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Colorado Statutes, Title 25.5

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Title 25.5, Health Care Policy and Financing

0 chapters · 455 sections in this title.

All chapters in Title 25.5455 Ch 6100 Ch 592 Ch 477 Ch 173 Ch 1060 Ch 324 Ch 813 Ch 2.511 Ch 25

77 sections·Filtered byTitle 25.5✕Ch 4✕

Colo. Rev. Stat. § 25.5-4-101 Short title
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This article and articles 5 and 6 of this title shall be known and may be cited as the "Colorado Medical Assistance Act". Source: L. 2006: Entire article added with relocations, p. 1815, § 7, effective July 1.
Colo. Rev. Stat. § 25.5-4-102 Legislative declaration
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It is the purpose of the "Colorado Medical Assistance Act" to promote the public health and welfare of the people of Colorado by providing, in cooperation with the federal government, medical and remedial care and services for individuals and families whose income and resources a…
Colo. Rev. Stat. § 25.5-4-103 Definitions
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As used in this article 4 and articles 5 and 6 of this title 25.5, unless the context otherwise requires: (1) Repealed. (1.5) "Accountable care collaborative" means a medicaid care delivery system established pursuant to section 25.5-5-419. (2) "Applicant" means an individual who…
Colo. Rev. Stat. § 25.5-4-104 State medical assistance program - single state agency
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(1) The state department, by rules, shall establish a program of medical assistance to provide necessary medical care for the categorically needy. The state department is designated as the single state agency to administer the medical assistance program in accordance with Title X…

Colo. Rev. Stat. § 25.5-4-105 Federal requirements under Title XIX

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Nothing in this article or articles 5 and 6 of this title shall prevent the state department from complying with federal requirements for a program of medical assistance in order for the state of Colorado to qualify for federal funds under Title XIX of the social security act and…

Colo. Rev. Stat. § 25.5-4-106 Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services

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(1) The state department shall be the sole state agency for administering the state plans for health and medical assistance pursuant to this title, and any other state plan relating to medical assistance that requires state action which is not specifically the responsibility of s…

Colo. Rev. Stat. § 25.5-4-107 Retaliation definition

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(1) For purposes of any rules promulgated by the state department or state board and any action taken by the state department against any person, "retaliation" means taking any of the following actions against a member or someone acting on behalf of a member after the member or s…

Colo. Rev. Stat. § 25.5-4-201 Cash system of accounting - financial administration of medical services premiums - medical programs administered by department of human services - federal contributions - rules

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(1) The state department shall utilize the cash system of accounting, as enunciated by the governmental accounting standards board, regardless of the source of revenues involved, for all activities of the state department relating to the financial administration of any nonadminis…

Colo. Rev. Stat. § 25.5-4-204 Automated medical assistance administration

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(1) The general assembly hereby finds and declares that the agency responsible for the administration of the state's medical assistance program would be more effective in its ability to streamline administrative functions of program administrators and providers under the program …

Colo. Rev. Stat. § 25.5-4-205 Application - verification of eligibility - demonstration project - rules

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(1) (a) Determination of eligibility for medical benefits shall be made by the county department in which the applicant resides, except as otherwise specified in this section. Local social security offices also determine eligibility for medicaid benefits at the same time the loca…

Colo. Rev. Stat. § 25.5-4-205.5 Confined persons - suspension of benefits

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(1) For purposes of this section, unless the context otherwise requires, "confined person" means a person who is: (a) An inmate confined to a correctional institution operated by or under contract with the department of corrections; (b) Confined in a jail; (c) Committed to a juve…

Colo. Rev. Stat. § 25.5-4-206 Reimbursement to counties - costs of administration

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The state department shall reimburse the county departments for costs of administration incurred by the counties under this article and articles 5 and 6 of this title in accordance with the provisions of section 26-1-122 (5), C.R.S. Source: L. 2006: Entire article added with relo…

Colo. Rev. Stat. § 25.5-4-207 Appeals - rules - applicability

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(1) (a) (I) If an application for medical assistance is not acted upon within a reasonable time after filing the application, or if an application is denied in whole or in part, or if medical assistance benefits are suspended, terminated, or modified, the applicant or member may …

Colo. Rev. Stat. § 25.5-4-208 County duties - transitional medicaid

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County departments shall assist families in completing the reporting requirements for transitional medicaid. This shall include informing families of the transitional medicaid eligibility requirements and the required reporting calendar. Source: L. 2006: Entire article added with…

Colo. Rev. Stat. § 25.5-4-209 Payments by third parties - copayments by members - review - appeal - children's waiting list reduction fund - rules

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(1) (a) Any member receiving benefits pursuant to this article 4 or article 5 or 6 of this title 25.5 who receives any supplemental income, available for medical purposes under rules of the state department, or who receives proceeds from sickness, accident, health, or casualty in…

Colo. Rev. Stat. § 25.5-4-210 Purchase of health insurance for members

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(1) (a) The state department shall purchase group health insurance for a medical assistance member who is eligible to enroll for coverage if enrollment of the member in the group plan would be cost-effective. In addition, the state department may purchase individual health insura…

Colo. Rev. Stat. § 25.5-4-211 Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year

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(1) Subject to the limitation in subsection (2) of this section, unexpended and unencumbered moneys from an appropriation in the annual general appropriation act to the state department for the medicaid management information system remain available for expenditure by the state d…

Colo. Rev. Stat. § 25.5-4-212 Medicaid member correspondence improvement process - legislative declaration - definition

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(1) (a) The general assembly finds and declares that: (I) Accurate, understandable, timely, informative, and clear correspondence from the state department is critical to the life and health of medicaid members and applicants and, in some cases, is a matter of life and death for …

Colo. Rev. Stat. § 25.5-4-213 Audit of medicaid member correspondence - definition

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(1) As used in this section, unless the context otherwise requires, "member correspondence" has the same meaning as defined in section 25.5-4-212. (2) During the 2020 calendar year and the 2023 calendar year, the office of the state auditor shall conduct or cause to be conducted …

Colo. Rev. Stat. § 25.5-4-217 Federal reimbursement for public expenditures - excess to general fund - notice to revisor of statutes - repeal

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(1) Notwithstanding any other provision of law, for the state fiscal year starting July 1, 2021, and any subsequent fiscal years, if a provider submits a certification of public expenditures pursuant to 42 CFR 433.51 (b), the state department shall retain any federal money payabl…

Colo. Rev. Stat. § 25.5-4-218 Multiple procedure payment reductions for outpatient therapy - prohibition - definitions

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(1) As used in this section, unless the context otherwise requires: (a) "Multiple procedure payment reduction" means a reimbursement methodology that reduces payment for one or more different services furnished to a member during the same date of service, encounter, or episode of…

Colo. Rev. Stat. § 25.5-4-219 Community engagement requirements for medicaid eligibility - notice to revisor of statutes - rules - reporting - repeal

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(1) On or before January 1, 2027, the state board shall adopt rules that are necessary to implement the community engagement requirements of Title XIX of the federal "Social Security Act of 1965", 42 U.S.C. sec. 1396a (xx), as amended or relocated, in a manner that ensures all ap…

Colo. Rev. Stat. § 25.5-4-300.4 Last resort for payment - legislative intent

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It is the intent of the general assembly that medicaid is the last resort for payment for medically necessary goods and services furnished to members and that all other sources of payment are primary to medical assistance provided by medicaid. Source: L. 2008: Entire section adde…

Colo. Rev. Stat. § 25.5-4-300.7 Prevention of coding errors - prepayment review of claims

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(1) The state department shall implement and maintain a system for reducing medical services coding errors in medicaid claims submitted to the state department for reimbursement. The system shall include automatic, prepayment review of medicaid claims through the use of nationall…

Colo. Rev. Stat. § 25.5-4-300.9 Explanation of benefits - medicaid members - legislative declaration

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(1) (a) The general assembly finds and declares that: (I) Colorado's medicaid program provides critical medical services to the state's poorest and most vulnerable residents; (II) Funding for these services is provided through a financial partnership between Colorado and the fede…

Colo. Rev. Stat. § 25.5-4-301 Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - cash fund - rules - definitions - repeal

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(1) (a) (I) Except as provided in section 25.5-4-302 and subsection (1)(a)(III) of this section, a member or estate of the member is not liable for the cost or the cost remaining after payment by medicaid, medicare, or a private insurer of medical benefits authorized by Title XIX…

Colo. Rev. Stat. § 25.5-4-302 Recovery of assets

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(1) The general assembly finds, determines, and declares that the cost of providing medical assistance to qualified members throughout the state has increased significantly in recent years; that such increasing costs have created an increased burden on state revenues while reduci…

Colo. Rev. Stat. § 25.5-4-303 State income tax refund intercept - garnishment of earning - failure to provide medical support for child

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(1) (a) At any time prescribed by the department of revenue, but not less frequently than annually, the state department may certify to the department of revenue information regarding any person who: (I) Is obligated to the state agency responsible for administering medical assis…

Colo. Rev. Stat. § 25.5-4-303.3 Provider fraud - attorney general report

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(1) No later than October 1, 2017, and no later than October 1 each year thereafter, the attorney general shall submit a written report to the state department for inclusion in a single, comprehensive report to the general assembly concerning medicaid fraud pursuant to section 25…

Colo. Rev. Stat. § 25.5-4-303.5 Short title

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This section and sections 25.5-4-304 to 25.5-4-310 shall be known and may be cited as the "Colorado Medicaid False Claims Act". Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1379, § 10, effective May 26.

Colo. Rev. Stat. § 25.5-4-304 Definitions

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As used in sections 25.5-4-303.5 to 25.5-4-309, unless the context otherwise requires: (1) (a) "Claim" means a request or demand for money or property, whether under a contract or otherwise, and regardless of whether the state has title to the money or property, under the "Colora…

Colo. Rev. Stat. § 25.5-4-305 False medicaid claims - liability for certain acts - false medicaid claims recovery fund

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(1) Except as otherwise provided in subsection (2) of this section, a person is liable to the state for a civil penalty of not less than five thousand five hundred dollars and not more than eleven thousand dollars; except that these upper and lower limits on liability shall autom…

Colo. Rev. Stat. § 25.5-4-306 Civil actions for false medicaid claims

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(1) Responsibility of attorney general. The attorney general shall diligently investigate a violation under section 25.5-4-305. If the attorney general finds that a person has violated or is violating section 25.5-4-305, the attorney general may bring a civil action under this se…

Colo. Rev. Stat. § 25.5-4-307 False medicaid claims procedures - statute of limitations

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(1) A civil action under section 25.5-4-306 (1) or (2) may not be brought after the later of: (a) More than six years after the date on which the violation of section 25.5-4-305 is committed; or (b) More than three years after the date when facts material to the right of action a…

Colo. Rev. Stat. § 25.5-4-308 False medicaid claims jurisdiction

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An action under section 25.5-4-306 may be brought in any judicial district in which the defendant or, in the case of multiple defendants, any one defendant can be found, resides, or transacts business or in which an act proscribed by section 25.5-4-305 occurred. A summons as requ…

Colo. Rev. Stat. § 25.5-4-309 False medicaid claims civil investigation demands

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(1) General. (a) (I) Whenever the attorney general has reason to believe that a person may be in possession, custody, or control of documentary material or information relevant to a false medicaid claims law investigation, the attorney general may, before commencing a civil proce…

Colo. Rev. Stat. § 25.5-4-310 Medicaid false claims report

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(1) Notwithstanding section 24-1-136 (11)(a)(I), on or before January 15, 2012, and on or before each January 15 thereafter, the attorney general shall submit a written report to the health and human services committees of the senate and the house of representatives, or any succe…

Colo. Rev. Stat. § 25.5-4-401 Providers - payments - rules

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(1) (a) The state department shall establish rules for the payment of providers under this article 4 and articles 5 and 6 of this title 25.5. Within the limits of available funds, the rules must provide reasonable compensation to providers, but no provider, by this section or any…

Colo. Rev. Stat. § 25.5-4-401.2 Performance-based payments - reporting

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(1) To improve health outcomes and lower health-care costs, the state department may develop payments to providers that are based on quantifiable performance or measures of quality of care. These performance-based payments may include, but are not limited to, payments to: (a) Pri…

Colo. Rev. Stat. § 25.5-4-401.5 Review of provider rates - advisory committee - recommendations - repeal

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(1) (a) On or before September 1, 2023, the state department shall establish a schedule for an annual review of provider rates paid under the "Colorado Medical Assistance Act" so that each provider rate is reviewed at least every three years and shall provide the schedule to the …

Colo. Rev. Stat. § 25.5-4-402 Providers - hospital reimbursement - hospital review program - rules

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(1) For all licensed or certified hospitals contracting for services under this article and articles 5 and 6 of this title, except those hospitals operated by the department of human services or those hospitals deemed exempt by the state board, the state department shall pay for …

Colo. Rev. Stat. § 25.5-4-402.4 Hospitals - healthcare affordability and sustainability hospital provider fee - healthcare affordability and sustainability nursing facility provider fee - healthcare affordability and sustainability intermediate care facility fee - receipt of public funds - Colorado healthcare affordability and sustainability enterprise - federal waiver - funds created - reports - rules - legislative declaration - definitions - repeal

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(1) Short title. The short title of this section is the "Colorado Healthcare Affordability and Sustainability Enterprise Act of 2017". (2) Legislative declaration. The general assembly finds and declares that: (a) The state and the providers of publicly funded medical services, a…

Colo. Rev. Stat. § 25.5-4-402.5 Providers - state university teaching hospitals

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Subject to appropriations by the general assembly, the state department shall make payments to state university teaching hospitals for providing care under the state's medical assistance program established pursuant to this article and articles 5 and 6 of this title. Source: L. 2…

Colo. Rev. Stat. § 25.5-4-402.8 Hospital transparency report and requirements - definitions

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(1) As used in this section, unless the context otherwise requires: (a) "Acquired" means the purchase by a hospital, or entity that is owned by or under common ownership and control with the hospital, of all or substantially all of an organization subject to subsection (1)(b)(I) …

Colo. Rev. Stat. § 25.5-4-403 Providers - behavioral health safety net providers - reimbursement

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(1) For the purpose of reimbursing essential behavioral health safety net and comprehensive community behavioral health providers, as defined in section 27-50-101, except for those that are also federally qualified health centers, as defined in the federal "Social Security Act", …

Colo. Rev. Stat. § 25.5-4-403.1 Providers - comprehensive community behavioral health providers - cost reporting

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(1) For the purposes of increased payment methodology transparency, no later than March 15, 2023, and each March 15 thereafter, the state department shall: (a) Publish cost reports for comprehensive community behavioral health providers, as defined in section 27-50-101; (b) Estab…

Colo. Rev. Stat. § 25.5-4-404 Payments for clinic services - restrictions on use

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All payments received by county or district public health agencies or boards of health for clinic services, as defined in section 25.5-5-301 (3), furnished to patients shall be used only to offset costs incurred for provision of services by such county or district public health a…

Colo. Rev. Stat. § 25.5-4-405 Mental health managed care service providers - requirements

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(1) Each contract between the state department and a managed care organization providing mental health services to a member under the medical assistance program must comply with all federal requirements, including but not limited to: (a) Ensuring that a member with complex or mul…

Colo. Rev. Stat. § 25.5-4-406 Rate setting - medicaid residential treatment service providers - monitoring and auditing - report

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(1) The state department shall approve a rate-setting process consistent with medicaid requirements for providers of medicaid residential treatment services in the state of Colorado as developed by the department of human services. The rate-setting process developed pursuant to t…

Colo. Rev. Stat. § 25.5-4-407 Services by licensed psychologists without a doctor's referral

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The executive director of the state department may authorize the providing of services of licensed psychologists without the requirement that the services be referred by a doctor of medicine or a doctor of osteopathy, but such services shall be subject to the cost containment pro…