HOUSE BILL 24-1149
BY REPRESENTATIVE(S) Bird and Frizell, Amabile, Armagost, Bacon,
Boesenecker, Bradfield, Clifford, deGruy Kennedy, Duran, English,
Froelich, Garcia, Hamrick, Hartsook, Hernandez, Jodeh, Kipp, Lieder,
Lindstedt, Mabrey, McLachlan, Ortiz, Rutinel, Sirota, Snyder, Soper,
Taggart, Titone, Valdez, Velasco, Weinberg, Willford, Wilson, Young,
Brown, Catlin, Lindsay, Marshall, Mauro, McCormick, Parenti, Weissman,
McCluskie;
also SENATOR(S) Roberts and Kirkmeyer, Ginal, Baisley, Bridges,
Buckner, Coleman, Cutter, Gonzales, Hansen, Hinrichsen, Kolker, Liston,
Marchman, Michaelson Jenet, Mullica, Pelton R., Rich, Van Winkle, Will,
Winter F., Zenzinger.
C
ONCERNING MODIFICATIONS TO REQUIREMENTS FOR PRIOR AUTHORIZATION
OF BENEFITS UNDER HEALTH BENEFIT PLANS
, AND, IN CONNECTION
THEREWITH
, MAKING AN APPROPRIATION.
Be it enacted by the General Assembly of the State of Colorado:
SECTION 1. Legislative declaration. (1) The general assembly
finds and declares that:
(a) Timely access to necessary health care is of vital importance to
NOTE: This bill has been prepared for the signatures of the appropriate legislative
officers and the Governor. To determine whether the Governor has signed the bill
or taken other action on it, please consult the legislative status sheet, the legislative
history, or the Session Laws.
________
Capital letters or bold & italic numbers indicate new material added to existing law; dashes
through words or numbers indicate deletions from existing law and such material is not part of
the act. Coloradans;
(b) The provider-patient relationship is paramount and should not
be subject to intrusion by a third party;
(c) Coloradans and their health-care providers deserve easy access
to information regarding health insurance benefits so that, together, they can
determine the proper course of treatment;
(d) Utilization management processes, such as prior authorization,
delay care, which, according to thirty-four percent of physicians surveyed
nationally, leads to serious adverse events for their patients, including
hospitalization, permanent disability, or even death;
(e) These outcomes due to delays in timely accessing services and
prescriptions are known to disproportionately impact historically
marginalized populations, such as Black and Hispanic patients, furthering
health disparities in the state;
(f) Surveys have found that over sixty percent of physicians also
report that it is difficult to determine whether a prescription medication or
medical service requires prior authorization, adding burdensome
administrative steps for health-care providers and patients to understand
requirements for accessing necessary medical services or prescriptions; and
(g) Health systems spend an average of twenty dollars, for a primary
care visit, to two hundred fifteen dollars, for an inpatient surgical procedure,
on administrative tasks to navigate insurer utilization management
processes like processing prior authorization requests.
(2) Therefore, it is the intent of the general assembly, by establishing
transparent prescription formularies and enabling access to prior
authorization requirements at the point of care delivery; requiring posting
of data on prior authorization practices; and requiring carriers, private
utilization review organizations, and pharmacy benefit managers to adopt
a program that streamlines the administrative process for qualifying
health-care providers who satisfy certain objective criteria regarding quality
and appropriateness of care and specialty area and experience, to:
(a) Ensure Coloradans have equitable access to medically necessary
PAGE 2-HOUSE BILL 24-1149 care;
(b) Reduce administrative burdens and costs borne by health-care
providers; and
(c) Reduce overall costs to the health-care system.
SECTION 2. In Colorado Revised Statutes, 10-16-112.5, amend
(2)(a), (2)(c), (3)(a)(I), (3)(c)(II), (4)(b), (5)(a), (6), and (7)(e); and add
(3)(c)(III), (3.5), and (4)(c) as follows:
10-16-112.5. Prior authorization for health-care services -
disclosures and notice - determination deadlines - criteria - limits and
exceptions - definitions - rules - enforcement. (2) Disclosure of
requirements - notice of changes. (a) (I) A carrier shall make
POST
current prior authorization requirements and restrictions, including written,
clinical criteria, readily accessible on the carrier's PUBLIC-FACING website
IN A READILY ACCESSIBLE, STANDARDIZED, SEARCHABLE FORMAT. The prior
authorization requirements must be described in detail and in clear and
easily understandable language.
(II) If a carrier contracts with a private utilization review
organization to perform prior authorization for health-care services, the
organization shall provide its prior authorization requirements and
restrictions, as required by this subsection (2), to the carrier with whom
WHICH the organization contracted, and that carrier shall post the
organization's prior authorization requirements and restrictions on its
PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION (2)(a)(I)
OF THIS SECTION.
(III) When posting prior authorization requirements and restrictionspursuant to this subsection (2)(a) or subsection (2)(b) of this section, a
carrier is neither required to post nor prohibited from posting the prior
authorization requirements and restrictions on a public-facing portion of its
website.
(c) (I) A carrier shall post, on a public-facing portion of its website,
data regarding approvals and denials of prior authorization requests,
including requests for drug benefits pursuant to section 10-16-124.5, in a
readily accessible,
STANDARDIZED, SEARCHABLE format and that include the
PAGE 3-HOUSE BILL 24-1149 following: categories, in the aggregate:
(A) Provider specialty THE TOTAL NUMBER OF PRIOR
AUTHORIZATION REQUESTS RECEIVED IN THE IMMEDIATELY PRECEDING
CALENDAR YEAR IN EACH OF THE FOLLOWING CATEGORIES OF SERVICES
:
M
EDICAL PROCEDURES; DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ;
PRESCRIPTION DRUGS; AND ALL OTHER CATEGORIES OF HEALTH -CARE
SERVICES OR DRUG BENEFITS FOR WHICH A PRIOR AUTHORIZATION REQUEST
WAS RECEIVED
;
(B) Medication or diagnostic test or procedure
THE TOTAL NUMBER
OF PRIOR AUTHORIZATION REQUESTS THAT WERE APPROVED IN EACH OF THE
CATEGORIES SPECIFIED IN SUBSECTION
(2)(c)(I)(A) OF THIS SECTION;
(B.5) T
HE TOTAL NUMBER OF PRIOR AUTHORIZATION REQUESTS FOR
WHICH AN ADVERSE DETERMINATION WAS ISSUED AND THE SERVICE WAS
DENIED IN EACH OF THE CATEGORIES SPECIFIED IN SUBSECTION
(2)(c)(I)(A)
OF THIS SECTION;
(C) T
HE reason for THE denial IN EACH OF THE CATEGORIES
SPECIFIED IN SUBSECTION
(2)(c)(I)(A) OF THIS SECTION, WITH THE DENIAL
REASONS SORTED BY CATEGORIES DEFINED BY RULE
; and
(D) Denials specified under subsection (2)(c)(I)(C) of this section
that are overturned on appeal IN EACH OF THE CATEGORIES SPECIFIED IN
SUBSECTION
(2)(c)(I)(A) OF THIS SECTION, THE TOTAL NUMBER OF ADVERSE
DETERMINATIONS THAT WERE APPEALED AND WHETHER THE
DETERMINATION WAS UPHELD OR REVERSED ON APPEAL
.
(II) An organization
OR PBM that provides prior authorization for
a carrier shall provide the data specified in subsection (2)(c)(I) of this
section to the carrier with whom
WHICH the organization OR PBM
contracted, and the carrier shall post the organization's
OR PBM'S data on
its
PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION
(2)(c)(I) OF THIS SECTION.
(III) Carriers and organizations shall use the data specified in this
subsection (2)(c) to refine and improve their utilization management
programs. C
ARRIERS AND ORGANIZATIONS SHALL REVIEW THE LIST OF
MEDICAL PROCEDURES
, DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ,
PAGE 4-HOUSE BILL 24-1149 PRESCRIPTION DRUGS, AND OTHER HEALTH-CARE SERVICES FOR WHICH THE
CARRIER OR ORGANIZATION REQUIRES PRIOR AUTHORIZATION AT LEAST
ANNUALLY AND SHALL ELIMINATE THE PRIOR AUTHORIZATION
REQUIREMENTS FOR THOSE PROCEDURES
, DIAGNOSTIC TESTS AND
DIAGNOSTIC IMAGES
, PRESCRIPTION DRUGS, OR OTHER HEALTH -CARE
SERVICES FOR WHICH PRIOR AUTHORIZATION NEITHER PROMOTES
HEALTH
-CARE QUALITY OR EQUITY NOR SUBSTANTIALLY REDUCES
HEALTH
-CARE SPENDING. EACH CARRIER AND ORGANIZATION SHALL
ANNUALLY ATTEST TO THE COMMISSIONER THAT IT HAS COMPLETED THE
REVIEW REQUIRED BY THIS SUBSECTION
(2)(c)(III) AND HAS ELIMINATED
PRIOR AUTHORIZATION REQUIREMENTS CONSISTENT WITH THE
REQUIREMENTS OF THIS SUBSECTION
(2)(c)(III).
(IV) A
CARRIER SHALL POST, ON A PUBLIC-FACING PORTION OF ITS
WEBSITE
, IN A READILY ACCESSIBLE, STANDARDIZED, SEARCHABLE FORMAT,
DATA ON THE NUMBER OF EXEMPTIONS FROM PRIOR AUTHORIZATION
REQUIREMENTS OR ALTERNATIVES TO PRIOR AUTHORIZATION REQUIREMENTS
PROVIDED PURSUANT TO A PROGRAM ADOPTED BY THE CARRIER
,
ORGANIZATION, OR PBM PURSUANT TO SUBSECTION (4)(b)(II) OF THIS
SECTION OR SECTION
10-16-124.5 (5.5), AS APPLICABLE. THE CARRIER SHALL
INCLUDE THE FOLLOWING DATA
:
(A) T
HE NUMBER OF PROVIDERS OFFERED AN EXEMPTION OR
ALTERNATIVE PROGRAM
, INCLUDING THEIR SPECIALTY AREAS;
(B) T
HE NUMBER AND CATEGORIZED TYPES OF EXEMPTIONS OR
ALTERNATIVE PROGRAMS OFFERED TO PROVIDERS
; AND
(C) THE PRESCRIPTION DRUG, DIAGNOSTIC TEST, PROCEDURE, OR
OTHER HEALTH
-CARE SERVICE FOR WHICH AN EXEMPTION OR ALTERNATIVE
PROGRAM WAS OFFERED
.
(V) T
HE COMMISSIONER SHALL ADOPT RULES TO :
(A) I
MPLEMENT SUBSECTIONS (2)(c)(I) AND (2)(c)(IV) OF THIS
SECTION TO ENSURE THAT THE DATA FIELDS REQUIRED TO BE POSTED
PURSUANT TO SUBSECTIONS
(2)(c)(I) AND (2)(c)(IV) OF THIS SECTION ARE
PRESENTED CONSISTENTLY BY CARRIERS
; AND
(B) DEFINE CATEGORIES OF PRIOR AUTHORIZATION REQUEST
PAGE 5-HOUSE BILL 24-1149 DENIALS FOR PURPOSES OF SUBSECTION (2)(c)(I)(C) OF THIS SECTION.
(3) Nonurgent and urgent health-care services - timely
determination - notice of determination - deemed approved. (a) Except
as provided in subsection (3)(b) of this section, a prior authorization request
is deemed granted if a carrier or organization fails to:
(I) (A) Notify the provider and covered person, within five business
days after receipt of the request, that the request is approved, denied, or
incomplete and
INDICATE: IF DENIED, WHAT RELEVANT ALTERNATIVE
SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR ARE REQUIRED
BEFORE APPROVAL OF THE DENIED SERVICE OR TREATMENT
; OR if
incomplete, indicate
the specific additional information, consistent with
criteria posted pursuant to subsection (2)(a) of this section, that is required
to process the request; or
(B) Notify the provider and covered person, within five business
days after receiving the additional information required by the carrier or
organization pursuant to subsection (3)(a)(I)(A) of this section, that the
request is approved or denied
AND, IF DENIED, INDICATE WHAT RELEVANT
ALTERNATIVE SERVICES OR TREATMENTS MAY BE A COVERED BENEFIT OR
ARE REQUIRED BEFORE APPROVAL OF THE DENIED SERVICE OR TREATMENT
;
and
(c) (II) If the carrier or organization denies a prior authorization
request based on a ground specified in section 10-16-113 (3)(a), the
notification is subject to the requirements of section 10-16-113 (3)(a) and
commissioner rules adopted pursuant to that section and must:
(A) Include information concerning whether the carrier or
organization requires an alternative treatment, test, procedure, or medication
AND WHAT ALTERNATIVE SERVICES OR TREATMENTS WOULD BE APPROVED
AS A COVERED BENEFIT UNDER THE HEALTH BENEFIT PLAN
; OR
(B) IN THE CASE OF THE DENIAL OF A PRIOR AUTHORIZATION
REQUEST FOR A PRESCRIPTION DRUG
, SPECIFY WHICH PRESCRIPTION DRUGS
AND DOSAGES IN THE SAME CLASS AS THE PRESCRIPTION DRUG FOR WHICH
THE PRIOR AUTHORIZATION REQUEST WAS DENIED ARE COVERED
PRESCRIPTION DRUGS UNDER THE HEALTH BENEFIT PLAN
.
PAGE 6-HOUSE BILL 24-1149 (III) A CARRIER'S, ORGANIZATION'S, OR PHARMACY BENEFIT
MANAGER
'S COMPLIANCE WITH SUBSECTION (3)(c)(II) OF THIS SECTION DOES
NOT CONSTITUTE THE PRACTICE OF MEDICINE
.
(3.5) (a) S
TARTING JANUARY 1, 2027, A CARRIER OR ORGANIZATION
SHALL HAVE
, MAINTAIN, AND USE A PRIOR AUTHORIZATION APPLICATION
PROGRAMMING INTERFACE THAT AUTOMATES THE PRIOR AUTHORIZATION
PROCESS TO ENABLE A PROVIDER TO
:
(I) D
ETERMINE WHETHER PRIOR AUTHORIZATION IS REQUIRED FOR
A HEALTH
-CARE SERVICE;
(II) I
DENTIFY PRIOR AUTHORIZATION INFORMATION AND
DOCUMENTATION REQUIREMENTS
; AND
(III) FACILITATE THE EXCHANGE OF PRIOR AUTHORIZATION
REQUESTS AND DETERMINATIONS FROM THE PROVIDER
'S ELECTRONIC
HEALTH RECORDS OR PRACTICE MANAGEMENT SYSTEMS THROUGH SECURE
ELECTRONIC TRANSMISSION
.
(b) A
CARRIER'S OR ORGANIZATION'S APPLICATION PROGRAMMING
INTERFACE MUST MEET THE MOST RECENT STANDARDS AND
IMPLEMENTATION SPECIFICATIONS ADOPTED BY THE SECRETARY OF THE
UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES AS
SPECIFIED IN
45 CFR 170.215 (a).
(c) I
F A PROVIDER SUBMITS A PRIOR AUTHORIZATION REQUEST
THROUGH THE CARRIER
'S OR ORGANIZATION'S APPLICATION PROGRAMMING
INTERFACE
, THE CARRIER OR ORGANIZATION SHALL ACCEPT AND RESPOND
TO THE REQUEST THROUGH THE INTERFACE
.
(4) Criteria, limits, and exceptions. (b) (I) Carriers and
organizations shall consider limiting the use of prior authorization to
providers whose prescribing or ordering patterns differ significantly from
the patterns of their peers after adjusting for patient mix and other relevant
factors and present opportunities for improvement in adherence to the
carrier's or organization's prior authorization requirements.
(II) (A)
NO LATER THAN JANUARY 1, 2026, a carrier or AN
organization may offer providers with a history of adherence to the carrier's
PAGE 7-HOUSE BILL 24-1149 or organization's prior authorization requirements at least one alternative to
prior authorization, including an exemption from prior authorization
requirements for a provider that has at least an eighty percent approval rate
of prior authorization requests over the immediately preceding twelve
months. SHALL ADOPT A PROGRAM , DEVELOPED IN CONSULTATION WITH
PROVIDERS PARTICIPATING WITH THE CARRIER
, TO ELIMINATE OR
SUBSTANTIALLY MODIFY PRIOR AUTHORIZATION REQUIREMENTS IN A
MANNER THAT REMOVES THE ADMINISTRATIVE BURDEN FOR QUALIFIED
PROVIDERS
, AS DEFINED UNDER THE PROGRAM , AND THEIR PATIENTS FOR
CERTAIN HEALTH
-CARE SERVICES AND RELATED BENEFITS BASED ON ANY OF
THE FOLLOWING
:
(A) T
HE PERFORMANCE OF PROVIDERS WITH RESPECT TO ADHERENCE
TO NATIONALLY RECOGNIZED
, EVIDENCE-BASED MEDICAL GUIDELINES ,
APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY CRITERIA; AND
(B) PROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE
FACTORS
; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE
LIMITED BY PROVIDER SPECIALTY
.
(III) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II)
OF THIS SECTION:
(A) M
UST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST
PARTICIPATION IN THE PROGRAM
; AND
(B) MAY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO
PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER
SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING FOR
PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO PRESENT
THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN ADHERENCE
TO THE CARRIER
'S OR ORGANIZATION 'S PRIOR AUTHORIZATION
REQUIREMENTS
.
(IV) At least annually, a carrier or
AN organization shall:
(A) Reexamine a provider's prescribing or ordering patterns; and
(B) Reevaluate the provider's status for exemption from or other
alternative to prior authorization requirements OR FOR INCLUSION IN THE
PAGE 8-HOUSE BILL 24-1149 PROGRAM DEVELOPED pursuant to this subsection (4)(b)(II) OF THIS
SECTION
; AND
(B)
(C) The carrier or organization shall inform NOTIFY the provider
of the provider's
STATUS FOR exemption status and provide information onthe data considered as part of its reexamination of the provider's prescribing
or ordering patterns for the twelve-month period of review OR INCLUSION
IN THE PROGRAM
.
(V) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II) OF
THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO REQUEST
:
(A) A
N EXPEDITED, INFORMAL RESOLUTION OF A CARRIER 'S OR AN
ORGANIZATION
'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE
PROGRAM
; AND
(B) IF THE MATTER IS NOT RESOLVED THROUGH INFORMAL
RESOLUTION
, BINDING ARBITRATION AS SPECIFIED IN SUBSECTION (4)(b)(VI)
OF THIS SECTION.
(VI) I
F A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT TO
THE PROCEDURES A CARRIER OR AN ORGANIZATION DEVELOPS UNDER
SUBSECTION
(4)(b)(V)(B) OF THIS SECTION, THE FOLLOWING PROVISIONS
GOVERN THE ARBITRATION PROCEDURE
:
(A) T
HE PROVIDER AND CARRIER OR ORGANIZATION SHALL JOINTLY
SELECT AN ARBITRATOR FROM THE LIST OF ARBITRATORS APPROVED
PURSUANT TO SECTION
10-16-704 (15)(b). NEITHER THE PROVIDER NOR THE
CARRIER OR ORGANIZATION IS REQUIRED TO NOTIFY THE DIVISION OF THE
ARBITRATION OR OF THE SELECTED ARBITRATOR
.
(B) T
HE SELECTED ARBITRATOR SHALL DETERMINE THE PROVIDER 'S
ELIGIBILITY TO PARTICIPATE IN THE CARRIER
'S OR ORGANIZATION'S PROGRAM
BASED ON THE PROGRAM CRITERIA DEVELOPED PURSUANT TO SUBSECTION
(4)(b)(II) OF THIS SECTION;
(C) W
ITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
ACCEPTS THE MATTER
, THE PROVIDER AND THE CARRIER OR ORGANIZATION
SHALL SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS IN SUPPORT OF
THEIR RESPECTIVE POSITIONS
;
PAGE 9-HOUSE BILL 24-1149 (D) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE
WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION
(4)(b)(VI)(C)
OF THIS SECTION OR MAY SCHEDULE A HEARING, LASTING NOT LONGER THAN
ONE DAY
, FOR THE PROVIDER AND CARRIER OR ORGANIZATION TO PRESENT
EVIDENCE
;
(E) W
ITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
RECEIVES THE WRITTEN MATERIALS OR
, IF A HEARING IS CONDUCTED, THE
DATE OF THE HEARING
, THE ARBITRATOR SHALL ISSUE A WRITTEN DECISION
STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE PROGRAM
; AND
(F) IF THE ARBITRATOR OVERTURNS THE CARRIER 'S OR
ORGANIZATION
'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE
PROGRAM
, THE CARRIER OR ORGANIZATION SHALL PAY THE ARBITRATOR 'S
FEES AND COSTS
, AND IF THE ARBITRATOR AFFIRMS THE CARRIER 'S OR
ORGANIZATION
'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE
PROGRAM
, THE PROVIDER SHALL PAY THE ARBITRATOR 'S FEES AND COSTS.
(c) (I) W
HEN A CARRIER OR AN ORGANIZATION APPROVES A PRIOR
AUTHORIZATION REQUEST FOR A SURGICAL PROCEDURE FOR WHICH PRIOR
AUTHORIZATION IS REQUIRED
, THE CARRIER OR ORGANIZATION SHALL NOT
DENY A CLAIM FOR AN ADDITIONAL OR A RELATED HEALTH
-CARE
PROCEDURE IDENTIFIED DURING THE AUTHORIZED SURGICAL PROCEDURE IF
:
(A) T
HE PROVIDER, WHILE PROVIDING THE APPROVED SURGICAL
PROCEDURE TO TREAT THE COVERED PERSON
, DETERMINES, IN ACCORDANCE
WITH GENERALLY ACCEPTED STANDARDS OF MEDICAL PRACTICE
, THAT
PROVIDING A RELATED HEALTH
-CARE PROCEDURE, INSTEAD OF OR IN
ADDITION TO THE APPROVED SURGICAL PROCEDURE
, IS MEDICALLY
NECESSARY AS PART OF THE TREATMENT OF THE COVERED PERSON AND
THAT
, IN THE PROVIDER'S CLINICAL JUDGMENT, TO INTERRUPT OR DELAY THE
PROVISION OF CARE TO THE COVERED PERSON IN ORDER TO OBTAIN PRIOR
AUTHORIZATION FOR THE ADDITIONAL OR RELATED HEALTH
-CARE
PROCEDURE WOULD NOT BE MEDICALLY ADVISABLE
;
(B) T
HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS A
COVERED BENEFIT UNDER THE COVERED PERSON
'S HEALTH BENEFIT PLAN;
(C) T
HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS NOT
EXPERIMENTAL OR INVESTIGATIONAL
;
PAGE 10-HOUSE BILL 24-1149 (D) AFTER COMPLETING THE ADDITIONAL OR RELATED HEALTH -CARE
PROCEDURE AND BEFORE SUBMITTING A CLAIM FOR PAYMENT
, THE PROVIDER
NOTIFIES THE CARRIER OR ORGANIZATION THAT THE PROVIDER PERFORMED
THE ADDITIONAL OR RELATED HEALTH
-CARE PROCEDURE AND INCLUDES IN
THE NOTICE THE INFORMATION REQUIRED UNDER THE CARRIER
'S OR
ORGANIZATION
'S CURRENT PRIOR AUTHORIZATION REQUIREMENTS POSTED
IN ACCORDANCE WITH SUBSECTION
(2)(a)(I) OF THIS SECTION; AND
(E) THE PROVIDER IS COMPLIANT WITH THE CARRIER 'S OR
ORGANIZATION
'S POST-SERVICE CLAIMS PROCESS, INCLUDING SUBMISSION OF
THE CLAIM WITHIN THE CARRIER
'S OR ORGANIZATION'S REQUIRED TIMELINE
FOR CLAIMS SUBMISSIONS
.
(II) W
HEN A PROVIDER PROVIDES AN ADDITIONAL OR A RELATED
HEALTH
-CARE PROCEDURE AS DESCRIBED IN THIS SUBSECTION (4)(c), THE
CARRIER OR ORGANIZATION SHALL NOT DENY THE CLAIM FOR THE INITIAL
SURGICAL PROCEDURE FOR WHICH THE CARRIER OR ORGANIZATION
APPROVED A PRIOR AUTHORIZATION REQUEST ON THE BASIS THAT THE
PROVIDER PROVIDED THE ADDITIONAL OR RELATED HEALTH
-CARE
PROCEDURE
.
(5) Duration of approval. (a) Upon approval by the carrier or
organization, a prior authorization is valid for at least one hundred eighty
days CALENDAR YEAR after the date of approval and continues for the
duration of the authorized course of treatment. Except as provided in
subsection (5)(b) of this section, once approved, a carrier or
AN organization
shall not retroactively deny the prior authorization request for a health-care
service.
(6) Rules - enforcement. (a) The commissioner may adopt rules as
necessary to implement this section.
(b) T
HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF THIS
SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A PERSON
THAT VIOLATES THIS SECTION
.
(7) Definitions. As used in this section:
(e) "Private utilization review organization" or "organization" has
the same meaning as set forth MEANS A PRIVATE UTILIZATION REVIEW
PAGE 11-HOUSE BILL 24-1149 ORGANIZATION, AS DEFINED in section 10-16-112 (1)(a), THAT HAS A
CONTRACT WITH AND PERFORMS PRIOR AUTHORIZATION ON BEHALF OF A
CARRIER
.
SECTION 3. In Colorado Revised Statutes, 10-16-124.5, amend
(2)(a)(II)(A), (2)(c)(II)(A), (3)(a) introductory portion, (3)(a)(I), (3)(a)(VI),
(3)(b) introductory portion, (5), and (6); repeal (3)(a)(II) and (4); and add
(3.3), (3.5), (5.5), and (6.5) as follows:
10-16-124.5. Prior authorization form - drug benefits - rules of
commissioner - definitions - repeal. (2) (a) Except as provided in
subsection (2)(b) or (2)(c) of this section, a prior authorization request is
deemed granted if a carrier or pharmacy benefit management firm fails to:
(II) For prior authorization requests submitted electronically:
(A) Notify the prescribing provider, within two business days after
receipt of the request, that the request is approved, denied, or incomplete,
and if incomplete, indicate the specific additional information, consistent
with criteria posted pursuant to subparagraph (II) of paragraph (a) of
subsection (3) SUBSECTION (3.5)(a) of this section, that is required to
process the request; or
(c) For nonurgent prior authorization requests related to a covered
person's HIV prescription drug coverage, the prior authorization request is
deemed granted if a carrier or pharmacy benefit management firm fails to:
(II) For prior authorization requests submitted electronically:
(A) Notify the prescribing provider within one business day after
receipt of the request that the request is approved, denied, or incomplete,
and if incomplete, indicate the specific additional information, consistent
with criteria posted pursuant to subsection (3)(a)(II)
SUBSECTION (3.5)(a)
of this section, that is required to process the request; or
(3) (a) On or before July 31, 2014, The commissioner shall develop,
by rule, a uniform prior authorization process that:
(I) Is made available electronically by the carrier or pharmacy
benefit management firm, but that does not require the prescribing provider
PAGE 12-HOUSE BILL 24-1149 to submit a prior authorization request electronically, AND SATISFIES THE
REQUIREMENTS OF SUBSECTION
(3.3) OF THIS SECTION;
(II) Requires each carrier and pharmacy benefit management firmto make the following available and accessible in a centralized location on
its website:
(A) Its prior authorization requirements and restrictions, including
a list of drugs that require prior authorization;
(B) Written clinical criteria that are easily understandable to the
prescribing provider and that include the clinical criteria for reauthorization
of a previously approved drug after the prior authorization period has
expired; and
(C) The standard form for submitting requests;
(VI) Requires carriers and pharmacy benefit management firms,
when notifying a prescribing provider of its decision to deny a prior
authorization request, to include
THE INFORMATION REQUIRED BY SECTION
10-16-112.5 (3)(c)(II) AND a notice that the covered person has a right to
appeal the adverse determination pursuant to sections 10-16-113 and
10-16-113.5.
(b) In developing the uniform prior authorization process, the
commissioner shall take into consideration the recommendations, if any, of
the work group established pursuant to subsection (4) of this section and the
following:
(3.3) S
TARTING JANUARY 1, 2027, IF A PROVIDER SUBMITS A PRIOR
AUTHORIZATION REQUEST TO A CARRIER OR
PBM THROUGH A SECURE
ELECTRONIC TRANSMISSION SYSTEM THE CARRIER OR
PBM USES THAT
COMPLIES WITH THE MOST RECENT VERSION OF THE
NATIONAL COUNCIL FOR
PRESCRIPTION DRUG PROGRAMS SCRIPT STANDARD, OR ITS SUCCESSOR
STANDARD
, AND 21 CFR 1311, THE CARRIER OR PBM SHALL ACCEPT AND
RESPOND TO THE REQUEST THROUGH THE SECURE ELECTRONIC
TRANSMISSION SYSTEM
.
(3.5) (a) O
N AND AFTER JANUARY 1, 2026, A CARRIER SHALL POST ON
THE CARRIER
'S PUBLIC-FACING WEBSITE, IN A READILY ACCESSIBLE ,
PAGE 13-HOUSE BILL 24-1149 STANDARDIZED, SEARCHABLE FORMAT , PRIOR AUTHORIZATION
REQUIREMENTS AS APPLICABLE TO THE PRESCRIPTION DRUG FORMULARY FOR
EACH HEALTH BENEFIT PLAN THE CARRIER OFFERS
, INCLUDING THE
FOLLOWING INFORMATION
:
(I) T
HE CARRIER'S PRIOR AUTHORIZATION REQUIREMENTS AND
RESTRICTIONS
, INCLUDING A LIST OF DRUGS THAT REQUIRE PRIOR
AUTHORIZATION
;
(II) W
RITTEN CLINICAL CRITERIA THAT ARE EASILY
UNDERSTANDABLE TO THE PRESCRIBING PROVIDER AND THAT INCLUDE THE
CLINICAL CRITERIA FOR REAUTHORIZATION OF A PREVIOUSLY APPROVED
DRUG AFTER THE PRIOR AUTHORIZATION PERIOD HAS EXPIRED
;
(III) T
HE STANDARD FORM FOR SUBMITTING PRIOR AUTHORIZATION
REQUESTS
;
(IV) T
HE HEALTH BENEFIT PLAN TO WHICH THE FORMULARY APPLIES ;
(V) E
ACH PRESCRIPTION DRUG THAT IS COVERED UNDER THE HEALTH
BENEFIT PLAN
, INCLUDING BOTH GENERIC AND BRAND -NAME VERSIONS OF
A PRESCRIPTION DRUG
;
(VI) A
NY PRESCRIPTION DRUGS ON THE FORMULARY THAT ARE
PREFERRED OVER OTHER PRESCRIPTION DRUGS OR ANY ALTERNATIVE
PRESCRIPTION DRUGS THAT DO NOT REQUIRE PRIOR AUTHORIZATION
;
(VII) A
NY EXCLUSIONS FROM OR RESTRICTIONS ON COVERAGE ,
INCLUDING:
(A) A
NY TIERING STRUCTURE , INCLUDING COPAYMENT AND
COINSURANCE REQUIREMENTS
;
(B) P
RIOR AUTHORIZATION, STEP THERAPY, AND OTHER UTILIZATION
MANAGEMENT CONTROLS
;
(C) Q
UANTITY LIMITS; AND
(D) WHETHER ACCESS IS DEPENDENT UPON THE LOCATION WHERE A
PRESCRIPTION DRUG IS OBTAINED OR ADMINISTERED
; AND
PAGE 14-HOUSE BILL 24-1149 (VIII) THE APPEAL PROCESS FOR A DENIAL OF COVERAGE OR
ADVERSE DETERMINATION FOR AN ITEM OR SERVICE FOR A PRESCRIPTION
DRUG
.
(b) T
HE COMMISSIONER SHALL ADOPT RULES AS NECESSARY TO
IMPLEMENT THIS SUBSECTION
(3.5).
(4) (a) Within thirty days after May 15, 2013, the commissioner
shall establish a work group comprised of representatives of:
(I) The department of regulatory agencies;
(II) Local and national carriers;
(III) Captive and noncaptive pharmacy benefit management firms;
(IV) Providers, including hospitals, physicians, advanced practice
registered nurses with prescriptive authority, and pharmacists;
(V) Drug manufacturers;
(VI) Medical practice managers;
(VII) Consumers; and
(VIII) Other stakeholders deemed appropriate by the commissioner.
(b) The work group shall assist the commissioner in developing the
prior authorization process and shall make recommendations to the
commissioner on the items set forth in paragraph (b) of subsection (3) of
this section. The work group shall report its recommendations to the
commissioner no later than six months after the commissioner appoints the
work group members. Regardless of whether the work group submits
recommendations to the commissioner, the commissioner shall not delay or
extend the deadline for the adoption of rules creating the prior authorization
process as specified in paragraph (a) of subsection (3) of this section.
(5) (a) Notwithstanding any other provision of law, on and after
January 1, 2015 AND EXCEPT AS PROVIDED IN SUBSECTIONS (5)(b) AND (5.5)
OF THIS SECTION, every prescribing provider shall use the prior authorization
PAGE 15-HOUSE BILL 24-1149 process developed pursuant to subsection (3) of this section to request prior
authorization for coverage of drug benefits, and every carrier and pharmacy
benefit management firm shall use that process for prior authorization for
drug benefits.
(b) (I) A
CARRIER OR PBM THAT PROVIDES DRUG BENEFITS UNDER
A HEALTH BENEFIT PLAN SHALL NOT IMPOSE PRIOR AUTHORIZATION
REQUIREMENTS UNDER THE HEALTH BENEFIT PLAN MORE THAN ONCE EVERY
THREE YEARS FOR A DRUG THAT IS APPROVED BY THE
FDA AND THAT IS A
CHRONIC MAINTENANCE DRUG IF THE CARRIER OR
PBM HAS PREVIOUSLY
APPROVED A PRIOR AUTHORIZATION FOR THE COVERED PERSON FOR USE OF
THE CHRONIC MAINTENANCE DRUG
.
(II) T
HIS SUBSECTION (5)(b) DOES NOT APPLY IF:
(A) T
HERE IS EVIDENCE THAT THE AUTHORIZATION WAS OBTAINED
FROM THE CARRIER OR
PBM BASED ON FRAUD OR MISREPRESENTATION ;
(B) F
INAL ACTION BY THE FDA OR OTHER REGULATORY AGENCIES ,
OR THE MANUFACTURER, REMOVES THE CHRONIC MAINTENANCE DRUG FROM
THE MARKET
, LIMITS ITS USE IN A MANNER THAT AFFECTS THE
AUTHORIZATION
, OR COMMUNICATES A PATIENT SAFETY ISSUE THAT WOULD
AFFECT THE AUTHORIZATION ALONE OR IN COMBINATION WITH OTHER
AUTHORIZATIONS
;
(C) A
GENERIC EQUIVALENT OR DRUG THAT IS BIOSIMILAR , AS
DEFINED IN
42 U.S.C. SEC. 262 (i)(2), TO THE PRESCRIBED CHRONIC
MAINTENANCE DRUG IS ADDED TO THE CARRIER
'S OR PBM'S DRUG
FORMULARY
; OR
(D) THE WHOLESALE ACQUISITION COST OF THE CHRONIC
MAINTENANCE DRUG EXCEEDS A DOLLAR AMOUNT AS ESTABLISHED BY THE
COMMISSIONER BY RULE
, WHICH AMOUNT MUST BE NO LESS THAN THIRTY
THOUSAND DOLLARS FOR A TWELVE
-MONTH SUPPLY OR FOR A COURSE OF
TREATMENT THAT IS LESS THAN TWELVE MONTHS IN DURATION
.
(III) N
OTHING IN THIS SUBSECTION (5)(b) REQUIRES A CARRIER OR
PBM TO PAY FOR A BENEFIT:
(A) T
HAT IS NOT A COVERED BENEFIT UNDER THE HEALTH BENEFIT
PAGE 16-HOUSE BILL 24-1149 PLAN; OR
(B) IF THE PATIENT IS NO LONGER A COVERED PERSON UNDER THE
HEALTH BENEFIT PLAN ON THE DATE THE CHRONIC MAINTENANCE DRUG WAS
PRESCRIBED
, DISPENSED, ADMINISTERED, OR DELIVERED.
(IV) A
S USED IN THIS SUBSECTION (5)(b), "CHRONIC MAINTENANCE
DRUG
" HAS THE MEANING SET FORTH IN SECTION 12-280-103 (9.5).
(5.5) (a) N
O LATER THAN JANUARY 1, 2026, A CARRIER OR PBM
SHALL ADOPT A PROGRAM, DEVELOPED IN CONSULTATION WITH PROVIDERS
PARTICIPATING WITH THE CARRIER
, TO ELIMINATE OR SUBSTANTIALLY
MODIFY PRIOR AUTHORIZATION REQUIREMENTS IN A MANNER THAT REMOVES
THE ADMINISTRATIVE BURDEN FOR QUALIFIED PROVIDERS
, AS DEFINED
UNDER THE PROGRAM
, AND THEIR PATIENTS FOR CERTAIN PRESCRIPTION
DRUGS AND RELATED DRUG BENEFITS BASED ON ANY OF THE FOLLOWING
:
(I) T
HE PERFORMANCE OF PROVIDERS WITH RESPECT TO ADHERENCE
TO NATIONALLY RECOGNIZED
, EVIDENCE-BASED MEDICAL GUIDELINES ,
APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY CRITERIA; AND
(II) PROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE
FACTORS
; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE
LIMITED BY PROVIDER SPECIALTY
.
(b) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF
THIS SECTION
:
(I) M
UST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST
PARTICIPATION IN THE PROGRAM
; AND
(II) MAY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO
PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER
SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING FOR
PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO PRESENT
THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN ADHERENCE
TO THE CARRIER
'S OR ORGANIZATION 'S PRIOR AUTHORIZATION
REQUIREMENTS
.
(c) A
T LEAST ANNUALLY, A CARRIER OR PBM SHALL:
PAGE 17-HOUSE BILL 24-1149 (I) REEXAMINE A PROVIDER'S PRESCRIBING OR ORDERING PATTERNS;
(II) R
EEVALUATE THE PROVIDER 'S STATUS FOR EXEMPTION FROM
PRIOR AUTHORIZATION REQUIREMENTS OR FOR INCLUSION IN THE PROGRAM
DEVELOPED PURSUANT TO SUBSECTION
(5.5)(a) OF THIS SECTION; AND
(III) NOTIFY THE PROVIDER OF THE PROVIDER 'S STATUS FOR
EXEMPTION OR INCLUSION IN THE PROGRAM
.
(d) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF
THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO REQUEST
:
(I) A
N EXPEDITED, INFORMAL RESOLUTION OF A CARRIER'S OR PBM'S
FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM
; AND
(II) IF THE MATTER IS NOT RESOLVED THROUGH INFORMAL
RESOLUTION
, BINDING ARBITRATION AS SPECIFIED IN SUBSECTION (5.5)(e) OF
THIS SECTION
.
(e) I
F A PROVIDER REQUESTS BINDING ARBITRATION PURSUANT TO
THE PROCEDURES A CARRIER OR A
PBM DEVELOPS UNDER SUBSECTION
(5.5)(d)(II) OF THIS SECTION, THE FOLLOWING PROVISIONS GOVERN THE
ARBITRATION PROCEDURE
:
(I) T
HE PROVIDER AND CARRIER OR PBM SHALL JOINTLY SELECT AN
ARBITRATOR FROM THE LIST OF ARBITRATORS APPROVED PURSUANT TO
SECTION
10-16-704 (15)(b). NEITHER THE PROVIDER NOR THE CARRIER OR
PBM IS REQUIRED TO NOTIFY THE DIVISION OF THE ARBITRATION OR OF THE
SELECTED ARBITRATOR
.
(II) T
HE SELECTED ARBITRATOR SHALL DETERMINE THE PROVIDER 'S
ELIGIBILITY TO PARTICIPATE IN THE CARRIER
'S OR PBM'S PROGRAM BASED
ON THE PROGRAM CRITERIA DEVELOPED PURSUANT TO SUBSECTION
(5.5)(a)
OF THIS SECTION;
(III) W
ITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
ACCEPTS THE MATTER
, THE PROVIDER AND THE CARRIER OR PBM SHALL
SUBMIT TO THE ARBITRATOR WRITTEN MATERIALS IN SUPPORT OF THEIR
RESPECTIVE POSITIONS
;
PAGE 18-HOUSE BILL 24-1149 (IV) THE ARBITRATOR MAY RENDER A DECISION BASED ON THE
WRITTEN MATERIALS SUBMITTED PURSUANT TO SUBSECTION
(5.5)(e)(III) OF
THIS SECTION OR MAY SCHEDULE A HEARING
, LASTING NOT LONGER THAN
ONE DAY
, FOR THE PROVIDER AND CARRIER OR PBM TO PRESENT EVIDENCE;
(V) W
ITHIN THIRTY DAYS AFTER THE DATE THE ARBITRATOR
RECEIVES THE WRITTEN MATERIALS OR
, IF A HEARING IS CONDUCTED, THE
DATE OF THE HEARING
, THE ARBITRATOR SHALL ISSUE A WRITTEN DECISION
STATING WHETHER THE PROVIDER IS ELIGIBLE FOR THE PROGRAM
; AND
(VI) IF THE ARBITRATOR OVERTURNS THE CARRIER 'S OR PBM'S
FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM
, THE
CARRIER OR
PBM SHALL PAY THE ARBITRATOR'S FEES AND COSTS, AND IF
THE ARBITRATOR AFFIRMS THE CARRIER
'S OR PBM'S FAILURE OR REFUSAL TO
INCLUDE THE PROVIDER IN THE PROGRAM
, THE PROVIDER SHALL PAY THE
ARBITRATOR
'S FEES AND COSTS.
(6) Upon approval by the carrier or pharmacy benefit management
firm, a prior authorization is valid for at least one hundred eighty days
CALENDAR YEAR after the date of approval. If, as a result of a change to the
carrier's formulary, the drug for which the carrier or pharmacy benefit
management firm has provided prior authorization is removed from the
formulary or moved to a less preferred tier status, the change in the status
of the previously approved drug does not affect a covered person who
received prior authorization before the effective date of the change for the
remainder of the covered person's plan year. Nothing in this subsection (6)
limits the ability of a carrier or pharmacy benefit management firm, in
accordance with the terms of the health benefit plan, to substitute a generic
drug, with the prescribing provider's approval and patient's consent, for a
previously approved brand-name drug.
(6.5) T
HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF THIS
SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A PERSON
THAT VIOLATES THIS SECTION
.
SECTION 4. Appropriation. (1) For the 2024-25 state fiscal year,
$36,514 is appropriated to the department of regulatory agencies for use by
the division of insurance. This appropriation is from the division of
insurance cash fund created in section 10-1-103 (3)(a)(I), C.R.S. To
implement this act, the division may use this appropriation as follows:
PAGE 19-HOUSE BILL 24-1149 (a) $29,332 for personal services, which amount is based on an
assumption that the division will require an additional 0.4 FTE; and
(b) $7,182 for operating expenses.
SECTION 5. Act subject to petition - effective date -
applicability. (1) This act takes effect at 12:01 a.m. on the day following
the expiration of the ninety-day period after final adjournment of the
general assembly; except that, if a referendum petition is filed pursuant to
section 1 (3) of article V of the state constitution against this act or an item,
section, or part of this act within such period, then the act, item, section, or
part will not take effect unless approved by the people at the general
PAGE 20-HOUSE BILL 24-1149 election to be held in November 2024 and, in such case, will take effect on
the date of the official declaration of the vote thereon by the governor.
(2) This act applies to conduct occurring on or after January 1, 2026.
____________________________ ____________________________
Julie McCluskie Steve Fenberg
SPEAKER OF THE HOUSE PRESIDENT OF
OF REPRESENTATIVES THE SENATE
____________________________ ____________________________
Robin Jones Cindi L. Markwell
CHIEF CLERK OF THE HOUSE SECRETARY OF
OF REPRESENTATIVES THE SENATE
APPROVED________________________________________
(Date and Time)
_________________________________________
Jared S. Polis
GOVERNOR OF THE STATE OF COLORADO
PAGE 21-HOUSE BILL 24-1149