(1) Notwithstanding any provision of law to the contrary, beginning January 1, 2020, a carrier that provides prescription drug benefits for the treatment of substance use disorders shall, for prescription medications that are on the carrier's formulary:
(a) Not impose prior authorization requirements on any prescription medication approved by the FDA for the treatment of substance use disorders;
(b) Not impose any step therapy requirements as a prerequisite for coverage for a prescription medication approved by the FDA for the treatment of substance use disorders;
(c) Place at least one covered prescription medication approved by the FDA for the treatment of substance use disorders on the lowest tier of the drug formulary developed and maintained by the carrier; and
(d) Not exclude coverage for any prescription medication approved by the FDA for the treatment of substance use disorders and any associated counseling or wraparound services solely on the grounds that the medications and services were court ordered.
(1.5) The commissioner, in consultation with the department of public health and environment, may promulgate rules or seek a revision to the prescription drug benefits required under the essential health benefits package concerning prescription medications that must be included on a carrier's formulary for medication-assisted treatment of substance use disorders.
(2) Repealed.
Source: L. 2019: Entire section added, (HB 19-1269), ch. 195, p. 2131, � 10, effective May 16. L. 2020: (1.5) added, (SB 20-007), ch. 286, p. 1391, � 8, effective July 13. L. 2022: (2) repealed, (HB 22-1264), ch. 126, p. 888, � 5, effective August 10.
Cross references: For the short title (Behavioral Health Care Coverage Modernization Act) in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
10-16-149. Commissioner report - parity effects on premiums - repeal. (Repealed)
Source: L. 2019: Entire section added, (HB 19-1269), ch. 195, p. 2131, � 10, effective May 16.
Editor's note: Subsection (2) provided for the repeal of this section, effective March 1, 2023. (See L. 2019, p. 2131.)
10-16-150. Primary care payment reform collaborative - created - powers and duties - report - definition - repeal. (1) The commissioner shall convene a primary care payment reform collaborative to:
(a) Consult with the department of personnel, the executive director of the department of health care policy and financing, and the administrator of the Colorado all-payer health claims database described in section 25.5-1-204;
(b) Advise in the development of the affordability standards and targets for carrier investments in primary care established in accordance with section 10-16-107 (3.5);
(c) In coordination with the administrator of the all-payer health claims database described in section 25.5-1-204, analyze the percentage of medical expenses allocated to primary care:
(I) By health insurers;
(II) Under the Colorado Medical Assistance Act, articles 4, 5, and 6 of title 25.5; and
(III) Under the Children's Basic Health Plan Act, article 8 of title 25.5;
(d) Develop a recommendation to the commissioner on the definition of primary care for the purposes of this section;
(e) Report on current health insurer practices and methods of reimbursement that direct greater health-care resources and investments toward health-care innovation and care improvement in primary care;
(f) Identify barriers to the adoption of alternative payment models by health insurers and providers, and develop recommendations to address the barriers;
(g) Develop recommendations to increase the use of alternative payment models that are not paid on a fee-for-service or per-claim basis to:
(I) Increase the investment in advanced primary care delivered by practices that are patient-centered medical homes as defined by national or state-recognized criteria or that have demonstrated the ability to provide high-quality primary care;
(II) Align primary care reimbursement by all consumers of primary care;
(III) Direct investment toward higher value primary care services with an aim toward reducing health disparities; and
(IV) Ensure the development and consideration of alternative payment models that are responsive to the needs of primary care delivery in pediatrics.
(h) Consider how to increase investment in advanced primary care without increasing costs to consumers or increasing the total cost of health care;
(i) Develop and share best practices and technical assistance with health insurers and consumers, which may include:
(I) Aligning quality metrics as developed in the state innovation model;
(II) Facilitating the integration of behavioral and physical primary care;
(III) Practice transformation; and
(IV) The delivery of advanced primary care that facilitates appropriate utilization of services in appropriate settings; and
(j) Annually review the alternative payment models developed by the division pursuant to section 10-16-157 (3) and provide the division with recommendations on the models.
(2) The commissioner shall invite representatives from the following to participate in the primary care payment reform collaborative:
(a) Health-care providers, including primary care providers and pediatric primary care providers;
(b) Health-care consumers;
(c) Employers that purchase health insurance for employees and employers that offer self-insured health benefit plans;
(d) Health insurers, including entities that contract with the department of health care policy and financing as managed care entities;
(e) The federal centers for medicare and medicaid services;
(f) The primary care office in the department of public health and environment created pursuant to section 25-1.5-403;
(g) The executive director of the department of health care policy and financing; and
(h) Experts in health insurance actuarial analysis.
(2.5) In carrying out the duties of subsection (1)(j) of this section, in addition to the members of the collaborative described in subsection (2) of this section, the commissioner shall include health insurers and health-care providers engaged in a range of alternative payment models.
(3) The commissioner shall convene the primary care payment reform collaborative on or before July 15, 2019.
(4) By February 15, 2023, and by each February 15 thereafter, the primary care payment reform collaborative shall publish primary care payment reform recommendations, informed by the primary care spending report prepared in accordance with section 25.5-1-204 (3)(c). The collaborative shall make the report available electronically to the general public.
(5) The division may seek, accept, and expend gifts, grants, or donations from private or public sources for the purposes of this section.
(6) As used in this section, health insurer means:
(a) A carrier that is subject to part 2, 3, or 4 of this article 16 and that is offering health benefit plans in Colorado; and
(b) A carrier that provides or administers a group benefit plan for state employees pursuant to part 6 of article 50 of title 24.
(7) This section is repealed, effective September 1, 2032. Before the repeal, the functions of the primary care payment reform collaborative are scheduled for review in accordance with section 2-3-1203.
Source: L. 2019: Entire section added, (HB 19-1233), ch. 194, p. 2119, � 2, effective May 16. L. 2022: (1)(h), (1)(i)(IV), and (4) amended and (1)(j) and (2.5) added, (HB 22-1325), ch. 181, p. 1208, � 2, effective August 10. L. 2025: (1)(g)(II), (1)(g)(III), (2)(a), and (7) amended and (1)(g)(IV) added, (SB 25-193), ch. 371, p. 2002, � 1, effective August 6.
Cross references: For the legislative declaration in HB 19-1233, see section 1 of chapter 194, Session Laws of Colorado 2019.
10-16-151. Cost sharing in prescription insulin drugs - limits - definition - rules. (1) As used in this section, unless the context otherwise requires, prescription insulin drug means a prescription drug, as defined in section 12-280-103 (42), that contains insulin and is used to treat diabetes.
(2) A carrier that provides coverage for prescription insulin drugs pursuant to the terms of a health coverage plan the carrier offers shall cap the total amount that a covered person is required to pay for all covered prescription insulin drugs at an amount not to exceed one hundred dollars for the covered person's entire thirty-day supply of insulin, regardless of the amount or type of insulin needed to fill the covered person's prescription or the number of prescriptions.
(3) Nothing in this section prevents a carrier from reducing a covered person's cost sharing by an amount greater than the amount specified in subsection (2) of this section.
(4) The commissioner may use any of the commissioner's enforcement powers to obtain a carrier's compliance with this section.
(5) The commissioner may promulgate rules as necessary to implement and administer this section and to align with federal requirements.
Source: L. 2019: Entire section added, (HB 19-1216), ch. 248, p. 2419, � 2, effective August 2. L. 2021: (2) amended, (HB 21-1307), ch. 437, p. 2894, � 2, effective September 7.
Cross references: For the legislative declaration in HB 19-1216, see section 1 of chapter 248, Session Laws of Colorado 2019. For the legislative declaration in HB 21-1307, see section 1 of chapter 437, Session Laws of Colorado 2021.
10-16-152. HIV prevention and treatment medication - limitations on carriers - step therapy - prior authorization - study - repeal. (1) A carrier shall not require a covered person to undergo step therapy or to receive prior authorization before a pharmacist may, pursuant to section 12-280-125.7, prescribe or dispense an HIV prevention drug.
(2) Before July 1, 2027, a carrier shall not require a covered person to undergo step therapy or to receive prior authorization before a provider may, acting within the provider's scope of practice, prescribe or dispense any drug approved by the FDA and used for the treatment or prevention of HIV that is included on the carrier's prescription drug formulary as of March 1, 2023.
(3) (a) The division shall contract with one or more entities to conduct a study that includes qualitative patient and provider experience information and an actuarial review to consider the predicted cost and health impacts of removing the requirement for a covered person to undergo step therapy or to receive prior authorization before a provider may, acting within the provider's scope of practice, prescribe or dispense a drug for the treatment of HIV. In conducting the study, the entity contracted to perform the study must consult with community organizations led by people living with HIV. The division shall provide the completed study to the general assembly no later than October 1, 2026.
(b) This subsection (3) is repealed, effective July 1, 2027.
Source: L. 2020: Entire section added, (HB 20-1061), ch. 281, p. 1375, � 3, effective July 13. L. 2023: Entire section amended, (SB 23-189), ch. 69, p. 257, � 3, effective April 14.
10-16-153. Coverage for opioid antagonists provided by a hospital - definition. (1) As used in this section, unless the context otherwise requires, opioid antagonist has the same meaning as set forth in section 12-30-110 (7)(d).
(2) A carrier that provides coverage for opioid antagonists pursuant to the terms of a health coverage plan the carrier offers shall reimburse a hospital for the hospital's cost of an opioid antagonist if the hospital gives a covered person an opioid antagonist upon discharge from the hospital.
Source: L. 2020: Entire section added, (HB 20-1065), ch. 287, p. 1419, � 1, effective September 14. L. 2024: Entire section amended, (HB 24-1037), ch. 458, p. 3165, � 8, effective June 6.
Editor's note: This section was numbered as � 10-16-154 in HB 20-1065 but was renumbered on revision for ease of location.
10-16-154. Disclosures - physical therapists - occupational therapists - chiropractors - acupuncturists - patients - carrier prohibitions - enforcement. (1) A carrier that has a contract with a physical therapist, an occupational therapist, a chiropractor, or an acupuncturist shall not:
(a) Prohibit the physical therapist, occupational therapist, chiropractor, or acupuncturist from providing a covered person information on the amount of the covered person's financial responsibility for the physical therapy, occupational therapy, chiropractic services, or acupuncture services provided to the covered person;
(b) Penalize the physical therapist, occupational therapist, chiropractor, or acupuncturist for disclosing the information described in subsection (1)(a) of this section to a covered person or providing a more affordable alternative to a covered person; or
(c) Require the physical therapist, occupational therapist, chiropractor, or acupuncturist to charge an amount to a covered person or collect a copayment from a covered person that exceeds the total charges submitted to the carrier by the physical therapist, occupational therapist, chiropractor, or acupuncturist.
(2) If the commissioner determines that a carrier has not complied with this section, the commissioner shall require the carrier to develop and provide to the division for approval a corrective action plan or use any of the commissioner's enforcement powers under this title 10 to ensure the carrier's compliance with this section.
Source: L. 2021: Entire section added, (HB 21-1276), ch. 364, p. 2397, � 4, effective July 1.
Cross references: For the legislative declaration in HB 21-1276, see section 1 of chapter 364, Session Laws of Colorado 2021.
10-16-155. Actuarial reviews of proposed health-care legislation - division to contract with third parties - required considerations - confidentiality - limits on expenditures - rate filings - repeal. (1) On or before November 1, 2022, the division shall retain by contract one or more entities that have experience in actuarial reviews, health-care policy, and health equity, referred to in this section as the contractors, for the purpose of performing actuarial reviews of legislative proposals that may impose a new health benefit coverage mandate on health benefit plans or reduce or eliminate coverage mandated under health benefit plans, referred to in this section as legislative proposals. At least one of the contractors must be an actuary or an actuarial firm with experience in analyzing health insurance premiums. The contractors, under the direction of the division, shall conduct actuarial reviews of up to six legislative proposals, regardless of the number of legislative proposals that are requested for each regular legislative session by members of the general assembly.
(2) Before September 1, 2022, the division shall convene a meeting to obtain input and recommendations from stakeholders, including representatives of the health-care industry, consumer advocates, and other interested individuals, concerning the methodology for conducting the analysis described in subsection (4) of this section.
(3) (a) A member of the general assembly who requests an actuarial review of a legislative proposal shall submit the request to the division no later than September 1 of the year preceding the regular legislative session in which the legislative proposal will be proposed.
(b) For each regular legislative session:
(I) Up to two members of the majority party of the house of representatives may submit a request for an actuarial review. If more than two requests are submitted, the division shall notify the majority leader of the house of representatives, who shall select the two proposals that the contractors review.
(II) One member of the minority party of the house of representatives may submit up to one request for an actuarial review. If more than one request is submitted, the division shall notify the minority leader of the house of representatives, who shall select the proposal that the contractors review.
(III) Up to two members of the majority party of the senate may submit a request for an actuarial review. If more than two requests are submitted, the division shall notify the majority leader of the senate, who shall select the two proposals that the contractors review.
(IV) One member of the minority party of the senate may submit up to one request for an actuarial review. If more than one request is submitted, the division shall notify the minority leader of the senate, who shall select the proposal that the contractors review.
(c) On or before each September 15, the majority and minority leaders of the house of representatives and the senate shall notify the division, as may be necessary as described in this subsection (3), of the legislative proposals subject to review under subsection (1) of this section.
(4) An actuarial review performed by the contractors pursuant to this section must consider the predicted effects of the legislative proposal during the five and ten years immediately following the effective date of the legislative proposal, or during another time period following the effective date of the legislative proposal if such consideration is more actuarially feasible, including:
(a) An estimate of the number of Colorado residents who will be directly affected by the legislative proposal;
(b) Estimates of changes in the rates of utilization of specific health-care services that may result from the legislative proposal;
(c) Estimates concerning any changes in consumer cost sharing that would result from the legislative proposal;
(d) Estimates of any increases or decreases in premiums charged to covered persons or employers for health benefit plans offered in the individual, small group, and large group markets that would result from the legislative proposal;
(e) An estimate of the out-of-pocket health-care cost changes associated with the legislative proposal;
(f) An estimate of the potential long-term health-care cost changes associated with the legislative proposal;
(g) Identification of any potential health benefits for individuals or communities that would result from the legislative proposal; and
(h) To the extent practicable, the social and economic impacts of the legislative proposal.
(5) An actuarial review performed pursuant to this section must:
(a) Present the information described in subsection (4)(d) of this section in terms of percentage increase or decrease and in terms of per-member, per-month charges;
(b) Present the information described in subsection (4)(e) of this section in terms of dollar amounts;
(c) Provide, if available, information concerning who would benefit from any cost changes and health benefits from the legislative proposal, as identified in subsections (4)(c), (4)(e), (4)(f), (4)(g), and (4)(h) of this section, and any disproportionate effects that the legislative proposal would have on Coloradans, which information, if available, must be disaggregated, at a minimum, by race, ethnicity, sex, gender, and age; and
(d) Include, to the extent practicable, a qualitative analysis of the impacts of the legislative proposal. For the purposes of this subsection (5)(d), a member of the general assembly who requests an actuarial review of a legislative proposal pursuant to this section may designate one or more persons to provide data to the contractors in order to inform a qualitative analysis of the legislative proposal.
(6) In performing actuarial reviews of legislative proposals, the contractors may utilize data from the all-payer health claims database described in section 25.5-1-204, data collected from carriers, or data from other sources. Carriers shall provide information to, and otherwise cooperate with, the contractors and the division for the purposes of this section.
(7) The commissioner is not required to comply with the state Procurement Code, articles 101 to 112 of title 24, for the purposes of hiring contractors by November 1, 2022, as described in subsection (1) of this section, or for contracting for the collection of data, but the commissioner shall comply with the state Procurement Code when hiring contractors or contracting for the collection of data after November 1, 2022.
(8) A request for an actuarial review pursuant to this section and the final report resulting from such a request shall be treated as confidential except by the member of the general assembly who made the request until the legislative proposal that is the subject of the actuarial review is introduced in the regular legislative session following the submission of the request for the actuarial review or, if no such legislative proposal is introduced, until after the end of the legislative session following the submission of the request.
(9) (a) Notwithstanding any other provision of this section to the contrary, the division shall not engage any contractor to perform an actuarial review as described in this section unless the division determines that there are adequate resources available within existing appropriations to compensate the contractor for the actuarial review.
(b) After July 1, 2025, the division shall use resources allocated for actuarial reviews of legislative proposals pursuant to this section for the review of rate filings filed with the commissioner pursuant to section 10-16-105.1 (3.5)(e).
(c) In the event that the division determines there are not adequate resources available within existing appropriations to compensate the contractor for an actuarial review in accordance with subsection (9)(a) of this section, the division shall prioritize resources to ensure that an actuarial review of the rate filings submitted to the commissioner pursuant to section 10-16-105.1 (3.5)(e) occurs before December 31, 2025.
(10) The division may seek, accept, and expend gifts, grants, and donations for the purposes of this section.
(11) This section is repealed, effective November 1, 2027.
Source: L. 2022: Entire section added, (SB 22-040), ch. 449, p. 3163, � 1, effective August 10. L. 2024: (9) amended, (SB 24-073), ch. 146, p. 591, � 3, effective May 1.