Second Regular Session
Seventy-fourth General Assembly
STATE OF COLORADO
REVISED
This Version Includes All Amendments Adopted
on Second Reading in the Second House
LLS NO. 24-0046.01 Shelby Ross x4510
SENATE BILL 24-176
Senate Committees House Committees
State, Veterans, & Military Affairs State, Civic, Military, & Veterans Affairs
A BILL FOR AN ACT
C
ONCERNING UPDATING THE TERMINO LOGY THAT REFERS TO AN101
INDIVIDUAL WHO IS ENROLLED IN THE STATE MEDICAL102
ASSISTANCE PROGRAM .103
Bill Summary
(Note: This summary applies to this bill as introduced and does
not reflect any amendments that may be subsequently adopted. If this bill
passes third reading in the house of introduction, a bill summary that
applies to the reengrossed version of this bill will be available at
http://leg.colorado.gov/
.)
Statutory Revision Committee. Current law refers to a
"member", "client", "consumer", and "recipient" interchangeably when
referring to an individual who is enrolled in the state medical assistance
program (medicaid). The bill updates the terminology to refer only to
medicaid "members".
HOUSE
2nd Reading Unamended
April 5, 2024
SENATE
3rd Reading Unamended
March 27, 2024
SENATE
Amended 2nd Reading
March 26, 2024
SENATE SPONSORSHIP
Ginal and Hinrichsen, Buckner, Cutter, Michaelson Jenet, Smallwood, Winter F.
HOUSE SPONSORSHIP
Epps and McLachlan,
Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
Capital letters or bold & italic numbers indicate new material to be added to existing law.
Dashes through the words or numbers indicate deletions from existing law. Be it enacted by the General Assembly of the State of Colorado:1
SECTION 1. In Colorado Revised Statutes, 25.5-1-103, amend2
(6) as follows:3
25.5-1-103. Definitions. As used in this title 25.5, unless the4
context otherwise requires:5
(6) "Recipient" "MEMBER" means any person who has been6
determined eligible to receive benefits or services under this title TITLE7
25.5.8
SECTION 2. In Colorado Revised Statutes, 25.5-1-107, amend9
(1) as follows:10
25.5-1-107. Final agency action - administrative law judge -11
authority of executive director. (1) The executive director may appoint12
one or more persons INDIVIDUALS to serve as administrative law judges13
for the state department pursuant to section 24-4-105 and pursuant to part14
10 of article 30 of title 24 subject to appropriations made to the15
department of personnel. Except as provided in subsection (2) of this16
section, hearings conducted by the administrative law judge are17
considered initial decisions of the state department and shall be reviewed18
by the executive director or a THE EXECUTIVE DIRECTOR'S designee of the19
executive director. In the event SHALL REVIEW THE INITIAL DECISIONS. IF20
exceptions to the initial decision are filed pursuant to section 24-4-10521
(14)(a)(I), the review must be
CONDUCTED in accordance with section22
24-4-105 (15). In the absence of any exception filed pursuant to section23
24-4-105 (14)(a)(I), the executive director
OR THE EXECUTIVE DIRECTOR'S24
DESIGNEE shall review the initial decision in accordance with a procedure25
adopted by the state board. The procedure must be consistent with federal26
176-2- mandates concerning the single state agency requirement. Review by the1
executive director
OR THE EXECUTIVE DIRECTOR'S DESIGNEE in accordance2
with section 24-4-105 (15) or the procedure adopted by the state board3
pursuant to this section constitutes final agency action. The administrative4
law judge may conduct hearings on appeals from decisions of county5
departments of human or social services brought by recipients
MEMBERS6
of and applicants for medical assistance and welfare that are required by7
law in order for the state to qualify for federal funds, and the8
administrative law judge may conduct other hearings for the state9
department. Notice of any such hearing must be served at least ten days10
prior to such THE hearing.11
SECTION 3. In Colorado Revised Statutes, 25.5-1-115, amend12
(3) as follows:13
25.5-1-115. Locating violators - recoveries. (3) Whenever a14
county department, a county board, a district attorney, or the state15
department on behalf of the county recovers any amount of medical16
assistance payments that were obtained through unintentional client17
MEMBER error, the federal government shall be IS entitled to a share18
proportionate to the amount of federal funds paid, unless a different19
amount is provided for by federal law; the state shall be IS entitled to a20
share proportionate to seventy-five percent of the amount of state funds21
paid;
AND the county shall be
IS entitled to a share proportionate to the22
amount of county funds paid, if any, and, in addition, a share23
proportionate to twenty-five percent of the amount of state funds paid.24
SECTION 4. In Colorado Revised Statutes, 25.5-1-115.5, amend25
(1) introductory portion, (1)(a), (1)(b), and (1)(e) as follows:26
25.5-1-115.5. Medical assistance fraud - report.27
176
-3- (1) Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or1
before November 1, 2017, and on or before EACH November 1 each year2
thereafter, the state department shall submit a written report to the joint3
budget committee;
TO the HOUSE OF REPRESENTATIVES judiciary4
committee and the
HOUSE OF REPRESENTATIVES public AND BEHAVIORAL5
health care
and human services committee, of the house of6
representatives, or their successor committees; and to the SENATE7
judiciary committee and the
SENATE health and human services8
committee, of the senate,
or their successor committees, concerning fraud9
in the medicaid program. The state department shall compile a single,10
comprehensive report that includes the information described in this11
subsection (1), as well as information that the attorney general provides12
to the state department pursuant to section 25.5-4-303.3. The state13
department shall report to the general assembly concerning the fraudulent14
receipt of medicaid benefits, including, at a minimum:15
(a) Investigations of client MEMBER fraud during the year;16
(b) Termination of client MEMBER medicaid benefits due to fraud;17
(e) Trends in methods used to commit client MEMBER fraud,18
excluding law enforcement-sensitive information; and19
SECTION 5. In Colorado Revised Statutes, 25.5-1-116, amend20
(1), (2)(c)(I), (2)(c)(III), (2)(d), and (3) as follows:21
25.5-1-116. Records confidential - authorization to obtain22
records of assets - release of location information to law enforcement23
agencies - outstanding felony arrest warrants. (1) The state24
department may establish reasonable rules to provide safeguards25
restricting the use or disclosure of information concerning applicants,26
recipients MEMBERS, and former and potential recipients MEMBERS of27
176
-4- medical assistance to FOR purposes directly connected with the1
administration of such medical assistance and related state department2
activities, and covering INCLUDING the custody, use, and preservation of3
the
STATE'S AND THE COUNTY DEPARTMENTS ' records, papers, files, and4
communications. of the state and county departments.
Whenever, under5
provisions of AS REQUIRED BY law, THE names and addresses of6
applicants for, recipients MEMBERS of, or former and potential recipients7
MEMBERS of medical assistance are furnished to or held by another8
agency or department of government, such THE agency or department9
shall be required to prevent the publication of lists thereof OF THE NAMES10
AND ADDRESSES and their uses PREVENT USING THE NAMES AND11
ADDRESSES for purposes not directly connected with the administration12
of such medical assistance.13
(2) (c) (I) In order to determine if applicants for or recipients14
MEMBERS of medical assistance have assets within eligibility limits, the15
state department may provide a list of information identifying these THE16
applicants or recipients MEMBERS to any financial institution, as defined17
in section 15-15-201 (4), C.R.S., or to any insurance company. This THE18
information
PROVIDED may include identification numbers or social19
security numbers. The state department may require any such
A financial20
institution or insurance company to provide a written statement disclosing21
any assets held on behalf of individuals adequately identified on the list22
provided. Before a termination notice is sent to the recipient MEMBER, the23
county department or the medical assistance site, in verifying the accuracy24
of the information obtained as a result of the match, shall contact the25
recipient MEMBER and inform the recipient MEMBER of the apparent26
results of the computer match and give the recipient MEMBER the27
176
-5- opportunity to explain or correct any erroneous information secured by1
the match. The requirement to run a computerized match shall apply2
APPLIES only to information that is entered in the financial institution's or3
insurance company's data processing system on the date the match is run4
and shall not be deemed to DOES NOT require any such FINANCIAL5
institution or
INSURANCE company to change its data or make new entries6
for the purpose of comparing identifying information. The
STATE7
DEPARTMENT SHALL PAY FOR THE cost of providing such
A computerized8
match. shall be borne by the state department.9
(III) The state department may expend funds appropriated10
pursuant to subparagraph (II) of this paragraph (c) SUBSECTION (2)(c)(II)11
OF THIS SECTION in an amount not to exceed the amount of annualized12
general fund savings that result from the termination of recipients13
MEMBERS from medical assistance specifically due to disclosure of assets14
pursuant to this subsection (2).15
(d) No AN applicant shall MUST NOT be denied nor OR any16
recipient MEMBER MUST NOT BE discontinued due to the disclosure of17
their assets unless and until the county department or medical assistance18
site has assured that such THE assets taken together with other assets19
exceed the limit for eligibility of countable assets. Any information20
concerning assets found may be used to determine if such THE applicant's21
or recipient's MEMBER'S eligibility for other medical assistance is affected. 22
(3) The applicant for or recipient MEMBER of medical assistance,23
or his or her THE APPLICANT'S OR MEMBER'S representative, shall have HAS24
an opportunity to examine all applications and pertinent records25
concerning said THE applicant or recipient which MEMBER THAT constitute26
a basis for denial, modification, or termination of such medical assistance27
176
-6- or to examine such THE records in case of a fair hearing.1
SECTION 6. In Colorado Revised Statutes, 25.5-1-124, amend2
(2) as follows:3
25.5-1-124. Early intervention payment system - participation4
by state department - rules - definitions. (2) The state department shall5
ensure that the early intervention services and payments for recipients6
MEMBERS of medical assistance pursuant to this title 25.5 are integrated7
into the coordinated early intervention payment system developed8
pursuant to part 4 of article 3 of title 26.5. To the extent necessary to9
achieve the coordinated payment system and coverage of those early10
intervention services pursuant to this title 25.5, the state department shall11
amend the state plan for medical assistance or seek the necessary federal12
authorization, promulgate rules, and modify the billing system for13
medical assistance to facilitate the coordinated payment system.14
SECTION 7. In Colorado Revised Statutes, amend 25.5-1-12715
as follows:16
25.5-1-127. Third-party benefit denials information. The state17
department shall provide information to recipients of benefits MEMBERS18
WHO RECEIVE BENEFITS under this title TITLE 25.5 concerning their THE19
MEMBERS' right to appeal a denial of benefits by a third party and shall20
post information on the state department's website concerning recipients'21
MEMBERS' abilities to appeal a third party's denial of benefits, including22
but not limited to providing a link to information on the insurance23
commissioner's website regarding such appeals.24
SECTION 8. In Colorado Revised Statutes, 25.5-1-128, amend25
(2) as follows:26
25.5-1-128. Provider payments - compliance with state fiscal27
176
-7- requirements - definitions - rules. (2) As used in this section, unless the1
context otherwise provides REQUIRES, "provider" means a health-care2
provider, a mental health-care provider, a pharmacist, a home health3
agency, a general provider as defined in section 25.5-3-103 (3),
A school4
district as defined in section 25.5-5-318 (1)(a), or any other entity that5
provides health care, health-care coordination, outreach, enrollment, or6
administrative support services to recipients
MEMBERS through7
fee-for-service, the primary care physician program, a managed care8
entity, a behavioral health organization, a medical home, or any system9
of care that coordinates health care or services as defined and authorized10
through rules promulgated by the state board or by the executive director. 11
SECTION 9. In Colorado Revised Statutes, amend 25.5-1-13012
as follows:13
25.5-1-130. Improving access to behavioral health services for14
individuals at risk of entering the criminal or juvenile justice system15
- duties of the state department. (1) On or before March 1, 2020, the16
state department shall develop measurable outcomes to monitor efforts to17
prevent medicaid recipients MEMBERS from becoming involved in the18
criminal or juvenile justice system.19
(2) On or before July 1, 2021, the state department shall work20
collaboratively with managed care entities to create incentives for21
behavioral health providers to accept medicaid recipients MEMBERS with22
severe behavioral health disorders. The incentives may include, but need23
not be limited to, higher reimbursement rates, quality payments to24
managed care entities for adequate networks, establishing performance25
measures and performance improvement plans related to network26
expansion, transportation solutions to incentivize medicaid recipients27
176
-8- MEMBERS to attend health-care appointments, and incentivizing providers1
to conduct outreach to medicaid recipients MEMBERS to ensure that they2
are engaged in needed behavioral health services, including technical3
assistance with billing procedures. The state department may seek any4
federal authorization necessary to create the incentives described in this5
subsection (2).6
SECTION 10. In Colorado Revised Statutes, 25.5-1-133, amend7
(1) as follows:8
25.5-1-133. Access to behavioral health services for individuals9
under twenty-one years of age - rules - report - repeal. (1) On or10
before July 1, 2024, the state department shall provide recipients11
MEMBERS under twenty-one years of age with access to limited services12
without requiring a diagnosis. The limited services must be provided as13
part of the statewide managed care system pursuant to part 4 of article 514
of this title 25.5 and the school health services detailed in section15
25.5-5-318.16
SECTION 11. In Colorado Revised Statutes, 25.5-1-205, amend17
(2) as follows:18
25.5-1-205. Providing for the efficient provision of health care19
through state-supervised cooperative action - rules. (2) The executive20
director shall facilitate departmental oversight of collaboration among21
providers, medicaid clients MEMBERS and advocates, and payors PAYERS22
that is designed to improve health outcomes and patient satisfaction and23
support the financial sustainability of the medicaid program.24
SECTION 12. In Colorado Revised Statutes, 25.5-1-303, amend25
(3)(b), (3)(c), (3)(d), (3)(e), and (3)(f) as follows:26
25.5-1-303. Powers and duties of the board - scope of authority27
176
-9- - rules. (3) The board shall adopt rules in connection with the programs1
set forth in subsection (1) of this section governing the following:2
(b) The establishment of eligibility requirements for persons3
MEMBERS receiving services from the state department;4
(c) The establishment of the type of benefits that a recipient of5
services may obtain ARE AVAILABLE TO AN APPLICANT if eligibility6
requirements are met, subject to the authorization, requirements, and7
availability of such THE benefits;8
(d) The requirements, obligations, and rights of clients and9
recipients MEMBERS AND APPLICANTS ;10
(e) The establishment of a procedure to resolve disputes that may11
arise between clients MEMBERS and the state department or clients12
MEMBERS and providers;13
(f) The requirements, obligations, and rights of providers,14
including policies and procedures related to provider payments that may15
affect client MEMBER benefits;16
SECTION 13. In Colorado Revised Statutes, 25.5-1-801, amend17
(2) and (5) as follows:18
25.5-1-801. Definitions. As used in this section, unless the19
context otherwise requires:20
(2) "Nonmedical transportation" means transportation to enable21
passengers who are recipients of medicaid MEMBERS to gain access to22
waiver and other community services, activities, and resources.23
(5) "Transportation services" means nonemergency medical24
transportation or nonmedical transportation services provided to medicaid25
recipients MEMBERS.26
SECTION 14. In Colorado Revised Statutes, 25.5-1-802, amend27
176
-10- (1) introductory portion as follows:1
25.5-1-802. Medicaid transportation services - safety and2
oversight - rules. (1) The state department shall collaborate with3
stakeholders, including, but not limited to, disability and member4
CONSUMER advocates, PACE providers operating pursuant to section5
25.5-5-412, transportation brokers, and transportation providers, to6
establish rules and processes for the safety and oversight of nonmedical7
transportation services and nonemergency medical transportation services8
provided to medicaid recipients MEMBERS pursuant to articles 4 to 6 of9
this title 25.5. The rules and processes must:10
SECTION 15. In Colorado Revised Statutes, 25.5-2-101, amend11
(2) as follows:12
25.5-2-101. Old age pension health and medical care fund -13
supplemental old age pension health and medical care fund - cash14
system of accounting - legislative declaration - rules. (2) Any money15
remaining in the state old age pension fund after full payment of basic16
minimum awards to qualified old age pension recipients MEMBERS, and17
after establishment and maintenance of the old age pension stabilization18
fund in the amount of five million dollars, shall MUST be transferred to a19
fund to be known as the old age pension health and medical care fund,20
which is hereby created. The state board shall establish and promulgate21
rules for administration of a program to provide health and medical care22
to persons who qualify to receive old age pensions and who are not23
patients in an institution for tuberculosis or behavioral or mental health24
disorders. The costs of such program, not to exceed ten million dollars in25
any fiscal year, are defrayed from the health and medical care fund, but26
all money available, accrued or accruing, received or receivable, in said27
176
-11- THE health and medical care fund in excess of ten million dollars in any1
fiscal year is transferred to the general fund of the state to be used2
pursuant to law. Money in the old age pension health and medical care3
fund is subject to annual appropriation by the general assembly.4
SECTION 16. In Colorado Revised Statutes, 25.5-2.5-204,5
amend (3)(a) as follows:6
25.5-2.5-204. Eligible prescription drugs - eligible Canadian7
suppliers - eligible importers - distribution requirements. (3) The8
following entities are eligible importers and may obtain imported9
prescription drugs:10
(a) A pharmacist or wholesaler employed by or under contract11
with a medicaid pharmacy, for dispensing to the pharmacy's medicaid12
recipients MEMBERS;13
SECTION 17. In Colorado Revised Statutes, 25.5-3-104, amend14
(2) as follows:15
25.5-3-104. Program for the medically indigent established -16
eligibility - rules. (2) A client's PERSON'S eligibility to receive discounted17
services under the program for the medically indigent shall be IS18
determined by rule of the state board based on a specified percentage of19
the federal poverty line, adjusted for family size, which percentage shall20
MUST not be less than two hundred fifty percent.21
SECTION 18. In Colorado Revised Statutes, 25.5-4-103, amend22
(11), (13), (22), (26), and (28); repeal (21); and add (13.2) as follows: 23
25.5-4-103. Definitions. As used in this article 4 and articles 524
and 6 of this title 25.5, unless the context otherwise requires:25
(11) "Liable" or "liability" means the legal liability of a third26
party, either by reason of judgment, settlement, compromise, or contract,27
176
-12- as the result of negligent acts or other wrongful acts or otherwise for all1
or any part of the medical cost of an injury, a disease, or the disability of2
an applicant for or recipient MEMBER of medical assistance.3
(13) "Medical assistance" means payment on behalf of recipients4
MEMBERS eligible for and enrolled in the STATE MEDICAL ASSISTANCE5
program established in articles 4, 5, and 6 PURSUANT TO THIS ARTICLE 46
AND ARTICLES 5 AND 6 of this title TITLE 25.5, which is funded through7
Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396u-1,8
to
PROVIDERS enrolled providers under
IN the state medical assistance9
program of WHO RENDER OR PROVIDE medical care, services, goods, and10
devices rendered or provided to recipients under this article TO MEMBERS11
PURSUANT TO THIS ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5,12
and other related payments, pursuant to this article ARTICLE 4 and articles13
5 and 6 of this title TITLE 25.5 and the rules of the state department.14
(13.2) "M
EMBER" MEANS A PERSON WHO HAS BEEN DETERMINED15
ELIGIBLE TO RECEIVE BENEFITS UNDER THIS ARTICLE 4 AND ARTICLES 516
AND 6 OF THIS TITLE 25.5.17
(21) "Recipient" means any person who has been determined
18
eligible to receive benefits under this article and articles 5 and 6 of this19
title, whose need for medical care has been professionally established,20
and for whose care less than full payment is available through the legal21
obligation of a contractor, public or private, to pay for or provide such22
care.23
(22) "Recovery" or "amount recovered" means the amount24
payable to the applicant or recipient MEMBER or his THE APPLICANT'S OR25
MEMBER'S heirs, assigns, or legal representatives as the result of any26
liability of a third party.27
176
-13- (26) "Third party" means an individual, institution, corporation,1
or public or private agency which THAT is or may be liable to pay all or2
any part of the medical cost of an injury, a disease, or the disability of an3
applicant for or recipient MEMBER of medical assistance.4
(28) "Transitional medicaid" means the medical assistance5
provided to recipients MEMBERS eligible pursuant to section 25.5-5-1016
(1)(b).7
SECTION 19. In Colorado Revised Statutes, amend 25.5-4-1048
as follows:9
25.5-4-104. State medical assistance program - single state10
agency. (1) The state department, by rules, shall establish a program of11
medical assistance to provide necessary medical care for the categorically12
needy. The state department is hereby designated as the single state13
agency to administer such THE MEDICAL ASSISTANCE program in14
accordance with Title XIX
OF THE FEDERAL "SOCIAL SECURITY ACT" and15
this article
ARTICLE 4 and articles 5 and 6 of this title. Such TITLE 25.5.16
T
HE program shall not be
IS NOT required to furnish recipients TO17
MEMBERS under sixty-five years of age the benefits that are provided to18
recipients MEMBERS sixty-five years of age and over under Title XVIII of19
the social security act FEDERAL "SOCIAL SECURITY ACT", but said THE20
MEDICAL ASSISTANCE program shall MUST otherwise be uniform to the21
extent required by Title XIX of the social security act FEDERAL "SOCIAL22
S
ECURITY ACT".23
(2) The state department may review any decision of a county24
department and may consider any application upon which a decision has25
not been made by the county department within a reasonable time to26
determine the propriety of the action or failure to take timely action on an27
176
-14- application for medical assistance. The state department shall make such1
CONDUCT ANY additional investigation as it the STATE DEPARTMENT2
deems necessary. and shall, After giving the county department an3
opportunity to rebut any THE STATE DEPARTMENT 'S findings or4
conclusions of the state department that the action or delay in taking5
action was a violation of or contrary to state department rules,
THE STATE6
DEPARTMENT SHALL make such
A decision as to the granting of WHETHER7
TO GRANT medical benefits and the amount thereof as in its opinion is8
justifiable OF MEDICAL BENEFITS pursuant to the provisions of this article9
THIS ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5 and the rules10
of the state department. Applicants or recipients MEMBERS affected by11
such THE STATE DEPARTMENT'S decisions, of the state department, upon12
request, shall MUST be given reasonable notice and opportunity for a fair13
hearing by the state department.14
SECTION 20. In Colorado Revised Statutes, amend 25.5-4-10715
as follows:16
25.5-4-107. Retaliation definition. (1) For purposes of any rules17
promulgated by the state department or state board and any action taken18
by the state department against any person, "retaliation" means taking any19
of the following actions against a recipient MEMBER or someone acting on20
behalf of a recipient MEMBER after the recipient MEMBER or someone21
acting on behalf of the recipient MEMBER files a complaint concerning22
services provided or not provided to the recipient MEMBER:23
(a) Indicating to a recipient MEMBER that the recipient MEMBER24
cannot have an advocate, family member, or other authorized25
representative assist the recipient MEMBER; or26
(b) (I) An adverse action that negatively affects a recipient's27
176
-15- MEMBER'S level of eligibility for or receipt of services received at the time1
of the complaint without verification of a change in the recipient's2
MEMBER'S income, resources, or health-care needs that justifies the3
adverse action.4
(II) No AN adverse action shall MUST NOT be taken against a5
recipient MEMBER after a complaint has been filed until the recipient6
MEMBER is notified of the proposed action, informed of the reason for the7
proposed action, and provided an opportunity to appeal the proposed8
action.9
(2) "Retaliation" shall DOES not include instances where WHEN a10
recipient MEMBER is not eligible for a service or program or where WHEN11
a provider documents a problem with a recipient MEMBER and shares the12
documentation with the recipient MEMBER or a third party prior to the13
recipient MEMBER filing a complaint.14
SECTION 21. In Colorado Revised Statutes, 25.5-4-203, amend15
(2) as follows:16
25.5-4-203. Advisory council established. (2) A
DVISORY17
COUNCIL members serve at the pleasure of the governor and receive no18
compensation but are entitled to reimbursement for their
actual and19
necessary expenses. The advisory council shall advise the state20
department on the provision of health and medical care services to21
recipients MEMBERS OF MEDICAL ASSISTANCE .22
SECTION 22. In Colorado Revised Statutes, 25.5-4-205, amend23
(3)(a) introductory portion, (3)(b)(I)(B), (3)(b)(I.5)(A), (3)(e)(I),24
(3)(e)(II)(A), and (3)(e)(II)(B) as follows:25
25.5-4-205. Application - verification of eligibility -26
demonstration project - rules - repeal. (3) (a) The state department27
176
-16- shall promulgate rules to simplify the processing of applications in order1
that medical benefits are furnished to recipients MEMBERS as soon as2
possible, including rules that:3
(b) (I) The state department shall promulgate rules that:4
(B) Require the state department at least annually to verify a5
recipient's MEMBER'S income eligibility at reenrollment through federally6
approved electronic data sources and, if the recipient MEMBER meets all7
eligibility requirements, permit the recipient MEMBER to remain enrolled8
in the
MEDICAL ASSISTANCE program. The rules shall
MUST only require9
an individual to provide documentation verifying income if electronic10
data is not available or the information obtained from electronic data11
sources is not reasonably compatible with information provided by or on12
behalf of an applicant.13
(I.5) (A) If the state department determines that a recipient14
MEMBER was not eligible for medical benefits solely based upon the15
recipient's MEMBER'S income after the recipient MEMBER had been16
determined to be eligible based upon electronic data obtained through a17
federally approved electronic data source, the state department shall not18
pursue recovery from a county department for the cost of medical services19
provided to the recipient MEMBER, and the county department is not20
responsible for any federal error rate sanctions resulting from such THE21
determination.22
(e) (I) In collaboration with and to augment the state department's23
efforts to simplify eligibility determinations for benefits under the state24
medical assistance program and the children's basic health plan, the state25
department shall establish a process so that a recipient, enrollee, MEMBER,26
or the parent or guardian of a recipient or enrollee MEMBER may apply for27
176
-17- reenrollment either over the telephone or through the internet.1
(II) (A) Subject to receipt of federal authorization and spending2
authority, the state department may implement a pilot program that allows3
a limited number of recipients or enrollees MEMBERS to apply for4
reenrollment either over the telephone or through the internet during a5
transition to a process that will serve recipients and enrollees MEMBERS6
statewide. The pilot program shall not serve as IS NOT a replacement for7
a statewide process.8
(B) Notwithstanding any other provision in this paragraph (e)9
SUBSECTION (3)(e), the state department shall not implement this10
paragraph (e) SUBSECTION (3)(e) until it THE STATE DEPARTMENT can11
verify the eligibility of a recipient or enrollee MEMBER over the telephone12
or through the internet as authorized by rules of the state department and13
federal law.14
SECTION 23. In Colorado Revised Statutes, 25.5-4-205.5,15
amend (2) as follows:16
25.5-4-205.5. Confined persons - suspension of benefits.17
(2) Notwithstanding any other provision of law, a person who,18
immediately prior to becoming a confined person, was a recipient19
MEMBER of medical assistance pursuant to this article 4 or article 5 or 620
of this title 25.5, remains eligible for medical assistance while a confined21
person; except that medical assistance may not be furnished pursuant to22
this article 4 or article 5 or 6 of this title 25.5 while the person is a23
confined person unless federal financial participation is available for the24
cost of the assistance, including, but not limited to, juveniles held in a25
facility operated by or under contract to the division of youth services26
established pursuant to section 19-2.5-1501 or the department of human27
176
-18- services. Once a person is no longer a confined person, the person1
continues to be IS eligible for receipt of medical benefits ASSISTANCE2
pursuant to this article 4 or article 5 or 6 of this title 25.5 until the person3
is determined to be ineligible for the receipt of the assistance. To the4
extent permitted by federal law, the time during which a person is a5
confined person is not included in any calculation of when the person6
must recertify his or her RENEW THE PERSON'S eligibility for medical7
assistance pursuant to this article 4 or article 5 or 6 of this title 25.5.8
SECTION 24. In Colorado Revised Statutes, 25.5-4-207, amend9
(1)(a), (1)(b), (1)(c), and (1)(d.5)(I) as follows:10
25.5-4-207. Appeals - rules - applicability. (1) (a) (I) If an11
application for medical assistance is not acted upon within a reasonable12
time after filing of the same THE APPLICATION, or if an application is13
denied in whole or in part, or if medical assistance benefits are14
suspended, terminated, or modified, the applicant or recipient, as the case15
may be, MEMBER may appeal to the state department in the manner and16
form prescribed by the rules of the state department. Except as permitted17
under federal law, state department rules must provide for at least a18
ten-day advance notice before the effective date of any suspension,19
termination, or modification of medical assistance. The county20
DEPARTMENT or designated service agency shall notify the applicant or21
recipient
MEMBER in writing of the basis for the county's decision or22
action and shall inform the applicant or recipient MEMBER of the right to23
a county
DEPARTMENT or service agency conference under the dispute24
resolution process described in paragraph (b) of this subsection (1)
25
SUBSECTION (1)(b) OF THIS SECTION and of the right to a state-level appeal26
and the process for appeal.27
176
-19- (II) The applicant or recipient MEMBER has sixty days after the1
date of the notice to file an appeal. If the recipient MEMBER files an2
appeal prior to the effective date of the intended action, existing medical3
assistance benefits must automatically continue unchanged until the4
appeal process is completed, unless the recipient MEMBER requests in5
writing that medical assistance benefits not continue during the appeal6
process; except that, to the extent authorized by federal law, the state7
department rules may permit existing medical assistance benefits to8
continue until the appeal process is completed even if the recipient's9
MEMBER'S appeal is filed after the effective date of the intended action.10
The state department shall promulgate rules consistent with federal law11
that prescribe the circumstances under which the county
DEPARTMENT or12
designated service agency may continue benefits if an appeal is filed after13
the effective date of the intended action. At a minimum, the rules must14
allow for continuing benefits when the recipient's
MEMBER'S health or15
safety is impacted, the recipient MEMBER was not able to timely respond16
due to the recipient's MEMBER'S disability or employment, the recipient's17
MEMBER'S caregiver was unavailable due to the caregiver's health or18
employment, or the recipient MEMBER did not receive the county's19
COUNTY DEPARTMENT 'S or designated service agency's notice prior to the20
effective date of the intended action.21
(III) Either prior to appeal or as part of the filing of an appeal, the22
applicant or recipient MEMBER may request the dispute resolution process23
described in paragraph (b) of this subsection (1) SUBSECTION (1)(b) OF24
THIS SECTION through the county department or service delivery agency.25
(b) Every county department or service delivery agency shall26
adopt procedures for the resolution of disputes arising between the county27
176
-20- department or the service delivery agency and any applicant for or1
recipient MEMBER of medical assistance. Such THE procedures are2
referred to in this section as the "dispute resolution process". Two or3
more counties may jointly establish the dispute resolution process. The4
dispute resolution process must be consistent with rules promulgated by5
the state board pursuant to article 4 of title 24. C.R.S. The dispute6
resolution process shall MUST include an opportunity for all clients7
MEMBERS to have a county DEPARTMENT conference, upon the client's8
MEMBER'S request, and such THE requirement may be met through a9
telephonic conference upon the agreement of the client MEMBER and the10
county department. The dispute resolution process need not DOES NOT11
NEED TO conform to the requirements of section 24-4-105 C.R.S., as long12
as the rules adopted by the state board include provisions specifically13
setting forth expeditious time frames, notice, and an opportunity to be14
heard and to present information. If the dispute is resolved through the15
county
DEPARTMENT or service delivery agency's dispute resolution16
process and the applicant or recipient
MEMBER has already filed an17
appeal, the county
DEPARTMENT shall inform the applicant or recipient
18
MEMBER of the process for dismissing the appeal.19
(c) The state board shall adopt rules setting forth what other20
issues, if any, may be appealed by an applicant or recipient MEMBER to the21
state department. T
HE STATE DEPARTMENT IS NOT REQUIRED TO GRANT a22
hearing need not be granted
when either state or federal law requires or23
results in a reduction or deletion of a medical assistance benefit unless the24
applicant or recipient MEMBER is arguing that his or her THE APPLICANT'S25
OR MEMBER'S case does not fit within the parameters set forth by the26
change in the law. In notifying the applicant or recipient MEMBER that an27
176
-21- appeal is being denied because of a change in state or federal law, the1
state's STATE DEPARTMENT'S notice must inform the applicant or recipient2
MEMBER that further appeal should be directed to the appropriate state or3
federal court.4
(d.5) (I) At the commencement of a hearing that concerns the5
termination or reduction of an existing benefit, the state department's6
administrative law judge shall review the legal sufficiency of the notice7
of action from which the recipient MEMBER is appealing. If the8
administrative law judge determines that the notice is legally insufficient,9
the administrative law judge shall inform the appellant that the10
termination or reduction may be set aside on the basis of insufficient11
notice without proceeding to a hearing on the merits. The appellant may12
affirmatively waive the defense of insufficient notice and agree to13
proceed with a hearing on the merits or may ask the administrative law14
judge to decide the appeal on the basis of his or her THE JUDGE'S finding15
that the notice is legally insufficient. The administrative law judge shall16
also inform the appellant that the state department may issue legally17
sufficient notice in the future and that the state department may seek18
recoupment of benefits if a basis for denial or reduction of benefits is19
subsequently determined.20
SECTION 25. In Colorado Revised Statutes, 25.5-4-209, amend21
(1)(a), (1)(b), (3)(a), and (3)(d) as follows:22
25.5-4-209. Payments by third parties - copayments by23
members - review - appeal - children's waiting list reduction fund -24
rules - repeal. (1) (a) Any recipient MEMBER receiving benefits under25
this article PURSUANT TO THIS ARTICLE 4 or article 5 or 6 of this title TITLE26
25.5 who receives any supplemental income, available for medical27
176
-22- purposes under rules of the state department, or who receives proceeds1
from sickness, accident, health, or casualty insurance, shall MUST apply2
the supplemental income or insurance proceeds to the cost of the benefits3
rendered, and the
STATE DEPARTMENT rules may require reports from4
providers of other payments received by them
from or on behalf of5
recipients MEMBERS.6
(b) Subject to any limitations imposed by Title XIX
OF THE7
FEDERAL "SOCIAL SECURITY ACT", a recipient
MEMBER shall pay at the8
time of service a portion of the cost of any medical benefit rendered to the9
recipient MEMBER or to the recipient's MEMBER'S dependents pursuant to10
this article 4 or article 5 or 6 of this title 25.5, as determined by rules of11
the state department.12
(3) (a) The rights assigned by a recipient MEMBER of medical13
assistance to the state department pursuant to section 25.5-4-205 (4) shall14
MUST include the right to appeal an adverse coverage decision by a third15
party for which the medical assistance program may be responsible for16
payment, including but not limited to the internal and external reviews17
provided for DESCRIBED in sections 10-16-113 and 10-16-113.5 C.R.S.,18
and a third party's reasonable appeal procedure under state and federal19
law. The state department or the independent contractor retained pursuant20
to paragraph (b) of this subsection (3) SUBSECTION (3)(b) OF THIS SECTION21
shall review and, if necessary, may appeal at any level an adverse22
coverage decision, except an adverse coverage decision relating to23
medicare, Title XVIII of the federal "Social Security Act", as amended.24
(d) Nothing in this subsection (3) shall be construed to authorize25
AUTHORIZES the denial of or delay of payment to a provider by the state26
department or the delay or interference with the provision of services to27
176
-23- a medical assistance recipient MEMBER.1
SECTION 26. In Colorado Revised Statutes, amend 25.5-4-2102
as follows:3
25.5-4-210. Purchase of health insurance for members.4
(1) (a) The state department shall purchase group health insurance for a5
medical assistance recipient MEMBER who is eligible to enroll for such6
coverage if enrollment of such recipient THE MEMBER in the group plan7
would be cost-effective. In addition, the state department may purchase8
individual health insurance for a medical assistance recipient MEMBER9
who is eligible to enroll in a health insurance plan if enrollment of such10
recipient THE MEMBER would be cost-effective to this state. A11
determination of cost-effectiveness shall MUST be in accordance with12
federal guidelines established by the secretary of the United States13
FEDERAL department of health and human services.14
(b) Notwithstanding any provision of paragraph (a) of this15
subsection (1) SUBSECTION (1)(a) OF THIS SECTION to the contrary, the16
state department, in purchasing health insurance for medical assistance17
recipients MEMBERS who are eligible to enroll for private coverage, shall18
not purchase such health insurance for more than two thousand19
individuals.20
(2) Enrollment in a group health insurance plan shall be IS21
required of recipients MEMBERS for whom enrollment has been22
determined to be cost-effective as a condition of obtaining or retaining23
medical assistance. A parent shall be IS required to enroll a dependent24
child recipient MEMBER, but medical assistance for such THE child shall25
not be IS NOT discontinued if a parent fails to enroll the child.26
(3) The state department shall pay any premium, deductible,27
176
-24- coinsurance, or other cost-sharing obligation required under the group1
plan for services covered under the state medical assistance plan. In2
addition, the state department shall pay any premium, deductible,3
coinsurance, or other cost-sharing obligation required under an individual4
plan purchased by the state department for a medical assistance recipient5
MEMBER pursuant to subsection (1) of this section. Payment of said THE6
services shall be ARE treated as payment for medical assistance. Coverage7
provided by the purchased health insurance plan shall be IS considered as8
third-party liability for the purposes of section 25.5-4-209.9
(4) Services not available to a recipient MEMBER under the10
purchased plan shall be ARE provided to the recipient if such MEMBER IF11
THE services would otherwise be provided as medical assistance services12
pursuant to this article ARTICLE 4 or article 5 or 6 of this title TITLE 25.5.13
Nothing in this section shall be construed to require that REQUIRES14
services provided under a group health insurance plan for medical15
assistance recipients shall TO be made available to recipients MEMBERS16
not enrolled in the plan. Enrollment in a group health insurance plan17
pursuant to this section shall DOES not affect the eligibility of a recipient18
MEMBER who otherwise qualifies for medical assistance pursuant to this19
article ARTICLE 4 or article 5 or 6 of this title TITLE 25.5.20
SECTION 27. In Colorado Revised Statutes, amend 25.5-4-21221
as follows:22
25.5-4-212. Medicaid member correspondence improvement23
process - legislative declaration - definition. (1) (a) The general24
assembly finds and declares that:25
(I) Accurate, understandable, timely, informative, and clear26
correspondence from the state department is critical to the life and health27
176
-25- of medicaid recipients, MEMBERS AND APPLICANTS and, in some cases, is1
a matter of life and death for our most vulnerable populations;2
(II) Unclear, confusing, and late correspondence from the state3
department causes an increased workload for the state, counties4
administering the medicaid program, and nonprofit advocacy groups5
assisting clients APPLICANTS AND MEMBERS ; and6
(III) Government should be a good steward of taxpayers' money,7
ensuring that it is spent in the most cost-effective manner.8
(b) Therefore, the general assembly finds that improving medicaid9
client MEMBER correspondence is critical to the health and safety of10
medicaid clients MEMBERS and will reduce unnecessary confusion that11
requires clients MEMBERS to call counties and the state department or file12
appeals.13
(2) As used in this section, unless the context otherwise requires,14
"client MEMBER correspondence" means any communication the purpose15
of which is to provide notice of an approval, denial, termination, or16
change to an individual's medicaid eligibility; to provide notice of the17
approval, denial, reduction, suspension, or termination of a medicaid18
benefit; or to request additional information that is relevant to19
determining an individual's medicaid eligibility or benefits. Client20
"M
EMBER correspondence" does not include communications regarding21
the state department's review of trusts or review of documents or records22
relating to trusts.23
(3) The state department shall improve medicaid client
MEMBER24
correspondence by ensuring that client MEMBER correspondence revised25
or created after January 1, 2018:26
(a) Is written using person-first, plain language;27
176
-26- (b) Is written in a format that includes the date of the1
correspondence and a client MEMBER greeting;2
(c) Is consistent, using the same terms throughout to the extent3
practicable, including commonly used program names;4
(d) Is accurately translated into the second most commonly spoken5
language in the state if a client MEMBER indicates that this THE LANGUAGE6
is the client's MEMBER'S written language of preference or as required by7
law;8
(e) Includes a statement translated into the top fifteen languages9
most commonly spoken by individuals in Colorado with limited English10
proficiency informing an applicant or client MEMBER how to seek further11
assistance in understanding the content of the correspondence;12
(f) Clearly conveys the purpose of the client APPLICANT OR13
MEMBER correspondence, the action or actions being taken by the state14
department or its THE STATE DEPARTMENT'S designated entity, if any, and15
the specific action or actions that the client must APPLICANT OR MEMBER16
SHALL or may take in response to the correspondence;17
(g) Includes a specific description of any necessary information18
or documents requested from the applicant or client MEMBER;19
(h) Includes contact information for client APPLICANT OR MEMBER20
questions; and21
(i) Includes a specific and plain language explanation of the basis22
for the denial, reduction, suspension, or termination of the benefit, if23
applicable.24
(4) Subject to the availability of sufficient appropriations and25
receipt of federal financial participation, on and after July 1, 2018, the26
state department shall make electronically available to a client MEMBER27
176
-27- specific and detailed information concerning the client's MEMBER'S1
household composition, assets, income sources, and income amounts, if2
relevant to a determination for which client MEMBER correspondence was3
issued. If implemented, the state department shall notify clients MEMBERS4
in the written correspondence of the option to access this information.5
(5) The state department is encouraged to promote the receipt of6
client MEMBER correspondence electronically or through mobile7
applications for clients MEMBERS who choose those methods of delivery8
as allowed by law.9
(6) As part of its ongoing process to create and improve client10
MEMBER correspondence, the state department may engage with experts11
in written communication and plain language to test client MEMBER12
correspondence against the criteria set forth in subsection (3) of this13
section with a geographically diverse and representative sample of14
medicaid clients MEMBERS relevant to the client MEMBER correspondence15
being revised. The state department shall also develop a process to review16
and consider feedback from stakeholders including client CONSUMER17
advocates and counties prior to implementing significant changes to18
correspondence.19
(7) The state department shall ensure that client APPLICANT OR20
MEMBER correspondence that may only affect a small number of clients21
APPLICANTS OR MEMBERS, but may, nonetheless, have a significant impact22
on the lives of those clients APPLICANTS OR MEMBERS, is appropriately23
prioritized for revision.24
(8) As part of its annual presentation made to its legislative25
committee of reference pursuant to section 2-7-203, the state department26
shall present information concerning:27
176
-28- (a) Its THE STATE DEPARTMENT 'S process for ongoing1
improvement of client MEMBER correspondence;2
(b) Client MEMBER correspondence revised pursuant to criteria set3
forth in subsection (3) of this section during the prior year and client4
MEMBER correspondence improvements that are planned for the upcoming5
year; and6
(c) A description of the results of testing of new or significantly7
revised client MEMBER correspondence pursuant to subsection (6) of this8
section, including a description of the stakeholder feedback.9
SECTION 28. In Colorado Revised Statutes, amend 25.5-4-21310
as follows:11
25.5-4-213. Audit of medicaid member correspondence -12
definition. (1) As used in this section, unless the context otherwise13
requires, "client MEMBER correspondence" has the same meaning as14
defined in section 25.5-4-212.15
(2) During the 2020 calendar year and the 2023 calendar year, the16
office of the state auditor shall conduct or cause to be conducted a17
performance audit of client MEMBER correspondence. Thereafter, the state18
auditor, in the exercise of his or her THE STATE AUDITOR'S discretion, may19
conduct or cause to be conducted additional performance audits of client20
MEMBER correspondence pursuant to this section. The audit shall MUST21
include correspondence generated through the Colorado benefits22
management system, as well as correspondence that is not generated23
through the Colorado benefits management system.24
(3) The performance audit conducted pursuant to this section shall25
MUST include:26
(a) A review of available data from counties,
FROM the STATE27
176
-29- department's customer service contract center, and from assistors within1
the health benefit exchange, created in article 22 of title 10, regarding2
customer service contacts that are related to client MEMBER OR APPLICANT3
confusion regarding correspondence received by medicaid clients4
MEMBERS or applicants;5
(b) A review of the accuracy of client MEMBER correspondence at6
the time it THE CORRESPONDENCE is generated;7
(c) A review of whether client MEMBER correspondence satisfies8
the requirements of any state or federal law, rule, or regulation relating to9
the sufficiency of any notice;10
(d) A review of any client MEMBER correspondence testing11
process conducted by the
STATE department and whether testing is done12
prior to implementing new or significantly revised client communications
13
MEMBER CORRESPONDENCE ;14
(e) A review of the results of any client MEMBER correspondence15
testing, including client MEMBER comprehension of the intended purpose16
or purposes of the correspondence; and17
(f) A review of the accuracy of client MEMBER income and18
household composition information that is communicated electronically,19
if applicable.20
(4) If audit findings include findings that information contained21
in client MEMBER correspondence is inaccurate at the time the22
correspondence was generated, the audit shall MUST identify, if possible,23
the source of the inaccurate information, which may include but is not24
limited to computer system or interface issues, county input error, or25
applicant error.26
(5) Based on the findings and conclusions identified during the27
176
-30- performance audit conducted pursuant to this section, the office of the1
state auditor shall make recommendations to the state department for2
improving client MEMBER correspondence. On or before December 30,3
2020, December 30, 2023, and December 30 in any calendar year in4
which an audit is conducted pursuant to this section, the office of the state5
auditor shall submit the findings, conclusions, and recommendations from6
the performance audit in the form of a written report to the legislative7
audit committee, which shall hold a public hearing for the purposes of a8
review of REVIEWING the report. The report shall MUST also be submitted9
to the joint budget committee, the public health care and human services10
committee of the house of representatives, the health and human services11
committee of the senate, and the joint technology committee, or any12
successor committees.13
SECTION 29. In Colorado Revised Statutes, amend14
25.5-4-300.4 as follows:15
25.5-4-300.4. Last resort for payment - legislative intent. It is16
the intent of the general assembly that medicaid be IS the last resort for17
payment for medically necessary goods and services furnished to18
recipients MEMBERS and that all other sources of payment are primary to19
medical assistance provided by medicaid.20
SECTION 30. In Colorado Revised Statutes, 25.5-4-300.9,21
amend (1)(a)(VI), (1)(a)(VII), (1)(a)(VIII), (1)(b), (2), (4)(a), (4)(f),22
(4)(g), (4)(h), (5), (6), and (7) as follows:23
25.5-4-300.9. Explanation of benefits - medicaid members -24
legislative declaration. (1) (a) The general assembly finds and declares25
that:26
(VI) While creating an explanation of benefits is not without cost27
176
-31- to the health-care system, only the client MEMBER receiving medical1
services or his or her THE MEMBER'S authorized representative is in the2
position to verify whether the claimed medical services were actually3
provided and for whom they were provided, which is a necessary first4
step in containing health-care costs;5
(VII) While medicaid clients MEMBERS may not appear to be6
affected financially by billing errors or fraudulent claims, medicaid7
clients MEMBERS who rely on these services for survival and8
independence are most severely affected by the inappropriate use of9
scarce resources; and10
(VIII) Further, medicaid clients MEMBERS and medicaid11
CONSUMER advocates for low-income and vulnerable Coloradans want the12
opportunity to partner with the state department and providers to ensure13
a well-run and fraud-free medicaid program in Colorado.14
(b) Therefore, the general assembly declares that creating an15
explanation of benefits for recipients MEMBERS of medicaid-funded16
services is a necessary step in managing the state's medicaid program and17
in safeguarding the significant public investment, both state and federal,18
in meeting the health-care needs of low-income and vulnerable19
Coloradans.20
(2) By ON or before July 1, 2017, the state department shall21
develop and implement an explanation of benefits for recipients MEMBERS22
of medical services pursuant to articles 4 to 6 of this title THIS ARTICLE 423
AND ARTICLE 5 OR 6 OF THIS TITLE 25.5. The purpose of the explanation24
of benefits is to inform a medicaid client MEMBER of a claim for25
reimbursement made for services provided to the client MEMBER or on his26
or her THE MEMBER'S behalf, so that the client MEMBER may discover and27
176
-32- report administrative or provider errors or fraudulent claims for1
reimbursement.2
(4) The explanation of benefits must include, at a minimum:3
(a) The name of the medicaid client MEMBER receiving the4
service;5
(f) A clear statement to the medicaid client MEMBER that the6
explanation of benefits is not a bill, but is only provided for the client's7
MEMBER'S information and to make sure that a provider is being8
reimbursed only for services actually provided;9
(g) Information regarding at least one verbal and one written10
method for the medicaid client MEMBER to report errors in the explanation11
of benefits that are relevant to provider reimbursement; and12
(h) Any other information that the state department determines is13
useful to the medicaid client MEMBER or for purposes of discovering14
administrative or provider error or fraud.15
(5) The state department shall develop the form and content of the16
explanation of benefits in conjunction with medicaid clients MEMBERS17
and medicaid CONSUMER advocates to ensure that medicaid clients18
MEMBERS understand the information provided and the purpose of the19
explanation of benefits. The state department shall also work with20
medicaid clients MEMBERS and medicaid CONSUMER advocates to develop21
educational materials for the state department's website and for22
distribution by advocacy and nonprofit organizations that explain the23
process for reporting errors and encourage clients MEMBERS to take24
responsibility for reporting errors. 25
(6) The state department shall provide the explanation of benefits26
to a medicaid client MEMBER not less frequently than once every two27
176
-33- months, if services have been provided to or on behalf of the client1
MEMBER during that time period. The state department shall determine the2
most cost-effective means for producing and distributing the explanation3
of benefits to medicaid clients MEMBERS, which may include e-mail or4
web-based distribution, with mailed copies by request only. Further, the5
state department may include the explanation of benefits with an existing6
mailing or existing electronic or web-based communication to medicaid7
clients MEMBERS.8
(7) Nothing in this section requires the state department to9
produce an explanation of benefits form if the information required to be10
included in the explanation of benefits pursuant to subsection (4) of this11
section is already included in another format that is understandable to the12
medicaid client MEMBER.13
SECTION 31. In Colorado Revised Statutes, 25.5-4-301, amend14
(1), (2)(a)(II), (4), (5), (6), (7), (8), (9), (10), (11)(a), (11)(c), (12)(b), and15
(15)(a) as follows:16
25.5-4-301. Recoveries - overpayments - penalties - interest -17
adjustments - liens - review or audit procedures - repeal.18
(1) (a) (I) Except as provided in section 25.5-4-302 and subparagraph19
(III) of this paragraph (a), no recipient SUBSECTION (1)(a)(III) OF THIS20
SECTION, A MEMBER or estate of the recipient shall be MEMBER IS NOT21
liable for the cost or the cost remaining after payment by medicaid,22
medicare, or a private insurer of medical benefits authorized by Title XIX23
of the social security act FEDERAL "SOCIAL SECURITY ACT", by this title24
TITLE 25.5, or by rules promulgated by the state board, which benefits are25
rendered to the recipient MEMBER by a provider of medical services26
authorized to render such THE service in the state of Colorado, except27
176
-34- those contributions required pursuant to section 25.5-4-209 (1). However,1
a recipient MEMBER may enter into a documented agreement with a2
provider under which the recipient MEMBER agrees to pay for items or3
services that are nonreimbursable under the medical assistance program.4
Under these circumstances, a recipient MEMBER is liable for the cost of5
such THE services and items.6
(II) The provisions of subparagraph (I) of this paragraph (a) shall7
SUBSECTION (1)(a)(I) OF THIS SECTION apply regardless of whether8
medicaid has actually reimbursed the provider and regardless of whether9
the provider is enrolled in the Colorado medical assistance program.10
(II.5) (A) A provider of medical services who bills or seeks11
collection through a third party from a recipient MEMBER or the estate of12
a recipient MEMBER for medical services authorized by Title XIX of the13
social security act FEDERAL "SOCIAL SECURITY ACT" in an amount in14
violation of subsection (1)(a)(I) of this section is liable for and subject to15
the following: A refund to the recipient MEMBER of any amount16
unlawfully received from the recipient MEMBER, plus statutory interest17
from the date of the receipt until the date of repayment; a civil monetary18
penalty of one hundred dollars for each violation of subsection (1)(a)(I)19
of this section; and all amounts submitted to a collection agency in the20
name of the medicaid recipient MEMBER. When determining income or21
resources for purposes of determining eligibility or benefit amounts for22
any state-funded program under this title 25.5, the state department shall23
exclude from consideration any money received by a recipient MEMBER24
pursuant to this subsection (1)(a)(II.5). The imposition of a civil monetary25
penalty by the state department may be appealed administratively.26
(A.5) A provider of medical services who, within thirty days of27
176
-35- notification by the state department, or longer if approved by the state1
department, voids the bill, returns any amount unlawfully received, and2
makes every reasonable effort to resolve any collection actions so that the3
recipient MEMBER or the estate of the recipient MEMBER has no adverse4
financial consequences is not subject to the provisions of subsection5
(1)(a)(II.5)(A) of this section.6
(B) In order to establish a claim for the civil monetary penalty7
established by subsection (1)(a)(II.5)(A) of this section, a recipient8
MEMBER or the estate of a recipient MEMBER, or a person acting on behalf9
of a recipient MEMBER or the estate of a recipient MEMBER, shall notify10
the state department.11
(C) The provisions of this subparagraph (II.5) shall SUBSECTION12
(1)(a)(II.5)
DO not apply to a long-term care facility licensed pursuant to13
section 25-3-101. C.R.S.
14
(D) The provisions of subsection (1)(a)(II.5)(A) of this section15
shall DO not apply if a recipient MEMBER knowingly misrepresents his or16
her THE MEMBER'S medicaid coverage status to a provider of medical17
services and the provider submits documentation to the state department18
that the recipient MEMBER knowingly misrepresented his or her THE19
MEMBER'S medicaid coverage status and the documentation clearly20
establishes a good cause basis for granting an exception to the provider.21
(III) (A) When a third party is primarily liable for the payment of22
the costs of a recipient's MEMBER'S medical benefits, prior to receiving23
nonemergency medical care, the recipient MEMBER shall comply with the24
protocols of the third party, including using providers within the third25
party's network or receiving a referral from the recipient's MEMBER'S26
primary care physician. Any recipient MEMBER failing to follow the third27
176
-36- party's protocols is liable for the payment or cost of any care or services1
that the third party would have been liable to pay; except that, if the third2
party or the service provider substantively fails to communicate the3
protocols to the recipient MEMBER, the items or services are4
nonreimbursable under this article ARTICLE 4 and articles 5 and 6 of this5
title TITLE 25.5 and the recipient MEMBER is not liable to the provider.6
(B) A recipient MEMBER may enter into a written agreement with7
a third party or provider under which the recipient MEMBER agrees to pay8
for items provided or services rendered that are outside of the network or9
plan protocols. The recipient's MEMBER'S agreement to be personally10
liable for such nonemergency, nonreimbursable items shall MUST be11
recorded on forms approved by the state board and signed and dated by12
both the recipient MEMBER and the provider in advance of the services13
being rendered.14
(b) Recipient MEMBER income applied pursuant to section15
25.5-4-209 (1) does not disqualify any recipient MEMBER, as defined in16
section 26-2-103 (8), from receiving benefits pursuant to this article 4,17
article 5 or 6 of this title 25.5, or public assistance pursuant to article 2 of18
title 26, and does not disqualify an individual from receiving child care19
assistance pursuant to part 1 of article 4 of title 26.5. If, at any time during20
the continuance of medical benefits, the recipient MEMBER becomes21
possessed GAINS POSSESSION of property having a value in excess of that22
amount set by law or by the rules of the state department or receives any23
increase in income, it is the duty of the recipient to THE MEMBER SHALL24
notify the county department thereof, and the county department may,25
after investigation, either revoke such THE medical benefits or alter the26
amount thereof OF MEDICAL BENEFITS, as the circumstances may require.27
176
-37- (c) Any medical assistance paid to which a recipient MEMBER was1
not lawfully entitled shall be IS recoverable from the recipient MEMBER2
or the estate of the recipient MEMBER by the county as a debt due the state3
pursuant to section 25.5-1-115, but no lien may be imposed against the4
property of a recipient MEMBER on account of medical assistance paid or5
to be paid on the recipient's MEMBER'S behalf under this article ARTICLE6
4 or article 5 or 6 of this title TITLE 25.5, except pursuant to the judgment7
of a court of competent jurisdiction or as provided by section 25.5-4-302.8
(d) If any such medical assistance was obtained fraudulently,9
interest shall MUST be charged and paid to the county department on the10
amount of such THE medical assistance calculated at the legal rate and11
calculated from the date that payment for medical services rendered on12
behalf of the recipient MEMBER is made to the date such THE amount is13
recovered.14
(2) Any overpayment to a provider, including those of personal15
needs funds made pursuant to section 25.5-6-206, are recoverable16
regardless of whether the overpayment is the result of an error by the state17
department, a county department of human or social services, an entity18
acting on behalf of either department, or by the provider or any agent of19
the provider as follows:20
(a) (II) If the state department makes a determination that such21
THE overpayment has been made for some other reason than a false22
representation by the provider specified in subparagraph (I) of this23
paragraph (a) SUBSECTION (2)(a)(I) OF THIS SECTION, the state department24
may collect the amount of overpayment, plus interest accruing at the25
statutory rate from the date the provider is notified of such THE26
overpayment, by the means specified in this subsection (2). Pursuant to27
176
-38- the criteria established in rules promulgated by the state board, the state1
department may waive the recovery or adjustment of all or part of the2
overpayment and accrued interest specified in this subparagraph (II)3
SUBSECTION (2)(a)(II) if it would be inequitable, uncollectible or4
administratively impracticable; except that no action shall be taken5
against a recipient MEMBER of medical services initially determined to be6
eligible pursuant to section 25.5-4-205 if the overpayment occurred7
through no fault of the recipient MEMBER. Amounts remaining8
uncollected for more than five years after the last repayment was made9
may be considered uncollectible.10
(4) If medical assistance is furnished to or on behalf of a recipient11
MEMBER pursuant to the provisions of this article ARTICLE 4 and articles12
5 and 6 of this title TITLE 25.5 for which a third party is liable, the state13
department has an enforceable right against such THE third party for the14
amount of such medical assistance, including the lien right specified in15
subsection (5) of this section. Whenever the recipient MEMBER has16
brought or may bring an action in court to determine the liability of the17
third party, the state department, without any other name, title, or18
authority to enforce the state department's right, may enter into19
appropriate agreements and assignments of rights with the recipient20
MEMBER and the recipient's MEMBER'S attorney, if any. Any such21
agreement shall MUST be filed with the court in which such an THE action22
is pending. The attorney named in such an THE agreement upon23
designation as a special assistant attorney general by the attorney general24
shall have the right to prove both the recipient's MEMBER'S claim and the25
state department's claim. The state department, without any other name,26
title, or authority, may take any necessary action to determine the27
176
-39- existence and amount of the state department's claims under this section,1
whether such THE claims are founded on judgment, contract, lien, or2
otherwise, and take any other action that is appropriate to recover from3
such third parties. To enforce such THE right, the attorney general,4
pursuant to section 24-31-101, C.R.S., on behalf of the state department5
may institute and prosecute, or intervene of right in legal proceedings6
against the third party having legal liability, either in the name of the state7
department or in the name of the recipient or his or her MEMBER OR THE8
MEMBER'S assignee, guardian, personal representative, estate, or9
survivors. When the state department intervenes in legal proceedings10
against the third party, it shall THE STATE DEPARTMENT IS not be liable for11
any portion of the attorney fees or costs of the recipient MEMBER.12
(5) (a) When the state department has furnished medical13
assistance to or on behalf of a recipient MEMBER pursuant to the14
provisions of this article, and ARTICLE 4 OR articles 5 and 6 of this title15
TITLE 25.5, for which a third party is liable, the state department shall16
have HAS an automatic statutory lien for all such medical assistance. The17
state department's lien shall be IS against any judgment, award, or18
settlement in a suit or claim against such THE third party and shall be IS19
in an amount that shall be IS the fullest extent allowed by federal law as20
applicable in this state, but not to exceed the amount of the medical21
assistance provided.22
(b) No judgment, award, or settlement in any action or claim by23
a recipient MEMBER to recover damages for injuries, where IN WHICH the24
state department has a lien, shall be IS satisfied without first satisfying the25
state department's lien. Failure by any party to the judgment, award, or26
settlement to comply with this section shall make MAKES each such party27
176
-40- liable for the full amount of medical assistance furnished to or on behalf1
of the recipient MEMBER for the injuries that are the subject of the2
judgment, award, or settlement.3
(c) Except as otherwise provided in this article ARTICLE 4, the4
entire amount of any judgment, award, or settlement of the recipient's5
MEMBER'S action or claim, with or without suit, regardless of how6
characterized by the parties, shall be IS subject to the state department's7
lien.8
(d) Where WHEN the action or claim is brought by the recipient9
MEMBER alone and the recipient MEMBER incurs a personal liability to pay10
attorney fees, the state department will SHALL pay its THE STATE11
DEPARTMENT'S reasonable share of attorney fees not to exceed12
twenty-five percent of the state department's lien. The state department13
shall not be IS NOT liable for costs.14
(e) The state department's right to recover under this section is15
independent of the recipient's MEMBER'S right.16
(6) When the applicant or recipient MEMBER, or his or her THE17
APPLICANT'S OR MEMBER'S guardian, executor, administrator, or other18
appropriate representative, brings an action or asserts a claim against any19
third party, such THE person shall give to the state department written20
notice of the action or claim by personal service or certified mail within21
fifteen days after filing the action or asserting the claim. Failure to22
comply with this subsection (6) shall make MAKES the recipient MEMBER,23
legal guardian, executor, administrator, attorney, or other representative24
liable for the entire amount of medical assistance furnished to or on25
behalf of the recipient MEMBER for the injuries that gave rise to the action26
or claim. The state department may, after thirty days' written notice to27
176
-41- such THE person, enforce its THE STATE DEPARTMENT 'S rights under1
subsection (5) of this section and this subsection (6) in the district court2
of the city and county of Denver; except that liability of a person other3
than the recipient shall exist MEMBER EXISTS only if such THE person had4
knowledge that the recipient MEMBER had received medical assistance or5
if excusable neglect is found by the court. The court shall award the state6
department its costs and attorney fees incurred in the prosecution of any7
such action.8
(7) When a legally responsible relative of the recipient MEMBER9
agrees or is ordered to provide medical support or health insurance10
coverage for his or her THE MEMBER'S dependents or other persons, and11
such THE dependents are applicants for, recipients MEMBERS of, or12
otherwise entitled to receive medical assistance pursuant to this article13
ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5, the state department14
shall be IS subrogated to any rights that the responsible persons may have15
to obtain reimbursement from a third party or insurance carrier for the16
cost of medical assistance provided for such dependents or persons.17
Where WHEN the state department gives written notice of subrogation,18
any third party or insurance carrier liable for reimbursement for the cost19
of medical care shall accord to the state department all rights and benefits20
available to the responsible relative that pertain to the provision of21
medical care to any persons entitled to medical assistance pursuant to this22
article ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5 for whom the23
relative is legally responsible.24
(8) All recipients MEMBERS of medical assistance under the25
medicaid program shall be ARE deemed to have authorized their THE26
MEMBER'S attorneys, all third parties, including but not limited to27
176
-42- insurance companies, and providers of medical care to release to the state1
department all information needed by the state department to secure and2
enforce its rights under subsections (4) and (5) of this section.3
(9) Nothing in part 6 of article 4 of title 10 C.R.S., shall be4
construed to limit LIMITS the right of the state department to recover the5
medical assistance furnished to or on behalf of a recipient MEMBER as the6
result of the negligence of a third party.7
(10) No action taken by the state department pursuant to8
subsection (4) of this section or any judgment rendered in such action9
shall be a bar to THE ACTION BARS any action upon the claim or cause of10
action of the applicant or recipient MEMBER or his or her THE MEMBER'S11
guardian, personal representative, estate, dependent, or survivors against12
the third party having legal liability, nor shall any such action or judgment13
operate to deny the applicant or recipient MEMBER the recovery for that14
portion of his or her THE MEMBER'S medical costs or other damages not15
provided as medical assistance under this article ARTICLE 4 or article 5 or16
6 of this title TITLE 25.5.17
(11) (a) The state department shall have a right to MAY recover18
any amount of medical assistance paid on behalf of a recipient MEMBER19
because:20
(I) The trustee of a trust for the benefit of the recipient MEMBER21
has used the trust property in a manner contrary to the terms of the trust;22
OR23
(II) A person holding the recipient's
MEMBER'S power of attorney24
has used the power for purposes other than the benefit of the recipient25
MEMBER.26
(c) No action taken by the county or state department pursuant to27
176
-43- this subsection (11) or any judgment rendered in such AN action or1
proceeding shall be a bar to BARS any action upon the claim or cause of2
action of the recipient MEMBER or his or her THE MEMBER'S guardian,3
personal representative, estate, dependent, or survivors against the trustee4
or person holding the power of attorney.5
(12) (b) Within fifteen days after filing an action or asserting a6
claim against a third party, a recipient MEMBER under a managed care7
plan or a guardian, executor, administrator, or other appropriate8
representative of the recipient MEMBER shall provide to the entity that9
administers the managed care plan written notice of the action or claim.10
Notice shall MUST be by personal service or certified mail.11
(15) (a) The state department may request a written response from12
any provider who fails to comply with the rules, manuals, or bulletins13
issued by the state department, state board, or the state department's fiscal14
agent, or from any provider whose activities endanger the health, safety,15
or welfare of medicaid recipients MEMBERS. The written response must16
describe how the provider will come into and ensure future compliance.17
If a written response is requested, a provider has thirty days, or longer if18
approved by the state department, to submit the written response.19
SECTION 32. In Colorado Revised Statutes, 25.5-4-302, amend20
(1) as follows:21
25.5-4-302. Recovery of assets. (1) The general assembly hereby22
finds, determines, and declares that the cost of providing medical23
assistance to qualified recipients MEMBERS throughout the state has24
increased significantly in recent years; that such increasing costs have25
created an increased burden on state revenues while reducing the amount26
of such revenues available for other state programs; that recovering some27
176
-44- of the medical assistance from the estates of medical assistance recipients1
MEMBERS would be a viable mechanism for such recipients MEMBERS to2
share in the cost of such assistance; and that such an estate recovery3
program would be a cost-efficient method of offsetting medical assistance4
costs in an equitable manner. The general assembly also declares that in5
order to ensure that medicaid is available for low-income individuals6
reasonable restrictions consistent with federal law should be placed on the7
ability of persons to become eligible for medicaid by means of making8
transfers of property without fair and valuable consideration.9
SECTION 33. In Colorado Revised Statutes, 25.5-4-401, amend10
(1)(a), (3)(a), (3)(b)(III), and (4) as follows:11
25.5-4-401. Providers - payments - rules. (1) (a) The state12
department shall establish rules for the payment of providers under this13
article ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5. Within the14
limits of available funds, such THE rules shall MUST provide reasonable15
compensation to such providers, but no provider shall, by this section or16
any other provision of this article ARTICLE 4 or article 5 or 6 of this title,17
be deemed to have TITLE 25.5, HAS any vested right to act as a provider18
under this article ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5 or19
to receive any payment in addition to or different from that which is20
currently payable on behalf of a recipient MEMBER at the time the medical21
benefits are provided by said THE provider.22
(3) (a) As used in this subsection (3), "capitated" means a method23
of payment by which a provider directly delivers or arranges for delivery24
of medical care benefits for a term established by contract with the state25
department based on a fixed rate of reimbursement per recipient MEMBER.26
(b) (III) The state department may define groups of recipients27
176
-45- MEMBERS by geographic area or other categories and may require that all1
members of the defined group obtain medical services through one or2
more provider contracts entered into pursuant to this subsection (3).3
(4) (a) The general assembly hereby finds, determines, and4
declares that access to health-care services would be improved and costs5
of health care would be restrained if the recipients MEMBERS of the6
medicaid program would choose a primary care physician through a7
managed care provider. For purposes of this subsection (4), "managed8
care provider" means either a primary care physician program, a health9
maintenance organization, or a prepaid health plan.10
(b) Subject to the provisions of paragraph (c) of this subsection11
(4) SUBSECTION (4)(c) OF THIS SECTION, the executive director of the state12
department has the authority to require a recipient MEMBER of the13
medicaid program to select a managed care provider and to assign a14
recipient MEMBER to a managed care provider if the recipient MEMBER has15
failed to make a selection within a reasonable time. To the extent16
possible, this requirement shall MUST be implemented on a statewide17
basis.18
(c) The state department shall ensure the following:19
(I) A managed care provider shall establish and implement20
consumer friendly MEMBER-FRIENDLY procedures and instructions for21
disenrollment and shall have adequate staff to explain issues concerning22
service delivery and disenrollment procedures to recipients MEMBERS,23
including staff to address the communications needs and requirements of24
recipients MEMBERS with disabilities.25
(II) All recipients MEMBERS shall be adequately informed about26
AVAILABLE service delivery options available to them consistent with the27
176
-46- provisions of this subparagraph (II) SUBSECTION (4)(c)(II). If a recipient1
MEMBER does not respond to a state department request for selection of2
a delivery option within AFTER forty-five calendar days, the state3
department shall send a second notification to the recipient MEMBER. If4
the recipient MEMBER does not respond within AFTER twenty days of the5
date of the second notification, the state department shall ensure that the6
recipient MEMBER remains with the recipient's MEMBER'S primary care7
physician, regardless of whether said THE primary care physician is8
enrolled in a health maintenance organization.9
SECTION 34. In Colorado Revised Statutes, 25.5-4-401.5,10
amend (2)(a), (2)(d)(II), (2)(e) introductory portion, (2)(e)(II)11
introductory portion, and (3)(a)(III) as follows:12
25.5-4-401.5. Review of provider rates - advisory committee13
- recommendations - repeal. (2) (a) In the first phase of the review14
process, the state department shall conduct an analysis of the access,15
service, quality, and utilization of each service subject to a provider rate16
review. The state department shall compare the rates paid with available17
benchmarks, including medicare rates and usual and customary rates paid18
by private pay parties, and use qualitative tools to assess whether19
payments are sufficient to allow for provider retention and client20
MEDICAID MEMBER access and to support appropriate reimbursement of21
high-value services.22
(d) (II) The state department shall submit, as part of the report23
required pursuant to this subsection (2)(d), a description of the24
information discussed during the quarterly public meeting; the state25
department's response to the public comments received from providers,26
recipients MEMBERS, and other interested parties; and an explanation of27
176
-47- how the public comments informed the provider rate review process and1
the recommendations concerning provider rates.2
(e) The state department shall conduct a public meeting at least3
quarterly to inform the state department's review of provider rates paid4
under the "Colorado Medical Assistance Act". The state department shall5
invite to the public meeting providers, recipients MEMBERS, and other6
interested parties directly affected by the services scheduled to be7
reviewed at the public meeting. At a minimum, each public meeting must8
consist of, but is not limited to:9
(II) Public comments from providers, recipients MEMBERS, and10
other interested parties concerning:11
(3) (a) There is created in the state department the medicaid12
provider rate review advisory committee, referred to in this section as the13
"advisory committee", to assist the state department in the review of the14
provider rate reimbursements under the "Colorado Medical Assistance15
Act". The advisory committee shall:16
(III) Review the comments received from providers, recipients17
MEMBERS, and other interested parties and the state department's response18
to the comments required pursuant to subsection (2)(d)(II) of this section;19
SECTION 35. In Colorado Revised Statutes, 25.5-4-402, amend20
(4)(c)(II) and (4)(d)(I); and repeal (4)(d)(IV) and (4)(d)(V) as follows:21
25.5-4-402. Providers - hospital reimbursement - hospital22
review program - rules. (4) (c) The following factors must be23
considered in any coverage determinations made pursuant to the hospital24
review programs:25
(II) Evidence-based clinical coverage criteria and recipient26
MEMBER coverage guidelines as established by the state department;27
176
-48- (d) (I) The state department shall consult with affected1
stakeholders prior to implementation of the hospital review program. At2
a minimum, the state department shall solicit feedback from recipients3
MEMBERS, hospitals within Colorado that participate in medicaid,4
providers participating in the accountable care collaborative pursuant to5
section 25.5-5-419, and the Colorado healthcare affordability and6
sustainability enterprise board established in section 25.5-4-402.4 (7). If7
the state department contracts with a third-party vendor to implement the8
hospital review program, the state department shall require the vendor to9
participate in the stakeholder outreach with hospitals required pursuant10
to this subsection (4)(d)(I).11
(IV) The state department shall provide a report to the joint budget12
committee on November 1, 2019, and November 1, 2020, detailing the13
estimates of the cost savings achieved and the impact of the cost-control14
measures authorized pursuant to this section on recipients and recipients'15
health outcomes.16
(V) Beginning in 2018, and every year thereafter through 2020,17
the state department shall report on the status of the implementation of the18
hospital review program, any cost savings estimated or achieved due to19
the program, and the impact on recipients and recipients' outcomes of any20
cost-control measures as part of its "State Measurement for Accountable,21
Responsive, and Transparent (SMART) Government Act" hearing22
required by section 2-7-203.23
SECTION 36. In Colorado Revised Statutes, amend 25.5-4-40524
as follows:25
25.5-4-405. Mental health managed care service providers -26
requirements. (1) Each contract between the state department and a27
176
-49- managed care organization providing mental health services to a recipient1
MEMBER under the medical assistance program shall MUST comply with2
all federal requirements, including but not limited to:3
(a) Ensuring that a recipient MEMBER with complex or multiple4
needs who requires mental health services shall have HAS access to5
mental health professionals with appropriate training and credentials and6
shall provide PROVIDING the recipient MEMBER with such THE services in7
collaboration with the recipient's MEMBER'S other providers; 8
(b) Informing each recipient of his or her MEMBER OF THE9
MEMBER'S right to and the process for appeal upon notification of denial,10
termination, or reduction of a requested service; and11
(c) Administering initial stabilization treatment for a recipient12
MEMBER and transferring the recipient MEMBER for appropriate continued13
services.14
(1.5) Each contract between the state department and a managed15
care organization providing mental health services to a recipient MEMBER16
under the medical assistance program shall MUST allow for the use of17
telemedicine pursuant to the provisions of section 25.5-5-320.18
(2) For mental health managed care recipients MEMBERS, the state19
department shall have a patient representative program for recipient20
MEMBER grievances that complies with all federal requirements and that21
shall MUST:22
(a) Be posted in a conspicuous place at each location at which23
mental health services are provided;24
(b) Allow for a patient representative to serve as a liaison between25
the recipient MEMBER and the provider;26
(c) Describe the qualifications for a patient representative;27
176
-50- (d) Outline the responsibilities of a patient representative;1
(e) Describe the authority of a patient representative; and2
(f) Establish a method by which each recipient MEMBER is3
informed of the patient representative program and how a patient4
representative may be contacted.5
SECTION 37. In Colorado Revised Statutes, 25.5-4-412, amend6
(5) as follows:7
25.5-4-412. Family planning services - family-planning-related8
services - rules - definitions. (5) Any recipient MEMBER may obtain9
family planning services or family-planning-related services from any10
licensed health-care provider, including a doctor of medicine, doctor of11
osteopathy, physician assistant, advanced practice registered nurse, or12
certified midwife who provides such services. The enrollment of a13
recipient MEMBER in a managed care organization, or a similar entity,14
does not restrict a recipient's MEMBER'S choice of the licensed provider15
from whom the recipient MEMBER may receive those services.16
SECTION 38. In Colorado Revised Statutes, 25.5-4-416, amend17
(1) and (2)(a)(III) as follows:18
25.5-4-416. Providers - medical equipment and supplies -19
requirements. (1) As used in this section, unless the context otherwise20
requires, "provider" means a person or entity that delivers disposable21
medical supplies or durable medical equipment products or services22
directly to a recipient MEMBER.23
(2) On and after January 1, 2007, the state board rules for the24
payment for disposable medical supplies and durable medical equipment,25
including but not limited to prosthetic and orthotic devices, shall prohibit26
a provider from being reimbursed unless the provider:27
176
-51- (a) (III) Is responsible for the delivery of and instructing the1
recipient MEMBER on the proper use of the equipment; and2
SECTION 39. In Colorado Revised Statutes, 25.5-4-422, amend3
(4)(b); and repeal (5)(c) and (6)(b) as follows:4
25.5-4-422. Cost control - legislative intent - use of technology5
- stakeholder feedback - reporting - rules. (4) (b) Prior to6
implementing and reporting on any new measures authorized by this7
section, the state department shall provide an opportunity for affected8
recipients MEMBERS, providers, and stakeholders to provide feedback and9
make recommendations on the state department's proposed10
implementation.11
(5) By November 1, 2018, the state department shall provide a12
report to the joint budget committee concerning:13
(c) A description of the expected impact on recipients and14
recipients' health outcomes and how the state department plans to15
measure the effect on recipients.16
(6) (b) The state department shall provide a report to the joint17
budget committee on November 1, 2019, and November 1, 2020,18
detailing the results of the independent evaluation, including estimates of19
the cost savings achieved and the impact of the cost-control measures20
authorized pursuant to this section on recipients and recipients' health21
outcomes.22
SECTION 40. In Colorado Revised Statutes, 25.5-4-428, amend23
(1), (2)(a), (2)(c), (3), and (5)(a) as follows:24
25.5-4-428. Prior authorization for a step-therapy exception25
- rules - definition. (1) As used in this section, unless the context26
otherwise requires, "step therapy" means a protocol that requires a27
176
-52- recipient MEMBER to use a prescription drug or sequence of prescription1
drugs, other than the drug that the recipient's MEMBER'S health-care2
provider recommends for the recipient's MEMBER'S treatment, before the3
state department provides coverage for the recommended prescription4
drug.5
(2) (a) The state department shall review and determine if an6
exception to step therapy is granted if the prescribing provider submits a7
prior authorization request with justification and supporting clinical8
documentation for treatment of a serious or complex medical condition,9
if required, that states:10
(I) The provider attests that the required prescription drug is11
contraindicated, or will likely cause intolerable side effects, a significant12
drug-drug interaction, or an allergic reaction to the recipient MEMBER;13
(II) The required prescription drug lacks efficacy based on the14
known clinical characteristics of the recipient MEMBER and the known15
characteristics of the prescription drug regimen;16
(III) The recipient MEMBER has tried the required prescription17
drug, and the use of the prescription drug by the recipient MEMBER was18
discontinued due to intolerable side effects, a significant drug-drug19
interaction, or an allergic reaction; or20
(IV) The recipient MEMBER is stable on a prescription drug21
selected by the prescribing provider for the medical condition.22
(c) If the prior authorization request for a step-therapy exception23
is denied, the state department shall inform the recipient MEMBER in24
writing that the recipient MEMBER has the right to appeal the adverse25
determination pursuant to state department rules.26
(3) If the prior authorization request for a step-therapy exception27
176
-53- request is granted, the state department shall authorize coverage for the1
prescription drug prescribed by the recipient's MEMBER'S prescribing2
provider.3
(5) This section does not prohibit:4
(a) The state department from requiring a recipient MEMBER to try5
a generic equivalent of a brand name drug, a biosimilar drug as defined6
in 42 U.S.C. sec. 262 (i)(2), or an interchangeable biological product as7
defined in 42 U.S.C. sec. 262 (i)(3), unless such a requirement meets any8
of the criteria set forth in subsection (2)(a) of this section for an exception9
to step therapy and a prior authorization request is granted for the10
requested drug;11
SECTION 41. In Colorado Revised Statutes, 25.5-4-506, amend12
(1)(b), (2) introductory portion, (3)(a), (7)(c)(III), and (7)(e) as follows:13
25.5-4-506. Coverage for doula services - stakeholder process14
- federal authorization - scholarship program - training - report -15
definitions - repeal. (1) As used in this section, unless the context16
otherwise requires:17
(b) "Maternity advisory committee" means the committee18
facilitated by the state department composed predominantly of Black,19
Indigenous, and other people of color with maternity care experience as20
recipients MEMBERS.21
(2) No later than September 1, 2023, the state department shall22
initiate a stakeholder process to promote the expansion and utilization of23
doula services for pregnant and postpartum recipients MEMBERS in the24
state. In conducting the stakeholder process, the state department shall:25
(3) Stakeholders must be diverse with regard to race, ethnicity,26
immigration status, sexual orientation, and gender, and must represent27
176
-54- other populations that experience greater health disparities and inequities.1
The state department may include the following in the stakeholder2
process:3
(a) Doulas and potential doulas who may serve recipients4
MEMBERS who include, but are not limited to, Black, Indigenous, and5
other people of color, refugees, non-English speakers, people living in6
rural areas, and people who were recently incarcerated;7
(7) (c) The state department shall define eligibility criteria for the8
doula scholarship program that includes, but is not limited to, the9
following:10
(III) A statement of intent to serve as a doula provider in Colorado11
for pregnant and postpartum recipients MEMBERS.12
(e) The state department may require individuals who receive13
scholarship money pursuant to the doula scholarship program described14
in this subsection (7) to submit to the state department, not later than six15
months after the individual's completion of doula training or certification,16
documentation that the individual is serving as a doula for recipients17
MEMBERS or is working toward enrollment as a doula for recipients18
MEMBERS. If an individual does not complete the documentation, the state19
department may seek repayment of the funds awarded to the individual20
through the doula scholarship program.21
SECTION 42. In Colorado Revised Statutes, 25.5-5-102, amend22
(1) introductory portion and (1)(h) as follows:23
25.5-5-102. Basic services for the categorically needy -24
mandated services. (1) Subject to the provisions of subsection (2) of this25
section and section 25.5-4-104, the program for the categorically needy26
shall MUST include the following services as mandated and defined by27
176
-55- federal law:1
(h) Family planning, including a one-year supply of any federal2
food and drug administration-approved contraceptive drug, device, or3
product, unless the recipient MEMBER requests a supply covering a shorter4
period of time;5
SECTION 43. In Colorado Revised Statutes, 25.5-5-103, amend6
(1)(e) as follows:7
25.5-5-103. Mandated programs with special state provisions8
- rules. (1) This section specifies programs developed by Colorado to9
meet federal mandates. These programs include but are not limited to:10
(e) Special provisions for the purchase of group health insurance11
for recipients MEMBERS, as specified in section 25.5-4-210;12
SECTION 44. In Colorado Revised Statutes, 25.5-5-202, amend13
(1)(a)(II) as follows:14
25.5-5-202. Basic services for the categorically needy - optional15
services. (1) Subject to the provisions of subsection (2) of this section,16
the following are services for which federal financial participation is17
available and that Colorado has selected to provide as optional services18
under the medical assistance program:19
(a) (II) Notwithstanding the provisions of subparagraph (I) of this20
paragraph (a) SUBSECTION (1)(a)(I) OF THIS SECTION, pursuant to the21
provisions of section 25.5-5-503, prescribed drugs shall not be ARE NOT22
a covered benefit under the medical assistance program for a recipient23
MEMBER who is enrolled in a prescription drug benefit program under24
medicare; except that, if a prescribed drug is not a covered Part D drug as25
defined in the "Medicare Prescription Drug, Improvement, and26
Modernization Act of 2003", Pub.L. 108-173, the prescribed drug may be27
176
-56- a covered benefit if it is otherwise covered under the medical assistance1
program and federal financial participation is available.2
SECTION 45. In Colorado Revised Statutes, 25.5-5-204, amend3
(2.7)(d) as follows:4
25.5-5-204. Presumptive eligibility - pregnant person -5
children - long-term care - state plan. (2.7) (d) If it is determined that6
a recipient MEMBER was not eligible for medical benefits after the7
recipient MEMBER had been determined to be eligible based upon8
presumptive eligibility, the state department shall not pursue recovery9
from a county department for the cost of medical services provided to the10
recipient MEMBER, and the county department shall not be responsible for11
any federal error rate sanctions resulting from such determination.12
SECTION 46. In Colorado Revised Statutes, 25.5-5-207, amend13
(2)(a) as follows:14
25.5-5-207. Adult dental benefit - adult dental fund - creation15
- legislative declaration. (2) (a) Pursuant to section 25.5-5-202 (1)(w),16
by April 1, 2014, the state department shall design and implement a17
limited dental benefit for adults using a collaborative stakeholder process18
to consider the components of the benefit, including but not limited to the19
cost, best practices, the effect on health outcomes, client MEMBER20
experience, service delivery models, and maximum efficiencies in the21
administration of the benefit.22
SECTION 47. In Colorado Revised Statutes, 25.5-5-303, amend23
(2) introductory portion as follows:24
25.5-5-303. Private-duty nursing. (2) A recipient MEMBER is25
eligible for private-duty nursing services if he or she THE MEMBER:26
SECTION 48. In Colorado Revised Statutes, 25.5-5-316, amend27
176
-57- (1) and (2) as follows:1
25.5-5-316. Legislative declaration - state department - disease2
management programs authorization - report. (1) The general3
assembly finds that, because Colorado is faced with rising health-care4
costs and limited resources, it is necessary to seek new ways to ensure the5
availability of high-quality, cost-efficient care for medicaid recipients6
MEMBERS. The general assembly further finds that disease management7
is a patient-focused, integrated approach to providing all components of8
care with attention to both quality of care and total cost. In addition, the9
general assembly finds that this approach may include coordination of10
physician care with pharmaceutical and institutional care. The general11
assembly further finds that disease management also addresses the12
various aspects of a disease state, including meeting the needs of persons13
who have multiple chronic illnesses. The general assembly declares that14
the improved coordination in disease management helps to provide15
chronically ill patients with access to the latest advances in treatment and16
teaches them how to be active participants in their health care through17
health education, thus reducing total health-care costs.18
(2) The state department, in consultation with the department of19
public health and environment, is authorized to develop and implement20
disease management programs, for fee-for-service and primary care21
physician program recipients, that are designed to address over- or22
under-utilization or the inappropriate use of services or prescription drugs23
and that may affect the total cost of health-care utilization by a particular24
medicaid recipient MEMBER with a particular disease or combination of25
diseases. The disease management programs shall target medicaid26
recipients MEMBERS who are receiving prescription drugs or services in27
176
-58- an amount that exceeds guidelines outlined by the state department. The1
state department shall not restrict a medicaid recipient's MEMBER'S access2
to the most cost-effective and medically appropriate prescription drugs or3
services. The state department may contract on a contingency basis for the4
development or implementation of the disease management programs5
authorized in this subsection (2).6
SECTION 49. In Colorado Revised Statutes, 25.5-5-321.5,7
amend (1) as follows:8
25.5-5-321.5. Telehealth - interim therapeutic restorations -9
reimbursement - definitions. (1) Subject to federal authorization and10
federal financial participation, on or after July 1, 2016, in-person contact11
between a health-care provider and a recipient MEMBER is not required12
under the state's medical assistance program for the diagnosis,13
development of a treatment plan, instruction to perform an interim14
therapeutic restoration procedure, or supervision of a dental hygienist15
performing an interim therapeutic restoration procedure. A health-care16
provider may provide these services through telehealth, including17
store-and-forward transfer, and is entitled to reimbursement for the18
delivery of those services via telehealth to the extent the services are19
otherwise eligible for reimbursement under the program when provided20
in person. The services are subject to the reimbursement policies21
developed pursuant to the state medical assistance program.22
SECTION 50. In Colorado Revised Statutes, 25.5-5-322, amend23
(1)(a) and (2)(b) as follows:24
25.5-5-322. Over-the-counter medications - rules.25
(1) (a) Subject to approval through the state budget process in paragraph26
(b) of this subsection (1) DESCRIBED IN SUBSECTION (1)(b) OF THIS27
176
-59- SECTION, the state board shall adopt by rule a system to allow pharmacies1
to be reimbursed for providing certain over-the-counter medications to2
recipients MEMBERS if prescribed by a licensed practitioner authorized to3
prescribe prescription drugs or, subject to the limitations contained in4
subsection (2) of this section, a licensed pharmacist. Over-the-counter5
medications subject to reimbursement pursuant to this section shall MUST6
be identified through the drug utilization review process established in7
section 25.5-5-506, and shall be ARE limited to medications that, if8
reimbursed, shall result in overall cost savings to the state.9
(2) (b) When prescribing over-the-counter medications under this10
section, a licensed pharmacist shall consult with the recipient MEMBER to11
determine necessity, provide drug counseling, review drug therapy for12
potential adverse interactions, and make referrals as needed to other13
health-care professionals.14
SECTION 51. In Colorado Revised Statutes, 25.5-5-323, amend15
(1)(a), (1)(c), (2)(a)(I), (2)(a)(III), (2)(b), (2)(d)(III)(A), (2)(d)(III)(C),16
(2)(d)(IV), (2)(d)(V), (2)(d)(VI), (3) introductory portion, (3)(a), (3)(c)17
introductory portion, (3)(d)(I), (3)(d)(III), (3)(e), (5)(a), (6), and (7) as18
follows:19
25.5-5-323. Complex rehabilitation technology - no prior20
authorization - metrics - report - rules - legislative declaration -21
definitions. (1) The general assembly finds and declares it is in the best22
interests of the people of the state of Colorado to:23
(a) Continue to protect access to important technology and24
supporting services for eligible clients MEMBERS;25
(c) Continue to provide supports for clients MEMBERS accessing26
complex rehabilitation technology to stay in the home or community27
176
-60- setting; engage in basic activities of daily living and instrumental1
activities of daily living, including employment; prevent2
institutionalization; and prevent hospitalization and other costly3
secondary complications; and4
(2) As used in this section, unless the context otherwise requires:5
(a) "Complex rehabilitation technology" means individually6
configured manual wheelchair systems, power wheelchair systems,7
adaptive seating systems, alternative positioning systems, standing8
frames, gait trainers, and specifically designated options and accessories9
classified as durable medical equipment that:10
(I) Are individually configured for individuals to meet their11
specific and unique medical, physical, and functional needs and capacities12
for basic activities of daily living and instrumental activities of daily13
living, including employment, identified as medically necessary to14
promote mobility in the home and community or prevent hospitalization15
or institutionalization of the client MEMBER;16
(III) Require certain services provided by a qualified complex17
rehabilitation technology provider to ensure appropriate design,18
configuration, and use of such items, including patient evaluation or19
assessment of the client MEMBER by a health-care professional, and that20
are consistent with the client's MEMBER'S medical condition, physical and21
functional needs and capacities, body size, period of need, and intended22
use.23
(b) "Individually configured" means that a device has features,24
adjustments, or modifications specific to a client MEMBER that a qualified25
complex rehabilitation technology supplier provides by measuring, fitting,26
programming, adjusting, adapting, and maintaining the device so that the27
176
-61- device is consistent with an assessment or evaluation of the client1
MEMBER by a health-care professional and consistent with the client's2
MEMBER'S medical condition, physical and functional needs and3
capacities, body size, period of need, and intended use.4
(d) "Qualified complex rehabilitation technology supplier" means5
a company or entity that:6
(III) Employs at least one qualified complex rehabilitation7
technology professional for each location to:8
(A) Analyze the needs and capacities of clients MEMBERS for a9
complex rehabilitation technology item in consultation with the10
evaluating clinical professionals;11
(C) Provide the client MEMBER technology-related training in the12
proper use and maintenance of the selected complex rehabilitation13
technology items;14
(IV) Has the qualified complex rehabilitation technology15
professional directly involved with the assessment, and determination of16
the appropriate individually configured complex rehabilitation technology17
for the client MEMBER, with such THE involvement to include seeing the18
client MEMBER visually either in person or by any other real-time means19
within a reasonable time frame during the determination process.20
(V) Maintains a reasonable supply of parts, adequate physical21
facilities, and qualified service or repair technicians to provide clients22
MEMBERS with prompt service and repair of all complex rehabilitation23
technology it sells or supplies; and24
(VI) Provides the client MEMBER written information at the time25
of sale as to how to access service and repair.26
(3) The state department shall provide a separate recognition27
176
-62- within the state's medicaid program established under articles 4, 5, and 61
of this title PURSUANT TO THIS ARTICLE 5 AND ARTICLES 4 AND 6 OF THIS2
TITLE 25.5 for complex rehabilitation technology and shall make other3
required changes to protect client MEMBER access to appropriate products4
and services. Such THE separate recognition must take into consideration5
the customized nature of complex rehabilitation technology and the broad6
range of related services necessary to meet the unique medical and7
functional needs of clients MEMBERS and include the following:8
(a) The state department notifying the qualified rehabilitation9
technology suppliers concerning the parameters of the complex10
rehabilitation technology benefit, which benefit must include the use of11
qualified rehabilitation technology suppliers as well as billing procedures12
that specify the types of equipment identified and included in the complex13
rehabilitation technology benefit. The state department shall create14
complex rehabilitation technology benefit parameters that are easily15
understood by and accessible to clients MEMBERS and qualified16
rehabilitation technology suppliers. The state department shall provide17
public notice no later than thirty days prior to a collaborative process that18
includes discussion of any proposed changes to the types of equipment19
identified and included in the complex rehabilitation technology benefit.20
(c) Ensuring that clients MEMBERS receiving complex21
rehabilitation technology are evaluated or assessed, as needed, by:22
(d) Continuing pricing policies for complex rehabilitation23
technology, unless specifically prohibited by the federal centers for24
medicare and medicaid services, including the following:25
(I) Continuing to ensure that the reimbursement amounts for26
complex rehabilitation technology, repairs, and supporting clinical27
176
-63- complex rehabilitation technology services are adequate to ensure that1
qualified clients ELIGIBLE MEMBERS have access to the items, taking into2
account the unique needs of the clients MEMBERS and the complexity and3
customization of complex rehabilitation technology. This includes4
developing pricing policies that ensure access to adequate and timely5
repairs.6
(III) Preserving the option for complex rehabilitation technology7
to be billed and paid for as a purchase allowing for lump sum payments8
for devices with a length of need of one year or greater, excluding9
approved crossover claims for clients MEMBERS enrolled in medicare and10
medicaid; and11
(e) Making other changes as needed to protect access to complex12
rehabilitation technology for clients MEMBERS.13
(5) (a) No later than October 1, 2023, the state board shall14
promulgate rules establishing repair metrics for all complex rehabilitation15
technology suppliers and complex rehabilitation technology professionals.16
At a minimum, the metrics must include requirements for repairing17
complex rehabilitation technology in a timely manner and the expected18
quality of each repair. Prior to promulgating rules pursuant to this19
subsection (5)(a), the state department shall engage in a stakeholder20
process, which process must include qualified complex rehabilitation21
technology professionals, qualified complex rehabilitation technology22
suppliers, and complex rehabilitation technology clients MEMBERS.23
(6) Three years after the date the repair metric rules are24
established pursuant to subsection (5)(a) of this section, the state25
department may engage in a stakeholder process to determine the need for26
additional accountability of a qualified complex rehabilitation technology27
176
-64- supplier through financial penalties, audits, or similar tools, for violations1
of the repair metrics rules. If such a stakeholder process is convened, the2
process must include qualified complex rehabilitation technology3
professionals, qualified complex rehabilitation technology suppliers,4
complex rehabilitation clients MEMBERS, and an advocacy group for5
persons with disabilities.6
(7) Beginning December 1, 2024, the state department shall7
reimburse labor costs for repairs of complex rehabilitation technology at8
a rate that is twenty-five percent higher for clients MEMBERS residing in9
rural areas than the rate for clients MEMBERS residing in urban areas.10
SECTION 52. In Colorado Revised Statutes, 25.5-5-326, amend11
(1)(d)(I) as follows:12
25.5-5-326. Access to clinical trials - definitions. (1) As used in13
this section, unless the context otherwise requires:14
(d) (I) "Routine costs" means medically necessary items and15
services that are included under the medical assistance program for a16
medical assistance recipient MEMBER, to the extent that the provision of17
such THE items or services to the individual outside the course of such18
participation would otherwise be covered under the medical assistance19
program, without regard to whether the recipient MEMBER is enrolled in20
a clinical trial. For medical assistance recipients MEMBERS participating21
in an approved clinical trial, "routine costs" include medically necessary22
items and services that are not otherwise excluded pursuant to subsection23
(1)(d)(II)(D) of this section, relating to the detection and treatment of24
complications arising from the medical assistance recipient's MEMBER'S25
medical care, including complications relating to participation in the26
clinical trial, to the extent that the provision of such THE items or services27
176
-65- to the individual outside the course of such participation would otherwise1
be included under the medical assistance program.2
SECTION 53. In Colorado Revised Statutes, 25.5-5-327, amend3
(2) as follows:4
25.5-5-327. Eligible peer support services - reimbursement -5
definitions. (2) Subject to available appropriations and to the extent6
permitted under federal law, the medical assistance program pursuant to7
this article 5 and articles 4 and 6 of this title 25.5 includes peer support8
professional services provided to recipients MEMBERS through a recovery9
support services organization. Peer support professional services must not10
be provided to recipients MEMBERS until federal approval has been11
obtained.12
SECTION 54. In Colorado Revised Statutes, 25.5-5-333, amend13
(3)(b)(II), (5)(d), and (5)(e) as follows:14
25.5-5-333. Primary care and behavioral health statewide15
integration grant program - creation - report - definition - repeal.16
(3) (b) Any money received through the grant program must supplement17
and not supplant existing health-care services. Grant recipients shall not18
use money received through the grant program for:19
(II) Services already covered by medicaid or a client's MEMBER'S20
OTHER insurance; or21
(5) Grant applicants shall demonstrate a commitment to22
maintaining models and programs that, at a minimum:23
(d) Serve publicly funded clients CONSUMERS;24
(e) Maintain a plan for how to address a client MEMBER with25
emergency needs;26
SECTION 55. In Colorado Revised Statutes, 25.5-5-335, amend27
176
-66- (1), (3), (4) introductory portion, and (4)(a)(II) as follows:1
25.5-5-335. Continuous medical coverage for children and2
adults feasibility study - federal authorization - rules - report -3
definition. (1) The state department shall study the feasibility of4
extending continuous medical coverage for additional children and adults5
and how to better meet the health-related social needs of medical6
assistance program recipients MEMBERS.7
(3) In addition to the study topics detailed in subsection (2) of this8
section, the feasibility study must study how to best meet the9
health-related social needs of medical assistance program recipients10
MEMBERS who are historically disadvantaged and underserved and must11
give consideration to concerns related to housing and food security.12
(4) In conducting the feasibility study pursuant to this section, the13
state department shall take into consideration the efforts of other states to14
improve the health-related social needs of medical assistance program15
recipients MEMBERS, including, but not limited to, housing and nutritional16
needs, initiatives to pay for rental housing assistance for up to six months,17
the needs of perinatal recipients MEMBERS, youth in or transitioning out18
of foster care, former foster care youth, people with substance use19
disorders, high-risk infants and children, and the needs of low-income20
individuals impacted by natural disasters, and the state department shall21
seek input from relevant stakeholders. In conducting the stakeholder22
process, the state department shall:23
(a) Engage directly with:24
(II) Service providers, particularly those whose patients are25
predominantly medical assistance program recipients MEMBERS or are26
uninsured;27
176
-67- SECTION 56. In Colorado Revised Statutes, 25.5-5-402, amend1
(1), (2)(b), (5), (6)(a), (9)(a), and (12) as follows:2
25.5-5-402. Statewide managed care system - rules -3
definitions - repeal. (1) The state board shall adopt rules to implement4
a statewide managed care system for Colorado medical assistance5
recipients MEMBERS pursuant to the provisions of this article 5 and6
articles 4 and 6 of this title 25.5. The statewide managed care system shall7
be implemented to the extent possible.8
(2) The statewide managed care system implemented pursuant to9
this article 5 does not include:10
(b) Long-term care services and the program of all-inclusive care11
for the elderly, as described in section 25.5-5-412. For purposes of this12
subsection (2), "long-term care services" means nursing facilities and13
home- and community-based services provided to eligible clients14
MEMBERS who have been determined to be in need of such services15
pursuant to the "Colorado Medical Assistance Act" and the state board's16
rules.17
(5) The statewide managed care system builds upon the lessons18
learned from previous managed care and community behavioral19
health-care programs in the state in order to reduce barriers that may20
negatively impact medicaid recipient MEMBER experience, medicaid21
recipient MEMBER health, and efficient use of state resources. The22
statewide managed care system is authorized to provide services under a23
single MCE type or a combination of MCE types.24
(6) (a) The state department is authorized to assign a medicaid25
recipient MEMBER to a particular MCE, consistent with federal26
requirements and rules promulgated by the state board.27
176
-68- (9) Bidding. (a) The state department is authorized to institute a1
program for competitive bidding pursuant to section 24-103-202 or2
24-103-203 for MCEs seeking to provide, arrange for, or otherwise be3
responsible for the provision of services to its enrollees MEMBERS. The4
state department is authorized to award contracts to more than one5
offeror. The state department shall use competitive bidding procedures to6
encourage competition and improve the quality of care available to7
medicaid recipients MEMBERS over the long term that meets the8
requirements of this section and section 25.5-5-406.1.9
(12) Graduate medical education. The state department shall10
continue the graduate medical education, referred to in this subsection11
(12) as "GME", funding to teaching hospitals that have graduate medical12
education expenses in their medicare cost report and are participating as13
providers under one or more MCEs with a contract with the state14
department under this part 4. GME funding for recipients MEMBERS15
enrolled in an MCE is excluded from the premiums paid to the MCE and16
must be paid directly to the teaching hospital. The state board shall adopt17
rules to implement this subsection (12) and establish the rate and method18
of reimbursement.19
SECTION 57. In Colorado Revised Statutes, 25.5-5-403, amend20
(2)(b) and (3) as follows:21
25.5-5-403. Definitions. As used in this part 4, unless the context22
otherwise requires:23
(2) "Essential community provider", referred to in this part 4 as an24
"ECP", means a health-care provider that:25
(b) Waives charges or charges for services on a sliding scale based26
on income and does not restrict access or services because of a client's27
176
-69- MEMBER'S financial limitations.1
(3) (a) "Managed care" means a health-care delivery system2
organized to manage costs, utilization, and quality. Medicaid managed3
care provides for the delivery of medicaid health benefits and additional4
services through contracted arrangements between state medicaid5
agencies and MCEs.6
(b) Nothing in this section shall be deemed to affect AFFECTS the7
benefits authorized for recipients MEMBERS of the state medical assistance8
program.9
SECTION 58. In Colorado Revised Statutes, 25.5-5-406.1,10
amend (1)(f)(II)(A), (1)(n)(II), (1)(p)(II)(A), (1)(q), (1)(r), and (1)(s)(II)11
as follows:12
25.5-5-406.1. Required features of statewide managed care13
system. (1) General features. All medicaid managed care programs14
must contain the following general features, in addition to others that the15
federal government, state department, and state board consider necessary16
for the effective and cost-efficient operation of those programs:17
(f) The MCE shall create, administer, and maintain a network of18
providers, building on the current network of medicaid providers, to serve19
the health-care needs of its members. In doing so, the MCE shall:20
(II) (A) Seek proposals from each ECP in a county in which the21
MCE is enrolling recipients MEMBERS for those services that the MCE22
provides or intends to provide and that an ECP provides or is capable of23
providing. The MCE shall consider such proposals in good faith and24
shall, when deemed reasonable by the MCE based on the needs of its25
enrollees MEMBERS, contract with ECPs. Each ECP shall be willing to26
negotiate on reasonably equitable terms with each MCE. ECPs making27
176
-70- proposals under this subsection (1)(f)(II) must be able to meet the1
contractual requirements of the MCE. The requirements of this subsection2
(1)(f)(II) do not apply to an MCE in areas in which the MCE operates3
entirely as a group health maintenance organization.4
(n) Grievances and appeals. (II) The MCE shall have an5
established grievance system that allows for client MEMBER expression of6
dissatisfaction at any time about any matter related to the MCE's7
contracted services, other than an adverse benefit determination. The8
grievance system must provide timely resolution of such THE matters in9
a manner consistent with the medical needs of the individual recipient10
MEMBER.11
(p) (II) Prepaid inpatient health plans shall not retroactively12
recover provider payments if:13
(A) A recipient MEMBER was initially determined to be eligible for14
medical benefits pursuant to section 25.5-4-205 when the provider has an15
eligibility guarantee number for the recipient MEMBER; or16
(q) Billing medicaid members. Notwithstanding any federal17
regulations or the general prohibition of section 25.5-4-301 against18
providers billing medicaid recipients MEMBERS, a provider may bill a19
medicaid recipient MEMBER who is enrolled with a specific medicaid20
PCCM or MCE and, in circumstances defined by the rules of the state21
board, receives care from a medical provider outside that organization's22
network or without referral by the recipient's MEMBER'S PCCM;23
(r) Marketing. In marketing coverage to medicaid recipients24
MEMBERS, all MCEs shall comply with all applicable provisions of title25
10 regarding health plan marketing. The state board is authorized to26
promulgate rules concerning the permissible marketing of medicaid27
176
-71- managed care. The purposes of such THE rules must include but not be1
limited to the avoidance of biased selection among the choices available2
to medicaid recipients MEMBERS.3
(s) Prescription drugs. All MCEs that have prescription drugs as4
a covered benefit shall provide prescription drug coverage in accordance5
with the provisions of section 25.5-5-202 (1)(a) as part of a6
comprehensive health benefit and with respect to any formulary or other7
access restrictions:8
(II) The MCE shall provide to all medicaid recipients MEMBERS9
at periodic intervals, and prior to and during enrollment upon request,10
clear and concise information about the prescription drug program in11
language understandable to the medicaid recipients MEMBERS, including12
information about such formulary or other access restrictions and13
procedures for gaining access to prescription drugs, including14
off-formulary products; and15
SECTION 59. In Colorado Revised Statutes, 25.5-5-408, amend16
(1)(d) and (1)(e) as follows:17
25.5-5-408. Capitation payments - availability of base data -18
adjustments - rate calculation - capitation payment proposal -19
preference - assignment of medicaid members - definition. (1) (d) The20
state department shall reimburse a federally qualified health center, as21
defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(4),22
for the total reasonable costs incurred by the center in providing23
health-care services to all recipients MEMBERS of medical assistance.24
(e) An MCE shall certify, as a condition of entering into a contract25
with the state department, that the capitation payments set forth in the26
contract between the MCE and the state department are sufficient to27
176
-72- ensure the financial stability of the MCE with respect to delivery of1
services to the medicaid recipients MEMBERS covered in the contract.2
SECTION 60. In Colorado Revised Statutes, 25.5-5-410, amend3
(2) and (3) as follows:4
25.5-5-410. Data collection for managed care programs.5
(2) The state department of human services, in conjunction with the state6
department, shall continue its existing efforts, which include obtaining and7
considering consumer MEMBER input, to develop managed care systems8
for the developmentally disabled population and to consider a pilot9
program for a certificate system to enable the developmentally disabled10
population to purchase managed care services or fee-for-service care,11
including long-term care community services. The department of human12
services shall not implement any managed care system for13
developmentally disabled services without the express approval of the14
joint budget committee. Any proposed implementation of fully capitated15
managed care in the developmental disabilities community service system16
shall require REQUIRES legislative review.17
(3) In addition to any other data collection and reporting18
requirements, each managed care organization shall submit the following19
types of data to the state department or its agent:20
(a) Medical access;21
(b) Consumer MEMBER outcomes based on statistics maintained22
on individual consumers MEMBERS as well as the total consumer MEMBER23
populations served;24
(c) Consumer MEMBER satisfaction;25
(d) Consumer MEMBER utilization;26
(e) Health status of consumers MEMBERS; and27
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-73- (f) Uncompensated care delivered.1
SECTION 61. In Colorado Revised Statutes, 25.5-5-412, amend2
(6)(b); and amend as it will become effective July 1, 2024, (6)(a) as3
follows:4
25.5-5-412. Program of all-inclusive care for the elderly -5
services - eligibility - rules - legislative declaration - definitions.6
(6) The state department, in cooperation with the case management7
agencies established in section 25.5-6-1703, shall develop and implement8
a coordinated plan to provide education about PACE program site9
operations under this section. The state board shall adopt rules:10
(a) To ensure that case managers and any other appropriate state11
department staff discuss the option and potential benefits of participating12
in the PACE program with all eligible long-term care clients MEMBERS.13
These rules must require additional and on-going training of the case14
management agency case managers in counties where a PACE program15
is operating. This training must be provided by a federally approved16
PACE provider. In addition, each case management agency may designate17
case managers who have knowledge about the PACE program.18
(b) To allow PACE providers to contract with an enrollment19
broker to include the PACE program in its marketing materials to eligible20
long-term clients MEMBERS.21
SECTION 62. In Colorado Revised Statutes, 25.5-5-415, amend22
(2)(a), (2)(b)(II), (2)(c)(II)(A), (2)(c)(II)(D), and (3) as follows:23
25.5-5-415. Medicaid payment reform and innovation pilot24
program - creation - selection of payment projects - report - rules -25
legislative declaration. (2) (a) There is hereby created the medicaid26
payment reform and innovation pilot program for purposes of fostering the27
176
-74- use of innovative payment methodologies in the medicaid program that are1
designed to provide greater value while ensuring good health outcomes2
and client MEMBER satisfaction.3
(b) (II) The design of the payment project or projects must address4
the client MEMBER population of the state department's statewide managed5
care system and be tailored to the region's health-care needs and the6
resources of the state department's statewide managed care system.7
(c) (II) For purposes of selecting payment projects for the pilot8
program, the state department shall consider, at a minimum:9
(A) The likely effect of the payment project on quality measures,10
health outcomes, and client MEMBER satisfaction;11
(D) The client MEMBER population served by the state department's12
statewide managed care system and the particular health needs of the13
region;14
(3) Pilot program participants shall provide data and information15
to the state department and any designated evaluator concerning health16
outcomes, cost, provider participation and satisfaction, client MEMBER17
satisfaction, and any other data and information necessary to evaluate the18
efficacy of the payment methodology.19
SECTION 63. In Colorado Revised Statutes, 25.5-5-419, amend20
(1)(a), (1)(c), (1)(d), (3)(a), (3)(f), and (3)(i)(III) as follows:21
25.5-5-419. Accountable care collaborative - reporting - rules.22
(1) In 2011, the state department created the accountable care23
collaborative, also referred to in this title 25.5 as the medicaid coordinated24
care system. The state department shall continue to provide care delivery25
through the accountable care collaborative. The goals of the accountable26
care collaborative are to improve member health and reduce costs in the27
176
-75- medicaid program. To achieve these goals, the state department's1
implementation of the accountable care collaborative must include, but2
need not be limited to:3
(a) Establishing primary care medical homes for medicaid clients4
MEMBERS within the accountable care collaborative;5
(c) Providing data to regional entities and providers to help6
manage client MEMBER care;7
(d) Integrating the delivery of behavioral health, including mental8
health and substance use disorders, and physical health services for clients9
MEMBERS;10
(3) On or before December 1, 2017, and on or before December11
1 each year thereafter, the state department shall prepare and submit a12
report to the joint budget committee, the public health care and human13
services committee of the house of representatives, and the health and14
human services committee of the senate, or any successor committees,15
concerning the implementation of the accountable care collaborative.16
Notwithstanding the provisions of section 24-1-136 (11)(a)(I), the report17
required pursuant to this subsection (3) continues indefinitely. At a18
minimum, the state department's report must include the following19
information concerning the accountable care collaborative:20
(a) The number of medicaid clients MEMBERS enrolled in the21
program;22
(f) A description of the state department's coordination with23
entities that authorize long-term care services for medicaid clients24
MEMBERS;25
(i) Information concerning efforts to reduce medicaid waste and26
inefficiencies through the accountable care collaborative, including:27
176
-76- (III) Any other efforts by regional entities or the state department1
to ensure that those who provide care for medicaid clients MEMBERS are2
aware of and actively participate in reducing waste within the medicaid3
system.4
SECTION 64. In Colorado Revised Statutes, amend 25.5-5-5035
as follows:6
25.5-5-503. Prescription drug benefits - authorization -7
dual-eligible participation. (1) The state department is authorized to8
ensure the participation of Colorado medical assistance recipients9
MEMBERS, who are also eligible for medicare, in any federal prescription10
drug benefit enacted for medicare recipients.11
(2) Prescribed drugs shall not be ARE NOT a covered benefit under12
the medical assistance program for a recipient MEMBER who is eligible for13
a prescription drug benefit program under medicare; except that, if a14
prescribed drug is not a covered Part D drug as defined in the "Medicare15
Prescription Drug, Improvement, and Modernization Act of 2003", Pub.L.16
108-173, the prescribed drug may be a covered benefit if it is otherwise17
covered under the medical assistance program and federal financial18
participation is available.19
SECTION 65. In Colorado Revised Statutes, amend 25.5-5-50420
as follows:21
25.5-5-504. Providers of pharmaceutical services.22
(1) Consistent with the provisions of section 25.5-4-401 (1) and23
consistent with subsections (2) and (3) of this section, and subject to24
available appropriations, no provider of pharmaceutical services who25
meets the conditions imposed by this article ARTICLE 5 and articles 4 and26
6 of this title TITLE 25.5 and who complies with the terms and conditions27
176
-77- established by the state department and contracting health maintenance1
organizations and prepaid health plans shall be excluded from contracting2
for the provision of pharmaceutical services to recipients MEMBERS3
authorized in this article ARTICLE 5 and articles 4 and 6 of this title TITLE4
25.5.5
(2) This provision shall DOES not apply to a health maintenance6
organization or prepaid health plan that enrolls less than forty percent of7
all the resident medicaid recipients MEMBERS in any county with over one8
thousand medicaid recipients MEMBERS.9
(3) The state board shall establish specifications in rules in order10
to provide criteria to health maintenance organizations and prepaid health11
plans which ensure the accessibility and quality of service to clients12
MEMBERS and the terms and conditions for pharmaceutical contracts.13
SECTION 66. In Colorado Revised Statutes, 25.5-5-505, amend14
(1)(a)(II), (1)(b), and (1.5) as follows:15
25.5-5-505. Prescribed drugs - mail order - rules.16
(1) (a) (II) The state board rules must include the definition of17
maintenance medications. The rules may allow a medical assistance18
recipient MEMBER to receive through the mail up to a three-month supply,19
or the maximum allowed under federal law, of maintenance medications20
used to treat chronic medical conditions.21
(b) To the extent allowed by federal law, the state department shall22
require that a medical assistance recipient MEMBER receiving prescription23
medication through the mail pay the same copayment amount as a medical24
assistance recipient MEMBER receiving prescription medication through25
any other method. The state department shall encourage medical26
assistance recipients MEMBERS who choose to receive maintenance27
176
-78- medications through the mail to use local retail pharmacies for mail1
delivery.2
(1.5) The state department shall publish on its website and include3
in the recipient MEMBER handbook the following information for4
recipients MEMBERS enrolled in fee-for-service medical assistance5
programs:6
(a) That a medical assistance recipient MEMBER may use the7
pharmacy of his or her THE MEMBER'S choice;8
(b) That a medical assistance recipient MEMBER may use a local9
retail pharmacy for mail delivery of maintenance medications, if offered;10
and11
(c) That the copayment amount for prescription medications is the12
same at any pharmacy enrolled in the medical assistance program.13
SECTION 67. In Colorado Revised Statutes, 25.5-5-509, amend14
(2)(b) as follows:15
25.5-5-509. Substance use disorder - prescription drugs -16
opiate antagonist. (2) (b) A hospital or emergency department shall17
receive reimbursement under the medical assistance program for the cost18
of an opiate antagonist if, in accordance with section 12-30-110, a19
prescriber, as defined in section 12-30-110 (7)(h), dispenses an opiate20
antagonist upon discharge to a medical assistance recipient MEMBER who21
is at risk of experiencing an opiate-related drug overdose event or to a22
family member, friend, or other person in a position to assist a medical23
assistance recipient MEMBER who is at risk of experiencing an24
opiate-related drug overdose event.25
SECTION 68. In Colorado Revised Statutes, 25.5-5-514, amend26
(2)(a) as follows:27
176
-79- 25.5-5-514. Prescription drugs used for treatment or1
prevention of HIV - prohibition on utilization management -2
definition. (2) (a) Before July 1, 2027, the state department shall not3
restrict by prior authorization or step therapy requirements any4
prescription drug approved by the federal food and drug administration5
that is used for the treatment or prevention of HIV if a prescribing6
practitioner licensed pursuant to title 12 has determined the prescription7
drug to be medically necessary for the treatment or prevention of HIV for8
a recipient MEMBER. Prescription drugs used for the treatment or9
prevention of HIV include protease inhibitors, non-nucleoside reverse10
transcriptase inhibitors, nucleoside reverse transcriptase inhibitors,11
antivirals, integrase inhibitors, long-acting medications, and fusion12
inhibitors.13
SECTION 69. In Colorado Revised Statutes, 25.5-6-102, amend14
(1) introductory portion and (1)(d) as follows:15
25.5-6-102. Court-approved trusts - transfer of property for16
persons seeking medical assistance for nursing home care - undue17
hardship - legislative declaration. (1) The general assembly hereby18
finds, determines, and declares that:19
(d) It is therefore appropriate to enact state laws which limit such20
court-approved trusts in a manner that is consistent with Title XIX of the21
federal "Social Security Act", 42 U.S.C. sec. 1396 et seq., as amended,22
and which provide that persons who qualify for assistance as a result of23
the creation of such trusts shall be ARE treated the same as any other24
recipient MEMBER of medical assistance for nursing home care;25
SECTION 70. In Colorado Revised Statutes, 25.5-6-104, amend26
(1)(b), (1)(c), (2)(b), (2)(d), (2)(e), (2)(f), (2)(i), (2)(j), (2)(k), (3)(a), (3)(b)27
176
-80- introductory portion, (3)(b)(VII), (3)(c), (3)(d) introductory portion,1
(3)(d)(I) introductory portion, (3)(d)(II), (3)(d)(III), (3)(d)(V), (3)(e), and2
(5)(a) as follows:3
25.5-6-104. Long-term care placements - comprehensive and4
uniform assessment instrument - report - legislative declaration -5
definitions - repeal. (1) (b) The general assembly further finds,6
determines, and declares that the state is in need of a long-term care7
system that organizes each long-term care client's APPLICANT'S AND8
MEMBER'S entry, assessment of need, and service delivery into a single9
unified system, and that such THE system must include, at a minimum, a10
locally established single entry point administered by a designated entity,11
a single client assessment instrument and administrative process, targeted12
case management in order to maximize existing federal, state, and local13
funding, case management, and an accountability mechanism designed to14
assure that budget allocations are being effectively managed. 15
(c) The general assembly therefore concludes that it is appropriate16
to develop and implement a comprehensive and uniform long-term care17
client assessment process and to study the establishment of a single entry18
point system that provides for the coordination of access and service19
delivery to long-term care clients MEMBERS at the local level, that is20
available to all persons INDIVIDUALS in need of long-term care, and that21
is well managed and cost-efficient.22
(2) As used in this section and in sections 25.5-6-105 to23
25.5-6-107, unless the context otherwise requires:24
(b) "Case management services" means the assessment of a AN25
INDIVIDUAL'S NEED FOR long-term care, client's needs, the development26
and implementation of a care plan for such client THE MEMBER, the27
176
-81- coordination and monitoring of long-term care service delivery, the direct1
delivery of services as provided by this article ARTICLE 6 or by rules2
adopted by the state board pursuant to this article ARTICLE 6, the3
evaluation of service effectiveness, and the reassessment of such client's4
THE MEMBER'S needs, all of which shall be performed by a single entry5
point as defined in paragraph (k) of this subsection (2) SUBSECTION (2)(k)6
OF THIS SECTION.7
(d) "Comprehensive and uniform client assessment process" means8
a standard procedure, which includes the use of a uniform assessment9
instrument, to measure a client's MEMBER'S OR APPLICANT'S functional10
capacity, to determine the social and medical needs of a current or11
potential client MEMBER OR APPLICANT of any long-term care program,12
and to target resources to the functionally impaired.13
(e) "Continuum of care" means an organized system of long-term14
care, benefits, and services to which a client MEMBER has access and15
which enables a client MEMBER to move from one level or type of care to16
another without encountering gaps in or barriers to service.17
(f) "Information and referral" means the provision of specific,18
accurate, and timely public information about services available to aging19
and disabled adults in need of long-term care and referral to alternative20
agencies, programs, and services based on client MEMBER inquiries.21
(i) "Resource development" means the study, establishment, and22
implementation of additional resources or services which will extend the23
capabilities of community long-term care systems to better serve24
long-term care clients MEMBERS.25
(j) "Screening" means a preliminary determination of need for26
long-term care services and, on the basis of such THE determination, the27
176
-82- making of an appropriate referral for a client AN assessment in accordance1
with subsection (3) of this section or referral to another community2
resource to assist clients INDIVIDUALS who are not in need of long-term3
care services.4
(k) "Single entry point" means the availability of a single access5
or entry point within a local area where a current or potential long-term6
care client MEMBER OR APPLICANT can obtain long-term care information,7
screening, assessment of need, and referral to appropriate long-term care8
program and case management services.9
(3) (a) On or before July 1, 1991, the state department shall10
establish, by rule in accordance with article 4 of title 24, C.R.S., a11
comprehensive and uniform client assessment process for all individuals12
in need of long-term care, the purpose of which is to determine the13
appropriate services and levels of care necessary to meet clients'14
MEMBERS' OR APPLICANTS' needs, to analyze alternative forms of care and15
the payment sources for such THE care, and to assist in the selection of16
long-term care programs and services that meet clients' MEMBERS' OR17
APPLICANTS' needs most cost-efficiently.18
(b) Participation in the
ASSESSMENT process shall be
IS mandatory19
for clients MEMBERS of publicly funded long-term care programs,20
including, but not limited to, the following:21
(VII) Home health services for long-term care clients MEMBERS;22
and23
(c) Private paying clients MEMBERS of long-term care programs24
may participate in the process for a fee to be established by the state25
department and adopted through rules.26
(d) The state department, through rules, shall develop and27
176
-83- implement no later than July 1, 1991, a uniform long-term care client1
needs assessment instrument for all individuals needing IN NEED OF2
long-term care. The instrument shall MUST be used as part of the3
comprehensive and uniform client assessment process to be established in4
accordance with subsection (3)(a) of this section and shall MUST serve the5
following functions:6
(I) To obtain information on each client's MEMBER'S OR7
APPLICANT'S status in the following areas:8
(II) To assess each client's MEMBER'S OR APPLICANT'S physical9
environment in terms of meeting the client's MEMBER'S OR APPLICANT'S10
needs;11
(III) To obtain information on each client's MEMBER'S OR12
APPLICANT'S payment sources, including obtaining financial eligibility13
information for publicly funded long-term care programs;14
(V) To prioritize a client's MEMBER'S OR APPLICANT'S need for care15
using criteria established by the state department for specific publicly16
funded long-term care programs;17
(e) On and after July 1, 1991, no publicly funded client shall A18
MEMBER MUST NOT be placed in a long-term care program unless such THE19
placement is in accordance with rules adopted by the state board in20
implementing this section.21
(5) (a) On or before July 1, 2018, pursuant to the state department's22
ongoing stakeholder process relating to eligibility determination for23
long-term services and supports pursuant to this article ARTICLE 6, the24
state department shall select a needs assessment tool for persons25
INDIVIDUALS receiving long-term services and supports, including persons26
INDIVIDUALS with intellectual and developmental disabilities who are27
176
-84- eligible for services pursuant to section 25.5-6-409. Once selected, the1
state department shall begin assessing client THE INDIVIDUAL'S needs using2
the needs assessment tool as soon as practicable.3
SECTION 71. In Colorado Revised Statutes, 25.5-6-105, amend4
(1) introductory portion, (1)(b), and (1)(c) as follows:5
25.5-6-105. Legislative declaration relating to implementation6
of single entry point system - repeal. (1) The general assembly hereby7
finds, determines, and declares that:8
(b) The establishment of a single entry point system for the9
coordination of access to existing services and service delivery for all10
long-term care clients MEMBERS at the local level can be implemented in11
a cost-efficient manner;12
(c) The implementation of a well-managed single entry point13
system will result in the utilization of more appropriate services by14
long-term care clients MEMBERS over time and will provide better15
information on the unmet service needs of clients MEMBERS; and16
SECTION 72. In Colorado Revised Statutes, 25.5-6-106, amend17
(2)(b) introductory portion, (2)(c) introductory portion, (2)(c)(III),18
(2)(c)(IV), (2)(c)(V), and (3)(b) as follows:19
25.5-6-106. Single entry point system - authorization - phases20
for implementation - services provided - repeal. (2) Single entry point21
agencies - service programs - functions. (b) The agency may serve22
private paying clients MEMBERS on a fee-for-service basis and shall serve23
clients MEMBERS of publicly funded long-term care programs, including,24
but not limited to, the following:25
(c) The major functions of a single entry point shall MUST include,26
but need not be limited to, the following:27
176
-85- (III) Assessing clients' MEMBERS' needs in accordance with section1
25.5-6-104;2
(IV) Developing plans of care for clients MEMBERS;3
(V) Determining payment sources available to clients MEMBERS for4
long-term care services;5
(3) State certification of a single entry point agency - quality6
assurance standards. (b) The state board shall adopt rules for the7
establishment of a quality assurance program for the purpose of8
monitoring the quality of services provided to clients MEMBERS and for9
recertifying single entry point agencies. The rules shall provide for:10
Procedures to evaluate the quality of services provided by the agency; an11
assessment of the agency's compliance with program requirements,12
including compliance with case management standards, which standards13
shall be adopted by the state department; an assessment of an agency's14
performance of administrative functions, including reasonable costs per15
client MEMBER, timely responses, managing programs in one consolidated16
unit, on-site visits to clients MEMBERS, community coordination and17
outreach, and client MEMBER monitoring; a determination as to whether18
targeted populations are being identified and served; and an evaluation19
concerning financial accountability.20
SECTION 73. In Colorado Revised Statutes, 25.5-6-107, amend21
(1) introductory portion, (1)(c)(II), and (2) as follows:22
25.5-6-107. Financing of single entry point system - repeal.23
(1) The single entry point system shall be financed with the following24
moneys FUNDING:25
(c) County contributions, as follows:26
(II) The amount contributed from each county in accordance with27
176
-86- subparagraph (I) of this paragraph (c) SUBSECTION (1)(c)(I) OF THIS1
SECTION after making an adjustment based on the percentage of an2
increase or decrease per fiscal year in the service costs for clients3
MEMBERS of such THE county. However, in no case shall a county be IS4
NOT required under this subparagraph (II) SUBSECTION (1)(c)(II) to5
contribute more than a five percent increase in said service costs.6
(2) County contributions for client MEMBER services made in7
accordance with subparagraph (I) of paragraph (c) of subsection (1)8
SUBSECTION (1)(c)(I) of this section shall MUST be expended only for9
clients MEMBERS of the county providing said THE contribution.10
SECTION 74. In Colorado Revised Statutes, 25.5-6-108.5,11
amend (1)(a), (2)(a) introductory portion, (2)(a)(I), and (2)(a)(II) as12
follows:13
25.5-6-108.5. Community long-term care studies - authority to14
implement - alternative care facility report. (1) (a) Subject to the15
receipt of sufficient moneys FUNDING pursuant to paragraph (c) of this16
subsection (1) SUBSECTION (1)(c) OF THIS SECTION, the state department17
shall contract for one or more studies of the population of recipients18
MEMBERS receiving services under the home- and community-based19
waivers authorized pursuant to this article ARTICLE 6. The state department20
shall make necessary data available to the contractor, including but not21
limited to data on activities of daily living. In selecting a contractor to22
perform any study conducted pursuant to this subsection (1), the state23
department is not required to follow the competitive bidding requirements24
of the "Procurement Code", articles 101 to 112 of title 24. C.R.S. The state25
department shall provide copies of all studies conducted pursuant to this26
subsection (1) to members of the health and human services committees27
176
-87- of the general assembly, or any successor committees, and to the members1
of the joint budget committee.2
(2) (a) Subject to the receipt of sufficient moneys FUNDING, one of3
the studies contracted for pursuant to subsection (1) of this section shall4
MUST include research and analysis of:5
(I) The number of recipients MEMBERS with incontinence,6
Alzheimer's disease, dementia, or other diagnoses of a chronic7
incapacitating condition that severely limit their THE MEMBER'S activities8
of daily living who would benefit from receiving additional services9
through an alternative care facility thereby avoiding TO AVOID nursing10
home placement;11
(II) The actuarially sound rate for providing services for the12
recipients MEMBERS at an alternative care facility;13
SECTION 75. In Colorado Revised Statutes, 25.5-6-113, amend14
(1)(a) introductory portion, (1)(a)(VIII), (1)(b), and (5) as follows:15
25.5-6-113. Health home - integrated services - contracting -16
legislative declaration - definitions. (1) (a) The general assembly hereby17
finds and declares that:18
(VIII) The system must ensure a comprehensive approach to19
long-term care that addresses the different demographic and geographic20
challenges in the state and the various long-term care services and21
supports that clients MEMBERS need.22
(b) Therefore, the general assembly declares that a comprehensive23
approach to long-term care requires that programs and policies integrating24
and coordinating care under the medicaid program be flexible and allow25
for full participation by providers of long-term care services to ensure26
quality of care for clients MEMBERS and efficient use of limited resources.27
176
-88- (5) Dually eligible clients MEMBERS may voluntarily elect to1
participate in a recognized medicare coordinated care system and may2
voluntarily elect to participate in the state department's medicaid3
coordinated care system.4
SECTION 76. In Colorado Revised Statutes, 25.5-6-116, amend5
(1) as follows:6
25.5-6-116. Community placement transformation - creation7
- report - repeal. (1) The state department shall undertake efforts to8
transform the state department's process for clients MEMBERS OR9
APPLICANTS attempting to receive long-term care in the community.10
SECTION 77. In Colorado Revised Statutes, 25.5-6-206, amend11
(1), (2), and (6) as follows:12
25.5-6-206. Personal needs benefits - amount - patient personal13
needs trust fund required - funeral and final disposition expenses -14
penalty for illegal retention and use. (1) The state department, pursuant15
to its rules, may include in medical care benefits provided under this16
article 6 and articles 4 and 5 of this title 25.5 reasonable amounts for the17
personal needs of any recipient MEMBER receiving nursing facility services18
or intermediate care facilities for individuals with intellectual disabilities,19
if the recipient MEMBER is not otherwise eligible for the amounts from20
other categories of public assistance, but the amounts for personal needs21
must not be less than the minimum amount provided for in subsection (2)22
of this section. Payments for funeral and final disposition expenses upon23
the death of a recipient MEMBER may be provided under rules of the state24
department in the same manner as provided to recipients MEMBERS of25
public assistance as defined by section 26-2-103 (8).26
(2) (a) The basic minimum amount payable pursuant to subsection27
176
-89- (1) of this section for personal needs to any recipient MEMBER admitted to1
a nursing facility or intermediate care facility for individuals with2
intellectual disabilities is seventy-five dollars monthly; except that,3
commencing January 1, 2015, and each January 1 thereafter, the basic4
minimum amount shall MUST increase annually by the same percentage5
applied to the general fund share of the aggregate statewide average of the6
per diem net of patient payment pursuant to section 25.5-6-202 (9)(b)(I).7
Commencing with the fiscal year beginning July 1, 2014, and each fiscal8
year thereafter, the reduction to patient payments received by nursing9
facilities resulting from an increase in the basic minimum amount shall be10
IS funded in full by general fund and applicable federal funds.11
(b) On and after October 1, 1992, the basic minimum amount12
payable pursuant to subsection (1) of this section for personal needs shall13
be IS ninety dollars for the following persons:14
(I) A medical assistance recipient MEMBER who receives a15
non-service connected disability pension from the United States veterans16
administration, has no spouse or dependent child, and is admitted to or is17
residing in a nursing facility; and18
(II) A medical assistance recipient MEMBER who is a surviving19
spouse of a person who received a non-service connected disability20
pension from the United States veterans administration, has no dependent21
child, and is admitted to or is residing in a nursing facility.22
(6) Any overpayment of personal needs funds to a nursing facility23
or an intermediate care facility for individuals with intellectual disabilities24
by the state department due to the omission, error, fraud, or defalcation of25
the nursing facility or intermediate care facility for individuals with26
intellectual disabilities or any shortage in an audited patient personal27
176
-90- needs trust fund shall be IS recoverable by the state on behalf of the1
recipient MEMBER in the same manner and following the same procedures2
as specified in section 25.5-4-301 (2) for an overpayment to a provider.3
SECTION 78. In Colorado Revised Statutes, 25.5-6-209, amend4
(1) as follows:5
25.5-6-209. Establishment of nursing facility provider6
demonstration of need - criteria - rules. (1) The state department, in7
making any medicaid certification determination, shall encourage an8
appropriate allocation of public health-care resources and the development9
of alternative or substitute methods of delivering health-care services so10
that adequate long-term care services are made reasonably available to11
every qualified recipient MEMBER within the state at the appropriate level12
of care, at the lowest reasonable aggregate cost, and in the least restrictive13
setting. Medicaid certification determinations shall be made in accordance14
with Olmstead v. L.C., 527 U.S. 581 (1999).15
SECTION 79. In Colorado Revised Statutes, 25.5-6-303, amend16
(20); and amend as it will become effective July 1, 2024, (7) as follows:17
25.5-6-303. Definitions - repeal. As used in this part 3, unless the18
context otherwise requires:19
(7) "Case plan" means a coordinated plan for the provision of20
long-term-care services in a setting other than a nursing home, developed21
and managed by a case management agency, in coordination with the22
client MEMBER, the client's MEMBER'S family or guardian, the client's23
MEMBER'S physician, and other providers of care.24
(20) "Respite care services" means services of a short-term nature25
provided to a client MEMBER, in the home or in a facility approved by the26
state department, in order to temporarily relieve the family or other home27
176
-91- providers from the care and maintenance of such client THE MEMBER,1
including room and board, maintenance, personal care, and other related2
services.3
SECTION 80. In Colorado Revised Statutes, 25.5-6-307, amend4
(5)(a)(III) and (5)(e)(I) as follows:5
25.5-6-307. Services for the elderly, blind, and disabled.6
(5) (a) No later than January 2024, the state department shall submit a7
report to the senate health and human services committee, the house of8
representatives public and behavioral health and human services9
committee, and the house of representatives health and insurance10
committee, or any successor committees, as part of its "State Measurement11
for Accountable, Responsive, and Transparent (SMART) Government12
Act" presentation required by section 2-7-203. At a minimum, the report13
must identify:14
(III) A system of common reporting to ensure a recipient MEMBER15
does not exceed the medicaid benefit in a multi-provider scenario; and16
(e) (I) The state department shall promulgate any necessary rules17
to ensure transportation network companies comply with federal and state18
oversight requirements and shall include all relevant stakeholders,19
including medicaid recipients MEMBERS, transportation network20
companies, current providers and drivers for nonmedical transportation21
services, and other
PARTIES interested parties
in the development of such22
DEVELOPING THE requirements.23
SECTION 81. In Colorado Revised Statutes, 25.5-6-310, amend24
(2) as follows:25
25.5-6-310. Special provisions - personal care services provided26
by a family - repeal. (2) The maximum reimbursement for the services27
176
-92- provided by a member of the person's family per year for each client shall1
MEDICAID MEMBER MUST not exceed the equivalent of four hundred2
forty-four service units per year for a member of the eligible person's3
family.4
SECTION 82. In Colorado Revised Statutes, 25.5-6-314, amend5
(1)(c) as follows:6
25.5-6-314. Training for staff providing direct-care services to7
members with dementia - rules - definitions. (1) As used in this8
section:9
(c) "Direct-care staff member" means a staff member caring for10
the physical, emotional, or mental health needs of clients MEMBERS of an11
adult day care facility and whose work involves regular contact with12
clients MEMBERS who are living with dementia diseases and related13
disabilities.14
SECTION 83. In Colorado Revised Statutes, 25.5-6-404, amend15
(4) as follows:16
25.5-6-404. Duties of the department of health care policy and17
financing and the department of human services. (4) The executive18
director and the state board shall promulgate such rules regarding this part19
4 as are necessary to fulfill the obligations of the state department as the20
single state agency to administer medical assistance programs in21
accordance with Title XIX of the federal "Social Security Act", as22
amended. Such THE rules may include, but shall ARE not be limited to,23
determination of the level of care requirements for long-term care, patient24
payment requirements, clients' MEMBERS' rights, medicaid eligibility, and25
appeal rights associated with these requirements.26
SECTION 84. In Colorado Revised Statutes, 25.5-6-409, amend27
176
-93- (5)(a)(III) and (5)(e)(I) as follows:1
25.5-6-409. Services for persons with intellectual and2
developmental disabilities. (5) (a) No later than January 2024, the state3
department shall submit a report to the senate health and human services4
committee, the house of representatives public and behavioral health and5
human services committee, and the house of representatives health and6
insurance committee, or any successor committees, as part of its "State7
Measurement for Accountable, Responsive, and Transparent (SMART)8
Government Act" presentation required by section 2-7-203. At a9
minimum, the report must identify:10
(III) A system of common reporting to ensure a recipient MEMBER11
does not exceed the medicaid benefit in a multi-provider scenario; and12
(e) (I) The state department shall promulgate any necessary rules13
to ensure transportation network companies comply with federal and state14
oversight requirements and shall include all relevant stakeholders,15
including medicaid recipients MEMBERS, transportation network16
companies, current providers and drivers for nonmedical transportation17
services, and other
PARTIES interested parties
in the development of such18
DEVELOPING THE requirements.19
SECTION 85. In Colorado Revised Statutes, 25.5-6-409.3,20
amend (3.3)(a) introductory portion, (3.3)(a)(I), and (3.3)(a)(III) as21
follows:22
25.5-6-409.3. Consolidated waiver - intellectual and23
developmental disabilities - conflict-free case management - legislative24
declaration - repeal. (3.3) (a) The state department's administration of25
the redesigned waiver shall MUST include:26
(I) A functional eligibility and needs assessment tool used for the27
176
-94- redesigned waiver that aligns with the recommendations of the community1
living advisory group and that is fully integrated with the assessment2
process for all clients MEMBERS receiving long-term services and supports;3
(III) A service payment system that ensures fair distribution of4
available resources and that is efficient, transparent, and equitable for both5
providers and consumers MEMBERS.6
SECTION 86. In Colorado Revised Statutes, amend 25.5-6-4117
as follows:8
25.5-6-411. Personal needs trust fund required. All personal9
needs funds shall MUST be held in trust by a residential facility authorized10
to provide services pursuant to this part 4, or its THE RESIDENTIAL11
FACILITY'S designated trustee, separate and apart from any other funds of12
the facility, in a checking account or savings account or any combination13
thereof established to protect and separate the personal needs funds of the14
clients MEMBERS. At all times, the principal and all income derived from15
said THE principal in the personal needs trust fund shall MUST remain the16
property of the participating clients MEMBERS, and the RESIDENTIAL17
facility or its THE FACILITY'S designated trustee is bound by all of the18
duties imposed by law upon fiduciaries in the handling of such THE fund19
including accounting for all expenditures from the fund.20
SECTION 87. In Colorado Revised Statutes, 25.5-6-606, amend21
(8)(a)(III) and (8)(e)(I) as follows:22
25.5-6-606. Implementation of program for persons with23
mental health disorders authorized - federal waiver - duties of the24
department of health care policy and financing and the department25
of human services - rules. (8) (a) No later than January 2024, the state26
department shall submit a report to the senate health and human services27
176
-95- committee, the house of representatives public and behavioral health and1
human services committee, and the house of representatives health and2
insurance committee, or any successor committees, as part of its "State3
Measurement for Accountable, Responsive, and Transparent (SMART)4
Government Act" presentation required by section 2-7-203. At a5
minimum, the report must identify:6
(III) A system of common reporting to ensure a recipient MEMBER7
does not exceed the medicaid benefit in a multi-provider scenario; and8
(e) (I) The state department shall promulgate any necessary rules9
to ensure transportation network companies comply with federal and state10
oversight requirements and shall include all relevant stakeholders,11
including medicaid recipients MEMBERS, transportation network12
companies, current providers and drivers for nonmedical transportation13
services, and other
PARTIES interested parties
in the development of such14
DEVELOPING THE requirements.15
SECTION 88. In Colorado Revised Statutes, 25.5-6-703, amend16
(1), (2), (6)(a), (7), and (10) as follows:17
25.5-6-703. Definitions - repeal. As used in this part 7, unless the18
context otherwise requires:19
(1) "Adult day care" means health and social services furnished20
two or more hours per day on a regularly scheduled basis for one or more21
days per week in an outpatient setting and for the purpose of ensuring the22
optimal functioning of the recipient MEMBER.23
(2) "Behavioral programming" means an individualized plan that24
sets forth strategies to decrease a recipient's MEMBER'S maladaptive25
behaviors that interfere with the recipient's MEMBER'S ability to remain in26
the community. Behavioral programming includes a complete assessment27
176
-96- of maladaptive behaviors of the recipient MEMBER, the development and1
implementation of a structured behavioral intervention plan, continuous2
training and supervision of caregivers and behavioral aides, and periodic3
reassessment of the individualized plan.4
(6) (a) "Personal care services" means assistance with eating,5
bathing, dressing, personal hygiene, and activities of daily living. Personal6
care services include assistance with the preparation of meals, but not the7
cost of the meals, and homemaker services that are necessary for the8
health and safety of the recipient MEMBER.9
(7) "Structured day treatment" means structured, nonresidential10
therapeutic treatment services that are directed at the development and11
maintenance of community living skills and are provided two or more12
hours per day on a regularly scheduled basis for one or more days per13
week. Day treatment services include supervision and specific training14
that allows a recipient MEMBER to function at the recipient's MEMBER'S15
maximum potential. The services include, but are not limited to, social16
skills training that allows for reintegration into the community, sensory17
and motor development services, and services aimed at reducing18
maladaptive behavior.19
(10) "Transitional living" means a nonmedical residential program20
that provides training and twenty-four-hour supervision to a recipient21
MEMBER that will enhance the recipient's MEMBER'S ability to live more22
independently.23
SECTION 89. In Colorado Revised Statutes, 25.5-6-704, amend24
(7)(a)(III) and (7)(e)(I) as follows:25
25.5-6-704. Implementation of home- and community-based26
services program for persons with brain injury authorized - federal27
176
-97- waiver - duties of the department - rules - repeal. (7) (a) No later than1
January 2024, the state department shall submit a report to the senate2
health and human services committee, the house of representatives public3
and behavioral health and human services committee, and the house of4
representatives health and insurance committee, or any successor5
committees, as part of its "State Measurement for Accountable,6
Responsive, and Transparent (SMART) Government Act" presentation7
required by section 2-7-203. At a minimum, the report must identify:8
(III) A system of common reporting to ensure a recipient MEMBER9
does not exceed the medicaid benefit in a multi-provider scenario; and10
(e) (I) The state department shall promulgate any necessary rules11
to ensure transportation network companies comply with federal and state12
oversight requirements and shall include all relevant stakeholders,13
including medicaid recipients MEMBERS, transportation network14
companies, current providers and drivers for nonmedical transportation15
services, and other
PARTIES interested parties
in the development of such16
DEVELOPING THE requirements.17
SECTION 90. In Colorado Revised Statutes, 25.5-6-903, amend18
(1) as follows:19
25.5-6-903. Residential child health-care program - waiver -20
home- and community-based services - rules. (1) Subject to federal21
authorization, the state department shall implement a program for22
medicaid-eligible children with intellectual and developmental disabilities,23
as defined in section 25.5-10-202, with significant behavioral support24
needs who are at risk of institutionalization. The state board shall25
establish, by rule, the type of services provided pursuant to the program,26
to the extent the services are cost-efficient, and the recipient MEMBER27
176
-98- eligibility criteria that may include, but are not limited to, a medical1
necessity determination and a financial eligibility determination.2
SECTION 91. In Colorado Revised Statutes, amend 25.5-6-12013
as follows: 4
25.5-6-1201. Legislative declaration - repeal. (1) The general5
assembly finds that there may be a more effective way to deliver home-6
and community-based services to the elderly, blind, and disabled; to7
disabled children; and to persons with spinal cord injuries, that allows for8
more self-direction in their care and a cost savings to the state. The9
general assembly also finds that every person that is currently receiving10
home- and community-based services does not need the same level of11
supervision and care from a licensed health-care professional in order to12
meet his or her THE PERSON'S care needs and remain living in the13
community. The general assembly, therefore, declares that it is beneficial14
to the elderly, blind, and disabled clients MEMBERS of home- and15
community-based services, to clients MEMBERS of the disabled children16
care program, and to clients MEMBERS enrolled in the spinal cord injury17
waiver pilot program, for the state department to develop a service that18
would allow these people THE MEMBERS to receive in-home support. 19
(2) The general assembly further finds that allowing clients20
MEMBERS more self-direction in their THE MEMBERS' care is a more21
effective way to deliver home- and community-based services to clients22
MEMBERS with major mental health disorders and brain injuries, as well23
as to clients MEMBERS receiving home- and community-based supportive24
living services and children's extensive support services. Therefore, the25
general assembly declares that it is appropriate for the state department to26
develop a plan for expanding the availability of in-home support services27
176
-99- to include these clients MEMBERS.1
(3) This section is repealed, effective July 1, 2025.2
SECTION 92. In Colorado Revised Statutes, 25.5-6-1203, amend3
(4); and amend as it will become effective July 1, 2024, (5) as follows:4
25.5-6-1203. In-home support services - eligibility - licensure5
exclusion - in-home support service agency responsibilities - rules -6
repeal. (4) (a) In-home support service agencies providing in-home7
support services shall provide twenty-four-hour back-up services to their8
clients THE AGENCIES' MEMBERS. In-home support service agencies shall9
either contract with or have on staff a state licensed health-care10
professional, as defined by the state board by rule, acting within the scope11
of the person's profession. The state board shall promulgate rules setting12
forth the training requirements for attendants providing in-home support13
services and the oversight and monitoring responsibilities of the state14
licensed health-care professional that is either contracting with or is on15
staff with the in-home support service agency. The state board rules must16
allow the eligible person or the eligible person's authorized representative,17
parent of a minor, or guardian to determine, in conjunction with the18
in-home support services agency, the amount of oversight needed in19
connection with the eligible person's in-home support services.20
(b) The state board shall promulgate rules that establish how an21
in-home support service agency can discontinue a client MEMBER under22
this part 12. The rules shall MUST establish that a client MEMBER can only23
be involuntarily discontinued when equivalent care in the community has24
been secured or that a client MEMBER can be discontinued after exhibiting25
documented prohibited behavior involving attendants, including abuse of26
attendants, and that dispute resolution has failed. The determination of27
176
-100- STATE DEPARTMENT SHALL DETERMINE whether an in-home support1
service agency has made adequate attempts at resolution. shall be made by2
the state department.3
(5) The case management agencies established in section4
25.5-6-1703 shall be ARE responsible for determining a person's eligibility5
for in-home support services; except that for eligible disabled children the6
state department shall designate the entity that will determine the child's7
eligibility. The state board shall promulgate rules specifying the case8
management agencies' responsibilities pursuant to this part 12. At a9
minimum, these THE rules must require that case managers discuss the10
option and potential benefits of in-home support services with all eligible11
long-term care clients MEMBERS.12
SECTION 93. In Colorado Revised Statutes, 25.5-6-1303, amend13
(5)(c), (8)(a)(III), and (8)(e)(I) as follows:14
25.5-6-1303. Pilot program - complementary or alternative15
medicine - rules. (5) The state department shall cause to be conducted an16
independent evaluation of the pilot program to be completed no later than17
January 1, 2025. The state department shall provide a report of the18
evaluation to the health and human services committee of the senate and19
the public health care and human services committee of the house of20
representatives, or any successor committees. The report on the evaluation21
must include the following:22
(c) Feedback from consumers MEMBERS and the state department23
concerning the progress and success of the pilot program;24
(8) (a) No later than January 2024, the state department shall25
submit a report to the senate health and human services committee, the26
house of representatives public and behavioral health and human services27
176
-101- committee, and the house of representatives health and insurance1
committee, or any successor committees, as part of its "State Measurement2
for Accountable, Responsive, and Transparent (SMART) Government3
Act" presentation required by section 2-7-203. At a minimum, the report4
must identify:5
(III) A system of common reporting to ensure a recipient MEMBER6
does not exceed the medicaid benefit in a multi-provider scenario; and7
(e) (I) The state department shall promulgate any necessary rules8
to ensure transportation network companies comply with federal and state9
oversight requirements and shall include all relevant stakeholders,10
including medicaid recipients MEMBERS, transportation network11
companies, current providers and drivers for nonmedical transportation12
services, and other
PARTIES interested parties
in the development of such13
DEVELOPING THE requirements.14
SECTION 94. In Colorado Revised Statutes, 25.5-6-1402, amend15
(1) and (5) as follows:16
25.5-6-1402. Definitions. As used in this part 14, unless the17
context otherwise requires:18
(1) "Basic coverage group" means the category of eligibility under19
the federal "Ticket to Work and Work Incentives Improvement Act of20
1999", Pub.L. 106-170, that provides an opportunity to buy into medicaid21
consistent with the federal "Social Security Act", 42 U.S.C. sec. 1396a22
(a)(10)(A)(ii)(XV), as amended, for each worker with disabilities who is23
at least sixteen years of age but less than sixty-five years of age and who,24
except for earnings, would be eligible for the supplemental security25
income program. A person who is eligible under the basic coverage group26
may also be a home- and community-based services waiver recipient27
176
-102- MEMBER.1
(5) "Medical improvement group" means the category of eligibility2
under the federal "Ticket to Work and Work Incentives Improvement Act3
of 1999", Pub.L. 106-170, that provides an opportunity to buy into4
medicaid consistent with the federal "Social Security Act", 42 U.S.C. sec.5
1496a (a)(10)(A)(ii)(XV), as amended, for each worker with a medically6
improved disability who is at least sixteen years of age but less than7
sixty-five years of age and who was previously in the basic coverage8
group and is no longer eligible for the basic coverage group due to9
medical improvement. A person who is eligible under the medical10
improvement group may also be a home- and community-based services11
waiver recipient MEMBER.12
SECTION 95. In Colorado Revised Statutes, 25.5-6-1602, amend13
(1) introductory portion and (2) as follows:14
25.5-6-1602. State department to request increase in15
reimbursement rate for certain services. (1) Not more than ninety days16
after May 28, 2019, the state department shall request from the federal17
government an increase of eight and one-tenth percent in the18
reimbursement rate for the following services delivered to consumers19
MEMBERS through the home- and community-based services waivers:20
(2) For the 2019-20 fiscal year, each home care agency shall pay21
one hundred percent of the funding that results from the rate increase22
described in subsection (1) of this section as compensation for employees23
who provide personal care services, homemaker services, and in-home24
support services to consumers MEMBERS. This compensation shall be IS25
provided in addition to the rate of compensation that the employee was26
receiving as of June 30, 2019. For an employee who was hired after June27
176
-103- 30, 2019, the home care agency shall use the lowest compensation paid to1
an employee of similar functions and duties as of June 30, 2019, as the2
base compensation to which the increase is applied.3
SECTION 96. In Colorado Revised Statutes, 25.5-6-1803, amend4
(1)(b), (1)(c) introductory portion, and (1)(e)(IV) as follows:5
25.5-6-1803. Development of spending plan. (1) In accordance6
with federal guidance issued by the federal centers for medicare and7
medicaid services regarding the implementation of section 9817 of the8
"American Rescue Plan Act", the state department shall develop a9
proposed spending plan using the enhanced funding, which plan may10
include but is not limited to the following components:11
(b) Incorporation of feedback from medical assistance recipients12
MEMBERS, advocates, and providers for the services for which the13
"American Rescue Plan Act" provides additional federal financial14
participation;15
(c) Expedition of the response and recovery for medical assistance16
recipients MEMBERS, providers, and other relevant organizations most17
significantly impacted by the COVID-19 pandemic. Response and18
recovery efforts may include but are not limited to:19
(e) Investment in infrastructure and technology innovation that has20
a long-term benefit to the system and the people of Colorado, including21
integration with other statewide and local efforts. Investments may include22
but are not limited to:23
(IV) Expanding recipient MEMBER access to technology and24
technology literacy training;25
SECTION 97. In Colorado Revised Statutes, 25.5-8-103, amend26
(6)(b) as follows:27
176
-104- 25.5-8-103. Definitions - rules. As used in this article 8, unless the1
context otherwise requires:2
(6) "Essential community provider" means a health-care provider3
that:4
(b) Waives charges or charges for services on a sliding scale based5
on income and does not restrict access or services because of a client's6
MEMBER'S financial limitations.7
SECTION 98. In Colorado Revised Statutes, 25.5-8-107, amend8
(1)(a)(III) as follows:9
25.5-8-107. Duties of the department - schedule of services -10
premiums - copayments - subsidies - purchase of childhood11
immunizations. (1) In addition to any other duties pursuant to this article12
8, the department has the following duties:13
(a) (III) In addition to the items specified in subparagraphs (I) and14
(II) of this paragraph (a) SUBSECTION (1)(a)(I) AND (1)(a)(II) OF THIS15
SECTION and any additional items approved by the medical services board,16
the medical services board shall include mental health services that are at17
least as comprehensive as the mental health services provided to medicaid18
recipients MEMBERS in the schedule of health-care services.19
SECTION 99. In Colorado Revised Statutes, 25.5-8-109, amend20
(4.5)(a)(II) and (4.5)(a)(III) as follows:21
25.5-8-109. Eligibility - children - pregnant women - rules -22
repeal. (4.5) (a) (II) The department shall annually verify the recipient's23
MEMBER'S income eligibility at reenrollment through federally approved24
electronic data sources. If a recipient MEMBER meets all eligibility25
requirements, a recipient MEMBER remains enrolled in the plan. The26
department shall also allow a recipient MEMBER to provide income27
176
-105- information more recent than the records of federally approved electronic1
data sources.2
(III) If the state department determines that a recipient MEMBER3
was not eligible for medical benefits solely based upon the recipient's4
MEMBER'S income after the recipient MEMBER had been determined to be5
eligible based upon information verified through federally approved6
electronic data sources, the state department shall not pursue recovery7
from a county department for the cost of medical services provided to the8
recipient MEMBER, and the county department is not responsible for any9
federal error rate sanctions resulting from such THE determination.10
SECTION 100. In Colorado Revised Statutes, 25.5-8-110, amend11
(4)(b), (5), and (9) as follows:12
25.5-8-110. Participation by managed care plans. (4) (b) The13
managed care organization shall seek proposals from each essential14
community provider in a county in which the managed care organization15
is enrolling recipients MEMBERS for those services that the managed care16
organization provides or intends to provide and that an essential17
community provider provides or is capable of providing. To assist18
managed care organizations in seeking proposals, the department shall19
provide managed care organizations with a list of essential community20
providers in each county. The managed care organization shall consider21
such THE proposals in good faith and shall, when deemed reasonable by22
the managed care organization based on the needs of its enrollees23
MEMBERS, contract with essential community providers. Each essential24
community provider shall MUST be willing to negotiate on reasonably25
equitable terms with each managed care organization. Essential26
community providers making proposals under PURSUANT TO this27
176
-106- subsection (4) shall MUST be able to meet the contractual requirements of1
the managed care organization. The requirement of this subsection (4)2
shall DOES not apply to a managed care organization in areas in which the3
managed care organization operates entirely as a group model health4
maintenance organization.5
(5) The department may receive and act upon complaints from6
enrollees MEMBERS regarding failure to provide covered services or efforts7
to obtain payment, other than authorized copayments, for covered services8
directly from eligible recipients MEMBERS.9
(9) The department shall allow, at least annually, an opportunity10
for enrollees MEMBERS to transfer among participating managed care plans11
serving their respective geographic regions. The department shall establish12
a period of at least twenty days annually when this THE opportunity TO13
TRANSFER is afforded TO eligible recipients MEMBERS. In geographic14
regions served by more than one participating managed care plan, the15
department shall endeavor to establish a uniform period for such THE16
opportunity
TO TRANSFER.17
SECTION 101. In Colorado Revised Statutes, 25.5-10-211.5,18
amend (3)(f), (3)(g), and (4)(f) as follows:19
25.5-10-211.5. Conflict-free case management - implementation20
- legislative declaration - definition - repeal. (3) A conflict-free case21
management system shall be implemented in Colorado as follows:22
(f) No later than June 30, 2021, at least twenty-five percent of23
clients
MEMBERS receiving home- and community-based services must be24
served through a system of conflict-free case management; and25
(g) No later than June 30, 2022, all clients MEMBERS receiving26
home- and community-based services must be served through a system of27
176
-107- conflict-free case management.1
(4) Rural-based services - exemption. (f) In order to ensure2
stability, client MEMBER choice, and access to services in rural3
communities, the state board shall promulgate rules, as permitted under4
federal law, that allow a qualified entity to provide both case management5
services and home- and community-based services to the same individual6
if there is insufficient choice or capacity among existing service agencies7
or case management agencies serving a designated service area of a rural8
community-centered board.9
SECTION 102. In Colorado Revised Statutes, 25.5-10-212,10
amend (1) introductory portion as follows:11
25.5-10-212. Procedure for resolving disputes over eligibility,12
modification of services or supports, and termination of services or13
supports. (1) Every state or local service agency receiving state money14
pursuant to section 25.5-10-206 shall adopt a procedure for the resolution15
of disputes arising between the service agency and any recipient MEMBER16
of, or applicant for, services or supports authorized pursuant to section17
25.5-10-206. Procedures for the resolution of disputes regarding early18
intervention services must comply with IDEA and with part 4 of article 319
of title 26.5. The procedures must be consistent with rules promulgated by20
the state board pursuant to article 4 of title 24 and must apply to the21
following disputes:22
SECTION 103. In Colorado Revised Statutes, 25-48-115, amend23
(4) as follows:24
25-48-115. Insurance or annuity policies. (4) An individual with25
a terminal illness who is a recipient MEMBER of medical assistance under26
the "Colorado Medical Assistance Act", articles 4, 5, and 6 of title 25.5,27
176
-108- C.R.S. shall not be denied benefits under the medical assistance program1
or have his or her THE MEMBER'S benefits under the program otherwise2
altered based on whether or not the individual MEMBER makes a request3
pursuant to this article ARTICLE 48.4
SECTION 104. In Colorado Revised Statutes, 26-7-107, amend5
(3)(b)(I) as follows:6
26-7-107. Determination of benefits - adoption assistance7
agreement - review - definitions. (3) (b) (I) In addressing the needs of8
an eligible adopted child or youth, adoptive parents may knowingly take9
on additional costs for items or services for the child or youth being10
adopted, which items or services are otherwise covered costs under the11
medical assistance program established in articles 4, 5, and 6 of title 25.512
and identified as benefits in section 26-7-106 (2)(b). The limitations on13
recipient MEMBER payments contained in sections 24-31-808 and14
25.5-4-301 do not apply to such THE additional costs so long as the15
adoptive parents consent to bear the costs as provided in subsection16
(3)(b)(II) of this section, and so long as the provisions of this subsection17
(3)(b) are not prohibited under federal law.18
SECTION 105. In Colorado Revised Statutes, repeal19
25.5-1-114.5.20
SECTION 106. Act subject to petition - effective date. This act21
takes effect at 12:01 a.m. on the day following the expiration of the22
ninety-day period after final adjournment of the general assembly; except23
that, if a referendum petition is filed pursuant to section 1 (3) of article V24
of the state constitution against this act or an item, section, or part of this25
act within such period, then the act, item, section, or part will not take26
effect unless approved by the people at the general election to be held in27
176
-109- November 2024 and, in such case, will take effect on the date of the1
official declaration of the vote thereon by the governor.2
176
-110-