2023 Colorado Revised Statutes › Title 25.5 - HEALTH CARE POLICY AND FINANCING (§§ 25.5-1-101 — 25.5-11-101) › COLORADO MEDICAL ASSISTANCE ACT (§§ 25.5-4-101 — 25.5-6-2001) › Article 4 - COLORADO MEDICAL ASSISTANCE ACT - GENERAL MEDICAL ASSISTANCE (§§ 25.5-4-101 — 25.5-4-506) › Part 4 - PROVIDERS - REIMBURSEMENT (§§ 25.5-4-401 — 25.5-4-433) › Section 25.5-4-401 - [Effective 8/7/2024] Providers - payments - rules

(1)
(a)
The state department shall establish rules for the payment of providers under this article 4 and articles 5 and 6 of this title 25.5. Within the limits of available funds, the rules must provide reasonable compensation to providers, but no provider , by this section or any other provision of this article 4 or article 5 or 6 of this title 25.5, has any vested right to act as a provider under this article 4 and articles 5 and 6 of this title 25.5 or to receive any payment in addition to or different from that which is currently payable on behalf of a Member at the time the medical benefits are provided by the provider.
(b)
(I)
On and after July 1, 1992, the state department rules established for the payment of providers under this article and articles
5
and
6
of this title shall provide that services that are compensable under both Title XIX and Title XVIII of the social security act shall be paid at either the rate established under Title XIX or the rate established under Title XVIII, whichever is lower.
(II)
If any provision of this paragraph (b) is found to be in conflict with any federal law or regulation, such conflicting portion of this paragraph (b) is declared to be inoperative to the extent of the conflict.
(c)
The state department shall exercise its overexpenditure authority under section
24-75-109
, C.R.S., and shall not intentionally interrupt the normal provider payment schedule unless notified jointly by the director of the office of state planning and budgeting and the state controller that there is the possibility that adequate cash will not be available to make payments to providers and for other state expenses. If it is determined that adequate cash is not available and the state department does interrupt the normal payment cycle, the state department shall notify the joint budget committee of the general assembly and any affected providers in writing of its decision to interrupt the normal payment schedule. Nothing in this paragraph (c) shall be interpreted to establish a right for any provider to be paid during any specific billing cycle.
(d)
Repealed.
(2)
As to all payments made pursuant to this article and articles
5
and
6
of this title, the state department rules for the payment of providers may include provisions that encourage the highest quality of medical benefits and the provision thereof at the least expense possible.
(3)
(a)
As used in this subsection (3), "capitated" means a method of payment by which a provider directly delivers or arranges for delivery of medical care benefits for a term established by contract with the state department based on a fixed rate of reimbursement per Member.
(b)
(I)
In order to provide medical benefits under this article and articles
5
and
6
of this title on a capitated basis and subject to the condition imposed in subparagraph (II) of this paragraph (b), the state department is authorized to solicit negotiated contracts with providers based upon the requirements of this subsection (3). The state department may contract with one or more providers concerning the same medical services in a single geographic area.
(II)
The state department may award a contract to one or more providers pursuant to subparagraph (I) of this paragraph (b) when the executive director determines that such contract will reduce the costs of providing medical benefits under this article and articles
5
and
6
of this title.
(III)
The state department may define groups of members by geographic area or other categories and may require that all members of the defined group obtain medical services through one or more provider contracts entered into pursuant to this subsection (3).
(4)
(a)
The general assembly finds, determines, and declares that access to health-care services would be improved and costs of health care would be restrained if the members of the medicaid program would choose a primary care physician through a managed care provider. For purposes of this subsection (4), "managed care provider" means either a primary care physician program, a health maintenance organization, or a prepaid health plan.
(b)
Subject to the provisions of subsection (4)(c) of this section, the executive director of the state department has the authority to require a Member of the medicaid program to select a managed care provider and to assign a Member to a managed care provider if the Member has failed to make a selection within a reasonable time. To the extent possible, this requirement must be implemented on a statewide basis.
(c)
The state department shall ensure the following:
(I)
A managed care provider shall establish and implement member-friendly procedures and instructions for disenrollment and shall have adequate staff to explain issues concerning service delivery and disenrollment procedures to members, including staff to address the communications needs and requirements of members with disabilities.
(II)
All members shall be adequately informed about available service delivery options consistent with the provisions of this subsection (4)(c)(II). If a Member does not respond to a state department request for selection of a delivery option after forty-five calendar days, the state department shall send a second notification to the Member. If the Member does not respond after twenty days of the date of the second notification, the state department shall ensure that the Member remains with the member's primary care physician, regardless of whether the primary care physician is enrolled in a health maintenance organization.
(5)
The state board may promulgate rules to provide for the implementation and administration of subsections (3) and (4) of this section.
(6)
The state department shall make good faith efforts to obtain a waiver or waivers from any requirements of Title XIX of the social security act which would prohibit the implementation of subsections (3) and (4) of this section. Such waiver or waivers shall be obtained from the federal department of health and human services, or any successor agency. If such waivers are not granted, the state department shall not act to implement or administer subsections (3) and (4) of this section to the extent that Title XIX prohibits it.
Amended by 2024 Ch. 152,§ 33, eff. 8/7/2024.
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
.
This section is similar to former § 26-4-404 as it existed prior to 2006.
2024 Ch. 152, was passed without a safety clause. See Colo. Const. art. V, § 1(3).
This section is set out more than once due to postponed, multiple, or conflicting amendments.