Title 25.5, Health Care Policy and Financing

(1) The general assembly finds that, because Colorado is faced with rising health-care costs and limited resources, it is necessary to seek new ways to ensure the availability of high-quality, cost-efficient care for medicaid members. The general assembly further finds that disea…

(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 Colora…

(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…

(1) On or after July 1, 2006, in-person contact between a health-care or mental health-care provider and a patient is not required under the state's medical assistance program for health-care or mental health-care services delivered through telemedicine that are otherwise eligibl…

(1) On or after August 11, 2010, at-home telemedicine shall be eligible for reimbursement under the state's medical assistance program. The services delivered through telemedicine shall be subject to reimbursement policies promulgated by rule of the state board after consultation…

(1) Subject to federal authorization and federal financial participation, on or after July 1, 2016, in-person contact between a health-care provider and a member is not required under the state's medical assistance program for the diagnosis, development of a treatment plan, instr…

(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…

(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 del…

(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…

(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 t…

(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 t…

(1) On or before January 1, 2023, the state department shall create a benefit for secure transportation services, as defined in section 25-3.5-103 (11.4). The state department shall research and create a plan to establish secure transportation services, which may include suppleme…

(1) As used in this section, unless the context otherwise requires: (a) "Eligible individual" means an individual who is not pregnant and whose income does not exceed the state's current effective income level for pregnant women under the children's basic health plan established …

(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 …

(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 …

(1) Subject to federal authorization and federal financial participation, on or after July 1, 2024, therapy using equine movement may be provided by a physical therapist licensed pursuant to article 285 of title 12, an occupational therapist licensed pursuant to article 270 of ti…

(1) As used in this section, unless the context otherwise requires, "grant program" means the primary care and behavioral health statewide integration grant program created in subsection (2) of this section. (2) There is created in the state department the primary care and behavi…

(1) As used in this section, unless the context otherwise requires, "community health worker" means a frontline public health worker who serves as a liaison between health-care providers or social service providers and community members in order to facilitate access to physical, …

(1) The state department shall study the feasibility of extending continuous medical coverage for additional children and adults and how to better meet the health-related social needs of medical assistance program members. (2) At a minimum, the feasibility study must consider the…

(1) (a) Beginning July 1, 2023, the state medical assistance program shall not utilize the body mass index, ideal body weight, or any other standard requiring an achieved weight when determining medical necessity or the appropriate level of care for an individual diagnosed with a…

(1) As used in this section, unless the context otherwise requires: (a) "Grant program" means the telehealth remote monitoring grant program created in subsection (6) of this section. (b) "Member" means any person who has been determined eligible to receive benefits or services u…

(1) As used in this section, unless the context otherwise requires, "continuous glucose monitor" means an instrument or a device designed for the purpose of aiding in the treatment of diabetes by measuring glucose levels on demand or at set intervals through a small electronic se…

(1) (a) The state department shall study the feasibility of providing nutrition, housing, and tenant supportive services that address members' health-related social needs in order to determine whether to seek a federal authorization to provide the services. (b) The feasibility st…

(1) As used in this section, unless the context otherwise requires: (a) "Federal authorization" means the authorization the state department received from the federal centers for medicare and medicaid services to provide coverage for health-related social needs through the state …

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.

(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…

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 demonstr…

(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 …

(1) (a) The state department shall make capitation payments to MCEs based upon a defined scope of services under a risk contract. (b) A certification by a qualified actuary retained by the state department is conclusive evidence that the state department has correctly calculated …

(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…

(1) (a) The general assembly hereby finds and declares that it is the intent of this section to replicate the ON LOK program in San Francisco, California, that has proven to be cost-effective at both the state and federal levels. The PACE program is part of a national replication…

(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, …

(1) (a) The general assembly finds that: (I) Increasing health-care costs in Colorado's medicaid program creates challenges for the state's budget. Further, the increasing health-care costs do not necessarily reflect improvements in either health outcomes for patients or in patie…

(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…

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 requirement…

(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…

(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 …

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 disorde…

(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 fo…

(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 Januar…

(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…

(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) Th…

The state department shall publish on the state department's website an easily accessible list of secure transportation providers, as defined in section 27-65-102, that have contracts with managed care entities. The list must include the contact information for the secure transpo…

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…

(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…

(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…