Title 25.5, Health Care Policy and Financing
0 chapters · 273 sections in this title.
Colo. Rev. Stat. § 25.5-5-101 Mandatory provisions - eligible groups - rules
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(1) In order to participate in the medicaid program, the federal government requires the state to provide medical assistance to certain eligible groups. Pursuant to federal law and except as provided in subsection (2) of this section, any person who is eligible for medical assist…
Colo. Rev. Stat. § 25.5-5-103 Mandated programs with special state provisions - rules
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(1) This section specifies programs developed by Colorado to meet federal mandates. These programs include but are not limited to: (a) Repealed. (b) Special provisions relating to nursing facilities, as specified in sections 25.5-4-402.4 (4.5) and (5.5), 25.5-6-201, 25.5-6-202, 2…
Colo. Rev. Stat. § 25.5-5-104 Qualified medicare beneficiaries
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Qualified medicare beneficiaries are medicare-eligible individuals with income and resources at a level which qualifies them as eligible under section 301 of Title III of the federal Medicare Catastrophic Coverage Act of 1988, as amended, or subsequent amending federal legislatio…
Colo. Rev. Stat. § 25.5-5-105 Qualified disabled and working individuals
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Qualified disabled and working individuals are persons with income and resources and disability status, as determined by the social security administration, which qualify them as qualified disabled and working individuals under sections 6012 and 6408 of the federal Omnibus Budget…
Colo. Rev. Stat. § 25.5-5-201 Optional provisions - optional groups - rules
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(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 i…
Colo. Rev. Stat. § 25.5-5-203 Optional programs with special state provisions
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(1) Subject to the provisions of subsection (2) of this section, this section specifies programs developed by Colorado to increase federal financial participation through selecting optional services or optional eligible groups. These programs include but are not limited to: (a) P…
Colo. Rev. Stat. § 25.5-5-204 Presumptive eligibility - pregnant person - children - long-term care - state plan
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(1) For purposes of this section, presumptive eligibility means the self-declaration of income, assets, and status in order to promptly receive medical assistance services prior to the verification of income, assets, and status. (2) (a) A pregnant person is presumptively eligible…
Colo. Rev. Stat. § 25.5-5-204.5 Continuous eligibility - children
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(1) A child who is determined to be eligible for benefits under this article or under article 4 or 6 of this title shall remain eligible for twelve months subsequent to the last day of the month in which the child was enrolled; except that a child shall no longer be eligible and …
Colo. Rev. Stat. § 25.5-5-205 Baby and kid care program - creation - eligibility. (Repealed)
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Source: L. 2006: Entire article added with relocations, p. 1864, � 7, effective July 1. L. 2007: (3)(d) amended, p. 1493, � 5, effective January 1, 2008. L. 2010: (3)(a) and (3)(c)(I) amended, (HB 10-1043), ch. 92, p. 313, � 4, effective April 15. L. 2011: (3)(b) amended, (SB 11-…
Colo. Rev. Stat. § 25.5-5-301 Clinic services
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(1) As used in this article and articles 4 and 6 of this title, unless the context otherwise requires, clinic services means preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services furnished to outpatients. (2) Under the federal option for clinic serv…
Colo. Rev. Stat. § 25.5-5-303 Private-duty nursing
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(1) The medical assistance program in this state shall include private-duty nursing to persons who are technology dependent and otherwise eligible as provided under this section. (2) A member is eligible for private-duty nursing services if the member: (a) Is dependent on technol…
Colo. Rev. Stat. § 25.5-5-304 Hospice care
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(1) The medical assistance program in this state shall include hospice care. Except as otherwise provided in subsection (2) of this section, hospice care shall be provided for a period of up to two hundred ten days in accordance with rules adopted by the state board, which rules …
Colo. Rev. Stat. § 25.5-5-307 Child mental health treatment and family support program
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(1) The general assembly finds that many parents in Colorado who have experienced challenging circumstances because their children have significant mental health needs and who have attempted to care for their children or seek services on their behalf often are burdened with the e…
Colo. Rev. Stat. § 25.5-5-318 Health services - provision by school districts - repeal
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(1) As used in this section: (a) School district means any board of cooperative services established pursuant to article 5 of title 22, C.R.S., any state educational institution that serves students in kindergarten through twelfth grade including, but not limited to, the Colorado…
Colo. Rev. Stat. § 25.5-5-319 Family planning pilot program - rules - federal waiver - repeal
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(1) There is hereby established a family planning pilot program for the provision of family planning services to categorically eligible individuals who are at or below a percentage of the federal poverty line established pursuant to the federal waiver sought pursuant to subsectio…
Colo. Rev. Stat. § 25.5-5-322 Over-the-counter medications - rules
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(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…
Colo. Rev. Stat. § 25.5-5-326 Access to clinical trials - definitions
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(1) As used in this section, unless the context otherwise requires: (a) Approved clinical trial means a phase I, II, III, or IV clinical trial involving the prevention, detection, diagnosis, or treatment of a life-threatening or debilitating disease or condition if any one of the…
Colo. Rev. Stat. § 25.5-5-327 Eligible peer support services - reimbursement - definitions
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(1) As used in this section, unless the context otherwise requires: (a) Peer support professional has the same meaning as defined in section 27-60-108 (2)(b). (b) Recovery support services organization has the same meaning as defined in section 27-60-108 (2)(c). (2) Subject to av…
Colo. Rev. Stat. § 25.5-5-330 Screening for perinatal mood and anxiety disorder
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(1) For the caregiver of each child enrolled in the medical assistance program in the state, the program must include screening for perinatal mood and anxiety disorders in accordance with the health resources and services administration guidelines. (2) The screening must be made …
Colo. Rev. Stat. § 25.5-5-331 Federally qualified health center - reimbursement - rules
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(1) Costs associated with services provided by clinical pharmacists through a federally qualified health center, as defined in the federal Social Security Act, 42 U.S.C. sec. 1395x (aa)(4), are considered allowable costs for the purpose of a federally qualified health center's co…
Colo. Rev. Stat. § 25.5-5-401 Short title
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This part 4 shall be known and may be cited as the Statewide Managed Care System. Source: L. 2006: Entire article added with relocations, p. 1883, � 7, effective July 1. Editor's note: This section is similar to former � 26-4-111 as it existed prior to 2006.
Colo. Rev. Stat. § 25.5-5-402 Statewide managed care system - rules - definitions - repeal
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(1) The state board shall adopt rules to implement a statewide managed care system for Colorado medical assistance members pursuant to the provisions of this article 5 and articles 4 and 6 of this title 25.5. The statewide managed care system shall be implemented to the extent po…
Colo. Rev. Stat. § 25.5-5-403 Definitions
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As used in this part 4, unless the context otherwise requires: (1) Repealed. (2) Essential community provider, referred to in this part 4 as an ECP, means a health-care provider that: (a) Has historically served medically needy or medically indigent patients and that demonstrates…
Colo. Rev. Stat. § 25.5-5-404 Selection of managed care entities. (Repealed)
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Source: L. 2006: Entire article added with relocations, p. 1885, � 7, effective July 1. L. 2008: Entire section amended, p. 392, � 3, effective August 5. L. 2014: (1)(v) added, (HB 14-1211), ch. 253, p. 1011, � 2, effective January 1, 2015. L. 2018: Entire section repealed, (HB 1…
Colo. Rev. Stat. § 25.5-5-405 Quality measurements. (Repealed)
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Source: L. 2006: Entire article added with relocations, p. 1889, � 7, effective July 1. L. 2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, � 7, effective August 8. Editor's note: This section was similar to former � 26-4-116 as it existed prior to 2006.
Colo. Rev. Stat. § 25.5-5-406 Required features of managed care system. (Repealed)
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Source: L. 2006: Entire article added with relocations, p. 1889, � 7, effective July 1. L. 2008: Entire section amended, p. 396, � 4, effective August 5. L. 2012: (2) amended, (HB 12-1281), ch. 246, p. 1187, � 5, effective June 4. L. 2016: (1)(f)(I) amended, (HB 16-1081), ch. 22,…
Colo. Rev. Stat. § 25.5-5-406.1 Required features of statewide managed care system
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(1) General features. All medicaid managed care programs must contain the following general features, in addition to others that the federal government, state department, and state board consider necessary for the effective and cost-efficient operation of those programs: (a) The …
Colo. Rev. Stat. § 25.5-5-407.7 Disability care coordination organization - rules. (Repealed)
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Source: L. 2007: Entire section added, p. 1352, � 1, effective May 29. L. 2008: Entire section amended, p. 1909, � 109, effective August 5. L. 2013: Entire section repealed, (SB 13-276), ch. 256, p. 1353, � 9, effective May 23. 25.5-5-408. Capitation payments - availability of ba…
Colo. Rev. Stat. § 25.5-5-409 State department - privatization. (Repealed)
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Source: L. 2006: Entire article added with relocations, p. 1896, � 7, effective July 1. L. 2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, � 7, effective August 8. Editor's note: This section was similar to former � 26-4-120 as it existed prior to 2006.
Colo. Rev. Stat. § 25.5-5-410 Data collection for managed care programs
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(1) Repealed. (2) The state department of human services, in conjunction with the state department, shall continue its existing efforts, which include obtaining and considering member input, to develop managed care systems for the developmentally disabled population and to consid…
Colo. Rev. Stat. § 25.5-5-414 Telemedicine - legislative intent
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(1) It is the intent of the general assembly to recognize the practice of telemedicine as a legitimate means by which an individual may receive medical services from a health-care provider without person-to-person contact with a provider. (2) Repealed. (3) On or after January 1, …
Colo. Rev. Stat. § 25.5-5-419 Accountable care collaborative - reporting - rules
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(1) In 2011, the state department created the accountable care collaborative, also referred to in this title 25.5 as the medicaid coordinated care system. The state department shall continue to provide care delivery through the accountable care collaborative. The goals of the acc…
Colo. Rev. Stat. § 25.5-5-420 Advancing care for exceptional kids
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Within one hundred twenty days of the enactment of the federal Advancing Care for Exceptional Kids Act, subject to available appropriations, the state department shall seek any federal approval necessary to fund, in cooperation with hospitals that meet the specified requirements,…
Colo. Rev. Stat. § 25.5-5-421 Parity reporting - state department - public input
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(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 he…
Colo. Rev. Stat. § 25.5-5-500.3 Authorization to bill third party
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As a condition of doing business in the state, each provider is deemed to authorize the state department, or an independent contractor retained by the state department, to bill a third party, as defined in section 25.5-4-209 (2)(g)(II), on behalf of the provider if the third part…
Colo. Rev. Stat. § 25.5-5-501 Providers - drug reimbursement
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(1) (a) As to drugs for which payment is made, the state board's rules for payment must include the requirement that the generic equivalent of a brand-name drug be prescribed if the generic equivalent is a therapeutic equivalent to the brand-name drug, except when reimbursement t…
Colo. Rev. Stat. § 25.5-5-502 Unused medications - reuse - rules - definition
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(1) As used in this section, unless the context otherwise requires, medication means prescription medication that is not a controlled substance. (2) A pharmacist participating in the medical assistance program may accept unused medication from a licensed facility, as defined in s…
Colo. Rev. Stat. § 25.5-5-504 Providers of pharmaceutical services
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(1) Consistent with the provisions of section 25.5-4-401 (1) and subsections (2) and (3) of this section, and subject to available appropriations, no provider of pharmaceutical services who meets the conditions imposed by this article 5 and articles 4 and 6 of this title 25.5 and…
Colo. Rev. Stat. § 25.5-5-505 Prescribed drugs - mail order - rules
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(1) (a) (I) The state board shall adopt by rule a system to allow medical assistance recipients the option to receive through the mail prescribed maintenance medications used to treat chronic medical conditions. (II) The state board rules must include the definition of maintenanc…
Colo. Rev. Stat. § 25.5-5-506 Prescribed drugs - utilization review
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(1) The state department shall develop and implement a drug utilization review process to assure the appropriate utilization of drugs by patients receiving medical assistance in the fee-for-service and primary care physician programs. The review process shall include the monitori…
Colo. Rev. Stat. § 25.5-5-508 Electronic prescriptions - study - report - repeal. (Repealed)
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Source: L. 2009: Entire section added, (HB 09-1073), ch. 282, p. 1286, � 1, effective August 5. Editor's note: Subsection (4) provided for the repeal of this section, effective July 1, 2010. (See L. 2009, p. 1286.) 25.5-5-509. Substance use disorder - prescription drugs - opioid …
Colo. Rev. Stat. § 25.5-5-513 Pharmacy benefits - prescription drugs - rebates - analysis
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(1) Beginning in 2023, the state department shall, in collaboration with the administrator of the all-payer health claims database described in section 25.5-1-204, conduct an annual analysis of the prescription drug rebates received in the previous calendar year, by health insura…
Colo. Rev. Stat. § 25.5-5-516 Serious mental illness - prescribed drugs
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Notwithstanding any provisions of this part 5 to the contrary, and subject to any necessary federal authorization, the state board shall require a review for coverage of a new drug approved by the federal food and drug administration for a serious mental illness within ninety day…
Colo. Rev. Stat. § 25.5-5-518 Coverage for choline dietary supplements - rules
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(1) No later than July 1, 2025, the state board shall promulgate rules to include coverage under the medical assistance program for over-the-counter choline dietary supplements for pregnant persons. (2) The state department shall seek federal approval, as necessary, for the cover…
Colo. Rev. Stat. § 25.5-5-801 Legislative declaration
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(1) The general assembly finds and declares that: (a) In order to provide quality behavioral health services to families of children and youth with behavioral health challenges, behavioral health services should be coordinated among state departments and political subdivisions of…
Colo. Rev. Stat. § 25.5-5-802 Definitions
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As used in this part 8, unless the context otherwise requires: (1) At risk of out-of-home placement means a child or youth who is eligible for medical assistance pursuant to articles 4, 5, and 6 of this title 25.5 and the child or youth: (a) Has been diagnosed as having a mental …
Colo. Rev. Stat. § 25.5-5-804 Integrated funding pilot
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Subject to available appropriations, the state department, in conjunction with the behavioral health administration in the department of human services, counties, and other relevant departments, shall design and recommend a child and youth behavioral health delivery system pilot …