(1) The state department shall distribute money appropriated for a payment to the Denver health and hospital authority created in section 25-29-103.
(2) (Deleted by amendment, L. 2024.)
Source: L. 2023: Entire section added, (SB 23-138), ch. 4, p. 13, � 2, effective March 3. L. 2024: Entire section amended, (HB 24-1086), ch. 46, p. 164, � 3, effective April 4; entire section amended, (HB 24-1401), ch. 100, p. 316, � 1, effective April 18.
Cross references: For the legislative declaration in SB 23-138, see section 1 of chapter 4, Session Laws of Colorado 2023. For the legislative declaration in HB 24-1086, see section 1 of chapter 46, Session Laws of Colorado 2024.
25.5-4-428. Prior authorization for a step-therapy exception - rules - definition. (1) As used in this section, unless the context otherwise requires, step therapy means a protocol that requires a member to use a prescription drug or sequence of prescription drugs, other than the drug that the member's health-care provider recommends for the member's treatment, before the state department provides coverage for the recommended prescription drug.
(2) (a) The state department shall review and determine if an exception to step therapy is granted if the prescribing provider submits a prior authorization request with justification and supporting clinical documentation for treatment of a serious or complex medical condition, if required, that states:
(I) The provider attests that the required prescription drug is contraindicated, or will likely cause intolerable side effects, a significant drug-drug interaction, or an allergic reaction to the member;
(II) The required prescription drug lacks efficacy based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen;
(III) The member has tried the required prescription drug, and the use of the prescription drug by the member was discontinued due to intolerable side effects, a significant drug-drug interaction, or an allergic reaction; or
(IV) The member is stable on a prescription drug selected by the prescribing provider for the medical condition.
(b) (I) Except as provided in subsection (2)(b)(II) of this section, the state department shall provide a response to a prior authorization request for a step-therapy exception within twenty-four hours after receipt of the request.
(II) If a prior authorization request for a step-therapy exception is incomplete or if additional clinically relevant information is required, the state department shall notify the prescribing provider within twenty-four hours after the submission of the request that the request is incomplete or that additional clinically relevant information is required. The state department shall specify the additional information that is required in order to consider the prior authorization request. If the state department does not receive a response within seventy-two hours after the state department's request for additional information, the prior authorization request is denied. If the state department receives a timely response from the provider, the state department shall provide a response within twenty-four hours after receiving the response.
(c) If the prior authorization request for a step-therapy exception is denied, the state department shall inform the member in writing that the member has the right to appeal the adverse determination pursuant to state department rules.
(3) If the prior authorization request for a step-therapy exception request is granted, the state department shall authorize coverage for the prescription drug prescribed by the member's prescribing provider.
(4) The state department shall make the prior authorization requirements for coverage of prescription drugs and a description of the step-therapy exemption process available on the state department's website.
(5) This section does not prohibit:
(a) The state department from requiring a member to try a generic equivalent of a brand name drug, a biosimilar drug as defined in 42 U.S.C. sec. 262 (i)(2), or an interchangeable biological product as defined in 42 U.S.C. sec. 262 (i)(3), unless such a requirement meets any of the criteria set forth in subsection (2)(a) of this section for an exception to step therapy and a prior authorization request is granted for the requested drug;
(b) The state department from denying a prior authorization request for a step-therapy exception when the request does not meet one of the criteria set forth in subsection (2)(a) of this section based on the justification and supporting clinical documentation submitted by the provider, if applicable; or
(c) A provider from prescribing a drug that, in the provider's clinical judgment, is determined to be medically appropriate.
(6) The state board may promulgate rules to implement this section.
Source: L. 2023: Entire section added, (HB 23-1183), ch. 133, p. 511, � 1, effective May 1. L. 2024: (1), (2)(a), (2)(c), (3), and (5)(a) amended, (SB 24-176), ch. 152, p. 643, � 40, effective August 7.
25.5-4-429. Hospital and provider billing requirements - description of service provided - rules. Beginning July 1, 2024, any patient bill for services rendered must follow industry standard billing practices, including, at a minimum, the date of service, the patient's name, the provider's name, a description of the services provided, and the charges for each service.
Source: L. 2023: Entire section added, (HB 23-1226), ch. 306, p. 1875, � 2, effective August 7.
25.5-4-430. Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates. (1) (a) The state department shall analyze how directed payment authority can be used as part of a comprehensive plan to facilitate an adequate network of services for children and youth with behavioral health needs who are under twenty-one years of age and receive medicaid benefits by requiring each managed care entity to pay no less than state department-established fee schedule rates to increase access to care for services needed to promote clinical stabilization. The state department shall analyze how directed payment authority may be applied to clinical stabilization services, including, but not limited to, residential treatment services, multisystemic therapy, functional family therapy, and psychotherapy services for children and youth.
(b) In analyzing directed payment authority and establishing fee schedule rates, the state department shall consider whether the rates should increase based on the acuity of the child or youth.
(2) No later than October 1, 2023, 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, and the joint budget committee whether directed payment authority should be pursued and whether funding should be requested to expand access to residential treatment services, multisystemic therapy, functional family therapy, and psychotherapy services. If the state department determines that directed payments are not appropriate to expand access to such services, the state department shall present an alternative plan to expanding access to the services.
Source: L. 2023: Entire section added, (HB 23-1269), ch. 377, p. 2262, � 1, effective June 5.
25.5-4-431. Preauthorization for treatment - request to share with insurance carrier. Subject to state and federal laws relating to the confidentiality of medical records, at the request and with the consent of an enrollee in the medical assistance program, the state department shall provide a copy of the enrollee's preauthorization for treatment to the enrollee's new insurance carrier within ten days after receipt of the request if the enrollee is no longer enrolled in the medical assistance program.
Source: L. 2024: Entire section added, (SB 24-093), ch. 41, p. 149, � 4, effective January 1, 2025.
Editor's note: Section 5(2) of chapter 41 (SB 24-093), Session Laws of Colorado 2024, provides that the act adding this section applies to health benefit plans issued on or after January 1, 2025.
25.5-4-432. Reimbursement guidance for screening, brief intervention, and referral to treatment. The state department shall publish guidance for providers concerning reimbursement for all variations of screening, brief intervention, and referral to treatment interventions.
Source: L. 2024: Entire section added, (SB 24-047), ch. 440, p. 3081, � 8, effective June 6.