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 1 - GENERAL PROVISIONS (§§ 25.5-4-101 — 25.5-4-107) › Section 25.5-4-103 - [Effective 8/7/2024] Definitions

As used in this article 4 and articles
5
and
6
of this title 25.5, unless the context otherwise requires:
(1)
Repealed.
(1.5)
"Accountable care collaborative" means a medicaid care delivery system established pursuant to section 25.5-5-419.
(2)
"Applicant" means an individual who is seeking an eligibility determination for himself or herself under this article and articles
5
and
6
of this title through an application submission or a transfer from another agency or insurance affordability program.
(2.5)
"Case management agency" has the same meaning as set forth in section 25.5-6-1702(2).
(3)
"Case management services" means services provided by case management agencies and comprehensive community behavioral health providers, as defined in section 27-50-101, to assist persons in gaining access to needed medical, social, educational, and other services.
(4)
"Categorically needy" means those persons who are eligible for medical assistance under this article and articles
5
and
6
of this title due to their eligibility for one or more of the federal categories of public assistance. A person may be categorically needy and eligible for medical assistance under mandatory provisions as provided under section 25.5-5-101 or may be categorically needy under optional provisions as provided under section 25.5-5-201.
(5)
"Clinic services" means those services as defined in section 25.5-5-301.
(5.5)
"Dementia diseases and related disabilities" has the same meaning set forth in section
25-1-502
(2.5).
(6)
"Essential person" means a person who meets the requirements of section
26-2-103(5)
, C.R.S.
(7)
"Home health services" is synonymous with "home health care" and includes the following services provided to an eligible person through a certified home health agency, pursuant to a home health plan of care:
(a)
Nursing services;
(b)
Home health aide services;
(c)
Provision of medical supplies, equipment, and appliances suitable for use in the home;
(d)
Physical therapy, occupational therapy, or speech and hearing therapy.
(8)
"Hospice care" means services provided by a public agency or private organization, or any subdivision thereof, which entity shall be known as a hospice and shall be primarily engaged in providing care to an individual for whom a certified medical prognosis has been made indicating a life expectancy of six months or less and who has elected to receive such care in lieu of other medical benefits available under this article and articles
5
and
6
of this title.
(9)
"Intermediate nursing facility for persons with intellectual and developmental disabilities" means a tax-supported, state-administered intermediate nursing facility, or a distinct part of such facility, which meets the state nursing home licensing standards set forth in section
25-1.5-103(1)(a)(I)
, C.R.S., and the requirements in
42 U.S.C. sec. 1396d
and which:
(a)
Is maintained primarily to provide health-related care on a regular basis for persons with intellectual and developmental disabilities, as defined in section
27-10.5-102(11)
, C.R.S., and section 25.5-10-202, C.R.S., who do not require the degree of services and supports that a hospital or skilled nursing facility can provide but who, because of their mental or physical condition, require care and services above the level of room and board, which can be made available only through institutional facilities; and
(b)
May provide care which includes but is not limited to moderate assistance or therapy functions; occasional direction, supervision, or therapy; moderate assistance or therapy for loss of mobility; routine, nonskilled nursing services; and monitoring of the drug regimen.
(10)
"Lawfully residing" means an individual who is not a citizen or national of the United States and who was lawfully admitted to the United States by the immigration and naturalization service, or any successor agency, as an actual or prospective permanent resident or whose extended physical presence in the United States is known to and allowed by the immigration and naturalization service, or any successor agency.
(11)
"Liable" or "liability" means the legal liability of a third party, either by reason of judgment, settlement, compromise, or contract, as the result of negligent acts or other wrongful acts or otherwise for all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or Member of medical assistance.
(12)
"Managed care system" means a health-care system organized to manage costs, utilization, and quality. The statewide managed care system provides for the delivery of health benefits and additional services through contracted arrangements between state medicaid agencies and MCEs.
(13)
"Medical assistance" means payment on behalf of members eligible for and enrolled in the state medical assistance program established pursuant to this article 4 and articles 5 and 6 of this title 25.5, which is funded through Title XIX of the federal "Social Security Act",
42 U.S.C. sec. 1396u-1
, to providers enrolled in the state medical assistance program who render or provide medical care, services, goods, and devices to members pursuant to this article 4 and articles 5 and 6 of this title 25.5, and other related payments, pursuant to this article 4 and articles 5 and 6 of this title 25.5 and the rules of the state department.
(13.2)
"Member" means a person who has been determined eligible to receive benefits under this article 4 and articles 5 and 6 of this title 25.5.
(13.5)
"Modified adjusted gross income" or "MAGI" means an amount of income, as determined pursuant to section 1902 (e)(14) of the federal "Social Security Act", that is used to establish eligibility for medical assistance.
(14)
"Nursing facility" means a facility, or a distinct part of a facility, that meets the state nursing home licensing standards in section
25-1.5-103(1)(a)(I)
, is maintained primarily for the care and treatment of inpatients under the direction of a physician, and meets the requirements in
42 U.S.C. sec. 1396r
for certification as a qualified provider of nursing facility services. The patients in such a facility require supportive, therapeutic, or compensating services and the availability of a licensed nurse for observation or treatment on a twenty-four-hour basis. Nursing care may include terminal care; extensive assistance or therapy in the activities of daily living; continual direction, supervision, or therapy; extensive assistance or therapy for loss of mobility; nursing assessment and services that involve assessment of the total needs of the patient, planning of patient care, and observing, monitoring, and recording the patient's response to treatment; and monitoring, observing, and evaluating the drug regimen. "Nursing facility" includes private, nonprofit, or proprietary intermediate nursing facilities for persons with intellectual and developmental disabilities.
(15)
"Overpayment" means the amount paid by an agency administering the medical assistance program to an enrolled provider under the state medical assistance program participating in the program, which amount is in excess of the amount that is allowable for services furnished and which is required by Title XIX of the social security act to be refunded to the appropriate medicaid agencies.
(16)
"Patient personal needs trust fund" means any fund or account established by the nursing care facility or intermediate care facility or its agents, employees, or designees to manage the personal needs funds of the facility's patients.
(17)
"Personal needs funds" means moneys received by any person admitted to a nursing care facility or intermediate care facility, which moneys are received by said person to purchase necessary clothing, incidentals, or other personal needs items which are not reimbursed by any federal or state program, or items of value, which moneys or items of value are in any way surrendered to the management or control of said facility, its agents, employees, or designees.
(18)
"Pilot program", as used in section 25.5-5-319, means the family planning pilot program established in section 25.5-5-319, which is carried out by all medicaid providers who provide family planning services and which shall be repealed, effective July 1 five years after the issuance of the federal waiver or July 1 in the year in which the waiver is terminated, whichever occurs first.
(19)
(a)
"Provider" means any person, public or private institution, agency, or business concern providing medical care, services, or goods authorized under this article and articles
5
and
6
of this title and holding, where applicable, a current valid license or certificate to provide such services or to dispense such goods and enrolled under the state medical assistance program. These services must be provided and goods must be dispensed only if performed, referred, or ordered by a doctor of medicine or a doctor of osteopathy. Services of dentists, podiatrists, and optometrists or services provided by a school district under section 25.5-5-318 need not be referred or ordered by a doctor of medicine or a doctor of osteopathy.
(b)
"Provider" includes a laboratory certified under the federal "Clinical Laboratories Improvement Act of 1967", as amended,
42 U.S.C. sec. 263a
, to perform high complexity testing.
(19.5)
"Psychiatric residential treatment facility" means a facility that is licensed as a residential child care facility, as defined in section 26-6-903, that is not a hospital, and that provides inpatient psychiatric services for individuals who are less than twenty-one years of age under the direction of a physician licensed pursuant to article 240 of title
12
, and that meets any other requirement established in rule by the state board.
(20)
"Qualified alien" shall have the meaning ascribed to that term in section 431 (b) of the federal "Personal Responsibility and Work Opportunity Reconciliation Act of 1996", Public Law 104-193, as amended.
(21)
[Repealed by 2024 Amendment.]
(22)
"Recovery" or "amount recovered" means the amount payable to the applicant or Member or the applicant's or member's heirs, assigns, or legal representatives as the result of any liability of a third party.
(23)
"Rehabilitative services" means any medical or remedial services recommended by a physician which may reduce physical or mental disability and which may improve functional level.
(24)
"Resident" means any individual who is living, other than temporarily, within the state. "Resident" includes any unemancipated child whose parent, or other person entitled to custody, lives within the state. The state board shall adopt rules for making this determination. Temporary absences from the state shall not cause an individual to lose his status as a resident of this state.
(24.5)
"Serious mental illness" means the following psychiatric illnesses, as defined by the American Psychiatric Association in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders:
(a)
Bipolar disorders (hypomanic, manic, depressive, and mixed);
(b)
Depression in childhood and adolescence;
(c)
Major depressive disorders (single episode or recurrent);
(d)
Obsessive-compulsive disorders;
(e)
Paranoid and other psychotic disorders;
(f)
Schizoaffective disorders (bipolar or depressive); and
(g)
Schizophrenia.
(25)
"Social security act" means the federal "Social Security Act" and amendments thereto.
(25.5)
"State university teaching hospital" means a hospital licensed or certified pursuant to section
25-1.5-103(1)(a)
, C.R.S.:
(a)
That provides supervised teaching experiences to graduate medical school interns and residents enrolled in a state institution of higher education as defined in section
23-18-102(10)
, C.R.S.; and
(b)
In which more than fifty percent of its credentialed physicians are members of the faculty at a state institution of higher education as defined in section
23-18-102(10)
, C.R.S.
(25.7)
"Telemedicine" means the delivery of medical and health-care services and any diagnosis, consultation, or treatment using interactive audio, interactive video, or interactive data communication.
(26)
"Third party" means an individual, institution, corporation, or public or private agency that is or may be liable to pay all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or Member of medical assistance.
(27)
"Title XIX" means Title XIX of the social security act, as amended, administered by the federal department of health and human services, or any successor agency, and includes amendments thereto and other federal social security laws replacing said title, in whole or in part.
(28)
"Transitional medicaid" means the medical assistance provided to members eligible pursuant to section
25.5-5-101 (1)(b)
.
Amended by 2024 Ch. 152,§ 18, eff. 8/7/2024.
Amended by 2023 Ch. 394,§ 2, eff. 8/7/2023.
Amended by 2022 Ch. 451, § 53, eff. 8/10/2022.
Amended by 2022 Ch. 399, § 11, eff. 6/7/2022.
Amended by 2022 Ch. 222, § 232, eff. 7/1/2024.
Amended by 2022 Ch. 222, § 66, eff. 7/1/2022.
Amended by 2022 Ch. 123, § 75, eff. 7/1/2022.
Amended by 2021 Ch. 152, § 3, eff. 5/18/2021.
Amended by 2021 Ch. 83, § 23, eff. 7/1/2024.
Amended by 2019 Ch. 136, § 177, eff. 10/1/2019.
Amended by 2018 Ch. 313, § 9, eff. 8/8/2018.
Amended by 2018 Ch. 74, § 2, eff. 8/8/2018.
Amended by 2017 Ch. 321, § 1, eff. 6/5/2017.
Amended by 2017 Ch. 263, § 198, eff. 5/25/2017.
Amended by 2017 Ch. 231, § 1, eff. 5/23/2017.
Amended by 2017 Ch. 50, § 13, eff. 3/16/2017.
Amended by 2016 Ch. 210, § 67, eff. 6/6/2016.
Amended by 2014 Ch. 12, § 1, eff. 2/27/2014.
Amended by 2013 Ch. 323, § 44, eff. 3/1/2014.
L. 2006: (19.5) added, p. 1202, § 1, effective May 26; entire article added with relocations, p. 1815, § 7, effective July 1; (3) amended, p. 1389, § 18, effective August 7. L. 2007: (19.5) amended, p. 2043, § 74, effective June 1. L. 2008: (25.5) added, p. 1184, § 2, effective May 22. L. 2010: (3) amended, (SB 10-175), ch. 800, p. 800, § 65, effective April 29. L. 2011: (10) amended, (HB 11-1303), ch. 1168, p. 1168, § 65, effective August 10. L. 2013: (3), IP(9), and (9)(a) amended, (HB 13-1314), ch. 1808, p. 1808, § 44, effective March 1. L. 2014: (1) repealed, (2) amended, and (13.5) added, (SB 14 -067), ch. 109, p. 109, § 1, effective February 27. L. 2016: (19.5) amended, (SB 16-189), ch. 773, p. 773, § 67, effective June 6. L. 2017: IP(1) and (14) amended, (HB 17 -1046), ch. 159, p. 159, § 13, effective March 16; IP amended and (1.5) added, (HB 17-1353), ch. 895, p. 895, § 1, effective May 23; IP and (3) amended, (SB 17-242), ch. 1327, p. 1327, § 198, effective May 25; IP and IP(7) amended, (SB 17-091), ch. 1731, p. 1731, § 1, effective June 5. L. 2018: (5.5) added, (HB 18-1091), ch. 642, p. 642, § 2, effective August 8; (12) amended, (HB 18-1431), ch. 1892, p. 1892, § 9, effective August 8. L. 2019: (19.5) amended, (HB 19-1172), ch. 1707, p. 1707, § 177, effective October 1. L. 2021: (2.5) added and (3) amended, (HB 21 -1187), ch. 331, p. 331, § 23, effective 7/1/2024; (25.7) added, (HB 21-1190), ch. 875, p. 875, § 3, effective May 18.
(1) This section is similar to former § 26-4-103 as it existed prior to 2006.
(2) Subsection (3) was originally numbered as § 26-4-103(2), and the amendments to it in House Bill 06-1277 were harmonized with subsection (3) as it appeared in Senate Bill 06-219.
(3) Subsection (19.5) was enacted as § 26-4-103 (13.6) in House Bill 06-1395 but was relocated due to its harmonization with this section as it appeared in Senate Bill 06-219.
2024 Ch. 152, was passed without a safety clause. See Colo. Const. art. V, § 1(3).
2023 Ch. 394, 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.
For the legislative declaration in SB 17-242, see section 1 of chapter 263, Session Laws of Colorado 2017.