(1) The state department shall require each MCE contracted with the state department to disclose all necessary information in order for the state department, by June 1, 2020, and by each June 1 thereafter, to submit a report to the health and insurance committee and the public health care and human services committee of the house of representatives, or their successor committees, and to the health and human services committee of the senate, or its successor committee, regarding behavioral, mental health, and substance use disorder parity. The report must contain the following information for the prior calendar year:
(a) A description of the process used to develop or select the medical necessity criteria for behavioral, mental health, and substance use disorder benefits and the process used to develop or select the medical necessity criteria for medical and surgical benefits;
(b) Identification of all nonquantitative treatment limitations that are applied to behavioral, mental health, and substance use disorder benefits and to medical and surgical benefits within each classification of benefits and a statement that the state is complying with 42 U.S.C. sec. 300gg-26 (a)(3)(A)(ii), as required by 42 U.S.C. sec. 1396u-2 (b)(8), prohibiting the application of nonquantitative treatment limitations to behavioral, mental health, and substance use disorder benefits that do not apply to medical and surgical benefits within any classification of benefits;
(c) (I) The results of analyses demonstrating that, for the medical necessity criteria described in subsection (1)(a) of this section and each nonquantitative treatment limitation identified in subsection (1)(b) of this section, as written and in operation, the processes, strategies, evidentiary standards, or other factors used in applying the medical necessity criteria and each nonquantitative treatment limitation to benefits for behavioral, mental health, and substance use disorders within each classification of benefits are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the medical necessity criteria and each nonquantitative treatment limitation to medical and surgical benefits within the corresponding classification of benefits.
(II) A report on the results of the analyses specified in this subsection (1)(c) must, at a minimum:
(A) Identify the factors used to determine that a nonquantitative treatment limitation will apply to a benefit, including factors that were considered but rejected;
(B) Identify and define the specific evidentiary standards used to define the factors and any other evidence relied on in designing each nonquantitative treatment limitation;
(C) Provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to design each nonquantitative treatment limitation, as written, and the written processes and strategies used to apply each nonquantitative treatment limitation for benefits for behavioral, mental health, and substance use disorders are comparable to, and are applied no more stringently than, the processes and strategies used to design and apply each nonquantitative treatment limitation, as written, and the written processes and strategies used to apply each nonquantitative treatment limitation for medical and surgical benefits;
(D) Provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to apply each nonquantitative treatment limitation, in operation, for benefits for behavioral, mental health, and substance use disorders are comparable to, and are applied no more stringently than, the processes and strategies used to apply each nonquantitative treatment limitation, in operation, for medical and surgical benefits; and
(E) Disclose the specific findings and conclusions that indicate that the state is in compliance with this section and with the MHPAEA.
(2) By October 1, 2019, for purposes of obtaining meaningful public input during the assessment process described in subsection (1) of this section, the state department shall seek input from stakeholders who may have competency in benefit and delivery systems, utilization management, managed care contracting, data and reporting, or compliance and audits. The state department shall consider the input received in conducting the analyses and developing the report pursuant to subsection (1) of this section.
(3) Notwithstanding section 24-1-136 (11)(a)(I), the reporting requirement specified in this section continues indefinitely.
(4) The state department shall contract with an external quality review organization at least annually to monitor MCEs' utilization management programs and policies, including those that govern adverse determinations, to ensure compliance with the MHPAEA. The quality review report must be readily available to the public.
Source: L. 2019: Entire section added, (HB 19-1269), ch. 195, p. 2134, � 15, effective May 16.
Cross references: For the short title (Behavioral Health Care Coverage Modernization Act) in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
25.5-5-422. Medication-assisted treatment - limitations on MCEs - definition. (1) As used in this section, FDA means the food and drug administration in the United States department of health and human services.
(2) Notwithstanding any provision of law to the contrary, each MCE that provides prescription drug benefits or methadone administration for the treatment of substance use disorders shall:
(a) Not impose any prior authorization requirements on any prescription medication approved by the FDA for the treatment of substance use disorders, regardless of the dosage amount;
(b) Not impose any step therapy requirements as a prerequisite to authorizing coverage for a prescription medication approved by the FDA for the treatment of substance use disorders;
(c) Not exclude coverage for any prescription medication approved by the FDA for the treatment of substance use disorders and any associated counseling or wraparound services solely on the grounds that the medications and services were court ordered; and
(d) Set the reimbursement rate for take-home methadone treatment and office-administered methadone treatment at the same rate.
Source: L. 2019: Entire section added, (HB 19-1269), ch. 195, p. 2136, � 15, effective May 16. L. 2024: (2) amended, (HB 24-1045), ch. 470, p. 3288, � 21, effective August 7.
Cross references: For the short title (Behavioral Health Care Coverage Modernization Act) in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
25.5-5-423. Independent review organization - review denial of residential and inpatient substance use disorder treatment claims - contract. No later than July 1, 2023, the state department shall contract with one or more independent review organizations to conduct external medical reviews requested for review by a medicaid provider when there is a denial or reduction for residential or inpatient substance use disorder treatment and medicaid appeals processes have been exhausted.
Source: L. 2021: Entire section added, (SB 21-137), ch. 362, p. 2364, � 9, effective June 28.
Cross references: For the short title (Behavioral Health Recovery Act of 2021) and the legislative declaration in SB 21-137, see sections 1 and 2 of chapter 362, Session Laws of Colorado 2021.
25.5-5-424. Residential and inpatient substance use disorder treatment - MCE standardized utilization management process - medical necessity - report. (1) On or before October 1, 2021, the state department shall consult with the behavioral health administration in the department of human services, residential treatment providers, and MCEs to develop standardized utilization management processes to determine medical necessity for residential and inpatient substance use disorder treatment. The processes must incorporate the version of The ASAM Criteria used by the state department and align with federal medicaid payment requirements.
(2) On or before January 1, 2022, the state department shall incorporate the standards developed pursuant to subsection (1) of this section into existing MCE contracts, and each MCE shall adhere to the standards when conducting utilization management for residential and inpatient substance use disorder treatment.
(3) On or before January 1, 2022, each MCE's notice of an adverse benefit determination must demonstrate how each dimension of the version of The ASAM Criteria used by the state department was considered when determining medical necessity.
(4) (a) Beginning July 1, 2024, and quarterly thereafter, the state department shall report on the residential and inpatient substance use disorder utilization management statistics on the state department's website.
(I) to (III) (Deleted by amendment, L. 2024.)
(b) (Deleted by amendment, L. 2024.)
(c) Any information reported pursuant to subsection (4)(a) of this section may be aggregated as necessary to ensure confidentiality pursuant to 42 CFR part 2.
Source: L. 2021: Entire section added, (SB 21-137), ch. 362, p. 2365, � 10, effective June 28. L. 2022: (1) and IP(4)(a) amended, (HB 22-1278), ch. 222, p. 1515, � 76, effective July 1. L. 2024: (1), (3), and (4) amended, (SB 24-135), ch. 34, p. 115, � 25, effective March 22.
Cross references: For the short title (Behavioral Health Recovery Act of 2021) and the legislative declaration in SB 21-137, see sections 1 and 2 of chapter 362, Session Laws of Colorado 2021.
25.5-5-425. Audit of MCE denials for residential and inpatient substance use disorder treatment authorization - report. (1) No later than July 1, 2022, the state department shall contract with an independent third-party vendor to audit thirty-three percent of all denials of authorization for inpatient and residential substance use disorder treatment for each MCE.
(2) Beginning no later than January 31, 2025, and no later than each January 31 thereafter, the state department shall submit the results of the audit conducted pursuant to subsection (1) of this section and any recommended changes to the residential and inpatient substance use disorder benefit to the house of representatives health and human services committee, the senate health and human services committee, or their successor committees, and the joint budget committee.
Source: L. 2021: Entire section added, (SB 21-137), ch. 362, p. 2366, � 11, effective June 28. L. 2024: (2) amended, (SB 24-135), ch. 34, p. 116, � 26, effective March 22.
Cross references: For the short title (Behavioral Health Recovery Act of 2021) and the legislative declaration in SB 21-137, see sections 1 and 2 of chapter 362, Session Laws of Colorado 2021.
25.5-5-426. Managed care entities - behavioral health providers - disclosure of reimbursement rates. (1) The state department shall require each MCE that contracts with the state department to disclose the aggregated average and lowest rates of reimbursement for a set of behavioral health services determined by the state department.
(2) Behavioral health providers are authorized to disclose the reimbursement rates paid by an MCE to the behavioral health provider.
Source: L. 2024: Entire section added, (HB 24-1045), ch. 470, p. 3288, � 23, effective August 7.
Editor's note: This section was numbered as � 25.5-5-427 in HB 24-1045 but was renumbered on revision for ease of location.
25.5-5-427. Managed care entities - disclosure of payment and medical loss ratio - definition. (1) The state department shall include in each new contract with, or renewal of a contract with, an MCE a provision requiring the MCE to submit to the state department, on an annual basis, the amount the MCE is paid for delivering services and the MCE's medical loss ratio.
(2) The state department shall annually publish the following information on its website:
(a) The information received pursuant to subsection (1) of this section;
(b) Historical medical loss ratio data for each MCE; and
(c) Audit findings regarding an MCE's most recently completed medical loss ratio audit.
(3) For purposes of subsection (1) of this section, medical loss ratio means the percentage of premium revenue that the MCE spends on health-care services and quality improvement activities.
Source: L. 2025: Entire section added, (HB 25-1213), ch. 276, p. 1438, � 6, effective August 6.