C.R.S. § 25.5-4-101 Short title
25.5-4-101. Short title. This article and articles 5 and 6 of this title shall be known and may be cited as the "Colorado Medical Assistance Act".
Colorado Medical Assistance Act - General Medical Assistance
C.R.S. tit. 25.5, art. 4
in effectC.R.S. § 25.5-4-102 Legislative declaration
25.5-4-102. Legislative declaration. 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 are insufficient to meet the costs of such necessary services and to assist such individuals and families to attain or retain their capabilities for independence and self-care, as contemplated by the provisions of Title XIX of the social security act. The state of Colorado and its various departments, agencies, and political subdivisions are authorized to promote and achieve these ends by any appropriate lawful means, through cooperation with and the utilization of available resources of the federal government and private individuals and organizations.
C.R.S. § 25.5-4-103 Definitions
25.5-4-103. Definitions. 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(1) Repealed.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 is seeking an eligibility determination for himself or herself under this article and articles 5 and 6 of this title through an application submission or a transfer from another agency or insurance affordability program.
(2.5) "Case management agency" has the same meaning as set forth in section 25.5-6-1702 (2).
(3) "Case management services" means services provided by case management agencies and comprehensive community behavioral health providers, as defined in section 27-50-101, to assist persons in gaining access to needed medical, social, educational, and other services.
(4) "Categorically needy" means those persons who are eligible for medical assistance under this article and articles 5 and 6 of this title due to their eligibility for one or more of the federal categories of public assistance. A person may be categorically needy and eligible for medical assistance under mandatory provisions as provided under section 25.5-5-101 or may be categorically needy under optional provisions as provided under section 25.5-5-201.
(5) "Clinic services" means those services as defined in section 25.5-5-301.
(5.5) "Dementia diseases and related disabilities" has the same meaning set forth in section 25-1-502 (2.5).
(6) "Essential person" means a person who meets the requirements of section 26-2-103 (5), C.R.S.
(7) "Home health services" is synonymous with "home health care" and includes the following services provided to an eligible person through a certified home health agency, pursuant to a home health plan of care:
(a) Nursing services;
(b) Home health aide services;
(c) Provision of medical supplies, equipment, and appliances suitable for use in the home;
(d) Physical therapy, occupational therapy, or speech and hearing therapy.
(8) "Hospice care" means services provided by a public agency or private organization, or any subdivision thereof, which entity shall be known as a hospice and shall be primarily engaged in providing care to an individual for whom a certified medical prognosis has been made indicating a life expectancy of six months or less and who has elected to receive such care in lieu of other medical benefits available under this article and articles 5 and 6 of this title.
(9) "Intermediate nursing facility for persons with intellectual and developmental disabilities" means a tax-supported, state-administered intermediate nursing facility, or a distinct part of such facility, which meets the state nursing home licensing standards set forth in section 25-1.5-103 (1)(a)(I), C.R.S., and the requirements in 42 U.S.C. sec. 1396d and which:
(a) Is maintained primarily to provide health-related care on a regular basis for persons with intellectual and developmental disabilities, as defined in section 27-10.5-102 (11), C.R.S., and section 25.5-10-202, C.R.S., who do not require the degree of services and supports that a hospital or skilled nursing facility can provide but who, because of their mental or physical condition, require care and services above the level of room and board, which can be made available only through institutional facilities; and
mental disabilities, as defined in section 27-10.5-102 (11), C.R.S., and section 25.5-10-202, C.R.S., who do not require the degree of services and supports that a hospital or skilled nursing facility can provide but who, because of their mental or physical condition, require care and services above the level of room and board, which can be made available only through institutional facilities; and
(b) May provide care which includes but is not limited to moderate assistance or therapy functions; occasional direction, supervision, or therapy; moderate assistance or therapy for loss of mobility; routine, nonskilled nursing services; and monitoring of the drug regimen.
(10) "Lawfully residing" means an individual who is not a citizen or national of the United States and who was lawfully admitted to the United States by the immigration and naturalization service, or any successor agency, as an actual or prospective permanent resident or whose extended physical presence in the United States is known to and allowed by the immigration and naturalization service, or any successor agency.
(11) "Liable" or "liability" means the legal liability of a third party, either by reason of judgment, settlement, compromise, or contract, as the result of negligent acts or other wrongful acts or otherwise for all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or member of medical assistance.
(12) "Managed care system" means a health-care system organized to manage costs, utilization, and quality. The statewide managed care system provides for the delivery of health benefits and additional services through contracted arrangements between state medicaid agencies and MCEs.
(13) "Medical assistance" means payment on behalf of members eligible for and enrolled in the state medical assistance program established pursuant to this article 4 and articles 5 and 6 of this title 25.5, which is funded through Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396u-1, to providers enrolled in the state medical assistance program who render or provide medical care, services, goods, and devices to members pursuant to this article 4 and articles 5 and 6 of this title 25.5, and other related payments, pursuant to this article 4 and articles 5 and 6 of this title 25.5 and the rules of the state department.
(13.2) "Member" means a person who has been determined eligible to receive benefits under this article 4 and articles 5 and 6 of this title 25.5.
(13.5) "Modified adjusted gross income" or "MAGI" means an amount of income, as determined pursuant to section 1902 (e)(14) of the federal "Social Security Act", that is used to establish eligibility for medical assistance.
(14) "Nursing facility" means a facility, or a distinct part of a facility, that meets the state nursing home licensing standards in section 25-1.5-103 (1)(a)(I), is maintained primarily for the care and treatment of inpatients under the direction of a physician, and meets the requirements in 42 U.S.C. sec. 1396r for certification as a qualified provider of nursing facility services. The patients in such a facility require supportive, therapeutic, or compensating services and the availability of a licensed nurse for observation or treatment on a twenty-four-hour basis. Nursing care may include terminal care; extensive assistance or therapy in the activities of daily living; continual direction, supervision, or therapy; extensive assistance or therapy for loss of mobility; nursing assessment and services that involve assessment of the total needs of the patient, planning of patient care, and observing, monitoring, and recording the patient's response to treatment; and monitoring, observing, and evaluating the drug regimen. "Nursing facility" includes private, nonprofit, or proprietary intermediate nursing facilities for persons with intellectual and developmental disabilities.
essment and services that involve assessment of the total needs of the patient, planning of patient care, and observing, monitoring, and recording the patient's response to treatment; and monitoring, observing, and evaluating the drug regimen. "Nursing facility" includes private, nonprofit, or proprietary intermediate nursing facilities for persons with intellectual and developmental disabilities.
(15) "Overpayment" means the amount paid by an agency administering the medical assistance program to an enrolled provider under the state medical assistance program participating in the program, which amount is in excess of the amount that is allowable for services furnished and which is required by Title XIX of the social security act to be refunded to the appropriate medicaid agencies.
(16) "Patient personal needs trust fund" means any fund or account established by the nursing care facility or intermediate care facility or its agents, employees, or designees to manage the personal needs funds of the facility's patients.
(17) "Personal needs funds" means moneys received by any person admitted to a nursing care facility or intermediate care facility, which moneys are received by said person to purchase necessary clothing, incidentals, or other personal needs items which are not reimbursed by any federal or state program, or items of value, which moneys or items of value are in any way surrendered to the management or control of said facility, its agents, employees, or designees.
(18) "Pilot program", as used in section 25.5-5-319, means the family planning pilot program established in section 25.5-5-319, which is carried out by all medicaid providers who provide family planning services and which shall be repealed, effective July 1 five years after the issuance of the federal waiver or July 1 in the year in which the waiver is terminated, whichever occurs first.
(19) (a) "Provider" means any person, public or private institution, agency, or business concern providing medical care, services, or goods authorized under this article and articles 5 and 6 of this title and holding, where applicable, a current valid license or certificate to provide such services or to dispense such goods and enrolled under the state medical assistance program. These services must be provided and goods must be dispensed only if performed, referred, or ordered by a doctor of medicine or a doctor of osteopathy. Services of dentists, podiatrists, and optometrists or services provided by a school district under section 25.5-5-318 need not be referred or ordered by a doctor of medicine or a doctor of osteopathy.
(b) "Provider" includes a laboratory certified under the federal "Clinical Laboratories Improvement Act of 1967", as amended, 42 U.S.C. sec. 263a, to perform high complexity testing.
(19.5) "Psychiatric residential treatment facility" means a facility that is licensed as a residential child care facility, as defined in section 26-6-903, that is not a hospital, and that provides inpatient psychiatric services for individuals who are less than twenty-one years of age under the direction of a physician licensed pursuant to article 240 of title 12, and that meets any other requirement established in rule by the state board.
(20) "Qualified alien" shall have the meaning ascribed to that term in section 431 (b) of the federal "Personal Responsibility and Work Opportunity Reconciliation Act of 1996", Public Law 104-193, as amended.
(21) Repealed.
(22) "Recovery" or "amount recovered" means the amount payable to the applicant or member or the applicant's or member's heirs, assigns, or legal representatives as the result of any liability of a third party.
(23) "Rehabilitative services" means any medical or remedial services recommended by a physician which may reduce physical or mental disability and which may improve functional level.
ed.
(22) "Recovery" or "amount recovered" means the amount payable to the applicant or member or the applicant's or member's heirs, assigns, or legal representatives as the result of any liability of a third party.
(23) "Rehabilitative services" means any medical or remedial services recommended by a physician which may reduce physical or mental disability and which may improve functional level.
(24) "Resident" means any individual who is living, other than temporarily, within the state. "Resident" includes any unemancipated child whose parent, or other person entitled to custody, lives within the state. The state board shall adopt rules for making this determination. Temporary absences from the state shall not cause an individual to lose his status as a resident of this state.
(24.5) "Serious mental illness" means the following psychiatric illnesses, as defined by the American Psychiatric Association in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders:
(a) Bipolar disorders (hypomanic, manic, depressive, and mixed);
(b) Depression in childhood and adolescence;
(c) Major depressive disorders (single episode or recurrent);
(d) Obsessive-compulsive disorders;
(e) Paranoid and other psychotic disorders;
(f) Schizoaffective disorders (bipolar or depressive); and
(g) Schizophrenia.
(25) "Social security act" means the federal "Social Security Act" and amendments thereto.
(25.5) "State university teaching hospital" means a hospital licensed or certified pursuant to section 25-1.5-103 (1)(a), C.R.S.:
(a) That provides supervised teaching experiences to graduate medical school interns and residents enrolled in a state institution of higher education as defined in section 23-18-102 (10), C.R.S.; and
(b) In which more than fifty percent of its credentialed physicians are members of the faculty at a state institution of higher education as defined in section 23-18-102 (10), C.R.S.
(25.7) "Telemedicine" means the delivery of medical and health-care services and any diagnosis, consultation, or treatment using interactive audio, interactive video, or interactive data communication.
(26) "Third party" means an individual, institution, corporation, or public or private agency that is or may be liable to pay all or any part of the medical cost of an injury, a disease, or the disability of an applicant for or member of medical assistance.
(27) "Title XIX" means Title XIX of the social security act, as amended, administered by the federal department of health and human services, or any successor agency, and includes amendments thereto and other federal social security laws replacing said title, in whole or in part.
(28) "Transitional medicaid" means the medical assistance provided to members eligible pursuant to section 25.5-5-101 (1)(b).
C.R.S. § 25.5-4-104 State medical assistance program - single state agency
25.5-4-104. State medical assistance program - single state agency. (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 XIX of the federal "Social Security Act" and this article 4 and articles 5 and 6 of this title 25.5. The program is not required to furnish to members under sixty-five years of age the benefits that are provided to members sixty-five years of age and over under Title XVIII of the federal "Social Security Act", but the medical assistance program must otherwise be uniform to the extent required by Title XIX of the federal "Social Security Act".
(2) The state department may review any decision of a county department and may consider any application upon which a decision has not been made by the county department within a reasonable time to determine the propriety of the action or failure to take timely action on an application for medical assistance. The state department shall conduct any additional investigation the state department deems necessary. After giving the county department an opportunity to rebut the state department's findings or conclusions that the action or delay in taking action was a violation of or contrary to state department rules, the state department shall make a decision whether to grant medical benefits and the amount of medical benefits pursuant to this article 4 and articles 5 and 6 of this title 25.5 and the rules of the state department. Applicants or members affected by the state department's decisions, upon request, must be given reasonable notice and opportunity for a fair hearing by the state department.
C.R.S. § 25.5-4-105 Federal requirements under Title XIX
25.5-4-105. Federal requirements under Title XIX. 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 to maintain a program within the limits of available appropriations.
C.R.S. § 25.5-4-106 Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services
25.5-4-106. Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services. (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 some other state department, division, section, board, commission, or committee under the provisions of federal or state law.
(2) (a) The state department may accept on behalf of the state of Colorado the provisions and benefits of acts of congress designed to provide funds or other property for particular medical assistance within the state, which funds or other property are designated for such purposes within the function of the state department, and may accept on behalf of the state any offers which have been or may from time to time be made of funds or other property by any persons, agencies, or entities for particular medical assistance activities within the state, which funds or other property are designated for such purposes within the function of the state department; but, unless otherwise expressly provided by law, such acceptance shall not be manifested unless and until the state department has recommended such acceptance to and received the written approval of the governor and the attorney general. Such approval shall authorize the acceptance of the funds or property in accordance with the restrictions and conditions for the purpose for which funds or property are intended.
(b) The state treasurer is designated as ex officio custodian of all medical assistance funds received by the state from the federal government and from any other source, if the approval provided for in paragraph (a) of this subsection (2) has been obtained.
(c) The state treasurer shall hold each such fund separate and distinct from state funds and is authorized to make disbursements from such funds for the designated purpose or for administrative costs, which may be provided in such grants upon warrants issued by the state controller upon the voucher of the state department.
(3) The state department shall cooperate with the federal department of health and human services and other federal agencies in any reasonable manner, in conformity with the laws of this state, which may be necessary to qualify for federal financial participation, including the preparation of state plans, the making of reports in such form and containing such information as any federal agency may from time to time require, and the compliance with such provisions as the federal government may from time to time find necessary to assure the correctness and verification of the reports.
(4) The rules of the state department may include provisions to accommodate requirements of contracts entered into between the state department and the federal department of health and human services, or any successor agency, for studies of guaranteed annual income or other forms of income maintenance research projects; and for such purpose, the requirements of this title as to eligibility for medical assistance shall not apply for the term of and in accordance with the contract for such purpose.
(5) The state department is responsible for administering the delivery of medical assistance by county departments of human or social services or any other public or private entities participating in the delivery of medical assistance pursuant to this article 4 and articles 5 and 6 of this title 25.5.
C.R.S. § 25.5-4-107 Retaliation definition
25.5-4-107. Retaliation definition. (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 someone acting on behalf of the member files a complaint concerning services provided or not provided to the member:
(a) Indicating to a member that the member cannot have an advocate, family member, or other authorized representative assist the member; or
(b) (I) An adverse action that negatively affects a member's level of eligibility for or receipt of services received at the time of the complaint without verification of a change in the member's income, resources, or health-care needs that justifies the adverse action.
(II) An adverse action must not be taken against a member after a complaint has been filed until the member is notified of the proposed action, informed of the reason for the proposed action, and provided an opportunity to appeal the proposed action.
(2) "Retaliation" does not include instances when a member is not eligible for a service or program or when a provider documents a problem with a member and shares the documentation with the member or a third party prior to the member filing a complaint.
C.R.S. § 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
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. (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 nonadministrative expenditure that qualifies for federal financial participation under Title XIX of the federal "Social Security Act", and for the administration of the state-funded health and medical care program, created pursuant to section 25.5-2-104, and for the state children's basic health plan, created pursuant to section 25.5-2-105, except for expenditures under the program for the medically indigent, article 3 of this title 25.5.
(1.5) (a) The state department shall utilize the cash system of accounting, as enunciated by the governmental accounting standards board, for the contributions required by 42 U.S.C. sec. 1396u-5 (c).
(b) The contributions required by 42 U.S.C. sec. 1396u-5 (c) shall be made in the manner required by the federal centers for medicare and medicaid services, or any successor agency. Nothing in this paragraph (b) shall require the state department to make the contribution before the contribution is due.
(2) The executive director shall promulgate rules to identify the programs utilizing the cash system of accounting.
C.R.S. § 25.5-4-202 Comprehensive plan for other services and benefits
25.5-4-202. Comprehensive plan for other services and benefits. (Repealed)
C.R.S. § 25.5-4-203 Advisory council established
25.5-4-203. Advisory council established. (1) There is created the state medical assistance and services advisory council, referred to in this article 4 as the "advisory council", consisting of sixteen members, as follows:
(a) The executive director of the state department and the executive director of the department of public health and environment, the executive directors' designees, or the executive directors' successors in function, as ex officio members; and
(b) Fourteen members, appointed by the governor and chosen by the governor to represent the various areas of medical services and the public as follows:
(I) Two members who are doctors of medicine licensed in this state;
(II) One member who is a doctor of osteopathy licensed in this state;
(III) One member who is a dentist licensed in this state;
(IV) One member who is an optometrist licensed in this state;
(V) One member who is an owner or operator of a licensed nursing facility in this state;
(VI) One member who represents licensed hospitals in this state;
(VII) One member who is a pharmacist licensed in this state;
(VIII) One member who is a professional nurse licensed in this state;
(IX) One member who has provided home health-care services for three years;
(X) Three members who are not directly associated with the areas of medical services to represent the public; and
(XI) One member who may represent any other area of medical services not specifically enumerated but shall not be limited thereto.
(2) Advisory council members serve at the pleasure of the governor and receive no compensation but are entitled to reimbursement for actual and necessary expenses. The advisory council shall advise the state department on the provision of health and medical care services to members of medical assistance.
C.R.S. § 25.5-4-204 Automated medical assistance administration
25.5-4-204. Automated medical assistance administration. (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 through the implementation of an automated system that will provide for the following:
(a) Electronic claim submittals;
(b) Online eligibility determinations;
(c) Electronic remittance statements;
(d) Electronic fund transfers; and
(e) Automation of other administrative functions associated with the medical assistance program.
(2) Therefore, the general assembly declares that it is appropriate to enact legislation, as set forth in subsection (3) of this section, that authorizes the state department to develop and implement an automated system for processing claims and payments under the medical assistance program, as well as for other administrative functions associated with the program.
(3) The executive director of the state department shall develop and implement an automated system through which medical assistance claims and payments and eligibility determinations or other related transactions may be processed. The system shall provide for the use of automated electronic technologies. The automated system may be implemented in phases if deemed necessary by the executive director. The automated system shall be implemented only after the executive director determines that:
(a) Technology is available and proven to perform satisfactorily in a production environment;
(b) Adequate financing is available to facilitate the implementation and maintenance of the system. Financing may include, but is not limited to, federal funds, appropriations from the general fund, provider transaction fees, or any other financing mechanisms which the state department may impose, and grants or contributions from public or private entities.
(c) The system has been successfully installed and fully tested; and
(d) Adequate provider training has been provided for an orderly implementation.
C.R.S. § 25.5-4-205 Application - verification of eligibility - demonstration project - rules
25.5-4-205. Application - verification of eligibility - demonstration project - rules. (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 local social security office determines eligibility for supplemental security income. The state department may accept medical assistance applications and determine medical assistance eligibility and may designate the private service contractor that administers the children's basic health plan, Denver health and hospital authority, created in section 25-29-103, a hospital that is designated as a regional pediatric trauma center, as defined in section 25-3.5-703 (4)(f), and other medical assistance sites determined necessary by the state department to accept medical assistance applications, to determine medical assistance eligibility, and to determine presumptive eligibility. A hospital licensed pursuant to part 1 of article 3 of title 25 or certified pursuant to section 25-1.5-103 (1)(a)(II) is authorized to determine presumptive eligibility for medical assistance pursuant to 42 U.S.C. sec. 1396a (a)(47)(B). When the state department determines that it is necessary to designate an additional medical assistance site, the state department shall notify the county in which the medical assistance site is located that an additional medical assistance site has been designated. A person who is determined to be eligible pursuant to the requirements of this article 4 and articles 5 and 6 of this title 25.5 is eligible for benefits until the person is determined to be ineligible. Upon determination that a person is ineligible for medical benefits, the county department, the state department, or other entity designated by the state department shall notify the applicant in writing of its decision and the reason. When an applicant is found ineligible for medical assistance eligibility programs, the applicant's application data and verifications must be automatically shared with the state insurance marketplace through a system interface. Separate determination of eligibility and formal application for benefits pursuant to this article 4 and articles 5 and 6 of this title 25.5 for persons eligible pursuant to sections 25.5-5-101 and 25.5-5-201 must be made in accordance with the rules of the state department.
(a.5) Repealed.
(a.7) As part of the medicaid eligibility modernization, the department is authorized to create a universal application for case management agencies for home- and community-based services waivers for children.
(b) The state department shall develop training safeguards to prevent actions taken by staff of medical assistance sites from affecting food and cash assistance eligibility.
(2) (a) Any married couple, at the beginning of a continuous period of institutionalization of one spouse, may request the county department to assess and document the total value of the resources of the couple, if the couple supplies to the county department the necessary information and documentation which is needed to make such an assessment.
(b) Any assessment prepared by the county department and provided to a couple shall contain a procedure for appealing any determinations which have been made.
may request the county department to assess and document the total value of the resources of the couple, if the couple supplies to the county department the necessary information and documentation which is needed to make such an assessment.
(b) Any assessment prepared by the county department and provided to a couple shall contain a procedure for appealing any determinations which have been made.
(c) If a request for assessment and documentation is not part of an application for medical assistance, the county department may establish a fee not exceeding the reasonable expenses of the county department of providing and documenting such assessment.
(3) (a) The state department shall promulgate rules to simplify the processing of applications in order that medical benefits are furnished to members as soon as possible, including rules that:
(I) Provide for initial processing of applications and determination of eligibility for medical assistance only at locations other than the county departments, at locations used for processing applications for the Colorado works program, or at the location used by the private service contractor that administers the children's basic health plan for determining eligibility of children for the plan; and
(II) May make provision for the payment of medical benefits for a period not to exceed three months prior to the date of application in cases where the applicant did not make application prior to his or her need for said medical benefits.
(b) (I) The state department shall promulgate rules that:
(A) To the extent authorized under federal law, require an applicant to state only the applicant's income and require the state department to verify the applicant's income through federally approved electronic data sources; except that, if electronic data is not available, or the information obtained from an electronic data source is not reasonably compatible with information provided by or on behalf of an applicant, the rules shall require an individual to provide documentation in order to verify the applicant's income; and
(B) Require the state department at least annually to verify a member's income eligibility at reenrollment through federally approved electronic data sources and, if the member meets all eligibility requirements, permit the member to remain enrolled in the medical assistance program. The rules must only require an individual to provide documentation verifying income if electronic data is not available or the information obtained from electronic data sources is not reasonably compatible with information provided by or on behalf of an applicant.
(C) and (D) (Deleted by amendment, L. 2009, (SB 09-292), ch. 369, p. 1974, § 96, effective August 5, 2009.)
(I.5) (A) If the state department determines that a member was not eligible for medical benefits solely based upon the member's income after the member had been determined to be eligible based upon electronic data obtained through a federally approved electronic data source, the state department shall not pursue recovery from a county department for the cost of medical services provided to the member and the county department is not responsible for any federal error rate sanctions resulting from the determination.
(B) Notwithstanding any other provision in this subsection (3)(b), for applications that contain self-employment income, the state department shall not implement this subsection (3)(b) until the state department can verify self-employment income through federally approved electronic data sources as authorized by rules of the state department and federal law.
ions resulting from the determination.
(B) Notwithstanding any other provision in this subsection (3)(b), for applications that contain self-employment income, the state department shall not implement this subsection (3)(b) until the state department can verify self-employment income through federally approved electronic data sources as authorized by rules of the state department and federal law.
(C) The state department may seek federal authorization to not require additional verification during a member's eligibility reenrollment process if information about the member's income is not verified through a federally approved electronic data source. The state department may use the information on file or the information that was originally collected during the application process to determine whether the member is eligible for reenrollment. Notwithstanding this subsection (3)(b)(I.5)(C) to the contrary, the state department shall require additional income verification if information about a member's income is not verified through a federally approved electronic data source for two or more consecutive years or as specified through federal authorization.
(D) The state department may seek federal authorization to not require additional verification during a member's eligibility reenrollment process if information about the member's assets is not verified through a federally approved electronic data source in a reasonable time, as determined by the state department. The state department may complete the member's eligibility reenrollment process without any additional verification of the member's assets if there has been no change in the member's assets since the initial verification during the application process or as specified through federal authorization.
(E) The state department may seek federal authorization to delay a member's procedural termination during the reenrollment process to allow the member to continue receiving necessary services during the reenrollment process. The state department may apply this delay in procedural termination to a specific population or as specified through federal authorization.
(F) The state department may seek federal authorization to allow an applicant's or member's eligibility for reenrollment to be based on financial findings from the supplemental nutrition assistance program established pursuant to part 3 of article 2 of title 26, the temporary assistance for needy families program established pursuant to part 7 of article 2 of title 26, and other means-tested benefit programs administered through the Colorado benefits management system. The state department may apply financial eligibility for medicaid to individuals whose gross income program and assets for applicable means-tested benefit programs are below applicable medicaid limits, regardless of differences in household composition and income-counting rules between programs or as specified through federal authorization.
(G) Subject to available appropriations and upon receiving necessary federal authorization, the state department may implement subsections (3)(b)(I.5)(C), (3)(b)(I.5)(D), (3)(b)(I.5)(E), and (3)(b)(I.5)(F) of this section.
(II) Repealed.
(c) Adequate safeguards shall be established by the state department to ensure that only eligible persons receive benefits under this article and articles 5 and 6 of this title.
ailable appropriations and upon receiving necessary federal authorization, the state department may implement subsections (3)(b)(I.5)(C), (3)(b)(I.5)(D), (3)(b)(I.5)(E), and (3)(b)(I.5)(F) of this section.
(II) Repealed.
(c) Adequate safeguards shall be established by the state department to ensure that only eligible persons receive benefits under this article and articles 5 and 6 of this title.
(d) (I) In addition, an applicant who is eighteen years of age or older shall be required to supply a form of personal photographic identification either by providing a valid Colorado driver's license or a valid identification card issued by the department of revenue pursuant to section 42-2-302, C.R.S. The state department may adopt rules that exempt applicants from the requirement of supplying a form of personal photographic identification if the requirement causes an unreasonable hardship or if the requirement is in conflict with federal law.
(II) The state department shall also adopt rules that allow for assistance to be provided until the applicant is able to obtain or qualify for a driver's license or identification card; however, a county department or an entity designated by the state department pursuant to subsection (1) of this section is not required to pursue recovery of assistance from an applicant who fails, upon recertification, to meet the photographic identification requirement.
(e) (I) In collaboration with and to augment the state department's efforts to simplify eligibility determinations for benefits under the state medical assistance program and the children's basic health plan, the state department shall establish a process so that a member, or the parent or guardian of a member, may apply for reenrollment either over the telephone or through the internet.
(II) (A) Subject to receipt of federal authorization and spending authority, the state department may implement a pilot program that allows a limited number of members to apply for reenrollment either over the telephone or through the internet during a transition to a process that will serve members statewide. The pilot program is not a replacement for a statewide process.
(B) Notwithstanding any other provision in this subsection (3)(e), the state department shall not implement this subsection (3)(e) until the state department can verify the eligibility of a member over the telephone or through the internet as authorized by rules of the state department and federal law.
(C) Notwithstanding any other provision in this paragraph (e), the state department shall not implement or administer any portion of this paragraph (e) until spending authority has been received in the general appropriation act or any supplemental appropriation and shall only implement and administer this paragraph (e) to the extent of such spending authority.
(III) The state department may solicit and accept gifts, grants, and donations from public or private sources for the development or implementation of reenrollment either over the telephone or through the internet process described in this paragraph (e); except that the state department may not accept a gift, grant, or donation that is subject to conditions that are inconsistent with this paragraph (e) or any other law. Any gifts, grants, or donations received by the state department shall be transmitted to the state treasurer, who shall credit the same to the department of health care policy and financing cash fund created pursuant to section 25.5-1-109.
hat the state department may not accept a gift, grant, or donation that is subject to conditions that are inconsistent with this paragraph (e) or any other law. Any gifts, grants, or donations received by the state department shall be transmitted to the state treasurer, who shall credit the same to the department of health care policy and financing cash fund created pursuant to section 25.5-1-109.
(f) (I) To ensure that the state department maintains access to state and federal funding provided by the federal "Families First Coronavirus Response Act", Pub.L. 116-127, and the federal "Consolidated Appropriations Act, 2023", subsections (3)(b)(I) and (3)(d) of this section requiring the collection or verification of any information related to medical assistance eligibility factors, including citizenship, household size, income, or assets for those individuals already enrolled in the medical assistance program, are suspended until January 1, 2025.
(II) The state board may adopt rules to implement this subsection (3)(f) to ensure that the state department can resume routine operations that follow guidance issued by the federal centers for medicare and medicaid services, including terminations of eligibility, the processing of eligibility renewals, and the transition between medical assistance and children's basic health plan eligibility categories.
(III) This subsection (3)(f) is repealed, effective January 1, 2025.
(4) (a) By signing an application for medical assistance, a person assigns to the state department, by operation of law, all rights the applicant may have to medical support or payments for medical expenses from any other person on the applicant's own behalf or on behalf of any other member of the applicant's family for whom application is made. For purposes of this subsection (4), an assignment takes effect upon the determination that the applicant is eligible for medical assistance and up to three months prior to the date of application if the applicant meets the requirements of subsection (3) of this section and shall remain in effect so long as an individual is eligible for and receives medical assistance benefits. The application shall contain a statement explaining this assignment.
(b) An applicant for medical benefits upon initial application and each redetermination shall disclose any third party who may be responsible for the payment of medical expenses on behalf of the applicant or any other member of the applicant's family for whom application is made. As part of its medicaid eligibility modernization, the state department shall require the county department or other entity designated to accept applications for medical benefits to enter the third-party information into the automated system developed pursuant to section 25.5-4-204.
(5) (a) The state department shall not pursue recovery from a county for the cost of medical services provided to a person who has been incorrectly determined eligible for medical assistance by that county or any other entity.
(b) (Deleted by amendment, L. 2008, p. 2024, § 1, effective June 3, 2008.)
C.R.S. § 25.5-4-205.5 Confined persons - suspension of benefits
25.5-4-205.5. Confined persons - suspension of benefits. (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 juvenile commitment facility;
(d) Committed to a department of human services facility pursuant to part 1 of article 8 of title 16, C.R.S.; or
(e) A patient placed in a department of human services facility pursuant to court order or certification.
(2) Notwithstanding any other provision of law, a person who, immediately prior to becoming a confined person, was a member of medical assistance pursuant to this article 4 or article 5 or 6 of this title 25.5, remains eligible for medical assistance while a confined person; except that medical assistance may not be furnished pursuant to this article 4 or article 5 or 6 of this title 25.5 while the person is a confined person unless federal financial participation is available for the cost of the assistance, including, but not limited to, juveniles held in a facility operated by or under contract to the division of youth services established pursuant to section 19-2.5-1501 or the department of human services. Once a person is no longer a confined person, the person is eligible for receipt of medical assistance pursuant to this article 4 or article 5 or 6 of this title 25.5 until the person is determined to be ineligible for the receipt of the assistance. To the extent permitted by federal law, the time during which a person is a confined person is not included in any calculation of when the person must renew the person's eligibility for medical assistance pursuant to this article 4 or article 5 or 6 of this title 25.5.
C.R.S. § 25.5-4-206 Reimbursement to counties - costs of administration
25.5-4-206. Reimbursement to counties - costs of administration. 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.
C.R.S. § 25.5-4-207 Appeals - rules - applicability
25.5-4-207. Appeals - rules - applicability. (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 appeal to the state department in the manner and form prescribed by the rules of the state department. Except as permitted under federal law, state department rules must provide for at least a ten-day advance notice before the effective date of any suspension, termination, or modification of medical assistance. The county department or designated service agency shall notify the applicant or member in writing of the basis for the decision or action and shall inform the applicant or member of the right to a county department or service agency conference under the dispute resolution process described in subsection (1)(b) of this section and of the right to a state-level appeal and the process for appeal.
(II) The applicant or member has sixty days after the date of the notice to file an appeal. If the member files an appeal prior to the effective date of the intended action, existing medical assistance benefits must automatically continue unchanged until the appeal process is completed, unless the member requests in writing that medical assistance benefits not continue during the appeal process; except that, to the extent authorized by federal law, state department rules may permit existing medical assistance benefits to continue until the appeal process is completed even if the member's appeal is filed after the effective date of the intended action. The state department shall promulgate rules consistent with federal law that prescribe the circumstances under which the county department or designated service agency may continue benefits if an appeal is filed after the effective date of the intended action. At a minimum, the rules must allow for continuing benefits when the member's health or safety is impacted, the member was not able to timely respond due to the member's disability or employment, the member's caregiver was unavailable due to the caregiver's health or employment, or the member did not receive the county department's or designated service agency's notice prior to the effective date of the intended action.
(III) Either prior to appeal or as part of the filing of an appeal, the applicant or member may request the dispute resolution process described in subsection (1)(b) of this section through the county department or service delivery agency.
(b) Every county department or service delivery agency shall adopt procedures for the resolution of disputes arising between the county department or the service delivery agency and any applicant for or member of medical assistance. The procedures are referred to in this section as the "dispute resolution process". Two or more counties may jointly establish the dispute resolution process. The dispute resolution process must be consistent with rules promulgated by the state board pursuant to article 4 of title 24. The dispute resolution process must include an opportunity for all members to have a county department conference, upon the member's request, and the requirement may be met through a telephonic conference upon the agreement of the member and the county department. The dispute resolution process does not need to conform to the requirements of section 24-4-105 as long as the rules adopted by the state board include provisions specifically setting forth expeditious time frames, notice, and an opportunity to be heard and to present information. If the dispute is resolved through the county department or service delivery agency's dispute resolution process and the applicant or member has already filed an appeal, the county department shall inform the applicant or member of the process for dismissing the appeal.
provisions specifically setting forth expeditious time frames, notice, and an opportunity to be heard and to present information. If the dispute is resolved through the county department or service delivery agency's dispute resolution process and the applicant or member has already filed an appeal, the county department shall inform the applicant or member of the process for dismissing the appeal.
(c) The state board shall adopt rules setting forth what other issues, if any, may be appealed by an applicant or member to the state department. The state department is not required to grant a hearing when either state or federal law requires or results in a reduction or deletion of a medical assistance benefit unless the applicant or member is arguing that the applicant's or member's case does not fit within the parameters set forth by the change in the law. In notifying the applicant or member that an appeal is being denied because of a change in state or federal law, the state department's notice must inform the applicant or member that further appeal should be directed to the appropriate state or federal court.
(d) Upon receipt of an appeal, the office of administrative courts shall give the appellant at least ten days' notice of the hearing date and an opportunity for a fair hearing in accordance with the rules of the state department. The fair hearing must comply with section 24-4-105, C.R.S., and the state department's administrative law judge shall preside.
(d.5) (I) At the commencement of a hearing that concerns the termination or reduction of an existing benefit, the state department's administrative law judge shall review the legal sufficiency of the notice of action from which the member is appealing. If the administrative law judge determines that the notice is legally insufficient, the administrative law judge shall inform the appellant that the termination or reduction may be set aside on the basis of insufficient notice without proceeding to a hearing on the merits. The appellant may affirmatively waive the defense of insufficient notice and agree to proceed with a hearing on the merits or may ask the administrative law judge to decide the appeal on the basis of the judge's finding that the notice is legally insufficient. The administrative law judge shall also inform the appellant that the state department may issue legally sufficient notice in the future and that the state department may seek recoupment of benefits if a basis for denial or reduction of benefits is subsequently determined.
(II) This subsection (1)(d.5) applies to hearings conducted on and after January 1, 2018.
(e) The appellant shall have an opportunity to examine all applications and pertinent records concerning the appellant that constitute a basis for the denial, suspension, termination, or modification of medical assistance benefits. The person or persons involved in the decision denying, suspending, terminating, or modifying medical assistance benefits or, if the person or persons are not reasonably available, a person familiar with the facts underlying the basis for the decision, shall be available for cross-examination if requested by the appellant.
(2) All decisions of the state department shall be binding upon the county department involved and shall be complied with by such county department.
C.R.S. § 25.5-4-208 County duties - transitional medicaid
25.5-4-208. County duties - transitional medicaid. 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.
C.R.S. § 25.5-4-209 Payments by third parties - copayments by members - review - appeal - children's waiting list reduction fund - rules
25.5-4-209. Payments by third parties - copayments by members - review - appeal - children's waiting list reduction fund - rules. (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 insurance, must apply the supplemental income or insurance proceeds to the cost of the benefits rendered, and the state department rules may require reports from providers of other payments received from or on behalf of members.
(b) Subject to any limitations imposed by Title XIX of the federal "Social Security Act", a member shall pay at the time of service a portion of the cost of any medical benefit rendered to the member or to the member's dependents pursuant to this article 4 or article 5 or 6 of this title 25.5, as determined by rules of the state department.
(c) to (e) Repealed.
(2) (a) Notwithstanding the provisions of section 26-1-114, C.R.S., the state department is authorized to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services available, including the collection of sufficient information from individuals who are eligible for medical assistance to pursue claims against the third parties. The state department shall collect the information at the time of any determination or redetermination of eligibility for medical assistance. A knowing or willful failure of an individual to provide the information may result in the termination of the individual's eligibility for medical assistance.
(b) A third party, as a condition of doing business in the state, shall:
(I) (A) Provide on a monthly basis to the state department or its business associate eligibility records identifying all persons covered by the third party in a manner prescribed by rule to allow the state department or its business associate to perform an analysis and determine which persons are eligible for medical assistance;
(B) The eligibility record data elements provided by the third party shall be the minimum necessary to achieve a satisfactory data match. The third party shall provide, upon request of the state department or its business associate, additional data elements as needed to confirm eligibility matches as determined by the initial analysis, including, but not limited to, the name, address, and identifying number of the third party's plan.
(II) Accept the state's right of recovery and the assignment to the state of any right of an individual or other entity to payment from the third party for an item or service for which payment has been made under the medical assistance plan to the extent that such service is covered by the third party;
(III) Respond to any inquiry by the state regarding a claim for payment for any health-care item or service that is submitted not later than three years after the date of the provision of the health-care item or service; and
(IV) Agree not to deny a claim submitted by the state solely on the basis of the date of submission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim, if:
(A) The claim is submitted by the state within the three-year period beginning on the date that the item or service is furnished; and
(B) Any action by the state to enforce its rights with respect to the claim is commenced within six years after the state's submission of the claim.
(c) The cost to a third party of providing data, including eligibility records, shall be borne by the state department.
(d) A third party that provides data required by the state department, whether confidential or not, shall not be held liable for the provision of such data to the state department or for any use made thereof.
commenced within six years after the state's submission of the claim.
(c) The cost to a third party of providing data, including eligibility records, shall be borne by the state department.
(d) A third party that provides data required by the state department, whether confidential or not, shall not be held liable for the provision of such data to the state department or for any use made thereof.
(e) (I) The state department's business associate shall not use, transfer, extract, copy, revise, or store any data required to be provided to the state department and its business associate, including the eligibility records, social security numbers, coverage, nature of coverage, period provided, or any other data elements, for purposes other than:
(A) The identification of persons eligible to receive medical assistance, as defined by section 25.5-1-103 (5);
(B) Cost avoidance;
(C) The remuneration of the state department for services provided or paid for;
(D) Any record retention requirements;
(E) Audit requirements; and
(F) Purposes related to litigation and testimony.
(II) The state department's business associate shall destroy all data once the functions specified in subparagraph (I) of this paragraph (e) have been accomplished.
(f) (I) A Colorado resident shall have a private right of action against the state department's business associate if the business associate negligently uses the data specified in paragraph (e) of this subsection (2) for purposes other than those stated in paragraph (e) of this subsection (2). The right of action shall be enforceable in the courts of Colorado and limited to the actual damages incurred by the individual bringing the action.
(II) A third party may bring an action on behalf of a Colorado resident for injunctive relief against the state department's business associate to prevent the business associate from intentionally using the data for purposes other than those specified in paragraph (e) of this subsection (2).
(g) As used in this section:
(I) "Business associate" shall have the same meaning as provided in 45 CFR 160.103.
(II) "Third party" means a health insurer, self-insured plan, group health plan as defined in 29 U.S.C. sec. 1167 (1), service benefit plan, managed care organization, pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health-care item or service.
(3) (a) The rights assigned by a member of medical assistance to the state department pursuant to section 25.5-4-205 (4) must include the right to appeal an adverse coverage decision by a third party for which the medical assistance program may be responsible for payment, including but not limited to the internal and external reviews described in sections 10-16-113 and 10-16-113.5 and a third party's reasonable appeal procedure under state and federal law. The state department or the independent contractor retained pursuant to subsection (3)(b) of this section shall review and, if necessary, may appeal at any level an adverse coverage decision, except an adverse coverage decision relating to medicare, Title XVIII of the federal "Social Security Act", as amended.
(b) The state department shall enter into one or more agreements with an independent contractor to pursue recoveries from third parties pursuant to paragraph (a) of this subsection (3). Any such agreement shall provide that the independent contractor's only compensation shall be a prudent and reasonable percentage of the amount recovered on behalf of the state department as determined by the state department.
e department shall enter into one or more agreements with an independent contractor to pursue recoveries from third parties pursuant to paragraph (a) of this subsection (3). Any such agreement shall provide that the independent contractor's only compensation shall be a prudent and reasonable percentage of the amount recovered on behalf of the state department as determined by the state department.
(c) (I) An independent contractor retained pursuant to paragraph (b) of this subsection (3) shall maintain a contemporaneous record of the hours of services provided and any costs incurred. When the matter is resolved, the independent contractor shall provide to the state department a statement of the hours of services provided, the amount of costs incurred, the total amount of the contingent fee, and the hourly rate for the services provided. The hourly rate for the services provided shall be determined by dividing the amount of the contingent fee, less the amount of costs incurred, by the number of hours of services provided by the independent contractor. The statement required by this subparagraph (I) shall be available for inspection and copying at reasonable times at the state department.
(II) Compliance with this paragraph (c) does not relieve a contracting attorney of any obligation or legal responsibility imposed by the Colorado rules of professional conduct or any provision of law.
(d) Nothing in this subsection (3) authorizes the denial of or delay of payment to a provider by the state department or the delay or interference with the provision of services to a medical assistance member.
(e) Repealed.
(4) With respect to programs administered by the state department, the state department shall access available data from the public assistance reporting information system for the purpose of identifying persons who are receiving certain public benefits from other states. The state department shall ensure that duplicate benefits are not being paid improperly to persons identified pursuant to the public assistance reporting information system.
C.R.S. § 25.5-4-210 Purchase of health insurance for members
25.5-4-210. Purchase of health insurance for members. (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 insurance for a medical assistance member who is eligible to enroll in a health insurance plan if enrollment of the member would be cost-effective to this state. A determination of cost-effectiveness must be in accordance with federal guidelines established by the secretary of the federal department of health and human services.
(b) Notwithstanding any provision of subsection (1)(a) of this section to the contrary, the state department, in purchasing health insurance for medical assistance members who are eligible to enroll for private coverage, shall not purchase health insurance for more than two thousand individuals.
(2) Enrollment in a group health insurance plan is required of members for whom enrollment has been determined to be cost-effective as a condition of obtaining or retaining medical assistance. A parent is required to enroll a dependent child member, but medical assistance for the child is not discontinued if a parent fails to enroll the child.
(3) The state department shall pay any premium, deductible, coinsurance, or other cost-sharing obligation required under the group plan for services covered under the state medical assistance plan. In addition, the state department shall pay any premium, deductible, coinsurance, or other cost-sharing obligation required under an individual plan purchased by the state department for a medical assistance member pursuant to subsection (1) of this section. Payment of the services is treated as payment for medical assistance. Coverage provided by the purchased health insurance plan is considered third-party liability for the purposes of section 25.5-4-209.
(4) Services not available to a member under the purchased plan are provided to the member if the services would otherwise be provided as medical assistance services pursuant to this article 4 or article 5 or 6 of this title 25.5. Nothing in this section requires services provided under a group health insurance plan for medical assistance to be made available to members not enrolled in the plan. Enrollment in a group health insurance plan pursuant to this section does not affect the eligibility of a member who otherwise qualifies for medical assistance pursuant to this article 4 or article 5 or 6 of this title 25.5.
C.R.S. § 25.5-4-211 Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year
25.5-4-211. Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year. (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 department in the next fiscal year without further appropriation. This section applies to appropriations made by the general assembly for fiscal years beginning on and after July 1, 2013.
(2) On or before June 30, 2014, and on or before June 30 of each year thereafter, the state department shall notify the state controller of the amount of the appropriation from the annual general appropriation act for the medicaid management information system for the current fiscal year that the state department needs to remain available for expenditure in the next fiscal year. The state department may not expend more than the amount notified under the authority granted in this section.
(3) Repealed.
C.R.S. § 25.5-4-212 Medicaid member correspondence improvement process - legislative declaration - definition
25.5-4-212. Medicaid member correspondence improvement process - legislative declaration - definition. (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 our most vulnerable populations;
(II) Unclear, confusing, and late correspondence from the state department causes an increased workload for the state, counties administering the medicaid program, and nonprofit advocacy groups assisting applicants and members; and
(III) Government should be a good steward of taxpayers' money, ensuring that it is spent in the most cost-effective manner.
(b) Therefore, the general assembly finds that improving medicaid member correspondence is critical to the health and safety of medicaid members and will reduce unnecessary confusion that requires members to call counties and the state department or file appeals.
(2) As used in this section, unless the context otherwise requires, "member correspondence" means any communication to provide notice of an approval, denial, termination, or change to an individual's medicaid eligibility; to provide notice of the approval, denial, reduction, suspension, or termination of a medicaid benefit; or to request additional information that is relevant to determining an individual's medicaid eligibility or benefits. "Member correspondence" does not include communications regarding the state department's review of trusts or review of documents or records relating to trusts.
(3) The state department shall improve medicaid member correspondence by ensuring that member correspondence revised or created after January 1, 2018:
(a) Is written using person-first, plain language;
(b) Is written in a format that includes the date of the correspondence and a member greeting;
(c) Is consistent, using the same terms throughout to the extent practicable, including commonly used program names;
(d) Is accurately translated into the second most commonly spoken language in the state if a member indicates that the language is the member's written language of preference or as required by law;
(e) Includes a statement translated into the top fifteen languages most commonly spoken by individuals in Colorado with limited English proficiency informing an applicant or member how to seek further assistance in understanding the content of the correspondence;
(f) Clearly conveys the purpose of the applicant or member correspondence, the action or actions being taken by the state department or the state department's designated entity, if any, and the specific action or actions that the applicant or member shall or may take in response to the correspondence;
(g) Includes a specific description of any necessary information or documents requested from the applicant or member;
(h) Includes contact information for applicant or member questions; and
ns being taken by the state department or the state department's designated entity, if any, and the specific action or actions that the applicant or member shall or may take in response to the correspondence;
(g) Includes a specific description of any necessary information or documents requested from the applicant or member;
(h) Includes contact information for applicant or member questions; and
(i) Includes a specific and plain language explanation of the basis for the denial, reduction, suspension, or termination of the benefit, if applicable.
(4) Subject to the availability of sufficient appropriations and receipt of federal financial participation, on and after July 1, 2018, the state department shall make electronically available to a member specific and detailed information concerning the member's household composition, assets, income sources, and income amounts, if relevant to a determination for which member correspondence was issued. If implemented, the state department shall notify members in the written correspondence of the option to access this information.
(5) The state department is encouraged to promote the receipt of member correspondence electronically or through mobile applications for members who choose those methods of delivery as allowed by law.
(6) As part of its ongoing process to create and improve member correspondence, the state department may engage with experts in written communication and plain language to test member correspondence against the criteria set forth in subsection (3) of this section with a geographically diverse and representative sample of medicaid members relevant to the member correspondence being revised. The state department shall also develop a process to review and consider feedback from stakeholders, including consumer advocates and counties, prior to implementing significant changes to correspondence.
(7) The state department shall ensure that applicant or member correspondence that may only affect a small number of applicants or members, but may, nonetheless, have a significant impact on the lives of those applicants or members, is appropriately prioritized for revision.
(8) As part of its annual presentation made to its legislative committee of reference pursuant to section 2-7-203, the state department shall present information concerning:
(a) The state department's process for ongoing improvement of member correspondence;
(b) Member correspondence revised pursuant to criteria set forth in subsection (3) of this section during the prior year and member correspondence improvements that are planned for the upcoming year; and
(c) A description of the results of testing of new or significantly revised member correspondence pursuant to subsection (6) of this section, including a description of the stakeholder feedback.
C.R.S. § 25.5-4-213 Audit of medicaid member correspondence - definition
25.5-4-213. Audit of medicaid member correspondence - definition. (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 a performance audit of member correspondence. Thereafter, the state auditor, in the exercise of the state auditor's discretion, may conduct or cause to be conducted additional performance audits of member correspondence pursuant to this section. The audit must include correspondence generated through the Colorado benefits management system, as well as correspondence that is not generated through the Colorado benefits management system.
(3) The performance audit conducted pursuant to this section must include:
(a) A review of available data from counties, from the state department's customer service contract center, and from assistors within the health benefit exchange, created in article 22 of title 10, regarding customer service contacts that are related to member or applicant confusion regarding correspondence received by medicaid members or applicants;
(b) A review of the accuracy of member correspondence at the time the correspondence is generated;
(c) A review of whether member correspondence satisfies the requirements of any state or federal law, rule, or regulation relating to the sufficiency of any notice;
(d) A review of any member correspondence testing process conducted by the state department and whether testing is done prior to implementing new or significantly revised member correspondence;
(e) A review of the results of any member correspondence testing, including member comprehension of the intended purpose or purposes of the correspondence; and
(f) A review of the accuracy of member income and household composition information that is communicated electronically, if applicable.
(4) If audit findings include findings that information contained in member correspondence is inaccurate at the time the correspondence was generated, the audit must identify, if possible, the source of the inaccurate information, which may include but is not limited to computer system or interface issues, county input error, or applicant error.
(5) Based on the findings and conclusions identified during the performance audit conducted pursuant to this section, the office of the state auditor shall make recommendations to the state department for improving member correspondence. On or before December 30, 2020, December 30, 2023, and December 30 in any calendar year in which an audit is conducted pursuant to this section, the office of the state auditor shall submit the findings, conclusions, and recommendations from the performance audit in the form of a written report to the legislative audit committee, which shall hold a public hearing for the purposes of reviewing the report. The report must also be submitted to the joint budget committee, the public health care and human services committee of the house of representatives, the health and human services committee of the senate, and the joint technology committee, or any successor committees.
C.R.S. § 25.5-4-214 Feasibility study - residential and inpatient substance use disorder treatment - report - repeal
25.5-4-214. Feasibility study - residential and inpatient substance use disorder treatment - report - repeal. (Repealed)
C.R.S. § 25.5-4-215 Study - benefits for persons on work release - repeal
25.5-4-215. Study - benefits for persons on work release - repeal. (Repealed)
C.R.S. § 25.5-4-216 Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal
25.5-4-216. Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal. (1) As used in this section:
(a) "Affiliated with" has the meaning set forth in section 6-20-102 (1)(a).
(b) "Campus" has the same meaning set forth in section 6-20-102 (1)(b).
(c) "CPT code" has the meaning set forth in section 25.5-1-204.7 (1)(d).
(d) "Facility fee" has the meaning set forth in section 6-20-102 (1)(d).
(e) "Health-care provider" has the meaning set forth in section 6-20-102 (1)(f).
(f) "Health system" has the meaning set forth in section 10-16-1303 (9).
(g) "Hospital" has the meaning set forth in section 6-20-102 (1)(j).
(h) "Owned by" has the meaning set forth in section 6-20-102 (1)(m).
(i) "Payer type" has the meaning set forth in section 6-20-102 (1)(n).
(j) "Steering committee" means the steering committee created in subsection (2) of this section.
(2) There is created in the state department a steering committee to research and report on the impact of outpatient facility fees. The steering committee consists of the following seven members appointed by the governor with relevant expertise in health-care billing and payment policy:
(a) Two members representing health-care consumers, with at least one of the members representing a health-care consumer advocacy organization;
(b) One member representing a health-care payer or payers;
(c) One member representing health-care providers not affiliated with or owned by a hospital or health system or who has independent physician billing expertise;
(d) One member representing a statewide association of hospitals;
(e) One member representing a rural, critical access, or independent hospital; and
(f) The executive director of the department of health care policy and financing, or the executive director's designee.
(3) (a) The steering committee shall facilitate the development of a report detailing the impact of outpatient facility fees on the Colorado health-care system, including the impact on consumers, employers, health-care providers, and hospitals. In developing various aspects of the report required in this section, the steering committee shall work with independent third parties to conduct related research and analysis necessary to identify and evaluate the impact of outpatient facility fees.
(b) The steering committee shall prepare a preliminary version of the report on or before August 1, 2024, unless more time is required, and a final report on or before October 1, 2024, that must be submitted to the house of representatives health and insurance committee and the senate health and human services committee, or their successor committees.
(4) (a) For purposes of developing the report, the steering committee, with administrative support from the state department, may:
(I) Select third-party contractors to assist in researching and creating the report, with an appropriation made to the state department for such purpose;
(II) Develop the format, scope, and templates for requests for information;
(III) Review drafts, provide feedback, and finalize the report;
(IV) Answer technical questions from third-party contractors; and
(V) Consult with external stakeholders.
(b) The steering committee, state department, and any third-party contractors engaged in the development of the report are encouraged to use both primary and secondary sources and research, where possible, and, to the extent feasible, ensure the report is well-informed by the perspectives of diverse stakeholders. The steering committee shall work only with third-party contractors that are already approved as one of the state department's project-based contracts.
(c) To the extent practicable, evaluation and analysis performed for the report must attempt to leverage Colorado-specific data sources and publicly available national data and research.
(5) The report must identify and evaluate:
se stakeholders. The steering committee shall work only with third-party contractors that are already approved as one of the state department's project-based contracts.
(c) To the extent practicable, evaluation and analysis performed for the report must attempt to leverage Colorado-specific data sources and publicly available national data and research.
(5) The report must identify and evaluate:
(a) Payer reimbursement and payment policies for outpatient facility fees across payer types, including insights, where available, into changes over time, as well as provider billing guidelines and practices for outpatient facility fees across provider types, including insights, where available, into changes made over time;
(b) Payments for outpatient facility fees, including insights into the associated care across payer types;
(c) Coverage and cost-sharing provisions for outpatient care services associated with facility fees across payers and payer types;
(d) Denied facility fee claims by payer type and provider type;
(e) The impact of facility fees and payer coverage policies on consumers, small and large employers, and the medical assistance program;
(f) The impact of facility fees and payer coverage policies on the charges for health-care services rendered by independent health-care providers, including a comparison of professional fee charges and facility fee charges; and
(g) The charges for health-care services rendered by health-care providers affiliated with or owned by a hospital or health system, and including a comparison of professional fee and facility fee charges.
(6) The report must include an analysis of:
(a) Data from the Colorado all-payer health claims database as reported under DSG14, including, at a minimum:
(I) The number of patient visits for which facility fees were charged, including, to the extent possible, a breakdown of which visits were in network and which were out of network;
(II) To the extent possible, the number of patient visits for which the facility fees were charged out of network and the professional fees were charged in network for the same outpatient service;
(III) The total allowed facility fee amounts billed and denied;
(IV) The top ten most frequent CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which facility fees were charged;
(V) The top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, with the highest total allowed amounts from facility fees;
(VI) The top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which facility fees are charged with the highest member cost sharing; and
(VII) The total number of facility fee claim denials, by site of service;
(b) Data from hospitals and health systems, which data shall be provided to the steering committee, including:
(I) The number of patient visits for which facility fees were charged;
(II) The total revenue collected in facility fees;
(III) A description of the most frequent health-care services for which facility fees were charged and net revenue received for each such service;
(IV) A description of health-care services that generated the greatest amount of gross facility fee revenue and net revenue received for each such service; and
(V) Data from off-campus health-care providers that are affiliated with or owned by a hospital or health system, including:
(A) Historic and current business names and addresses;
(B) Historic and current tax identification numbers and national provider identifiers;
(C) Health-care provider acquisition or affiliation date;
(D) Facility fee billing policies, including whether any changes were made to such policies before or after the acquisition or affiliation date; and
wned by a hospital or health system, including:
(A) Historic and current business names and addresses;
(B) Historic and current tax identification numbers and national provider identifiers;
(C) Health-care provider acquisition or affiliation date;
(D) Facility fee billing policies, including whether any changes were made to such policies before or after the acquisition or affiliation date; and
(E) The top ten CPT codes, revenue codes, or combination thereof, at the state department's discretion, for which a facility fee is billed and the professional fee amount for the same service;
(c) Data, if available, from the state department, the division of insurance, and commercial payers, including:
(I) The payment policy each payer uses for payment of facility fees for network products, including any changes that were made to such policies within the last five years;
(II) A list of common procedures associated with facility fees;
(III) Each payer's network product names;
(IV) Paid aggregate facility fee billings from outpatient providers and the associated number of facility fee claims, broken down by hospital or health system; and
(V) A description of the estimated impact of facility fees on premium rates, out-of-network claims, member cost sharing, and employer costs;
(d) Data from independent health-care providers that are not affiliated with or owned by a hospital or health system, including:
(I) Historic and current business names and addresses;
(II) Historic and current tax identification numbers and national provider identifiers;
(III) Facility fee billing policies, including whether any changes were made to such policies in the past five years; and
(IV) Where applicable, the top ten CPT codes, revenue codes, or combination thereof, at the steering committee's discretion, for which a facility fee is billed and the professional fee amount for the same service;
(e) The impact of facility fees and payer coverage policies on the Colorado healthcare affordability and sustainability enterprise, created in section 25.5-4-402.4, the medicaid expansion, uncompensated care, and undercompensated care;
(f) The impact of facility fees on access to care, including specialty care, primary care, and behavioral health care; integrated care systems; health equity; and the health-care workforce; and
(g) A description of the way in which health-care providers may be paid or reimbursed by payers for outpatient health-care services, with or without facility fees, that explores any legal and historical reasons for split billing between professional and facility fees at:
(I) On-campus locations;
(II) Off-campus locations by health-care providers affiliated with or owned by a hospital or health system; and
(III) Locations by independent health-care providers not affiliated with or owned by a hospital system.
(7) To the extent feasible, data analyzed for purposes of subsection (6) of this section must be sourced from 2014 through 2022, as determined by the steering committee and third-party contractors, and shall be disaggregated by:
(a) Year;
(b) Hospital or health system, where applicable;
(c) Type of service;
(d) Facility site type, including on- or off-campus; and
r owned by a hospital system.
(7) To the extent feasible, data analyzed for purposes of subsection (6) of this section must be sourced from 2014 through 2022, as determined by the steering committee and third-party contractors, and shall be disaggregated by:
(a) Year;
(b) Hospital or health system, where applicable;
(c) Type of service;
(d) Facility site type, including on- or off-campus; and
(e) Payer.
(8) The steering committee may include in the report information received in accordance with this section; except that the steering committee shall not share publicly any information submitted to the steering committee that is confidential, is proprietary, contains trade secrets, or is not a public record pursuant to part 2 of article 72 of title 24 except in aggregated and de-identified form.
(9) The data described in this section must be sought in a form and manner determined by the steering committee, state department, or third-party contractors to facilitate submission of information. The steering committee shall seek to exhaust existing data sources before making additional requests for information for purposes of the report, and every effort must be made to minimize the number of data requests. The report must include a description of which entities were contacted for information and the outcome of each request.
(10) A statewide association of hospitals may also provide data specified in subsection (6)(b) of this section to the steering committee.
(11) This section is repealed, effective January 1, 2025.
C.R.S. § 25.5-4-300.4 Last resort for payment - legislative intent
25.5-4-300.4. Last resort for payment - legislative intent. 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.
C.R.S. § 25.5-4-300.7 Prevention of coding errors - prepayment review of claims
25.5-4-300.7. Prevention of coding errors - prepayment review of claims. (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 nationally recognized correct coding methods in the medicaid management information system, in accordance with 42 U.S.C. sec. 1396b (r) and regulations thereunder, as amended by Pub.L. 111-148, and any other subsequent acts of congress. The state department shall acquire and maintain any information technology necessary to implement the automated, prepayment review of medicaid claims.
(2) Repealed.
C.R.S. § 25.5-4-300.9 Explanation of benefits - medicaid members - legislative declaration
25.5-4-300.9. Explanation of benefits - medicaid members - legislative declaration. (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 federal government;
(III) For the 2015-16 state budget year, the general assembly appropriated $8,891,000,000 for Colorado's medicaid program, of which $2,508,000,000 is from the general fund and $677,000,000 is from the hospital provider fee, with the remainder from federal money;
(IV) It is in the best interest of Colorado to do everything possible to minimize error, inefficiency, and fraud in providing medicaid services to ensure the long-term viability of this safety net program;
(V) In the private sector, as well as the medicare program, insurers routinely provide an explanation of benefits to their clients, listing claims submitted by providers for services rendered to the client even when the insurer is not seeking a co-payment for the service and the provider is not claiming an amount due from the client;
(VI) While creating an explanation of benefits is not without cost to the health-care system, only the member receiving medical services or the member's authorized representative is in the position to verify whether the claimed medical services were actually provided and for whom they were provided, which is a necessary first step in containing health-care costs;
(VII) While medicaid members may not appear to be affected financially by billing errors or fraudulent claims, medicaid members who rely on these services for survival and independence are most severely affected by the inappropriate use of scarce resources; and
(VIII) Further, medicaid members and consumer advocates for low-income and vulnerable Coloradans want the opportunity to partner with the state department and providers to ensure a well-run and fraud-free medicaid program in Colorado.
(b) Therefore, the general assembly declares that creating an explanation of benefits for members of medicaid-funded services is a necessary step in managing the state's medicaid program and in safeguarding the significant public investment, both state and federal, in meeting the health-care needs of low-income and vulnerable Coloradans.
(2) On or before July 1, 2017, the state department shall develop and implement an explanation of benefits for members of medical services pursuant to this article 4 and article 5 or 6 of this title 25.5. The purpose of the explanation of benefits is to inform a medicaid member of a claim for reimbursement made for services provided to the member or on the member's behalf, so that the member may discover and report administrative or provider errors or fraudulent claims for reimbursement.
(3) The explanation of benefits is required for all acute and long-term care services for which a provider is seeking reimbursement under a fee-for-service model.
(4) The explanation of benefits must include, at a minimum:
(a) The name of the medicaid member receiving the service;
(b) The name of the service provider;
(c) A description of the service provided;
(d) The billing code for the service;
(e) The date of service, or range of dates for services, if multiple services are provided in a set period of time, such as personal care services;
(f) A clear statement to the medicaid member that the explanation of benefits is not a bill, but is only provided for the member's information and to make sure that a provider is being reimbursed only for services actually provided;
(g) Information regarding at least one verbal and one written method for the medicaid member to report errors in the explanation of benefits that are relevant to provider reimbursement; and
o the medicaid member that the explanation of benefits is not a bill, but is only provided for the member's information and to make sure that a provider is being reimbursed only for services actually provided;
(g) Information regarding at least one verbal and one written method for the medicaid member to report errors in the explanation of benefits that are relevant to provider reimbursement; and
(h) Any other information that the state department determines is useful to the medicaid member or for purposes of discovering administrative or provider error or fraud.
(5) The state department shall develop the form and content of the explanation of benefits in conjunction with medicaid members and consumer advocates to ensure that medicaid members understand the information provided and the purpose of the explanation of benefits. The state department shall also work with medicaid members and consumer advocates to develop educational materials for the state department's website and for distribution by advocacy and nonprofit organizations that explain the process for reporting errors and encourage members to take responsibility for reporting errors.
(6) The state department shall provide the explanation of benefits to a medicaid member not less frequently than once every two months, if services have been provided to or on behalf of the member during that time period. The state department shall determine the most cost-effective means for producing and distributing the explanation of benefits to medicaid members, which may include e-mail or web-based distribution, with mailed copies by request only. Further, the state department may include the explanation of benefits with an existing mailing or existing electronic or web-based communication to medicaid members.
(7) Nothing in this section requires the state department to produce an explanation of benefits form if the information required to be included in the explanation of benefits pursuant to subsection (4) of this section is already included in another format that is understandable to the medicaid member.
C.R.S. § 25.5-4-301 Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - definitions - repeal
25.5-4-301. Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - definitions - repeal. (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 of the federal "Social Security Act", by this title 25.5, or by rules promulgated by the state board, which benefits are rendered to the member by a provider of medical services authorized to render the service in the state of Colorado, except those contributions required pursuant to section 25.5-4-209 (1). However, a member may enter into a documented agreement with a provider under which the member agrees to pay for items or services that are nonreimbursable under the medical assistance program. Under these circumstances, a member is liable for the cost of the services and items.
(II) The provisions of subsection (1)(a)(I) of this section apply regardless of whether medicaid has actually reimbursed the provider and regardless of whether the provider is enrolled in the Colorado medical assistance program.
(II.5) (A) A provider of medical services who bills or seeks collection through a third party from a member or the estate of a member for medical services authorized by Title XIX of the federal "Social Security Act" in an amount in violation of subsection (1)(a)(I) of this section is liable for and subject to the following: A refund to the member of any amount unlawfully received from the member, plus statutory interest from the date of the receipt until the date of repayment; a civil monetary penalty of one hundred dollars for each violation of subsection (1)(a)(I) of this section; and all amounts submitted to a collection agency in the name of the medicaid member. When determining income or resources for purposes of determining eligibility or benefit amounts for any state-funded program under this title 25.5, the state department shall exclude from consideration any money received by a member pursuant to this subsection (1)(a)(II.5). The imposition of a civil monetary penalty by the state department may be appealed administratively.
(A.5) A provider of medical services who, within thirty days of notification by the state department, or longer if approved by the state department, voids the bill, returns any amount unlawfully received, and makes every reasonable effort to resolve any collection actions so that the member or the estate of the member has no adverse financial consequences is not subject to the provisions of subsection (1)(a)(II.5)(A) of this section.
(B) In order to establish a claim for the civil monetary penalty established by subsection (1)(a)(II.5)(A) of this section, a member or the estate of a member, or a person acting on behalf of a member or the estate of a member, shall notify the state department.
(C) The provisions of this subsection (1)(a)(II.5) do not apply to a long-term care facility licensed pursuant to section 25-3-101.
(D) The provisions of subsection (1)(a)(II.5)(A) of this section do not apply if a member knowingly misrepresents the member's medicaid coverage status to a provider of medical services and the provider submits documentation to the state department that the member knowingly misrepresented the member's medicaid coverage status and the documentation clearly establishes a good cause basis for granting an exception to the provider.
n (1)(a)(II.5)(A) of this section do not apply if a member knowingly misrepresents the member's medicaid coverage status to a provider of medical services and the provider submits documentation to the state department that the member knowingly misrepresented the member's medicaid coverage status and the documentation clearly establishes a good cause basis for granting an exception to the provider.
(III) (A) When a third party is primarily liable for the payment of the costs of a member's medical benefits, prior to receiving nonemergency medical care, the member shall comply with the protocols of the third party, including using providers within the third party's network or receiving a referral from the member's primary care physician. Any member failing to follow the third party's protocols is liable for the payment or cost of any care or services that the third party would have been liable to pay; except that, if the third party or the service provider substantively fails to communicate the protocols to the member, the items or services are nonreimbursable under this article 4 and articles 5 and 6 of this title 25.5 and the member is not liable to the provider.
(B) A member may enter into a written agreement with a third party or provider under which the member agrees to pay for items provided or services rendered that are outside of the network or plan protocols. The member's agreement to be personally liable for nonemergency, nonreimbursable items must be recorded on forms approved by the state board and signed and dated by both the member and the provider in advance of the services being rendered.
(b) Member income applied pursuant to section 25.5-4-209 (1) does not disqualify any member, as defined in section 26-2-103 (8), from receiving benefits pursuant to this article 4, article 5 or 6 of this title 25.5, or public assistance pursuant to article 2 of title 26, and does not disqualify an individual from receiving child care assistance pursuant to part 1 of article 4 of title 26.5. If, at any time during the continuance of medical benefits, the member gains possession of property having a value in excess of that amount set by law or by the rules of the state department or receives any increase in income, the member shall notify the county department and the county department may, after investigation, either revoke the medical benefits or alter the amount of medical benefits, as the circumstances may require.
(c) Any medical assistance paid to which a member was not lawfully entitled is recoverable from the member or the estate of the member by the county as a debt due the state pursuant to section 25.5-1-115, but no lien may be imposed against the property of a member on account of medical assistance paid or to be paid on the member's behalf under this article 4 or article 5 or 6 of this title 25.5, except pursuant to the judgment of a court of competent jurisdiction or as provided by section 25.5-4-302.
(d) If any medical assistance was obtained fraudulently, interest must be charged and paid to the county department on the amount of the medical assistance calculated at the legal rate and calculated from the date that payment for medical services rendered on behalf of the member is made to the date the amount is recovered.
(2) Any overpayment to a provider, including those of personal needs funds made pursuant to section 25.5-6-206, are recoverable regardless of whether the overpayment is the result of an error by the state department, a county department of human or social services, an entity acting on behalf of either department, or by the provider or any agent of the provider as follows:
the amount is recovered.
(2) Any overpayment to a provider, including those of personal needs funds made pursuant to section 25.5-6-206, are recoverable regardless of whether the overpayment is the result of an error by the state department, a county department of human or social services, an entity acting on behalf of either department, or by the provider or any agent of the provider as follows:
(a) (I) If the state department makes a determination that such overpayment has been made as a result of the provider's false representation, the state department may collect the overpayment, plus a civil monetary penalty equal to one-half the amount of the overpayment, and interest on the sum of the two amounts accruing at the statutory rate from the date the overpayment is identified, by the means specified in this subsection (2). Such sum may be collected for up to the amount of time prescribed in section 13-80-103.5, C.R.S., after the overpayment is identified. Amounts remaining uncollected for more than the time period prescribed in section 13-80-103.5, C.R.S., after the last repayment was made may be considered uncollectible. For the purposes of this subparagraph (I), "false representation" means an inaccurate statement that is relevant to a claim for reimbursement and is made by a provider who has actual knowledge of the truth of false nature of the statement or by a provider acting in deliberate ignorance of or with reckless disregard for the truth of the statement. A provider acts with reckless disregard for truth if the provider fails to maintain records required by the department or if the provider fails to become familiar with rules, manuals, and bulletins issued by the department, board, or the department's fiscal agent.
(II) If the state department makes a determination that the overpayment has been made for some other reason than a false representation by the provider specified in subsection (2)(a)(I) of this section, the state department may collect the amount of overpayment, plus interest accruing at the statutory rate from the date the provider is notified of the overpayment, by the means specified in this subsection (2). Pursuant to the criteria established in rules promulgated by the state board, the state department may waive the recovery or adjustment of all or part of the overpayment and accrued interest specified in this subsection (2)(a)(II) if it would be inequitable, uncollectible, or administratively impracticable; except that no action shall be taken against a member of medical services initially determined to be eligible pursuant to section 25.5-4-205 if the overpayment occurred through no fault of the member. Amounts remaining uncollected for more than five years after the last repayment was made may be considered uncollectible.
(b) In order to collect the amounts specified in paragraph (a) of this subsection (2), the state department may withhold subsequent payments to which the provider is or becomes entitled and apply the amount withheld as an offset. The state board shall establish in rules the rate at which an overpayment may be offset, with provision for a reduction of such rate upon a good cause shown by the provider that the rate at which payment will be withheld will result in an undue hardship for the provider. In determining whether to grant a good cause reduction, the state department shall consider the impact of collecting the amount provided by state board rules on the quality of patient care and the financial viability of the provider. The state department may also take such other steps administratively as are available for the collection of the amounts specified in paragraph (a) of this subsection (2).
etermining whether to grant a good cause reduction, the state department shall consider the impact of collecting the amount provided by state board rules on the quality of patient care and the financial viability of the provider. The state department may also take such other steps administratively as are available for the collection of the amounts specified in paragraph (a) of this subsection (2).
(c) If a provider defaults on repayment of the amounts specified in paragraph (a) of this subsection (2), the state department may bring a suit against the provider in the appropriate court. Court costs shall not be assessed against the state department but shall be assessed against the provider if the court finds in favor of the state department. Any costs collected by the state department shall be paid into the registry of the court. Once the amount has been reduced to judgment, the state department may proceed with all available postjudgment remedies.
(d) Repealed.
(e) Any provider adversely affected by actions taken pursuant to this subsection (2), except when a suit is filed against the provider pursuant to paragraph (c) of this subsection (2), may appeal the determination of the state department pursuant to the provisions in section 24-4-105, C.R.S.
(f) If the state department, either directly or through a contracting agent, undertakes a review or an audit of a provider to determine whether an overpayment has been made to that provider, the review or audit shall be subject to the procedures required in subsection (3) of this section.
(3) (a) A review or audit of a provider is subject to the following procedures:
(I) The reviewer or auditor shall conduct a review or audit in accordance with applicable state and federal law.
(II) The reviewer or auditor shall apply uniform standards and procedures to each class of providers subject to a review or an audit to determine an overpayment.
(III) The reviewer or auditor shall prepare findings for the entire period under review or audit, and a provider shall be subject to only one demand for repayment in connection with the review or audit.
(IV) Prior to a review or audit requiring an inspection of a provider's records, the reviewer or auditor, or a qualified agent contracted with the state department pursuant to subsection (3)(b) of this section, shall confirm the provider's contact information with the provider. After confirming the provider's contact information, the reviewer or auditor, or qualified agent, shall notify the provider of additional information concerning the review or audit, including instructions, correspondence timelines, and a state department contact for the provider to notify if the provider does not receive the written request for records. The reviewer or auditor shall initiate each review or audit requiring an inspection of the provider's records by delivering to the provider not less than ten business days prior to the commencement of the audit a written request through both e-mail and certified mail describing in detail such records and offering the provider the option of providing either a reproduction of such records or inspection by the reviewer or auditor at the provider's site. The request must also clearly define milestone dates pertaining to records' requested due dates, permissible extensions of dates, the timelines for informal reconsideration, and deadlines for requesting a formal appeal. The records subject to the request must be limited to records directly related to claims for reimbursement submitted by the provider. Prior to a qualified agent commencing any review or audit, the state department shall ensure providers understand the relationship between the state department and the qualified agent and how to contact the qualified agent
d deadlines for requesting a formal appeal. The records subject to the request must be limited to records directly related to claims for reimbursement submitted by the provider. Prior to a qualified agent commencing any review or audit, the state department shall ensure providers understand the relationship between the state department and the qualified agent and how to contact the qualified agent. In the event such records are available from a county department of human or social services or another agency, subdivision, or contractor of the state, the reviewer or auditor shall request such records from such other agencies as may be appropriate prior to making a request to the provider. The reviewer or auditor shall conduct on-site inspections at reasonable times during regular business hours, and the reviewer or auditor shall make arrangements necessary for the reproduction of such records on site. If the provider chooses to provide a reproduction of the records requested by the reviewer or auditor instead of on-site inspection, the reviewer or auditor shall give the provider a reasonable period of time, not less than forty-five days, to provide such records, taking into account the scope of the request, the time frame covered, and the reproduction arrangements available to the provider.
(IV.5) At the request of the provider, the reviewer or auditor shall conduct an in-person or telephonic interview with the provider prior to the preparation of a preliminary draft of the report of the reviewer or auditor at which the reviewer or auditor and the provider shall discuss:
(A) The findings of the reviewer or auditor;
(B) Any documentation useful for the provider to refute the findings of the reviewer or auditor; and
(C) The next steps in the review or audit process.
(V) A physician's record or other order for health-care services, drugs, or medicinal supplies in a form transmitted electronically shall be sufficient to validate the provider's records regarding the ordering of the health-care services, drugs, or medicinal supplies.
(VI) Whenever possible, the reviewer or auditor shall base a determination of an overpayment to a provider upon a review of actual records of the department, its agents, or the provider. In the event sufficient records are not available to the reviewer or auditor, an overpayment determination may be based upon a sampling of records so long as the sampling and any extrapolation therefrom is reasonably valid from a statistical standpoint and is in accordance with generally accepted auditing standards.
(VII) If a reviewer or auditor determines that there has been an overpayment to the provider, then, at the time demand for repayment is made, the state department shall offer the provider an informal reconsideration of the review or audit findings. The state department shall notify the provider in writing of the right to an informal reconsideration prior to implementing any recovery of an overpayment and give the provider an opportunity to request an informal reconsideration. In the event informal reconsideration is requested or a formal appeal is filed pursuant to subparagraph (VIII) of this paragraph (a), the state department shall not implement recovery of the overpayment until such informal reconsideration or formal appeal has been completed. Within forty-five days after the request for an informal reconsideration, the state department shall render a decision on the request and notify the provider of the decision. The notification shall include information concerning requesting a formal appeal, including informing the provider that the request must be filed within thirty days after the date of the state department's decision on the request for an informal reconsideration
uest for an informal reconsideration, the state department shall render a decision on the request and notify the provider of the decision. The notification shall include information concerning requesting a formal appeal, including informing the provider that the request must be filed within thirty days after the date of the state department's decision on the request for an informal reconsideration. If the state department is unable to render a decision on the request for informal reconsideration within forty-five days after the request, within forty-five days after the request, the state department shall notify the provider of its inability to complete the decision and shall include information concerning requesting a formal appeal, including informing the provider that the request must be filed within thirty days after the receipt of the notification that the state department is unable to render a decision. For purposes of this subparagraph (VII), an informal reconsideration shall be considered final thirty days after the earlier of the date on which the provider withdraws its request or the date on which the state department issues a written decision on the request.
(VIII) In accordance with paragraph (e) of subsection (2) of this section, any provider adversely affected by the actions of the state department or its contracting agent in connection with a review or an audit, including whether the state department or its contracting agent adhered to the provisions of this subsection (3) in making an overpayment determination, may appeal such actions pursuant to the provisions of section 24-4-105, C.R.S.
(IX) For audits conducted pursuant to 42 CFR 455.506, at least quarterly, the state department shall publish on its website an audit activity report detailing current and recently completed audits and reviews and summaries of the findings of such audits and reviews, including the number and amounts of overpayments and underpayments found, the number and results of appeals, the amounts collected, and the error rates identified. At least quarterly, the state department shall conduct trainings for providers and hold stakeholder meetings regarding audits and reviews. In addition, when the state department enters into contracts pursuant to this subsection (3)(a), the state department shall publish on its website a copy of the contract, scope of work, and information regarding supervision of contractor deliverables.
(a.5) Any additional review or audit procedures shall be adopted by rule of the state board and shall be specifically referenced in any contract with a provider.
(b) The state department is authorized to engage the services of a qualified agent through a competitive contract issued pursuant to the state's procurement code for the purpose of conducting a review or audit of a provider to assist in determining whether there has been an overpayment to a provider and the amount of that overpayment. In addition to such terms and conditions as the state department may deem necessary, any contract shall be subject to the requirements for conducting a review or an audit in accordance with paragraph (a) of this subsection (3). The state department is further authorized to enter into a contract with a qualified agent for the purpose of conducting a review or an audit of a provider that provides that the compensation of the contracting agent shall be contingent and based upon a percentage of the amount of the recovery collected from the provider. A contract issued by the state department for the purpose of conducting a review or an audit of a provider to determine whether the provider has received an overpayment shall also be subject to the following conditions:
f a provider that provides that the compensation of the contracting agent shall be contingent and based upon a percentage of the amount of the recovery collected from the provider. A contract issued by the state department for the purpose of conducting a review or an audit of a provider to determine whether the provider has received an overpayment shall also be subject to the following conditions:
(I) The compensation paid to the contracting agent under a contingency-based contract shall not exceed eighteen percent of the amount finally collected from the provider overpayment, and the state department may establish a limit on the amount of annual compensation that may be paid to a contracting agent under a contingency-based contract and may further establish a limit on the amount that may be paid to a contracting agent under a contingency-based contract for recovery from any one provider.
(II) Reimbursement of the contracting agent's costs in performing the review or audit under a contingency-based contract shall be deemed included in the percentage compensation due the agent under the contract.
(III) No employee or agent of the contracting agent involved in the performance of a contingency-based contract shall be compensated by the contracting agent based upon the amount recovered under the contract.
(IV) The state department shall retain all authority for providing notice and otherwise making demand upon a provider for recovery of an overpayment, and the state department shall review and approve any written demand, request, or determination by the contracting agent regarding a review or an audit of a provider under this subsection (3).
(V) In any contingency-based contract authorized pursuant to this paragraph (b), the state of Colorado shall not be obligated to pay the contracting agent for amounts not actually collected from the provider.
(3.5) (a) Prior to the start of a contract to review or audit providers, the state department is encouraged to meet with organizations or associations of providers to educate providers on the review or audit process and the responsibilities of both the providers and the state department throughout the review or audit process. The state department is also encouraged to prepare an annual report on common findings following a contract to review or audit providers and distribute the report to organizations or associations of providers. The annual report should include information to prevent similar findings in future reviews or audits and should direct providers to resource information.
(b) Repealed.
(c) The state department shall create a provider advisory group for recovery audits consisting of employees of the state department and members from different provider groups, including physicians, hospitals, and any other provider types directly impacted by audits conducted pursuant to this section, appointed by the executive director. The provider advisory group shall meet at least quarterly to review quarterly activity reports required by subsection (3)(a)(IX) of this section and advise the state department on issues providers experience with audits of the recovery audit contractors program.
(3.7) (a) During the 2023-24 state fiscal year, the office of the state auditor shall conduct an independent review of the state department's recovery audit contractor program pursuant to 42 CFR 455.506 for compliance with requirements of the federal centers for medicare and medicaid services medicaid recovery audit program, compliance with coding practice standards, and state law. To the extent possible, the audit shall examine and issue policy recommendations to the joint budget committee of the general assembly, the health and human services committee of the senate, and the public and behavioral health and human services committee of the house of representatives, or their successor committees, regarding:
t program, compliance with coding practice standards, and state law. To the extent possible, the audit shall examine and issue policy recommendations to the joint budget committee of the general assembly, the health and human services committee of the senate, and the public and behavioral health and human services committee of the house of representatives, or their successor committees, regarding:
(I) The effectiveness and level of the payment model used for the state department's recovery audit contractor, including the level of payments sufficient to maintain a contractor, the scope of the contract and deliverables, and impacts on providers related to a contingency fee-based system significantly above the federal standard;
(II) The methods and effectiveness of the state department's current approach to addressing provider concerns regarding the medicaid recovery audit contractor program;
(III) The design, effectiveness, and methods used by other states in meeting the federal standard, including:
(A) An assessment of requirements imposed by other states in regard to overall recovery audit contractor staffing and qualifications of reviewers to ensure alignment of specialty and subspecialty expertise for conducting initial audits and final determinations;
(B) An assessment of other states' lookback periods and the states' relative financing mechanisms;
(C) Best practices employed by other states or recommended by Colorado providers to help improve billing practices and compliance and to provide support throughout the recovery audit contractor process; and
(D) Models from other states used to incentivize identification of underpayments, along with a feasibility assessment for the use of such models in Colorado;
(IV) Implications for providers and the state's general fund of adjusting the lookback period used for the recovery audit contractor audits. The office of the state auditor shall examine, compare to other states, and, to the extent feasible, disaggregated by dates of service, audit finding date, and provider type:
(A) The number, proportion, and value of claims reviewed, relative to total potential claims subject to the recovery audit contractor program;
(B) The number and proportion of providers impacted by claim reviews and contested payments;
(C) The number, proportion, and value of contested payments, including underpayments, overpayments, and recoupments; and
(D) The number, proportion, value, and result of contested payments by disposition status, including those resolved through interview requests pursuant to subsection (3)(a)(IV.5) of this section, informal reconsiderations, and appeals;
(V) Provider administrative burdens associated with the recovery audit contractor program;
(VI) The feasibility of incentives for underpayment identification, including models from other states and methods for identifying underpayments;
(VII) The impact of audits on provider participation and access to care, and opportunities to increase meaningful provider participation and access to care; and
(VIII) An assessment of the duplication of utilization management reviews and approvals, such as prior authorization, with post-payment and audit reviews.
ion, including models from other states and methods for identifying underpayments;
(VII) The impact of audits on provider participation and access to care, and opportunities to increase meaningful provider participation and access to care; and
(VIII) An assessment of the duplication of utilization management reviews and approvals, such as prior authorization, with post-payment and audit reviews.
(b) (I) The office of the state auditor shall contract with an entity that reviews state plans and amendments submitted to the federal centers for medicare and medicaid services on behalf of states for the entity to assess federal flexibilities pursuant to 42 CFR 455.516 that Colorado can utilize in order to improve the recovery audit contractor program and assist in pursuing those flexibilities, when already authorized. The contracted entity must not be a contractor under the recovery audit contractor program, nor a competitor of such a contractor, nor a provider of similar program integrity products.
(II) The contracted entity shall consider the following issues:
(A) What are the impacts on providers and medicaid beneficiaries of contractor contingency fees and a lookback period that exceeds federal standards for medicaid recovery audit contractor programs?
(B) Using information from other states or similar audit programs in the public and private sectors, how can Colorado optimize staffing to balance potential overpayment claims and medical necessity reviews?
(C) What is the level of federal flexibility for adjusting the timing and procedure when assessing when a potential overpayment is "identified" or "determined", and how could modifications to that timing or procedure improve the recovery audit contractor program?
(D) How should the state evaluate the cost benefit analysis to determine whether the medicaid recovery audit contractor program is striking the right balance between accountability and access to care?
(E) What are other states' best practices in exercising federal flexibilities in the recovery audit contractor program to improve provider education, training, and error rates?
(c) This subsection (3.7) is repealed, effective July 1, 2025.
(4) If medical assistance is furnished to or on behalf of a member pursuant to the provisions of this article 4 and articles 5 and 6 of this title 25.5 for which a third party is liable, the state department has an enforceable right against the third party for the amount of medical assistance, including the lien right specified in subsection (5) of this section. Whenever the member has brought or may bring an action in court to determine the liability of the third party, the state department, without any other name, title, or authority to enforce the state department's right, may enter into appropriate agreements and assignments of rights with the member and the member's attorney, if any. Any agreement must be filed with the court in which the action is pending. The attorney named in the agreement upon designation as a special assistant attorney general by the attorney general shall prove both the member's claim and the state department's claim. The state department, without any other name, title, or authority, may take any necessary action to determine the existence and amount of the state department's claims under this section, whether the claims are founded on judgment, contract, lien, or otherwise, and take any other action that is appropriate to recover from third parties. To enforce the right, the attorney general, pursuant to section 24-31-101, on behalf of the state department, may institute and prosecute, or intervene of right in legal proceedings against the third party having legal liability, either in the name of the state department or in the name of the member or the member's assignee, guardian, personal representative, estate, or survivors
m third parties. To enforce the right, the attorney general, pursuant to section 24-31-101, on behalf of the state department, may institute and prosecute, or intervene of right in legal proceedings against the third party having legal liability, either in the name of the state department or in the name of the member or the member's assignee, guardian, personal representative, estate, or survivors. When the state department intervenes in legal proceedings against the third party, the state department is not liable for any portion of the attorney fees or costs of the member.
(5) (a) When the state department has furnished medical assistance to or on behalf of a member pursuant to the provisions of this article 4 or articles 5 and 6 of this title 25.5 for which a third party is liable, the state department has an automatic statutory lien for all medical assistance. The state department's lien is against any judgment, award, or settlement in a suit or claim against the third party and is in an amount that is the fullest extent allowed by federal law as applicable in this state, but not to exceed the amount of the medical assistance provided.
(b) No judgment, award, or settlement in any action or claim by a member to recover damages for injuries in which the state department has a lien is satisfied without first satisfying the state department's lien. Failure by any party to the judgment, award, or settlement to comply with this section makes each party liable for the full amount of medical assistance furnished to or on behalf of the member for the injuries that are the subject of the judgment, award, or settlement.
(c) Except as otherwise provided in this article 4, the entire amount of any judgment, award, or settlement of the member's action or claim, with or without suit, regardless of how characterized by the parties, is subject to the state department's lien.
(d) When the action or claim is brought by the member alone and the member incurs a personal liability to pay attorney fees, the state department shall pay the state department's reasonable share of attorney fees not to exceed twenty-five percent of the state department's lien. The state department is not liable for costs.
(e) The state department's right to recover under this section is independent of the member's right.
(6) When the applicant or member, or the applicant's or member's guardian, executor, administrator, or other appropriate representative, brings an action or asserts a claim against any third party, the person shall give the state department written notice of the action or claim by personal service or certified mail within fifteen days after filing the action or asserting the claim. Failure to comply with this subsection (6) makes the member, legal guardian, executor, administrator, attorney, or other representative liable for the entire amount of medical assistance furnished to or on behalf of the member for the injuries that gave rise to the action or claim. The state department may, after thirty days' written notice to the person, enforce the state department's rights under subsection (5) of this section and this subsection (6) in the district court of the city and county of Denver; except that liability of a person other than the member exists only if the person had knowledge that the member had received medical assistance or if excusable neglect is found by the court. The court shall award the state department its costs and attorney fees incurred in the prosecution of any such action.
is section and this subsection (6) in the district court of the city and county of Denver; except that liability of a person other than the member exists only if the person had knowledge that the member had received medical assistance or if excusable neglect is found by the court. The court shall award the state department its costs and attorney fees incurred in the prosecution of any such action.
(7) When a legally responsible relative of the member agrees or is ordered to provide medical support or health insurance coverage for the member's dependents or other persons, and the dependents are applicants for, members of, or otherwise entitled to receive medical assistance pursuant to this article 4 and articles 5 and 6 of this title 25.5, the state department is subrogated to any rights that the responsible persons may have to obtain reimbursement from a third party or insurance carrier for the cost of medical assistance provided for such dependents or persons. When the state department gives written notice of subrogation, any third party or insurance carrier liable for reimbursement for the cost of medical care shall accord to the state department all rights and benefits available to the responsible relative that pertain to the provision of medical care to any persons entitled to medical assistance pursuant to this article 4 and articles 5 and 6 of this title 25.5 for whom the relative is legally responsible.
(8) All members of medical assistance under the medicaid program are deemed to have authorized the member's attorneys, all third parties, including but not limited to insurance companies, and providers of medical care to release to the state department all information needed by the state department to secure and enforce its rights under subsections (4) and (5) of this section.
(9) Nothing in part 6 of article 4 of title 10 limits the right of the state department to recover the medical assistance furnished to or on behalf of a member as the result of the negligence of a third party.
(10) No action taken by the state department pursuant to subsection (4) of this section or any judgment rendered in the action bars any action upon the claim or cause of action of the applicant or member or the member's guardian, personal representative, estate, dependent, or survivors against the third party having legal liability, nor shall any action or judgment operate to deny the applicant or member the recovery for that portion of the member's medical costs or other damages not provided as medical assistance under this article 4 or article 5 or 6 of this title 25.5.
(11) (a) The state department may recover any amount of medical assistance paid on behalf of a member because:
(I) The trustee of a trust for the benefit of the member has used the trust property in a manner contrary to the terms of the trust; or
(II) A person holding the member's power of attorney has used the power for purposes other than the benefit of the member.
(b) To enforce the right under this subsection (11), the county or state department may institute or intervene in legal proceedings against the trustee or person holding the power of attorney. Any amount of medical assistance recovered pursuant to this subsection (11) shall be distributed between the state and county in proportion to the amount of medical assistance paid by each respectively, if any.
To enforce the right under this subsection (11), the county or state department may institute or intervene in legal proceedings against the trustee or person holding the power of attorney. Any amount of medical assistance recovered pursuant to this subsection (11) shall be distributed between the state and county in proportion to the amount of medical assistance paid by each respectively, if any.
(c) No action taken by the county or state department pursuant to this subsection (11) or any judgment rendered in an action or proceeding bars any action upon the claim or cause of action of the member or the member's guardian, personal representative, estate, dependent, or survivors against the trustee or person holding the power of attorney.
(12) (a) An entity that provides managed care, as defined in section 25.5-5-403, that has entered into a risk contract with the state department shall have the same rights of the department set forth in this section except with respect to the rights described in subsections (5) and (6) of this section. In addition, the attorney general may not enforce the rights set forth in this subsection (12). Venue for an action brought by or on behalf of an entity pursuant to this subsection (12) shall be governed by the Colorado rules of civil procedure.
(b) Within fifteen days after filing an action or asserting a claim against a third party, a member under a managed care plan or a guardian, executor, administrator, or other appropriate representative of the member shall provide to the entity that administers the managed care plan written notice of the action or claim. Notice must be by personal service or certified mail.
(c) In cases where the state department has recovery rights against a third party pursuant to subsections (4) and (5) of this section and an entity that provides managed care has subrogation rights against the same party pursuant to paragraph (a) of this subsection (12), the recovery rights of the state department shall take precedence over the rights of the managed care plan.
(13) To the extent allowable under federal law, the state department shall recover from the sponsor of a lawfully residing individual all medical assistance paid on behalf of the sponsored lawfully residing individual who is enrolled in the medical assistance program.
(14) Notwithstanding any provision of this section to the contrary:
(a) (I) The state department, or the state department's designated agent, shall conduct pre-enrollment and post-enrollment site visits of providers who are designated as moderate or high categorical risks to the medicaid program. The purpose of the site visit is to verify that the information submitted to the state department is accurate and to determine compliance with federal and state enrollment requirements.
(II) As established in rules promulgated by the state board, the state department may waive pre-enrollment and post-enrollment site visits of providers if the site visits are conducted by medicare or other federally designated entities.
(III) A provider is designated as a limited, moderate, or high categorical risk pursuant to the medicare program and federal regulations. If a provider is not designated in a risk category pursuant to the medicare program and federal regulations, the provider's risk category shall be established pursuant to rules promulgated by the state board.
by medicare or other federally designated entities.
(III) A provider is designated as a limited, moderate, or high categorical risk pursuant to the medicare program and federal regulations. If a provider is not designated in a risk category pursuant to the medicare program and federal regulations, the provider's risk category shall be established pursuant to rules promulgated by the state board.
(b) A provider enrolled in the medicaid program shall permit the federal centers for medicare and medicaid services or its agent or designated contractors and the state department or its agent to conduct unannounced, on-site inspections of any and all provider locations. Payment for any agent designated by the state department to perform on-site inspections shall not be based on any recoveries paid to the state department by a provider for violations discovered as a result of the on-site inspection.
(15) (a) The state department may request a written response from any provider who fails to comply with the rules, manuals, or bulletins issued by the state department, state board, or the state department's fiscal agent, or from any provider whose activities endanger the health, safety, or welfare of medicaid members. The written response must describe how the provider will come into and ensure future compliance. If a written response is requested, a provider has thirty days, or longer if approved by the state department, to submit the written response.
(b) If the provider does not agree with the state department's findings that resulted in the request issued pursuant to subsection (15)(a) of this section, then the provider's written response must include an explanation and specific reasons for the provider's disagreement.
(16) (a) The state department may suspend the enrollment of a provider, including a children's basic health plan provider, only if:
(I) The state department identifies that the provider is participating in an alleged and ongoing organized crime or organized fraud scheme that impacts the state medical assistance program, this article 4 and articles 5 and 6 of this title 25.5, or the children's basic health plan, article 8 of this title 25.5; and
(II) The state department documents in writing that at least three of the following factors are met:
(A) The provider has been enrolled in the state medical assistance program or children's basic health plan for less than three years;
(B) At least three providers are involved in the organized crime or organized fraud scheme;
(C) The collective billing amount identified in the organized crime or organized fraud scheme exceeds one million dollars;
(D) The provider's billing indicates a pattern of abuse or noncompliance;
(E) The volume of claims or billing amount has increased at a significant rate and there is no other reasonable explanation for the increase;
(F) The federal centers for medicare and medicaid services has approved a provider enrollment moratorium for the provider type involved in the organized crime or organized fraud scheme; or
(G) The state department has notified law enforcement of the organized crime or organized fraud scheme.
(b) The state department shall notify the provider of the suspension in writing and include the reasons for the suspension.
nters for medicare and medicaid services has approved a provider enrollment moratorium for the provider type involved in the organized crime or organized fraud scheme; or
(G) The state department has notified law enforcement of the organized crime or organized fraud scheme.
(b) The state department shall notify the provider of the suspension in writing and include the reasons for the suspension.
(c) The state department may suspend a provider's enrollment pursuant to subsection (16)(a) of this section for an initial period of six months while the state department conducts a review of the organized crime or organized fraud scheme. After the state department's review is complete, regardless of whether the six-month period has ended, the state department must reinstate the provider's enrollment if the state department determines the provider did not engage in an organized crime or organized fraud scheme. If the state department's review cannot be completed during the initial six-month period, the state department may extend the review period in additional six-month increments if the state department documents in writing the necessity for extending the review.
(d) As used in this subsection (16):
(I) "Organized crime or organized fraud scheme" means a provider is allegedly participating in a coercive, fraudulent, extortionary, criminal, or otherwise illegal coordinated scheme or operation that repeatedly or consistently defrauds the state medical assistance program or children's basic health plan that may put members' health, safety, or welfare at immediate risk.
(II) "Suspend" means temporarily prohibiting a provider from participating in the state medical assistance program or children's basic health plan, from rendering services or supplies to a member, and from submitting claims to the state department for any services or supplies rendered to a member.
(e) This section does not apply to a provider that has been enrolled in the state medical assistance program, including the children's basic health plan, for three years or more and that has consistently rendered services and received payment for those services during the provider's enrollment.
C.R.S. § 25.5-4-302 Recovery of assets
25.5-4-302. Recovery of assets. (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 reducing the amount of revenues available for other state programs; that recovering some of the medical assistance from the estates of medical assistance members would be a viable mechanism for members to share in the cost of assistance; and that an estate recovery program would be a cost-efficient method of offsetting medical assistance costs in an equitable manner. The general assembly also declares that, in order to ensure that medicaid is available for low-income individuals, reasonable restrictions consistent with federal law should be placed on the ability of persons to become eligible for medicaid by means of making transfers of property without fair and valuable consideration.
(2) (a) Medical assistance paid on behalf of any individual who was fifty-five years of age or older when the individual received such assistance may be recovered by the state department from the estate of such individual in accordance with paragraph (c) of this subsection (2).
(b) Medical assistance paid on behalf of any individual who is institutionalized may be recovered by the state department from the estate of such individual in accordance with paragraph (c) of this subsection (2).
(c) The state department shall establish an estate recovery program only insofar as such program is in accordance with Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended, and shall not take any action to recover medical assistance when the amount of assistance to be recovered is economically inappropriate in relation to expenses of recovery.
(3) The state department is authorized to file liens against any property of an individual who is institutionalized and from whom the state department may recover medical assistance pursuant to paragraph (b) of subsection (2) of this section.
(4) The state department may compromise, settle, or waive any recovery of medical assistance authorized pursuant to subsection (2) of this section upon good cause shown.
(5) Subject to any limitation concerning estate recovery in Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended, the amount of any medical assistance paid pursuant to the provisions of this article and articles 5 and 6 of this title is a claim against the estate pursuant to the provisions of section 15-12-805 (1), C.R.S.
(6) The state board shall promulgate rules to implement the provisions of this section, including rules limiting the eligibility for medical assistance if the person made a voluntary assignment or transfer of property without fair and valuable consideration prior to applying for medical assistance. A contract for an exempt burial fund for an individual shall include a provision restricting the full amount to the cost of the burial and stating that any portion not expended for the burial costs shall be refunded to the state department by the mortuary as reimbursement for the cost of medical assistance provided to the individual. Said rules shall be in accordance with Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396p, as amended.
(7) Effective upon the implementation of a private-public partnership program for financing long-term care pursuant to section 25.5-6-110, this section shall apply to participants of such program only after excluding from the amount that may otherwise be recovered from such person's estate an amount allowed by rules adopted by the state board in accordance with section 25.5-6-110.
C.R.S. § 25.5-4-303 State income tax refund intercept - garnishment of earning - failure to provide medical support for child
25.5-4-303. State income tax refund intercept - garnishment of earning - failure to provide medical support for child. (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 assistance in this state for medical support based on medical assistance provided to the obligor's dependent child; and
(II) Has received payment from a third party to cover the health-care costs of the child but has neither applied such payment to cover the child's health-care costs nor to reimburse the state department, the custodial parent of the child, or the provider of medical care.
(b) The information provided to the department of revenue shall include the name and the social security number of the person described in paragraph (a) of this subsection (1), the amount of medical assistance provided to the child during the period for which medical support was ordered but not provided as described in subparagraph (II) of paragraph (a) of this subsection (1), and any other identifying information required by the department of revenue.
(2) Prior to a final certification of the information described in subsection (1) of this section to the department of revenue, the state department shall notify the obligated person, in writing, that the state intends to refer the person's name to the department of revenue in an attempt to offset the person's medical support obligation against the person's state income tax refund. Such notification shall include information on the parent's right to object to the offset.
(3) Upon notification by the department of revenue of amounts deposited with the state treasurer pursuant to section 39-21-108 (3), C.R.S., the state department may recover the amount of the medical assistance described in paragraph (b) of subsection (1) of this section.
(4) The state department may garnish the wages and other earnings of a person described in paragraph (a) of subsection (1) of this section. The garnishment of wages and earning shall be in accordance with articles 54 and 54.5 of title 13, C.R.S.
(5) The state board shall adopt rules as are necessary for the implementation of this section.
C.R.S. § 25.5-4-303.3 Provider fraud - attorney general report
25.5-4-303.3. Provider fraud - attorney general report. (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 25.5-1-115.5. The attorney general shall provide information relating to medicaid provider fraud including, at a minimum:
(a) Investigations of provider fraud during the year;
(b) Criminal complaints requested, cases dismissed, cases acquitted, convictions, and confessions of judgment;
(c) Recoveries, including fines and penalties, restitution ordered, and restitution collected;
(d) Civil claims;
(e) Trends in methods used to commit provider fraud, excluding law enforcement-sensitive information; and
(f) An estimate of the total savings, total cost, and net cost-effectiveness of fraud detection and recovery efforts.
C.R.S. § 25.5-4-303.5 Short title
25.5-4-303.5. Short title. 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".
C.R.S. § 25.5-4-304 Definitions
25.5-4-304. Definitions. 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 "Colorado Medical Assistance Act" that is:
(I) Presented to an officer, employee, or agent of the state; or
(II) Made to a contractor, grantee, or other recipient if the money or property is to be spent or used on the state's behalf or to advance a program or interest of the state and if the state:
(A) Provides or has provided any portion of the money or property requested or demanded; or
(B) Will reimburse the contractor, grantee, or other recipient for any portion of the money or property that is requested or demanded.
(b) "Claim" does not include a request or demand for money or property that the state has paid to an individual as compensation for employment by the state or as an income subsidy with no restriction on that individual's use of the money or property.
(2) "Colorado Medical Assistance Act" means this article and articles 5 and 6 of this title.
(3) (a) "Knowing" or "knowingly" means that a person, with respect to information:
(I) Has actual knowledge of the information;
(II) Acts in deliberate ignorance of the truth or falsity of the information; or
(III) Acts in reckless disregard of the truth or falsity of the information.
(b) "Knowing" or "knowingly" does not require proof of specific intent to defraud.
(4) "Material" means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.
(5) "Obligation" means a fixed or contingent duty arising from an express or implied contractual, quasi-contractual, grantor-grantee, licensor-licensee, statutory, fee-based, or similar relationship, or the retention of overpayment.
C.R.S. § 25.5-4-305 False medicaid claims - liability for certain acts
25.5-4-305. False medicaid claims - liability for certain acts. (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 automatically increase to equal the civil penalty allowed under the federal "False Claims Act", 31 U.S.C. sec. 3729, et seq., if and as the penalties in such federal act may be adjusted for inflation as described in said act in accordance with the federal "Civil Penalties Inflation Adjustment Act of 1990", Pub. L. No. 101-410, plus three times the amount of damages that the state sustains because of the act of that person, if the person:
(a) Knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;
(b) Knowingly makes, uses, or causes to be made or used a false record or statement material to a false or fraudulent claim;
(c) Has possession, custody, or control of property or money used, or to be used, by the state in connection with the "Colorado Medical Assistance Act"and knowingly delivers, or causes to be delivered, less than all of the money or property;
(d) Authorizes the making or delivery of a document certifying receipt of property used, or to be used, by the state in connection with the "Colorado Medical Assistance Act" and, intending to defraud the state, makes or delivers the receipt without completely knowing that the information on the receipt is true;
(e) Knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the state in connection with the "Colorado Medical Assistance Act" who lawfully may not sell or pledge the property;
(f) Knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the state in connection with the "Colorado Medical Assistance Act", or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the state in connection with the "Colorado Medical Assistance Act";
(g) Conspires to commit a violation of paragraphs (a) to (f) of this subsection (1).
(2) Notwithstanding the amount of damages authorized in subsection (1) of this section, for a person who violates subsection (1) of this section, the court may assess not less than twice the amount of damages that the state sustains because of the act of the person if the court finds that:
(a) The person who committed the violation of subsection (1) of this section furnished to the officials of the state responsible for investigating false claims violations all information about the violation known to the person and furnished said information within thirty days after the date on which the person first obtained the information;
(b) At the time the person furnished the information about the violation to the state, a criminal prosecution, civil action, or administrative action had not commenced with respect to the violation and the person did not have actual knowledge of the existence of an investigation into the violation; and
(c) The person fully cooperated with any investigation of the violation by the state.
(3) A person violating this section shall also be liable to the state for the costs of a civil action brought to recover any penalty or damages.
(4) Any information furnished pursuant to subsection (2) of this section shall be exempt from disclosure under part 2 of article 72 of this title.
C.R.S. § 25.5-4-306 Civil actions for false medicaid claims
25.5-4-306. Civil actions for false medicaid claims. (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 section against the person.
(2) Actions by private persons. (a) A relator may bring a civil action for a violation of section 25.5-4-305 on behalf of the relator and the state. The action shall be brought in the name of the state. The action may be dismissed only if the court and the attorney general give written consent to the dismissal and their reasons for consenting.
(b) A copy of the complaint and written disclosure of substantially all material evidence and information the relator possesses shall be served on the state pursuant to rule 4 of the Colorado rules of civil procedure. The complaint shall be filed in camera, shall remain under seal for at least sixty days, and shall not be served on the defendant until the court so orders. The state may elect to intervene and proceed with the action within sixty days after it receives both the complaint and the material evidence and information.
(c) The state may, for good cause shown, move the court for extensions of the time during which the complaint remains under seal under paragraph (b) of this subsection (2). Any such motion may be supported by affidavits or other submissions in camera. The defendant shall not be required to respond to a complaint filed under this section until twenty days after the complaint is unsealed and served upon the defendant pursuant to rule 4 of the Colorado rules of civil procedure.
(d) Before the expiration of the sixty-day period pursuant to paragraph (b) of this subsection (2) or any extensions obtained under paragraph (c) of this subsection (2), the state shall:
(I) Proceed with the action, in which case the state shall conduct the action; or
(II) Notify the court that it declines to take over the action, in which case the relator shall have the right to conduct the action.
(e) When a relator brings an action under this subsection (2), no person other than the state may intervene or bring a related action based on the facts underlying the pending action.
(3) Rights of parties to private actions. (a) If the state proceeds with an action brought under subsection (2) of this section, it shall have the primary responsibility for prosecuting the action and shall not be bound by an act of the relator. The relator shall have the right to continue as a party to the action, subject to the limitations set forth in paragraph (b) of this subsection (3).
(b) (I) The state may dismiss the action notwithstanding the objections of the relator if the relator has been notified by the state of the filing of the motion and the court has provided the relator with an opportunity for a hearing on the motion.
(II) The state may settle the action with the defendant notwithstanding the objections of the relator if the court determines, after a hearing, that the proposed settlement is fair, adequate, and reasonable under all the circumstances. Upon a showing of good cause, the hearing may be held in camera.
(III) Upon a showing by the state that unrestricted participation during the course of the litigation by the relator would interfere with or unduly delay the state's prosecution of the case, or would be repetitious, irrelevant, or for purposes of harassment, the court may, in its discretion, impose limitations on the relator's participation, including but not limited to:
(A) Limiting the number of witnesses the relator may call;
(B) Limiting the length of the testimony of the witnesses;
(C) Limiting the relator's cross-examination of witnesses; or
(D) Otherwise limiting the participation by the relator in the litigation.
or purposes of harassment, the court may, in its discretion, impose limitations on the relator's participation, including but not limited to:
(A) Limiting the number of witnesses the relator may call;
(B) Limiting the length of the testimony of the witnesses;
(C) Limiting the relator's cross-examination of witnesses; or
(D) Otherwise limiting the participation by the relator in the litigation.
(IV) Upon a showing by the defendant that unrestricted participation during the course of the litigation by the relator would be for purposes of harassment or would cause the defendant undue burden or unnecessary expense, the court may limit the participation by the relator in the litigation.
(c) If the state elects not to proceed with the action, the relator who initiated the action shall have the right to conduct the action. If the state so requests, it shall be served with copies of all pleadings filed in the action and, at the state's expense, shall be supplied with copies of all deposition transcripts. When a relator proceeds with the action, the court, without limiting the status and rights of the relator, may nevertheless permit the state to intervene at a later date upon a showing of good cause.
(d) Regardless of whether the state proceeds with the action, upon a showing by the state that certain actions of discovery by the relator would interfere with the state's investigation or prosecution of a criminal or civil matter arising out of the same facts, the court may stay the discovery for a period of not more than sixty days. The showing shall be conducted in camera. The court may extend the sixty-day period upon a further showing in camera that the state has pursued the criminal or civil investigation or proceedings with reasonable diligence and that any proposed discovery in the civil action will interfere with the ongoing criminal or civil investigation or proceedings.
(e) Notwithstanding the provisions of subsection (2) of this section, the state may elect to pursue its claim through any alternate remedy available to the state, including any administrative proceeding to determine a civil money penalty. If an alternate remedy is pursued in another proceeding, the relator shall have the same rights in the proceeding as the relator would have had if the action had continued under this section. Any finding of fact or conclusion of law made in another proceeding that has become final shall be conclusive on all parties to an action under this section. For purposes of this paragraph (e), a finding or conclusion is final if it has been finally determined on appeal to the appropriate court of the state, if all time for filing such an appeal with respect to the finding or conclusion has expired, or if the finding or conclusion is not subject to judicial review.
hat has become final shall be conclusive on all parties to an action under this section. For purposes of this paragraph (e), a finding or conclusion is final if it has been finally determined on appeal to the appropriate court of the state, if all time for filing such an appeal with respect to the finding or conclusion has expired, or if the finding or conclusion is not subject to judicial review.
(4) Award to private persons. (a) (I) If the state proceeds with an action brought by a relator under subsection (2) of this section, the relator shall, subject to subparagraph (II) of this paragraph (a), receive at least fifteen percent but not more than twenty-five percent of the proceeds of the action or settlement of the claim, depending upon the extent to which the relator substantially contributed to the prosecution of the action.
(II) If the court finds the action to be based primarily on disclosures of specific information, other than information provided by the relator, relating to allegations or transactions in a criminal, civil, or administrative hearing, in a legislative, administrative, or state auditor's report, hearing, audit, or investigation, or from the news media, the court may award to the relator such sums as it considers appropriate, but in no case more than ten percent of the proceeds, taking into account the significance of the information and the role of the relator in advancing the case to litigation.
(III) Any payment to a relator under subparagraph (I) or (II) of this paragraph (a) shall be made from the proceeds. The relator shall also receive an amount for reasonable expenses that the court finds to have been necessarily incurred plus reasonable attorney fees and costs. All such expenses, fees, and costs shall be awarded against the defendant.
(b) If the state does not proceed with an action brought under subsection (2) of this section, the relator bringing the action or settling the claim shall receive an amount that the court decides is reasonable for collecting the civil penalty and damages. The amount shall be not less than twenty-five percent and not more than thirty percent of the proceeds of the action or settlement and shall be paid out of the proceeds. The relator shall also receive an amount for reasonable expenses that the court finds to have been necessarily incurred, plus reasonable attorney fees and costs. All such expenses, fees, and costs shall be awarded against the defendant.
(c) Regardless of whether the state proceeds with an action brought under subsection (2) of this section, if the court finds that the action was brought by a relator who planned and initiated the violation of section 25.5-4-305 upon which the action was brought, then the court may, to the extent the court considers appropriate, reduce the share of the proceeds of the action that the relator would otherwise receive under paragraph (a) or (b) of this subsection (4), taking into account the role of the relator in advancing the case to litigation and any relevant circumstances pertaining to the violation. If the relator is convicted of criminal conduct arising from his or her role in the violation of section 25.5-4-305, the relator shall be dismissed from the civil action and shall not receive any share of the proceeds of the action. Such dismissal shall not prejudice the right of the state to continue the action.
ng the case to litigation and any relevant circumstances pertaining to the violation. If the relator is convicted of criminal conduct arising from his or her role in the violation of section 25.5-4-305, the relator shall be dismissed from the civil action and shall not receive any share of the proceeds of the action. Such dismissal shall not prejudice the right of the state to continue the action.
(d) If the state does not proceed with an action brought under subsection (2) of this section and the relator bringing the action conducts the action, the court may award to the defendant its reasonable attorney fees and expenses if the defendant prevails in the action and the court finds that the claim of the relator was clearly frivolous, clearly vexatious, or brought primarily for purposes of harassment.
(5) Certain actions barred. (a) A court shall not have jurisdiction over an action brought under this section against a member of the general assembly, a member of the state judiciary, or an elected official in the executive branch of the state of Colorado if the action is based on evidence or information known to the state when the action was brought.
(b) A relator shall not bring an action under subsection (2) of this section that is based upon allegations or transactions that are the subject of a civil suit or an administrative civil money penalty proceeding in which the state is already a party.
(c) (I) A court shall dismiss an action or claim brought under subsection (2) of this section unless opposed by the state, if substantially the same allegations or transactions as alleged in the action or claim were publicly disclosed in a state criminal, civil, or administrative hearing in which the state or its agent is a party, in a legislative, administrative, or state auditor's report, hearing, audit, or investigation, or by the news media, unless the action is brought by the state or the relator is an original source of the information.
(II) For purposes of this paragraph (c), "original source" means an individual who, prior to a public disclosure under subparagraph (I) of this paragraph (c), has voluntarily disclosed to the state the information on which the allegations or transactions in a claim are based, or who has knowledge that is independent of and materially adds to the publicly disclosed allegations or transactions, and has voluntarily provided the information to the state before filing an action under subsection (2) of this section.
(6) State not liable for certain expenses. The state is not liable for expenses that a relator incurs in bringing an action under this section.
(7) Private action for retaliation. (a) An employee, contractor, or agent shall be entitled to all relief necessary to make the employee, contractor, or agent whole, if the employee, contractor, or agent is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by the defendant or by any other person because of lawful acts done by the employee, contractor, or agent, or associated others in furtherance of an action under this section or in furtherance of an effort to stop any violations of section 25.5-4-305.
(b) (I) An employee, contractor, or agent who seeks relief pursuant to this subsection (7) shall be entitled to all relief necessary to make the employee, contractor, or agent whole. Such relief shall include:
(A) Reinstatement with the same seniority status the employee, contractor, or agent would have had but for the discrimination, twice the amount of back pay, and interest on the back pay; and
(B) Compensation for any special damages sustained as a result of the discrimination or retaliation, including litigation costs and reasonable attorney fees.
(II) An employee, contractor, or agent may bring an action in the appropriate court of the state for the relief provided in this subsection (7).
C.R.S. § 25.5-4-307 False medicaid claims procedures - statute of limitations
25.5-4-307. False medicaid claims procedures - statute of limitations. (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 are known or reasonably should have been known by the official of the state charged with responsibility to act in the circumstances, but in no event more than ten years after the date on which the violation of section 25.5-4-305 is committed.
(2) If the state elects to intervene and proceed with an action brought under section 25.5-4-306, the state may file its own complaint or amend the relator's complaint to clarify or add detail to the claims in which the state is intervening and to add any additional claims with respect to which the state contends it is entitled to relief. For statute of limitations purposes, any such pleadings by the state shall relate back to the filing date of the relator's complaint, to the extent that the state's claim arises out of the conduct, transactions, or occurrences set forth, or attempted to be set forth, in the prior complaint of the relator.
(3) In an action brought under section 25.5-4-306, the state or relator must prove all essential elements of the cause of action, including damages, by a preponderance of the evidence.
(4) Notwithstanding any other provision of law, the Colorado rules of criminal procedure, or the Colorado rules of evidence, a final judgment rendered in favor of the state in a criminal proceeding charging fraud or false statements, whether upon a verdict after trial or upon a plea of guilty or nolo contendere, shall estop the defendant from denying the essential elements of the offense in any action that involves the same transaction as in the criminal proceeding and that is brought under section 25.5-4-306.
(5) A private action for retaliation under section 25.5-4-306 (7) may not be brought more than three years after the date when the retaliation occurred.
C.R.S. § 25.5-4-308 False medicaid claims jurisdiction
25.5-4-308. False medicaid claims jurisdiction. 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 required by the Colorado rules of civil procedure shall be issued by the appropriate district court and served at any place.
C.R.S. § 25.5-4-309 False medicaid claims civil investigation demands
25.5-4-309. False medicaid claims civil investigation demands. (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 proceeding under section 25.5-4-306 or other false medicaid claims law or making an election under section 25.5-4-306 (2)(d), issue in writing and cause to be served upon the person a civil investigative demand requiring the person to:
(A) Produce the documentary material for inspection and copying;
(B) Answer in writing written interrogatories with respect to the documentary material or information;
(C) Give oral testimony concerning the documentary material or information; or
(D) Furnish any combination of such material, answers, or testimony.
(II) The attorney general may not delegate the authority to issue civil investigative demands under this subsection (1). Whenever a civil investigative demand is an express demand for any product of discovery, the attorney general, the deputy attorney general, or an assistant attorney general shall cause to be served, in any manner authorized by this section, a copy of the demand upon the person from whom the discovery was obtained and shall notify the person to whom the demand is issued of the date on which the copy was served.
(b) (I) Each civil investigative demand issued under this subsection (1) shall state the nature of the conduct constituting the alleged violation of a false medicaid claims law that is under investigation and the applicable provision of law alleged to be violated.
(II) If the demand is for the production of documentary material, the demand shall:
(A) Describe each class of documentary material to be produced with such definiteness and certainty as to permit the material to be fairly identified;
(B) Prescribe a return date for each such class that will provide a reasonable period of time within which the material so demanded may be assembled and made available for inspection and copying; and
(C) Identify the false medicaid claims law investigator to whom the material shall be made available.
(III) If the demand is for answers to written interrogatories, the demand shall:
(A) Specify the written interrogatories to be answered;
(B) Prescribe dates on which answers to written interrogatories shall be submitted; and
(C) Identify the false medicaid claims law investigator to whom the answers shall be submitted.
(IV) If the demand is for the giving of oral testimony, the demand shall:
(A) Prescribe a date, time, and place at which oral testimony shall be commenced and notify the deponent if the oral testimony is to be video or audio recorded;
(B) Identify a false medicaid claims law investigator who shall conduct the examination and the custodian to whom the transcript of the examination shall be submitted;
(C) Specify that such attendance and testimony are necessary to the conduct of the investigation;
(D) Notify the person receiving the demand of the right to be accompanied by an attorney and any other representative; and
(E) Describe the general purpose for which the demand is being issued and the general nature of the testimony, including the primary areas of inquiry, that will be taken pursuant to the demand.
(V) A civil investigative demand issued under this section that is an express demand for any product of discovery shall not be returned or returnable until twenty days after a copy of the demand has been served upon the person from whom the discovery was obtained.
ing issued and the general nature of the testimony, including the primary areas of inquiry, that will be taken pursuant to the demand.
(V) A civil investigative demand issued under this section that is an express demand for any product of discovery shall not be returned or returnable until twenty days after a copy of the demand has been served upon the person from whom the discovery was obtained.
(VI) The date prescribed for the commencement of oral testimony pursuant to a civil investigative demand issued under this section shall be a date that is not less than seven days after the date on which the demand is received, unless the attorney general or an assistant attorney general designated by the attorney general determines that exceptional circumstances are present that warrant the commencement of the testimony within a lesser period of time.
(VII) The attorney general shall not authorize the issuance under this section of more than one civil investigative demand for oral testimony by the same person unless the person requests otherwise or unless the attorney general, after investigation, notifies that person in writing that an additional demand for oral testimony is necessary. Notwithstanding section 24-31-103, C.R.S., the attorney general shall not authorize the performance, by any other officer, employee, or agency, of any function vested in the attorney general under this subparagraph (VII).
(2) Protected material or information. (a) A civil investigative demand issued under subsection (1) of this section shall not require the production of documentary material, the submission of answers to written interrogatories, or the giving of oral testimony if the material, answers, or testimony would be protected from disclosure under:
(I) The standards applicable to subpoenas or subpoenas duces tecum issued by a court of this state to aid in a grand jury investigation; or
(II) The standards applicable to discovery requests under the Colorado rules of civil procedure, to the extent that the application of the standards to any such demand is appropriate and consistent with the provisions and purposes of this section.
(b) A demand that is an express demand for a product of discovery supersedes any inconsistent order, rule, or provision of law, other than this section, preventing or restraining disclosure of the product of discovery to a person. Disclosure of a product of discovery pursuant to an express demand does not constitute a waiver of any right or privilege that the person making the disclosure may be entitled to invoke to resist discovery of trial preparation materials.
(3) Service and jurisdiction. (a) A civil investigative demand issued under subsection (1) of this section or a petition brought pursuant to subsection (10) of this section may be served by a false medicaid claims law investigator, a sheriff, or a deputy sheriff at any place within the state.
erson making the disclosure may be entitled to invoke to resist discovery of trial preparation materials.
(3) Service and jurisdiction. (a) A civil investigative demand issued under subsection (1) of this section or a petition brought pursuant to subsection (10) of this section may be served by a false medicaid claims law investigator, a sheriff, or a deputy sheriff at any place within the state.
(b) A civil investigative demand issued under subsection (1) of this section or a petition filed under subsection (10) of this section may be served upon a person who is not found within the state in the manner prescribed by the Colorado rules of civil procedure for service in another state or a foreign country. To the extent that the courts of this state can assert jurisdiction over any such person consistent with due process, the district court for the city and county of Denver shall have the same jurisdiction to take an action respecting compliance with this section by any such person that the court would have if the person were personally within the jurisdiction of the court.
(4) Service on legal entities and natural persons. (a) Service of a civil investigative demand issued under subsection (1) of this section or of a petition filed under subsection (10) of this section may be made upon a partnership, corporation, association, or other legal entity by:
(I) Delivering an executed copy of the demand or petition to a partner, executive officer, managing agent, or general agent of the partnership, corporation, association, or entity, or to an agent authorized by appointment or by law to receive service of process on behalf of the partnership, corporation, association, or entity;
(II) Delivering an executed copy of the demand or petition to the principal office or place of business of the partnership, corporation, association, or entity; or
(III) Depositing an executed copy of the demand or petition in the United States mail by registered or certified mail, with a return receipt requested, addressed to the partnership, corporation, association, or entity at its principal office or place of business.
(b) Service of a civil investigative demand issued under subsection (1) of this section or of a petition filed under subsection (10) of this section may be made upon a natural person by:
(I) Delivering an executed copy of the demand or petition to the person; or
(II) Depositing an executed copy of the demand or petition in the United States mail by registered or certified mail, with a return receipt requested, addressed to the person at the person's residence, principal office, or place of business.
(5) Proof of service. A verified return by the individual serving a civil investigative demand issued under subsection (1) of this section or a petition filed under subsection (10) of this section setting forth the manner of the service shall be proof of the service. In the case of service by registered or certified mail, the return shall be accompanied by the return post office receipt of delivery of the demand.
(6) Documentary material. (a) (I) The production of documentary material in response to a civil investigative demand issued under subsection (1) of this section shall be made under a sworn certificate, in the form as the demand designates, by:
(A) In the case of a natural person, the person to whom the demand is directed; or
(B) In the case of a person other than a natural person, a person having knowledge of the facts and circumstances relating to the production and authorized to act on behalf of the person.
(II) The certificate shall state that all of the documentary material required by the demand and in the possession, custody, or control of the person to whom the demand is directed has been produced and made available to the false medicaid claims law investigator identified in the demand.
edge of the facts and circumstances relating to the production and authorized to act on behalf of the person.
(II) The certificate shall state that all of the documentary material required by the demand and in the possession, custody, or control of the person to whom the demand is directed has been produced and made available to the false medicaid claims law investigator identified in the demand.
(b) A person upon whom a civil investigative demand for the production of documentary material has been served under this section shall make the material available for inspection and copying to the false medicaid claims law investigator identified in the demand at the principal place of business of the person, or at such other place as the false medicaid claims law investigator and the person thereafter may agree and prescribe in writing, or as the court may direct under subsection (10) of this section. The material shall be made so available on the return date specified in the demand, or on such later date as the false medicaid claims law investigator may prescribe in writing. The person may, upon written agreement between the person and the false medicaid claims law investigator, substitute copies for originals of all or any part of the material.
(7) Interrogatories. (a) Each interrogatory in a civil investigative demand issued under subsection (1) of this section shall be answered separately and fully in writing under oath and shall be submitted under a sworn certificate, in the form the demand designates, by:
(I) In the case of a natural person, the person to whom the demand is directed; or
(II) In the case of a person other than a natural person, the person or persons responsible for answering each interrogatory.
(b) If an interrogatory is objected to, the reasons for the objection shall be stated in the certificate instead of an answer. The certificate shall state that all information required by the demand and in the possession, custody, control, or knowledge of the person to whom the demand is directed has been submitted. To the extent that any information is not furnished, the information shall be identified and reasons set forth with particularity regarding the reasons why the information was not furnished.
(8) Oral examinations. (a) The examination of a person pursuant to a civil investigative demand for oral testimony issued under subsection (1) of this section shall be taken before an officer authorized to administer oaths and affirmations by the laws of the United States, the state of Colorado, or the place where the examination is held. The officer before whom the testimony is to be taken shall put the witness on oath or affirmation and shall, personally or with the assistance of someone acting under the direction of the officer and in the officer's presence, record the testimony of the witness. The testimony shall be taken stenographically and shall be transcribed. When the testimony is fully transcribed, the officer before whom the testimony is taken shall promptly transmit a copy of the transcript of the testimony to the custodian. This subsection (8) shall not preclude the taking of testimony by any means authorized by, and in a manner consistent with, the Colorado rules of civil procedure.
(b) The false medicaid claims law investigator conducting the examination shall exclude from the place where the examination is held all persons except the person giving the testimony, the attorney for and any other representative of the person giving the testimony, the attorney for the state, any person who may be agreed upon by the attorney for the state and the person giving the testimony, the officer before whom the testimony is to be taken, and the stenographer who is recording the testimony.
where the examination is held all persons except the person giving the testimony, the attorney for and any other representative of the person giving the testimony, the attorney for the state, any person who may be agreed upon by the attorney for the state and the person giving the testimony, the officer before whom the testimony is to be taken, and the stenographer who is recording the testimony.
(c) The oral testimony of a person taken pursuant to a civil investigative demand served under this section shall be taken in the judicial district of the state within which the person resides, is found, or transacts business, or in another place as may be agreed upon by the false medicaid claims law investigator conducting the examination and the person.
(d) When the testimony is fully transcribed, the false medicaid claims law investigator or the officer before whom the testimony is taken shall afford the witness, who may be accompanied by counsel, a reasonable opportunity to examine and read the transcript, unless the witness waives the examination and reading. Any changes in form or substance that the witness desires to make shall be entered and identified upon the transcript by the officer or the false medicaid claims law investigator, with a statement of the reasons given by the witness for making the changes. The transcript shall then be signed by the witness, unless the witness in writing waives the signing, is ill, cannot be found, or refuses to sign. If the witness does not sign the transcript within thirty days after being afforded a reasonable opportunity to examine it, the officer or the false medicaid claims law investigator shall sign it and state on the record the fact of the waiver, illness, absence of the witness, or refusal to sign, together with the reasons, if any, given therefor.
(e) The officer before whom the testimony is taken shall certify on the transcript that the witness was sworn by the officer and that the transcript is a true record of the testimony given by the witness, and the officer or false medicaid claims law investigator shall promptly deliver the transcript, or send the transcript by registered or certified mail, to the custodian.
(f) Upon payment of reasonable charges therefor, the false medicaid claims law investigator shall furnish a copy of the transcript to the witness only; except that the attorney general, the deputy attorney general, or an assistant attorney general may, for good cause, limit the witness to inspection of the official transcript of the testimony of the witness.
(g) (I) A person compelled to appear for oral testimony under a civil investigative demand issued under subsection (1) of this section may be accompanied, represented, and advised by counsel. Counsel may advise the person, in confidence, with respect to any question asked of the person. The person or counsel may object on the record to any question, in whole or in part, and shall briefly state for the record the reason for the objection. An objection may be made, received, and entered upon the record when it is claimed that the person is entitled to refuse to answer the question on the grounds of any constitutional or other legal right or privilege, including the privilege against self-incrimination. The person may not otherwise object to or refuse to answer any question and may not directly or through counsel otherwise interrupt the oral examination. If the person refuses to answer a question, the false medicaid claims law investigator may file a petition in a district court under paragraph (a) of subsection (10) of this section for an order compelling the person to answer the question.
(II) If the person refuses to answer a question on the grounds of the privilege against self-incrimination, the false medicaid claims law investigator may compel the testimony of the person in accordance with the provisions of section 13-90-118, C.R.S.
e a petition in a district court under paragraph (a) of subsection (10) of this section for an order compelling the person to answer the question.
(II) If the person refuses to answer a question on the grounds of the privilege against self-incrimination, the false medicaid claims law investigator may compel the testimony of the person in accordance with the provisions of section 13-90-118, C.R.S.
(III) A person appearing for oral testimony under a civil investigative demand issued under subsection (1) of this section shall be entitled to the same fees and allowances that are paid to witnesses in the district courts of this state.
(9) Custodian of documents, answers, and transcripts. (a) The attorney general shall designate a false medicaid claims law investigator to serve as custodian of documentary material, answers to interrogatories, and transcripts of oral testimony received under this section and shall designate such additional false medicaid claims law investigators as the attorney general determines from time to time to be necessary to serve as deputies to the custodian.
(b) (I) A false medicaid claims law investigator who receives any documentary material, answers to interrogatories, or transcripts of oral testimony under this section shall transmit them to the custodian. The custodian shall take physical possession of the material, answers, or transcripts and shall be responsible for the use made of them and for the return of documentary material under paragraph (d) of this subsection (9).
(II) The custodian may cause the preparation of copies of the documentary material, answers to interrogatories, or transcripts of oral testimony as may be required for official use by a false medicaid claims law investigator or other officer or employee of the department of law who is authorized for such use under regulations that the attorney general shall issue. The material, answers, and transcripts may be used by any such authorized false medicaid claims law investigator or other officer or employee in connection with the taking of oral testimony under this section.
(III) (A) Except as otherwise provided in this subsection (9), documentary material, answers to interrogatories, or transcripts of oral testimony, or copies thereof, while in the possession of the custodian, shall not be available for examination by an individual other than a false medicaid claims law investigator or other officer or employee of the department of law authorized under subparagraph (II) of this paragraph (b).
(B) Sub-subparagraph (A) of this subparagraph (III) shall not apply if consent is given by the person who produced the material, answers, or transcripts or, in the case of any product of discovery produced pursuant to an express demand for the material, if consent is given by the person from whom the discovery was obtained.
(C) Nothing in this subparagraph (III) is intended to prevent disclosure to the general assembly, including any committee of the general assembly, or to any other agency of the state for use by the agency in furtherance of its statutory responsibilities. Disclosure of information to any such other agency shall be allowed only upon application, made by the attorney general to a district court, showing substantial need for the use of the information by the agency in furtherance of its statutory responsibilities.
(IV) While in the possession of the custodian and under such reasonable terms and conditions as the attorney general shall prescribe:
(A) Documentary material and answers to interrogatories shall be available for examination by the person who produced the material or answers, or by a representative of that person authorized by that person to examine the material and answers; and
(B) Transcripts of oral testimony shall be available for examination by the person who produced the testimony or by a representative of that person authorized by that person to examine the transcripts.
ories shall be available for examination by the person who produced the material or answers, or by a representative of that person authorized by that person to examine the material and answers; and
(B) Transcripts of oral testimony shall be available for examination by the person who produced the testimony or by a representative of that person authorized by that person to examine the transcripts.
(c) Whenever an attorney of the department of law has been designated to appear before a court, grand jury, or state agency in a case or proceeding, the custodian of any documentary material, answers to interrogatories, or transcripts of oral testimony received under this section may deliver to the attorney such material, answers, or transcripts for official use in connection with the case or proceeding as the attorney determines to be required. Upon the completion of the case or proceeding, the attorney shall return to the custodian the material, answers, or transcripts so delivered that are not in the control of the court, grand jury, or agency through introduction into the record of the case or proceeding.
(d) The custodian shall, upon written request of a person who produced any documentary material in the course of any false medicaid claims law investigation pursuant to a civil investigative demand under this section, return to the person any such material, other than copies furnished to the false medicaid claims law investigator under paragraph (b) of subsection (6) of this section or made for the department of law under subparagraph (II) of paragraph (b) of this subsection (9), that is not in the control of a court, grand jury, or agency through introduction into the record of the case or proceeding, if:
(I) A case or proceeding before a court or grand jury arising out of the investigation or any proceeding before a state agency involving the material has been completed; or
(II) A case or proceeding in which the material may be used has not been commenced within a reasonable time after completion of the examination and analysis of all documentary material and other information assembled in the course of the investigation.
(e) (I) In the event of the death, disability, or separation from service in the department of law of the custodian of any documentary material, answers to interrogatories, or transcripts of oral testimony produced pursuant to a civil investigative demand under this section, or in the event of the official relief of the custodian from responsibility for the custody and control of the material, answers, or transcripts, the attorney general shall promptly:
(A) Designate another false medicaid claims law investigator to serve as custodian of the material, answers, or transcripts; and
(B) Transmit in writing to the person who produced the material, answers, or testimony notice of the identity and address of the successor so designated.
(II) A person who is designated to be a successor under this paragraph (e) shall have, with regard to the material, answers, or transcripts, the same duties and responsibilities as were imposed by this section upon that person's predecessor in office; except that the successor shall not be held responsible for any default or dereliction that occurred before that designation.
(10) Judicial proceedings. (a) Whenever a person fails to comply with a civil investigative demand issued under subsection (1) of this section, or whenever satisfactory copying or reproduction of the material requested in a demand cannot be done and the person refuses to surrender the material, the attorney general may file, in a district court for the judicial district in which the person resides, is found, or transacts business, and serve upon the person a petition for an order of the court for the enforcement of the civil investigative demand.
ver satisfactory copying or reproduction of the material requested in a demand cannot be done and the person refuses to surrender the material, the attorney general may file, in a district court for the judicial district in which the person resides, is found, or transacts business, and serve upon the person a petition for an order of the court for the enforcement of the civil investigative demand.
(b) (I) A person who has received a civil investigative demand issued under subsection (1) of this section may file a petition for an order of the court to modify or set aside the demand. The person shall file the petition in a district court for the judicial district within which the person resides, is found, or transacts business and shall serve a copy of the petition upon the false medicaid claims law investigator identified in the demand. In the case of a petition addressed to an express demand for a product of discovery, the person may file a petition to modify or set aside the demand only in the district court for the judicial district in which the proceeding in which the discovery was obtained is or was last pending. The person shall file a petition under this subparagraph (I):
(A) Within twenty days after the date of service of the civil investigative demand or at any time before the return date specified in the demand, whichever date is earlier; or
(B) Within such longer period as may be prescribed in writing by a false medicaid claims law investigator identified in the demand.
(II) The petition shall specify each ground upon which the petitioner relies in seeking relief under subparagraph (I) of this paragraph (b) and may be based upon any failure of the demand to comply with the provisions of this section or upon any constitutional or other legal right or privilege of the person. During the pendency of the petition in the court, the court may stay, as it deems proper, the running of the time allowed for compliance with the demand, in whole or in part; except that the person filing the petition shall comply with any portions of the demand not sought to be modified or set aside.
(c) (I) In the case of a civil investigative demand issued under subsection (1) of this section that is an express demand for a product of discovery, the person from whom the discovery was obtained may file a petition for an order of the court to modify or set aside those portions of the demand requiring production of any product of discovery. The person shall file the petition in the district court for the judicial district in which the proceeding in which the discovery was obtained is or was last pending and shall serve a copy of the petition upon the false medicaid claims law investigator identified in the demand and upon the recipient of the demand. The person shall file a petition under this subparagraph (I):
(A) Within twenty days after the date of service of the civil investigative demand or at any time before the return date specified in the demand, whichever date is earlier; or
(B) Within such longer period as may be prescribed in writing by the false medicaid claims law investigator identified in the demand.
(II) The petition shall specify each ground upon which the petitioner relies in seeking relief under subparagraph (I) of this paragraph (c), and may be based upon any failure of the portions of the demand from which relief is sought to comply with the provisions of this section or upon any constitutional or other legal right or privilege of the petitioner. During the pendency of the petition, the court may stay, as it deems proper, compliance with the demand and the running of the time allowed for compliance with the demand.
graph (c), and may be based upon any failure of the portions of the demand from which relief is sought to comply with the provisions of this section or upon any constitutional or other legal right or privilege of the petitioner. During the pendency of the petition, the court may stay, as it deems proper, compliance with the demand and the running of the time allowed for compliance with the demand.
(d) At any time during which a custodian is in custody or control of any documentary material or answers to interrogatories produced, or transcripts of oral testimony given, by a person in compliance with a civil investigative demand issued under subsection (1) of this section, the person, and in the case of an express demand for any product of discovery, the person from whom the discovery was obtained, may file a petition for an order of the court to require the performance by the custodian of any duty imposed upon the custodian by this section. The person shall file the petition in the district court for the judicial district within which the office of the custodian is situated and shall serve a copy of the petition upon the custodian.
(e) Whenever a petition is filed in a district court under this subsection (10), the court shall have jurisdiction to hear and determine the matter so presented and to enter such order or orders as may be required to carry out the provisions of this section. A final order so entered shall be subject to appeal under section 13-4-102, C.R.S. Any disobedience of a final order entered by a court under this section shall be punished as a contempt of the court.
(f) The Colorado rules of civil procedure shall apply to a petition under this subsection (10) to the extent that the rules are consistent with the provisions of this section.
(11) Disclosure exemption. Any documentary material, answers to written interrogatories, or oral testimony provided under a civil investigative demand issued under subsection (1) of this section shall be exempt from disclosure under section 24-72-203, C.R.S.
(12) Definitions. As used in this section, unless the context otherwise requires:
(a) "Custodian" means the custodian, or any deputy custodian, designated by the attorney general under paragraph (a) of subsection (9) of this section.
(b) "Documentary material" means the original or a copy of a book, record, report, memorandum, paper, communication, tabulation, chart, or other document, or data compilations stored in or accessible through computer or other information retrieval systems, together with instructions and all other materials necessary to use or interpret the data compilations, and any product of discovery.
(c) "False medicaid claims law" means:
(I) This section and sections 25.5-4-303.5 to 25.5-4-308; and
(II) Any law enacted before, on, or after May 26, 2010, that prohibits or makes available to the state in a court of the state a civil remedy with respect to a false medicaid claim against, bribery of, or corruption of an officer or employee of the state.
(d) "False medicaid claims law investigation" means an inquiry conducted by a false medicaid claims law investigator for the purpose of ascertaining whether a person is or has been engaged in a violation of a false medicaid claims law.
(e) "False medicaid claims law investigator" means an attorney or investigator employed by the department of law who is charged with the duty of enforcing or carrying into effect a false medicaid claims law or an officer or employee of the state acting under the direction and supervision of the attorney or investigator in connection with a false medicaid claims law investigation.
(f) "Person" means a natural person, partnership, corporation, association, or other legal entity.
loyed by the department of law who is charged with the duty of enforcing or carrying into effect a false medicaid claims law or an officer or employee of the state acting under the direction and supervision of the attorney or investigator in connection with a false medicaid claims law investigation.
(f) "Person" means a natural person, partnership, corporation, association, or other legal entity.
(g) "Product of discovery" means:
(I) The original or duplicate of a deposition, interrogatory, document, thing, result of the inspection of land or other property, examination, or admission, any one of which is obtained by a method of discovery in a judicial or administrative proceeding of an adversarial nature;
(II) A digest, analysis, selection, compilation, or derivation of an item listed in subparagraph (I) of this paragraph (g); and
(III) An index or other manner of access to an item listed in subparagraph (I) of this paragraph (g).
C.R.S. § 25.5-4-310 Medicaid false claims report
25.5-4-310. Medicaid false claims report. (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 successor committees, and to the joint budget committee of the general assembly concerning claims brought under the "Colorado Medicaid False Claims Act" during the previous fiscal year. The report shall include, but not be limited to:
(a) The number of actions filed by the attorney general;
(b) The number of actions filed by the attorney general that were completed;
(c) The amount that was recovered in actions filed by the attorney general through settlement or through a judgment and, if known, the amount recovered for damages, penalties, and litigation costs;
(d) The number of actions filed by a person other than the attorney general;
(e) The number of actions filed by a person other than the attorney general that were completed;
(f) The amount that was recovered in actions filed by a person other than the attorney general through settlement or through a judgment and, if known, the amount recovered for damages, penalties, and litigation costs, and the amount recovered by the state and the person; and
(g) The amount expended by the state for investigation, litigation, and all other costs for claims related to the "Colorado Medicaid False Claims Act".
C.R.S. § 25.5-4-401 Providers - payments - rules
25.5-4-401. Providers - payments - rules. (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 other provision of this article 4 or article 5 or 6 of this title 25.5, has any vested right to act as a provider under this article 4 and articles 5 and 6 of this title 25.5 or to receive any payment in addition to or different from that which is currently payable on behalf of a member at the time the medical benefits are provided by the provider.
(b) (I) On and after July 1, 1992, the state department rules established for the payment of providers under this article and articles 5 and 6 of this title shall provide that services that are compensable under both Title XIX and Title XVIII of the social security act shall be paid at either the rate established under Title XIX or the rate established under Title XVIII, whichever is lower.
(II) If any provision of this paragraph (b) is found to be in conflict with any federal law or regulation, such conflicting portion of this paragraph (b) is declared to be inoperative to the extent of the conflict.
(c) The state department shall exercise its overexpenditure authority under section 24-75-109, C.R.S., and shall not intentionally interrupt the normal provider payment schedule unless notified jointly by the director of the office of state planning and budgeting and the state controller that there is the possibility that adequate cash will not be available to make payments to providers and for other state expenses. If it is determined that adequate cash is not available and the state department does interrupt the normal payment cycle, the state department shall notify the joint budget committee of the general assembly and any affected providers in writing of its decision to interrupt the normal payment schedule. Nothing in this paragraph (c) shall be interpreted to establish a right for any provider to be paid during any specific billing cycle.
(d) Repealed.
(2) As to all payments made pursuant to this article and articles 5 and 6 of this title, the state department rules for the payment of providers may include provisions that encourage the highest quality of medical benefits and the provision thereof at the least expense possible.
(3) (a) As used in this subsection (3), "capitated" means a method of payment by which a provider directly delivers or arranges for delivery of medical care benefits for a term established by contract with the state department based on a fixed rate of reimbursement per member.
(b) (I) In order to provide medical benefits under this article and articles 5 and 6 of this title on a capitated basis and subject to the condition imposed in subparagraph (II) of this paragraph (b), the state department is authorized to solicit negotiated contracts with providers based upon the requirements of this subsection (3). The state department may contract with one or more providers concerning the same medical services in a single geographic area.
(II) The state department may award a contract to one or more providers pursuant to subparagraph (I) of this paragraph (b) when the executive director determines that such contract will reduce the costs of providing medical benefits under this article and articles 5 and 6 of this title.
(III) The state department may define groups of members by geographic area or other categories and may require that all members of the defined group obtain medical services through one or more provider contracts entered into pursuant to this subsection (3).
ctor determines that such contract will reduce the costs of providing medical benefits under this article and articles 5 and 6 of this title.
(III) The state department may define groups of members by geographic area or other categories and may require that all members of the defined group obtain medical services through one or more provider contracts entered into pursuant to this subsection (3).
(4) (a) The general assembly finds, determines, and declares that access to health-care services would be improved and costs of health care would be restrained if the members of the medicaid program would choose a primary care physician through a managed care provider. For purposes of this subsection (4), "managed care provider" means either a primary care physician program, a health maintenance organization, or a prepaid health plan.
(b) Subject to the provisions of subsection (4)(c) of this section, the executive director of the state department has the authority to require a member of the medicaid program to select a managed care provider and to assign a member to a managed care provider if the member has failed to make a selection within a reasonable time. To the extent possible, this requirement must be implemented on a statewide basis.
(c) The state department shall ensure the following:
(I) A managed care provider shall establish and implement member-friendly procedures and instructions for disenrollment and shall have adequate staff to explain issues concerning service delivery and disenrollment procedures to members, including staff to address the communications needs and requirements of members with disabilities.
(II) All members shall be adequately informed about available service delivery options consistent with the provisions of this subsection (4)(c)(II). If a member does not respond to a state department request for selection of a delivery option after forty-five calendar days, the state department shall send a second notification to the member. If the member does not respond after twenty days of the date of the second notification, the state department shall ensure that the member remains with the member's primary care physician, regardless of whether the primary care physician is enrolled in a health maintenance organization.
(5) The state board may promulgate rules to provide for the implementation and administration of subsections (3) and (4) of this section.
(6) The state department shall make good faith efforts to obtain a waiver or waivers from any requirements of Title XIX of the social security act which would prohibit the implementation of subsections (3) and (4) of this section. Such waiver or waivers shall be obtained from the federal department of health and human services, or any successor agency. If such waivers are not granted, the state department shall not act to implement or administer subsections (3) and (4) of this section to the extent that Title XIX prohibits it.
C.R.S. § 25.5-4-401.2 Performance-based payments - reporting
25.5-4-401.2. Performance-based payments - reporting. (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) Primary care providers;
(b) Federally qualified health centers;
(c) Providers of long-term care services and supports; and
(d) Behavioral health providers, including, but not limited to:
(I) Repealed.
(II) Behavioral health safety net providers, as defined in section 27-50-101; and
(III) Entities contracted with the state department to administer the statewide system of community behavioral health care established in section 25.5-5-402.
(2) (a) Prior to implementing performance-based payments in the medicaid program pursuant to this article 4 and articles 5 and 6 of this title 25.5, including performance-based payments set forth in this section, the state department shall submit to the joint budget committee:
(I) (A) Evidence that the performance-based payments are designed to achieve budget savings; or
(B) A budget request for costs associated with the performance-based payments;
(II) The estimated performance-based payments compared to total reimbursements for the affected service; and
(III) A description of the stakeholder engagement process for developing the performance-based payments, including the participants in the process and a summary of the stakeholder feedback, and the state department's response to stakeholder feedback.
(b) The information required pursuant to subsection (2)(a) of this section must be provided on or before November 1 for performance-based payments that will take effect in the following fiscal year unless the state department includes with its submission an explanation of the need for faster implementation of the payment. If faster implementation is requested, the state department shall provide the information at least three months prior to the implementation of the performance-based payments unless compliance with federal law necessitates shorter notice.
(3) On or before November 1, 2017, and on or before November 1 each year thereafter, the state department shall submit a report to the joint budget committee, the public health care and human services committee of the house of representatives, and the health and human services committee of the senate, or any successor committees, describing rules adopted by the state board and contract provisions approved by the federal centers for medicare and medicaid services in the preceding calendar year that authorize payments to providers based on performance. Notwithstanding the provisions of section 24-1-136 (11)(a)(I), the report required pursuant to this subsection (3) continues indefinitely. The report must include, at a minimum:
(a) A description of performance-based payments included in state board rules, including which performance standards are targeted with each performance-based payment;
(b) A description of the goals and objectives of the performance-based payments, and how those goals and objectives align with other quality improvement initiatives;
(c) A summary of the research-based evidence for the performance-based payments, to the extent such evidence is available;
(d) A summary of the anticipated impact and clinical and nonclinical outcomes of implementing the performance-based payments;
(e) A description of how the impact or outcomes will be evaluated;
(f) An explanation of steps taken by the state department to limit the administrative burden on providers;
(g) A summary of the stakeholder engagement process with respect to each performance-based payment, including major concerns raised through the stakeholder process and how those concerns were remediated;
(h) When available, evaluation results for performance-based payments that were implemented in prior years; and
eps taken by the state department to limit the administrative burden on providers;
(g) A summary of the stakeholder engagement process with respect to each performance-based payment, including major concerns raised through the stakeholder process and how those concerns were remediated;
(h) When available, evaluation results for performance-based payments that were implemented in prior years; and
(i) A description of proposed modifications to current performance-based payments.
C.R.S. § 25.5-4-401.5 Review of provider rates - advisory committee - recommendations - repeal
25.5-4-401.5. Review of provider rates - advisory committee - recommendations - repeal. (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 advisory committee established pursuant to subsection (3) of this section and the joint budget committee. If the state department receives any petitions or proposals for provider rates to be reviewed or adjusted, the state department shall forward a copy of the petition or proposal to the advisory committee and the joint budget committee.
(b) The state department shall review each of the provider rates scheduled for review pursuant to the process described in this section. The advisory committee or the joint budget committee may, by a majority vote, direct that the state department conduct a review of a provider rate that is not scheduled for review during that year. The advisory committee or the joint budget committee shall notify the state department of the request for an out-of-cycle review by December 1 of the year prior to the year in which the out-of-cycle review will take place. If the state department determines that the request for an out-of-cycle review cannot be conducted, the state department shall provide written notification to the advisory committee and the joint budget committee within thirty days after the request for an out-of-cycle review. The notification must include a description of the reasons the out-of-cycle review cannot be conducted.
(c) (I) The state department may propose to exclude rates from the schedule established pursuant to subsection (1)(a) of this section if those rates are adjusted on a periodic basis as a result of other state statute or federal law or regulation. The state department shall include the proposed list of exclusions with the schedule established pursuant to subsection (1)(a) of this section.
(II) The advisory committee or the joint budget committee may, by a majority vote, direct the state department to include any rate that the state department has proposed to exclude from the schedule.
(2) (a) In the first phase of the review process, the state department shall conduct an analysis of the access, service, quality, and utilization of each service subject to a provider rate review. The state department shall compare the rates paid with available benchmarks, including medicare rates and usual and customary rates paid by private pay parties, and use qualitative tools to assess whether payments are sufficient to allow for provider retention and medicaid member access and to support appropriate reimbursement of high-value services.
(b) Following the analysis required by subsection (2)(a) of this section, the state department shall work with the advisory committee and any stakeholders identified by the state department or the advisory committee to review the analysis and develop strategies for responding to the findings, including any nonfiscal approaches or rebalancing of rates and strategies to address capacity issues that may exist in certain regions of the state.
(c) Following the review required by subsection (2)(b) of this section, the state department shall work with the office of state planning and budgeting to determine achievable goals and executive branch priorities within the statewide budget.
ndings, including any nonfiscal approaches or rebalancing of rates and strategies to address capacity issues that may exist in certain regions of the state.
(c) Following the review required by subsection (2)(b) of this section, the state department shall work with the office of state planning and budgeting to determine achievable goals and executive branch priorities within the statewide budget.
(d) (I) Notwithstanding section 24-1-136 (11)(a)(I), on or before November 1, 2023, and each November 1 thereafter, the state department shall submit a written report to the joint budget committee and the advisory committee on the analysis required pursuant to subsection (2)(a) of this section, a description of the information discussed during the quarterly public meeting conducted pursuant to subsection (2)(e) of this section, and the state department's recommendations on all of the provider rates reviewed pursuant to this section and all of the data relied upon by the state department in making the recommendations. The joint budget committee shall consider the recommendations in formulating the state department's budget.
(II) The state department shall submit, as part of the report required pursuant to this subsection (2)(d), a description of the information discussed during the quarterly public meeting; the state department's response to the public comments received from providers, members, and other interested parties; and an explanation of how the public comments informed the provider rate review process and the recommendations concerning provider rates.
(e) The state department shall conduct a public meeting at least quarterly to inform the state department's review of provider rates paid under the "Colorado Medical Assistance Act". The state department shall invite to the public meeting providers, members, and other interested parties directly affected by the services scheduled to be reviewed at the public meeting. At a minimum, each public meeting must consist of, but is not limited to:
(I) A discussion of the analysis and review performed pursuant to subsection (2)(a) of this section; and
(II) Public comments from providers, members, and other interested parties concerning:
(A) The analysis and review performed pursuant to subsection (2)(a) of this section; and
(B) Recommended changes to the provider rate review process that may enhance or improve the process.
(3) (a) There is created in the state department the medicaid provider rate review advisory committee, referred to in this section as the "advisory committee", to assist the state department in the review of the provider rate reimbursements under the "Colorado Medical Assistance Act". The advisory committee shall:
(I) Review the schedule for annual review of provider rates established by the state department pursuant to subsection (1)(a) of this section and recommend any changes to the schedule;
(II) Review the analysis performed pursuant to subsection (2)(a) of this section and the reports prepared by the state department on its analysis of provider rates pursuant to subsection (2)(d) of this section and provide comments and feedback to the state department and the joint budget committee on the reports;
(III) Review the comments received from providers, members, and other interested parties and the state department's response to the comments required pursuant to subsection (2)(d)(II) of this section;
(IV) Review proposals or petitions received by the advisory committee for provider rates to be reviewed or adjusted;
(V) Determine whether any provider rates not scheduled for review during the next calendar year should be reviewed during that calendar year;
(VI) Recommend to the state department and to the joint budget committee any changes to the process of reviewing provider rates, including measures to increase access to the process, such as by providing for electronic comments by providers and the public; and
Determine whether any provider rates not scheduled for review during the next calendar year should be reviewed during that calendar year;
(VI) Recommend to the state department and to the joint budget committee any changes to the process of reviewing provider rates, including measures to increase access to the process, such as by providing for electronic comments by providers and the public; and
(VII) Provide other assistance to the state department and the joint budget committee as requested by the state department or the joint budget committee.
(b) (I) The advisory committee consists of the following seven members:
(A) Three members appointed by the governor;
(B) Two members appointed by the president of the senate, or the president's designee; and
(C) Two members appointed by the speaker of the house of representatives, or the speaker's designee.
(II) Each member appointed to the advisory committee must have proven expertise related to the medical assistance program in one or more of the following areas:
(A) Service delivery or case management services provided to one or more eligible populations;
(B) Provider finance or budget;
(C) Service capacity analysis;
(D) Business processes;
(E) Claims filing or processing; or
(F) Implementation of state and federal medicaid rules, regulations, and guidance.
(III) The state department may make recommendations to the governor, the president of the senate, and the speaker of the house of representatives concerning the qualifications of members appointed to the advisory committee.
(c) The appointing authorities shall make initial appointments to the advisory committee no later than January 1, 2023. In making appointments to the advisory committee, the appointing authorities shall make a concerted effort to include members of diverse political, racial, cultural, income, and ability groups and members from urban and rural areas.
(d) Each member of the advisory committee serves at the pleasure of the official who appointed the member. Each member of the advisory committee serves a four-year term and may be reappointed.
(e) The members of the advisory committee serve without compensation and without reimbursement for expenses.
(f) At the first meeting of the advisory committee, to be held on or after March 1, 2023, the members shall elect a chair and vice-chair from among the members.
(g) The advisory committee shall meet at least once every quarter. The chair may call additional meetings as may be necessary for the advisory committee to complete its duties.
(h) The advisory committee shall develop bylaws and procedures to govern its operations.
(i) On or before December 1, 2023, and each December 1 thereafter, the advisory committee shall present to the joint budget committee an overview of the provider rate review process, a summary of the provider rates that were reviewed, and the strategies for responding to the findings of the provider rate review, including any fiscal or nonfiscal approaches or rebalancing of rates, any advisory committee recommendations for rate adjustments made to the state department, and any recommendations for improving capacity and access to services in regions of the state where reduced capacity results in limited access to services.
(j) (I) This subsection (3) is repealed, effective September 1, 2034.
(II) Prior to repeal, the department of regulatory agencies shall conduct a sunset review of the advisory committee pursuant to the provisions of section 2-3-1203.
C.R.S. § 25.5-4-402 Providers - hospital reimbursement - hospital review program - rules
25.5-4-402. Providers - hospital reimbursement - hospital review program - rules. (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 inpatient hospital services pursuant to a system of prospective payment, generally based on the elements of a diagnosis-related group system. The state department shall develop and administer a system for ensuring appropriate utilization and quality of care provided by those providers who are reimbursed under this section. Subject to available appropriations, the state department may also make supplemental medicaid payments to certain hospitals. The state board shall promulgate rules to provide for the implementation of this section.
(2) (a) A hospital that receives payment under this article and articles 5 and 6 of this title for telemedicine services shall employ its existing quality-of-care protocols and patient confidentiality guidelines to ensure that such services meet the requirements of this article and articles 5 and 6 of this title.
(b) The executive director of the state department shall adopt rules in furtherance of this subsection (2), including, without limitation, rules to:
(I) Ensure the provision of appropriate care to patients;
(II) Prevent fraud and abuse; and
(III) Establish methods and procedures to avoid overuse of telemedicine services.
(3) (a) In addition to the reimbursement rate process described in subsection (1) of this section and subject to adequate funding being made available pursuant to section 25.5-4-402.4, the Colorado healthcare affordability and sustainability enterprise created in section 25.5-4-402.4 (3) shall pay an additional amount based upon performance to those hospitals that provide services that improve health-care outcomes for their patients. The state department shall determine this amount based upon nationally recognized performance measures established in rules adopted by the state board. The state quality standards must be consistent with federal quality standards published by an organization with expertise in health-care quality, including but not limited to, the federal centers for medicare and medicaid services, the agency for healthcare research and quality, or the national quality forum.
(b) The amount of the payments made pursuant to this subsection (3) shall be computed annually. For the first two fiscal years that payments are made pursuant to this subsection (3), the total amount of the payments shall be up to five percent of the total reimbursements made to hospitals in the previous year. For each fiscal year after the first two fiscal years, the total amount of the payments shall be up to seven percent of the total reimbursements made to hospitals in the previous year.
(4) (a) Subject to federal approval, and notwithstanding any other provision of the "Colorado Medical Assistance Act", the state department shall design and implement an evidence-based hospital review program to ensure appropriate utilization of hospital services.
(b) Consistent with federal regulations set forth in 42 CFR 456, the hospital review program may include the following:
(I) Preadmission review;
(II) Continued stay review;
(III) Transfer planning;
(IV) Discharge planning;
(V) Care coordination; and
(VI) Retrospective claims review.
(c) The following factors must be considered in any coverage determinations made pursuant to the hospital review programs:
(I) Information provided, diagnosis determined, and treatment recommended by the treating provider or providers;
(II) Evidence-based clinical coverage criteria and member coverage guidelines as established by the state department;
(III) Nationally recognized utilization and technology assessment guidelines; and
(IV) Industry standard criteria, as appropriate.
t to the hospital review programs:
(I) Information provided, diagnosis determined, and treatment recommended by the treating provider or providers;
(II) Evidence-based clinical coverage criteria and member coverage guidelines as established by the state department;
(III) Nationally recognized utilization and technology assessment guidelines; and
(IV) Industry standard criteria, as appropriate.
(d) (I) The state department shall consult with affected stakeholders prior to implementation of the hospital review program. At a minimum, the state department shall solicit feedback from members, hospitals within Colorado that participate in medicaid, providers participating in the accountable care collaborative pursuant to section 25.5-5-419, and the Colorado healthcare affordability and sustainability enterprise board established in section 25.5-4-402.4 (7). If the state department contracts with a third-party vendor to implement the hospital review program, the state department shall require the vendor to participate in the stakeholder outreach with hospitals required pursuant to this subsection (4)(d)(I).
(II) Prior to implementation of the hospital review program, the state department shall provide an opportunity for hospitals to test connectivity to and workability of any new electronic interface created or implemented as part of this section. The state department shall select a limited group of hospitals to test any new requirements prior to full implementation.
(III) The state department shall provide a report to the joint budget committee by November 1, 2018, on the status of the implementation of the hospital review program. The report must include the comments received as part of the stakeholder process described in subsection (4)(d)(I) of this section and a description of, and any available results from, the testing process described in subsection (4)(d)(II) of this section.
(IV) and (V) Repealed.
(e) The state board shall adopt any rules necessary for the administration and implementation of this section.
C.R.S. § 25.5-4-402.3 Providers - hospital - provider fees - legislative declaration - federal waiver - fund created - rules - advisory board - repeal
25.5-4-402.3. Providers - hospital - provider fees - legislative declaration - federal waiver - fund created - rules - advisory board - repeal. (Repealed)
C.R.S. § 25.5-4-402.4 Hospitals - healthcare affordability and sustainability fee - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - reports - rules - legislative declaration - repeal
25.5-4-402.4. Hospitals - healthcare affordability and sustainability fee - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - reports - rules - legislative declaration - repeal. (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 hereby finds and declares that:
(a) The state and the providers of publicly funded medical services, and hospitals in particular, share a common commitment to comprehensive health-care reform;
(b) Hospitals within the state incur significant costs by providing uncompensated emergency department care and other uncompensated medical services to low-income and uninsured populations;
(c) This section is enacted as part of a comprehensive health-care reform and is intended to provide the following services and benefits to hospitals and individuals:
(I) Providing a payer source for some low-income and uninsured populations who may otherwise be cared for in emergency departments and other settings in which uncompensated care is provided;
(II) Reducing the underpayment to Colorado hospitals participating in publicly funded health insurance programs;
(III) Reducing the number of persons in Colorado who are without health-care benefits;
(IV) Reducing the need of hospitals and other health-care providers to shift the cost of providing uncompensated care to other payers;
(V) Expanding access to high-quality, affordable health care for low-income and uninsured populations; and
(VI) Providing the additional business services specified in subsection (4)(a)(IV) of this section to hospitals that pay the healthcare affordability and sustainability fee charged and collected as authorized by subsection (4) of this section by the Colorado healthcare affordability and sustainability enterprise created in subsection (3)(a) of this section;
(d) The Colorado healthcare affordability and sustainability enterprise provides business services to hospitals when, in exchange for payment of healthcare affordability and sustainability fees by hospitals, it:
(I) [Editor's note: This version of subsection (2)(d)(I) is effective until July 1, 2025.] Obtains federal matching money and returns both the healthcare affordability and sustainability fee and the federal matching money to hospitals to increase reimbursement rates to hospitals for providing medical care under the state medical assistance program and the Colorado indigent care program and to increase the number of individuals covered by public medical assistance; and
(I) [Editor's note: This version of subsection (2)(d)(I) is effective July 1, 2025.] Obtains federal matching money and returns both the healthcare affordability and sustainability fee and the federal matching money to hospitals to increase reimbursement rates to hospitals for providing medical care under the state medical assistance program, including disproportionate share hospital payments pursuant to 42 U.S.C. sec. 1396r-4, and to increase the number of individuals covered by public medical assistance; and
(II) Provides additional business services to hospitals as specified in subsection (4)(a)(IV) of this section;
(e) It is necessary, appropriate, and in the best interest of the state to acknowledge that by providing the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section, the Colorado healthcare affordability and sustainability enterprise engages in an activity conducted in the pursuit of a benefit, gain, or livelihood and therefore operates as a business;
of this section;
(e) It is necessary, appropriate, and in the best interest of the state to acknowledge that by providing the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section, the Colorado healthcare affordability and sustainability enterprise engages in an activity conducted in the pursuit of a benefit, gain, or livelihood and therefore operates as a business;
(f) Consistent with the determination of the Colorado supreme court in Nicholl v. E-470 Public Highway Authority, 896 P.2d 859 (Colo. 1995), that the power to impose taxes is inconsistent with enterprise status under section 20 of article X of the state constitution, it is the conclusion of the general assembly that the healthcare affordability and sustainability fee charged and collected by the Colorado healthcare affordability and sustainability enterprise is a fee, not a tax, because the fee is imposed for the specific purposes of allowing the enterprise to defray the costs of providing the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section to hospitals that pay the fee and is collected at rates that are reasonably calculated based on the benefits received by those hospitals; and
(g) So long as the Colorado healthcare affordability and sustainability enterprise qualifies as an enterprise for purposes of section 20 of article X of the state constitution, the revenues from the healthcare affordability and sustainability fee charged and collected by the enterprise are not state fiscal year spending, as defined in section 24-77-102 (17), or state revenues, as defined in section 24-77-103.6 (6)(c), and do not count against either the state fiscal year spending limit imposed by section 20 of article X of the state constitution or the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I).
(3) Colorado healthcare affordability and sustainability enterprise. (a) The Colorado healthcare affordability and sustainability enterprise, referred to in this section as the "enterprise", is created. The enterprise is and operates as a government-owned business within the state department for the purpose of charging and collecting the healthcare affordability and sustainability fee, leveraging healthcare affordability and sustainability fee revenue to obtain federal matching money, and utilizing and deploying the healthcare affordability and sustainability fee revenue and federal matching money to provide the business services specified in subsections (2)(d)(I) and (2)(d)(II) of this section to hospitals that pay the healthcare affordability and sustainability fee.
(b) The enterprise constitutes an enterprise for purposes of section 20 of article X of the state constitution so long as it retains the authority to issue revenue bonds and receives less than ten percent of its total revenues in grants from all Colorado state and local governments combined. So long as it constitutes an enterprise pursuant to this subsection (3)(b), the enterprise is not subject to any provisions of section 20 of article X of the state constitution.
0 of article X of the state constitution so long as it retains the authority to issue revenue bonds and receives less than ten percent of its total revenues in grants from all Colorado state and local governments combined. So long as it constitutes an enterprise pursuant to this subsection (3)(b), the enterprise is not subject to any provisions of section 20 of article X of the state constitution.
(c) (I) The repeal of the hospital provider fee program, as it existed pursuant to section 25.5-4-402.3 before its repeal, effective July 1, 2017, by Senate Bill 17-267, enacted in 2017, and the creation of the Colorado healthcare affordability and sustainability enterprise as a new enterprise to charge and collect a new healthcare affordability and sustainability fee as authorized by subsection (4) of this section and provide healthcare affordability and sustainability fee-funded business services to hospitals that replace and supplement services previously funded by hospital provider fees is the creation of a new government-owned business that provides business services to hospitals as a new enterprise for purposes of section 20 of article X of the state constitution, does not constitute the qualification of an existing government-owned business as an enterprise for purposes of section 20 of article X of the state constitution or section 24-77-103.6 (6)(b)(II), and, therefore, does not require or authorize adjustment of the state fiscal year spending limit calculated pursuant to section 20 of article X of the state constitution or the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I).
(II) Notwithstanding subsection (3)(c)(I) of this section, because the repeal of the hospital provider fee program, as it existed pursuant to section 25.5-4-402.3 before its repeal by Senate Bill 17-267, enacted in 2017, will allow the state to spend more general fund money for general governmental purposes than it would otherwise be able to spend below the excess state revenues cap, as defined in section 24-77-103.6 (6)(b)(I), it is appropriate to restrain the growth of government by lowering the base amount used to calculate the excess state revenues cap for the 2017-18 state fiscal year by two hundred million dollars.
(d) The enterprise's primary powers and duties are:
(I) To charge and collect the healthcare affordability and sustainability fee as specified in subsection (4) of this section;
(II) To leverage healthcare affordability and sustainability fee revenue collected to obtain federal matching money, working with or through the state department and the state board to the extent required by federal law or otherwise necessary;
(III) To expend healthcare affordability and sustainability fee revenue, matching federal money, and any other money from the healthcare affordability and sustainability fee cash fund as specified in subsections (4) and (5) of this section;
(IV) To issue revenue bonds payable from the revenues of the enterprise;
(V) To enter into agreements with the state department to the extent necessary to collect and expend healthcare affordability and sustainability fee revenue;
(VI) To engage the services of private persons or entities serving as contractors, consultants, and legal counsel for professional and technical assistance and advice and to supply other services related to the conduct of the affairs of the enterprise, including the provision of additional business services to hospitals as specified in subsection (4)(a)(IV) of this section; and
(VII) To adopt and amend or repeal policies for the regulation of its affairs and the conduct of its business consistent with the provisions of this section.
nical assistance and advice and to supply other services related to the conduct of the affairs of the enterprise, including the provision of additional business services to hospitals as specified in subsection (4)(a)(IV) of this section; and
(VII) To adopt and amend or repeal policies for the regulation of its affairs and the conduct of its business consistent with the provisions of this section.
(e) The enterprise is a type 2 entity, as defined in section 24-1-105, and exercises its powers and performs its duties and functions under the department.
(4) Healthcare affordability and sustainability fee. (a) [Editor's note: This version of the introductory portion to subsection (4)(a) is effective until July 1, 2025.] For the fiscal year commencing July 1, 2017, and for each fiscal year thereafter, the enterprise is authorized to charge and collect a healthcare affordability and sustainability fee, as described in 42 CFR 433.68 (b), on outpatient and inpatient services provided by all licensed or certified hospitals, referred to in this section as "hospitals", for the purpose of obtaining federal financial participation under the state medical assistance program as described in this article 4 and articles 5 and 6 of this title 25.5, referred to in this section as the "state medical assistance program", and the Colorado indigent care program described in part 1 of article 3 of this title 25.5, referred to in this section as the "Colorado indigent care program". If the amount of healthcare affordability and sustainability fee revenue collected exceeds the federal net patient revenue-based limit on the amount of such fee revenue that may be collected, requiring repayment to the federal government of excess federal matching money received, hospitals that received such excess federal matching money shall be responsible for repaying the excess federal money and any associated federal penalties to the federal government. The enterprise shall use the healthcare affordability and sustainability fee revenue to:
(4) Healthcare affordability and sustainability fee. (a) [Editor's note: This version of the introductory portion to subsection (4)(a) is effective July 1, 2025.] For the fiscal year commencing July 1, 2017, and for each fiscal year thereafter, the enterprise is authorized to charge and collect a healthcare affordability and sustainability fee, as described in 42 CFR 433.68 (b), on outpatient and inpatient services provided by all licensed or certified hospitals, referred to in this section as "hospitals", for the purpose of obtaining federal financial participation under the state medical assistance program as described in this article 4 and articles 5 and 6 of this title 25.5, referred to in this section as the "state medical assistance program", including disproportionate share hospital payments pursuant to 42 U.S.C. sec. 1396r-4. If the amount of healthcare affordability and sustainability fee revenue collected exceeds the federal net patient revenue-based limit on the amount of such fee revenue that may be collected, requiring repayment to the federal government of excess federal matching money received, hospitals that received such excess federal matching money are responsible for repaying the excess federal money and any associated federal penalties to the federal government. The enterprise shall use the healthcare affordability and sustainability fee revenue to:
(I) [Editor's note: This version of subsection (4)(a)(I) is effective until July 1, 2025.] Provide a business service to hospitals by increasing reimbursement to hospitals for providing medical care under:
(A) The state medical assistance program; and
(B) The Colorado indigent care program;
(I) [Editor's note: This version of subsection (4)(a)(I) is effective July 1, 2025.] Provide a business service to hospitals by increasing reimbursement to hospitals for providing:
(A) Medical care under the state medical assistance program; and
ing reimbursement to hospitals for providing medical care under:
(A) The state medical assistance program; and
(B) The Colorado indigent care program;
(I) [Editor's note: This version of subsection (4)(a)(I) is effective July 1, 2025.] Provide a business service to hospitals by increasing reimbursement to hospitals for providing:
(A) Medical care under the state medical assistance program; and
(B) Hospital financial assistance programs for care provided to uninsured patients;
(II) Provide a business service to hospitals by increasing the number of individuals covered by public medical assistance and thereby reducing the amount of uncompensated care that the hospitals must provide;
(II.3) (A) For state fiscal years 2019-20, 2020-21, and any subsequent fiscal years, as long as the increased reimbursements and payments pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, and the "American Rescue Plan Act of 2021", Pub.L. 116-260, are still available only, offset general fund expenditures for the state medical assistance program.
(B) This subsection (4)(a)(II.3) is repealed, effective December 31, 2024.
(II.5) Repealed.
(III) Pay the administrative costs to the enterprise in implementing and administering this section subject to the limitation that administrative costs of the enterprise are limited to three percent of the enterprise's expenditures based on a methodology approved by the office of state planning and budgeting and the staff of the joint budget committee of the general assembly; and
(IV) Provide or contract for or arrange the provision of additional business services to hospitals by:
(A) Consulting with hospitals to help them improve both cost efficiency and patient safety in providing medical services and the clinical effectiveness of those services;
(B) Advising hospitals regarding potential changes to federal and state laws and regulations that govern the provision of and reimbursement paid for medical services under the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5;
(C) Providing coordinated services to hospitals to help them adapt and transition to any new or modified performance tracking and payment systems for the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5, which may include data sharing, telehealth coordination and support, establishment of performance metrics, benchmarking to such metrics, and clinical and administrative process consulting and other appropriate services;
(D) Providing any other services to hospitals that aid them in efficiently and effectively participating in the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5; and
(E) Providing funding for, and in cooperation with the state department and hospitals supporting the implementation of, a health-care delivery system reform incentive payments program as described in subsection (8) of this section.
spitals that aid them in efficiently and effectively participating in the programs administered pursuant to this article 4 and articles 5 and 6 of this title 25.5; and
(E) Providing funding for, and in cooperation with the state department and hospitals supporting the implementation of, a health-care delivery system reform incentive payments program as described in subsection (8) of this section.
(b) The enterprise shall recommend for approval and establishment by the state board the amount of the healthcare affordability and sustainability fee that it intends to charge and collect. The state board must establish the final amount of the fee by rules promulgated in accordance with article 4 of title 24. The state board shall not establish any amount that exceeds the federal limit for such fees. The state board may deviate from the recommendations of the enterprise, but shall express in writing the reasons for any deviations. In establishing the amount of the fee and in promulgating the rules governing the fee, the state board shall:
(I) Consider recommendations of the enterprise;
(II) Establish the amount of the healthcare affordability and sustainability fee so that the amount collected from the fee and federal matching funds associated with the fee are sufficient to pay for the items described in subsection (4)(a) of this section, but nothing in this subsection (4)(b)(II) requires the state board to increase the fee above the amount recommended by the enterprise; and
(III) For the 2017-18 fiscal year, establish the amount of the healthcare affordability and sustainability fee so that the amount collected from the fee is approximately equal to the sum of the amounts of the appropriations specified for the fee in the general appropriation act, Senate Bill 17-254, enacted in 2017, and any other supplemental appropriation act.
(c) (I) In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1) and (e)(2), the enterprise, acting in concert with or through an agreement with the state department if required by federal law, may seek a waiver from the broad-based healthcare affordability and sustainability fee requirement or the uniform healthcare affordability and sustainability fee requirement, or both. In addition, the enterprise, acting in concert with or through an agreement with the state department if required by federal law, shall seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health-care delivery system reform incentive payments program as described in subsection (8) of this section. Subject to federal approval and to minimize the financial impact on certain hospitals, the enterprise may exempt from payment of the healthcare affordability and sustainability fee certain types of hospitals, including but not limited to:
(A) Psychiatric hospitals, as licensed by the department of public health and environment;
(B) Hospitals that are licensed as general hospitals and certified as long-term care hospitals by the department of public health and environment;
(C) [Editor's note: This version of subsection (4)(c)(I)(C) is effective until July 1, 2026.] Critical access hospitals that are licensed as general hospitals and are certified by the department of public health and environment under 42 CFR part 485, subpart F;
(C) [Editor's note: This version of subsection (4)(c)(I)(C) is effective July 1, 2026.] Critical access hospitals that are licensed and certified by the department of public health and environment under 42 CFR 485, subpart F;
(D) Inpatient rehabilitation facilities; or
(E) Hospitals specified for exemption under 42 CFR 433.68 (e).
(II) In determining whether a hospital may be excluded, the enterprise shall use one or more of the following criteria:
(A) A hospital that is located in a rural area;
hospitals that are licensed and certified by the department of public health and environment under 42 CFR 485, subpart F;
(D) Inpatient rehabilitation facilities; or
(E) Hospitals specified for exemption under 42 CFR 433.68 (e).
(II) In determining whether a hospital may be excluded, the enterprise shall use one or more of the following criteria:
(A) A hospital that is located in a rural area;
(B) A hospital with which the state department does not contract to provide services under the state medical assistance program;
(C) A hospital whose inclusion or exclusion would not significantly affect the net benefit to hospitals paying the healthcare affordability and sustainability fee; or
(D) A hospital that must be included to receive federal approval.
(III) The enterprise may reduce the amount of the healthcare affordability and sustainability fee for certain hospitals to obtain federal approval and to minimize the financial impact on certain hospitals. In determining for which hospitals the enterprise may reduce the amount of the healthcare affordability and sustainability fee, the enterprise shall use one or more of the following criteria:
(A) The hospital is a type of hospital described in subsection (4)(c)(I) of this section;
(B) The hospital is located in a rural area;
(C) The hospital serves a higher percentage than the average hospital of persons covered by the state medical assistance program, medicare, or commercial insurance or persons enrolled in a managed care organization;
(D) The hospital does not contract with the state department to provide services under the state medical assistance program;
(E) If the hospital paid a reduced healthcare affordability and sustainability fee, the reduced fee would not significantly affect the net benefit to hospitals paying the healthcare affordability and sustainability fee; or
(F) The hospital is required not to pay a reduced healthcare affordability and sustainability fee as a condition of federal approval.
(IV) The enterprise may change how it pays hospital reimbursement or quality incentive payments, or both, in whole or in part, under the authority of a federal waiver if the total reimbursement to hospitals is equal to or above the federal upper payment limit calculation under the waiver.
(d) The enterprise may alter the process prescribed in this subsection (4) to the extent necessary to meet the federal requirements and to obtain federal approval.
(e) (I) The enterprise shall establish policies on the calculation, assessment, and timing of the healthcare affordability and sustainability fee. The enterprise shall assess the healthcare affordability and sustainability fee on a schedule to be set by the enterprise board as provided in subsection (7)(d) of this section. The periodic healthcare affordability and sustainability fee payments from a hospital and the enterprise's reimbursement to the hospital under subsections (5)(b)(I) and (5)(b)(II) of this section are due as nearly simultaneously as feasible; except that the enterprise's reimbursement to the hospital is due no more than two days after the periodic healthcare affordability and sustainability fee payment is received from the hospital. The healthcare affordability and sustainability fee must be imposed on each hospital even if more than one hospital is owned by the same entity. The fee must be prorated and adjusted for the expected volume of service for any year in which a hospital opens or closes.
(II) The enterprise is authorized to refund any unused portion of the healthcare affordability and sustainability fee. For any portion of the healthcare affordability and sustainability fee that has been collected by the enterprise but for which the enterprise has not received federal matching funds, the enterprise shall refund back to the hospital that paid the fee the amount of that portion of the fee within five business days after the fee is collected.
on of the healthcare affordability and sustainability fee. For any portion of the healthcare affordability and sustainability fee that has been collected by the enterprise but for which the enterprise has not received federal matching funds, the enterprise shall refund back to the hospital that paid the fee the amount of that portion of the fee within five business days after the fee is collected.
(III) The enterprise shall establish requirements for the reports that hospitals must submit to the enterprise to allow the enterprise to calculate the amount of the healthcare affordability and sustainability fee. Notwithstanding the provisions of part 2 of article 72 of title 24 or subsection (7)(f) of this section, information provided to the enterprise pursuant to this section is confidential and is not a public record. Nonetheless, the enterprise may prepare and release summaries of the reports to the public.
(f) A hospital shall not include any amount of the healthcare affordability and sustainability fee as a separate line item in its billing statements.
(g) [Editor's note: This version of subsection (4)(g) is effective until July 1, 2025.] The state board shall promulgate any rules pursuant to the "State Administrative Procedure Act", article 4 of title 24, necessary for the administration and implementation of this section. Prior to submitting any proposed rules concerning the administration or implementation of the healthcare affordability and sustainability fee to the state board, the enterprise shall consult with the state board on the proposed rules as specified in subsection (7)(d) of this section.
(g) [Editor's note: This version of subsection (4)(g) is effective July 1, 2025.] (I) The state board shall promulgate any rules pursuant to the "State Administrative Procedure Act", article 4 of title 24, necessary for the administration and implementation of this section. Prior to submitting any proposed rules concerning the administration or implementation of the healthcare affordability and sustainability fee to the state board, the enterprise shall consult with the state board on the proposed rules as specified in subsection (7)(d) of this section.
(II) No later than July 1, 2025, the state board, in consultation with the enterprise, shall promulgate rules concerning the policy for qualification for disproportionate share hospital payments. Subject to the requirements under federal law, the disproportionate share hospital payment policy must direct funding to hospitals serving a greater proportion of medicaid and uninsured patients compared to other hospitals and offering financial assistance to lower-income Coloradans.
(5) Healthcare affordability and sustainability fee cash fund. (a) Any healthcare affordability and sustainability fee collected pursuant to this section by the enterprise must be transmitted to the state treasurer, who shall credit the fee to the healthcare affordability and sustainability fee cash fund, which fund is hereby created and referred to in this section as the "fund". The state treasurer shall credit all interest and income derived from the deposit and investment of money in the fund to the fund. The state treasurer shall invest any money in the fund not expended for the purposes specified in subsection (5)(b) of this section as provided by law. Money in the fund shall not be transferred to any other fund and shall not be used for any purpose other than the purposes specified in this subsection (5) and in subsection (4) of this section.
osit and investment of money in the fund to the fund. The state treasurer shall invest any money in the fund not expended for the purposes specified in subsection (5)(b) of this section as provided by law. Money in the fund shall not be transferred to any other fund and shall not be used for any purpose other than the purposes specified in this subsection (5) and in subsection (4) of this section.
(b) All money in the fund is subject to federal matching as authorized under federal law and, subject to annual appropriation by the general assembly, shall be expended by the enterprise for the following purposes:
(I) To maximize the inpatient and outpatient hospital reimbursements to up to the upper payment limits as defined in 42 CFR 447.272 and 42 CFR 447.321;
(II) [Editor's note: This version of subsection (5)(b)(II) is effective until July 1, 2025.] To increase hospital reimbursements under the Colorado indigent care program to up to one hundred percent of the hospital's costs of providing medical care under the program;
(II) [Editor's note: This version of subsection (5)(b)(II) is effective July 1, 2025.] To increase hospital reimbursements through disproportionate share hospital payments to up to one hundred percent of the hospital's hospital-specific disproportionate share hospital limit;
(III) To pay the quality incentive payments provided in section 25.5-4-402 (3);
(IV) Subject to available revenue from the healthcare affordability and sustainability fee and federal matching funds, to expand eligibility for public medical assistance by:
(A) Increasing the eligibility level for parents and caretaker relatives of children who are eligible for medical assistance, pursuant to section 25.5-5-201 (1)(m), from sixty-one percent to one hundred thirty-three percent of the federal poverty line;
(B) Increasing the eligibility level for children and pregnant women under the children's basic health plan to up to two hundred sixty percent of the federal poverty line;
(C) Providing eligibility under the state medical assistance program for a childless adult or an adult without a dependent child in the home, pursuant to section 25.5-5-201 (1)(p), who earns up to one hundred thirty-three percent of the federal poverty line; and
(D) Providing a buy-in program in the state medical assistance program for disabled adults and children whose families have income of up to four hundred fifty percent of the federal poverty line;
(V) To provide continuous eligibility for twelve months for children enrolled in the state medical assistance program;
(VI) To pay the enterprise's actual administrative costs of implementing and administering this section, including but not limited to the following costs:
(A) Administrative expenses of the enterprise;
(B) The enterprise's actual costs related to implementing and maintaining the healthcare affordability and sustainability fee, including personal services, operating, and consulting expenses;
(C) The enterprise's actual costs for the changes and updates to the medicaid management information system for the implementation of subsections (5)(b)(I) to (5)(b)(III) of this section;
(D) [Editor's note: This version of subsection (5)(b)(VI)(D) is effective until July 1, 2025.] The enterprise's personal services and operating costs related to personnel, consulting services, and for review of hospital costs necessary to implement and administer the increases in inpatient and outpatient hospital payments made pursuant to subsection (5)(b)(I) of this section, increases in the Colorado indigent care program payments made pursuant to subsection (5)(b)(II) of this section, and quality incentive payments made pursuant to subsection (5)(b)(III) of this section;
ing services, and for review of hospital costs necessary to implement and administer the increases in inpatient and outpatient hospital payments made pursuant to subsection (5)(b)(I) of this section, increases in the Colorado indigent care program payments made pursuant to subsection (5)(b)(II) of this section, and quality incentive payments made pursuant to subsection (5)(b)(III) of this section;
(D) [Editor's note: This version of subsection (5)(b)(VI)(D) is effective July 1, 2025.] The enterprise's personal services and operating costs related to personnel, consulting services, and for review of hospital costs necessary to implement and administer the increases in inpatient and outpatient hospital payments made pursuant to subsection (5)(b)(I) of this section, disproportionate share hospital payments made pursuant to subsection (5)(b)(II) of this section, and quality incentive payments made pursuant to subsection (5)(b)(III) of this section;
(E) The enterprise's actual costs for the changes and updates to the Colorado benefits management system and medicaid management information system to implement and maintain the expanded eligibility provided for in subsections (5)(b)(IV) and (5)(b)(V) of this section;
(F) The enterprise's personal services and operating costs related to personnel necessary to implement and administer the expanded eligibility for public medical assistance provided for in subsections (5)(b)(IV) and (5)(b)(V) of this section, including but not limited to administrative costs associated with the determination of eligibility for public medical assistance by county departments; and
(G) The enterprise's personal services, operating, and systems costs related to expanding the opportunity for individuals to apply for public medical assistance directly at hospitals or through another entity outside the county departments, in connection with section 25.5-4-205, that would increase access to public medical assistance and reduce the number of uninsured served by hospitals;
(VII) To offset the loss of any federal matching money due to a decrease in the certification of the public expenditure process for outpatient hospital services for medical services premiums that were in effect as of July 1, 2008;
(VIII) Subject to any necessary federal waivers being obtained, to provide funding for a health-care delivery system reform incentive payments program as described in subsection (8) of this section;
(VIII.3) (A) For state fiscal years 2019-20, 2020-21, and any subsequent fiscal years, as long as the increased reimbursements and payments pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, and the "American Rescue Plan Act of 2021", Pub.L. 116-260, are still available only, and regardless of when this federal money is made available, the amount in excess of the fifty percent federal financial participation generated by increased reimbursements and payments appropriated for use in subsections (5)(b)(I) to (5)(b)(III) of this section pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto, to offset general fund expenditures for the state medical assistance program.
(B) This subsection (5)(b)(VIII.3) is repealed, effective December 31, 2024.
(VIII.5) and (VIII.7) Repealed.
(IX) To provide additional business services to hospitals as specified in subsection (4)(a)(IV) of this section.
the federal "Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto, to offset general fund expenditures for the state medical assistance program.
(B) This subsection (5)(b)(VIII.3) is repealed, effective December 31, 2024.
(VIII.5) and (VIII.7) Repealed.
(IX) To provide additional business services to hospitals as specified in subsection (4)(a)(IV) of this section.
(c) ARPA home- and community-based services account. (I) (A) There is created the "ARPA home- and community-based services account" within the fund, referred to in this subsection (5)(c) as the "ARPA account". Notwithstanding any other provision of this section to the contrary, money in the ARPA account as a result of fund savings and federal matching dollars must be used in accordance with section 9817 of the federal "American Rescue Plan Act of 2021", Pub.L. 117-2, as amended, referred to in this section as "ARPA", to implement or supplement the implementation of home- and community-based services under the medical assistance program pursuant to the provisions of part 18 of article 6 of this title 25.5.
(B) Notwithstanding subsection (5)(c)(I)(A) or any other provision of this section, money in the ARPA account may be used for a purpose that is ineligible for a federal match but otherwise authorized pursuant to the ARPA if the general assembly appropriates the money for that purpose.
(II) (A) On June 30, 2021, the state treasurer shall transfer nineteen million eight hundred thirty thousand nine hundred eighteen dollars from the fund to the ARPA account.
(B) If the fund savings due to the enhanced federal match under ARPA is greater than the amount transferred to the ARPA account under subsection (5)(c)(II)(A) of this section, then the state department shall notify the state treasurer of the amount by which the savings exceeds the transfer. The state treasurer shall transfer this amount from the fund to the ARPA account.
(C) If the fund savings due to the enhanced federal match under ARPA is less than the amount transferred to the ARPA account under subsection (5)(c)(II)(A) of this section, then the state department shall notify the state treasurer of the amount by which the transfer exceeds the savings. The state treasurer shall transfer this amount from the ARPA account to the fund.
(III) The state treasurer shall credit all interest and income derived from the money in the ARPA account to the fund.
(IV) Money in the ARPA account is subject to annual appropriation by the general assembly consistent with the purposes specified in this section and ARPA, and pursuant to part 18 of article 6 of this title 25.5.
(V) Money in the ARPA account remains in the ARPA account until the end of the spending period authorized under ARPA, at which time money remaining in the ARPA account becomes part of the fund.
(VI) This subsection (5)(c) is repealed, effective July 1, 2025.
general assembly consistent with the purposes specified in this section and ARPA, and pursuant to part 18 of article 6 of this title 25.5.
(V) Money in the ARPA account remains in the ARPA account until the end of the spending period authorized under ARPA, at which time money remaining in the ARPA account becomes part of the fund.
(VI) This subsection (5)(c) is repealed, effective July 1, 2025.
(6) Appropriations. (a) (I) Except as otherwise provided in subsection (6)(b)(I.5) or (6)(b)(I.7) of this section, the healthcare affordability and sustainability fee is to supplement, not supplant, general fund appropriations to support hospital reimbursements. General fund appropriations for hospital reimbursements shall be maintained at the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008; except that general fund appropriations for hospital reimbursements may be reduced if an index of appropriations to other providers shows that general fund appropriations are reduced for other providers. If the index shows that general fund appropriations are reduced for other providers, the general fund appropriations for hospital reimbursements shall not be reduced by a greater percentage than the reductions of appropriations for the other providers as shown by the index.
(II) If general fund appropriations for hospital reimbursements are reduced below the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008, the general fund appropriations will be increased back to the level of appropriations in the medical services premium line item made for the fiscal year commencing July 1, 2008, at the same percentage as the appropriations for other providers as shown by the index. The general assembly is not obligated to increase the general fund appropriations back to the level of appropriations in the medical services premium line item in a single fiscal year, and such increases may occur over nonconsecutive fiscal years.
(III) For purposes of this subsection (6)(a), the "index of appropriations to other providers" or "index" means the average percent change in reimbursement rates through appropriations or legislation enacted by the general assembly to home health providers, physician services, and outpatient pharmacies, excluding dispensing fees. The state board, after consultation with the enterprise board, is authorized to clarify this definition as necessary by rule.
(b) If the revenue from the healthcare affordability and sustainability fee is insufficient to fully fund all of the purposes described in subsection (5)(b) of this section:
(I) The general assembly is not obligated to appropriate general fund revenues to fund such purposes;
(I.3) Repealed.
(I.5) (A) The amount in excess of the fifty percent federal financial participation generated by increased reimbursements and payments appropriated for use in subsections (5)(b)(I) to (5)(b)(III) of this section pursuant to the federal "Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto, shall be appropriated to offset general fund expenditures for the state medical assistance program.
(B) This subsection (6)(b)(I.5) is repealed, effective December 31, 2024.
(I.7) Repealed.
(II) The hospital provider reimbursement and quality incentive payment increases described in subsections (5)(b)(I) to (5)(b)(III) of this section and the costs described in subsection (5)(b)(VI) of this section shall be fully funded using revenue from the healthcare affordability and sustainability fee and federal matching funds before any eligibility expansion is funded; and
4.
(I.7) Repealed.
(II) The hospital provider reimbursement and quality incentive payment increases described in subsections (5)(b)(I) to (5)(b)(III) of this section and the costs described in subsection (5)(b)(VI) of this section shall be fully funded using revenue from the healthcare affordability and sustainability fee and federal matching funds before any eligibility expansion is funded; and
(III) (A) If the state board promulgates rules that expand eligibility for medical assistance to be paid for pursuant to subsection (5)(b)(IV) of this section, and the state department thereafter notifies the enterprise board that the revenue available from the healthcare affordability and sustainability fee and the federal matching funds will not be sufficient to pay for all or part of the expanded eligibility, the enterprise board shall recommend to the state board reductions in medical benefits or eligibility so that the revenue will be sufficient to pay for all of the reduced benefits or eligibility. After receiving the recommendations of the enterprise board, the state board shall adopt rules providing for reduced benefits or reduced eligibility for which the revenue will be sufficient and shall forward any adopted rules to the joint budget committee. Notwithstanding the provisions of section 24-4-103 (8) and (12), following the adoption of rules pursuant to this subsection (6)(b)(III)(A), the state board shall not submit the rules to the attorney general and shall not file the rules with the secretary of state until the joint budget committee approves the rules pursuant to subsection (6)(b)(III)(B) of this section.
(B) The joint budget committee shall promptly consider any rules adopted by the state board pursuant to subsection (6)(b)(III)(A) of this section. The joint budget committee shall promptly notify the state department, the state board, and the enterprise board of any action on the rules. If the joint budget committee does not approve the rules, the joint budget committee shall recommend a reduction in benefits or eligibility so that the revenue from the healthcare affordability and sustainability fee and the matching federal funds will be sufficient to pay for the reduced benefits or eligibility. After approving the rules pursuant to this subsection (6)(b)(III)(B), the joint budget committee shall request that the committee on legal services, created pursuant to section 2-3-501, extend the rules as provided for in section 24-4-103 (8) unless the committee on legal services finds after review that the rules do not conform with section 24-4-103 (8)(a).
(C) After the state board has received notification of the approval of rules adopted pursuant to subsection (6)(b)(III)(A) of this section, the state board shall submit the rules to the attorney general pursuant to section 24-4-103 (8)(b) and shall file the rules and the opinion of the attorney general with the secretary of state pursuant to section 24-4-103 (12) and with the office of legislative legal services. Pursuant to section 24-4-103 (5), the rules are effective twenty days after publication of the rules and are only effective until the following May 15 unless the rules are extended pursuant to a bill enacted pursuant to section 24-4-103 (8).
rules and the opinion of the attorney general with the secretary of state pursuant to section 24-4-103 (12) and with the office of legislative legal services. Pursuant to section 24-4-103 (5), the rules are effective twenty days after publication of the rules and are only effective until the following May 15 unless the rules are extended pursuant to a bill enacted pursuant to section 24-4-103 (8).
(c) Notwithstanding any other provision of this section, if, after receipt of authorization to receive federal matching funds for money in the fund, the authorization is withdrawn or changed so that federal matching funds are no longer available, the enterprise shall cease collecting the healthcare affordability and sustainability fee and shall repay to the hospitals any money received by the fund that is not subject to federal matching funds.
(7) Colorado healthcare affordability and sustainability enterprise board. (a) (I) Except as otherwise provided in subsection (7)(a)(II) of this section, the enterprise board consists of thirteen members appointed by the governor, with the advice and consent of the senate, as follows:
(A) Five members who are employed by hospitals in Colorado, including at least one person who is employed by a hospital in a rural area, one person who is employed by a safety-net hospital for which the percent of medicaid-eligible inpatient days relative to its total inpatient days is equal to or greater than one standard deviation above the mean, and one person who is employed by a hospital in an urban area;
(B) One member who is a representative of a statewide organization of hospitals;
(C) One member who represents a statewide organization of health insurance carriers or a health insurance carrier licensed pursuant to title 10 and who is not a representative of a hospital;
(D) One member of the health-care industry who does not represent a hospital or a health insurance carrier;
(E) One member who is a consumer of health care and who is not a representative or an employee of a hospital, health insurance carrier, or other health-care industry entity;
(F) One member who is a representative of persons with disabilities, who is living with a disability, and who is not a representative or an employee of a hospital, health insurance carrier, or other health-care industry entity;
(G) One member who is a representative of a business that purchases or otherwise provides health insurance for its employees; and
(H) Two employees of the state department.
(II) The initial members of the enterprise board are the members of the hospital provider fee oversight and advisory board that was created and existed pursuant to section 25.5-4-402.3 (6), prior to July 1, 2017, and such members shall serve on and after July 1, 2017, for the remainder of the terms for which they were appointed as members of the advisory board. The powers, duties, and functions of the enterprise board include the powers, duties, and functions of the former hospital provider fee oversight and advisory board, and the hospital provider fee oversight and advisory board is abolished.
(III) The governor shall consult with representatives of a statewide organization of hospitals in making the appointments pursuant to subsections (7)(a)(I)(A) and (7)(a)(I)(B) of this section. No more than six members of the enterprise board may be members of the same political party.
(IV) Members of the enterprise board serve at the pleasure of the governor. All terms are for four years. A member who is appointed to fill a vacancy shall serve the remainder of the unexpired term of the former member.
(V) The governor shall designate a chair from among the members of the enterprise board appointed pursuant to subsections (7)(a)(I)(A) to (7)(a)(I)(G) of this section. The enterprise board shall elect a vice-chair from among its members.
of the governor. All terms are for four years. A member who is appointed to fill a vacancy shall serve the remainder of the unexpired term of the former member.
(V) The governor shall designate a chair from among the members of the enterprise board appointed pursuant to subsections (7)(a)(I)(A) to (7)(a)(I)(G) of this section. The enterprise board shall elect a vice-chair from among its members.
(b) Members of the enterprise board serve without compensation but must be reimbursed from money in the fund for actual and necessary expenses incurred in the performance of their duties pursuant to this section.
(c) The enterprise board may contract for a group facilitator to assist the members of the enterprise board in performing their required duties.
(d) The enterprise board has, at a minimum, the following duties:
(I) To determine the timing and method by which the enterprise assesses the healthcare affordability and sustainability fee and the amount of the fee;
(II) If requested by the health and human services committee of the senate or the public health care and human services committee of the house of representatives, or any successor committees, to consult with the committees on any legislation that may impact the healthcare affordability and sustainability fee or hospital reimbursements established pursuant to this section;
(III) To determine changes in the healthcare affordability and sustainability fee that increase the number of hospitals benefitting from the uses of the healthcare affordability and sustainability fee described in subsections (5)(b)(I) to (5)(b)(IV) of this section or that minimize the number of hospitals that suffer losses as a result of paying the healthcare affordability and sustainability fee;
(IV) To recommend to the state department reforms or changes to the inpatient hospital and outpatient hospital reimbursements and quality incentive payments made under the state medical assistance program to increase provider accountability, performance, and reporting;
(V) To direct and oversee the enterprise in seeking, in concert with or through an agreement with the state department if required by federal law, any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health-care delivery system reform incentive payments program as described in subsection (8) of this section;
(VI) To recommend to the state department the schedule and approach to the implementation of subsections (5)(b)(IV) and (5)(b)(V) of this section;
(VII) If money in the fund is insufficient to fully fund all of the purposes specified in subsection (5)(b) of this section, to recommend to the state board changes to the expanded eligibility provisions described in subsection (5)(b)(IV) of this section;
(VIII) To prepare the reports specified in subsection (7)(e) of this section;
(IX) To monitor the impact of the healthcare affordability and sustainability fee on the broader health-care marketplace;
(X) To establish requirements for the reports that hospitals must submit to the enterprise to allow the enterprise to calculate the amount of the healthcare affordability and sustainability fee; and
(XI) To perform any other duties required to fulfill the enterprise board's charge or those assigned to it by the state board or the executive director.
ty fee on the broader health-care marketplace;
(X) To establish requirements for the reports that hospitals must submit to the enterprise to allow the enterprise to calculate the amount of the healthcare affordability and sustainability fee; and
(XI) To perform any other duties required to fulfill the enterprise board's charge or those assigned to it by the state board or the executive director.
(e) On or before January 15, 2018, and on or before January 15 each year thereafter, the enterprise board shall submit a written report to the health and human services committee of the senate and the public health care and human services committee of the house of representatives, or any successor committees, the joint budget committee of the general assembly, the governor, and the state board. The report shall include, but need not be limited to:
(I) The recommendations made to the state board pursuant to this section;
(II) A description of the formula for how the healthcare affordability and sustainability fee is calculated and the process by which the healthcare affordability and sustainability fee is assessed and collected;
(III) An itemization of the total amount of the healthcare affordability and sustainability fee paid by each hospital and any projected revenue that each hospital is expected to receive due to:
(A) The increased reimbursements made pursuant to subsections (5)(b)(I) and (5)(b)(II) of this section and the quality incentive payments made pursuant to subsection (5)(b)(III) of this section; and
(B) The increased eligibility described in subsections (5)(b)(IV) and (5)(b)(V) of this section;
(IV) An itemization of the costs incurred by the enterprise in implementing and administering the healthcare affordability and sustainability fee;
(V) Estimates of the differences between the cost of care provided and the payment received by hospitals on a per-patient basis, aggregated for all hospitals, for patients covered by each of the following:
(A) Medicaid;
(B) Medicare; and
(C) All other payers; and
(VI) A summary of:
(A) The efforts made by the enterprise, acting in concert with or through an agreement with the state department if required by federal law, to seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation of a health-care delivery system reform incentive payments program as described in subsection (8) of this section; and
(B) The progress actually made by the enterprise, in cooperation with the state department and hospitals, towards the goal of implementing such a program.
(e.5) The enterprise board shall calculate the estimates described in subsection (7)(e)(V) of this section by using appropriate information provided to the state department by hospitals and any state department analysis of that information.
nd
(B) The progress actually made by the enterprise, in cooperation with the state department and hospitals, towards the goal of implementing such a program.
(e.5) The enterprise board shall calculate the estimates described in subsection (7)(e)(V) of this section by using appropriate information provided to the state department by hospitals and any state department analysis of that information.
(f) (I) The enterprise is subject to the open meetings provisions of the "Colorado Sunshine Act of 1972", contained in part 4 of article 6 of title 24, and the "Colorado Open Records Act", part 2 of article 72 of title 24.
(II) For purposes of the "Colorado Open Records Act", part 2 of article 72 of title 24, and except as may otherwise be provided by federal law or regulation or state law, the records of the enterprise are public records, as defined in section 24-72-202 (6), regardless of whether the enterprise receives less than ten percent of its total annual revenues in grants, as defined in section 24-77-102 (7), from all Colorado state and local governments combined.
(III) The enterprise is a public entity for purposes of part 2 of article 57 of title 11.
(8) Health-care delivery system reform incentive payments program - funding and implementation. The enterprise, acting in concert with or through an agreement with the state department if required by federal law, shall seek any federal waiver necessary to fund and, in cooperation with the state department and hospitals, support the implementation, no earlier than October 1, 2019, of a health-care delivery system reform incentive payments program that will improve health-care access and outcomes for individuals served by the state department while efficiently utilizing available financial resources. Such a program must, at a minimum:
(a) Include an initial planning phase to:
(I) Assess needs; and
(II) Develop achievable outcome-based metrics to be used to measure progress towards program goals, including the goals of health-care delivery system integration, improved patient outcomes, and more efficient provision of care; and
(b) Address the following focus areas:
(I) Care coordination and care transition management;
(II) Integration of physical and behavioral health-care services;
(III) Chronic condition management;
(IV) Targeted population health; and
(V) Data-driven accountability and outcome measurement.
C.R.S. § 25.5-4-402.5 Providers - state university teaching hospitals
25.5-4-402.5. Providers - state university teaching hospitals. 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.
C.R.S. § 25.5-4-402.7 Unexpended hospital provider fee cash fund - creation - transfer from hospital provider fee cash fund - use of fund - repeal
25.5-4-402.7. Unexpended hospital provider fee cash fund - creation - transfer from hospital provider fee cash fund - use of fund - repeal. (Repealed)
C.R.S. § 25.5-4-402.8 Hospital transparency report and requirements - definitions
25.5-4-402.8. Hospital transparency report and requirements - definitions. (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) or (1)(b)(II) of this section through an asset, equity, or similar purchase agreement that is a single transaction or series of transactions.
(b) "Affiliated" or "affiliate" means there is a contractual relationship between a hospital or an entity that is owned by or under common ownership and control with the hospital where the contractual relationship enables the hospital or an entity that is owned by or under common ownership and control with the hospital to exercise control over one of the following entities:
(I) Another hospital;
(II) An entity owned by or under common ownership and control with another hospital; or
(III) A physician group practice.
(c) "Control" means the possession, direct or indirect, of the power to direct or cause the direction of management and policies of an affiliate, whether through the ownership of equity or membership, by contract or otherwise.
(d) [Editor's note: This version of subsection (1)(d) is effective until July 1, 2025.] "Major payer group" includes commercial insurers, medicare, medicaid, individuals who self-pay, a financial assistance plan, and the "Colorado Indigent Care Program", established in part 1 of article 3 of this title 25.5.
(d) [Editor's note: This version of subsection (1)(d) is effective July 1, 2025.] "Major payer group" includes commercial insurers, medicare, medicaid, individuals who self-pay, and a financial assistance plan.
(2) (a) The state department shall annually prepare a written hospital transparency report detailing hospital costs, including uncompensated care costs, and the different categories of expenditures, by major payer group, made by hospitals in the state. The state department shall coordinate the analysis, review, and release of the hospital transparency report and the reports required pursuant to sections 25.5-1-703 (3) and 25.5-4-402.4 (7)(e), including the opportunity to review and consult on the reports made by the Colorado healthcare affordability and sustainability enterprise board, created pursuant to section 25.5-4-402.4 (7) and referred to in this section as the "enterprise board". The state department may share any information and analytics of information that it receives from hospitals with the enterprise board. The state department may include information it receives from hospitals in accordance with subsection (2)(b) of this section and that is not otherwise publicly available in the transparency report and share such information with the enterprise board; except that information the state department receives from hospitals in accordance with subsections (2)(b)(II)(D), (2)(b)(III)(N), (2)(b)(III)(O), (2)(b.5)(I), and (2)(b.5)(II) of this section is confidential, proprietary, contains trade secrets, and is not a public record pursuant to part 2 of article 72 of title 24. The state department shall not include in the transparency report, share with the enterprise board, or otherwise publish or distribute information derived from reports pursuant to subsections (2)(b)(II)(D), (2)(b)(III)(N), (2)(b)(III)(O), (2)(b.5)(I), and (2)(b.5)(II) of this section, although the state department may share this information if such information has been de-identified and aggregated in a manner to prevent identification of the transaction price of any individual acquisition or affiliation.
ise publish or distribute information derived from reports pursuant to subsections (2)(b)(II)(D), (2)(b)(III)(N), (2)(b)(III)(O), (2)(b.5)(I), and (2)(b.5)(II) of this section, although the state department may share this information if such information has been de-identified and aggregated in a manner to prevent identification of the transaction price of any individual acquisition or affiliation.
(b) Except as provided in subsection (2)(c) of this section, each hospital licensed pursuant to part 1 of article 3 of title 25, or certified pursuant to section 25-1.5-103 (1)(a)(II), shall make information available to the state department for purposes of preparing the annual hospital transparency report. The state board shall establish the format of the information provided by each hospital on an annual basis. Each hospital shall provide the following information to the state department:
(I) The hospital cost report submitted to the federal centers for medicare and medicaid services (CMS) pursuant to 42 CFR 413.20, including a copy of the final forms and worksheets submitted to CMS as part of the hospital cost report;
(II) (A) Annual audited financial statements, prepared in accordance with generally accepted accounting principles. Each hospital shall submit the statements within one hundred twenty days after the end of its fiscal year unless the state department grants an extension in writing in advance of that date.
(B) Notwithstanding the provisions of subsection (2)(b)(II)(A) of this section, if a hospital is operating within a health system or other corporate structure and is normally included in that health system or other corporate structure's financial statement, the hospital may submit the health system or other corporate structure's financial statement if the statement separately identifies the financial information for each of the health system or other corporate structure's licensed hospitals operating in this state.
(C) In lieu of an audited financial statement, each hospital operating within a health system or other corporate structure that does not produce an annual audited financial statement specific to each individual hospital, but instead produces consolidated financial statements, shall submit a reconciliation of the consolidated financial statement and hospital-specific revenue and expenses reported on the medicare cost report pursuant to the federal centers for medicare and medicaid services provider reimbursement manual form 339.
(D) An annual summary of the hospital's transfers of cash, equity, investments, or other assets to and from related parties, including but not limited to the hospital's parent organization. The summary must include the purpose of the transfers and whether the transfers were made within or outside of Colorado. A hospital may aggregate the transfers for each entity receiving or making the transfer.
(E) A hospital-specific statement of cash flow within a time frame specified annually by the state department, but not less than one hundred twenty days after the hospital's fiscal year end.
(F) Changes to no more than twenty-five categories of specific major service lines, as requested by the state department.
(G) A narrative report of major planned and completed projects and capital investments greater than twenty-five million dollars; except that the information the state department receives from hospitals regarding planned activities is confidential, proprietary, contains trade secrets, and is not a public record pursuant to part 2 of article 72 of title 24.
(III) A report that contains the following information:
(A) The total number of available beds and licensed beds;
(B) Inpatient statistics in total and by major payer group and by care setting, including but not limited to inpatient discharges and patient days;
tivities is confidential, proprietary, contains trade secrets, and is not a public record pursuant to part 2 of article 72 of title 24.
(III) A report that contains the following information:
(A) The total number of available beds and licensed beds;
(B) Inpatient statistics in total and by major payer group and by care setting, including but not limited to inpatient discharges and patient days;
(C) Other inpatient statistics, including but not limited to the number of inpatient surgeries, number of births, number of newborn patient days, number of admissions from the hospital-based emergency department, and number of admissions from free-standing emergency departments;
(D) Outpatient statistics in total and by type of visit, including but not limited to hospital-based emergency department visits, free-standing emergency department visits, ambulatory surgery visits, home health visits, and all other outpatient visits;
(E) Gross charges in total, by major payer group, and by care setting, including but not limited to inpatient care and outpatient care;
(F) Contractual allowances in total and by major payer group;
(G) Bad debt write-offs in total and by major payer group;
(H) Charity write-offs in total and by major payer group;
(I) Operating expenses in total and by expense classification, including but not limited to nonphysician payroll expenses and associated hours, physician payroll expenses and associated hours, total payroll expenses and associated hours, contract labor expenses and associated hours, employee benefits expenses, business development, marketing and advertising expenses, supply expenses, depreciation expenses, interest expenses, and all other operating expenses;
(J) Other operating revenue, operating margin, nonoperating gains and losses, gross revenue, net profit, and total margin;
(K) A balance sheet, including but not limited to details for current assets, restricted assets, long-term assets, other assets, current liabilities, long-term debt, other liabilities, and equity or net assets;
(L) Staffing information, including but not limited to full-time equivalents, staff turnover, and staff vacancy rates;
(M) A roll forward of property, plant, and equipment accounts by asset type from the beginning to the end of the reporting period by asset category, including but not limited to purchases, other acquisitions, sales, disposals, and other changes;
(N) The names and transaction price of acquired hospitals, affiliated hospitals, newly constructed hospitals, and rehabilitated hospitals; the names and transaction price of acquired or affiliated physician group practices; and the number and transaction price of individual physician practices acquired;
(O) Information on current affiliations and a report of physician practice acquisitions;
ges;
(N) The names and transaction price of acquired hospitals, affiliated hospitals, newly constructed hospitals, and rehabilitated hospitals; the names and transaction price of acquired or affiliated physician group practices; and the number and transaction price of individual physician practices acquired;
(O) Information on current affiliations and a report of physician practice acquisitions;
(P) Salary and total compensation data of the top five highest paid administrative positions of each nonprofit hospital, including the title, a brief description of duties, base compensation, incentive or bonus compensation, and other compensation. The compensation reported must indicate what performance measures were included in the chief executive officer's performance evaluation generated by the hospital's governing board, including, at a minimum, quality of care outcomes performance, patient satisfaction performance, community benefit performance, consumer and employer affordability performance, market share performance, profits or margins, revenue growth, change in days cash on hand or cash reserves, and workforce. The state department may include information it receives from public hospitals pursuant to this subsection (2)(b)(III)(P) that is not otherwise publicly available in the hospital transparency report; except that information the state department receives from a nonprofit hospital is not a public record pursuant to part 2 of article 72 of title 24. The state department may only report information received pursuant to this subsection (2)(b)(III)(P) in an aggregated format that does not name individual hospitals or administrators.
(Q) In a form and manner specified by the state department, details of significant other revenue that would otherwise be reported in the medicare cost report; and
(IV) (A) A quarterly financial report that includes an income statement and balance sheet. If a hospital is owned or affiliated with a health system that is comprised of three or more hospitals or that has more than one billion dollars in reserves, the health system may submit a consolidated quarterly financial report.
(B) Any quarterly financial report made publicly available must clearly state that the quarterly financial report is unaudited, if applicable. The state department shall provide any analysis, report, or presentation based on the quarterly financial report to each hospital at least fifteen days prior to the public release of the analysis, report, or presentation.
(b.5) No later than July 1, 2024, each hospital shall provide the following information to the state department:
(I) For each fiscal year 2014-15 through 2019-20, a summary of the hospital's transfers of cash, equity, investments, or other assets to and from related parties, including but not limited to the hospital's parent organization. The summary must include the purpose of the transfers and whether the transfers were made within or outside of Colorado. A hospital may aggregate the transfers for each entity receiving or making the transfer.
(II) For each fiscal year from 2014-15 through 2019-20, information on affiliations and a report of physician practice acquisitions; and
(III) For each fiscal year from 2019-20 through 2022-23, in a form and manner specified by the state department, details of significant other revenue that would otherwise be reported in the medicare cost report.
for each entity receiving or making the transfer.
(II) For each fiscal year from 2014-15 through 2019-20, information on affiliations and a report of physician practice acquisitions; and
(III) For each fiscal year from 2019-20 through 2022-23, in a form and manner specified by the state department, details of significant other revenue that would otherwise be reported in the medicare cost report.
(c) The state department may exempt from certain reporting requirements described in subsections (2)(b) and (2)(b.5) of this section certain types of hospitals, including but not limited to:
(I) Psychiatric hospitals, as licensed by the department of public health and environment;
(II) Hospitals that are licensed as general hospitals and certified as long-term care hospitals by the department of public health and environment;
(III) [Editor's note: This version of subsection (2)(c)(III) is effective until July 1, 2026.] Critical access hospitals that are licensed as general hospitals and are certified by the department of public health and environment pursuant to 42 CFR 485 subpart F;
(III) [Editor's note: This version of subsection (2)(c)(III) is effective July 1, 2026.] Critical access hospitals that are licensed and certified by the department of public health and environment pursuant to 42 CFR 485 subpart F;
(IV) Inpatient rehabilitation facilities; and
(V) Hospitals specified for exemption under 42 CFR 433.68 (e).
(d) Repealed.
(e) Prior to issuing the hospital transparency report, the state department shall provide any hospital referenced in the hospital transparency report a copy of the report. Each hospital must have a minimum of fifteen days to review the hospital transparency report and any underlying data and submit corrections or clarifications to the state department.
(f) The state department shall provide a statewide hospital association any information received pursuant to this section in a machine-readable format at no cost to the association.
(g) (I) If a hospital does not provide all of the information required pursuant to subsection (2)(b) of this section, the state department shall inform the hospital of its noncompliance within sixty days and identify the information that needs to be provided. If a hospital does not comply, the state department shall issue a corrective action plan with a timeline of sixty days required for compliance. If a hospital continues to not comply, the state department may create a mandatory pay-for-reporting compliance measure within the hospital transformation program that is tied to the healthcare affordability and sustainability fee supplemental payment and is based on compliance with subsection (2)(b) of this section.
(II) If the state department determines a hospital's noncompliance with this section is knowing or willful or there is a repeated pattern of noncompliance, the state department shall consider the size of the hospital and the seriousness of the violation in setting a fine amount which, for hospitals owned or affiliated with a hospital system comprised of three or more hospitals, must not exceed twenty thousand dollars per violation per week until the hospital takes corrective action and, for all other hospitals, must not exceed five thousand dollars per week until the hospital takes corrective action.
(3) The hospital transparency report must include, but not be limited to:
(a) A description of the methods of analysis and definitions of report components;
(b) Uncompensated care costs by major payer group; and
er violation per week until the hospital takes corrective action and, for all other hospitals, must not exceed five thousand dollars per week until the hospital takes corrective action.
(3) The hospital transparency report must include, but not be limited to:
(a) A description of the methods of analysis and definitions of report components;
(b) Uncompensated care costs by major payer group; and
(c) The percentage that each of the following categories contributes to overall expenses of hospitals:
(I) Delivery of inpatient health care and services by major payer group;
(II) Delivery of outpatient health care and services by major payer group and site location;
(III) Administrative costs;
(IV) Capital construction costs and associated bond liabilities;
(V) Maintenance;
(VI) Capital expenditures;
(VII) Personnel services;
(VIII) Uncompensated care by major payer group; and
(IX) Other expenditure categories, as determined by the state department.
(4) (a) On or before January 15, 2020, and on or before January 15 each year thereafter, the state department shall submit the annual hospital transparency report to:
(I) The house of representatives health and insurance committee and the house of representatives public and behavioral health and human services committee, or any successor committee;
(II) The health and human services committee of the senate, or any successor committee;
(III) The joint budget committee of the general assembly;
(IV) The governor; and
(V) The state board.
(b) The state department may request that the enterprise board combine the hospital transparency report described in this section with the report of the enterprise board specified in section 25.5-4-402.4 (7)(e), so long as the specific requirements of this section are fulfilled, and so long as the enterprise board agrees to the request. The state department shall post the annual report on its website by January 15 of each year.
(c) Notwithstanding section 24-1-136 (11)(a)(I), the report required in this section continues indefinitely.
(4.5) The state department shall report on the annual hospital transparency report during the state department's "SMART Act" hearing.
(5) The state department, in consultation with the department of public health and environment and the division of insurance, shall review the hospital report card, created pursuant to section 25-3-703, and the hospital charge report, created pursuant to section 25-3-705, and make recommendations to the general assembly by November 1, 2019. The recommendations must identify any structural or substantive changes that should be made to the hospital report card or hospital charge report to increase the value of those reports, including a consideration of whether the hospital report card or hospital charge report still provides value to consumers and policymakers.
C.R.S. § 25.5-4-403 Providers - behavioral health safety net providers - reimbursement
25.5-4-403. Providers - behavioral health safety net providers - reimbursement. (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", 42 U.S.C. sec. 1395x(aa)(4), which have payment methodology pursuant to section 25.5-5-408, the state department shall establish an appropriate cost accounting methodology annually with the behavioral health administration in the department of human services in order to support sustainable access to behavioral health safety net services, as defined in section 27-50-101. In establishing the payment methodology, the state department shall consider:
(a) Actual costs of services, including services to address language and cultural barriers necessary to serve communities of color and other underserved populations;
(b) Costs that are reasonable, as determined by the state department in collaboration with the behavioral health administration in the department of human services;
(c) Quality and accessibility of behavioral health safety net care provided, as determined by the state department, in collaboration with the behavioral health administration in the department of human services, by rule;
(d) Health equity;
(e) Access by priority populations as determined by the behavioral health administration in the department of human services; and
(f) Value-based payment approaches that incentivize providers to expand access to cost-effective behavioral health services to serve the behavioral health safety net.
(2) The standards and processes for determining the payment methodology will be determined by an auditing and accounting committee. The members of the committee are selected by the state department to include behavioral health administrative service organizations, managed care entities, behavioral health safety net providers as defined in section 27-50-101, independent auditors, actuaries, consumer and family advocates, local government representatives, other state agencies, and other relevant stakeholders.
C.R.S. § 25.5-4-403.1 Providers - community mental health centers - cost reporting
25.5-4-403.1. Providers - community mental health centers - cost reporting. (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 community mental health centers;
(b) Establish a cost-reporting template and cost-reporting schedule to assist providers in providing cost reports;
(c) Redact information to maintain compliance with state and federal law including, but not limited to, personally identifying information and protected health information as necessary to protect the privacy of patients;
(d) Create a publicly available website that provides insight to medicaid members, medicaid providers, and members of the public regarding behavioral health reimbursement rates. The website must include the following:
(I) All completed cost reports for each behavioral health safety net provider, as defined in section 27-50-101 (7);
(II) An overview of the purpose of the cost report described in this subsection (1);
(III) Information on how to interpret the cost reports and where to find information in the cost reports;
(IV) An overview of:
(A) How reimbursement rates are determined;
(B) What constitutes a reasonable and allowable cost; and
(C) How value-based payments impact reimbursement rates; and
(V) The state department's plan to improve behavioral health reimbursement rates and annual updates to the plan.
C.R.S. § 25.5-4-403.2 Certified community behavioral health clinic - application - repeal
25.5-4-403.2. Certified community behavioral health clinic - application - repeal. (1) (a) No later than February 1, 2025, the state department, in collaboration with the behavioral health administration in the department of human services, shall:
(I) Submit an application to the federal substance abuse and mental health services administration for a certified community behavioral health clinic demonstration planning grant. The grant application must:
(A) Address the feedback the state department received from the federal substance abuse and mental health services administration after the state department's previous grant application, including how the state will establish a prospective payment system rate for behavioral health services provided by certified community behavioral health clinics in accordance with the federal centers for medicare and medicaid guidance;
(B) Be structured in accordance with the demonstration program established by section 223 of the federal "Protecting Access to Medicare Act of 2014", 42 U.S.C. sec. 1396a; and
(C) Be developed in collaboration with stakeholders, including providers, consumer advocates, county representatives, state agencies, and other interested parties identified by the state department; and
(II) Submit a report to the joint budget committee on the status of the grant application described in subsection (1)(a)(I) of this section.
(b) In developing the grant application, the state department and the behavioral health administration shall conduct a robust stakeholder engagement process with community partners and demonstrate that the demonstration planning grant is in the best interest of the state by ensuring the following items are addressed in the demonstration planning grant:
(I) The requirement to serve priority populations, as defined in section 27-50-101;
(II) The provision of behavioral health safety net services, as defined in section 27-50-101;
(III) The requirement for a certified community behavioral health clinic to serve all populations, regardless of an individual's condition or ability to pay for services, as described in section 27-50-301;
(IV) Peer supports and peer counseling;
(V) The requirement for incorporating meaningful participation from individuals with lived experience of a mental health disorder or substance use disorder and the individual's family members, including youth, in all aspects of the decision-making process;
(VI) Quality and reporting requirements, including ensuring the state is not limited to certified community behavioral health clinic outcome or reporting requirements alone;
(VII) The availability of certified community behavioral health clinic certification for any behavioral health entity that is designated by the behavioral health administration as a comprehensive community behavioral health provider or essential community behavioral health provider and which meets the federal requirements;
(VIII) A lack of geographic limitation on the number of certified community behavioral health clinics in a region;
(IX) Assurance that certified community behavioral health clinic crisis services are delivered within the parameter of Colorado's statewide crisis response system, that any crisis services delivered by the certified community behavioral health clinic are aligned with the services provided through the statewide crisis response system, and that services do not duplicate or impede services provided through the statewide crisis response system;
(X) No negative impact on rural access, as well as ensuring certified community behavioral health clinics will not reduce other agencies' ability to provide behavioral health safety net services in the state; and
(XI) That the state department has the ability to implement financial accountability standards for providers.
e or impede services provided through the statewide crisis response system;
(X) No negative impact on rural access, as well as ensuring certified community behavioral health clinics will not reduce other agencies' ability to provide behavioral health safety net services in the state; and
(XI) That the state department has the ability to implement financial accountability standards for providers.
(c) The state department and behavioral health administration shall work with the joint budget committee to determine how to proceed with the grant if, during the grant application process, there are substantial changes to federal funding that would negatively affect the state of Colorado.
(2) If the state department is awarded the certified community behavioral health clinic demonstration planning grant after applying pursuant to this section, the state department shall comply with all necessary guidelines established by the federal substance abuse and mental health services administration for a certified community behavioral health clinic grant awardee.
(3) This section is repealed, effective January 1, 2026.
C.R.S. § 25.5-4-404 Payments for clinic services - restrictions on use
25.5-4-404. Payments for clinic services - restrictions on use. 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 agencies or boards of health or to cash fund health-care services in the county where the services were provided.
C.R.S. § 25.5-4-405 Mental health managed care service providers - requirements
25.5-4-405. Mental health managed care service providers - requirements. (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 multiple needs who requires mental health services has access to mental health professionals with appropriate training and credentials and providing the member with the services in collaboration with the member's other providers;
(b) Informing each member of the member's right to and the process for appeal upon notification of denial, termination, or reduction of a requested service; and
(c) Administering initial stabilization treatment for a member and transferring the member for appropriate continued services.
(1.5) Each contract between the state department and a managed care organization providing mental health services to a member under the medical assistance program must allow for the use of telemedicine pursuant to section 25.5-5-320.
(2) For mental health managed care members, the state department shall have a patient representative program for member grievances that complies with all federal requirements and that must:
(a) Be posted in a conspicuous place at each location at which mental health services are provided;
(b) Allow for a patient representative to serve as a liaison between the member and the provider;
(c) Describe the qualifications for a patient representative;
(d) Outline the responsibilities of a patient representative;
(e) Describe the authority of a patient representative; and
(f) Establish a method by which each member is informed of the patient representative program and how a patient representative may be contacted.
C.R.S. § 25.5-4-406 Rate setting - medicaid residential treatment service providers - monitoring and auditing - report
25.5-4-406. Rate setting - medicaid residential treatment service providers - monitoring and auditing - report. (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 this section may include, but shall not be limited to:
(a) A range for reimbursement that represents a base-treatment rate for serving a child who is subject to out-of-home placement due to dependency and neglect, a child placed in a residential child care facility pursuant to the "Children and Youth Mental Health Treatment Act", article 67 of title 27, or a child who has been adjudicated a delinquent, which includes a defined service package to meet the needs of the child;
(b) A request for proposal to contract for specialized service needs of a child, including but not limited to: Substance-abuse treatment services; sex offender services; and services for the developmentally disabled; and
(c) Negotiated incentives for achieving outcomes for the child as defined by the state department, counties, and providers.
(2) The medicaid rate-setting process approved by the state department shall include a two- or three-year implementation timeline with implementation beginning in state fiscal year 2008-09.
(3) The state department and the department of human services, in consultation with the representatives of the counties and the provider community, shall review the rate-setting process every two years and shall submit any changes to the joint budget committee of the general assembly.
C.R.S. § 25.5-4-407 Services by licensed psychologists without a doctor's referral
25.5-4-407. Services by licensed psychologists without a doctor's referral. 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 program specified under section 25.5-4-408. The executive director may except from the authorization those services the director determines to be necessary for the purpose of promoting the primary care physician program.
C.R.S. § 25.5-4-408 Services provided by licensed psychologists - cost containment program
25.5-4-408. Services provided by licensed psychologists - cost containment program. (1) Working in conjunction with licensed psychologists in the state, the state board shall promulgate rules to establish and implement mechanisms for containing the costs of services provided by licensed psychologists under the medical assistance programs established pursuant to this article and articles 5 and 6 of this title. The cost containment mechanism shall ensure that the costs to the medical assistance program will result in no increase in the total cost of the program solely as a result of the reimbursement for services of licensed psychologists pursuant to section 25.5-4-407. The cost containment mechanisms may include the following:
(a) Limiting the number of days a licensed psychologist may be reimbursed per patient for inpatient hospitalization, partial hospitalization, and outpatient visits without an order for continued treatment from a doctor of medicine or osteopathy;
(b) Limiting the number of hours a licensed psychologist may be reimbursed for diagnostic testing and evaluation per patient per year;
(c) Provision of group therapy when needed or appropriate;
(d) Provision of licensed psychologists' services from a pool of those licensed psychologists requesting to be included in such pool;
(e) Provision of a licensed psychologist's services through the use of telemedicine pursuant to the provisions of section 25.5-5-320.
C.R.S. § 25.5-4-409 Authorization of services - nurse anesthetists - advanced practice registered nurses
25.5-4-409. Authorization of services - nurse anesthetists - advanced practice registered nurses. (1) When services by a certified registered nurse anesthetist are provided pursuant to an order by a physician in accordance with this article 4, articles 5 and 6 of this title 25.5, and section 12-255-104 (10), the executive director of the state department shall authorize reimbursement for said services. Payment for such services shall be made directly to the nurse anesthetist, if requested by the nurse anesthetist; except that this section shall not apply to nurse anesthetists when acting within the scope of their employment as salaried employees of public or private institutions or physicians.
(2) When services by an advanced practice registered nurse registered pursuant to section 12-255-111 are provided in accordance with this article 4 and articles 5 and 6 of this title 25.5, the executive director of the state department shall authorize reimbursement for said services. Payment for the services shall be made directly to the advanced practice registered nurse, if requested by the advanced practice registered nurse; except that this section shall not apply to advanced practice registered nurses when acting within the scope of their employment as salaried employees of public or private institutions or physicians.
C.R.S. § 25.5-4-410 Services of audiologists and speech pathologists without supervision
25.5-4-410. Services of audiologists and speech pathologists without supervision. (1) When medical or diagnostic services by an audiologist or speech pathologist are provided pursuant to an order by a physician in accordance with this article and articles 5 and 6 of this title, the executive director of the state department shall authorize reimbursement for said services. For the purposes of this section, "audiologist" or "speech pathologist" means an individual who meets the requirements set forth in the federal "Social Security Act", as amended, or any federal regulations adopted pursuant thereto, for participating providers of audiology or speech pathology services.
(2) Nothing in this section shall be construed as expanding the provision of services available as a part of the medical assistance program established pursuant to this article and articles 5 and 6 of this title. For the purposes of making payments to audiologists or speech pathologists pursuant to this section, the state board shall establish rules implementing this section. The rules promulgated pursuant to this subsection (2) shall ensure that the costs to the medical assistance program will result in no increase in the total cost of the program solely as a result of the reimbursement for services of an audiologist or speech pathologist pursuant to this section.
(3) Payments for services included in this section shall be made directly to the audiologist or speech pathologist, if requested by the audiologist or speech pathologist; except that this section shall not apply to audiologists or speech pathologists when acting within the scope of their employment as salaried employees of public or private institutions or physicians.
C.R.S. § 25.5-4-411 Authorization of services provided by dental hygienists
25.5-4-411. Authorization of services provided by dental hygienists. (1) When dental hygiene services are provided to children by a licensed dental hygienist or dental therapist who is providing dental hygiene services pursuant to section 12-220-503 without the supervision of a licensed dentist, the executive director of the state department shall authorize reimbursement for said services, subject to the requirements of this section. Payment for the services shall be made directly to the licensed dental hygienist or dental therapist, if requested by the licensed dental hygienist or dental therapist; except that this section does not apply to licensed dental hygienists or dental therapists when acting within the scope of their employment as salaried employees of public or private institutions, physicians, or dentists.
(2) For each child provided dental hygiene services pursuant to this section, the dental hygienist or dental therapist shall attempt to identify a dentist participating in medicaid for the child.
C.R.S. § 25.5-4-412 Family planning services - family-planning-related services - rules - definitions
25.5-4-412. Family planning services - family-planning-related services - rules - definitions. (1) When family planning services or family-planning-related services are provided in accordance with this article 4 and articles 5 and 6 of this title 25.5, the executive director of the state department shall authorize reimbursement for the services, subject to section 50 of article V of the state constitution. The state department, any intermediary, or any managed care organization shall reimburse the provider of those services. Family planning services and family-planning-related services are not subject to policy deductibles, copayments, or coinsurance.
(2) As used in this section, unless the context otherwise requires:
(a) "Family-planning-related services" means services provided in a family planning setting as part of or as a follow-up to a family planning visit, including:
(I) Medically necessary evaluations or preventive services, such as tobacco utilization screening, counseling, testing, and cessation services;
(II) Cervical cancer screening and prevention;
(III) Diagnosis or treatment of a sexually transmitted infection or sexually transmitted disease, and medication and supplies to prevent a sexually transmitted infection or sexually transmitted disease; and
(IV) Any other medical diagnosis, treatment, or preventive service that is routinely provided pursuant to a family planning visit.
(b) "Family planning services" means all services covered by the federal Title X family planning program, regardless of an individual's age, sex, or gender identity, or the age, sex, or gender identity of the individual's partner, including but not limited to:
(I) All contraception, as defined in section 2-4-401 (1.5);
(II) Health-care and counseling services focused on preventing, delaying, or planning for a pregnancy;
(III) Follow-up visits to evaluate or manage problems associated with contraceptive methods;
(IV) Sterilization services, regardless of an individual's sex; and
(V) Basic fertility services.
(3) (Deleted by amendment, L. 2021.)
(4) For purposes of making payments to providers, the state board shall establish rules implementing this section.
(5) Any member may obtain family planning services or family-planning-related services from any licensed health-care provider, including a doctor of medicine, doctor of osteopathy, physician assistant, advanced practice registered nurse, or certified midwife who provides such services. The enrollment of a member in a managed care organization, or a similar entity, does not restrict a member's choice of the licensed provider from whom the member may receive those services.
(6) The state board shall promulgate rules establishing the specific family-planning-related services and family planning services identified in subsections (2)(a) and (2)(b) of this section. Prior to promulgating the rules, the state department shall engage in a stakeholder process that attempts to include individuals who have received family planning services through the state's medical assistance program or the children's basic health plan, representatives of consumer advocacy organizations, and family planning providers. The stakeholders must be diverse with regard to race, ethnicity, immigration status, age, ability, sexual orientation, gender identity, or geographic region of the state.
C.R.S. § 25.5-4-413 Certain providers to inform patients of rights concerning advance medical directives
25.5-4-413. Certain providers to inform patients of rights concerning advance medical directives. (1) On and after November 5, 1991, with regard to any service rendered on and after said date, each hospital, nursing care facility, home health agency, hospice program, and health maintenance organization participating in the state medical assistance program or providing medical assistance pursuant to parts 3 to 12 of article 6 of this title shall provide written information to all adult patients of such providers concerning patients' rights under state law to make medical treatment decisions, including the right to accept or refuse any medical or surgical treatment and the right to formulate advance directives regarding said decisions. As used in this section, "advance directives" includes any written or oral instructions recognized under state law concerning the making of medical treatment decisions on behalf of or the provision of medical care for the person who provided the instructions in the event such person becomes incapacitated. Advance directives include, but are not limited to, medical durable powers of attorney, durable powers of attorney, or living wills.
(2) Providers listed in subsection (1) of this section shall provide educational programs for staff and the community concerning advance directives and shall maintain written policies detailing methods for safeguarding patients' rights concerning medical treatment decisions, including documenting in the patient's medical or patient record whether the patient has executed, amended, or revoked an advance directive. No provider shall condition the provision of services or otherwise discriminate against a patient on the basis of whether the patient has executed an advance directive.
C.R.S. § 25.5-4-414 Providers - physicians - prohibition of certain referrals - definitions
25.5-4-414. Providers - physicians - prohibition of certain referrals - definitions. (1) As used in this section, unless the context otherwise requires:
(a) "Designated health services" means any of the following services:
(I) Clinical laboratory services;
(II) Physical therapy services;
(III) Occupational therapy services;
(IV) Radiology and other diagnostic services;
(V) Radiation therapy services;
(VI) Durable medical equipment;
(VII) Parenteral or enteral nutrients, equipment, and supplies;
(VIII) Prosthetics, orthotics, and prosthetic devices;
(IX) Home health services;
(X) Outpatient prescription drugs; and
(XI) Inpatient and outpatient hospital services.
(b) "Financial relationship" means an ownership or investment interest in an entity furnishing designated health services or a compensation arrangement between a provider or an immediate family member of the provider and the entity. An ownership or investment interest may be reflected in equity, debt, or other instruments.
(c) "Immediate family member of the provider" means any spouse, natural or adoptive parent, natural or adoptive child, stepparent, stepchild, stepbrother, stepsister, in-law, grandparent, or grandchild of the provider.
(d) "Provider" means:
(I) A doctor of medicine or osteopathy who is licensed to practice medicine pursuant to article 240 of title 12;
(II) A doctor of dental surgery or of dental medicine who is licensed to practice dentistry pursuant to article 220 of title 12;
(III) A doctor of podiatric medicine who is licensed to practice podiatry pursuant to article 290 of title 12;
(IV) A doctor of optometry who is licensed to practice optometry pursuant to article 275 of title 12; or
(V) A chiropractor who is licensed to practice chiropractic pursuant to article 215 of title 12.
(2) (a) Except as otherwise provided in this subsection (2), a provider participating in the medical assistance program under this article and articles 5 and 6 of this title is prohibited from making a referral to an entity for designated health services for which payment may be made under the state's medical assistance program if the provider or an immediate family member of the provider has a financial relationship with the entity.
(b) Paragraph (a) of this subsection (2) shall not apply to any financial relationship that meets the requirements of an exception to the prohibitions established by 42 U.S.C. sec. 1395nn, as amended, or any regulations promulgated thereunder, as amended.
(c) Paragraph (a) of this subsection (2) shall not apply to a financial relationship or referral for designated health services if the financial relationship or referral for designated health services would not violate 42 U.S.C. sec. 1395nn, as amended, and any regulations promulgated thereunder, as amended, if the designated health services were eligible for payment under medicare rather than the "Colorado Medical Assistance Act".
(3) An entity that provides designated health services as a result of a prohibited referral shall not present a claim or bill to any individual, any third-party payor, the state department, or any other entity for the designated health services.
(4) An entity that provides designated health services shall provide to the state department, upon its request and in the form specified by the state department, information concerning the entity's ownership arrangements including:
(a) The items and services provided by the entity;
(b) The names and provider identification numbers of all providers with a financial interest in the entity or whose immediate family members have a financial interest in the entity.
(5) If a provider refers a patient for designated health services in violation of paragraph (a) of subsection (2) of this section or the entity refuses to provide the information required in subsection (4) of this section, the state department may:
(a) Deny any claims for payment from the provider or entity;
in the entity or whose immediate family members have a financial interest in the entity.
(5) If a provider refers a patient for designated health services in violation of paragraph (a) of subsection (2) of this section or the entity refuses to provide the information required in subsection (4) of this section, the state department may:
(a) Deny any claims for payment from the provider or entity;
(b) Require the provider or entity to refund payments for services;
(c) Refer the matter to the appropriate agency for medical assistance fraud investigation; or
(d) Terminate the provider's or entity's participation in the medical assistance program.
C.R.S. § 25.5-4-415 No public funds for abortion - exception - definitions - repeal
25.5-4-415. No public funds for abortion - exception - definitions - repeal. (1) It is the purpose of this section to implement the provisions of section 50 of article V of the Colorado constitution, adopted by the registered electors of the state of Colorado at the general election November 6, 1984, which prohibits the use of public funds by the state of Colorado or its agencies or political subdivisions to pay or otherwise reimburse, directly or indirectly, any person, agency, or facility for any induced abortion.
(2) If every reasonable effort has been made to preserve the lives of a pregnant woman and her unborn child, then public funds may be used pursuant to this section to pay or reimburse for necessary medical services, not otherwise provided for by law.
(3) (a) Any medically necessary services performed pursuant to this section shall be performed only by a provider who is licensed by the state and acting within the scope of the provider's license and in accordance with applicable federal regulations.
(b) (Deleted by amendment, L. 2021.)
(4) (a) Any physician who renders necessary medical services pursuant to subsection (2) of this section shall report the following information to the state department:
(I) The age of the pregnant woman and the gestational age of the unborn child at the time the necessary medical services were performed;
(II) The necessary medical services which were performed;
(III) The medical condition which necessitated the performance of necessary medical services;
(IV) The date such necessary medical services were performed and the name of the facility in which such services were performed.
(b) The information required to be reported pursuant to paragraph (a) of this subsection (4) shall be compiled by the state department and such compilation shall be an ongoing public record; except that the privacy of the pregnant woman and the attending physician shall be preserved.
(5) For purposes of this section, pregnancy is a medically diagnosable condition.
(6) For the purposes of this section:
(a) (I) "Death" means:
(A) The irreversible cessation of circulatory and respiratory functions; or
(B) The irreversible cessation of all functions of the entire brain, including the brain stem.
(II) A determination of death under this section shall be in accordance with accepted medical standards.
(b) "Life-endangering circumstance" means:
(I) The presence of a medical condition, other than a psychiatric condition, as determined by the attending physician, which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term;
(II) The presence of a lethal medical condition in the unborn child, as determined by the attending physician and one other physician, which would result in the impending death of the unborn child during the term of pregnancy or at birth; or
(III) The presence of a psychiatric condition which represents a serious and substantial threat to the life of the pregnant woman if the pregnancy continues to term. In such case, unless the pregnant woman has been receiving prolonged psychiatric care, the attending licensed physician shall obtain consultation from a licensed physician specializing in psychiatry confirming the presence of such a psychiatric condition. The attending physician shall report the findings of such consultation to the state department.
egnant woman if the pregnancy continues to term. In such case, unless the pregnant woman has been receiving prolonged psychiatric care, the attending licensed physician shall obtain consultation from a licensed physician specializing in psychiatry confirming the presence of such a psychiatric condition. The attending physician shall report the findings of such consultation to the state department.
(c) "Necessary medical services" means any medical procedures deemed necessary to prevent the death of a pregnant woman or her unborn child due to life-endangering circumstances.
(7) If any provision of this section or application thereof is held invalid, such invalidity shall not affect other provisions or applications of this section which can be given effect without the invalid provision or application, and to this end the provisions of this section are declared severable.
(8) Use of the term "unborn child" in this section is solely for the purposes of facilitating the implementation of section 50 of article V of the state constitution, and its use shall not affect any other law or statute nor shall it create any presumptions relating to the legal status of an unborn child or create or affect any distinction between the legal status of an unborn child and the legal status of a fetus.
(9) This section shall be repealed if section 50 of article V of the Colorado constitution is repealed.
C.R.S. § 25.5-4-416 Providers - medical equipment and supplies - requirements
25.5-4-416. Providers - medical equipment and supplies - requirements. (1) As used in this section, unless the context otherwise requires, "provider" means a person or entity that delivers disposable medical supplies or durable medical equipment products or services directly to a member.
(2) On and after January 1, 2007, the state board rules for the payment for disposable medical supplies and durable medical equipment, including but not limited to prosthetic and orthotic devices, shall prohibit a provider from being reimbursed unless the provider:
(a) (I) Has one or more physical locations within the state of Colorado or within fifty miles of a border of Colorado with a street address, a local business telephone number, an inventory, and a sufficient staff to service or repair products; except that the requirements of this paragraph (a) shall not apply to durable medical equipment or disposable medical supplies that are medically necessary and cannot be purchased from a provider meeting the requirements of this paragraph (a);
(II) Complies with all state and local licensing, insurance, and regulatory requirements for operating the provider's business;
(III) Is responsible for the delivery of and instructing the member on the proper use of the equipment; and
(IV) Provides repairs, replacements, or adjustments to the provider's products pursuant to rules of the state board; or
(b) Contracts with a provider who meets the criteria established in paragraph (a) of this subsection (2).
(3) The provisions of this section shall apply to fee-for-service and primary care physician program recipients.
C.R.S. § 25.5-4-417 Provider fee - medicaid providers - state plan amendment - rules - definitions
25.5-4-417. Provider fee - medicaid providers - state plan amendment - rules - definitions. (1) For purposes of this section, unless the context otherwise requires:
(a) "Local government" means a county, home rule county, home rule or statutory city, town, territorial charter city, or city and county.
(b) "Provider fee" means a licensing fee, assessment, or other mandatory payment that is related to health-care items or services as specified under 42 CFR 433.55.
(c) "Qualified provider" means a hospital licensed pursuant to section 25-3-101, C.R.S., or a certified home health-care agency within the territorial boundaries of the local government.
(2) For the purpose of sustaining or increasing reimbursement for providing medical care under the state's medical assistance program and to low-income populations, the state department shall amend the state plan effective July 1, 2006. Implementation of the state plan amendment shall be subject to the approval of the federal government. The imposition and collection of a provider fee by a local government pursuant to article 28 of title 29, C.R.S., shall be prohibited without the federal government's approval of a state plan amendment authorizing federal financial participation for the provider fees.
(3) In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1) and (e)(2), the state department may seek a waiver from the broad-based provider fee requirement or the uniform provider fee requirement, or both, to exclude qualified providers from the provider fee.
(4) To the extent authorized by federal law, the state department may exclude a governmental qualified provider from payment of the provider fee, benefits from the provider fee, or any federal financial participation due to the fee.
(5) [Editor's note: This version of subsection (5) is effective until July 1, 2025.] To the extent authorized by federal law, the state department shall distribute the provider fee and any associated federal financial participation either to a local government that has certified payment to qualified providers within the local government or directly to the qualified providers. The state department shall establish reimbursement methods to distribute the provider fee and associated federal financial participation to qualified providers. The state department may alter reimbursement methods to qualified providers participating under the state's medical assistance program and Colorado indigent care program to the extent necessary to meet the federal requirements and to obtain federal approval of the provider fee. The state department shall work with a statewide association of hospitals on changes to reimbursement methods or provider fees that impact hospital providers. The state department shall work with a statewide association of home health-care agencies on changes to reimbursement methods or provider fees that impact home health-care agencies.
rements and to obtain federal approval of the provider fee. The state department shall work with a statewide association of hospitals on changes to reimbursement methods or provider fees that impact hospital providers. The state department shall work with a statewide association of home health-care agencies on changes to reimbursement methods or provider fees that impact home health-care agencies.
(5) [Editor's note: This version of subsection (5) is effective July 1, 2025.] To the extent authorized by federal law, the state department shall distribute the provider fee and any associated federal financial participation either to a local government that has certified payment to qualified providers within the local government or directly to the qualified providers. The state department shall establish reimbursement methods to distribute the provider fee and associated federal financial participation to qualified providers. The state department may alter reimbursement methods to qualified providers participating under the state's medical assistance program to the extent necessary to meet the federal requirements and to obtain federal approval of the provider fee. The state department shall work with a statewide association of hospitals on changes to reimbursement methods or provider fees that impact hospital providers. The state department shall work with a statewide association of home health-care agencies on changes to reimbursement methods or provider fees that impact home health-care agencies.
(6) The state board shall adopt any rules necessary for the administration and implementation of this section.
C.R.S. § 25.5-4-418 Integration of physical and behavioral health services - department review - report - repeal
25.5-4-418. Integration of physical and behavioral health services - department review - report - repeal. (Repealed)
C.R.S. § 25.5-4-419 Supplemental state payment to qualified providers - office-administered drugs - no federal financial participation - definition - rules - repeal
25.5-4-419. Supplemental state payment to qualified providers - office-administered drugs - no federal financial participation - definition - rules - repeal. (Repealed)
C.R.S. § 25.5-4-420 Providers to obtain unique NPI - service site - provider type - definitions
25.5-4-420. Providers to obtain unique NPI - service site - provider type - definitions. (1) As used in this section:
(a) "Health care clearinghouse" has the same meaning as set forth in 45 CFR 160.103.
(b) "NPI" or "national provider identifier" means the standard, unique health identifier for health-care providers that is issued by the national provider system in accordance with 45 CFR part 162.
(c) "Off-campus location" means a facility:
(I) Whose operations are directly or indirectly owned or controlled by, in whole or in part, or affiliated with a hospital, regardless of whether the operations are under the same governing body as the hospital;
(II) That is located more than two hundred fifty yards from the hospital's main campus;
(III) That provides services that are organizationally and functionally integrated with the hospital; and
(IV) That is an outpatient facility providing preventive, diagnostic, treatment, or emergency services.
(d) "Organization health-care provider" means a provider that is not an individual and includes a hospital.
(e) "Subpart" has the same meaning as that term is used in 45 CFR part 162 and means a component or separate physical location of an organization health-care provider that may be separately licensed or certified by the state.
(2) (a) Each organization health-care provider and each subpart that is required or eligible to obtain an NPI pursuant to 45 CFR 162.410 must apply for, obtain, and use, on all claims for payment for medical care, services, or goods authorized under this article 4 and articles 5 and 6 of this title 25.5, a unique NPI for each site at which the organization health-care provider or its subparts deliver medical care, services, or goods.
(b) Each organization health-care provider and each subpart that is required or eligible to obtain an NPI pursuant to 45 CFR 162.410 must apply for, obtain, and use, on all claims for payment for medical care, services, or goods authorized under this article 4 and articles 5 and 6 of this title 25.5, a unique NPI for each provider type, as specified by the state department, under which the organization health-care provider or its subparts deliver medical care, services, or goods.
(c) An organization health-care provider or subpart submitting a claim for payment for medical care, services, or goods rendered under this article 4 or article 5 or 6 of this title 25.5 shall include on the claim the unique NPI that identifies both the site where the medical care, services, or goods were provided and the provider type, as specified by the state department, regardless of whether the claim is filed or submitted by or through a central office of the organization health-care provider or a health care clearinghouse.
(3) (a) For an organization health-care provider that is a licensed or certified hospital contracting for services under this article 4 and articles 5 and 6 of this title 25.5, the hospital shall obtain and use a unique, separate, and distinct NPI for:
(I) Its main campus;
(II) Each off-campus location of the hospital; and
(III) Each provider type, if specified by the state department, when the hospital delivers medical care, services, or goods at either the hospital's main campus or at an off-campus location.
er this article 4 and articles 5 and 6 of this title 25.5, the hospital shall obtain and use a unique, separate, and distinct NPI for:
(I) Its main campus;
(II) Each off-campus location of the hospital; and
(III) Each provider type, if specified by the state department, when the hospital delivers medical care, services, or goods at either the hospital's main campus or at an off-campus location.
(b) A hospital submitting a claim for payment for medical care, services, or goods rendered under this article 4 or article 5 or 6 of this title 25.5 shall include on the claim the unique NPI that identifies both the site where the medical care, services, or goods were provided and the provider type, as specified by the state department, regardless of whether the claim is filed or submitted by or through a central office of the hospital or a health care clearinghouse.
(4) (a) Starting January 1, 2020, an organization health-care provider applying to enroll as a new provider under this article 4 and articles 5 and 6 of this title 25.5 shall demonstrate that it has obtained one or more NPIs as required by this section, and upon enrollment, shall use its unique NPI on every claim for payment in the manner required by this section.
(b) Starting January 1, 2021, an organization health-care provider enrolled and applying for revalidation as a provider under this article 4 and articles 5 and 6 of this title 25.5 shall demonstrate that it has obtained one or more NPIs as required by this section as a condition of receiving revalidation, and upon receiving revalidation as a provider, shall use its unique NPI on every claim for payment in the manner required by this section.
C.R.S. § 25.5-4-421 Supplemental state payment to qualified durable medical equipment providers - no federal financial participation - definition - rules - repeal
25.5-4-421. Supplemental state payment to qualified durable medical equipment providers - no federal financial participation - definition - rules - repeal. (Repealed)
C.R.S. § 25.5-4-422 Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules
25.5-4-422. Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules. (1) It is the intent of the general assembly that:
(a) The department of health care policy and financing pursue strategies to control costs in the medicaid program authorized in the "Colorado Medical Assistance Act";
(b) The state department dedicate permanent staff and resources to pursue cost-control strategies, value-based payments, and other approaches to reduce the rate of expenditure growth in the medicaid program; and
(c) This section not preclude the state department from pursuing other cost-containment activities that are not specifically described in this section.
(2) (a) The state department shall provide information regarding medicaid expenditures and the quality of medical services provided by providers participating in the medicaid program to providers participating in the accountable care collaborative pursuant to section 25.5-5-419.
(b) The state department shall provide information regarding medicaid expenditures and the quality of available pharmaceuticals prescribed by providers participating in the medicaid program to providers participating in the accountable care collaborative pursuant to section 25.5-5-419.
(c) The state department may provide the information described in subsections (2)(a) and (2)(b) of this section to other providers participating in the medicaid program.
(3) (a) The state department shall utilize the medicaid management information system to ensure that claims are automatically reviewed prior to payment to identify and correct improper coding that leads to inappropriate payment in medicaid claims.
(b) The state department may procure commercial technology to implement the requirements of subsection (3)(a) of this section.
(4) (a) The state department shall pursue cost-control strategies, value-based payments, and other approaches to reduce the rate of expenditure growth in the medicaid program.
(b) Prior to implementing and reporting on any new measures authorized by this section, the state department shall provide an opportunity for affected members, providers, and stakeholders to provide feedback and make recommendations on the state department's proposed implementation.
(5) By November 1, 2018, the state department shall provide a report to the joint budget committee concerning:
(a) The feedback received pursuant to subsection (4)(b) of this section; and
(b) The timelines for implementation of any cost-control measures enacted pursuant to this section.
(c) Repealed.
(6) (a) The state department shall contract with a third party to perform an independent evaluation of the cost-control measures authorized pursuant to this section.
(b) Repealed.
(7) The state board shall adopt any rules necessary for the administration and implementation of this section.
C.R.S. § 25.5-4-423 Targets for investments in primary care
25.5-4-423. Targets for investments in primary care. The state department shall adopt appropriate targets for investments in primary care to support value-based health-care delivery in alignment with the affordability standards developed in accordance with section 10-16-107 (3.5). The state department shall consider the recommendations of the primary care payment reform collaborative created in section 10-16-150. Targets established under this section do not apply in the case of a nonprofit, nongovernmental health maintenance organization with respect to managed care plans that provide a majority of covered professional services through a single contracted medical group.
C.R.S. § 25.5-4-424 State payments to qualified hospice providers - dually eligible persons - no federal financial participation - rules - legislative declaration - definitions - repeal
25.5-4-424. State payments to qualified hospice providers - dually eligible persons - no federal financial participation - rules - legislative declaration - definitions - repeal. (Repealed)
C.R.S. § 25.5-4-425 Providers - health-care services related to labor and delivery - reimbursement
25.5-4-425. Providers - health-care services related to labor and delivery - reimbursement. (1) The state department shall reimburse all eligible providers that provide health-care services related to labor and delivery within the scope of the provider's practice in a manner that:
(a) Promotes high-quality, cost-effective, and evidence-based care;
(b) Promotes high-value, evidence-based payment models; and
(c) Prevents risk in subsequent pregnancies.
C.R.S. § 25.5-4-426 Supplemental state payment to urban Indian organizations - definition - repeal
25.5-4-426. Supplemental state payment to urban Indian organizations - definition - repeal. (Repealed)
C.R.S. § 25.5-4-427 State payment to the Denver health and hospital authority
25.5-4-427. State payment to the Denver health and hospital authority. (1) The state department shall distribute money appropriated for a payment to the Denver health and hospital authority created in section 25-29-103.
(2) (Deleted by amendment, L. 2024.)
C.R.S. § 25.5-4-428 Prior authorization for a step-therapy exception - rules - definition
25.5-4-428. Prior authorization for a step-therapy exception - rules - definition. (1) As used in this section, unless the context otherwise requires, "step therapy" means a protocol that requires a member to use a prescription drug or sequence of prescription drugs, other than the drug that the member's health-care provider recommends for the member's treatment, before the state department provides coverage for the recommended prescription drug.
(2) (a) The state department shall review and determine if an exception to step therapy is granted if the prescribing provider submits a prior authorization request with justification and supporting clinical documentation for treatment of a serious or complex medical condition, if required, that states:
(I) The provider attests that the required prescription drug is contraindicated, or will likely cause intolerable side effects, a significant drug-drug interaction, or an allergic reaction to the member;
(II) The required prescription drug lacks efficacy based on the known clinical characteristics of the member and the known characteristics of the prescription drug regimen;
(III) The member has tried the required prescription drug, and the use of the prescription drug by the member was discontinued due to intolerable side effects, a significant drug-drug interaction, or an allergic reaction; or
(IV) The member is stable on a prescription drug selected by the prescribing provider for the medical condition.
(b) (I) Except as provided in subsection (2)(b)(II) of this section, the state department shall provide a response to a prior authorization request for a step-therapy exception within twenty-four hours after receipt of the request.
(II) If a prior authorization request for a step-therapy exception is incomplete or if additional clinically relevant information is required, the state department shall notify the prescribing provider within twenty-four hours after the submission of the request that the request is incomplete or that additional clinically relevant information is required. The state department shall specify the additional information that is required in order to consider the prior authorization request. If the state department does not receive a response within seventy-two hours after the state department's request for additional information, the prior authorization request is denied. If the state department receives a timely response from the provider, the state department shall provide a response within twenty-four hours after receiving the response.
(c) If the prior authorization request for a step-therapy exception is denied, the state department shall inform the member in writing that the member has the right to appeal the adverse determination pursuant to state department rules.
(3) If the prior authorization request for a step-therapy exception request is granted, the state department shall authorize coverage for the prescription drug prescribed by the member's prescribing provider.
(4) The state department shall make the prior authorization requirements for coverage of prescription drugs and a description of the step-therapy exemption process available on the state department's website.
(5) This section does not prohibit:
(a) The state department from requiring a member to try a generic equivalent of a brand name drug, a biosimilar drug as defined in 42 U.S.C. sec. 262 (i)(2), or an interchangeable biological product as defined in 42 U.S.C. sec. 262 (i)(3), unless such a requirement meets any of the criteria set forth in subsection (2)(a) of this section for an exception to step therapy and a prior authorization request is granted for the requested drug;
a member to try a generic equivalent of a brand name drug, a biosimilar drug as defined in 42 U.S.C. sec. 262 (i)(2), or an interchangeable biological product as defined in 42 U.S.C. sec. 262 (i)(3), unless such a requirement meets any of the criteria set forth in subsection (2)(a) of this section for an exception to step therapy and a prior authorization request is granted for the requested drug;
(b) The state department from denying a prior authorization request for a step-therapy exception when the request does not meet one of the criteria set forth in subsection (2)(a) of this section based on the justification and supporting clinical documentation submitted by the provider, if applicable; or
(c) A provider from prescribing a drug that, in the provider's clinical judgment, is determined to be medically appropriate.
(6) The state board may promulgate rules to implement this section.
C.R.S. § 25.5-4-429 Hospital and provider billing requirements - description of service provided - rules
25.5-4-429. Hospital and provider billing requirements - description of service provided - rules. Beginning July 1, 2024, any patient bill for services rendered must follow industry standard billing practices, including, at a minimum, the date of service, the patient's name, the provider's name, a description of the services provided, and the charges for each service.
C.R.S. § 25.5-4-430 Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates
25.5-4-430. Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates. (1) (a) The state department shall analyze how directed payment authority can be used as part of a comprehensive plan to facilitate an adequate network of services for children and youth with behavioral health needs who are under twenty-one years of age and receive medicaid benefits by requiring each managed care entity to pay no less than state department-established fee schedule rates to increase access to care for services needed to promote clinical stabilization. The state department shall analyze how directed payment authority may be applied to clinical stabilization services, including, but not limited to, residential treatment services, multisystemic therapy, functional family therapy, and psychotherapy services for children and youth.
(b) In analyzing directed payment authority and establishing fee schedule rates, the state department shall consider whether the rates should increase based on the acuity of the child or youth.
(2) No later than October 1, 2023, the state department shall report to the house of representatives public and behavioral health and human services committee and the senate health and human services committee, or their successor committees, and the joint budget committee whether directed payment authority should be pursued and whether funding should be requested to expand access to residential treatment services, multisystemic therapy, functional family therapy, and psychotherapy services. If the state department determines that directed payments are not appropriate to expand access to such services, the state department shall present an alternative plan to expanding access to the services.
C.R.S. § 25.5-4-431 Preauthorization for treatment - request to share with insurance carrier
25.5-4-431. Preauthorization for treatment - request to share with insurance carrier. [Editor's note: This section is effective January 1, 2025.] Subject to state and federal laws relating to the confidentiality of medical records, at the request and with the consent of an enrollee in the medical assistance program, the state department shall provide a copy of the enrollee's preauthorization for treatment to the enrollee's new insurance carrier within ten days after receipt of the request if the enrollee is no longer enrolled in the medical assistance program.
C.R.S. § 25.5-4-432 Reimbursement guidance for screening, brief intervention, and referral to treatment
25.5-4-432. Reimbursement guidance for screening, brief intervention, and referral to treatment. The state department shall publish guidance for providers concerning reimbursement for all variations of screening, brief intervention, and referral to treatment interventions.
C.R.S. § 25.5-4-433 Rural hospital cash fund - creation - definition
25.5-4-433. Rural hospital cash fund - creation - definition. (1) The rural hospital cash fund is created in the state treasury and is referred to in this section as the "fund". The fund consists of money credited to the fund and any other money that the general assembly may appropriate or transfer to the fund.
(2) The state treasurer shall credit all interest and income derived from the deposit and investment of money in the fund to the fund.
(3) Money in the fund is continuously appropriated to the department of health care policy and financing for the purpose of distributing money in equal amounts to rural hospitals.
(4) On July 1, 2024, the state treasurer shall transfer one million seven hundred forty-two thousand twenty-nine dollars from the general fund to the fund.
(5) As used in this section, "rural hospital" means a hospital licensed or certified pursuant to section 25-1.5-103 (1)(a) or an affiliate owned or controlled, as defined in section 25.5-4-402.8 (1)(c), by a hospital, and that is located in a county with a population of fewer than fifty thousand residents or in a municipality with a population of fewer than twenty-five thousand residents if the municipality is not contiguous to a municipality with a population of twenty-five thousand or more residents.
C.R.S. § 25.5-4-501 State plan amendment - federal authorization - repeal
25.5-4-501. State plan amendment - federal authorization - repeal. (Repealed)
C.R.S. § 25.5-4-502 Federal authorization - repeal
25.5-4-502. Federal authorization - repeal. (Repealed)
C.R.S. § 25.5-4-503 Waiver applications - authorization
25.5-4-503. Waiver applications - authorization. (1) The state department is authorized to apply for health insurance flexibility and accountability waivers that will enable the state to add more flexibility to Colorado's medicaid program and that will result in a cost-effective method of providing health-care services to Coloradans.
(2) The state department shall pursue and, if approved, implement a demonstration waiver that authorizes the state to use federal medical assistance payments authorized pursuant to section 1903(v) of the federal "Social Security Act", as amended, in coordination with the division of insurance to enhance or expand a state-subsidized individual health coverage plan as defined in section 10-16-1203 (15) and, only if needed to maximize federal financial participation, for Coloradans receiving state medical assistance pursuant to section 25.5-2-104 or 25.5-5-201 (6). To the extent such federal funds are used to enhance or expand a state-subsidized individual health coverage plan, as defined in section 10-16-1203 (15), the health insurance affordability enterprise created pursuant to section 10-16-1204 must receive, deposit into the health insurance affordability cash fund created in section 10-16-1206, and allocate the federal share of the medical assistance payments pursuant to section 10-16-1205 (2), subject to any conditions set forth in the approval of the waiver.
C.R.S. § 25.5-4-504 Federal authorization - repeal
25.5-4-504. Federal authorization - repeal. (Repealed)
C.R.S. § 25.5-4-505 Federal authorization related to persons involved in the criminal justice system - assessment - report - repeal
25.5-4-505. Federal authorization related to persons involved in the criminal justice system - assessment - report - repeal. (Repealed)
C.R.S. § 25.5-4-505.5 Federal authorization related to persons involved in the criminal justice system - report - rules - legislative declaration
25.5-4-505.5. Federal authorization related to persons involved in the criminal justice system - report - rules - legislative declaration. (1) (a) The general assembly finds that:
(I) For decades, federal medicaid policy prohibited the use of federal funding for incarcerated medicaid members;
(II) With the emerging opportunity to allow for coverage of incarcerated medicaid members, Colorado is supportive of ensuring these members have access to needed services and treatment; and
(III) Colorado is committed to ensuring medicaid members have access to a civil, community-based system that meets members' needs and ensures Colorado's county jails, juvenile facilities, and prisons do not become primary access points for health-care services for people experiencing behavioral health conditions.
(b) Therefore, the general assembly declares it is in the best interest of all Coloradans, and especially Coloradans living with behavioral health conditions, to require the department of health care policy and financing to seek a federal waiver of the medicaid inmate exclusion policy that includes annual data reporting requirements that:
(I) Inform Coloradans regarding the unmet health needs of individuals involved in the criminal justice system;
(II) Promote the establishment of continuous civil systems of care within communities demonstrably committed to diversion or deflection efforts, including, but not limited to, mobile outreach, co-responder programs, and prosecutor- or judicial-led initiatives; and
(III) Aim to reduce unnecessary involvement with the criminal justice system and increase access to community-based housing, health care, supports, and services.
(2) (a) No later than April 1, 2024, the state department shall seek a federal authorization to provide, through the state medical assistance program, medication-assisted treatment and case management to a member prior to the member's release and a thirty-day supply of prescription medications to a member upon the member's release from a juvenile institutional facility, as defined in section 25-1.5-301 (2)(b), or a department of corrections facility.
(b) Beginning July 1, 2025, and subject to available appropriations, the services described in subsection (2)(a) of this section are available upon receipt of the necessary federal authorization.
(3) (a) (I) No later than April 1, 2025, the state department shall seek a federal authorization to provide, through the state medical assistance program, medication-assisted treatment and case management to a member prior to the member's release from jail and a thirty-day supply of prescription medications to a member upon the member's release from jail.
(II) The state department shall implement subsection (3)(a)(I) of this section only if the state department determines that providing the services described in subsection (3)(a)(I) of this section is budget neutral.
(b) Beginning July 1, 2026, and subject to available appropriations, the services described in subsection (3)(a) of this section are available upon receipt of the necessary federal authorization.
(4) Upon receipt of the necessary federal authorization, the state department shall:
(a) Conduct a rigorous stakeholder process that includes, but is not limited to, receiving feedback from individuals with lived experience in accessing, or the inability to access, behavioral health services in civil settings, county jails, juvenile institutional facilities, and the department of corrections; and
(4) Upon receipt of the necessary federal authorization, the state department shall:
(a) Conduct a rigorous stakeholder process that includes, but is not limited to, receiving feedback from individuals with lived experience in accessing, or the inability to access, behavioral health services in civil settings, county jails, juvenile institutional facilities, and the department of corrections; and
(b) Require each county with a county jail seeking to provide services pursuant to this section to demonstrate a commitment to diversion or deflection efforts, including, but not limited to, mobile outreach, co-responder programs, and prosecutor- or judicial-led initiatives that aim to reduce unnecessary involvement with the criminal justice system and increase access to community-based housing, health care, supports, and services.
(5) (a) The state department shall only reimburse an opioid treatment program, as defined in section 27-80-203, for administering medication-assisted treatment in a jail setting. At a minimum, an opioid treatment program that administers medication-assisted treatment shall:
(I) Employ a physician medical director;
(II) Ensure the individual receiving medication-assisted treatment undergoes a minimum observation period after receiving medication-assisted treatment as determined by behavioral health administration rule pursuant to section 27-80-204; and
(III) Meet all critical incident reporting requirements as determined by behavioral health administration rule pursuant to section 27-80-204.
(b) The state department shall ensure as part of the state department's quality oversight that opioid treatment programs that administer medication-assisted treatment in a jail setting maintain emergency policies and procedures that address adverse outcomes.
(6) The state department may expand services available pursuant to this section as authorized pursuant to federal law and regulations. If the state department seeks to expand services, the state department shall demonstrate how the state department will ensure quality of care and client safety, which must include addressing quality and safety in administering medications in a jail setting.
(7) (a) Beginning July 1, 2025, and each July 1 thereafter, the state department shall annually report to the house of representatives public and behavioral health and human services committee and the senate health and human services committee, or their successor committees, the following information:
(I) De-identified information of individuals who have accessed services, including each individual's demographics, the type of services the individual accessed, the duration of the services offered in a carceral setting compared to the duration of the same services offered in a civil setting, and the individual's experiences before and after incarceration, including but not limited to:
(A) Emergency room or crisis system visits;
(B) Inpatient stays for a primary behavioral health condition; and
(C) Services accessed in a qualified residential treatment program, as defined in section 19-1-103, or a psychiatric residential treatment facility, as defined in section 25.5-4-103;
(II) The total number of medicaid members who were unhoused before or after incarceration, if available;
(III) The total number of unique incarceration stays by medicaid members, as demonstrated by the services accessed;
(IV) The total number of individuals who accessed services in a civil setting prior to arrest or detainment and were subsequently evaluated for competency, ordered to competency restoration, restored to competency, or found incompetent to proceed in a forensic setting; and
(V) Persistent gaps in continuity of care in least-restrictive civil settings.
(b) Notwithstanding section 24-1-136 (11)(a)(I) to the contrary, the state department's report continues indefinitely.
(8) The state department may promulgate rules for the implementation of this section.
C.R.S. § 25.5-4-506 Coverage for doula services - stakeholder process - federal authorization - scholarship program - training - report - definitions - repeal
25.5-4-506. Coverage for doula services - stakeholder process - federal authorization - scholarship program - training - report - definitions - repeal. (1) As used in this section, unless the context otherwise requires:
(a) "Doula" means a trained birth companion who provides personal, nonmedical support to pregnant and postpartum people and their families prior to childbirth, during labor and delivery, and during the postpartum period.
(b) "Maternity advisory committee" means the committee facilitated by the state department composed predominantly of Black, Indigenous, and other people of color with maternity care experience as members.
(2) No later than September 1, 2023, the state department shall initiate a stakeholder process to promote the expansion and utilization of doula services for pregnant and postpartum members in the state. In conducting the stakeholder process, the state department shall:
(a) Design an outreach strategy that includes best practices in community engagement, including, but not limited to:
(I) Engaging trusted community partners to support the work;
(II) Reimbursement of participation costs for individuals who are not otherwise paid to participate;
(III) Reimbursement of child care costs for individuals who participate; and
(IV) Translation services and meeting times that allow diverse and inclusive participation;
(b) Solicit feedback related to:
(I) An approved doula certification process that incorporates national and local training programs;
(II) A billing process for doula services;
(III) Ways to recruit doulas and integrate them into hospital deliveries;
(IV) Support needed to build and retain a doula workforce;
(V) Community outreach to determine how to best promote doula services; and
(VI) The doula scholarship program created in subsection (7) of this section.
(3) Stakeholders must be diverse with regard to race, ethnicity, immigration status, sexual orientation, and gender, and must represent other populations that experience greater health disparities and inequities. The state department may include the following in the stakeholder process:
(a) Doulas and potential doulas who may serve members who include, but are not limited to, Black, Indigenous, and other people of color, refugees, non-English speakers, people living in rural areas, and people who were recently incarcerated;
(b) Individuals indirectly involved in the delivery of doula services, including, but not limited to, clinical providers, hospitals, managed care entities, and state partners, including, but not limited to, the department of public health and environment, department of human services, department of early childhood, and department of regulatory agencies;
(c) Representatives from the division of insurance with subject matter expertise;
(d) Representatives from the maternity advisory committee;
(e) Consumer advocates; and
tals, managed care entities, and state partners, including, but not limited to, the department of public health and environment, department of human services, department of early childhood, and department of regulatory agencies;
(c) Representatives from the division of insurance with subject matter expertise;
(d) Representatives from the maternity advisory committee;
(e) Consumer advocates; and
(f) Experts on perinatal care and quality.
(4) For state fiscal year 2024-25, the state department shall submit a report to the general assembly as part of the state department's "SMART Act" presentation required by section 2-7-203. The report must include findings and recommendations from the stakeholder process as described in subsection (2) of this section. The state department shall work with the maternity advisory committee to create the report.
(5) In carrying out the stakeholder process described in subsection (2) of this section, the state department is exempt from the "Procurement Code", articles 101 to 112 of title 24.
(6) Not later than July 1, 2024, the state department shall seek federal authorization to provide doula services for pregnant and postpartum people to improve health outcomes of pregnant and postpartum people who face a disproportionately greater risk of poor birth outcomes.
(7) (a) Not later than July 1, 2024, the state department shall create a doula scholarship program that grants funds to individuals without sufficient financial resources to complete doula training and certification programs necessary to provide doula services.
(b) In designing the doula scholarship program, the state department shall solicit input from groups identified in subsection (3) of this section.
(c) The state department shall define eligibility criteria for the doula scholarship program that includes, but is not limited to, the following:
(I) Proof of financial hardship;
(II) Proof of state residency; and
(III) A statement of intent to serve as a doula provider in Colorado for pregnant and postpartum members.
(d) The state department shall define criteria for organizations to conduct training and certification programs for doulas that include, but are not limited to:
(I) An approved certification process for doulas;
(II) An equitable approach to doula recruitment and training; and
(III) An approved budget to provide free training to attendees.
(e) The state department may require individuals who receive scholarship money pursuant to the doula scholarship program described in this subsection (7) to submit to the state department, not later than six months after the individual's completion of doula training or certification, documentation that the individual is serving as a doula for members or is working toward enrollment as a doula for members. If an individual does not complete the documentation, the state department may seek repayment of the funds awarded to the individual through the doula scholarship program.
(f) (I) Any money appropriated to the doula scholarship program and not expended prior to July 1, 2024, is further appropriated to the state department through June 30, 2025, to be used for the same purpose.
(II) This subsection (7)(f) is repealed, effective July 1, 2026.
(g) Notwithstanding section 24-1-136 (11)(a)(I), the state department shall report annually beginning in 2025 to the general assembly as part of the state department's "SMART Act" presentation, as required by section 2-7-203, on the utilization and outcomes of the doula scholarship program.
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://leg.colorado.gov/sites/default/files/images/olls/crs2024-title-25.5.docxFetched: 10/6/2026