursing facility rates. No later than July 1, 2023, the state department shall initiate a process to remove medicare costs from the provider rate setting by July 1, 2026. The state board shall promulgate rules establishing the specific methodology used for removing medicare costs.

(II) Repealed.

(III) The specific methodology for calculating the limitations and cost-reporting requirements described in this paragraph (c) shall be established by rules promulgated by the state board.

(d) The reimbursement rate components pursuant to subsections (5) to (7) of this section shall be funded entirely through the provider fee assessed pursuant to the provisions of section 25.5-6-203 and any associated federal funds. No general fund moneys shall be used to pay for the reimbursement rate components established pursuant to subsections (5) to (7) of this section.

(10) The state board shall promulgate rules pursuant to the "State Administrative Procedure Act", article 4 of title 24, C.R.S.,to implement this section, including establishing uniform accounting, reporting, and payment procedures consistent with this section, to determine a nursing facility provider's costs and payments to the provider.

(11) (Deleted by amendment, L. 2009, (SB 09-263), ch. 203, p. 912, § 2, effective May 1, 2009.)

(12) The state department may exempt facilities with five or fewer medicaid beds from the methodology described in this section and instead require the facilities to be reimbursed at the statewide average rate.

(13) (a) As a condition of receiving medicaid funds, the state department may require a nursing facility to submit any documentation necessary to ensure the state's interest in transparency, stability, and sound fiscal stewardship, including, but not limited to:

(I) Annual audited financial statements, prepared by an independent accountant, for a facility, management company, and any related party conducting business with a medicaid-certified nursing facility, including audited and consolidated financial statements for any parent company that accepts, or whose subsidiaries accept, medicaid payments from the state of Colorado;

(II) Details on transactions between related parties or entities that have common ownership; and

(III) Ownership interest in real estate, management companies, facility operators, and all related parties.

(b) The state department shall determine the format for the documentation provided by each nursing facility.

(c) The state board shall establish by rule any penalties for noncompliance with the financial reporting required pursuant to this subsection (13).

(d) The costs associated with the financial reporting required pursuant to this subsection (13), including any audit costs incurred by a nursing facility, are an allowable expense on the medicaid cost report and must be incorporated as a component of the overall reimbursement methodology.

(14) The general assembly finds that the inflexible nature of statutorily fixed reimbursement rates is not in the best interest of the state of Colorado. Therefore, the state department shall develop and implement a transition plan to regulate nursing facility reimbursement aimed at improving the health and safety of residents, promoting innovation and improved infection control efforts, improving access to care, and promoting innovation in Colorado nursing facilities. As part of this process, the state department shall:

(a) No later than July 1, 2026, define "nursing home reimbursement" through rules promulgated by the state board and provide payments to nursing facilities consistent with the promulgated rules;

(b) Engage with stakeholders regularly to seek input on any proposed methodology changes and ensure the methodology is reasonable and adequate to meet the costs of an efficiently and economically operated nursing facility that provides care and services in conformity with applicable state and federal laws, regulations, and quality and safety standards based on the most recent audit and finalized cost and utilization data available; and

(c) From November 1, 2023, to November 1, 2026, submit an annual report to the joint budget committee of the general assembly regarding the implementation progress described in this subsection (14), including, at a minimum:

(I) Records of stakeholder engagement;

(II) Conclusions drawn from financial oversight activities;

(III) Issues regarding payment equity and access to care coordination; and

(IV) Expected budgetary impacts of any methodology change.

(15) (a) Each nursing facility that receives medicaid funds shall develop and submit a plan to the state department that meets state department standards and demonstrates how the nursing facility will:

(I) Improve the health and safety of the nursing facility's residents, including infection control and staffing;

(II) Increase access to care;

(III) Improve financial sustainability, including opportunities for diversification of business lines and stabilization of revenue streams; and

(IV) Promote innovation to meet the emerging needs of individuals with disabilities and aging and older adults.

(b) The state board shall promulgate rules implementing this subsection (15).

(16) Subsections (1) to (9) of this section and this subsection (16) are repealed, effective July 1, 2026.
C.R.S. § 25.5-10-205 — CO Code / Title 25.5 / Article 10 / Part 2 / Section 25.5-10-205
25.5-10-205. Case management agencies - local public procurement units
Status: in_force

25.5-10-205. Case management agencies - local public procurement units. For purposes of entering into a cooperative purchasing agreement pursuant to section 24-110-201, a nonprofit case management agency or a nonprofit service agency may be certified as a local public procurement unit as provided in section 24-110-207.5.
C.R.S. § 25.5-6-204 — CO Code / Title 25.5 / Article 6 / Part 2 / Section 25.5-6-204
25.5-6-204. Providers - reimbursement - intermediate care facility for individuals with inte
Status: repealed

25.5-6-204. Providers - reimbursement - intermediate care facility for individuals with intellectual disabilities - reimbursement - maximum allowable. (1) (a) For the purpose of making payments to intermediate care facilities for individuals with intellectual disabilities, the state department shall establish a price schedule to be readjusted every twelve months, that shall reimburse, subject to available appropriations, each provider, as nearly as possible, for its actual or reasonable cost of services rendered, whichever is less, its case-mix adjusted direct health-care services costs as defined in section 25.5-6-201 (9), and a fair rental allowance for capital-related assets as defined in section 25.5-6-201 (7). The state board shall adopt rules, including uniform accounting or reporting procedures, in order to determine the actual or reasonable cost of services and case-mix adjusted direct health-care services costs and the reimbursement therefor. The provisions of this paragraph (a) shall not apply to state-operated intermediate care facilities for individuals with intellectual disabilities.

(b) State-operated intermediate care facilities for individuals with intellectual disabilities shall be reimbursed based on the actual costs of administration, property, including capital-related assets, and room and board, and the actual costs of providing health-care services, and such costs shall be projected by such facilities and submitted to the state department by July 1 of each year for the ensuing twelve-month period. Reimbursement to state-operated intermediate care facilities for individuals with intellectual disabilities shall be adjusted retrospectively at the close of each twelve-month period. The state board shall adopt rules to be effective by June 30, 1988, implementing the provisions of this paragraph (b). In the implementation of such rules, the state department shall ensure, by the establishment of classes of facilities, that the reimbursement to private, nonprofit, or proprietary state-operated intermediate care facilities for individuals with intellectual disabilities, as defined in section 25.5-10-202, is not adversely impacted.

(c) (I) Beginning in fiscal year 2013-14, and for each fiscal year thereafter, the state department is authorized to charge both privately owned intermediate care facilities for individuals with intellectual disabilities and state-operated intermediate care facilities for individuals with intellectual disabilities a service fee for the purposes of maintaining the quality and continuity of services provided by intermediate care facilities for individuals with intellectual disabilities. The service fee charged by the state department pursuant to this paragraph (c) will be assessed pursuant to rules adopted by the state board but must not exceed five percent of the total costs incurred by all intermediate care facilities for the fiscal year in which the service fee is charged. The state board shall adopt rules consistent with federal law in order to implement the provisions of this paragraph (c).

(II) The moneys collected in each fiscal year pursuant to subparagraph (I) of this paragraph (c) shall be transmitted by the state department to the state treasurer, who shall credit the same to the service fee fund, which fund is hereby created and referred to in this paragraph (c) as the "fund". The moneys in the fund shall be subject to annual appropriation by the general assembly to the state department to be used toward the state match for the federal financial participation to reimburse intermediate care facilities for individuals with intellectual disabilities pursuant to this section. Any unexpended and unencumbered moneys remaining in the fund at the end of any fiscal year shall remain in the fund and not be credited or transferred to the general fund or any other fund.

(2) (a) In addition to the actual or reasonable costs and the reimbursement therefor, the state department shall, subject to available appropriations, include an allowance equal to the change in the national bureau of labor statistics consumer price index from the preceding year to compensate for fluctuating costs. This amount shall be determined every twelve months when the statewide average cost is determined by adjusting for inflation. The provider's allowable cost shall be multiplied by the change in the consumer price index measured from the midpoint of the provider's cost report period to the midpoint of the provider's rate period. This allowance is applied to all costs, including case-mix adjusted direct health-care services costs as defined in section 25.5-6-201 (9), less interest, up to the reasonable cost established and will be allowed to proprietary, nonprofit, and tax-supported homes; except that the allowance shall not be applied to the costs of state-operated intermediate facilities for individuals with intellectual disabilities.

(b) (I) The state board shall adopt rules to:

(A) Determine and pay to privately owned intermediate care facilities for individuals with intellectual disabilities a reasonable share of the amount by which the reasonable costs of the categories of administration, property, and room and board, excluding food costs, exceed the actual cost in these categories only. The reasonable share shall be defined as twenty-five percent of the amount in the categories for each facility, not to exceed twelve percent of the reasonable cost.

(B) (Deleted by amendment, L. 2008, p. 1783, § 5, effective July 1, 2008.)

(II) (Deleted by amendment, L. 2008, p. 1783, § 5, effective July 1, 2008.)

(c) to (e) (Deleted by amendment, L. 2008, p. 1783, § 5, effective July 1, 2008.)

(3) to (5) (Deleted by amendment, L. 2008, p. 1783, § 5, effective July 1, 2008.)

(6) and (7) Repealed.
C.R.S. § 25.5-6-104 — CO Code / Title 25.5 / Article 6 / Part 1 / Section 25.5-6-104
25.5-6-104. Long-term care placements - comprehensive and uniform client assessment instrume
Status: repealed

25.5-6-104. Long-term care placements - comprehensive and uniform client assessment instrument - report - legislative declaration - definitions - repeal. (Repealed)
C.R.S. § 25.5-10-202 — CO Code / Title 25.5 / Article 10 / Part 2 / Section 25.5-10-202
25.5-10-202. Definitions
Status: repealed

25.5-10-202. Definitions. As used in this article 10, unless the context otherwise requires:

(1) "Abuse" means any of the following acts or omissions committed against a person with an intellectual and developmental disability:

(a) The nonaccidental infliction of physical pain or injury, as demonstrated by, but not limited to, substantial or multiple skin bruising, bleeding, malnutrition, dehydration, burns, bone fractures, poisoning, subdural hematoma, soft tissue swelling, or suffocation;

(b) Confinement or restraint that is unreasonable under generally accepted caretaking standards; or

(c) Unlawful sexual behavior as defined in section 16-22-102 (9).

(1.3) "Authorized representative" means a person designated by the person receiving services, or by the parent or guardian of the person receiving services, if appropriate, to assist the person receiving services in acquiring or utilizing services or supports pursuant to this article. The extent of the authorized representative's involvement shall be determined upon designation.

(1.6) "Caretaker" means a person who:

(a) Is responsible for the care of a person with an intellectual and developmental disability as a result of a family or legal relationship;

(b) Has assumed responsibility for the care of a person with an intellectual and developmental disability; or

(c) Is paid to provide care, services, or oversight of services to a person with an intellectual and developmental disability.

(1.8) (a) "Caretaker neglect" means neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision, or other treatment necessary for the health and safety of a person with an intellectual and developmental disability is not secured for a person with an intellectual and developmental disability or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence, or intimidation to create a hostile or fearful environment for an at-risk adult with an intellectual and developmental disability.

(b) Notwithstanding the provisions of paragraph (a) of this subsection (1.8), the withholding, withdrawing, or refusing of any medication, any medical procedure or device, or any treatment, including but not limited to resuscitation, cardiac pacing, mechanical ventilation, dialysis, artificial nutrition and hydration, any medication or medical procedure or device, in accordance with any valid medical directive or order, or as described in a palliative plan of care, shall not be deemed caretaker neglect.

(c) As used in this subsection (1.8), "medical directive or order" includes a medical durable power of attorney, a declaration as to medical treatment executed pursuant to section 15-18-104, C.R.S., a medical order for scope of treatment form executed pursuant to article 18.7 of title 15, C.R.S., and a CPR directive executed pursuant to article 18.6 of title 15, C.R.S.

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

(2) "Case management services" has the same meaning as set forth in section 25.5-6-1702 (3).

(3) "Case manager" has the same meaning as set forth in section 25.5-6-1702 (4).

(4) Repealed.

(5) "Community residential home" means a group living situation accommodating at least four but no more than eight persons, which is licensed by the state and in which services and supports are provided to persons with intellectual and developmental disabilities.

(5.5) "Competitive integrated employment" has the same meaning as set forth in section 8-84-301, C.R.S.

(5.7) "Conflict-free case management" has the same meaning as set forth in section 25.5-6-1702 (6).

(6) "Consent" means an informed assent that is expressed in writing and freely given. Consent shall always be preceded by the following:

(a) A fair explanation of the procedures to be followed, including an identification of procedures that are experimental;

(b) A description of the attendant discomforts and risks;

(c) A description of the expected benefits;

(d) A disclosure of appropriate alternative procedures together with an explanation of the respective benefits, discomforts, and risks;

(e) An offer to answer any inquiries concerning procedures;

(f) An instruction that the person giving consent is free to withdraw consent and to discontinue participation in the project or activity at any time; and

(g) A statement that withholding or withdrawal of consent shall not prejudice future provision of appropriate services and supports to persons.

(7) "Contribution" means the benefits gained by the household or community in which a person lives as the result of the person engaging in meaningful activities, including but not limited to income-producing work, volunteer work, continuing education, and participation in community activities.

(8) "Court" means a district court of the state of Colorado or the probate court in the appropriate jurisdiction.

(9) "Defined service area" has the same meaning as set forth in section 25.5-6-1702 (7).

(10) "Developmental disabilities professional" has the same meaning as "intellectual and developmental disabilities professional" as set forth in subsection (25) of this section.

(11) (a) "Developmental disability" has the same meaning as "intellectual and developmental disability" as set forth in paragraph (a) of subsection (26) of this section.

(b) "Person with a developmental disability" or "individual with a developmental disability" has the same meaning as "person with an intellectual and developmental disability" as set forth in paragraph (b) of subsection (26) of this section.

(c) "Child with a developmental delay" has the same meaning as set forth in paragraph (c) of subsection (26) of this section.

(12) "Division" means the division of intellectual and developmental disabilities, created in this part 2.

(13) "Early intervention services and supports" has the same meaning as set forth in section 27-10.5-102, C.R.S.

(13.5) "Eligible for home- and community-based services" means a "person with an intellectual and developmental disability", as defined in section 25.5-6-403, who meets the definition of an "eligible person", as defined in section 25.5-6-403.

(14) "Eligible for supports and services" refers to any person with an intellectual and developmental disability as determined by a case management agency pursuant to section 25.5-6-1704.

(15) "Enrolled" means that a person with an intellectual and developmental disability who is eligible for supports and services has been authorized, as defined by rules promulgated by the state board, to participate in the program funded pursuant to this section.

(15.3) "Entity" has the same meaning as set forth in section 25.5-6-1702 (8).

(15.5) "Exploitation" means an act or omission that:

(a) Uses deception, harassment, intimidation, or undue influence to permanently or temporarily deprive a person with an intellectual and developmental disability of the use, benefit, or possession of any thing of value;

(b) Employs the services of a third party for the profit or advantage of the person or another person to the detriment of the person with an intellectual and developmental disability;

(c) Forces, compels, coerces, or entices a person with an intellectual and developmental disability to perform services for the profit or advantage of the person or another person against the will of the person with an intellectual and developmental disability; or

(d) Misuses the property of a person with an intellectual and developmental disability in a manner that adversely affects the person with an intellectual and developmental disability's ability to receive health care or health-care benefits or to pay bills for basic needs or obligations.

(16) (a) "Family" means the interdependent group of persons that consists of:

(I) A parent, child, sibling, grandparent, aunt, uncle, spouse, or any combination thereof and a family member with an intellectual and developmental disability;

(II) An adoptive parent of and a family member with an intellectual and developmental disability;

(III) One or more persons to whom legal custody of a person with an intellectual and developmental disability has been given by a court and in whose home such person resides; or

(IV) Any other family unit as may be defined in rules developed pursuant to section 25.5-10-306.

(b) State board rules must define the families that are eligible to receive services and supports pursuant to this article, and rules of the state board of human services must define the families that are eligible to receive services and supports pursuant to article 10.5 of title 27, C.R.S.

(17) "Family caregiver" means a family member of the person with an intellectual and developmental disability who provides care to the person with an intellectual and developmental disability in the family home, who meets the requirements for a qualified family caregiver, as established by rule of the state board, and who is working through a program-approved service agency, as established by rule of the state board.

(18) "Gastrostomy tube" means a tube that has been surgically inserted into the stomach through the abdominal wall, or a tube that has been inserted through the nasal passage into the stomach, or both.

(18.5) "Harmful act" means an act committed against a person with an intellectual and developmental disability by a person with a relationship to the person with an intellectual and developmental disability when such act is not defined as abuse, caretaker neglect, or exploitation but causes harm to the health, safety, or welfare of a person with an intellectual and developmental disability.

(19) "Human rights committee" means a third-party mechanism to adequately safeguard the legal rights of persons receiving services by participating in the granting of informed consent, monitoring the suspension of rights of persons receiving services, monitoring behavioral development programs in which persons with intellectual and developmental disabilities are involved, monitoring the use of psychotropic medication by persons with intellectual and developmental disabilities, and reviewing investigations of allegations of mistreatment of persons with intellectual and developmental disabilities who are receiving services or supports under this article.

(20) "IDEA" has the same meaning as set forth in section 27-10.5-102, C.R.S.

(21) "Inclusion" means:

(a) The use by persons with intellectual and developmental disabilities of the same community resources that are used by and available to other persons;

(b) The participation by persons with intellectual and developmental disabilities in the same community activities in which persons without intellectual and developmental disabilities participate. Participation includes regular contact with persons without intellectual and developmental disabilities.

(c) Vocational experiences for persons with intellectual and developmental disabilities in community settings that offer opportunities to associate with other persons who do not have intellectual and developmental disabilities; and

(d) Living in homes that are in residential neighborhoods and in proximity to community resources.

(22) "Independent residential support services" means a community living situation, defined by rule of the state board, in which services and supports are provided to no more than three persons with intellectual and developmental disabilities and for which a state license is not required.

(23) "Individualized family service plan" or "IFSP" has the same meaning as set forth in section 27-10.5-102, C.R.S.

(24) (a) "Individualized plan" means a written plan designed by an interdisciplinary team for the purpose of identifying:

(I) The needs and preferences of the person or family receiving services;

(II) The specific services and supports appropriate to meet those needs and preferences;

(III) The projected date for initiation of services and supports; and

(IV) The anticipated results to be achieved by receiving the services and supports.

(b) Every individualized plan must include a statement of agreement with the plan, signed by the person receiving services or other such person legally authorized to sign on behalf of the person and by a representative of the case management agency.

(c) Any other service or support plan designated by the state department that meets all of the requirements of an individualized plan is considered to be an individualized plan pursuant to this article.

(d) (I) Every individualized plan that includes the provision of respite care for medical purposes, pursuant to section 25.5-10-205, shall include a process by which the person receiving services and supports may receive necessary care if the person's family or caregiver is unavailable due to an emergency situation or unforeseen circumstances. The family or caregiver must be duly informed by the interdisciplinary team of these alternative care provisions at the time the individualized plan is initiated.

(II) Nothing in this paragraph (d) requires the provision of respite care. However, any individual plan that includes the provision of respite care for medical purposes must contain a contingency plan.

(25) "Intellectual and developmental disabilities professional" means a person who has professional training and experience in the intellectual and developmental disabilities field, as defined by rule of the state board.

(26) (a) "Intellectual and developmental disability" means a disability that manifests before the person reaches twenty-two years of age, that constitutes a substantial disability to the affected person, and that is attributable to an intellectual and developmental disability or related conditions, including Prader-Willi syndrome, cerebral palsy, epilepsy, autism, or other neurological conditions when the condition or conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of a person with an intellectual and developmental disability. Unless otherwise specifically stated, the federal definition of "developmental disability" found in 42 U.S.C. sec. 15002 (8) does not apply.

(b) "Person with an intellectual and developmental disability" means a person determined by a case management agency to have an intellectual and developmental disability and includes a child with a developmental delay.

(c) "Child with a developmental delay" means:

(I) A person less than five years of age with delayed development as defined by rule of the state board; or

(II) A person less than five years of age who is at risk of having an intellectual and developmental disability as defined by rule of the state board.

(27) "Interdependence" means those multiple interactive relationships that are necessary to create a sense of belonging and support between and among people that are mutually sought, sustained over time, and beneficial to those involved.

(28) "Interdisciplinary team" means a group of people convened by a designated case management agency that includes the person receiving services; the parents or guardian of a minor; a guardian or an authorized representative, as appropriate; the person who coordinates the provisions of long-term services and supports; and others chosen by the person receiving services, who are assembled to work in a cooperative manner to develop or review the individualized plan.

(29) "Least restrictive environment" means an environment that represents the least departure from the typical patterns of living and that effectively meets the needs and preferences of the person receiving services. "Least restrictive environment" may include, but need not be limited to, receiving services from a service agency, a case management agency, or a family caregiver in the family home.

(29.5) "Mistreated" or "mistreatment" means:

(a) Abuse;

(b) Caretaker neglect;

(c) Exploitation; or

(d) A harmful act.

(e) Repealed.

(30) "Office" means the office of community living created in part 1 of this article.

(31) "Person receiving services" means a person with an intellectual and developmental disability who is enrolled in a program funded pursuant to this article.

(32) "Program" means a specific group of services or supports as defined by rules promulgated by the state board and for which funding is available pursuant to this article to a person with an intellectual and developmental disability who is eligible for supports and services.

(33) "Regional center" has the same meaning as set forth in section 27-10.5-102, C.R.S.

(34) "Service agency" means a person or any publicly or privately operated program, organization, or business providing services or supports for persons with intellectual and developmental disabilities.

(35) "Service and support coordination" means planning, locating, facilitating access to, coordinating, and reviewing all aspects of needed services, supports, and resources that are provided in cooperation with the person receiving services, the person's family, as appropriate, the family of a child with a developmental delay, and the involved public or private agencies. Planning includes the development or review of an existing individualized plan. "Service and support coordination" also includes the reassessment of the needs and preferences of the person receiving services or the needs of the family of the person, with maximum participation of the person receiving services and the person's parents, guardian, or authorized representative, as appropriate.

(36) "Services and supports" or "supports and services" means one or more of the following: Education, training, independent or supported living assistance, therapies, identification of natural supports, and other activities provided:

(a) To enable persons with intellectual and developmental disabilities to make responsible choices, exert greater control over their lives, experience presence and inclusion in their communities, develop their competencies and talents, maintain relationships, foster a sense of belonging, and experience personal security and self-respect;

(b) To enhance child development and healthy parent-child and family interaction for eligible persons and their families; and

(c) To enable families, who choose or desire to maintain a family member with an intellectual and developmental disability at home, to obtain support and to enjoy a typical lifestyle.

(37) "Sterilization" means any surgical or other medical procedure that has as its primary purpose to render a person permanently incapable of reproduction.

(37.5) "Undue influence" means the use of influence to take advantage of a person with an intellectual and developmental disability's vulnerable state of mind, neediness, pain, or emotional distress.

(38) "Waiting list" means the list of persons with intellectual and developmental disabilities who are waiting for enrollment into a program provided pursuant to this article.