Colorado 2025 Regular Session

Colorado House Bill HB1002 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
	1	+	First Regular Session
	2	+	Seventy-fifth General Assembly
	3	+	STATE OF COLORADO
	4	+	REREVISED
	5	+	This Version Includes All Amendments
	6	+	Adopted in the Second House
	7	+	LLS NO. 25-0094.01 Kristen Forrestal x4217
1	8		HOUSE BILL 25-1002
2		-	BY REPRESENTATIVE(S) Brown and Gilchrist, Johnson, McCormick,
3		-	Winter T., Bacon, Bird, Clifford, Duran, English, Froelich, Garcia,
4		-	Hamrick, Jackson, Joseph, Lieder, Lindsay, Mabrey, Marshall, Paschal,
5		-	Rutinel, Rydin, Smith, Stewart K., Stewart R., Story, Taggart, Titone,
6		-	Valdez, Woodrow, McCluskie, Boesenecker, Camacho, Lukens, Ricks,
7		-	Sirota;
8		-	also SENATOR(S) Amabile and Pelton B., Simpson, Ball, Bridges, Cutter,
9		-	Daugherty, Exum, Gonzales J., Hinrichsen, Jodeh, Kipp, Kolker,
10		-	Marchman, Michaelson Jenet, Mullica, Snyder, Weissman, Winter F.,
11		-	Coleman.
	9	+	House Committees Senate Committees
	10	+	Health & Human Services Health & Human Services
	11	+	A BILL FOR AN ACT
12	12		C
13		-	ONCERNING THE DETERMINATION OF HEALTH BENEFITS COVERAGE FOR
14		-	MENTAL HEALTH SERVICES
15		-	.
16		-
17		-	Be it enacted by the General Assembly of the State of Colorado:
18		-	SECTION 1. In Colorado Revised Statutes, 10-16-104, amend
19		-	(5.5)(a)(I), (5.5)(a)(V)(A), (5.5)(a)(V)(B), (5.5)(a)(V)(D), (5.5)(b), and
	13	+	ONCERNING THE DETERMINATION OF HEALTH BENEFITS COVERAGE101
	14	+	FOR MENTAL HEALTH SERVICES .102
	15	+	Bill Summary
	16	+	(Note: This summary applies to this bill as introduced and does
	17	+	not reflect any amendments that may be subsequently adopted. If this bill
	18	+	passes third reading in the house of introduction, a bill summary that
	19	+	applies to the reengrossed version of this bill will be available at
	20	+	http://leg.colorado.gov
	21	+	.)
	22	+	The bill clarifies that the health benefits coverage for the
	23	+	prevention of, screening for, and treatment of behavioral, mental health,
	24	+	and substance use disorders must be no less extensive than the coverage
	25	+	provided for any physical illness. The bill requires that every health
	26	+	benefit plan must provide coverage for:
	27	+	! The placement, including admission, continued stay,
	28	+	SENATE
	29	+	3rd Reading Unamended
	30	+	February 26, 2025
	31	+	SENATE
	32	+	Amended 2nd Reading
	33	+	February 25, 2025
	34	+	HOUSE
	35	+	3rd Reading Unamended
	36	+	February 10, 2025
	37	+	HOUSE
	38	+	Amended 2nd Reading
	39	+	February 7, 2025
	40	+	HOUSE SPONSORSHIP
	41	+	Brown and Gilchrist, Johnson, McCormick, Winter T., Bacon, Bird, Clifford, Duran,
	42	+	English, Froelich, Garcia, Hamrick, Jackson, Joseph, Lieder, Lindsay, Mabrey, Marshall,
	43	+	McCluskie, Paschal, Rutinel, Rydin, Smith, Stewart K., Stewart R., Story, Taggart, Titone,
	44	+	Valdez, Woodrow
	45	+	SENATE SPONSORSHIP
	46	+	Amabile and Pelton B., Simpson, Ball, Bridges, Coleman, Cutter, Daugherty, Exum,
	47	+	Gonzales J., Hinrichsen, Jodeh, Kipp, Kolker, Marchman, Michaelson Jenet, Mullica, Snyder,
	48	+	Weissman, Winter F.
	49	+	Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
	50	+	Capital letters or bold & italic numbers indicate new material to be added to existing law.
	51	+	Dashes through the words or numbers indicate deletions from existing law. transfer, and discharge of a covered person and
	52	+	determinations relating to mental health disorders in
	53	+	accordance with criteria developed by the American
	54	+	Academy of Child and Adolescent Psychiatry or the
	55	+	American Association for Community Psychiatry; and
	56	+	! Medically necessary treatment of covered behavioral,
	57	+	mental health, and substance use disorder benefits,
	58	+	consistent with specified criteria.
	59	+	The bill also specifies criteria to be used for utilization review,
	60	+	service intensity, the level of care for covered persons, and provider
	61	+	reimbursement.
	62	+	Be it enacted by the General Assembly of the State of Colorado:1
	63	+	SECTION 1. In Colorado Revised Statutes, 10-16-104, amend2
	64	+	(5.5)(a)(I), (5.5)(a)(V)(A), (5.5)(a)(V)(B), (5.5)(a)(V)(D), (5.5)(b) and3
20	65		(5.5)(d); and add (5.5)(a)(I.5), (5.5)(a)(V)(F), (5.5)(a)(VI), (5.5)(c.3),
21		-	(5.5)(c.5), and (5.5)(e) as follows:
22		-	10-16-104. Mandatory coverage provisions - definitions - rules
23		-	NOTE: This bill has been prepared for the signatures of the appropriate legislative
24		-	officers and the Governor. To determine whether the Governor has signed the bill
25		-	or taken other action on it, please consult the legislative status sheet, the legislative
26		-	history, or the Session Laws.
27		-	________
28		-	Capital letters or bold & italic numbers indicate new material added to existing law; dashes
29		-	through words or numbers indicate deletions from existing law and such material is not part of
30		-	the act. - applicability. (5.5) Behavioral, mental health, and substance use
31		-	disorders - utilization review criteria - federal treatment limitation
32		-	requirements - meaningful benefits - rules - definitions. (a) (I) Every
33		-	health benefit plan subject to part 2, 3, or 4 of this article 16, except those
34		-	described in section 10-16-102 (32)(b), must provide coverage:
35		-	(A) For the prevention of, screening for, and treatment of
36		-	behavioral, mental health, and substance use disorders that is no less
37		-	extensive than the coverage provided for any physical illness, and
38		-	that
	66	+	4
	67	+	(5.5)(c.5), and (5.5)(e) as follows:5
	68	+	10-16-104. Mandatory coverage provisions - definitions - rules6
	69	+	- applicability. (5.5) Behavioral, mental health, and substance use7
	70	+	disorders - utilization review criteria - federal treatment limitation8
	71	+	requirements - meaningful benefits - rules - definitions. (a) (I) Every9
	72	+	health benefit plan subject to part 2, 3, or 4 of this article 16, except those10
	73	+	described in section 10-16-102 (32)(b), must provide coverage:11
	74	+	(A) For the prevention of, screening for, and treatment of12
	75	+	behavioral, mental health, and substance use disorders that is no less13
	76	+	extensive than the coverage provided for any physical illness, and that14
39	77		complies with the requirements of the MHPAEA, and
40		-	THAT DOES NOT
41		-	DISCRIMINATE IN ITS BENEFIT DESIGN AGAINST INDIVIDUALS BECAUSE OF
42		-	THEIR PRESENT OR PREDICTED BEHAVIORAL
43		-	, MENTAL HEALTH , OR
44		-	SUBSTANCE USE DISORDER
45		-	;
46		-	(B) At a minimum, for the treatment of substance use disorders in
47		-	accordance with the American Society of Addiction Medicine criteria for
48		-	placement, medical necessity, and utilization management determinations
49		-	as set forth in the most recent edition of "The ASAM Criteria: T
50		-	REATMENT
51		-	CRITERIA for Addictive, Substance-related, and Co-occurring Conditions";
52		-	except that the commissioner may identify by rule, in consultation with the
53		-	department of health care policy and financing and the behavioral health
54		-	administration in the department of human services, an
55		-	alternate nationally
56		-	recognized and evidence-based substance-use-disorder-specific
57		-	NOT-FOR-PROFIT UTILIZATION REVIEW criteria THAT IS CONSISTENT WITH
58		-	GENERALLY ACCEPTED STANDARDS OF SUBSTANCE USE DISORDER CARE
59		-	for
60		-	placement, medical necessity, or utilization management
61		-	REVIEW, if the
62		-	American Society of Addiction Medicine criteria are no longer available or
63		-	relevant or do not follow best practices for substance use disorder treatment;
64		-	AND
65		-	(C) FOR MEDICALLY NECESSARY TREATMENT OF COVERED
66		-	BEHAVIORAL
67		-	, MENTAL HEALTH, AND SUBSTANCE USE DISORDER BENEFITS ,
68		-	INCLUDING SERVICES THAT ARE CONSISTENT WITH CRITERIA , GUIDELINES, OR
69		-	CONSENSUS RECOMMENDATIONS FROM NATIONALLY RECOGNIZED
70		-	NOT
71		-	-FOR-PROFIT CLINICAL SPECIALTY ASSOCIATIONS OF THE RELEVANT
72		-	BEHAVIORAL
73		-	, MENTAL HEALTH, OR SUBSTANCE USE DISORDER SPECIALTY .
	78	+	THAT DOES NOT15
	79	+	DISCRIMINATE IN ITS BENEFIT DESIGN AGAINST INDIVIDUALS BECAUSE OF16
	80	+	THEIR PRESENT OR PREDICTED BEHAVIORAL , MENTAL HEALTH , OR17
	81	+	SUBSTANCE USE DISORDER;18
	82	+	(B) At a minimum, for the treatment of substance use disorders in19
	83	+	1002-2- accordance with the American Society of Addiction Medicine criteria for1
	84	+	placement, medical necessity, and utilization management determinations2
	85	+	as set forth in the most recent edition of "The ASAM Criteria:3
	86	+	T
	87	+	REATMENT CRITERIA for Addictive, Substance-related, and Co-occurring4
	88	+	Conditions"; except that the commissioner may identify by rule, in5
	89	+	consultation with the department of health care policy and financing and6
	90	+	the behavioral health administration in the department of human services,7
	91	+	an
	92	+	alternate nationally recognized and evidence-based8
	93	+	substance-use-disorder-specific
	94	+	NOT-FOR-PROFIT UTILIZATION REVIEW9
	95	+	criteria
	96	+	THAT IS CONSISTENT WITH GENERALLY ACCEPTED STANDARDS OF10
	97	+	SUBSTANCE USE DISORDER CARE for placement, medical necessity, or11
	98	+	utilization management
	99	+	REVIEW, if the American Society of Addiction12
	100	+	Medicine criteria are no longer available or relevant or do not follow best13
	101	+	practices for substance use disorder treatment; AND14
	102	+	15
	103	+	(C) FOR MEDICALLY NECESSARY TREATMENT OF COVERED16
	104	+	BEHAVIORAL, MENTAL HEALTH, AND SUBSTANCE USE DISORDER BENEFITS,17
	105	+	INCLUDING SERVICES THAT ARE CONSISTENT WITH CRITERIA , GUIDELINES,18
	106	+	OR CONSENSUS RECOMMENDATIONS FROM NATIONALLY RECOGNIZED19
	107	+	NOT-FOR-PROFIT CLINICAL SPECIALTY ASSOCIATIONS OF THE RELEVANT20
	108	+	BEHAVIORAL, MENTAL HEALTH, OR SUBSTANCE USE DISORDER SPECIALTY.21
74	109		(I.5) (A) A
75		-	LL UTILIZATION REVIEW AND UTILIZATION REVIEW
76		-	CRITERIA MUST BE CONSISTENT WITH CURRENT GENERALLY ACCEPTED
77		-	STANDARDS OF BEHAVIORAL
78		-	, MENTAL HEALTH, AND SUBSTANCE USE
79		-	PAGE 2-HOUSE BILL 25-1002 DISORDER CARE.
80		-	(B) I
81		-	N CONDUCTING UTILIZATION REVIEW OF COVERED SERVICES FOR
82		-	THE DIAGNOSIS
83		-	, PREVENTION, AND TREATMENT OF BEHAVIORAL OR MENTAL
84		-	HEALTH DISORDERS
85		-	, A HEALTH BENEFIT PLAN SHALL APPLY THE CRITERIA
86		-	AND GUIDELINES SET FORTH IN THE MOST RECENT VERSION OF THE
87		-	TREATMENT CRITERIA DEVELOPED BY UNAFFILIATED NATI ONALLY
88		-	RECOGNIZED NOT
89		-	-FOR-PROFIT CLINICAL SPECIALTY ASSOCIATIONS OF THE
90		-	RELEVANT BEHAVIORAL OR MENTAL HEALTH DISORDERS
91		-	. IN CONDUCTING
92		-	UTILIZATION REVIEW OF COVERED SERVICES FOR THE DIAGNOSIS
93		-	,
94		-	PREVENTION, AND TREATMENT OF SUBSTANCE USE DISORDERS , A HEALTH
95		-	BENEFIT PLAN SHALL APPLY THE CRITERIA SPECIFIED IN SUBSECTION
96		-	(5.5)(a)(I)(B) OF THIS SECTION.
97		-	(C) I
98		-	N CONDUCTING UTILIZATION REVIEW RELATING TO SERVICE
99		-	INTENSITY
100		-	, LEVEL OF CARE PLACEMENT , OR ANY OTHER PATIENT CARE
101		-	DECISIONS THAT ARE WITHIN THE SCOPE OF THE SOURCES SPECIFIED IN
102		-	SUBSECTIONS
103		-	(5.5)(a)(I)(B) AND (5.5)(a)(I.5)(B) OF THIS SECTION, A HEALTH
104		-	BENEFIT PLAN SHALL NOT APPLY DIFFERENT
105		-	, ADDITIONAL, CONFLICTING, OR
106		-	MORE RESTRICTIVE UTILIZATION REVIEW CRITERIA THAN THE CRITERIA SET
107		-	FORTH IN THOSE SOURCES
108		-	. IF THE REQUESTED SERVICE INTENSITY OR LEVEL
109		-	OF CARE PLACEMENT IS INCONSISTENT WITH THE HEALTH BENEFIT PLAN
110		-	'S
111		-	ASSESSMENT USING THE RELEVANT CRITERIA
112		-	, AS PART OF ANY ADVERSE
113		-	BENEFIT DETERMINATION
114		-	, THE HEALTH BENEFIT PLAN SHALL PROVIDE FULL
115		-	DETAIL OF ITS ASSESSMENT AND THE RELE VANT CRITERIA USED IN THE
116		-	ASSESSMENT TO THE PROVIDER AND THE COVERED PERSON
117		-	.
118		-	(D) I
119		-	N CONDUCTING UTILIZATION REVIEW THAT IS OUTSIDE THE
120		-	SCOPE OF THE CRITERIA SPECIFIED IN SUBSECTIONS
121		-	(5.5)(a)(I)(B) AND
122		-	(5.5)(a)(I.5)(B) OF THIS SECTION OR RELATED TO ADVANCEMENTS IN
123		-	TECHNOLOGY OR TYPES OF LEVELS OF CARE THAT ARE NOT ADDRESSED IN
124		-	THE MOST RECENT VERSIONS OF THE SOURCES SPECIFIED IN THOSE
125		-	SUBSECTIONS
126		-	, A HEALTH BENEFIT PLAN SHALL CONDUCT UTILIZATION
127		-	REVIEW IN ACCORDANCE WITH SUBSECTION
128		-	(5.5)(a)(I.5)(A) OF THIS
129		-	SECTION
130		-	. IF A HEALTH BENEFIT PLAN PURCHASES OR LICENSES UTILIZATION
131		-	REVIEW CRITERIA PURSUANT TO THIS SUBSECTION
132		-	(5.5)(a)(I.5)(D), THE
133		-	HEALTH BENEFIT PLAN SHALL VERIFY AND DOCUMENT BEFORE USE THAT THE
134		-	CRITERIA COMPLY WITH THE REQUIREMENTS OF SUBSECTION
135		-	(5.5)(a)(I.5)(A)
136		-	OF THIS SECTION.
137		-	PAGE 3-HOUSE BILL 25-1002 (E) A HEALTH BENEFIT PLAN MUST NOT LIMIT BENEFITS OR
138		-	COVERAGE FOR CHRONIC BEHAVIORAL
139		-	, MENTAL HEALTH, OR SUBSTANCE USE
140		-	DISORDERS TO SHORT
141		-	-TERM SYMPTOM REDUCTION AT ANY LEVEL -OF-CARE
142		-	PLACEMENT
143		-	.
144		-	(V) A carrier offering a health benefit plan subject to the
145		-	requirements of this subsection (5.5) shall:
146		-	(A) Comply with the nonquantitative treatment limitation
147		-	requirements specified in 45 CFR 146.136 (c)(4)
148		-	45 CFR 146.136 OR 29
	110	+	LL UTILIZATION REVIEW AND UTILIZATION REVIEW22
	111	+	CRITERIA MUST BE CONSISTENT WITH CURRENT GENERALLY ACCEPTED23
	112	+	STANDARDS OF BEHAVIORAL , MENTAL HEALTH, AND SUBSTANCE USE24
	113	+	DISORDER CARE.25 26
	114	+	(B) IN CONDUCTING UTILIZATION REVIEW OF COVERED SERVICES27
	115	+	1002
	116	+	-3- FOR THE DIAGNOSIS, PREVENTION, AND TREATMENT OF BEHAVIORAL OR1
	117	+	MENTAL HEALTH DISORDERS, A HEALTH BENEFIT PLAN SHALL APPLY THE2
	118	+	CRITERIA AND GUIDELINES SET FORTH IN THE MOST RECENT VERSION OF3
	119	+	THE TREATMENT CRITERIA DEVELOPED BY UNAFFILIATED NATIONALLY4
	120	+	RECOGNIZED NOT-FOR-PROFIT CLINICAL SPECIALTY ASSOCIATIONS OF THE5
	121	+	RELEVANT BEHAVIORAL OR MENTAL HEALTH DISORDERS. IN CONDUCTING6
	122	+	UTILIZATION REVIEW OF COVERED SERVICES FOR THE DIAGNOSIS ,7
	123	+	PREVENTION, AND TREATMENT OF SUBSTANCE USE DISORDERS, A HEALTH8
	124	+	BENEFIT PLAN SHALL APPLY THE CRITERIA SPECIFIED IN SUBSECTION9
	125	+	(5.5)(a)(I)(B) OF THIS SECTION.10
	126	+	(C) IN CONDUCTING UTILIZATION REVIEW RELATING TO SERVICE11
	127	+	INTENSITY, LEVEL OF CARE PLACEMENT, OR ANY OTHER PATIENT CARE12
	128	+	DECISIONS THAT ARE WITHIN THE SCOPE OF THE SOURCES SPECIFIED IN13
	129	+	SUBSECTIONS (5.5)(a)(I)(B) AND (5.5)(a)(I.5)(B) OF THIS SECTION, A14
	130	+	HEALTH BENEFIT PLAN SHALL NOT APPLY DIFFERENT , ADDITIONAL,15
	131	+	CONFLICTING, OR MORE RESTRICTIVE UTILIZATION REVIEW CRITERIA THAN16
	132	+	THE CRITERIA SET FORTH IN THOSE SOURCES. IF THE REQUESTED SERVICE17
	133	+	INTENSITY OR LEVEL OF CARE PLACEMENT IS INCONSISTENT WITH THE18
	134	+	HEALTH BENEFIT PLAN'S ASSESSMENT USING THE RELEVANT CRITERIA , AS19
	135	+	PART OF ANY ADVERSE BENEFIT DETERMINATION , THE HEALTH BENEFIT20
	136	+	PLAN SHALL PROVIDE FULL DETAIL OF ITS ASSESSMENT AND THE RELEVANT21
	137	+	CRITERIA USED IN THE ASSESSMENT TO THE PROVIDER AND THE COVERED22
	138	+	PERSON.23
	139	+	(D) IN CONDUCTING UTILIZATION REVIEW THAT IS OUTSIDE THE24
	140	+	SCOPE OF THE CRITERIA SPECIFIED IN SUBSECTIONS (5.5)(a)(I)(B) AND25
	141	+	(5.5)(a)(I.5)(B) OF THIS SECTION OR RELATED TO ADVANCEMENTS IN26
	142	+	TECHNOLOGY OR TYPES OF LEVELS OF CARE THAT ARE NOT ADDRESSED IN27
	143	+	1002
	144	+	-4- THE MOST RECENT VERSIONS OF THE SOURCES SPECIFIED IN THOSE1
	145	+	SUBSECTIONS, A HEALTH BENEFIT PLAN SHALL CONDUCT UTILIZATION2
	146	+	REVIEW IN ACCORDANCE WITH SUBSECTION (5.5)(a)(I.5)(A) OF THIS3
	147	+	SECTION. IF A HEALTH BENEFIT PLAN PURCHASES OR LICENSES UTILIZATION4
	148	+	REVIEW CRITERIA PURSUANT TO THIS SUBSECTION (5.5)(a)(I.5)(D), THE5
	149	+	HEALTH BENEFIT PLAN SHALL VERIFY AND DOCUMENT BEFORE USE THAT6
	150	+	THE CRITERIA COMPLY WITH THE REQUIREMENTS OF SUBSECTION7
	151	+	(5.5)(a)(I.5)(A) OF THIS SECTION.8
	152	+	(E) A HEALTH BENEFIT PLAN MUST NOT LIMIT BENEFITS OR9
	153	+	COVERAGE FOR CHRONIC BEHAVIORAL , MENTAL HEALTH, OR SUBSTANCE10
	154	+	USE DISORDERS TO SHORT -TERM SYMPTOM REDUCTION AT ANY11
	155	+	LEVEL-OF-CARE PLACEMENT.12
	156	+	(V) A carrier offering a health benefit plan subject to the13
	157	+	requirements of this subsection (5.5) shall:14
	158	+	(A) Comply with the nonquantitative treatment limitation15
	159	+	requirements specified in 45 CFR 146.136 (c)(4) 45 CFR 146.136 OR 2916
149	160		CFR
150		-	2590.712, or any successor regulation, regarding any limitations that
151		-	are not expressed numerically but otherwise limit the scope or duration of
152		-	benefits for treatment, which, in addition to the limitations and examples
153		-	listed in 45 CFR 146.136 (c)(4)(ii) and (c)(4)(iii)
154		-	(c)(4)(vi) OR 29 CFR
155		-	2590.712 (c)(4)(ii)
156		-	AND (c)(4)(vi), or any successor regulation, and 78 FR68246 78 FED. REG. 68246 (NOVEMBER 13, 2013) AND 89 FED. REG. 77586
157		-	(S
158		-	EPTEMBER 23, 2024), include the methods by which the carrier establishes
159		-	and maintains its provider networks pursuant to section 10-16-704 and
160		-	responds to deficiencies in the ability of its networks to provide timely
161		-	access to care;
162		-	(B) Comply with the financial requirements and quantitative
163		-	treatment limitations specified in 45 CFR 146.136 (c)(2) and (c)(3) or any
	161	+	2590.712, or any successor regulation, regarding any limitations that17
	162	+	are not expressed numerically but otherwise limit the scope or duration18
	163	+	of benefits for treatment, which, in addition to the limitations and19
	164	+	examples listed in 45 CFR 146.136 (c)(4)(ii) and (c)(4)(iii)
	165	+	(c)(4)(vi) OR20
	166	+	29
	167	+	CFR 2590.712 (c)(4)(ii) AND (c)(4)(vi), or any successor regulation,21
	168	+	and 78 FR 68246
	169	+	78 FED. REG. 68246 (NOVEMBER 13, 2013) AND 89 FED.22
	170	+	R
	171	+	EG. 77586 (SEPTEMBER 23, 2024), include the methods by which the23
	172	+	carrier establishes and maintains its provider networks pursuant to section24
	173	+	10-16-704 and responds to deficiencies in the ability of its networks to25
	174	+	provide timely access to care;26
	175	+	(B) Comply with the financial requirements and quantitative27
	176	+	1002
	177	+	-5- treatment limitations specified in 45 CFR 146.136 (c)(2) and (c)(3) or any1
164	178		successor regulation
165		-	OR 29 CFR 2590.712 (c)(2) AND (c)(3);
	179	+	OR 29 CFR 2590.712 (c)(2) AND (c)(3);2
166	180		(D) Establish procedures to authorize
167		-	MEDICALLY ~~NECESSARY~~
	181	+	MEDICALLY NECESSARY3
168	182		treatment with a
169		-	AN APPROPRIATE nonparticipating provider AND TO
170		-	PROVIDE SERVICES TO MAKE AVAILABLE THE COVERED SERVICE
171		-	if a covered
172		-	service is not available within established time and distance standards, and
173		-	within a reasonable period, after a service is requested, and with the same
174		-	coinsurance, deductible, or copayment requirements,
175		-	ACCRUING TO
176		-	IN
177		-	-NETWORK ANNUAL COST -SHARING LIMITS, as would apply if the services
178		-	were provided by a participating provider, and at no greater cost to the
179		-	covered person than if the services were obtained at or from a participating
180		-	provider; and
181		-	(F) NOT REVERSE OR ALTER A DETERMINATION OF MEDICAL
182		-	NECESSITY MADE PURSUANT TO THIS SUBSECTION
183		-	(5.5), INCLUDING
184		-	DOWNGRADING OR BUNDLING THE CODING OF A CLAIM
185		-	, THROUGH A REVIEW
186		-	OR AUDIT OF A CLAIM
187		-	, EXCEPT IN CASES OF FRAUD OR WHERE THE COVERED
188		-	PAGE 4-HOUSE BILL 25-1002 PERSON DID NOT HAVE A VALID POLICY WHEN THE SERVICE WAS PROVIDED .
	183	+	AN APPROPRIATE nonparticipating provider AND TO4
	184	+	PROVIDE SERVICES TO MAKE AVAILABLE THE COVERED SERVICE if a5
	185	+	covered service is not available within established time and distance6
	186	+	standards, and within a reasonable period, after a service is requested, and7
	187	+	with the same coinsurance, deductible, or copayment requirements,8
	188	+	ACCRUING TO IN-NETWORK ANNUAL COST -SHARING LIMITS, as would9
	189	+	apply if the services were provided by a participating provider, and at no10
	190	+	greater cost to the covered person than if the services were obtained at or11
	191	+	from a participating provider; and
	192	+	12
	193	+	(F) N
	194	+	OT REVERSE OR ALTER A DETERMINATION OF MEDICAL13
	195	+	NECESSITY MADE PURSUANT TO THIS SUBSECTION (5.5), INCLUDING14
	196	+	DOWNGRADING OR BUNDLING THE CODING OF A CLAIM , THROUGH A15
	197	+	REVIEW OR AUDIT OF A CLAIM, EXCEPT IN CASES OF FRAUD OR WHERE THE16
	198	+	COVERED PERSON DID NOT HAVE A VALID POLICY WHEN THE SERVICE WAS17
	199	+	PROVIDED.18
189	200		(VI) I
190		-	F A HEALTH BENEFIT PLAN PROVIDES ANY BENEFITS FOR A
191		-	MENTAL HEALTH CONDITION OR SUBSTANCE USE DISORDER IN ANY
192		-	CLASSIFICATION OF BENEFITS
193		-	, IT MUST PROVIDE MEANINGFUL BENEFITS FOR
194		-	THAT MENTAL HEALTH CONDITION OR SUBSTANCE USE DISORDER IN EVERY
195		-	CLASSIFICATION IN WHICH MEDICAL OR SURGICAL BENEFITS ARE PROVIDED
196		-	.
197		-	W
198		-	HETHER THE BENEFITS PROVIDED ARE MEANINGFUL BENEFITS IS
199		-	DETERMINED IN COMPARISON TO THE BENEFITS PROVIDED FOR MEDICAL
200		-	CONDITIONS AND SURGICAL PROCEDURES IN THE CLASSIFICATION AND
201		-	REQUIRES
202		-	, AT A MINIMUM, COVERAGE OF BENEFITS FOR THAT CONDITION OR
203		-	DISORDER IN EACH CLASSIFICATION IN WHICH THE HEALTH BENEFIT PLAN
204		-	PROVIDES BENEFITS FOR ONE OR MORE MEDICAL CONDITIONS OR SURGICAL
205		-	PROCEDURES
206		-	. A HEALTH BENEFIT PLAN DOES NOT PROVIDE MEANINGFUL
207		-	BENEFITS UNLESS IT PROVIDES BENEFITS FOR A CORE TREATMENT FOR THAT
208		-	CONDITION OR DISORDER IN EACH CLASSIFICATION IN WHICH THE HEALTH
209		-	BENEFIT PLAN PROVIDES BENEFITS FOR A CORE TREATMENT FOR ONE OR
210		-	MORE MEDICAL CONDITIONS OR SURGICAL PROCEDURES
211		-	. A CORE TREATMENT
212		-	FOR A CONDITION OR DISORDER IS A STANDARD TREATMENT OR COURSE OF
213		-	TREATMENT
214		-	, THERAPY, SERVICE, OR INTERVENTION INDICATED BY
215		-	GENERALLY ACCEPTED STANDARDS OF BEHAVIORAL
216		-	, MENTAL HEALTH, AND
217		-	SUBSTANCE USE DISORDER CARE
218		-	. IF THERE IS NO CORE TREATMENT FOR A
219		-	COVERED MENTAL HEALTH CONDITION OR SUBSTANCE USE DISORDER WITH
220		-	RESPECT TO A CLASSIFICATION
221		-	, THE HEALTH BENEFIT PLAN IS NOT REQUIRED
222		-	TO PROVIDE BENEFITS FOR A CORE TREATMENT FOR SUCH CONDITION OR
223		-	DISORDER IN THAT CLASSIFICATION
224		-	, BUT MUST PROVIDE BENEFITS FOR SUCH
225		-	CONDITION OR DISORDER IN EVERY CLASSIFICATION IN WHICH MEDICAL OR
226		-	SURGICAL BENEFITS ARE PROVIDED
227		-	.
228		-	(b) The commissioner:
229		-	(I) May adopt rules as necessary to ensure that this subsection (5.5)
230		-	is implemented and
231		-	COMPLIANTLY administered; in compliance with federal
232		-	law and shall adopt rules to establish reasonable time periods for visits with
233		-	a provider for treatment of a behavioral, mental health, or substance use
234		-	disorder after an initial visit with a provider.
235		-	(II) MAY ADOPT RULES TO ESTABLISH CARRIER UTILIZATION REVIEW
236		-	COMPLIANCE IN ACCORDANCE WITH SUBSECTION
237		-	(5.5)(a)(I.5) OF THIS
238		-	SECTION
239		-	;
240		-	PAGE 5-HOUSE BILL 25-1002 (III) MAY ADOPT RULES AS NECESSARY TO SPECIFY DATA TESTING
241		-	REQUIREMENTS TO DETERMINE PLAN DESIGN AND APPLICATION OF PARITY
242		-	COMPLIANCE FOR NONQUANTITATIVE TREATMENT LIMITATIONS USING
243		-	OUTCOMES DATA
244		-	;
245		-	(IV) M
246		-	AY ADOPT RULES TO SET STANDARD DEFINITIONS FOR
247		-	COVERAGE REQUIREMENTS
248		-	, INCLUDING PROCESSES , STRATEGIES,
249		-	EVIDENTIARY STANDARDS , AND OTHER FACTORS;
250		-	(V) M
251		-	AY ADOPT RULES TO ESTABLISH SPECIFIC TIMELINES FOR
252		-	CARRIER COMPLIANCE TO PROVIDE COMPARATIVE ANALYSIS INFORMATION
253		-	TO THE DIVISION FOR REVIEW
254		-	, INCLUDING THE EFFECT OF A CARRIER'S LACK
255		-	OF SUFFICIENT COMPARATIVE ANALYSES TO DEMONSTRATE COMPLIANCE
256		-	;
257		-	AND
258		-	(VI) MAY ADOPT RULES TO ESTABLISH REASONABLE TIME PERIODS
259		-	AND DOCUMENTATION OF SUCH TIME PERIODS FOR VISITS WITH A PROVIDER
260		-	FOR TREATMENT OF A BEHAVIORAL
261		-	, MENTAL HEALTH, OR SUBSTANCE USE
262		-	DISORDER AFTER AN INITIAL VISIT WITH A PROVIDER
263		-	.
	201	+	F A HEALTH BENEFIT PLAN PROVIDES ANY BENEFITS FOR A19
	202	+	MENTAL HEALTH CONDITION OR SUBSTANCE USE DISORDER IN ANY20
	203	+	CLASSIFICATION OF BENEFITS, IT MUST PROVIDE MEANINGFUL BENEFITS21
	204	+	FOR THAT MENTAL HEALTH CONDITION OR SUBSTANCE USE DISORDER IN22
	205	+	EVERY CLASSIFICATION IN WHICH MEDICAL OR SURGICAL BENEFITS ARE23
	206	+	PROVIDED. WHETHER THE BENEFITS PROVIDED ARE MEANINGFUL BENEFITS24
	207	+	IS DETERMINED IN COMPARISON TO THE BENEFITS PROVIDED FOR MEDICAL25
	208	+	CONDITIONS AND SURGICAL PROCEDURES IN THE CLASSIFICATION AND26
	209	+	REQUIRES, AT A MINIMUM, COVERAGE OF BENEFITS FOR THAT CONDITION27
	210	+	1002
	211	+	-6- OR DISORDER IN EACH CLASSIFICATION IN WHICH THE HEALTH BENEFIT1
	212	+	PLAN PROVIDES BENEFITS FOR ONE OR MORE MEDICAL CONDITIONS OR2
	213	+	SURGICAL PROCEDURES. A HEALTH BENEFIT PLAN DOES NOT PROVIDE3
	214	+	MEANINGFUL BENEFITS UNLESS IT PROVIDES BENEFITS FOR A CORE4
	215	+	TREATMENT FOR THAT CONDITION OR DISORDER IN EACH CLASSIFICATION5
	216	+	IN WHICH THE HEALTH BENEFIT PLAN PROVIDES BENEFITS FOR A CORE6
	217	+	TREATMENT FOR ONE OR MORE MEDICAL CONDITIONS OR SURGICAL7
	218	+	PROCEDURES. A CORE TREATMENT FOR A CONDITION OR DISORDER IS A8
	219	+	STANDARD TREATMENT OR COURSE OF TREATMENT , THERAPY, SERVICE,9
	220	+	OR INTERVENTION INDICATED BY GENERALLY ACCEPTED STANDARDS OF10
	221	+	BEHAVIORAL, MENTAL HEALTH, AND SUBSTANCE USE DISORDER CARE . IF11
	222	+	THERE IS NO CORE TREATMENT FOR A COVERED MENTAL HEALTH12
	223	+	CONDITION OR SUBSTANCE USE DISORDER WITH RESPECT TO A13
	224	+	CLASSIFICATION, THE HEALTH BENEFIT PLAN IS NOT REQUIRED TO PROVIDE14
	225	+	BENEFITS FOR A CORE TREATMENT FOR SUCH CONDITION OR DISORDER IN15
	226	+	THAT CLASSIFICATION, BUT MUST PROVIDE BENEFITS FOR SUCH CONDITION16
	227	+	OR DISORDER IN EVERY CLASSIFICATION IN WHICH MEDICAL OR SURGICAL17
	228	+	BENEFITS ARE PROVIDED.18
	229	+	(b) The commissioner:19
	230	+	(I) May adopt rules as necessary to ensure that this subsection20
	231	+	(5.5) is implemented and COMPLIANTLY administered; in compliance with21
	232	+	federal law and shall adopt rules to establish reasonable time periods for22
	233	+	visits with a provider for treatment of a behavioral, mental health, or23
	234	+	substance use disorder after an initial visit with a provider.24
	235	+	(II) MAY ADOPT RULES TO ESTABLISH CARRIER UTILIZATION25
	236	+	REVIEW COMPLIANCE IN ACCORDANCE WITH SUBSECTION (5.5)(a)(I.5) OF26
	237	+	THIS SECTION;27
	238	+	1002
	239	+	-7- (III) MAY ADOPT RULES AS NECESSARY TO SPECIFY DATA TESTING1
	240	+	REQUIREMENTS TO DETERMINE PLAN DESIGN AND APPLICATION OF PARITY2
	241	+	COMPLIANCE FOR NONQUANTITATIVE TREATMENT LIMITATIONS USING3
	242	+	OUTCOMES DATA;4
	243	+	(IV) MAY ADOPT RULES TO SET STANDARD DEFINITIONS FOR5
	244	+	COVERAGE REQUIREMENTS , INCLUDING PROCESSES , STRATEGIES,6
	245	+	EVIDENTIARY STANDARDS , AND OTHER FACTORS;7
	246	+	(V) MAY ADOPT RULES TO ESTABLISH SPECIFIC TIMELINES FOR8
	247	+	CARRIER COMPLIANCE TO PROVIDE COMPARATIVE ANALYSIS INFORMATION9
	248	+	TO THE DIVISION FOR REVIEW, INCLUDING THE EFFECT OF A CARRIER'S10
	249	+	LACK OF SUFFICIENT COMPARATIVE ANALYSES TO DEMONSTRATE11
	250	+	COMPLIANCE; AND12
	251	+	(V) MAY ADOPT RULES TO ESTABLISH REASONABLE TIME PERIODS13
	252	+	AND DOCUMENTATION OF SUCH TIME PERIODS FOR VISITS WITH A14
	253	+	PROVIDER FOR TREATMENT OF A BEHAVIORAL, MENTAL HEALTH, OR15
	254	+	SUBSTANCE USE DISORDER AFTER AN INITIAL VISIT WITH A PROVIDER. 16
264	255		(c.3) T
265		-	HIS SUBSECTION (5.5) APPLIES TO ANY INDIVIDUAL, ENTITY,
266		-	OR CONTRACTING PROVIDER THAT PERFORMS UTILIZATION REVIEW
267		-	FUNCTIONS ON BEHALF OF A HEALTH BENEFIT PLAN
268		-	.
	256	+	HIS SUBSECTION (5.5) APPLIES TO ANY INDIVIDUAL, ENTITY,17
	257	+	OR CONTRACTING PROVIDER THAT PERFORMS UTILIZATION REVIEW18
	258	+	FUNCTIONS ON BEHALF OF A HEALTH BENEFIT PLAN .19
269	259		(c.5) A
270		-	CARRIER OFFERING A HEALTH BENEFIT PLAN SHALL NOT
271		-	ADOPT
272		-	, IMPOSE, OR ENFORCE TERMS IN ITS POLICIES OR PROVIDER
273		-	AGREEMENT
274		-	, IN WRITING OR IN OPERATION, THAT UNDERMINE, ALTER, OR
275		-	CONFLICT WITH THE REQUIREMENTS OF THIS SUBSECTION
276		-	(5.5).
277		-	(d) As used in this subsection (5.5):
	260	+	CARRIER OFFERING A HEALTH BENEFIT PLAN SHALL NOT20
	261	+	ADOPT, IMPOSE, OR ENFORCE TERMS IN ITS POLICIES OR PROVIDER21
	262	+	AGREEMENT, IN WRITING OR IN OPERATION, THAT UNDERMINE, ALTER, OR22
	263	+	CONFLICT WITH THE REQUIREMENTS OF THIS SUBSECTION (5.5).23
	264	+	(d) As used in this subsection (5.5):24
278	265		(I) "A
279		-	PPROPRIATE NONPARTICIPATING PROVIDER " MEANS A
280		-	PROVIDER WHO IS ACCESSIBLE AND HAS THE TRAINING AND EXPERIENCE
281		-	NECESSARY TO PROVIDE AGE
282		-	-APPROPRIATE, MEDICALLY NECESSARY
283		-	TREATMENT OF A BEHAVIORAL
284		-	, MENTAL HEALTH, OR SUBSTANCE USE
285		-	DISORDER
286		-	.
287		-	(II) "Behavioral, mental health, and substance use disorder":
288		-	(I)
289		-	(A) Means a condition or disorder, regardless of etiology, that
290		-	PAGE 6-HOUSE BILL 25-1002 may be the result of a combination of genetic and environmental factors and
291		-	that falls under any of the diagnostic categories listed in the mental
292		-	disorders section of the most recent version of
293		-	(A)
294		-	the "International Statistical Classification of Diseases and
295		-	Related Health Problems",
296		-	(B) the "Diagnostic and Statistical Manual of Mental Disorders", or
297		-	(C) the "Diagnostic Classification of Mental Health and
298		-	Developmental Disorders of Infancy and Early Childhood"; and
299		-	(II) (B) Includes autism spectrum disorders, as defined in subsection
300		-	(1.4)(a)(III) of this section.
	266	+	PPROPRIATE NONPARTICIPATING PROVIDER " MEANS A25
	267	+	PROVIDER WHO IS ACCESSIBLE AND HAS THE TRAINING AND EXPERIENCE26
	268	+	NECESSARY TO PROVIDE AGE -APPROPRIATE, MEDICALLY NECESSARY27
	269	+	1002
	270	+	-8- TREATMENT OF A BEHAVIORAL , MENTAL HEALTH, OR SUBSTANCE USE1
	271	+	DISORDER.2
	272	+	(II) "Behavioral, mental health, and substance use disorder":3
	273	+	(I) (A) Means a condition or disorder, regardless of etiology, that4
	274	+	may be the result of a combination of genetic and environmental factors5
	275	+	and that falls under any of the diagnostic categories listed in the mental6
	276	+	disorders section of the most recent version of7
	277	+	(A) the "International Statistical Classification of Diseases and8
	278	+	Related Health Problems",9
	279	+	(B) the "Diagnostic and Statistical Manual of Mental Disorders",10
	280	+	or11
	281	+	(C) the "Diagnostic Classification of Mental Health and12
	282	+	Developmental Disorders of Infancy and Early Childhood"; and13
	283	+	(II) (B) Includes autism spectrum disorders, as defined in14
	284	+	subsection (1.4)(a)(III) of this section.15
301	285		(III) "G
302		-	ENERALLY ACCEPTED STANDARDS OF BEHAVIORAL , MENTAL
303		-	HEALTH
304		-	, AND SUBSTANCE USE DISORDER CARE" MEANS STANDARDS OF CARE
305		-	AND CLINICAL PRACTICE THAT ARE GENERALLY RECOGNIZED BY
306		-	HEALTH
307		-	-CARE PROVIDERS PRACTICING IN RELEVANT CLINICAL SPECIALTIES
308		-	SUCH AS PSYCHIATRY
309		-	, PSYCHOLOGY, CLINICAL SOCIAL WORK, PSYCHIATRIC
310		-	NURSING
311		-	, ADDICTION MEDICINE AND COUNSELING, AND BEHAVIORAL HEALTH
312		-	TREATMENT
313		-	. VALID, EVIDENCE-BASED SOURCES REFLECTING GENERALLY
314		-	ACCEPTED STANDARDS OF BEHAVIORAL
315		-	, MENTAL HEALTH, AND SUBSTANCE
316		-	USE DISORDER CARE INCLUDE PEER
317		-	-REVIEWED SCIENTIFIC STUDIES AND
318		-	MEDICAL LITERATURE
319		-	; CLINICAL PRACTICE GUIDELINES AND
320		-	RECOMMENDATIONS OF NONPROFIT HEALTH
321		-	-CARE PROVIDER PROFESSIONAL
322		-	ASSOCIATIONS
323		-	, SPECIALTY SOCIETIES, AND FEDERAL GOVERNMENT
324		-	AGENCIES
325		-	; AND DRUG LABELING APPROVED BY THE FDA.
	286	+	ENERALLY ACCEPTED STANDARDS OF BEHAVIORAL ,16
	287	+	MENTAL HEALTH, AND SUBSTANCE USE DISORDER CARE " MEANS17
	288	+	STANDARDS OF CARE AND CLINICAL PRACTICE THAT ARE GENERALLY18
	289	+	RECOGNIZED BY HEALTH -CARE PROVIDERS PRACTICING IN RELEVANT19
	290	+	CLINICAL SPECIALTIES SUCH AS PSYCHIATRY , PSYCHOLOGY, CLINICAL20
	291	+	SOCIAL WORK, PSYCHIATRIC NURSING , ADDICTION MEDICINE AND21
	292	+	COUNSELING, AND BEHAVIORAL HEALTH TREATMENT . VALID,22
	293	+	EVIDENCE-BASED SOURCES REFLECTING GENERALLY ACCEPTED23
	294	+	STANDARDS OF BEHAVIORAL , MENTAL HEALTH, AND SUBSTANCE USE24
	295	+	DISORDER CARE INCLUDE PEER -REVIEWED SCIENTIFIC STUDIES AND25
	296	+	MEDICAL LITERATURE ; CLINICAL PRACTICE GUIDELINES AND26
	297	+	RECOMMENDATIONS OF NONPROFIT HEALTH -CARE PROVIDER27
	298	+	1002
	299	+	-9- PROFESSIONAL ASSOCIATIONS , SPECIALTY SOCIETIES, AND FEDERAL1
	300	+	GOVERNMENT AGENCIES ; AND DRUG LABELING APPROVED BY THE FDA.2
326	301		(IV) "M
327		-	EDICALLY NECESSARY TREATMENT " MEANS A SERVICE OR
328		-	PRODUCT ADDRESSING THE SPECIFIC NEEDS OF A PATIENT FOR THE PURPOSE
329		-	OF SCREENING
330		-	, PREVENTING, DIAGNOSING, MANAGING, OR TREATING A
331		-	BEHAVIORAL
332		-	, MENTAL HEALTH, OR SUBSTANCE USE DISORDER OR ITS
333		-	SYMPTOMS
334		-	, INCLUDING MINIMIZING THE PROGRESSION OF THE DISORDER , IN
335		-	A MANNER THAT IS
336		-	:
	302	+	EDICALLY NECESSARY TREATMENT " MEANS A SERVICE OR3
	303	+	PRODUCT ADDRESSING THE SPECIFIC NEEDS OF A PATIENT FOR THE4
	304	+	PURPOSE OF SCREENING , PREVENTING, DIAGNOSING, MANAGING, OR5
	305	+	TREATING A BEHAVIORAL, MENTAL HEALTH, OR SUBSTANCE USE DISORDER6
	306	+	OR ITS SYMPTOMS, INCLUDING MINIMIZING THE PROGRESSION OF THE7
	307	+	DISORDER, IN A MANNER THAT IS:8
337	308		(A) I
338		-	N ACCORDANCE WITH THE GENERALLY ACCEPTED STANDARDS
339		-	OF BEHAVIORAL
340		-	, MENTAL HEALTH, AND SUBSTANCE USE DISORDER CARE ;
	309	+	N ACCORDANCE WITH THE GENERALLY ACCEPTED STANDARDS9
	310	+	OF BEHAVIORAL, MENTAL HEALTH, AND SUBSTANCE USE DISORDER CARE;10
341	311		(B) C
342		-	LINICALLY APPROPRIATE IN TERMS OF TYPE , FREQUENCY,
343		-	PAGE 7-HOUSE BILL 25-1002 EXTENT, SITE, AND DURATION; AND
344		-	(C) NOT PRIMARILY FOR THE ECONOMIC BENEFIT OF THE INSURER OR
345		-	PURCHASER OR FOR THE CONVENIENCE OF THE COVERED PERSON
346		-	, TREATING
347		-	PHYSICIAN
348		-	, OR OTHER HEALTH-CARE PROVIDER.
	312	+	LINICALLY APPROPRIATE IN TERMS OF TYPE , FREQUENCY,11
	313	+	EXTENT, SITE, AND DURATION; AND12
	314	+	(C) N
	315	+	OT PRIMARILY FOR THE ECONOMIC BENEFIT OF THE INSURER13
	316	+	OR PURCHASER OR FOR THE CONVENIENCE OF THE COVERED PERSON ,14
	317	+	TREATING PHYSICIAN, OR OTHER HEALTH-CARE PROVIDER.15
349	318		(V) "U
350		-	TILIZATION REVIEW " MEANS PROSPECTIVELY ,
351		-	RETROSPECTIVELY, OR CONCURRENTLY REVIEWING AND APPROVING ,
352		-	MODIFYING, DELAYING, OR DENYING REQUESTS BY HEALTH -CARE
353		-	PROVIDERS
354		-	, COVERED PERSONS, OR THEIR AUTHORIZED REPRESENTATIVES
355		-	FOR COVERAGE
356		-	, BASED IN WHOLE OR IN PART ON MEDICAL NECESSITY , OR
357		-	FOR OUT
358		-	-OF-NETWORK SERVICES REQUIRED PURSUANT TO SUBSECTION
359		-	(5.5)(a)(V)(D) OF THIS SECTION.
360		-	(VI) "U
361		-	TILIZATION REVIEW CRITERIA" MEANS AN EVALUATION OF
362		-	THE NECESSITY
363		-	, APPROPRIATENESS, AND EFFICIENCY OF THE USE OF
364		-	HEALTH
365		-	-CARE SERVICES, PROCEDURES, AND FACILITIES, INCLUDING
366		-	OUT
367		-	-OF-NETWORK SERVICES REQUIRED PURSUANT TO SUBSECTION
368		-	(5.5)(a)(V)(D) OF THIS SECTION. "UTILIZATION REVIEW CRITERIA" DOES NOT
369		-	INCLUDE AN INDEPENDENT MEDICAL EXAMINATION PROVIDED FOR IN ANY
370		-	POLICY
371		-	.
372		-	(e) (I) T
373		-	HIS SUBSECTION (5.5) DOES NOT EXPAND COVERAGE
374		-	REQUIREMENTS BEYOND THE STATE ESSENTIAL HEALTH BENEFITS
375		-	BENCHMARK PLAN AS REQUIRED PURSUANT TO
376		-	45 CFR 156.111.
377		-	(II) I
378		-	F AN EXCLUSION FOR BEHAVIORAL HEALTH , MENTAL HEALTH,
379		-	OR SUBSTANCE USE DISORDER SERVICES IS NOT PERMITTED UNDER THE
380		-	MHPAEA, COVERAGE FOR THESE SERVICES MUST MEET THE REQUIREMENTS
381		-	OF THIS SUBSECTION
382		-	(5.5).
383		-	SECTION 2. Act subject to petition - effective date. This act
384		-	takes effect January 1, 2026; except that, if a referendum petition is filed
385		-	pursuant to section 1 (3) of article V of the state constitution against this act
386		-	or an item, section, or part of this act within the ninety-day period after final
387		-	adjournment of the general assembly, then the act, item, section, or part will
388		-	not take effect unless approved by the people at the general election to be
389		-	PAGE 8-HOUSE BILL 25-1002 held in November 2026 and, in such case, will take effect on the date of the
390		-	official declaration of the vote thereon by the governor.
391		-	____________________________ ____________________________
392		-	Julie McCluskie James Rashad Coleman, Sr.
393		-	SPEAKER OF THE HOUSE PRESIDENT OF
394		-	OF REPRESENTATIVES THE SENATE
395		-	____________________________ ____________________________
396		-	Vanessa Reilly Esther van Mourik
397		-	CHIEF CLERK OF THE HOUSE SECRETARY OF
398		-	OF REPRESENTATIVES THE SENATE
399		-	APPROVED________________________________________
400		-	(Date and Time)
401		-	_________________________________________
402		-	Jared S. Polis
403		-	GOVERNOR OF THE STATE OF COLORADO
404		-	PAGE 9-HOUSE BILL 25-1002
	319	+	TILIZATION REVIEW" MEANS PROSPECTIVELY ,16
	320	+	RETROSPECTIVELY, OR CONCURRENTLY REVIEWING AND APPROVING ,17
	321	+	MODIFYING, DELAYING, OR DENYING REQUESTS BY HEALTH -CARE18
	322	+	PROVIDERS, COVERED PERSONS, OR THEIR AUTHORIZED REPRESENTATIVES19
	323	+	FOR COVERAGE, BASED IN WHOLE OR IN PART ON MEDICAL NECESSITY , OR20
	324	+	FOR OUT-OF-NETWORK SERVICES REQUIRED PURSUANT TO SUBSECTION21
	325	+	(5.5)(a)(V)(D)
	326	+	OF THIS SECTION.22
	327	+	(VI) "UTILIZATION REVIEW CRITERIA" MEANS AN EVALUATION OF23
	328	+	THE NECESSITY, APPROPRIATENESS, AND EFFICIENCY OF THE USE OF24
	329	+	HEALTH-CARE SERVICES, PROCEDURES, AND FACILITIES, INCLUDING25
	330	+	OUT-OF-NETWORK SERVICES REQUIRED PURSUANT TO SUBSECTION26
	331	+	(5.5)(a)(V)(D) OF THIS SECTION. "UTILIZATION REVIEW CRITERIA" DOES27
	332	+	1002
	333	+	-10- NOT INCLUDE AN INDEPENDENT MEDICAL EXAMINATION PROVIDED FOR IN1
	334	+	ANY POLICY.2
	335	+	(e) (I) THIS SUBSECTION (5.5) DOES NOT EXPAND COVERAGE3
	336	+	REQUIREMENTS BEYOND THE STATE ESSENTIAL HEALTH BENEFITS4
	337	+	BENCHMARK PLAN AS REQUIRED PURSUANT TO 45 CFR 156.111.5
	338	+	(II) IF AN EXCLUSION FOR BEHAVIORAL HEALTH , MENTAL HEALTH,6
	339	+	OR SUBSTANCE USE DISORDER SERVICES IS NOT PERMITTED UNDER THE7
	340	+	MHPAEA, COVERAGE FOR THESE SERVICES MUST MEET THE8
	341	+	REQUIREMENTS OF THIS SUBSECTION (5.5).9
	342	+	SECTION 2. Act subject to petition - effective date. This act10
	343	+	takes effect January 1, 2026; except that, if a referendum petition is filed11
	344	+	pursuant to section 1 (3) of article V of the state constitution against this12
	345	+	act or an item, section, or part of this act within the ninety-day period13
	346	+	after final adjournment of the general assembly, then the act, item,14
	347	+	section, or part will not take effect unless approved by the people at the15
	348	+	general election to be held in November 2026 and, in such case, will take16
	349	+	effect on the date of the official declaration of the vote thereon by the17
	350	+	governor.18
	351	+	1002
	352	+	-11-