HOUSE BILL 25-1002
BY REPRESENTATIVE(S) Brown and Gilchrist, Johnson, McCormick,
Winter T., Bacon, Bird, Clifford, Duran, English, Froelich, Garcia,
Hamrick, Jackson, Joseph, Lieder, Lindsay, Mabrey, Marshall, Paschal,
Rutinel, Rydin, Smith, Stewart K., Stewart R., Story, Taggart, Titone,
Valdez, Woodrow, McCluskie, Boesenecker, Camacho, Lukens, Ricks,
Sirota;
also SENATOR(S) Amabile and Pelton B., Simpson, Ball, Bridges, Cutter,
Daugherty, Exum, Gonzales J., Hinrichsen, Jodeh, Kipp, Kolker,
Marchman, Michaelson Jenet, Mullica, Snyder, Weissman, Winter F.,
Coleman.
C
ONCERNING THE DETERMINATION OF HEALTH BENEFITS COVERAGE FOR
MENTAL HEALTH SERVICES
.
Be it enacted by the General Assembly of the State of Colorado:
SECTION 1. In Colorado Revised Statutes, 10-16-104, amend
(5.5)(a)(I), (5.5)(a)(V)(A), (5.5)(a)(V)(B), (5.5)(a)(V)(D), (5.5)(b), and
(5.5)(d); and add (5.5)(a)(I.5), (5.5)(a)(V)(F), (5.5)(a)(VI), (5.5)(c.3),
(5.5)(c.5), and (5.5)(e) as follows:
10-16-104. Mandatory coverage provisions - definitions - rules
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. - applicability. (5.5) Behavioral, mental health, and substance use
disorders - utilization review criteria - federal treatment limitation
requirements - meaningful benefits - rules - definitions. (a) (I) Every
health benefit plan subject to part 2, 3, or 4 of this article 16, except those
described in section 10-16-102 (32)(b), must provide coverage:
(A) For the prevention of, screening for, and treatment of
behavioral, mental health, and substance use disorders that is no less
extensive than the coverage provided for any physical illness, and
that
complies with the requirements of the MHPAEA, and
THAT DOES NOT
DISCRIMINATE IN ITS BENEFIT DESIGN AGAINST INDIVIDUALS BECAUSE OF
THEIR PRESENT OR PREDICTED BEHAVIORAL
, MENTAL HEALTH , OR
SUBSTANCE USE DISORDER
;
(B) At a minimum, for the treatment of substance use disorders in
accordance with the American Society of Addiction Medicine criteria for
placement, medical necessity, and utilization management determinations
as set forth in the most recent edition of "The ASAM Criteria: T
REATMENT
CRITERIA for Addictive, Substance-related, and Co-occurring Conditions";
except that the commissioner may identify by rule, in consultation with the
department of health care policy and financing and the behavioral health
administration in the department of human services, an
alternate nationally
recognized and evidence-based substance-use-disorder-specific
NOT-FOR-PROFIT UTILIZATION REVIEW criteria THAT IS CONSISTENT WITH
GENERALLY ACCEPTED STANDARDS OF SUBSTANCE USE DISORDER CARE
for
placement, medical necessity, or utilization management
REVIEW, if the
American Society of Addiction Medicine criteria are no longer available or
relevant or do not follow best practices for substance use disorder treatment;
AND
(C) FOR MEDICALLY NECESSARY TREATMENT OF COVERED
BEHAVIORAL
, MENTAL HEALTH, AND SUBSTANCE USE DISORDER BENEFITS ,
INCLUDING SERVICES THAT ARE CONSISTENT WITH CRITERIA , GUIDELINES, OR
CONSENSUS RECOMMENDATIONS FROM NATIONALLY RECOGNIZED
NOT
-FOR-PROFIT CLINICAL SPECIALTY ASSOCIATIONS OF THE RELEVANT
BEHAVIORAL
, MENTAL HEALTH, OR SUBSTANCE USE DISORDER SPECIALTY .
(I.5) (A) A
LL UTILIZATION REVIEW AND UTILIZATION REVIEW
CRITERIA MUST BE CONSISTENT WITH CURRENT GENERALLY ACCEPTED
STANDARDS OF BEHAVIORAL
, MENTAL HEALTH, AND SUBSTANCE USE
PAGE 2-HOUSE BILL 25-1002 DISORDER CARE.
(B) I
N CONDUCTING UTILIZATION REVIEW OF COVERED SERVICES FOR
THE DIAGNOSIS
, PREVENTION, AND TREATMENT OF BEHAVIORAL OR MENTAL
HEALTH DISORDERS
, A HEALTH BENEFIT PLAN SHALL APPLY THE CRITERIA
AND GUIDELINES SET FORTH IN THE MOST RECENT VERSION OF THE
TREATMENT CRITERIA DEVELOPED BY UNAFFILIATED NATI ONALLY
RECOGNIZED NOT
-FOR-PROFIT CLINICAL SPECIALTY ASSOCIATIONS OF THE
RELEVANT BEHAVIORAL OR MENTAL HEALTH DISORDERS
. IN CONDUCTING
UTILIZATION REVIEW OF COVERED SERVICES FOR THE DIAGNOSIS
,
PREVENTION, AND TREATMENT OF SUBSTANCE USE DISORDERS , A HEALTH
BENEFIT PLAN SHALL APPLY THE CRITERIA SPECIFIED IN SUBSECTION
(5.5)(a)(I)(B) OF THIS SECTION.
(C) I
N CONDUCTING UTILIZATION REVIEW RELATING TO SERVICE
INTENSITY
, LEVEL OF CARE PLACEMENT , OR ANY OTHER PATIENT CARE
DECISIONS THAT ARE WITHIN THE SCOPE OF THE SOURCES SPECIFIED IN
SUBSECTIONS
(5.5)(a)(I)(B) AND (5.5)(a)(I.5)(B) OF THIS SECTION, A HEALTH
BENEFIT PLAN SHALL NOT APPLY DIFFERENT
, ADDITIONAL, CONFLICTING, OR
MORE RESTRICTIVE UTILIZATION REVIEW CRITERIA THAN THE CRITERIA SET
FORTH IN THOSE SOURCES
. IF THE REQUESTED SERVICE INTENSITY OR LEVEL
OF CARE PLACEMENT IS INCONSISTENT WITH THE HEALTH BENEFIT PLAN
'S
ASSESSMENT USING THE RELEVANT CRITERIA
, AS PART OF ANY ADVERSE
BENEFIT DETERMINATION
, THE HEALTH BENEFIT PLAN SHALL PROVIDE FULL
DETAIL OF ITS ASSESSMENT AND THE RELE VANT CRITERIA USED IN THE
ASSESSMENT TO THE PROVIDER AND THE COVERED PERSON
.
(D) I
N CONDUCTING UTILIZATION REVIEW THAT IS OUTSIDE THE
SCOPE OF THE CRITERIA SPECIFIED IN SUBSECTIONS
(5.5)(a)(I)(B) AND
(5.5)(a)(I.5)(B) OF THIS SECTION OR RELATED TO ADVANCEMENTS IN
TECHNOLOGY OR TYPES OF LEVELS OF CARE THAT ARE NOT ADDRESSED IN
THE MOST RECENT VERSIONS OF THE SOURCES SPECIFIED IN THOSE
SUBSECTIONS
, A HEALTH BENEFIT PLAN SHALL CONDUCT UTILIZATION
REVIEW IN ACCORDANCE WITH SUBSECTION
(5.5)(a)(I.5)(A) OF THIS
SECTION
. IF A HEALTH BENEFIT PLAN PURCHASES OR LICENSES UTILIZATION
REVIEW CRITERIA PURSUANT TO THIS SUBSECTION
(5.5)(a)(I.5)(D), THE
HEALTH BENEFIT PLAN SHALL VERIFY AND DOCUMENT BEFORE USE THAT THE
CRITERIA COMPLY WITH THE REQUIREMENTS OF SUBSECTION
(5.5)(a)(I.5)(A)
OF THIS SECTION.
PAGE 3-HOUSE BILL 25-1002 (E) A HEALTH BENEFIT PLAN MUST NOT LIMIT BENEFITS OR
COVERAGE FOR CHRONIC BEHAVIORAL
, MENTAL HEALTH, OR SUBSTANCE USE
DISORDERS TO SHORT
-TERM SYMPTOM REDUCTION AT ANY LEVEL -OF-CARE
PLACEMENT
.
(V) A carrier offering a health benefit plan subject to the
requirements of this subsection (5.5) shall:
(A) Comply with the nonquantitative treatment limitation
requirements specified in 45 CFR 146.136 (c)(4)
45 CFR 146.136 OR 29
CFR
2590.712, or any successor regulation, regarding any limitations that
are not expressed numerically but otherwise limit the scope or duration of
benefits for treatment, which, in addition to the limitations and examples
listed in 45 CFR 146.136 (c)(4)(ii) and (c)(4)(iii)
(c)(4)(vi) OR 29 CFR
2590.712 (c)(4)(ii)
AND (c)(4)(vi), or any successor regulation, and 78 FR68246 78 FED. REG. 68246 (NOVEMBER 13, 2013) AND 89 FED. REG. 77586
(S
EPTEMBER 23, 2024), include the methods by which the carrier establishes
and maintains its provider networks pursuant to section 10-16-704 and
responds to deficiencies in the ability of its networks to provide timely
access to care;
(B) Comply with the financial requirements and quantitative
treatment limitations specified in 45 CFR 146.136 (c)(2) and (c)(3) or any
successor regulation
OR 29 CFR 2590.712 (c)(2) AND (c)(3);
(D) Establish procedures to authorize
MEDICALLY NECESSARY
treatment with a
AN APPROPRIATE nonparticipating provider AND TO
PROVIDE SERVICES TO MAKE AVAILABLE THE COVERED SERVICE
if a covered
service is not available within established time and distance standards, and
within a reasonable period, after a service is requested, and with the same
coinsurance, deductible, or copayment requirements,
ACCRUING TO
IN
-NETWORK ANNUAL COST -SHARING LIMITS, as would apply if the services
were provided by a participating provider, and at no greater cost to the
covered person than if the services were obtained at or from a participating
provider; and
(F) NOT REVERSE OR ALTER A DETERMINATION OF MEDICAL
NECESSITY MADE PURSUANT TO THIS SUBSECTION
(5.5), INCLUDING
DOWNGRADING OR BUNDLING THE CODING OF A CLAIM
, THROUGH A REVIEW
OR AUDIT OF A CLAIM
, EXCEPT IN CASES OF FRAUD OR WHERE THE COVERED
PAGE 4-HOUSE BILL 25-1002 PERSON DID NOT HAVE A VALID POLICY WHEN THE SERVICE WAS PROVIDED .
(VI) I
F A HEALTH BENEFIT PLAN PROVIDES ANY BENEFITS FOR A
MENTAL HEALTH CONDITION OR SUBSTANCE USE DISORDER IN ANY
CLASSIFICATION OF BENEFITS
, IT MUST PROVIDE MEANINGFUL BENEFITS FOR
THAT MENTAL HEALTH CONDITION OR SUBSTANCE USE DISORDER IN EVERY
CLASSIFICATION IN WHICH MEDICAL OR SURGICAL BENEFITS ARE PROVIDED
.
W
HETHER THE BENEFITS PROVIDED ARE MEANINGFUL BENEFITS IS
DETERMINED IN COMPARISON TO THE BENEFITS PROVIDED FOR MEDICAL
CONDITIONS AND SURGICAL PROCEDURES IN THE CLASSIFICATION AND
REQUIRES
, AT A MINIMUM, COVERAGE OF BENEFITS FOR THAT CONDITION OR
DISORDER IN EACH CLASSIFICATION IN WHICH THE HEALTH BENEFIT PLAN
PROVIDES BENEFITS FOR ONE OR MORE MEDICAL CONDITIONS OR SURGICAL
PROCEDURES
. A HEALTH BENEFIT PLAN DOES NOT PROVIDE MEANINGFUL
BENEFITS UNLESS IT PROVIDES BENEFITS FOR A CORE TREATMENT FOR THAT
CONDITION OR DISORDER IN EACH CLASSIFICATION IN WHICH THE HEALTH
BENEFIT PLAN PROVIDES BENEFITS FOR A CORE TREATMENT FOR ONE OR
MORE MEDICAL CONDITIONS OR SURGICAL PROCEDURES
. A CORE TREATMENT
FOR A CONDITION OR DISORDER IS A STANDARD TREATMENT OR COURSE OF
TREATMENT
, THERAPY, SERVICE, OR INTERVENTION INDICATED BY
GENERALLY ACCEPTED STANDARDS OF BEHAVIORAL
, MENTAL HEALTH, AND
SUBSTANCE USE DISORDER CARE
. IF THERE IS NO CORE TREATMENT FOR A
COVERED MENTAL HEALTH CONDITION OR SUBSTANCE USE DISORDER WITH
RESPECT TO A CLASSIFICATION
, THE HEALTH BENEFIT PLAN IS NOT REQUIRED
TO PROVIDE BENEFITS FOR A CORE TREATMENT FOR SUCH CONDITION OR
DISORDER IN THAT CLASSIFICATION
, BUT MUST PROVIDE BENEFITS FOR SUCH
CONDITION OR DISORDER IN EVERY CLASSIFICATION IN WHICH MEDICAL OR
SURGICAL BENEFITS ARE PROVIDED
.
(b) The commissioner:
(I) May adopt rules as necessary to ensure that this subsection (5.5)
is implemented and
COMPLIANTLY administered; in compliance with federal
law and shall adopt rules to establish reasonable time periods for visits with
a provider for treatment of a behavioral, mental health, or substance use
disorder after an initial visit with a provider.
(II) MAY ADOPT RULES TO ESTABLISH CARRIER UTILIZATION REVIEW
COMPLIANCE IN ACCORDANCE WITH SUBSECTION
(5.5)(a)(I.5) OF THIS
SECTION
;
PAGE 5-HOUSE BILL 25-1002 (III) MAY ADOPT RULES AS NECESSARY TO SPECIFY DATA TESTING
REQUIREMENTS TO DETERMINE PLAN DESIGN AND APPLICATION OF PARITY
COMPLIANCE FOR NONQUANTITATIVE TREATMENT LIMITATIONS USING
OUTCOMES DATA
;
(IV) M
AY ADOPT RULES TO SET STANDARD DEFINITIONS FOR
COVERAGE REQUIREMENTS
, INCLUDING PROCESSES , STRATEGIES,
EVIDENTIARY STANDARDS , AND OTHER FACTORS;
(V) M
AY ADOPT RULES TO ESTABLISH SPECIFIC TIMELINES FOR
CARRIER COMPLIANCE TO PROVIDE COMPARATIVE ANALYSIS INFORMATION
TO THE DIVISION FOR REVIEW
, INCLUDING THE EFFECT OF A CARRIER'S LACK
OF SUFFICIENT COMPARATIVE ANALYSES TO DEMONSTRATE COMPLIANCE
;
AND
(VI) MAY ADOPT RULES TO ESTABLISH REASONABLE TIME PERIODS
AND DOCUMENTATION OF SUCH TIME PERIODS FOR VISITS WITH A PROVIDER
FOR TREATMENT OF A BEHAVIORAL
, MENTAL HEALTH, OR SUBSTANCE USE
DISORDER AFTER AN INITIAL VISIT WITH A PROVIDER
.
(c.3) T
HIS SUBSECTION (5.5) APPLIES TO ANY INDIVIDUAL, ENTITY,
OR CONTRACTING PROVIDER THAT PERFORMS UTILIZATION REVIEW
FUNCTIONS ON BEHALF OF A HEALTH BENEFIT PLAN
.
(c.5) A
CARRIER OFFERING A HEALTH BENEFIT PLAN SHALL NOT
ADOPT
, IMPOSE, OR ENFORCE TERMS IN ITS POLICIES OR PROVIDER
AGREEMENT
, IN WRITING OR IN OPERATION, THAT UNDERMINE, ALTER, OR
CONFLICT WITH THE REQUIREMENTS OF THIS SUBSECTION
(5.5).
(d) As used in this subsection (5.5):
(I) "A
PPROPRIATE NONPARTICIPATING PROVIDER " MEANS A
PROVIDER WHO IS ACCESSIBLE AND HAS THE TRAINING AND EXPERIENCE
NECESSARY TO PROVIDE AGE
-APPROPRIATE, MEDICALLY NECESSARY
TREATMENT OF A BEHAVIORAL
, MENTAL HEALTH, OR SUBSTANCE USE
DISORDER
.
(II) "Behavioral, mental health, and substance use disorder":
(I)
(A) Means a condition or disorder, regardless of etiology, that
PAGE 6-HOUSE BILL 25-1002 may be the result of a combination of genetic and environmental factors and
that falls under any of the diagnostic categories listed in the mental
disorders section of the most recent version of
(A)
the "International Statistical Classification of Diseases and
Related Health Problems",
(B) the "Diagnostic and Statistical Manual of Mental Disorders", or
(C) the "Diagnostic Classification of Mental Health and
Developmental Disorders of Infancy and Early Childhood"; and
(II) (B) Includes autism spectrum disorders, as defined in subsection
(1.4)(a)(III) of this section.
(III) "G
ENERALLY ACCEPTED STANDARDS OF BEHAVIORAL , MENTAL
HEALTH
, AND SUBSTANCE USE DISORDER CARE" MEANS STANDARDS OF CARE
AND CLINICAL PRACTICE THAT ARE GENERALLY RECOGNIZED BY
HEALTH
-CARE PROVIDERS PRACTICING IN RELEVANT CLINICAL SPECIALTIES
SUCH AS PSYCHIATRY
, PSYCHOLOGY, CLINICAL SOCIAL WORK, PSYCHIATRIC
NURSING
, ADDICTION MEDICINE AND COUNSELING, AND BEHAVIORAL HEALTH
TREATMENT
. VALID, EVIDENCE-BASED SOURCES REFLECTING GENERALLY
ACCEPTED STANDARDS OF BEHAVIORAL
, MENTAL HEALTH, AND SUBSTANCE
USE DISORDER CARE INCLUDE PEER
-REVIEWED SCIENTIFIC STUDIES AND
MEDICAL LITERATURE
; CLINICAL PRACTICE GUIDELINES AND
RECOMMENDATIONS OF NONPROFIT HEALTH
-CARE PROVIDER PROFESSIONAL
ASSOCIATIONS
, SPECIALTY SOCIETIES, AND FEDERAL GOVERNMENT
AGENCIES
; AND DRUG LABELING APPROVED BY THE FDA.
(IV) "M
EDICALLY NECESSARY TREATMENT " MEANS A SERVICE OR
PRODUCT ADDRESSING THE SPECIFIC NEEDS OF A PATIENT FOR THE PURPOSE
OF SCREENING
, PREVENTING, DIAGNOSING, MANAGING, OR TREATING A
BEHAVIORAL
, MENTAL HEALTH, OR SUBSTANCE USE DISORDER OR ITS
SYMPTOMS
, INCLUDING MINIMIZING THE PROGRESSION OF THE DISORDER , IN
A MANNER THAT IS
:
(A) I
N ACCORDANCE WITH THE GENERALLY ACCEPTED STANDARDS
OF BEHAVIORAL
, MENTAL HEALTH, AND SUBSTANCE USE DISORDER CARE ;
(B) C
LINICALLY APPROPRIATE IN TERMS OF TYPE , FREQUENCY,
PAGE 7-HOUSE BILL 25-1002 EXTENT, SITE, AND DURATION; AND
(C) NOT PRIMARILY FOR THE ECONOMIC BENEFIT OF THE INSURER OR
PURCHASER OR FOR THE CONVENIENCE OF THE COVERED PERSON
, TREATING
PHYSICIAN
, OR OTHER HEALTH-CARE PROVIDER.
(V) "U
TILIZATION REVIEW " MEANS PROSPECTIVELY ,
RETROSPECTIVELY, OR CONCURRENTLY REVIEWING AND APPROVING ,
MODIFYING, DELAYING, OR DENYING REQUESTS BY HEALTH -CARE
PROVIDERS
, COVERED PERSONS, OR THEIR AUTHORIZED REPRESENTATIVES
FOR COVERAGE
, BASED IN WHOLE OR IN PART ON MEDICAL NECESSITY , OR
FOR OUT
-OF-NETWORK SERVICES REQUIRED PURSUANT TO SUBSECTION
(5.5)(a)(V)(D) OF THIS SECTION.
(VI) "U
TILIZATION REVIEW CRITERIA" MEANS AN EVALUATION OF
THE NECESSITY
, APPROPRIATENESS, AND EFFICIENCY OF THE USE OF
HEALTH
-CARE SERVICES, PROCEDURES, AND FACILITIES, INCLUDING
OUT
-OF-NETWORK SERVICES REQUIRED PURSUANT TO SUBSECTION
(5.5)(a)(V)(D) OF THIS SECTION. "UTILIZATION REVIEW CRITERIA" DOES NOT
INCLUDE AN INDEPENDENT MEDICAL EXAMINATION PROVIDED FOR IN ANY
POLICY
.
(e) (I) T
HIS SUBSECTION (5.5) DOES NOT EXPAND COVERAGE
REQUIREMENTS BEYOND THE STATE ESSENTIAL HEALTH BENEFITS
BENCHMARK PLAN AS REQUIRED PURSUANT TO
45 CFR 156.111.
(II) I
F AN EXCLUSION FOR BEHAVIORAL HEALTH , MENTAL HEALTH,
OR SUBSTANCE USE DISORDER SERVICES IS NOT PERMITTED UNDER THE
MHPAEA, COVERAGE FOR THESE SERVICES MUST MEET THE REQUIREMENTS
OF THIS SUBSECTION
(5.5).
SECTION 2. Act subject to petition - effective date. This act
takes effect January 1, 2026; 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 the ninety-day period after final
adjournment of the general assembly, then the act, item, section, or part will
not take effect unless approved by the people at the general election to be
PAGE 8-HOUSE BILL 25-1002 held in November 2026 and, in such case, will take effect on the date of the
official declaration of the vote thereon by the governor.
____________________________ ____________________________
Julie McCluskie James Rashad Coleman, Sr.
SPEAKER OF THE HOUSE PRESIDENT OF
OF REPRESENTATIVES THE SENATE
____________________________ ____________________________
Vanessa Reilly Esther van Mourik
CHIEF CLERK OF THE HOUSE SECRETARY OF
OF REPRESENTATIVES THE SENATE
APPROVED________________________________________
(Date and Time)
_________________________________________
Jared S. Polis
GOVERNOR OF THE STATE OF COLORADO
PAGE 9-HOUSE BILL 25-1002