(1) (a) Subject to approval through the state budget process described in subsection (1)(b) of this section, the state board shall adopt by rule a system to allow pharmacies to be reimbursed for providing certain over-the-counter medications to members if prescribed by a licensed practitioner authorized to prescribe prescription drugs or, subject to the limitations contained in subsection (2) of this section, a licensed pharmacist. Over-the-counter medications subject to reimbursement pursuant to this section must be identified through the drug utilization review process established in section 25.5-5-506, and are limited to medications that, if reimbursed, result in overall cost savings to the state.
(b) After the list of over-the-counter medications is identified pursuant to paragraph (a) of this subsection (1), the state department shall request, through the state budget process, that the reimbursements be implemented. The state department shall report to the joint budget committee annually concerning the amount of any savings realized from the reimbursements.
(2) (a) The state board, in consultation with the state board of pharmacy created pursuant to section 12-280-104, shall establish by rule standards for when a licensed pharmacist may prescribe over-the-counter medications as provided under this section for purposes of receiving reimbursement under the medical assistance program.
(b) When prescribing over-the-counter medications under this section, a licensed pharmacist shall consult with the member to determine necessity, provide drug counseling, review drug therapy for potential adverse interactions, and make referrals as needed to other health-care professionals.
Source: L. 2010: Entire section added, (SB 10-117), ch. 227, p. 985, � 2, effective July 1. L. 2012: (2)(a) amended, (HB 12-1311), ch. 281, p. 1628, � 75, effective July 1. L. 2019: (2)(a) amended, (HB 19-1172), ch. 136, p. 1709, � 183, effective October 1. L. 2024: (1)(a) and (2)(b) amended, (SB 24-176), ch. 152, p. 647, � 50, effective August 7.
25.5-5-323. Complex rehabilitation technology - no prior authorization - metrics - report - rules - legislative declaration - definitions. (1) The general assembly finds and declares it is in the best interests of the people of the state of Colorado to:
(a) Continue to protect access to important technology and supporting services for eligible members;
(b) Establish and improve current safeguards relating to the delivery, provision, and repair of medically necessary complex rehabilitation technology;
(c) Continue to provide supports for members accessing complex rehabilitation technology to stay in the home or community setting; engage in basic activities of daily living and instrumental activities of daily living, including employment; prevent institutionalization; and prevent hospitalization and other costly secondary complications; and
(d) Continue adequate pricing for complex rehabilitation technology for the purpose of allowing continued access to appropriate products and related services including maintenance and repair.
(2) As used in this section, unless the context otherwise requires:
(a) Complex rehabilitation technology means individually configured manual wheelchair systems, power wheelchair systems, adaptive seating systems, alternative positioning systems, standing frames, gait trainers, and specifically designated options and accessories classified as durable medical equipment that:
(I) Are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living, including employment, identified as medically necessary to promote mobility in the home and community or prevent hospitalization or institutionalization of the member;
(II) Are primarily used to serve a medical purpose and generally not useful to a person in the absence of illness or injury; and
(III) Require certain services provided by a qualified complex rehabilitation technology provider to ensure appropriate design, configuration, and use of such items, including patient evaluation or assessment of the member by a health-care professional, and that are consistent with the member's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
(b) Individually configured means that a device has features, adjustments, or modifications specific to a member that a qualified complex rehabilitation technology supplier provides by measuring, fitting, programming, adjusting, adapting, and maintaining the device so that the device is consistent with an assessment or evaluation of the member by a health-care professional and consistent with the member's medical condition, physical and functional needs and capacities, body size, period of need, and intended use.
(c) Qualified complex rehabilitation technology professional means an individual who is certified by the rehabilitation engineering and assistive technology society of North America or other nationally recognized accrediting organizations as an assistive technology professional.
(d) Qualified complex rehabilitation technology supplier means a company or entity that:
(I) Is accredited by a recognized accrediting organization as a supplier of complex rehabilitation technology;
(II) Meets the supplier and quality standards established for durable medical equipment suppliers under the medicare or medicaid program;
(III) Employs at least one qualified complex rehabilitation technology professional for each location to:
(A) Analyze the needs and capacities of members for a complex rehabilitation technology item in consultation with the evaluating clinical professionals;
(B) Assist in selecting appropriate complex rehabilitation technology items for such needs and capacities; and
(C) Provide the member technology-related training in the proper use and maintenance of the selected complex rehabilitation technology items;
(IV) Has the qualified complex rehabilitation technology professional directly involved with the assessment and determination of the appropriate individually configured complex rehabilitation technology for the member, with the involvement to include seeing the member visually either in person or by any other real-time means within a reasonable time frame during the determination process.
(V) Maintains a reasonable supply of parts, adequate physical facilities, and qualified service or repair technicians to provide members with prompt service and repair of all complex rehabilitation technology it sells or supplies; and
(VI) Provides the member written information at the time of sale as to how to access service and repair.
(3) The state department shall provide a separate recognition within the state's medicaid program established pursuant to this article 5 and articles 4 and 6 of this title 25.5 for complex rehabilitation technology and shall make other required changes to protect member access to appropriate products and services. The separate recognition must take into consideration the customized nature of complex rehabilitation technology and the broad range of related services necessary to meet the unique medical and functional needs of members and include the following:
(a) The state department notifying the qualified rehabilitation technology suppliers concerning the parameters of the complex rehabilitation technology benefit, which benefit must include the use of qualified rehabilitation technology suppliers as well as billing procedures that specify the types of equipment identified and included in the complex rehabilitation technology benefit. The state department shall create complex rehabilitation technology benefit parameters that are easily understood by and accessible to members and qualified rehabilitation technology suppliers. The state department shall provide public notice no later than thirty days prior to a collaborative process that includes discussion of any proposed changes to the types of equipment identified and included in the complex rehabilitation technology benefit.
(b) Adopting specific supplier standards, as described in paragraph (d) of subsection (2) of this section, for companies or entities that provide complex rehabilitation technology and restricting the provision of complex rehabilitation technology to those companies or entities that are qualified complex rehabilitation suppliers;
(c) Ensuring that members receiving complex rehabilitation technology are evaluated or assessed, as needed, by:
(I) A qualified health-care professional, including but not limited to a licensed physical therapist, a licensed occupational therapist, or other licensed health-care professional who has no financial relationship with the qualified complex rehabilitation technology supplier and performs specialty evaluations within his or her scope of practice; and
(II) A qualified complex rehabilitation technology professional employed by the qualified complex rehabilitation technology supplier. The assessment and determination performed by the qualified complex rehabilitation technology professional employed by the qualified complex rehabilitation supplier shall continue to be included in the reimbursement for the purchased or rented complex rehabilitation technology;
(d) Continuing pricing policies for complex rehabilitation technology, unless specifically prohibited by the federal centers for medicare and medicaid services, including the following:
(I) Continuing to ensure that the reimbursement amounts for complex rehabilitation technology, repairs, and supporting clinical complex rehabilitation technology services are adequate to ensure that eligible members have access to the items, taking into account the unique needs of the members and the complexity and customization of complex rehabilitation technology. This includes developing pricing policies that ensure access to adequate and timely repairs.
(II) Exempting complex rehabilitation technology from inclusion in competitive bidding programs or similar processes; and
(III) Preserving the option for complex rehabilitation technology to be billed and paid for as a purchase allowing for lump sum payments for devices with a length of need of one year or greater, excluding approved crossover claims for members enrolled in medicare and medicaid; and
(e) Making other changes as needed to protect access to complex rehabilitation technology for members.
(4) The state department shall not require prior authorization for any repair of complex rehabilitation technology.
(5) (a) No later than October 1, 2023, the state board shall promulgate rules establishing repair metrics for all complex rehabilitation technology suppliers and complex rehabilitation technology professionals. At a minimum, the metrics must include requirements for repairing complex rehabilitation technology in a timely manner and the expected quality of each repair. Prior to promulgating rules pursuant to this subsection (5)(a), the state department shall engage in a stakeholder process, which process must include qualified complex rehabilitation technology professionals, qualified complex rehabilitation technology suppliers, and complex rehabilitation technology members.
(b) Beginning January 2024, and each January thereafter, the state department shall report on the metrics developed pursuant to subsection (5)(a) of this section and compliance with the metrics as part of its State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act hearing required by section 2-7-203.
(6) Three years after the date the repair metric rules are established pursuant to subsection (5)(a) of this section, the state department may engage in a stakeholder process to determine the need for additional accountability of a qualified complex rehabilitation technology supplier through financial penalties, audits, or similar tools, for violations of the repair metrics rules. If a stakeholder process is convened, the process must include qualified complex rehabilitation technology professionals, qualified complex rehabilitation technology suppliers, complex rehabilitation members, and an advocacy group for persons with disabilities.
(7) Beginning December 1, 2024, the state department shall reimburse labor costs for repairs of complex rehabilitation technology at a rate that is twenty-five percent higher for members residing in rural areas than the rate for members residing in urban areas.
Source: L. 2014: Entire section added, (HB 14-1211), ch. 253, p. 1008, � 1, effective January 1, 2015. L. 2022: (4), (5), (6), and (7) added, (HB 22-1290), ch. 328, p. 2313, � 1, effective June 2. L. 2023: IP(3)(d) amended, (HB 23-1301), ch. 303, p. 1831, � 51, effective August 7. L. 2024: (1)(a), (1)(c), (2)(a)(I), (2)(a)(III), (2)(b), (2)(d)(III)(A), (2)(d)(III)(C), (2)(d)(IV), (2)(d)(V), (2)(d)(VI), IP(3), (3)(a), IP(3)(c), (3)(d)(I), (3)(d)(III), (3)(e), (5)(a), (6), and (7) amended, (SB 24-176), ch. 152, p. 647, � 51, effective August 7.
25.5-5-324. Nonemergency medical transportation - urgent and secure transportation need - report - repeal. (Repealed)
Source: L. 2018: Entire section added, (HB 18-1321), ch. 346, p. 2064, � 1, effective May 30. L. 2019: (4)(a) amended, (SB 19-252), ch. 254, p. 2452, � 5, effective August 2. L. 2021: (4)(a) amended, (HB 21-1085), ch. 355, p. 2311, � 3, effective June 27; (4)(a) amended, (SB 21-266), ch. 423, p. 2802, � 23, effective July 2.
Editor's note: Subsection (4)(c) provided for the repeal of this section, effective July 1, 2025. (See L. 2018, p. 2064.)
25.5-5-325. Partial hospitalization and residential and inpatient substance use disorder treatment - medical detoxification services - federal approval - performance review report. (1) Subject to available appropriations and to the extent permitted under federal law, the medical assistance program pursuant to this article 5 and articles 4 and 6 of this title 25.5 includes partial hospitalization and residential and inpatient substance use disorder treatment and medical detoxification services. Participation in partial hospitalization and the residential and inpatient substance use disorder treatment and medical detoxification services benefit is limited to persons who meet nationally recognized, evidence-based level of care criteria for partial hospitalization or residential and inpatient substance use disorder treatment and medical detoxification services. The benefit must serve persons with substance use disorders, including those with co-occurring mental health disorders. All levels of nationally recognized, evidence-based levels of care for partial hospitalization and residential and inpatient substance use disorder treatment and medical detoxification services must be included in the benefit.
(2) (a) No later than October 1, 2018, the state department shall seek federal authorization to provide residential and inpatient substance use disorder treatment and medical detoxification services with full federal financial participation. Residential and inpatient substance use disorder treatment and medical detoxification services shall not take effect until federal approval has been obtained.
(b) Prior to seeking federal approval pursuant to subsection (2)(a) of this section, the state department shall seek input from relevant stakeholders, including existing providers of substance use disorder treatment and medical detoxification services and behavioral health administrative services organizations. The state department shall seek input and involve stakeholders in decisions regarding:
(I) The coordination of benefits with behavioral health administrative services organizations and the department of human services;
(II) The most appropriate entity for administration of the benefit;
(III) The provision of wraparound services needed during treatment and the provision of required services following treatment that may not be covered through the medical assistance program;
(IV) The authorization process for approval of services; and
(V) The development of a reimbursement rate methodology to ensure sustainability that considers a provider's cost of providing care, including lower-volume providers in rural areas.
(2.5) No later than July 1, 2026, the state department shall seek federal authorization to provide partial hospitalization for substance use disorder treatment with full federal financial participation. Partial hospitalization for substance use disorder treatment shall not take effect until federal approval has been obtained.
(3) (a) No later than January 15, 2022, the state department shall prepare and submit a performance review report to the joint budget committee and to the joint health and human services committee, or any successor committees, concerning the residential and inpatient substance use disorder treatment pursuant to this section, including, at a minimum:
(I) The number of persons who received services pursuant to this section and the service provided;
(II) The length of time that services were provided;
(III) The location where services were provided;
(IV) The effectiveness of the services provided, including the rate of relapse to substance use disorder following treatment; and
(V) Any other information as determined by the state department that is relevant to the benefit.
(b) After considering the state department's performance review report, the general assembly may enact legislation modifying or repealing the benefit.
Source: L. 2018: Entire section added, (HB 18-1136), ch. 373, p. 2269, � 2, effective June 5. L. 2022: IP(2)(b) and (2)(b)(I) amended, (HB 22-1278), ch. 222, p. 1597, � 242, effective August 10. L. 2023: (2)(b)(I) amended, (HB 23-1236), ch. 206, p. 1054, � 14, effective May 16. L. 2024: (1) amended and (2.5) added, (HB 24-1045), ch. 470, p. 3287, � 20, effective August 7.