(1) There is hereby created in the state department the office of the insurance ombudsman to act as the advocate for consumer interests in matters related to access to and the affordability of the standardized health benefit plan created pursuant to section 10-16-1304. The ombudsman shall:
(a) Interact with consumers regarding their access to, the affordability of, and coverage issues with the standardized plan;
(b) Evaluate data to assess the standardized plan's network and affordability; and
(c) Represent the interests of consumers in public hearings held pursuant to section 10-16-1306.
(2) In the performance of the ombudsman's duties, the ombudsman shall act independently of the state department. Any recommendations made or positions taken by the ombudsman do not reflect those of the state department.
Source: L. 2021: Entire section added, (HB 21-1232), ch. 241, p. 1294, � 7, effective June 16.
25.5-1-132. Report of medicaid reimbursement rates paid to comprehensive community behavioral health providers and independent providers - definition. (1) On or before August 15, 2022, the state department shall publish a behavioral health rates report of medicaid reimbursement rates for comprehensive community behavioral health providers, as defined in section 27-50-101, and independent mental health and substance abuse treatment providers, as described in subsection (2) of this section. The state department shall contract with an independent auditor to prepare the behavioral health rates report, as described in this subsection (1). The state department shall prepare, in coordination with the behavioral health rates report, a set of recommendations on creating equitable payment and payment models that minimize inappropriate payment variation in comparable behavioral health services between comprehensive community behavioral health providers and independent mental health and substance use treatment providers. The state department shall present the behavioral health rates report and recommendations to the house of representatives health and human services committee, or any successor committee.
(2) The report prepared pursuant to subsection (1) of this section must reflect data from state fiscal year 2020-21 and identify discrepancies, if any, and the reasons for such discrepancies in medicaid reimbursement rates paid to providers of a community mental health center and independent mental health and substance abuse treatment providers for comparable services. The report must include a determination of and recommendations on whether reimbursement rates paid to community mental health center providers and independent mental health and substance use treatment providers are adequate to meet or exceed network adequacy standards in every region of the state. The data must be aggregated to ensure individual community mental health centers and independent providers are not identifiable and must comply with any other state and federal privacy laws. On or before November 15, 2022, the state department shall present an action plan for implementation to the joint budget committee. The state department shall produce a progress report on the state department's progress made in implementing the action plan presented to the joint budget committee on November 15, 2022, on or before August 1, 2023, and annually thereafter through August 1, 2025, and provide an update during its State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act hearing pursuant to section 2-7-203 on the findings and additional recommendations. The state department must fully implement the action plan no later than December 31, 2025.
(3) As used in this section, unless the context otherwise requires, independent mental health and substance abuse treatment providers means any outpatient behavioral health provider enrolled in medicaid and contracted with a managed care entity, as defined in section 25.5-5-403 (4), that is not licensed or designated as a community mental health center.
Source: L. 2022: Entire section added, (HB 22-1268), ch. 363, p. 2597, � 2, effective June 3. L. 2025: (1) amended, (HB 25-1326), ch. 309, p. 1611, � 3, effective August 6.
Cross references: For the legislative declaration in HB 22-1268, see section 1 of chapter 363, Session Laws of Colorado 2022.
25.5-1-133. Access to behavioral health services for individuals under twenty-one years of age - rules - report - repeal. (1) On or before July 1, 2024, the state department shall provide members under twenty-one years of age with access to limited services without requiring a diagnosis. The limited services must be provided as part of the statewide managed care system pursuant to part 4 of article 5 of this title 25.5 and the school health services detailed in section 25.5-5-318.
(2) The limited services must include:
(a) Family therapy;
(b) Group therapy;
(c) Individual therapy;
(d) Services related to prevention, promotion, education, or outreach;
(e) Evaluation, intake, case management, and treatment planning; and
(f) Any other service determined necessary by the state department based on feedback received from stakeholders.
(3) In providing the limited services pursuant to this section, the state department must notify patients, providers, the department of human services, county departments of human or social services, law enforcement agencies, schools, and any other entity that may be impacted that the limited services are available on and after July 1, 2024.
(4) In implementing this section, the state department shall engage with interested and impacted stakeholders to solicit feedback.
(5) (a) Notwithstanding section 24-1-136 (11)(a)(I), on or before November 1, 2025, and on or before November 1 each year thereafter, the state department shall report to the house of representatives public and behavioral health and human services committee and the senate health and human services committee, or their successor committees, regarding the utilization of the services described in subsection (2) of this section. The contents of the report must be determined through the stakeholder process described in subsection (4) of this section. At a minimum, the report must include data on the utilization of services, by code, and any differences in utilization within the school health services program authorized by section 25.5-5-318.
(b) This subsection (5) is repealed, effective July 1, 2031.
Source: L. 2023: Entire section added, (SB 23-174), ch. 232, p. 1219, � 1, effective August 7. L. 2024: (1) amended, (SB 24-176), ch. 152, p. 619, � 10, effective August 7; (3) amended, (HB 24-1450), ch. 490, p. 3419, � 56, effective August 7.
25.5-1-134. Prescription benefits - department and pharmacy benefit manager - contracts - audit - rules. (1) For contracts between a pharmacy benefit manager and the state department or one of its affiliated managed care organizations offering a prescription benefit plan that is issued or renewed on or after January 1, 2025, the amount charged by the pharmacy benefit manager to the state department or managed care organization for a prescription drug dispensed to an enrollee in the program of medical assistance created pursuant to section 25.5-4-104 must be equal to or less than the amount paid by the pharmacy benefit manager to a medicaid pharmacy for the prescription drug dispensed to the enrollee.
(2) The state board shall promulgate rules to implement this section, including rules guiding an audit of managed care or fee-for-service claims, to ensure that there is no violation of subsection (1) of this section.
Source: L. 2023: Entire section added, (HB 23-1201), ch. 158, p. 688, � 2, effective August 7.
25.5-1-135. Statewide health-care analysis collaborative - creation - membership - duties - repeal. (1) (a) There is created in the state department the statewide health-care analysis collaborative, referred to in this section as the analysis collaborative, for the purpose of advising the Colorado school of public health in completing the analysis required by section 23-20-146.
(b) The analysis collaborative is merely advisory, and the Colorado school of public health is the entity responsible for conducting the analysis pursuant to section 23-20-146.
(2) (a) On or before August 1, 2025, the executive director shall invite the following representatives to participate in the analysis collaborative:
(I) One member who represents a statewide hospital association;
(II) One member who represents organized labor;
(III) One member who represents an organization that advocates for communities with disabilities;
(IV) One member who is a reproductive health-care advocate;
(V) One member who represents a statewide association of physicians;
(VI) One member who represents a statewide association of mental health-care providers;
(VII) One member who is a state tax expert or an expert on section 20 of article X of the state constitution;
(VIII) One member who is a rural health-care advocate;
(IX) One member who is a registered nurse representing a statewide association of nurses;
(X) One member who represents a Colorado advocacy organization for people experiencing homelessness;
(XI) One member who represents an advocacy organization for health-care consumers;
(XII) One member who represents a statewide association of dentists;
(XIII) One member who represents an advocacy organization for historically marginalized communities;
(XIV) One member who represents an advocacy organization for lesbian, gay, bisexual, transgender, and queer communities;
(XV) One member who represents a statewide association of pharmacists;
(XVI) One member who represents small employer interests;
(XVII) One member who represents large employer interests;
(XVIII) One member who represents a pharmacy benefit management firm, as defined in section 10-16-102 (49);
(XIX) One member who represents a self-insured employer that provides health insurance to its employees under a health insurance plan covered by the federal Employee Retirement Income Security Act of 1974, 29 U.S.C. sec. 1001 et seq.; and
(XX) One member who represents management of organized labor that provides health insurance coverage for individuals who are insured under a health insurance plan covered by the federal Employee Retirement Income Security Act of 1974, 29 U.S.C. sec. 1001 et seq.
(b) In inviting representatives to participate in the analysis collaborative pursuant to subsection (2)(a) of this section, the executive director shall ensure that the invitees:
(I) Have demonstrated an ability to represent the interests of all Coloradans and, regardless of the invitees' backgrounds or affiliations, are able to present objective, nonpartisan, factual, and evidence-based ideas and to objectively advise the Colorado school of public health concerning a single-payer, nonprofit, universal health-care system, as defined in section 23-20-146 (2); and
(II) Reflect the social, demographic, and geographic diversity of the state, including historically marginalized communities.
(c) If a vacancy occurs on the analysis collaborative, the executive director may invite a new representative to fill the vacancy.
(3) The commissioner of insurance and the chief executive officer of the Colorado health benefit exchange created in article 22 of title 10, or the designee of the commissioner or the chief executive officer, shall serve on the analysis collaborative.
(4) (a) The chief executive officer of the Colorado health benefit exchange shall call the first meeting of the analysis collaborative.
(b) The analysis collaborative shall meet at least two times before October 1, 2026, and the chief executive officer of the Colorado health benefit exchange may convene additional meetings of the analysis collaborative as determined by consulting with the members of the analysis collaborative and the Colorado school of public health.
(c) All meetings of the analysis collaborative must be open to the public, and the analysis collaborative shall post notice of a meeting at least one week in advance of the meeting on the Colorado school of public health's website and the state department's website.
(d) All meetings of the analysis collaborative must be held virtually and allow for attendance and participation by members of the analysis collaborative and members of the public virtually.
(e) The analysis collaborative may hold meetings without a quorum of the members present.
(5) At the first meeting of the analysis collaborative, a representative from the entity providing the draft model legislation selected by the Colorado school of public health pursuant to section 23-20-146 (3) shall present the draft model legislation to the analysis collaborative for feedback.
(6) Nonlegislative analysis collaborative members invited pursuant to subsection (2)(a) of this section are not entitled to receive per diem or other compensation for performance of services for the analysis collaborative but may be reimbursed for actual and necessary expenses incurred in the performance of official duties of the analysis collaborative. Legislators who serve on the analysis collaborative are reimbursed pursuant to section 2-2-307 (3).
(7) (a) The state department may seek, accept, and expend gifts, grants, or donations from private or public sources for the purpose of establishing the analysis collaborative.
(b) Unless the state department receives an amount of appropriations, gifts, grants, and donations sufficient to cover the costs of establishing the analysis collaborative, and the Colorado school of public health receives enough money pursuant to section 23-20-146 (8) to implement the costs of research and analysis to implement section 23-20-146, the state department shall not implement this section.
(8) This section is repealed, effective December 1, 2027.
Source: L. 2025: Entire section added, (SB 25-045), ch. 191, p. 852, � 2, effective May 14.