CO Code § 25.5-4-401 (2021)
2021 Colorado Code|Title 25.5 - Health Care Policy and Financing|Article 4 - Colorado Medical Assistance Act - General Medical Assistance|Part 4 - Providers - Reimbursement|§ 25.5-4-401. Providers - Payments - Rules

     The state department shall establish rules for the payment of providers under this article and articles 5 and 6 of this title. Within the limits of available funds, such rules shall provide reasonable compensation to such providers, but no provider shall, by this section or any other provision of this article or article 5 or 6 of this title, be deemed to have any vested right to act as a provider under this article and articles 5 and 6 of this title or to receive any payment in addition to or different from that which is currently payable on behalf of a recipient at the time the medical benefits are provided by said provider.      On and after July 1, 1992, the state department rules established for the payment of providers under this article and articles 5 and 6 of this title shall provide that services that are compensable under both Title XIX and Title XVIII of the social security act shall be paid at either the rate established under Title XIX or the rate established under Title XVIII, whichever is lower. (b) (I) On and after July 1, 1992, the state department rules established for the payment of providers under this article and articles 5 and 6 of this title shall provide that services that are compensable under both Title XIX and Title XVIII of the social security act shall be paid at either the rate established under Title XIX or the rate established under Title XVIII, whichever is lower.    If any provision of this paragraph (b) is found to be in conflict with any federal law or regulation, such conflicting portion of this paragraph (b) is declared to be inoperative to the extent of the conflict.       The state department shall exercise its overexpenditure authority under section 24-75-109, C.R.S., and shall not intentionally interrupt the normal provider payment schedule unless notified jointly by the director of the office of state planning and budgeting and the state controller that there is the possibility that adequate cash will not be available to make payments to providers and for other state expenses. If it is determined that adequate cash is not available and the state department does interrupt the normal payment cycle, the state department shall notify the joint budget committee of the general assembly and any affected providers in writing of its decision to interrupt the normal payment schedule. Nothing in this paragraph (c) shall be interpreted to establish a right for any provider to be paid during any specific billing cycle.    Repealed.       As to all payments made pursuant to this article and articles 5 and 6 of this title, the state department rules for the payment of providers may include provisions that encourage the highest quality of medical benefits and the provision thereof at the least expense possible.      As used in this subsection (3), “capitated” means a method of payment by which a provider directly delivers or arranges for delivery of medical care benefits for a term established by contract with the state department based on a fixed rate of reimbursement per recipient.      In order to provide medical benefits under this article and articles 5 and 6 of this title on a capitated basis and subject to the condition imposed in subparagraph (II) of this paragraph (b), the state department is authorized to solicit negotiated contracts with providers based upon the requirements of this subsection 3. The state department may contract with one or more providers concerning the same medical services in a single geographic area. (b) (I) In order to provide medical benefits under this article and articles 5 and 6 of this title on a capitated basis and subject to the condition imposed in subparagraph (II) of this paragraph (b), the state department is authorized to solicit negotiated contracts with providers based upon the requirements of this subsection 3. The state department may contract with one or more providers concerning the same medical services in a single geographic area.    The state department may award a contract to one or more providers pursuant to subparagraph (I) of this paragraph (b) when the executive director determines that such contract will reduce the costs of providing medical benefits under this article and articles 5 and 6 of this title.    The state department may define groups of recipients by geographic area or other categories and may require that all members of the defined group obtain medical services through one or more provider contracts entered into pursuant to this subsection 3.            The general assembly hereby finds, determines, and declares that access to health-care services would be improved and costs of health care would be restrained if the recipients of the medicaid program would choose a primary care physician through a managed care provider. For purposes of this subsection (4), “managed care provider” means either a primary care physician program, a health maintenance organization, or a prepaid health plan.    Subject to the provisions of paragraph (c) of this subsection (4), the executive director of the state department has the authority to require a recipient of the medicaid program to select a managed care provider and to assign a recipient to a managed care provider if the recipient has failed to make a selection within a reasonable time. To the extent possible, this requirement shall be implemented on a statewide basis.    The state department shall ensure the following:   A managed care provider shall establish and implement consumer friendly procedures and instructions for disenrollment and shall have adequate staff to explain issues concerning service delivery and disenrollment procedures to recipients, including staff to address the communications needs and requirements of recipients with disabilities.    All recipients shall be adequately informed about service delivery options available to them consistent with the provisions of this subparagraph (II). If a recipient does not respond to a state department request for selection of a delivery option within forty-five calendar days, the state department shall send a second notification to the recipient. If the recipient does not respond within twenty days of the date of the second notification, the state department shall ensure that the recipient remains with the recipient's primary care physician, regardless of whether said primary care physician is enrolled in a health maintenance organization.          The state board may promulgate rules to provide for the implementation and administration of subsections (3) and (4) of this section.    The state department shall make good faith efforts to obtain a waiver or waivers from any requirements of Title XIX of the social security act which would prohibit the implementation of subsections (3) and (4) of this section. Such waiver or waivers shall be obtained from the federal department of health and human services, or any successor agency. If such waivers are not granted, the state department shall not act to implement or administer subsections (3) and (4) of this section to the extent that Title XIX prohibits it.     History. Source: L. 2006: Entire article added with relocations, p. 1841, § 7, effective July 1. L. 2009: (1)(d) added,(SB 09-265), ch. 205, p. 935, § 2, effective May 1. L. 2010: (1)(d) repealed,(HB 10-1382), ch. 217, p. 939, § 1, effective May 6.    Editor's note:   This section is similar to former § 26-4-404 as it existed prior to 2006.   ANNOTATION   Annotator's note. Since § 25.5-4-401 is similar to § 26-4-404 as it existed prior to the 2006 amendments relocating article 4 of title 26 to title 25.5 and § 26-4-404 is similar to § 26-4-110 (1) as it existed prior to the 1991 repeal and reenactment of article 4 of title 26, relevant cases construing those provisions have been included in the annotations to this section.   Where a recipient's chosen provider would no longer exist as an independent primary care physician program and, therefore, the recipient's selection could no longer be honored, Colorado acted reasonably and did not violate subsection (4) when it automatically enrolled thousands of recipients into a health maintenance organization. RX Pharmacies Plus, Inc. v. Weil, 883 F. Supp. 549 (D. Colo. 1995 ).   The medical provider's right to payment is limited to that amount payable by the department of social services when the medical benefit is provided, and the medical provider has no vested right under the Colorado Medical Assistance Act to any greater amount. Colo. Dept. of Soc. Servs. v. Health Care Management Consultants, Inc., 813 P.2d 829 (Colo. App. 1991).