(1) The federal government allows the state to select optional groups to receive medical assistance. Pursuant to federal law, any person who is eligible for medical assistance under the optional groups specified in this section must receive both the mandatory services specified in sections 25.5-5-102 and 25.5-5-103 and the optional services specified in sections 25.5-5-202 and 25.5-5-203. Subject to the availability of federal financial aid funds, the following are the individuals or groups that Colorado has selected as optional groups to receive medical assistance pursuant to this article 5 and articles 4 and 6 of this title 25.5:
(a) Individuals who would be eligible for but are not receiving cash assistance;
(b) Individuals who would be eligible for cash assistance except for their institutionalized status;
(c) Individuals receiving home- and community-based services as specified in article 6 of this title;
(d) and (e) Repealed.
(f) Individuals receiving only optional state supplement;
(g) Individuals in institutions who are eligible under a special income level. Colorado's program for citizens sixty-five years of age or older or physically disabled or blind, whose gross income does not exceed three hundred percent of the current federal supplemental security income benefit level, qualifies for federal funding under this provision.
(h) Persons who are eligible for cash assistance under the works program pursuant to section 26-2-706, C.R.S.;
(i) Persons who are eligible for the breast and cervical cancer prevention and treatment program pursuant to section 25.5-5-308;
(j) Individuals who are qualified aliens and were or would have been eligible for supplemental security income as a result of a disability but are not eligible for such supplemental security income as a result of the passage of the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Public Law 104-193;
(k) Other qualified aliens who entered or were present in the United States before August 22, 1996;
(l) Children for whom subsidized adoption assistance payments are made by the state pursuant to article 7 of title 26, C.R.S., or foster care maintenance payments are made by the state pursuant to article 5 of title 26, C.R.S., but who do not meet the requirements of Title IV-E of the Social Security Act, as amended;
(m) Parents and caretaker relatives of children who are eligible for the medical assistance program whose family income does not exceed one hundred thirty-three percent of the federal poverty line, adjusted for family size;
(m.5) Pregnant women, whose family income does not exceed one hundred ninety-five percent of the federal poverty line, adjusted for family size;
(n) Repealed.
(o) (I) Individuals with disabilities who are participating in the medicaid buy-in program established in part 14 of article 6 of this title.
(II) Notwithstanding the provisions of subsection (1)(o)(I) of this section, if the money in the healthcare affordability and sustainability hospital provider fee cash fund established pursuant to section 25.5-4-402.4, together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), for individuals with disabilities who are participating in the medicaid buy-in program established in part 14 of article 6 of this title 25.5, the state board by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) may reduce the medical benefits offered or the percentage of the federal poverty line to below four hundred fifty percent or may eliminate this eligibility group.
(III) Repealed.
(p) Subject to federal approval, adults who are childless or without a dependent child in the home, as described in section 1902 (a)(10)(A)(i)(VIII) of the social security act, 42 U.S.C. sec. 1396a, who have attained nineteen years of age but have not attained sixty-five years of age, and whose family income does not exceed one hundred thirty-three percent of the federal poverty line, adjusted for family size;
(q) Children who are continuously eligible for twelve months pursuant to section 25.5-5-204.5;
(r) (I) Persons eligible for a medicaid buy-in program established pursuant to section 25.5-5-206 whose family income does not exceed a specified percentage of the federal poverty line, adjusted for family size and as set by the state board by rule, which percentage shall be not more than four hundred fifty percent.
(II) Notwithstanding the provisions of subsection (1)(r)(I) of this section, if the money in the healthcare affordability and sustainability hospital provider fee cash fund established pursuant to section 25.5-4-402.4, together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), for persons eligible for a medicaid buy-in program established pursuant to section 25.5-5-206, the state board by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) may reduce the medical benefits offered, or the percentage of the federal poverty line, or may eliminate this eligibility group.
(III) Repealed.
(2) (a) A qualified alien, who entered the United States on or after August 22, 1996, shall not be eligible for benefits under this article and articles 4 and 6 of this title, except as provided in section 25.5-5-103 (3), for five years after the date of entry into the United States unless he or she meets the exceptions described in the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Public Law 104-193, as amended. After five years, such qualified alien shall be eligible for benefits under this article and articles 4 and 6 of this title but shall have sponsor income and resources deemed to the individual or family under rules established by the state board of human services pursuant to section 26-2-137, C.R.S.
(b) Notwithstanding the five-year waiting period established in paragraph (a) of this subsection (2), but subject to the availability of sufficient appropriations and the receipt of federal financial participation, the state department may provide benefits under this article and articles 4 and 6 of this title to a pregnant woman who is a qualified alien and a child under nineteen years of age who is a qualified alien so long as such woman or child meets eligibility criteria other than citizenship.
(3) A lawfully residing person who is receiving medicaid nursing facility care or home- and community-based services on July 1, 1997, must continue to receive such services as long as the person meets the eligibility requirements other than citizen status. State general funds may be used to reimburse such care in the event that federal financial participation is not available.
(4) A pregnant person who is lawfully residing is eligible to receive medical assistance as long as the individual meets eligibility requirements other than those related to citizen or immigration status. State general funds may be used to reimburse such care in the event that federal financial participation is not available.
(4.5) (a) Subject to the receipt of federal financial participation, to the maximum extent allowed under federal law, a person who was eligible for the medical assistance program for the sixty days following the pregnancy remains continuously eligible for all services under the medical assistance program for the twelve-month postpartum period.
(b) The state department shall seek any plan amendment necessary to implement a twelve-month postpartum benefit pursuant to this subsection (4.5) and shall implement the benefit only upon receipt of federal authorization and financial participation, and no later than July 1, 2022.
(c) If permissible under federal law, an eligible individual within the postpartum period may resume coverage under the medical assistance program upon implementation of this section.
(5) An asset test shall not be applied as a condition of eligibility for individuals or families described in paragraphs (a), (h), and (m.5) of subsection (1) of this section.
(6) (a) Beginning no later than January 1, 2025, a pregnant person who is not a citizen and who is not eligible for medical assistance pursuant to subsection (4) of this section is eligible to receive medical assistance pursuant to this subsection (6)(a) if the individual meets the eligibility requirements other than those related to citizenship and immigration status.
(b) A pregnant person who is eligible for medical assistance pursuant to this subsection (6) remains continuously eligible for all medical services pursuant to the medical assistance program for the twelve-month postpartum period, so long as eligibility remains in effect pursuant to subsection (4.5)(a) of this section.
(c) The state department shall seek any necessary federal approvals to maximize any available federal financial participation in implementing this subsection (6). Benefits for services obtained pursuant to this subsection (6) must be provided with only state funds if federal financial participation is unavailable for such services.
(d) (I) During its 2024 presentation to the joint budget committee of the general assembly and in its presentation to the health and human services committee of the senate and the health and insurance committee of the house of representatives, or any successor committees, at the hearing held pursuant to section 2-7-203 (2)(a) of the State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act, the state department shall report on its plans and progress in implementing the coverage expansion created pursuant to this subsection (6).
(II) Beginning January 1, 2026, and continuing every January thereafter, the state department, in its presentation to the joint budget committee of the general assembly and in its presentation to the health and human services committee of the senate and the health and insurance committee of the house of representatives, or any successor committees, at the hearing held pursuant to section 2-7-203 (2)(a) of the State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act, shall report on the cost savings and health improvements associated with the coverage expansion created pursuant to this subsection (6).
(7) and (8) Repealed.
Source: L. 2006: Entire article added with relocations, p. 1858, � 7, effective July 1. L. 2007: (1)(n) added, p. 897, � 1, effective May 15. L. 2008: (1)(l) and (1)(n) amended and (1)(o) added, pp. 1532, 2200, �� 1, 2, effective July 1. L. 2009: (1)(m)(I) and (1)(o) amended and (1)(p), (1)(q), and (1)(r) added, (HB 09-1293, ch. 152, p. 645, � 5, effective July 1; (2) amended, (HB 09-1353), ch. 390, p. 1869, � 2, effective July 1, 2010. L. 2010: (5)(c) added, (HB 10-1043), ch. 92, p. 312, � 2, effective April 15; (1)(m)(I), (1)(o)(II), (1)(p)(I), (1)(p)(II), (1)(r)(I), and (1)(r)(II) amended, (HB 10-1422), ch. 419, p. 2111, � 144, effective August 11. L. 2013: (1)(m) and (1)(p) amended, (SB 13-200), ch. 216, p. 898, � 2, effective May 13. L. 2014: (1)(d), (1)(e), and (1)(n) repealed, (1)(m.5) added, and (5) amended, (SB 14-067), ch. 12, p. 113, � 5, effective February 27. L. 2017: IP(1), (1)(o)(II), and (1)(r)(II) amended, (SB 17-267), ch. 267, p. 1465, � 19, effective July 1. L. 2021: (4.5) added, (SB 21-194), ch. 434, p. 2871, � 7, effective September 7. L. 2022: IP(1) and (1)(m.5) amended, (SB 22-052), ch. 43, p. 217, � 3, effective March 24; (3), (4), and (4.5)(a) amended and (6) added, (HB 22-1289), ch. 399, p. 2842, � 16, effective June 7. L. 2023: (7) and (8) added, (SB 23-182), ch. 118, p. 430, � 2, effective April 27. L. 2024: IP(7)(a), (7)(b), and (7)(c) amended, (HB 24-1400), ch. 77, p. 261, � 2, effective April 18. L. 2025: (1)(o)(II) and (1)(r)(II) amended, (SB 25-270), ch. 151, p. 605, � 13, effective May 1.
Editor's note: (1) This section is similar to former � 26-4-301 as it existed prior to 2006.
(2) Prior to the amendment of subsection (1)(m) in 2013, subsection (1)(m)(II)(B) provided for the repeal of subsection (1)(m)(II), effective January 1, 2007. (See L. 2006, p. 1858.)
(3) Prior to the amendment of subsection (5) in 2014, subsection (5)(b)(II) provided for the repeal of subsection (5)(b), effective July 1, 2007. (See L. 2006, p. 1858.)
(4) Subsection (1)(o)(III)(C) provided for the repeal of subsection (1)(o)(III), effective the July 1 following the revisor of statutes' receipt of the notice required pursuant to subsection (1)(o)(III)(B). (See L. 2009, p. 645.) The revisor of statutes received said notice dated March 23, 2012.
(5) Prior to the amendment of subsection (1)(p) in 2013, subsection (1)(p)(III)(C) provided for the repeal of subsection (1)(p)(III), effective the July 1 following the revisor of statutes' receipt of the notice required pursuant to subsection (1)(p)(III)(B). (See L. 2009, p. 645.) The revisor of statutes received said notice dated April 2, 2012.
(6) Subsection (1)(r)(III)(C) provided for the repeal of subsection (1)(r)(III), effective the July 1 following the revisor of statutes' receipt of the notice required pursuant to subsection (1)(r)(III)(B). (See L. 2009, p. 645.) The revisor of statutes received said notice dated February 17, 2017.
(7) Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017, provides that the section of the act changing this section does not take effect if the centers for medicare and medicaid services determine that the amendments do not comply with federal law. For more information, see SB 17-267. (L. 2017, p. 1478.) The executive director of the department of health care policy and financing did not notify the revisor of statutes by June 1, 2017, of such determination; therefore, the changes to this section took effect July 1, 2017.
(8) Subsection (8)(c) provided for the repeal of subsection (8), effective May 31, 2023. (See L. 2023, p. 430.)
(9) Subsection (7)(c) provided for the repeal of subsection (7), effective January 1, 2025. (See L. 2024, p. 261.)
Cross references: For the legislative declaration in SB 17-267, see section 1 of chapter 267, Session Laws of Colorado 2017. For the legislative declaration in HB 22-1289, see section 1 of chapter 399, Session Laws of Colorado 2022.
25.5-5-202. Basic services for the categorically needy - optional services - repeal. (1) Subject to the provisions of subsection (2) of this section, the following are services for which federal financial participation is available and that Colorado has selected to provide as optional services under the medical assistance program:
(a) (I) Prescribed drugs.
(II) Notwithstanding subsection (1)(a)(I) of this section, pursuant to section 25.5-5-503, prescribed drugs are not a covered benefit under the medical assistance program for a member who is enrolled in a prescription drug benefit program under medicare; except that, if a prescribed drug is not a covered Part D drug as defined in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub.L. 108-173, the prescribed drug may be a covered benefit if it is otherwise covered under the medical assistance program and federal financial participation is available.
(a.5) Over-the-counter medications, as specified in section 25.5-5-322;
(b) Clinic services, as defined in sections 25.5-5-301 and 25.5-5-302;
(c) Home- and community-based services, as specified in article 6 of this title 25.5, which include:
(I) Home- and community-based services for individuals who are elderly or blind and individuals with disabilities, as specified in part 3 of article 6 of this title;
(II) Home- and community-based services for persons with intellectual and developmental disabilities, as specified in part 4 of article 6 of this title;
(III) Repealed.
(IV) Home- and community-based services for persons with major mental health disorders, as specified in part 6 of article 6 of this title 25.5;
(V) Home- and community-based services for persons with brain injury, as specified in part 7 of article 6 of this title;
(d) Optometrist services;
(e) Eyeglasses when necessary after surgery;
(f) Prosthetic devices, including medically necessary augmentative communication devices; except that nonsurgically implanted prosthetic devices shall be included only after July 1, 1998, and only if the general assembly approves appropriations for these devices as a new benefit;
(g) Rehabilitation services as appropriate to behavioral health safety net providers as defined in section 27-50-101;
(h) Intermediate care facilities for individuals with intellectual disabilities;
(i) Inpatient psychiatric services for persons under twenty-one years of age;
(j) Inpatient psychiatric services for persons over the age of sixty-five;
(k) Case management;
(l) Therapies under home health services, including:
(I) Speech and audiology;
(II) Physical;
(III) Occupational;
(m) Services of a licensed psychologist;
(n) Private duty nursing services;
(o) Podiatry services;
(p) Hospice care;
(q) The program of all-inclusive care for the elderly;
(r) For any pregnant woman who is enrolled or eligible for services pursuant to section 25.5-5-101 (1)(c), alcohol and substance use disorder counseling and treatment, including outpatient and residential care but not including room and board while receiving residential care;
(s) (I) Outpatient substance use disorder treatment.
(II) Repealed.
(t) Cervical cancer immunization for all females under twenty years of age;
(u) (I) Screening, brief intervention, and referral to treatment for individuals at risk of substance abuse, including referral to the appropriate level of intervention and treatment.
(II) Notwithstanding the provisions of subparagraph (I) of this paragraph (u), services relating to screening, brief intervention, and referral to treatment shall not take effect unless all necessary approvals under federal law and regulation have been obtained to receive federal financial participation for the costs of such services.
(v) (I) Counseling by primary care providers and other specialty providers caring for persons with serious, chronic, or terminal illness relating to medical orders for scope of treatment, which counseling may be reimbursed.
(II) Notwithstanding the provisions of subparagraph (I) of this paragraph (v), counseling relating to medical orders for scope of treatment shall not take effect unless all necessary approvals under federal law and regulation have been obtained to receive federal financial participation for the costs of such services.
(w) Dental services for adults.
(x) (I) Residential and inpatient substance use disorder treatment and medical detoxification services pursuant to section 25.5-5-325.
(II) Notwithstanding the provisions of subsection (1)(x)(I) of this section, residential and inpatient substance use disorder treatment shall not take effect unless all necessary approvals under federal law and regulation have been obtained to receive federal financial participation for the costs of such services.
(y) For any perinatal person, comprehensive lactation support services, lactation supplies and equipment, and maintenance of multi-user loaned equipment. An individual trained in advanced lactation support shall provide the lactation support services. Lactation equipment must include a single-user double electric breast pump, pump parts and pump collection kit, and access to a loaned multi-user hospital grade electric breast pump along with a compatible individual collection kit. Individuals must have access to single-user lactation supplies and equipment prior to delivery. Access to multi-user loaned breast pumps shall be authorized by a health-care provider. Access to multi-user loaned breast pumps is prioritized for individuals with premature, medically fragile, low birth weight infants, and with lactation complications. Individuals cannot be required to enroll in separate or additional programs in order to receive covered lactation equipment or lactation support services.
(2) In addition to the services described in subsection (1) of this section and subject to continued federal financial participation, Colorado has selected to provide transportation services as an administrative cost.
(3) In order to keep expenditures within approved appropriations, the state board may, by rule, establish limits on a service provided pursuant to this section so long as the service provided is sufficient in the amount, duration, and scope to reasonably achieve the purpose of the service as required by federal law or regulation. When a rule is promulgated pursuant to this subsection (3), the state board shall provide a summary report of the limitations established by the rule and any fiscal impact of the rule to members of the health and human services committees of the senate and house of representatives, or any successor committees, and any other members of the general assembly who request the reports.
(4) The state department and the behavioral health administration in the department of human services, in collaboration with community mental health services providers and substance use disorder providers, shall establish rules that standardize utilization management authority timelines for the nonpharmaceutical components of medication-assisted treatment for substance use disorders.
(5) (a) No later than December 1, 2025, the state department shall, in collaboration with the department of human services, the behavioral health administration, and relevant stakeholders, develop policies to transition qualified residential treatment programs, as defined in section 26-5.4-102, and psychiatric residential treatment facilities, as defined in section 25.5-4-103, to the statewide managed care system, part 4 of this article 5, for members who are in the care and custody of a county department of human or social services. The policies may include improving discharge planning, connection across systems, standard utilization management policies, and step-down service plans.
(b) No later than July 1, 2026, the state department shall implement the policies developed pursuant to subsection (5)(a) of this section.
(c) This subsection (5) is repealed, effective July 1, 2027.
Source: L. 2006: Entire article added with relocations, p. 1860, � 7, effective July 1. L. 2007: (1)(t) added, p. 1348, � 2, effective May 29. L. 2010: (1)(r) amended, (HB 10-1043), ch. 92, p. 313, � 3, effective April 15; (1)(a.5) added, (SB 10-117), ch. 227, p. 985, � 1, effective July 1; (1)(u) added, (HB 10-1033), ch. 346, p. 1601, � 1, effective August 11. L. 2013: (1)(h) amended, (SB 13-167), ch. 394, p. 2290, � 2, effective June 5; (1)(u)(II) amended and (1)(w) added, (SB 13-242), ch. 189, p. 761, � 1, effective August 7; (1)(v) added, (HB 13-1202), ch. 117, p. 401, � 1, effective August 7. L. 2014: (1)(r) amended, (SB 14-067), ch. 12, p. 114, � 6, effective February 27; (1)(c)(I) and (1)(c)(II) amended, (SB 14-118), ch. 250, p. 985, � 20, effective August 6. L. 2017: IP(1), (1)(r), and (1)(s)(I) amended, (SB 17-242), ch. 263, p. 1327, � 199, effective May 25; (1)(s)(II) repealed, (SB 17-294), ch. 264, p. 1409, � 92, effective May 25. L. 2018: (1)(x) added, (HB 18-1136), ch. 373, p. 2269, � 1, effective June 5; IP(1)(c) and (1)(c)(IV) amended, (SB 18-091), ch. 35, p. 388, � 25, effective August 8; (1)(c)(III) repealed, (SB 18-093), ch. 62, p. 610, � 3, effective August 8; (4) added, (HB 18-1431), ch. 313, p. 1893, � 14, effective January 1, 2019. L. 2022: (1)(y) added, (HB 22-1289), ch. 399, p. 2843, � 17, effective June 7; (4) amended, (HB 22-1278), ch. 222, p. 1513, � 69, effective July 1; (1)(g) amended, (HB 22-1278), ch. 222, p. 1593, � 233, effective July 1, 2024. L. 2024: (1)(a)(II) amended, (SB 24-176), ch. 152, p. 645, � 44, effective August 7. L. 2025: (5) added, (SB 25-294), ch. 329, p. 1710, � 2, effective May 31.
Editor's note: (1) This section is similar to former � 26-4-302 as it existed prior to 2006.
(2) The legislative audit committee did not adopt a resolution by March 31, 2011, as provided for in subsection (1)(s)(II).
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter 263, Session Laws of Colorado 2017. For the legislative declaration in SB 18-091, see section 1 of chapter 35, Session Laws of Colorado 2018. For the legislative declaration in SB 18-093, see section 1 of chapter 62, Session Laws of Colorado 2018. For the legislative declaration in HB 22-1289, see section 1 of chapter 399, Session Laws of Colorado 2022.