(1) As used in this section, unless the context otherwise requires, provider means a person or entity that delivers disposable medical supplies or durable medical equipment products or services directly to a member.
(2) On and after January 1, 2007, the state board rules for the payment for disposable medical supplies and durable medical equipment, including but not limited to prosthetic and orthotic devices, shall prohibit a provider from being reimbursed unless the provider:
(a) (I) Has one or more physical locations within the state of Colorado or within fifty miles of a border of Colorado with a street address, a local business telephone number, an inventory, and a sufficient staff to service or repair products; except that the requirements of this paragraph (a) shall not apply to durable medical equipment or disposable medical supplies that are medically necessary and cannot be purchased from a provider meeting the requirements of this paragraph (a);
(II) Complies with all state and local licensing, insurance, and regulatory requirements for operating the provider's business;
(III) Is responsible for the delivery of and instructing the member on the proper use of the equipment; and
(IV) Provides repairs, replacements, or adjustments to the provider's products pursuant to rules of the state board; or
(b) Contracts with a provider who meets the criteria established in paragraph (a) of this subsection (2).
(3) The provisions of this section shall apply to fee-for-service and primary care physician program recipients.
Source: L. 2006: Entire section added, p. 525, � 1, effective August 7. L. 2024: (1) and (2)(a)(III) amended, (SB 24-176), ch. 152, p. 642, � 38, effective August 7.
Editor's note: This section was originally numbered as � 26-4-410.7 in House Bill 06-1299. Section 2 of the act provided for the renumbering and relocation of � 26-4-410.7 to this section. (See L. 2006, p. 526.)
25.5-4-417. Provider fee - medicaid providers - state plan amendment - rules - definitions. (1) For purposes of this section, unless the context otherwise requires:
(a) Local government means a county, home rule county, home rule or statutory city, town, territorial charter city, or city and county.
(b) Provider fee means a licensing fee, assessment, or other mandatory payment that is related to health-care items or services as specified under 42 CFR 433.55.
(c) Qualified provider means a hospital licensed pursuant to section 25-3-101, C.R.S., or a certified home health-care agency within the territorial boundaries of the local government.
(2) For the purpose of sustaining or increasing reimbursement for providing medical care under the state's medical assistance program and to low-income populations, the state department shall amend the state plan effective July 1, 2006. Implementation of the state plan amendment shall be subject to the approval of the federal government. The imposition and collection of a provider fee by a local government pursuant to article 28 of title 29, C.R.S., shall be prohibited without the federal government's approval of a state plan amendment authorizing federal financial participation for the provider fees.
(3) In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1) and (e)(2), the state department may seek a waiver from the broad-based provider fee requirement or the uniform provider fee requirement, or both, to exclude qualified providers from the provider fee.
(4) To the extent authorized by federal law, the state department may exclude a governmental qualified provider from payment of the provider fee, benefits from the provider fee, or any federal financial participation due to the fee.
(5) To the extent authorized by federal law, the state department shall distribute the provider fee and any associated federal financial participation either to a local government that has certified payment to qualified providers within the local government or directly to the qualified providers. The state department shall establish reimbursement methods to distribute the provider fee and associated federal financial participation to qualified providers. The state department may alter reimbursement methods to qualified providers participating under the state's medical assistance program to the extent necessary to meet the federal requirements and to obtain federal approval of the provider fee. The state department shall work with a statewide association of hospitals on changes to reimbursement methods or provider fees that impact hospital providers. The state department shall work with a statewide association of home health-care agencies on changes to reimbursement methods or provider fees that impact home health-care agencies.
(6) The state board shall adopt any rules necessary for the administration and implementation of this section.
Source: L. 2006: Entire section added, p. 887, � 2, effective May 5. L. 2008: Entire section amended, p. 927, � 1, effective May 20. L. 2024: (5) amended, (HB 24-1399), ch. 76, p. 258, � 28, effective July 1, 2025.
Editor's note: This section was enacted as � 26-4-427 in Senate Bill 06-145 but was relocated due to its harmonization with this article as it appeared in Senate Bill 06-219.
25.5-4-418. Integration of physical and behavioral health services - department review - report - repeal. (Repealed)
Source: L. 2011: Entire section added, (HB 11-1242), ch. 271, p. 1230, � 1, effective July 1.
Editor's note: Subsection (4) provided for the repeal of this section, effective July 1, 2012. (See L. 2011, p. 1230.)
25.5-4-419. Supplemental state payment to qualified providers - office-administered drugs - no federal financial participation - definition - rules - repeal. (Repealed)
Source: L. 2018: Entire section added, (HB 18-1330), ch. 146, p. 932, � 1, effective April 23.
Editor's note: Subsection (6) provided for the repeal of this section, effective July 1, 2019. (See L. 2018, p. 932.)
25.5-4-420. Providers to obtain unique NPI - service site - provider type - definitions. (1) As used in this section:
(a) Health care clearinghouse has the same meaning as set forth in 45 CFR 160.103.
(b) NPI or national provider identifier means the standard, unique health identifier for health-care providers that is issued by the national provider system in accordance with 45 CFR part 162.
(c) Off-campus location means a facility:
(I) Whose operations are directly or indirectly owned or controlled by, in whole or in part, or affiliated with a hospital, regardless of whether the operations are under the same governing body as the hospital;
(II) That is located more than two hundred fifty yards from the hospital's main campus;
(III) That provides services that are organizationally and functionally integrated with the hospital; and
(IV) That is an outpatient facility providing preventive, diagnostic, treatment, or emergency services.
(d) Organization health-care provider means a provider that is not an individual and includes a hospital.
(e) Subpart has the same meaning as that term is used in 45 CFR part 162 and means a component or separate physical location of an organization health-care provider that may be separately licensed or certified by the state.
(2) (a) Each organization health-care provider and each subpart that is required or eligible to obtain an NPI pursuant to 45 CFR 162.410 must apply for, obtain, and use, on all claims for payment for medical care, services, or goods authorized under this article 4 and articles 5 and 6 of this title 25.5, a unique NPI for each site at which the organization health-care provider or its subparts deliver medical care, services, or goods.
(b) Each organization health-care provider and each subpart that is required or eligible to obtain an NPI pursuant to 45 CFR 162.410 must apply for, obtain, and use, on all claims for payment for medical care, services, or goods authorized under this article 4 and articles 5 and 6 of this title 25.5, a unique NPI for each provider type, as specified by the state department, under which the organization health-care provider or its subparts deliver medical care, services, or goods.
(c) An organization health-care provider or subpart submitting a claim for payment for medical care, services, or goods rendered under this article 4 or article 5 or 6 of this title 25.5 shall include on the claim the unique NPI that identifies both the site where the medical care, services, or goods were provided and the provider type, as specified by the state department, regardless of whether the claim is filed or submitted by or through a central office of the organization health-care provider or a health care clearinghouse.
(3) (a) For an organization health-care provider that is a licensed or certified hospital contracting for services under this article 4 and articles 5 and 6 of this title 25.5, the hospital shall obtain and use a unique, separate, and distinct NPI for:
(I) Its main campus;
(II) Each off-campus location of the hospital; and
(III) Each provider type, if specified by the state department, when the hospital delivers medical care, services, or goods at either the hospital's main campus or at an off-campus location.
(b) A hospital submitting a claim for payment for medical care, services, or goods rendered under this article 4 or article 5 or 6 of this title 25.5 shall include on the claim the unique NPI that identifies both the site where the medical care, services, or goods were provided and the provider type, as specified by the state department, regardless of whether the claim is filed or submitted by or through a central office of the hospital or a health care clearinghouse.
(4) (a) Starting January 1, 2020, an organization health-care provider applying to enroll as a new provider under this article 4 and articles 5 and 6 of this title 25.5 shall demonstrate that it has obtained one or more NPIs as required by this section, and upon enrollment, shall use its unique NPI on every claim for payment in the manner required by this section.
(b) Starting January 1, 2021, an organization health-care provider enrolled and applying for revalidation as a provider under this article 4 and articles 5 and 6 of this title 25.5 shall demonstrate that it has obtained one or more NPIs as required by this section as a condition of receiving revalidation, and upon receiving revalidation as a provider, shall use its unique NPI on every claim for payment in the manner required by this section.
Source: L. 2018: Entire section added, (HB 18-1282), ch. 158, p. 1109, � 3, effective August 8.
Cross references: For the legislative declaration in HB 18-1282, see section 1 of chapter 158, Session Laws of Colorado 2018.
25.5-4-421. Supplemental state payment to qualified durable medical equipment providers - no federal financial participation - definition - rules - repeal. (Repealed)
Source: L. 2018: Entire section added, (HB 18-1329), ch. 206, p. 1323, � 1, effective May 4.
Editor's note: Subsection (6) provided for the repeal of this section, effective July 1, 2019. (See L. 2018, p. 1323.)
25.5-4-422. Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules. (1) It is the intent of the general assembly that:
(a) The department of health care policy and financing pursue strategies to control costs in the medicaid program authorized in the Colorado Medical Assistance Act;
(b) The state department dedicate permanent staff and resources to pursue cost-control strategies, value-based payments, and other approaches to reduce the rate of expenditure growth in the medicaid program; and
(c) This section not preclude the state department from pursuing other cost-containment activities that are not specifically described in this section.
(2) (a) The state department shall provide information regarding medicaid expenditures and the quality of medical services provided by providers participating in the medicaid program to providers participating in the accountable care collaborative pursuant to section 25.5-5-419.
(b) The state department shall provide information regarding medicaid expenditures and the quality of available pharmaceuticals prescribed by providers participating in the medicaid program to providers participating in the accountable care collaborative pursuant to section 25.5-5-419.
(c) The state department may provide the information described in subsections (2)(a) and (2)(b) of this section to other providers participating in the medicaid program.
(3) (a) The state department shall utilize the medicaid management information system to ensure that claims are automatically reviewed prior to payment to identify and correct improper coding that leads to inappropriate payment in medicaid claims.
(b) The state department may procure commercial technology to implement the requirements of subsection (3)(a) of this section.
(4) (a) The state department shall pursue cost-control strategies, value-based payments, and other approaches to reduce the rate of expenditure growth in the medicaid program.
(b) Prior to implementing and reporting on any new measures authorized by this section, the state department shall provide an opportunity for affected members, providers, and stakeholders to provide feedback and make recommendations on the state department's proposed implementation.
(5) By November 1, 2018, the state department shall provide a report to the joint budget committee concerning:
(a) The feedback received pursuant to subsection (4)(b) of this section; and
(b) The timelines for implementation of any cost-control measures enacted pursuant to this section.
(c) Repealed.
(6) (a) The state department shall contract with a third party to perform an independent evaluation of the cost-control measures authorized pursuant to this section.
(b) Repealed.
(7) The state board shall adopt any rules necessary for the administration and implementation of this section.
Source: L. 2018: Entire section added, (SB 18-266), ch. 264, p. 1622, � 1, effective May 29. L. 2024: (4)(b) amended and (5)(c) and (6)(b) repealed, (SB 24-176), ch. 152, p. 642, � 39, effective August 7.