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 3 - RECOVERY (§§ 25.5-4-300.4 — 25.5-4-310) › Section 25.5-4-300.9 - [Effective 8/7/2024] 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 recipients 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.
Amended by 2024 Ch. 152,§ 30, eff. 8/7/2024.
Added by 2016 Ch. 254, § 1, eff. 8/10/2016.
L. 2016: Entire section added, (SB 16-120), ch. 254, p. 1044, § 1, effective August 10.
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.