The state department shall provide information to members who receive benefits under this title 25.5 concerning the members' right to appeal a denial of benefits by a third party and shall post information on the state department's website concerning members' abilities to appeal a third party's denial of benefits, including but not limited to providing a link to information on the insurance commissioner's website regarding appeals.
Source: L. 2010: Entire section added, (SB 10-002), ch. 366, p. 1727, � 2, effective June 7. L. 2024: Entire section amended, (SB 24-176), ch. 152, p. 618, � 7, effective August 7.
Cross references: For the legislative declaration in the 2010 act adding this section, see section 1 of chapter 366, Session Laws of Colorado 2010.
25.5-1-128. Provider payments - compliance with state fiscal requirements - rules - definitions. (1) (a) Notwithstanding any provision of law to the contrary, when the state department has regulatory authority over a program and when the provider has already signed a state department-approved provider application to provide a service or to bill the state department or its authorized contractor for a service, the state department-approved provider application shall serve to fulfill the requirements of a commitment voucher and the fiscal requirements of section 24-30-202 (1), C.R.S.
(b) The executive director may promulgate rules to exempt a provider who provides services through a program as described in subsection (1)(a) of this section for any program the state department is authorized by law to administer, including but not limited to:
(I) The Colorado Medical Assistance Act, articles 4 to 6 of this title;
(II) The Children's Basic Health Plan Act, article 8 of this title;
(III) Repealed.
(IV) The school health services program authorized by section 25.5-5-318;
(V) Programs that are funded through the primary care fund, created in section 24-22-117 (2)(b), C.R.S.; and
(VI) The state-funded old age pension health and medical care program pursuant to article 2 of this title.
(1.5) The state department shall maintain a list of enrolled school-based health centers and school-linked health-care services providers. The state department shall develop the list based on grant enrollment data pursuant to section 25-20.5-503 that is provided to the state department by the department of public health and environment. The state department shall establish a process for identifying claims for services provided in these settings.
(2) As used in this section, unless the context otherwise requires, provider means a health-care provider; a mental health-care provider; a pharmacist; a home health agency; a general hospital, birth center, or community clinic licensed or certified by the department of public health and environment pursuant to section 25-1.5-103 (1)(a)(I) or (1)(a)(II); a federally qualified health center, as defined in the federal Social Security Act, 42 U.S.C. sec 1395x (aa)(4); a rural health clinic, as defined in the federal Social Security Act, 42 U.S.C. sec. 1395x (aa)(2); a health maintenance organization issued a certificate of authority pursuant to section 10-16-402; a school district as defined in section 25.5-5-318 (1)(a); or any other entity that provides health care, health-care coordination, outreach, enrollment, or administrative support services to members through fee-for-service, a managed care entity, a behavioral health organization, a medical home, or any system of care that coordinates health care or services as defined and authorized through rules promulgated by the state board or by the executive director.
Source: L. 2012: Entire section added, (HB 12-1054), ch. 14, p. 36, � 1, effective March 15. L. 2024: (1.5) added, (SB 24-034), ch. 404, p. 2775, � 4, effective August 7; (2) amended, (SB 24-176), ch. 152, p. 618, � 8, effective August 7; IP(1)(b) and (2) amended, (HB 24-1399), ch. 76, p. 256, � 21, effective July 1, 2025; and (1)(b)(III)(B) added by revision, (HB 24-1399), ch. 76, pp. 256, 260, �� 21, 33.
Editor's note: (1) Amendments to subsection (2) by HB 24-1399 and SB 24-176 were harmonized, effective July 1, 2025.
(2) Subsection (1)(b)(III)(B) provided for the repeal of subsection (1)(b)(III), effective July 1, 2025. (See L. 2024, pp. 256, 260.)
25.5-1-129. State department proposal - state option for health-care coverage - report to general assembly - waiver authorization - legislative declaration. (1) (a) The general assembly finds that:
(I) Every Coloradan deserves access to high-quality, affordable health care to help support his or her well-being and economic security;
(II) To achieve these goals, Colorado has successfully implemented provisions of the federal Patient Protection and Affordable Care Act that have helped expand access and increase affordability to thousands of Coloradans, including expanding medicaid coverage to more low-income adults and creating the Colorado health benefit exchange;
(III) Despite this success, in several regions of the state, health insurance is not affordable due to high health-care costs and limited or no competition among insurance carriers as well as other marketplace factors, and Coloradans cannot afford the health insurance premiums and out-of-pocket expenses;
(IV) Specifically, Coloradans in fourteen counties have access to only a single health insurance carrier participating in the Colorado health benefit exchange, and the number of uninsured Coloradans in those counties is rising;
(V) Colorado has historically been a national leader in health-care innovation;
(VI) Uncertainty at the federal level requires Colorado to be proactive and explore and implement its own innovative solutions to provide greater access to affordable, high-quality health-care coverage for Colorado residents; and
(VII) A state option for health-care coverage that uses existing state health-care infrastructure may decrease costs for Coloradans, increase competition, and improve access to high-quality, affordable, and efficient health care.
(b) Therefore, the general assembly declares that tasking the state department and the division of insurance in the department of regulatory agencies, referred to in this section as the division, with developing a proposal that considers the feasibility and cost of implementing a state option for health-care coverage that leverages existing state health-care infrastructure, increases competition, improves quality, and provides stable access to affordable health insurance will enable policymakers to consider and create an innovative state option for health insurance coverage to benefit Colorado.
(2) (a) On or before November 15, 2019, the state department and the division shall develop and submit a proposal to the joint budget committee; the public health care and human services and health and insurance committees of the house of representatives; and the health and human services committee of the senate, or any successor committees, for a state option for health-care coverage that leverages existing state infrastructure.
(b) In addition to submitting the proposal to the committees of the general assembly listed in subsection (2)(a) of this section, the state department and the division shall present a summary of the proposal at the annual joint meeting of the house and senate committees conducted during the legislative interim prior to the 2020 legislative session pursuant to section 2-7-203.
(3) The proposal must describe a state option for health-care coverage. The proposal must identify the most effective implementation of a state option based on affordability to consumers at different income levels, administrative and financial burden to the state, ease of implementation, and likelihood of success in meeting the objectives described in subsection (1) of this section.
(4) In developing the proposal, the state department and the division shall:
(a) Conduct actuarial research to identify the potential cost of premiums and cost sharing to pay claims in a plan that is, at a minimum, an essential health-benefit-compliant plan, as defined in section 10-16-102 (22);
(b) Evaluate provider rates necessary to incentivize participation and encourage network adequacy and high-quality health-care delivery;
(c) Evaluate eligibility criteria for individuals and small businesses to participate;
(d) Determine the impact, if any, on the state budget;
(e) Determine the impact on the stability of the individual market, the small group market, and the Colorado health benefit exchange created in article 22 of title 10;
(f) Evaluate the impact on consumers eligible for financial assistance for plans purchased on the exchange;
(g) Determine whether a state option plan should be offered on or off the exchange;
(h) Determine whether the state option plan should be a fully at-risk, managed care, fee-for-service, or accountable care collaborative plan, or a combination thereof;
(i) Determine whether the state option should be offered through the state department, and identify the expected impact, if any, to the Colorado medical assistance program established in articles 4, 5, and 6 of this title 25.5;
(j) Identify the expected impact, if any, to the children's basic health plan established in article 8 of this title 25.5;
(k) Investigate funding options, including but not limited to state funds and federal funds secured through available waivers;
(l) Evaluate the feasibility, legality, and scope of any necessary federal waivers;
(m) Repealed.
(n) Create a statewide definition of affordability for consumers.
(5) In developing the proposal, the state department and the division shall consult with the Colorado health benefit exchange and shall engage in a stakeholder process that includes public and private health insurance experts, as well as consumers, consumer advocates, employers, providers, and carriers.
(6) The proposal submitted to the committees of the general assembly pursuant to this section must include detailed analysis of the proposed state option and the various methods for implementing the proposed state option, as well as any identified statutory or rule changes necessary to implement the proposed state option.
(7) (a) (I) After the proposal created pursuant to this section is submitted and presented to the committees of the general assembly, the state department and the division shall prepare and submit any federal waivers or state plan amendments necessary to fund and implement the state option for health-care coverage as described in the proposal created pursuant to subsection (2)(a) of this section.
(II) The state department's and the division's requests for federal authorization must seek to obtain the maximum amount of federal money available to the state and to persons participating in the state option for health-care coverage.
(b) Notwithstanding the provisions of subsection (7)(a)(I) of this section to the contrary, the preparation and submission of federal waivers or amendments must be delayed if a member of the general assembly files a bill during the 2020 legislative session by the regular bill filing deadline of the house of representatives, as set forth in rule 23 of the joint rules of the senate and house of representatives, that substantially alters the federal authorization required pursuant to the proposal to implement the state option for health-care coverage, and such bill is not postponed indefinitely in the first committee of reference. The department's and the division's waiver preparation process shall resume after the bill is postponed indefinitely or, if passed by the general assembly, the requested waivers or state plan amendments must reflect the requirements in the passed legislation.
(c) Subject to the conditions described in subsection (7)(b) of this section, the state department and the division may promulgate rules, as necessary, for the preparation and submission of federal waivers or state plan amendments necessary to fund and implement the proposal.
Source: L. 2019: Entire section added, (HB 19-1004), ch. 206, p. 2199, � 1, effective May 17. L. 2021: (4)(m) repealed, (SB 21-266), ch. 423, p. 2801, � 19, effective July 2.
25.5-1-130. Improving access to behavioral health services for individuals at risk of entering the criminal or juvenile justice system - duties of the state department. (1) On or before March 1, 2020, the state department shall develop measurable outcomes to monitor efforts to prevent medicaid members from becoming involved in the criminal or juvenile justice system.
(2) On or before July 1, 2021, the state department shall work collaboratively with managed care entities to create incentives for behavioral health providers to accept medicaid members with severe behavioral health disorders. The incentives may include, but need not be limited to, higher reimbursement rates, quality payments to managed care entities for adequate networks, establishing performance measures and performance improvement plans related to network expansion, transportation solutions to incentivize medicaid members to attend health-care appointments, and incentivizing providers to conduct outreach to medicaid members to ensure that they are engaged in needed behavioral health services, including technical assistance with billing procedures. The state department may seek any federal authorization necessary to create the incentives described in this subsection (2).
Source: L. 2019: Entire section added, (SB 19-222), ch. 226, p. 2265, � 2, effective May 20. L. 2020: (2) amended, (SB 20-136), ch. 70, p. 300, � 56, effective September 14. L. 2024: Entire section amended, (SB 24-176), ch. 152, p. 618, � 9, effective August 7.
Cross references: For the legislative declaration in SB 19-222, see section 1 of chapter 226, Session Laws of Colorado 2019. For the legislative declaration in SB 20-136, see section 1 of chapter 70, Session Laws of Colorado 2020.