(1) The division shall contract with an independent entity to conduct an actuarial review of the potential health-care costs and benefits of including coverage for doula services for pregnant and postpartum persons covered by health benefit plans.
(2) The division shall present the results from the actuarial review conducted pursuant to subsection (1) of this section to the general assembly as part of the division's SMART Act presentation required by section 2-7-203 during state fiscal year 2024-25.
(3) As used in this section, unless the context otherwise requires, doula means a trained birth companion who provides personal, nonmedical support to pregnant and postpartum people and their families prior to childbirth, during labor and delivery, and during the postpartum period.
Source: L. 2023: Entire section added, (SB 23-288), ch. 279, p. 1655, � 3, effective May 30.
Cross references: For the legislative declaration in SB 23-288, see section 1 of chapter 279, Session Laws of Colorado 2023.
10-16-156. Prescription drugs - rebates - consumer cost reduction - point of sale - study - report - rules - definitions. (1) As used in this section, unless the context otherwise requires:
(a) Discount means price reductions or concessions, including base price concessions or other contractual agreements made by a manufacturer or its affiliate, that reduce payment or liability for prescription drugs, including a reduction in the total amount paid for prescription drugs, without regard to performance, volume, or utilization of the drugs, and all other compensation that reduces payment or liability for prescription drugs. Discount does not include a rebate.
(b) Health insurer means a carrier:
(I) As defined in section 10-16-102 (8); and
(II) As defined in section 24-50-603 (2).
(c) Manufacturer has the same meaning as set forth in section 10-16-1401 (16).
(d) Prescription drug has the same meaning as set forth in section 12-280-103 (42); except that the term includes only prescription drugs that are intended for human use.
(e) Rebate means all price concessions made by a manufacturer or its affiliate that accrue to a PBM or its health insurer client, including credits or incentives that are based on actual or estimated utilization of prescription drugs; that result in the placement of a prescription drug in a preferred drug list or formulary or preferred formulary position; or that are associated with claims administered on behalf of an insurer client. Rebate also includes credits, incentives, refunds, and all other compensation that is performance-based. Rebate does not include a discount.
(2) For each health benefit plan issued or renewed on or after January 1, 2024, a health insurer shall ensure that one hundred percent of discounts received or to be received from a manufacturer in connection with dispensing or administering prescription drugs included in the health insurer's formulary, as demonstrated in the health insurer's rate filing pursuant to section 10-16-107, for that plan year are used to reduce costs.
(3) For each health benefit plan issued or renewed on or after January 1, 2024, a health insurer shall ensure that:
(a) One hundred percent of the estimated rebates received or to be received in connection with dispensing or administering prescription drugs included in the health insurer's formulary for that plan year are used to reduce policyholder costs;
(b) For small group and large group health benefit plans, all rebates are used to reduce employer or individual employee costs; and
(c) For individual health benefit plans, all rebates are used to reduce consumer premiums and out-of-pocket costs for prescription drugs and that health insurers will maximize the use of rebates to reduce consumer out-of-pocket costs at the point of sale, not to exceed the consumer's actual out-of-pocket costs for the prescription drug, if the use of such rebates will not:
(I) Increase premiums;
(II) Change the actuarial value of the plan inconsistent with federal and state requirements; or
(III) Otherwise result in an impact that is not in the best interest of consumers.
(4) (a) On or before June 1, 2023, the division shall conduct and complete a study to evaluate how rebates may be applied in the individual market to reduce a covered person's out-of-pocket costs at the point of sale or to reduce out-of-pocket costs in prescription drug tiers, taking into consideration the following factors:
(I) Premium impacts;
(II) Changes in the plan's actuarial value; and
(III) Other potential impacts to consumers.
(b) Regardless of the results of the study, a health insurer shall comply with subsection (3) of this section.
(c) The division may contract with a third party to conduct the study required by this subsection (4). The commissioner is not required to comply with the Procurement Code, articles 101 to 112 of title 24, for the purposes of this section, but shall ensure a competitive process is used to select a third party to conduct the study.
(5) Each health insurer shall report annually:
(a) In a form and manner determined by the commissioner, data demonstrating that all discounts and rebates received by health insurers are used to reduce costs for policyholders in compliance with this section. The commissioner may use discount and rebate data submitted by health insurers to the all-payer health claims database described in section 25.5-1-204 to the extent such data are available from the all-payer health claims database.
(b) An actuarial certification that attests that:
(I) The health insurer and PBM are in compliance with subsections (2) and (3) of this section; and
(II) The data reported as required by this section are accurate.
(6) The division may use data from the department of health care policy and financing, the all-payer health claims database described in section 25.5-1-204, and other sources to verify that a health insurer and PBM are in compliance with this section.
(7) Information submitted by the health insurers and PBMs to the division in accordance with this section is subject to public inspection only to the extent allowed under the Colorado Open Records Act, part 2 of article 72 of title 24, and in no case shall trade-secret, confidential, or proprietary information be disclosed to any person who is not otherwise authorized to access such information.
(8) This section does not prohibit a health insurer from decreasing cost-sharing amounts or premiums by an amount greater than the amount required in subsection (2) or (3) of this section.
(9) The requirements of subsections (2), (3), and (5) of this section apply to a self-funded health benefit plan and its plan members only if the entity that provides the plan elects to be subject to subsections (2), (3), and (5) of this section for its members in Colorado.
(10) The commissioner shall promulgate rules to implement and enforce this section.
Source: L. 2022: Entire section added, (HB 22-1370), ch. 184, p. 1234, � 6, effective August 10.
10-16-157. Alternative payment model parameters - parameters to include an aligned quality measure set - primary care providers - requirement for carriers to submit alternative payment models to the division - legislative declaration - report - rules - definitions. (1) Legislative declaration. The general assembly hereby finds and declares that:
(a) Fee-for-service health-care payment models have long been criticized for incentivizing a higher volume of health-care services rather than a greater value, perpetuating health disparities by failing to meet the needs of patients with the highest barriers to care;
(b) Underinvestment in primary care has created barriers to access that have deterred patients from seeking timely preventive care and made it more difficult for providers to expand team-based, comprehensive care models that improve health outcomes and reduce downstream costs;
(c) Numerous efforts have been made to move our health-care system from a fee-for-service model to a value-based payment model, including comprehensive primary care plus, patient-centered medical homes, the state innovation model, the multi-payer collaborative, the health-care payment learning and action network, and the primary care payment reform collaborative;
(d) Value-based payment models also have not always recognized the unique nature of pediatrics, which requires approaches that reflect specific needs in pediatric populations;
(e) Colorado is part of the center for medicare and medicaid innovation's state transformation collaborative project, which creates an opportunity for alignment between medicare, medicaid, and commercial insurance plans;
(f) By establishing aligned parameters for primary care alternative payment models, including quality metrics and prospective payments, it is the intent of the general assembly to:
(I) Improve health-care quality and outcomes in a manner that reduces health disparities and actively advances health equity;
(II) Increase the number of Coloradans who receive the right care in the right place at the right time at an affordable cost;
(III) Encourage more primary care practices to participate in alternative payment models; provide consistent expectations; reduce administrative burdens; and help small, rural, and independent practices stay independent;
(IV) Support collaboration between physical and behavioral health-care services and local public health agencies and human services departments to improve population health; and
(V) Facilitate practice transformation toward integrated, whole-person care, so practices can coordinate care and address social determinants of health such as housing stability, social support, and food insecurity.
(2) As used in this section:
(a) Aligned quality measure set means any set of nationally recognized, evidence-based quality measures developed for primary care provider contracts that incorporate quality measures into the payment terms.
(b) Alternative payment model means a health-care payment method that uses financial incentives, including shared-risk payments, population-based payments, and other payment mechanisms, to reward providers for delivering high-quality and high-value care.
(c) Primary care or primary care services means the provision of integrated, equitable, and accessible health-care services by clinicians who are accountable for addressing a large majority of personal health-care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
(d) Primary care payment reform collaborative means the primary care payment reform collaborative convened pursuant to section 10-16-150.
(e) Primary care provider or provider means the following providers, when the provider is practicing general primary care in an outpatient setting:
(I) Family medicine physicians;
(II) General pediatric physicians and adolescent medicine physicians;
(III) Geriatric medicine physicians;
(IV) Internal medicine physicians, excluding internists who specialize in areas such as cardiology, oncology, and other common internal medicine specialties beyond the scope of general primary care;
(V) Obstetrics and gynecology physicians;
(VI) Advanced practice registered nurses and physician assistants;
(VII) Behavioral health providers, including psychiatrists, providing mental health and substance use disorder services when integrated into a primary care setting; and
(VIII) Other provider types specified by the commissioner by rule.
(f) Prospective payment means a payment made in advance of services that is determined using a methodology intended to facilitate care delivery transformation by paying providers according to a formula based on an attributed patient population to provide predictable revenue and flexibility to manage care within a budget to optimize patient outcomes and better manage population health.
(g) Risk adjustment means an adjustment to the payment for primary care services that is determined by quantifying a patient's complexity based on observable data, addressing the time and effort primary care providers spend in caring for patients of different anticipated health needs, and including social factors such as housing instability, behavioral health issues, disability, and neighborhood-level stressors.
(3) (a) (I) The division shall develop alternative payment model parameters by rule for primary care services offered through health benefit plans.
(II) The division shall develop the primary care alternative payment model parameters in partnership with the department of health care policy and financing, the department of personnel, the department of public health and environment, the primary care payment reform collaborative, and carriers and providers participating in alternative payment models in order to optimize and create positive incentives for alignment between health benefit plans offered by carriers and public payers and achieve the following objectives:
(A) Increased access to high-quality primary care services;
(B) Improved health outcomes and reduced health disparities;
(C) Improved patient and family engagement and satisfaction;
(D) Increased provider satisfaction and retention; and
(E) Increased primary care investment that results in increased health-care value.
(III) At a minimum, the alternative payment model parameters must:
(A) Include transparent risk adjustment parameters that ensure that primary care providers are not penalized for or disincentivized from accepting vulnerable, high-risk patients and are rewarded for caring for patients with more severe or complex health conditions and patients who have inadequate access to affordable housing, healthy food, or other social determinants of health;
(B) Utilize patient attribution methodologies that are transparent and reattribute patients on a regular basis, which must ensure that population-based payments are made to a patient's primary care provider rather than other providers who may only offer sporadic primary care services to the patient and include a process for correcting misattribution that minimizes the administrative burden on providers and patients;
(C) Include a set of core competencies around whole-person care delivery that primary care providers should incorporate in practice transformation efforts to take full advantage of various types of alternative payment models; and
(D) Require an aligned quality measure set that considers the quality measures and the types of quality reporting that carriers and providers are engaging in under current state and federal law and includes quality measures that are patient-centered and patient-informed and address: Pediatric, perinatal, and other critical populations; the prevention, treatment, and management of chronic diseases; and the screening for and treatment of behavioral health conditions.
(IV) The division shall annually consider the recommendations on the alternative payment model parameters and positive carrier incentive arrangements provided by the primary care payment reform collaborative and by carriers and providers participating in alternative payment models but not participating in the primary care payment reform collaborative.
(V) The alternative payment models must also:
(A) Ensure that any risk or shared savings arrangements minimize significant financial risk for providers when patient costs exceed what can be predicted;
(B) Incentivize the integration of behavioral health-care services through local partnerships or the hiring of in-house behavioral health staff;
(C) Include prospective payments to providers for health promotion, care coordination, health navigation, care management, patient education, and other services designed to prevent and manage chronic conditions and address social determinants of health;
(D) Recognize the various levels of advancement of alternative payment models and preserve options for carriers and providers to negotiate models suited to the competencies of each individual primary care practice; and
(E) Support evidence-based models of integrated care that focus on measurable patient outcomes.
(b) (I) Except as provided in subsection (3)(b)(II) of this section, for health benefit plans that are issued or renewed on or after January 1, 2025, a carrier shall ensure that any alternative payment models for primary care incorporate the parameters established in this subsection (3).
(II) For managed care plans that are issued or renewed on or after January 1, 2025, and in which services are primarily offered through one medical group contracted with a nonprofit health maintenance organization, a carrier shall ensure that any alternative payment models for primary care incorporate the aligned quality measure set established in subsection (3)(a)(III)(D) of this section.
(c) By December 1, 2023, the commissioner shall promulgate rules detailing the requirements for alternative payment model parameters alignment. The division shall allow carriers the flexibility to determine which network providers and products are best suited to achieve the goals and incentives set by the division in this section.
(4) Once the division has five years of data, the division shall analyze the data and, subject to available appropriations, produce a report on the data that aggregates data across all carriers. The division shall present the findings to the general assembly during the department of regulatory agencies' presentation to legislative committees at hearings held pursuant to the State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act, part 2 of article 7 of title 2.
(5) The division shall retain a third-party contractor to design an evaluation plan for the implementation of primary care alternative payment models by carriers. The plan must include alternative payment models implemented by carriers and providers prior to January 1, 2025. In designing the evaluation plan, the contractor shall, to the extent practicable:
(a) Report on the effects of the alternative payment models on populations that have historically faced systemic barriers to health access;
(b) Report on the effects of the alternative payment models on primary care providers, primary care practices, and primary care practices' ability to stay independent, including the effects on primary care providers' administrative burdens; and
(c) Consider and identify any available data sources or data limitations that should be included or addressed in the evaluation plan to allow for measurement and reporting on the effects of the primary care payment model parameters on such populations, including the collection or analysis of data that is disaggregated, at a minimum, by race, ethnicity, sex, gender, and age.
(6) To support the implementation of aligned primary care alternative payment model parameters by carriers, the division shall retain a third-party contractor to provide technical assistance to carriers. The division shall work with carriers to determine the nature and scope of the technical assistance and other supports that will best facilitate the implementation of aligned primary care alternative payment model parameters.
(7) The commissioner may promulgate rules necessary to implement this section.
(8) Any information submitted to the division in accordance with this section is subject to public inspection only to the extent allowed under the Colorado Open Records Act, part 2 of article 72 of title 24. The division shall not disclose any trade secret or confidential or proprietary information to any person who is not otherwise authorized to access the information, including any confidential or proprietary contractual information between carriers and providers.
Source: L. 2022: Entire section added, (HB 22-1325), ch. 181, p. 1203, � 1, effective August 10.
10-16-158. Treatment of sexually transmitted infection - cost sharing - rules - definition. (1) For health benefit plans issued or renewed on or after January 1, 2025, if the treatment of a sexually transmitted infection, as defined in section 25-4-402 (10), is a covered service, the health benefit plan must provide the coverage without deductibles, copayments, coinsurance, annual or lifetime maximum benefit limits, or other cost sharing for or limits on the coverage for the treatment of a sexually transmitted infection.
(2) The provisions of this section do not apply to a high deductible health benefit plan pursuant to 26 U.S.C. sec. 223, as amended, issued or renewed in this state until an eligible insured's deductible has been met, unless allowed pursuant to federal law.
(3) The commissioner may promulgate rules to implement this section.
(4) As used in this section, treatment means medically necessary care for the management of the existing sexually transmitted infection.
Source: L. 2023: Entire section added, (SB 23-189), ch. 69, p. 257, � 4, effective April 14.
Editor's note: This section is similar to former � 12-170-109 (7) as it existed prior to 2023.