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 25.5-4-401.5 - [Effective 8/7/2024] Review of provider rates - advisory committee - recommendations - repeal

(1)
(a)
On or before September 1, 2023, the state department shall establish a schedule for an annual review of provider rates paid under the "Colorado Medical Assistance Act" so that each provider rate is reviewed at least every three years and shall provide the schedule to the advisory committee established pursuant to subsection (3) of this section and the joint budget committee. If the state department receives any petitions or proposals for provider rates to be reviewed or adjusted, the state department shall forward a copy of the petition or proposal to the advisory committee and the joint budget committee.
(b)
The state department shall review each of the provider rates scheduled for review pursuant to the process described in this section. The advisory committee or the joint budget committee may, by a majority vote, direct that the state department conduct a review of a provider rate that is not scheduled for review during that year. The advisory committee or the joint budget committee shall notify the state department of the request for an out-of-cycle review by December 1 of the year prior to the year in which the out-of-cycle review will take place. If the state department determines that the request for an out-of-cycle review cannot be conducted, the state department shall provide written notification to the advisory committee and the joint budget committee within thirty days after the request for an out-of-cycle review. The notification must include a description of the reasons the out-of-cycle review cannot be conducted.
(c)
(I)
The state department may propose to exclude rates from the schedule established pursuant to subsection (1)(a) of this section if those rates are adjusted on a periodic basis as a result of other state statute or federal law or regulation. The state department shall include the proposed list of exclusions with the schedule established pursuant to subsection (1)(a) of this section.
(II)
The advisory committee or the joint budget committee may, by a majority vote, direct the state department to include any rate that the state department has proposed to exclude from the schedule.
(2)
(a)
In the first phase of the review process, the state department shall conduct an analysis of the access, service, quality, and utilization of each service subject to a provider rate review. The state department shall compare the rates paid with available benchmarks, including medicare rates and usual and customary rates paid by private pay parties, and use qualitative tools to assess whether payments are sufficient to allow for provider retention and medicaid member access and to support appropriate reimbursement of high-value services.
(b)
Following the analysis required by subsection (2)(a) of this section, the state department shall work with the advisory committee and any stakeholders identified by the state department or the advisory committee to review the analysis and develop strategies for responding to the findings, including any nonfiscal approaches or rebalancing of rates and strategies to address capacity issues that may exist in certain regions of the state.
(c)
Following the review required by subsection (2)(b) of this section, the state department shall work with the office of state planning and budgeting to determine achievable goals and executive branch priorities within the statewide budget.
(d)
(I)
Notwithstanding section
24-1-136 (11)(a)(I)
, on or before November 1, 2023, and each November 1 thereafter, the state department shall submit a written report to the joint budget committee and the advisory committee on the analysis required pursuant to subsection (2)(a) of this section, a description of the information discussed during the quarterly public meeting conducted pursuant to subsection (2)(e) of this section, and the state department's recommendations on all of the provider rates reviewed pursuant to this section and all of the data relied upon by the state department in making the recommendations. The joint budget committee shall consider the recommendations in formulating the state department's budget.
(II)
The state department shall submit, as part of the report required pursuant to this subsection (2)(d), a description of the information discussed during the quarterly public meeting; the state department's response to the public comments received from providers, members, and other interested parties; and an explanation of how the public comments informed the provider rate review process and the recommendations concerning provider rates.
(e)
The state department shall conduct a public meeting at least quarterly to inform the state department's review of provider rates paid under the "Colorado Medical Assistance Act". The state department shall invite to the public meeting providers, members, and other interested parties directly affected by the services scheduled to be reviewed at the public meeting. At a minimum, each public meeting must consist of, but is not limited to:
(I)
A discussion of the analysis and review performed pursuant to subsection (2)(a) of this section; and
(II)
Public comments from providers, members, and other interested parties concerning:
(A)
The analysis and review performed pursuant to subsection (2)(a) of this section; and
(B)
Recommended changes to the provider rate review process that may enhance or improve the process.
(3)
(a)
There is created in the state department the medicaid provider rate review advisory committee, referred to in this section as the "advisory committee", to assist the state department in the review of the provider rate reimbursements under the "Colorado Medical Assistance Act". The advisory committee shall:
(I)
Review the schedule for annual review of provider rates established by the state department pursuant to subsection (1)(a) of this section and recommend any changes to the schedule;
(II)
Review the analysis performed pursuant to subsection (2)(a) of this section and the reports prepared by the state department on its analysis of provider rates pursuant to subsection (2)(d) of this section and provide comments and feedback to the state department and the joint budget committee on the reports;
(III)
Review the comments received from providers, members, and other interested parties and the state department's response to the comments required pursuant to subsection (2)(d)(II) of this section;
(IV)
Review proposals or petitions received by the advisory committee for provider rates to be reviewed or adjusted;
(V)
Determine whether any provider rates not scheduled for review during the next calendar year should be reviewed during that calendar year;
(VI)
Recommend to the state department and to the joint budget committee any changes to the process of reviewing provider rates, including measures to increase access to the process, such as by providing for electronic comments by providers and the public; and
(VII)
Provide other assistance to the state department and the joint budget committee as requested by the state department or the joint budget committee.
(b)
(I)
The advisory committee consists of the following seven members:
(A)
Three members appointed by the governor;
(B)
Two members appointed by the president of the senate, or the president's designee; and
(C)
Two members appointed by the speaker of the house of representatives, or the speaker's designee.
(II)
Each member appointed to the advisory committee must have proven expertise related to the medical assistance program in one or more of the following areas:
(A)
Service delivery or case management services provided to one or more eligible populations;
(B)
Provider finance or budget;
(C)
Service capacity analysis;
(D)
Business processes;
(E)
Claims filing or processing; or
(F)
Implementation of state and federal medicaid rules, regulations, and guidance.
(III)
The state department may make recommendations to the governor, the president of the senate, and the speaker of the house of representatives concerning the qualifications of members appointed to the advisory committee.
(c)
The appointing authorities shall make initial appointments to the advisory committee no later than January 1, 2023. In making appointments to the advisory committee, the appointing authorities shall make a concerted effort to include members of diverse political, racial, cultural, income, and ability groups and members from urban and rural areas.
(d)
Each member of the advisory committee serves at the pleasure of the official who appointed the member. Each member of the advisory committee serves a four-year term and may be reappointed.
(e)
The members of the advisory committee serve without compensation and without reimbursement for expenses.
(f)
At the first meeting of the advisory committee, to be held on or after March 1, 2023, the members shall elect a chair and vice-chair from among the members.
(g)
The advisory committee shall meet at least once every quarter. The chair may call additional meetings as may be necessary for the advisory committee to complete its duties.
(h)
The advisory committee shall develop bylaws and procedures to govern its operations.
(i)
On or before December 1, 2023, and each December 1 thereafter, the advisory committee shall present to the joint budget committee an overview of the provider rate review process, a summary of the provider rates that were reviewed, and the strategies for responding to the findings of the provider rate review, including any fiscal or nonfiscal approaches or rebalancing of rates, any advisory committee recommendations for rate adjustments made to the state department, and any recommendations for improving capacity and access to services in regions of the state where reduced capacity results in limited access to services.
(j)
(I)
This subsection (3) is repealed, effective September 1, 2034.
(II)
Prior to repeal, the department of regulatory agencies shall conduct a sunset review of the advisory committee pursuant to the provisions of section
2-3-1203
.
Amended by 2024 Ch. 152,§ 34, eff. 8/7/2024.
Amended by 2023 Ch. 74,§ 2, eff. 4/1/2023.
Amended by 2023 Ch. 74,§ 1, eff. 4/1/2023.
Amended by 2022 Ch. 410, § 1, eff. 7/1/2023, except that (2) is effective 5/1/2025 and (3) is effective 12/1/2022.
Amended by 2021 Ch. 83, § 25, eff. 7/1/2024.
Amended by 2017 Ch. 6, § 9, eff. 3/1/2017.
Added by 2015 Ch. 288, § 1, eff. 6/5/2015.
L. 2015: Entire section added, (SB 15-228), ch. 1177, p. 1177, § 1, effective June 5. L. 2017: (2)(a) and (2)(d) amended, (HB 17 -1060), ch. 17, p. 17, § 9, effective March 1. L. 2021: (3)(b)(III)(D) amended, (HB 21 -1187), ch. 332, p. 332, § 25, effective 7/1/2024.
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.