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 5 - COLORADO MEDICAL ASSISTANCE ACT - SERVICES AND PROGRAMS (§§ 25.5-5-101 — 25.5-5-804) › Part 4 - STATEWIDE MANAGED CARE SYSTEM (§§ 25.5-5-401 — 25.5-5-427) › Section 25.5-5-406.1 - [Effective 8/7/2024] Required features of statewide managed care system

(1)
General features.
All medicaid managed care programs must contain the following general features, in addition to others that the federal government, state department, and state board consider necessary for the effective and cost-efficient operation of those programs:
(a)
The MCE shall accept all enrollees that the state department assigns to the MCE in the order in which they are assigned, without restriction, regardless of health status or need for health-care services;
(b)
The MCE shall not discriminate against enrolled members on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity, gender expression, disability, religion, creed, or political beliefs, and shall not use any policy or practice that has the effect of discriminating on the basis of race, color, ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity, gender expression, disability, religion, creed, or political beliefs;
(c)
The MCE shall allow each enrolled member to choose his or her network provider to the extent possible and appropriate;
(d)
Notwithstanding any waivers authorized by the federal department of health and human services, or any successor agency, each contract between the state department and an MCE selected to participate in the statewide managed care system under this part 4 shall comply with the requirements of
42 U.S.C. sec. 1396a (a)(23)(B)
;
(e)
The MCE shall ensure access to care for all enrolled members in need of medically necessary services covered in the contract;
(f)
The MCE shall create, administer, and maintain a network of providers, building on the current network of medicaid providers, to serve the health-care needs of its members. In doing so, the MCE shall:
(I)
Support providers in serving the medicaid population and implement value-based payment methodologies for network providers that incentivize and reward providers for the effective and efficient delivery of high-quality services to enrolled members;
(II)
(A)
Seek proposals from each ECP in a county in which the MCE is enrolling members for those services that the MCE provides or intends to provide and that an ECP provides or is capable of providing. The MCE shall consider such proposals in good faith and shall, when deemed reasonable by the MCE based on the needs of its members, contract with ECPs. Each ECP shall be willing to negotiate on reasonably equitable terms with each MCE. ECPs making proposals under this subsection (1)(f)(II) must be able to meet the contractual requirements of the MCE. The requirements of this subsection (1)(f)(II) do not apply to an MCE in areas in which the MCE operates entirely as a group health maintenance organization.
(B)
In selecting MCEs, the state department shall not penalize an MCE for paying cost-based reimbursement to federally qualified health centers as defined in the federal "Social Security Act".
(III)
Demonstrate that there are sufficient Indian health-care providers participating in the provider network to ensure timely access to services available under the contract from such providers for Indian enrollees who are eligible to receive services.
(IV)
Enter into single case agreements with willing providers of behavioral health services enrolled in the medical assistance program when network development and access standards established by the state department are not met and a member needs access to a medically necessary behavioral health service covered under the scope of the MCE's contract with the state department. The MCE:
(A)
Shall consider any behavioral health provider enrolled in the medical assistance program for a single case agreement if the MCE cannot provide a covered service through its contracted provider network;
(B)
Shall ensure all care coordination staff and staff who provide member and provider support are trained in the single case agreement process;
(C)
Can refuse to offer single case agreements based on factors of provider cost and quality concerns;
(D)
Shall offer both member and out-of-network providers assistance in navigating its single case agreement process;
(E)
Shall ensure the single case agreement process is executed within the standards and timeliness requirements established by the state department;
(F)
Shall not require providers that enter into a single case agreement to serve additional members; and
(G)
Shall complete single case agreements on a timeline that is informed by stakeholder input.
(g)
The MCE shall ensure that its contracted network providers are capable of serving all members, including contracting with providers with specialized training and expertise across all ages, levels of ability, gender identities, and cultural identities;
(h)
The MCE shall meet the network adequacy standards, as established by the state department, describing the maximum time and distance an enrolled member is expected to travel in order to access the provider types covered under the state contract;
(i)
The MCE shall meet, and require its network providers to meet, standards as established by the state department for timely access to care and services, taking into account the urgency of the need for services;
(j)
(I)
The MCE shall not interfere with appropriate medical care decisions rendered by its contracted network providers;
(II)
A prepaid inpatient health plan shall not require prior authorization for outpatient psychotherapy services, as defined in the most recent version of the "Current Procedural Terminology", as developed and copyrighted by the American Medical Association or its successor entity;
(k)
The MCE shall comply with the state department's transition of care policy to ensure continued access to services during a transition from fee-for-service to an MCE or transition from one MCE to another when an enrollee, in the absence of continued access to services, would suffer serious detriment to his or her health or be at risk of hospitalization or institutionalization;
(l)
The MCE shall provide and facilitate the delivery of services in a culturally competent manner to all members, including those with limited English proficiency, diverse cultural and ethnic backgrounds, and disabilities, and regardless of gender, sexual orientation, gender identity, or gender expression;
(m)
The MCE shall provide communications in a manner and format that may be easily understood and is readily accessible by members;
(n)
Grievances and appeals.
(I)
(A)
Each MCE shall establish a grievance and appeal system that complies with rules established by the state board and federal government.
(B)
An enrollee is entitled to designate a representative, including but not limited to an attorney, the ombudsman for medicaid managed care, a lay advocate, or the enrollee's physician, to file and pursue a grievance or appeal on behalf of the enrollee. The procedure must allow for the unencumbered participation of physicians.
(II)
The MCE shall have an established grievance system that allows for Member expression of dissatisfaction at any time about any matter related to the MCE's contracted services, other than an adverse benefit determination. The grievance system must provide timely resolution of the matters in a manner consistent with the medical needs of the individual Member.
(III)
(A)
The MCE shall have an appeal system for review of any determination by the MCE to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested.
(B)
Each MCE shall utilize an appeal process for expedited reviews that complies with rules established by the state board. The appeal process for expedited reviews must provide a means by which an enrollee may complain and seek resolution concerning any action or failure to act in an emergency situation that immediately impacts the enrollee's access to quality health-care services, treatments, or providers.
(C)
The state department shall establish the position of ombudsman for medicaid managed care. The ombudsman shall, if the enrollee requests, act as the enrollee's representative in resolving appeals with the MCE. It is the intent of the general assembly that the ombudsman for medicaid managed care be independent from the state department and selected through a competitive bidding process. In the event the state department is unable to contract with an independent ombudsman, an employee of the state department may serve as the ombudsman for medicaid managed care. An enrollee whose appeal is not resolved to his or her satisfaction by a procedure described in this subsection (1)(n), or whose appeal is deemed exhausted, is entitled to request a state fair hearing by an independent hearing officer, further judicial review, or both, as provided for by federal law and any state statute or rule.
(o)
The MCE shall maintain and participate in an ongoing comprehensive quality assessment and performance improvement program that must include but not be limited to the following:
(I)
Performance improvement projects designed to achieve significant improvement, sustained over time, in clinical care and nonclinical care areas that are expected to have a favorable effect on health outcomes and member satisfaction;
(II)
The collection and submission of performance measurement data as required by the state department;
(III)
The implementation and maintenance of mechanisms to detect overutilization and underutilization of services and to assess the quality and appropriateness of care furnished to its members, including members with special health-care needs; and
(IV)
Annual participation in an independent quality review and validation of performance improvement projects, performance measures, and other contract requirements;
(p)
(I)
The MCE shall administer a program integrity system to ensure compliance with all requirements established by the federal government, state of Colorado, state department, and state board that includes, but is not limited to:
(A)
Procedures to detect and prevent fraud, waste, and abuse;
(B)
Screening and disclosure processes to prevent relationships with individuals or entities that are debarred, suspended, or otherwise excluded from participating in any federal health-care program, procurement activities, or nonprocurement activities; and
(C)
Treatment of recoveries of overpayment to providers;
(II)
Prepaid inpatient health plans shall not retroactively recover provider payments if:
(A)
A Member was initially determined to be eligible for medical benefits pursuant to section
25.5-4-205
when the provider has an eligibility guarantee number for the Member; or
(B)
The prepaid inpatient health plan makes an error processing the claim but the claim is otherwise accurately submitted by the provider.
(III)
(A)
Prepaid inpatient health plans shall not retroactively recover provider payments after twelve months from the date a claim was paid, except when medicare, commercial insurance, or third-party liability is the primary payer for a claim; the claim is the subject of a state or federal audit, including audits contractually required by the state department; the claim is subject to a law enforcement investigation; the claim submitted is a duplicate; the claim is fraudulent; the provider improperly bills the claim; or the claim is submitted with a billing code or diagnosis code that inaccurately or incorrectly resulted in reimbursement or bypassed prior authorization requirements.
(B)
If a prepaid inpatient health plan retroactively recovers a provider payment that is equal to one thousand dollars or more, the prepaid inpatient health plan shall work with the provider to develop a payment plan if the provider requests a payment plan.
(q)
Billing medicaid members.
Notwithstanding any federal regulations or the general prohibition of section
25.5-4-301
against providers billing medicaid members, a provider may bill a medicaid Member who is enrolled with a specific medicaid PCCM or MCE and, in circumstances defined by the rules of the state board, receives care from a medical provider outside that organization's network or without referral by the member's PCCM;
(r)
Marketing.
In marketing coverage to medicaid members, all MCEs shall comply with all applicable provisions of title 10 regarding health plan marketing. The state board is authorized to promulgate rules concerning the permissible marketing of medicaid managed care. The purposes of the rules must include but not be limited to the avoidance of biased selection among the choices available to medicaid members.
(s)
Prescription drugs.
All MCEs that have prescription drugs as a covered benefit shall provide prescription drug coverage in accordance with the provisions of section
25.5-5-202 (1)(a)
as part of a comprehensive health benefit and with respect to any formulary or other access restrictions:
(I)
The MCE shall supply participating providers who may prescribe prescription drugs for MCE enrollees with a current copy of such formulary or other access restrictions, including information about coverage, payment, or any requirement for prior authorization;
(II)
The MCE shall provide to all medicaid members at periodic intervals, and prior to and during enrollment upon request, clear and concise information about the prescription drug program in language understandable to the medicaid members, including information about such formulary or other access restrictions and procedures for gaining access to prescription drugs, including off-formulary products; and
(III)
The MCE shall follow state department policies for prescribing any prescription drugs that are not covered under the MCE contract;
(t)
Each MCE must include the following statements prominently in the enrollee handbook, on the state department's website, and on the MCE's enrollment website:
(I)
A statement indicating that the MCE is subject to the MHPAEA and that a denial, restriction, or withholding of benefits for behavioral health services that are covered under the medical assistance program could be a potential violation of that act; and
(II)
A statement directing the enrollee to contact the office of the ombudsman for behavioral health access to care established pursuant to part 3 of article
80
of title
27
if the enrollee wants further assistance pursuing action regarding potential parity violations, which statement must include the telephone number for the office and a link to the office's website.
Amended by 2024 Ch. 152,§ 58, eff. 8/7/2024.
Amended by 2023 Ch. 429,§ 1, eff. 8/7/2023.
Amended by 2022 Ch. 153, § 1, eff. 1/1/2023.
Amended by 2021 Ch. 156, § 40, eff. 9/7/2021.
Amended by 2019 Ch. 390, § 38, eff. 8/2/2019.
Amended by 2019 Ch. 195, § 14, eff. 5/16/2019.
Added by 2018 Ch. 313, § 3, eff. 8/8/2018.
L. 2018: Entire section added with relocations, (HB 18-1431), ch. 1882, p. 1882, § 3, effective August 8. L. 2019: (1)(t) added, (HB 19-1269), ch. 2134, p. 2134, § 14, effective May 16; (1)(o)(IV) amended, (SB 19-241), ch. 3473, p. 3473, § 38, effective August 2. L. 2021: (1)(b) and (1)(l) amended, (HB 21-1108), ch. 896, p. 896, § 40, effective September 7.
Provisions of this section are similar to provisions of former §§ 25.5-5-404, 25.5-5-405, and 25.5-5-406, as they existed prior to 2018.
2024 Ch. 152, was passed without a safety clause. See Colo. Const. art. V, § 1(3).
2023 Ch. 429, 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.
(1) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019. (2) For the legislative declaration in HB 21-1108, see section 1 of chapter 156, Session Laws of Colorado 2021.