reglab/statecodes huggingface dataset:
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 25.5-4-300.7 - Prevention of coding errors - prepayment review of claims

(1)
The state department shall implement and maintain a system for reducing medical services coding errors in medicaid claims submitted to the state department for reimbursement. The system shall include automatic, prepayment review of medicaid claims through the use of nationally recognized correct coding methods in the medicaid management information system, in accordance with
42 U.S.C. sec. 1396b (r)
and regulations thereunder, as amended by Pub.L. 111-148, and any other subsequent acts of congress. The state department shall acquire and maintain any information technology necessary to implement the automated, prepayment review of medicaid claims.
(2)
Repealed.
Amended by 2016 Ch. 22, § 2, eff. 8/10/2016.
L. 2010: Entire section added, (SB 10 -167), ch. 296, p. 1379, § 8, effective May 26. L. 2016: (2) repealed, (HB 16-1081), ch. 22, p. 50, § 2, effective August 10.
For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.
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 25.5-4-303 - State income tax refund intercept - garnishment of earning - failure to provide medical support for child

(1)
(a)
At any time prescribed by the department of revenue, but not less frequently than annually, the state department may certify to the department of revenue information regarding any person who:
(I)
Is obligated to the state agency responsible for administering medical assistance in this state for medical support based on medical assistance provided to the obligor's dependent child; and
(II)
Has received payment from a third party to cover the health-care costs of the child but has neither applied such payment to cover the child's health-care costs nor to reimburse the state department, the custodial parent of the child, or the provider of medical care.
(b)
The information provided to the department of revenue shall include the name and the social security number of the person described in paragraph (a) of this subsection (1), the amount of medical assistance provided to the child during the period for which medical support was ordered but not provided as described in subparagraph (II) of paragraph (a) of this subsection (1), and any other identifying information required by the department of revenue.
(2)
Prior to a final certification of the information described in subsection (1) of this section to the department of revenue, the state department shall notify the obligated person, in writing, that the state intends to refer the person's name to the department of revenue in an attempt to offset the person's medical support obligation against the person's state income tax refund. Such notification shall include information on the parent's right to object to the offset.
(3)
Upon notification by the department of revenue of amounts deposited with the state treasurer pursuant to section
39-21-108(3)
, C.R.S., the state department may recover the amount of the medical assistance described in paragraph (b) of subsection (1) of this section.
(4)
The state department may garnish the wages and other earnings of a person described in paragraph (a) of subsection (1) of this section. The garnishment of wages and earning shall be in accordance with articles
54
and
54.5
of title
13
, C.R.S.
(5)
The state board shall adopt rules as are necessary for the implementation of this section.
L. 2006: Entire article added with relocations, p. 1838, § 7, effective July 1.
This section is similar to former § 26-4-403.4 as it existed prior to 2006.
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 25.5-4-303.3 - Provider fraud - attorney general report

(1)
No later than October 1, 2017, and no later than October 1 each year thereafter, the attorney general shall submit a written report to the state department for inclusion in a single, comprehensive report to the general assembly concerning medicaid fraud pursuant to section
25.5-1-115.5
. The attorney general shall provide information relating to medicaid provider fraud including, at a minimum:
(a)
Investigations of provider fraud during the year;
(b)
Criminal complaints requested, cases dismissed, cases acquitted, convictions, and confessions of judgment;
(c)
Recoveries, including fines and penalties, restitution ordered, and restitution collected;
(d)
Civil claims;
(e)
Trends in methods used to commit provider fraud, excluding law enforcement-sensitive information; and
(f)
An estimate of the total savings, total cost, and net cost-effectiveness of fraud detection and recovery efforts.
Amended by 2017 Ch. 298, § 2, eff. 8/9/2017.
L. 2012: Entire section added, (SB 12-060), ch. 166, p. 578, § 2, effective August 8. L. 2017: IP(1), (1)(d), and (1)(e) amended and (1)(f) added, (SB 17-295), ch. 298, p. 1637, § 2, effective August 9.
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 25.5-4-303.5 - Short title

This section and sections
25.5-4-304
to
25.5-4-310
shall be known and may be cited as the "Colorado Medicaid False Claims Act".
L. 2010: Entire section added, (SB 10 -167), ch. 296, p. 1379, § 10, effective May 26.
For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.
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 25.5-4-304 - Definitions

As used in sections
25.5-4-303.5
to
25.5-4-309
, unless the context otherwise requires:
(1)
(a)
"Claim" means a request or demand for money or property, whether under a contract or otherwise, and regardless of whether the state has title to the money or property, under the "Colorado Medical Assistance Act" that is:
(I)
Presented to an officer, employee, or agent of the state; or
(II)
Made to a contractor, grantee, or other recipient if the money or property is to be spent or used on the state's behalf or to advance a program or interest of the state and if the state:
(A)
Provides or has provided any portion of the money or property requested or demanded; or
(B)
Will reimburse the contractor, grantee, or other recipient for any portion of the money or property that is requested or demanded.
(b)
"Claim" does not include a request or demand for money or property that the state has paid to an individual as compensation for employment by the state or as an income subsidy with no restriction on that individual's use of the money or property.
(2)
"Colorado Medical Assistance Act" means this article and articles
5
and
6
of this title.
(3)
(a)
"Knowing" or "knowingly" means that a person, with respect to information:
(I)
Has actual knowledge of the information;
(II)
Acts in deliberate ignorance of the truth or falsity of the information; or
(III)
Acts in reckless disregard of the truth or falsity of the information.
(b)
"Knowing" or "knowingly" does not require proof of specific intent to defraud.
(4)
"Material" means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.
(5)
"Obligation" means a fixed or contingent duty arising from an express or implied contractual, quasi-contractual, grantor-grantee, licensor-licensee, statutory, fee-based, or similar relationship, or the retention of overpayment.
Amended by 2013 Ch. 276, § 3, eff. 8/7/2013.
L. 2006: Entire article added with relocations, p. 1838, § 7, effective July 1. L. 2010: Entire section R&RE, (SB 10 -167), ch. 296, p. 1379, § 11, effective May 26. L. 2013: (5) amended, (SB 13-205), ch. 276, p. 1441, § 3, effective August 7.
This section is similar to former §§ 26-4-1102 and 26-4-1103(3) as they existed prior to 2006.
For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.
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 25.5-4-307 - False medicaid claims procedures - statute of limitations

(1)
A civil action under section
25.5-4-306 (1) or (2)
may not be brought after the later of:
(a)
More than six years after the date on which the violation of section
25.5-4-305
is committed; or
(b)
More than three years after the date when facts material to the right of action are known or reasonably should have been known by the official of the state charged with responsibility to act in the circumstances, but in no event more than ten years after the date on which the violation of section
25.5-4-305
is committed.
(2)
If the state elects to intervene and proceed with an action brought under section
25.5-4-306
, the state may file its own complaint or amend the relator's complaint to clarify or add detail to the claims in which the state is intervening and to add any additional claims with respect to which the state contends it is entitled to relief. For statute of limitations purposes, any such pleadings by the state shall relate back to the filing date of the relator's complaint, to the extent that the state's claim arises out of the conduct, transactions, or occurrences set forth, or attempted to be set forth, in the prior complaint of the relator.
(3)
In an action brought under section
25.5-4-306
, the state or relator must prove all essential elements of the cause of action, including damages, by a preponderance of the evidence.
(4)
Notwithstanding any other provision of law, the Colorado rules of criminal procedure, or the Colorado rules of evidence, a final judgment rendered in favor of the state in a criminal proceeding charging fraud or false statements, whether upon a verdict after trial or upon a plea of guilty or nolo contendere, shall estop the defendant from denying the essential elements of the offense in any action that involves the same transaction as in the criminal proceeding and that is brought under section
25.5-4-306
.
(5)
A private action for retaliation under section
25.5-4-306 (7)
may not be brought more than three years after the date when the retaliation occurred.
Amended by 2013 Ch. 276, § 6, eff. 8/7/2013.
L. 2010: Entire section added, (SB 10 -167), ch. 296, p. 1386, § 14, effective May 26. L. 2013: (5) added, (SB 13-205), ch. 276, p. 1442, § 6, effective August 7.
For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.
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 25.5-4-308 - False medicaid claims jurisdiction

An action under section
25.5-4-306
may be brought in any judicial district in which the defendant or, in the case of multiple defendants, any one defendant can be found, resides, or transacts business or in which an act proscribed by section
25.5-4-305
occurred. A summons as required by the Colorado rules of civil procedure shall be issued by the appropriate district court and served at any place.
L. 2010: Entire section added, (SB 10 -167), ch. 296, p. 1387, § 14, effective May 26.
For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.
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 25.5-4-310 - Medicaid false claims report

(1)
Notwithstanding section
24-1-136(11)(a)(I)
, on or before January 15, 2012, and on or before each January 15 thereafter, the attorney general shall submit a written report to the health and human services committees of the senate and the house of representatives, or any successor committees, and to the joint budget committee of the general assembly concerning claims brought under the "Colorado Medicaid False Claims Act" during the previous fiscal year. The report shall include, but not be limited to:
(a)
The number of actions filed by the attorney general;
(b)
The number of actions filed by the attorney general that were completed;
(c)
The amount that was recovered in actions filed by the attorney general through settlement or through a judgment and, if known, the amount recovered for damages, penalties, and litigation costs;
(d)
The number of actions filed by a person other than the attorney general;
(e)
The number of actions filed by a person other than the attorney general that were completed;
(f)
The amount that was recovered in actions filed by a person other than the attorney general through settlement or through a judgment and, if known, the amount recovered for damages, penalties, and litigation costs, and the amount recovered by the state and the person; and
(g)
The amount expended by the state for investigation, litigation, and all other costs for claims related to the "Colorado Medicaid False Claims Act".
Amended by 2017 Ch. 175,§ 3, eff. 8/9/2017.
L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1399, §14, effective May 26. L. 2017: IP(1) amended, (SB 17-233), ch. 175, p. 637, § 3, effective August 9.
(1) For the "Colorado Medicaid False Claims Act", see section 25.5-4-303.5. (2) For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.
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 25.5-4-402.3 - [Repealed]

Repealed by 2017 Ch. 267, § 16, eff. 7/1/2017.
Amended by 2017 Ch. 198, § 1, eff. 5/8/2017.
Amended by 2013 Ch. 216, § 1, eff. 5/13/2013.
L. 2009: Entire section added, (HB 09 -1293), ch. 152, p. 633, § 1, effective July 1. L. 2010: (4)(b)(VIII) added, (SB 10 -169), ch. 307, p. 1445, § 1, effective May 27; (4)(b)(IV) amended, (HB 10 -1422), ch. 419, p. 2110, § 141, effective August 11. L. 2011: (3)(a)(II) and (3)(a)(III) amended and (3)(a)(IV), (4)(b)(IX), and (5)(b.5) added, (SB 11-212), ch. 146, pp. 508, 509, §§ 1, 2, 3, effective May 5. L. 2013: (4)(b)(IV)(A) and (4)(b)(IV)(C) amended, (SB 13-200), ch. 216, p. 897, § 1, effective May 13. L. 2017: (5)(b.3) added, (SB 17-256), ch. 198, p. 720, § 1, effective May 8; entire section repealed, (SB 17-267), ch. 267, p. 1448, § 16, effective July 1.
Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017, provides that the section of the act repealing this section does not take effect if the centers for medicare and medicaid services determine that the amendments do not comply with federal law. For more information, see SB 17-267. ( L. 2017, p. 1478.) The executive director of the department of health care policy and financing did not notify the revisor of statutes by June 1, 2017, of such determination; therefore, the repeal of this section took effect July 1, 2017.
For the legislative declaration in SB 17-267, see section 1 of chapter 267, Session Laws of Colorado 2017.
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 25.5-4-402.5 - Providers - state university teaching hospitals

Subject to appropriations by the general assembly, the state department shall make payments to state university teaching hospitals for providing care under the state's medical assistance program established pursuant to this article and articles
5
and 6 of this title.
L. 2008: Entire section added, p. 1185, § 3, effective May 22.
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 25.5-4-402.7 - [Repealed]

Added by 2017 Ch. 267, § 18, eff. 7/1/2017.
L. 2017: Entire section added, (SB 17-267), ch. 267, p. 1464, § 18, effective July 1.
Subsection (2) provided for the repeal of this section, effective November 1, 2018. (See L. 2017, p. 1464.)
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 25.5-4-403 - Providers - behavioral health safety net providers - reimbursement

(1)
For the purpose of reimbursing essential behavioral health safety net and comprehensive community behavioral health providers, as defined in section
27-50-101
, except for those that are also federally qualified health centers, as defined in the federal "Social Security Act",
42 U.S.C. sec. 1395x(aa)(4)
, which have payment methodology pursuant to section
25.5-5-408
, the state department shall establish an appropriate cost accounting methodology annually with the behavioral health administration in the department of human services in order to support sustainable access to behavioral health safety net services, as defined in section
27-50-101
. In establishing the payment methodology, the state department shall consider:
(a)
Actual costs of services, including services to address language and cultural barriers necessary to serve communities of color and other underserved populations;
(b)
Costs that are reasonable, as determined by the state department in collaboration with the behavioral health administration in the department of human services;
(c)
Quality and accessibility of behavioral health safety net care provided, as determined by the state department, in collaboration with the behavioral health administration in the department of human services, by rule;
(d)
Health equity;
(e)
Access by priority populations as determined by the behavioral health administration in the department of human services; and
(f)
Value-based payment approaches that incentivize providers to expand access to cost-effective behavioral health services to serve the behavioral health safety net.
(2)
The standards and processes for determining the payment methodology will be determined by an auditing and accounting committee. The members of the committee are selected by the state department to include behavioral health administrative service organizations, managed care entities, behavioral health safety net providers as defined in section
27-50-101
, independent auditors, actuaries, consumer and family advocates, local government representatives, other state agencies, and other relevant stakeholders.
Amended by 2022 Ch. 222, § 68, eff. 7/1/2022.
L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1.
This section is similar to former § 26-4-409 as it existed prior to 2006.
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 25.5-4-403.1 - Providers - community mental health centers - cost reporting

(1)
For the purposes of increased payment methodology transparency, no later than March 15, 2023, and each March 15 thereafter, the state department shall:
(a)
Publish cost reports for community mental health centers;
(b)
Establish a cost-reporting template and cost-reporting schedule to assist providers in providing cost reports;
(c)
Redact information to maintain compliance with state and federal law including, but not limited to, personally identifying information and protected health information as necessary to protect the privacy of patients;
(d)
Create a publicly available website that provides insight to medicaid members, medicaid providers, and members of the public regarding behavioral health reimbursement rates. The website must include the following:
(I)
All completed cost reports for each behavioral health safety net provider, as defined in section
27-50-101 (7)
;
(II)
An overview of the purpose of the cost report described in this subsection (1);
(III)
Information on how to interpret the cost reports and where to find information in the cost reports;
(IV)
An overview of:
(A)
How reimbursement rates are determined;
(B)
What constitutes a reasonable and allowable cost; and
(C)
How value-based payments impact reimbursement rates; and
(V)
The state department's plan to improve behavioral health reimbursement rates and annual updates to the plan.
Added by 2022 Ch. 363, § 3, eff. 6/3/2022.
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 25.5-4-404 - Payments for clinic services - restrictions on use

All payments received by county or district public health agencies or boards of health for clinic services, as defined in section
25.5-5-301 (3)
, furnished to patients shall be used only to offset costs incurred for provision of services by such county or district public health agencies or boards of health or to cash fund health-care services in the county where the services were provided.
L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1. L. 2010: Entire section amended, (HB 10 -1422), ch. 419, p. 2110, § 142, effective August 11.
This section is similar to former § 26-4-515 as it existed prior to 2006.
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 25.5-4-405 - [Effective Until 8/7/2024] Mental health managed care service providers - requirements

(1)
Each contract between the state department and a managed care organization providing mental health services to a recipient under the medical assistance program shall comply with all federal requirements, including but not limited to:
(a)
Ensuring that a recipient with complex or multiple needs who requires mental health services shall have access to mental health professionals with appropriate training and credentials and shall provide the recipient with such services in collaboration with the recipient's other providers;
(b)
Informing each recipient of his or her right to and the process for appeal upon notification of denial, termination, or reduction of a requested service; and
(c)
Administering initial stabilization treatment for a recipient and transferring the recipient for appropriate continued services.
(1.5)
Each contract between the state department and a managed care organization providing mental health services to a recipient under the medical assistance program shall allow for the use of telemedicine pursuant to the provisions of section
25.5-5-320
.
(2)
For mental health managed care recipients, the state department shall have a patient representative program for recipient grievances that complies with all federal requirements and that shall:
(a)
Be posted in a conspicuous place at each location at which mental health services are provided;
(b)
Allow for a patient representative to serve as a liaison between the recipient and the provider;
(c)
Describe the qualifications for a patient representative;
(d)
Outline the responsibilities of a patient representative;
(e)
Describe the authority of a patient representative; and
(f)
Establish a method by which each recipient is informed of the patient representative program and how a patient representative may be contacted.
L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1. L. 2008: (1.5) added, p. 111, § 1, effective August 5.
This section is similar to former § 26-4-409.5 as it existed prior to 2006.
This section is set out more than once due to postponed, multiple, or conflicting amendments.
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 25.5-4-405 - [Effective 8/7/2024] Mental health managed care service providers - requirements

(1)
Each contract between the state department and a managed care organization providing mental health services to a Member under the medical assistance program must comply with all federal requirements, including but not limited to:
(a)
Ensuring that a Member with complex or multiple needs who requires mental health services has access to mental health professionals with appropriate training and credentials and providing the Member with the services in collaboration with the member's other providers;
(b)
Informing each member of the member's right to and the process for appeal upon notification of denial, termination, or reduction of a requested service; and
(c)
Administering initial stabilization treatment for a Member and transferring the Member for appropriate continued services.
(1.5)
Each contract between the state department and a managed care organization providing mental health services to a Member under the medical assistance program must allow for the use of telemedicine pursuant to section
25.5-5-320
.
(2)
For mental health managed care members, the state department shall have a patient representative program for Member grievances that complies with all federal requirements and that must:
(a)
Be posted in a conspicuous place at each location at which mental health services are provided;
(b)
Allow for a patient representative to serve as a liaison between the Member and the provider;
(c)
Describe the qualifications for a patient representative;
(d)
Outline the responsibilities of a patient representative;
(e)
Describe the authority of a patient representative; and
(f)
Establish a method by which each Member is informed of the patient representative program and how a patient representative may be contacted.
Amended by 2024 Ch. 152,§ 36, eff. 8/7/2024.
L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1. L. 2008: (1.5) added, p. 111, § 1, effective August 5.
This section is similar to former § 26-4-409.5 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.
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 25.5-4-406 - Rate setting - medicaid residential treatment service providers - monitoring and auditing - report

(1)
The state department shall approve a rate-setting process consistent with medicaid requirements for providers of medicaid residential treatment services in the state of Colorado as developed by the department of human services. The rate-setting process developed pursuant to this section may include, but shall not be limited to:
(a)
A range for reimbursement that represents a base-treatment rate for serving a child who is subject to out-of-home placement due to dependency and neglect, a child placed in a residential child care facility pursuant to the "Children and Youth Mental Health Treatment Act", article
67
of title
27
, or a child who has been adjudicated a delinquent, which includes a defined service package to meet the needs of the child;
(b)
A request for proposal to contract for specialized service needs of a child, including but not limited to: Substance-abuse treatment services; sex offender services; and services for the developmentally disabled; and
(c)
Negotiated incentives for achieving outcomes for the child as defined by the state department, counties, and providers.
(2)
The medicaid rate-setting process approved by the state department shall include a two- or three-year implementation timeline with implementation beginning in state fiscal year 2008-09.
(3)
The state department and the department of human services, in consultation with the representatives of the counties and the provider community, shall review the rate-setting process every two years and shall submit any changes to the joint budget committee of the general assembly.
Amended by 2018 Ch. 343,§ 10, eff. 6/30/2018.
L. 2006: Entire article added with relocations, p. 1845, § 7, effective July 1. L. 2007: (1)(a), (2), and (3) amended, p. 618, § 2, effective August 3. L. 2010: (1)(a) amended, (SB 10-175), ch. 188, p. 800, §66, effective April 29. L. 2018: (1)(a) amended, (HB 18-1094), ch. 343, p. 2044, § 10, effective June 30.
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 25.5-4-407 - Services by licensed psychologists without a doctor's referral

The executive director of the state department may authorize the providing of services of licensed psychologists without the requirement that the services be referred by a doctor of medicine or a doctor of osteopathy, but such services shall be subject to the cost containment program specified under section
25.5-4-408
. The executive director may except from the authorization those services the director determines to be necessary for the purpose of promoting the primary care physician program.
L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1.
This section is similar to former § 26-4-412 as it existed prior to 2006.
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 25.5-4-408 - Services provided by licensed psychologists - cost containment program

(1)
Working in conjunction with licensed psychologists in the state, the state board shall promulgate rules to establish and implement mechanisms for containing the costs of services provided by licensed psychologists under the medical assistance programs established pursuant to this article and articles
5
and
6
of this title. The cost containment mechanism shall ensure that the costs to the medical assistance program will result in no increase in the total cost of the program solely as a result of the reimbursement for services of licensed psychologists pursuant to section
25.5-4-407
. The cost containment mechanisms may include the following:
(a)
Limiting the number of days a licensed psychologist may be reimbursed per patient for inpatient hospitalization, partial hospitalization, and outpatient visits without an order for continued treatment from a doctor of medicine or osteopathy;
(b)
Limiting the number of hours a licensed psychologist may be reimbursed for diagnostic testing and evaluation per patient per year;
(c)
Provision of group therapy when needed or appropriate;
(d)
Provision of licensed psychologists' services from a pool of those licensed psychologists requesting to be included in such pool;
(e)
Provision of a licensed psychologist's services through the use of telemedicine pursuant to the provisions of section
25.5-5-320
.
L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1. L. 2008: (1)(e) added, p. 111, § 2, effective August 5.
This section is similar to former § 26-4-516 as it existed prior to 2006.
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 25.5-4-409 - Authorization of services - nurse anesthetists - advanced practice registered nurses

(1)
When services by a certified registered nurse anesthetist are provided pursuant to an order by a physician in accordance with this article 4, articles
5
and
6
of this title 25.5, and section
12-255-104(10)
, the executive director of the state department shall authorize reimbursement for said services. Payment for such services shall be made directly to the nurse anesthetist, if requested by the nurse anesthetist; except that this section shall not apply to nurse anesthetists when acting within the scope of their employment as salaried employees of public or private institutions or physicians.
(2)
When services by an advanced practice registered nurse registered pursuant to section
12-255-111
are provided in accordance with this article 4 and articles
5
and
6
of this title 25.5, the executive director of the state department shall authorize reimbursement for said services. Payment for the services shall be made directly to the advanced practice registered nurse, if requested by the advanced practice registered nurse; except that this section shall not apply to advanced practice registered nurses when acting within the scope of their employment as salaried employees of public or private institutions or physicians.
Amended by 2019 Ch. 136,§178, eff. 10/1/2019.
L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1. L. 2008: (2) amended, p. 138, § 1, effective July 1. L. 2019: Entire section amended, (HB 19-1172), ch. 1707, p. 1707, § 178, effective October 1.
This section is similar to former § 26-4-413 as it existed prior to 2006.
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 25.5-4-410 - Services of audiologists and speech pathologists without supervision

(1)
When medical or diagnostic services by an audiologist or speech pathologist are provided pursuant to an order by a physician in accordance with this article and articles
5
and
6
of this title, the executive director of the state department shall authorize reimbursement for said services. For the purposes of this section, "audiologist" or "speech pathologist" means an individual who meets the requirements set forth in the federal "Social Security Act", as amended, or any federal regulations adopted pursuant thereto, for participating providers of audiology or speech pathology services.
(2)
Nothing in this section shall be construed as expanding the provision of services available as a part of the medical assistance program established pursuant to this article and articles
5
and
6
of this title. For the purposes of making payments to audiologists or speech pathologists pursuant to this section, the state board shall establish rules implementing this section. The rules promulgated pursuant to this subsection (2) shall ensure that the costs to the medical assistance program will result in no increase in the total cost of the program solely as a result of the reimbursement for services of an audiologist or speech pathologist pursuant to this section.
(3)
Payments for services included in this section shall be made directly to the audiologist or speech pathologist, if requested by the audiologist or speech pathologist; except that this section shall not apply to audiologists or speech pathologists when acting within the scope of their employment as salaried employees of public or private institutions or physicians.
L. 2006: Entire article added with relocations, p. 1847, § 7, effective July 1.
This section is similar to former § 26-4-414 as it existed prior to 2006.
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 25.5-4-411 - Authorization of services provided by dental hygienists

(1)
When dental hygiene services are provided to children by a licensed dental hygienist or dental therapist who is providing dental hygiene services pursuant to section
12-220-503
without the supervision of a licensed dentist, the executive director of the state department shall authorize reimbursement for said services, subject to the requirements of this section. Payment for the services shall be made directly to the licensed dental hygienist or dental therapist, if requested by the licensed dental hygienist or dental therapist; except that this section does not apply to licensed dental hygienists or dental therapists when acting within the scope of their employment as salaried employees of public or private institutions, physicians, or dentists.
(2)
For each child provided dental hygiene services pursuant to this section, the dental hygienist or dental therapist shall attempt to identify a dentist participating in medicaid for the child.
Amended by 2022 Ch. 381, § 39, eff. 1/1/2023.
Amended by 2020 Ch. 64, § 9, eff. 9/14/2020.
Amended by 2019 Ch. 136, § 179, eff. 10/1/2019.
L. 2006: Entire article added with relocations, p. 1847, § 7, effective July 1.
This section is similar to former § 26-4-414.3 as it existed prior to 2006.
2022 Ch. 381, was passed without a safety clause. See Colo. Const. art. V, § 1(3).
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 25.5-4-413 - Certain providers to inform patients of rights concerning advance medical directives

(1)
On and after November 5, 1991, with regard to any service rendered on and after said date, each hospital, nursing care facility, home health agency, hospice program, and health maintenance organization participating in the state medical assistance program or providing medical assistance pursuant to parts 3 to 12 of article
6
of this title shall provide written information to all adult patients of such providers concerning patients' rights under state law to make medical treatment decisions, including the right to accept or refuse any medical or surgical treatment and the right to formulate advance directives regarding said decisions. As used in this section, "advance directives" includes any written or oral instructions recognized under state law concerning the making of medical treatment decisions on behalf of or the provision of medical care for the person who provided the instructions in the event such person becomes incapacitated. Advance directives include, but are not limited to, medical durable powers of attorney, durable powers of attorney, or living wills.
(2)
Providers listed in subsection (1) of this section shall provide educational programs for staff and the community concerning advance directives and shall maintain written policies detailing methods for safeguarding patients' rights concerning medical treatment decisions, including documenting in the patient's medical or patient record whether the patient has executed, amended, or revoked an advance directive. No provider shall condition the provision of services or otherwise discriminate against a patient on the basis of whether the patient has executed an advance directive.
L. 2006: Entire article added with relocations, p. 1848, § 7, effective July 1.
This section is similar to former § 26-4-403.5 as it existed prior to 2006.
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 25.5-4-416 - [Effective Until 8/7/2024] Providers - medical equipment and supplies - requirements

(1)
As used in this section, unless the context otherwise requires, "provider" means a person or entity that delivers disposable medical supplies or durable medical equipment products or services directly to a recipient.
(2)
On and after January 1, 2007, the state board rules for the payment for disposable medical supplies and durable medical equipment, including but not limited to prosthetic and orthotic devices, shall prohibit a provider from being reimbursed unless the provider:
(a)
(I)
Has one or more physical locations within the state of Colorado or within fifty miles of a border of Colorado with a street address, a local business telephone number, an inventory, and a sufficient staff to service or repair products; except that the requirements of this paragraph (a) shall not apply to durable medical equipment or disposable medical supplies that are medically necessary and cannot be purchased from a provider meeting the requirements of this paragraph (a);
(II)
Complies with all state and local licensing, insurance, and regulatory requirements for operating the provider's business;
(III)
Is responsible for the delivery of and instructing the recipient on the proper use of the equipment; and
(IV)
Provides repairs, replacements, or adjustments to the provider's products pursuant to rules of the state board; or
(b)
Contracts with a provider who meets the criteria established in paragraph (a) of this subsection (2).
(3)
The provisions of this section shall apply to fee-for-service and primary care physician program recipients.
L. 2006: Entire section added, p. 525, § 1, effective August 7.
This section was originally numbered as § 26-4-410.7 in House Bill 06-1299. Section 2 of the act provided for the renumbering and relocation of § 26-4-410.7 to this section. (See L. 2006, p. 526.)
This section is set out more than once due to postponed, multiple, or conflicting amendments.
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 25.5-4-416 - [Effective 8/7/2024] Providers - medical equipment and supplies - requirements

(1)
As used in this section, unless the context otherwise requires, "provider" means a person or entity that delivers disposable medical supplies or durable medical equipment products or services directly to a Member.
(2)
On and after January 1, 2007, the state board rules for the payment for disposable medical supplies and durable medical equipment, including but not limited to prosthetic and orthotic devices, shall prohibit a provider from being reimbursed unless the provider:
(a)
(I)
Has one or more physical locations within the state of Colorado or within fifty miles of a border of Colorado with a street address, a local business telephone number, an inventory, and a sufficient staff to service or repair products; except that the requirements of this paragraph (a) shall not apply to durable medical equipment or disposable medical supplies that are medically necessary and cannot be purchased from a provider meeting the requirements of this paragraph (a);
(II)
Complies with all state and local licensing, insurance, and regulatory requirements for operating the provider's business;
(III)
Is responsible for the delivery of and instructing the Member on the proper use of the equipment; and
(IV)
Provides repairs, replacements, or adjustments to the provider's products pursuant to rules of the state board; or
(b)
Contracts with a provider who meets the criteria established in paragraph (a) of this subsection (2).
(3)
The provisions of this section shall apply to fee-for-service and primary care physician program recipients.
Amended by 2024 Ch. 152,§ 38, eff. 8/7/2024.
L. 2006: Entire section added, p. 525, § 1, effective August 7.
This section was originally numbered as § 26-4-410.7 in House Bill 06-1299. Section 2 of the act provided for the renumbering and relocation of § 26-4-410.7 to this section. (See L. 2006, p. 526.)
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.
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 25.5-4-418 - [Repealed]

L. 2011: Entire section added, (HB 11-1242), ch. 271, p. 1230, §1, effective July 1.
Subsection (4) provided for the repeal of this section, effective July 1, 2012. (See L. 2011, p. 1230.)
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 25.5-4-419 - [Repealed]

Added by 2018 Ch. 146,§1, eff. 4/23/2018.
L. 2018: Entire section added, (HB 18-1330), ch. 146, p. 932, § 1, effective April 23.
Subsection (6) provided for the repeal of this section, effective July 1, 2019. (See L. 2018, p. 932.)