SENATE BILL 24-176
BY SENATOR(S) Ginal and Hinrichsen, Buckner, Cutter,
Michaelson Jenet, Smallwood, Winter F.;
also REPRESENTATIVE(S) Epps and McLachlan, Bacon, Jodeh, Mabrey,
Ortiz, Ricks.
C
ONCERNING UPDATING THE TERMINOLOGY THAT REFERS TO AN INDIVI DUAL
WHO IS ENROLLED IN THE STATE MEDICAL ASSISTANCE PROGRAM
.
Be it enacted by the General Assembly of the State of Colorado:
SECTION 1. In Colorado Revised Statutes, 25.5-1-103, amend (6)
as follows:
25.5-1-103. Definitions. As used in this title 25.5, unless the context
otherwise requires:
(6) "Recipient"
"MEMBER" means any person who has been
determined eligible to receive benefits or services under this title TITLE 25.5.
SECTION 2. In Colorado Revised Statutes, 25.5-1-107, amend (1)
as follows:
NOTE: This bill has been prepared for the signatures of the appropriate legislative
officers and the Governor. To determine whether the Governor has signed the bill
or taken other action on it, please consult the legislative status sheet, the legislative
history, or the Session Laws.
________
Capital letters or bold & italic numbers indicate new material added to existing law; dashes
through words or numbers indicate deletions from existing law and such material is not part of
the act. 25.5-1-107. Final agency action - administrative law judge -
authority of executive director. (1) The executive director may appoint
one or more persons INDIVIDUALS to serve as administrative law judges for
the state department pursuant to section 24-4-105 and pursuant to part 10
of article 30 of title 24 subject to appropriations made to the department of
personnel. Except as provided in subsection (2) of this section, hearings
conducted by the administrative law judge are considered initial decisions
of the state department and shall be reviewed by
the executive director or
a THE EXECUTIVE DIRECTOR'S designee of the executive director. In the
event SHALL REVIEW THE INITIAL DECISIONS. IF exceptions to the initial
decision are filed pursuant to section 24-4-105 (14)(a)(I), the review must
be
CONDUCTED in accordance with section 24-4-105 (15). In the absence of
any exception filed pursuant to section 24-4-105 (14)(a)(I), the executive
director
OR THE EXECUTIVE DIRECTOR'S DESIGNEE shall review the initial
decision in accordance with a procedure adopted by the state board. The
procedure must be consistent with federal mandates concerning the single
state agency requirement. Review by the executive director
OR THE
EXECUTIVE DIRECTOR
'S DESIGNEE in accordance with section 24-4-105 (15)
or the procedure adopted by the state board pursuant to this section
constitutes final agency action. The administrative law judge may conduct
hearings on appeals from decisions of county departments of human or
social services brought by recipients
MEMBERS of and applicants for medical
assistance and welfare that are required by law in order for the state to
qualify for federal funds, and the administrative law judge may conduct
other hearings for the state department. Notice of any such
hearing must be
served at least ten days prior to such THE hearing.
SECTION 3. In Colorado Revised Statutes, 25.5-1-115, amend (3)
as follows:
25.5-1-115. Locating violators - recoveries. (3) Whenever a
county department, a county board, a district attorney, or the state
department on behalf of the county recovers any amount of medical
assistance payments that were obtained through unintentional client
MEMBER error, the federal government shall be IS entitled to a share
proportionate to the amount of federal funds paid, unless a different amount
is provided for by federal law; the state shall be
IS entitled to a share
proportionate to seventy-five percent of the amount of state funds paid;
AND
the county shall be
IS entitled to a share proportionate to the amount of
county funds paid, if any, and, in addition, a share proportionate to
PAGE 2-SENATE BILL 24-176 twenty-five percent of the amount of state funds paid.
SECTION 4. In Colorado Revised Statutes, 25.5-1-115.5, amend
(1) introductory portion, (1)(a), (1)(b), and (1)(e) as follows:
25.5-1-115.5. Medical assistance fraud - report.
(1) Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or
before November 1, 2017, and on or before EACH November 1 each year
thereafter, the state department shall submit a written report to the joint budget committee;
TO the HOUSE OF REPRESENTATIVES judiciary committee
and the
HOUSE OF REPRESENTATIVES public AND BEHAVIORAL health careand human services committee, of the house of representatives, or their
successor committees; and to the
SENATE judiciary committee and the
SENATE health and human services committee, of the senate,
or their
successor committees, concerning fraud in the medicaid program. The state
department shall compile a single, comprehensive report that includes the
information described in this subsection (1), as well as information that the
attorney general provides to the state department pursuant to section
25.5-4-303.3. The state department shall report to the general assembly
concerning the fraudulent receipt of medicaid benefits, including, at a
minimum:
(a) Investigations of client
MEMBER fraud during the year;
(b) Termination of client MEMBER medicaid benefits due to fraud;
(e) Trends in methods used to commit client MEMBER fraud,
excluding law enforcement-sensitive information; and
SECTION 5. In Colorado Revised Statutes, 25.5-1-116, amend (1),
(2)(c)(I), (2)(c)(III), (2)(d), and (3) as follows:
25.5-1-116. Records confidential - authorization to obtain
records of assets - release of location information to law enforcement
agencies - outstanding felony arrest warrants. (1) The state department
may establish reasonable rules to provide safeguards restricting the use or
disclosure of information concerning applicants, recipients
MEMBERS, and
former and potential recipients MEMBERS of medical assistance to FOR
purposes directly connected with the administration of such medical
assistance and related state department activities, and covering INCLUDING
PAGE 3-SENATE BILL 24-176 the custody, use, and preservation of the STATE'S AND THE COUNTY
DEPARTMENTS
' records, papers, files, and communications. of the state andcounty departments. Whenever, under provisions of AS REQUIRED BY law,
THE names and addresses of applicants for, recipients MEMBERS of, or
former and potential recipients MEMBERS of medical assistance are
furnished to or held by another agency or department of government, such
THE agency or department shall be required to prevent the publication of
lists thereof OF THE NAMES AND ADDRESSES and their uses PREVENT USING
THE NAMES AND ADDRESSES
for purposes not directly connected with the
administration of such
medical assistance.
(2) (c) (I) In order to determine if applicants for or recipients
MEMBERS of medical assistance have assets within eligibility limits, the
state department may provide a list of information identifying these THE
applicants or recipients MEMBERS to any financial institution, as defined in
section 15-15-201 (4), C.R.S., or to any insurance company. This THE
information PROVIDED may include identification numbers or social security
numbers. The state department may require any such A financial institution
or insurance company to provide a written statement disclosing any assets
held on behalf of individuals adequately identified on the list provided.
Before a termination notice is sent to the recipient
MEMBER, the county
department or the medical assistance site, in verifying the accuracy of the
information obtained as a result of the match, shall contact the recipient
MEMBER and inform the recipient MEMBER of the apparent results of the
computer match and give the recipient MEMBER the opportunity to explain
or correct any erroneous information secured by the match. The requirement
to run a computerized match shall apply
APPLIES only to information that is
entered in the financial institution's or insurance company's data processing
system on the date the match is run and shall not be deemed to
DOES NOT
require any such FINANCIAL institution or INSURANCE company to change
its data or make new entries for the purpose of comparing identifying
information. The
STATE DEPARTMENT SHALL PAY FOR THE cost of providing
such A computerized match. shall be borne by the state department.
(III) The state department may expend funds appropriated pursuant
to subparagraph (II) of this paragraph (c) SUBSECTION (2)(c)(II) OF THIS
SECTION
in an amount not to exceed the amount of annualized general fund
savings that result from the termination of recipients
MEMBERS from
medical assistance specifically due to disclosure of assets pursuant to this
subsection (2).
PAGE 4-SENATE BILL 24-176 (d) No AN applicant shall MUST NOT be denied nor OR any recipient
MEMBER MUST NOT BE discontinued due to the disclosure of their assets
unless and until the county department or medical assistance site has
assured that such
THE assets taken together with other assets exceed the
limit for eligibility of countable assets. Any information concerning assets
found may be used to determine if such
THE applicant's or recipient's
MEMBER'S eligibility for other medical assistance is affected.
(3) The applicant for or recipient MEMBER of medical assistance, or
his or her THE APPLICANT'S OR MEMBER'S representative, shall have HAS an
opportunity to examine all applications and pertinent records concerning
said
THE applicant or recipient which MEMBER THAT constitute a basis for
denial, modification, or termination of such medical assistance or to
examine such THE records in case of a fair hearing.
SECTION 6. In Colorado Revised Statutes, 25.5-1-124, amend (2)
as follows:
25.5-1-124. Early intervention payment system - participation
by state department - rules - definitions. (2) The state department shall
ensure that the early intervention services and payments for recipients
MEMBERS of medical assistance pursuant to this title 25.5 are integrated into
the coordinated early intervention payment system developed pursuant to
part 4 of article 3 of title 26.5. To the extent necessary to achieve the
coordinated payment system and coverage of those early intervention
services pursuant to this title 25.5, the state department shall amend the state
plan for medical assistance or seek the necessary federal authorization,
promulgate rules, and modify the billing system for medical assistance to
facilitate the coordinated payment system.
SECTION 7. In Colorado Revised Statutes, amend 25.5-1-127 as
follows:
25.5-1-127. Third-party benefit denials information. The state
department shall provide information to recipients of benefits
MEMBERS
WHO RECEIVE BENEFITS
under this title
TITLE 25.5 concerning their THE
MEMBERS
' right to appeal a denial of benefits by a third party and shall post
information on the state department's website concerning recipients'MEMBERS' abilities to appeal a third party's denial of benefits, including but
not limited to providing a link to information on the insurance
PAGE 5-SENATE BILL 24-176 commissioner's website regarding such appeals.
SECTION 8. In Colorado Revised Statutes, 25.5-1-128, amend (2)
as follows:
25.5-1-128. Provider payments - compliance with state fiscal
requirements - definitions - rules. (2) As used in this section, unless the
context otherwise provides REQUIRES, "provider" means a health-care
provider, a mental health-care provider, a pharmacist, a home health
agency, a general provider as defined in section 25.5-3-103 (3),
A school
district as defined in section 25.5-5-318 (1)(a), or any other entity that
provides health care, health-care coordination, outreach, enrollment, or
administrative support services to recipients
MEMBERS through
fee-for-service, the primary care physician program, a managed care entity,
a behavioral health organization, a medical home, or any system of care that
coordinates health care or services as defined and authorized through rules
promulgated by the state board or by the executive director.
SECTION 9. In Colorado Revised Statutes, amend 25.5-1-130 as
follows:
25.5-1-130. Improving access to behavioral health services for
individuals at risk of entering the criminal or juvenile justice system -
duties of the state department. (1) On or before March 1, 2020, the state
department shall develop measurable outcomes to monitor efforts to prevent
medicaid recipients
MEMBERS from becoming involved in the criminal or
juvenile justice system.
(2) On or before July 1, 2021, the state department shall work
collaboratively with managed care entities to create incentives for
behavioral health providers to accept medicaid recipients
MEMBERS with
severe behavioral health disorders. The incentives may include, but need not
be limited to, higher reimbursement rates, quality payments to managed care
entities for adequate networks, establishing performance measures and
performance improvement plans related to network expansion,
transportation solutions to incentivize medicaid recipients
MEMBERS to
attend health-care appointments, and incentivizing providers to conduct
outreach to medicaid recipients
MEMBERS to ensure that they are engaged
in needed behavioral health services, including technical assistance with
billing procedures. The state department may seek any federal authorization
PAGE 6-SENATE BILL 24-176 necessary to create the incentives described in this subsection (2).
SECTION 10. In Colorado Revised Statutes, 25.5-1-133, amend
(1) as follows:
25.5-1-133. Access to behavioral health services for individuals
under twenty-one years of age - rules - report - repeal. (1) On or before
July 1, 2024, the state department shall provide recipients MEMBERS under
twenty-one years of age with access to limited services without requiring a
diagnosis. The limited services must be provided as part of the statewide
managed care system pursuant to part 4 of article 5 of this title 25.5 and the
school health services detailed in section 25.5-5-318.
SECTION 11. In Colorado Revised Statutes, 25.5-1-205, amend
(2) as follows:
25.5-1-205. Providing for the efficient provision of health care
through state-supervised cooperative action - rules. (2) The executive
director shall facilitate departmental oversight of collaboration among
providers, medicaid clients
MEMBERS and advocates, and payors PAYERS
that is designed to improve health outcomes and patient satisfaction and support the financial sustainability of the medicaid program.
SECTION 12. In Colorado Revised Statutes, 25.5-1-303, amend
(3)(b), (3)(c), (3)(d), (3)(e), and (3)(f) as follows:
25.5-1-303. Powers and duties of the board - scope of authority
- rules. (3) The board shall adopt rules in connection with the programs set
forth in subsection (1) of this section governing the following:
(b) The establishment of eligibility requirements for persons
MEMBERS receiving services from the state department;
(c) The establishment of the type of benefits that a recipient of
services may obtain ARE AVAILABLE TO AN APPLICANT if eligibility
requirements are met, subject to the authorization, requirements, and
availability of such
THE benefits;
(d) The requirements, obligations, and rights of clients and
recipients MEMBERS AND APPLICANTS ;
PAGE 7-SENATE BILL 24-176 (e) The establishment of a procedure to resolve disputes that may
arise between clients MEMBERS and the state department or clients MEMBERS
and providers;
(f) The requirements, obligations, and rights of providers, including
policies and procedures related to provider payments that may affect client
MEMBER benefits;
SECTION 13. In Colorado Revised Statutes, 25.5-1-801, amend
(2) and (5) as follows:
25.5-1-801. Definitions. As used in this section, unless the context
otherwise requires:
(2) "Nonmedical transportation" means transportation to enable
passengers who are recipients of medicaid MEMBERS to gain access to
waiver and other community services, activities, and resources.
(5) "Transportation services" means nonemergency medical
transportation or nonmedical transportation services provided to medicaid
recipients
MEMBERS.
SECTION 14. In Colorado Revised Statutes, 25.5-1-802, amend
(1) introductory portion as follows:
25.5-1-802. Medicaid transportation services - safety and
oversight - rules. (1) The state department shall collaborate with
stakeholders, including, but not limited to, disability and member
CONSUMER advocates, PACE providers operating pursuant to section
25.5-5-412, transportation brokers, and transportation providers, to establish
rules and processes for the safety and oversight of nonmedical
transportation services and nonemergency medical transportation services
provided to medicaid recipients
MEMBERS pursuant to articles 4 to 6 of this
title 25.5. The rules and processes must:
SECTION 15. In Colorado Revised Statutes, 25.5-2-101, amend
(2) as follows:
25.5-2-101. Old age pension health and medical care fund -
supplemental old age pension health and medical care fund - cash
PAGE 8-SENATE BILL 24-176 system of accounting - legislative declaration - rules. (2) Any money
remaining in the state old age pension fund after full payment of basic
minimum awards to qualified old age pension recipients
MEMBERS, and
after establishment and maintenance of the old age pension stabilization
fund in the amount of five million dollars, shall
MUST be transferred to a
fund to be known as the old age pension health and medical care fund,
which is hereby
created. The state board shall establish and promulgate
rules for administration of a program to provide health and medical care to
persons who qualify to receive old age pensions and who are not patients
in an institution for tuberculosis or behavioral or mental health disorders.
The costs of such program, not to exceed ten million dollars in any fiscal
year, are defrayed from the health and medical care fund, but all money
available, accrued or accruing, received or receivable, in said
THE health
and medical care fund in excess of ten million dollars in any fiscal year is
transferred to the general fund of the state to be used pursuant to law.
Money in the old age pension health and medical care fund is subject to
annual appropriation by the general assembly.
SECTION 16. In Colorado Revised Statutes, 25.5-2.5-204, amend
(3)(a) as follows:
25.5-2.5-204. Eligible prescription drugs - eligible Canadian
suppliers - eligible importers - distribution requirements. (3) The
following entities are eligible importers and may obtain imported
prescription drugs:
(a) A pharmacist or wholesaler employed by or under contract with
a medicaid pharmacy, for dispensing to the pharmacy's medicaid recipients
MEMBERS;
SECTION 17. In Colorado Revised Statutes, 25.5-3-104, amend
(2) as follows:
25.5-3-104. Program for the medically indigent established -
eligibility - rules. (2) A client's PERSON'S eligibility to receive discounted
services under the program for the medically indigent shall be IS determined
by rule of the state board based on a specified percentage of the federal
poverty line, adjusted for family size, which percentage shall
MUST not be
less than two hundred fifty percent.
PAGE 9-SENATE BILL 24-176 SECTION 18. In Colorado Revised Statutes, 25.5-4-103, amend
(11), (13), (22), (26), and (28); repeal (21); and add (13.2) as follows:
25.5-4-103. Definitions. As used in this article 4 and articles 5 and
6 of this title 25.5, unless the context otherwise requires:
(11) "Liable" or "liability" means the legal liability of a third party,
either by reason of judgment, settlement, compromise, or contract, as the
result of negligent acts or other wrongful acts or otherwise for all or any
part of the medical cost of an injury, a disease, or the disability of an
applicant for or recipient
MEMBER of medical assistance.
(13) "Medical assistance" means payment on behalf of recipients
MEMBERS eligible for and enrolled in the STATE MEDICAL ASSISTANCE
program established in articles 4, 5, and 6 PURSUANT TO THIS ARTICLE 4 AND
ARTICLES
5 AND 6 of this title
TITLE 25.5, which is funded through Title XIX
of the federal "Social Security Act", 42 U.S.C. sec. 1396u-1, to
PROVIDERS
enrolled providers under
IN the state medical assistance program of WHO
RENDER OR PROVIDE
medical care, services, goods, and devices rendered orprovided to recipients under this article TO MEMBERS PURSUANT TO THIS
ARTICLE
4 and articles 5 and 6 of this title
TITLE 25.5, and other related
payments, pursuant to this article ARTICLE 4 and articles 5 and 6 of this title
TITLE 25.5 and the rules of the state department.
(13.2) "M
EMBER" MEANS A PERSON WHO HAS BEEN DETERMINED
ELIGIBLE TO RECEIVE BENEFITS UNDER THIS ARTICLE
4 AND ARTICLES 5 AND
6 OF THIS TITLE 25.5.
(21) "Recipient" means any person who has been determined
eligible to receive benefits under this article and articles 5 and 6 of this title,
whose need for medical care has been professionally established, and for
whose care less than full payment is available through the legal obligation
of a contractor, public or private, to pay for or provide such care.
(22) "Recovery" or "amount recovered" means the amount payable
to the applicant or recipient MEMBER or his THE APPLICANT'S OR MEMBER'S
heirs, assigns, or legal representatives as the result of any liability of a third party.
(26) "Third party" means an individual, institution, corporation, or
PAGE 10-SENATE BILL 24-176 public or private agency which THAT is or may be liable to pay all or any
part of the medical cost of an injury, a disease, or the disability of an
applicant for or recipient
MEMBER of medical assistance.
(28) "Transitional medicaid" means the medical assistance provided
to recipients MEMBERS eligible pursuant to section 25.5-5-101 (1)(b).
SECTION 19. In Colorado Revised Statutes, amend 25.5-4-104 as
follows:
25.5-4-104. State medical assistance program - single state
agency. (1) The state department, by rules, shall establish a program of
medical assistance to provide necessary medical care for the categorically
needy. The state department is hereby
designated as the single state agency
to administer such THE MEDICAL ASSISTANCE program in accordance with
Title XIX
OF THE FEDERAL "SOCIAL SECURITY ACT" and this article
ARTICLE
4 and articles 5 and 6 of this title. Such TITLE 25.5. THE program shall not
be IS NOT required to furnish recipients TO MEMBERS under sixty-five years
of age the benefits that are provided to recipients MEMBERS sixty-five years
of age and over under Title XVIII of the social security act FEDERAL
"SOCIAL SECURITY ACT", but said THE MEDICAL ASSISTANCE program shall
MUST otherwise be uniform to the extent required by Title XIX of the social
security act FEDERAL "SOCIAL SECURITY ACT".
(2) The state department may review any decision of a county
department and may consider any application upon which a decision has not
been made by the county department within a reasonable time to determine
the propriety of the action or failure to take timely action on an application
for medical assistance. The state department shall make such
CONDUCT ANY
additional investigation as it the STATE DEPARTMENT deems necessary. and
shall, After giving the county department an opportunity to rebut any THE
STATE DEPARTMENT
'S findings or conclusions of the state department
that
the action or delay in taking action was a violation of or contrary to state
department rules,
THE STATE DEPARTMENT SHALL make such A decision as
to the granting of WHETHER TO GRANT medical benefits and the amount
thereof as in its opinion is justifiable OF MEDICAL BENEFITS pursuant to the
provisions of this article THIS ARTICLE 4 and articles 5 and 6 of this title
TITLE 25.5 and the rules of the state department. Applicants or recipients
MEMBERS affected by such THE STATE DEPARTMENT'S decisions, of the state
department, upon request, shall MUST be given reasonable notice and
PAGE 11-SENATE BILL 24-176 opportunity for a fair hearing by the state department.
SECTION 20. In Colorado Revised Statutes, amend 25.5-4-107 as
follows:
25.5-4-107. Retaliation definition. (1) For purposes of any rules
promulgated by the state department or state board and any action taken by
the state department against any person, "retaliation" means taking any of
the following actions against a recipient
MEMBER or someone acting on
behalf of a recipient MEMBER after the recipient MEMBER or someone acting
on behalf of the recipient MEMBER files a complaint concerning services
provided or not provided to the recipient MEMBER:
(a) Indicating to a recipient MEMBER that the recipient MEMBER
cannot have an advocate, family member, or other authorized representative
assist the recipient MEMBER; or
(b) (I) An adverse action that negatively affects a recipient's
MEMBER'S level of eligibility for or receipt of services received at the time
of the complaint without verification of a change in the recipient's
MEMBER'S income, resources, or health-care needs that justifies the adverse
action.
(II) No AN adverse action shall MUST NOT be taken against a
recipient MEMBER after a complaint has been filed until the recipient
MEMBER is notified of the proposed action, informed of the reason for the
proposed action, and provided an opportunity to appeal the proposed action.
(2) "Retaliation" shall DOES not include instances where WHEN a
recipient MEMBER is not eligible for a service or program or where WHEN
a provider documents a problem with a recipient MEMBER and shares the
documentation with the recipient MEMBER or a third party prior to the
recipient MEMBER filing a complaint.
SECTION 21. In Colorado Revised Statutes, 25.5-4-203, amend
(2) as follows:
25.5-4-203. Advisory council established. (2) A
DVISORY COUNCIL
members serve at the pleasure of the governor and receive no compensation
but are entitled to reimbursement for their
actual and necessary expenses.
PAGE 12-SENATE BILL 24-176 The advisory council shall advise the state department on the provision of
health and medical care services to recipients MEMBERS OF MEDICAL
ASSISTANCE
.
SECTION 22. In Colorado Revised Statutes, 25.5-4-205, amend
(3)(a) introductory portion, (3)(b)(I)(B), (3)(b)(I.5)(A), (3)(e)(I),
(3)(e)(II)(A), and (3)(e)(II)(B) as follows:
25.5-4-205. Application - verification of eligibility -
demonstration project - rules - repeal. (3) (a) The state department shall
promulgate rules to simplify the processing of applications in order that
medical benefits are furnished to recipients
MEMBERS as soon as possible,
including rules that:
(b) (I) The state department shall promulgate rules that:
(B) Require the state department at least annually to verify a
recipient's
MEMBER'S income eligibility at reenrollment through federally
approved electronic data sources and, if the recipient MEMBER meets all
eligibility requirements, permit the recipient MEMBER to remain enrolled in
the
MEDICAL ASSISTANCE program. The rules shall
MUST only require an
individual to provide documentation verifying income if electronic data is
not available or the information obtained from electronic data sources is not
reasonably compatible with information provided by or on behalf of an
applicant.
(I.5) (A) If the state department determines that a recipient
MEMBER
was not eligible for medical benefits solely based upon the recipient's
MEMBER'S income after the recipient MEMBER had been determined to be
eligible based upon electronic data obtained through a federally approved
electronic data source, the state department shall not pursue recovery from
a county department for the cost of medical services provided to the
recipient
MEMBER, and the county department is not responsible for any
federal error rate sanctions resulting from such THE determination.
(e) (I) In collaboration with and to augment the state department's
efforts to simplify eligibility determinations for benefits under the state
medical assistance program and the children's basic health plan, the state
department shall establish a process so that a recipient, enrollee,
MEMBER,
or the parent or guardian of a recipient or enrollee MEMBER may apply for
PAGE 13-SENATE BILL 24-176 reenrollment either over the telephone or through the internet.
(II) (A) Subject to receipt of federal authorization and spending
authority, the state department may implement a pilot program that allows
a limited number of recipients or enrollees
MEMBERS to apply for
reenrollment either over the telephone or through the internet during a
transition to a process that will serve recipients and enrollees
MEMBERS
statewide. The pilot program shall not serve as IS NOT a replacement for a
statewide process.
(B) Notwithstanding any other provision in this paragraph (e)
SUBSECTION (3)(e), the state department shall not implement this paragraph
(e) SUBSECTION (3)(e) until it THE STATE DEPARTMENT can verify the
eligibility of a recipient or enrollee MEMBER over the telephone or through
the internet as authorized by rules of the state department and federal law.
SECTION 23. In Colorado Revised Statutes, 25.5-4-205.5, amend
(2) as follows:
25.5-4-205.5. Confined persons - suspension of benefits.
(2) Notwithstanding any other provision of law, a person who, immediately
prior to becoming a confined person, was a recipient MEMBER of medical
assistance pursuant to this article 4 or article 5 or 6 of this title 25.5, remains
eligible for medical assistance while a confined person; except that medical
assistance may not be furnished pursuant to this article 4 or article 5 or 6 of
this title 25.5 while the person is a confined person unless federal financial
participation is available for the cost of the assistance, including, but not
limited to, juveniles held in a facility operated by or under contract to the
division of youth services established pursuant to section 19-2.5-1501 or the
department of human services. Once a person is no longer a confined
person, the person continues to be
IS eligible for receipt of medical benefits
ASSISTANCE pursuant to this article 4 or article 5 or 6 of this title 25.5 until
the person is determined to be ineligible for the receipt of the assistance. To
the extent permitted by federal law, the time during which a person is a
confined person is not included in any calculation of when the person must
recertify his or her
RENEW THE PERSON'S eligibility for medical assistance
pursuant to this article 4 or article 5 or 6 of this title 25.5.
SECTION 24. In Colorado Revised Statutes, 25.5-4-207, amend
(1)(a), (1)(b), (1)(c), and (1)(d.5)(I) as follows:
PAGE 14-SENATE BILL 24-176 25.5-4-207. Appeals - rules - applicability. (1) (a) (I) If an
application for medical assistance is not acted upon within a reasonable
time after filing of the same
THE APPLICATION, or if an application is denied
in whole or in part, or if medical assistance benefits are suspended,
terminated, or modified, the applicant or recipient, as the case may be,
MEMBER may appeal to the state department in the manner and form
prescribed by the rules of the state department. Except as permitted under
federal law, state department rules must provide for at least a ten-day
advance notice before the effective date of any suspension, termination, or
modification of medical assistance. The county
DEPARTMENT or designated
service agency shall notify the applicant or recipient
MEMBER in writing of
the basis for the county's decision or action and shall inform the applicant
or recipient MEMBER of the right to a county DEPARTMENT or service agency
conference under the dispute resolution process described in paragraph (b)
of this subsection (1) SUBSECTION (1)(b) OF THIS SECTION and of the right
to a state-level appeal and the process for appeal.
(II) The applicant or recipient MEMBER has sixty days after the date
of the notice to file an appeal. If the recipient MEMBER files an appeal prior
to the effective date of the intended action, existing medical assistance
benefits must automatically continue unchanged until the appeal process is
completed, unless the recipient
MEMBER requests in writing that medical
assistance benefits not continue during the appeal process; except that, to
the extent authorized by federal law, the
state department rules may permit
existing medical assistance benefits to continue until the appeal process is
completed even if the recipient's
MEMBER'S appeal is filed after the effective
date of the intended action. The state department shall promulgate rules
consistent with federal law that prescribe the circumstances under which the
county
DEPARTMENT or designated service agency may continue benefits if
an appeal is filed after the effective date of the intended action. At a
minimum, the rules must allow for continuing benefits when the recipient's
MEMBER'S health or safety is impacted, the recipient MEMBER was not able
to timely respond due to the recipient's MEMBER'S disability or employment,
the recipient's MEMBER'S caregiver was unavailable due to the caregiver's
health or employment, or the recipient MEMBER did not receive the county's
COUNTY DEPARTMENT 'S or designated service agency's notice prior to the
effective date of the intended action.
(III) Either prior to appeal or as part of the filing of an appeal, the
applicant or recipient MEMBER may request the dispute resolution process
PAGE 15-SENATE BILL 24-176 described in paragraph (b) of this subsection (1) SUBSECTION (1)(b) OF THIS
SECTION
through the county department or service delivery agency.
(b) Every county department or service delivery agency shall adopt
procedures for the resolution of disputes arising between the county
department or the service delivery agency and any applicant for or recipient
MEMBER of medical assistance. Such THE procedures are referred to in this
section as the "dispute resolution process". Two or more counties may
jointly establish the dispute resolution process. The dispute resolution
process must be consistent with rules promulgated by the state board
pursuant to article 4 of title 24. C.R.S.
The dispute resolution process shall
MUST include an opportunity for all clients MEMBERS to have a county
DEPARTMENT conference, upon the client's MEMBER'S request, and such THE
requirement may be met through a telephonic conference upon the
agreement of the client MEMBER and the county department. The dispute
resolution process need not DOES NOT NEED TO conform to the requirements
of section 24-4-105 C.R.S., as long as the rules adopted by the state board
include provisions specifically setting forth expeditious time frames, notice,
and an opportunity to be heard and to present information. If the dispute is
resolved through the county
DEPARTMENT or service delivery agency's
dispute resolution process and the applicant or recipient
MEMBER has
already filed an appeal, the county
DEPARTMENT shall inform the applicant
or recipient
MEMBER of the process for dismissing the appeal.
(c) The state board shall adopt rules setting forth what other issues,
if any, may be appealed by an applicant or recipient MEMBER to the state
department. T
HE STATE DEPARTMENT IS NOT REQUIRED TO GRANT a hearing
need not be granted
when either state or federal law requires or results in a
reduction or deletion of a medical assistance benefit unless the applicant or
recipient
MEMBER is arguing that his or her THE APPLICANT'S OR MEMBER'S
case does not fit within the parameters set forth by the change in the law. In notifying the applicant or recipient
MEMBER that an appeal is being denied
because of a change in state or federal law, the state's STATE DEPARTMENT'S
notice must inform the applicant or recipient MEMBER that further appeal
should be directed to the appropriate state or federal court.
(d.5) (I) At the commencement of a hearing that concerns the
termination or reduction of an existing benefit, the state department's
administrative law judge shall review the legal sufficiency of the notice of
action from which the recipient
MEMBER is appealing. If the administrative
PAGE 16-SENATE BILL 24-176 law judge determines that the notice is legally insufficient, the
administrative law judge shall inform the appellant that the termination or
reduction may be set aside on the basis of insufficient notice without
proceeding to a hearing on the merits. The appellant may affirmatively
waive the defense of insufficient notice and agree to proceed with a hearing
on the merits or may ask the administrative law judge to decide the appeal
on the basis of his or her
THE JUDGE'S finding that the notice is legally
insufficient. The administrative law judge shall also inform the appellant
that the state department may issue legally sufficient notice in the future and
that the state department may seek recoupment of benefits if a basis for
denial or reduction of benefits is subsequently determined.
SECTION 25. In Colorado Revised Statutes, 25.5-4-209, amend
(1)(a), (1)(b), (3)(a), and (3)(d) as follows:
25.5-4-209. Payments by third parties - copayments by members
- review - appeal - children's waiting list reduction fund - rules - repeal.
(1) (a) Any recipient
MEMBER receiving benefits under this article
PURSUANT TO THIS ARTICLE 4 or article 5 or 6 of this title TITLE 25.5 who
receives any supplemental income, available for medical purposes under
rules of the state department, or who receives proceeds from sickness,
accident, health, or casualty insurance, shall
MUST apply the supplemental
income or insurance proceeds to the cost of the benefits rendered, and the
STATE DEPARTMENT rules may require reports from providers of other
payments received by them
from or on behalf of recipients MEMBERS.
(b) Subject to any limitations imposed by Title XIX
OF THE FEDERAL
"SOCIAL SECURITY ACT", a recipient
MEMBER shall pay at the time of
service a portion of the cost of any medical benefit rendered to the recipient
MEMBER or to the recipient's MEMBER'S dependents pursuant to this article
4 or article 5 or 6 of this title 25.5, as determined by rules of the state
department.
(3) (a) The rights assigned by a recipient
MEMBER of medical
assistance to the state department pursuant to section 25.5-4-205 (4) shall
MUST include the right to appeal an adverse coverage decision by a third
party for which the medical assistance program may be responsible for
payment, including but not limited to the internal and external reviews
provided for
DESCRIBED in sections 10-16-113 and 10-16-113.5 C.R.S., and
a third party's reasonable appeal procedure under state and federal law. The
PAGE 17-SENATE BILL 24-176 state department or the independent contractor retained pursuant to
paragraph (b) of this subsection (3) SUBSECTION (3)(b) OF THIS SECTION
shall review and, if necessary, may appeal at any level an adverse coverage decision, except an adverse coverage decision relating to medicare, Title XVIII of the federal "Social Security Act", as amended.
(d) Nothing in this subsection (3) shall be construed to authorize
AUTHORIZES the denial of or delay of payment to a provider by the state
department or the delay or interference with the provision of services to a
medical assistance recipient
MEMBER.
SECTION 26. In Colorado Revised Statutes, amend 25.5-4-210 as
follows:
25.5-4-210. Purchase of health insurance for members.
(1) (a) The state department shall purchase group health insurance for a
medical assistance recipient MEMBER who is eligible to enroll for such
coverage if enrollment of such recipient THE MEMBER in the group plan
would be cost-effective. In addition, the state department may purchase
individual health insurance for a medical assistance recipient
MEMBER who
is eligible to enroll in a health insurance plan if enrollment of such recipient
THE MEMBER would be cost-effective to this state. A determination of
cost-effectiveness shall MUST be in accordance with federal guidelines
established by the secretary of the United States FEDERAL department of
health and human services.
(b) Notwithstanding any provision of paragraph (a) of this
subsection (1) SUBSECTION (1)(a) OF THIS SECTION to the contrary, the state
department, in purchasing health insurance for medical assistance recipients
MEMBERS who are eligible to enroll for private coverage, shall not purchase
such health insurance for more than two thousand individuals.
(2) Enrollment in a group health insurance plan shall be IS required
of recipients MEMBERS for whom enrollment has been determined to be
cost-effective as a condition of obtaining or retaining medical assistance. A
parent shall be
IS required to enroll a dependent child recipient MEMBER, but
medical assistance for such THE child shall not be IS NOT discontinued if a
parent fails to enroll the child.
(3) The state department shall pay any premium, deductible,
PAGE 18-SENATE BILL 24-176 coinsurance, or other cost-sharing obligation required under the group plan
for services covered under the state medical assistance plan. In addition, the
state department shall pay any premium, deductible, coinsurance, or other
cost-sharing obligation required under an individual plan purchased by the
state department for a medical assistance recipient
MEMBER pursuant to
subsection (1) of this section. Payment of said THE services shall be ARE
treated as payment for medical assistance. Coverage provided by the purchased health insurance plan shall be
IS considered as third-party liability
for the purposes of section 25.5-4-209.
(4) Services not available to a recipient MEMBER under the
purchased plan shall be ARE provided to the recipient if such MEMBER IF THE
services would otherwise be provided as medical assistance services pursuant to this article
ARTICLE 4 or article 5 or 6 of this title TITLE 25.5.
Nothing in this section shall be construed to require that REQUIRES services
provided under a group health insurance plan for medical assistance
recipients shall
TO be made available to recipients MEMBERS not enrolled in
the plan. Enrollment in a group health insurance plan pursuant to this
section shall
DOES not affect the eligibility of a recipient MEMBER who
otherwise qualifies for medical assistance pursuant to this article ARTICLE
4 or article 5 or 6 of this title TITLE 25.5.
SECTION 27. In Colorado Revised Statutes, amend 25.5-4-212 as
follows:
25.5-4-212. Medicaid member correspondence improvement
process - legislative declaration - definition. (1) (a) The general assembly
finds and declares that:
(I) Accurate, understandable, timely, informative, and clear
correspondence from the state department is critical to the life and health of
medicaid recipients,
MEMBERS AND APPLICANTS and, in some cases, is a
matter of life and death for our most vulnerable populations;
(II) Unclear, confusing, and late correspondence from the state
department causes an increased workload for the state, counties
administering the medicaid program, and nonprofit advocacy groups
assisting clients
APPLICANTS AND MEMBERS ; and
(III) Government should be a good steward of taxpayers' money,
PAGE 19-SENATE BILL 24-176 ensuring that it is spent in the most cost-effective manner.
(b) Therefore, the general assembly finds that improving medicaid
client MEMBER correspondence is critical to the health and safety of
medicaid clients MEMBERS and will reduce unnecessary confusion that
requires clients MEMBERS to call counties and the state department or file
appeals.
(2) As used in this section, unless the context otherwise requires,
"client MEMBER correspondence" means any communication the purpose of
which is to provide notice of an approval, denial, termination, or change to
an individual's medicaid eligibility; to provide notice of the approval,
denial, reduction, suspension, or termination of a medicaid benefit; or to
request additional information that is relevant to determining an individual's
medicaid eligibility or benefits. Client
"MEMBER correspondence" does not
include communications regarding the state department's review of trusts
or review of documents or records relating to trusts.
(3) The state department shall improve medicaid client
MEMBER
correspondence by ensuring that client MEMBER correspondence revised or
created after January 1, 2018:
(a) Is written using person-first, plain language;
(b) Is written in a format that includes the date of the
correspondence and a client
MEMBER greeting;
(c) Is consistent, using the same terms throughout to the extent
practicable, including commonly used program names;
(d) Is accurately translated into the second most commonly spoken
language in the state if a client MEMBER indicates that this THE LANGUAGE
is the client's MEMBER'S written language of preference or as required by
law;
(e) Includes a statement translated into the top fifteen languages
most commonly spoken by individuals in Colorado with limited English
proficiency informing an applicant or client
MEMBER how to seek further
assistance in understanding the content of the correspondence;
PAGE 20-SENATE BILL 24-176 (f) Clearly conveys the purpose of the client APPLICANT OR MEMBER
correspondence, the action or actions being taken by the state department
or its THE STATE DEPARTMENT'S designated entity, if any, and the specific
action or actions that the client must APPLICANT OR MEMBER SHALL or may
take in response to the correspondence;
(g) Includes a specific description of any necessary information or
documents requested from the applicant or client MEMBER;
(h) Includes contact information for client APPLICANT OR MEMBER
questions; and
(i) Includes a specific and plain language explanation of the basis
for the denial, reduction, suspension, or termination of the benefit, if
applicable.
(4) Subject to the availability of sufficient appropriations and receipt
of federal financial participation, on and after July 1, 2018, the state
department shall make electronically available to a client
MEMBER specific
and detailed information concerning the client's MEMBER'S household
composition, assets, income sources, and income amounts, if relevant to a
determination for which client
MEMBER correspondence was issued. If
implemented, the state department shall notify clients MEMBERS in the
written correspondence of the option to access this information.
(5) The state department is encouraged to promote the receipt of
client MEMBER correspondence electronically or through mobile
applications for clients MEMBERS who choose those methods of delivery as
allowed by law.
(6) As part of its ongoing process to create and improve client
MEMBER correspondence, the state department may engage with experts in
written communication and plain language to test client MEMBER
correspondence against the criteria set forth in subsection (3) of this section with a geographically diverse and representative sample of medicaid clients
MEMBERS relevant to the client MEMBER correspondence being revised. The
state department shall also develop a process to review and consider
feedback from stakeholders including client
CONSUMER advocates and
counties prior to implementing significant changes to correspondence.
PAGE 21-SENATE BILL 24-176 (7) The state department shall ensure that client APPLICANT OR
MEMBER
correspondence that may only affect a small number of clientsAPPLICANTS OR MEMBERS, but may, nonetheless, have a significant impact
on the lives of those clients APPLICANTS OR MEMBERS , is appropriately
prioritized for revision.
(8) As part of its annual presentation made to its legislative
committee of reference pursuant to section 2-7-203, the state department
shall present information concerning:
(a) Its
THE STATE DEPARTMENT'S process for ongoing improvement
of client MEMBER correspondence;
(b) Client MEMBER correspondence revised pursuant to criteria set
forth in subsection (3) of this section during the prior year and client
MEMBER correspondence improvements that are planned for the upcoming
year; and
(c) A description of the results of testing of new or significantly
revised client MEMBER correspondence pursuant to subsection (6) of this
section, including a description of the stakeholder feedback.
SECTION 28. In Colorado Revised Statutes, amend 25.5-4-213 as
follows:
25.5-4-213. Audit of medicaid member correspondence -
definition. (1) As used in this section, unless the context otherwise
requires, "client MEMBER correspondence" has the same meaning as defined
in section 25.5-4-212.
(2) During the 2020 calendar year and the 2023 calendar year, the
office of the state auditor shall conduct or cause to be conducted a
performance audit of client MEMBER correspondence. Thereafter, the state
auditor, in the exercise of his or her THE STATE AUDITOR'S discretion, may
conduct or cause to be conducted additional performance audits of client
MEMBER correspondence pursuant to this section. The audit shall MUST
include correspondence generated through the Colorado benefits management system, as well as correspondence that is not generated through the Colorado benefits management system.
PAGE 22-SENATE BILL 24-176 (3) The performance audit conducted pursuant to this section shall
MUST include:
(a) A review of available data from counties,
FROM the STATE
department's customer service contract center, and from assistors within the
health benefit exchange, created in article 22 of title 10, regarding customer
service contacts that are related to client MEMBER OR APPLICANT confusion
regarding correspondence received by medicaid clients MEMBERS or
applicants;
(b) A review of the accuracy of client MEMBER correspondence at
the time it THE CORRESPONDENCE is generated;
(c) A review of whether client MEMBER correspondence satisfies the
requirements of any state or federal law, rule, or regulation relating to the
sufficiency of any notice;
(d) A review of any client
MEMBER correspondence testing process
conducted by the
STATE department and whether testing is done prior to
implementing new or significantly revised client communications
MEMBER
CORRESPONDENCE
;
(e) A review of the results of any client
MEMBER correspondence
testing, including client MEMBER comprehension of the intended purpose or
purposes of the correspondence; and
(f) A review of the accuracy of client MEMBER income and
household composition information that is communicated electronically, if
applicable.
(4) If audit findings include findings that information contained in
client
MEMBER correspondence is inaccurate at the time the correspondence
was generated, the audit shall MUST identify, if possible, the source of the
inaccurate information, which may include but is not limited to computer
system or interface issues, county input error, or applicant error.
(5) Based on the findings and conclusions identified during the
performance audit conducted pursuant to this section, the office of the state
auditor shall make recommendations to the state department for improving
client
MEMBER correspondence. On or before December 30, 2020,
PAGE 23-SENATE BILL 24-176 December 30, 2023, and December 30 in any calendar year in which an
audit is conducted pursuant to this section, the office of the state auditor
shall submit the findings, conclusions, and recommendations from the
performance audit in the form of a written report to the legislative audit
committee, which shall hold a public hearing for the purposes of a review
of REVIEWING the report. The report shall MUST also be submitted to the
joint budget committee, the public health care and human services
committee of the house of representatives, the health and human services
committee of the senate, and the joint technology committee, or any
successor committees.
SECTION 29. In Colorado Revised Statutes, amend 25.5-4-300.4
as follows:
25.5-4-300.4. Last resort for payment - legislative intent. It is the
intent of the general assembly that medicaid be
IS the last resort for payment
for medically necessary goods and services furnished to recipients MEMBERS
and that all other sources of payment are primary to medical assistance provided by medicaid.
SECTION 30. In Colorado Revised Statutes, 25.5-4-300.9, amend
(1)(a)(VI), (1)(a)(VII), (1)(a)(VIII), (1)(b), (2), (4)(a), (4)(f), (4)(g), (4)(h),
(5), (6), and (7) as follows:
25.5-4-300.9. Explanation of benefits - medicaid members -
legislative declaration. (1) (a) The general assembly finds and declares
that:
(VI) While creating an explanation of benefits is not without cost to
the health-care system, only the client
MEMBER receiving medical services
or his or her THE MEMBER'S authorized representative is in the position to
verify whether the claimed medical services were actually provided and for
whom they were provided, which is a necessary first step in containing
health-care costs;
(VII) While medicaid clients
MEMBERS may not appear to be
affected financially by billing errors or fraudulent claims, medicaid clients
MEMBERS who rely on these services for survival and independence are
most severely affected by the inappropriate use of scarce resources; and
PAGE 24-SENATE BILL 24-176 (VIII) Further, medicaid clients MEMBERS and medicaid CONSUMER
advocates for low-income and vulnerable Coloradans want the opportunity
to partner with the state department and providers to ensure a well-run and
fraud-free medicaid program in Colorado.
(b) Therefore, the general assembly declares that creating an
explanation of benefits for recipients
MEMBERS of medicaid-funded services
is a necessary step in managing the state's medicaid program and in
safeguarding the significant public investment, both state and federal, in
meeting the health-care needs of low-income and vulnerable Coloradans.
(2) By
ON or before July 1, 2017, the state department shall develop
and implement an explanation of benefits for recipients MEMBERS of
medical services pursuant to articles 4 to 6 of this title THIS ARTICLE 4 AND
ARTICLE
5 OR 6 OF THIS TITLE 25.5. The purpose of the explanation of
benefits is to inform a medicaid client
MEMBER of a claim for
reimbursement made for services provided to the client MEMBER or on his
or her THE MEMBER'S behalf, so that the client MEMBER may discover and
report administrative or provider errors or fraudulent claims for
reimbursement.
(4) The explanation of benefits must include, at a minimum:
(a) The name of the medicaid client
MEMBER receiving the service;
(f) A clear statement to the medicaid client MEMBER that the
explanation of benefits is not a bill, but is only provided for the client's
MEMBER'S information and to make sure that a provider is being reimbursed
only for services actually provided;
(g) Information regarding at least one verbal and one written method
for the medicaid client MEMBER to report errors in the explanation of
benefits that are relevant to provider reimbursement; and
(h) Any other information that the state department determines is
useful to the medicaid client MEMBER or for purposes of discovering
administrative or provider error or fraud.
(5) The state department shall develop the form and content of the
explanation of benefits in conjunction with medicaid clients MEMBERS and
PAGE 25-SENATE BILL 24-176 medicaid CONSUMER advocates to ensure that medicaid clients MEMBERS
understand the information provided and the purpose of the explanation of
benefits. The state department shall also work with medicaid clients
MEMBERS and medicaid CONSUMER advocates to develop educational
materials for the state department's website and for distribution by advocacy
and nonprofit organizations that explain the process for reporting errors and
encourage clients
MEMBERS to take responsibility for reporting errors.
(6) The state department shall provide the explanation of benefits to
a medicaid client MEMBER not less frequently than once every two months,
if services have been provided to or on behalf of the client MEMBER during
that time period. The state department shall determine the most
cost-effective means for producing and distributing the explanation of
benefits to medicaid clients
MEMBERS, which may include e-mail or
web-based distribution, with mailed copies by request only. Further, the
state department may include the explanation of benefits with an existing
mailing or existing electronic or web-based communication to medicaid
clients
MEMBERS.
(7) Nothing in this section requires the state department to produce
an explanation of benefits form if the information required to be included
in the explanation of benefits pursuant to subsection (4) of this section is
already included in another format that is understandable to the medicaid
client
MEMBER.
SECTION 31. In Colorado Revised Statutes, 25.5-4-301, amend
(1), (2)(a)(II), (4), (5), (6), (7), (8), (9), (10), (11)(a), (11)(c), (12)(b), and
(15)(a) as follows:
25.5-4-301. Recoveries - overpayments - penalties - interest -
adjustments - liens - review or audit procedures - repeal.
(1) (a) (I) Except as provided in section 25.5-4-302 and subparagraph (III)
of this paragraph (a), no recipient SUBSECTION (1)(a)(III) OF THIS SECTION,
A MEMBER or estate of the recipient shall be MEMBER IS NOT liable for the
cost or the cost remaining after payment by medicaid, medicare, or a private
insurer of medical benefits authorized by Title XIX of the social security act
FEDERAL "SOCIAL SECURITY ACT", by this title TITLE 25.5, or by rules
promulgated by the state board, which benefits are rendered to the recipient
MEMBER by a provider of medical services authorized to render such THE
service in the state of Colorado, except those contributions required
PAGE 26-SENATE BILL 24-176 pursuant to section 25.5-4-209 (1). However, a recipient MEMBER may enter
into a documented agreement with a provider under which the recipient
MEMBER agrees to pay for items or services that are nonreimbursable under
the medical assistance program. Under these circumstances, a recipient
MEMBER is liable for the cost of such THE services and items.
(II) The provisions of subparagraph (I) of this paragraph (a) shall
SUBSECTION (1)(a)(I) OF THIS SECTION apply regardless of whether medicaid
has actually reimbursed the provider and regardless of whether the provider
is enrolled in the Colorado medical assistance program.
(II.5) (A) A provider of medical services who bills or seeks
collection through a third party from a recipient
MEMBER or the estate of a
recipient MEMBER for medical services authorized by Title XIX of the social
security act FEDERAL "SOCIAL SECURITY ACT" in an amount in violation of
subsection (1)(a)(I) of this section is liable for and subject to the following:
A refund to the recipient
MEMBER of any amount unlawfully received from
the recipient MEMBER, plus statutory interest from the date of the receipt
until the date of repayment; a civil monetary penalty of one hundred dollars
for each violation of subsection (1)(a)(I) of this section; and all amounts
submitted to a collection agency in the name of the medicaid recipient
MEMBER. When determining income or resources for purposes of
determining eligibility or benefit amounts for any state-funded program
under this title 25.5, the state department shall exclude from consideration
any money received by a recipient
MEMBER pursuant to this subsection
(1)(a)(II.5). The imposition of a civil monetary penalty by the state
department may be appealed administratively.
(A.5) A provider of medical services who, within thirty days of
notification by the state department, or longer if approved by the state
department, voids the bill, returns any amount unlawfully received, and
makes every reasonable effort to resolve any collection actions so that the
recipient
MEMBER or the estate of the recipient MEMBER has no adverse
financial consequences is not subject to the provisions of subsection
(1)(a)(II.5)(A) of this section.
(B) In order to establish a claim for the civil monetary penalty
established by subsection (1)(a)(II.5)(A) of this section, a recipient
MEMBER
or the estate of a recipient MEMBER, or a person acting on behalf of a
recipient MEMBER or the estate of a recipient MEMBER, shall notify the state
PAGE 27-SENATE BILL 24-176 department.
(C) The provisions of this subparagraph (II.5) shall SUBSECTION
(1)(a)(II.5) DO not apply to a long-term care facility licensed pursuant to
section 25-3-101. C.R.S.
(D) The provisions of subsection (1)(a)(II.5)(A) of this section shall
DO not apply if a recipient MEMBER knowingly misrepresents his or her THE
MEMBER
'S medicaid coverage status to a provider of medical services and
the provider submits documentation to the state department that the
recipient
MEMBER knowingly misrepresented his or her THE MEMBER'S
medicaid coverage status and the documentation clearly establishes a good cause basis for granting an exception to the provider.
(III) (A) When a third party is primarily liable for the payment of the
costs of a recipient's
MEMBER'S medical benefits, prior to receiving
nonemergency medical care, the recipient MEMBER shall comply with the
protocols of the third party, including using providers within the third
party's network or receiving a referral from the recipient's
MEMBER'S
primary care physician. Any recipient MEMBER failing to follow the third
party's protocols is liable for the payment or cost of any care or services that
the third party would have been liable to pay; except that, if the third party
or the service provider substantively fails to communicate the protocols to
the recipient
MEMBER, the items or services are nonreimbursable under this
article ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5 and the
recipient MEMBER is not liable to the provider.
(B) A recipient MEMBER may enter into a written agreement with a
third party or provider under which the recipient MEMBER agrees to pay for
items provided or services rendered that are outside of the network or plan
protocols. The recipient's
MEMBER'S agreement to be personally liable for
such nonemergency, nonreimbursable items shall MUST be recorded on
forms approved by the state board and signed and dated by both the
recipient
MEMBER and the provider in advance of the services being
rendered.
(b) Recipient MEMBER income applied pursuant to section
25.5-4-209 (1) does not disqualify any recipient MEMBER, as defined in
section 26-2-103 (8), from receiving benefits pursuant to this article 4,
article 5 or 6 of this title 25.5, or public assistance pursuant to article 2 of
PAGE 28-SENATE BILL 24-176 title 26, and does not disqualify an individual from receiving child care
assistance pursuant to part 1 of article 4 of title 26.5. If, at any time during
the continuance of medical benefits, the recipient
MEMBER becomes
possessed GAINS POSSESSION of property having a value in excess of that
amount set by law or by the rules of the state department or receives any
increase in income, it is the duty of the recipient to
THE MEMBER SHALL
notify the county department thereof, and the county department may, after
investigation, either revoke such THE medical benefits or alter the amount
thereof OF MEDICAL BENEFITS, as the circumstances may require.
(c) Any medical assistance paid to which a recipient MEMBER was
not lawfully entitled shall be IS recoverable from the recipient MEMBER or
the estate of the recipient MEMBER by the county as a debt due the state
pursuant to section 25.5-1-115, but no lien may be imposed against the
property of a recipient
MEMBER on account of medical assistance paid or to
be paid on the recipient's MEMBER'S behalf under this article ARTICLE 4 or
article 5 or 6 of this title TITLE 25.5, except pursuant to the judgment of a
court of competent jurisdiction or as provided by section 25.5-4-302.
(d) If any such medical assistance was obtained fraudulently, interest
shall MUST be charged and paid to the county department on the amount of
such THE medical assistance calculated at the legal rate and calculated from
the date that payment for medical services rendered on behalf of the
recipient
MEMBER is made to the date such THE amount is recovered.
(2) Any overpayment to a provider, including those of personal
needs funds made pursuant to section 25.5-6-206, are recoverable regardless
of whether the overpayment is the result of an error by the state department,
a county department of human or social services, an entity acting on behalf
of either department, or by the provider or any agent of the provider as
follows:
(a) (II) If the state department makes a determination that such
THE
overpayment has been made for some other reason than a false
representation by the provider specified in subparagraph (I) of this
paragraph (a) SUBSECTION (2)(a)(I) OF THIS SECTION, the state department
may collect the amount of overpayment, plus interest accruing at the
statutory rate from the date the provider is notified of such THE
overpayment, by the means specified in this subsection (2). Pursuant to the criteria established in rules promulgated by the state board, the state
PAGE 29-SENATE BILL 24-176 department may waive the recovery or adjustment of all or part of the
overpayment and accrued interest specified in this subparagraph (II)
SUBSECTION (2)(a)(II) if it would be inequitable, uncollectible or
administratively impracticable; except that no action shall be taken against
a recipient
MEMBER of medical services initially determined to be eligible
pursuant to section 25.5-4-205 if the overpayment occurred through no fault
of the recipient
MEMBER. Amounts remaining uncollected for more than five
years after the last repayment was made may be considered uncollectible.
(4) If medical assistance is furnished to or on behalf of a recipient
MEMBER pursuant to the provisions of this article ARTICLE 4 and articles 5
and 6 of this title TITLE 25.5 for which a third party is liable, the state
department has an enforceable right against such THE third party for the
amount of such medical assistance, including the lien right specified in
subsection (5) of this section. Whenever the recipient MEMBER has brought
or may bring an action in court to determine the liability of the third party,
the state department, without any other name, title, or authority to enforce
the state department's right, may enter into appropriate agreements and
assignments of rights with the recipient
MEMBER and the recipient's
MEMBER'S attorney, if any. Any such agreement shall MUST be filed with the
court in which such an THE action is pending. The attorney named in such
an THE agreement upon designation as a special assistant attorney general
by the attorney general shall have the right to prove both the recipient's
MEMBER'S claim and the state department's claim. The state department,
without any other name, title, or authority, may take any necessary action
to determine the existence and amount of the state department's claims
under this section, whether such
THE claims are founded on judgment,
contract, lien, or otherwise, and take any other action that is appropriate to
recover from such
third parties. To enforce such THE right, the attorney
general, pursuant to section 24-31-101, C.R.S., on behalf of the state
department may institute and prosecute, or intervene of right in legal
proceedings against the third party having legal liability, either in the name
of the state department or in the name of the recipient or his or her
MEMBER
OR THE MEMBER
'S assignee, guardian, personal representative, estate, or
survivors. When the state department intervenes in legal proceedings
against the third party, it shall
THE STATE DEPARTMENT IS not be liable for
any portion of the attorney fees or costs of the recipient MEMBER.
(5) (a) When the state department has furnished medical assistance
to or on behalf of a recipient MEMBER pursuant to the provisions of this
PAGE 30-SENATE BILL 24-176 article, and ARTICLE 4 OR articles 5 and 6 of this title TITLE 25.5, for which
a third party is liable, the state department shall have HAS an automatic
statutory lien for all such medical assistance. The state department's lien
shall be IS against any judgment, award, or settlement in a suit or claim
against such THE third party and shall be IS in an amount that shall be IS the
fullest extent allowed by federal law as applicable in this state, but not to
exceed the amount of the medical assistance provided.
(b) No judgment, award, or settlement in any action or claim by a
recipient
MEMBER to recover damages for injuries, where IN WHICH the state
department has a lien, shall be IS satisfied without first satisfying the state
department's lien. Failure by any party to the judgment, award, or settlement
to comply with this section shall make
MAKES each such party liable for the
full amount of medical assistance furnished to or on behalf of the recipient
MEMBER for the injuries that are the subject of the judgment, award, or
settlement.
(c) Except as otherwise provided in this article ARTICLE 4, the entire
amount of any judgment, award, or settlement of the recipient's MEMBER'S
action or claim, with or without suit, regardless of how characterized by the parties, shall be
IS subject to the state department's lien.
(d) Where WHEN the action or claim is brought by the recipient
MEMBER alone and the recipient MEMBER incurs a personal liability to pay
attorney fees, the state department will SHALL pay its THE STATE
DEPARTMENT
'S reasonable share of attorney fees not to exceed twenty-five
percent of the state department's lien. The state department shall not be
IS
NOT
liable for costs.
(e) The state department's right to recover under this section is
independent of the recipient's
MEMBER'S right.
(6) When the applicant or recipient MEMBER, or his or her THE
APPLICANT
'S OR MEMBER'S guardian, executor, administrator, or other
appropriate representative, brings an action or asserts a claim against any
third party, such
THE person shall give to the state department written notice
of the action or claim by personal service or certified mail within fifteen
days after filing the action or asserting the claim. Failure to comply with
this subsection (6) shall make
MAKES the recipient MEMBER, legal guardian,
executor, administrator, attorney, or other representative liable for the entire
PAGE 31-SENATE BILL 24-176 amount of medical assistance furnished to or on behalf of the recipient
MEMBER for the injuries that gave rise to the action or claim. The state
department may, after thirty days' written notice to such THE person, enforce
its THE STATE DEPARTMENT'S rights under subsection (5) of this section and
this subsection (6) in the district court of the city and county of Denver;
except that liability of a person other than the recipient shall exist
MEMBER
EXISTS
only if such
THE person had knowledge that the recipient MEMBER
had received medical assistance or if excusable neglect is found by the
court. The court shall award the state department its costs and attorney fees
incurred in the prosecution of any such action.
(7) When a legally responsible relative of the recipient
MEMBER
agrees or is ordered to provide medical support or health insurance coverage
for his or her THE MEMBER'S dependents or other persons, and such THE
dependents are applicants for, recipients MEMBERS of, or otherwise entitled
to receive medical assistance pursuant to this article ARTICLE 4 and articles
5 and 6 of this title TITLE 25.5, the state department shall be IS subrogated
to any rights that the responsible persons may have to obtain reimbursement
from a third party or insurance carrier for the cost of medical assistance
provided for such dependents or persons. Where
WHEN the state department
gives written notice of subrogation, any third party or insurance carrier
liable for reimbursement for the cost of medical care shall accord to the
state department all rights and benefits available to the responsible relative
that pertain to the provision of medical care to any persons entitled to
medical assistance pursuant to this article
ARTICLE 4 and articles 5 and 6 of
this title TITLE 25.5 for whom the relative is legally responsible.
(8) All recipients MEMBERS of medical assistance under the
medicaid program shall be ARE deemed to have authorized their THE
MEMBER
'S attorneys, all third parties, including but not limited to insurance
companies, and providers of medical care to release to the state department
all information needed by the state department to secure and enforce its
rights under subsections (4) and (5) of this section.
(9) Nothing in part 6 of article 4 of title 10 C.R.S., shall be
construed to limit LIMITS the right of the state department to recover the
medical assistance furnished to or on behalf of a recipient MEMBER as the
result of the negligence of a third party.
(10) No action taken by the state department pursuant to subsection
PAGE 32-SENATE BILL 24-176 (4) of this section or any judgment rendered in such action shall be a bar to
THE ACTION BARS any action upon the claim or cause of action of the
applicant or recipient MEMBER or his or her THE MEMBER'S guardian,
personal representative, estate, dependent, or survivors against the third
party having legal liability, nor shall any such
action or judgment operate
to deny the applicant or recipient MEMBER the recovery for that portion of
his or her THE MEMBER'S medical costs or other damages not provided as
medical assistance under this article ARTICLE 4 or article 5 or 6 of this title
TITLE 25.5.
(11) (a) The state department shall have a right to MAY recover any
amount of medical assistance paid on behalf of a recipient MEMBER
because:
(I) The trustee of a trust for the benefit of the recipient MEMBER has
used the trust property in a manner contrary to the terms of the trust;
OR
(II) A person holding the recipient's
MEMBER'S power of attorney has
used the power for purposes other than the benefit of the recipient MEMBER.
(c) No action taken by the county or state department pursuant to
this subsection (11) or any judgment rendered in such AN action or
proceeding shall be a bar to BARS any action upon the claim or cause of
action of the recipient MEMBER or his or her THE MEMBER'S guardian,
personal representative, estate, dependent, or survivors against the trustee
or person holding the power of attorney.
(12) (b) Within fifteen days after filing an action or asserting a claim
against a third party, a recipient
MEMBER under a managed care plan or a
guardian, executor, administrator, or other appropriate representative of the
recipient
MEMBER shall provide to the entity that administers the managed
care plan written notice of the action or claim. Notice shall MUST be by
personal service or certified mail.
(15) (a) The state department may request a written response from
any provider who fails to comply with the rules, manuals, or bulletins issued
by the state department, state board, or the state department's fiscal agent,
or from any provider whose activities endanger the health, safety, or welfare
of medicaid recipients
MEMBERS. The written response must describe how
the provider will come into and ensure future compliance. If a written
PAGE 33-SENATE BILL 24-176 response is requested, a provider has thirty days, or longer if approved by
the state department, to submit the written response.
SECTION 32. In Colorado Revised Statutes, 25.5-4-302, amend
(1) as follows:
25.5-4-302. Recovery of assets. (1) The general assembly hereby
finds, determines, and declares that the cost of providing medical assistance
to qualified recipients MEMBERS throughout the state has increased
significantly in recent years; that such increasing costs have created an
increased burden on state revenues while reducing the amount of such
revenues available for other state programs; that recovering some of the medical assistance from the estates of medical assistance recipients
MEMBERS would be a viable mechanism for such recipients MEMBERS to
share in the cost of such assistance; and that such an estate recovery
program would be a cost-efficient method of offsetting medical assistance
costs in an equitable manner. The general assembly also declares that in
order to ensure that medicaid is available for low-income individuals
reasonable restrictions consistent with federal law should be placed on the
ability of persons to become eligible for medicaid by means of making
transfers of property without fair and valuable consideration.
SECTION 33. In Colorado Revised Statutes, 25.5-4-401, amend
(1)(a), (3)(a), (3)(b)(III), and (4) as follows:
25.5-4-401. Providers - payments - rules. (1) (a) The state
department shall establish rules for the payment of providers under this
article
ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5. Within the
limits of available funds, such THE rules shall MUST provide reasonable
compensation to such providers, but no provider shall, by this section or any
other provision of this article ARTICLE 4 or article 5 or 6 of this title, be
deemed to have TITLE 25.5, HAS any vested right to act as a provider under
this article ARTICLE 4 and articles 5 and 6 of this title TITLE 25.5 or to
receive any payment in addition to or different from that which is currently
payable on behalf of a recipient
MEMBER at the time the medical benefits are
provided by said THE provider.
(3) (a) As used in this subsection (3), "capitated" means a method
of payment by which a provider directly delivers or arranges for delivery of
medical care benefits for a term established by contract with the state
PAGE 34-SENATE BILL 24-176 department based on a fixed rate of reimbursement per recipient MEMBER.
(b) (III) The state department may define groups of recipients
MEMBERS by geographic area or other categories and may require that all
members of the defined group obtain medical services through one or more
provider contracts entered into pursuant to this subsection (3).
(4) (a) The general assembly hereby
finds, determines, and declares
that access to health-care services would be improved and costs of health
care would be restrained if the recipients
MEMBERS of the medicaid program
would choose a primary care physician through a managed care provider.
For purposes of this subsection (4), "managed care provider" means either
a primary care physician program, a health maintenance organization, or a
prepaid health plan.
(b) Subject to the provisions of paragraph (c) of this subsection (4)
SUBSECTION (4)(c) OF THIS SECTION, the executive director of the state
department has the authority to require a recipient MEMBER of the medicaid
program to select a managed care provider and to assign a recipient
MEMBER to a managed care provider if the recipient MEMBER has failed to
make a selection within a reasonable time. To the extent possible, this
requirement shall
MUST be implemented on a statewide basis.
(c) The state department shall ensure the following:
(I) A managed care provider shall establish and implement
consumer friendly
MEMBER-FRIENDLY procedures and instructions for
disenrollment and shall have adequate staff to explain issues concerning
service delivery and disenrollment procedures to recipients
MEMBERS,
including staff to address the communications needs and requirements of
recipients
MEMBERS with disabilities.
(II) All recipients MEMBERS shall be adequately informed about
AVAILABLE service delivery options available to them consistent with the
provisions of this subparagraph (II) SUBSECTION (4)(c)(II). If a recipient
MEMBER does not respond to a state department request for selection of a
delivery option within AFTER forty-five calendar days, the state department
shall send a second notification to the recipient MEMBER. If the recipient
MEMBER does not respond within AFTER twenty days of the date of the
second notification, the state department shall ensure that the recipient
PAGE 35-SENATE BILL 24-176 MEMBER remains with the recipient's MEMBER'S primary care physician,
regardless of whether said THE primary care physician is enrolled in a health
maintenance organization.
SECTION 34. In Colorado Revised Statutes, 25.5-4-401.5, amend
(2)(a), (2)(d)(II), (2)(e) introductory portion, (2)(e)(II) introductory portion,
and (3)(a)(III) as follows:
25.5-4-401.5. Review of provider rates - advisory committee -
recommendations - repeal. (2) (a) In the first phase of the review process,
the state department shall conduct an analysis of the access, service, quality,
and utilization of each service subject to a provider rate review. The state
department shall compare the rates paid with available benchmarks,
including medicare rates and usual and customary rates paid by private pay
parties, and use qualitative tools to assess whether payments are sufficient
to allow for provider retention and client
MEDICAID MEMBER access and to
support appropriate reimbursement of high-value services.
(d) (II) The state department shall submit, as part of the report
required pursuant to this subsection (2)(d), a description of the information
discussed during the quarterly public meeting; the state department's
response to the public comments received from providers, recipients
MEMBERS, and other interested parties; and an explanation of how the public
comments informed the provider rate review process and the
recommendations concerning provider rates.
(e) The state department shall conduct a public meeting at least
quarterly to inform the state department's review of provider rates paid
under the "Colorado Medical Assistance Act". The state department shall
invite to the public meeting providers, recipients
MEMBERS, and other
interested parties directly affected by the services scheduled to be reviewed
at the public meeting. At a minimum, each public meeting must consist of,
but is not limited to:
(II) Public comments from providers, recipients
MEMBERS, and other
interested parties concerning:
(3) (a) There is created in the state department the medicaid provider
rate review advisory committee, referred to in this section as the "advisory
committee", to assist the state department in the review of the provider rate
PAGE 36-SENATE BILL 24-176 reimbursements under the "Colorado Medical Assistance Act". The
advisory committee shall:
(III) Review the comments received from providers, recipients
MEMBERS, and other interested parties and the state department's response
to the comments required pursuant to subsection (2)(d)(II) of this section;
SECTION 35. In Colorado Revised Statutes, 25.5-4-402, amend
(4)(c)(II) and (4)(d)(I); and repeal (4)(d)(IV) and (4)(d)(V) as follows:
25.5-4-402. Providers - hospital reimbursement - hospital review
program - rules. (4) (c) The following factors must be considered in any
coverage determinations made pursuant to the hospital review programs:
(II) Evidence-based clinical coverage criteria and recipient MEMBER
coverage guidelines as established by the state department;
(d) (I) The state department shall consult with affected stakeholders
prior to implementation of the hospital review program. At a minimum, the
state department shall solicit feedback from recipients
MEMBERS, hospitals
within Colorado that participate in medicaid, providers participating in the
accountable care collaborative pursuant to section 25.5-5-419, and the
Colorado healthcare affordability and sustainability enterprise board
established in section 25.5-4-402.4 (7). If the state department contracts
with a third-party vendor to implement the hospital review program, the
state department shall require the vendor to participate in the stakeholder
outreach with hospitals required pursuant to this subsection (4)(d)(I).
(IV) The state department shall provide a report to the joint budget
committee on November 1, 2019, and November 1, 2020, detailing the
estimates of the cost savings achieved and the impact of the cost-control
measures authorized pursuant to this section on recipients and recipients'
health outcomes.
(V) Beginning in 2018, and every year thereafter through 2020, the
state department shall report on the status of the implementation of the
hospital review program, any cost savings estimated or achieved due to the
program, and the impact on recipients and recipients' outcomes of any
cost-control measures as part of its "State Measurement for Accountable,
Responsive, and Transparent (SMART) Government Act" hearing required
PAGE 37-SENATE BILL 24-176 by section 2-7-203.
SECTION 36. In Colorado Revised Statutes, amend 25.5-4-405 as
follows:
25.5-4-405. Mental health managed care service providers -
requirements. (1) Each contract between the state department and a
managed care organization providing mental health services to a recipient
MEMBER under the medical assistance program shall MUST comply with all
federal requirements, including but not limited to:
(a) Ensuring that a recipient MEMBER with complex or multiple
needs who requires mental health services shall have HAS access to mental
health professionals with appropriate training and credentials and shall
provide PROVIDING the recipient MEMBER with such THE services in
collaboration with the recipient's MEMBER'S other providers;
(b) Informing each recipient of his or her MEMBER OF THE MEMBER'S
right to and the process for appeal upon notification of denial, termination,
or reduction of a requested service; and
(c) Administering initial stabilization treatment for a recipient
MEMBER and transferring the recipient MEMBER for appropriate continued
services.
(1.5) Each contract between the state department and a managed
care organization providing mental health services to a recipient MEMBER
under the medical assistance program shall MUST allow for the use of
telemedicine pursuant to the provisions of section 25.5-5-320.
(2) For mental health managed care recipients MEMBERS, the state
department shall have a patient representative program for recipient
MEMBER grievances that complies with all federal requirements and that
shall MUST:
(a) Be posted in a conspicuous place at each location at which
mental health services are provided;
(b) Allow for a patient representative to serve as a liaison between
the recipient MEMBER and the provider;
PAGE 38-SENATE BILL 24-176 (c) Describe the qualifications for a patient representative;
(d) Outline the responsibilities of a patient representative;
(e) Describe the authority of a patient representative; and
(f) Establish a method by which each recipient
MEMBER is informed
of the patient representative program and how a patient representative may
be contacted.
SECTION 37. In Colorado Revised Statutes, 25.5-4-412, amend
(5) as follows:
25.5-4-412. Family planning services - family-planning-related
services - rules - definitions. (5) Any recipient
MEMBER may obtain family
planning services or family-planning-related services from any licensed
health-care provider, including a doctor of medicine, doctor of osteopathy,
physician assistant, advanced practice registered nurse, or certified midwife
who provides such services. The enrollment of a recipient
MEMBER in a
managed care organization, or a similar entity, does not restrict a recipient's
MEMBER'S choice of the licensed provider from whom the recipient MEMBER
may receive those services.
SECTION 38. In Colorado Revised Statutes, 25.5-4-416, amend
(1) and (2)(a)(III) as follows:
25.5-4-416. Providers - medical equipment and supplies -
requirements. (1) As used in this section, unless the context otherwise
requires, "provider" means a person or entity that delivers disposable
medical supplies or durable medical equipment products or services directly
to a recipient
MEMBER.
(2) On and after January 1, 2007, the state board rules for the
payment for disposable medical supplies and durable medical equipment,
including but not limited to prosthetic and orthotic devices, shall prohibit
a provider from being reimbursed unless the provider:
(a) (III) Is responsible for the delivery of and instructing the
recipient
MEMBER on the proper use of the equipment; and
PAGE 39-SENATE BILL 24-176 SECTION 39. In Colorado Revised Statutes, 25.5-4-422, amend
(4)(b); and repeal (5)(c) and (6)(b) as follows:
25.5-4-422. Cost control - legislative intent - use of technology -
stakeholder feedback - reporting - rules. (4) (b) Prior to implementing
and reporting on any new measures authorized by this section, the state
department shall provide an opportunity for affected recipients
MEMBERS,
providers, and stakeholders to provide feedback and make
recommendations on the state department's proposed implementation.
(5) By November 1, 2018, the state department shall provide a
report to the joint budget committee concerning:
(c) A description of the expected impact on recipients and recipients'
health outcomes and how the state department plans to measure the effect
on recipients.
(6) (b) The state department shall provide a report to the joint budget
committee on November 1, 2019, and November 1, 2020, detailing the
results of the independent evaluation, including estimates of the cost
savings achieved and the impact of the cost-control measures authorized
pursuant to this section on recipients and recipients' health outcomes.
SECTION 40. In Colorado Revised Statutes, 25.5-4-428, amend
(1), (2)(a), (2)(c), (3), and (5)(a) as follows:
25.5-4-428. Prior authorization for a step-therapy exception -
rules - definition. (1) As used in this section, unless the context otherwise
requires, "step therapy" means a protocol that requires a recipient MEMBER
to use a prescription drug or sequence of prescription drugs, other than the drug that the recipient's
MEMBER'S health-care provider recommends for the
recipient's MEMBER'S treatment, before the state department provides
coverage for the recommended prescription drug.
(2) (a) The state department shall review and determine if an
exception to step therapy is granted if the prescribing provider submits a
prior authorization request with justification and supporting clinical
documentation for treatment of a serious or complex medical condition, if
required, that states:
PAGE 40-SENATE BILL 24-176 (I) The provider attests that the required prescription drug is
contraindicated, or will likely cause intolerable side effects, a significant
drug-drug interaction, or an allergic reaction to the recipient
MEMBER;
(II) The required prescription drug lacks efficacy based on the
known clinical characteristics of the recipient MEMBER and the known
characteristics of the prescription drug regimen;
(III) The recipient MEMBER has tried the required prescription drug,
and the use of the prescription drug by the recipient MEMBER was
discontinued due to intolerable side effects, a significant drug-drug
interaction, or an allergic reaction; or
(IV) The recipient
MEMBER is stable on a prescription drug selected
by the prescribing provider for the medical condition.
(c) If the prior authorization request for a step-therapy exception is
denied, the state department shall inform the recipient MEMBER in writing
that the recipient MEMBER has the right to appeal the adverse determination
pursuant to state department rules.
(3) If the prior authorization request for a step-therapy exception
request is granted, the state department shall authorize coverage for the
prescription drug prescribed by the recipient's
MEMBER'S prescribing
provider.
(5) This section does not prohibit:
(a) The state department from requiring a recipient
MEMBER to try
a generic equivalent of a brand name drug, a biosimilar drug as defined in
42 U.S.C. sec. 262 (i)(2), or an interchangeable biological product as
defined in 42 U.S.C. sec. 262 (i)(3), unless such a requirement meets any
of the criteria set forth in subsection (2)(a) of this section for an exception
to step therapy and a prior authorization request is granted for the requested
drug;
SECTION 41. In Colorado Revised Statutes, 25.5-4-506, amend
(1)(b), (2) introductory portion, (3)(a), (7)(c)(III), and (7)(e) as follows:
25.5-4-506. Coverage for doula services - stakeholder process -
PAGE 41-SENATE BILL 24-176 federal authorization - scholarship program - training - report -
definitions - repeal. (1) As used in this section, unless the context
otherwise requires:
(b) "Maternity advisory committee" means the committee facilitated
by the state department composed predominantly of Black, Indigenous, and
other people of color with maternity care experience as recipients
MEMBERS.
(2) No later than September 1, 2023, the state department shall
initiate a stakeholder process to promote the expansion and utilization of
doula services for pregnant and postpartum recipients
MEMBERS in the state.
In conducting the stakeholder process, the state department shall:
(3) Stakeholders must be diverse with regard to race, ethnicity,
immigration status, sexual orientation, and gender, and must represent other
populations that experience greater health disparities and inequities. The
state department may include the following in the stakeholder process:
(a) Doulas and potential doulas who may serve recipients
MEMBERS
who include, but are not limited to, Black, Indigenous, and other people of
color, refugees, non-English speakers, people living in rural areas, and
people who were recently incarcerated;
(7) (c) The state department shall define eligibility criteria for the
doula scholarship program that includes, but is not limited to, the following:
(III) A statement of intent to serve as a doula provider in Colorado
for pregnant and postpartum recipients
MEMBERS.
(e) The state department may require individuals who receive
scholarship money pursuant to the doula scholarship program described in
this subsection (7) to submit to the state department, not later than six
months after the individual's completion of doula training or certification,
documentation that the individual is serving as a doula for recipients
MEMBERS or is working toward enrollment as a doula for recipients
MEMBERS. If an individual does not complete the documentation, the state
department may seek repayment of the funds awarded to the individual
through the doula scholarship program.
SECTION 42. In Colorado Revised Statutes, 25.5-5-102, amend
PAGE 42-SENATE BILL 24-176 (1) introductory portion and (1)(h) as follows:
25.5-5-102. Basic services for the categorically needy - mandated
services. (1) Subject to the provisions of subsection (2) of this section and
section 25.5-4-104, the program for the categorically needy shall MUST
include the following services as mandated and defined by federal law:
(h) Family planning, including a one-year supply of any federal food
and drug administration-approved contraceptive drug, device, or product,
unless the recipient
MEMBER requests a supply covering a shorter period of
time;
SECTION 43. In Colorado Revised Statutes, 25.5-5-103, amend
(1)(e) as follows:
25.5-5-103. Mandated programs with special state provisions -
rules. (1) This section specifies programs developed by Colorado to meet
federal mandates. These programs include but are not limited to:
(e) Special provisions for the purchase of group health insurance for
recipients MEMBERS, as specified in section 25.5-4-210;
SECTION 44. In Colorado Revised Statutes, 25.5-5-202, amend
(1)(a)(II) as follows:
25.5-5-202. Basic services for the categorically needy - optional
services. (1) Subject to the provisions of subsection (2) of this section, the
following are services for which federal financial participation is available
and that Colorado has selected to provide as optional services under the
medical assistance program:
(a) (II) Notwithstanding the provisions of subparagraph (I) of this
paragraph (a) SUBSECTION (1)(a)(I) OF THIS SECTION, pursuant to the
provisions of section 25.5-5-503, prescribed drugs shall not be ARE NOT a
covered benefit under the medical assistance program for a recipient
MEMBER who is enrolled in a prescription drug benefit program under
medicare; except that, if a prescribed drug is not a covered Part D drug as
defined in the "Medicare Prescription Drug, Improvement, and
Modernization Act of 2003", Pub.L. 108-173, the prescribed drug may be
a covered benefit if it is otherwise covered under the medical assistance
PAGE 43-SENATE BILL 24-176 program and federal financial participation is available.
SECTION 45. In Colorado Revised Statutes, 25.5-5-204, amend
(2.7)(d) as follows:
25.5-5-204. Presumptive eligibility - pregnant person - children
- long-term care - state plan. (2.7) (d) If it is determined that a recipient
MEMBER was not eligible for medical benefits after the recipient MEMBER
had been determined to be eligible based upon presumptive eligibility, the
state department shall not pursue recovery from a county department for the
cost of medical services provided to the recipient
MEMBER, and the county
department shall not be responsible for any federal error rate sanctions
resulting from such determination.
SECTION 46. In Colorado Revised Statutes, 25.5-5-207, amend
(2)(a) as follows:
25.5-5-207. Adult dental benefit - adult dental fund - creation -
legislative declaration. (2) (a) Pursuant to section 25.5-5-202 (1)(w), by
April 1, 2014, the state department shall design and implement a limited
dental benefit for adults using a collaborative stakeholder process to
consider the components of the benefit, including but not limited to the cost,
best practices, the effect on health outcomes, client
MEMBER experience,
service delivery models, and maximum efficiencies in the administration of
the benefit.
SECTION 47. In Colorado Revised Statutes, 25.5-5-303, amend
(2) introductory portion as follows:
25.5-5-303. Private-duty nursing. (2) A recipient
MEMBER is
eligible for private-duty nursing services if he or she THE MEMBER:
SECTION 48. In Colorado Revised Statutes, 25.5-5-316, amend
(1) and (2) as follows:
25.5-5-316. Legislative declaration - state department - disease
management programs authorization - report. (1) The general assembly
finds that, because Colorado is faced with rising health-care costs and
limited resources, it is necessary to seek new ways to ensure the availability
of high-quality, cost-efficient care for medicaid recipients
MEMBERS. The
PAGE 44-SENATE BILL 24-176 general assembly further finds that disease management is a
patient-focused, integrated approach to providing all components of care
with attention to both quality of care and total cost. In addition, the general
assembly finds that this approach may include coordination of physician
care with pharmaceutical and institutional care. The general assembly
further finds that disease management also addresses the various aspects of
a disease state, including meeting the needs of persons who have multiple
chronic illnesses. The general assembly declares that the improved
coordination in disease management helps to provide chronically ill patients
with access to the latest advances in treatment and teaches them how to be
active participants in their health care through health education, thus
reducing total health-care costs.
(2) The state department, in consultation with the department of
public health and environment, is authorized to develop and implement
disease management programs, for fee-for-service and primary care
physician program recipients, that are designed to address over- or
under-utilization or the inappropriate use of services or prescription drugs
and that may affect the total cost of health-care utilization by a particular
medicaid recipient
MEMBER with a particular disease or combination of
diseases. The disease management programs shall target medicaid recipients
MEMBERS who are receiving prescription drugs or services in an amount that
exceeds guidelines outlined by the state department. The state department
shall not restrict a medicaid recipient's
MEMBER'S access to the most
cost-effective and medically appropriate prescription drugs or services. The
state department may contract on a contingency basis for the development
or implementation of the disease management programs authorized in this
subsection (2).
SECTION 49. In Colorado Revised Statutes, 25.5-5-321.5, amend
(1) as follows:
25.5-5-321.5. Telehealth - interim therapeutic restorations -
reimbursement - definitions. (1) Subject to federal authorization and
federal financial participation, on or after July 1, 2016, in-person contact
between a health-care provider and a recipient
MEMBER is not required
under the state's medical assistance program for the diagnosis, development
of a treatment plan, instruction to perform an interim therapeutic restoration
procedure, or supervision of a dental hygienist performing an interim
therapeutic restoration procedure. A health-care provider may provide these
PAGE 45-SENATE BILL 24-176 services through telehealth, including store-and-forward transfer, and is
entitled to reimbursement for the delivery of those services via telehealth to
the extent the services are otherwise eligible for reimbursement under the
program when provided in person. The services are subject to the
reimbursement policies developed pursuant to the state medical assistance
program.
SECTION 50. In Colorado Revised Statutes, 25.5-5-322, amend
(1)(a) and (2)(b) as follows:
25.5-5-322. Over-the-counter medications - rules. (1) (a) Subject
to approval through the state budget process in paragraph (b) of this
subsection (1) DESCRIBED IN SUBSECTION (1)(b) OF THIS SECTION, the state
board shall adopt by rule a system to allow pharmacies to be reimbursed for
providing certain over-the-counter medications to recipients
MEMBERS if
prescribed by a licensed practitioner authorized to prescribe prescription
drugs or, subject to the limitations contained in subsection (2) of this
section, a licensed pharmacist. Over-the-counter medications subject to
reimbursement pursuant to this section shall
MUST be identified through the
drug utilization review process established in section 25.5-5-506, and shall
be ARE limited to medications that, if reimbursed, shall result in overall cost
savings to the state.
(2) (b) When prescribing over-the-counter medications under this
section, a licensed pharmacist shall consult with the recipient MEMBER to
determine necessity, provide drug counseling, review drug therapy for
potential adverse interactions, and make referrals as needed to other
health-care professionals.
SECTION 51. In Colorado Revised Statutes, 25.5-5-323, amend
(1)(a), (1)(c), (2)(a)(I), (2)(a)(III), (2)(b), (2)(d)(III)(A), (2)(d)(III)(C),
(2)(d)(IV), (2)(d)(V), (2)(d)(VI), (3) introductory portion, (3)(a), (3)(c)
introductory portion, (3)(d)(I), (3)(d)(III), (3)(e), (5)(a), (6), and (7) as
follows:
25.5-5-323. Complex rehabilitation technology - no prior
authorization - metrics - report - rules - legislative declaration -
definitions. (1) The general assembly finds and declares it is in the best
interests of the people of the state of Colorado to:
PAGE 46-SENATE BILL 24-176 (a) Continue to protect access to important technology and
supporting services for eligible clients MEMBERS;
(c) Continue to provide supports for clients MEMBERS accessing
complex rehabilitation technology to stay in the home or community setting;
engage in basic activities of daily living and instrumental activities of daily
living, including employment; prevent institutionalization; and prevent
hospitalization and other costly secondary complications; and
(2) As used in this section, unless the context otherwise requires:
(a) "Complex rehabilitation technology" means individually
configured manual wheelchair systems, power wheelchair systems, adaptive
seating systems, alternative positioning systems, standing frames, gait
trainers, and specifically designated options and accessories classified as
durable medical equipment that:
(I) Are individually configured for individuals to meet their specific
and unique medical, physical, and functional needs and capacities for basic
activities of daily living and instrumental activities of daily living, including
employment, identified as medically necessary to promote mobility in the
home and community or prevent hospitalization or institutionalization of the
client
MEMBER;
(III) Require certain services provided by a qualified complex
rehabilitation technology provider to ensure appropriate design,
configuration, and use of such items, including patient evaluation or
assessment of the client
MEMBER by a health-care professional, and that are
consistent with the client's MEMBER'S medical condition, physical and
functional needs and capacities, body size, period of need, and intended use.
(b) "Individually configured" means that a device has features,
adjustments, or modifications specific to a client MEMBER that a qualified
complex rehabilitation technology supplier provides by measuring, fitting,
programming, adjusting, adapting, and maintaining the device so that the
device is consistent with an assessment or evaluation of the client
MEMBER
by a health-care professional and consistent with the client's MEMBER'S
medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
PAGE 47-SENATE BILL 24-176 (d) "Qualified complex rehabilitation technology supplier" means
a company or entity that:
(III) Employs at least one qualified complex rehabilitation
technology professional for each location to:
(A) Analyze the needs and capacities of clients MEMBERS for a
complex rehabilitation technology item in consultation with the evaluating
clinical professionals;
(C) Provide the client
MEMBER technology-related training in the
proper use and maintenance of the selected complex rehabilitation
technology items;
(IV) Has the qualified complex rehabilitation technology
professional directly involved with the assessment, and determination of the
appropriate individually configured complex rehabilitation technology for
the client
MEMBER, with such THE involvement to include seeing the client
MEMBER visually either in person or by any other real-time means within a
reasonable time frame during the determination process.
(V) Maintains a reasonable supply of parts, adequate physical
facilities, and qualified service or repair technicians to provide clients
MEMBERS with prompt service and repair of all complex rehabilitation
technology it sells or supplies; and
(VI) Provides the client MEMBER written information at the time of
sale as to how to access service and repair.
(3) The state department shall provide a separate recognition within
the state's medicaid program established under articles 4, 5, and 6 of this
title PURSUANT TO THIS ARTICLE 5 AND ARTICLES 4 AND 6 OF THIS TITLE 25.5
for complex rehabilitation technology and shall make other required
changes to protect client
MEMBER access to appropriate products and
services. Such THE separate recognition must take into consideration the
customized nature of complex rehabilitation technology and the broad range
of related services necessary to meet the unique medical and functional
needs of clients
MEMBERS and include the following:
(a) The state department notifying the qualified rehabilitation
PAGE 48-SENATE BILL 24-176 technology suppliers concerning the parameters of the complex
rehabilitation technology benefit, which benefit must include the use of
qualified rehabilitation technology suppliers as well as billing procedures
that specify the types of equipment identified and included in the complex
rehabilitation technology benefit. The state department shall create complex
rehabilitation technology benefit parameters that are easily understood by
and accessible to clients
MEMBERS and qualified rehabilitation technology
suppliers. The state department shall provide public notice no later than
thirty days prior to a collaborative process that includes discussion of any
proposed changes to the types of equipment identified and included in the
complex rehabilitation technology benefit.
(c) Ensuring that clients
MEMBERS receiving complex rehabilitation
technology are evaluated or assessed, as needed, by:
(d) Continuing pricing policies for complex rehabilitation
technology, unless specifically prohibited by the federal centers for
medicare and medicaid services, including the following:
(I) Continuing to ensure that the reimbursement amounts for
complex rehabilitation technology, repairs, and supporting clinical complex
rehabilitation technology services are adequate to ensure that qualified
clients ELIGIBLE MEMBERS have access to the items, taking into account the
unique needs of the clients MEMBERS and the complexity and customization
of complex rehabilitation technology. This includes developing pricing
policies that ensure access to adequate and timely repairs.
(III) Preserving the option for complex rehabilitation technology to
be billed and paid for as a purchase allowing for lump sum payments for
devices with a length of need of one year or greater, excluding approved
crossover claims for clients
MEMBERS enrolled in medicare and medicaid;
and
(e) Making other changes as needed to protect access to complex
rehabilitation technology for clients MEMBERS.
(5) (a) No later than October 1, 2023, the state board shall
promulgate rules establishing repair metrics for all complex rehabilitation
technology suppliers and complex rehabilitation technology professionals.
At a minimum, the metrics must include requirements for repairing complex
PAGE 49-SENATE BILL 24-176 rehabilitation technology in a timely manner and the expected quality of
each repair. Prior to promulgating rules pursuant to this subsection (5)(a),
the state department shall engage in a stakeholder process, which process
must include qualified complex rehabilitation technology professionals,
qualified complex rehabilitation technology suppliers, and complex
rehabilitation technology clients
MEMBERS.
(6) Three years after the date the repair metric rules are established
pursuant to subsection (5)(a) of this section, the state department may
engage in a stakeholder process to determine the need for additional
accountability of a qualified complex rehabilitation technology supplier
through financial penalties, audits, or similar tools, for violations of the
repair metrics rules. If such
a stakeholder process is convened, the process
must include qualified complex rehabilitation technology professionals,
qualified complex rehabilitation technology suppliers, complex
rehabilitation clients
MEMBERS, and an advocacy group for persons with
disabilities.
(7) Beginning December 1, 2024, the state department shall
reimburse labor costs for repairs of complex rehabilitation technology at a
rate that is twenty-five percent higher for clients
MEMBERS residing in rural
areas than the rate for clients MEMBERS residing in urban areas.
SECTION 52. In Colorado Revised Statutes, 25.5-5-326, amend
(1)(d)(I) as follows:
25.5-5-326. Access to clinical trials - definitions. (1) As used in
this section, unless the context otherwise requires:
(d) (I) "Routine costs" means medically necessary items and services
that are included under the medical assistance program for a medical
assistance recipient
MEMBER, to the extent that the provision of such THE
items or services to the individual outside the course of such participation would otherwise be covered under the medical assistance program, without regard to whether the recipient
MEMBER is enrolled in a clinical trial. For
medical assistance recipients MEMBERS participating in an approved clinical
trial, "routine costs" include medically necessary items and services that are
not otherwise excluded pursuant to subsection (1)(d)(II)(D) of this section,
relating to the detection and treatment of complications arising from the
medical assistance recipient's
MEMBER'S medical care, including
PAGE 50-SENATE BILL 24-176 complications relating to participation in the clinical trial, to the extent that
the provision of such THE items or services to the individual outside the
course of such participation would otherwise be included under the medical
assistance program.
SECTION 53. In Colorado Revised Statutes, 25.5-5-327, amend
(2) as follows:
25.5-5-327. Eligible peer support services - reimbursement -
definitions. (2) Subject to available appropriations and to the extent
permitted under federal law, the medical assistance program pursuant to this
article 5 and articles 4 and 6 of this title 25.5 includes peer support
professional services provided to recipients
MEMBERS through a recovery
support services organization. Peer support professional services must not
be provided to recipients
MEMBERS until federal approval has been obtained.
SECTION 54. In Colorado Revised Statutes, 25.5-5-333, amend
(3)(b)(II), (5)(d), and (5)(e) as follows:
25.5-5-333. Primary care and behavioral health statewide
integration grant program - creation - report - definition - repeal.
(3) (b) Any money received through the grant program must supplement
and not supplant existing health-care services. Grant recipients shall not use
money received through the grant program for:
(II) Services already covered by medicaid or a client's
MEMBER'S
OTHER
insurance; or
(5) Grant applicants shall demonstrate a commitment to maintaining
models and programs that, at a minimum:
(d) Serve publicly funded clients
CONSUMERS;
(e) Maintain a plan for how to address a client MEMBER with
emergency needs;
SECTION 55. In Colorado Revised Statutes, 25.5-5-335, amend
(1), (3), (4) introductory portion, and (4)(a)(II) as follows:
25.5-5-335. Continuous medical coverage for children and adults
PAGE 51-SENATE BILL 24-176 feasibility study - federal authorization - rules - report - definition.
(1) The state department shall study the feasibility of extending continuous
medical coverage for additional children and adults and how to better meet
the health-related social needs of medical assistance program recipients
MEMBERS.
(3) In addition to the study topics detailed in subsection (2) of this
section, the feasibility study must study how to best meet the health-related
social needs of medical assistance program recipients
MEMBERS who are
historically disadvantaged and underserved and must give consideration to
concerns related to housing and food security.
(4) In conducting the feasibility study pursuant to this section, the
state department shall take into consideration the efforts of other states to
improve the health-related social needs of medical assistance program
recipients
MEMBERS, including, but not limited to, housing and nutritional
needs, initiatives to pay for rental housing assistance for up to six months,
the needs of perinatal recipients
MEMBERS, youth in or transitioning out of
foster care, former foster care youth, people with substance use disorders,
high-risk infants and children, and the needs of low-income individuals
impacted by natural disasters, and the state department shall seek input from
relevant stakeholders. In conducting the stakeholder process, the state
department shall:
(a) Engage directly with:
(II) Service providers, particularly those whose patients are
predominantly medical assistance program recipients
MEMBERS or are
uninsured;
SECTION 56. In Colorado Revised Statutes, 25.5-5-402, amend
(1), (2)(b), (5), (6)(a), (9)(a), and (12) as follows:
25.5-5-402. Statewide managed care system - rules - definitions
- repeal. (1) The state board shall adopt rules to implement a statewide
managed care system for Colorado medical assistance recipients MEMBERS
pursuant to the provisions of this article 5 and articles 4 and 6 of this title 25.5. The statewide managed care system shall be implemented to the extent possible.
PAGE 52-SENATE BILL 24-176 (2) The statewide managed care system implemented pursuant to
this article 5 does not include:
(b) Long-term care services and the program of all-inclusive care for
the elderly, as described in section 25.5-5-412. For purposes of this
subsection (2), "long-term care services" means nursing facilities and home-
and community-based services provided to eligible clients
MEMBERS who
have been determined to be in need of such services pursuant to the
"Colorado Medical Assistance Act" and the state board's rules.
(5) The statewide managed care system builds upon the lessons
learned from previous managed care and community behavioral health-care
programs in the state in order to reduce barriers that may negatively impact
medicaid recipient
MEMBER experience, medicaid recipient MEMBER health,
and efficient use of state resources. The statewide managed care system is
authorized to provide services under a single MCE type or a combination
of MCE types.
(6) (a) The state department is authorized to assign a medicaid
recipient
MEMBER to a particular MCE, consistent with federal requirements
and rules promulgated by the state board.
(9) Bidding. (a) The state department is authorized to institute a
program for competitive bidding pursuant to section 24-103-202 or
24-103-203 for MCEs seeking to provide, arrange for, or otherwise be
responsible for the provision of services to its enrollees
MEMBERS. The state
department is authorized to award contracts to more than one offeror. The
state department shall use competitive bidding procedures to encourage
competition and improve the quality of care available to medicaid recipients
MEMBERS over the long term that meets the requirements of this section and
section 25.5-5-406.1.
(12) Graduate medical education. The state department shall
continue the graduate medical education, referred to in this subsection (12)
as "GME", funding to teaching hospitals that have graduate medical
education expenses in their medicare cost report and are participating as
providers under one or more MCEs with a contract with the state
department under this part 4. GME funding for recipients
MEMBERS enrolled
in an MCE is excluded from the premiums paid to the MCE and must be
paid directly to the teaching hospital. The state board shall adopt rules to
PAGE 53-SENATE BILL 24-176 implement this subsection (12) and establish the rate and method of
reimbursement.
SECTION 57. In Colorado Revised Statutes, 25.5-5-403, amend
(2)(b) and (3) as follows:
25.5-5-403. Definitions. As used in this part 4, unless the context
otherwise requires:
(2) "Essential community provider", referred to in this part 4 as an
"ECP", means a health-care provider that:
(b) Waives charges or charges for services on a sliding scale based
on income and does not restrict access or services because of a client's
MEMBER'S financial limitations.
(3) (a) "Managed care" means a health-care delivery system
organized to manage costs, utilization, and quality. Medicaid managed care
provides for the delivery of medicaid health benefits and additional services
through contracted arrangements between state medicaid agencies and
MCEs.
(b) Nothing in this section shall be deemed to affect
AFFECTS the
benefits authorized for recipients MEMBERS of the state medical assistance
program.
SECTION 58. In Colorado Revised Statutes, 25.5-5-406.1, amend
(1)(f)(II)(A), (1)(n)(II), (1)(p)(II)(A), (1)(q), (1)(r), and (1)(s)(II) as follows:
25.5-5-406.1. Required features of statewide managed care
system. (1) General features. All medicaid managed care programs must
contain the following general features, in addition to others that the federal
government, state department, and state board consider necessary for the
effective and cost-efficient operation of those programs:
(f) The MCE shall create, administer, and maintain a network of
providers, building on the current network of medicaid providers, to serve
the health-care needs of its members. In doing so, the MCE shall:
(II) (A) Seek proposals from each ECP in a county in which the
PAGE 54-SENATE BILL 24-176 MCE is enrolling recipients MEMBERS for those services that the MCE
provides or intends to provide and that an ECP provides or is capable of
providing. The MCE shall consider such proposals in good faith and shall,
when deemed reasonable by the MCE based on the needs of its enrollees
MEMBERS, contract with ECPs. Each ECP shall be willing to negotiate on
reasonably equitable terms with each MCE. ECPs making proposals under
this subsection (1)(f)(II) must be able to meet the contractual requirements
of the MCE. The requirements of this subsection (1)(f)(II) do not apply to
an MCE in areas in which the MCE operates entirely as a group health
maintenance organization.
(n) Grievances and appeals. (II) The MCE shall have an
established grievance system that allows for client
MEMBER expression of
dissatisfaction at any time about any matter related to the MCE's contracted
services, other than an adverse benefit determination. The grievance system
must provide timely resolution of such
THE matters in a manner consistent
with the medical needs of the individual recipient MEMBER.
(p) (II) Prepaid inpatient health plans shall not retroactively recover
provider payments if:
(A) A recipient MEMBER was initially determined to be eligible for
medical benefits pursuant to section 25.5-4-205 when the provider has an
eligibility guarantee number for the recipient
MEMBER; or
(q) Billing medicaid members. Notwithstanding any federal
regulations or the general prohibition of section 25.5-4-301 against
providers billing medicaid recipients
MEMBERS, a provider may bill a
medicaid recipient MEMBER who is enrolled with a specific medicaid PCCM
or MCE and, in circumstances defined by the rules of the state board,
receives care from a medical provider outside that organization's network
or without referral by the recipient's
MEMBER'S PCCM;
(r) Marketing. In marketing coverage to medicaid recipients
MEMBERS, all MCEs shall comply with all applicable provisions of title 10
regarding health plan marketing. The state board is authorized to
promulgate rules concerning the permissible marketing of medicaid
managed care. The purposes of such
THE rules must include but not be
limited to the avoidance of biased selection among the choices available to
medicaid recipients
MEMBERS.
PAGE 55-SENATE BILL 24-176 (s) Prescription drugs. All MCEs that have prescription drugs as
a covered benefit shall provide prescription drug coverage in accordance
with the provisions of section 25.5-5-202 (1)(a) as part of a comprehensive
health benefit and with respect to any formulary or other access restrictions:
(II) The MCE shall provide to all medicaid recipients
MEMBERS at
periodic intervals, and prior to and during enrollment upon request, clear
and concise information about the prescription drug program in language
understandable to the medicaid recipients
MEMBERS, including information
about such formulary or other access restrictions and procedures for gaining
access to prescription drugs, including off-formulary products; and
SECTION 59. In Colorado Revised Statutes, 25.5-5-408, amend
(1)(d) and (1)(e) as follows:
25.5-5-408. Capitation payments - availability of base data -
adjustments - rate calculation - capitation payment proposal -
preference - assignment of medicaid members - definition. (1) (d) The
state department shall reimburse a federally qualified health center, as
defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(4),
for the total reasonable costs incurred by the center in providing health-care
services to all recipients
MEMBERS of medical assistance.
(e) An MCE shall certify, as a condition of entering into a contract
with the state department, that the capitation payments set forth in the
contract between the MCE and the state department are sufficient to ensure
the financial stability of the MCE with respect to delivery of services to the
medicaid recipients
MEMBERS covered in the contract.
SECTION 60. In Colorado Revised Statutes, 25.5-5-410, amend
(2) and (3) as follows:
25.5-5-410. Data collection for managed care programs. (2) The
state department of human services, in conjunction with the state
department, shall continue its existing efforts, which include obtaining and
considering consumer
MEMBER input, to develop managed care systems for
the developmentally disabled population and to consider a pilot program for
a certificate system to enable the developmentally disabled population to
purchase managed care services or fee-for-service care, including long-term
care community services. The department of human services shall not
PAGE 56-SENATE BILL 24-176 implement any managed care system for developmentally disabled services
without the express approval of the joint budget committee. Any proposed
implementation of fully capitated managed care in the developmental
disabilities community service system shall require
REQUIRES legislative
review.
(3) In addition to any other data collection and reporting
requirements, each managed care organization shall submit the following
types of data to the state department or its agent:
(a) Medical access;
(b) Consumer
MEMBER outcomes based on statistics maintained on
individual consumers MEMBERS as well as the total consumer MEMBER
populations served;
(c) Consumer MEMBER satisfaction;
(d) Consumer MEMBER utilization;
(e) Health status of consumers MEMBERS; and
(f) Uncompensated care delivered.
SECTION 61. In Colorado Revised Statutes, 25.5-5-412, amend
(6)(b); and amend as it will become effective July 1, 2024, (6)(a) as
follows:
25.5-5-412. Program of all-inclusive care for the elderly -
services - eligibility - rules - legislative declaration - definitions. (6) The
state department, in cooperation with the case management agencies
established in section 25.5-6-1703, shall develop and implement a
coordinated plan to provide education about PACE program site operations
under this section. The state board shall adopt rules:
(a) To ensure that case managers and any other appropriate state
department staff discuss the option and potential benefits of participating
in the PACE program with all eligible long-term care clients
MEMBERS.
These rules must require additional and on-going training of the case
management agency case managers in counties where a PACE program is
PAGE 57-SENATE BILL 24-176 operating. This training must be provided by a federally approved PACE
provider. In addition, each case management agency may designate case
managers who have knowledge about the PACE program.
(b) To allow PACE providers to contract with an enrollment broker
to include the PACE program in its marketing materials to eligible
long-term clients
MEMBERS.
SECTION 62. In Colorado Revised Statutes, 25.5-5-415, amend
(2)(a), (2)(b)(II), (2)(c)(II)(A), (2)(c)(II)(D), and (3) as follows:
25.5-5-415. Medicaid payment reform and innovation pilot
program - creation - selection of payment projects - report - rules -
legislative declaration. (2) (a) There is hereby
created the medicaid
payment reform and innovation pilot program for purposes of fostering the
use of innovative payment methodologies in the medicaid program that are
designed to provide greater value while ensuring good health outcomes and
client
MEMBER satisfaction.
(b) (II) The design of the payment project or projects must address
the client MEMBER population of the state department's statewide managed
care system and be tailored to the region's health-care needs and the
resources of the state department's statewide managed care system.
(c) (II) For purposes of selecting payment projects for the pilot
program, the state department shall consider, at a minimum:
(A) The likely effect of the payment project on quality measures,
health outcomes, and client
MEMBER satisfaction;
(D) The client MEMBER population served by the state department's
statewide managed care system and the particular health needs of the
region;
(3) Pilot program participants shall provide data and information to
the state department and any designated evaluator concerning health
outcomes, cost, provider participation and satisfaction, client
MEMBER
satisfaction, and any other data and information necessary to evaluate the efficacy of the payment methodology.
PAGE 58-SENATE BILL 24-176 SECTION 63. In Colorado Revised Statutes, 25.5-5-419, amend
(1)(a), (1)(c), (1)(d), (3)(a), (3)(f), and (3)(i)(III) as follows:
25.5-5-419. Accountable care collaborative - reporting - rules.
(1) In 2011, the state department created the accountable care collaborative,
also referred to in this title 25.5 as the medicaid coordinated care system.
The state department shall continue to provide care delivery through the
accountable care collaborative. The goals of the accountable care
collaborative are to improve member health and reduce costs in the
medicaid program. To achieve these goals, the state department's
implementation of the accountable care collaborative must include, but need
not be limited to:
(a) Establishing primary care medical homes for medicaid clients
MEMBERS within the accountable care collaborative;
(c) Providing data to regional entities and providers to help manage
client MEMBER care;
(d) Integrating the delivery of behavioral health, including mental
health and substance use disorders, and physical health services for clients
MEMBERS;
(3) On or before December 1, 2017, and on or before December 1
each year thereafter, the state department shall prepare and submit a report
to the joint budget committee, the public health care and human services
committee of the house of representatives, and the health and human
services committee of the senate, or any successor committees, concerning
the implementation of the accountable care collaborative. Notwithstanding
the provisions of section 24-1-136 (11)(a)(I), the report required pursuant
to this subsection (3) continues indefinitely. At a minimum, the state
department's report must include the following information concerning the
accountable care collaborative:
(a) The number of medicaid clients
MEMBERS enrolled in the
program;
(f) A description of the state department's coordination with entities
that authorize long-term care services for medicaid clients MEMBERS;
PAGE 59-SENATE BILL 24-176 (i) Information concerning efforts to reduce medicaid waste and
inefficiencies through the accountable care collaborative, including:
(III) Any other efforts by regional entities or the state department to
ensure that those who provide care for medicaid clients MEMBERS are aware
of and actively participate in reducing waste within the medicaid system.
SECTION 64. In Colorado Revised Statutes, amend 25.5-5-503 as
follows:
25.5-5-503. Prescription drug benefits - authorization -
dual-eligible participation. (1) The state department is authorized to
ensure the participation of Colorado medical assistance recipients
MEMBERS, who are also eligible for medicare, in any federal prescription
drug benefit enacted for medicare recipients.
(2) Prescribed drugs shall not be ARE NOT a covered benefit under
the medical assistance program for a recipient MEMBER who is eligible for
a prescription drug benefit program under medicare; except that, if a
prescribed drug is not a covered Part D drug as defined in the "Medicare
Prescription Drug, Improvement, and Modernization Act of 2003", Pub.L.
108-173, the prescribed drug may be a covered benefit if it is otherwise
covered under the medical assistance program and federal financial
participation is available.
SECTION 65. In Colorado Revised Statutes, amend 25.5-5-504 as
follows:
25.5-5-504. Providers of pharmaceutical services. (1) Consistent
with the provisions of section 25.5-4-401 (1) and consistent with
subsections (2) and (3) of this section, and subject to available appropriations, no provider of pharmaceutical services who meets the conditions imposed by this article
ARTICLE 5 and articles 4 and 6 of this title
TITLE 25.5 and who complies with the terms and conditions established by
the state department and contracting health maintenance organizations and
prepaid health plans shall be excluded from contracting for the provision of
pharmaceutical services to recipients
MEMBERS authorized in this article
ARTICLE 5 and articles 4 and 6 of this title TITLE 25.5.
(2) This provision shall DOES not apply to a health maintenance
PAGE 60-SENATE BILL 24-176 organization or prepaid health plan that enrolls less than forty percent of all
the resident medicaid recipients MEMBERS in any county with over one
thousand medicaid recipients MEMBERS.
(3) The state board shall establish specifications in rules in order to
provide criteria to health maintenance organizations and prepaid health
plans which ensure the accessibility and quality of service to clients
MEMBERS and the terms and conditions for pharmaceutical contracts.
SECTION 66. In Colorado Revised Statutes, 25.5-5-505, amend
(1)(a)(II), (1)(b), and (1.5) as follows:
25.5-5-505. Prescribed drugs - mail order - rules. (1) (a) (II) The
state board rules must include the definition of maintenance medications.
The rules may allow a medical assistance recipient
MEMBER to receive
through the mail up to a three-month supply, or the maximum allowed
under federal law, of maintenance medications used to treat chronic medical
conditions.
(b) To the extent allowed by federal law, the state department shall
require that a medical assistance recipient
MEMBER receiving prescription
medication through the mail pay the same copayment amount as a medical
assistance recipient
MEMBER receiving prescription medication through any
other method. The state department shall encourage medical assistance
recipients
MEMBERS who choose to receive maintenance medications
through the mail to use local retail pharmacies for mail delivery.
(1.5) The state department shall publish on its website and include
in the recipient MEMBER handbook the following information for recipients
MEMBERS enrolled in fee-for-service medical assistance programs:
(a) That a medical assistance recipient MEMBER may use the
pharmacy of his or her THE MEMBER'S choice;
(b) That a medical assistance recipient MEMBER may use a local
retail pharmacy for mail delivery of maintenance medications, if offered;
and
(c) That the copayment amount for prescription medications is the
same at any pharmacy enrolled in the medical assistance program.
PAGE 61-SENATE BILL 24-176 SECTION 67. In Colorado Revised Statutes, 25.5-5-509, amend
(2)(b) as follows:
25.5-5-509. Substance use disorder - prescription drugs - opiate
antagonist. (2) (b) A hospital or emergency department shall receive
reimbursement under the medical assistance program for the cost of an
opiate antagonist if, in accordance with section 12-30-110, a prescriber, as
defined in section 12-30-110 (7)(h), dispenses an opiate antagonist upon
discharge to a medical assistance recipient
MEMBER who is at risk of
experiencing an opiate-related drug overdose event or to a family member,
friend, or other person in a position to assist a medical assistance recipient
MEMBER who is at risk of experiencing an opiate-related drug overdose
event.
SECTION 68. In Colorado Revised Statutes, 25.5-5-514, amend
(2)(a) as follows:
25.5-5-514. Prescription drugs used for treatment or prevention
of HIV - prohibition on utilization management - definition.
(2) (a) Before July 1, 2027, the state department shall not restrict by prior
authorization or step therapy requirements any prescription drug approved
by the federal food and drug administration that is used for the treatment or
prevention of HIV if a prescribing practitioner licensed pursuant to title 12
has determined the prescription drug to be medically necessary for the
treatment or prevention of HIV for a recipient
MEMBER. Prescription drugs
used for the treatment or prevention of HIV include protease inhibitors,
non-nucleoside reverse transcriptase inhibitors, nucleoside reverse
transcriptase inhibitors, antivirals, integrase inhibitors, long-acting
medications, and fusion inhibitors.
SECTION 69. In Colorado Revised Statutes, 25.5-6-102, amend
(1) introductory portion and (1)(d) as follows:
25.5-6-102. Court-approved trusts - transfer of property for
persons seeking medical assistance for nursing home care - undue
hardship - legislative declaration. (1) The general assembly hereby
finds,
determines, and declares that:
(d) It is therefore appropriate to enact state laws which limit such
court-approved trusts in a manner that is consistent with Title XIX of the
PAGE 62-SENATE BILL 24-176 federal "Social Security Act", 42 U.S.C. sec. 1396 et seq., as amended, and
which provide that persons who qualify for assistance as a result of the
creation of such trusts shall be
ARE treated the same as any other recipient
MEMBER of medical assistance for nursing home care;
SECTION 70. In Colorado Revised Statutes, 25.5-6-104, amend
(1)(b), (1)(c), (2)(b), (2)(d), (2)(e), (2)(f), (2)(i), (2)(j), (2)(k), (3)(a), (3)(b)
introductory portion, (3)(b)(VII), (3)(c), (3)(d) introductory portion,
(3)(d)(I) introductory portion, (3)(d)(II), (3)(d)(III), (3)(d)(V), (3)(e), and
(5)(a) as follows:
25.5-6-104. Long-term care placements - comprehensive and
uniform assessment instrument - report - legislative declaration -
definitions - repeal. (1) (b) The general assembly further finds,
determines, and declares that the state is in need of a long-term care system
that organizes each long-term care client's
APPLICANT'S AND MEMBER'S
entry, assessment of need, and service delivery into a single unified system, and that such
THE system must include, at a minimum, a locally established
single entry point administered by a designated entity, a single client
assessment instrument and administrative process, targeted case management in order to maximize existing federal, state, and local funding, case management, and an accountability mechanism designed to assure that budget allocations are being effectively managed.
(c) The general assembly therefore concludes that it is appropriate
to develop and implement a comprehensive and uniform long-term care
client
assessment process and to study the establishment of a single entry
point system that provides for the coordination of access and service
delivery to long-term care clients
MEMBERS at the local level, that is
available to all persons INDIVIDUALS in need of long-term care, and that is
well managed and cost-efficient.
(2) As used in this section and in sections 25.5-6-105 to 25.5-6-107,
unless the context otherwise requires:
(b) "Case management services" means the assessment of a AN
INDIVIDUAL
'S NEED FOR long-term care, client's needs,
the development and
implementation of a care plan for such client THE MEMBER, the coordination
and monitoring of long-term care service delivery, the direct delivery of
services as provided by this article
ARTICLE 6 or by rules adopted by the
PAGE 63-SENATE BILL 24-176 state board pursuant to this article ARTICLE 6, the evaluation of service
effectiveness, and the reassessment of such client's THE MEMBER'S needs, all
of which shall be performed by a single entry point as defined in paragraph
(k) of this subsection (2) SUBSECTION (2)(k) OF THIS SECTION.
(d) "Comprehensive and uniform client assessment process" means
a standard procedure, which includes the use of a uniform assessment
instrument, to measure a client's
MEMBER'S OR APPLICANT'S functional
capacity, to determine the social and medical needs of a current or potential
client
MEMBER OR APPLICANT of any long-term care program, and to target
resources to the functionally impaired.
(e) "Continuum of care" means an organized system of long-term
care, benefits, and services to which a client MEMBER has access and which
enables a client MEMBER to move from one level or type of care to another
without encountering gaps in or barriers to service.
(f) "Information and referral" means the provision of specific,
accurate, and timely public information about services available to aging
and disabled adults in need of long-term care and referral to alternative
agencies, programs, and services based on client
MEMBER inquiries.
(i) "Resource development" means the study, establishment, and
implementation of additional resources or services which will extend the
capabilities of community long-term care systems to better serve long-term
care clients
MEMBERS.
(j) "Screening" means a preliminary determination of need for
long-term care services and, on the basis of such THE determination, the
making of an appropriate referral for a client AN assessment in accordance
with subsection (3) of this section or referral to another community resource
to assist clients
INDIVIDUALS who are not in need of long-term care services.
(k) "Single entry point" means the availability of a single access or
entry point within a local area where a current or potential long-term care
client
MEMBER OR APPLICANT can obtain long-term care information,
screening, assessment of need, and referral to appropriate long-term care
program and case management services.
(3) (a) On or before July 1, 1991, the state department shall
PAGE 64-SENATE BILL 24-176 establish, by rule in accordance with article 4 of title 24, C.R.S., a
comprehensive and uniform client assessment process for all individuals in
need of long-term care, the purpose of which is to determine the appropriate
services and levels of care necessary to meet clients'
MEMBERS' OR
APPLICANTS
' needs, to analyze alternative forms of care and the payment
sources for such
THE care, and to assist in the selection of long-term care
programs and services that meet clients' MEMBERS' OR APPLICANTS' needs
most cost-efficiently.
(b) Participation in the
ASSESSMENT process shall be
IS mandatory
for clients MEMBERS of publicly funded long-term care programs, including,
but not limited to, the following:
(VII) Home health services for long-term care clients MEMBERS; and
(c) Private paying clients MEMBERS of long-term care programs may
participate in the process for a fee to be established by the state department
and adopted through rules.
(d) The state department, through rules, shall develop and
implement no later than July 1, 1991, a uniform long-term care client
needs
assessment instrument for all individuals needing IN NEED OF long-term
care. The instrument shall MUST be used as part of the comprehensive and
uniform client assessment process to be established in accordance with
subsection (3)(a) of this section and shall MUST serve the following
functions:
(I) To obtain information on each client's MEMBER'S OR APPLICANT'S
status in the following areas:
(II) To assess each client's MEMBER'S OR APPLICANT'S physical
environment in terms of meeting the client's MEMBER'S OR APPLICANT'S
needs;
(III) To obtain information on each client's MEMBER'S OR
APPLICANT
'S payment sources, including obtaining financial eligibility
information for publicly funded long-term care programs;
(V) To prioritize a client's
MEMBER'S OR APPLICANT'S need for care
using criteria established by the state department for specific publicly
PAGE 65-SENATE BILL 24-176 funded long-term care programs;
(e) On and after July 1, 1991, no publicly funded client shall A
MEMBER MUST NOT
be placed in a long-term care program unless such
THE
placement is in accordance with rules adopted by the state board in
implementing this section.
(5) (a) On or before July 1, 2018, pursuant to the state department's
ongoing stakeholder process relating to eligibility determination for
long-term services and supports pursuant to this article
ARTICLE 6, the state
department shall select a needs assessment tool for persons INDIVIDUALS
receiving long-term services and supports, including persons INDIVIDUALS
with intellectual and developmental disabilities who are eligible for services
pursuant to section 25.5-6-409. Once selected, the state department shall
begin assessing client
THE INDIVIDUAL'S needs using the needs assessment
tool as soon as practicable.
SECTION 71. In Colorado Revised Statutes, 25.5-6-105, amend
(1) introductory portion, (1)(b), and (1)(c) as follows:
25.5-6-105. Legislative declaration relating to implementation
of single entry point system - repeal. (1) The general assembly hereby
finds, determines, and declares that:
(b) The establishment of a single entry point system for the
coordination of access to existing services and service delivery for all
long-term care clients
MEMBERS at the local level can be implemented in a
cost-efficient manner;
(c) The implementation of a well-managed single entry point system
will result in the utilization of more appropriate services by long-term care
clients
MEMBERS over time and will provide better information on the unmet
service needs of clients MEMBERS; and
SECTION 72. In Colorado Revised Statutes, 25.5-6-106, amend
(2)(b) introductory portion, (2)(c) introductory portion, (2)(c)(III),
(2)(c)(IV), (2)(c)(V), and (3)(b) as follows:
25.5-6-106. Single entry point system - authorization - phases for
implementation - services provided - repeal. (2) Single entry point
PAGE 66-SENATE BILL 24-176 agencies - service programs - functions. (b) The agency may serve
private paying clients MEMBERS on a fee-for-service basis and shall serve
clients MEMBERS of publicly funded long-term care programs, including, but
not limited to, the following:
(c) The major functions of a single entry point shall MUST include,
but need not be limited to, the following:
(III) Assessing clients' MEMBERS' needs in accordance with section
25.5-6-104;
(IV) Developing plans of care for clients MEMBERS;
(V) Determining payment sources available to clients MEMBERS for
long-term care services;
(3) State certification of a single entry point agency - quality
assurance standards. (b) The state board shall adopt rules for the
establishment of a quality assurance program for the purpose of monitoring
the quality of services provided to clients
MEMBERS and for recertifying
single entry point agencies. The rules shall provide for: Procedures to
evaluate the quality of services provided by the agency; an assessment of
the agency's compliance with program requirements, including compliance
with case management standards, which standards shall be adopted by the
state department; an assessment of an agency's performance of
administrative functions, including reasonable costs per client
MEMBER,
timely responses, managing programs in one consolidated unit, on-site visits
to clients MEMBERS, community coordination and outreach, and client
MEMBER monitoring; a determination as to whether targeted populations are
being identified and served; and an evaluation concerning financial
accountability.
SECTION 73. In Colorado Revised Statutes, 25.5-6-107, amend
(1) introductory portion, (1)(c)(II), and (2) as follows:
25.5-6-107. Financing of single entry point system - repeal.
(1) The single entry point system shall be financed with the following
moneys
FUNDING:
(c) County contributions, as follows:
PAGE 67-SENATE BILL 24-176 (II) The amount contributed from each county in accordance with
subparagraph (I) of this paragraph (c) SUBSECTION (1)(c)(I) OF THIS SECTION
after making an adjustment based on the percentage of an increase or decrease per fiscal year in the service costs for clients
MEMBERS of such THE
county. However, in no case shall a county be IS NOT required under this
subparagraph (II) SUBSECTION (1)(c)(II) to contribute more than a five
percent increase in said service costs.
(2) County contributions for client MEMBER services made in
accordance with subparagraph (I) of paragraph (c) of subsection (1)
SUBSECTION (1)(c)(I) of this section shall MUST be expended only for clients
MEMBERS of the county providing said THE contribution.
SECTION 74. In Colorado Revised Statutes, 25.5-6-108.5, amend
(1)(a), (2)(a) introductory portion, (2)(a)(I), and (2)(a)(II) as follows:
25.5-6-108.5. Community long-term care studies - authority to
implement - alternative care facility report. (1) (a) Subject to the receipt
of sufficient moneys FUNDING pursuant to paragraph (c) of this subsection
(1) SUBSECTION (1)(c) OF THIS SECTION, the state department shall contract
for one or more studies of the population of recipients MEMBERS receiving
services under the home- and community-based waivers authorized
pursuant to this article
ARTICLE 6. The state department shall make
necessary data available to the contractor, including but not limited to data
on activities of daily living. In selecting a contractor to perform any study
conducted pursuant to this subsection (1), the state department is not
required to follow the competitive bidding requirements of the
"Procurement Code", articles 101 to 112 of title 24. C.R.S.
The state
department shall provide copies of all studies conducted pursuant to this
subsection (1) to members of the health and human services committees of
the general assembly, or any successor committees, and to the members of
the joint budget committee.
(2) (a) Subject to the receipt of sufficient moneys
FUNDING, one of
the studies contracted for pursuant to subsection (1) of this section shall
MUST include research and analysis of:
(I) The number of recipients MEMBERS with incontinence,
Alzheimer's disease, dementia, or other diagnoses of a chronic
incapacitating condition that severely limit their
THE MEMBER'S activities of
PAGE 68-SENATE BILL 24-176 daily living who would benefit from receiving additional services through
an alternative care facility thereby avoiding TO AVOID nursing home
placement;
(II) The actuarially sound rate for providing services for the
recipients MEMBERS at an alternative care facility;
SECTION 75. In Colorado Revised Statutes, 25.5-6-113, amend
(1)(a) introductory portion, (1)(a)(VIII), (1)(b), and (5) as follows:
25.5-6-113. Health home - integrated services - contracting -
legislative declaration - definitions. (1) (a) The general assembly hereby
finds and declares that:
(VIII) The system must ensure a comprehensive approach to
long-term care that addresses the different demographic and geographic
challenges in the state and the various long-term care services and supports
that clients
MEMBERS need.
(b) Therefore, the general assembly declares that a comprehensive
approach to long-term care requires that programs and policies integrating
and coordinating care under the medicaid program be flexible and allow for
full participation by providers of long-term care services to ensure quality
of care for clients
MEMBERS and efficient use of limited resources.
(5) Dually eligible clients MEMBERS may voluntarily elect to
participate in a recognized medicare coordinated care system and may
voluntarily elect to participate in the state department's medicaid
coordinated care system.
SECTION 76. In Colorado Revised Statutes, 25.5-6-116, amend
(1) as follows:
25.5-6-116. Community placement transformation - creation -
report - repeal. (1) The state department shall undertake efforts to
transform the state department's process for clients
MEMBERS OR
APPLICANTS
attempting to receive long-term care in the community.
SECTION 77. In Colorado Revised Statutes, 25.5-6-206, amend
(1), (2), and (6) as follows:
PAGE 69-SENATE BILL 24-176 25.5-6-206. Personal needs benefits - amount - patient personal
needs trust fund required - funeral and final disposition expenses -
penalty for illegal retention and use. (1) The state department, pursuant
to its rules, may include in medical care benefits provided under this article
6 and articles 4 and 5 of this title 25.5 reasonable amounts for the personal
needs of any recipient
MEMBER receiving nursing facility services or
intermediate care facilities for individuals with intellectual disabilities, if
the recipient
MEMBER is not otherwise eligible for the amounts from other
categories of public assistance, but the amounts for personal needs must not
be less than the minimum amount provided for in subsection (2) of this
section. Payments for funeral and final disposition expenses upon the death
of a recipient
MEMBER may be provided under rules of the state department
in the same manner as provided to recipients MEMBERS of public assistance
as defined by section 26-2-103 (8).
(2) (a) The basic minimum amount payable pursuant to subsection
(1) of this section for personal needs to any recipient MEMBER admitted to
a nursing facility or intermediate care facility for individuals with
intellectual disabilities is seventy-five dollars monthly; except that,
commencing January 1, 2015, and each January 1 thereafter, the basic
minimum amount shall
MUST increase annually by the same percentage
applied to the general fund share of the aggregate statewide average of the
per diem net of patient payment pursuant to section 25.5-6-202 (9)(b)(I).
Commencing with the fiscal year beginning July 1, 2014, and each fiscal
year thereafter, the reduction to patient payments received by nursing
facilities resulting from an increase in the basic minimum amount shall be
IS funded in full by general fund and applicable federal funds.
(b) On and after October 1, 1992, the basic minimum amount
payable pursuant to subsection (1) of this section for personal needs shall
be IS ninety dollars for the following persons:
(I) A medical assistance recipient MEMBER who receives a
non-service connected disability pension from the United States veterans
administration, has no spouse or dependent child, and is admitted to or is
residing in a nursing facility; and
(II) A medical assistance recipient
MEMBER who is a surviving
spouse of a person who received a non-service connected disability pension
from the United States veterans administration, has no dependent child, and
PAGE 70-SENATE BILL 24-176 is admitted to or is residing in a nursing facility.
(6) Any overpayment of personal needs funds to a nursing facility
or an intermediate care facility for individuals with intellectual disabilities
by the state department due to the omission, error, fraud, or defalcation of
the nursing facility or intermediate care facility for individuals with
intellectual disabilities or any shortage in an audited patient personal needs
trust fund shall be
IS recoverable by the state on behalf of the recipient
MEMBER in the same manner and following the same procedures as
specified in section 25.5-4-301 (2) for an overpayment to a provider.
SECTION 78. In Colorado Revised Statutes, 25.5-6-209, amend
(1) as follows:
25.5-6-209. Establishment of nursing facility provider
demonstration of need - criteria - rules. (1) The state department, in
making any medicaid certification determination, shall encourage an
appropriate allocation of public health-care resources and the development
of alternative or substitute methods of delivering health-care services so that
adequate long-term care services are made reasonably available to every
qualified recipient
MEMBER within the state at the appropriate level of care,
at the lowest reasonable aggregate cost, and in the least restrictive setting.
Medicaid certification determinations shall be made in accordance with
Olmstead v. L.C., 527 U.S. 581 (1999).
SECTION 79. In Colorado Revised Statutes, 25.5-6-303, amend
(20); and amend as it will become effective July 1, 2024, (7) as follows:
25.5-6-303. Definitions - repeal. As used in this part 3, unless the
context otherwise requires:
(7) "Case plan" means a coordinated plan for the provision of
long-term-care services in a setting other than a nursing home, developed
and managed by a case management agency, in coordination with the client
MEMBER, the client's MEMBER'S family or guardian, the client's MEMBER'S
physician, and other providers of care.
(20) "Respite care services" means services of a short-term nature
provided to a client MEMBER, in the home or in a facility approved by the
state department, in order to temporarily relieve the family or other home
PAGE 71-SENATE BILL 24-176 providers from the care and maintenance of such client THE MEMBER,
including room and board, maintenance, personal care, and other related
services.
SECTION 80. In Colorado Revised Statutes, 25.5-6-307, amend
(5)(a)(III) and (5)(e)(I) as follows:
25.5-6-307. Services for the elderly, blind, and disabled.
(5) (a) No later than January 2024, the state department shall submit a
report to the senate health and human services committee, the house of
representatives public and behavioral health and human services committee,
and the house of representatives health and insurance committee, or any
successor committees, as part of its "State Measurement for Accountable,
Responsive, and Transparent (SMART) Government Act" presentation
required by section 2-7-203. At a minimum, the report must identify:
(III) A system of common reporting to ensure a recipient
MEMBER
does not exceed the medicaid benefit in a multi-provider scenario; and
(e) (I) The state department shall promulgate any necessary rules to
ensure transportation network companies comply with federal and state
oversight requirements and shall include all relevant stakeholders, including
medicaid recipients
MEMBERS, transportation network companies, current
providers and drivers for nonmedical transportation services, and other
PARTIES interested parties
in the development of such DEVELOPING THE
requirements.
SECTION 81. In Colorado Revised Statutes, 25.5-6-310, amend
(2) as follows:
25.5-6-310. Special provisions - personal care services provided
by a family - repeal. (2) The maximum reimbursement for the services
provided by a member of the person's family per year for each client shall
MEDICAID MEMBER MUST not exceed the equivalent of four hundred
forty-four service units per year for a member of the eligible person's
family.
SECTION 82. In Colorado Revised Statutes, 25.5-6-314, amend
(1)(c) as follows:
PAGE 72-SENATE BILL 24-176 25.5-6-314. Training for staff providing direct-care services to
members with dementia - rules - definitions. (1) As used in this section:
(c) "Direct-care staff member" means a staff member caring for the
physical, emotional, or mental health needs of clients MEMBERS of an adult
day care facility and whose work involves regular contact with clients
MEMBERS who are living with dementia diseases and related disabilities.
SECTION 83. In Colorado Revised Statutes, 25.5-6-404, amend
(4) as follows:
25.5-6-404. Duties of the department of health care policy and
financing and the department of human services. (4) The executive
director and the state board shall promulgate such rules regarding this part
4 as are necessary to fulfill the obligations of the state department as the
single state agency to administer medical assistance programs in accordance
with Title XIX of the federal "Social Security Act", as amended. Such
THE
rules may include, but shall ARE not be limited to, determination of the level
of care requirements for long-term care, patient payment requirements,
clients'
MEMBERS' rights, medicaid eligibility, and appeal rights associated
with these requirements.
SECTION 84. In Colorado Revised Statutes, 25.5-6-409, amend
(5)(a)(III) and (5)(e)(I) as follows:
25.5-6-409. Services for persons with intellectual and
developmental disabilities. (5) (a) No later than January 2024, the state
department shall submit a report to the senate health and human services
committee, the house of representatives public and behavioral health and
human services committee, and the house of representatives health and
insurance committee, or any successor committees, as part of its "State
Measurement for Accountable, Responsive, and Transparent (SMART)
Government Act" presentation required by section 2-7-203. At a minimum,
the report must identify:
(III) A system of common reporting to ensure a recipient
MEMBER
does not exceed the medicaid benefit in a multi-provider scenario; and
(e) (I) The state department shall promulgate any necessary rules to
ensure transportation network companies comply with federal and state
PAGE 73-SENATE BILL 24-176 oversight requirements and shall include all relevant stakeholders, including
medicaid recipients MEMBERS, transportation network companies, current
providers and drivers for nonmedical transportation services, and other
PARTIES interested parties
in the development of such DEVELOPING THE
requirements.
SECTION 85. In Colorado Revised Statutes, 25.5-6-409.3, amend
(3.3)(a) introductory portion, (3.3)(a)(I), and (3.3)(a)(III) as follows:
25.5-6-409.3. Consolidated waiver - intellectual and
developmental disabilities - conflict-free case management - legislative
declaration - repeal. (3.3) (a) The state department's administration of the
redesigned waiver shall
MUST include:
(I) A functional eligibility and needs assessment tool used for the
redesigned waiver that aligns with the recommendations of the community
living advisory group and that is fully integrated with the assessment
process for all clients
MEMBERS receiving long-term services and supports;
(III) A service payment system that ensures fair distribution of
available resources and that is efficient, transparent, and equitable for both
providers and consumers
MEMBERS.
SECTION 86. In Colorado Revised Statutes, amend 25.5-6-411 as
follows:
25.5-6-411. Personal needs trust fund required. All personal
needs funds shall MUST be held in trust by a residential facility authorized
to provide services pursuant to this part 4, or its THE RESIDENTIAL
FACILITY
'S designated trustee, separate and apart from any other funds of the
facility, in a checking account or savings account or any combination
thereof
established to protect and separate the personal needs funds of the
clients MEMBERS. At all times, the principal and all income derived from
said THE principal in the personal needs trust fund shall MUST remain the
property of the participating clients MEMBERS, and the RESIDENTIAL facility
or its THE FACILITY'S designated trustee is bound by all of the duties
imposed by law upon fiduciaries in the handling of such THE fund including
accounting for all expenditures from the fund.
SECTION 87. In Colorado Revised Statutes, 25.5-6-606, amend
PAGE 74-SENATE BILL 24-176 (8)(a)(III) and (8)(e)(I) as follows:
25.5-6-606. Implementation of program for persons with mental
health disorders authorized - federal waiver - duties of the department
of health care policy and financing and the department of human
services - rules. (8) (a) No later than January 2024, the state department
shall submit a report to the senate health and human services committee, the
house of representatives public and behavioral health and human services
committee, and the house of representatives health and insurance
committee, or any successor committees, as part of its "State Measurement
for Accountable, Responsive, and Transparent (SMART) Government Act"
presentation required by section 2-7-203. At a minimum, the report must
identify:
(III) A system of common reporting to ensure a recipient
MEMBER
does not exceed the medicaid benefit in a multi-provider scenario; and
(e) (I) The state department shall promulgate any necessary rules to
ensure transportation network companies comply with federal and state
oversight requirements and shall include all relevant stakeholders, including
medicaid recipients
MEMBERS, transportation network companies, current
providers and drivers for nonmedical transportation services, and other
PARTIES interested parties
in the development of such DEVELOPING THE
requirements.
SECTION 88. In Colorado Revised Statutes, 25.5-6-703, amend
(1), (2), (6)(a), (7), and (10) as follows:
25.5-6-703. Definitions - repeal. As used in this part 7, unless the
context otherwise requires:
(1) "Adult day care" means health and social services furnished two
or more hours per day on a regularly scheduled basis for one or more days
per week in an outpatient setting and for the purpose of ensuring the optimal
functioning of the recipient
MEMBER.
(2) "Behavioral programming" means an individualized plan that
sets forth strategies to decrease a recipient's MEMBER'S maladaptive
behaviors that interfere with the recipient's MEMBER'S ability to remain in
the community. Behavioral programming includes a complete assessment
PAGE 75-SENATE BILL 24-176 of maladaptive behaviors of the recipient MEMBER, the development and
implementation of a structured behavioral intervention plan, continuous
training and supervision of caregivers and behavioral aides, and periodic
reassessment of the individualized plan.
(6) (a) "Personal care services" means assistance with eating,
bathing, dressing, personal hygiene, and activities of daily living. Personal
care services include assistance with the preparation of meals, but not the
cost of the meals, and homemaker services that are necessary for the health
and safety of the recipient
MEMBER.
(7) "Structured day treatment" means structured, nonresidential
therapeutic treatment services that are directed at the development and
maintenance of community living skills and are provided two or more hours
per day on a regularly scheduled basis for one or more days per week. Day
treatment services include supervision and specific training that allows a
recipient
MEMBER to function at the recipient's MEMBER'S maximum
potential. The services include, but are not limited to, social skills training
that allows for reintegration into the community, sensory and motor
development services, and services aimed at reducing maladaptive behavior.
(10) "Transitional living" means a nonmedical residential program
that provides training and twenty-four-hour supervision to a recipient
MEMBER that will enhance the recipient's MEMBER'S ability to live more
independently.
SECTION 89. In Colorado Revised Statutes, 25.5-6-704, amend
(7)(a)(III) and (7)(e)(I) as follows:
25.5-6-704. Implementation of home- and community-based
services program for persons with brain injury authorized - federal
waiver - duties of the department - rules - repeal. (7) (a) No later than
January 2024, the state department shall submit a report to the senate health
and human services committee, the house of representatives public and
behavioral health and human services committee, and the house of
representatives health and insurance committee, or any successor
committees, as part of its "State Measurement for Accountable, Responsive,
and Transparent (SMART) Government Act" presentation required by
section 2-7-203. At a minimum, the report must identify:
PAGE 76-SENATE BILL 24-176 (III) A system of common reporting to ensure a recipient MEMBER
does not exceed the medicaid benefit in a multi-provider scenario; and
(e) (I) The state department shall promulgate any necessary rules to
ensure transportation network companies comply with federal and state
oversight requirements and shall include all relevant stakeholders, including
medicaid recipients
MEMBERS, transportation network companies, current
providers and drivers for nonmedical transportation services, and other
PARTIES interested parties
in the development of such DEVELOPING THE
requirements.
SECTION 90. In Colorado Revised Statutes, 25.5-6-903, amend
(1) as follows:
25.5-6-903. Residential child health-care program - waiver -
home- and community-based services - rules. (1) Subject to federal
authorization, the state department shall implement a program for
medicaid-eligible children with intellectual and developmental disabilities,
as defined in section 25.5-10-202, with significant behavioral support needs
who are at risk of institutionalization. The state board shall establish, by
rule, the type of services provided pursuant to the program, to the extent the
services are cost-efficient, and the recipient
MEMBER eligibility criteria that
may include, but are not limited to, a medical necessity determination and
a financial eligibility determination.
SECTION 91. In Colorado Revised Statutes, amend 25.5-6-1201
as follows:
25.5-6-1201. Legislative declaration - repeal. (1) The general
assembly finds that there may be a more effective way to deliver home- and
community-based services to the elderly, blind, and disabled; to disabled
children; and to persons with spinal cord injuries, that allows for more
self-direction in their care and a cost savings to the state. The general
assembly also finds that every person that is currently receiving home- and
community-based services does not need the same level of supervision and
care from a licensed health-care professional in order to meet his or her
THE
PERSON
'S care needs and remain living in the community. The general
assembly, therefore, declares that it is beneficial to the elderly, blind, and
disabled clients
MEMBERS of home- and community-based services, to
clients MEMBERS of the disabled children care program, and to clients
PAGE 77-SENATE BILL 24-176 MEMBERS enrolled in the spinal cord injury waiver pilot program, for the
state department to develop a service that would allow these people THE
MEMBERS
to receive in-home support.
(2) The general assembly further finds that allowing clientsMEMBERS more self-direction in their THE MEMBERS' care is a more effective
way to deliver home- and community-based services to clients MEMBERS
with major mental health disorders and brain injuries, as well as to clients
MEMBERS receiving home- and community-based supportive living services
and children's extensive support services. Therefore, the general assembly
declares that it is appropriate for the state department to develop a plan for
expanding the availability of in-home support services to include these
clients
MEMBERS.
(3) This section is repealed, effective July 1, 2025.
SECTION 92. In Colorado Revised Statutes, 25.5-6-1203, amend
(4); and amend as it will become effective July 1, 2024, (5) as follows:
25.5-6-1203. In-home support services - eligibility - licensure
exclusion - in-home support service agency responsibilities - rules -
repeal. (4) (a) In-home support service agencies providing in-home support
services shall provide twenty-four-hour back-up services to their clients
THE
AGENCIES
' MEMBERS. In-home support service agencies shall either contract
with or have on staff a state licensed health-care professional, as defined by
the
state board by rule, acting within the scope of the person's profession.
The state board shall promulgate rules setting forth the training
requirements for attendants providing in-home support services and the
oversight and monitoring responsibilities of the state licensed health-care
professional that is either contracting with or is on staff with the in-home
support service agency. The state board rules must allow the eligible person
or the eligible person's authorized representative, parent of a minor, or
guardian to determine, in conjunction with the in-home support services
agency, the amount of oversight needed in connection with the eligible
person's in-home support services.
(b) The state board shall promulgate rules that establish how an
in-home support service agency can discontinue a client
MEMBER under this
part 12. The rules shall MUST establish that a client MEMBER can only be
involuntarily discontinued when equivalent care in the community has been
PAGE 78-SENATE BILL 24-176 secured or that a client MEMBER can be discontinued after exhibiting
documented prohibited behavior involving attendants, including abuse of
attendants, and that dispute resolution has failed. The determination of
STATE DEPARTMENT SHALL DETERMINE whether an in-home support service
agency has made adequate attempts at resolution. shall be made by the state
department.
(5) The case management agencies established in section
25.5-6-1703 shall be ARE responsible for determining a person's eligibility
for in-home support services; except that for eligible disabled children the
state department shall designate the entity that will determine the child's
eligibility. The state board shall promulgate rules specifying the case
management agencies' responsibilities pursuant to this part 12. At a
minimum, these
THE rules must require that case managers discuss the
option and potential benefits of in-home support services with all eligible
long-term care clients
MEMBERS.
SECTION 93. In Colorado Revised Statutes, 25.5-6-1303, amend
(5)(c), (8)(a)(III), and (8)(e)(I) as follows:
25.5-6-1303. Pilot program - complementary or alternative
medicine - rules. (5) The state department shall cause to be conducted an
independent evaluation of the pilot program to be completed no later than
January 1, 2025. The state department shall provide a report of the
evaluation to the health and human services committee of the senate and the
public health care and human services committee of the house of
representatives, or any successor committees. The report on the evaluation
must include the following:
(c) Feedback from consumers
MEMBERS and the state department
concerning the progress and success of the pilot program;
(8) (a) No later than January 2024, the state department shall submit
a report to the senate health and human services committee, the house of
representatives public and behavioral health and human services committee,
and the house of representatives health and insurance committee, or any
successor committees, as part of its "State Measurement for Accountable,
Responsive, and Transparent (SMART) Government Act" presentation
required by section 2-7-203. At a minimum, the report must identify:
PAGE 79-SENATE BILL 24-176 (III) A system of common reporting to ensure a recipient MEMBER
does not exceed the medicaid benefit in a multi-provider scenario; and
(e) (I) The state department shall promulgate any necessary rules to
ensure transportation network companies comply with federal and state
oversight requirements and shall include all relevant stakeholders, including
medicaid recipients
MEMBERS, transportation network companies, current
providers and drivers for nonmedical transportation services, and other
PARTIES interested parties
in the development of such DEVELOPING THE
requirements.
SECTION 94. In Colorado Revised Statutes, 25.5-6-1402, amend
(1) and (5) as follows:
25.5-6-1402. Definitions. As used in this part 14, unless the context
otherwise requires:
(1) "Basic coverage group" means the category of eligibility under
the federal "Ticket to Work and Work Incentives Improvement Act of
1999", Pub.L. 106-170, that provides an opportunity to buy into medicaid
consistent with the federal "Social Security Act", 42 U.S.C. sec. 1396a
(a)(10)(A)(ii)(XV), as amended, for each worker with disabilities who is at
least sixteen years of age but less than sixty-five years of age and who,
except for earnings, would be eligible for the supplemental security income
program. A person who is eligible under the basic coverage group may also
be a home- and community-based services waiver recipient
MEMBER.
(5) "Medical improvement group" means the category of eligibility
under the federal "Ticket to Work and Work Incentives Improvement Act
of 1999", Pub.L. 106-170, that provides an opportunity to buy into medicaid
consistent with the federal "Social Security Act", 42 U.S.C. sec. 1496a
(a)(10)(A)(ii)(XV), as amended, for each worker with a medically improved
disability who is at least sixteen years of age but less than sixty-five years
of age and who was previously in the basic coverage group and is no longer
eligible for the basic coverage group due to medical improvement. A person
who is eligible under the medical improvement group may also be a home-
and community-based services waiver recipient
MEMBER.
SECTION 95. In Colorado Revised Statutes, 25.5-6-1602, amend
(1) introductory portion and (2) as follows:
PAGE 80-SENATE BILL 24-176 25.5-6-1602. State department to request increase in
reimbursement rate for certain services. (1) Not more than ninety days
after May 28, 2019, the state department shall request from the federal
government an increase of eight and one-tenth percent in the reimbursement
rate for the following services delivered to consumers
MEMBERS through the
home- and community-based services waivers:
(2) For the 2019-20 fiscal year, each home care agency shall pay one
hundred percent of the funding that results from the rate increase described
in subsection (1) of this section as compensation for employees who
provide personal care services, homemaker services, and in-home support
services to consumers
MEMBERS. This compensation shall be IS provided in
addition to the rate of compensation that the employee was receiving as of
June 30, 2019. For an employee who was hired after June 30, 2019, the
home care agency shall use the lowest compensation paid to an employee
of similar functions and duties as of June 30, 2019, as the base
compensation to which the increase is applied.
SECTION 96. In Colorado Revised Statutes, 25.5-6-1803, amend
(1)(b), (1)(c) introductory portion, and (1)(e)(IV) as follows:
25.5-6-1803. Development of spending plan. (1) In accordance
with federal guidance issued by the federal centers for medicare and
medicaid services regarding the implementation of section 9817 of the
"American Rescue Plan Act", the state department shall develop a proposed
spending plan using the enhanced funding, which plan may include but is
not limited to the following components:
(b) Incorporation of feedback from medical assistance recipients
MEMBERS, advocates, and providers for the services for which the
"American Rescue Plan Act" provides additional federal financial
participation;
(c) Expedition of the response and recovery for medical assistance
recipients
MEMBERS, providers, and other relevant organizations most
significantly impacted by the COVID-19 pandemic. Response and recovery
efforts may include but are not limited to:
(e) Investment in infrastructure and technology innovation that has
a long-term benefit to the system and the people of Colorado, including
PAGE 81-SENATE BILL 24-176 integration with other statewide and local efforts. Investments may include
but are not limited to:
(IV) Expanding recipient MEMBER access to technology and
technology literacy training;
SECTION 97. In Colorado Revised Statutes, 25.5-8-103, amend
(6)(b) as follows:
25.5-8-103. Definitions - rules. As used in this article 8, unless the
context otherwise requires:
(6) "Essential community provider" means a health-care provider
that:
(b) Waives charges or charges for services on a sliding scale based
on income and does not restrict access or services because of a client's
MEMBER'S financial limitations.
SECTION 98. In Colorado Revised Statutes, 25.5-8-107, amend
(1)(a)(III) as follows:
25.5-8-107. Duties of the department - schedule of services -
premiums - copayments - subsidies - purchase of childhood
immunizations. (1) In addition to any other duties pursuant to this article
8, the department has the following duties:
(a) (III) In addition to the items specified in subparagraphs (I) and
(II) of this paragraph (a) SUBSECTION (1)(a)(I) AND (1)(a)(II) OF THIS
SECTION
and any additional items approved by the medical services board,
the medical services board shall include mental health services that are at
least as comprehensive as the mental health services provided to medicaid
recipients
MEMBERS in the schedule of health-care services.
SECTION 99. In Colorado Revised Statutes, 25.5-8-109, amend
(4.5)(a)(II) and (4.5)(a)(III) as follows:
25.5-8-109. Eligibility - children - pregnant women - rules -
repeal. (4.5) (a) (II) The department shall annually verify the recipient's
MEMBER'S income eligibility at reenrollment through federally approved
PAGE 82-SENATE BILL 24-176 electronic data sources. If a recipient MEMBER meets all eligibility
requirements, a recipient MEMBER remains enrolled in the plan. The
department shall also allow a recipient MEMBER to provide income
information more recent than the records of federally approved electronic
data sources.
(III) If the state department determines that a recipient
MEMBER was
not eligible for medical benefits solely based upon the recipient's MEMBER'S
income after the recipient MEMBER had been determined to be eligible based
upon information verified through federally approved electronic data
sources, the state department shall not pursue recovery from a county
department for the cost of medical services provided to the recipient
MEMBER, and the county department is not responsible for any federal error
rate sanctions resulting from such THE determination.
SECTION 100. In Colorado Revised Statutes, 25.5-8-110, amend
(4)(b), (5), and (9) as follows:
25.5-8-110. Participation by managed care plans. (4) (b) The
managed care organization shall seek proposals from each essential
community provider in a county in which the managed care organization is
enrolling recipients
MEMBERS for those services that the managed care
organization provides or intends to provide and that an essential community
provider provides or is capable of providing. To assist managed care
organizations in seeking proposals, the department shall provide managed
care organizations with a list of essential community providers in each
county. The managed care organization shall consider such
THE proposals
in good faith and shall, when deemed reasonable by the managed care
organization based on the needs of its enrollees
MEMBERS, contract with
essential community providers. Each essential community provider shall
MUST be willing to negotiate on reasonably equitable terms with each
managed care organization. Essential community providers making
proposals under
PURSUANT TO this subsection (4) shall MUST be able to meet
the contractual requirements of the managed care organization. The
requirement of this subsection (4) shall
DOES not apply to a managed care
organization in areas in which the managed care organization operates
entirely as a group model health maintenance organization.
(5) The department may receive and act upon complaints from
enrollees
MEMBERS regarding failure to provide covered services or efforts
PAGE 83-SENATE BILL 24-176 to obtain payment, other than authorized copayments, for covered services
directly from eligible recipients MEMBERS.
(9) The department shall allow, at least annually, an opportunity for
enrollees MEMBERS to transfer among participating managed care plans
serving their respective geographic regions. The department shall establish
a period of at least twenty days annually when this
THE opportunity TO
TRANSFER
is afforded TO eligible recipients
MEMBERS. In geographic
regions served by more than one participating managed care plan, the
department shall endeavor to establish a uniform period for such
THE
opportunity TO TRANSFER.
SECTION 101. In Colorado Revised Statutes, 25.5-10-211.5,
amend (3)(f), (3)(g), and (4)(f) as follows:
25.5-10-211.5. Conflict-free case management - implementation
- legislative declaration - definition - repeal. (3) A conflict-free case
management system shall be implemented in Colorado as follows:
(f) No later than June 30, 2021, at least twenty-five percent of
clients MEMBERS receiving home- and community-based services must be
served through a system of conflict-free case management; and
(g) No later than June 30, 2022, all clients MEMBERS receiving
home- and community-based services must be served through a system of
conflict-free case management.
(4) Rural-based services - exemption. (f) In order to ensure
stability, client
MEMBER choice, and access to services in rural communities,
the state board shall promulgate rules, as permitted under federal law, that
allow a qualified entity to provide both case management services and
home- and community-based services to the same individual if there is
insufficient choice or capacity among existing service agencies or case
management agencies serving a designated service area of a rural
community-centered board.
SECTION 102. In Colorado Revised Statutes, 25.5-10-212, amend
(1) introductory portion as follows:
25.5-10-212. Procedure for resolving disputes over eligibility,
PAGE 84-SENATE BILL 24-176 modification of services or supports, and termination of services or
supports. (1) Every state or local service agency receiving state money
pursuant to section 25.5-10-206 shall adopt a procedure for the resolution
of disputes arising between the service agency and any recipient
MEMBER
of, or applicant for, services or supports authorized pursuant to section 25.5-10-206. Procedures for the resolution of disputes regarding early intervention services must comply with IDEA and with part 4 of article 3 of title 26.5. The procedures must be consistent with rules promulgated by the state board pursuant to article 4 of title 24 and must apply to the following disputes:
SECTION 103. In Colorado Revised Statutes, 25-48-115, amend
(4) as follows:
25-48-115. Insurance or annuity policies. (4) An individual with
a terminal illness who is a recipient
MEMBER of medical assistance under
the "Colorado Medical Assistance Act", articles 4, 5, and 6 of title 25.5,
C.R.S.
shall not be denied benefits under the medical assistance program or
have his or her THE MEMBER'S benefits under the program otherwise altered
based on whether or not the individual MEMBER makes a request pursuant
to this article ARTICLE 48.
SECTION 104. In Colorado Revised Statutes, 26-7-107, amend
(3)(b)(I) as follows:
26-7-107. Determination of benefits - adoption assistance
agreement - review - definitions. (3) (b) (I) In addressing the needs of an
eligible adopted child or youth, adoptive parents may knowingly take on
additional costs for items or services for the child or youth being adopted,
which items or services are otherwise covered costs under the medical
assistance program established in articles 4, 5, and 6 of title 25.5 and
identified as benefits in section 26-7-106 (2)(b). The limitations on recipient
MEMBER payments contained in sections 24-31-808 and 25.5-4-301 do not
apply to such THE additional costs so long as the adoptive parents consent
to bear the costs as provided in subsection (3)(b)(II) of this section, and so
long as the provisions of this subsection (3)(b) are not prohibited under
federal law.
SECTION 105. In Colorado Revised Statutes, repeal 25.5-1-114.5.
PAGE 85-SENATE BILL 24-176 SECTION 106. Act subject to petition - effective date. This act
takes effect at 12:01 a.m. on the day following the expiration of the
ninety-day period after final adjournment of the general assembly; except
that, if a referendum petition is filed pursuant to section 1 (3) of article V
of the state constitution against this act or an item, section, or part of this act
within such period, then the act, item, section, or part will not take effect
unless approved by the people at the general election to be held in
November 2024 and, in such case, will take effect on the date of the official
declaration of the vote thereon by the governor.
____________________________ ____________________________
Steve Fenberg Julie McCluskie
PRESIDENT OF SPEAKER OF THE HOUSE
THE SENATE OF REPRESENTATIVES
____________________________ ____________________________
Cindi L. Markwell Robin Jones
SECRETARY OF CHIEF CLERK OF THE HOUSE
THE SENATE OF REPRESENTATIVES
APPROVED________________________________________
(Date and Time)
_________________________________________
Jared S. Polis
GOVERNOR OF THE STATE OF COLORADO
PAGE 86-SENATE BILL 24-176