Children's Basic Health Plan

C.R.S. tit. 25.5, art. 8
in effect

C.R.S. § 25.5-8-101 Short title

25.5-8-101. Short title. This article shall be known and may be cited as the "Children's Basic Health Plan Act".

C.R.S. § 25.5-8-102 Legislative declaration

25.5-8-102. Legislative declaration. (1) The general assembly hereby finds and declares that a significant percentage of children are uninsured. This lack of health insurance coverage decreases children's access to preventive health-care services, compromises the productivity of the state's future workforce, and results in avoidable expenditures for emergency and remedial health care. Health-care providers, health-care facilities, and all purchasers of health care, including the state, bear the costs of this uncompensated care. (2) [Editor's note: This version of subsection (2) is effective until July 1, 2025.] The general assembly further finds and declares that the coordination and consolidation of funding sources currently available to provide services to uninsured children such as the Colorado indigent care program pursuant to part 1 of article 3 of this title, the children's basic health plan, and other children's health programs would efficiently and effectively meet the health-care needs of uninsured children and would help to reduce the volume of uncompensated care in the state. (2) [Editor's note: This version of subsection (2) is effective July 1, 2025.] The general assembly further finds and declares that the coordination and consolidation of funding sources currently available to provide services to uninsured children such as the children's basic health plan, and other children's health programs would efficiently and effectively meet the health-care needs of uninsured children and would help to reduce the volume of uncompensated care in the state. (3) (a) It is the intent of the general assembly to make health insurance coverage available and affordable and to support employers in their efforts to provide their employees and their dependents with health insurance coverage and to support increased availability of affordable health insurance in the individual market. (b) It is the intent of the general assembly that the savings and efficiencies realized through actual reductions in administrative and programmatic costs associated with the implementation of this article and achieved in consolidating other health-care programs should be identified. (4) It is not the intent of the general assembly to create an entitlement for health insurance coverage. (5) The general assembly hereby declares that the following principles shall be used in implementing the children's basic health plan set forth in this article: (a) The department shall establish and maintain a goal of inter-program communication in order to maximize existing state appropriations for the population served in the program; (b) There shall be efficient program utilization through inter-program coordination and program consolidation and, where appropriate, through contracting with the private sector and with essential community providers; (c) The policies enacted in House Bill 97-1304 regarding a strong managed care direction shall be emphasized; (d) The private sector shall be involved to the greatest possible degree with respect to contracting for managed care; (e) There shall be maximum emphasis on coordination with local and state public health programs and initiatives for children. (6) The general assembly hereby finds and declares: (a) That the goal of the "Children's Basic Health Plan Act" is to support low-income, working parents and families in overcoming barriers in obtaining good quality, affordable health-care services for their children; (b) That the health services that low-income children receive through the children's basic health plan should be cost-effective, of high quality, and promote positive health outcomes for enrolled children; e "Children's Basic Health Plan Act" is to support low-income, working parents and families in overcoming barriers in obtaining good quality, affordable health-care services for their children; (b) That the health services that low-income children receive through the children's basic health plan should be cost-effective, of high quality, and promote positive health outcomes for enrolled children; (c) That the children's basic health plan was designed as, and should continue to be, a private-public partnership that encourages enrollment and seeks every opportunity to operate with the efficiency and creativity that is found in utilizing private sector systems and business practices while maintaining the highest level of accountability to the general assembly, the executive branch, and the public through administration of the plan by the department; (d) That the children's basic health plan was designed as, and should continue to be, a community-based program that encourages local participation in enrolling children in and supporting its goals.

C.R.S. § 25.5-8-103 Definitions - rules

25.5-8-103. Definitions - rules. As used in this article 8, unless the context otherwise requires: (1) "Child" means a person who is less than nineteen years of age. (2) "Children's basic health plan" or "plan" means the subsidized health insurance product designed by the department of health care policy and financing and provided to enrollees, as defined in this section. (3) "Department" means the department of health care policy and financing created in section 25.5-1-104. (4) "Eligible person" means: (a) (I) A person who is less than nineteen years of age, who is a citizen or meets the immigration status requirements set forth in section 25.5-8-109 (6) or 25.5-8-109 (7), whose family income does not exceed two hundred sixty percent of the federal poverty line, adjusted for family size, and who is not eligible for medical assistance pursuant to articles 4, 5, and 6 of this title 25.5. (II) Notwithstanding the provisions of subsection (4)(a)(I) of this section, if the money in the healthcare affordability and sustainability fee cash fund established pursuant to section 25.5-4-402.4 (5), together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), for persons less than nineteen years of age, the state board may by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) reduce the percentage of the federal poverty line to below two hundred sixty percent, but the percentage shall not be reduced to below two hundred thirteen percent. (III) Repealed. (b) (I) A pregnant person who is a citizen or meets the immigration status requirements set forth in section 25.5-8-109 (6) or 25.5-8-109 (7), whose family income does not exceed two hundred sixty percent of the federal poverty line, adjusted for family size, and who is not eligible for medical assistance pursuant to articles 4, 5, and 6 of this title 25.5. (II) Notwithstanding the provisions of subsection (4)(b)(I) of this section, if the money in the healthcare affordability and sustainability fee cash fund established pursuant to section 25.5-4-402.4 (5), together with the corresponding federal matching funds, is insufficient to fully fund all of the purposes described in section 25.5-4-402.4 (5)(b), after receiving recommendations from the Colorado healthcare affordability and sustainability enterprise established pursuant to section 25.5-4-402.4 (3), for pregnant women, the state board by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) may reduce the percentage of the federal poverty line to below two hundred sixty percent, but the percentage shall not be reduced to below two hundred thirteen percent. (III) Repealed. (5) "Enrollee" means any eligible person that has enrolled in the plan. (6) "Essential community provider" means a health-care provider that: (a) Has historically served medically needy or medically indigent patients and demonstrates a commitment to serve low-income and medically indigent populations who make up a significant portion of its patient population, or in the case of a sole community provider, serves the medically indigent patients within its medical capability; and tial community provider" means a health-care provider that: (a) Has historically served medically needy or medically indigent patients and demonstrates a commitment to serve low-income and medically indigent populations who make up a significant portion of its patient population, or in the case of a sole community provider, serves the medically indigent patients within its medical capability; and (b) Waives charges or charges for services on a sliding scale based on income and does not restrict access or services because of a member's financial limitations. (7) "Health-care program" means any health-care program in the state that is supported with state general fund or federal dollars. (8) "Master settlement agreement" means the master settlement agreement, the smokeless tobacco master settlement agreement, and the consent decree approved and entered by the court in the case denominated State of Colorado, ex rel. Gale A. Norton, Attorney General v. R.J. Reynolds Tobacco Co.; American Tobacco Co., Inc.; Brown & Williamson Tobacco Corp.; Liggett & Myers, Inc.; Lorillard Tobacco Co., Inc.; Philip Morris, Inc.; United States Tobacco Co.; B.A.T. Industries, P.L.C.; The Council For Tobacco Research--U.S.A., Inc.; and Tobacco Institute, Inc., Case No. 97 CV 3432, in the district court for the city and county of Denver. (9) "Medical services board" means the medical services board created in section 25.5-1-301. (10) "Subsidized enrollee" means an eligible person who receives a subsidy from the department to purchase coverage under the plan or a comparable health insurance. (11) "Subsidy" means the amount paid by the department to assist an eligible person in purchasing coverage under the plan or a comparable health insurance product available to the eligible person through another coverage entity. (12) "Trust" means the children's basic health plan trust created in section 25.5-8-105.

C.R.S. § 25.5-8-104 Children's basic health plan - rules

25.5-8-104. Children's basic health plan - rules. The medical services board is authorized to adopt rules to implement the children's basic health plan to provide health insurance coverage to eligible persons on a statewide basis pursuant to the provisions of this article. Any rules adopted by the children's basic health plan policy board in accordance with the requirements of the "State Administrative Procedure Act", article 4 of title 24, C.R.S., shall be enforceable and shall be valid until amended or repealed by the medical services board.

C.R.S. § 25.5-8-105 Trust - created

25.5-8-105. Trust - created. (1) A fund to be known as the children's basic health plan trust is hereby created and established in the state treasury. Except as provided for in subsection (8) of this section, all moneys deposited in the trust and all interest earned on moneys in the trust shall remain in the trust for the purposes set forth in this article, and no part thereof shall be expended or appropriated for any other purpose. The principal of the trust shall be expended, subject to annual appropriation by the general assembly, solely for the purposes set forth in this article. (2) (a) Except as provided for in subsection (8) of this section, all or a portion of the moneys in the trust shall be annually appropriated by the general assembly for the purposes of this article and shall not be transferred to or revert to the general fund of the state at the end of any fiscal year. (b) Notwithstanding the provisions of paragraph (a) of this subsection (2), moneys in the trust may be used to pay the state's portion of any computer system changes necessary to expand eligibility in the plan. (3) (a) Pursuant to section 24-75-1104.5 (1.7)(b), C.R.S., and except as otherwise provided in section 24-75-1104.5 (5), C.R.S., beginning in the 2016-17 fiscal year and in each fiscal year thereafter so long as the state receives moneys pursuant to the master settlement agreement, the state treasurer shall transfer to the trust eighteen percent of the total amount of the moneys annually received by the state pursuant to the master settlement agreement, not including attorney fees and costs, during the preceding fiscal year. The state treasurer shall transfer the amount specified in this subsection (3) from moneys credited to the tobacco litigation settlement cash fund created in section 24-22-115, C.R.S. The amount transferred pursuant to this subsection (3) is in addition to and not in replacement of any general fund moneys appropriated to the trust. (b) Repealed. (4) Repealed. (5) (a) Beginning in fiscal year 1998, appropriations to the trust may be made by the general assembly based on the savings achieved through reforms, consolidations, and streamlining of health-care programs realized through actual reductions in administrative and programmatic costs associated with the implementation of this article and not decreases in the number of caseloads of such programs. Beginning with and subsequent to fiscal year 2000-01, the general assembly may make annual appropriations to the trust. (b) and (c) Repealed. (6) As part of its annual savings report to the general assembly on November 1 of each year, the department may identify efficiencies and consolidations that produce savings in the department's annual budget request that result in actual reductions in administrative and programmatic costs associated with the implementation of this article and not decreases in the number of caseloads of such programs. (7) The department may receive payment for coverage offered and may receive or contract for donations, gifts, and grants from any source. Such funds shall be transmitted to the state treasurer who shall credit the same to the trust. The department may expend such funds from the trust for the purposes of this article. (8) (a) Beginning in the 2011-2012 fiscal year and for each fiscal year thereafter, moneys in the trust may be used for costs associated with children enrolled in the medical assistance program, articles 4, 5, and 6 of this title, whose family income is more than one hundred percent but does not exceed one hundred thirty-three percent of the federal poverty line and who would have been eligible for enrollment in the children's basic health plan prior to September 1, 2011. (b) On July 1, 2016, the state treasurer shall transfer twenty million dollars from the children's basic health plan trust to the primary care provider sustainability fund created in section 25.5-5-418.

C.R.S. § 25.5-8-107 Duties of the department - schedule of services - premiums - copayments - subsidies - purchase of childhood immunizations

25.5-8-107. Duties of the department - schedule of services - premiums - copayments - subsidies - purchase of childhood immunizations. (1) In addition to any other duties pursuant to this article 8, the department has the following duties: (a) (I) To design, and from time to time revise, a schedule of health-care services included in the plan and to propose said schedule to the medical services board for approval or modification. The schedule of health-care services as proposed by the department and approved by the medical services board shall include, but shall not be limited to, preventive care, physician services, prenatal care and postpartum care, inpatient and outpatient hospital services, prescription drugs and medications, and other services that may be medically necessary for the health of enrollees; except that the department may modify the schedule of health-care services to meet specific federal requirements or to accommodate those changes necessary for a program designed specifically for children. (II) In addition to the items specified in subsection (1)(a)(I) of this section and any additional items approved by the medical services board, on and after January 1, 2001, the medical services board shall include dental services for all enrolled children, and on and after October 1, 2019, for all enrolled pregnant women, in the schedule of health-care services. (III) In addition to the items specified in subsections (1)(a)(I) and (1)(a)(II) of this section and any additional items approved by the medical services board, the medical services board shall include mental health services that are at least as comprehensive as the mental health services provided to medicaid members in the schedule of health-care services. (IV) The schedule of health-care services included in the plan shall not include coverage pursuant to the mandatory coverage provisions of section 10-16-104 (1.4), C.R.S. (V) In addition to the items specified in subsections (1)(a)(I), (1)(a)(II), and (1)(a)(III) of this section, and any additional items approved by the medical services board, the medical services board shall include, for all perinatal people, comprehensive lactation support services, lactation supplies and equipment, and maintenance of multi-user loaned equipment. An individual trained in advanced lactation support shall provide the lactation support services. Lactation equipment must include a single-user double electric breast pump, pump parts and pump collection kit, and access to a loaned multi-user hospital grade electric breast pump along with a compatible individual collection kit. Individuals must have access to single-user lactation supplies and equipment prior to delivery. Access to multi-user loaned breast pumps shall be authorized by a health-care provider. Access to multi-user loaned breast pumps is prioritized for individuals with premature, medically fragile, low birth weight infants, and with lactation complications. Individuals cannot be required to enroll in separate or additional programs in order to receive covered lactation equipment or lactation support services. (b) Repealed. (c) To design and implement a structure of copayments due to providers of managed health-care plans from enrollees. Enrollees in the plan may use funds from a medical savings account to pay copayments. (d) To design and propose to the medical services board for adoption detailed rules of eligibility and enrollment processes for the plan; (e) To design a procedure whereby a financial sponsor may pay the annual enrollment fee or some portion thereof on behalf of a subsidized or nonsubsidized enrollee; except that the payment made on behalf of said enrollee shall not exceed the total enrollment fee due from the enrollee; (f) To design a procedure whereby the plan may pay subsidies for eligible persons to purchase coverage under the plan or a comparable health insurance product; sponsor may pay the annual enrollment fee or some portion thereof on behalf of a subsidized or nonsubsidized enrollee; except that the payment made on behalf of said enrollee shall not exceed the total enrollment fee due from the enrollee; (f) To design a procedure whereby the plan may pay subsidies for eligible persons to purchase coverage under the plan or a comparable health insurance product; (g) To establish criteria to allow a managed care plan, the department, or some other entity to verify eligibility pursuant to section 25.5-8-109; (h) To conduct pilot projects including, but not limited to, testing models of marketing, enrollment, eligibility determination, and premium structures, to be implemented where appropriate and as approved by the joint budget committee. (i) (I) The department shall develop and implement an outreach strategy for Coloradans who become eligible for health coverage pursuant to section 25.5-2-104, 25.5-2-105, 25.5-5-201 (6), or 25.5-8-109 (7). The state department shall work with stakeholders to develop an outreach strategy that includes: (A) Funding for community-based organizations to partner with the department on outreach; (B) A method for providing information related to eligibility and enrollment that can be provided to nonprofit partners, school districts, and charter schools for outreach purposes; and (C) At a minimum, providing information related to eligibility and coverage in English, Spanish, and in each language spoken by at least two-and-one-half percent of the population of any county who speak English less than very well, as defined by the United States bureau of the census American community survey, and who speak the minority language at home; (II) Approximately twelve and twenty-four months after implementation of the strategy required pursuant to subsection (1)(i)(I) of this section, the department shall convene stakeholders, including directly impacted individuals, service providers, and advocacy organizations that are diverse with regard to race, ethnicity, immigration status, sexual orientation, and gender identity and who are affected by higher rates of health disparities and inequities. The department shall report on the outreach and enrollment strategy outcomes, including enrollment of eligible persons into these programs compared to those persons who are eligible for coverage, but not enrolled. (2) The department is authorized to institute a program for competitive bidding pursuant to section 24-103-202 or 24-103-203, C.R.S., for providing medical services on a managed care basis for children under this article. The department shall select more than one managed care contractor to serve counties in which there are providers contracting with more than one managed care plan. In counties where there is only one operational managed care plan, the department may contract with that managed care plan to serve children enrolled in the plan. The department shall assure the utilization of essential community providers for the provision of services including eligibility determination, enrollment, and outreach when reasonable. The department shall contract with managed care organizations for the delivery of health services pursuant to this article. The department may contract with essential community providers for health-care services in areas of the state that are not adequately served by managed care organizations. the provision of services including eligibility determination, enrollment, and outreach when reasonable. The department shall contract with managed care organizations for the delivery of health services pursuant to this article. The department may contract with essential community providers for health-care services in areas of the state that are not adequately served by managed care organizations. (3) The department may contract for billing and premium collection functions for the children's basic health plan with vendors who provide billing and premium collection functions for other state insurance programs in order to consolidate billing and premium collection functions among multiple state programs. Such contracts may be entered into if the department determines that the scope of work provided by the vendor is similar to the work requirements for the children's basic health plan and that it would be more efficient and cost-effective to contract with the same vendor on multiple programs. (4) Commencing with fiscal year 2001-02, the annual administrative costs for the children's basic health plan shall not exceed ten percent of the total annual program costs. (5) The department may purchase vaccines recommended by the advisory committee on immunization practices to the centers for disease control and prevention in the federal department of health and human services, or its successor entity, through a vaccine purchasing system, if such a system is developed pursuant to section 25-4-2403 (1), C.R.S., for children enrolled in the children's basic health plan.

C.R.S. § 25.5-8-108 Financial management - cash system of accounting

25.5-8-108. Financial management - cash system of accounting. (1) The department shall propose rules for approval by the medical services board to implement financial management of the plan. Pursuant to such rules, the department shall adjust benefit levels, eligibility guidelines, and any other measure to ensure that sufficient funds are present to implement the provisions of this article. The department shall develop and use quality assurance measures, such as the health employer data information set (HEDIS) reports regarding provider compensation, adapted to children's needs, to ensure that appropriate health-care outcomes are met and to justify the continued use of taxpayer dollars for the plan. The department shall implement performance-based contracting based on such quality assurance measures. (2) The department shall make a quarterly assessment of the expected expenditures for the plan for the remainder of the current biennium and for the following biennium. The estimated expenditures, including minimum reserve requirements, shall be compared to an estimate of the revenues that will be deposited in the trust fund. Based on this comparison, the department shall make adjustments as necessary to ensure that expenditures remain within the limits of available revenues for the remainder of the current biennium and the following biennium. (3) The department may, in addition to any other measure it determines to be necessary, decrease subsidies for annual enrollment fees or limit enrollment in the plan to ensure that the trust retains sufficient funds pursuant to subsection (1) of this section. (4) (a) Nothing in this article or any rules promulgated pursuant to the plan shall be interpreted to create a legal entitlement in any person to coverage under the plan. If enrollment in the plan is limited, the department shall give priority to children with family incomes under one hundred thirty-three percent of the federal poverty line. (b) The department shall report quarterly to the joint budget committee on any enrollment caps that have been instituted for the plan and the number of children who are on waiting lists. (5) The 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 department relating to the financial administration of any nonadministrative expenditure for the plan.

C.R.S. § 25.5-8-109 Eligibility - children - pregnant women - rules - repeal

25.5-8-109. Eligibility - children - pregnant women - rules - repeal. (1) To be eligible for a subsidy, a child must not be insured by a comparable health plan through an employer. (2) If one child from a family is enrolled in the plan, all children must be enrolled, unless the other children have alternative health insurance coverage. (3) The department may establish procedures such that children with family incomes that exceed the percent of the federal poverty guidelines specified in section 25.5-8-103 (4)(a) may enroll in the plan, but are not eligible for subsidies from the department. (4) A child whose family income does not exceed the applicable level specified in section 25.5-8-103 (4)(a) shall be presumptively eligible for the plan. Children who are determined to be eligible for the plan shall remain eligible for twelve months subsequent to the last day of the month in which they were enrolled; except that a child shall no longer be eligible for the plan and shall be disenrolled from the plan if the department becomes aware of or is notified that any of the following has occurred: (a) The child has moved out of the state; or (b) Repealed. (c) The child has been enrolled in a commercial health insurance plan during the twelve-month period following enrollment in the plan under this article. (4.5) (a) (I) To the extent authorized by federal law, the department shall require an applicant to state only the applicant's family income and shall notify the applicant that the applicant's family income will be verified by federally approved electronic data sources. The department shall allow an applicant to provide income information more recent than the records of the federally approved electronic data sources. (II) The department shall annually verify the member's income eligibility at reenrollment through federally approved electronic data sources. If a member meets all eligibility requirements, a member remains enrolled in the plan. The department shall also allow a member to provide income information more recent than the records of federally approved electronic data sources. (III) 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 information verified through federally approved electronic data sources, 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. (IV) Notwithstanding any other provision in this paragraph (a), for applications that contain self-employment income, the state department shall not implement this paragraph (a) until it can verify self-employment income through federally approved electronic data sources as authorized by rules of the state department and federal law. (V) The county department, state department, or other entity designated by the state department to make the eligibility determination shall automatically transfer to the state insurance marketplace through a system interface the application data and verifications of a child or pregnant woman who is determined ineligible for medical assistance benefits pursuant to this section. nt and federal law. (V) The county department, state department, or other entity designated by the state department to make the eligibility determination shall automatically transfer to the state insurance marketplace through a system interface the application data and verifications of a child or pregnant woman who is determined ineligible for medical assistance benefits pursuant to this section. (VI) 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 (4.5)(a)(VI) 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. (VII) 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. (VIII) 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. (IX) 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. (X) Subject to available appropriations and upon receiving necessary federal authorization, the state department may implement subsections (4.5)(a)(VI), (4.5)(a)(VII), (4.5)(a)(VIII), and (4.5)(a)(IX) of this section. (b) Repealed. plicable medicaid limits, regardless of differences in household composition and income-counting rules between programs or as specified through federal authorization. (X) Subject to available appropriations and upon receiving necessary federal authorization, the state department may implement subsections (4.5)(a)(VI), (4.5)(a)(VII), (4.5)(a)(VIII), and (4.5)(a)(IX) of this section. (b) Repealed. (c) Subject to the provisions and requirements of section 25.5-4-205 (3)(e), the department shall establish a process so that an enrollee or the parent or guardian of an enrollee may apply for reenrollment either over the telephone or through the internet. (5) (a) (I) A pregnant woman whose family income does not exceed the applicable level specified in section 25.5-8-103 (4)(b) shall be presumptively eligible for the plan. Once determined eligible for the plan, a pregnant woman shall be considered to be continuously eligible throughout the pregnancy and for the sixty days following the pregnancy, even if the woman's eligibility would otherwise terminate during such period due to an increase in income. Upon birth, a child born to a woman eligible for the plan shall be eligible for the plan and shall be automatically enrolled in the plan in accordance with the eligibility requirements for children specified in subsection (4) of this section. (II) Repealed. (b) (I) Under the plan, prenatal and postpartum primary health-care providers shall implement policies regarding the integration of evidence-based tobacco use treatments into the regular health-care delivery system, including, but not limited to: (A) Assessment of tobacco use and exposure to second-hand smoke; (B) Education on the dangers of tobacco use during pregnancy and postpartum; (C) Referrals to appropriate cessation services. (II) Health-care providers may coordinate the implementation of such policies with the tobacco education, prevention, and cessation programs established in section 25-3.5-804, C.R.S. (c) The addition of coverage under the plan for pregnant women shall only be implemented if the department obtains a waiver from the federal department of health and human services. (d) Enrollment of a pregnant woman in the plan shall be limited based upon annual appropriations made out of the trust by the general assembly as described in section 25.5-8-105 and any grants and donations. The general assembly shall annually establish maximum enrollment figures for pregnant women in the plan. The department shall not exceed the enrollment caps regardless of whether the funding comes from annual appropriations or grants and donations. (5.5) (a) Subject to the receipt of federal financial participation, to the maximum extent allowed under federal law, a person who was eligible for the plan while pregnant and who remains eligible for the plan for the sixty days following the pregnancy remains continuously eligible for all services under the plan for the twelve-month postpartum period. (b) The department shall seek any plan amendment necessary to implement a twelve-month postpartum benefit pursuant to this subsection (5.5) and shall implement the benefit only upon receipt of federal authorization and financial participation, and no later than July 1, 2022. llowing the pregnancy remains continuously eligible for all services under the plan for the twelve-month postpartum period. (b) The department shall seek any plan amendment necessary to implement a twelve-month postpartum benefit pursuant to this subsection (5.5) and shall implement the benefit only upon receipt of federal authorization and financial participation, and no later than July 1, 2022. (c) If permissible under federal law, an eligible individual within the postpartum period may resume coverage under the plan upon implementation of this section. (6) (a) Notwithstanding any other provision of law, but subject to the receipt of federal financial participation, the department shall provide benefits pursuant to this article 8 to a pregnant person who is lawfully residing, as defined in section 25.5-4-103 (10), and a child less than nineteen years of age, who is lawfully residing, so long as such pregnant person or child meets eligibility criteria other than those related to citizenship or immigration status. (7) (a) Beginning no later than January 1, 2025, notwithstanding any other provision of law, the department shall provide benefits pursuant to this article 8 to a pregnant person who is not a citizen and is not eligible pursuant to subsection (6) of this section, so long as the pregnant person meets the eligibility criteria other than those related to citizenship or immigration status. Eligibility pursuant to this section extends continuously through the twelve-month postpartum period, so long as eligibility remains in effect pursuant to subsection (5.5)(a) of this section. (b) The department shall seek any necessary federal approvals to maximize any available federal financial participation in implementing this subsection (7). (c) (I) During its 2024 presentation to the joint budget committee of the general assembly and in its presentation to the health and human services committee of the senate and the health and insurance committee of the house of representatives, or any successor committees, at the hearing held pursuant to section 2-7-203 (2)(a) of the "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act", the state department shall report on its plans and progress in implementing the coverage expansion created pursuant to this subsection (7). (II) Beginning January 1, 2026, and continuing every January thereafter, the state department, in its presentation to the joint budget committee of the general assembly and in its presentation to the health and human services committee of the senate and the health and insurance committee of the house of representatives, or any successor committees, at the hearing held pursuant to section 2-7-203 (2)(a) of the "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act", shall report on the cost savings and health improvements associated with the coverage expansion created pursuant to this subsection (7). (d) This subsection (7) constitutes state authority within the meaning of 8 U.S.C. sec. 1621 (d), as that law existed on January 1, 2022. (8) (a) 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 (4) and (4.5)(a)(II) of this section requiring the state department to disenroll an individual enrolled in the children's basic health plan due to the annual verification of income, as authorized by the centers for medicare and medicaid services, are suspended until January 1, 2025. irst Coronavirus Response Act", Pub.L. 116-127, and the federal "Consolidated Appropriations Act, 2023", subsections (4) and (4.5)(a)(II) of this section requiring the state department to disenroll an individual enrolled in the children's basic health plan due to the annual verification of income, as authorized by the centers for medicare and medicaid services, are suspended until January 1, 2025. (b) The state board may adopt rules to implement this subsection (8) 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. (c) This subsection (8) is repealed, effective January 1, 2025.

C.R.S. § 25.5-8-109.3 Health services initiatives

25.5-8-109.3. Health services initiatives. (1) To the extent federal financial participation is available, the department shall design and implement health service initiatives pursuant to section 2105(a)(1)(D)(ii) of the federal "Social Security Act", as amended, to provide funding for continuous enrollment for the twelve-month postpartum period for a person who is enrolled in health-care coverage pursuant to section 25.5-5-201 (6) or 25.5-8-109 (7). (2) To the extent additional federal financial participation is available, the department shall establish a stakeholder process in collaboration with department staff to determine additional priorities and budget allocations that draw down at least fifty percent of the remaining health services initiative funds to expand access to perinatal and postpartum supports. The department shall report on the established priorities and budget allocations and the ways in which they are inclusive of stakeholder input during the department's 2024 presentation to the joint budget committee of the general assembly and in the department's presentation to the health and human services committee of the senate and the health and insurance committee of the house of representatives, or any successor committees, at the hearing held pursuant to section 2-7-203 (2)(a) of the "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act". In conducting the stakeholder process, the department shall: (a) Engage directly with impacted individuals, service providers, advocacy organizations, and individuals working in or representing communities who are diverse with regard to race, ethnicity, immigration status, age, ability, sexual orientation, gender identity, or geographic region of the state and who are affected by higher rates of health disparities and inequities; (b) Publicize, conduct, and report outcomes of stakeholder meetings in, at a minimum, English and Spanish; (c) Include opportunities for participation in the stakeholder process outside of regular work hours; (d) Conduct a minimum of five stakeholder meetings and conduct additional meetings focused on hearing input from individual constituencies listed in subsection (2)(a) of this section; (e) Take into consideration research and information from reports issued by the maternal mortality review committee, as required by section 25-52-104 (6); (f) Take into consideration data from the health survey for birthing parents to inform stakeholder decision-making; and (g) Consider initiatives to reduce diaper need, expand access to group-based prenatal and pediatric care models, and expand home visitation programs, including voluntary newborn nurse visitation programs that are universally offered to all families in a given community and provide at least one nurse visit within the first three months of life. (3) (a) The department shall seek any necessary federal approvals to obtain federal financial participation in implementing subsection (1) of this section. (b) To the extent allowable, the department shall maximize federal financial participation in implementing this section.

C.R.S. § 25.5-8-109.5 Telehealth - interim therapeutic restorations - reimbursement - definitions

25.5-8-109.5. Telehealth - interim therapeutic restorations - reimbursement - definitions. (1) Subject to federal authorization and financial participation, on or after July 1, 2016, in-person contact between a health-care provider and an enrollee is not required under the children's basic health plan for the diagnosis, development of a treatment plan, instruction to perform an interim therapeutic restoration procedure, or supervision of a dental hygienist performing an interim therapeutic restoration procedure. A health-care provider may provide these services through telehealth, including store-and-forward transfer, and is entitled to reimbursement for the delivery of those services via telehealth to the extent the services are otherwise eligible for reimbursement under the plan. The services are subject to the reimbursement policies developed pursuant to the children's basic health plan. (2) As used in this section: (a) "Interim therapeutic restoration" has the same meaning as set forth in section 12-220-104 (10). (b) "Store-and-forward transfer" means the asynchronous transmission of medical or dental information to be reviewed by a dentist at a later time at a distant site without the patient present in real time.

C.R.S. § 25.5-8-110 Participation by managed care plans

25.5-8-110. Participation by managed care plans. (1) Managed care plans, as defined in section 10-16-102 (43), C.R.S., that participate in the plan shall do so by contract with the department and shall provide the health-care services covered by the plan to each enrollee. (2) Managed care plans participating in the plan shall not discriminate against any potential or current enrollee based upon health status, disability, sex, sexual orientation, gender identity, gender expression, marital status, race, creed, color, national origin, ancestry, ethnicity, or religion. (3) Managed care plans that contract with the department to provide the plan to enrollees shall also be willing to contract with the medicaid managed care program, as administered by the department. (4) (a) Managed care plans shall be selected by the department to participate in the children's basic health plan based upon the managed care plans' assurances and the department's verification that the managed care plan is utilizing within its network essential community providers to the extent that this action does not result in a net increase in the cost for providing services to the managed care plan. (b) The managed care organization shall seek proposals from each essential community provider in a county in which the managed care organization is enrolling members for those services that the managed care organization provides or intends to provide and that an essential community provider provides or is capable of providing. To assist managed care organizations in seeking proposals, the department shall provide managed care organizations with a list of essential community providers in each county. The managed care organization shall consider the proposals in good faith and shall, when deemed reasonable by the managed care organization based on the needs of its members, contract with essential community providers. Each essential community provider must be willing to negotiate on reasonably equitable terms with each managed care organization. Essential community providers making proposals pursuant to this subsection (4) must be able to meet the contractual requirements of the managed care organization. The requirement of this subsection (4) does not apply to a managed care organization in areas in which the managed care organization operates entirely as a group model health maintenance organization. (c) Any disputes between a managed care organization and an essential community provider that cannot be resolved through good faith negotiations may be resolved through an informal review by the department at the request of one of the parties, or through the department's aggrieved provider appeal process in accordance with section 25.5-1-107 (2), if requested by one of the parties. (d) In selecting managed care organizations through competitive bidding, the department shall give preference to those managed care organizations that have executed contracts for services with one or more essential community providers. In selecting managed care organizations, the department shall not penalize a managed care organization for paying cost-based reimbursement to federally qualified health centers as defined in the federal "Social Security Act". (5) The department may receive and act upon complaints from members regarding failure to provide covered services or efforts to obtain payment, other than authorized copayments, for covered services directly from eligible members. hall not penalize a managed care organization for paying cost-based reimbursement to federally qualified health centers as defined in the federal "Social Security Act". (5) The department may receive and act upon complaints from members regarding failure to provide covered services or efforts to obtain payment, other than authorized copayments, for covered services directly from eligible members. (6) Parents or guardians of children shall choose a participating health maintenance organization before enrolling in the plan in areas of the state where a participating health maintenance organization is available. The department will assign children who are currently enrolled in the plan and whose parents or guardians have not selected a health maintenance organization within a time period determined by the department to a participating health maintenance organization with the child's primary care physician in the network. The department shall seek to maintain continuity of the health plan between medicaid and the children's basic health plan. (7) In areas of the state in which a participating managed care plan does not have providers, the department may contract with essential community providers and other health-care providers to provide health-care services under the children's basic health plan using a managed care model. (8) The department may contract with essential community providers or other providers or develop other administrative arrangements to provide health-care services under the children's basic health plan to enrollees prior to the effective date of enrollment in the selected managed care plan. (9) The department shall allow, at least annually, an opportunity for members to transfer among participating managed care plans serving their respective geographic regions. The department shall establish a period of at least twenty days annually when the opportunity to transfer is afforded to eligible members. In geographic regions served by more than one participating managed care plan, the department shall endeavor to establish a uniform period for the opportunity to transfer. (10) (a) The department shall make a capitation payment to managed care plans based upon a defined scope of services at an agreed upon rate. The department shall only use market rate bids that do not discriminate and are adequate to assure quality, network sufficiency, and long-term competitiveness in the children's basic health plan managed care market. The department shall retain a qualified actuary to establish a lower limit for such bids. A certification by such actuary to the appropriate lower limit shall be conclusive evidence of the department's compliance with the requirements of this subsection (10). For the purposes of this subsection (10), a "qualified actuary" shall be a person deemed as such under rules promulgated by the commissioner of insurance. (b) Repealed. (11) All managed care plans participating in the plan shall meet standards regarding the quality of services to be provided, financial integrity, and responsiveness to the unmet health-care needs of eligible persons that may be served.

C.R.S. § 25.5-8-111 Department - administration - outsourcing

25.5-8-111. Department - administration - outsourcing. (1) (a) The department may: (I) Pursuant to section 24-50-504 (2)(a), C.R.S., enter into personal services contracts for the administration of the children's basic health plan. Any contracts established pursuant to this section shall contain performance measures that shall be monitored by the department. (II) Use county departments of human or social services to perform functions relating to the administration of the children's basic health plan; (III) Perform administrative functions at the department, including consolidation of functions with other administrative functions handled by the department. (b) In deciding how to allocate functions relating to the administration of the children's basic health plan as allowed under paragraph (a) of this subsection (1), the department shall determine and base its decisions upon what is the most cost-effective method to handle the particular function and to deliver the services. (2) The implementation of subparagraph (I) of paragraph (a) of subsection (1) of this section is contingent upon a finding by the state personnel director that any of the conditions of section 24-50-504 (2), C.R.S., have been met or that the conditions of section 24-50-503 (1), C.R.S., have been met. (3) If the state department uses county departments of human or social services to perform functions relating to the administration of the children's basic health plan pursuant to subsection (1)(a)(II) of this section and allocates money to a county for that purpose, the state department shall make the allocation in accordance with the results of the public assistance programs funding model described in section 26-1-121.5.

C.R.S. § 25.5-8-112 Authority to the department to apply for federal waivers

25.5-8-112. Authority to the department to apply for federal waivers. The department is hereby authorized and required to apply for any federal waivers necessary to implement the purposes of this article.

C.R.S. § 25.5-8-113 Reports by contractors to medical services board

25.5-8-113. Reports by contractors to medical services board. (Repealed)
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

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