Colorado Revised Statutes 2023
TITLE 25.5
HEALTH CARE POLICY AND FINANCING
Cross references: For the legislative declaration contained in the 1993 act enacting this
title, see section 1 of chapter 230, Session Laws of Colorado 1993.
ADMINISTRATION
ARTICLE 1
Department of
Health Care Policy and Financing
PART 1
GENERAL PROVISIONS
25.5-1-101. Short title. This title shall be known and may be cited as the "State Health
Care Policy and Financing Act".
Source: L. 93: Entire title added, p. 1097, § 15, effective July 1, 1994. L. 2006: Entire
part amended, p. 1781, § 1, effective July 1.
25.5-1-102. Legislative declaration. (1) The general assembly declares that state and
local policymakers and health and human services administrators recognize that the management
of and the delivery system for health and human services have become complex, fragmented,
and costly and that the health and human services delivery system in this state should be
restructured to adequately address the needs of Colorado citizens.
(2) The general assembly further finds and declares that a continuing budget crisis
makes it unlikely that funding sources will keep pace with the increasing demands of health and
human services.
(3) Therefore, the general assembly finds that it is appropriate to restructure principal
departments responsible for overseeing the delivery of health and human services and to reform
the state's health and human services administration and delivery system, using guiding
principles and within the time frames set forth in article 1.7 of title 24, C.R.S., as said article
existed prior to July 1, 1997. It is the general assembly's intent that the departments of public
health and environment, health care policy and financing, and human services be operational,
effective July 1, 1994.
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Source: L. 93: Entire title added, p. 1097, § 15, effective July 1, 1994. L. 2006: Entire
part amended, p. 1781, § 1, effective July 1.
25.5-1-103. Definitions. As used in this title 25.5, unless the context otherwise requires:
(1) "County board" means the county or district board of human or social services;
except that, in the city and county of Denver, "county board" means the department or agency
with the responsibility for public assistance and welfare activities, and, in the city and county of
Broomfield, "county board" means the city council or a board or commission with the
responsibility for public assistance and welfare activities appointed by the city and county of
Broomfield.
(2) "County department" means the county or district department of human or social
services.
(3) "County director" means the director of the county or district department of human
or social services.
(4) "Executive director" means the executive director of the department of health care
policy and financing.
(5) "Medical assistance" means any program administered by the state department,
including but not limited to the "Colorado Medical Assistance Act", as specified in articles 4, 5,
and 6 of this title, the "Children's Basic Health Plan Act", article 8 of this title, the old age
pension health and medical care program, and the supplemental old age pension health and
medical care program; except that "medical assistance" for purposes of articles 4, 5, and 6 of this
title shall have the meaning as defined in section 25.5-4-103 (13).
(5.5) "Medical home" means an appropriately qualified medical specialty,
developmental, therapeutic, or mental health-care practice that verifiably ensures continuous,
accessible, and comprehensive access to and coordination of community-based medical care,
mental health care, oral health care, and related services for a child. A medical home may also be
referred to as a health-care home. If a child's medical home is not a primary medical care
provider, the child must have a primary medical care provider to ensure that a child's primary
medical care needs are appropriately addressed. All medical homes shall ensure, at a minimum,
the following:
(a) Health maintenance and preventive care;
(b) Anticipatory guidance and health education;
(c) Acute and chronic illness care;
(d) Coordination of medications, specialists, and therapies;
(e) Provider participation in hospital care; and
(f) Twenty-four-hour telephone care.
(6) "Recipient" means any person who has been determined eligible to receive benefits
or services under this title.
(7) "State board" or "board" means the medical services board created pursuant to
section 25.5-1-301.
(8) "State department" means the department of health care policy and financing.
(9) [Editor's note: This version of subsection (9) is effective until July 1, 2024.] "State
designated agency" means an agency designated to perform specified functions that would
otherwise be performed by the county departments, including the single entry point agencies and
medical assistance sites.
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(9) [Editor's note: This version of subsection (9) is effective July 1, 2024.] "State
designated agency" means an agency designated to perform specified functions that would
otherwise be performed by the county departments, including case management agencies, as
defined in section 25.5-6-1702, and medical assistance sites.
Source: L. 93: Entire title added, p. 1098, § 15, effective July 1, 1994. L. 95: (2.5)
added, p. 903, § 2, effective May 25. L. 96: (1) repealed, p. 1473, § 25, effective June 1. L.
2006: Entire part amended, p. 1782, § 1, effective July 1. L. 2007: (5.5) added, p. 1487, § 1,
effective May 31. L. 2018: IP and (1) to (3) amended, (SB 18-092), ch. 38, p. 443, § 106,
effective August 8. L. 2021: (9) amended, (HB 21-1187), ch. 83, p. 331, § 21, effective July 1,
2024.
Cross references: For the legislative declaration in SB 18-092, see section 1 of chapter
38, Session Laws of Colorado 2018.
25.5-1-104. Department of health care policy and financing created - executive
director - powers, duties, and functions - report. (1) There is hereby created the department
of health care policy and financing, the head of which shall be the executive director of the
department of health care policy and financing, which office is hereby created. The executive
director shall be appointed by the governor, with the consent of the senate, and shall serve at the
pleasure of the governor. The reappointment of an executive director after an initial election of a
governor shall be subject to the provisions of section 24-20-109, C.R.S. The executive director
has those powers, duties, and functions prescribed for the heads of principal departments in the
"Administrative Organization Act of 1968", article 1 of title 24, C.R.S., and any powers, duties,
and functions set forth in this title.
(2) The department of health care policy and financing shall consist of an executive
director of the department of health care policy and financing, the medical services board, and
such divisions, sections, and other units as shall be established by the executive director pursuant
to the provisions of subsection (3) of this section.
(3) The executive director may establish such divisions, sections, and other units within
the state department as are necessary for the proper and efficient discharge of the powers, duties,
and functions of the state department; except that such action by the executive director shall not
conflict with the implementation requirements for the plan for restructuring the delivery of
health and human services in this state, as set forth in article 1.7 of title 24, C.R.S.
(4) The department of health care policy and financing shall be responsible for the
administration of the functions and programs as set forth in this title.
(5) (a) The executive director of the state department shall appoint an internal auditor
who shall have the status of a division director and, as such, shall have the authority to appoint
such personnel as may be necessary to carry out the duties of the internal auditor.
(b) The internal auditor appointed by the executive director pursuant to paragraph (a) of
this subsection (5) shall:
(I) Conduct and supervise internal audits of the state department;
(II) Coordinate and facilitate external audits that are performed on the state department
by state and federal entities;
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(III) Conduct and supervise performance audits for the purpose of determining the
efficiency and effectiveness of the state department's operation and administration of programs;
and
(IV) Conduct such other audits and perform such other duties as may be specified by the
executive director.
(6) (a) (I) The state department shall collaborate with the department of education, the
department of public health and environment, and the department of human services to develop
an interagency resource guide pursuant to section 22-2-410 to assist facilities to become licensed
or authorized as approved facility schools and to recommend changes related to the interagency
resource guide to the state department's statute, rule, or administrative procedures.
(II) The state department shall prominently post the interagency resource guide created
pursuant to subsection (6)(a)(I) of this section on the department's website.
(b) On or before November 1, 2023, the state department, after consulting with the
facility school work group created in section 22-2-407.5, shall recommend a plan to provide
guidance to approved facility schools on the eligibility standards required to request and receive
medicaid reimbursement funding for therapeutic services to the maximum extent possible to
reduce reliance on school district revenues for tuition payments required pursuant to section
22-20-109. The plan must include best practices from other states, recommendations on required
federal or state authority changes, cost estimates, and cost-saving potentials.
Source: L. 93: Entire title added, p. 1098, § 15, effective July 1, 1994. L. 94: (2)
amended, p. 1559, § 4, effective July 1. L. 96: (2) amended, p. 1474, § 26, effective June 1. L.
2006: Entire part amended, p. 1783, § 1, effective July 1. L. 2010: (5) added, (SB 10-167), ch.
296, p. 1376, § 2, effective May 26. L. 2023: (6) added, (SB 23-219), ch. 88, p. 333, § 13,
effective April 20.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
25.5-1-105. Transfer of functions. (1) The state department shall, on and after July 1,
1994, execute, administer, perform, and enforce the rights, powers, duties, functions, and
obligations vested prior to July 1, 1994, in the Colorado health data commission within the
department of local affairs, the department of social services concerning the "Colorado Medical
Assistance Act", and the university of Colorado health sciences center concerning health care for
the medically indigent.
(2) All rules, regulations, and orders of the department of local affairs, the state
department of social services, the state board of social services, the department of regulatory
agencies, and the university of Colorado health sciences center adopted prior to July 1, 1994, in
connection with the powers, duties, and functions transferred to the state department shall
continue to be effective until revised, amended, repealed, or nullified pursuant to law. On and
after July 1, 1994, the state board or the executive director, whichever is appropriate, shall adopt
rules necessary for the administration of the state department and the administration of the
programs set forth in this title.
(3) No suit, action, or other judicial or administrative proceeding lawfully commenced
prior to July 1, 1994, or which could have been commenced prior to such date, by or against the
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department of local affairs, the state department of social services, the department of regulatory
agencies, or the university of Colorado health sciences center, or any officer thereof in such
officer's official capacity or in relation to the discharge of the official's duties, shall abate by
reason of the transfer of duties and functions from said departments to the state department.
(4) The executive director, or a designee of the executive director, may accept, on behalf
of and in the name of the state, gifts, donations, and grants for any purpose connected with the
work and programs of the state department. Any property so given shall be held by the state
treasurer, but the executive director, or the designee therefor, shall have the power to direct the
disposition of any property so given for any purpose consistent with the terms and conditions
under which such gift was created.
(5) The revisor of statutes is hereby authorized to change all references in the Colorado
Revised Statutes to the department of local affairs, the state department of social services, the
department of regulatory agencies, and the university of Colorado health sciences center from
said references to the state department, as appropriate and with respect to the powers, duties, and
functions transferred to the state department. In connection with such authority, the revisor of
statutes is hereby authorized to amend or delete provisions of the Colorado Revised Statutes so
as to make the statutes consistent with the powers, duties, and functions transferred pursuant to
this section.
(6) On and after July 1, 2003, the powers, duties, and functions relating to the old age
pension health and medical care program, as specified in section 25.5-2-101, are transferred by a
type 2 transfer to the department of health care policy and financing.
Source: L. 93: Entire title added, p. 1099, § 15, effective July 1, 1994. L. 94: (2)
amended, p. 2610, § 12, effective July 1; (6) amended, p. 1559, § 5, effective July 1. L. 2003:
(10) added, p. 2583, § 1, effective July 1. L. 2005: (1) amended, p. 772, § 50, effective June 1.
L. 2006: Entire part amended, p. 1783, § 1, effective July 1. L. 2011: (6) amended, (SB 11-210),
ch. 187, p. 721, § 6, effective July 15, 2012.
25.5-1-105.5. Chief medical officer - qualifications. (1) The executive director shall
appoint a chief medical officer who shall:
(a) Have a degree of doctor of medicine or doctor of osteopathy and be licensed to
practice medicine in the state of Colorado;
(b) Have at least two years of postgraduate experience in primary care; and
(c) Have at least two years of experience in an administrative capacity in a health-care
organization.
(2) The chief medical officer shall, with the assistance of advisory committees of the
state department, provide medical judgment and advice regarding all medical issues involving
programs administered by the state department.
(3) The chief medical officer shall receive a salary within the limits of moneys made
available to the state department by appropriation of the general assembly or otherwise.
Source: L. 2007: Entire section added, p. 1492, § 3, effective July 1. L. 2010: (1)
amended and (3) added, (SB 10-167), ch. 296, p. 1377, § 3, effective May 26.
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Cross references: For the legislative declaration contained in the 2007 act enacting this
section, see section 1 of chapter 347, Session Laws of Colorado 2007. For the legislative
declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010.
25.5-1-106. Restructure of health and human services - development of plan -
participation of department required. (Deleted by amendment)
Source: L. 93: Entire title added, p. 1101, § 15, effective July 1, 1994. L. 2006: Entire
part amended, p. 1785, § 1, effective July 1.
25.5-1-107. Final agency action - administrative law judge - authority of executive
director. (1) The executive director may appoint one or more persons to serve as administrative
law judges for the state department pursuant to section 24-4-105 and pursuant to part 10 of
article 30 of title 24 subject to appropriations made to the department of personnel. Except as
provided in subsection (2) of this section, hearings conducted by the administrative law judge are
considered initial decisions of the state department and shall be reviewed by the executive
director or a designee of the executive director. In the event exceptions to the initial decision are
filed pursuant to section 24-4-105 (14)(a)(I), the review must be in accordance with section
24-4-105 (15). In the absence of any exception filed pursuant to section 24-4-105 (14)(a)(I), the
executive director shall review the initial decision in accordance with a procedure adopted by the
state board. The procedure must be consistent with federal mandates concerning the single state
agency requirement. Review by the executive director in accordance with section 24-4-105 (15)
or the procedure adopted by the state board pursuant to this section constitutes final agency
action. The administrative law judge may conduct hearings on appeals from decisions of county
departments of human or social services brought by recipients of and applicants for medical
assistance and welfare that are required by law in order for the state to qualify for federal funds,
and the administrative law judge may conduct other hearings for the state department. Notice of
any such hearing must be served at least ten days prior to such hearing.
(2) Hearings initiated by a licensed or certified provider of services shall be conducted
by an administrative law judge for the state department and shall be considered final agency
action and subject to judicial review in accordance with the provisions of section 24-4-106,
C.R.S., for any party, including the state department, which shall be considered a person for such
purposes.
Source: L. 93: Entire title added, p. 1101, § 15, effective July 1, 1994. L. 95: (1)(a) and
(2) amended, p. 903, § 3, effective May 25; (1)(a) and (1)(c) amended, p. 664, § 101, effective
July 1. L. 97: (1)(b) amended, p. 1190, § 10, effective July 1. L. 2005: (1)(c) amended, p. 859, §
25, effective June 1. L. 2006: Entire part amended, p. 1785, § 1, effective July 1. L. 2018: (1)
amended, (SB 18-092), ch. 38, p. 443, § 107, effective August 8.
Editor's note: Amendments to subsection (1)(a) by Senate Bill 95-78 and House Bill
95-1362 were harmonized.
Cross references: For the legislative declaration contained in the 1995 act amending
subsections (1)(a) and (1)(c), see section 112 of chapter 167, Session Laws of Colorado 1995.
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For the legislative declaration in SB 18-092, see section 1 of chapter 38, Session Laws of
Colorado 2018.
25.5-1-108. Executive director - rules. (1) The executive director shall have authority
to promulgate rules in connection with the policies and procedures governing the administration
of the department including, but not limited to, rules concerning the following:
(a) Matters of internal administration of the department, including organization, staffing,
records, reports, systems, and procedures;
(b) Fiscal and personnel administration for the department;
(c) Accounting and fiscal reporting policies and procedures for disbursement of federal
funds, contingency funds, and distribution of available appropriations;
(d) Such other rules relating to those functions the executive director is required to carry
out pursuant to the provisions of this title.
(2) Nothing in this section shall be construed to affect any specific statutory provision
granting rule-making authority in relation to a specific program to the executive director.
Source: L. 94: Entire section added, p. 1556, § 1, effective July 1. L. 95: (4) amended,
p.1105, § 43, effective May 31. L. 2006: Entire part amended, p. 1786, § 1, effective July 1.
25.5-1-109. Department of health care policy and financing cash fund. All moneys
collected by the state department as fees or otherwise shall be transmitted to the state treasurer,
who shall credit the same to the department of health care policy and financing cash fund, which
fund is hereby created in the state treasury. Moneys in the fund shall be subject to annual
appropriation by the general assembly for the direct and indirect costs of the state department's
duties as provided by law.
Source: L. 94: Entire section added, p. 1941, § 3, effective July 1. L. 2006: Entire part
amended, p. 1787, § 1, effective July 1.
25.5-1-109.5. Clinical standards - development. (1) The general assembly finds that:
(a) It is important to collect and analyze objective clinical standards to maximize the
scarce dollars available for medical care; and
(b) The development of an ongoing, transparent measurement of health outcomes is
essential to ensure quality health care for Coloradans.
(2) (a) The state department, following consultation with external clinical advisors, shall
develop clinical standards and methods for collecting, analyzing, and disclosing information
regarding clinical performance, including but not limited to immunization rates, medical home
standards, clinical care guidelines, care coordination, case management, disease management,
and coordination and integration of mental health services. The standards and methods shall be
consistent with national guidelines and standards regarding the collection and analysis of health
data, where feasible, and shall meet the federal reporting requirements established under Titles
XIX and XXI of the federal "Social Security Act", 42 U.S.C. secs. 1396 and 1397.
(b) Repealed.
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Source: L. 2007: Entire section added, p. 1495, § 9, effective July 1. L. 2016: (2)(b)
repealed, (HB 16-1081), ch. 22, p. 50, § 1, effective August 10.
Cross references: For the legislative declaration contained in the 2007 act enacting this
section, see section 1 of chapter 347, Session Laws of Colorado 2007.
25.5-1-110. Study of children's access to health care coverage - acceptance of
donations - repeal. (Repealed)
Source: L. 2002: Entire section added, p. 1612, § 1, effective June 7. L. 2003: (4)
amended, p. 2009, § 89, effective May 22. L. 2006: Entire part amended, p. 1787, § 1, effective
July 1.
Editor's note: Subsection (6) provided for the repeal of this section, effective July 1,
2005. (See L. 2002, p. 1612.)
25.5-1-111. Waiver applications - authorization. (Deleted by amendment)
Source: L. 2002: Entire section added, p. 1308, § 27, effective June 7. L. 2006: Entire
part amended, p. 1787, § 1, effective July 1.
25.5-1-112. Drug-purchasing pool - report - repeal. (Repealed)
Source: L. 2004: Entire section added, p. 1995, § 9, effective June 5. L. 2006: Entire
part amended, p. 1787, § 1, effective July 1.
Editor's note: Subsection (3) provided for the repeal of this section, effective July 1,
2005. (See L. 2004, p. 1995.)
25.5-1-113. Federal authorization - repeal. (Deleted by amendment)
Source: L. 2005: Entire section added, p. 1230, § 9, effective June 3. L. 2006: Entire
part amended, p. 1787, § 1, effective July 1.
25.5-1-113.5. Children's access to health care - reports. (Repealed)
Source: L. 2007: Entire section added, p. 1494, § 8, effective July 1. L. 2017: Entire
section repealed, (HB 17-1060), ch. 6, p. 14, § 1, effective March 1.
25.5-1-114. Grants-in-aid - county supervision. (1) The state department shall consult
with and coordinate with the counties before making any changes that affect county operations
in the implementation of this section, when possible under state statutes and federal statutes and
regulations.
(2) In administering any funds appropriated or made available to the state department for
medical assistance administration, the state department has the power to:
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(a) Require as a condition for receiving grants-in-aid that each county in this state shall
bear the proportion of the total expense of furnishing medical assistance administration as is
fixed by law relating to such assistance;
(b) Terminate any grants-in-aid to any county of this state if the laws and regulations
providing such grants-in-aid and the minimum standards prescribed by rules of the state
department thereunder are not complied with;
(c) Undertake forthwith the administration of any or all medical assistance within any
county of this state which has had any or all of its grants-in-aid terminated pursuant to paragraph
(b) of this subsection (2); but the county shall continue to meet the requirements of paragraph (a)
of this subsection (2);
(d) Recover any moneys owed by a county to the state by reducing the amount of any
payments due from the state in connection with the administration of medical assistance;
(e) Take any other action which may be necessary or desirable for carrying out the
provisions of this title.
(3) The state department, under the supervision of the executive director, shall provide
supervision of county departments for the effective administration of medical assistance as set
out in the rules of the executive director and the rules of the state board pursuant to section
25.5-1-301; except that nothing in this subsection (3) shall be construed to allow counties to
continue to receive an amount equal to the increased funding in the event the said funding is no
longer available from the federal government.
Source: L. 2006: Entire part amended, p. 1787, § 1, effective July 1.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
25.5-1-114.5. Medicaid fraud detection - request for information. (1) In enacting this
section, the general assembly intends to:
(a) Implement waste, fraud, and abuse detection, prevention, and recovery solutions to
improve program integrity in the state's medicaid program and create efficiency and cost savings
through a shift from a retrospective "pay and chase" model to a prospective prepayment model;
and
(b) Invest in the most cost-effective technologies or strategies that yield the highest
return on investment.
(2) By September 30, 2013, the state department shall issue a request for information to
seek input from potential contractors on capabilities that the state department does not currently
possess, functions that the state department is not currently performing, and the cost structures
associated with implementing:
(a) Advanced predictive modeling and analytics technologies to provide a
comprehensive and accurate view across all providers, recipients, and geographic locations
within the medicaid program in order to:
(I) Identify and analyze those billing and utilization patterns that represent a high risk of
fraudulent activity;
(II) Be easily integrated into the existing medicaid program claims operations;
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(III) Undertake and automate such analysis before payment is made to minimize
disruptions to state department operations and speed claim resolution;
(IV) Prioritize the identified transactions for additional review before payment is made
based upon the likelihood of potential waste, fraud, or abuse;
(V) Obtain outcome information from adjudicated claims to allow for refinement and
enhancement of the predictive analytics technologies based on historical data and algorithms
with the system; and
(VI) Prevent the payment of claims for reimbursement that have been identified as
potentially wasteful, fraudulent, or abusive until the claims have been automatically verified as
valid;
(b) Provider and recipient data verification and screening technology solutions, which
may use publicly available records, for the purposes of automating reviews and identifying and
preventing inappropriate payments by:
(I) Identifying associations between providers, practitioners, and beneficiaries that
indicate rings of collusive fraudulent activity; and
(II) Discovering recipient attributes that indicate improper eligibility, including but not
limited to death, out-of-state residency, inappropriate asset ownership, or incarceration; and
(c) Fraud investigation services that combine retrospective claims analysis and
prospective waste, fraud, or abuse detection techniques. These services must include analysis of
historical claims data, medical records, suspect provider databases, and high-risk identification
lists, as well as direct recipient and provider interviews. Emphasis must be placed on the state
department providing education to providers and allowing them the opportunity to review and
correct any problems identified prior to administrative proceedings.
(3) In addition to the information provided pursuant to subsection (2) of this section, a
potential contractor responding to the request for information shall include information
concerning:
(a) The extent to which the potential contractor will seek clinical and technical expertise
from Colorado providers concerning the design and implementation of the medicaid fraud
detection system described in this section and the method or methods for seeking that expertise;
and
(b) The potential contractor's ability to create an education and outreach program that is
widely available and easily accessible to Colorado providers for purposes of educating providers
on issues relating to coverage and coding.
(4) (a) The state department is encouraged to use the results of the request for
information to create formal requests for proposals to carry out the work identified in this section
if the following conditions are met:
(I) The state department expects to generate state savings by preventing fraud, waste,
and abuse;
(II) This work can be integrated into the state department's current medicaid operations
without creating additional costs to the state; and
(III) The reviews or audits are not anticipated to delay or improperly deny the payment
of legitimate claims to providers.
(b) Prior to awarding any contract pursuant to this section, the state department shall
establish an appeal process for providers that minimizes the administrative burden placed on
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providers, limits the number of medical records requests, and provides adequate time for
providers to respond to inquiries.
(5) It is the intent of the general assembly that the savings achieved through this section
must more than cover the cost of implementation and administration. Therefore, to the extent
possible, technology services used in carrying out this section must be secured using the savings
generated by the program, with the state's direct cost funded through the actual savings achieved.
Source: L. 2013: Entire section added, (SB 13-137), ch. 285, p. 1501, § 1, effective
August 7.
25.5-1-115. Locating violators - recoveries. (1) The executive director of the state
department, or district attorneys may request and shall receive from departments, boards,
bureaus, or other agencies of the state or any of its political subdivisions, and the same are
authorized to provide, such assistance and data as will enable the state department and county
departments properly to carry out their powers and duties to locate and prosecute any person
who has fraudulently obtained medical assistance under this title. Any records established
pursuant to the provisions of this section shall be available only to the state department, the
department of human services, the county departments, the attorney general, and the district
attorneys, county attorneys, and courts having jurisdiction in fraud or recovery proceedings or
actions.
(2) (a) All departments and agencies of the state and local governments shall cooperate
in the location and prosecution of any person who has fraudulently obtained medical assistance
under this title, and, on request of the county board, the county director, the state department, or
the district attorney of any judicial district in this state, shall supply all information on hand
relative to the location, employment, income, and property of such persons, notwithstanding any
other provision of law making such information confidential, except the laws pertaining to
confidentiality of any tax returns filed pursuant to law with the department of revenue. The
department of revenue shall furnish at no cost to inquiring departments and agencies such
information as may be necessary to effectuate the purposes of this article. The procedures
whereby this information will be requested and provided shall be established by rule of the state
department. The state department or county departments shall use such information only for the
purposes of administering medical assistance under this title, and the district attorney shall use it
only for the prosecution of persons who have fraudulently obtained medical assistance under this
title, and shall not use the information, or disclose it, for any other purpose.
(b) (I) Whenever the state department, or a district attorney for the state department, or
the state department on behalf of a county department, recovers any amount of fraudulently
obtained medical assistance funds, the federal government shall be entitled to a share
proportionate to the amount of federal funds paid unless a different amount is otherwise
provided by federal law, the state shall be entitled to a share proportionate to the amount of state
funds paid and such additional amounts of federal funds recovered as provided by federal law,
and the county department shall be entitled to a share proportionate to the amount of county
funds paid unless a different amount is provided pursuant to federal law or this section.
(II) (A) Whenever a county department, a county board, a district attorney, or a state
department on behalf of a county department recovers any amount of fraudulently obtained
public assistance funds in the form of assistance payments, it shall be deposited in the county
Colorado Revised Statutes 2023 Uncertified PrintoutPage 11 of 510
social services fund, and the federal government is entitled to a share proportionate to the
amount of federal funds paid, unless a different amount is provided for by federal law, the state
is entitled to a share proportionate to one-half the amount of state funds paid, and the county is
entitled to a share proportionate to the amount of county funds paid and, in addition, a share
proportionate to one-half the amount of state funds paid.
(B) Whenever a county department, a county board, a district attorney, or a state
department on behalf of a county department recovers any amount of fraudulently obtained
medical assistance, it shall be deposited in the county social services fund, and the federal
government is entitled to a share proportionate to the amount of federal funds paid, unless a
different amount is provided for by federal law, and the county is entitled to the remaining funds.
(3) Whenever a county department, a county board, a district attorney, or the state
department on behalf of the county recovers any amount of medical assistance payments that
were obtained through unintentional client error, the federal government shall be entitled to a
share proportionate to the amount of federal funds paid, unless a different amount is provided for
by federal law, the state shall be entitled to a share proportionate to seventy-five percent of the
amount of state funds paid, the county shall be entitled to a share proportionate to the amount of
county funds paid, if any, and, in addition, a share proportionate to twenty-five percent of the
amount of state funds paid.
(4) Actual costs and expenses incurred by the district attorney's office in carrying out the
provisions of subsection (2) of this section shall be billed to counties or a county within the
judicial district in the proportions specified in section 20-1-302, C.R.S. Each county shall make
an annual accounting to the state department on all amounts recovered.
Source: L. 2006: Entire part amended, p. 1788, § 1, effective July 1. L. 2012: (2)(b)(II)
amended, (SB 12-060), ch. 166, p. 578, § 3, effective August 8.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
25.5-1-115.5. Medical assistance fraud - report. (1) Notwithstanding the provisions of
section 24-1-136 (11)(a)(I), on or before November 1, 2017, and on or before November 1 each
year thereafter, the state department shall submit a written report to the joint budget committee;
the judiciary committee and the public health care and human services committee of the house of
representatives, or their successor committees; and to the judiciary committee and the health and
human services committee of the senate, or their successor committees, concerning fraud in the
medicaid program. The state department shall compile a single, comprehensive report that
includes the information described in this subsection (1), as well as information that the attorney
general provides to the state department pursuant to section 25.5-4-303.3. The state department
shall report to the general assembly concerning the fraudulent receipt of medicaid benefits,
including, at a minimum:
(a) Investigations of client fraud during the year;
(b) Termination of client medicaid benefits due to fraud;
(c) District attorney action, including, at a minimum, criminal complaints requested,
cases dismissed, cases acquitted, convictions, and confessions of judgment;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 12 of 510
(d) Recoveries, including fines and penalties, restitution ordered, and restitution
collected;
(e) Trends in methods used to commit client 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.
Source: L. 2012: Entire section added, (SB 12-060), ch. 166, p. 577, § 1, effective
August 8. L. 2017: IP(1) amended, (HB 17-1060), ch. 6, p. 14, § 2, effective March 1; IP(1),
(1)(d), and (1)(e) amended and (1)(f) added, (SB 17-295), ch. 298, p. 1636, § 1, effective August
9.
Editor's note: Amendments to the introductory portion of subsection (1) by HB 17-1060
and SB 17-295 were harmonized.
25.5-1-116. Records confidential - authorization to obtain records of assets - release
of location information to law enforcement agencies - outstanding felony arrest warrants.
(1) The state department may establish reasonable rules to provide safeguards restricting the use
or disclosure of information concerning applicants, recipients, and former and potential
recipients of medical assistance to purposes directly connected with the administration of such
medical assistance and related state department activities and covering the custody, use, and
preservation of the records, papers, files, and communications of the state and county
departments. Whenever, under provisions of law, names and addresses of applicants for,
recipients of, or former and potential recipients of medical assistance are furnished to or held by
another agency or department of government, such agency or department shall be required to
prevent the publication of lists thereof and their uses for purposes not directly connected with the
administration of such medical assistance.
(2) (a) (I) Except as provided in subparagraphs (II) and (III) of this paragraph (a), it is
unlawful for any person to solicit, disclose, or make use of or to authorize, knowingly permit,
participate in, or acquiesce in the use of any lists or names of or any information concerning
persons applying for or receiving public assistance and welfare directly or indirectly derived
from the records, papers, files, or communications of the state or county departments or
subdivisions or agencies thereof or acquired in the course of the performance of official duties.
No financial institution or insurance company that provides the data, whether confidential or not,
required by the state department, in accordance with the provisions of this subsection (2), shall
be liable for the provision of the data to the state department nor for any use made thereof by the
state department.
(II) The information described in subparagraph (I) of this paragraph (a) may be disclosed
for purposes directly connected with the administration of medical assistance and in accordance
with this paragraph (a) and paragraphs (b) and (c) of this subsection (2) and with the rules of the
state department.
(III) (A) Notwithstanding any provision of state law to the contrary and to the extent
allowable under federal law, at the request of the Colorado bureau of investigation, the state
department shall provide the bureau with information concerning the location of any person
whose name appears in the department's records who is the subject of an outstanding felony
Colorado Revised Statutes 2023 Uncertified PrintoutPage 13 of 510
arrest warrant. Upon receipt of such information, it shall be the responsibility of the bureau to
provide appropriate law enforcement agencies with location information obtained from the state
department. Location information provided pursuant to this section shall be used solely for law
enforcement purposes. The state department and the bureau shall determine and employ the most
cost-effective method for obtaining and providing location information pursuant to this section.
Neither the state department nor its employees or agents shall be liable in civil action for
providing information in accordance with the provisions of this sub-subparagraph (A).
(B) As used in sub-subparagraph (A) of this subparagraph (III), "law enforcement
agency" means any agency of the state or its political subdivisions that is responsible for
enforcing the laws of this state. "Law enforcement agency" includes but is not limited to any
police department, sheriff's department, district attorney's office, the office of the state attorney
general, and the Colorado bureau of investigation.
(b) By signing an application or redetermination of eligibility form for medical
assistance, an applicant authorizes the state department to obtain records pertaining to
information provided in that application or redetermination of eligibility form from a financial
institution, as defined in section 15-15-201 (4), C.R.S., or from any insurance company. The
application or redetermination of eligibility form shall contain language clearly indicating that
signing constitutes such an authorization.
(c) (I) In order to determine if applicants for or recipients of medical assistance have
assets within eligibility limits, the state department may provide a list of information identifying
these applicants or recipients to any financial institution, as defined in section 15-15-201 (4),
C.R.S., or to any insurance company. This information may include identification numbers or
social security numbers. The state department may require any such financial institution or
insurance company to provide a written statement disclosing any assets held on behalf of
individuals adequately identified on the list provided. Before a termination notice is sent to the
recipient, the county department or the medical assistance site in verifying the accuracy of the
information obtained as a result of the match shall contact the recipient and inform the recipient
of the apparent results of the computer match and give the recipient the opportunity to explain or
correct any erroneous information secured by the match. The requirement to run a computerized
match shall apply only to information that is entered in the financial institution's or insurance
company's data processing system on the date the match is run and shall not be deemed to
require any such institution or company to change its data or make new entries for the purpose of
comparing identifying information. The cost of providing such computerized match shall be
borne by the state department.
(II) For the fiscal year beginning July 1, 1984, and thereafter, all funds expended by the
state department to pay the cost of providing such computerized matches shall be subject to an
annual appropriation by the general assembly.
(III) The state department may expend funds appropriated pursuant to subparagraph (II)
of this paragraph (c) in an amount not to exceed the amount of annualized general fund savings
that result from the termination of recipients from medical assistance specifically due to
disclosure of assets pursuant to this subsection (2).
(d) No applicant shall be denied nor any recipient discontinued due to the disclosure of
their assets unless and until the county department or medical assistance site has assured that
such assets taken together with other assets exceed the limit for eligibility of countable assets.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 14 of 510
Any information concerning assets found may be used to determine if such applicant's or
recipient's eligibility for other medical assistance is affected.
(3) The applicant for or recipient of medical assistance, or his or her representative, shall
have an opportunity to examine all applications and pertinent records concerning said applicant
or recipient which constitute a basis for denial, modification, or termination of such medical
assistance or to examine such records in case of a fair hearing.
(4) Any person who violates subsection (1) or (2) of this section commits a petty
offense.
Source: L. 2006: Entire part amended, p. 1790, § 1, effective July 1. L. 2021: (4)
amended, (SB 21-271), ch. 462, p. 3240, § 481, effective March 1, 2022.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
25.5-1-117. County departments - district departments. (1) Except as provided in
subsection (2) of this section, there is established in each county of the state a county department
of human or social services that consists of a county board of human or social services, a county
director of human or social services, and any additional employees as may be necessary for the
efficient performance of public assistance, as defined in section 26-2-103 (7), and medical
assistance.
(2) [Editor's note: This version of subsection (2) is effective until July 1, 2024.] Single
entry point agencies established pursuant to part 1 of article 6 of this title 25.5, other than county
departments of human or social services acting as single entry point agencies, may act as state
designated agencies and are authorized to carry out functions as specified in part 1 of article 6 of
this title 25.5 that are otherwise performed by county departments of human or social services.
(2) [Editor's note: This version of subsection (2) is effective July 1, 2024.] Case
management agencies established pursuant to part 17 of article 6 of this title 25.5 may act as
state designated agencies and are authorized to carry out functions as specified in part 17 of
article 6 of this title 25.5 that are otherwise performed by county departments of human or social
services.
(3) With the approval of the state department of human services, two or more counties
may jointly establish a district department of human or social services. All duties and
responsibilities for county departments of human or social services set forth in this title 25.5 also
apply to district departments of human or social services.
Source: L. 2006: Entire part amended, p. 1792, § 1, effective July 1. L. 2018: Entire
section amended, (SB 18-092), ch. 38, p. 444, § 108, effective August 8. L. 2021: (2) amended,
(HB 21-1187), ch. 83, p. 331, § 22, effective July 1, 2024.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
Cross references: For the legislative declaration in SB 18-092, see section 1 of chapter
38, Session Laws of Colorado 2018.
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25.5-1-118. Duties of county departments. (1) The county departments or other state
designated agencies, where applicable, shall serve as agents of the state department and shall be
charged with the administration of medical assistance and related activities in the respective
counties in accordance with the rules of the state department.
(2) The county departments or other state designated agencies, where applicable, shall
report to the state department at such times and in such manner and form as the state department
may from time to time direct.
(3) The county department or other state designated agencies, where applicable, in each
county shall submit quarterly and annually to the board of county commissioners a budget
containing an estimate and supporting data setting forth the amount of money needed to carry
out the provisions of this title.
Source: L. 2006: Entire part amended, p. 1793, § 1, effective July 1.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
25.5-1-119. County staff. The county director, with the approval of the county board,
shall appoint such staff as may be necessary as determined by the state department rules to
administer medical assistance within the county. The staff shall be appointed and shall serve in
accordance with a merit system for the selection, retention, and promotion of county department
employees as described in section 26-1-120, C.R.S. The salaries of the staff members shall be
fixed in accordance with the rules and salary schedules prescribed by the state department or the
department of human services, whichever is appropriate; except that, once a county transfers its
county employees to a successor merit system as provided in section 26-1-120, C.R.S., the
salaries shall be fixed by the county commissioners.
Source: L. 2006: Entire part amended, p. 1793, § 1, effective July 1.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
25.5-1-120. Appropriations. (1) (a) For carrying out the duties and obligations of the
state department and county departments under the provisions of this title and for matching such
federal funds or meeting maintenance of effort requirements as may be available for public
assistance and welfare activities in the state, including medical assistance administration and
related activities, the general assembly, in accordance with the constitution and laws of the state
of Colorado, shall make adequate appropriations for the payment of such costs, pursuant to the
budget prepared by the executive director.
(b) If the federal law shall provide federal funds, in cash or in another form such as
medical assistance, not otherwise provided for in this title, the state department is authorized to
make such payments or offer such services in accordance with the requirements accompanying
said federal funds within the limits of available state appropriations.
(c) When the executive director determines that adequate appropriations for the payment
of the costs described in paragraph (a) of this subsection (1) have not been made and that an
Colorado Revised Statutes 2023 Uncertified PrintoutPage 16 of 510
overexpenditure of an appropriation will occur based upon the state department's estimates, the
state board may take actions consistent with state and federal law to bring the rate of expenditure
into line with available funds. The general assembly declares that case load and utilization based
on medical necessity are legitimate reasons for supplemental funding.
(2) The general assembly shall appropriate from the general fund to the state department
moneys for the costs of administering medical assistance programs and the state's share of the
costs of administering such functions by the county departments amounts sufficient for the
proper and efficient performance of the duties imposed upon them by law, including a legal
advisor appointed by the attorney general. The general assembly shall make two separate
appropriations, one for the administrative costs of the state department and another for the
administrative costs of the county departments. Any applicable matching federal funds shall be
apportioned in accordance with the federal regulations accompanying such funds. Any
unobligated and unexpended balances of appropriated state general funds remaining at the end of
each fiscal year shall be credited to the state general fund.
(3) The expenses of training personnel for special skills relating to medical assistance, as
such expenses shall be determined and approved by the state department, may be paid from state
and federal funds available for such training purposes.
Source: L. 2006: Entire part amended, p. 1793, § 1, effective July 1.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
25.5-1-121. County expenditures - advancements - procedures. (1) For purposes of
this article, under rules of the state department, administrative costs shall include: Salaries of the
county director and employees of the county department staff engaged in the performance of
medical assistance activities; the county's payments on behalf of such employees for old age and
survivors' insurance or pursuant to a county officers' and employees' retirement plan and for any
health insurance plan, if approved by the state department; the necessary travel expenses of the
county board and the administrative staff of the county department in the performance of their
duties; necessary telephone and other electronic means of communication; necessary equipment
and supplies; necessary payments for postage and printing, including the printing and
preparation of county warrants required for the administration of the county department; and
such other administrative costs as may be approved by the state department; but advancements
for office space, utilities, and fixtures may be made from state funds only if federal matching
funds are available.
(2) Notwithstanding any other provision of this article, the county department may spend
in excess of twenty percent of actual costs for the purpose of matching federal funds for the
administration of the child support enforcement program or for the administrative costs of
activities involving food stamp, public assistance, or medical assistance fraud investigations or
prosecutions.
(3) (a) Notwithstanding any other provision of this article, the county department may
receive and spend federal funds to which it is entitled based on the county's certification of
public expenditures for administrative costs made by other entities within the county, which
expenditures:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 17 of 510
(I) Are from sources other than the county social services fund;
(II) Are in excess of the county department's portion, as required pursuant to section
25.5-1-114 (2)(a), of the administrative costs; and
(III) Are for an administrative activity that has been approved by the state department as
an activity that is eligible for reimbursement under a federal program.
(b) Acceptance and expenditure of federal funds pursuant to paragraph (a) of this
subsection (3) shall not affect the state's share of and contribution to the administrative costs.
The county shall be solely responsible for certifying the nonfederal share that is in excess of the
county's required portion of the administrative costs. The state department may retain up to five
percent of any federal funds received by a county department pursuant to this subsection (3). In
addition, the state, in accordance with the provisions of section 26-1-109 (4)(d), C.R.S., shall
recover any federal funds received by the county through the certification of public expenditures
that are subsequently determined to be ineligible for federal reimbursement.
Source: L. 2006: Entire part amended, p. 1794, § 1, effective July 1. L. 2011: (3) added,
(HB 11-1196), ch. 160, p. 555, § 6, effective August 10.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
25.5-1-122. County appropriation increases - limitations. (1) Beginning in calendar
fiscal year 1994 and for each calendar fiscal year thereafter to and including calendar fiscal year
1997, the board of county commissioners in each county of this state shall annually appropriate
funds for the county share of the administrative costs of medical assistance in the county in an
amount equal to the actual county share for the previous fiscal year adjusted by an amount equal
to the actual county share for the previous fiscal year multiplied by the percentage of change in
property tax revenue.
(2) For the purposes of this section:
(a) "County share" means the actual amount of the county share for the previous fiscal
year. "County share" shall not include:
(I) The amount expended by the county from the county contingency fund or the county
tax base relief fund pursuant to section 26-1-126, C.R.S.;
(II) The amount expended by the county for general assistance pursuant to part 1 of
article 17 of title 30, C.R.S.; and
(III) The amount expended by the county for programs or services provided by the
county on its own, without requirements or funding from any other governmental agency.
(b) "Percentage of change in property tax revenue" means the difference between the
total property tax levied for the previous fiscal year less the amount levied for debt service for
the previous fiscal year and the total property tax levied for the year for which the percentage of
change in tax revenue is being calculated less the amount levied for debt service for the year in
which the percentage of change in tax revenue is being calculated divided by the total property
tax levied for the previous fiscal year less the amount levied for debt service for the previous
fiscal year.
(3) Notwithstanding the provisions of section 25.5-1-121, a county in the state shall not
be required to contribute more than the amount set forth in subsection (1) of this section in any
Colorado Revised Statutes 2023 Uncertified PrintoutPage 18 of 510
fiscal year. Nothing in this section shall be construed to limit the ability of a county to establish
programs or services provided by the county on its own, without requirements or funding from
any other governmental agency.
(4) (Deleted by amendment, L. 2008, p. 1812, § 3, effective June 2, 2008.)
(5) Any amounts remaining in the county social services fund created in section
26-1-123, C.R.S., at the end of any fiscal year shall remain in the county fund for expenditure as
determined by the board of county commissioners for administrative costs of public assistance,
medical assistance, and food stamps, and program costs of public assistance and food stamps.
(6) The limitation set forth in this section on the increase in the county share of the
administrative costs of medical assistance will result in increased costs to the state. By making
state funds available, the state is encouraging counties not to exercise any right a county may
have pursuant to section 20 (9) of article X of the Colorado constitution to reduce or end its
share of the costs of medical assistance administration for the county for three fiscal years
following the fiscal year in which the state funds are received. If a county accepts funds from the
state based on the limitation provided in this section for any fiscal year, the county agrees not to
exercise any rights the county may have to reduce or end its share of the costs of medical
assistance administration for the fiscal year in which the funds are accepted. Nothing in this
subsection (6) or any agreement pursuant to this subsection (6) shall be construed to affect the
existence or status of any rights accruing to the state or any county pursuant to section 20 (9) of
article X of the Colorado constitution.
Source: L. 2006: Entire part amended, p. 1795, § 1, effective July 1. L. 2008: (2)(a)(I)
and (4) amended, p. 1812, § 3, effective June 2.
Editor's note: This section was contained in a 2006 act that amended this part, resulting
in the addition of this section.
25.5-1-123. Medical homes for children - legislative declaration - duties of the
department. (1) The general assembly hereby finds and declares that:
(a) The best medical care for infants, children, and adolescents is provided through a
medical home, as defined in section 25.5-1-103, and that is consistent with the joint principles of
a patient-centered medical home. Those principles shall include a whole-person orientation, care
that is coordinated and integrated across all elements of the complex health-care system and the
patient's community, and care that provides for quality and safety of the patient where qualified
health-care practitioners provide primary care and help manage and facilitate all aspects of
medical care.
(b) Infants, children, and adolescents and their families work best with a health-care
practitioner who knows the family and who develops a partnership of mutual responsibility and
trust;
(c) Medical care provided through emergency departments, walk-in clinics, and other
urgent-care facilities is often more costly and less effective than care given by a physician with
prior knowledge of the child and his or her family; and
(d) The state department should strive to find a medical home for each child receiving
services through the state medical assistance program, articles 4, 5, and 6 of this title, or the
children's basic health plan, article 8 of this title.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 19 of 510
(2) On or before July 1, 2008, the state department, in conjunction with the Colorado
medical home initiative in the department of public health and environment, shall develop
systems and standards to maximize the number of children enrolled in the state medical
assistance program or the children's basic health plan who have a medical home. The systems
and standards developed shall include, but need not be limited to, ways to ensure that a medical
home shall offer family-centered, compassionate, culturally effective care and sensitive,
respectful communication to a child and his or her family.
(3) Repealed.
Source: L. 2007: Entire section added, p. 1488, § 2, effective May 31. L. 2017: (3)
repealed, (HB 17-1060), ch. 6, p. 15, § 3, effective March 1.
25.5-1-124. Early intervention payment system - participation by state department -
rules - definitions. (1) The state department shall participate in the development and
implementation of the coordinated system of payment for early intervention services authorized
pursuant to part 4 of article 3 of title 26.5 and part C of the federal "Individuals with Disabilities
Education Act", 20 U.S.C. sec. 1400 et seq., as amended.
(2) The state department shall ensure that the early intervention services and payments
for recipients of medical assistance pursuant to this title 25.5 are integrated into the coordinated
early intervention payment system developed pursuant to part 4 of article 3 of title 26.5. To the
extent necessary to achieve the coordinated payment system and coverage of those early
intervention services pursuant to this title 25.5, the state department shall amend the state plan
for medical assistance or seek the necessary federal authorization, promulgate rules, and modify
the billing system for medical assistance to facilitate the coordinated payment system.
(3) The state department shall also make any modifications necessary to the "Children's
Basic Health Plan Act", article 8 of this title 25.5, including promulgating rules, to ensure that
the children's basic health plan is integrated into the coordinated early intervention payment
system developed pursuant to part 4 of article 3 of title 26.5.
(4) Repealed.
(5) (a) As used in this section, unless the context otherwise requires, "early intervention
services" means those services defined as early intervention services by the department of early
childhood in accordance with section 26.5-3-402 (9) that are determined, through negotiation
between the state department and the department of early childhood, to be medically necessary
under medical assistance and cost-effective. After negotiating the scope of early intervention
services to be covered under medical assistance, the state department and the department of early
childhood shall submit to the joint budget committee of the general assembly, as part of each
department's annual budget request, a proposal for the scope of coverage of early intervention
services under medical assistance, including the anticipated costs of such coverage and whether
the payment of such costs through medical assistance is cost-effective.
(b) "Early intervention services" shall not include the following:
(I) Nonemergency medical transportation;
(II) Respite care;
(III) Service coordination, as defined in 34 CFR 303.12 (d)(11); and
(IV) (A) Assistive technology.
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(B) The exclusion of assistive technology shall not apply to durable medical equipment
that is otherwise covered under the children's basic health plan, as defined in section 25.5-8-103
(2).
Source: L. 2007: Entire section added, p. 888, § 2, effective July 1. L. 2008: (5)(a)
amended, p. 1468, § 14, effective August 5. L. 2012: (4) repealed, (HB 12-1247), ch. 53, p. 196,
§ 6, effective March 22. L. 2022: (1), (2), (3), and (5)(a) amended, (HB 22-1295), ch. 123, p.
847, § 74, effective July 1.
25.5-1-125. Centennial care choices - value benefit plans - request for information -
request for proposals - report to general assembly - definitions - legislative declaration.
(Repealed)
Source: L. 2008: Entire section added, p. 2057, § 1, effective June 3. L. 2010: (2)(b)(VI)
amended, (HB 10-1422), ch. 419, p. 2109, § 137, effective August 11. L. 2013: Entire section
repealed, (HB 13-1139), ch. 120, p. 407, § 1, effective August 7.
25.5-1-126. Discounted prices for durable medical equipment and supplies. (1) The
state department shall work with one or more nonprofit organizations to develop a link of
approved vendors who are willing to sell durable medical equipment and medical supplies at
discounted prices to persons who have applied for, but are not yet receiving, benefits under the
"Colorado Medical Assistance Act". The state department shall provide the exclusive criteria for
a nonprofit organization to use to approve a vendor for placement on the approved vendor list.
(2) The state department shall maintain a link of approved vendors developed pursuant
to this section and shall:
(a) Make the link available on the state department's website; and
(b) Provide copies of the list to county departments and to sites authorized to accept
medical assistance applications pursuant to section 25.5-4-205 (1), through the survey given to
applicants.
Source: L. 2010: Entire section added, (HB 10-1029), ch. 219, p. 958, § 1, effective May
10.
25.5-1-127. Third-party benefit denials information. The state department shall
provide information to recipients of benefits under this title concerning their right to appeal a
denial of benefits by a third party and shall post information on the state department's website
concerning recipients' abilities to appeal a third party's denial of benefits, including but not
limited to providing a link to information on the insurance commissioner's website regarding
such appeals.
Source: L. 2010: Entire section added, (SB 10-002), ch. 366, p. 1727, § 2, effective June
7.
Cross references: For the legislative declaration in the 2010 act adding this section, see
section 1 of chapter 366, Session Laws of Colorado 2010.
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25.5-1-128. Provider payments - compliance with state fiscal requirements -
definitions - rules. (1) (a) Notwithstanding any provision of law to the contrary, when the state
department has regulatory authority over a program and when the provider has already signed a
state department-approved provider application to provide a service or to bill the state
department or its authorized contractor for a service, the state department-approved provider
application shall serve to fulfill the requirements of a commitment voucher and the fiscal
requirements of section 24-30-202 (1), C.R.S.
(b) The executive director may promulgate rules to exempt a provider who provides
services through a program as described in paragraph (a) of this subsection (1) for any program
the state department is authorized by law to administer, including but not limited to:
(I) The "Colorado Medical Assistance Act", articles 4 to 6 of this title;
(II) The "Children's Basic Health Plan Act", article 8 of this title;
(III) The "Colorado Indigent Care Program", part 1 of article 3 of this title;
(IV) The school health services program authorized by section 25.5-5-318;
(V) Programs that are funded through the primary care fund, created in section
24-22-117 (2)(b), C.R.S.; and
(VI) The state-funded old age pension health and medical care program pursuant to
article 2 of this title.
(2) As used in this section, unless the context otherwise provides, "provider" means a
health-care provider, a mental health-care provider, a pharmacist, a home health agency, a
general provider as defined in section 25.5-3-103 (3), school district as defined in section
25.5-5-318 (1)(a), or any other entity that provides health care, health-care coordination,
outreach, enrollment, or administrative support services to recipients through fee-for-service, the
primary care physician program, a managed care entity, a behavioral health organization, a
medical home, or any system of care that coordinates health care or services as defined and
authorized through rules promulgated by the state board or by the executive director.
Source: L. 2012: Entire section added, (HB 12-1054), ch. 14, p. 36, § 1, effective March
15.
25.5-1-129. State department proposal - state option for health-care coverage -
report to general assembly - waiver authorization - legislative declaration. (1) (a) The
general assembly finds that:
(I) Every Coloradan deserves access to high-quality, affordable health care to help
support his or her well-being and economic security;
(II) To achieve these goals, Colorado has successfully implemented provisions of the
federal "Patient Protection and Affordable Care Act" that have helped expand access and
increase affordability to thousands of Coloradans, including expanding medicaid coverage to
more low-income adults and creating the Colorado health benefit exchange;
(III) Despite this success, in several regions of the state, health insurance is not
affordable due to high health-care costs and limited or no competition among insurance carriers
as well as other marketplace factors, and Coloradans cannot afford the health insurance
premiums and out-of-pocket expenses;
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(IV) Specifically, Coloradans in fourteen counties have access to only a single health
insurance carrier participating in the Colorado health benefit exchange, and the number of
uninsured Coloradans in those counties is rising;
(V) Colorado has historically been a national leader in health-care innovation;
(VI) Uncertainty at the federal level requires Colorado to be proactive and explore and
implement its own innovative solutions to provide greater access to affordable, high-quality
health-care coverage for Colorado residents; and
(VII) A state option for health-care coverage that uses existing state health-care
infrastructure may decrease costs for Coloradans, increase competition, and improve access to
high-quality, affordable, and efficient health care.
(b) Therefore, the general assembly declares that tasking the state department and the
division of insurance in the department of regulatory agencies, referred to in this section as "the
division", with developing a proposal that considers the feasibility and cost of implementing a
state option for health-care coverage that leverages existing state health-care infrastructure,
increases competition, improves quality, and provides stable access to affordable health
insurance will enable policymakers to consider and create an innovative state option for health
insurance coverage to benefit Colorado.
(2) (a) On or before November 15, 2019, the state department and the division shall
develop and submit a proposal to the joint budget committee; the public health care and human
services and health and insurance committees of the house of representatives; and the health and
human services committee of the senate, or any successor committees, for a state option for
health-care coverage that leverages existing state infrastructure.
(b) In addition to submitting the proposal to the committees of the general assembly
listed in subsection (2)(a) of this section, the state department and the division shall present a
summary of the proposal at the annual joint meeting of the house and senate committees
conducted during the legislative interim prior to the 2020 legislative session pursuant to section
2-7-203.
(3) The proposal must describe a state option for health-care coverage. The proposal
must identify the most effective implementation of a state option based on affordability to
consumers at different income levels, administrative and financial burden to the state, ease of
implementation, and likelihood of success in meeting the objectives described in subsection (1)
of this section.
(4) In developing the proposal, the state department and the division shall:
(a) Conduct actuarial research to identify the potential cost of premiums and cost sharing
to pay claims in a plan that is, at a minimum, an essential health-benefit-compliant plan, as
defined in section 10-16-102 (22);
(b) Evaluate provider rates necessary to incentivize participation and encourage network
adequacy and high-quality health-care delivery;
(c) Evaluate eligibility criteria for individuals and small businesses to participate;
(d) Determine the impact, if any, on the state budget;
(e) Determine the impact on the stability of the individual market, the small group
market, and the Colorado health benefit exchange created in article 22 of title 10;
(f) Evaluate the impact on consumers eligible for financial assistance for plans
purchased on the exchange;
(g) Determine whether a state option plan should be offered on or off the exchange;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 23 of 510
(h) Determine whether the state option plan should be a fully at-risk, managed care,
fee-for-service, or accountable care collaborative plan, or a combination thereof;
(i) Determine whether the state option should be offered through the state department,
and identify the expected impact, if any, to the Colorado medical assistance program established
in articles 4, 5, and 6 of this title 25.5;
(j) Identify the expected impact, if any, to the children's basic health plan established in
article 8 of this title 25.5;
(k) Investigate funding options, including but not limited to state funds and federal funds
secured through available waivers;
(l) Evaluate the feasibility, legality, and scope of any necessary federal waivers;
(m) Repealed.
(n) Create a statewide definition of affordability for consumers.
(5) In developing the proposal, the state department and the division shall consult with
the Colorado health benefit exchange and shall engage in a stakeholder process that includes
public and private health insurance experts, as well as consumers, consumer advocates,
employers, providers, and carriers.
(6) The proposal submitted to the committees of the general assembly pursuant to this
section must include detailed analysis of the proposed state option and the various methods for
implementing the proposed state option, as well as any identified statutory or rule changes
necessary to implement the proposed state option.
(7) (a) (I) After the proposal created pursuant to this section is submitted and presented
to the committees of the general assembly, the state department and the division shall prepare
and submit any federal waivers or state plan amendments necessary to fund and implement the
state option for health-care coverage as described in the proposal created pursuant to subsection
(2)(a) of this section.
(II) The state department's and the division's requests for federal authorization must seek
to obtain the maximum amount of federal money available to the state and to persons
participating in the state option for health-care coverage.
(b) Notwithstanding the provisions of subsection (7)(a)(I) of this section to the contrary,
the preparation and submission of federal waivers or amendments must be delayed if a member
of the general assembly files a bill during the 2020 legislative session by the regular bill filing
deadline of the house of representatives, as set forth in rule 23 of the joint rules of the senate and
house of representatives, that substantially alters the federal authorization required pursuant to
the proposal to implement the state option for health-care coverage, and such bill is not
postponed indefinitely in the first committee of reference. The department's and the division's
waiver preparation process shall resume after the bill is postponed indefinitely or, if passed by
the general assembly, the requested waivers or state plan amendments must reflect the
requirements in the passed legislation.
(c) Subject to the conditions described in subsection (7)(b) of this section, the state
department and the division may promulgate rules, as necessary, for the preparation and
submission of federal waivers or state plan amendments necessary to fund and implement the
proposal.
Source: L. 2019: Entire section added, (HB 19-1004), ch. 206, p. 2199, § 1, effective
May 17. L. 2021: (4)(m) repealed, (SB 21-266), ch. 423, p. 2801, § 19, effective July 2.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 24 of 510
25.5-1-130. Improving access to behavioral health services for individuals at risk of
entering the criminal or juvenile justice system - duties of the state department. (1) On or
before March 1, 2020, the state department shall develop measurable outcomes to monitor
efforts to prevent medicaid recipients from becoming involved in the criminal or juvenile justice
system.
(2) On or before July 1, 2021, the state department shall work collaboratively with
managed care entities to create incentives for behavioral health providers to accept medicaid
recipients with severe behavioral health disorders. The incentives may include, but need not be
limited to, higher reimbursement rates, quality payments to managed care entities for adequate
networks, establishing performance measures and performance improvement plans related to
network expansion, transportation solutions to incentivize medicaid recipients to attend
health-care appointments, and incentivizing providers to conduct outreach to medicaid recipients
to ensure that they are engaged in needed behavioral health services, including technical
assistance with billing procedures. The state department may seek any federal authorization
necessary to create the incentives described in this subsection (2).
Source: L. 2019: Entire section added, (SB 19-222), ch. 226, p. 2265, § 2, effective May
20. L. 2020: (2) amended, (SB 20-136), ch. 70, p. 300, § 56, effective September 14.
Cross references: For the legislative declaration in SB 19-222, see section 1 of chapter
226, Session Laws of Colorado 2019. For the legislative declaration in SB 20-136, see section 1
of chapter 70, Session Laws of Colorado 2020.
25.5-1-131. Insurance ombudsman - consumer advocate - duties. (1) There is hereby
created in the state department the office of the insurance ombudsman to act as the advocate for
consumer interests in matters related to access to and the affordability of the standardized health
benefit plan created pursuant to section 10-16-1304. The ombudsman shall:
(a) Interact with consumers regarding their access to, the affordability of, and coverage
issues with the standardized plan;
(b) Evaluate data to assess the standardized plan's network and affordability; and
(c) Represent the interests of consumers in public hearings held pursuant to section
10-16-1306.
(2) In the performance of the ombudsman's duties, the ombudsman shall act
independently of the state department. Any recommendations made or positions taken by the
ombudsman do not reflect those of the state department.
Source: L. 2021: Entire section added, (HB 21-1232), ch. 241, p. 1294, § 7, effective
June 16.
25.5-1-132. Report of medicaid reimbursement rates paid to community mental
health center providers and independent providers - definition. (1) On or before August 15,
2022, the state department shall publish a behavioral health rates report of medicaid
reimbursement rates for providers of community mental health centers, as defined in section
27-66-101 (2), and independent mental health and substance abuse treatment providers, as
described in subsection (2) of this section. The state department shall contract with an
Colorado Revised Statutes 2023 Uncertified PrintoutPage 25 of 510
independent auditor to prepare the behavioral health rates report, as described in this subsection
(1). The state department shall prepare, in coordination with the behavioral health rates report, a
set of recommendations on creating equitable payment and payment models that minimize
inappropriate payment variation in comparable behavioral health services between the providers
of community mental health centers and independent mental health and substance use treatment
providers. The state department shall present the behavioral health rates report and
recommendations to the house of representatives public and behavioral health and human
services committee, or any successor committee.
(2) The report prepared pursuant to subsection (1) of this section must reflect data from
state fiscal year 2020-21 and identify discrepancies, if any, and the reasons for such
discrepancies in medicaid reimbursement rates paid to providers of a community mental health
center and independent mental health and substance abuse treatment providers for comparable
services. The report must include a determination of and recommendations on whether
reimbursement rates paid to community mental health center providers and independent mental
health and substance use treatment providers are adequate to meet or exceed network adequacy
standards in every region of the state. The data must be aggregated to ensure individual
community mental health centers and independent providers are not identifiable and must
comply with any other state and federal privacy laws. On or before November 15, 2022, the state
department shall present an action plan for implementation to the joint budget committee. The
state department shall produce a progress report on the state department's progress made in
implementing the action plan presented to the joint budget committee on November 15, 2022, on
or before August 1, 2023, and annually thereafter through August 1, 2025, and provide an update
during its "State Measurement for Accountable, Responsive, and Transparent (SMART)
Government Act" hearing pursuant to section 2-7-203 on the findings and additional
recommendations. The state department must fully implement the action plan no later than
December 31, 2025.
(3) As used in this section, unless the context otherwise requires, "independent mental
health and substance abuse treatment providers" means any outpatient behavioral health provider
enrolled in medicaid and contracted with a managed care entity, as defined in section 25.5-5-403
(4), that is not licensed or designated as a community mental health center.
Source: L. 2022: Entire section added, (HB 22-1268), ch. 363, p. 2597, § 2, effective
June 3.
Cross references: For the legislative declaration in HB 22-1268, see section 1 of chapter
363, Session Laws of Colorado 2022.
25.5-1-133. Access to behavioral health services for individuals under twenty-one
years of age - rules - report - repeal. (1) On or before July 1, 2024, the state department shall
provide recipients under twenty-one years of age with access to limited services without
requiring a diagnosis. The limited services must be provided as part of the statewide managed
care system pursuant to part 4 of article 5 of this title 25.5 and the school health services detailed
in section 25.5-5-318.
(2) The limited services must include:
(a) Family therapy;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 26 of 510
(b) Group therapy;
(c) Individual therapy;
(d) Services related to prevention, promotion, education, or outreach;
(e) Evaluation, intake, case management, and treatment planning; and
(f) Any other service determined necessary by the state department based on feedback
received from stakeholders.
(3) In providing the limited services pursuant to this section, the state department must
notify patients, providers, human services departments, counties, law enforcement agencies,
schools, and any other entity that may be impacted that the limited services are available on and
after July 1, 2024.
(4) In implementing this section, the state department shall engage with interested and
impacted stakeholders to solicit feedback.
(5) (a) Notwithstanding section 24-1-136 (11)(a)(I), on or before November 1, 2025, and
on or before November 1 each year thereafter, 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, regarding the utilization of the
services described in subsection (2) of this section. The contents of the report must be
determined through the stakeholder process described in subsection (4) of this section. At a
minimum, the report must include data on the utilization of services, by code, and any
differences in utilization within the school health services program authorized by section
25.5-5-318.
(b) This subsection (5) is repealed, effective July 1, 2031.
Source: L. 2023: Entire section added, (SB 23-174), ch. 232, p. 1219, § 1, effective
August 7.
25.5-1-134. Prescription benefits - department and pharmacy benefit manager -
contracts - audit - rules. (1) For contracts between a pharmacy benefit manager and the state
department or one of its affiliated managed care organizations offering a prescription benefit
plan that is issued or renewed on or after January 1, 2025, the amount charged by the pharmacy
benefit manager to the state department or managed care organization for a prescription drug
dispensed to an enrollee in the program of medical assistance created pursuant to section
25.5-4-104 must be equal to or less than the amount paid by the pharmacy benefit manager to a
medicaid pharmacy for the prescription drug dispensed to the enrollee.
(2) The state board shall promulgate rules to implement this section, including rules
guiding an audit of managed care or fee-for-service claims, to ensure that there is no violation of
subsection (1) of this section.
Source: L. 2023: Entire section added, (HB 23-1201), ch. 158, p. 688, § 2, effective
August 7.
PART 2
PROGRAMS TO BE ADMINISTERED BY THE DEPARTMENT
Colorado Revised Statutes 2023 Uncertified PrintoutPage 27 of 510
25.5-1-201. Programs to be administered by the department of health care policy
and financing. (1) The state department shall administer the following programs and perform
the following functions:
(a) The "Colorado Medical Assistance Act", as specified in articles 4, 5, and 6 of this
title;
(b) The "Colorado Indigent Care Program", as specified in part 1 of article 3 of this title;
(c) Effective July 1, 1996, school entry immunization, as specified in part 9 of article 4
of title 25, C.R.S. Commencing on and after the fiscal year beginning July 1, 1996, the state
department is authorized to contract with the department of public health and environment for
the purpose of enforcing the school entry immunization requirements.
(d) Repealed.
(e) The "Children's Basic Health Plan Act", as specified in article 8 of this title;
(f) The old age pension health and medical care program, as specified in section
25.5-2-101;
(f.5) The reproductive health-care program that provides reproductive health-care
services, as specified in section 25.5-2-103;
(g) Programs, services, and supports for persons with intellectual and developmental
disabilities, as specified in article 10 of this title 25.5; and
(h) Any program concerning the wholesale importation of prescription drugs pursuant to
part 2 of article 2.5 of this title 25.5.
Source: L. 93: Entire title added, p. 1102, § 15, effective July 1, 1994. L. 94: (1)(f) and
(1)(g) amended and (1)(h) added, p. 1669, § 4, effective July 1. L. 95: (1)(g) and (1)(h)(II)
amended and (1)(j) added, p. 511, § 4, effective May 16; (1)(j) added, p. 916, § 15, effective
May 25. L. 96: (1)(b) and (1)(h)(I) repealed, p. 1474, § 27, effective June 1; (1)(i) and (1)(j)
amended and (1)(k) added, p. 1437, § 7, effective July 1. L. 99: (1)(l) added, p. 700, § 6,
effective July 1. L. 2001: (1)(m) added, p. 916, § 11, effective August 8. L. 2002: (1)(h)
repealed, p. 427, § 5, effective July 1. L. 2003: (1)(l) and (1)(m) amended and (1)(n) added, p.
2583, § 3, effective July 1. L. 2005: (1)(a) repealed, p. 772, § 51, effective June 1. L. 2006:
Entire part amended, p. 1796, § 2, effective July 1. L. 2007: (1)(d) repealed, p. 2042, § 70,
effective June 1. L. 2011: (1)(f) amended, (SB 11-210), ch. 187, p. 721, § 7, effective July 15,
2012. L. 2013: (1)(e) and (1)(f) amended and (1)(g) added, (HB 13-1314), ch. 323, p. 1808, §
42, effective March 1, 2014. L. 2019: IP(1), (1)(f), and (1)(g) amended and (1)(h) added, (SB
19-005), ch. 184, p. 2065, § 2, effective August 2. L. 2021: (1)(f.5) added, (SB 21-009), ch. 430,
p. 2847, § 4, effective September 7. L. 2023: IP(1) and (1)(f.5) amended, (SB 23-189), ch. 69, p.
260, § 8, effective April 14.
Cross references: For the legislative declaration in SB 19-005, see section 1 of chapter
184, Session Laws of Colorado 2019. For the legislative declaration in SB 21-009, see section 1
of chapter 430, Session Laws of Colorado 2021.
25.5-1-202. Advisory committee on covering all children in Colorado - reports -
definitions - repeal. (Repealed)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 28 of 510
Source: L. 2007: Entire section added, p. 1491, § 2, effective July 1. L. 2008:
(3)(b)(IV.5) added, p. 2027, § 3, effective June 3. L. 2012: Entire section repealed, (HB
12-1207), ch. 65, p. 229, § 1, effective March 24.
25.5-1-203. Prescription drug information and technical assistance program -
expansion. The state department may expand the prescription drug information and technical
assistance program created in section 25.5-5-507 to include persons receiving drug benefits
pursuant to any program that is administered by the state department.
Source: L. 2008: Entire section added, p. 231, § 1, effective August 5.
25.5-1-204. Advisory committee to oversee the all-payer health claims database -
creation - members - duties - legislative declaration - rules - report. (1) The general
assembly hereby finds and declares that an advisory committee for the all-payer health claims
database would support the database in its established mission of facilitating the reporting of
health-care and health quality data that results in transparent and public reporting of safety,
quality, cost, and efficiency information; and analysis of health-care spending and utilization
patterns for purposes that improve the population's health, improve the care experience, and
control costs.
(2) (a) No later than August 1, 2013, the executive director shall appoint an advisory
committee to oversee the Colorado all-payer health claims database. The advisory committee
shall include the following members:
(I) A member of academia with experience in health-care data and cost efficiency
research;
(II) A representative of:
(A) A statewide association of hospitals;
(B) An integrated multi-specialty organization;
(C) Physicians and surgeons;
(D) An organization that processes insurance claims or certain aspects of employee
benefit plans for a separate entity;
(E) A nonprofit organization that demonstrates experience working with employers to
enhance value and affordability in health insurance;
(F) Dental insurers;
(G) Pharmacists or an affiliate society;
(H) Pharmacy benefit managers;
(I) A statewide association of ambulatory surgical centers;
(III) A representative, who is not a supplier or broker of health insurance, of:
(A) Small employers that purchase group health insurance for employees;
(B) Large employers that purchase health insurance for employees;
(C) Self-insured employers;
(IV) [Editor's note: This version of subsection (2)(a)(IV) is effective until July 1,
2024.] A representative from a community mental health center who has experience in
behavioral health data collection;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 29 of 510
(IV) [Editor's note: This version of subsection (2)(a)(IV) is effective July 1, 2024.] A
representative from a comprehensive community behavioral health provider, as defined in
section 27-50-101, who has experience in behavioral health data collection;
(V) Three representatives with a demonstrated record of advocating health-care issues
on behalf of consumers;
(VI) Two representatives of health insurers, one who represents nonprofit insurers and
one who represents for-profit insurers;
(VII) Two representatives of nonprofit organizations that facilitate health information
exchange to improve health care for all Coloradans;
(VIII) The executive director or his or her designee, serving as an ex officio member;
(IX) The commissioner of insurance or his or her designee, serving as an ex officio
member;
(X) A representative of the department of personnel, serving as an ex officio member;
(XI) The director of the office of information and technology or his or her designee,
serving as an ex officio member; and
(XII) Two members of the general assembly, one appointed by the majority leader of the
senate and one appointed by the majority leader of the house of representatives; except that, if
the majority leaders are from the same political party, the minority leader of the house of
representatives shall appoint the second member. The two members of the general assembly
shall serve as ex officio members.
(b) The advisory committee shall make recommendations to the executive director and
the Colorado all-payer health claims database administrator related to the Colorado all-payer
health claims database. The recommendations include the following:
(I) Procedures for the collection, retention, use, and disclosure of data from the Colorado
all-payer health claims database, including procedures and safeguards to protect the privacy,
integrity, confidentiality, and availability of any data;
(II) Guidelines for charging for custom reports from the Colorado all-payer health claims
database;
(III) Procedures to ensure compliance with the "Health Insurance Portability and
Accountability Act of 1996", Pub.L. 104-191, as amended, and implementing federal
regulations;
(IV) Procedures to ensure compliance with other state and federal privacy laws; and
(V) Procedures for data confidentiality and data disposal if the Colorado all-payer health
claims database ceases to exist.
(c) The members of the advisory committee appointed pursuant to subparagraph (XII) of
paragraph (a) of this subsection (2) are entitled to receive compensation and reimbursement of
expenses as provided in section 2-2-326, C.R.S.
(3) (a) The administrator shall prepare and file annual reports to the legislature by March
1 of each year. The annual report must contain:
(I) The uses of the data in the all-payer health claims database;
(II) Public studies produced by the administrator;
(III) The cost of administering the Colorado all-payer health claims database, the sources
of the funding, and the total revenue taken in by the database;
(IV) The recipients of the data, the purposes for the data requests, and whether a fee was
charged for the data;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 30 of 510
(V) A fee schedule displaying the fees for providing custom data reports from the
Colorado all-payer health claims database.
(b) The executive director shall require an evaluation of the Colorado all-payer health
claims database initiative every five years beginning in 2018, to ensure that the database
accomplishes the goals of this section. The report must contain metrics that document and
demonstrate the achievements or challenges of the program goals.
(c) (I) By November 15, 2022, and by each November 15 thereafter, subject to available
appropriations, the administrator shall provide a primary care spending report to the
commissioner of insurance for use by the primary care payment reform collaborative established
in section 10-16-150 regarding primary care spending:
(A) By carriers, as defined in sections 10-16-102 (8) and 24-50-603 (2);
(B) Under the "Colorado Medical Assistance Act", articles 4, 5, and 6 of this title 25.5;
and
(C) Under the "Children's Basic Health Plan Act", article 8 of this title 25.5.
(II) The report prepared in accordance with this subsection (3)(c) must include:
(A) The percentage of the medical expenses allocated to primary care;
(B) The share of payments that are made through nationally recognized alternative
payment models and the share of payments that are not paid on a fee-for-service or per-claim
basis; and
(C) Data related to the aligned quality measure set determined by the division of
insurance in accordance with section 10-16-157 (3).
(4) (a) The administrator shall seek funding for the creation of the all-payer health
claims database and develop a plan for the financial stability of the database. If sufficient
funding is received through gifts, grants, and donations on or before January 1, 2012, as
determined by the executive director, the administrator shall, in consultation with the advisory
committee, create the Colorado all-payer claims database.
(b) The general assembly may annually appropriate general fund money to the state
department to pay for expenses related to the all-payer health claims database.
(5) If sufficient funding is received, the executive director shall direct the administrator
to create the database and the administrator shall:
(a) Determine the data to be collected from payers and the method of collection,
including mandatory and voluntary reporting of health-care and health quality data;
(b) Seek to establish agreements for voluntary reporting of health-care claims data from
health-care payers that are not subject to mandatory reporting requirements in order to ensure
availability of the most comprehensive and systemwide data on health-care costs and quality;
(c) Seek to establish agreements or requests with the federal centers for medicare and
medicaid services to obtain medicare health claims data;
(d) Determine the measures necessary to implement the reporting requirements in a
manner that is cost-effective and reasonable for data sources and timely, relevant, and reliable
for consumers, public and private purchasers, providers, and policymakers;
(e) Determine the reports and data to be made available to the public with
recommendations from the advisory committee in order to accomplish the purposes of this
section, including conducting studies and reporting the results of the studies;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 31 of 510
(f) Collect, aggregate, distribute, and publicly report performance data on quality, health
outcomes, health disparities, cost, utilization, and pricing in a manner accessible for consumers,
public and private purchasers, providers, and policymakers;
(g) Protect patient privacy in compliance with state and federal medical privacy laws
while preserving the ability to analyze data and share with providers and payers to ensure
accuracy prior to the public release of information;
(h) Repealed.
(i) Provide leadership and coordination of public and private health-care quality and
performance measurements to ensure efficiency, cost-effectiveness, transparency, and informed
choice by consumers and public and private purchasers; and
(j) Subject to available appropriations and at the request of the commissioner of
insurance, publish information to the public concerning dental loss ratio information collected by
the division of insurance pursuant to section 10-16-165.
(6) The administrator, with input from the advisory committee:
(a) Shall incorporate and utilize publicly available data other than administrative claims
data if necessary to measure and analyze a significant health-care quality, safety, or cost issue
that cannot be adequately measured with administrative claims data alone;
(b) Shall require payer data sources to submit data necessary to implement the all-payer
claims database;
(c) Shall determine the data elements to be collected, the reporting formats for data
submitted, and the use and reporting of any data submitted. Data collection shall align with
national, regional, and other uniform all-payer claims databases' standards where possible.
(d) May audit the accuracy of all data submitted;
(e) May contract with third parties to collect and process the health-care data collected
pursuant to this section. The contract shall prohibit the collection of unencrypted social security
numbers and the use of the data for any purpose other than those specifically authorized by the
contract. The contract shall require the third party to transmit the data collected and processed
under the contract to the administrator or other designated entity.
(f) May share data regionally or help develop a multistate effort if recommended by the
advisory committee.
(7) The all-payer health claims database shall:
(a) Be available to the public when disclosed in a form and manner that ensures the
privacy and security of personal health information as required by state and federal law, as a
resource to insurers, consumers, employers, providers, purchasers of health care, and state
agencies to allow for continuous review of health-care utilization, expenditures, and quality and
safety performance in Colorado;
(b) Be available to state agencies and private entities in Colorado engaged in efforts to
improve health care, subject to rules promulgated by the executive director;
(c) Be presented to allow for comparisons of geographic, demographic, and economic
factors and institutional size;
(d) Present data in a consumer-friendly manner.
(8) The collection, storage, and release of health-care data and other information
pursuant to this section is subject to the federal "Health Insurance Portability and Accountability
Act of 1996", Pub.L. 104-191, as amended.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 32 of 510
(9) The executive director shall promulgate rules as necessary to implement this section,
which rules shall include the assessment of a fine for a payer required to submit data that does
not comply with this section. Any fines collected shall be deposited in the all-payer health claims
database cash fund, which is hereby created in the state treasury. The moneys in the fund shall be
appropriated to the department of health care policy and financing for the purpose of maintaining
the all-payer health claims database. The moneys in the fund shall remain in the fund and not
revert to the general fund or any other fund at the end of any fiscal year.
(10) Repealed.
(11) If at any time, there is not sufficient funding to finance the ongoing operations of
the database, the database shall cease operating and the advisory committee and administrator
shall no longer have the duty to carry out the functions required pursuant to this section. If the
database ceases to operate, the data submitted shall be destroyed or returned to its original
source.
Source: L. 2010: Entire section added, (HB 10-1330), ch. 299, p. 1406, § 1, effective
August 11. L. 2013: (1), (2), and (3) R&RE, (SB 13-149), ch. 152, p. 495, § 1, effective July 1;
(10) repealed, (HB 13-1300), ch. 316, p. 1689, § 80, effective August 7; (5)(a) amended, (HB
13-1115), ch. 338, p. 1973, § 16, effective March 31, 2015. L. 2014: (2)(a)(X) amended, (HB
14-1363), ch. 302, p. 1269, § 29, effective May 31; (2)(c) amended, (SB 14-153), ch. 390, p.
1965, § 24, effective June 6. L. 2017: (4) amended and (5)(h) repealed, (HB 17-1060), ch. 6, p.
15, § 4, effective March 1. L. 2018: (4) amended, (HB 18-1327), ch. 150, p. 942, § 1, effective
April 23. L. 2019: (3)(c) added, (HB 19-1233), ch. 194, p. 2122, § 6, effective May 16. L. 2022:
IP(3)(c)(I) and (3)(c)(II) amended, (HB 22-1325), ch. 181, p. 1209, § 3, effective August 10;
(2)(a)(IV) amended, (HB 22-1278), ch. 222, p. 1593, § 231, effective July 1, 2024. L. 2023:
(5)(j) added, (SB 23-179), ch. 332, p. 1993, § 5, effective August 7.
Cross references: For the legislative declaration in HB 19-1233, see section 1 of chapter
194, Session Laws of Colorado 2019. For the legislative declaration in SB 23-179, see section 1
of chapter 332, Session Laws of Colorado 2023.
25.5-1-204.5. All-payer health claims database scholarship grant program - creation
- definitions. (1) As used in this section, unless the context otherwise requires:
(a) "Advisory committee" means the advisory committee to oversee the all-payer health
claims database created pursuant to section 25.5-1-204.
(b) "Governmental entity" means a state or local governmental entity, including a
state-supported institution of higher education, but does not include the state department.
(c) "Program" means the all-payer health claims database scholarship grant program
established pursuant to this section.
(2) There is created in the state department the all-payer health claims database
scholarship grant program to defray the costs of nonprofit and governmental entities in accessing
the all-payer health claims database to conduct research.
(3) The state department shall:
(a) In consultation with the advisory committee, develop a grant application under the
program consistent with the rules of the executive director;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 33 of 510
(b) Accept applications for scholarship grants from any nonprofit or governmental entity
needing access to the all-payer health claims database to conduct research;
(c) After considering the recommendations of the advisory committee, determine which
grant applications to approve and the amount of each grant; and
(d) Distribute approved scholarship grants to nonprofit or governmental entities.
(4) The executive director shall, following recommendations of the state department and
the advisory committee, adopt rules pursuant to section 24-4-103 governing the program,
including procedures, criteria, and standards for awarding scholarship grants.
(5) The advisory committee shall:
(a) Consult with the state department on the development of a grant application form;
and
(b) Review applications for scholarship grants and recommend which scholarship grants
to approve and the amount of each recommended grant.
Source: L. 2018: Entire section added, (HB 18-1327), ch. 150, p. 942, § 2, effective
April 23.
25.5-1-204.7. All-payer health claims database - creation of tool for review of data
included in the database - definitions. (1) As used in this section, unless the context otherwise
requires:
(a) "Administrator" means the administrator of the all-payer health claims database.
(b) "All-payer health claims database" or "database" means the all-payer health claims
database created pursuant to section 25.5-1-204.
(c) "Code" means CPT code, HCPCS code, or other packaged services or industry
standard procedure code that may include time units, base unit values, or modifiers.
(d) "CPT code" means the current procedural terminology code, or its successor code, as
developed and copyrighted by the American Medical Association or its successor entity.
(e) "Healthcare common procedure coding system code" or "HCPCS code" means the
code established by the federal centers for medicare and medicaid services' alpha-numeric
editorial panel for identifying health-care services in a consistent and standardized manner.
(f) "Private health-care payer" means a carrier, as defined in section 10-16-102 (8), that
reports claims received from an out-of-network provider pursuant to section 12-30-113 (4).
(g) "Tool" means the tool developed by the administrator pursuant to this section to
enable users to review certain health claims reimbursement data in the database.
(2) (a) To facilitate the accurate determination of the reimbursement rates pursuant to
sections 10-16-704 (3)(d) and (5.5)(b), 12-30-113 (4), and 25-3-122 (3) and to provide
transparency in the process, subject to available appropriations, the administrator shall create and
maintain a tool for implementation by January 1, 2023, that enables users to review certain
health claims reimbursement data included in the all-payer health claims database. The tool must
include 2018 health claims reimbursement data as the first year of data.
(b) To the extent practicable, the tool must, at a minimum:
(I) Include twenty-fifth, fiftieth, sixtieth, and seventy-fifth percentile of in-network
reimbursement rates based on claims and the number of claims submitted for each code by payer
type, for all codes with sufficient volume reported to the database, for three years of data; and
(II) Be viewable and searchable by:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 34 of 510
(A) Year;
(B) County;
(C) Geographic rating area and statewide;
(D) Payer type, including medicaid, medicare, and private health-care payers;
(E) Setting, including inpatient and outpatient services; and
(F) Specialty.
(c) The administrator shall ensure that the viewing or reporting of health claims data
through the tool complies with all state and federal data privacy laws and antitrust laws.
(3) Subject to available appropriations, the administrator shall update the tool annually
and may update the tool more frequently as determined by the administrator.
Source: L. 2022: Entire section added, (SB 22-068), ch. 266, p. 1935, § 1, effective May
27.
25.5-1-205. Providing for the efficient provision of health care through
state-supervised cooperative action - rules. (1) Cooperation among health-care payors,
including both private sector entities and federal and state-administered health-care programs,
has the potential to eliminate needless and costly complexity in the administration of the
programs and to benefit patients, payors, and the government. Further, alignment of financial
incentives among private and public entities may accelerate and reinforce improvements in
health-care quality and patient outcomes.
(2) The executive director shall facilitate departmental oversight of collaboration among
providers, medicaid clients and advocates, and payors that is designed to improve health
outcomes and patient satisfaction and support the financial sustainability of the medicaid
program.
(3) The executive director may promulgate rules relating to the collaborative process set
forth in this section.
Source: L. 2012: Entire section added, (HB 12-1281), ch. 246, p. 1182, § 1, effective
June 4.
25.5-1-206. School-based substance abuse prevention and intervention program -
creation - reporting - legislative declaration - definitions. (1) (a) The general assembly finds
and declares that:
(I) The 2011 healthy kids Colorado survey indicates that the top three substances that
high school students report they use are alcohol, marijuana, and prescription drugs;
(II) With the legalization of marijuana by citizen initiative in Colorado, there is an
increased availability of marijuana in the community and, at the same time, a decreased
perception of harm related to marijuana use;
(III) Evidence-based prevention and intervention programs and education awareness
programs targeted to school children who are twelve to nineteen years of age are needed to:
(A) Increase the perceived risk of harm associated with marijuana and alcohol use and
prescription drug misuse;
(B) Decrease the rates of youth marijuana and alcohol use and prescription drug misuse
and delay the age of first-time use; and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 35 of 510
(C) Decrease the number of drug- and alcohol-related violations, suspensions, and
expulsions reported by schools.
(b) Therefore, the general assembly declares that it is appropriate to award grants to
schools, community-based organizations, and health organizations to provide school-based
prevention and intervention programs that use evidence-based strategies, practices, and
approaches to reduce the risk of marijuana and alcohol use and prescription drug misuse by
school-aged children. Successful school-based programs will lead to increased overall health,
behavioral health, and educational outcomes for Colorado's youth.
(2) As used in this section, unless the context otherwise requires:
(a) "Entity" means a school, school district, board of cooperative services, a nonprofit or
not-for-profit community-based organization, or a community-based behavioral health
organization.
(b) "Grant program" means the school-based substance abuse prevention and
intervention grant program created in subsection (3) of this section.
(3) (a) The school-based substance abuse prevention and intervention grant program is
created within the state department. The purpose of the grant program is to award competitive
grants to entities to provide school-based prevention and intervention programs for youth twelve
to nineteen years of age primarily focused on reducing marijuana use, but including strategies
and efforts to reduce alcohol use and prescription drug misuse.
(b) To be considered for a competitive grant, the entity must demonstrate in the grant
proposal that:
(I) The grant will be used to implement evidence-based programs and strategies
delivered in the school setting that are designed to improve overall health, behavioral health, and
educational outcomes for youth who are twelve to nineteen years of age;
(II) The entity is delivering the program and strategies to at-risk youth, regardless of the
youths' eligibility for Colorado's medical assistance program; and
(III) The evidence-based programs and strategies are designed to achieve the following
outcomes:
(A) An increase in the perceived risk of harm associated with marijuana use, prescription
drug misuse, and underage alcohol use among youth who are twelve to nineteen years of age;
(B) A decrease in the rates of youth marijuana use, alcohol use, and prescription drug
misuse;
(C) A delay in the age of first use of marijuana, alcohol, or prescription drug misuse;
(D) A decrease in the rates of youth who have ever used marijuana or alcohol or misused
prescription drugs in their lifetime; and
(E) A decrease in the number of drug- and alcohol-related violations on school property,
suspensions, and expulsions reported by schools.
(4) On or before September 1, 2014, the state department shall establish procedures and
timelines for grant applications, criteria for determining grant amounts and grantee reporting
requirements, and any other grant program policies. The state department may amend these
policies at any time.
(5) Subject to available appropriations, the state department shall award grants for the
2014-15 academic year and for each academic year thereafter. There is no limit on the number of
grants that the state department may award, and the same entity may receive more than one grant
Colorado Revised Statutes 2023 Uncertified PrintoutPage 36 of 510
if the state department considers the needs of at-risk students in communities throughout the
state for school-based substance abuse prevention and intervention programs.
(6) Repealed.
Source: L. 2014: Entire section added, (SB 14-215), ch. 352, p. 1612, § 6, effective July
1. L. 2017: (6) amended, (HB 17-1060), ch. 6, p. 15, § 5, effective March 1.
Editor's note: Subsection (6)(b) provided for the repeal of subsection (6), effective
November 2, 2017. (See L. 2017, p. 15.)
25.5-1-207. Rural provider access and affordability stimulus grant program -
advisory committee - fund - reporting - rules - definitions - repeal. (1) Definitions - rules.
As used in this section:
(a) "Advisory committee" means the rural provider access and affordability advisory
committee created in subsection (3)(a) of this section.
(b) "Affiliate" has the meaning set forth in section 25.5-4-402.8 (1)(b).
(c) "Frontier provider" means a provider that is located in a county in the state with a
population density of six or fewer residents per one square mile.
(d) "Fund" means the rural provider access and affordability fund created in subsection
(6)(a) of this section.
(e) "Grant program" means the rural provider access and affordability stimulus grant
program established in subsection (2) of this section.
(f) "Health-care access projects" means the projects described in subsection (2)(c)(II) of
this section.
(g) "Health-care affordability projects" means the projects described in subsection
(2)(c)(I) of this section.
(h) "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 the
hospital.
(i) "Qualified rural provider" means a rural hospital that has a lower net patient revenue
or fund balance compared with other rural hospitals, as determined by the state board by rule.
(j) "Rural community" means:
(I) A county with a population of fewer than fifty thousand residents; or
(II) 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.
(k) "Rural provider" means a hospital that is located in a rural community.
(l) "Telemedicine" has the meaning set forth in section 12-240-104 (6).
(2) Grant program - permissible uses of grant money. (a) The rural provider access
and affordability stimulus grant program is hereby created in the state department. The purpose
of the grant program is to provide state assistance in the form of grants to qualified rural
providers based on financial need or the ability to expand health-care access. The grant program
is intended to improve health-care affordability and access in rural communities.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 37 of 510
(b) In consultation with the advisory committee, the state department shall administer
the grant program and shall award grants to qualified rural providers in accordance with this
section. The grants are paid out of money in the fund.
(c) Subject to the guidelines adopted pursuant to subsection (4) of this section and the
rules promulgated by the state board pursuant to subsection (5)(b) of this section, qualified rural
providers may use the money received through the grant program for:
(I) Projects that modernize the information technology infrastructure of rural providers,
including projects that:
(A) Create a shared analytics platform and care coordination platforms among rural
providers; and
(B) Enable technologies, including telehealth and e-consult systems, that allow rural
providers to communicate, share clinical information, and consult electronically to manage
patient care; and
(II) Projects that expand access to health care in rural communities, including projects
that:
(A) Extend hours for access to health care in rural communities, including access to
primary care and behavioral health services;
(B) Invest in dual track emergency department management in rural communities;
(C) Expand access to telemedicine in rural communities, including remote monitoring
support;
(D) Provide new or replacement hospital beds in rural communities;
(E) Expand access to remote patient monitoring systems in rural communities;
(F) Expand access in rural communities to long-term care and recovery care in skilled
nursing facilities; and
(G) Create or expand sites that provide access in rural communities to surgical care;
chemotherapy centers; imaging and advanced imaging, including magnetic resonance imaging
and computerized tomography scans; and behavioral health care.
(d) To be eligible to receive grant money for a capital expenditure, a grant recipient must
submit to the state department a written justification as set forth in 31 CFR 35.6 (b)(4) for the
capital expenditure; except that this requirement does not apply if the state department
determines that the written justification is not required based on how the expenditures authorized
under this section will be reported to the United States department of the treasury.
(3) Advisory committee. (a) The rural provider access and affordability advisory
committee is hereby created in the state department.
(b) The advisory committee consists of the following voting members, appointed by the
executive director:
(I) One member representing the state department;
(II) One member representing the department of public health and environment;
(III) One member representing the office of ehealth innovation in the lieutenant
governor's office;
(IV) One member representing a nonprofit organization with expertise in health care in
rural communities;
(V) Four members representing rural providers, including at least two frontier providers;
and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 38 of 510
(VI) One health-care consumer located in a rural community who is a member of the
disabled community.
(c) The executive director shall make all appointments to the advisory committee no
later than August 1, 2022. Advisory committee members serve for the duration of the advisory
committee. The executive director shall fill any vacancy by appointment.
(d) The executive director shall convene the first meeting of the advisory committee no
later than September 1, 2022. At the first meeting, the advisory committee shall select a chair
and vice-chair from among its members. The advisory committee shall conduct at least two
meetings each year and may agree to conduct meetings more frequently.
(e) The advisory committee shall advise and make formal recommendations to:
(I) The state department on:
(A) The administration of the grant program;
(B) The guidelines adopted pursuant to subsection (4) of this section; and
(C) The selection of grant recipients; and
(II) The state board on the rules promulgated pursuant to subsection (5) of this section.
(4) Guidelines. (a) On or before December 31, 2022, the state department, in
consultation with the advisory committee, shall adopt guidelines for the grant program that
include:
(I) Procedures and timelines by which a qualified rural provider may apply for a grant;
(II) Criteria for determining grant eligibility and grant amounts; and
(III) Reporting requirements for grant recipients in accordance with subsection (8)(b) of
this section and the rules promulgated by the state board pursuant to subsection (5)(c) of this
section.
(b) The state department shall post the guidelines on the state department's website.
(5) Rules. On or before December 31, 2022, the state board, in consultation with the
state department, shall promulgate rules as necessary for the administration of this section that
include:
(a) A methodology to determine which rural providers are considered qualified rural
providers;
(b) Permissible uses of grant money; and
(c) Reporting requirements for grant recipients.
(6) Fund. (a) The rural provider access and affordability fund is hereby created in the
state treasury. The fund consists of:
(I) Money transferred to the fund pursuant to subsection (7) of this section;
(II) Money appropriated or transferred to the fund by the general assembly; and
(III) Any gifts, grants, or donations from any public or private sources, including
governmental entities.
(b) The state department is authorized to seek, accept, and expend gifts, grants, or
donations from public or private sources for the purposes of the grant program. The state
department shall transmit all public or private money received through gifts, grants, and
donations to the state treasurer, who shall credit the same to the fund.
(c) Except as otherwise required by this subsection (6)(c), all money not expended or
encumbered, and all interest earned on the investment or deposit of money in the fund, must
remain in the fund and shall not revert to the general fund or any other fund at the end of any
fiscal year. The money in the fund is continuously appropriated to the state department for the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 39 of 510
purposes of this section. Any money in the fund not expended or encumbered by July 1, 2024,
must revert to the economic recovery and relief cash fund created in section 24-75-228 (2)(a).
(7) Transfer. No later than July 1, 2022, the state treasurer shall transfer ten million
dollars from the economic recovery and relief cash fund created in section 24-75-228 (2)(a) to
the fund. The state department shall use:
(a) Four million eight hundred thousand dollars for awarding grants for health-care
affordability projects;
(b) Four million eight hundred thousand dollars for awarding grants for health-care
access projects; and
(c) Up to four hundred thousand dollars for the costs of administering the grant program.
(8) Reporting. (a) In its presentation to the joint committees of reference pursuant to
section 2-7-203, the state department shall report on the progress of the grant program, including
a report on the amount of grant money awarded to each grant recipient and a description of each
grant recipient's use of the grant money.
(b) The state department and any person that receives money from the state department,
including each grant recipient, shall comply with the compliance, reporting, record-keeping, and
program evaluation requirements established by the office of state planning and budgeting and
the state controller in accordance with section 24-75-226 (5).
(9) Repeal. This section is repealed, effective July 1, 2025.
Source: L. 2022: Entire section added, (SB 22-200), ch. 297, p. 2123, § 2, effective June
1.
Cross references: For the legislative declaration in SB 22-200, see section 1 of chapter
297, Session Laws of Colorado 2022.
PART 3
MEDICAL SERVICES BOARD
25.5-1-301. Medical services board - creation. (1) (a) There is created in the state
department the medical services board, referred to in this part 3 as the "board". The board
consists of members appointed by the governor with the consent of the senate as follows:
(I) One member from each congressional district in the state; and
(II) Three members from the state at large.
(b) The governor shall appoint persons to the board who have knowledge of medical
assistance programs, and one or more of the appointments may include a person or persons who
have received services through programs administered by the department within two years of the
date of appointment.
(c) No more than a minimum majority of the members of the board may be affiliated
with the same political party.
(d) In making appointments to the board, the governor shall include:
(I) One member from the private sector who has experience with the delivery of health
care;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 40 of 510
(II) One member who has experience or expertise in caring for medically underserved
children; and
(III) Representation by at least one member who is a person with a disability, as defined
in section 24-34-301, a family member of a person with a disability, or a member of an advocacy
group for persons with disabilities, provided that the other requirements of this subsection (1) are
met.
(2) Each member serves at the pleasure of the governor for a term of four years; except
that the terms shall be staggered so that no more than a minimum majority of members' terms
expire in the same year.
(3) Members shall receive no compensation but shall be reimbursed for reasonable and
necessary actual expenses incurred in the performance of their official duties as members of the
board.
(4) Vacancies on the board shall be filled by appointment of the governor for the
remainder of any unexpired term.
(5) The board is a type 1 entity, as defined in section 24-1-105.
Source: L. 94: Entire part added, p. 1557, § 2, effective July 1. L. 2001: (1) and (2)
amended, p. 916, § 12, effective August 8. L. 2006: Entire part amended, p. 1797, § 3, effective
July 1. L. 2009: (1) amended, (HB 09-1281), ch. 399, p. 2154, § 4, effective August 5. L. 2011:
(1) amended, (SB 11-183), ch. 132, p. 465, § 2, effective August 10. L. 2018: (1) amended, (HB
18-1364), ch. 351, p. 2082, § 7, effective July 1. L. 2022: (1) and (2) amended, (SB 22-013), ch.
2, p. 62, § 85, effective February 25; (5) added, (SB 22-162), ch. 469, p. 3371, § 59, effective
August 10. L. 2023: (1)(d)(III) amended, (HB 23-1296), ch. 269, p. 1600, § 9, effective May 25.
Cross references: For the short title (the "Debbie Haskins 'Administrative Organization
Act of 1968' Modernization Act") in SB 22-162, see section 1 of chapter 469, Session Laws of
Colorado 2022.
25.5-1-302. Medical services board - organization. (1) The board shall elect from its
members a president, a vice-president, and such other board officers as it shall determine. All
board officers shall hold their offices at the pleasure of the board.
(2) Regular meetings of the board shall be held not less than once every three months at
such times as may be fixed by resolution of the board. All meetings of the board, in every suit
and proceeding, shall be considered to have been duly called and regularly held and all orders
and proceedings of the board to have been authorized, unless the contrary is proven.
(3) The board shall adopt, and at any time may amend, bylaws in relation to its meetings
and the transaction of its business. A majority shall constitute a quorum of the board. The vote of
a majority of a quorum of the board shall constitute the action of the board. The board shall act
only by resolution adopted at a duly called meeting of the board, and no individual of the board
shall exercise any individual administrative authority with respect to the department.
Source: L. 94: Entire part added, p. 1557, § 2, effective July 1. L. 2006: Entire part
amended, p. 1798, § 3, effective July 1.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 41 of 510
25.5-1-303. Powers and duties of the board - scope of authority - rules. (1) The board
shall have the authority set forth in subsection (3) of this section over the following programs
administered by the state department:
(a) The "Colorado Medical Assistance Act", as specified in articles 4, 5, and 6 of this
title;
(b) The "Colorado indigent care program", as specified in part 1 of article 3 of this title;
(c) Repealed.
(d) The "Children's Basic Health Plan Act", as specified in article 8 of this title;
(e) The old age pension health and medical care program, as specified in section
25.5-2-101;
(f) Programs, services, and supports for persons with intellectual and developmental
disabilities, as specified in article 10 of this title.
(2) Nothing in this section shall be construed to affect any specific statutory provision
granting rule-making authority to the board in relation to a specific program.
(3) The board shall adopt rules in connection with the programs set forth in subsection
(1) of this section governing the following:
(a) The implementation of legislative and departmental policies and procedures for such
programs; except that no rules shall be promulgated for any policy or procedure which governs
the administration of the state department as specified in section 25.5-1-108 (1);
(b) The establishment of eligibility requirements for persons receiving services from the
state department;
(c) The establishment of the type of benefits that a recipient of services may obtain if
eligibility requirements are met, subject to the authorization, requirements, and availability of
such benefits;
(d) The requirements, obligations, and rights of clients and recipients;
(e) The establishment of a procedure to resolve disputes that may arise between clients
and the state department or clients and providers;
(f) The requirements, obligations, and rights of providers, including policies and
procedures related to provider payments that may affect client benefits;
(g) The establishment of a procedure to resolve disputes that may arise between
providers and between the state department and providers.
(4) At the request of the executive director, the board shall advise the executive director
as to any proposed policies or rules governing programs administered by the state department
that are not set forth in subsection (1) of this section.
(5) The board shall have no authority over the revenue of the state department.
(6) All rules and orders of the department of human services in connection with the old
age pension health and medical care program shall continue to be effective until revised,
amended, repealed, or nullified pursuant to law.
(7) The rules issued by the state board shall be binding upon the county departments. At
any public hearing relating to a proposed rule-making, interested persons shall have the right to
present their data, views, or arguments orally. Proposed rules of the state board shall be subject
to the provisions of section 24-4-103, C.R.S.
(8) To the extent that rules are promulgated by the state board of human services for
programs or providers that receive either medicaid only or both medicaid and nonmedicaid
Colorado Revised Statutes 2023 Uncertified PrintoutPage 42 of 510
funding, the rules shall be developed in cooperation with the state department and shall not
conflict with state statutes or federal statutes or regulations.
(9) The rules and orders of the department of human services and the state board of
human services in connection with the programs, services, and supports specified in paragraph
(f) of subsection (1) of this section shall continue to be effective until revised, amended,
repealed, or nullified pursuant to law.
Source: L. 94: Entire part added, p. 1558, § 2, effective July 1. L. 95: (3)(e) to (3)(g)
amended, p. 928, § 32, effective May 25. L. 99: (1)(c) amended and (1)(e) added, p. 701, § 7,
effective July 1. L. 2001: (1)(f) and (7) added, pp. 916, 917, §§ 13, 14, effective August 8. L.
2003: (7) amended, p. 2009, § 90, effective May 22; (4) amended and (8) added, p. 2584, § 4,
effective July 1. L. 2006: Entire part amended, p. 1798, § 3, effective July 1. L. 2007: (1)(c)
repealed, p. 2042, § 71, effective June 1. L. 2011: (1)(e) and (6) amended, (SB 11-210), ch. 187,
p. 722, § 8, effective July 15, 2012. L. 2013: (1)(f) and (9) added, (HB 13-1314), ch. 323, p.
1808, § 43, effective March 1, 2014.
Cross references: For the legislative declaration contained in the 1999 act amending
subsection (1)(c) and enacting subsection (1)(e), see section 1 of chapter 203, Session Laws of
Colorado 1999.
25.5-1-304. Repeal of part. (Deleted by amendment)
Source: L. 94: Entire part added, p. 1559, § 2, effective July 1. L. 2000: Entire section
amended, p. 410, § 9, effective April 13. L. 2006: Entire part amended, p. 1800, § 3, effective
July 1.
PART 4
HEALTH CARE COVERAGE COOPERATIVE
RULE-MAKING AUTHORITY
25.5-1-401. (Repealed)
Source: L. 2004: Entire part repealed, p. 1011, § 23, effective August 4.
Editor's note: This part 4 was added in 1994. For amendments to this part 4 prior to its
repeal in 2004, consult the Colorado statutory research explanatory note and the table itemizing
the replacement volumes and supplements to the original volume of C.R.S. 1973 beginning on
page vii in the front of this volume.
PART 5
COOPERATIVE HEALTH CARE AGREEMENTS
INVOLVING HOSPITALS
Colorado Revised Statutes 2023 Uncertified PrintoutPage 43 of 510
25.5-1-501 to 25.5-1-516. (Repealed)
Source: L. 2006: Entire part repealed, p. 1800, § 4, effective July 1.
Editor's note: This part 5 was added in 1995. For amendments to this part 5 prior to its
repeal in 2006, consult the Colorado statutory research explanatory note and the table itemizing
the replacement volumes and supplements to the original volume of C.R.S. 1973 beginning on
page vii in the front of this volume.
PART 6
COMMISSION ON FAMILY MEDICINE
Editor's note: This part 6 was added with relocations in 2017. Former C.R.S. section
numbers are shown in editor's notes following those sections that were relocated.
25.5-1-601. Legislative declaration. (1) The general assembly hereby finds and declares
that:
(a) Physicians engaged in family medicine are in critically short supply in this state;
(b) Because of the distribution of such physicians, many rural and urban areas of the
state are underserved;
(c) A significant portion of the state population is medically underserved because of
indigency;
(d) Family physicians provide health care to all segments of the population;
(e) The provision of more competent family physicians is a public purpose of great
importance; and
(f) The creation of the commission on family medicine is a desirable, necessary, and
cost-effective means of addressing the needs described in this subsection (1).
Source: L. 2017: Entire part added, (HB 17-1024), ch. 7, p. 19, § 1, effective August 9.
Editor's note: This section is similar to former § 25-1-901 as it existed prior to 2017.
25.5-1-602. Commission created - composition - terms of office. (1) There is created,
in the department of health care policy and financing, the commission on family medicine,
referred to in this part 6 as the "commission". The commission consists of the following
members:
(a) The deans of accredited allopathic and osteopathic schools of medicine in the state or
their designated representatives;
(b) The director of all family medicine programs in the state accredited by the
accreditation council on graduate medical education of the American medical association or the
American osteopathic association;
(c) A representative of the Colorado academy of family physicians; and
(d) A health-care consumer to be appointed by the governor from each congressional
district in the state. No more than a minimum majority of the members of the commission
Colorado Revised Statutes 2023 Uncertified PrintoutPage 44 of 510
appointed by the governor pursuant to this subsection (1)(d) may be affiliated with the same
political party. A vacancy on the commission occurs whenever any health-care consumer
member moves out of the congressional district from which the member was appointed. A
health-care consumer member who moves out of the congressional district shall promptly notify
the governor of the date of the move, but notice is not necessary for the vacancy to occur. The
governor shall fill the vacancy in accordance with subsection (2) of this section.
(2) The members appointed under subsection (1)(d) of this section serve three-year
terms. All members serve at the pleasure of the governor. The governor shall fill any vacancy by
appointment for the remainder of the unexpired term.
(3) The commission shall elect a chairperson and a vice-chairperson from among its
members. Members of the commission serve without compensation, but members described in
subsections (1)(b), (1)(c), and (1)(d) of this section are entitled to their actual and necessary
expenses incurred in the performance of their duties. The commission shall meet on call of the
chairperson, but not less than once every three months. A majority of the members of the
commission constitutes a quorum for the transaction of business.
Source: L. 2017: Entire part added, (HB 17-1024), ch. 7, p. 20, § 1, effective August 9.
L. 2022: IP(1), (1)(d), and (2) amended, (SB 22-013), ch. 2, p. 63, § 86, effective February 25.
Editor's note: This section is similar to former § 25-1-902 as it existed prior to 2017.
25.5-1-603. Duties of commission - reporting. (1) The commission shall:
(a) Assure that family medicine residency program standards are equal to or more
stringent than the standards established by the accreditation council on graduate medical
education of the American medical association or the American osteopathic association for
residency training in family medicine;
(b) In cooperation with the dean of the school of medicine, approve and recommend
allocation of any funds which are identified and appropriated in the general appropriation bill as
a line item for any community family medicine residency training program;
(c) Monitor the state's family medicine residency programs and recommend from time to
time that the general assembly appropriate funds for said programs;
(d) Locate specific areas of the state which are underserved by family physicians and
determine the priority of need among such areas;
(e) Offer to the general assembly alternative ideas on providing medical care to the
medically indigent in the state; and
(f) (I) Support the development and maintenance of family medicine residency programs
in rural and other underserved areas of the state for purposes of cultivating family medicine
practitioners who are likely to continue practicing in rural and underserved areas of the state at
the conclusion of their residency programs.
(II) On or before each November 1, the commission shall report to the office of state
planning and budgeting and to the department of health care policy and financing concerning
rural family medicine residency programs in the state and the role of the commission with
respect to supporting the development and maintenance of those programs. In addition,
notwithstanding section 24-1-136 (11), the commission shall present the report to the joint
budget committee as part of its annual presentation to that committee.
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Source: L. 2017: Entire part added, (HB 17-1024), ch. 7, p. 20, § 1, effective August 9.
Editor's note: This section is similar to former § 25-1-903 as it existed prior to 2017.
PART 7
HEALTH-CARE PROVIDERS' ACCOUNTABILITY
TO COMMUNITIES
25.5-1-701. Definitions. As used in this part 7, unless the context otherwise requires:
(1) "Community" means the community that a hospital has defined as the community
that it serves pursuant to 26 CFR 1.501(r)-3 (b)(3).
(2) "Community benefit implementation plan" means a plan that satisfies the
requirements of an implementation strategy, as set forth in 26 CFR 1.501(r)-3 (c).
(3) "Community health needs assessment" means a community health needs assessment
that satisfies the requirements of 26 CFR 1.501(r)-3.
(4) "Community-identified health need" means a health need of a community that is
identified in a community health needs assessment.
(5) (a) "Reporting hospital" means:
(I) A hospital licensed as a general hospital pursuant to part 1 of article 3 of title 25 and
exempt from federal taxation pursuant to section 501 (c)(3) of the federal internal revenue code;
(II) A hospital established pursuant to section 25-29-103; or
(III) A hospital established pursuant to section 23-21-503.
(b) Notwithstanding subsection (5)(a) of this section, "reporting hospital" does not
include a hospital that is licensed as a general hospital with the department of public health and
environment and that is:
(I) Federally certified or undergoing federal certification as a long-term care hospital
pursuant to 42 CFR 412.23 (e); or
(II) Federally certified or undergoing federal certification as a critical access hospital
pursuant to 42 CFR 485 subpart F.
Source: L. 2019: Entire part added, (HB 19-1320), ch. 191, p. 2106, § 1, effective
August 2.
25.5-1-702. Hospitals - public community meeting requirement - rules. (1) At least
once each year, each reporting hospital shall convene a public meeting to seek feedback
regarding the reporting hospital's community benefit activities during the previous year and the
reporting hospital's community benefit implementation plan for the following year. The
presentation of the community benefit activities for the previous year must include the reporting
hospital's discrete community benefit activities, the amount funded for each activity, and a
description of how the activities and funding amounts align with the community's identified
priorities.
(2) (a) Each reporting hospital shall invite, at a minimum, representatives from the
following entities to participate in the meeting described in subsection (1) of this section, if any
such entities operate in the reporting hospital's community:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 46 of 510
(I) Local public health agencies;
(II) Local chambers of commerce and economic development organizations;
(III) Local health-care consumer organizations;
(IV) School districts;
(V) County governments;
(VI) City and town governments;
(VII) Community health centers;
(VIII) Certified rural health clinics or primary care clinics located in a county that has
been designated by the federal office of management and budget as a rural or frontier county;
(IX) Area agencies on aging;
(X) Health-care consumer advocacy organizations;
(XI) A member of the tribal council or the member's designee for a hospital whose
community includes one of Colorado's land-based tribes;
(XII) A member from the urban Indian organization for a hospital whose community
includes a federally designated urban Indian health center or urban Indian organization; and
(XIII) A member from an institution of higher learning for a hospital whose community
includes such institutions.
(b) In addition to the entities described in subsection (2)(a) of this section, each reporting
hospital shall invite, at a minimum, representatives from the following state agencies to
participate in the meeting described in subsection (1) of this section:
(I) The state department;
(II) The department of public health and environment;
(III) The department of human services;
(IV) The Colorado commission on higher education; and
(V) The office of saving people money on healthcare in the lieutenant governor's office.
(c) In addition to the entities described in subsections (2)(a) and (2)(b) of this section,
each reporting hospital shall invite the general public to the annual meeting described in
subsection (1) of this section. The reporting hospital shall issue such invitation in an
advertisement placed in any major newspaper published in the reporting hospital's community,
posted on the reporting hospital's public website and social media accounts or other online
presence, distributed through the reporting hospital's electronic newsletter or e-mail lists, and
distributed by any other means through which the reporting hospital regularly communicates
with the community it serves. The invitation must be published at least thirty days prior to the
scheduled meeting.
(2.5) When presenting the proposed community benefit implementation plan described
in subsection (1) of this section, the reporting hospital must:
(a) Present priority areas identified in the reporting hospital's most recent community
health needs assessment and any other community benefit investment option recommended by
the reporting hospital. Each priority recommendation presented must clearly identify the source
of the recommendation.
(b) Solicit public input for any additional community benefit investment priority; and
(c) Review and incorporate the public feedback received before the reporting hospital
finalizes its annual community benefit implementation plan.
(2.7) A reporting hospital may only add community benefit priorities to the reporting
hospital's implementation plan if the community benefit priorities were presented at the annual
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meeting and the public was provided an opportunity to provide feedback. The reporting hospital
must indicate that the implemented community benefit priorities are a result of reporting hospital
recommendations and not from community feedback.
(2.8) The state board shall promulgate rules to define terms and establish specific
processes regarding the requirements for reporting hospitals to solicit, review, and incorporate
public input pursuant to subsections (2.5) and (2.7) of this section.
(3) To satisfy the requirements of this section, a reporting hospital may convene a joint
public meeting with one or more other reporting hospitals that share some or all of the hospital's
community.
(4) For each public meeting and community health needs assessment community
engagement meeting held, each reporting hospital shall submit a report to the state department
and make the report available to community members by making the report publicly available on
the reporting hospital's website. The report must include, at a minimum, the following:
(a) Meeting minutes;
(b) A list of the meeting attendees;
(c) The content of the meeting discussion, including any community benefit priorities
discussed and the decisions made regarding those discussed community benefit priorities;
(d) Community feedback received and how the hospital plans to incorporate the
feedback into the reporting hospital's community benefit implementation plan; and
(e) Any data collected from attendees, such as data concerning race, ethnicity, or
income.
(5) The state department must conduct a stakeholder meeting with consumer advocates,
community organizers, community organizations, and hospital representatives to identify and
develop, at a minimum, best practices to ensure low-income residents, residents of color, people
with serious mental illness, people with disabilities, and other populations experiencing
disproportionate health outcomes in local communities are meaningfully engaged and to ensure
their input is incorporated into the data used to identify community priorities for the community
health needs assessment and community benefit implementation plan. This stakeholder
engagement must also include best practices for hospitals to collaborate with local public health
agencies and community organizations to reduce redundant community needs assessments.
(6) The state board shall promulgate rules to establish accommodation standards for the
annual community benefit public meetings and community health needs assessment that include
language accessibility, adequate advanced public notice, and any other type of accessibility
measures deemed necessary by the state board, and to implement the best practices identified
and developed pursuant to subsection (5) of this section.
(7) The state board shall promulgate any additional rules that may be necessary for
conducting the annual community benefit public meetings described in this section.
Source: L. 2019: Entire part added, (HB 19-1320), ch. 191, p. 2107, § 1, effective
August 2. L. 2023: (1), (2), and (3) amended and (2.5), (2.7), (2.8), (4), (5), (6), and (7) added,
(HB 23-1243), ch. 156, p. 670, § 2, effective August 7.
Cross references: For the legislative declaration in HB 23-1243, see section 1 of chapter
156, Session Laws of Colorado 2023.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 48 of 510
25.5-1-703. Hospitals - community health needs assessments - community benefit
implementation plans - reports - rules. (1) On or before a date to be determined by rules
promulgated by the state board, and on or before such date every three years thereafter, each
reporting hospital shall complete a community health needs assessment.
(2) On or before a date to be determined by rules promulgated by the state board, and on
or before such date each year thereafter, each reporting hospital shall complete a community
benefit implementation plan that:
(a) Addresses the needs described by the reporting hospital's community health needs
assessment;
(b) Includes an explanation of the community served by the hospital facility; and
(c) Describes how the community was determined pursuant to 26 CFR 1.501(r) 3(b).
(3) On or before a date to be determined by rules promulgated by the state board, and on
or before such date each year thereafter, each reporting hospital shall prepare and submit to the
state department a report on certain community benefits, costs, and shortfalls. The report must
include:
(a) The reporting hospital's most recent community health needs assessment completed
pursuant to subsection (1) of this section;
(b) The reporting hospital's community benefit implementation plan for the coming year
completed pursuant to subsection (2) of this section;
(c) A copy of the reporting hospital's most recent form 990 submitted to the federal
internal revenue service; and
(d) A description of certain spending and investments made by the reporting hospital
during the preceding year, including:
(I) A list of the investments made by the reporting hospital that were included in part I,
part II, and part III of schedule H of the reporting hospital's form 990. For each such investment,
the reporting hospital shall:
(A) Indicate the cost of the investment;
(B) Indicate whether the investment addressed a community-identified health need;
(C) For any investment that addressed a community-identified health need, identify any
of the following categories, which may be further defined by rules promulgated by the state
board, that are applicable: Free or discounted health-care services; behavioral health;
community-based health care; social determinants of health spending, including spending to
address individuals' needs, such as housing, food, transportation, interpersonal violence,
education, and job opportunities; and provider recruitment, education, and research and training.
In identifying these categories, the reporting hospital shall distinguish direct or cash expenditures
from in-kind contributions.
(D) For any investment that addressed a community-identified health need, provide
evidence showing how the investment improves community health outcomes and how the
investment directly corresponds to community-identified needs.
(II) The reporting hospital's total expenses included in line 18 of section 1 of the form
990 submitted by the reporting hospital or by the reporting hospital's ownership entity; and
(III) The reporting hospital's revenue less expenses included in line 19 of section 1 of the
form 990 submitted by the reporting hospital or by the reporting hospital's ownership entity.
(3.5) On or before a date to be determined by rules promulgated by the state board, and
on or before such date every three years thereafter, the state department shall review each
Colorado Revised Statutes 2023 Uncertified PrintoutPage 49 of 510
reporting hospital's community health needs assessment and each reporting hospital's annual
community benefit implementation plan to identify the highest priority areas as reported by
communities as compared to the reporting hospital's reported spending. The state department
shall include such information in the report described in subsection (7) of this section.
(4) A reporting hospital that prepares and submits a report pursuant to subsection (3) of
this section shall post the report to the reporting hospital's public website.
(5) (a) The state board shall promulgate rules that establish:
(I) Reporting requirements for reporting hospitals that are not required to complete
schedule H of the form 990. The rules must promote uniformity with the requirements set forth
in subsection (3) of this section.
(II) Requirements for the evidence-based supporting documentation that is required
pursuant to subsection (3)(d)(I)(D) of this section.
(b) A general hospital that is licensed as a general hospital pursuant to part 1 of article 3
of title 25 and that is not a reporting hospital may submit a report on certain community benefits,
costs, and shortfalls that is consistent with this section.
(6) To facilitate the submission of the reports described in subsection (3) of this section,
the state department shall develop and provide a website at which each reporting hospital shall
submit the reports. The state department shall ensure that the website and the reports remain
available to the public.
(7) As part of the report authorized in section 25.5-4-402.8, the state department shall
include a summary of the reports submitted to the state department pursuant to subsection (3) of
this section during the preceding year. The summary must include:
(a) The amount that each reporting hospital invested in:
(I) Free or reduced-cost health-care services that addressed community-identified health
needs;
(II) Programs that addressed health behaviors or risks;
(III) Programs that addressed social determinants of health; and
(IV) All services and programs that addressed community-identified health needs;
(b) A summary of the reporting hospitals' investments that have been effective in
improving community health outcomes;
(c) Any legislative recommendations the state department has for the general assembly;
and
(d) The estimated federal and state income tax exemptions and the property tax
exemptions received by each hospital, which shall be calculated by the department of revenue.
(8) The state department shall post the reports completed pursuant to subsection (7) of
this section to a public web page that the state department creates for this sole purpose.
Source: L. 2019: Entire part added, (HB 19-1320), ch. 191, p. 2108, § 1, effective
August 2. L. 2023: (2), (3)(d)(I)(C), (3)(d)(I)(D), (5)(a), (7)(b), and (7)(c) amended and (3.5)
and (7)(d) added, (HB 23-1243), ch. 156, p. 673, § 3, effective August 7.
Cross references: For the legislative declaration in HB 23-1243, see section 1 of chapter
156, Session Laws of Colorado 2023.
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25.5-1-704. Hospital community investment compliance - rules. (1) (a) If the state
department finds that a reporting hospital is not in compliance with the community benefit
requirements of this part 7, the state department shall notify the reporting hospital of its
noncompliance and identify the information that needs to be provided. If a reporting hospital
does not comply, the state department shall require the reporting hospital to submit to the state
department a corrective action plan within one hundred and twenty days for approval by the state
department.
(b) If noncompliance continues or a reporting hospital fails to submit a corrective action
plan, or if the state department determines a hospital's noncompliance with this section is
knowing or willful or a repeated pattern of noncompliance exists, the state department shall
consider the size of the hospital and the seriousness of the violation in setting a fine amount. For
a reporting hospital owned by or affiliated with a hospital system comprised of three or more
hospitals, the fine must be not more than twenty thousand dollars per week per violation. For all
other reporting hospitals, the fine must be not more than five thousand dollars per week per
violation.
(2) Reporting hospitals shall expend the amount fined pursuant to subsection (1)(b) of
this section on community benefit investment priorities described in the hospital's current
community benefit implementation plan within one year after the fine is imposed. Each reporting
hospital shall report on how the money collected through fines is expended in the reporting
hospital's annual report to the state department pursuant to section 25.5-1-703.
(3) The state board shall promulgate any rules necessary for the implementation of this
section.
Source: L. 2023: Entire section added, (HB 23-1243), ch. 156, p. 674, § 4, effective
August 7.
Cross references: For the legislative declaration in HB 23-1243, see section 1 of chapter
156, Session Laws of Colorado 2023.
PART 8
MEDICAID NONMEDICAL AND
NONEMERGENCY MEDICAL TRANSPORTATION
25.5-1-801. Definitions. As used in this section, unless the context otherwise requires:
(1) "Nonemergency medical transportation" means transportation to or from medically
necessary nonemergency treatment.
(2) "Nonmedical transportation" means transportation to enable passengers who are
recipients of medicaid to gain access to waiver and other community services, activities, and
resources.
(3) "Transportation broker" means an entity designated by the department of health care
policy and financing to administer nonemergency medical transportation.
(4) "Transportation provider" means an individual or business entity, other than a
transportation broker, that:
(a) Provides transportation services; or
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(b) Arranges the facilitation of transportation services by an individual.
(5) "Transportation services" means nonemergency medical transportation or
nonmedical transportation services provided to medicaid recipients.
Source: L. 2021: Entire part added, (HB 21-1206), ch. 381, p. 2551, § 1, effective June
29.
25.5-1-802. Medicaid transportation services - safety and oversight - rules. (1) The
state department shall collaborate with stakeholders, including but not limited to disability and
member advocates, PACE providers operating pursuant to section 25.5-5-412, transportation
brokers, and transportation providers, to establish rules and processes for the safety and
oversight of nonmedical transportation services and nonemergency medical transportation
services provided to medicaid recipients pursuant to articles 4 to 6 of this title 25.5. The rules
and processes must:
(a) Ensure the safety of passengers;
(b) Protect passenger access to transportation services; and
(c) Establish driver and vehicle requirements that minimize financial and administrative
burdens for transportation providers, direct support professionals as defined in section
25.5-6-406, long-term care direct care workers, independent contractors, and employees
providing transportation services.
(2) To the extent possible, the state department shall use existing oversight procedures to
ensure compliance with the requirements as described in subsection (1) of this section.
(3) If a provider of transportation services already complies with transportation safety
standards established by another state department which meet or exceed the rules and processes
established pursuant to subsection (1) of this section, demonstrating such compliance to the state
department is sufficient to verify compliance with the requirements of this section.
Source: L. 2021: Entire part added, (HB 21-1206), ch. 381, p. 2552, § 1, effective June
29.
PART 9
HOSPITAL PRICE TRANSPARENCY
Editor's note: This part 9 was added with relocations 2023. Former C.R.S. section
numbers are shown in editor's notes following those sections that were relocated.
25.5-1-901. Legislative declaration. (1) The general assembly finds and declares that:
(a) Section 1001 of the "Patient Protection and Affordable Care Act", Pub.L. 111-148, as
amended by the "Health Care and Education Reconciliation Act of 2010", Pub.L. 111-152,
amended Title XXVII of the "Public Health Service Act", Pub.L. 78-410, in part, by adding a
new section 2718 (e), requiring, in part, that each hospital operating within the United States
establish, update, and make public a list of the hospital's standard charges for the items and
services that the hospital provides;
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(b) Effective January 1, 2021, the federal centers for medicare and medicaid services
published the final rule to implement the law, codified at 45 CFR 180;
(c) In its summary of the final rule, CMS states that information on hospital standard
charges is necessary for the public to "make more informed decisions about their care" and that
the "impact of these final policies will help to increase market competition, and ultimately drive
down the cost of health care services, making them more affordable for all patients";
(d) On July 9, 2021, President Biden, building upon efforts of past presidents, issued the
"Executive Order on Promoting Competition in the American Economy", directing the secretary
of the United States department of health and human services to support new and existing price
transparency initiatives for hospitals;
(e) Health-care price transparency is in the best interest of all Coloradans, including:
(I) The state government, which purchases health-care services for almost one-fourth of
all Coloradans;
(II) Colorado businesses, which fund employee medical expenses; and
(III) Colorado residents, who ultimately bear the brunt of high health-care costs in the
form of higher taxes, lower wages, and residents' own out-of-pocket spending;
(f) Moreover, health-care prices in Colorado are among the highest in the nation;
(g) However, not all Colorado hospitals are in compliance with all of the disclosure
requirements under federal law and other state laws governing health-care price transparency;
and
(h) This lack of compliance with health-care price transparency laws by Colorado
hospitals decreases the likelihood that Colorado consumers will be fully aware of affordable
health-care options before purchasing items and services from hospitals, placing health-care
consumers at greater risk of collection actions and other adverse actions relating to unpaid
medical bills.
(2) Therefore, the general assembly finds and declares that it is imperative to protect
Colorado health-care consumers from collection actions and other adverse actions taken by
Colorado hospitals during the time when the hospital was not in material compliance with
hospital price transparency laws intended to protect health-care consumers.
Source: L. 2023: Entire part added with relocations, (SB 23-252), ch. 305, p. 1864, § 3,
effective August 7.
Editor's note: This section is similar to former § 25-3-801 as it existed prior to 2023.
25.5-1-902. Definitions. As used in this part 9, unless the context otherwise requires:
(1) "Collection action" means any of the following actions taken with respect to a debt
for items and services that were purchased from or provided to a patient by a hospital on a date
during which the hospital was not in material compliance with hospital price transparency laws:
(a) Attempting to collect a debt from a patient or patient guarantor by referring the debt,
directly or indirectly, to a debt collector, a collection agency, or other third party retained by or
on behalf of the hospital;
(b) Suing the patient or patient guarantor or enforcing an arbitration or mediation clause
in any hospital documents, including contracts, agreements, statements, or bills; or
(c) Directly or indirectly causing a report to be made to a consumer reporting agency.
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(2) (a) "Collection agency" means any:
(I) Person who engages in a business, the principal purpose of which is the collection of
debts; or
(II) Person who:
(A) Regularly collects or attempts to collect, directly or indirectly, debts owed or due or
asserted to be owed or due to another;
(B) Takes assignment of debts for collection purposes;
(C) Directly or indirectly solicits for collection debts owed or due or asserted to be owed
or due to another; or
(D) Collects debt for the department of personnel.
(b) "Collection agency" does not include:
(I) Any officer or employee of a creditor while, in the name of the creditor, collecting
debts for such creditor;
(II) Any person while acting as a collection agency for another person, both of whom are
related by common ownership or affiliated by corporate control, if the person acting as a
collection agency does so only for creditors to whom it is so related or affiliated and if the
principal business of the person is not the collection of debts;
(III) Any officer or employee of the United States or any state to the extent that
collecting or attempting to collect any debt is in the performance of the officer's or employee's
official duties;
(IV) Any person while serving or attempting to serve legal process on any other person
in connection with the judicial enforcement of any debt;
(V) Any debt-management services provider operating in compliance with or exempt
from the "Uniform Debt-Management Services Act", part 2 of article 19 of title 5;
(VI) Any person collecting or attempting to collect any debt owed or due or asserted to
be owed or due another to the extent that:
(A) The activity is incidental to a bona fide fiduciary obligation or a bona fide escrow
arrangement;
(B) The activity concerns a debt that was extended by the person;
(C) The activity concerns a debt that was not in default at the time it was obtained by the
person; or
(D) The activity concerns a debt obtained by the person as a secured party in a
commercial credit transaction involving the creditor;
(VII) Any person whose principal business is the making of loans or the servicing of
debt not in default and who acts as a loan correspondent, seller and servicer for the owner, or
holder of a debt that is secured by a deed of trust on real property, whether or not the debt is also
secured by an interest in personal property; or
(VIII) A limited gaming or racing licensee acting pursuant to article 33 of title 44.
(c) Notwithstanding the provisions of subsection (2)(b) of this section, "collection
agency" includes any person who, in the process of collecting the person's own debts, uses
another name that would indicate that a third person is collecting or attempting to collect such
debts.
(3) (a) "Consumer reporting agency" means any person that, for monetary fees or dues or
on a cooperative nonprofit basis, regularly engages, in whole or in part, in the practice of
assembling or evaluating consumer credit information or other information on consumers for the
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purpose of furnishing consumer reports to third parties. "Consumer reporting agency" includes
any person defined in 15 U.S.C. sec. 1681a (f) or section 5-18-103 (4).
(b) "Consumer reporting agency" does not include any business entity that provides
check verification or check guarantee services only.
(4) (a) "Debt" means any obligation or alleged obligation of a consumer to pay money
arising out of a transaction, whether or not the obligation has been reduced to judgment.
(b) "Debt" does not include a debt for business, investment, commercial, or agricultural
purposes or a debt incurred by a business.
(5) "Debt collector" means any person employed or engaged by a collection agency to
perform the collection of debts owed or due or asserted to be owed or due to another.
(6) "Federal centers for medicare and medicaid services" or "CMS" means the centers
for medicare and medicaid services in the United States department of health and human
services.
(7) "Hospital" means, consistent with 45 CFR 180.20, a hospital:
(a) Licensed or certified by the department of public health and environment pursuant to
section 25-1.5-103 (1)(a); or
(b) Approved by the department of public health and environment as meeting the
standards established for licensing a hospital.
(8) "Hospital price transparency laws" means section 2718 (e) of the "Public Health
Service Act", Pub.L. 78-410, as amended, and rules adopted by the United States department of
health and human services implementing section 2718 (e).
(9) "Items and services" or "items or services" means "items and services" as defined in
45 CFR 180.20.
Source: L. 2023: Entire part added with relocations, (SB 23-252), ch. 305, p. 1866, § 3,
effective August 7.
Editor's note: This section is similar to former § 25-3-802 as it existed prior to 2023.
25.5-1-903. Failure to comply with hospital price transparency laws - prohibiting
collection of debt - penalty. (1) A hospital that is not in material compliance with hospital price
transparency laws on the date that items or services are purchased from or provided to a patient
by the hospital shall not initiate or pursue a collection action against the patient or patient
guarantor for a debt owed for the items or services.
(2) If a patient believes that a hospital was not in material compliance with hospital price
transparency laws on the date that items or services were purchased by or provided to the patient,
and the hospital takes a collection action against the patient or patient guarantor, the patient or
patient guarantor may file suit to determine if:
(a) The hospital was materially out of compliance with hospital price transparency laws,
rules, or regulations on the date the items or services were provided; and
(b) The noncompliance is related to the items or services. The hospital shall not take a
collection action against the patient or patient guarantor while the lawsuit is pending.
(3) If a judge or jury, considering compliance standards issued by the federal centers for
medicare and medicaid services, finds a hospital to be materially out of compliance with hospital
price transparency laws, rules, or regulations, the hospital shall:
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(a) Refund the payer any amount of the debt the payer has paid and shall pay a penalty to
the patient or patient guarantor in an amount equal to the total amount of the debt;
(b) Dismiss or cause to be dismissed any court action with prejudice and pay any
attorney fees and costs incurred by the patient or patient guarantor relating to the action;
(c) Remove or cause to be removed from the patient's or patient guarantor's credit report
any report made to a consumer reporting agency relating to the debt; and
(d) Notify the state department of the material noncompliance with hospital price
transparency laws, rules, or regulations.
(4) Nothing in this part 9:
(a) Prohibits a hospital from billing a patient, patient guarantor, or third-party payer,
including a health insurer, for items or services provided to the patient; or
(b) Requires a hospital to refund any payment made to the hospital for items or services
provided to the patient, so long as no collection action is taken in violation of this part 9.
Source: L. 2023: Entire part added with relocations, (SB 23-252), ch. 305, p. 1868, § 3,
effective August 7.
Editor's note: This section is similar to former § 25-3-803 as it existed prior to 2023.
25.5-1-904. Transparency - hospitals - standard charges - shoppable services -
enforcement. (1) On or before October 1, 2023, each hospital shall make public and post the
hospital's medicare reimbursement rates, if applicable.
(2) (a) The state department shall conduct performance assessments for adherence to
federal transparency rules by:
(I) Reviewing relevant information provided to the state department concerning a
hospital's performance assessment in connection with this section;
(II) Auditing hospital websites for performance relative to federal price transparency
rules, and in evaluating performance, the department shall follow rules, standards, and guidance
published by the federal centers for medicare and medicaid; and
(III) Confirming that each hospital submitted the lists required by this section.
(b) If the state department determines that a hospital has performed poorly in its
performance assessment, the state department may:
(I) Issue a written notice to the hospital that clearly explains the manner in which the
department determined that the hospital performed poorly on the adherence to price
transparency; and
(II) Provide technical assistance to the hospital to improve performance.
(3) On or before February 1, 2024, the state department shall create and maintain a
publicly available list on its website of hospitals that perform poorly on the department's
performance assessment. Such notices and communications are subject to public disclosure
under 5 U.S.C. sec. 552, as amended, notwithstanding any exemptions or exclusions to the
contrary, in full without redaction. The state department shall update the list at least annually.
(4) A person that violates subsection (1) of this section commits a deceptive trade
practice under section 6-1-105.
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Source: L. 2023: Entire part added with relocations, (SB 23-252), ch. 305, p. 1869, § 3,
effective August 7.
PART 10
HOSPITAL COLLABORATIVE AGREEMENTS
25.5-1-1001. Hospital collaborative agreements - review of proposed collaborative
agreements - immunity - legislative declaration - definitions - rules. (1) The general
assembly finds and declares that:
(a) (I) Frontier and rural hospitals continue to struggle to deliver high-quality, accessible,
low-cost care due to the rising costs of medications, supplies, medical equipment, and contract
labor;
(II) Frontier and rural hospitals are largely independent governmental facilities that are
governed by local community boards;
(III) Frontier and rural hospitals are generally separated by large distances and are
challenged by the need to provide essential services to local communities due to the sparse
population in rural areas;
(IV) Frontier and rural hospitals are increasingly challenged by complex requirements
imposed by government and private payers that disproportionately negatively impact these
providers and unnecessarily drive up administrative costs; and
(V) In cases where the state department, the division of insurance, if applicable, and the
attorney general approve collaborative arrangements, it is the general assembly's intent to
provide protection to frontier and rural hospitals from certain antitrust scrutiny that impedes
frontier and rural hospitals from working collaboratively to improve quality, increase access, and
reduce costs of care to the communities they serve;
(b) (I) Forty-seven of Colorado's sixty-four counties include rural and frontier
communities yet contain only twelve percent of Colorado's population;
(II) Thirty-two counties are served by critical access hospitals that have twenty-five or
fewer beds and are generally located more than thirty-five miles from the next closest hospital;
eleven counties lack any hospital;
(III) The scarcity of nearby hospitals causes many residents to struggle to find quality,
affordable health care near their homes;
(IV) Further, many residents in Colorado's rural and frontier communities forgo
preventive and behavioral health care and lack comprehensive or specialized care or choice in
health-care services, and twenty-four counties in Colorado are considered maternal care
"deserts";
(V) Where hospitals do exist in rural and frontier areas, those hospitals receive low
reimbursement rates due to a preponderance of government payers and declining local tax
dollars, which results in a reduced amount of money available to invest in expanding or
upgrading facilities or to purchase necessary, new, or innovative medical supplies, equipment, or
technology;
(VI) Many hospitals in rural and frontier communities have difficulty recruiting and
retaining qualified health-care professionals and making available needed services; and
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(VII) County public hospitals, health service districts, and hospital affiliates perform
essential public functions on behalf of the state;
(c) As part of the government's interest in providing needed health-care services in
Colorado's rural and frontier communities, it is important for the government to support efforts
to find collaborative, innovative solutions to the many problems confronting rural health care,
including collaborative or coordinated activities that offer the opportunity to expand health-care
options through joint purchasing and staffing, shared services, and joint acquisition of new and
expensive diagnostic and treatment solutions;
(d) It is the general assembly's intent to exempt from state antitrust laws, and to provide
state action immunity from federal antitrust laws for, certain activities that might be
characterized as anticompetitive or that might result in the displacement of competition in the
provision of hospital, physician, or other health-care-related services or administrative or general
business services; and
(e) In order to promote improved quality of, increase access to, and reduce costs of
health-care services in rural and frontier communities through collaborative agreements
authorized by this section, the general assembly further intends to provide a system of review of
relevant collaborative agreements by the state department, the division of insurance, if
applicable, and the attorney general to ensure that any potential benefits of such collaborative
agreements are not outweighed by the harm to competition in rural and frontier communities.
(2) As used in this section, unless the context otherwise requires:
(a) "Collaborative agreement" means an agreement or similar arrangement between two
or more hospitals or hospital affiliates that complies with the requirements set forth in this
section.
(b) "County public hospital" means a public hospital established pursuant to section
25-3-301.
(c) "Division of insurance" means the division of insurance in the department of
regulatory agencies.
(d) "Health service district" has the same meaning as set forth in section 32-1-103 (9).
(e) "Hospital" means a facility with fewer than fifty beds that is:
(I) A county public hospital;
(II) A hospital established, maintained, or operated directly or indirectly by a health
service district; or
(III) A hospital affiliate.
(f) "Hospital affiliate" means an affiliate of a county public hospital or health service
district that is under the sole control of the county public hospital or health service district.
(3) Except as provided in subsection (4) of this section, and subject to the requirements
in subsections (5), (6), and (7) of this section, a hospital is authorized to enter into collaborative
agreements with one or more hospitals or hospital affiliates to engage in the following activities:
(a) Ancillary clinical services, acquisition of equipment, clinic management, or
health-care provider recruitment;
(b) Joint purchasing or leasing arrangements, including the joint purchasing or leasing
of:
(I) Medical and general supplies;
(II) Medical and general equipment;
(III) Pharmaceuticals; or
Colorado Revised Statutes 2023 Uncertified PrintoutPage 58 of 510
(IV) Temporary staffing through a staffing agency;
(c) Consulting services with a focus on public health in rural or frontier communities and
non-hospital-specific innovations in health-care delivery in those communities;
(d) Purchasing joint professional, general liability, or property insurance;
(e) Sharing back-office services, such as sharing a business office, accounting and
finance services, human resources, and risk management and compliance services, but not
including sharing service charging expenses or rates among hospitals;
(f) Sharing data services, including shared services for electronic health records and data
extraction and analysis services, charge management, and population health analysis; and
(g) Negotiating with health insurance or government payers, which negotiations are
limited to:
(I) Shared care protocols intended to improve patient management and outcomes,
including implementation of evidence-based protocols, clinical pathways, and recognized best
practices in the care and treatment of patients, including clinical therapies, nutrition, exercise,
diagnostic testing, and medication management;
(II) Collaborative efforts with payers to promote appropriate and essential services to be
provided in the local community;
(III) Management of prior authorization requests; and
(IV) Analysis of aggregate data to compare costs of procedures and to analyze patient
outcomes.
(4) Notwithstanding any collaborative agreements described in subsection (3) of this
section, the immunity and protections granted to hospitals and hospital affiliates entering into
collaborative agreements pursuant to this section do not extend to collaborative agreements with
another hospital or hospital affiliate that have the effect of:
(a) Setting reimbursement rates or other compensation from any commercial self-insured
or commercial health insurance or government payer;
(b) Dividing or allocating among hospitals or hospital affiliates specific markets for the
delivery of any general acute care or specialty lines of health-care services; or
(c) Negotiating or agreeing to compensation under health-care staffing arrangements for
hospital employees that results in a reduction of wages of hospital staff, whether employed by
the hospital, a staffing agency, or other employer.
(5) Prior to engaging in any joint activity described by a proposed collaborative
agreement executed pursuant to subsection (3) of this section, the hospitals or hospital affiliates
shall jointly submit the proposed collaborative agreement to the state department and to the
division of insurance, if the proposed collaborative agreement includes negotiating with health
insurance payers as described in subsection (3)(g) of this section, pursuant to rules that may be
promulgated for the submission and review of proposals by the state department and by the
division of insurance, if applicable. The state department and the division of insurance, if
applicable, may request additional information necessary to review the proposal.
(6) Within fifteen days after receipt of a proposed collaborative agreement and the
receipt of additional information requested by the state department and by the division of
insurance, if applicable, if the state department and the division of insurance, if applicable,
conclude that a proposed collaborative activity will result in cost savings or other efficiencies
that will improve or expand the delivery of health-care services in rural and frontier communities
in Colorado, the state department and the division of insurance, if applicable, shall refer the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 59 of 510
proposal to the attorney general to determine, pursuant to rules which may be promulgated for
such purpose, that the benefits of the collaborative activity are not outweighed by any
anticompetitive harm that may arise from the collaborative activity.
(7) Within forty-five days after receiving a referral and review from the state department
and the division of insurance, if applicable, the attorney general shall review the proposed
collaborative agreement and either approve or deny the proposed collaborative agreement or
request additional information related to the proposal. If a request for additional information is
made, the attorney general has an additional forty-five days to complete the review following
receipt of the requested information.
(8) (a) A collaborative agreement is approved if:
(I) The state department and the division of insurance, if applicable, conclude that the
proposed collaborative agreement will result in improved quality, increased access or cost
savings, or other efficiencies that will improve or expand the delivery of health-care services in
rural and frontier communities in Colorado; and
(II) The attorney general concludes that the benefits identified by the state department
and by the division of insurance, if applicable, are outweighed by any competitive concerns
identified by the attorney general, or the attorney general does not respond within the time
frames specified in subsection (7) of this section.
(b) (I) Except as provided in subsection (8)(b)(III) of this section, if a proposed
collaborative agreement is denied, the hospitals or hospital affiliates may request reconsideration
by resubmitting the proposed agreement to the attorney general within thirty days after the denial
along with additional materials, information, or other evidence that was not previously submitted
relating to the determination of the benefits or anticompetitive harm associated with the
proposed collaborative agreement.
(II) The attorney general has forty-five days from the date of the request to reconsider
the denial and may consult with the state department and the division of insurance as part of the
reconsideration. The proposed collaborative agreement is not deemed approved if the attorney
general fails to respond within the forty-five-day reconsideration period.
(III) A request for reconsideration of a proposed collaborative agreement may be made
only once within the thirty-day period following the denial of the proposed collaborative
agreement. The attorney general's decision on a proposed collaborative agreement that is not
submitted for reconsideration within thirty days or that is denied upon reconsideration is final
and non-appealable.
(c) The state department, the division of insurance, if applicable, or the attorney general
may review a collaborative agreement annually to ensure the outcomes related to the
collaborative agreement are consistent with this section.
Source: L. 2023: Entire part added, (SB 23-298), ch. 343, p. 2053, § 1, effective August
7.
ARTICLE 2
State-funded Health and Medical Care
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Editor's note: This article was added in 1994 and was repealed in 2002. This article was
subsequently amended in 2006 resulting in the recreation of the article with relocated provisions.
For amendments to this article prior to 2002, consult the Colorado statutory research explanatory
note and the table itemizing the replacement volumes and supplements to the original volume of
C.R.S. 1973 beginning on page vii in the front of this volume. Former C.R.S. section numbers
are shown in editor's notes following those sections that were relocated. For a detailed
comparison of this article, see the comparative tables located in the back of the index.
25.5-2-101. Old age pension health and medical care fund - supplemental old age
pension health and medical care fund - cash system of accounting - legislative declaration -
rules.
(1) (Deleted by amendment, L. 2011, (SB 11-210), ch. 187, p. 719, § 2, effective July
15, 2012.)
(2) Any money remaining in the state old age pension fund after full payment of basic
minimum awards to qualified old age pension recipients and after establishment and
maintenance of the old age pension stabilization fund in the amount of five million dollars shall
be transferred to a fund to be known as the old age pension health and medical care fund, which
is hereby created. The state board shall establish and promulgate rules for administration of a
program to provide health and medical care to persons who qualify to receive old age pensions
and who are not patients in an institution for tuberculosis or behavioral or mental health
disorders. The costs of such program, not to exceed ten million dollars in any fiscal year, are
defrayed from the health and medical care fund, but all money available, accrued or accruing,
received or receivable, in said health and medical care fund in excess of ten million dollars in
any fiscal year is transferred to the general fund of the state to be used pursuant to law. Money in
the old age pension health and medical care fund is subject to annual appropriation by the
general assembly.
(3) Repealed.
(4) 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 for the health and medical care programs described in subsection (2) of this section.
Source: L. 2006: Entire article amended with relocations, p. 1800, § 5, effective July 1.
L. 2007: (4) added, p. 465, § 1, effective July 1. L. 2009: (3) amended, (SB 09-261), ch. 201, p.
905, § 1, effective May 1. L. 2010: (3)(b)(III) amended and (3)(b)(IV) and (3)(b)(V) added, (HB
10-1380), ch. 215, p. 932, § 1, effective May 6. L. 2011: (3)(b)(VI) added, (SB 11-164), ch. 33,
p. 93, § 5, effective March 18; (3) amended, (SB 11-210), ch. 187, p. 718, § 1, effective July 1;
(1) and (4) amended, (SB 11-210), ch. 187, p. 719, § 2, effective July 15, 2012. L. 2017: (2)
amended, (SB 17-242), ch. 263, p. 1326, § 197, effective May 25.
Editor's note: (1) This section is similar to former § 26-2-117 as it existed prior to
2006.
(2) Amendments to subsection (3) by Senate Bill 11-210 and Senate Bill 11-164 were
harmonized.
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(3) Subsection (3)(a)(II) provided for the repeal of subsection (3)(a), effective July 15,
2012. (See L. 2011, p. 718.) Subsection (3)(b)(V) provided for the repeal of subsection (3)(b),
effective July 15, 2012. (See L. 2011, p. 718.)
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017.
25.5-2-102. Health and medical care program - aid to the needy disabled. (Repealed)
Source: L. 2006: Entire article amended with relocations, p. 1801, § 5, effective July 1.
L. 2007: Entire section repealed, p. 2043, § 72, effective June 1.
Editor's note: This section was similar to former § 26-2-119.5 as it existed prior to 2006.
25.5-2-103. Reproductive health-care program - report - rules - definitions. (1) As
used in this section, unless the context otherwise requires:
(a) Repealed.
(b) "Eligible individual" means an individual with reproductive capacity, regardless of
gender, who would be eligible to enroll in the medical assistance program, as described in
section 25.5-4-103 (13), but is not eligible due solely to the individual's immigration status, and
who is not eligible for, or declines to enroll in, state medical assistance, as described in section
25.5-2-104.
(c) "FDA" means the federal food and drug administration.
(d) "Participant" means an eligible individual enrolled in the reproductive health-care
program.
(e) "Pharmacist" means a licensed pharmacist who has entered into a collaborative
pharmacy practice agreement pursuant to section 12-280-602 to prescribe and dispense hormonal
contraceptive patches and oral hormonal contraceptives.
(f) "Provider" has the same meaning as set forth in section 25.5-4-103 (19)(a).
(g) "Reproductive health-care services" means family planning services, as defined in
section 25.5-4-412 (2)(b), and family-planning-related services, as defined in section 25.5-4-412
(2)(a).
(2) On and after July 1, 2022, the state department shall administer a reproductive
health-care program, referred to in this section as the "program", that provides reproductive
health-care services to participants.
(3) Upon the participant's initial and follow-up visits to the participant's provider, and
unless the participant requests a shorter period of time, the program shall comply with the
federal centers for disease control and prevention's selected practice recommendations for
contraceptive use by ensuring the participant is offered at least a one-year supply of either:
(a) The requested contraceptive drug, device, or product or one or more therapeutic
equivalents of the requested drug, device, or product, if the therapeutic equivalent is available
and approved by the FDA; or
(b) An alternative contraceptive drug, device, or product, if a contraceptive drug, device,
or product is deemed medically inadvisable by the participant's provider.
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(4) A participant's choice of a contraceptive drug, device, or product must not be
infringed upon and must not require prior authorization, step therapy, or other utilization control
techniques for medically appropriate contraceptive drugs, devices, or products approved by the
FDA.
(5) The state board shall adopt rules as necessary to implement this section, including
rules specifying the manner in which eligible individuals will be notified about the program and
the manner in which eligible individuals may enroll in the program.
(5.5) To the extent practicable, the state department shall ensure that eligible individuals
seeking to participate in the program are able to apply for and enroll in the program through their
local county office, a state medical assistance program site, an online application, or any other
mechanism that is available to applicants for the state medical assistance program.
(6) The state department shall provide reproductive health-care services to participants
without imposing any cost-sharing requirements.
(7) Beginning in state fiscal year 2023-24, the state department shall analyze and report
the cost-effectiveness of the program to the public through the annual hearing, pursuant to the
"State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act",
part 2 of article 7 of title 2. At a minimum, the report must include:
(a) The total number of eligible individuals;
(b) The total number of participants enrolled in the program, disaggregated by race,
ethnicity, gender identity, and income level;
(c) The cost of providing reproductive health-care services to participants;
(d) The participants' preferred method of contraceptive methods; and
(e) The cost savings realized due to avoided unintended pregnancies, including avoided
hospital costs.
Source: L. 2021: Entire section added, (SB 21-009), ch. 430, p. 2845, § 2, effective
September 7. L. 2022: (2) amended, (HB 22-1191), ch. 9, p. 113, § 1, effective March 7; (1)(b)
amended, (HB 22-1289), ch. 399, p. 2838, § 9, effective June 7. L. 2023: (1)(a) repealed, (1)(g)
and (5.5) added, and (2), (6), and (7)(c) amended, (SB 23-189), ch. 69, p. 259, § 7, effective
April 14.
Cross references: For the legislative declaration in SB 21-009, see section 1 of chapter
430, Session Laws of Colorado 2021. For the legislative declaration in HB 22-1289, see section
1 of chapter 399, Session Laws of Colorado 2022.
25.5-2-104. State-funded health and medical care. (1) Beginning no later than January
1, 2025, there is created the state medical assistance program, referred to in this section as "state
medical assistance". State medical assistance includes all benefits and services at the same cost
to the beneficiary as are offered pursuant to the medical assistance program defined in section
25.5-4-103 (13), such that, to the maximum extent possible, eligible individuals must not be able
to tell that the person is enrolled in a different program from medical assistance pursuant to
section 25.5-4-103 (13).
(2) A child who is less than nineteen years of age is eligible to receive state medical
assistance if the child would be eligible for medical assistance as defined in section 25.5-4-103
(13) but is not eligible due solely to the child's immigration status.
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(3) A child who is less than nineteen years of age is presumptively eligible for state
medical assistance and will receive services specified by state law only if a parent or legal
guardian of the child declares all pertinent information relating to the criteria of income and
assets of the child's family.
(4) State medical assistance must be funded by state funds only, except to the extent
federal funds are made available through express written authorization through a federal waiver,
state plan amendment, or otherwise, by the federal centers for medicare and medicaid services.
(5) The state department shall seek any necessary federal approvals to maximize any
available federal financial participation in implementing this section.
(6) To the maximum extent allowable under federal law, the state department shall,
using appropriate funding, use the same infrastructure and provider network to deliver state
medical assistance as it does to deliver medical assistance as defined in section 25.5-4-103 (13).
(7) This section constitutes state authority within the meaning of 8 U.S.C. sec. 1621 (d),
as that law existed on January 1, 2022.
(8) (a) 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 state medical assistance.
(b) 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 state medical assistance.
Source: L. 2022: Entire section added, (HB 22-1289), ch. 399, p. 2838, § 10, effective
June 7. L. 2023: (4) amended, (HB 23-1301), ch. 303, p. 1829, § 44, effective August 7.
Cross references: For the legislative declaration in HB 22-1289, see section 1 of chapter
399, Session Laws of Colorado 2022.
25.5-2-105. State children's basic health plan. (1) Beginning no later than January 1,
2025, there is created the state children's basic health plan. The state children's basic health plan
includes all benefits and services, at the same cost to the beneficiary, as are offered pursuant to
the children's basic health plan in section 25.5-8-107, such that, to the maximum extent possible,
eligible individuals must not be able to tell that they are enrolled in a different program from the
plan described in section 25.5-8-107.
(2) A child who is less than nineteen years of age is eligible to receive the state
children's basic health plan if the child would be eligible for the children's basic health plan as
described in section 25.5-8-107, but is not eligible due solely to the child's immigration status.
(3) A child who is less than nineteen years of age is presumptively eligible for the state
children's basic health plan and will receive services specified by state law only if a parent or
Colorado Revised Statutes 2023 Uncertified PrintoutPage 64 of 510
legal guardian of the child declares all pertinent information relating to the criteria of income
and assets of the child's family.
(4) The state children's basic health plan must be funded by state funds only, except to
the extent federal funds are made available through express written authorization through a
federal waiver, state plan amendment, or otherwise, by the centers for medicare and medicaid
services.
(5) The state department shall seek any necessary federal approvals to maximize any
available federal financial participation in implementing this section.
(6) To the maximum extent allowable under federal law, the state department shall,
using appropriate funding, use the same infrastructure and provider network to deliver the state's
children's basic health plan as it does to deliver the children's basic health plan described in
section 25.5-8-107.
(7) This section constitutes state authority within the meaning of 8 U.S.C. sec. 1621 (d),
as that law existed on January 1, 2022.
(8) (a) 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 state children's basic health plan.
(b) 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 state children's basic health plan.
Source: L. 2022: Entire section added, (HB 22-1289), ch. 399, p. 2838, § 10, effective
June 7.
Cross references: For the legislative declaration in HB 22-1289, see section 1 of chapter
399, Session Laws of Colorado 2022.
PRESCRIPTION DRUGS
ARTICLE 2.5
Prescription Drugs
PART 1
COLORADO CARES RX ACT
25.5-2.5-101. Short title. The short title of this part 1 is the "Colorado Cares Rx Act".
Colorado Revised Statutes 2023 Uncertified PrintoutPage 65 of 510
Source: L. 2007: Entire article added, p. 1, § 1, effective February 5. L. 2019: Entire
section amended, (SB 19-005), ch. 184, p. 2073, § 4, effective August 2.
Cross references: For the legislative declaration in SB 19-005, see section 1 of chapter
184, Session Laws of Colorado 2019.
25.5-2.5-102. Legislative declaration. (1) The general assembly finds that:
(a) Uninsured, underinsured, and older Coloradans pay a disproportionately greater share
of their income for prescription drugs. In many cases, current drug prices have the effect of
denying residents access to necessary medical care, thereby threatening their health and safety.
(b) Prescription drugs play an increasingly important role in improving or stabilizing a
person's health and in reducing overall health-care costs;
(c) Additionally, the new medicare prescription drug benefit restricts persons from
purchasing insurance in order to fully cover their prescription drug needs. This restriction on a
person's ability to purchase adequate coverage may threaten the person's health and safety.
(d) Currently, there is no limit on the amount that a pharmacy may charge for a generic
or nonpatented drug, and, although some retail pharmacies are offering some generic and
nonpatented drugs at discounted prices, there are no guarantees that the pharmacies will continue
to do so.
(2) The general assembly, therefore, declares that it is important to make information
available to the public concerning ways to purchase lower-cost generic and nonpatented
prescription drugs through the "Colorado Cares Rx Act" in order to protect the health of
uninsured, underinsured, and older Coloradans. The general assembly further declares that the
state should continue to actively research cost-effective mechanisms or programs that may
provide additional options to address this need in Colorado.
Source: L. 2007: Entire article added, p. 1, § 1, effective February 5. L. 2009: Entire
section amended, (SB 09-132), ch. 224, p. 1011, § 1, effective May 4.
25.5-2.5-103. Lower-cost prescription drugs - information - research - reporting. (1)
The state department shall make information available to the public concerning lower-cost
prescription drug programs. The information shall include, but need not be limited to:
(a) Ways in which low-income, uninsured persons can obtain lower-cost prescription
drugs; and
(b) Contact information concerning programs for lower-cost prescription drugs.
(2) The state department shall research cost-effective programs or mechanisms by which
low-income, uninsured persons may purchase lower-cost prescription drugs.
(3) The state department shall report annually to the health and human services
committees of the house of representatives and the senate, or any successor committees,
concerning the provisions of this article.
Source: L. 2007: Entire article added, p. 2, § 1, effective February 5. L. 2009: Entire
section R&RE, (SB 09-132), ch. 224, p. 1012, § 2, effective May 4.
25.5-2.5-104. Program - rules - repeal. (Repealed)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 66 of 510
Source: L. 2007: Entire article added, p. 2, § 1, effective February 5. L. 2009: Entire
section repealed, (SB 09-132), ch. 224, p. 1012, § 3, effective May 4.
25.5-2.5-105. Cash fund. (Repealed)
Source: L. 2007: Entire article added, p. 4, § 1, effective February 5. L. 2009: Entire
section repealed, (SB 09-132), ch. 224, p. 1012, § 3, effective May 4.
25.5-2.5-106. Repeal of article. (Repealed)
Source: L. 2007: Entire article added, p. 4, § 1, effective February 5. L. 2009: Entire
section repealed, (SB 09-132), ch. 224, p. 1012, § 3, effective May 4.
PART 2
CANADIAN PRESCRIPTION DRUG IMPORTATION PROGRAM
Cross references: For the legislative declaration in SB 19-005, see section 1 of chapter
184, Session Laws of Colorado 2019.
25.5-2.5-201. Short title. The short title of this part 2 is the "Dr. Irene Aguilar Canadian
Prescription Drug Importation Act".
Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2065, § 3, effective August
2.
25.5-2.5-202. Definitions. As used in this part 2, unless the context otherwise requires:
(1) "Canadian supplier" means a manufacturer, wholesale distributor, or pharmacy that is
appropriately licensed or permitted under Canadian federal and provincial laws and regulations
to manufacture, distribute, or dispense prescription drugs.
(2) "Eligible importer" means an importer that is described in section 25.5-2.5-204 (3).
(3) "Federal act" means the "Federal Food, Drug, and Cosmetic Act", 21 U.S.C. sec. 301
et seq.
(4) "Medicaid pharmacy" means a pharmacy registered pursuant to section 12-280-119
that has a provider agreement in effect with the state department and is in good standing with the
state department.
(5) "Pharmacist" means a person who holds an active and unencumbered license to
practice pharmacy pursuant to section 12-280-114.
(6) "Prescription drug" has the same meaning set forth in section 12-280-103 (42);
except that the term includes only drugs that are intended for human use.
(7) "Program" means the Canadian prescription drug importation program created in
section 25.5-2.5-203.
(8) "Vendor" means a vendor with which the state department contracts for the provision
of services under the program pursuant to section 25.5-2.5-203 (1).
Colorado Revised Statutes 2023 Uncertified PrintoutPage 67 of 510
Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2065, § 3, effective August
2.
25.5-2.5-203. Canadian prescription drug importation program - created -
importation process - contract with vendor - vendor duties. (1) The Canadian prescription
drug importation program is created in the state department. Upon receiving approval of the
program as described in section 25.5-2.5-205 (1), the state department shall contract with one or
more vendors to provide services under the program. For three years following August 2, 2019,
the selection of any vendor pursuant to this subsection (1) is exempt from the requirements of
the procurement code, articles 101 to 112 of title 24.
(2) (a) Each vendor, in consultation with the state department and any other vendors,
shall establish a wholesale prescription drug importation list that identifies the prescription drugs
that have the highest potential for cost savings to the state. In developing the list, each vendor
shall consider, at a minimum, which prescription drugs will provide the greatest cost savings to
the state, including prescription drugs for which there are shortages, specialty prescription drugs,
and high-volume prescription drugs. Each vendor shall revise the list at least annually and at the
direction of the state department pursuant to subsection (2)(b) of this section.
(b) The state department shall review the wholesale prescription drug importation list at
least every three months to ensure that it continues to meet the requirements of the program. The
state department may direct a vendor to revise the list, as necessary.
(c) Each vendor, in consultation with the state department, shall identify Canadian
suppliers that are in full compliance with relevant Canadian federal and provincial laws and
regulations and that have agreed to export prescription drugs identified on the wholesale
prescription drug importation list. Each vendor shall verify that such Canadian suppliers meet all
of the requirements of the program and will export prescription drugs at prices that will provide
cost savings to the state. Each vendor shall contract with such eligible Canadian suppliers, or
facilitate contracts between eligible importers and Canadian suppliers, to import prescription
drugs under the program.
(d) Each vendor shall assist the state department in developing and administering a
distribution program within the program.
(e) Each vendor shall assist the state department with the annual report described in
section 25.5-2.5-206 and provide any information requested by the state department for the
report.
(f) Each vendor shall ensure the safety and quality of drugs imported under the program,
as follows:
(I) (A) For an initial imported shipment, ensure that each batch of the drug in the
shipment is statistically sampled and tested for authenticity and degradation in a manner
consistent with the federal act; and
(B) For any subsequent imported shipment, ensure that a statistically valid sample of the
shipment is tested for authenticity and degradation in a manner consistent with the federal act;
(II) Certify that each drug:
(A) Is approved for marketing in the United States and is not adulterated or misbranded;
and
(B) Meets all of the labeling requirements under 21 U.S.C. sec. 352;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 68 of 510
(III) Maintain qualified laboratory records, including complete data derived from all
tests necessary to ensure that the drug is in compliance with the requirements of this section; and
(IV) Maintain documentation demonstrating that the testing required by this section was
conducted at a qualified laboratory in accordance with the federal act and any other applicable
federal and state laws and regulations governing laboratory qualifications.
(3) All testing required by this section must be conducted in a qualified laboratory that
meets the standards under the federal act and any other applicable federal and state laws and
regulations governing laboratory qualifications for drug testing.
(4) Each vendor shall maintain a list of all eligible importers that participate in the
program.
(5) Each vendor shall ensure compliance with Title II of the federal "Drug Quality and
Security Act", Pub.L. 113-54, by all Canadian suppliers, eligible importers, distributors, and
other participants in the program.
(6) Each vendor shall provide an annual financial audit of its operations to the state
department. Each vendor shall also provide quarterly financial reports specific to the program
and shall include information concerning the performance of its subcontractors and vendors. The
state department shall determine the format and contents of the reports.
(7) Each vendor shall submit evidence of a surety bond with any bid or initial contract
negotiation documents and shall maintain documentation of evidence of such a bond with the
state department throughout the contract term. The surety bond may be from this state or any
other state in the United States and must be in an amount of at least twenty-five thousand dollars.
The surety bond or comparable security arrangement must include the state of Colorado as a
beneficiary. In lieu of the surety bond, a vendor may provide a comparable security agreement,
such as an irrevocable letter of credit or a deposit into a trust account or financial institution that
includes the state of Colorado as a beneficiary, payable to the state of Colorado. The purposes of
the bond or other security arrangement are to:
(a) Ensure participation of the vendor in any civil or criminal legal action by the state
department, any other state agency, or private individuals or entities against the vendor because
of the vendor's failure to perform under the contract, including but not limited to causes of
actions for personal injury, negligence, and wrongful death;
(b) Ensure payment by the vendor through the use of a bond or other comparable
security arrangement of any legal judgments and claims that are awarded to the state, other
entities acting on behalf of the state, individuals, or organizations if the vendor is assessed a final
judgment or other monetary penalty in a court of law for a civil or criminal action under the
program. The bond or comparable security arrangement may be accessed if the vendor fails to
pay any judgment or claim within sixty days after final judgment.
(c) Allow for civil and criminal litigation claims to be made against the bond or other
comparable security arrangements for up to one year after the vendor's contract under the
program has ended with the state department, the vendor's license is no longer valid, or the
program has ended, whichever occurs last.
(8) Each vendor shall maintain information and documentation submitted under this
section for a period of at least seven years.
(9) The state department may require each vendor to collect any other information
necessary to ensure the protection of the public health.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 69 of 510
Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2066, § 3, effective August
2.
25.5-2.5-204. Eligible prescription drugs - eligible Canadian suppliers - eligible
importers - distribution requirements. (1) An eligible importer may import a prescription
drug from a Canadian supplier if:
(a) The drug that is to be imported meets the federal food and drug administration's
standards related to safety, effectiveness, misbranding, and adulteration;
(b) Importing the drug would not violate federal patent laws;
(c) Importing the drug is expected to generate cost savings; and
(d) The drug is not:
(I) A controlled substance as defined in 21 U.S.C. sec. 802 (6);
(II) A biological product as defined in 42 U.S.C. sec. 262 (i);
(III) An infused drug;
(IV) An intravenously injected drug;
(V) A drug that is inhaled during surgery; or
(VI) A drug that is a parenteral drug, the importation of which is determined by the
federal secretary of health and human services to pose a threat to public health.
(2) A Canadian supplier may export prescription drugs into the state under the program
if the supplier:
(a) Is in full compliance with relevant Canadian federal and provincial laws and
regulations;
(b) Is identified by the vendor as eligible to participate in the program pursuant to
section 25.5-2.5-203 (2)(c); and
(c) Submits an attestation that the supplier has a registered agent in the United States,
which attestation includes the name and United States address of the registered agent.
(3) The following entities are eligible importers and may obtain imported prescription
drugs:
(a) A pharmacist or wholesaler employed by or under contract with a medicaid
pharmacy, for dispensing to the pharmacy's medicaid recipients;
(b) A pharmacist or wholesaler employed by or under contract with the department of
corrections, for dispensing to inmates in the custody of the department of corrections;
(c) Commercial plans, as defined by rules promulgated by the state board and as
approved by the federal government; and
(d) A licensed Colorado pharmacist or registered wholesaler approved by the state
department.
(4) (a) The state department shall designate an office or division that must be a
registered wholesaler or that shall contract with a wholesaler registered pursuant to part 3 of
article 280 of title 12.
(b) The office or division designated by the state department pursuant to subsection
(4)(a) of this section shall:
(I) Set a maximum profit margin so that a wholesaler, distributor, pharmacy, or other
licensed provider participating in the program maintains a profit margin that is no greater than
the profit margin that the wholesaler, distributor, pharmacy, or other licensed provider would
have earned on the equivalent nonimported drug;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 70 of 510
(II) Exclude generic products if the importation of the products would violate United
States patent laws applicable to United States-branded products;
(III) Comply with the requirements of 21 U.S.C. sec. 360eee to 360eee-4 as enacted in
Title II of the federal "Drug Quality and Security Act"; and
(IV) Determine a method for covering the administrative costs of the program, which
method may include a fee imposed on each prescription pharmaceutical product sold through the
program or any other appropriate method as determined by the state department, but the state
department shall not require a fee in an amount the state department determines would
significantly reduce consumer savings.
(5) Canadian suppliers and eligible importers participating under the program:
(a) Shall comply with the tracking and tracing requirements of 21 U.S.C. sec. 360eee et
seq.; and
(b) Shall not distribute, dispense, or sell prescription drugs imported under the program
outside of the state.
(6) A participating eligible importer shall submit to the vendor all of following
information about each drug to be acquired by the importer under the program:
(a) The name and quantity of the active ingredient of the drug;
(b) A description of the dosage form of the drug;
(c) The date on which the drug is received;
(d) The quantity of the drug that is received;
(e) The point of origin and destination of the drug; and
(f) The price paid by the importer for the drug.
(7) A participating Canadian supplier shall submit to the vendor the following
information about each drug to be supplied by the Canadian supplier under the program:
(a) The original source of the drug, including:
(I) The name of the manufacturer of the drug;
(II) The date on which the drug was manufactured; and
(III) The country, state or province, and city where the drug was manufactured;
(b) The date on which the drug is shipped;
(c) The quantity of the drug that is shipped;
(d) The quantity of each lot of the drug originally received and the source of the lot; and
(e) The lot or control number and the batch number assigned to the drug by the
manufacturer.
(8) The state department shall immediately suspend the importation of a specific drug or
the importation of drugs by a specific eligible importer if it discovers that any drug or activity is
in violation of this section or any federal or state law or regulation. The state department may
revoke the suspension if, after conducting an investigation, it determines that the public is
adequately protected from counterfeit or unsafe drugs being imported into this state.
Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2068, § 3, effective August
2. L. 2021: (3)(d) and (4)(a) amended, (SB 21-094), ch. 314, p. 1945, § 35, effective September
1.
25.5-2.5-205. Federal approval. (1) On or before September 1, 2020, the state
department shall submit a request to the United States secretary of health and human services for
Colorado Revised Statutes 2023 Uncertified PrintoutPage 71 of 510
approval of the program under 21 U.S.C. sec. 384. The state department shall begin operating the
program not later than six months after receiving such approval. The request must, at a
minimum:
(a) Describe the state department's plan for operating the program;
(b) Demonstrate how the prescription drugs imported into the state under the program
will meet the applicable federal and state standards for safety, effectiveness, misbranding, and
adulteration;
(c) Include a list of prescription drugs that have the highest potential for cost savings to
the state through importation at the time that the request is submitted;
(d) Estimate the total cost savings attributable to the program; and
(e) Include a list of potential Canadian suppliers from which the state would import
prescription drugs and demonstrate that the suppliers are in full compliance with relevant
Canadian federal and provincial laws and regulations.
(2) Notwithstanding any provision of this part 2 to the contrary, the state department
may expend money for the purpose of requesting approval of the program as described in
subsection (1) of this section but the state department shall not spend any other money to
implement the program until the state department receives approval of the program as described
in said subsection (1).
(3) Upon receipt of federal approval of the program, the state department shall notify the
president of the senate and the speaker of the house of representatives, as well as the health and
human services committee of the senate and the health and insurance committee of the house of
representatives, or any successor committees. After approval is received and before the start of
the next regular session of the general assembly in which the proposal could be funded, the state
department shall submit to all parties specified in this subsection (3) a proposal for program
implementation and program funding.
Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2071, § 3, effective August
2.
25.5-2.5-206. Reports. (1) Notwithstanding section 24-1-136 (11)(a)(I), on or before
December 1, 2021, and on or before December 1 each year thereafter, the state department shall
submit a report to the governor, the president of the senate, and the speaker of the house of
representatives concerning the operation of the program during the previous fiscal year. The
report must include, at a minimum:
(a) A list of the prescription drugs that were imported under the program;
(b) The number of participating Canadian suppliers and eligible importers;
(c) The number of prescriptions dispensed through the program;
(d) The estimated cost savings during the previous fiscal year and to date;
(e) A description of the methodology used to determine which prescription drugs should
be included on the wholesale prescription drug importation list established pursuant to section
25.5-2.5-203 (2)(a); and
(f) Documentation demonstrating how the program ensures that:
(I) The vendor verifies that Canadian suppliers participating in the program are in full
compliance with relevant Canadian federal and provincial laws and regulations;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 72 of 510
(II) Prescription drugs imported under the program are not shipped, sold, or dispensed
outside of the state once in the possession of the eligible importer;
(III) Prescription drugs imported under the program are pure, unadulterated, potent, and
safe;
(IV) The program does not put consumers at a higher health and safety risk than if the
program did not exist; and
(V) The program provides cost savings to the state on imported prescription drugs.
Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2072, § 3, effective August
2.
25.5-2.5-207. Importation program authorized - rules. (1) Upon approval by the
United States secretary of health and human services, in accordance with section 25.5-2.5-205,
the state department shall administer an importation program.
(2) The state department shall approve a method of financing the administrative costs of
the importation program, which method may include imposing a fee on each prescription
pharmaceutical product sold through the importation program or any other appropriate method
determined by the state department to finance administrative costs. The state department shall
not require a fee in an amount that the state department determines would significantly reduce
consumer savings.
(3) The executive director shall promulgate rules, in accordance with article 4 of title 24
and section 25.5-1-108, as necessary for the administration of this part 2.
Source: L. 2019: Entire part added, (SB 19-005), ch. 184, p. 2073, § 3, effective August
2. L. 2021: (1) amended, (SB 21-266), ch. 423, p. 2802, § 20, effective July 2.
25.5-2.5-208. Expansion of program to include additional foreign suppliers - federal
action required - notice to general assembly. (1) Notwithstanding any provision of this part 2
to the contrary, the state department may expand the program to allow a manufacturer, wholesale
distributor, or pharmacy from a nation other than Canada to export prescription drugs into the
state under the program if:
(a) The United States congress enacts legislation to amend 21 U.S.C. sec. 384 or
otherwise enacts legislation to permit states, including Colorado, to import prescription drugs
from foreign countries other than Canada;
(b) A vendor, in consultation with the state department, has identified the manufacturer,
wholesale distributor, or pharmacy as a supplier that satisfies the requirements of the program
and that will export prescription drugs at prices that will provide cost savings to the state;
(c) The manufacturer, wholesale distributor, or pharmacy is appropriately licensed or
permitted under that nation's laws and regulations pertaining to the manufacturing, distribution,
or dispensing of prescription drugs;
(d) The manufacturer, wholesale distributor, or pharmacy is located in a nation that is
approved to export prescription drugs into Colorado by the United States secretary of health and
human services or by another authority that is designated for such purpose by federal law; and
(e) The state department submits evidence to the president of the senate, the speaker of
the house of representatives, and the health and human services committee of the senate and the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 73 of 510
health and insurance committee of the house of representatives, or any successor committees,
which evidence compares the exporting nation's regulatory system for prescription drugs to the
regulatory system for prescription drugs administered by the United States food and drug
administration pursuant to the federal act and demonstrates that the exporting nation's regulatory
system is as stringent as the system in the United States or otherwise ensures the safety, purity,
and potency of the prescription drugs from the exporting nation. The evidence must compare the
regulations for:
(I) Securing the supply chain for prescription drugs;
(II) Prescription drug manufacturing;
(III) Prescription drug labeling; and
(IV) Prescription drug tracking and tracing.
(2) If, upon the satisfaction of the conditions described in subsection (1) of this section,
the state department decides to expand the program to allow a manufacturer, wholesale
distributor, or pharmacy from a nation other than Canada to export prescription drugs into the
state under the program, the executive director shall notify the president of the senate, the
speaker of the house of representatives, and the health and human services committee of the
senate and the health and insurance committee of the house of representatives, or any successor
committees, of the state department's intent to do so. The executive director shall provide the
notice at least thirty days before the program is expanded, and the notice may include any
recommendations of the state department for legislation to amend this part 2 to reflect the
expansion of the program.
(3) If the state department expands the program in accordance with this section, an
eligible importer may import a prescription drug from a foreign supplier pursuant to this section
if the drug that is to be imported is a prescription drug, as defined in 21 U.S.C. sec. 384 (a)(3).
Source: L. 2021: Entire section added, (SB 21-123), ch. 57, p. 233, § 2, effective
September 7.
Cross references: For the legislative declaration in SB 21-123, see section 1 of chapter
57, Session Laws of Colorado 2021.
INDIGENT CARE
ARTICLE 3
Indigent Care
Editor's note: This article was added in 2005. This article was amended in 2006,
resulting in the relocation of provisions. For the text of this article prior to 2006, consult the
2005 Colorado Revised Statutes. Former C.R.S. section numbers are shown in editor's notes
following those sections that were relocated. For a detailed comparison of this article, see the
comparative tables located in the back of the index.
PART 1
Colorado Revised Statutes 2023 Uncertified PrintoutPage 74 of 510
COLORADO INDIGENT CARE PROGRAM
25.5-3-101. Short title. This part 1 shall be known and may be cited as the "Colorado
Indigent Care Program".
Source: L. 2006: Entire article amended with relocations, p. 1802, § 6, effective July 1.
Editor's note: This section is similar to former § 26-15-101 as it existed prior to 2006.
25.5-3-102. Legislative declaration. (1) The general assembly hereby determines, finds,
and declares that:
(a) The state has insufficient resources to pay for all medical services for persons who
are indigent and must therefore allocate available resources in a manner that will provide
treatment of those conditions constituting the most serious threats to the health of such medically
indigent persons, as well as increase access to primary medical care to prevent deterioration of
the health conditions among medically indigent people; and
(b) Such allocation of resources will require the prioritization of medical services by
providers and the coordination of administration and delivery of medical services.
(2) The general assembly further determines, finds, and declares that the eligibility of
medically indigent persons to receive medical services rendered under the conditions specified in
subsection (1) of this section exists only to the extent of available appropriations, as well as to
the extent of the individual provider facility's physical, staff, and financial capabilities. The
general assembly also recognizes that the program for the medically indigent is a partial solution
to the health-care needs of Colorado's medically indigent citizens. Therefore, medically indigent
persons accepting medical services from such program shall be subject to the limitations and
requirements imposed in this part 1.
Source: L. 2006: Entire article amended with relocations, p. 1802, § 6, effective July 1.
Editor's note: This section is similar to former § 26-15-102 as it existed prior to 2006.
25.5-3-103. Definitions. As used in this part 1, unless the context otherwise requires:
(1) "Emergency care" means treatment for conditions of an acute, severe nature which
are life, limb, or disability threats requiring immediate attention, where any delay in treatment
would, in the judgment of the responsible physician, threaten life or loss of function of a patient
or viable fetus.
(2) "Executive director" means the executive director of the state department.
(3) "General provider" means a general hospital, birth center, or community health clinic
licensed or certified by the department of public health and environment pursuant to section
25-1.5-103 (1)(a)(I) or (1)(a)(II); a federally qualified health center, as defined in the federal
"Social Security Act", 42 U.S.C. sec. 1395x (aa)(4); a rural health clinic, as defined in the federal
"Social Security Act", 42 U.S.C. sec. 1395x (aa)(2); a health maintenance organization issued a
certificate of authority pursuant to section 10-16-402; and the health sciences center when acting
pursuant to section 25.5-3-108 (5)(a)(I) or (5)(a)(II)(A). For the purposes of the program,
"general provider" includes associated physicians.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 75 of 510
(4) "Health sciences center" means the schools of medicine, dentistry, nursing, and
pharmacy established by the regents of the university of Colorado under section 5 of article VIII
of the Colorado constitution.
(5) "Program" means the program for the medically indigent established by section
25.5-3-104.
(6) "University hospital" means the university hospital operated pursuant to article 21 of
title 23, C.R.S.
Source: L. 2006: Entire article amended with relocations, p. 1803, § 6, effective July 1.
L. 2011: (3) amended, (HB 11-1101), ch. 94, p. 278, § 3, effective April 8; (3) amended, (HB
11-1323), ch. 265, p. 1199, § 3, effective June 2. L. 2020: (3) amended, (SB 20-136), ch. 70, p.
288, § 26, effective September 14.
Editor's note: This section is similar to former § 26-15-103 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 20-136, see section 1 of chapter
70, Session Laws of Colorado 2020.
25.5-3-104. Program for the medically indigent established - eligibility - rules. (1) A
program for the medically indigent is hereby established, to commence July 1, 1983, which shall
be administered by the state department, to provide payment to providers for the provision of
medical services to eligible persons who are medically indigent. The state board may promulgate
rules as are necessary for the implementation of this part 1 in accordance with article 4 of title
24, C.R.S.
(2) A client's eligibility to receive discounted services under the program for the
medically indigent shall be determined by rule of the state board based on a specified percentage
of the federal poverty line, adjusted for family size, which percentage shall not be less than two
hundred fifty percent.
(3) No later than June 1, 2022, for providers defined as hospital providers in 10 CCR
2505-10, sec. 8.901.J, the state department shall promulgate rules:
(a) Prohibiting hospitals from considering assets when determining whether a patient
meets the specified percentage of the federal poverty line required in subsection (2) of this
section; and
(b) Ensuring the method used to determine whether a patient meets the specified
percentage of the federal poverty line is uniform across hospitals and aligned with the method
for counting income for the purposes of determining eligibility for discounted care, as described
in section 25.5-3-503.
Source: L. 2006: Entire section amended, p. 1606, § 2, effective June 2; entire article
amended with relocations, p. 1803, § 6, effective July 1. L. 2010: (2) amended, (HB 10-1422),
ch. 419, p. 2109, § 138, effective August 11. L. 2021: (3) added, (HB 21-1198), ch. 435, p. 2885,
§ 6, effective September 7.
Editor's note: (1) This section is similar to former § 26-15-104 as it existed prior to
2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 76 of 510
(2) Amendments to section 26-15-104 by Senate Bill 06-044 were harmonized with this
section as it appeared in Senate Bill 06-219.
Cross references: For the legislative declaration contained in the 2006 act amending this
section, see section 1 of chapter 323, Session Laws of Colorado 2006.
25.5-3-105. Eligibility of legal immigrants for services. The county departments
responsible for administering benefits programs under the department of health care policy and
financing and the department of human services shall identify and review all current county
guidance materials, including forms, training materials, websites, and any other materials that
reference a prohibition on sponsorship as a condition of eligibility for benefits and shall remove
all such references from verbal and digital communications and from all physical materials
currently provided to applicants or beneficiaries.
Source: L. 2006: Entire article amended with relocations, p. 1804, § 6, effective July 1.
L. 2023: Entire section amended, (HB 23-1117), ch. 65, p. 231, § 2, effective August 7.
Editor's note: This section is similar to former § 26-15-104.3 as it existed prior to 2006.
Cross references: For the legislative declaration in HB 23-1117, see section 1 of chapter
65, Session Laws of Colorado 2023.
25.5-3-106. No public funds for abortion - exception - definitions - repeal. (1) It is
the purpose of this section to implement the provisions of amendment 3 to 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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 77 of 510
(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.
(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, 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.
Source: L. 2006: Entire article amended with relocations, p. 1804, § 6, effective July 1.
L. 2021: (3) amended, (SB 21-142), ch. 168, p. 934, § 2, effective May 21.
Editor's note: This section is similar to former § 26-15-104.5 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 78 of 510
Cross references: (1) For the text of "amendment 3 to article V of the Colorado
constitution" referenced in subsection (1) of this section, see section 50 of article V of the state
constitution.
(2) For the legislative declaration in SB 21-142, see section 1 of chapter 168, Session
Laws of Colorado 2021.
25.5-3-107. Report concerning the program. Notwithstanding the provisions of section
24-1-136 (11)(a)(I), the executive director shall prepare an annual report concerning the status of
the medically indigent program to be submitted to the health and human services committees of
the senate and the house of representatives, or any successor committees, no later than February
1 of each year. The report shall be prepared following consultation with providers in the
program, state department personnel, and other agencies, organizations, or individuals as the
executive director deems appropriate in order to obtain comprehensive and objective information
about the program.
Source: L. 2006: Entire article amended with relocations, p. 1806, § 6, effective July 1.
L. 2017: Entire section amended, (HB 17-1060), ch. 6, p. 16, § 6, effective March 1.
Editor's note: This section is similar to former § 26-15-105 as it existed prior to 2006.
25.5-3-108. Responsibility of the department of health care policy and financing -
provider reimbursement - repeal. (1) The state department shall be responsible for:
(a) Execution of such contracts with providers for partial reimbursement of costs for
medical services rendered to the medically indigent as the state department shall determine are
necessary for the program;
(b) Promulgation of such reasonable rules as are necessary for the program;
(c) Submission of the report required in section 25.5-3-107; and
(d) Application for federal financial participation under the program.
(2) The contracts required by paragraph (a) of subsection (1) of this section shall be
negotiated between the state department and the various general providers, as defined in section
25.5-3-103 (3), and shall include contracts with providers to provide tertiary or specialized
services. The state department may award such contracts upon a determination that it would not
be cost effective nor result in adequate quality of care for such services to be developed by the
contract providers, or upon a determination that the contract providers are unable or unwilling to
provide such services.
(3) The state department shall establish procedures requiring the provider to provide for
proof of indigency to be submitted by the person seeking assistance, but the provider shall be
responsible for the determination of eligibility.
(4) The state department shall establish procedures so that the providers of medical
services rendered to the medically indigent cover geographic regions of the state.
(5) (a) The responsibilities of providers who provide medical care through the program
for the medically indigent are as follows:
(I) Denver health and hospitals, including associated physicians, shall, up to its physical,
staff, and financial capabilities as provided for under this program, be the primary providers of
medical services to the medically indigent for the city and county of Denver.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 79 of 510
(II) (A) University hospital and the physicians and other faculty members of the health
sciences center shall, up to their physical, staff, and financial capabilities as provided for under
this program, be the primary provider of medical services to the medically indigent for the
Denver primary metropolitan statistical area.
(B) University hospital and the physicians and other faculty members of the health
sciences center shall be the primary provider of such complex care as is not available or is not
contracted for in the remaining areas of the state up to their physical, staff, and financial
capabilities as provided for under this program.
(b) Any two or more providers awarded contracts may, with the approval of the state
department, redistribute their respective populations and associated funds.
(c) Every provider who provides medical care through the program for the medically
indigent shall comply with all procedures established by the state department.
(6) The state department shall establish procedures that allocate funds to providers based
on the anticipated utilization of services.
(7) A provider receiving reimbursement pursuant to this section shall transfer a
medically indigent patient to another provider only with the prior agreement of the provider.
(8) (a) Every provider receiving reimbursement pursuant to this section shall prioritize
for each fiscal year the medical services which it will be able to render, within the limits of the
funds which will be made available by the state department.
(b) Such medical services shall be prioritized in the following order:
(I) Emergency care for the full year;
(II) Any additional medical care for those conditions the state department determines to
be the most serious threat to the health of medically indigent persons;
(III) Any other additional medical care.
(9) A provider receiving reimbursement pursuant to this section shall not be liable in
civil damages for refusing to admit for treatment or for refusing to treat any medically indigent
person for a condition which the state department or the provider has determined to be outside of
the scope of the program.
(10) (a) A medically indigent person who wishes to be determined eligible for assistance
under this part 1 shall comply with the eligibility requirements set by the state department.
(b) A medically indigent person requesting assistance under this part 1 specifically
authorizes the state department or provider to:
(I) Use any information required by the eligibility requirements set by the state
department for the purpose of verifying eligibility; and
(II) Obtain records pertaining to eligibility from a financial institution, as defined in
section 15-15-201 (4), C.R.S., or from any insurance company.
(c) A medically indigent person requesting assistance under this part 1 shall be provided
language clearly explaining the provisions of this subsection (10).
(11) With the approval of the state department, any provider awarded a contract may
enter into subcontracts or other agreements for services related to the program.
(12) Providers awarded contracts shall not be paid from funds made available for this
program up to the extent, if any, of their annual financial obligation under the Hill-Burton act.
(13) When adopting or modifying procedures under this part 1, the state department shall
notify each provider, who is contracted to provide medical care through the program for the
medically indigent, at least thirty days prior to implementation of a new procedure. The state
Colorado Revised Statutes 2023 Uncertified PrintoutPage 80 of 510
department shall hold a meeting for all providers at least thirty days prior to the implementation
of a new procedure.
(14) The state department shall require any hospital provider who may receive payment
under the program to annually submit data relating to the hospital's number of medicaid-eligible
in-patient days and the hospital's total in-patient days in a form specified by the state department.
The hospital provider shall verify the data to the state department through the program audit
procedures required by the state department. The state department shall include this information
by hospital in the department's annual budget request to the joint budget committee of the
general assembly and in the report required by section 25.5-3-107.
(15) To qualify for the program's payment formula disproportionate share hospital
factor, as described in rule by the state board consistent with the provisions of this part 1, a
hospital provider's percent of medicaid-eligible in-patient days relative to total in-patient days
shall be equal to or exceed one standard deviation above the mean.
(16) After receiving approval by the state department, a community health clinic may
utilize moneys received pursuant to this article, and any gifts, grants, and donations, for the
development and implementation of demonstration projects that may include but need not be
limited to coordination of care and disease management.
(17) Subject to adequate funding being made available under section 25.5-4-402.4, the
Colorado healthcare affordability and sustainability enterprise created in section 25.5-4-402.4 (3)
shall increase hospital reimbursements up to one hundred percent of hospital costs for providing
medical care under the program.
(18) and (19) Repealed.
(20) (a) Notwithstanding any other provision of law, for the state fiscal year starting July
1, 2021, and any subsequent fiscal years, if a provider submits a certification of public
expenditures pursuant to 42 CFR 433.51 (b), the state department shall retain any federal money
payable as reimbursement for the expenditure in excess of fifty percent of the expenditure
amount; except that the state department shall only retain the federal money based on the date of
service as long as the increased reimbursements and payments pursuant to the federal "Families
First Coronavirus Response Act", Pub.L. 116-127, are still available. The state treasurer shall
transfer such money to the general fund created in section 24-75-201 for appropriation to the
state medical assistance program.
(b) This subsection (20) is repealed, effective December 31, 2024.
Source: L. 2006: (1) amended and (16) added, p. 1606, § 3, effective June 2; entire
article amended with relocations, p. 1806, § 6, effective July 1. L. 2009: (18) added, (SB
09-264), ch. 204, p. 928, § 4, effective May 1; (17) added, (HB 09-1293), ch. 152, p. 644, § 3,
effective July 1. L. 2017: (17) amended, (SB 17-267), ch. 267, p. 1447, § 13, effective July 1. L.
2020: (19) added, (HB 20-1385), ch. 173, p. 795, § 1, effective June 29. L. 2021: (20) added,
(SB 21-213), ch. 88, p. 363, § 1, effective May 4.
Editor's note: (1) This section is similar to former § 26-15-106 as it existed prior to
2006.
(2) (a) Amendments to section 26-15-106 (1) by Senate Bill 06-044 were harmonized
with subsection (1) as it appeared in Senate Bill 06-219.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 81 of 510
(b) Subsection (16) was enacted as § 26-15-106 (20) in Senate Bill 06-044 but was
relocated due to its harmonization with this section as it appeared in Senate Bill 06-219.
(3) Subsection (18)(b) provided for the repeal of subsection (18), effective July 1, 2011.
(See L. 2009, p. 928.)
(4) Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017, provides
that the section of the act changing this section does not take effect if the centers for medicare
and medicaid services determine that the amendments do not comply with federal law. For more
information, see SB 17-267. (L. 2017, p. 1478.) The executive director of the department of
health care policy and financing did not notify the revisor of statutes by June 1, 2017, of such
determination; therefore, the changes to this section took effect July 1, 2017.
(5) Subsection (19)(b) provided for the repeal of subsection (19), effective December 31,
2021. (See L. 2020, p. 795.)
Cross references: (1) For the legislative declaration contained in the 2006 act amending
subsection (1) and enacting subsection (16), see section 1 of chapter 323, Session Laws of
Colorado 2006. For the legislative declaration in SB 17-267, see section 1 of chapter 267,
Session Laws of Colorado 2017.
(2) For the "Hill-Burton Act" referenced in subsection (12), also known as the "Hospital
Survey and Construction Act", see Pub.L. 725, 79th Congress, 60 Stat. 1040.
25.5-3-109. Appropriations. The general assembly shall make annual appropriations to
the state department to accomplish the purposes of this part 1.
Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1.
Editor's note: This section is similar to former § 26-15-110 as it existed prior to 2006.
25.5-3-110. Effect of part 1. This part 1 does not affect the responsibilities of the
behavioral health administration in the department of human services for the provision of mental
health care in accordance with article 66 of title 27, and this part 1 does not affect any provisions
of article 22 of title 23 or any other provisions of law relating to the university of Colorado
psychiatric hospital.
Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1.
L. 2010: Entire section amended, (SB 10-175), ch. 188, p. 800, § 64, effective April 29. L. 2022:
Entire section amended, (HB 22-1278), ch. 222, p. 1511, § 65, effective July 1.
Editor's note: This section is similar to former § 26-15-111 as it existed prior to 2006.
25.5-3-111. Penalties. Any person who represents that any medical service is
reimbursable or subject to payment pursuant to this part 1 when the person knows that it is not
commits a petty offense. Any person who represents that the person is eligible for assistance
pursuant to this part 1 when the person knows that the person is not commits a class 2
misdemeanor and shall be punished as provided in section 18-1.3-503.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 82 of 510
Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1.
L. 2021: Entire section amended, (SB 21-271), ch. 462, p. 3241, § 482, effective March 1, 2022.
L. 2022: Entire section amended, (HB 22-1229), ch. 68, p. 349, § 42, effective March 1.
Editor's note: (1) This section is similar to former § 26-15-112 as it existed prior to
2006.
(2) Section 47 of chapter 68 (HB 22-1229), Session Laws of Colorado 2022, provides
that the act changing this section is effective March 1, 2022, but the governor did not approve
the act until April 7, 2022.
25.5-3-112. Health care services fund - creation - state plan amendment - primary
care special distribution fund. (1) (a) There is hereby created in the state treasury the Colorado
health care services fund, referred to in this section as the "fund". The fund shall consist of
moneys credited thereto pursuant to this section.
(b) In fiscal year 2005-06, the general assembly shall appropriate fourteen million nine
hundred sixty-two thousand four hundred eight dollars from the general fund to the fund. Of the
moneys in the general fund exempt account created in section 24-77-103.6 (2), C.R.S., the
following amounts shall be appropriated by the general assembly to the fund:
(I) In fiscal year 2007-08, fifteen million dollars; and
(II) In fiscal year 2008-09, twelve million nine hundred eighteen thousand seven
hundred fifty dollars.
(III) (Deleted by amendment, L. 2010, (HB 10-1321), ch. 48, p. 179, § 1, effective
March 29, 2010.)
(b.5) In fiscal year 2009-10, the general assembly shall appropriate ten million three
hundred ninety thousand dollars from the general fund to the fund.
(b.6) In fiscal year 2011-12, the treasurer shall transfer one million dollars from the
general fund to the fund.
(c) All moneys appropriated to the fund shall be used as provided in this section and
shall not be deposited in or transferred to the general fund of this state or to any other fund.
Notwithstanding any provision of section 24-36-114, C.R.S., to the contrary, all interest derived
from the deposit and investment of moneys in the fund shall be credited to the fund.
(1.5) Notwithstanding any provision of subsection (1) of this section to the contrary, on
April 20, 2009, the state treasurer shall deduct five hundred thousand dollars from the fund and
transfer such sum to the general fund.
(2) In fiscal year 2006-07, and each of the two fiscal years thereafter, notwithstanding
the requirements of section 25.5-3-108 (8)(b), the moneys deposited into the fund shall be
appropriated as follows:
(a) Of the moneys appropriated pursuant to this subsection (2), eighteen percent of the
moneys annually appropriated shall be to Denver health and hospitals as the community health
clinic provider for the city and county of Denver.
(b) (I) For fiscal year 2006-07, eighty-two percent of the moneys remaining after the
appropriation pursuant to paragraph (a) of this subsection (2) shall be appropriated to community
health clinics to provide primary care services pursuant to this article.
(II) For fiscal year 2006-07, eighteen percent of the moneys remaining after the
appropriation pursuant to paragraph (a) of this subsection (2) shall be appropriated to primary
Colorado Revised Statutes 2023 Uncertified PrintoutPage 83 of 510
care clinics operated by a licensed or certified health-care facility to provide primary care
services pursuant to this article.
(III) For fiscal years 2007-08 and 2008-09, the allocation of the moneys remaining after
the appropriation pursuant to paragraph (a) of this subsection (2) shall be determined based on
prior utilization as specified in rule by the state board.
(2.5) In fiscal year 2009-10, notwithstanding the requirements of section 25.5-3-108
(8)(b), the moneys deposited into the fund shall be appropriated as follows:
(a) Twenty percent of the moneys shall be appropriated to the state department for
distribution to Denver health and hospitals as the community health clinic provider for the city
and county of Denver;
(b) Eighty percent of the moneys shall be appropriated to the state department for
distribution to community health clinics based upon prior utilizations as determined by the state
department to mitigate reductions the clinics experience due to reductions in moneys available
from the primary care fund created pursuant to section 24-22-117 (2)(b), C.R.S.
(2.7) In the 2010-11 fiscal year, notwithstanding the requirements of section 25.5-3-108
(8)(b), the moneys deposited into the fund shall be appropriated to the state department for
distribution to Denver health and hospitals, as the community health clinic for the city and
county of Denver, and to community health clinics. The state department shall develop a
distribution formula specifying the distributions based upon prior utilizations and, to the extent
possible, mitigation of the reductions in funding that the clinics experience due to reductions in
moneys available from the primary care fund established pursuant to section 24-22-117 (2)(b),
C.R.S.
(2.8) In the 2011-12 fiscal year, notwithstanding the requirements of section 25.5-3-108
(8)(b), the moneys deposited into the fund shall be appropriated to the state department for
distribution to Denver health and hospitals, as the community health clinic for the city and
county of Denver, to community health clinics, and to federally qualified health centers. The
state department shall develop a distribution formula specifying the distributions based upon
prior utilizations and, to the extent possible, mitigation of the reductions in funding that the
clinics experience due to reductions in moneys available from the primary care fund established
pursuant to section 24-22-117 (2)(b), C.R.S.
(3) (a) The state department shall submit a state plan amendment for federal financial
participation for moneys appropriated to primary care clinics operated by a licensed or certified
health-care facility. Upon approval of the state plan amendment, the state department is
authorized to receive and expend all available federal moneys without a corresponding reduction
in spending authority from the fund.
(b) To the extent possible under federal law, the state department shall pursue available
federal financial participation for moneys appropriated to community health clinics.
(4) Repealed.
Source: L. 2006: Entire section added, p. 1606, § 4, effective June 2. L. 2007: (2) and
(3) amended, p. 559, § 1, effective April 16; (2)(b)(III) amended, p. 2043, § 73, effective June 1.
L. 2008: (3)(a) amended, p. 276, § 6, effective March 31. L. 2009: (1.5) added , (SB 09-208),
ch. 149, p. 627, § 31, effective April 20; (1)(b) amended, (SB 09-264), ch. 204, p. 928, § 5,
effective May 1. L. 2010: (1)(b), IP(2), and (2)(b)(III) amended and (1)(b.5), (2.5), and (4)
added, (HB 10-1321), ch. 48, p. 179, §§ 1, 2, effective March 29; (4) amended and (2.7) added,
Colorado Revised Statutes 2023 Uncertified PrintoutPage 84 of 510
(HB 10-1378), ch. 213, p. 927, § 3, effective May 27. L. 2011: (1)(b.6) and (2.8) added and (4)
amended, (SB 11-219), ch. 188, p. 725, §§ 3, 4, 5, effective June 3.
Editor's note: (1) This section was originally numbered as § 26-15-114 in Senate Bill
06-044. Section 8 of the act provided for the renumbering and relocation of § 26-15-114 to this
section. (See L. 2006, p. 1612.)
(2) Amendments to subsection (2) by House Bill 07-1258 and House Bill 07-1367 were
harmonized.
(3) Subsection (4)(d) provided for the repeal of subsection (4), effective July 1, 2012.
(See L. 2011, p. 725.)
Cross references: For the legislative declaration contained in the 2006 act enacting this
section, see section 1 of chapter 323, Session Laws of Colorado 2006.
PART 2
COMPREHENSIVE PRIMARY AND
PREVENTIVE CARE GRANT PROGRAM
25.5-3-201. Short title. (Repealed)
Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1.
L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.
25.5-3-202. Legislative declaration. (Repealed)
Source: L. 2006: Entire article amended with relocations, p. 1809, § 6, effective July 1.
L. 2010: (3) amended, (HB 10-1422), ch. 419, p. 2109, § 139, effective August 11. L. 2011:
Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.
25.5-3-203. Definitions. (Repealed)
Source: L. 2006: Entire article amended with relocations, p. 1810, § 6, effective July 1.
L. 2010: (7)(a) amended, (HB 10-1422), ch. 419, p. 2109, § 140, effective August 11. L. 2011:
Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.
25.5-3-204. Comprehensive primary and preventive care grant program - creation.
(Repealed)
Source: L. 2006: Entire article amended with relocations, p. 1811, § 6, effective July 1.
L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.
25.5-3-205. Grant-making process. (Repealed)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 85 of 510
Source: L. 2006: Entire article amended with relocations, p. 1811, § 6, effective July 1.
L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.
25.5-3-206. Reports. (Repealed)
Source: L. 2006: Entire article amended with relocations, p. 1812, § 6, effective July 1.
L. 2011: Entire section repealed, (SB 11-216), ch. 149, p. 520, § 4, effective May 5.
25.5-3-207. Program funding - comprehensive primary and preventive care fund -
creation - repeal. (Repealed)
Source: L. 2006: (1) and (3) amended, p. 1039, § 9, effective May 25; entire article
amended with relocations, p. 1813, § 6, effective July 1. L. 2007: (4) added, p. 149, § 9,
effective March 22. L. 2008: (4)(b) amended, p. 276, § 7, effective March 31. L. 2009: (3)
amended, (SB 09-269), ch. 333, p. 1768, § 8, effective June 1. L. 2010: (4)(c) added, (HB
10-1323), ch. 35, p. 131, § 4, effective March 22. L. 2011: Entire section amended, (SB 11-216),
ch. 149, p. 520, § 5, effective May 5.
Editor's note: Subsection (5) provided for the repeal of this section, effective September
15, 2011. (See L. 2011, p. 520.)
PART 3
COMPREHENSIVE PRIMARY CARE SERVICES
Editor's note: This part 3 was added in 2006. It was repealed in 2011 and was
subsequently recreated and reenacted in 2012, resulting in the addition, relocation, or elimination
of sections as well as subject matter. For amendments to this part 3 prior to 2011, consult the
2010 Colorado Revised Statutes and the Colorado statutory research explanatory note beginning
on page vii in the front of this volume.
25.5-3-301. Definitions. As used in this part 3, unless the context otherwise requires:
(1) "Comprehensive primary care" means the basic, entry-level health care provided by
health-care practitioners or non-physician health-care practitioners that is generally provided in
an outpatient setting. "Comprehensive primary care", at a minimum, includes providing or
arranging for the provision of the following services on a year-round basis: Primary health care;
maternity care, including prenatal care; preventive, developmental, and diagnostic services for
infants and children; adult preventive services; diagnostic laboratory and radiology services;
emergency care for minor trauma; pharmaceutical services; and coordination and follow-up for
hospital care. "Comprehensive primary care" may also include optional services based on a
patient's needs. For the purposes of this subsection (1) and subsection (2) of this section,
"arranging for the provision" means demonstrating established referral relationships with
health-care providers for any of the comprehensive primary care services not directly provided
by an entity. An entity in a rural area may be exempt from this requirement if it can demonstrate
Colorado Revised Statutes 2023 Uncertified PrintoutPage 86 of 510
that there are no providers in the community to provide one or more of the comprehensive
primary care services.
(2) "Qualified provider" means an entity that provides comprehensive primary care
services and that:
(a) Accepts all patients regardless of their ability to pay and uses a sliding fee schedule
for payments or that provides comprehensive primary care services free of charge;
(b) Serves a designated medically underserved area or population, as provided in section
330(b) of the federal "Public Health Service Act", 42 U.S.C. sec. 254b, or demonstrates to the
state department that the entity serves a population or area that lacks adequate health-care
services for low-income, uninsured persons;
(c) Has a demonstrated track record of providing cost-effective care;
(d) Provides or arranges for the provision of comprehensive primary care services to
persons of all ages; and
(e) Completes initial screening for eligibility for the state medical assistance program,
the children's basic health plan, and any other relevant government health-care program and
referral to the appropriate agency for eligibility determination.
(3) "Uninsured or medically indigent patient" means a patient receiving services from a
qualified provider:
(a) Whose yearly family income is below two hundred percent of the federal poverty
line; and
(b) Who is not eligible for medicaid, medicare, or any other type of governmental
reimbursement for health-care costs; and
(c) Who is not receiving third-party payments.
Source: L. 2012: Entire part RC&RE, (HB 12-1203), ch. 5, p. 15, § 1, effective March 1.
25.5-3-302. Annual allocation - primary care services - qualified provider - rules. (1)
The state department shall annually allocate the moneys appropriated by the general assembly to
the primary care fund created in section 24-22-117 (2)(b), C.R.S., to all eligible qualified
providers in the state who comply with the requirements of subsection (2) of this section. The
state department shall allocate the moneys in amounts proportionate to the number of uninsured
or medically indigent patients served by the qualified provider. For a qualified provider to be
eligible for an allocation pursuant to this section, the qualified provider shall meet either of the
following criteria:
(a) The qualified provider is a community health center, as defined in section 330 of the
federal "Public Health Service Act", 42 U.S.C. sec. 254b; or
(b) At least fifty percent of the patients served by the qualified provider are uninsured or
medically indigent patients, or patients who are enrolled in the medical assistance program,
articles 4, 5, and 6 of this title, or the children's basic health plan, article 8 of this title, or any
combination thereof.
(2) A qualified provider shall annually submit to the state department information
sufficient to establish the provider's eligibility status. A qualified provider, except for a provider
specified in paragraph (a) of subsection (1) of this section, shall provide an annual report that
includes the total number of patients served, the number of uninsured or medically indigent
patients served, and the number of patients served who are enrolled in the medical assistance
Colorado Revised Statutes 2023 Uncertified PrintoutPage 87 of 510
program, articles 4, 5, and 6 of this title, or the children's basic health plan, article 8 of this title.
A community health center specified in paragraph (a) of subsection (1) of this section shall
annually provide to the state department the number of uninsured or medically indigent patients
served. Each eligible qualified provider shall annually develop and submit to the state
department documentation regarding the quality assurance program in place at the provider's
facility to ensure that quality comprehensive primary care services are being provided. All
qualified providers shall submit to the state department the information required under this
section, as specified in rule by the state board. The data regarding the number of patients served
shall be verified by an outside entity. For purposes of this part 3, the number of patients served is
the number of unduplicated users of health-care services and is not the number of visits by a
patient.
(3) The state department shall make annual direct allocations of the total amount of
money annually appropriated by the general assembly to the primary care fund pursuant to
section 24-22-117 (2)(b), C.R.S., minus three percent for the administrative costs of the program,
to all eligible qualified providers. An eligible qualified provider's allocation shall be based on the
number of uninsured or medically indigent patients served by the provider in proportion to the
total number of uninsured or medically indigent patients served by all eligible qualified
providers in the previous calendar year. The state department shall establish a schedule for
allocating the moneys in the primary care fund for eligible qualified providers. The disbursement
of moneys in the primary care fund to eligible qualified providers under this part 3 are exempt
from the provisions of the "Procurement Code", articles 101 to 112 of title 24, C.R.S.
(4) Beginning in the 2021-22 state fiscal year, and to the extent available and permitted
by the federal government and section 21 of article X of the state constitution, the state
department shall maximize federal funds for payment to qualified providers pursuant to this
section by aligning payments with the "Colorado Medical Assistance Act", articles 4, 5, and 6 of
this title 25.5.
(5) The state board shall adopt any rules necessary for the administration and
implementation of this part 3.
Source: L. 2012: Entire part RC&RE, (HB 12-1203), ch. 5, p. 16, § 1, effective March 1.
L. 2021: (4) amended and (5) added, (SB 21-212), ch. 87, p. 361, § 1, effective May 4.
25.5-3-303. Consultation. At least annually, the state department shall consult with
representatives of federally qualified health centers, school-based health centers, family
residency directors, certified rural health clinics, other qualified providers, and consumer
advocates regarding the implementation and administration of the allocation of moneys to
qualified providers under this part 3.
Source: L. 2012: Entire part RC&RE, (HB 12-1203), ch. 5, p. 17, § 1, effective March 1.
Cross references: For the definition of "federally qualified health centers" in the federal
"Social Security Act", see 42 U.S.C. sec. 1395x.
PART 4
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COLORADO DENTAL HEALTH CARE PROGRAM
FOR LOW-INCOME SENIORS
25.5-3-401. Short title. This part 4 is known as and may be cited as the "Colorado Dental
Health Care Program for Low-income Seniors".
Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1358, § 1, effective May 31.
25.5-3-402. Legislative declaration. (1) The general assembly hereby finds and declares
that:
(a) The purpose of this part 4 is to promote the health and welfare of Colorado
low-income seniors by providing access to patient-centered dental care and services to
individuals sixty years of age or older whose income and resources are insufficient to meet the
costs of such care and thereby support individuals and families to live independently with a good
quality of life;
(b) By relocating and reorganizing the "Colorado Dental Care Act of 1977", which
provided dental services to certain eligible seniors, the state department can align those dental
health-care services with adult dental benefits provided through other dental health-care
programs for seniors and thereby target the resources effectively to low-income seniors who may
not qualify for those programs;
(c) The state department shall implement this part 4 through collaboration among
various executive departments, agencies, and political subdivisions of the state; private
individuals; and organizations, including but not limited to:
(I) The local area agencies on aging;
(II) Community health centers;
(III) Safety-net clinics;
(IV) Private practice dental providers; and
(V) Foundations; and
(d) The state department shall implement this part 4 as a grant program throughout all
geographic regions of the state using best practices and experience from other grant programs
operated by the state department to provide maximum flexibility to safety-net and
private-practice dental providers in order to promote the health and welfare of low-income
seniors.
Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1358, § 1, effective May 31.
25.5-3-403. Definitions. As used in this part 4, unless the context otherwise requires:
(1) "Advisory committee" means the senior dental advisory committee created in section
25.5-3-406.
(2) "Covered dental care services" are to be defined by rules of the medical services
board pursuant to section 25.5-3-404 and include but are not limited to diagnostic, preventive,
and restorative care.
(3) "Dental health-care services grant" means a grant awarded to a qualified grantee
pursuant to section 25.5-3-404.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 89 of 510
(4) "Eligible senior" means an adult who is sixty years of age or older and who is
economically disadvantaged as specified by rule of the medical services board.
(5) "Program" means the Colorado dental health care program for low-income seniors
created pursuant to section 25.5-3-404.
(6) "Qualified grantee" means an entity that can demonstrate that it can provide or
arrange for the provision of comprehensive dental and oral care services and may include but is
not limited to:
(a) An area agency on aging, as defined in section 26-11-203, C.R.S.;
(b) A community-based organization or foundation;
(c) A federally qualified health center, as defined in the federal "Social Security Act", 42
U.S.C. sec. 1395x (aa)(4); safety-net clinic; or health district;
(d) A local public health agency; or
(e) A private dental practice.
(7) "Qualified provider" means any person who is licensed to practice dentistry in
Colorado or who employs a dentist licensed in Colorado and who is willing to accept
reimbursement for covered dental services pursuant to this program.
Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1359, § 1, effective May 31.
L. 2020: (6)(c) amended, (SB 20-136), ch. 70, p. 289, § 27, effective September 14.
Cross references: For the legislative declaration in SB 20-136, see section 1 of chapter
70, Session Laws of Colorado 2020.
25.5-3-404. Colorado dental health care program for low-income seniors - rules. (1)
(a) There is created in the state department the Colorado dental health care program for
low-income seniors to provide covered dental care services for eligible seniors who are not
eligible for dental services under medicaid, the old age pension health and medical care program,
or private insurance.
(b) To ensure the continuity of dental health care to low-income seniors, the state
department and the department of public health and environment shall ensure that any individual
who meets, on June 30, 2014, the eligibility requirements for dental services under the "Colorado
Dental Care Act of 1977", article 21 of title 25, C.R.S., prior to its repeal, remains eligible for
dental services after June 30, 2014, through the "Colorado Dental Care Act of 1977", medicaid,
the old age pension health and medical care fund, or the program.
(2) The state department shall:
(a) In consultation with the advisory committee, review the operation and effectiveness
of the program and develop a grant application under the program consistent with rules of the
medical services board;
(b) Accept applications for dental health-care services grants from any qualified grantee;
(c) On and after July 1, 2015, award dental health-care services grants to qualified
grantees to provide covered dental care services to eligible seniors;
(d) Pay dental health-care services grants within thirty days after approval by the state
department;
(e) Ensure that all eligible seniors have access to services through the program; and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 90 of 510
(f) Consider geographic distribution of funds among urban and rural areas in the state
when making funding decisions.
(3) (a) Qualified grantees shall:
(I) Submit an application for a dental health-care services grant to the state department
on the form developed by the state department;
(II) Provide outreach to targeted eligible seniors and dental care providers;
(III) Identify eligible seniors and qualified providers;
(IV) Demonstrate collaboration with community organizations;
(V) Ensure that eligible seniors receive covered dental care services efficiently without
duplication of services;
(VI) Maintain records of eligible seniors served, dental care services provided, and
moneys spent for a minimum of six years; and
(VII) Distribute grant funds to qualified providers in their service area or directly
provide covered dental care services to eligible seniors in their service area.
(b) A qualified grantee may expend no more than seven percent of the amount of its
grant for administrative purposes.
(c) A qualified grantee may also be a qualified provider if the person meets the
qualifications of a qualified provider.
(4) Following recommendations of the state department and the advisory committee, the
medical services board shall adopt rules pursuant to section 24-4-103, C.R.S., governing the
program, including but not limited to:
(a) A definition of "economically disadvantaged" for purposes of eligibility;
(b) A description of dental services that may be provided to eligible seniors under the
program; except that such services must include but not be limited to oral examination,
diagnosis, treatment planning, emergency treatment, prophylaxis, X rays, partial and full
dentures, replacement or repair of permanent teeth, removal of permanent teeth, fillings,
periodontal treatment, and soft tissue treatment;
(c) Whether to require eligible seniors to make a co-payment and, if so, the
circumstances and amount of the co-payment;
(d) A distribution formula for the availability of moneys to each area of the state; and
(e) Procedures, criteria, and standards for awarding dental health-care services grants.
Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1360, § 1, effective May 31.
L. 2019: (2)(a) amended, (HB 19-1326), ch. 172, p. 2000, § 1, effective May 14.
25.5-3-405. Program reporting. (1) On or before September 1, 2015, and each
September 1 thereafter, each qualified grantee receiving a dental health-care services grant shall
report to the state department concerning the number of eligible seniors served, the types of
dental and oral health services provided, recommendations regarding the operation and
effectiveness of the program, and any other information deemed relevant by the state
department.
(2) (a) Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or before
November 1, 2016, and each November 1 thereafter, the state department shall submit a report to
the joint budget committee of the general assembly and to the health and human services
committee of the senate and the public health care and human services committee of the house of
Colorado Revised Statutes 2023 Uncertified PrintoutPage 91 of 510
representatives, or any successor committees, on the operation and effectiveness of the program,
including an itemization of the department's administrative expenditures in implementing and
administering the program and any recommendations for legislative changes to the program.
(b) Repealed.
Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1362, § 1, effective May 31.
L. 2017: (2) amended, (HB 17-1060), ch. 6, p. 16, § 7, effective March 1. L. 2019: Entire
section amended, (HB 19-1326), ch. 172, p. 2000, § 2, effective May 14.
Editor's note: Subsection (2)(b)(II) provided for the repeal of subsection (2)(b),
effective January 1, 2020. (See L. 2019, p. 2000.)
25.5-3-406. Senior dental advisory committee - creation - duties - repeal. (1) (a)
There is created in the state department a senior dental advisory committee comprised of eleven
members appointed by the executive director as follows:
(I) A member representing the state department;
(II) A dentist in private practice providing dental care to the senior population who
represents a statewide organization of dentists;
(III) A dental hygienist providing dental care to seniors;
(IV) A representative of either an agency that coordinates services for low-income
seniors or the office in the department of human services responsible for overseeing services to
the elderly;
(V) A representative of an organization of Colorado community health centers, as
defined in the federal "Public Health Service Act", 42 U.S.C. sec. 254b;
(VI) A representative of an organization of safety-net health providers that are not
community health centers;
(VII) A representative of the university of Colorado school of dental medicine;
(VIII) Two consumer advocates;
(IX) A senior who is eligible for services under the program; and
(X) A representative of a foundation with experience in making dental care grants.
(b) Members of the committee shall serve three-year terms. Of the members initially
appointed to the advisory committee, the executive director shall appoint six for two-year terms
and five for three-year terms. In the event of a vacancy on the advisory committee, the executive
director shall appoint a successor to fill the unexpired portion of the term of such member.
(c) (I) The executive director shall designate a member to serve as the chair of the
advisory committee. The advisory committee shall meet as necessary at the call of the chair.
(II) Members of the advisory committee serve without compensation or reimbursement
of expenses.
(III) Pursuant to section 24-18-108.5, C.R.S., a member of the advisory committee shall
not perform an official act that may have a direct economic benefit on a business or other
undertaking in which the member has a direct or substantial financial interest.
(d) Repealed.
(e) The state department shall provide staff assistance to the advisory committee.
(2) The advisory committee shall:
(a) Advise the state department on the operation of the program;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 92 of 510
(b) Make recommendations to the medical services board regarding rules to be
promulgated pursuant to section 25.5-3-404, including but not limited to:
(I) Defining covered dental care services;
(II) Whether to require eligible seniors to make a co-payment and, if so, the
circumstances and amount of the co-payment;
(III) The distribution formula for the availability of funds to each area of the state;
(IV) Dental health-care services grant procedures, criteria, and standards, including
preference for qualified grantees who demonstrate collaboration with community organizations
such as a local area agency on aging; and
(V) A maximum amount per procedure that can be spent by qualified grantees and
qualified providers that must not be less than the reimbursement schedule for fee-for-service
dental fees under the medical assistance program established in articles 4, 5, and 6 of this title
25.5.
(3) (a) This section is repealed, effective September 1, 2024.
(b) Prior to said repeal, the advisory committee must be reviewed as provided for in
section 2-3-1203, C.R.S.
Source: L. 2014: Entire part added, (SB 14-180), ch. 314, p. 1362, § 1, effective May 31.
L. 2016: IP(2)(b) amended, (SB 16-189), ch. 210, p. 773, § 66, effective June 6. L. 2019:
(2)(b)(V) amended, (HB 19-1326), ch. 172, p. 2001, § 3, effective May 14.
Editor's note: Subsection (1)(d)(II) provided for the repeal of subsection (1)(d),
effective July 1, 2016. (See L. 2014, p. 1362.)
PART 5
HEALTH-CARE BILLING FOR INDIGENT PATIENTS
RECEIVING SERVICES NOT REIMBURSED THROUGH
THE COLORADO INDIGENT CARE PROGRAM
25.5-3-501. Definitions. As used in this part 5, unless the context otherwise requires:
(1) "Health-care facility" means:
(a) A hospital licensed as a general hospital pursuant to part 1 of article 3 of title 25;
(b) A hospital established pursuant to section 23-21-503 or 25-29-103;
(c) Any freestanding emergency department licensed pursuant to section 25-1.5-114; or
(d) Any outpatient health-care facility that is licensed as an on-campus department or
service of a hospital or that is listed as an off-campus location under a hospital's license, except:
(I) A federally qualified health center, as defined in the federal "Social Security Act", 42
U.S.C. sec. 1395x (aa)(4); or
(II) A student-learning medical and dental clinic that is established for the purpose of
student learning, offering discounted patient care as part of a program of student learning, and is
physically situated within a health sciences school.
(2) "Health-care services" has the same meaning as set forth in section 10-16-102 (33).
(3) "Licensed health-care professional" means any health-care professional who is
registered, certified, or licensed pursuant to title 12 or who provides services under the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 93 of 510
supervision of a health-care professional who is registered, certified, or licensed pursuant to title
12, and who provides health-care services in a health-care facility.
(4) "Non-CICP health-care services" means health-care services provided in a
health-care facility for which reimbursement under the Colorado indigent care program,
established in part 1 of this article 3, is not available.
(5) "Qualified patient" means an individual whose household income is not more than
two hundred fifty percent of the federal poverty level and who received a health-care service at a
health-care facility.
(6) "Screen" or "screening" means a process identified in rule by the state department
whereby health-care facilities assess a patient's circumstances related to eligibility criteria and
determine whether the patient is likely to qualify for public health-care coverage or discounted
care, inform the patient of the health-care facility's determination, and provide information to the
patient about how the patient can enroll in public health-care coverage.
(7) "Uninsured" means an uninsured individual, as defined in section 10-22-113 (5)(d).
Source: L. 2021: Entire part added, (HB 21-1198), ch. 435, p. 2874, § 1, effective
September 7.
25.5-3-502. Requirement to screen patients for eligibility for public health-care
programs and discounted care - rules. (1) Beginning September 1, 2022, a health-care facility
shall screen, unless a patient declines, each uninsured patient for eligibility for:
(a) Public health insurance programs including but not limited to medicare; the state
medical assistance program, articles 4, 5, and 6 of this title 25.5; emergency medicaid; and the
children's basic health plan, article 8 of this title 25.5;
(b) Discounted care through the Colorado indigent care program, established in part 1 of
this article 3, if the patient receives a service eligible for reimbursement through the program;
and
(c) Discounted care, as described in section 25.5-3-503.
(2) Health-care facilities shall use a single uniform application developed by the state
department when screening a patient pursuant to subsection (1) of this section.
(3) If a health-care facility determines that a patient is ineligible for discounted care, the
facility shall provide the patient notice of the determination and an opportunity for the patient to
appeal the determination in accordance with state department rules.
(4) If the patient declines the screening described in subsection (1) of this section, the
health-care facility shall document the patient's decision in accordance with state department
rules. A patient's decision to decline the screening that is documented and complies with state
department rules is a complete defense to a claim brought by a patient under section 25.5-3-506
(2) for a violation of section 25.5-3-506 (1)(a) or (1)(b).
(5) If requested by the patient, a health-care facility shall screen an insured patient for
discounted care pursuant to subsections (1)(b) and (1)(c) of this section.
Source: L. 2021: Entire part added, (HB 21-1198), ch. 435, p. 2875, §1, effective
September 7. L. 2022: IP(1) amended, (HB 22-1403), ch. 203, p. 1362, § 1, effective May 20.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 94 of 510
25.5-3-503. Health-care discounts on services not eligible for Colorado indigent care
program reimbursement. (1) Beginning September 1, 2022, if a patient is screened pursuant to
section 25.5-3-502 and is determined to be a qualified patient, a health-care facility and a
licensed health-care professional shall, for emergency and other non-CICP health-care services:
(a) Limit the amounts charged to not more than the discounted rate established in state
department rule pursuant to section 25.5-3-505 (2)(j);
(b) Collect amounts charged, not including amounts owed by third-party payers, in
monthly installments such that the patient is not paying more than four percent of the patient's
monthly household income on a bill from a health-care facility and not paying more than two
percent of the patient's monthly household income on a bill from each licensed health-care
professional; and
(c) After a cumulative thirty-six months of payments, consider the patient's bill paid in
full and permanently cease any and all collection activities on any balance that remains unpaid.
(2) A health-care facility shall not:
(a) Deny discounted care on the basis that the patient has not applied for any public
benefits program; or
(b) Adopt or maintain any policies that result in the denial of admission or treatment of a
patient because the patient lacks health insurance coverage, may qualify for discounted care,
requires extended or long-term treatment, or has an unpaid medical bill.
Source: L. 2021: Entire part added, (HB 21-1198), ch. 435, p. 2876 § 1, effective
September 7. L. 2022: IP(1) amended, (HB 22-1403), ch. 203, p. 1362, § 2, effective May 20.
25.5-3-504. Notification of patients' rights. (1) Beginning September 1, 2022, a
health-care facility shall make information developed by the state department about patients'
rights under this part 5 and the uniform application developed by the state department pursuant
to section 25.5-3-505 (2)(i) available to the public and to each patient. At a minimum, the
health-care facility shall:
(a) Post the information in all required languages pursuant to this subsection (1)
conspicuously on the health-care facility's website, including a link to the information on the
health-care facility's main landing page;
(b) Make the information available in patient waiting areas;
(c) Make the information available to each patient, or the patient's legal guardian,
verbally, which may include using a professional interpretation service, or in writing in the
patient's or legal guardian's primary language before the patient is discharged from the
health-care facility; and
(d) Inform each patient on the patient's billing statement of the patient's rights pursuant
to this part 5, including the right to apply for discounted care, and provide the website, e-mail
address, and telephone number where the information may be obtained in the patient's primary
language.
Source: L. 2021: Entire part added, (HB 21-1198), ch. 435, p. 2877, § 1, effective
September 7. L. 2022: IP(1) amended, (HB 22-1403), ch. 203, p. 1362, § 3, effective May 20.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 95 of 510
25.5-3-505. Health-care facility reporting requirements - agency enforcement -
report - rules. (1) Beginning September 1, 2023, and each September 1 thereafter, each
health-care facility shall report to the state department data that the state department determines
is necessary to evaluate compliance across race, ethnicity, age, and primary-language-spoken
patient groups with the screening, discounted care, payment plan, and collections practices
required pursuant to this part 5. If a health-care facility is not capable of disaggregating the data
required pursuant to this subsection (1) by race, ethnicity, age, and primary language spoken, the
health-care facility shall report to the state department the steps the facility is taking to improve
race, ethnicity, age, and primary-language-spoken data collection and the date by which the
facility will be able to disaggregate the reported data.
(2) No later than April 1, 2022, the state board shall promulgate rules necessary for the
administration and implementation of this part 5. At a minimum, the rules must:
(a) Outline a process for an insured patient to request a screening pursuant to section
25.5-3-502 (5);
(b) Outline a process for documenting, pursuant to section 25.5-3-502 (4), that a patient
has made an informed decision to decline the screening, including procedures for retaining such
documentation;
(c) Establish the process for and the maximum number of days that a health-care facility
has to:
(I) Initiate a screening after a patient receives services;
(II) Request information from the patient needed for the screening process; and
(III) Complete the screening process;
(d) Outline the requirements for notifying the patient of the results of the screening,
including an explanation of the basis for a denial of discounted care and the process for
appealing a denial;
(e) Establish guidelines for patient appeals regarding eligibility for discounted care
pursuant to section 25.5-3-503;
(f) Establish a methodology that all health-care facilities must use to determine monthly
household income. The methodology must not consider a patient's assets.
(g) Identify the documents that may be required to establish income eligibility for
discounted care using the minimum amount of information needed to determine eligibility;
(h) Identify the steps a health-care facility and licensed health-care professional must
take before sending patient debt to collections;
(i) Create a single uniform application that a health-care facility shall use when
screening a patient for eligibility for the Colorado indigent care program and discounted care, as
described in section 25.5-3-502; and
(j) Annually establish rates for discounted care pursuant to section 25.5-3-503 (1)(a).
The rates should approximate and not be less than one hundred percent of the medicare rate or
one hundred percent of the medicaid base rate, whichever is greater. The state department shall
publicly post the established rates on the state department's website.
(3) In promulgating rules pursuant to this section, the state department shall:
(a) Align the processes of qualifying for and appealing denials of eligibility for the
Colorado indigent care program with discounted care, as described in section 25.5-3-502; and
(b) Consider potential limitations relating to the federal "Emergency Medical Treatment
and Labor Act", 42 U.S.C. sec. 1395dd.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 96 of 510
(4) Prior to promulgating rules pursuant to this section, the state department shall hold at
least one stakeholder meeting with hospital representatives, health-care consumers, and
health-care consumer advocates that is accessible to individuals whose primary language is not
English, if requested.
(5) No later than April 1, 2022, the state department shall:
(a) Using feedback from hospital health-care consumers and health-care consumer
advocate stakeholders, develop a written explanation of a patient's rights under this section that
is written in plain language at a sixth-grade reading level and translated into all languages
spoken by ten percent or more of the population in each county of the state and post the written
explanation in all required languages on the state department's website. Each health-care facility
shall make the explanation available to the public and each patient as provided in section
25.5-3-504.
(b) (I) Establish a process for patients to submit a complaint relating to noncompliance
with this part 5 to the state department by phone, mail, or online. The state department shall
conduct a review within thirty days after receiving a complaint.
(II) The state department shall periodically review health-care facilities and licensed
health-care professionals to ensure compliance with this section. If the state department finds
that a health-care facility or licensed health-care professional is not in compliance with this
section, the state department shall notify the health-care facility or licensed health-care
professional and the facility or professional has ninety days to file a corrective action plan with
the state department that must include measures to inform the patient about the noncompliance
and provide a financial correction consistent with this part 5. A health-care facility or licensed
health-care professional may request up to one hundred twenty days to submit a corrective action
plan. The state department may require a health-care facility or licensed health-care professional
that is not in compliance with this part 5 or any state board rules adopted pursuant to this part 5
to develop and operate under a corrective action plan until the state department determines the
health-care facility or licensed health-care professional is in compliance.
(III) If a health-care facility's or licensed health-care professional's noncompliance with
this section is determined by the state department to be knowing or willful or there is a repeated
pattern of noncompliance, the state department may fine the facility or professional no more than
five thousand dollars. If the health-care facility or licensed health-care professional fails to take
corrective action or fails to file a corrective action plan with the state department pursuant to
subsection (5)(b)(II) of this section, the state department may fine the facility or professional no
more than five thousand dollars a week until the facility or professional takes corrective action.
The state department shall consider the size of the health-care facility and the seriousness of the
violation in setting the fine amount.
(6) The state department shall make the information reported pursuant to subsection (1)
of this section and any corrective action plans for which fines were imposed pursuant to
subsection (5)(b) of this section available to the public and shall annually report the information
as a part of its presentation to its committees of reference at a hearing held pursuant to section
2-7-203 (2)(a) of the "State Measurement for Accountable, Responsive, and Transparent
(SMART) Government Act".
Source: L. 2021: Entire part added, (HB 21-1198), ch. 435, p. 2877, § 1, effective
September 7. L. 2022: (1) amended, (HB 22-1403), ch. 203, p. 1363, § 4, effective May 20.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 97 of 510
25.5-3-506. Limitations on collection actions - private enforcement. (1) Beginning
September 1, 2022, before assigning or selling patient debt to a collection agency, as defined in
section 5-16-103 (3)(a), or a debt buyer, as defined in section 5-16-103 (8.5), or before pursuing,
either directly or indirectly, any permissible extraordinary collection action, as defined in section
6-20-201 (7):
(a) A health-care facility shall meet the screening requirements in section 25.5-3-502;
(b) A health-care facility and licensed health-care professional shall provide discounted
care to a patient pursuant to section 25.5-3-503;
(c) A health-care facility and licensed health-care professional shall provide a plain
language explanation of the health-care services and fees being billed and notify the patient of
potential collection actions; and
(d) A health-care facility and health-care professional shall bill any third-party payer that
is responsible for providing health-care coverage to the patient. If a health-care professional is an
out-of-network provider under a qualified patient's health insurance plan, the health-care
professional and health insurance carrier shall comply with the out-of-network billing
requirements described in sections 10-16-704 (3) and 12-30-113.
(2) A health-care facility or licensed health-care professional that fails to comply with
the requirements of this section is liable to the patient in an amount equal to the sum of:
(a) Any actual damages sustained by the patient as a result of such failure;
(b) In the case of such action brought by an individual, any additional damages that the
court may allow, not to exceed one thousand dollars;
(c) In the case of a class action, such amount for each named plaintiff that may recover
damages under subsection (2)(b) of this section, and such amount that the court may allow for all
other class members without regard to a minimum individual recovery, not to exceed the lesser
of five hundred thousand dollars or one percent of the net worth of the health-care facility or
licensed health-care professional; and
(d) In the case of any successful action to enforce the foregoing liability, the costs of the
action together with reasonable attorney fees as determined by the court. On a finding by the
court that the action was brought in bad faith, the court may award reasonable attorney fees to
the defendant that are related to the work expended and costs.
(3) In determining the amount of liability in any action pursuant to subsection (2) of this
section, the court shall consider, among other relevant factors:
(a) In any individual action brought pursuant to subsection (2)(a) of this section, the
frequency and persistence of noncompliance by the health-care facility or licensed health-care
professional, the nature of such noncompliance, and the extent to which such noncompliance
was intentional; or
(b) In any individual action brought pursuant to subsection (2)(b) of this section, the
frequency and persistence of noncompliance by the health-care facility or licensed health-care
professional, the nature of such noncompliance, the resources of the health-care facility or
licensed health-care professional, the number of individuals adversely affected, and the extent to
which the health-care facility's or licensed health-care professional's noncompliance was
intentional.
Source: L. 2021: Entire part added, (HB 21-1198), ch. 435, p. 2880, § 1, effective
September 7. L. 2022: IP(1) amended, (HB 22-1403), ch. 203, p. 1363, § 5, effective May 20.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 98 of 510
COLORADO MEDICAL ASSISTANCE ACT
ARTICLE 4
Colorado Medical Assistance Act -
General Medical Assistance
Editor's note: This article was added with relocations in 2006 containing provisions of
some sections formerly located in article 4 of title 26 or in article 1 of this title. Former C.R.S.
section numbers are shown in editor's notes following those sections that were relocated. For a
detailed comparison of this article, see the comparative tables located in the back of the index.
PART 1
GENERAL PROVISIONS
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".
Source: L. 2006: Entire article added with relocations, p. 1815, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-101 as it existed prior to 2006.
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.
Source: L. 2006: Entire article added with relocations, p. 1815, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-102 as it existed prior to 2006.
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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 99 of 510
(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) [Editor's note: This subsection (2.5) is effective July 1, 2024.] "Case management
agency" has the same meaning as set forth in section 25.5-6-1702 (2).
(3) [Editor's note: This version of subsection (3) is effective until July 1, 2024.] "Case
management services" means services provided by community-centered boards, as defined in
section 25.5-10-202; comprehensive and essential behavioral health safety net providers, as
defined in section 27-50-101; and community mental health centers and community mental
health clinics, as defined in section 27-66-101, to assist persons with intellectual and
developmental disabilities, as defined in section 25.5-10-202, and persons with mental health
disorders, as defined in section 27-65-102, by case management agencies, as defined in section
25.5-6-303 (5), providing case management services, as defined in sections 25.5-6-104 (2)(b)
and 25.5-6-303 (6), to persons with a disability, persons who are elderly or blind, and long-term
care clients, in gaining access to needed medical, social, educational, and other services.
(3) [Editor's note: This version of subsection (3) is effective July 1, 2024.] "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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 100 of 510
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
(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 recipient 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 recipients eligible for and
enrolled in the program established in articles 4, 5, and 6 of this title, which is funded through
Title XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396u-1, to enrolled providers
under the state medical assistance program of medical care, services, goods, and devices
rendered or provided to recipients under this article and articles 5 and 6 of this title, and other
related payments, pursuant to this article and articles 5 and 6 of this title and the rules of the state
department.
(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"
Colorado Revised Statutes 2023 Uncertified PrintoutPage 101 of 510
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) "Recipient" means any person who has been determined eligible to receive benefits
under this article and articles 5 and 6 of this title, whose need for medical care has been
professionally established, and for whose care less than full payment is available through the
legal obligation of a contractor, public or private, to pay for or provide such care.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 102 of 510
(22) "Recovery" or "amount recovered" means the amount payable to the applicant or
recipient or his 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 which 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 recipient 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 recipients eligible
pursuant to section 25.5-5-101 (1)(b).
Source: L. 2006: (19.5) added, p. 1202, § 1, effective May 26; entire article added with
relocations, p. 1815, § 7, effective July 1; (3) amended, p. 1389, § 18, effective August 7. L.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 103 of 510
2007: (19.5) amended, p. 2043, § 74, effective June 1. L. 2008: (25.5) added, p. 1184, § 2,
effective May 22. L. 2010: (3) amended, (SB 10-175), ch. 188, p. 800, § 65, effective April 29.
L. 2011: (10) amended, (HB 11-1303), ch. 264, p. 1168, § 65, effective August 10. L. 2013: (3),
IP(9), and (9)(a) amended, (HB 13-1314), ch. 323, p. 1808, § 44, effective March 1. L. 2014: (1)
repealed, (2) amended, and (13.5) added, (SB 14-067), ch. 12, p. 109, § 1, effective February 27.
L. 2016: (19.5) amended, (SB 16-189), ch. 210, p. 773, § 67, effective June 6. L. 2017: IP(1)
and (14) amended, (HB 17-1046), ch. 50, p. 159, § 13, effective March 16; IP amended and (1.5)
added, (HB 17-1353), ch. 231, p. 895, § 1, effective May 23; IP and (3) amended, (SB 17-242),
ch. 263, p. 1327, § 198, effective May 25; IP and IP(7) amended, (SB 17-091), ch. 321, p. 1731,
§ 1, effective June 5. L. 2018: (5.5) added, (HB 18-1091), ch. 74, p. 642, § 2, effective August 8;
(12) amended, (HB 18-1431), ch. 313, p. 1892, § 9, effective August 8. L. 2019: (19.5)
amended, (HB 19-1172), ch. 136, p. 1707, § 177, effective October 1. L. 2021: (2.5) added and
(3) amended, (HB 21-1187), ch. 83, p. 331, § 23, effective July 1, 2024; (25.7) added, (HB
21-1190), ch. 152, p. 875, § 3, effective May 18. L. 2022: (10) amended, (HB 22-1289), ch. 399,
p. 2841, § 11, effective June 7; (3) amended, (HB 22-1278), ch. 222, p. 1511, § 66, effective July
1; (19.5) amended, (HB 22-1295), ch. 123, p. 848, § 75, effective July 1; (3) amended, (HB
22-1256), ch. 451, p. 3239, § 53, effective August 10; (3) amended, (HB 22-1278), ch. 222, p.
1593, § 232, effective July 1, 2024. L. 2023: (24.5) added, (HB 23-1130), ch. 394, p. 2356, § 2,
effective August 7.
Editor's note: (1) This section is similar to former § 26-4-103 as it existed prior to
2006.
(2) Subsection (3) was originally numbered as § 26-4-103 (2), and the amendments to it
in House Bill 06-1277 were harmonized with subsection (3) as it appeared in Senate Bill 06-219.
(3) Subsection (19.5) was enacted as § 26-4-103 (13.6) in House Bill 06-1395 but was
relocated due to its harmonization with this section as it appeared in Senate Bill 06-219.
(4) Amendments to subsection (3) by HB 22-1256 and HB 22-1278 were harmonized.
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017. For the legislative declaration in HB 22-1289, see section
1 of chapter 399, Session Laws of Colorado 2022.
25.5-4-104. Program of medical assistance - 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 hereby designated as the single
state agency to administer such program in accordance with Title XIX and this article and
articles 5 and 6 of this title. Such program shall not be required to furnish recipients under
sixty-five years of age the benefits that are provided to recipients sixty-five years of age and over
under Title XVIII of the social security act; but said program shall otherwise be uniform to the
extent required by Title XIX of the 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 make such additional
investigation as it deems necessary and shall, after giving the county department an opportunity
Colorado Revised Statutes 2023 Uncertified PrintoutPage 104 of 510
to rebut any findings or conclusions of the state department that the action or delay in taking
action was a violation of or contrary to state department rules, make such decision as to the
granting of medical benefits and the amount thereof as in its opinion is justifiable pursuant to the
provisions of this article and articles 5 and 6 of this title and the rules of the state department.
Applicants or recipients affected by such decisions of the state department, upon request, shall
be given reasonable notice and opportunity for a fair hearing by the state department.
Source: L. 2006: Entire article added with relocations, p. 1819, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-104 as it existed prior to 2006.
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.
Source: L. 2006: Entire article added with relocations, p. 1820, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-105 as it existed prior to 2006.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 105 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1820, § 7, effective July 1. L.
2018: (5) amended, (SB 18-092), ch. 38, p. 444, § 109, effective August 8.
Editor's note: This section is similar to former § 26-4-110 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 18-092, see section 1 of chapter
38, Session Laws of Colorado 2018.
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 recipient or someone acting on
behalf of a recipient after the recipient or someone acting on behalf of the recipient files a
complaint concerning services provided or not provided to the recipient:
(a) Indicating to a recipient that the recipient cannot have an advocate, family member,
or other authorized representative assist the recipient; or
(b) (I) An adverse action that negatively affects a recipient's level of eligibility for or
receipt of services received at the time of the complaint without verification of a change in the
recipient's income, resources, or health-care needs that justifies the adverse action.
(II) No adverse action shall be taken against a recipient after a complaint has been filed
until the recipient 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" shall not include instances where a recipient is not eligible for a service
or program or where a provider documents a problem with a recipient and shares the
documentation with the recipient or a third party prior to the recipient filing a complaint.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 106 of 510
Source: L. 2006: Entire section added, p. 1019, § 1, effective May 25.
Editor's note: This section was originally numbered as § 26-4-402.5 in House Bill
06-1211. Section 2 of the act provided for the renumbering and relocation of § 26-4-402.5 to this
section. (See L. 2006, p. 1020.)
PART 2
ADMINISTRATION
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.
Source: L. 2006: Entire section amended, p. 917, § 1, effective May 11; entire article
added with relocations, p. 1821, § 7, effective July 1. L. 2007: (1.5) added, p. 465, § 2, effective
July 1. L. 2009: (1.5) amended, (SB 09-265), ch. 205, p. 935, § 1, effective May 1. L. 2022: (1)
amended, (HB 22-1289), ch. 399, p. 2841, § 12, effective June 7.
Editor's note: (1) This section is similar to former § 26-4-110.7 as it existed prior to
2006.
(2) Amendments to section 26-4-110.7 by Senate Bill 06-129 were harmonized with this
section as it appeared in Senate Bill 06-219.
Cross references: For the legislative declaration in HB 22-1289, see section 1 of chapter
399, Session Laws of Colorado 2022.
25.5-4-202. Comprehensive plan for other services and benefits. (Repealed)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 107 of 510
Source: L. 2006: Entire article added with relocations, p. 1821, § 7, effective July 1. L.
2016: Entire section repealed, (HB 16-1081), ch. 22, p. 52, § 6, effective August 10.
Editor's note: This section was similar to former § 26-4-107 as it existed prior to 2006.
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) Members serve at the pleasure of the governor and receive no compensation but are
entitled to reimbursement for their actual and necessary expenses. The advisory council shall
advise the state department on the provision of health and medical care services to recipients.
Source: L. 2006: Entire article added with relocations, p. 1822, § 7, effective July 1. L.
2022: Entire section amended, (SB 22-013), ch. 2, p. 64, § 87, effective February 25. L. 2023:
(1)(a) amended, (HB 23-1301), ch. 303, p. 1829, § 45, effective August 7.
Editor's note: This section is similar to former § 26-4-108 as it existed prior to 2006.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 108 of 510
(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.
Source: L. 2006: Entire article added with relocations, p. 1822, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-403.7 as it existed prior to 2006.
25.5-4-205. Application - verification of eligibility - demonstration project - rules -
repeal. (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 they
determine 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
hospitals, a hospital that is designated as a regional pediatric trauma center, as defined in section
25-3.5-703 (4)(f), C.R.S., 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. 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. Any person who is determined to be eligible pursuant to the requirements
of this article and articles 5 and 6 of this title shall be eligible for benefits until such person is
determined to be ineligible. Upon determination that any 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 therefor. When an
applicant is found ineligible for medical assistance eligibility programs, the applicant's
application data and verifications shall be automatically shared with the state insurance
Colorado Revised Statutes 2023 Uncertified PrintoutPage 109 of 510
marketplace through a system interface. Separate determination of eligibility and formal
application for benefits under this article and articles 5 and 6 of this title for persons eligible as
provided in sections 25.5-5-101 and 25.5-5-201 shall be made in accordance with the rules of the
state department.
(a.5) Repealed.
(a.7) [Editor's note: This version of subsection (1)(a.7) is effective until July 1, 2024.]
As part of the medicaid eligibility modernization, the department is authorized to create a
universal application for single point of entry for home- and community-based services waivers
for children.
(a.7) [Editor's note: This version of subsection (1)(a.7) is effective July 1, 2024.] 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.
(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 recipients 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 recipient's income
eligibility at reenrollment through federally approved electronic data sources and, if the recipient
meets all eligibility requirements, permit the recipient to remain enrolled in the program. The
Colorado Revised Statutes 2023 Uncertified PrintoutPage 110 of 510
rules shall 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 recipient was not eligible for medical
benefits solely based upon the recipient's income after the recipient 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 recipient, and the county department is not responsible for any federal
error rate sanctions resulting from such determination.
(B) Notwithstanding any other provision in this paragraph (b), for applications that
contain self-employment income, the state department shall not implement this paragraph (b)
until it can verify self-employment income through federally approved electronic data sources as
authorized by rules of the state department and federal law.
(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 recipient,
enrollee, or the parent or guardian of a recipient or enrollee 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 recipients or
enrollees to apply for reenrollment either over the telephone or through the internet during a
transition to a process that will serve recipients and enrollees statewide. The pilot program shall
not serve as a replacement for a statewide process.
(B) Notwithstanding any other provision in this paragraph (e), the state department shall
not implement this paragraph (e) until it can verify the eligibility of a recipient or enrollee 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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 111 of 510
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.
(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 June 1, 2024.
(II) The state board may adopt rules to implement this subsection (3)(f) to ensure that the
state department can resume routine operations by June 1, 2024, 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 June 1, 2024.
(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.)
Source: L. 2006: (1)(a.5) added, p. 1592, § 2, effective June 2; entire article added with
relocations, p. 1823, § 7, effective July 1. L. 2008: (3) and (5)(b) amended, p. 2024, § 1,
effective June 3. L. 2009: (3)(e) added, (HB09-1020), ch. 298, p. 1595, § 1, effective May 21;
(3)(b)(I)(C) and (3)(B)(I)(D) amended and (3)(b)(I.5) added, (SB 09-292), ch. 369, p. 1974, § 96,
Colorado Revised Statutes 2023 Uncertified PrintoutPage 112 of 510
effective August 5. L. 2010: (4) amended, (SB 10-002), ch. 366, p. 1727, § 3, effective June 7;
(1)(a.7) added, (HB 10-1041), ch. 25, p. 100, § 1, effective August 11. L. 2012: (3)(b)(I)(A),
(3)(b)(I)(B), and (3)(b)(I.5)(A) amended, (HB 12-1120), ch. 27, p. 108, § 25, effective June 1. L.
2014: (1)(a), (3)(b)(I)(A), (3)(b)(I)(B), (3)(b)(I.5), and (3)(d)(II) amended, (SB 14-067), ch. 12,
p. 109, § 2, effective February 27. L. 2021: (1)(a.7) amended, (HB 21-1187), ch. 83, p. 332, §
24, effective July 1, 2024. L. 2023: (3)(f) added, (SB 23-182), ch. 118, p. 431, § 3, effective
April 27.
Editor's note: (1) This section is similar to former § 26-4-106 as it existed prior to
2006.
(2) Subsection (1)(a.5) was enacted as § 26-4-106 (1)(b.5) in House Bill 06-1270 but
was relocated due to its harmonization with this section as it appeared in Senate Bill 06-219.
(3) Subsection (3)(b)(II)(B) provided for the repeal of subsection (3)(b)(II), effective
July 1, 2009. (See L. 2008, p. 2024.)
(4) Subsection (1)(a.5)(VIII) provided for the repeal of subsection (1)(a.5), effective July
1, 2010. (See L. 2006, p. 1592.)
(5) The effective date for amendments to subsections (3)(b)(I)(A), (3)(b)(I)(B), and
(3)(b)(I.5)(A) of this section by House Bill 12-1120 (chapter 27, Session Laws of Colorado
2012) was changed from August 8, 2012, to June 1, 2012, by House Bill 12S-1002 (First
Extraordinary Session, chapter 2, p. 2432, Session Laws of Colorado 2012.)
Cross references: For the legislative declaration contained in the 2006 act enacting
subsection (1)(a.5), see section 1 of chapter 320, Session Laws of Colorado 2006. For the
legislative declaration in the 2010 act amending subsection (4), see section 1 of chapter 366,
Session Laws of Colorado 2010.
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 recipient 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 continues to be eligible for receipt of medical benefits pursuant to this article 4 or
Colorado Revised Statutes 2023 Uncertified PrintoutPage 113 of 510
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 recertify his or her eligibility
for medical assistance pursuant to this article 4 or article 5 or 6 of this title 25.5.
Source: L. 2008: Entire section added, p. 903, § 1, effective May 20. L. 2017: (2)
amended, (HB 17-1329), ch. 381, p. 1983, § 59, effective June 6. L. 2021: (2) amended, (SB
21-059), ch. 136, p. 746, § 122, effective October 1.
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.
Source: L. 2006: Entire article added with relocations, p. 1825, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-411 as it existed prior to 2006.
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 of the same, or if an application
is denied in whole or in part, or if medical assistance benefits are suspended, terminated, or
modified, the applicant or recipient, as the case may be, 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
or designated service agency shall notify the applicant or recipient in writing of the basis for the
county's decision or action and shall inform the applicant or recipient of the right to a county or
service agency conference under the dispute resolution process described in paragraph (b) of this
subsection (1) and of the right to a state-level appeal and the process for appeal.
(II) The applicant or recipient has sixty days after the date of the notice to file an appeal.
If the recipient 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 recipient requests in writing that medical assistance benefits not continue during the
appeal process; except that, to the extent authorized by federal law, the state department rules
may permit existing medical assistance benefits to continue until the appeal process is completed
even if the recipient'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 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 recipient's health or safety is impacted, the recipient was not able to timely
respond due to the recipient's disability or employment, the recipient's caregiver was unavailable
due to the caregiver's health or employment, or the recipient did not receive the county's or
designated service agency's notice prior to the effective date of the intended action.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 114 of 510
(III) Either prior to appeal or as part of the filing of an appeal, the applicant or recipient
may request the dispute resolution process described in paragraph (b) of this subsection (1)
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 recipient of medical assistance. Such 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, C.R.S. The dispute resolution
process shall include an opportunity for all clients to have a county conference, upon the client's
request, and such requirement may be met through a telephonic conference upon the agreement
of the client and the county department. The dispute resolution process need not conform to the
requirements of section 24-4-105, C.R.S., 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 or service delivery
agency's dispute resolution process and the applicant or recipient has already filed an appeal, the
county shall inform the applicant or recipient 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 recipient to the state department. A hearing need not be granted
when either state or federal law requires or results in a reduction or deletion of a medical
assistance benefit unless the applicant or recipient is arguing that his or her case does not fit
within the parameters set forth by the change in the law. In notifying the applicant or recipient
that an appeal is being denied because of a change in state or federal law, the state's notice must
inform the applicant or recipient 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 recipient 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 his or her
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 115 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1825, § 7, effective July 1. L.
2016: (1) amended, (HB 16-1277), ch. 198, p. 698, § 1, effective September 1. L. 2017: (1)(d.5)
added, (HB 17-1126), ch. 123, p. 427, § 1, effective April 6.
Editor's note: This section is similar to former § 26-4-402 as it existed prior to 2006.
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.
Source: L. 2006: Entire article added with relocations, p. 1826, § 7, effective July 1. L.
2014: Entire section amended, (SB 14-067), ch. 12, p. 116, § 11, effective February 27.
Editor's note: This section is similar to former § 26-4-106.5 as it existed prior to 2006.
25.5-4-209. Payments by third parties - copayments by recipients - review - appeal -
children's waiting list reduction fund - rules - repeal. (1) (a) Any recipient receiving benefits
under this article or article 5 or 6 of this title 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 shall apply the supplemental income or
insurance proceeds to the cost of the benefits rendered, and the rules may require reports from
providers of other payments received by them from or on behalf of recipients.
(b) Subject to any limitations imposed by Title XIX, a recipient shall pay at the time of
service a portion of the cost of any medical benefit rendered to the recipient or to the recipient'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) and (d) Repealed.
(e) (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 (1)(b) and (1)(c) of this section
requiring copayments or member cost sharing for COVID-19 testing, vaccines, specialized
equipment, and therapies to comply with the "Family First Coronavirus Response Act", Pub.L.
116-127, and the "American Rescue Plan Act of 2021", Pub.L. 117-2, are suspended until the
last day of the twelfth month following the end of the declared federal public health emergency
as a result of the coronavirus disease 2019, known as "COVID-19".
(II) The state board may adopt rules to implement this subsection (1)(e) 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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 116 of 510
of eligibility renewals, and the transition between medical assistance and children's basic health
plan eligibility categories.
(III) This subsection (1)(e) is repealed, effective September 30, 2024.
(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.
(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);
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(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 recipient of medical assistance to the state department
pursuant to section 25.5-4-205 (4) shall 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 provided for in sections 10-16-113
and 10-16-113.5, C.R.S., and a third party's reasonable appeal procedure under state and federal
law. The state department or the independent contractor retained pursuant to paragraph (b) of
this subsection (3) 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.
(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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 118 of 510
(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) shall be construed to authorize 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 recipient.
(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.
Source: L. 2006: Entire article added with relocations, p. 1826, § 7, effective July 1. L.
2008: (1)(a), (2), and (3)(a) amended, p. 1768, § 1, effective June 2. L. 2010: (4) added, (SB
10-167), ch. 296, p. 1378, § 5, effective May 26; (3)(a) amended and (3)(e) added, (SB 10-002),
ch. 366, p. 1727, § 4, effective June 7. L. 2017: (1)(b) amended and (1)(c) and (1)(d) added, (SB
17-267), ch. 267, p. 1447, § 14, effective May 30. L. 2023: (1)(b) amended and (1)(c) and (1)(d)
repealed, (SB 23-222), ch. 90, p. 342, § 1, effective April 20; (1)(e) added, (SB 23-182), ch. 118,
p. 432, § 6, effective April 27.
Editor's note: (1) This section is similar to former § 26-4-518 as it existed prior to
2006.
(2) Subsection (3)(e)(IV) provided for the repeal of subsection (3)(e), effective July 1,
2013. (See L. 2010, p. 1727.)
Cross references: For the legislative declaration in SB 10-002, see section 1 of chapter
366, Session Laws of Colorado 2010. For the legislative declaration in SB 10-167, see section 1
of chapter 296, Session Laws of Colorado 2010. For the legislative declaration in SB 17-267, see
section 1 of chapter 267, Session Laws of Colorado 2017.
25.5-4-210. Purchase of health insurance for recipients. (1) (a) The state department
shall purchase group health insurance for a medical assistance recipient who is eligible to enroll
for such coverage if enrollment of such recipient in the group plan would be cost-effective. In
addition, the state department may purchase individual health insurance for a medical assistance
recipient who is eligible to enroll in a health insurance plan if enrollment of such recipient would
be cost-effective to this state. A determination of cost-effectiveness shall be in accordance with
federal guidelines established by the secretary of the United States department of health and
human services.
(b) Notwithstanding any provision of paragraph (a) of this subsection (1) to the contrary,
the state department, in purchasing health insurance for medical assistance recipients who are
eligible to enroll for private coverage, shall not purchase such health insurance for more than
two thousand individuals.
(2) Enrollment in a group health insurance plan shall be required of recipients for whom
enrollment has been determined to be cost-effective as a condition of obtaining or retaining
Colorado Revised Statutes 2023 Uncertified PrintoutPage 119 of 510
medical assistance. A parent shall be required to enroll a dependent child recipient, but medical
assistance for such child shall not be 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 recipient pursuant to subsection (1) of this section.
Payment of said services shall be treated as payment for medical assistance. Coverage provided
by the purchased health insurance plan shall be considered as third-party liability for the
purposes of section 25.5-4-209.
(4) Services not available to a recipient under the purchased plan shall be provided to the
recipient if such services would otherwise be provided as medical assistance services pursuant to
this article or article 5 or 6 of this title. Nothing in this section shall be construed to require that
services provided under a group health insurance plan for medical assistance recipients shall be
made available to recipients not enrolled in the plan. Enrollment in a group health insurance plan
pursuant to this section shall not affect the eligibility of a recipient who otherwise qualifies for
medical assistance pursuant to this article or article 5 or 6 of this title.
Source: L. 2006: Entire article added with relocations, p. 1828, § 7, effective July 1. L.
2010: (1) amended, (SB 10-167), ch. 296, p. 1378, § 6, effective May 26.
Editor's note: This section is similar to former § 26-4-518.5 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
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.
Source: L. 2013: Entire section added, (HB 13-1281), ch. 205, p. 851, § 1, effective May
11. L. 2017: (3) amended, (HB 17-1060), ch. 6, p. 16, § 8, effective March 1.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 120 of 510
Editor's note: Subsection (3)(b) provided for the repeal of subsection (3), effective
January 3, 2018. (See L. 2017, p. 16.)
25.5-4-212. Medicaid client 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 recipients, 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 clients; 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 client correspondence
is critical to the health and safety of medicaid clients and will reduce unnecessary confusion that
requires clients to call counties and the state department or file appeals.
(2) As used in this section, unless the context otherwise requires, "client
correspondence" means any communication, the purpose of which is 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. "Client 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 client correspondence by ensuring that
client 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 client
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 client indicates that this is the client'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 client how
to seek further assistance in understanding the content of the correspondence;
(f) Clearly conveys the purpose of the client correspondence, the action or actions being
taken by the state department or its designated entity, if any, and the specific action or actions
that the client must or may take in response to the correspondence;
(g) Includes a specific description of any necessary information or documents requested
from the applicant or client;
(h) Includes contact information for client 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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 121 of 510
to a client specific and detailed information concerning the client's household composition,
assets, income sources, and income amounts, if relevant to a determination for which client
correspondence was issued. If implemented, the state department shall notify clients in the
written correspondence of the option to access this information.
(5) The state department is encouraged to promote the receipt of client correspondence
electronically or through mobile applications for clients who choose those methods of delivery
as allowed by law.
(6) As part of its ongoing process to create and improve client correspondence, the state
department may engage with experts in written communication and plain language to test client
correspondence against the criteria set forth in subsection (3) of this section with a
geographically diverse and representative sample of medicaid clients relevant to the client
correspondence being revised. The state department shall also develop a process to review and
consider feedback from stakeholders including client advocates and counties prior to
implementing significant changes to correspondence.
(7) The state department shall ensure that client correspondence that may only affect a
small number of clients, but may, nonetheless, have a significant impact on the lives of those
clients, 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) Its process for ongoing improvement of client correspondence;
(b) Client correspondence revised pursuant to criteria set forth in subsection (3) of this
section during the prior year and client correspondence improvements that are planned for the
upcoming year; and
(c) A description of the results of testing of new or significantly revised client
correspondence pursuant to subsection (6) of this section, including a description of the
stakeholder feedback.
Source: L. 2017: Entire section added, (SB 17-121), ch. 303, p. 1651, § 1, effective
August 9.
25.5-4-213. Audit of medicaid client correspondence - definition. (1) As used in this
section, unless the context otherwise requires, "client 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 client correspondence.
Thereafter, the state auditor, in the exercise of his or her discretion, may conduct or cause to be
conducted additional performance audits of client correspondence pursuant to this section. The
audit shall 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 shall include:
(a) A review of available data from counties, the 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 client confusion regarding correspondence
received by medicaid clients or applicants;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 122 of 510
(b) A review of the accuracy of client correspondence at the time it is generated;
(c) A review of whether client 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 client correspondence testing process conducted by the department
and whether testing is done prior to implementing new or significantly revised client
communications;
(e) A review of the results of any client correspondence testing, including client
comprehension of the intended purpose or purposes of the correspondence; and
(f) A review of the accuracy of client income and household composition information
that is communicated electronically, if applicable.
(4) If audit findings include findings that information contained in client correspondence
is inaccurate at the time the correspondence was generated, the audit shall 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 client 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 a review of the report.
The report shall 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.
Source: L. 2017: Entire section added, (HB 17-1143), ch. 67, p. 211, § 1, effective
August 9; (1) amended, (SB 17-121), ch. 303, p. 1653, § 2, effective August 9.
25.5-4-214. Feasibility study - residential and inpatient substance use disorder
treatment - report - repeal. (Repealed)
Source: L. 2017: Entire section added, (HB 17-1351), ch. 288, p. 1600, § 2, effective
June 2.
Editor's note: Subsection (5) provided for the repeal of this section, effective July 1,
2019. (See L. 2017, p. 1600.)
25.5-4-215. Study - benefits for persons on work release - repeal. (1) The state
department shall determine whether federal authority is necessary to provide benefit coverage
under the medical assistance program to people who are on work release from jail, as described
in section 18-1.3-207. On or before October 1, 2023, the state department shall report the results
of the assessment and analysis to the joint budget committee of the general assembly.
(2) This section is repealed, effective June 30, 2024.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 123 of 510
Source: L. 2022: Entire section added, (SB 22-196), ch. 193, p. 1293, § 8, effective May
19.
Cross references: For the legislative declaration in SB 22-196, see section 1 of chapter
193, Session Laws of Colorado 2022.
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:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 124 of 510
(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:
(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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 125 of 510
(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
(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;
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(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
(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.
Source: L. 2023: Entire section added, (HB 23-1215), ch. 277, p. 1636, § 4, effective
May 30.
PART 3
RECOVERY
25.5-4-300.4. Last resort for payment - legislative intent. It is the intent of the general
assembly that medicaid be the last resort for payment for medically necessary goods and services
furnished to recipients and that all other sources of payment are primary to medical assistance
provided by medicaid.
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Source: L. 2008: Entire section added, p. 1771, § 2, effective June 2.
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.
Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1379, § 8, effective May
26. L. 2016: (2) repealed, (HB 16-1081), ch. 22, p. 50, § 2, effective August 10.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
25.5-4-300.9. Explanation of benefits - medicaid recipients - 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 client receiving medical services or his or her 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 clients may not appear to be affected financially by billing errors
or fraudulent claims, medicaid clients who rely on these services for survival and independence
are most severely affected by the inappropriate use of scarce resources; and
(VIII) Further, medicaid clients and medicaid 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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 128 of 510
(b) Therefore, the general assembly declares that creating an explanation of benefits for
recipients 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) By or before July 1, 2017, the state department shall develop and implement an
explanation of benefits for recipients of medical services pursuant to articles 4 to 6 of this title.
The purpose of the explanation of benefits is to inform a medicaid client of a claim for
reimbursement made for services provided to the client or on his or her behalf, so that the client
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 client 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 client that the explanation of benefits is not a bill,
but is only provided for the client'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
client 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
client 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 clients and medicaid advocates to ensure that medicaid
clients understand the information provided and the purpose of the explanation of benefits. The
state department shall also work with medicaid clients and medicaid 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 clients to take
responsibility for reporting errors.
(6) The state department shall provide the explanation of benefits to a medicaid client
not less frequently than once every two months, if services have been provided to or on behalf of
the client during that time period. The state department shall determine the most cost-effective
means for producing and distributing the explanation of benefits to medicaid clients, 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 clients.
(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 client.
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Source: L. 2016: Entire section added, (SB 16-120), ch. 254, p. 1044, § 1, effective
August 10.
25.5-4-301. Recoveries - overpayments - penalties - interest - adjustments - liens -
review or audit procedures - repeal. (1) (a) (I) Except as provided in section 25.5-4-302 and
subparagraph (III) of this paragraph (a), no recipient or estate of the recipient shall be 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 social security act, by this title, or by rules
promulgated by the state board, which benefits are rendered to the recipient by a provider of
medical services authorized to render such service in the state of Colorado, except those
contributions required pursuant to section 25.5-4-209 (1). However, a recipient may enter into a
documented agreement with a provider under which the recipient agrees to pay for items or
services that are nonreimbursable under the medical assistance program. Under these
circumstances, a recipient is liable for the cost of such services and items.
(II) The provisions of subparagraph (I) of this paragraph (a) shall 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 recipient or the estate of a recipient for medical services authorized by Title XIX of
the 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 recipient of any amount unlawfully received from
the recipient, 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 recipient.
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 recipient 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 recipient or the estate of the recipient 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 recipient or the estate of a recipient, or a person acting on behalf
of a recipient or the estate of a recipient, shall notify the state department.
(C) The provisions of this subparagraph (II.5) shall not apply to a long-term care facility
licensed pursuant to section 25-3-101, C.R.S.
(D) The provisions of subsection (1)(a)(II.5)(A) of this section shall not apply if a
recipient knowingly misrepresents his or her medicaid coverage status to a provider of medical
services and the provider submits documentation to the state department that the recipient
knowingly misrepresented his or her medicaid coverage status and the documentation clearly
establishes a good cause basis for granting an exception to the provider.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 130 of 510
(III) (A) When a third party is primarily liable for the payment of the costs of a
recipient's medical benefits, prior to receiving nonemergency medical care, the recipient shall
comply with the protocols of the third party, including using providers within the third party's
network or receiving a referral from the recipient's primary care physician. Any recipient 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 recipient, the items or services
are nonreimbursable under this article and articles 5 and 6 of this title and the recipient is not
liable to the provider.
(B) A recipient may enter into a written agreement with a third party or provider under
which the recipient agrees to pay for items provided or services rendered that are outside of the
network or plan protocols. The recipient's agreement to be personally liable for such
nonemergency, nonreimbursable items shall be recorded on forms approved by the state board
and signed and dated by both the recipient and the provider in advance of the services being
rendered.
(b) Recipient income applied pursuant to section 25.5-4-209 (1) does not disqualify any
recipient, 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 recipient becomes possessed
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, it is the duty of the recipient to notify the county
department thereof, and the county department may, after investigation, either revoke such
medical benefits or alter the amount thereof, as the circumstances may require.
(c) Any medical assistance paid to which a recipient was not lawfully entitled shall be
recoverable from the recipient or the estate of the recipient 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 recipient on
account of medical assistance paid or to be paid on the recipient's behalf under this article or
article 5 or 6 of this title, except pursuant to the judgment of a court of competent jurisdiction or
as provided by section 25.5-4-302.
(d) If any such medical assistance was obtained fraudulently, interest shall be charged
and paid to the county department on the amount of such medical assistance calculated at the
legal rate and calculated from the date that payment for medical services rendered on behalf of
the recipient is made to the date such 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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 131 of 510
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 such overpayment has been made
for some other reason than a false representation by the provider specified in subparagraph (I) of
this paragraph (a), the state department may collect the amount of overpayment, plus interest
accruing at the statutory rate from the date the provider is notified of such 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 subparagraph (II) if it would be
inequitable, uncollectible or administratively impracticable; except that no action shall be taken
against a recipient of medical services initially determined to be eligible pursuant to section
25.5-4-205 if the overpayment occurred through no fault of the recipient. 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).
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 132 of 510
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. 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.
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(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. 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.
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(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:
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 135 of 510
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:
(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 section 25.5-4-301
(3)(a)(IV.5), informal reconsiderations, and appeals.
(V) Provider administrative burdens associated with the recovery audit contractor
program;
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(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.
(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 recipient pursuant to the
provisions of this article and articles 5 and 6 of this title for which a third party is liable, the state
department has an enforceable right against such third party for the amount of such medical
assistance, including the lien right specified in subsection (5) of this section. Whenever the
recipient 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 recipient and the
recipient's attorney, if any. Any such agreement shall be filed with the court in which such an
action is pending. The attorney named in such an agreement upon designation as a special
assistant attorney general by the attorney general shall have the right to prove both the recipient'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 such claims are founded on judgment, contract,
lien, or otherwise, and take any other action that is appropriate to recover from such third parties.
To enforce such right, the attorney general, pursuant to section 24-31-101, C.R.S., on behalf of
the state department may institute and prosecute, or intervene of right in legal proceedings
Colorado Revised Statutes 2023 Uncertified PrintoutPage 137 of 510
against the third party having legal liability, either in the name of the state department or in the
name of the recipient or his or her assignee, guardian, personal representative, estate, or
survivors. When the state department intervenes in legal proceedings against the third party, it
shall not be liable for any portion of the attorney fees or costs of the recipient.
(5) (a) When the state department has furnished medical assistance to or on behalf of a
recipient pursuant to the provisions of this article, and articles 5 and 6 of this title, for which a
third party is liable, the state department shall have an automatic statutory lien for all such
medical assistance. The state department's lien shall be against any judgment, award, or
settlement in a suit or claim against such third party and shall be in an amount that shall be 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 recipient to recover
damages for injuries, where the state department has a lien, shall be satisfied without first
satisfying the state department's lien. Failure by any party to the judgment, award, or settlement
to comply with this section shall make each such party liable for the full amount of medical
assistance furnished to or on behalf of the recipient for the injuries that are the subject of the
judgment, award, or settlement.
(c) Except as otherwise provided in this article, the entire amount of any judgment,
award, or settlement of the recipient's action or claim, with or without suit, regardless of how
characterized by the parties, shall be subject to the state department's lien.
(d) Where the action or claim is brought by the recipient alone and the recipient incurs a
personal liability to pay attorney fees, the state department will pay its reasonable share of
attorney fees not to exceed twenty-five percent of the state department's lien. The state
department shall not be liable for costs.
(e) The state department's right to recover under this section is independent of the
recipient's right.
(6) When the applicant or recipient, or his or her guardian, executor, administrator, or
other appropriate representative, brings an action or asserts a claim against any third party, such
person shall give to 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) shall make the recipient, legal guardian, executor, administrator,
attorney, or other representative liable for the entire amount of medical assistance furnished to or
on behalf of the recipient for the injuries that gave rise to the action or claim. The state
department may, after thirty days' written notice to such person, enforce its 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 recipient shall exist only if such person
had knowledge that the recipient 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 recipient agrees or is ordered to provide
medical support or health insurance coverage for his or her dependents or other persons, and
such dependents are applicants for, recipients of, or otherwise entitled to receive medical
assistance pursuant to this article and articles 5 and 6 of this title, the state department shall be
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 138 of 510
persons. Where 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
and articles 5 and 6 of this title for whom the relative is legally responsible.
(8) All recipients of medical assistance under the medicaid program shall be deemed to
have authorized their 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, C.R.S., shall be construed to limit the right
of the state department to recover the medical assistance furnished to or on behalf of a recipient
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 such action shall be a bar to any action upon the claim or cause of
action of the applicant or recipient or his or her guardian, personal representative, estate,
dependent, or survivors against the third party having legal liability, nor shall any such action or
judgment operate to deny the applicant or recipient the recovery for that portion of his or her
medical costs or other damages not provided as medical assistance under this article or article 5
or 6 of this title.
(11) (a) The state department shall have a right to recover any amount of medical
assistance paid on behalf of a recipient because:
(I) The trustee of a trust for the benefit of the recipient has used the trust property in a
manner contrary to the terms of the trust;
(II) A person holding the recipient's power of attorney has used the power for purposes
other than the benefit of the recipient.
(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.
(c) No action taken by the county or state department pursuant to this subsection (11) or
any judgment rendered in such action or proceeding shall be a bar to any action upon the claim
or cause of action of the recipient or his or her 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
recipient under a managed care plan or a guardian, executor, administrator, or other appropriate
representative of the recipient shall provide to the entity that administers the managed care plan
written notice of the action or claim. Notice shall be by personal service or certified mail.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 139 of 510
(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.
(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 recipients. 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.
Source: L. 2006: Entire article added with relocations, p. 1829, § 7, effective July 1;
(1)(a)(II.5) added, p. 107, § 1, effective January 1, 2007. L. 2007: (3)(a)(IV) and (3)(a)(VII)
amended and (3)(a)(IV.5), (3)(a.5), and (3.5) added, pp. 1467, 1469, 1468, §§ 1, 3, 2, effective
May 30. L. 2009: (5)(a) and (5)(c) amended, (HB 09-1191), ch. 100, p. 372, § 1, effective
August 5. L. 2010: (2)(a)(II) amended, (SB 10-167), ch. 296, p. 1378, § 7, effective May 26. L.
2013: (14) added, (HB 13-1068), ch. 119, p. 405, § 1, effective April 8. L. 2017: (1)(a)(II.5)(A)
and (1)(a)(II.5)(B) amended and (1)(a)(II.5)(A.5), (1)(a)(II.5)(D), and (15) added, (HB 17-1139),
ch. 376, p. 1942, § 2, effective June 6. L. 2018: IP(2), IP(3)(a), and (3)(a)(IV) amended, (SB
Colorado Revised Statutes 2023 Uncertified PrintoutPage 140 of 510
18-092), ch. 38, p. 444, § 110, effective August 8. L. 2021: (2)(d) repealed, (SB 21-055), ch. 12,
p. 78, § 14, effective March 21; (3)(a)(IV) amended, (SB 21-022), ch. 167, p. 931, § 1, effective
September 7. L. 2022: (13) amended, (HB 2-1289), ch. 399, p. 2841, § 13, effective June 7;
(1)(b) amended, (HB 22-1295), ch. 123, p. 848, § 76, effective July 1. L. 2023: (3)(a)(IX),
(3.5)(c), and (3.7) added, (HB 23-1295), ch. 299, p. 1801, § 2, effective June 1; (14)(b) amended,
(HB 23-1301), ch. 303, p. 1829, § 46, effective August 7.
Editor's note: (1) This section is similar to former § 26-4-403 as it existed prior to
2006.
(2) Subsection (1)(a)(II.5) was enacted as § 26-4-403 (1)(a)(II.5) in House Bill 06-1079
but was relocated due to its harmonization with this section as it appeared in Senate Bill 06-219.
(3) Subsection (3.5)(b)(II) provided for the repeal of subsection (3.5)(b), effective July 1,
2011. (See L. 2007, p. 1468.)
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010. For the legislative declaration in HB 17-1139, see section
1 of chapter 376, Session Laws of Colorado 2017. For the legislative declaration in SB 18-092,
see section 1 of chapter 38, Session Laws of Colorado 2018. For the legislative declaration in
HB 22-1289, see section 1 of chapter 399, Session Laws of Colorado 2022. For the legislative
declaration in HB 23-1295, see section 1 of chapter 299, Session Laws of Colorado 2023.
25.5-4-302. Recovery of assets. (1) The general assembly hereby finds, determines, and
declares that the cost of providing medical assistance to qualified recipients 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 such revenues available for other state
programs; that recovering some of the medical assistance from the estates of medical assistance
recipients would be a viable mechanism for such recipients to share in the cost of such
assistance; and that such 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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 141 of 510
(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.
Source: L. 2006: Entire article added with relocations, p. 1836, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-403.3 as it existed prior to 2006.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 142 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1838, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-403.4 as it existed prior to 2006.
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.
Source: L. 2012: Entire section added, (SB 12-060), ch. 166, p. 578, § 2, effective
August 8. L. 2017: IP(1), (1)(d), and (1)(e) amended and (1)(f) added, (SB 17-295), ch. 298, p.
1637, § 2, effective August 9.
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".
Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1379, § 10, effective
May 26.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 143 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1838, § 7, effective July 1. L.
2010: Entire section R&RE, (SB 10-167), ch. 296, p. 1379, § 11, effective May 26. L. 2013: (5)
amended, (SB 13-205), ch. 276, p. 1441, § 3, effective August 7.
Editor's note: This section is similar to former §§ 26-4-1102 and 26-4-1103 (3) as they
existed prior to 2006.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 144 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1839, § 7, effective July 1. L.
2010: Entire section R&RE, (SB 10-167), ch. 296, p. 1380, § 12, effective May 26. L. 2011:
IP(1) amended, (HB 11-1303), ch. 264, p. 1168, § 66, effective August 10. L. 2013: IP(1) and
(1)(a) amended, (SB 13-205), ch. 276, p. 1441, § 4, effective August 7.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 145 of 510
Editor's note: This section is similar to former § 26-4-1103 (1) and (2) as they existed
prior to 2006.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
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.
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(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.
(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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 147 of 510
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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 148 of 510
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).
Source: L. 2006: Entire article added with relocations, p. 1840, § 7, effective July 1. L.
2009: IP(1)(b), IP(1)(c), and (4) amended, (SB 09-292), ch. 369, p. 1974, § 97, effective August
5. L. 2010: Entire section R&RE, (SB 10-167), ch. 296, p. 1382, § 13, effective May 26. L.
2013: (2)(e), (5), and (7) amended, (SB 13-205), ch. 276, p. 1441, § 5, effective August 7.
Editor's note: This section is similar to former § 26-4-1104 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 149 of 510
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.
Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1386, § 14, effective
May 26. L. 2013: (5) added, (SB 13-205), ch. 276, p. 1442, § 6, effective August 7.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
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.
Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1387, § 14, effective
May 26.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 150 of 510
(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.
(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
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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.
(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:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 152 of 510
(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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 153 of 510
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.
(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
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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.
(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:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 155 of 510
(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.
(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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 156 of 510
(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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 157 of 510
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.
(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).
Colorado Revised Statutes 2023 Uncertified PrintoutPage 158 of 510
Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1387, § 14, effective
May 26.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
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".
Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1399, § 14, effective
May 26. L. 2017: IP(1) amended, (SB 17-233), ch. 175, p. 637, § 3, effective August 9.
Cross references: (1) For the "Colorado Medicaid False Claims Act", see section
25.5-4-303.5.
(2) For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session
Laws of Colorado 2010.
PART 4
PROVIDERS - REIMBURSEMENT
25.5-4-401. Providers - payments - rules. (1) (a) The state department shall establish
rules for the payment of providers under this article and articles 5 and 6 of this title. Within the
limits of available funds, such rules shall provide reasonable compensation to such providers, but
no provider shall, by this section or any other provision of this article or article 5 or 6 of this
title, be deemed to have any vested right to act as a provider under this article and articles 5 and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 159 of 510
6 of this title or to receive any payment in addition to or different from that which is currently
payable on behalf of a recipient at the time the medical benefits are provided by said 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 recipient.
(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 recipients 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 hereby finds, determines, and declares that access to
health-care services would be improved and costs of health care would be restrained if the
recipients 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 paragraph (c) of this subsection (4), the executive
director of the state department has the authority to require a recipient of the medicaid program
Colorado Revised Statutes 2023 Uncertified PrintoutPage 160 of 510
to select a managed care provider and to assign a recipient to a managed care provider if the
recipient has failed to make a selection within a reasonable time. To the extent possible, this
requirement shall be implemented on a statewide basis.
(c) The state department shall ensure the following:
(I) A managed care provider shall establish and implement consumer friendly
procedures and instructions for disenrollment and shall have adequate staff to explain issues
concerning service delivery and disenrollment procedures to recipients, including staff to address
the communications needs and requirements of recipients with disabilities.
(II) All recipients shall be adequately informed about service delivery options available
to them consistent with the provisions of this subparagraph (II). If a recipient does not respond to
a state department request for selection of a delivery option within forty-five calendar days, the
state department shall send a second notification to the recipient. If the recipient does not
respond within twenty days of the date of the second notification, the state department shall
ensure that the recipient remains with the recipient's primary care physician, regardless of
whether said 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.
Source: L. 2006: Entire article added with relocations, p. 1841, § 7, effective July 1. L.
2009: (1)(d) added, (SB 09-265), ch. 205, p. 935, § 2, effective May 1. L. 2010: (1)(d) repealed,
(HB 10-1382), ch. 217, p. 939, § 1, effective May 6.
Editor's note: This section is similar to former § 26-4-404 as it existed prior to 2006.
25.5-4-401.2. Performance-based payments - reporting - repeal. (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) (A) Community mental health centers, as defined in section 27-66-101.
(B) This subsection (1)(d)(I) is repealed, effective July 1, 2024.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 161 of 510
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
(i) A description of proposed modifications to current performance-based payments.
Source: L. 2017: Entire section added, (HB 17-1353), ch. 231, p. 898, § 3, effective May
23. L. 2018: (1)(d)(II) amended, (HB 18-1431), ch. 313, p. 1892, § 10, effective August 8. L.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 162 of 510
2022: (1)(d) amended, (HB 22-1278), ch. 222, p. 1512, § 67, effective July 1. L. 2023: IP(3)
amended, (HB 23-1301), ch. 303, p. 1830, § 47, effective August 7.
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 client 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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 163 of 510
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, recipients, 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, recipients, 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, recipients, 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, recipients, 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
(VII) Provide other assistance to the state department and the joint budget committee as
requested by the state department or the joint budget committee.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 164 of 510
(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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 165 of 510
Source: L. 2015: Entire section added, (SB 15-228), ch. 288, p. 1177, § 1, effective June
5. L. 2017: (2)(a) and (2)(d) amended, (HB 17-1060), ch. 6, p. 17, § 9, effective March 1. L.
2021: (3)(b)(III)(D) amended, (HB 21-1187), ch. 83, p. 332, § 25, effective July 1, 2024. L.
2022: Entire section amended, (SB 22-236), ch. 410, p. 2897, § 1, effective July 1, 2023. L.
2023: (2)(d)(I) amended, (SB 23-223), ch. 74, p. 273, § 1, effective April 17.
Editor's note: (1) Section 3 of chapter 410, (SB 22-236), Session Laws of Colorado
2022, provides that subsection (3) takes effect December 1, 2022, subsection (2)(d) takes effect
May 1, 2025, and the remainder of the section takes effect July 1, 2023.
(2) Section 2 of chapter 74, (SB 23-223), Session Laws of Colorado 2023, amended
section 3 of chapter 410, (SB 22-236), Session Laws of Colorado 2022, to change the effective
date for amendments to subsection (2)(a) by SB 22-236 from July 1, 2023, to April 30, 2023, and
to change the effective date for amendments to subsection (2)(d) by SB 22-236 from May 1,
2025, to July 1, 2023.
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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 166 of 510
(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 recipient 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 recipients, 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) The state department shall provide a report to the joint budget committee on
November 1, 2019, and November 1, 2020, detailing the estimates of the cost savings achieved
Colorado Revised Statutes 2023 Uncertified PrintoutPage 167 of 510
and the impact of the cost-control measures authorized pursuant to this section on recipients and
recipients' health outcomes.
(V) Beginning in 2018, and every year thereafter through 2020, the state department
shall report on the status of the implementation of the hospital review program, any cost savings
estimated or achieved due to the program, and the impact on recipients and recipients' outcomes
of any cost-control measures as part of its "State Measurement for Accountable, Responsive, and
Transparent (SMART) Government Act" hearing required by section 2-7-203.
(e) The state board shall adopt any rules necessary for the administration and
implementation of this section.
Source: L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1;
entire section amended, p. 1546, § 3, effective July 1. L. 2009: (1) amended and (3) added, (HB
09-1293), ch. 152, p. 645, § 4, effective July 1. L. 2017: (3)(a) amended, (SB 17-267), ch. 267,
p. 1448, § 15, effective July 1. L. 2018: (4) added, (SB 18-266), ch. 264, p. 1624, § 2, effective
May 29. L. 2023: (3)(a) amended, (HB 23-1301), ch. 303, p. 1830, § 48, effective August 7.
Editor's note: (1) This section is similar to former § 26-4-405 as it existed prior to
2006.
(2) Amendments to section 26-4-405 by Senate Bill 06-165 were harmonized with this
section as it appeared in Senate Bill 06-219.
(3) Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017, provides
that the section of the act changing this section does not take effect if the centers for medicare
and medicaid services determine that the amendments do not comply with federal law. For more
information, see SB 17-267. (L. 2017, p. 1478.) The executive director of the department of
health care policy and financing did not notify the revisor of statutes by June 1, 2017, of such
determination; therefore, the changes to this section took effect July 1, 2017.
Cross references: (1) For the legislative declaration contained in the 2006 act amending
this section, see section 1 of chapter 312, Session Laws of Colorado 2006.
(2) For the legislative declaration in SB 17-267, see section 1 of chapter 267, Session
Laws of Colorado 2017.
25.5-4-402.3. Providers - hospital - provider fees - legislative declaration - federal
waiver - fund created - rules - advisory board - repeal. (Repealed)
Source: L. 2009: Entire section added, (HB 09-1293), ch. 152, p. 633, § 1, effective July
1. L. 2010: (4)(b)(VIII) added, (SB 10-169), ch. 307, p. 1445, § 1, effective May 27; (4)(b)(IV)
amended, (HB 10-1422), ch. 419, p. 2110, § 141, effective August 11. L. 2011: (3)(a)(II) and
(3)(a)(III) amended and (3)(a)(IV), (4)(b)(IX), and (5)(b.5) added, (SB 11-212), ch. 146, pp. 508,
509, §§ 1, 2, 3, effective May 5. L. 2013: (4)(b)(IV)(A) and (4)(b)(IV)(C) amended, (SB
13-200), ch. 216, p. 897, § 1, effective May 13. L. 2017: (5)(b.3) added, (SB 17-256), ch. 198, p.
720, § 1, effective May 8; entire section repealed, (SB 17-267), ch. 267, p. 1448, § 16, effective
July 1.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 168 of 510
Editor's note: Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017,
provides that the section of the act repealing this section does not take effect if the centers for
medicare and medicaid services determine that the amendments do not comply with federal law.
For more information, see SB 17-267. (L. 2017, p. 1478.) The executive director of the
department of health care policy and financing did not notify the revisor of statutes by June 1,
2017, of such determination; therefore, the repeal of this section took effect July 1, 2017.
Cross references: For the legislative declaration in SB 17-267, see section 1 of chapter
267, Session Laws of Colorado 2017.
25.5-4-402.4. Hospitals - healthcare affordability and sustainability fee - legislative
declaration - Colorado healthcare affordability and sustainability enterprise - federal
waiver - fund created - rules - reports - 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) 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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 169 of 510
(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;
(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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 170 of 510
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.
(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) 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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 171 of 510
associated federal penalties to the federal government. The enterprise shall use the healthcare
affordability and sustainability fee revenue to:
(I) 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;
(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.
(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:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 172 of 510
(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) 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;
(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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 173 of 510
(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.
(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) 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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 174 of 510
consult with the state board on the proposed rules as specified in subsection (7)(d) of this
section.
(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.
(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) 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;
(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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 175 of 510
(D) 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;
(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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 176 of 510
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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 177 of 510
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
(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).
Colorado Revised Statutes 2023 Uncertified PrintoutPage 178 of 510
(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).
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 179 of 510
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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 180 of 510
(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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 181 of 510
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.
Source: L. 2017: Entire section added, (SB 17-267), ch. 267, p. 1448, § 17, effective
July 1. L. 2018: IP(5)(b) amended, (SB 18-195), ch. 173, p. 1205, § 1, effective July 1. L. 2019:
(7)(e.5) added, (HB 19-1001), ch. 52, p. 177, § 1, effective August 2. L. 2020: (5)(b)(VIII) and
(6)(a)(I) amended and (4)(a)(II.5), (5)(b)(VIII.5), and (6)(b)(I.3) added, (HB 20-1361), ch. 161,
p. 756, § 2, effective June 29; (5)(b)(VIII) and (6)(a)(I) amended and (4)(a)(II.3), (5)(b)(VIII.3),
and (6)(b)(I.5) added, (HB 20-1385), ch. 173, p. 795, § 2, effective June 29; IP(4)(a),
(5)(b)(VIII), and (6)(a)(I) amended and (4)(a)(II.5), (5)(b)(VIII.7), and (6)(b)(I.7) added, (HB
20-1386), ch. 210, p. 1023, § 1, effective June 30. L. 2021: (4)(a)(II.3), (5)(b)(VIII.3), and
(6)(b)(I.5)(B) amended, (SB 21-213), ch. 88, p. 363, § 2, effective May 4; (4)(a)(II.5),
(5)(b)(VIII.5), and (6)(b)(I.3) repealed and (6)(a)(I) amended, (SB 21-211), ch. 86, p. 358, § 2,
effective May 4; (5)(c) added, (SB 21-286), ch. 395, p. 2626, § 2, effective June 30. L. 2022:
(5)(c)(I) amended, (HB 22-1188), ch. 14, p. 124, § 1, effective March 7; (5)(b)(IV)(B) amended,
(SB 22-052), ch. 43, p. 216, § 1, effective March 24; (3)(e) and (7)(a)(II) amended, (SB 22-162),
ch. 469, p. 3371, § 60; effective August 10.
Editor's note: (1) Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado
2017, provides that the section of the act adding this section does not take effect if the centers for
medicare and medicaid services determine that the amendments do not comply with federal law.
For more information, see SB 17-267. (L. 2017, p. 1478.) The executive director of the
department of health care policy and financing did not notify the revisor of statutes by June 1,
2017, of such determination; therefore, this section took effect July 1, 2017.
(2) Amendments to subsection (6)(a)(I) by HB 20-1361, HB 20-1385, and HB 20-1386
were harmonized.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 182 of 510
(3) Subsection (4)(a)(II.5) was added in HB 20-1361. It was superseded by the addition
of subsection (4)(a)(II.5) in HB 20-1386.
(4) Subsection (5)(b)(VIII.7)(B) provided for the repeal of subsection (5)(b)(VIII.7),
effective December 31, 2021. (See L. 2020, p. 1023.)
(5) Subsection (6)(b)(I.7)(B) provided for the repeal of subsection (6)(b)(I.7), effective
December 31, 2021. (See L. 2020, p. 1023.)
Cross references: (1) For the legislative declaration in SB 17-267, see section 1 of
chapter 267, Session Laws of Colorado 2017.
(2) For the short title (the "Debbie Haskins 'Administrative Organization Act of 1968'
Modernization Act") in SB 22-162, see section 1 of chapter 469, Session Laws of Colorado
2022.
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.
Source: L. 2008: Entire section added, p. 1185, § 3, effective May 22.
25.5-4-402.7. Unexpended hospital provider fee cash fund - creation - transfer from
hospital provider fee cash fund - use of fund - repeal. (Repealed)
Source: L. 2017: Entire section added, (SB 17-267), ch. 267, p. 1464, § 18, effective
July 1.
Editor's note: Subsection (2) provided for the repeal of this section, effective November
1, 2018. (See L. 2017, p. 1464.)
25.5-4-402.8. Hospital transparency report - 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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 183 of 510
(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) "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.
(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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 184 of 510
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;
(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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 185 of 510
(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;
(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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 186 of 510
(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) 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;
(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 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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 187 of 510
(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.
Source: L. 2019: Entire section added, (HB 19-1001), ch. 52, p. 177, § 2, effective
August 2. L. 2021: (2)(c)(III) amended, (SB 21-266), ch. 423, p. 2802, § 21, effective July 2. L.
2023: (2)(a), IP(2)(b), (2)(b)(II)(A), (2)(b)(III)(J), (2)(b)(III)(M), IP(2)(c), (2)(e), IP(3), IP(4)(a),
(4)(a)(I), and (4)(b) amended, (2)(b)(II)(D), (2)(b)(II)(E), (2)(b)(II)(F), (2)(b)(II)(G),
(2)(b)(III)(O), (2)(b)(III)(P), (2)(b)(III)(Q), (2)(b)(IV), (2)(b.5), (2)(g), and (4.5) added, and
(2)(d) repealed, (HB 23-1226), ch. 306, p. 1871, § 1, effective August 7.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 188 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1. L.
2022: Entire section amended, (HB 22-1278), ch. 222, p. 1512, § 68, effective July 1.
Editor's note: This section is similar to former § 26-4-409 as it existed prior to 2006.
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);
Colorado Revised Statutes 2023 Uncertified PrintoutPage 189 of 510
(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.
Source: L. 2022: Entire section added, (HB 22-1268), ch. 363, p. 2598, § 3, effective
June 3.
Cross references: For the legislative declaration in HB 22-1268, see section 1 of chapter
363, Session Laws of Colorado 2022.
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.
Source: L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1. L.
2010: Entire section amended, (HB 10-1422), ch. 419, p. 2110, § 142, effective August 11.
Editor's note: This section is similar to former § 26-4-515 as it existed prior to 2006.
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 recipient under the medical assistance program shall comply with all federal
requirements, including but not limited to:
(a) Ensuring that a recipient with complex or multiple needs who requires mental health
services shall have access to mental health professionals with appropriate training and
credentials and shall provide the recipient with such services in collaboration with the recipient's
other providers;
(b) Informing each recipient of his or her 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 recipient and transferring the
recipient for appropriate continued services.
(1.5) Each contract between the state department and a managed care organization
providing mental health services to a recipient under the medical assistance program shall allow
for the use of telemedicine pursuant to the provisions of section 25.5-5-320.
(2) For mental health managed care recipients, the state department shall have a patient
representative program for recipient grievances that complies with all federal requirements and
that shall:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 190 of 510
(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 recipient 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 recipient is informed of the patient representative
program and how a patient representative may be contacted.
Source: L. 2006: Entire article added with relocations, p. 1844, § 7, effective July 1. L.
2008: (1.5) added, p. 111, § 1, effective August 5.
Editor's note: This section is similar to former § 26-4-409.5 as it existed prior to 2006.
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.
Source: L. 2006: Entire article added with relocations, p. 1845, § 7, effective July 1. L.
2007: (1)(a), (2), and (3) amended, p. 618, § 2, effective August 3. L. 2010: (1)(a) amended, (SB
10-175), ch. 188, p. 800, § 66, effective April 29. L. 2018: (1)(a) amended, (HB 18-1094), ch.
343, p. 2044, § 10, effective June 30.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 191 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-412 as it existed prior to 2006.
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.
Source: L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1. L.
2008: (1)(e) added, p. 111, § 2, effective August 5.
Editor's note: This section is similar to former § 26-4-516 as it existed prior to 2006.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 192 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1846, § 7, effective July 1. L.
2008: (2) amended, p. 138, § 1, effective July 1. L. 2019: Entire section amended, (HB
19-1172), ch. 136, p. 1707, § 178, effective October 1.
Editor's note: This section is similar to former § 26-4-413 as it existed prior to 2006.
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.
Source: L. 2006: Entire article added with relocations, p. 1847, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-414 as it existed prior to 2006.
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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 193 of 510
(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.
Source: L. 2006: Entire article added with relocations, p. 1847, § 7, effective July 1. L.
2019: (1) amended, (HB 19-1172), ch. 136, p. 1707, § 179, effective October 1. L. 2020: (1)
amended, (HB 20-1056), ch. 64, p. 263, § 9, effective September 14. L. 2022: Entire section
amended, (SB 22-219), ch. 381, p. 2727, § 39, effective January 1, 2023.
Editor's note: This section is similar to former § 26-4-414.3 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 22-219, see section 1 of chapter
381, Session Laws of Colorado 2022.
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.)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 194 of 510
(4) For purposes of making payments to providers, the state board shall establish rules
implementing this section.
(5) Any recipient 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 recipient in a managed care organization, or a
similar entity, does not restrict a recipient's choice of the licensed provider from whom the
recipient 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.
Source: L. 2006: Entire article added with relocations, p. 1848, § 7, effective July 1. L.
2016: (2) amended, (SB 16-158), ch. 204, p. 729, § 21, effective August 10. L. 2021: Entire
section amended, (SB 21-016), ch. 428, p. 2835, § 3, effective July 6. L. 2023: (5) amended, (SB
23-167), ch. 261, p. 1549, § 62, effective May 25.
Editor's note: This section is similar to former § 26-4-414.5 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 16-158, see section 1 of chapter
204, Session Laws of Colorado 2016.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 195 of 510
of services or otherwise discriminate against a patient on the basis of whether the patient has
executed an advance directive.
Source: L. 2006: Entire article added with relocations, p. 1848, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-403.5 as it existed prior to 2006.
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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 196 of 510
(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;
(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.
Source: L. 2006: Entire article added with relocations, p. 1849, § 7, effective July 1. L.
2019: (1)(d) amended, (HB 19-1172), ch. 136, p. 1708, § 180, effective October 1.
Editor's note: This section is similar to former § 26-4-410.5 as it existed prior to 2006.
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.)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 197 of 510
(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.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 198 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1851, § 7, effective July 1. L.
2021: (3) amended, (SB 21-142), ch. 168, p. 934, § 3, effective May 21.
Editor's note: This section is similar to former § 26-4-512 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 21-142, see section 1 of chapter
168, Session Laws of Colorado 2021.
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 recipient.
(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 recipient 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.
Source: L. 2006: Entire section added, p. 525, § 1, effective August 7.
Editor's note: This section was originally numbered as § 26-4-410.7 in House Bill
06-1299. Section 2 of the act provided for the renumbering and relocation of § 26-4-410.7 to this
section. (See L. 2006, p. 526.)
25.5-4-417. Provider fee - medicaid providers - state plan amendment - rules -
definitions. (1) For purposes of this section, unless the context otherwise requires:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 199 of 510
(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) 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.
(6) The state board shall adopt any rules necessary for the administration and
implementation of this section.
Source: L. 2006: Entire section added, p. 887, § 2, effective May 5. L. 2008: Entire
section amended, p. 927, § 1, effective May 20.
Editor's note: This section was enacted as § 26-4-427 in Senate Bill 06-145 but was
relocated due to its harmonization with this article as it appeared in Senate Bill 06-219.
25.5-4-418. Integration of physical and behavioral health services - department
review - report - repeal. (Repealed)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 200 of 510
Source: L. 2011: Entire section added, (HB 11-1242), ch. 271, p. 1230, § 1, effective
July 1.
Editor's note: Subsection (4) provided for the repeal of this section, effective July 1,
2012. (See L. 2011, p. 1230.)
25.5-4-419. Supplemental state payment to qualified providers - office-administered
drugs - no federal financial participation - definition - rules - repeal. (Repealed)
Source: L. 2018: Entire section added, (HB 18-1330), ch. 146, p. 932, § 1, effective
April 23.
Editor's note: Subsection (6) provided for the repeal of this section, effective July 1,
2019. (See L. 2018, p. 932.)
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 201 of 510
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.
(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.
Source: L. 2018: Entire section added, (HB 18-1282), ch. 158, p. 1109, § 3, effective
August 8.
Cross references: For the legislative declaration in HB 18-1282, see section 1 of chapter
158, Session Laws of Colorado 2018.
25.5-4-421. Supplemental state payment to qualified durable medical equipment
providers - no federal financial participation - definition - rules - repeal. (Repealed)
Source: L. 2018: Entire section added, (HB 18-1329), ch. 206, p. 1323, § 1, effective
May 4.
Editor's note: Subsection (6) provided for the repeal of this section, effective July 1,
2019. (See L. 2018, p. 1323.)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 202 of 510
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 recipients, 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;
(b) The timelines for implementation of any cost-control measures enacted pursuant to
this section; and
(c) A description of the expected impact on recipients and recipients' health outcomes
and how the state department plans to measure the effect on recipients.
(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) The state department shall provide a report to the joint budget committee on
November 1, 2019, and November 1, 2020, detailing the results of the independent evaluation,
including estimates of the cost savings achieved and the impact of the cost-control measures
authorized pursuant to this section on recipients and recipients' health outcomes.
(7) The state board shall adopt any rules necessary for the administration and
implementation of this section.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 203 of 510
Source: L. 2018: Entire section added, (SB 18-266), ch. 264, p. 1622, § 1, effective May
29.
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.
Source: L. 2019: Entire section added, (HB 19-1233), ch. 194, p. 2123, § 7, effective
May 16.
Cross references: For the legislative declaration in HB 19-1233, see section 1 of chapter
194, Session Laws of Colorado 2019.
25.5-4-424. State payments to qualified hospice providers - dually eligible persons -
no federal financial participation - rules - legislative declaration - definitions - repeal.
(Repealed)
Source: L. 2021: Entire section added, (SB 21-214), ch. 89, p. 367, § 1, effective May 4.
Editor's note: Subsection (5) provided for the repeal of this section, effective July 1,
2022. (See L. 2021, p. 369.)
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.
Source: L. 2021: Entire section added, (SB 21-194), ch. 434, p. 2871, § 6, effective
September 7.
25.5-4-426. Supplemental state payment to urban Indian organizations - definition -
repeal. (Repealed)
Source: L. 2022: Entire section added, (HB 22-1190), ch. 16, p. 128, § 1, effective
March 7.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 204 of 510
Editor's note: Subsection (3) provided for the repeal of this section, effective July 1,
2023. (See L. 2022, p. 128.)
25.5-4-427. Supplemental state payment to the Denver health and hospital authority
- repeal. (1) The state department shall distribute money appropriated for a supplemental
payment to the Denver health and hospital authority created in section 25-29-103.
(2) This section is repealed, effective July 1, 2024.
Source: L. 2023: Entire section added, (SB 23-138), ch. 4, p. 13, § 2, effective March 3.
Cross references: For the legislative declaration in SB 23-138, see section 1 of chapter
4, Session Laws of Colorado 2023.
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 recipient to use a prescription drug or sequence of prescription drugs, other than
the drug that the recipient's health-care provider recommends for the recipient'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 recipient;
(II) The required prescription drug lacks efficacy based on the known clinical
characteristics of the recipient and the known characteristics of the prescription drug regimen;
(III) The recipient has tried the required prescription drug, and the use of the prescription
drug by the recipient was discontinued due to intolerable side effects, a significant drug-drug
interaction, or an allergic reaction; or
(IV) The recipient 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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 205 of 510
(c) If the prior authorization request for a step-therapy exception is denied, the state
department shall inform the recipient in writing that the recipient 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 recipient'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 recipient 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.
Source: L. 2023: Entire section added, (HB 23-1183), ch. 133, p. 511, § 1, effective May
1.
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.
Source: L. 2023: Entire section added, (HB 23-1226), ch. 306, p. 1875, § 2, effective
August 7.
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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 206 of 510
(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.
Source: L. 2023: Entire section added, (HB 23-1269), ch. 377, p. 2262, § 1, effective
June 5.
PART 5
STATE PLAN AMENDMENTS -
WAIVER AUTHORITY
25.5-4-501. State plan amendment - federal authorization - repeal. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1853, § 7, effective July 1.
Editor's note: (1) This section was similar to former § 26-4-105.8 as it existed prior to
2006.
(2) Subsection (3) provided for the repeal of this section, effective July 1, 2007. (See L.
2006, p. 1853.)
25.5-4-502. Federal authorization - repeal. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1853, § 7, effective July 1.
Editor's note: (1) This section was similar to former § 25.5-1-113 as it existed prior to
2006.
(2) Subsection (3) provided for the repeal of this section, effective July 1, 2007. (See L.
2006, p. 1853.)
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 207 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1853, § 7, effective July 1. L.
2022: Entire section amended, (HB 22-1289), ch. 399, p. 2841, § 14, effective June 7.
Editor's note: This section is similar to former § 25.5-1-111 as it existed prior to 2006.
Cross references: For the legislative declaration in HB 22-1289, see section 1 of chapter
399, Session Laws of Colorado 2022.
25.5-4-504. Federal authorization - repeal. (Repealed)
Source: L. 2019: Entire section added, (SB 19-222), ch. 226, p. 2265, § 3, effective May
20.
Editor's note: Subsection (3) provided for the repeal of this section, effective July 1,
2020. (See L. 2019, p. 2265.)
Cross references: For the legislative declaration in SB 19-222, see section 1 of chapter
226, Session Laws of Colorado 2019.
25.5-4-505. Federal authorization related to persons involved in the criminal justice
system - assessment - report - repeal. (1) The state department shall evaluate and determine
whether the state should seek additional federal authority to provide screening, brief
intervention, and care coordination services through the medical assistance program to persons
immediately prior to release from jail or a department of corrections facility and to improve
processes for determining and redetermining individuals for medical assistance eligibility in
order to improve continuity and access to health-care services. If the state department determines
that securing additional federal authority will ensure improved access to care and continuity of
care for individuals involved in the criminal justice system, the state department shall, subject to
available resources, seek approval from the federal centers for medicare and medicaid services
for any additional federal authority. If the state department seeks approval, it shall notify the
members of 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 members of the joint budget committee of the general assembly. If the state department
receives federal approval, the state department, subject to available resources, shall provide the
benefits described in this subsection (1).
Colorado Revised Statutes 2023 Uncertified PrintoutPage 208 of 510
(2) If the state department determines that pursuing additional federal authority as
described in subsection (1) of this section is inappropriate, the state department shall submit a
report to the joint budget committee of the general assembly on or before October 1, 2023, that
includes the following information:
(a) An explanation of why the state department believes pursuing additional federal
authority is not an appropriate way to improve continuity of care for justice-involved
populations;
(b) An alternative plan developed by the state department to ensure improved access to
care and continuity of care for individuals involved in the criminal justice system who are being
released from incarceration that details how the state department plans to ensure continuity of
care for individuals being released from jail or prison;
(c) A proposed timeline for implementation of the alternative plan; and
(d) Any necessary fiscal or legislative proposals for the implementation of the state
department's alternative plan.
(3) This section is repealed, effective June 30, 2024.
Source: L. 2022: Entire section added, (SB 22-196), ch. 193, p. 1292, § 7, effective May
19. L. 2023: (1) amended, (HB 23-1301), ch. 303, p. 1830, § 49, effective August 7.
Cross references: For the legislative declaration in SB 22-196, see section 1 of chapter
193, Session Laws of Colorado 2022.
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 recipients.
(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
recipients 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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 209 of 510
(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 recipients 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
(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 recipients.
(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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 210 of 510
(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 recipients or is working
toward enrollment as a doula for recipients. 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: L. 2023: Entire section added, (SB 23-288), ch. 279, p. 1652, § 2, effective May
30.
Cross references: For the legislative declaration in SB 23-288, see section 1 of chapter
279, Session Laws of Colorado 2023.
ARTICLE 5
Colorado Medical Assistance Act -
Services and Programs
Editor's note: This article was added with relocations in 2006 containing provisions of
some sections formerly located in article 4 of title 26. Former C.R.S. section numbers are shown
in editor's notes following those sections that were relocated. For a detailed comparison of this
article, see the comparative tables located in the back of the index.
Cross references: For definitions applicable to this article, see § 25.5-4-103.
PART 1
MANDATORY PROVISIONS
25.5-5-101. Mandatory provisions - eligible groups - rules - repeal. (1) In order to
participate in the medicaid program, the federal government requires the state to provide medical
assistance to certain eligible groups. Pursuant to federal law and except as provided in subsection
(2) of this section, any person who is eligible for medical assistance under the mandated groups
specified in this section must receive both the mandatory services that are specified in sections
Colorado Revised Statutes 2023 Uncertified PrintoutPage 211 of 510
25.5-5-102 and 25.5-5-103 and the optional services that are specified in sections 25.5-5-202 and
25.5-5-203. Subject to the availability of federal financial participation, the following are the
individuals or groups that are mandated under federal law to receive benefits under this article 5
and articles 4 and 6 of this title 25.5:
(a) Repealed.
(b) Parents and caretaker relatives living with a dependent child who meet the eligibility
criteria pursuant to section 1902 (a)(10)(A) of the federal "Social Security Act", including those
who subsequently would have become ineligible under such eligibility criteria because of
increased earnings or increased hours of employment whose eligibility is specified for a period
of time by the federal government;
(c) Pregnant women whose family income does not exceed one hundred thirty-three
percent of the federal poverty line, adjusted for family size, who meet the requirements pursuant
to section 1902 (a)(10)(A) of the federal "Social Security Act". Once initial eligibility has been
established, the pregnant woman is 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.
(d) A newborn child born of a woman who is categorically needy. Such child is deemed
medicaid-eligible on the date of birth and remains eligible for one year.
(e) Children for whom adoption assistance or foster care maintenance payments are
made under Title IV-E of the federal "Social Security Act", as amended, including foster care
children, pursuant to section 1902 (a)(10)(A)(i)(IX) of the federal "Social Security Act", who are
under twenty-six years of age, who were in foster care under the responsibility of the state or a
tribe, and who were enrolled in medicaid under the state medicaid plan when they turned
eighteen years of age;
(f) Individuals receiving supplemental security income;
(g) Individuals receiving mandatory state supplement, including but not limited to
individuals receiving old age pensions;
(h) Institutionalized individuals who were eligible for medical assistance in December
1973;
(i) Individuals who would be eligible except for the increase in old-age, survivors, and
disability insurance under Pub.L. 92-336;
(j) Individuals who become ineligible for cash assistance as a result of old-age,
survivors, and disability insurance cost-of-living increases after April 1977;
(k) Disabled widows or widowers fifty through sixty years of age who have become
ineligible for federal supplemental security income or state supplementation as a result of
becoming eligible for federal social security survivor's benefits, in accordance with the social
security act, 42 U.S.C. sec. 1383c;
(l) Individuals with income and resources at a level which qualifies them as
medicare-eligible under section 301 of Title III of the federal "Medicare Catastrophic Coverage
Act";
(m) Children under the age of nineteen who meet the eligibility criteria pursuant to
section 1902 (a)(10)(A) of the federal "Social Security Act".
(2) (a) A qualified alien who entered the United States before August 22, 1996, who
meets the exceptions described in the federal "Personal Responsibility and Work Opportunity
Colorado Revised Statutes 2023 Uncertified PrintoutPage 212 of 510
Reconciliation Act of 1996", Public Law 104-193, as amended, shall receive benefits under this
article and articles 4 and 6 of this title.
(b) (I) A qualified alien who entered the United States on or after August 22, 1996, shall
not be eligible for benefits under this article or article 4 or 6 of this title, except as provided in
section 25.5-5-103 (3), for five years after the date of entry into the United States unless he or
she meets the exceptions described in the federal "Personal Responsibility and Work
Opportunity Reconciliation Act of 1996", Public Law 104-193, as amended.
(II) Notwithstanding the five-year waiting period established in subparagraph (I) of this
paragraph (b), but subject to the availability of sufficient appropriations and the receipt of federal
financial participation, the state department may provide benefits under this article and articles 4
and 6 of this title to a pregnant woman who is a qualified alien and a child under nineteen years
of age who is a qualified alien so long as such woman or child meets eligibility criteria other
than citizenship.
(3) Repealed.
(4) An asset test shall not be applied as a condition of eligibility for individuals or
families described in paragraphs (b), (c), (d), and (e) of subsection (1) of this section.
(5) The county departments responsible for administering benefits programs under the
department of health care policy and financing and the department of human services shall
identify and review all current county guidance materials, including forms, training materials,
websites, and any other materials that reference a prohibition on sponsorship as a condition of
eligibility for benefits and shall remove all such references from verbal and digital
communications and from all physical materials currently provided to applicants or
beneficiaries.
(6) (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", the following subsections of this section are
suspended until June 1, 2024:
(I) Subsection (1)(c) of this section requiring the state department to disenroll a woman
receiving medical assistance sixty days following the woman's pregnancy;
(II) Subsection (1)(d) of this section requiring the state department to disenroll a child at
one year of age who was eligible to receive medical assistance at birth;
(III) Subsection (1)(e) of this section requiring the state department to disenroll former
foster care children; and
(IV) Any other provision of this section that requires the state department to disenroll an
individual receiving medical assistance prior to the state department processing the individual's
next annual renewal for eligibility following the end of the continuous enrollment requirements
implemented pursuant to the federal "Families First Coronavirus Response Act", Pub.L.
116-127, and the federal "Consolidated Appropriations Act, 2023".
(b) The state board may adopt rules to implement this subsection (6) to ensure that the
state department can resume routine operations by June 1, 2024, 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 (6) is repealed, effective June 1, 2024.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 213 of 510
Source: L. 2006: Entire article added with relocations, p. 1854, § 7, effective July 1. L.
2009: (2)(b) amended, (HB 09-1353), ch. 360, p. 1869, § 1, effective July 1, 2010. L. 2010:
(4)(c) added, (HB 10-1043), ch. 92, p. 312, § 1, effective April 15; (1)(m) amended, (HB
10-1422), ch. 419, p. 2110, § 143, effective August 11. L. 2011: (3) amended, (HB 11-1303), ch.
264, p. 1168, § 67, effective August 10. L. 2014: (1)(a) repealed and (1)(b), (1)(c), (1)(d), (1)(e),
(1)(m), and (4) amended, (SB 14-067), ch. 12, p. 111, § 3, effective February 27. L. 2022: IP(1)
amended, (SB 22-052), ch. 43, p. 216, § 2, effective March 24; (3) amended, (HB 22-1289), ch.
399, p. 2842, § 15, effective June 7. L. 2023: (6) added, (SB 23-182), ch. 118, p. 429, § 1,
effective April 27; (3) repealed and (5) added, (HB 23-1117), ch. 65, p. 232, § 3, effective
August 7.
Editor's note: (1) This section is similar to former § 26-4-201 as it existed prior to
2006.
(2) Prior to the amendment to subsection (4) in 2014, subsection (4)(b)(II) provided for
the repeal of subsection (4)(b), effective July 1, 2007. (See L. 2006, p. 1854.)
Cross references: (1) For provisions of the federal "Medicare Catastrophic Coverage
Act of 1988" referenced in this section, see section 301 of Pub.L. 100-360, codified at 42 U.S.C.
sec. 1396a et seq.
(2) For the legislative declaration in HB 22-1289, see section 1 of chapter 399, Session
Laws of Colorado 2022. For the legislative declaration in HB 23-1117, see section 1 of chapter
65, Session Laws of Colorado 2023.
25.5-5-102. Basic services for the categorically needy - mandated services. (1)
Subject to the provisions of subsection (2) of this section and section 25.5-4-104, the program
for the categorically needy shall include the following services as mandated and defined by
federal law:
(a) Inpatient hospital services;
(b) Outpatient hospital services;
(c) Other laboratory and X-ray services;
(d) Physicians' services, wherever furnished;
(e) Nursing facility services;
(f) Home health services;
(g) Early and periodic screening, diagnosis, and treatment, as required by federal law;
(h) Family planning, including a one-year supply of any federal food and drug
administration-approved contraceptive drug, device, or product, unless the recipient requests a
supply covering a shorter period of time;
(i) Rural health services;
(j) Advanced practice registered nurse services;
(k) and (l) (Deleted by amendment, L. 2008, p. 138, § 2, effective July 1, 2008.)
(m) Federally qualified health centers.
(2) In order to keep expenditures within approved appropriations, the state board may,
by rule, establish limits on a service provided pursuant to this section so long as the service
provided is sufficient in the amount, duration, and scope to reasonably achieve the purpose of the
service as required by federal law or regulation. When a rule is promulgated pursuant to this
Colorado Revised Statutes 2023 Uncertified PrintoutPage 214 of 510
subsection (2), the state board shall provide a summary report of the limitations established by
the rule and any fiscal impact of the rule to members of the health and human services
committees of the senate and house of representatives, or any successor committees, and any
other members of the general assembly who request the reports.
Source: L. 2006: Entire article added with relocations, p. 1856, § 7, effective July 1. L.
2008: (1)(j), (1)(k), and (1)(l) amended, p. 138, § 2, effective July 1. L. 2021: (1)(h) amended,
(SB 21-009), ch. 430, p. 2847, § 3, effective September 7.
Editor's note: This section is similar to former § 26-4-202 as it existed prior to 2006.
Cross references: (1) For the definition of "federally qualified health centers" in the
federal "Social Security Act", see 42 U.S.C. sec. 1395x.
(2) For the legislative declaration in SB 21-009, see section 1 of chapter 430, Session
Laws of Colorado 2021.
25.5-5-103. Mandated programs with special state provisions - rules. (1) This section
specifies programs developed by Colorado to meet federal mandates. These programs include
but are not limited to:
(a) Repealed.
(b) Special provisions relating to nursing facilities, as specified in sections 25.5-6-201 to
25.5-6-203, 25.5-6-205, and 25.5-6-206;
(c) The program for qualified medicare beneficiaries, as specified in section 25.5-5-104;
(d) The program for qualified disabled and working individuals, as specified in section
25.5-5-105;
(e) Special provisions for the purchase of group health insurance for recipients, as
specified in section 25.5-4-210;
(f) The program to provide health services to students by school districts as specified in
section 25.5-5-318.
(2) The medical assistance program also is subject to special provisions relating to the
use of public funds for abortion which are required by section 50 of article V of the Colorado
constitution. Those special provisions are specified in section 25.5-4-415.
(3) (a) Emergency medical assistance shall be provided to any person who is not a
citizen of the United States, including undocumented aliens, aliens who are not qualified aliens,
and qualified aliens who entered the United States on or after August 22, 1996, who has an
emergency medical condition and meets one of the categorical requirements set forth in section
25.5-5-101; except that such persons shall not be required to meet any residency requirement
other than that required by federal law.
(b) The state board shall adopt rules necessary for the implementation of this subsection
(3), including in such rules definitions of "emergency services", "emergency medical condition",
"geographic area", and "prenatal care".
(4) (a) The state department shall ensure that benefits under the medical assistance
program for behavioral, mental health, and substance use disorder services are no less extensive
than benefits for any physical illness and are in compliance with the MHPAEA, as defined in
section 25.5-5-403 (5.7), including the quantitative and nonquantitative treatment limitation
Colorado Revised Statutes 2023 Uncertified PrintoutPage 215 of 510
requirements specified in 42 CFR 438.910 (c) and (d). On or after January 1, 2020, if an MCE,
as defined in section 25.5-5-403 (4), denies coverage for a covered behavioral, mental health, or
substance use disorder benefit or service based on diagnosis, the state board shall establish, by
rule, a procedure to allow for reimbursement of medically necessary state plan services under the
medical assistance program. The state department may use multiple payment modalities to
comply with this subsection (4).
(b) The state board shall adopt rules establishing the procedures for reimbursement
pursuant to this subsection (4) by January 1, 2020.
Source: L. 2006: Entire article added with relocations, p. 1856, § 7, effective July 1. L.
2014: (1)(a) repealed, (SB 14-067), ch. 12, p. 113, § 4, effective February 27. L. 2019: (4)
added, (HB 19-1269), ch. 195, p. 2132, § 11, effective May 16. L. 2021: (4)(a) amended, (SB
21-266), ch. 423, p. 2802, § 22, effective July 2.
Editor's note: This section is similar to former § 26-4-203 as it existed prior to 2006.
Cross references: For the short title ("Behavioral Health Care Coverage Modernization
Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
25.5-5-104. Qualified medicare beneficiaries. Qualified medicare beneficiaries are
medicare-eligible individuals with income and resources at a level which qualifies them as
eligible under section 301 of Title III of the federal "Medicare Catastrophic Coverage Act of
1988", as amended, or subsequent amending federal legislation. For purposes of this article and
articles 4 and 6 of this title, such individuals shall be referred to as "qualified medicare
beneficiaries". The state department is hereby designated as the single state agency to administer
benefits available to qualified medicare beneficiaries in accordance with Title XIX and this
article and articles 4 and 6 of this title. Such benefits are limited to medicare cost-sharing
expenses as determined by the federal government. Accordingly, the state department shall not
be required to provide qualified medicare beneficiaries the entire range of services set forth in
section 25.5-5-102.
Source: L. 2006: Entire article added with relocations, p. 1857, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-510 as it existed prior to 2006.
Cross references: For provisions of the federal "Medicare Catastrophic Coverage Act of
1988" referenced in this section, see section 301 of Pub.L. 100-360, codified at 42 U.S.C. sec.
1396a et seq.
25.5-5-105. Qualified disabled and working individuals. Qualified disabled and
working individuals are persons with income and resources and disability status, as determined
by the social security administration, which qualify them as "qualified disabled and working
individuals" under sections 6012 and 6408 of the federal "Omnibus Budget Reconciliation Act
of 1989", or subsequent amending federal legislation. The state department is hereby designated
as the single state agency to administer benefits available to qualified disabled and working
Colorado Revised Statutes 2023 Uncertified PrintoutPage 216 of 510
individuals. Such benefits are limited to medicare cost-sharing expenses as determined by the
federal government. Accordingly, the state department shall not be required to provide qualified
disabled and working individuals the entire range of services set forth in section 25.5-5-102.
Source: L. 2006: Entire article added with relocations, p. 1858, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-511 as it existed prior to 2006.
Cross references: For provisions of the federal "Omnibus Budget Reconciliation Act of
1989" referenced in this section, see sections 6012 and 6408 of Pub.L. 101-239, codified at 42
U.S.C. secs. 1395i and 1396a.
PART 2
OPTIONAL PROVISIONS
25.5-5-201. Optional provisions - optional groups - rules - repeal. (1) The federal
government allows the state to select optional groups to receive medical assistance. Pursuant to
federal law, any person who is eligible for medical assistance under the optional groups specified
in this section must receive both the mandatory services specified in sections 25.5-5-102 and
25.5-5-103 and the optional services specified in sections 25.5-5-202 and 25.5-5-203. Subject to
the availability of federal financial aid funds, the following are the individuals or groups that
Colorado has selected as optional groups to receive medical assistance pursuant to this article 5
and articles 4 and 6 of this title 25.5:
(a) Individuals who would be eligible for but are not receiving cash assistance;
(b) Individuals who would be eligible for cash assistance except for their
institutionalized status;
(c) Individuals receiving home- and community-based services as specified in article 6
of this title;
(d) and (e) Repealed.
(f) Individuals receiving only optional state supplement;
(g) Individuals in institutions who are eligible under a special income level. Colorado's
program for citizens sixty-five years of age or older or physically disabled or blind, whose gross
income does not exceed three hundred percent of the current federal supplemental security
income benefit level, qualifies for federal funding under this provision.
(h) Persons who are eligible for cash assistance under the works program pursuant to
section 26-2-706, C.R.S.;
(i) Persons who are eligible for the breast and cervical cancer prevention and treatment
program pursuant to section 25.5-5-308;
(j) Individuals who are qualified aliens and were or would have been eligible for
supplemental security income as a result of a disability but are not eligible for such supplemental
security income as a result of the passage of the federal "Personal Responsibility and Work
Opportunity Reconciliation Act of 1996", Public Law 104-193;
(k) Other qualified aliens who entered or were present in the United States before
August 22, 1996;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 217 of 510
(l) Children for whom subsidized adoption assistance payments are made by the state
pursuant to article 7 of title 26, C.R.S., or foster care maintenance payments are made by the
state pursuant to article 5 of title 26, C.R.S., but who do not meet the requirements of Title IV-E
of the "Social Security Act", as amended;
(m) Parents and caretaker relatives of children who are eligible for the medical
assistance program whose family income does not exceed one hundred thirty-three percent of the
federal poverty line, adjusted for family size;
(m.5) Pregnant women, whose family income does not exceed one hundred ninety-five
percent of the federal poverty line, adjusted for family size;
(n) Repealed.
(o) (I) Individuals with disabilities who are participating in the medicaid buy-in program
established in part 14 of article 6 of this title.
(II) Notwithstanding the provisions of subsection (1)(o)(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, 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 individuals with disabilities who are
participating in the medicaid buy-in program established in part 14 of article 6 of this title 25.5,
the state board by rule adopted pursuant to the provisions of section 25.5-4-402.4 (6)(b)(III) may
reduce the medical benefits offered or the percentage of the federal poverty line to below four
hundred fifty percent or may eliminate this eligibility group.
(III) Repealed.
(p) Subject to federal approval, adults who are childless or without a dependent child in
the home, as described in section 1902 (a)(10)(A)(i)(VIII) of the social security act, 42 U.S.C.
sec. 1396a, who have attained nineteen years of age but have not attained sixty-five years of age,
and whose family income does not exceed one hundred thirty-three percent of the federal
poverty line, adjusted for family size;
(q) Children who are continuously eligible for twelve months pursuant to section
25.5-5-204.5;
(r) (I) Persons eligible for a medicaid buy-in program established pursuant to section
25.5-5-206 whose family income does not exceed a specified percentage of the federal poverty
line, adjusted for family size and as set by the state board by rule, which percentage shall be not
more than four hundred fifty percent.
(II) Notwithstanding the provisions of subsection (1)(r)(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, 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 eligible for a medicaid buy-in
program established pursuant to section 25.5-5-206, the state board by rule adopted pursuant to
the provisions of section 25.5-4-402.4 (6)(b)(III) may reduce the medical benefits offered, or the
percentage of the federal poverty line, or may eliminate this eligibility group.
(III) Repealed.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 218 of 510
(2) (a) A qualified alien, who entered the United States on or after August 22, 1996, shall
not be eligible for benefits under this article and articles 4 and 6 of this title, except as provided
in section 25.5-5-103 (3), for five years after the date of entry into the United States unless he or
she meets the exceptions described in the federal "Personal Responsibility and Work
Opportunity Reconciliation Act of 1996", Public Law 104-193, as amended. After five years,
such qualified alien shall be eligible for benefits under this article and articles 4 and 6 of this title
but shall have sponsor income and resources deemed to the individual or family under rules
established by the state board of human services pursuant to section 26-2-137, C.R.S.
(b) Notwithstanding the five-year waiting period established in paragraph (a) of this
subsection (2), but subject to the availability of sufficient appropriations and the receipt of
federal financial participation, the state department may provide benefits under this article and
articles 4 and 6 of this title to a pregnant woman who is a qualified alien and a child under
nineteen years of age who is a qualified alien so long as such woman or child meets eligibility
criteria other than citizenship.
(3) A lawfully residing person who is receiving medicaid nursing facility care or home-
and community-based services on July 1, 1997, must continue to receive such services as long as
the person meets the eligibility requirements other than citizen status. State general funds may be
used to reimburse such care in the event that federal financial participation is not available.
(4) A pregnant person who is lawfully residing is eligible to receive medical assistance
as long as the individual meets eligibility requirements other than those related to citizen or
immigration status. State general funds may be used to reimburse such care in the event that
federal financial participation is not available.
(4.5) (a) Subject to the receipt of federal financial participation, to the maximum extent
allowed under federal law, a person who was eligible for the medical assistance program for the
sixty days following the pregnancy remains continuously eligible for all services under the
medical assistance program for the twelve-month postpartum period.
(b) The state department shall seek any plan amendment necessary to implement a
twelve-month postpartum benefit pursuant to this subsection (4.5) 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 medical assistance program upon implementation of this section.
(5) An asset test shall not be applied as a condition of eligibility for individuals or
families described in paragraphs (a), (h), and (m.5) of subsection (1) of this section.
(6) (a) Beginning no later than January 1, 2025, a pregnant person who is not a citizen
and who is not eligible for medical assistance pursuant to subsection (4) of this section is eligible
to receive medical assistance pursuant to this subsection (6)(a) if the individual meets the
eligibility requirements other than those related to citizenship and immigration status.
(b) A pregnant person who is eligible for medical assistance pursuant to this subsection
(6) remains continuously eligible for all medical services pursuant to the medical assistance
program for the twelve-month postpartum period, so long as eligibility remains in effect
pursuant to subsection (4.5)(a) of this section.
(c) The state department shall seek any necessary federal approvals to maximize any
available federal financial participation in implementing this subsection (6). Benefits for services
Colorado Revised Statutes 2023 Uncertified PrintoutPage 219 of 510
obtained pursuant to this subsection (6) must be provided with only state funds if federal
financial participation is unavailable for such services.
(d) (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 (6).
(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 (6).
(7) (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", the following subsections of this section are
suspended until June 1, 2024:
(I) Subsection (1)(p) of this section requiring the state department to disenroll an
individual enrolled in the medical assistance program who reaches sixty-five years of age; and
(II) Any other provision of this section that requires the state department to disenroll an
individual receiving medical assistance prior to the state department processing the individual's
next annual renewal for eligibility following the end of the continuous enrollment requirements
implemented pursuant to the federal "Families First Coronavirus Response Act", Pub.L.
116-127, and the federal "Consolidated Appropriations Act, 2023".
(b) The state board may adopt rules to implement this subsection (7) to ensure that the
state department can resume routine operations by June 1, 2024, 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 (7) is repealed, effective June 1, 2024.
(8) (a) The state department may continue to provide coverage for the testing and
treatment for COVID-19 for uninsured individuals pursuant to section 1902
(a)(10)(A)(ii)(XXIII) of the federal "Social Security Act" through May 31, 2023, without federal
financial participation.
(b) The state board may adopt rules to implement this subsection (8) to ensure that the
state department can resume routine operations in an orderly process that follows guidance
provided by the federal centers for medicare and medicaid services, including terminations of
eligibility, the processing of eligibility renewals, and the transition between medicaid and
children's basic health plan eligibility categories.
(c) This subsection (8) is repealed, effective May 31, 2023.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 220 of 510
Source: L. 2006: Entire article added with relocations, p. 1858, § 7, effective July 1. L.
2007: (1)(n) added, p. 897, § 1, effective May 15. L. 2008: (1)(l) and (1)(n) amended and (1)(o)
added, pp. 1532, 2200, §§ 1, 2, effective July 1. L. 2009: (1)(m)(I) and (1)(o) amended and
(1)(p), (1)(q), and (1)(r) added, (HB 09-1293, ch. 152, p. 645, § 5, effective July 1; (2) amended,
(HB 09-1353), ch. 390, p. 1869, § 2, effective July 1, 2010. L. 2010: (5)(c) added, (HB
10-1043), ch. 92, p. 312, § 2, effective April 15; (1)(m)(I), (1)(o)(II), (1)(p)(I), (1)(p)(II),
(1)(r)(I), and (1)(r)(II) amended, (HB 10-1422), ch. 419, p. 2111, § 144, effective August 11. L.
2013: (1)(m) and (1)(p) amended, (SB 13-200), ch. 216, p. 898, § 2, effective May 13. L. 2014:
(1)(d), (1)(e), and (1)(n) repealed, (1)(m.5) added, and (5) amended, (SB 14-067), ch. 12, p. 113,
§ 5, effective February 27. L. 2017: IP(1), (1)(o)(II), and (1)(r)(II) amended, (SB 17-267), ch.
267, p. 1465, § 19, effective July 1. L. 2021: (4.5) added, (SB 21-194), ch. 434, p. 2871, § 7,
effective September 7. L. 2022: IP(1) and (1)(m.5) amended, (SB 22-052), ch. 43, p. 217, § 3,
effective March 24; (3), (4), and (4.5)(a) amended and (6) added, (HB 22-1289), ch. 399, p.
2842, § 16, effective June 7. L. 2023: (7) and (8) added, (SB 23-182), ch. 118, p. 430, § 2,
effective April 27.
Editor's note: (1) This section is similar to former § 26-4-301 as it existed prior to
2006.
(2) Prior to the amendment of subsection (1)(m) in 2013, subsection (1)(m)(II)(B)
provided for the repeal of subsection (1)(m)(II), effective January 1, 2007. (See L. 2006, p.
1858.)
(3) Prior to the amendment of subsection (5) in 2014, subsection (5)(b)(II) provided for
the repeal of subsection (5)(b), effective July 1, 2007. (See L. 2006, p. 1858.)
(4) Subsection (1)(o)(III)(C) provided for the repeal of subsection (1)(o)(III), effective
the July 1 following the revisor of statutes' receipt of the notice required pursuant to subsection
(1)(o)(III)(B). (See L. 2009, p. 645.) The revisor of statutes received said notice dated March 23,
2012.
(5) Prior to the amendment of subsection (1)(p) in 2013, subsection (1)(p)(III)(C)
provided for the repeal of subsection (1)(p)(III), effective the July 1 following the revisor of
statutes' receipt of the notice required pursuant to subsection (1)(p)(III)(B). (See L. 2009, p.
645.) The revisor of statutes received said notice dated April 2, 2012.
(6) Subsection (1)(r)(III)(C) provided for the repeal of subsection (1)(r)(III), effective
the July 1 following the revisor of statutes' receipt of the notice required pursuant to subsection
(1)(r)(III)(B). (See L. 2009, p. 645.) The revisor of statutes received said notice dated February
17, 2017.
(7) Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017, provides
that the section of the act changing this section does not take effect if the centers for medicare
and medicaid services determine that the amendments do not comply with federal law. For more
information, see SB 17-267. (L. 2017, p. 1478.) The executive director of the department of
health care policy and financing did not notify the revisor of statutes by June 1, 2017, of such
determination; therefore, the changes to this section took effect July 1, 2017.
Cross references: For the legislative declaration in SB 17-267, see section 1 of chapter
267, Session Laws of Colorado 2017. For the legislative declaration in HB 22-1289, see section
1 of chapter 399, Session Laws of Colorado 2022.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 221 of 510
25.5-5-202. Basic services for the categorically needy - optional services. (1) Subject
to the provisions of subsection (2) of this section, the following are services for which federal
financial participation is available and that Colorado has selected to provide as optional services
under the medical assistance program:
(a) (I) Prescribed drugs.
(II) Notwithstanding the provisions of subparagraph (I) of this paragraph (a), pursuant to
the provisions of section 25.5-5-503, prescribed drugs shall not be a covered benefit under the
medical assistance program for a recipient who is enrolled in a prescription drug benefit program
under medicare; except that, if a prescribed drug is not a covered Part D drug as defined in the
"Medicare Prescription Drug, Improvement, and Modernization Act of 2003", Pub.L. 108-173,
the prescribed drug may be a covered benefit if it is otherwise covered under the medical
assistance program and federal financial participation is available.
(a.5) Over-the-counter medications, as specified in section 25.5-5-322;
(b) Clinic services, as defined in sections 25.5-5-301 and 25.5-5-302;
(c) Home- and community-based services, as specified in article 6 of this title 25.5,
which include:
(I) Home- and community-based services for individuals who are elderly or blind and
individuals with disabilities, as specified in part 3 of article 6 of this title;
(II) Home- and community-based services for persons with intellectual and
developmental disabilities, as specified in part 4 of article 6 of this title;
(III) Repealed.
(IV) Home- and community-based services for persons with major mental health
disorders, as specified in part 6 of article 6 of this title 25.5;
(V) Home- and community-based services for persons with brain injury, as specified in
part 7 of article 6 of this title;
(d) Optometrist services;
(e) Eyeglasses when necessary after surgery;
(f) Prosthetic devices, including medically necessary augmentative communication
devices; except that nonsurgically implanted prosthetic devices shall be included only after July
1, 1998, and only if the general assembly approves appropriations for these devices as a new
benefit;
(g) [Editor's note: This version of subsection (1)(g) is effective until July 1, 2024.]
Rehabilitation services as appropriate to community mental health centers;
(g) [Editor's note: This version of subsection (1)(g) is effective July 1, 2024.]
Rehabilitation services as appropriate to behavioral health safety net providers as defined in
section 27-50-101;
(h) Intermediate care facilities for individuals with intellectual disabilities;
(i) Inpatient psychiatric services for persons under twenty-one years of age;
(j) Inpatient psychiatric services for persons over the age of sixty-five;
(k) Case management;
(l) Therapies under home health services, including:
(I) Speech and audiology;
(II) Physical;
(III) Occupational;
(m) Services of a licensed psychologist;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 222 of 510
(n) Private duty nursing services;
(o) Podiatry services;
(p) Hospice care;
(q) The program of all-inclusive care for the elderly;
(r) For any pregnant woman who is enrolled or eligible for services pursuant to section
25.5-5-101 (1)(c), alcohol and substance use disorder counseling and treatment, including
outpatient and residential care but not including room and board while receiving residential care;
(s) (I) Outpatient substance use disorder treatment.
(II) Repealed.
(t) Cervical cancer immunization for all females under twenty years of age;
(u) (I) Screening, brief intervention, and referral to treatment for individuals at risk of
substance abuse, including referral to the appropriate level of intervention and treatment.
(II) Notwithstanding the provisions of subparagraph (I) of this paragraph (u), services
relating to screening, brief intervention, and referral to treatment shall not take effect unless all
necessary approvals under federal law and regulation have been obtained to receive federal
financial participation for the costs of such services.
(v) (I) Counseling by primary care providers and other specialty providers caring for
persons with serious, chronic, or terminal illness relating to medical orders for scope of
treatment, which counseling may be reimbursed.
(II) Notwithstanding the provisions of subparagraph (I) of this paragraph (v), counseling
relating to medical orders for scope of treatment shall not take effect unless all necessary
approvals under federal law and regulation have been obtained to receive federal financial
participation for the costs of such services.
(w) Dental services for adults.
(x) (I) Residential and inpatient substance use disorder treatment and medical
detoxification services pursuant to section 25.5-5-325.
(II) Notwithstanding the provisions of subsection (1)(x)(I) of this section, residential and
inpatient substance use disorder treatment shall not take effect unless all necessary approvals
under federal law and regulation have been obtained to receive federal financial participation for
the costs of such services.
(y) For any perinatal person, 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.
(2) In addition to the services described in subsection (1) of this section and subject to
continued federal financial participation, Colorado has selected to provide transportation services
as an administrative cost.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 223 of 510
(3) In order to keep expenditures within approved appropriations, the state board may,
by rule, establish limits on a service provided pursuant to this section so long as the service
provided is sufficient in the amount, duration, and scope to reasonably achieve the purpose of the
service as required by federal law or regulation. When a rule is promulgated pursuant to this
subsection (3), the state board shall provide a summary report of the limitations established by
the rule and any fiscal impact of the rule to members of the health and human services
committees of the senate and house of representatives, or any successor committees, and any
other members of the general assembly who request the reports.
(4) The state department and the behavioral health administration in the department of
human services, in collaboration with community mental health services providers and substance
use disorder providers, shall establish rules that standardize utilization management authority
timelines for the nonpharmaceutical components of medication-assisted treatment for substance
use disorders.
Source: L. 2006: Entire article added with relocations, p. 1860, § 7, effective July 1. L.
2007: (1)(t) added, p. 1348, § 2, effective May 29. L. 2010: (1)(r) amended, (HB 10-1043), ch.
92, p. 313, § 3, effective April 15; (1)(a.5) added, (SB 10-117), ch. 227, p. 985, § 1, effective
July 1; (1)(u) added, (HB 10-1033), ch. 346, p. 1601, § 1, effective August 11. L. 2013: (1)(h)
amended, (SB 13-167), ch. 394, p. 2290, § 2, effective June 5; (1)(u)(II) amended and (1)(w)
added, (SB 13-242), ch. 189, p. 761, § 1, effective August 7; (1)(v) added, (HB 13-1202), ch.
117, p. 401, § 1, effective August 7. L. 2014: (1)(r) amended, (SB 14-067), ch. 12, p. 114, § 6,
effective February 27; (1)(c)(I) and (1)(c)(II) amended, (SB 14-118), ch. 250, p. 985, § 20,
effective August 6. L. 2017: IP(1), (1)(r), and (1)(s)(I) amended, (SB 17-242), ch. 263, p. 1327,
§ 199, effective May 25; (1)(s)(II) repealed, (SB 17-294), ch. 264, p. 1409, § 92, effective May
25. L. 2018: (1)(x) added, (HB 18-1136), ch. 373, p. 2269, § 1, effective June 5; IP(1)(c) and
(1)(c)(IV) amended, (SB 18-091), ch. 35, p. 388, § 25, effective August 8; (1)(c)(III) repealed,
(SB 18-093), ch. 62, p. 610, § 3, effective August 8; (4) added, (HB 18-1431), ch. 313, p. 1893, §
14, effective January 1, 2019. L. 2022: (1)(y) added, (HB 22-1289), ch. 399, p. 2843, § 17,
effective June 7; (4) amended, (HB 22-1278), ch. 222, p. 1513, § 69, effective July 1; (1)(g)
amended, (HB 22-1278), ch. 222, p. 1593, § 233, effective July 1, 2024.
Editor's note: (1) This section is similar to former § 26-4-302 as it existed prior to
2006.
(2) The legislative audit committee did not adopt a resolution by March 31, 2011, as
provided for in subsection (1)(s)(II).
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017. For the legislative declaration in SB 18-091, see section 1
of chapter 35, Session Laws of Colorado 2018. For the legislative declaration in SB 18-093, see
section 1 of chapter 62, Session Laws of Colorado 2018. For the legislative declaration in HB
22-1289, see section 1 of chapter 399, Session Laws of Colorado 2022.
25.5-5-203. Optional programs with special state provisions - repeal. (1) Subject to
the provisions of subsection (2) of this section, this section specifies programs developed by
Colorado Revised Statutes 2023 Uncertified PrintoutPage 224 of 510
Colorado to increase federal financial participation through selecting optional services or
optional eligible groups. These programs include but are not limited to:
(a) Pharmaceutical services, as specified in section 25.5-5-504;
(b) The home- and community-based services program for the elderly, blind, and
disabled, as specified in part 3 of article 6 of this title;
(c) The home- and community-based services program for the developmentally disabled,
as specified in part 4 of article 6 of this title;
(d) Repealed.
(e) The home- and community-based services program for persons with major mental
health disorders, as specified in part 6 of article 6 of this title 25.5;
(f) The home- and community-based services program for persons with brain injury, as
specified in part 7 of article 6 of this title;
(g) Clinic services, as defined in sections 25.5-5-301 and 25.5-5-302;
(h) The program for private duty nursing, as specified in section 25.5-5-303;
(i) The disabled children care program, as specified in section 25.5-6-901;
(j) The program of all-inclusive care for the elderly, as specified in section 25.5-5-412;
(k) Hospice care, as specified in section 25.5-5-304;
(l) The treatment program for high-risk pregnant women, as specified in section
27-80-112, C.R.S., and sections 25.5-5-309, 25.5-5-310, and 25.5-5-311;
(m) The program for residential child health care, as specified in section 25.5-6-903;
(n) The children's personal assistance services and family support waiver program, as
specified in section 25.5-6-902;
(o) (I) Home- and community-based services for children with autism, as specified in
part 8 of article 6 of this title.
(II) This subsection (1)(o) is repealed, effective July 1, 2025.
(2) In order to keep expenditures within approved appropriations, the state board may,
by rule, establish limits on a service provided pursuant to this section so long as the service
provided is sufficient in the amount, duration, and scope to reasonably achieve the purpose of the
service as required by federal law or regulation. When a rule is promulgated pursuant to this
subsection (2), the state board shall provide a summary report of the limitations established by
the rule and any fiscal impact of the rule to members of the health and human services
committees of the senate and house of representatives, or any successor committees, and any
other members of the general assembly who request the reports.
Source: L. 2006: Entire article added with relocations, p. 1862, § 7, effective July 1. L.
2010: (1)(l) amended, (SB 10-175), ch. 188, p. 801, § 67, effective April 29. L. 2018: (1)(d)
repealed, (SB 18-093), ch. 62, p. 610, § 4, effective August 8; (1)(e) amended, (SB 18-091), ch.
35, p. 388, § 26, effective August 8; (1)(m) amended, (HB 18-1328), ch. 184, p. 1244, § 5,
effective June 7, 2019. L. 2023: (1)(o)(II) added by revision, (SB 23-289), ch. 270, pp. 1606,
1611 §§ 2, 19.
Editor's note: (1) This section is similar to former § 26-4-303 as it existed prior to
2006.
(2) Section 10 of chapter 184 (HB 18-1328), Session Laws of Colorado 2018, provides
that section 5 of the act changing this section takes effect upon notice to the revisor of statutes
Colorado Revised Statutes 2023 Uncertified PrintoutPage 225 of 510
pursuant to § 25.5-5-306 (6) as enacted in section 2 of the act. For more information, see HB
18-1328. (L. 2018, p. 1247.) On August 14, 2019, the revisor of statutes received the notice
referred to in § 25.5-5-306 (6) that the federal department of health and human services
approved the waiver on June 7, 2019.
Cross references: For the legislative declaration in SB 18-091, see section 1 of chapter
35, Session Laws of Colorado 2018. For the legislative declaration in SB 18-093, see section 1
of chapter 62, Session Laws of Colorado 2018. For the legislative declaration in HB 18-1328,
see section 1 of chapter 184, Session Laws of Colorado 2018.
25.5-5-204. Presumptive eligibility - pregnant person - children - long-term care -
state plan. (1) For purposes of this section, "presumptive eligibility" means the self-declaration
of income, assets, and status in order to promptly receive medical assistance services prior to the
verification of income, assets, and status.
(2) (a) A pregnant person is presumptively eligible for the medical assistance program
and shall receive services specified by federal law only if the person declares all pertinent
information relating to the criteria of income, assets, and, only if necessary to administer
reimbursement for services, status.
(b) (Deleted by amendment, L. 2022.)
(2.5) A child less than nineteen years of age is presumptively eligible for the medical
assistance program and shall receive services specified by federal law only if a parent or legal
guardian of the child declares all pertinent information relating to the criteria of income, assets,
and, only if necessary to administer reimbursement for services, status of the child's family.
(2.7) (a) [Editor's note: This version of subsection (2.7)(a) is effective until July 1,
2024.] The state department is authorized to seek federal authorization to allow a person who is
in need of long-term care, as defined in section 25.5-6-104, to be presumptively eligible for the
medical assistance program pursuant to this article and articles 4 and 6 of this title.
(2.7) (a) [Editor's note: This version of subsection (2.7)(a) is effective July 1, 2024.]
The state department is authorized to seek federal authorization to allow a person who is in need
of long-term services and supports, as defined in section 25.5-6-1702 (10), to be presumptively
eligible for the medical assistance program pursuant to this article 5 and articles 4 and 6 of this
title 25.5.
(b) [Editor's note: This version of subsection (2.7)(b) is effective until July 1, 2024.] If
the state department receives federal authorization pursuant to paragraph (a) of this subsection
(2.7) and sufficient spending authority, a person in need of long-term care shall be presumptively
eligible for the medical assistance program if the person or the person's legal representative
declares all pertinent information relating to the criteria of income, assets, and immigration
status. Such person shall be assessed for the appropriate level of care pursuant to section
25.5-6-104. If required due to limitations of federal authorization or spending authority, the state
department may implement this paragraph (b) as a pilot program rather than statewide.
(b) [Editor's note: This version of subsection (2.7)(b) is effective July 1, 2024.] If the
state department receives federal authorization pursuant to subsection (2.7)(a) of this section and
sufficient spending authority, a person in need of long-term services and supports shall be
presumptively eligible for the medical assistance program if the person or the person's legal
representative declares all pertinent information relating to the criteria of income, assets, and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 226 of 510
immigration status. The person shall be assessed for the appropriate level of care pursuant to
section 25.5-6-1704. If required due to limitations of federal authorization or spending authority,
the state department may implement this subsection (2.7)(b) as a pilot program rather than
statewide.
(c) The state department shall make any necessary changes to the state plan and waivers
for home- and community-based service programs authorized pursuant to this article and articles
4 and 6 of this title to comply with this subsection (2.7).
(d) If it is determined that a recipient was not eligible for medical benefits after the
recipient had been determined to be eligible based upon presumptive eligibility, the state
department shall not pursue recovery from a county department for the cost of medical services
provided to the recipient, and the county department shall not be responsible for any federal
error rate sanctions resulting from such determination.
(3) The state department shall make any necessary changes to the state plan to comply
with this section.
Source: L. 2006: Entire article added with relocations, p. 1864, § 7, effective July 1. L.
2007: (2.5) added, p. 1493, § 4, effective January 1, 2008. L. 2009: (2.7) added, (HB 09-1103),
ch. 160, p. 694, § 1, effective April 22. L. 2021: (2.7)(a) and (2.7)(b) amended, (HB 21-1187),
ch. 83, p. 332, § 26, effective July 1, 2024. L. 2022: (2) and (2.5) amended, (HB 22-1289), ch.
399, p. 2844, § 18, effective June 7.
Editor's note: This section is similar to former § 26-4-304 as it existed prior to 2006.
Cross references: For the legislative declaration contained in the 2007 act enacting
subsection (2.5), see section 1 of chapter 347, Session Laws of Colorado 2007. For the
legislative declaration in HB 22-1289, see section 1 of chapter 399, Session Laws of Colorado
2022.
25.5-5-204.5. Continuous eligibility - children. (1) A child who is determined to be
eligible for benefits under this article or under article 4 or 6 of this title shall remain eligible for
twelve months subsequent to the last day of the month in which the child was enrolled; except
that a child shall no longer be eligible and shall be disenrolled from the state medical assistance
program if the state department becomes aware of or is notified that the child has moved out of
the state or has reached nineteen years of age.
(2) Notwithstanding the provisions of subsection (1) of this section, if the money in the
healthcare affordability and sustainability fee cash fund established pursuant to section
25.5-4-402.4, 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), the state board by rule adopted pursuant to the
provisions of section 25.5-4-402.4 (6)(b)(III) may eliminate the continuous enrollment
requirement pursuant to this section.
(3) Repealed.
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Source: L. 2009: Entire section added, (HB 09-1293), ch. 152, p. 648, § 6, effective July
1. L. 2017: (2) amended, (SB 17-267), ch. 267, p. 1466, § 20, effective July 1.
Editor's note: (1) Subsection (3)(c) provided for the repeal of subsection (3), effective
the July 1 following the revisor of statutes' receipt of the notice required pursuant to subsection
(3)(b). (See L. 2009, p. 648.) The revisor of statutes received said notice dated February 17,
2017.
(2) Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017, provides
that the section of the act amending this section does not take effect if the centers for medicare
and medicaid services determine that the amendments do not comply with federal law. For more
information, see SB 17-267. (L. 2017, p. 1478.) The executive director of the department of
health care policy and financing did not notify the revisor of statutes by June 1, 2017, of such
determination; therefore, the changes to this section took effect July 1, 2017.
Cross references: For the legislative declaration in SB 17-267, see section 1 of chapter
267, Session Laws of Colorado 2017.
25.5-5-205. Baby and kid care program - creation - eligibility. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1864, § 7, effective July 1. L.
2007: (3)(d) amended, p. 1493, § 5, effective January 1, 2008. L. 2010: (3)(a) and (3)(c)(I)
amended, (HB 10-1043), ch. 92, p. 313, § 4, effective April 15. L. 2011: (3)(b) amended, (SB
11-250), ch. 219, p. 950, § 1, effective May 27; (3)(c) amended, (SB 11-008), ch. 100, p. 293, §
2, effective September 1. L. 2014: Entire section repealed, (SB 14-067), ch. 12, p. 114, § 7,
effective February 27.
Editor's note: This section was similar to former § 26-4-508 as it existed prior to 2006.
25.5-5-206. Medicaid buy-in program - disabled children - disabled adults - federal
authorization - rules. (1) (a) Subject to available appropriations, the state department is
authorized to seek federal authorization to and to establish a medicaid buy-in program or
programs for:
(I) Disabled children; or
(II) Disabled adults who do not qualify for the medicaid buy-in program established
pursuant to part 14 of article 6 of this title.
(b) The medicaid buy-in program or programs established pursuant to paragraph (a) of
this subsection (1) may provide for premium and cost-sharing charges on a sliding fee scale
based upon a family's income.
(2) The state board shall promulgate rules consistent with any federal authorization to
implement and administer the medicaid buy-in program or programs established pursuant to
paragraph (a) of subsection (1) of this section.
Source: L. 2009: Entire section added, (HB 09-1293), ch. 152, p. 698, § 6, effective July
1.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 228 of 510
25.5-5-207. Adult dental benefit - adult dental fund - creation - legislative
declaration. (1) (a) The general assembly finds that:
(I) As of 2011, Colorado was one of only ten states that did not offer basic oral health
services to adults under medicaid;
(II) Research has shown that untreated oral health conditions negatively affect a person's
overall health and that gum disease has been linked to diabetes, heart disease, strokes, kidney
disease, dementia diseases and related disabilities, and even behavioral or mental health
disorders;
(III) Regular dental care and prevention are the most cost-effective methods available to
prevent minor oral conditions from developing into more complex oral and physical health
conditions that would eventually require emergency and palliative care;
(IV) Further, one in four adults has untreated tooth decay. Early detection and access to
preventive and restorative treatments for oral health conditions can be up to ten times less
expensive than treating those same conditions in an emergency setting.
(V) Research has also shown that good oral health improves medicaid beneficiaries'
ability to obtain and keep employment. Employed adults lose more than one hundred and
sixty-four million hours of work each year due to dental problems.
(VI) Children are more likely to receive regular dental services if their parents have
access to dental services; and
(VII) Pregnant women are one of the most vulnerable adult populations that are without
oral health benefits under medicaid. During pregnancy, the physical changes a woman's body
undergoes can negatively affect oral health. Untreated decay and periodontal disease are
associated with adverse pregnancy outcomes such as increased risk for preeclampsia, pre-term
labor, and low birth weight babies.
(b) Therefore, the general assembly declares that in order to improve overall health,
promote savings in medicaid programs, and prevent future health conditions caused by oral
health problems, it is in the best interest of the state of Colorado to create a limited oral health
benefit for adults in the medicaid program.
(2) (a) Pursuant to section 25.5-5-202 (1)(w), by April 1, 2014, the state department shall
design and implement a limited dental benefit for adults using a collaborative stakeholder
process to consider the components of the benefit, including but not limited to the cost, best
practices, the effect on health outcomes, client experience, service delivery models, and
maximum efficiencies in the administration of the benefit.
(b) The state department shall determine the most cost-effective method for providing
the adult dental benefit, including but not limited to a comparison of a capitated or
fee-for-service method of payment and the purchase of dental insurance.
(c) The state department shall seek any federal authorization necessary to provide the
adult dental benefit.
(d) Subject to federal authorization and federal financial participation, on or after July 1,
2016, 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 may be provided through telehealth, including
store-and-forward transfer, in accordance with section 25.5-5-321.5.
(2.5) Repealed.
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(3) If the state department chooses to use an administrative service organization to
manage the adult dental benefit:
(a) The contract with the administrative service organization must provide that the
contracting entity is prohibited from requiring dental providers to participate in any other public
or private program or to accept any other insurance products as a condition of participating as a
dental provider; and
(b) The state department shall retain policy-making authority, including but not limited
to policies concerning covered benefits and rate setting.
(4) (a) There is hereby created in the state treasury the adult dental fund, referred to in
this section as the "fund", consisting of money transferred to the fund from the unclaimed
property trust fund pursuant to section 38-13-801 (3) and any money that may be appropriated to
the fund by the general assembly. The money in the fund is subject to annual appropriation by
the general assembly to the state department for the direct and indirect costs associated with
implementing the adult dental benefit pursuant to section 25.5-5-202 (1)(w).
(b) The state treasurer may invest any unexpended moneys in the fund as provided by
law. The state treasurer shall credit all interest and income derived from the investment and
deposit of moneys in the fund to the fund.
(c) Any unexpended and unencumbered moneys remaining in the fund at the end of a
fiscal year remain in the fund and shall not be credited or transferred to the general fund or
another fund.
Source: L. 2013: Entire section added, (SB 13-242), ch. 189, p. 761, § 2, effective
August 7. L. 2015: (2)(d) added, (HB 15-1309), ch. 326, p. 1334, § 7, effective August 5. L.
2017: IP(1)(a) and (1)(a)(II) amended, (SB 17-242), ch. 263, p. 1327, § 200, effective May 25.
L. 2018: (1)(a)(II) amended, (HB 18-1091), ch. 74, p. 642, § 3, effective August 8. L. 2019:
(4)(a) amended, (SB 19-088), ch. 110, p. 467, § 11, effective July 1, 2020. L. 2020: (2.5) added,
(HB 20-1361), ch. 161, p. 756, § 1, effective June 29. L. 2021: (2.5) repealed, (SB 21-211), ch.
86, p. 358, § 1, effective May 4.
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017.
25.5-5-208. Additional services - training - grants - screening, brief intervention, and
referral. (1) On or after July 1, 2018, the state department shall grant, through a competitive
grant program, one million five hundred thousand dollars to one or more organizations to operate
a substance abuse screening, brief intervention, and referral to treatment practice. The grant
program must require:
(a) Training for health-care professionals statewide, including providers who serve
women of childbearing age, that is evidence-based and that may be attended either in person or
online. The training must include training for reimbursement and billing codes in the "Colorado
Medical Assistance Act", articles 4 to 6 of this title 25.5.
(b) Consultation and technical assistance for health-care providers, health-care
organizations, and stakeholders;
(c) Outreach, communication, and education to providers and patients;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 230 of 510
(d) Coordination with primary care, mental health care, integrated health care, and
substance use prevention, treatment, and recovery efforts; and
(e) Campaigning to increase public awareness of the risks related to alcohol, marijuana,
tobacco, and drug use and to reduce any stigma associated with treatment.
(2) (a) The state department contractor shall develop a patient education tool for women
of childbearing age to learn about the risks of substance-exposed pregnancies, to be deployed for
public use in the state.
(b) Repealed.
Source: L. 2015: Entire section added, (HB 15-1367), ch. 271, p. 1078, § 17, effective
January 1, 2016. L. 2018: Entire section amended, (HB 18-1003), ch. 224, p. 1428, § 4, effective
May 21.
Editor's note: (1) Section 23(2) of chapter 271 (HB 15-1367), Session Laws of
Colorado 2015, provides that this section takes effect only if a majority of voters approve the
ballot issue referred in accordance with section 39-28.8-603 (1) at the November 2015 statewide
election. If the voters approve the ballot measure, this section is effective on the date of the
official declaration of the vote by the governor, or January 1, 2016, whichever is later. The ballot
issue was approved by voters on November 3, 2015. The governor's proclamation was issued on
December 28, 2015, establishing an effective date of January 1, 2016, for this section. The vote
count for the measure was as follows:
FOR: 847,380
AGAINST: 373,734
(2) Subsection (2)(b)(II) provided for the repeal of subsection (2)(b), effective
September 1, 2019. (See L. 2018, p. 1428.)
Cross references: For the legislative declaration in HB 15-1367, see section 1 of chapter
271, Session Laws of Colorado 2015.
PART 3
SERVICES WITH SPECIAL STATE PROVISIONS
25.5-5-301. Clinic services. (1) As used in this article and articles 4 and 6 of this title,
unless the context otherwise requires, "clinic services" means preventive, diagnostic, therapeutic,
rehabilitative, or palliative items or services furnished to outpatients.
(2) Under the federal option for clinic services, Colorado has selected clinic services
provided by the following:
(a) Community mental health centers or clinics;
(b) [Editor's note: This version of subsection (2)(b) is effective until July 1, 2024.]
Community centered boards;
(b) [Editor's note: This version of subsection (2)(b) is effective July 1, 2024.] Case
management agencies;
(c) Birthing centers;
(d) Ambulatory surgery facilities;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 231 of 510
(e) Freestanding dialysis clinics.
(3) "Clinic services" also means preventive, therapeutic, or palliative items or services
that are furnished to patients by county or district public health agencies or county or district
boards of health established pursuant to part 5 of article 1 of title 25, C.R.S., that are
recommended for certification by the department of public health and environment as qualified
to receive payments pursuant to this article and articles 4 and 6 of this title.
(4) "Clinic services" also means preventive, diagnostic, therapeutic, rehabilitative, or
palliative items or services furnished to a pregnant woman who is enrolled or eligible for
services pursuant to section 25.5-5-101 (1)(c) or 25.5-5-201 (1)(m.5) in a facility that is not a
part of a hospital but is organized and operated as a freestanding substance use disorder
treatment program approved and licensed by the behavioral health administration in the
department of human services pursuant to section 27-80-108 (1)(c).
(5) "Clinic services" also means preventive, diagnostic, therapeutic, rehabilitative, or
palliative items or services that are furnished to children up to age twenty-one or to high-risk
pregnant women in a facility which is not a part of a hospital but is organized and operated as a
school-based clinic.
(6) "Clinic services" also means preventive, diagnostic, therapeutic, rehabilitative, or
palliative items or services that are furnished to students by a school district, board of
cooperative services, or state educational institution within the scope of the "Colorado Medical
Assistance Act" pursuant to the provisions of section 25.5-5-318.
Source: L. 2006: Entire article added with relocations, p. 1866, § 7, effective July 1. L.
2010: (4) amended, (HB 10-1043), ch. 92, p. 314, § 5, effective April 15; (4) amended, (SB
10-175), ch. 188, p. 801, § 68, effective April 29; (3) amended, (HB 10-1422), ch. 419, p. 2113,
§ 145, effective August 11. L. 2014: (4) amended, (SB 14-067), ch. 12, p. 116, § 12, effective
February 27. L. 2017: (4) amended, (SB 17-242), ch. 263, p. 1328, § 201, effective May 25. L.
2021: (2)(b) amended, (HB 21-1187), ch. 83, p. 332, § 27, effective July 1, 2024. L. 2022: (4)
amended, (HB 22-1278), ch. 222, p. 1513, § 70, effective July 1.
Editor's note: (1) This section is similar to former § 26-4-513 as it existed prior to
2006.
(2) Amendments to subsection (4) by House Bill 10-1043 and Senate Bill 10-175 were
harmonized.
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017.
25.5-5-302. Clinic services - children and pregnant women - utilization of certain
providers. (1) The state department shall utilize, to the extent possible and appropriate, county
or district public health agencies or boards of health established pursuant to part 5 of article 1 of
title 25, C.R.S., that are certified by the department of public health and environment as qualified
to receive payments pursuant to this article and articles 4 and 6 of this title and that meet the
requirements and standards set forth in rules promulgated by the state board in the state
department pursuant to section 25.5-4-104 to provide clinic services to patients who are children
under age seven or patients who are pregnant women.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 232 of 510
(2) In complying with the provisions of subsection (1) of this section, the state
department shall utilize, to the extent possible and appropriate, the county or district public
health agencies and boards of health specified in subsection (1) of this section to provide
outreach to eligible pregnant women and children and to provide clinic services:
(a) Upon the referral of any physician; or
(b) When there exists no primary care physician who agrees to provide clinic services to
such patients.
Source: L. 2006: Entire article added with relocations, p. 1867, § 7, effective July 1. L.
2010: (1) and IP(2) amended, (HB 10-1422), ch. 419, p. 2113, § 146, effective August 11.
Editor's note: This section is similar to former § 26-4-514 as it existed prior to 2006.
25.5-5-303. Private-duty nursing. (1) The medical assistance program in this state shall
include private-duty nursing to persons who are technology dependent and otherwise eligible as
provided under this section.
(2) A recipient is eligible for private-duty nursing services if he or she:
(a) Is dependent on technology at least part of each day;
(b) Requires private-duty nursing care as determined in accordance with state
department rules;
(c) Is able to be served safely under the limitations of the private-duty nursing benefit
and within the availability of services; and
(d) Is not residing in a nursing facility or hospital at the time of the delivery of the
private-duty nursing services.
(3) (a) The state board shall establish rules in accordance with this section that identify
medical criteria for determining the circumstances under which private-duty nursing services
will be delivered to assure that only persons who need the services receive them and only to the
extent medically necessary.
(b) Private-duty nursing services shall not be provided as twenty-four-hour care except
in special circumstances and for limited time periods as established by the state department
pursuant to this section.
(c) The home health agency, in conjunction with the family or in-home caregiver and the
attending physician, shall include in a care plan that includes private-duty nursing services a
process by which the eligible person may receive necessary care, which may include respite
care, if the family or in-home caregiver is unavailable due to an emergency situation or to
unforeseen circumstances. The family or in-home caregiver shall be duly informed by the home
health agency of these alternative care provisions at the time the care plan is initiated.
(4) As used in this section, unless the context otherwise requires, "private-duty nursing"
means nursing care that is more individualized and continuous than both the nursing care
available under the home health benefit and the nursing care routinely provided in a hospital or
nursing facility.
Source: L. 2006: Entire article added with relocations, p. 1867, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-517 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 233 of 510
25.5-5-304. Hospice care. (1) The medical assistance program in this state shall include
hospice care. Except as otherwise provided in subsection (2) of this section, hospice care shall be
provided for a period of up to two hundred ten days in accordance with rules adopted by the state
board, which rules shall comply with 42 U.S.C. sec. 1396d, and shall include at least the
following requirements:
(a) That a person shall obtain a certified medical prognosis indicating a life expectancy
of nine months or less, which certification shall comply with rules adopted by the state board;
(b) That a person shall execute a waiver of other medical benefits available under this
article and articles 4 and 6 of this title, which election shall be executed in accordance with rules
adopted by the state board;
(c) That the service shall be reasonable and necessary for the palliation or management
of the terminal illness and related conditions.
(2) Hospice care may be provided to a person beyond two hundred ten days if such
person is recertified by a physician or hospice medical director as terminally ill in accordance
with subsection (1) of this section.
(3) (a) Subject to the receipt of any necessary federal authorization, for a person who has
executed the waiver described in paragraph (b) of subsection (1) of this section and who is a
resident in a class I facility, as defined in section 25.5-6-201 (13), the class I facility shall bill the
state department and the state department shall pay the class I facility for the room and board
costs of the person.
(b) Subject to the receipt of any necessary federal authorization, the hospice care
provided pursuant to this section may include room and board in a hospice inpatient facility
licensed pursuant to section 25-3-101, C.R.S. The state department is authorized to establish the
reimbursement rate for the costs for room and board at a licensed hospice inpatient facility for
patients eligible for the routine level of hospice care.
(c) (I) If required, the state department shall seek the appropriate federal authorization,
conditioned on the receipt of gifts, grants, or donations sufficient to provide for the state's
administrative costs of preparing and submitting the request, to make the payment described in
paragraph (a) of this subsection (3) and to include room and board at a licensed hospice inpatient
facility as described in paragraph (b) of this subsection (3). On or before January 15, 2011, the
state department shall submit a brief report to the members of the health and human services
committees of the senate and house of representatives, or any successor committees, on the
status of any request for authorization pursuant to this subparagraph (I). If federal authorization
to implement the changes described in paragraphs (a) and (b) of this subsection (3) is obtained,
the state department shall request, through the state budget process, that the changes be
implemented during the fiscal year following the year in which the approval is obtained.
(II) The state department is authorized to seek and accept gifts, grants, or donations from
private or public sources for the purpose of providing for the administrative costs of preparing
and submitting the request for federal approval for the payments described in paragraphs (a) and
(b) of this subsection (3). All such private and public funds received through gifts, grants, or
donations shall be transmitted to the state treasurer, who shall credit the same to the hospice care
account in the department of health care policy and financing cash fund created pursuant to
section 25.5-1-109, which account is hereby created. Moneys in the account shall be subject to
appropriation and shall only be used for the purposes described in this subparagraph (II).
(4) Repealed.
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Source: L. 2006: Entire article added with relocations, p. 1868, § 7, effective July 1. L.
2010: IP(1) and (1)(a) amended and (4) added, (HB 10-1027), ch. 274, p. 1256, § 1, effective
August 11; (3) added, (SB 10-061), ch. 247, p. 1104, § 1, effective August 11.
Editor's note: (1) This section is similar to former § 26-4-520 as it existed prior to
2006.
(2) Subsection (4)(b) provided for the repeal of subsection (4), effective the July 1
following the revisor of statutes' receipt of the required notice. (See L. 2010, p. 1256.) The
revisor of statutes received the required notice on May 31, 2012.
25.5-5-305. Pediatric hospice care - legislative declaration - federal authorization -
rules - fund. (1) Legislative declaration. (a) The general assembly finds and declares that:
(I) The death of a child has a devastating and enduring impact on the child's family;
(II) Too often, children with fatal conditions and their families fail to receive
compassionate and consistent care that meets their physical, emotional, and spiritual needs;
(III) Better care is possible but current methods of organizing and financing palliative,
end-of-life, and bereavement care impede the provision of services that are both more
appropriate and more cost-efficient;
(IV) Current federal medicaid regulations contain inherent barriers to providing
appropriate palliative and end-of-life care to pediatric patients. These barriers include
requirements that preclude the pursuit of curative treatments, mandate a do-not-resuscitate order,
and require physician certification that death is expected within six months.
(b) The general assembly declares that it is in the best interest of the state to investigate
and implement hospice guidelines that provide appropriate, compassionate care to dying children
and their families while proving to be cost-neutral or cost-saving to the state and federal
medicaid programs.
(c) The general assembly further finds and declares that, while this direction
immediately concerns federal approval for hospice care that recognizes the distinct
circumstances of children facing life-threatening illnesses and their families, it is the intent of the
general assembly that the information and data produced as a result of this act shall be used to
improve the delivery of palliative and end-of-life services to persons of all ages when such
improvements can be made in a manner that is cost-neutral or cost-saving to the state.
(2) Definitions. As used in this section, unless the context otherwise requires:
(a) "Eligible child" means a child who:
(I) Is less than nineteen years of age; and
(II) Is eligible for the state's medicaid program pursuant to section 25.5-5-101,
25.5-5-201, or 25.5-5-203;
(b) "Pediatric hospice care" means hospice care for eligible children as authorized in this
section.
(3) Pediatric hospice care. (a) (I) The state department shall seek the appropriate
federal authorization, conditioned on the receipt of gifts, grants, or donations sufficient to
provide for the state's administrative costs of preparing and submitting the request, for pediatric
hospice care that shall include but may not be limited to:
(A) Respite care;
(B) Expressive therapies, as defined in rule by the state board;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 235 of 510
(C) Palliative care from the time of diagnosis of a potentially life-threatening illness; and
(D) A continuum of care through the coordination of services, which may include
skilled, intermittent, and around-the-clock nursing care.
(II) The state department is authorized to seek federal approval for modifications to the
provision of hospice care for adults who are eligible for the state's medicaid program.
(b) For the provision of pediatric hospice care, the state department shall seek an
exemption from the following federal medicaid requirements for the eligibility of and election
for hospice care:
(I) The mandatory do-not-resuscitate order;
(II) A physician's certification that a patient is expected to live less than six months; and
(III) The nonallowance of curative care therapies concurrent with palliative and hospice
care.
(c) In any application for federal authorization pursuant to this section, the state
department shall retain bereavement services to the extent available under federal law.
(d) Pediatric hospice care, as authorized pursuant to this section, shall meet aggregate
federal waiver budget neutrality requirements.
(e) The state department shall implement the provision of pediatric hospice care to the
extent authorized by the federal government.
(4) Review. The state department shall notify the joint budget committee of the general
assembly of the extent to which the state department received federal authorization for pediatric
hospice care services pursuant to this section in order for the joint budget committee to review
the approved budget neutrality analysis for such services prior to the state department's
implementation.
(5) Rules. The state department shall develop the service provisions for pediatric
hospice care in consultation with medical professionals who have expertise in providing
end-of-life and palliative care to pediatric patients and family members who have experienced
the death of a child. The state board shall adopt rules necessary to implement and administer the
provisions of this section.
(6) Fund. The state department is authorized to seek and accept gifts, grants, or
donations from private or public sources for the purpose of providing for the administrative costs
of preparing and submitting the request for federal approval for the provision of pediatric
hospice care. All private and public funds received through gifts, grants, or donations shall be
transmitted to the state treasurer, who shall credit the same to the pediatric hospice care cash
fund, which fund is hereby created and referred to in this section as the "fund". The moneys in
the fund shall be subject to annual appropriation by the general assembly for preparing and
submitting the request for federal approval pursuant to this section. Any moneys in the fund not
expended for the purpose of this section may be invested by the state treasurer as provided by
law. All interest and income derived from the investment and deposit of moneys in the fund shall
be credited to the fund. Any unexpended and unencumbered moneys remaining in the fund at the
end of a fiscal year shall remain in the fund and shall not be credited or transferred or revert to
the general fund or another fund.
Source: L. 2006: Entire article added with relocations, p. 1868, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-533 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 236 of 510
25.5-5-306. Residential child health care - waiver - program - rules - notice to
revisor - repeal. (Repealed)
Source: L. 2006: (1) and (3) amended and (4) added, p. 1202, § 2, effective May 26;
entire article added with relocations, p. 1871, § 7, effective July 1. L. 2008: (3) amended, p.
1517, § 1, effective May 28. L. 2010: (1) amended, (SB 10-175), ch. 188, p. 801, § 69, effective
April 29. L. 2013: (1) amended, (HB 13-1314), ch. 323, p. 1809, § 45, effective March 1, 2014.
L. 2016: (1) amended, (SB 16-189), ch. 210, p. 773, § 68, effective June 6. L. 2018: (5) and (6)
added, (HB 18-1328), ch. 184, p. 1242, § 2, effective July 1; (1) amended, (SB 18-092), ch. 38,
p. 445, § 111, effective August 8. L. 2019: (3) and (4) amended, (HB 19-1172), ch. 136, p. 1708,
§ 181, effective October 1.
Editor's note: (1) This section was similar to former § 26-4-527 as it existed prior to
2006.
(2) Subsection (6) provided for the repeal of this section, effective June 7, 2019. On
August 14, 2019, the revisor of statutes received the notice referred to in subsection (6) related to
the repeal. For more information about the repeal and notice, see HB 18-1328. (L. 2018, p.
1242.)
Cross references: (1) For the legislative declaration in SB 18-092, see section 1 of
chapter 38, Session Laws of Colorado 2018. For the legislative declaration in HB 18-1328, see
section 1 of chapter 184, Session Laws of Colorado 2018.
(2) For current provisions relating to the residential health care program, see §
25.5-6-903.
25.5-5-307. Child mental health treatment and family support program. (1) The
general assembly finds that many parents in Colorado who have experienced challenging
circumstances because their children have significant mental health needs and who have
attempted to care for their children or seek services on their behalf often are burdened with the
excessive financial and personal costs of providing such care. Private insurance companies may
not cover mental health services and rarely cover residential mental health treatment services;
those that do seldom cover a sufficient percentage of the expense to make such mental health
treatment a viable option for many families in need. The result is that many families do not have
the ability to obtain the mental health services that they feel their children desperately need. The
general assembly finds that it is in the best interests of these families and the citizens of the state
to encourage the preservation of family units by making mental health treatment available to
these children pursuant to article 67 of title 27, C.R.S.
(2) In order to make mental health treatment available, it is the intent of the general
assembly that each medicaid-eligible child who is diagnosed as a person with a mental health
disorder, as that term is defined in section 27-65-102 (11.5), must receive mental health
treatment, which may include in-home family mental health treatment, other family preservation
services, residential treatment, or any post-residential follow-up services, that must be paid for
through federal medicaid funding.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 237 of 510
Source: L. 2006: Entire article added with relocations, p. 1872, § 7, effective July 1; (2)
amended, p. 1389, § 19, effective August 7. L. 2010: Entire section amended, (SB 10-175), ch.
188, p. 802, § 70, effective April 29. L. 2017: (2) amended, (SB 17-242), ch. 263, p. 1328, §
202, effective May 25.
Editor's note: (1) This section is similar to former § 26-4-509.5 as it existed prior to
2006.
(2) Amendments to section 26-4-509.5 (2) by House Bill 06-1277 were harmonized with
subsection (2) as it appeared in Senate Bill 06-219.
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017.
25.5-5-308. Breast and cervical cancer prevention and treatment program - creation
- legislative declaration - definitions - funds - repeal. (1) The general assembly hereby finds
and declares that breast and cervical cancer are significant health problems for women in this
state. The general assembly further finds and declares that these cancers can and should be
prevented and treated whenever possible. It is therefore the intent of the general assembly to
enact this section to provide for the prevention and treatment of breast and cervical cancer to
women where it is not otherwise available for reasons of cost.
(2) As used in this section, unless the context otherwise requires:
(a) "Eligible person" means a person who:
(I) (A) Has been screened for breast or cervical cancer under the centers for disease
control and prevention's national breast and cervical cancer early detection program established
under Title XV of the federal "Public Health Service Act", 42 U.S.C. sec. 300k et seq., in
accordance with the requirements of section 1504 of such act, 42 U.S.C. sec. 300n, on or after
July 1, 2002, unless the centers for medicare and medicaid services approves the state
department's amendment to the medical assistance plan and the state department is able to
implement the breast and cervical cancer prevention and treatment program before such date,
then the person must be screened on or after the implementation date of such program; or
(B) Has been screened for breast or cervical cancer by any provider, within the
provider's scope of practice, who does not receive funds through the federal centers for disease
control and prevention's national breast and cervical cancer early detection program but whose
screening activities are recognized by the department of public health and environment as part of
screening activities under the centers for disease control and prevention's national breast and
cervical cancer early detection program;
(II) Has been diagnosed with breast or cervical cancer and is in need of breast or cervical
cancer treatment;
(III) Has not yet attained sixty-five years of age; and
(IV) Does not have any creditable coverage as defined under federal law pursuant to 42
U.S.C. sec. 300gg-3 (c).
(b) "Qualified entity" shall be defined pursuant to 42 U.S.C. sec. 1396r-1b(b)(2).
(3) There is hereby created a breast and cervical cancer prevention and treatment
program to provide medical benefits to eligible persons under this section.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 238 of 510
(4) (a) Benefits for medical assistance to an eligible person shall be made available
beginning on the day on which a determination is made that the person is eligible for medical
assistance and throughout the period in which such person meets the definition of an eligible
person.
(b) Benefits for medical assistance to an eligible person shall also be available for the
following period of presumptive eligibility:
(I) Such period of presumptive eligibility shall begin when a qualified entity determines
that the eligible person is in need of treatment for breast or cervical cancer.
(II) Such period of presumptive eligibility shall end with the earlier of:
(A) The day on which a determination is made that the person is eligible or not eligible
for medical assistance; or
(B) If the eligible person does not file a simplified application for medical assistance
developed by the state department and approved by the federal centers for medicare and
medicaid services on or before the last day of the month following the month during which the
eligible person was found to be qualified for services under this section, then benefits shall end
on such last day.
(5) The state department shall have the following powers and duties:
(a) To establish, operate, and monitor the breast and cervical cancer prevention and
treatment program to provide medical assistance to eligible persons in accordance with the
provisions of the federal "Breast and Cervical Cancer Prevention and Treatment Act of 2000",
enacted October 24, 2000, Pub.L. 106-354, as amended;
(b) To amend the state's medical assistance plan to incorporate the breast and cervical
cancer prevention and treatment program. The state department shall submit such proposed
amendment to the federal centers for medicare and medicaid services regional office for
approval.
(c) To accept and expend any grant or award of moneys from the federal government,
any moneys appropriated by the general assembly, any moneys received through gifts, grants, or
donations from nonprofit or for-profit entities, and any interest and income earned on such
moneys for the purposes set forth in this section;
(d) To inform the joint budget committee of the general assembly in writing as soon as
practicable about any change in the rate of federal financial participation in the program.
(6) The state board shall adopt such rules as are necessary to carry out the provisions of
this section.
(7) The breast and cervical cancer prevention and treatment program is subject to the
annual financial and compliance audit of the "Colorado Medical Assistance Act" performed by
the state auditor's office and shall not be considered a tobacco settlement program for purposes
of section 2-3-113, C.R.S.
(8) (a) (I) There is hereby created in the state treasury the breast and cervical cancer
prevention and treatment fund, referred to in this subsection (8) as the "fund". The fund shall
consist of any moneys credited thereto pursuant to section 24-22-115 (1), C.R.S., any gifts,
grants, and donations, any moneys appropriated thereto by the general assembly, and moneys
credited thereto pursuant to section 42-3-217.5 (3)(c), C.R.S. Except as provided for in
paragraph (b.5) of this subsection (8), all moneys credited to the fund and all interest and income
earned on the moneys in the fund shall remain in the fund for the purposes set forth in this
section. Any unexpended and unencumbered moneys remaining in the fund at the end of a fiscal
Colorado Revised Statutes 2023 Uncertified PrintoutPage 239 of 510
year shall remain in the fund and shall not be credited or transferred to the general fund or
another fund. The state department is encouraged to secure private gifts, grants, and donations to
fund the state costs of the breast and cervical cancer prevention and treatment program.
(II) Moneys in the fund may be used to cover the administrative costs of the department
of public health and environment to recognize providers in accordance with sub-subparagraph
(B) of subparagraph (I) of paragraph (a) of subsection (2) of this section as providing screening
activities under the centers for disease control and prevention's national breast and cervical
cancer early detection program.
(b) Repealed.
(b.5) Until section 24-30-2204.5 is repealed, the state treasurer shall transfer any interest
or income earned on moneys in the fund to the disability support fund, created in section
24-30-2205.5.
(c) Repealed.
(9) (a) For the fiscal year 2005-06, the general assembly shall appropriate fifty percent
of the state costs of the breast and cervical cancer prevention and treatment program from the
general fund and fifty percent from the moneys credited to the breast and cervical cancer
prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such program.
(b) For the fiscal year 2006-07, the general assembly shall appropriate seventy-five
percent of the state costs of the breast and cervical cancer prevention and treatment program
from the general fund and twenty-five percent from the moneys credited to the breast and
cervical cancer prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such
program.
(c) For the fiscal year 2007-08, the general assembly shall appropriate one hundred
percent of the state costs of the breast and cervical cancer prevention and treatment program
from the moneys credited to the breast and cervical cancer prevention and treatment fund
pursuant to section 24-22-115 (1), C.R.S., to such program.
(d) For the fiscal year 2008-09, the general assembly shall appropriate one hundred
percent of the state costs of the breast and cervical cancer prevention and treatment program
from the moneys credited to the breast and cervical cancer prevention and treatment fund
pursuant to section 24-22-115 (1), C.R.S., to such program.
(e) For the fiscal years 2009-10 through 2011-12, the general assembly shall annually
appropriate one hundred percent of the state costs of the breast and cervical cancer prevention
and treatment program from the moneys credited to the breast and cervical cancer prevention
and treatment fund pursuant to section 24-22-115 (1), C.R.S., to such program.
(f) For the fiscal years 2012-13 and 2013-14, the general assembly shall annually
appropriate fifty percent of the state costs of the breast and cervical cancer prevention and
treatment program from the general fund and fifty percent from the moneys credited to the breast
and cervical cancer prevention and treatment fund pursuant to section 24-22-115 (1), C.R.S., to
such program.
(g) For the fiscal years 2014-15 through 2028-29, the general assembly shall annually
appropriate one hundred percent of the state costs of the breast and cervical cancer prevention
and treatment program from the money credited to the breast and cervical cancer prevention and
treatment fund to the program; except that, if the money in the breast and cervical cancer
prevention and treatment fund is insufficient to fully fund the program, the general assembly
shall appropriate sufficient money from the general fund.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 240 of 510
(10) This section is repealed, effective July 1, 2029, unless, in any fiscal year before
such date, money received as federal financial participation provided pursuant to the federal
"Breast and Cervical Cancer Prevention and Treatment Act of 2000", enacted October 24, 2000,
Pub.L. 106-354, as amended, is no longer available to the fund or the rate of federal financial
participation has been decreased, in which case the general assembly may repeal this section at
the regular session of the general assembly immediately following such decrease or
discontinuation of federal money.
Source: L. 2006: (8) amended, p. 1117, § 2, effective May 25; entire article added with
relocations, p. 1872, § 7, effective July 1. L. 2008: (8)(a), (9)(b), (9)(c), and (10) amended and
(9)(d) and (9)(e) added, p. 1830, § 1, effective June 2. L. 2009: (9)(e) amended and (9)(f) added,
(SB 09-262), ch. 202, p. 912, § 1, effective May 1; (2)(a)(I) and (8)(a) amended and (8)(c)
added, (HB 09-1164), ch. 215, p. 973, § 4, effective May 2. L. 2013: (8)(a)(I) and (8)(c)(II)
amended, (8)(b) repealed, and (8)(b.5) added, (SB 13-276), ch. 256, p. 1352, § 8, effective May
23. L. 2014: (2)(a)(I)(B), (8)(a)(I), and (10) amended, (8)(c) repealed, and (9)(g) added, (HB
14-1045), ch. 137, p. 468, § 1, effective July 1. L. 2015: (7) amended, (SB 15-189), ch. 104, p.
304, § 5, effective April 16. L. 2018: (2)(a)(IV) and (8)(b.5) amended, (HB 18-1375), ch. 274, p.
1714, § 64, effective May 29. L. 2019: (9)(g) and (10) amended, (HB 19-1302), ch. 193, p. 2115,
§ 1, effective May 16. L. 2023: (2)(a)(I)(B), (4)(b)(II)(B), and (5)(b) amended, (HB 23-1301),
ch. 303, p. 1831, § 50, effective August 7.
Editor's note: (1) This section is similar to former § 26-4-532 as it existed prior to
2006.
(2) Subsection (8) was originally numbered as § 26-4-532 (7), and the amendments to it
in Senate Bill 06-128 were harmonized with subsection (8) as it appeared in Senate Bill 06-219.
Cross references: (1) For the "Breast and Cervical Cancer Prevention and Treatment
Act of 2000", Pub.L. 106-354, see 42 U.S.C. sec. 1396r-1b.
(2) For the legislative declaration in HB 09-1164, see section 1 of chapter 215, Session
Laws of Colorado 2009.
25.5-5-309. Pregnant women - needs assessment - referral to treatment program -
definition. (1) The health-care practitioner for each pregnant woman who is enrolled or eligible
for services pursuant to section 25.5-5-101 (1)(c) or 25.5-5-201 (1)(m.5) is encouraged to
identify as soon as possible after the woman is determined to be pregnant whether the woman is
at risk of a poor birth outcome due to substance use during the prenatal period and in need of
special assistance in order to reduce the risk. If the health-care practitioner makes such
determination regarding any pregnant woman, the health-care practitioner is encouraged to refer
the woman to any entity approved and licensed by the behavioral health administration in the
department of human services for the performance of a needs assessment. Any county
department of human or social services may refer an eligible woman for a needs assessment, or
any pregnant woman who is eligible for services pursuant to section 25.5-5-201 (1)(m.5) may
refer herself for a needs assessment.
(2) For the purposes of this section, unless the context otherwise requires, a "needs
assessment" means an assessment that is designed to determine the services that are needed for a
Colorado Revised Statutes 2023 Uncertified PrintoutPage 241 of 510
pregnant woman to minimize the occurrence of a poor birth outcome due to substance use by the
pregnant woman.
Source: L. 2006: Entire article added with relocations, p. 1875, § 7, effective July 1. L.
2010: (1) amended, (HB 10-1043), ch. 92, p. 314, § 6, effective April 15. L. 2014: (1) amended,
(SB 14-067), ch. 12, p. 116, § 13, effective February 27. L. 2019: Entire section amended, (HB
19-1193), ch. 272, p. 2568, § 2, effective May 23. L. 2022: (1) amended, (HB 22-1278), ch. 222,
p. 1513, § 71, effective July 1.
Editor's note: This section is similar to former § 26-4-508.2 as it existed prior to 2006.
Cross references: For the legislative declaration in HB 19-1193, see section 1 of chapter
272, Session Laws of Colorado 2019.
25.5-5-310. Treatment program for high-risk pregnant and parenting women -
cooperation with private entities - definition. (1) (a) As used in this section, "parenting
woman" means a woman up to one year postpartum who is in need of substance use disorder
services.
(b) The state department, the behavioral health administration in the department of
human services, the department of human services, and the department of public health and
environment shall cooperate with any organizations that desire to assist the departments and the
administration in the provision of services connected with the treatment program for high-risk
pregnant and parenting women. Organizations may provide services that are not provided to
persons pursuant to this article 5 or article 4 or 6 of this title 25.5 or article 2 of title 26, which
services may include but are not limited to needs assessment services, preventive services,
rehabilitative services, care coordination, nutrition assessment, psychosocial counseling,
intensive health education, home visits, transportation, development of provider training, child
care, child care navigation, and other necessary components of residential or outpatient treatment
or care.
(2) (a) Health-care practitioners and county departments of human or social services are
encouraged to identify any pregnant or parenting woman. If a practitioner or county department
of human or social services makes such determination regarding any pregnant or parenting
woman up to one year postpartum, the practitioner or county department of human or social
services is encouraged to refer the woman to any entity approved and licensed by the behavioral
health administration in the department of human services for a needs assessment in order to
improve outcomes for the pregnant or parenting woman and child and reduce the likelihood of
out-of-home placement. Any pregnant or parenting woman up to one year postpartum may also
refer herself for a needs assessment.
(b) The behavioral health administration in the department of human services is
authorized to use state money to provide services to women, including women enrolled in the
medical assistance program established pursuant to this article 5 and articles 4 and 6 of this title
25.5, who enroll, up to one year postpartum, in residential substance use disorder treatment and
recovery services, until such time as those services are covered by the medical assistance
program. The behavioral health administration in the department of human services may
Colorado Revised Statutes 2023 Uncertified PrintoutPage 242 of 510
continue to use state money to enroll parenting women in residential services who qualify as
indigent but who are not eligible for services under the medical assistance program.
(c) Facilities approved and licensed by the behavioral health administration in the
department of human services to provide substance use disorder services to high-risk pregnant
and parenting women and that offer child care services must allow a woman to begin treatment
without first presenting up-to-date health records for her child, including those referenced in
section 25-4-902. The parenting woman in treatment must present up-to-date health records for
her child, including those referenced in section 25-4-902, within thirty days after commencing
treatment.
Source: L. 2006: Entire article added with relocations, p. 1875, § 7, effective July 1. L.
2019: Entire section amended, (HB 19-1193), ch. 272, p. 2568, § 3, effective May 23. L. 2021:
(2)(b) amended, (HB 21-1021), ch. 256, p. 1511, § 5, effective September 7. L. 2022: (1)(b) and
(2) amended, (HB 22-1278), ch. 222, p. 1514, § 72, effective July 1.
Editor's note: This section is similar to former § 26-4-508.4 as it existed prior to 2006.
Cross references: For the legislative declaration in HB 19-1193, see section 1 of chapter
272, Session Laws of Colorado 2019.
25.5-5-311. Treatment program for high-risk pregnant and parenting women - data
collection. The state department, in cooperation with the behavioral health administration in the
department of human services, shall create a data collection mechanism regarding persons
receiving services pursuant to the treatment program for high-risk pregnant and parenting
women that includes the collection of any data that the state department and behavioral health
administration in the department of human services deem appropriate.
Source: L. 2006: Entire article added with relocations, p. 1875, § 7, effective July 1. L.
2019: Entire section amended, (HB 19-1193), ch. 272, p. 2569, § 4, effective May 23. L. 2022:
Entire section amended, (HB 22-1278), ch. 222, p. 1514, § 73, effective July 1.
Editor's note: This section is similar to former § 26-4-508.5 as it existed prior to 2006.
Cross references: For the legislative declaration in HB 19-1193, see section 1 of chapter
272, Session Laws of Colorado 2019.
25.5-5-312. Treatment program for high-risk pregnant and parenting women -
extended coverage - federal approval. (1) The state department shall seek federal approval to
continue providing substance use disorder treatment and recovery services for twelve months
following a pregnancy to women who are eligible to receive services under the medical
assistance program, who are receiving services pursuant to the treatment program for high-risk
pregnant and parenting women, and who continue to participate in the treatment program. The
state department shall implement the continued services to the extent allowed by the federal
government.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 243 of 510
(2) The state department is authorized to request any federal changes necessary to permit
high-risk pregnant and parenting women to further access treatment for pregnant and parenting
women with substance use disorders. Any changes to federal waiver programs for this
population must preserve the family-oriented specialty services needed by pregnant and
parenting women and their dependent children, including those services described in section
25.5-5-310 (1).
Source: L. 2006: Entire article added with relocations, p. 1876, § 7, effective July 1. L.
2019: Entire section amended, (HB 19-1193), ch. 272, p. 2570, § 5, effective May 23. L. 2021:
(1) amended, (HB 21-1021), ch. 256, p. 1511, § 6, effective September 7.
Editor's note: This section is similar to former § 26-4-508.6 as it existed prior to 2006.
Cross references: For the legislative declaration in HB 19-1193, see section 1 of chapter
272, Session Laws of Colorado 2019.
25.5-5-313. Outpatient substance abuse treatment - report of state auditor -
amendment to state plan - repeal. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1876, § 7, effective July 1.
Editor's note: (1) This section was similar to former § 26-4-536 as it existed prior to
2006.
(2) Subsection (3) provided for the repeal of this section, effective July 1, 2011. (See L.
2006, p. 1876.)
25.5-5-314. Substance use disorder treatment for Native Americans - federal
approval. (1) The state department shall request federal approval, conditioned on the receipt of
gifts, grants, or donations sufficient to provide for the state's administrative costs of preparing
and submitting the request, to include any substance use disorder treatment benefits available to
Native Americans in which there is one hundred percent federal financial participation.
(2) Repealed.
Source: L. 2006: Entire article added with relocations, p. 1876, § 7, effective July 1. L.
2014: (2) repealed, (HB 14-1363), ch. 302, p. 1269, § 30, effective May 31. L. 2017: (1)
amended, (SB 17-242), ch. 263, p. 1328, § 203, effective May 25.
Editor's note: This section is similar to former § 26-4-422 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017.
25.5-5-315. Acceptance of gifts, grants, and donations - Native American substance
abuse treatment cash fund. (1) The executive director may accept and expend money from
gifts, grants, and donations for purposes of providing for the administrative costs of preparing
Colorado Revised Statutes 2023 Uncertified PrintoutPage 244 of 510
and submitting the request for federal approval to provide substance use disorder treatment and
recovery services to Native Americans as provided for in section 25.5-5-314. All such gifts,
grants, and donations must be transmitted to the state treasurer who shall credit the same to the
Native American substance abuse treatment cash fund, which fund is created and referred to in
this section as the "fund". The money in the fund is subject to annual appropriation by the
general assembly. All investment earnings derived from the deposit and investment of money in
the fund remains in the fund and shall not be transferred or revert to the general fund of the state
at the end of any fiscal year.
(2) Repealed.
Source: L. 2006: Entire article added with relocations, p. 1876, § 7, effective July 1. L.
2014: (2) repealed, (HB 14-1363), ch. 302, p. 1269, § 31, effective May 31. L. 2017: (1)
amended, (SB 17-242), ch. 263, p. 1328, § 204, effective May 25. L. 2021: (1) amended, (HB
21-1021), ch. 256, p. 1511, § 7, effective September 7.
Editor's note: This section is similar to former § 26-4-423 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017.
25.5-5-316. Legislative declaration - state department - disease management
programs authorization - report. (1) The general assembly finds that, because Colorado is
faced with rising health- care costs and limited resources, it is necessary to seek new ways to
ensure the availability of high-quality, cost-efficient care for medicaid recipients. The general
assembly further finds that disease management is a patient-focused, integrated approach to
providing all components of care with attention to both quality of care and total cost. In addition,
the general assembly finds that this approach may include coordination of physician care with
pharmaceutical and institutional care. The general assembly further finds that disease
management also addresses the various aspects of a disease state, including meeting the needs of
persons who have multiple chronic illnesses. The general assembly declares that the improved
coordination in disease management helps to provide chronically ill patients with access to the
latest advances in treatment and teaches them how to be active participants in their health care
through health education, thus reducing total health-care costs.
(2) The state department, in consultation with the department of public health and
environment, is authorized to develop and implement disease management programs, for
fee-for-service and primary care physician program recipients, that are designed to address over-
or under-utilization or the inappropriate use of services or prescription drugs and that may affect
the total cost of health-care utilization by a particular medicaid recipient with a particular disease
or combination of diseases. The disease management programs shall target medicaid recipients
who are receiving prescription drugs or services in an amount that exceeds guidelines outlined
by the state department. The state department shall not restrict a medicaid recipient's access to
the most cost-effective and medically appropriate prescription drugs or services. The state
department may contract on a contingency basis for the development or implementation of the
disease management programs authorized in this subsection (2).
Colorado Revised Statutes 2023 Uncertified PrintoutPage 245 of 510
(3) If the state department implements any disease management programs authorized in
subsection (2) of this section, the state department shall report to the joint budget committee of
the general assembly an estimate of the fiscal implications generated by the implementation of
the disease management programs. Such report shall be made on or before February 1 of the year
following the implementation of a disease management program and on or before each February
1 thereafter in which such program is in place.
Source: L. 2006: Entire article added with relocations, p. 1877, § 7, effective July 1. L.
2008: (2) amended, p. 800, § 2, effective May 14.
Editor's note: This section is similar to former § 26-4-408.5 as it existed prior to 2006.
25.5-5-317. Obesity treatment pilot program - development and implementation -
report - repeal. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1878, § 7, effective July 1.
Editor's note: (1) This section was similar to former § 26-4-534 as it existed prior to
2006.
(2) Subsection (4) provided for the repeal of this section, effective July 1, 2010. (See L.
2006, p. 1878.)
25.5-5-318. Health services - provision by school districts - repeal. (1) As used in this
section:
(a) "School district" means any board of cooperative services established pursuant to
article 5 of title 22, C.R.S., any state educational institution that serves students in kindergarten
through twelfth grade including, but not limited to, the Colorado school for the deaf and the
blind, created in article 80 of title 22, C.R.S., and any public school district organized under the
laws of Colorado, except a local college district.
(b) "Underinsured" means a person who has some health insurance, but whose insurance
does not adequately cover the types of health services for which a school district may receive
federal matching funds under this section.
(2) (a) Any school district may contract with the state department under this section to
receive federal matching funds for amounts spent in providing health services through the public
schools to students who are receiving medicaid benefits pursuant to this article and articles 4 and
6 of this title.
(a.5) Repealed.
(b) Approval of contracts under this section does not constitute a commitment by the
general assembly to continue providing health services to students through the public schools
using state general funds if federal matching funds are not available in the future. Any moneys
provided to a school district pursuant to a contract entered into under this section shall not
supplant state or local moneys provided to school districts pursuant to the provisions of articles
20 to 28 or article 54 of title 22, C.R.S.
(c) Nothing in this section shall be construed as requiring any school district to enter into
a contract as provided in this section. Participation in a contract by a school district is voluntary.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 246 of 510
(d) The state department may make contracting and reimbursement of moneys under this
section contingent upon either:
(I) The contracting school district certifying to the state department, through the
department of education, that it has expended local and state moneys in an amount sufficient to
meet the nonfederal share of expenditures being claimed for federal financial participation; or
(II) The contracting school district meeting the requirements of the intergovernmental
transfer provisions of the federal medicaid law, 42 U.S.C. sec. 1396 et seq.
(3) Each year, by a date established by rule of the state board, the department of
education shall notify the state department concerning any school district that chooses to enter
into a contract as provided in this section and the anticipated level of funding for the school
district. Nothing in this section shall be construed to require a school district to maintain the
same level of funding or services from year to year.
(4) (a) (I) Each school district that chooses to enter into a contract as provided in this
section shall develop a services plan with input from the local community that identifies the
types of health services needed by students within the school district and the services it
anticipates providing. Except for medical emergencies and services related to allegations of child
abuse, a student's participation in any psychological, behavioral, social, or emotional services,
including counseling or referrals, shall be optional and shall require the prior written and
informed consent of a parent or legal guardian of the student.
(II) (A) Any health questionnaire or form related to services funded in part through this
section shall only relate to the student's personal health, habits, or conduct and shall not include
questions concerning the habits or conduct of any other member of the student's family.
(B) No medical or health data or information identifying the student or the student's
family shall be disclosed to any person other than a person specifically authorized to receive the
information or data without the prior written and informed consent of a parent or legal guardian
of the student.
(b) Each school district that chooses to enter into a contract as provided in this section
shall perform an assessment of the health-care needs of its uninsured and underinsured students
and may spend an appropriate portion, not to exceed thirty percent, of the federal moneys
received on health care for low-income students. For purposes of this paragraph (b),
"low-income students" means students whose families are below one hundred eighty-five
percent of the federal poverty line.
(c) The school district shall submit the services plan to the department of education with
a notice of participation for purposes of technical assistance evaluation and to the executive
director for approval.
(5) Each year not less than ninety days prior to the notification date established pursuant
to subsection (3) of this section, the state department shall provide information through the
department of education to school districts regarding the amount of available moneys and the
administrative activities required to enter into a contract for federal matching funds for that year.
To the extent allowed by existing resources, the department of education shall provide technical
assistance to school districts in determining levels of funding, meeting administrative
requirements, and developing services plans.
(6) Following the notification date established pursuant to subsection (3) of this section,
each contracting school district, through the department of education, shall enter into a contract
with the state department specifying the health services to be provided by the school district, the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 247 of 510
amount to be expended in providing the services, and the amount of federal matching funds for
which the school district is eligible under the contract.
(7) The state department is authorized to accept and expend donations, contributions,
grants, including federal matching funds, and other moneys that it may receive to finance the
costs associated with implementing this section.
(8) (a) Under the contract entered into pursuant to this section, a contracting school
district shall receive from the state department all of the federal matching funds for which it is
eligible under the contract, less the amount of state administrative costs allowed under paragraph
(b) of this subsection (8). All moneys received by a school district pursuant to this section shall
be used only to offset costs incurred for provision of student health services by the school district
or to cash fund student health services in the school district.
(b) Total allowable state administrative costs for contracts entered into under this section
for both the state department and the department of education shall not exceed ten percent of the
total annual amount of federal funds reflected by the general assembly for such contracts in the
annual general appropriations bill. State administrative costs include costs incurred in evaluating
the implementation of this section.
(9) The state board shall specify by rule the types of health services for which a school
district may receive federal matching funds under a contract created under this section, including
but not limited to:
(a) Basic primary, physical, dental, and mental health services;
(b) Rehabilitation services;
(c) Early and periodic screening, diagnosis, and treatment services; and
(d) Service coordination, outreach, enrollment, and administrative support.
(10) (a) A school district that provides health services under contract pursuant to this
section may provide the health services directly or through contractual relationships or
agreements with public or private entities, as allowed by applicable federal regulations.
However, no moneys shall be expended in any form for abortions, except as provided in section
25.5-4-415 or as required by federal law.
(b) Where possible, the school district shall coordinate the provision of health services to
a student with the student's primary health-care provider. Except for those services that are
required by an individualized educational program developed pursuant to section 22-20-108 (4),
C.R.S., or by a section 504 plan developed pursuant to the federal "Rehabilitation Act of 1973",
29 U.S.C. sec. 701 et seq., school districts shall not claim reimbursement under this section for
direct services to students enrolled in health maintenance organizations that would normally be
provided to students by their health maintenance organization.
(11) (a) The executive director shall apply for and secure any federal waivers and state
plan amendments required to implement this section.
(b) This section shall remain in effect only for so long as federal financial participation
is available for reimbursements to school districts. In the event, as specified in writing by the
attorney general to the governor that federal law does not allow or is amended to disallow
reimbursements to school districts or otherwise prevent the implementation of this section, this
section is repealed, effective on the date of the attorney general's opinion.
(12) The state department and the department of education shall work with the office of
state planning and budgeting and the joint budget committee in implementing this section.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 248 of 510
(13) The state department and the department of education shall enter into an
interagency agreement to provide for the implementation of this section. The state board and the
state board of education are authorized to promulgate rules as may be necessary in accordance
with the agreement.
(14) The state department shall annually, or more often as necessary, hold a public
hearing to receive comments from school districts, state agencies, and interested persons
regarding implementation of this section.
(15) On or before December 15, 2002, the state department shall submit a formal
evaluation of the implementation of this section to the committees on education and the
committees on health and human services of the house of representatives and the senate, or any
successor committees.
Source: L. 2006: Entire article added with relocations, p. 1878, § 7, effective July 1. L.
2009: (2)(a.5) added, (SB 09-264), ch. 204, p. 928, § 6, effective May 1. L. 2010: (4)(b)
amended, (HB 10-1422), ch. 419, p. 2113, § 147, effective August 11.
Editor's note: (1) This section is similar to former § 26-4-531 as it existed prior to
2006.
(2) Subsection (2)(a.5)(II) provided for the repeal of subsection (2)(a.5), effective July 1,
2011. (See L. 2009, p. 928.)
25.5-5-319. Family planning pilot program - rules - federal waiver - repeal. (1)
There is hereby established a family planning pilot program for the provision of family planning
services to categorically eligible individuals who are at or below a percentage of the federal
poverty line established pursuant to the federal waiver sought pursuant to subsection (2) of this
section. The state board shall promulgate rules setting forth the family planning services to be
provided under the family planning pilot program.
(2) The executive director of the state department, in consultation with the department of
public health and environment, shall seek a federal waiver that is cost-neutral to the state general
fund for the implementation of the family planning pilot program established pursuant to this
section such that ten percent of the family planning services provided to low-income families
pursuant to the program as described in subsection (1) of this section would be funded with state
general fund moneys and ninety percent would be funded with federal matching funds. In the
federal waiver, the executive director shall not seek authority to waive or disregard the
provisions of 42 U.S.C. sec. 1396a (a)(23)(B).
(3) (a) Upon issuance of the federal waiver sought pursuant to subsection (2) of this
section, the departments of health care policy and financing and public health and environment
shall seek the necessary appropriation of general funds through the normal budgetary process for
the implementation of this act.
(b) The executive director of the state department is authorized to accept and expend on
behalf of the state any funds, grants, gifts, and donations from any private or public source for
the purpose of implementing the family planning pilot program established in this section;
except that no gift, grant, donation, or funds shall be accepted if the conditions attached thereto
require the expenditure thereof in a manner contrary to law.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 249 of 510
(4) The executive director of the state department, or such executive director's designee,
shall prepare a written report for the members of the general assembly concerning the findings of
the department based upon the family planning pilot program. Such report shall be provided to
the members of the general assembly not more than three years after commencement of the
program. The report shall address the number of individuals served, the type of services
provided, the cost of the program, and such other information as the executive director deems
appropriate.
(5) The implementation of this section is conditioned upon the issuance of any necessary
waiver by the federal government and available appropriations pursuant to paragraph (a) of
subsection (3) of this section. The provisions of this section shall be implemented to the extent
authorized by federal waiver. The pilot program established by this section shall continue for
five years from the receipt of the federal waiver or for so long as specified in the federal waiver.
The executive director of the state department shall provide written notice to the revisor of
statutes of the final termination date of the waiver, and this section 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.
Source: L. 2006: Entire article added with relocations, p. 1882, § 7, effective July 1. L.
2008: (1) and (2) amended, p. 41, § 1, effective March 13. L. 2010: (1) amended, (HB 10-1422),
ch. 419, p. 2113, § 148, effective August 11.
Editor's note: (1) This section is similar to former § 26-4-414.7 as it existed prior to
2006.
(2) As of publication date, the revisor of statutes has not received the notice referred to
in subsection (5).
25.5-5-320. Telemedicine - reimbursement - disclosure statement - rules - definition.
(1) On or after July 1, 2006, in-person contact between a health-care or mental health-care
provider and a patient is not required under the state's medical assistance program for health-care
or mental health-care services delivered through telemedicine that are otherwise eligible for
reimbursement under the program. The state department shall promulgate rules specifically
relating to entities that deliver health-care or mental health-care services exclusively or
predominately through telemedicine. Any health-care or mental health-care service delivered
through telemedicine must meet the same standard of care as an in-person visit. Telemedicine
may be provided through interactive audio, interactive video, or interactive data communication,
including but not limited to telephone, relay calls, interactive audiovisual modalities, and live
chat, as long as the technologies are compliant with the federal "Health Insurance Portability and
Accountability Act of 1996", Pub.L. 104-191, as amended. The health-care or mental health-care
services are subject to reimbursement policies developed pursuant to the medical assistance
program. This section also applies to managed care organizations that contract with the state
department pursuant to the statewide managed care system only to the extent that:
(a) Health-care or mental health-care services delivered through telemedicine are
covered by and reimbursed under the medicaid per diem payment program; and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 250 of 510
(b) Managed care contracts with managed care organizations are amended to add
coverage of health-care or mental health-care services delivered through telemedicine and any
appropriate per diem rate adjustments are incorporated.
(2) The reimbursement rate for a telemedicine service shall, as a minimum, be set at the
same rate as the medical assistance program rate for a comparable in-person service. The state
department may consider setting the reimbursement rate on a monthly basis as well as on a daily
or per-visit basis.
(2.1) For the purposes of reimbursement for services provided by home care agencies, as
defined in section 25-27.5-102 (3), the services may be supervised through telemedicine or
telehealth.
(2.5) (a) A telemedicine service meets the definition of a face-to-face encounter for a
rural health clinic, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(2).
The reimbursement rate for a telemedicine service provided by a rural health clinic must be set at
a rate that is no less than the medical assistance program rate for a comparable face-to-face
encounter or visit.
(b) A telemedicine service meets the definition of a face-to-face encounter for a medical
care program of the federal Indian health service. The reimbursement rate for a telemedicine
service provided by a medical care program of the federal Indian health service must be set at a
rate that is no less than the medical assistance program rate for a comparable face-to-face
encounter or visit.
(c) A telemedicine service meets the definition of a face-to-face encounter for a federally
qualified health center, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x
(aa)(4). The reimbursement rate for a telemedicine service provided by a federally qualified
health center must be set at a rate that is no less than the medical assistance program rate for a
comparable face-to-face encounter or visit.
(3) The state department shall establish rates for transmission cost reimbursement for
telemedicine services, considering, to the extent applicable, reductions in travel costs by
health-care or mental health-care providers and patients to deliver or to access such services and
such other factors as the state department deems relevant.
(4) A health-care or mental health-care provider who delivers health-care or mental
health-care services through telemedicine shall provide to each patient, before treating that
patient through telemedicine for the first time, the following written statements:
(a) That the patient retains the option to refuse the delivery of the services via
telemedicine at any time without affecting the patient's right to future care or treatment and
without risking the loss or withdrawal of any program benefits to which the patient would
otherwise be entitled;
(b) That all applicable confidentiality protections shall apply to the services; and
(c) That the patient shall have access to all medical information resulting from the
telemedicine services as provided by applicable law for patient access to his or her medical
records.
(5) Subsection (4) of this section shall not apply in an emergency.
(6) Repealed.
(7) As used in this section, "health-care or mental health-care services" includes speech
therapy, physical therapy, occupational therapy, dental care, hospice care, home health care, and
pediatric behavioral health care.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 251 of 510
Source: L. 2006: Entire section added, p. 1548, § 5, effective July 1. L. 2008: (1), (3),
IP(4), and (4)(a) amended, p. 112, § 3, effective August 5. L. 2020: IP(1) amended and (2.1),
(2.5), (6), and (7) added, (SB 20-212), ch. 235, p. 1141, § 5, effective July 6. L. 2021: (7)
amended, (SB 21-139), ch. 113, p. 443, § 2, effective May 7; IP(1) amended, (HB 21-1256), ch.
193, p. 1017, § 1, effective May 27.
Editor's note: (1) This section was enacted as § 26-4-421.5 in Senate Bill 06-165.
Section 9 of the bill provided for the renumbering of that section. (See L. 2006, p. 1552.)
(2) Subsection (6)(b) provided for the repeal of subsection (6), effective July 1, 2022.
(See L. 2020, p. 1141.)
Cross references: For the legislative declaration contained in the 2006 act enacting this
section, see section 1 of chapter 312, Session Laws of Colorado 2006. For the legislative
declaration in SB 20-212, see section 1 of chapter 235, Session Laws of Colorado 2020.
25.5-5-321. Telemedicine - home health care - home health telemedicine cash fund -
rules - repeal. (1) On or after August 11, 2010, at-home telemedicine shall be eligible for
reimbursement under the state's medical assistance program. The services delivered through
telemedicine shall be subject to reimbursement policies promulgated by rule of the state board
after consultation with home health-care and home- and community-based services providers.
This section also applies to managed care organizations that contract with the state department
pursuant to the statewide managed care system, but only to the extent that:
(a) Home health care or home- and community-based services delivered through
telemedicine are covered by and reimbursed under the medicaid program; and
(b) Managed care contracts with managed care organizations are amended to add
coverage of home health care or home- and community-based services delivered through
telemedicine.
(2) (a) The reimbursement rate for home health care or home- and community-based
services delivered through telemedicine that are otherwise eligible for reimbursement under the
medical assistance program shall be set by rule of the state board and shall be:
(I) In the form of a flat fee in one or more levels, depending on acuity.
(II) (Deleted by amendment, L. 2010, (HB 10-1005), ch. 345, p. 1598, § 1, effective
August 11, 2010.)
(b) Any cost savings identified pursuant to this section shall be considered for use in
paying for home- and community-based services under part 6 of this article, community-based
long-term care, and home health services.
(c) For the first two years after August 11, 2010, gifts, grants, and donations shall be
used to implement this section. Gifts, grants, and donations made for this purpose shall be
transferred to the home health telemedicine cash fund, which is hereby created in the state
treasury. Moneys in the home health telemedicine cash fund shall be appropriated to the state
board and used to implement this section. Moneys in the fund shall remain in the fund and not be
transferred to the general fund at the end of any fiscal year. After two years or if the moneys in
the cash fund are depleted, the department is authorized to go through the normal budget process
to continue implementation of this section.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 252 of 510
(3) (a) Reimbursement shall not be provided for purchase or lease of telemedicine
equipment.
(b) (I) Subsection (3)(a) of this section does not apply to expenditures made pursuant to
part 18 of article 6 of this title 25.5.
(II) This subsection (3)(b) is repealed, effective July 1, 2025.
(4) (a) A home health-care or home- and community-based services provider who
delivers services through telemedicine shall provide to each patient, before treating that patient
through telemedicine for the first time, the following written statements:
(I) That the patient retains the option to refuse the delivery of home health care or home-
and community-based services via telemedicine at any time without affecting the patient's right
to future care or treatment and without risking the loss or withdrawal of any program benefits to
which the patient would otherwise be entitled;
(II) That all applicable confidentiality protections shall apply to the services; and
(III) That the patient shall have access to all medical information resulting from the
telemedicine services as provided by applicable law for patient access to his or her medical
records.
(b) The provisions of paragraph (a) of this subsection (4) shall not apply in an
emergency.
(5) Nothing in this section shall be construed to:
(a) Alter the scope of practice of any home health-care or home- and community-based
services provider; or
(b) Authorize the delivery of home health care or home- and community-based services
in a setting or manner not otherwise authorized by law.
Source: L. 2007: Entire section added, p. 1182, § 2, effective January 1, 2008. L. 2010:
(1), (2), and (3) amended, (HB 10-1005), ch. 345, p. 1598, § 1, effective August 11. L. 2021: (3)
amended, (SB 21-286), ch. 395, p. 2627, § 3, effective June 30.
25.5-5-321.5. Telehealth - interim therapeutic restorations - reimbursement -
definitions. (1) Subject to federal authorization and federal financial participation, on or after
July 1, 2016, in-person contact between a health-care provider and a recipient is not required
under the state's medical assistance program 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 program when provided in person. The services
are subject to the reimbursement policies developed pursuant to the state medical assistance
program.
(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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 253 of 510
Source: L. 2015: Entire section added, (HB 15-1309), ch. 326, p. 1334, § 8, effective
August 5. L. 2019: (2) amended, (HB 19-1172), ch. 136, p. 1709, § 182, effective October 1. L.
2021: (2)(b) amended, (SB 21-102), ch. 31, p. 130, § 10, effective September 1.
25.5-5-322. Over-the-counter medications - rules. (1) (a) Subject to approval through
the state budget process in paragraph (b) of this subsection (1), the state board shall adopt by rule
a system to allow pharmacies to be reimbursed for providing certain over-the-counter
medications to recipients if prescribed by a licensed practitioner authorized to prescribe
prescription drugs or, subject to the limitations contained in subsection (2) of this section, a
licensed pharmacist. Over-the-counter medications subject to reimbursement pursuant to this
section shall be identified through the drug utilization review process established in section
25.5-5-506, and shall be limited to medications that, if reimbursed, shall result in overall cost
savings to the state.
(b) After the list of over-the-counter medications is identified pursuant to paragraph (a)
of this subsection (1), the state department shall request, through the state budget process, that
the reimbursements be implemented. The state department shall report to the joint budget
committee annually concerning the amount of any savings realized from the reimbursements.
(2) (a) The state board, in consultation with the state board of pharmacy created pursuant
to section 12-280-104, shall establish by rule standards for when a licensed pharmacist may
prescribe over-the-counter medications as provided under this section for purposes of receiving
reimbursement under the medical assistance program.
(b) When prescribing over-the-counter medications under this section, a licensed
pharmacist shall consult with the recipient to determine necessity, provide drug counseling,
review drug therapy for potential adverse interactions, and make referrals as needed to other
health-care professionals.
Source: L. 2010: Entire section added, (SB 10-117), ch. 227, p. 985, § 2, effective July
1. L. 2012: (2)(a) amended, (HB 12-1311), ch. 281, p. 1628, § 75, effective July 1. L. 2019:
(2)(a) amended, (HB 19-1172), ch. 136, p. 1709, § 183, effective October 1.
25.5-5-323. Complex rehabilitation technology - no prior authorization - metrics -
report - rules - legislative declaration - definitions. (1) The general assembly finds and
declares it is in the best interests of the people of the state of Colorado to:
(a) Continue to protect access to important technology and supporting services for
eligible clients;
(b) Establish and improve current safeguards relating to the delivery, provision, and
repair of medically necessary complex rehabilitation technology;
(c) Continue to provide supports for clients accessing complex rehabilitation technology
to stay in the home or community setting; engage in basic activities of daily living and
instrumental activities of daily living, including employment; prevent institutionalization; and
prevent hospitalization and other costly secondary complications; and
(d) Continue adequate pricing for complex rehabilitation technology for the purpose of
allowing continued access to appropriate products and related services including maintenance
and repair.
(2) As used in this section, unless the context otherwise requires:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 254 of 510
(a) "Complex rehabilitation technology" means individually configured manual
wheelchair systems, power wheelchair systems, adaptive seating systems, alternative positioning
systems, standing frames, gait trainers, and specifically designated options and accessories
classified as durable medical equipment that:
(I) Are individually configured for individuals to meet their specific and unique medical,
physical, and functional needs and capacities for basic activities of daily living and instrumental
activities of daily living, including employment, identified as medically necessary to promote
mobility in the home and community or prevent hospitalization or institutionalization of the
client;
(II) Are primarily used to serve a medical purpose and generally not useful to a person in
the absence of illness or injury; and
(III) Require certain services provided by a qualified complex rehabilitation technology
provider to ensure appropriate design, configuration, and use of such items, including patient
evaluation or assessment of the client by a health-care professional, and that are consistent with
the client's medical condition, physical and functional needs and capacities, body size, period of
need, and intended use.
(b) "Individually configured" means that a device has features, adjustments, or
modifications specific to a client that a qualified complex rehabilitation technology supplier
provides by measuring, fitting, programming, adjusting, adapting, and maintaining the device so
that the device is consistent with an assessment or evaluation of the client by a health-care
professional and consistent with the client's medical condition, physical and functional needs and
capacities, body size, period of need, and intended use.
(c) "Qualified complex rehabilitation technology professional" means an individual who
is certified by the rehabilitation engineering and assistive technology society of North America
or other nationally recognized accrediting organizations as an assistive technology professional.
(d) "Qualified complex rehabilitation technology supplier" means a company or entity
that:
(I) Is accredited by a recognized accrediting organization as a supplier of complex
rehabilitation technology;
(II) Meets the supplier and quality standards established for durable medical equipment
suppliers under the medicare or medicaid program;
(III) Employs at least one qualified complex rehabilitation technology professional for
each location to:
(A) Analyze the needs and capacities of clients for a complex rehabilitation technology
item in consultation with the evaluating clinical professionals;
(B) Assist in selecting appropriate complex rehabilitation technology items for such
needs and capacities; and
(C) Provide the client technology-related training in the proper use and maintenance of
the selected complex rehabilitation technology items;
(IV) Has the qualified complex rehabilitation technology professional directly involved
with the assessment, and determination of the appropriate individually configured complex
rehabilitation technology for the client, with such involvement to include seeing the client
visually either in person or by any other real-time means within a reasonable time frame during
the determination process.
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(V) Maintains a reasonable supply of parts, adequate physical facilities, and qualified
service or repair technicians to provide clients with prompt service and repair of all complex
rehabilitation technology it sells or supplies; and
(VI) Provides the client written information at the time of sale as to how to access
service and repair.
(3) The state department shall provide a separate recognition within the state's medicaid
program established under articles 4, 5, and 6 of this title for complex rehabilitation technology
and shall make other required changes to protect client access to appropriate products and
services. Such separate recognition must take into consideration the customized nature of
complex rehabilitation technology and the broad range of related services necessary to meet the
unique medical and functional needs of clients and include the following:
(a) The state department notifying the qualified rehabilitation technology suppliers
concerning the parameters of the complex rehabilitation technology benefit, which benefit must
include the use of qualified rehabilitation technology suppliers as well as billing procedures that
specify the types of equipment identified and included in the complex rehabilitation technology
benefit. The state department shall create complex rehabilitation technology benefit parameters
that are easily understood by and accessible to clients and qualified rehabilitation technology
suppliers. The state department shall provide public notice no later than thirty days prior to a
collaborative process that includes discussion of any proposed changes to the types of equipment
identified and included in the complex rehabilitation technology benefit.
(b) Adopting specific supplier standards, as described in paragraph (d) of subsection (2)
of this section, for companies or entities that provide complex rehabilitation technology and
restricting the provision of complex rehabilitation technology to those companies or entities that
are qualified complex rehabilitation suppliers;
(c) Ensuring that clients receiving complex rehabilitation technology are evaluated or
assessed, as needed, by:
(I) A qualified health-care professional, including but not limited to a licensed physical
therapist, a licensed occupational therapist, or other licensed health-care professional who has no
financial relationship with the qualified complex rehabilitation technology supplier and performs
specialty evaluations within his or her scope of practice; and
(II) A qualified complex rehabilitation technology professional employed by the
qualified complex rehabilitation technology supplier. The assessment and determination
performed by the qualified complex rehabilitation technology professional employed by the
qualified complex rehabilitation supplier shall continue to be included in the reimbursement for
the purchased or rented complex rehabilitation technology;
(d) Continuing pricing policies for complex rehabilitation technology, unless specifically
prohibited by the federal centers for medicare and medicaid services, including the following:
(I) Continuing to ensure that the reimbursement amounts for complex rehabilitation
technology, repairs, and supporting clinical complex rehabilitation technology services are
adequate to ensure that qualified clients have access to the items, taking into account the unique
needs of the clients and the complexity and customization of complex rehabilitation technology.
This includes developing pricing policies that ensure access to adequate and timely repairs.
(II) Exempting complex rehabilitation technology from inclusion in competitive bidding
programs or similar processes; and
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(III) Preserving the option for complex rehabilitation technology to be billed and paid
for as a purchase allowing for lump sum payments for devices with a length of need of one year
or greater, excluding approved crossover claims for clients enrolled in medicare and medicaid;
and
(e) Making other changes as needed to protect access to complex rehabilitation
technology for clients.
(4) The state department shall not require prior authorization for any repair of complex
rehabilitation technology.
(5) (a) No later than October 1, 2023, the state board shall promulgate rules establishing
repair metrics for all complex rehabilitation technology suppliers and complex rehabilitation
technology professionals. At a minimum, the metrics must include requirements for repairing
complex rehabilitation technology in a timely manner and the expected quality of each repair.
Prior to promulgating rules pursuant to this subsection (5)(a), the state department shall engage
in a stakeholder process, which process must include qualified complex rehabilitation
technology professionals, qualified complex rehabilitation technology suppliers, and complex
rehabilitation technology clients.
(b) Beginning January 2024, and each January thereafter, the state department shall
report on the metrics developed pursuant to subsection (5)(a) of this section and compliance with
the metrics as part of its "State Measurement for Accountable, Responsive, and Transparent
(SMART) Government Act" hearing required by section 2-7-203.
(6) Three years after the date the repair metric rules are established pursuant to
subsection (5)(a) of this section, the state department may engage in a stakeholder process to
determine the need for additional accountability of a qualified complex rehabilitation technology
supplier through financial penalties, audits, or similar tools, for violations of the repair metrics
rules. If such a stakeholder process is convened, the process must include qualified complex
rehabilitation technology professionals, qualified complex rehabilitation technology suppliers,
complex rehabilitation clients, and an advocacy group for persons with disabilities.
(7) Beginning December 1, 2024, the state department shall reimburse labor costs for
repairs of complex rehabilitation technology at a rate that is twenty-five percent higher for
clients residing in rural areas than the rate for clients residing in urban areas.
Source: L. 2014: Entire section added, (HB 14-1211), ch. 253, p. 1008, § 1, effective
January 1, 2015. L. 2022: (4), (5), (6), and (7) added, (HB 22-1290), ch. 328, p. 2313, § 1,
effective June 2. L. 2023: IP(3)(d) amended, (HB 23-1301), ch. 303, p. 1831, § 51, effective
August 7.
25.5-5-324. Nonemergency medical transportation - urgent and secure
transportation need - report - repeal. (1) On or before January 1, 2019, the state department
shall create and implement an efficient and cost-effective method for meeting urgent
transportation needs within the existing nonemergency medical transportation benefit under the
medical assistance program. Urgent transportation needs include discharge from inpatient,
emergency services, and other urgent but nonemergency services, as determined by the state
department.
(2) The method created by the state department must include, at a minimum:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 257 of 510
(a) Medical service provider or facility access to approved transportation providers for
patients with urgent transportation needs;
(b) Access to transportation providers that have obtained the necessary background
checks, drug tests, training, and vehicle inspections, as required by the state department; and
(c) An efficient method for obtaining and paying for transportation services for urgent
transportation needs.
(3) The state department may contract for background checks, drug tests, training, and
vehicle inspections that may be required pursuant to subsection (2) of this section.
(4) (a) The state department shall annually report on the implementation and
effectiveness of the process created in this section for meeting urgent and secure transportation
needs within the nonemergency medical transportation benefit and secure transportation services
benefit. The state department shall present the report as part of its annual "State Measurement for
Accountable, Responsive, and Transparent (SMART) Government Act" presentation required by
section 2-7-203 to 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 any
successor committees.
(b) Notwithstanding the provisions of section 24-1-136 (11)(a)(I) to the contrary, the
report required pursuant to this section shall continue until the beginning of the 2025 legislative
session.
(c) This section is repealed, effective July 1, 2025.
Source: L. 2018: Entire section added, (HB 18-1321), ch. 346, p. 2064, § 1, effective
May 30. L. 2019: (4)(a) amended, (SB 19-252), ch. 254, p. 2452, § 5, effective August 2. L.
2021: (4)(a) amended, (HB 21-1085), ch. 355, p. 2311, § 3, effective June 27; (4)(a) amended,
(SB 21-266), ch. 423, p. 2802, § 23, effective July 2.
Editor's note: Amendments to subsection (4)(a) by SB 21-266 and HB 21-1085 were
harmonized.
25.5-5-325. Residential and inpatient substance use disorder treatment - medical
detoxification services - federal approval - performance review report. (1) Subject to
available appropriations and to the extent permitted under federal law, the medical assistance
program pursuant to this article 5 and articles 4 and 6 of this title 25.5 includes residential and
inpatient substance use disorder treatment and medical detoxification services. Participation in
the residential and inpatient substance use disorder treatment and medical detoxification services
benefit is limited to persons who meet nationally recognized, evidence-based level of care
criteria for residential and inpatient substance use disorder treatment and medical detoxification
services. The benefit shall serve persons with substance use disorders, including those with
co-occurring mental health disorders. All levels of nationally recognized, evidence-based levels
of care for residential and inpatient substance use disorder treatment and medical detoxification
services must be included in the benefit.
(2) (a) No later than October 1, 2018, the state department shall seek federal
authorization to provide residential and inpatient substance use disorder treatment and medical
detoxification services with full federal financial participation. Residential and inpatient
Colorado Revised Statutes 2023 Uncertified PrintoutPage 258 of 510
substance use disorder treatment and medical detoxification services shall not take effect until
federal approval has been obtained.
(b) Prior to seeking federal approval pursuant to subsection (2)(a) of this section, the
state department shall seek input from relevant stakeholders, including existing providers of
substance use disorder treatment and medical detoxification services and behavioral health
administrative services organizations. The state department shall seek input and involve
stakeholders in decisions regarding:
(I) The coordination of benefits with behavioral health administrative services
organizations and the department of human services;
(II) The most appropriate entity for administration of the benefit;
(III) The provision of wraparound services needed during treatment and the provision of
required services following treatment that may not be covered through the medical assistance
program;
(IV) The authorization process for approval of services; and
(V) The development of a reimbursement rate methodology to ensure sustainability that
considers a provider's cost of providing care, including lower-volume providers in rural areas.
(3) (a) No later than January 15, 2022, the state department shall prepare and submit a
performance review report to the joint budget committee and to the joint health and human
services committee, or any successor committees, concerning the residential and inpatient
substance use disorder treatment pursuant to this section, including, at a minimum:
(I) The number of persons who received services pursuant to this section and the service
provided;
(II) The length of time that services were provided;
(III) The location where services were provided;
(IV) The effectiveness of the services provided, including the rate of relapse to substance
use disorder following treatment; and
(V) Any other information as determined by the state department that is relevant to the
benefit.
(b) After considering the state department's performance review report, the general
assembly may enact legislation modifying or repealing the benefit.
Source: L. 2018: Entire section added, (HB 18-1136), ch. 373, p. 2269, § 2, effective
June 5. L. 2022: IP(2)(b) and (2)(b)(I) amended, (HB 22-1278), ch. 222, p. 1597, § 242,
effective August 10. L. 2023: (2)(b)(I) amended, (HB 23-1236), ch. 206, p. 1054, § 14, effective
May 16.
25.5-5-326. Access to clinical trials - definitions. (1) As used in this section, unless the
context otherwise requires:
(a) "Approved clinical trial" means a phase I, II, III, or IV clinical trial involving the
prevention, detection, diagnosis, or treatment of a life-threatening or debilitating disease or
condition if any one of the following conditions apply:
(I) The clinical trial is conducted under an investigational new drug application or an
investigational device exemption reviewed by the federal food and drug administration, or is
exempted from review by the federal food and drug administration; or
(II) The clinical trial is approved or funded by:
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(A) The national institutes of health;
(B) The centers for disease control and prevention;
(C) The agency for health care research and quality;
(D) The federal centers for medicare and medicaid services;
(E) A cooperative group or center of any of the entities described in subsections
(1)(a)(II)(A) to (1)(a)(II)(D) of this section, the federal department of defense, or the federal
department of veterans affairs;
(F) A qualified nongovernmental research entity identified in guidelines issued by the
national institutes of health for center support grants; or
(G) The federal department of veterans affairs, the federal department of defense, or the
federal department of energy, provided that review and approval of the clinical trial occurs
through a system of peer review that is comparable to the peer review of clinical trials performed
by the national institutes of health, including an unbiased review of the highest scientific
standards by qualified individuals who have no interest in the outcome of the review.
(b) "Life-threatening or debilitating disease or condition" means a disease or condition
from which the likelihood of death is probable, or the disease or condition is progressive or
significantly debilitating, unless the course of the disease or condition is interrupted.
(c) "Qualified individual" means an individual who is eligible for and enrolled in the
state medical assistance program and who a treating physician determines has a life-threatening
or debilitating disease or condition and meets the selection criteria for the approved clinical trial.
(d) (I) "Routine costs" means medically necessary items and services that are included
under the medical assistance program for a medical assistance recipient, to the extent that the
provision of such items or services to the individual outside the course of such participation
would otherwise be covered under the medical assistance program, without regard to whether the
recipient is enrolled in a clinical trial. For medical assistance recipients participating in an
approved clinical trial, "routine costs" include medically necessary items and services that are
not otherwise excluded pursuant to subsection (1)(d)(II)(D) of this section, relating to the
detection and treatment of complications arising from the medical assistance recipient's medical
care, including complications relating to participation in the clinical trial, to the extent that the
provision of such items or services to the individual outside the course of such participation
would otherwise be included under the medical assistance program.
(II) "Routine costs" do not include:
(A) The investigational item, device, or service itself;
(B) Items and services provided solely to satisfy the data collection and analysis needs of
the clinical trial;
(C) Items, drugs, or services customarily provided free of charge to any qualified
individual enrolled in the clinical trial; or
(D) Items, drugs, or services that the clinical trial is required to provide.
(2) The medical assistance program established pursuant to this article 5 and articles 4
and 6 of this title 25.5 must include coverage and payment for the routine costs associated with
participation in an approved clinical trial for a qualified individual.
Source: L. 2020: Entire section added, (HB 20-1232), ch. 266, p. 1277, § 1, effective
July 10.
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25.5-5-327. Eligible peer support services - reimbursement - definitions. (1) As used
in this section, unless the context otherwise requires:
(a) "Peer support professional" has the same meaning as defined in section 27-60-108
(2)(b).
(b) "Recovery support services organization" has the same meaning as defined in section
27-60-108 (2)(c).
(2) Subject to available appropriations and to the extent permitted under federal law, the
medical assistance program pursuant to this article 5 and articles 4 and 6 of this title 25.5
includes peer support professional services provided to recipients through a recovery support
services organization. Peer support professional services must not be provided to recipients until
federal approval has been obtained.
Source: L. 2021: Entire section added, (HB 21-1021), ch. 256, p. 1509, § 2, effective
September 7.
25.5-5-328. Secure transportation for behavioral health crises - benefit - funding. (1)
On or before January 1, 2023, the state department shall create a benefit for secure transportation
services, as defined in section 25-3.5-103 (11.4). The state department shall research and create a
plan to establish secure transportation services, which may include supplemental and
coordinated community response services, to be implemented on or before July 1, 2023. The
state department shall collaborate with the behavioral health administration in the department of
human services in its research and planning efforts to determine how this benefit may align with
co-responder, mobile crisis, and emergency crisis dispatch.
(2) The state department is authorized to seek, accept, and expend gifts, grants, and
donations from public or private sources for the purpose of funding the urgent transportation
needs within the existing nonemergency medical transportation benefit and secure transportation
services benefit under the medical assistance program, as set forth in subsection (1) of this
section and section 25.5-5-324 (1).
Source: L. 2021: Entire section added, (HB 21-1085), ch. 355, p. 2312, § 4, effective
June 27. L. 2022: (1) amended, (HB 22-1278), ch. 222, p. 1515, § 75, effective July 1.
25.5-5-329. Family planning services - federal authorization - rules - definitions. (1)
As used in this section, unless the context otherwise requires:
(a) "Eligible individual" means an individual who is not pregnant and whose income
does not exceed the state's current effective income level for pregnant women under the
children's basic health plan established pursuant to article 8 of title 25.5, and whose income is
adjusted for family size based on the methodology allowed under federal law to count the
applicant as a household of two in addition to any other household members, and who meets
other requirements under federal law.
(b) "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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 261 of 510
(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.
(c) "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.
(d) "Presumptive eligibility" has the same meaning as defined in section 25.5-5-204 (1).
(2) (a) No later than January 31, 2022, the state department shall seek federal
authorization through an amendment to the state medical assistance plan to provide family
planning services to eligible individuals.
(b) The state plan amendment must:
(I) Not impose age, sex, or gender identity limitations on eligible individuals; and
(II) Include a process by which an eligible individual may be presumptively eligible to
receive family planning services.
(3) Upon approval of the state plan amendment, the state department shall:
(a) Unless requested otherwise by the eligible individual, ensure that an eligible
individual receives a one-year supply of self-administered hormonal contraceptives at one time
as permitted by the eligible individual's prescription; and
(b) Collaborate with the state insurance marketplace, health-care consumer advocates,
and other interested stakeholders to educate eligible individuals about all available health-care
coverage options and encourage eligible individuals to enroll in full health insurance coverage
through available sources, including the medical assistance program, the children's basic health
plan, a public benefit corporation, or the state insurance marketplace.
(4) The state department shall promulgate any rules necessary to implement this section,
including rules establishing the specific family-planning-related services and family planning
services identified in subsections (1)(b) and (1)(c) 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.
Source: L. 2021: Entire section added, (SB 21-025), ch. 432, p. 2855, § 2, effective
September 7.
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Cross references: For the legislative declaration in SB 21-025, see section 1 of chapter
432, Session Laws of Colorado 2021.
25.5-5-330. Screening for perinatal mood and anxiety disorder. (1) For the caregiver
of each child enrolled in the medical assistance program in the state, the program must include
screening for perinatal mood and anxiety disorders in accordance with the health resources and
services administration guidelines.
(2) The screening must be made available to the caregiver of each child enrolled in the
medical assistance program, regardless of whether the caregiver is enrolled in the medical
assistance program, so long as the caregiver's child is enrolled in the medical assistance program.
Source: L. 2021: Entire section added, (SB 21-137), ch. 362, p. 2366, § 12, effective
June 28.
Cross references: For the short title ("Behavioral Health Recovery Act of 2021") and the
legislative declaration in SB 21-137, see sections 1 and 2 of chapter 362, Session Laws of
Colorado 2021.
25.5-5-331. Federally qualified health center - clinical pharmacy services -
reimbursement - rules. (1) Costs associated with services provided by clinical pharmacists
through a federally qualified health center, as defined in the federal "Social Security Act", 42
U.S.C. sec. 1395x (aa)(4), are considered allowable costs for the purpose of a federally qualified
health center's cost report and must be included in the calculation of the reimbursement rate for a
patient visit at a federally qualified health center.
(2) The state department shall promulgate rules to implement the provisions of this
section.
Source: L. 2021: Entire section added, (HB 21-1275), ch. 470, p. 3379, § 2, effective
September 7.
25.5-5-332. Therapy using equine movement - federal authorization - definition. (1)
Subject to federal authorization and federal financial participation, on or after July 1, 2024,
therapy using equine movement may be provided by a physical therapist licensed pursuant to
article 285 of title 12, an occupational therapist licensed pursuant to article 270 of title 12, or a
speech-language pathologist certified pursuant to article 305 of title 12.
(2) As used in this section, unless the context otherwise requires, "therapy using equine
movement" means therapeutic activities that leverage horse-human interactions to facilitate
progression toward meeting therapeutic goals.
Source: L. 2022: Entire section added, (HB 22-1068), ch. 311, p. 2229, § 2, effective
June 2.
Cross references: For the legislative declaration in HB 22-1068, see section 1 of chapter
311, Session Laws of Colorado 2022.
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25.5-5-333. Primary care and behavioral health statewide integration grant
program - creation - report - definition - repeal. (1) As used in this section, unless the
context otherwise requires, "grant program" means the primary care and behavioral health
statewide integration grant program created in subsection (2) of this section.
(2) There is created in the state department the primary care and behavioral health
statewide integration grant program to provide grants to physical and behavioral health-care
providers for implementation of evidence-based clinical integration care models, as defined by
the state department, in collaboration with the behavioral health administration in the department
of human services.
(3) (a) Grant recipients may use the money received through the grant program for the
following purposes:
(I) Developing infrastructure for primary care, pediatric, and behavioral health-care
providers to better serve individuals with behavioral health needs in outpatient health-care
settings;
(II) Increasing access to quality health care for individuals with behavioral health needs;
(III) Investing in early interventions for children, youth, and adults that reduce escalation
and exacerbation of behavioral health conditions;
(IV) Addressing the need to expand the behavioral health-care workforce;
(V) Developing and implementing alternative payment models, including the
development of protocols, processes, work flow, and partnerships; and
(VI) Training primary care providers in trauma-informed care, adverse childhood
experiences, and trauma recovery.
(b) Any money received through the grant program must supplement and not supplant
existing health-care services. Grant recipients shall not use money received through the grant
program for:
(I) Ongoing or existing executive and senior staff salaries;
(II) Services already covered by medicaid or a client's insurance; or
(III) Ongoing or existing electronic health records costs.
(c) (I) (A) If a grant recipient is a hospital-owned or hospital-affiliated practice that is
not part of a hospital system and has less than ten percent total profit as measured by state
department transparency reporting, the grant recipient shall provide a twenty-five percent match
for the awarded amount. The grant recipient may use community benefit funds, in-kind
personnel time, or federal relief funding for the twenty-five percent match required pursuant to
this subsection (3)(c)(I)(A).
(B) If a grant recipient is a hospital-owned or hospital-affiliated practice that is part of a
hospital system or has ten percent or more total profit as measured by state department
transparency reporting, the grant recipient shall provide a fifty percent match for the awarded
amount. The grant recipient may use community benefit funds, in-kind personnel time, or federal
relief funding for the fifty percent match required pursuant to this subsection (3)(c)(I)(B).
(C) If a grant recipient is a critical access hospital, as defined in section 10-16-1303 (2),
the grant recipient shall provide a ten percent match for the awarded amount. The grant recipient
may use community benefit funds, in-kind personnel time, or federal relief funding for the ten
percent match required pursuant to this subsection (3)(c)(I)(C).
(II) For the purposes of this subsection (3)(c), "hospital-affiliated" means there is a
contractual relationship between a hospital or an entity that is owned by or under common
Colorado Revised Statutes 2023 Uncertified PrintoutPage 264 of 510
ownership and control with the hospital in which the contractual relationship enables the hospital
or entity that is owned by or under common ownership and control with the hospital to exercise
control over one of the following entities:
(A) Another hospital;
(B) An entity owned by or under common ownership and control with another hospital;
or
(C) A physician group practice.
(d) The state department may provide funding to physical and behavioral health-care
providers through infrastructure building and population-based payment mechanisms.
(e) Grant recipients shall participate in technical assistance education and training and
related workgroups as determined by the state department.
(4) (a) The state department shall administer the grant program and, subject to available
appropriations, shall award grants as provided in this section. Subject to available appropriations,
grants shall be paid out of the behavioral and mental health cash fund created in section
24-75-230.
(b) In order to support real-time transformation and access to care, the state department
shall ensure timely payment to grant recipients for services related to the grant program.
(5) Grant applicants shall demonstrate a commitment to maintaining models and
programs that, at a minimum:
(a) Measurably increase access to behavioral health screening, referral, treatment, and
recovery care;
(b) Implement or expand evidence-based models for integration that improve patient
health as evidenced by relevant and meaningful outcomes measures, including patient-reported
outcomes;
(c) Leverage multidisciplinary treatment teams;
(d) Serve publicly funded clients;
(e) Maintain a plan for how to address a client with emergency needs;
(f) Maintain a plan for how technology will be leveraged for whole-person care, which
may include plans for data security, electronic health records reforms, care management
platforms, and telehealth implementation or expansion; and
(g) Implement or engage in state-department-specified tools and shared learning and
resources, including but not limited to:
(I) Peer learning collaboratives to develop sustainable population-based payment models
led by the state department;
(II) Use of electronic tools for screening, measurement-based care management, and
referrals; and
(III) Data-sharing best practices.
(6) In selecting grant recipients, the state department shall first prioritize applicants that
serve priority populations that experience disparities in health-care access and outcomes,
including but not limited to historically marginalized and underserved communities, determined
by the communities with the highest proportion of patients receiving assistance through the
"Colorado Medical Assistance Act", this article 5 and articles 4 and 6 of this title 25.5. The state
department shall then prioritize applicants that meet as many of the following criteria as
possible:
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(a) Serve individuals with co-occurring and complex care needs, serious mental
illnesses, or disabilities;
(b) Serve children and youth;
(c) Include opportunities to build out community health worker, behavioral health aide,
or similar programs, supported by population-based payments;
(d) Serve pregnant and postpartum people;
(e) The practice is considered a small and independent practice;
(f) Demonstrate the ability and intent to serve culturally diverse populations and
populations with limited English proficiency;
(g) Include workforce capacity-building components;
(h) Include high-intensity outpatient services;
(i) Improve data exchange and data integration that supports whole-person care;
(j) Utilize telehealth;
(k) Align with or participate in commercial alternative payment models;
(l) Demonstrate community partnerships; or
(m) Participate in the regional health connector program created in section
25-20.5-2001.
(7) (a) The state department shall establish a set of statewide resources to support grant
recipients. At a minimum, the resources must include:
(I) A clinical consultation and practice transformation support team provided by the
Colorado health extension system in the practice innovation program; and
(II) A sustainable billing and data partnership team that will train and support grant
recipients in meeting standards and core competencies for alternative payment models,
transforming the primary care providers' payment systems to focus on integrative, whole-person
care, and creating and implementing data-sharing practices and policies that support mental
health disorders, substance use disorders, and co-occurring disorders.
(b) The state department may enter into interagency agreements or procure contracts to
establish the resources pursuant to this subsection (7).
(8) The state department may procure a grant application and support team to assist the
state department with drafting the grant application, reviewing applications, and administering
and processing grant awards.
(9) A grant recipient must spend or obligate any money received pursuant to this section
in accordance with section 24-75-226 (4)(d).
(10) (a) The state department shall establish a steering committee to:
(I) Provide continuous input into grant application requirements;
(II) Provide feedback and direction on data collection standards and review; and
(III) Engage with community partners who will help support the integrated care practices
through referrals and trusted communications.
(b) The state department shall select a state department employee to chair the steering
committee, staff the steering committee, and reimburse any participant who is not a state
employee for reasonable travel expenses.
(11) The state department shall, in collaboration with the behavioral health
administration and the division of insurance, prepare a report that includes recommendations on
best practices for sustaining integrated care models. In preparing the report, the state department
shall collect data from each grant recipient related to clinical quality improvement and access to
Colorado Revised Statutes 2023 Uncertified PrintoutPage 266 of 510
care. Grant recipients shall provide data to the state department in a timely manner, as
determined by the state department. The state department is authorized to recoup or discontinue
grant funding for grant recipients that do not comply with the data reporting requirements or
grant standards set by the state department.
(12) The state department and any person who receives money from the state department
pursuant to this section shall comply with the compliance, reporting, record-keeping, and
program evaluation requirements established by the office of state planning and budgeting and
the state controller in accordance with section 24-75-226 (5).
(13) This section is repealed, effective July 1, 2027.
Source: L. 2022: Entire section added, (HB 22-1302), ch. 180, p. 1195, § 2, effective
May 18; (9) amended, (HB 22-1411), ch. 271, p. 1960, § 15, effective May 27. L. 2023: IP(6)
and (6)(m) amended, (HB 23-1244), ch. 436, p. 2570, § 5, effective August 7.
Cross references: For the legislative declaration in HB 22-1302, see section 1 of chapter
180, Session Laws of Colorado 2022. For the legislative declaration in HB 23-1244, see section
1 of chapter 436, Session Laws of Colorado 2023.
25.5-5-334. Community health worker services - federal authorization - reporting -
rules - definition. (1) As used in this section, unless the context otherwise requires,
"community health worker" means a frontline public health worker who serves as a liaison
between health-care providers or social service providers and community members in order to
facilitate access to physical, behavioral, or dental health-related services, or services to address
social determinants of health, and who improves the quality and cultural responsiveness of
health-related service delivery.
(2) No later than July 1, 2024, the state department shall seek federal authorization from
the centers for medicare and medicaid services to provide reimbursement for community health
worker services including, but not limited to, the delivery of preventive services, group and
individual health education and health coaching, health navigation, transitions of care supports,
screening and assessment for nonclinical and social needs, and individual support and health
advocacy.
(3) Prior to seeking federal authorization, the state department shall hold at least four
public stakeholder meetings to facilitate public engagement and solicit input from relevant
stakeholders on the development of the required elements for federal authorization. Relevant
stakeholders include, but are not limited to, community health workers, representatives from a
statewide group representing community health workers, consumer advocates, local public
health agencies, public health nonprofits and institutes, representatives from Colorado
department of public health and environment-recognized training programs for health navigators
and community health workers, health-care providers, managed care entities, representatives
from schools and school-based health centers, and the Colorado department of public health and
environment. At a minimum, the state department shall seek input from stakeholders regarding:
(a) Ways to ensure community health workers serve to reduce health disparities and
increase health equity;
(b) Minimum qualifications for community health workers, such as training and
skills-based experience requirements;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 267 of 510
(c) Methods for minimizing the burden of entering into the community health workforce;
(d) A patient safety monitoring responsibilities and grievance process;
(e) What services provided by a community health worker will be considered covered
services and noncovered services;
(f) Processes and requirements regarding provider types, provider enrollment, billing
codes, places of service, and any other operational component necessary for implementation in
the medicaid management information system;
(g) Reimbursement using the fee-for-service managed care or values-based payment
models for community health workers with consideration of the use of alternative payment
methodologies in the future;
(h) New provider types that could facilitate community health worker services outside of
traditional health-care settings, such as community-based organizations; and
(i) Clarification on community health workers' role and scope of practice as part of a
delivery system that may include case management, care management, and care coordination
services provided by managed care entities, community-centered boards, single entry points,
behavioral health administrative service organizations, case management agencies, and
health-care providers.
(4) In consideration of opportunities for future expansion of the community health
worker workforce, the Colorado department of public health and environment is encouraged to
partner with the state department and stakeholders to make recommendations for training and
competency standards related to specialization that would enable community health workers to
specialize their work with different populations and health conditions.
(5) Costs associated with services provided by community health workers through a
federally qualified health center, as defined in the federal "Social Security Act", 42 U.S.C. sec.
1395x (aa)(4), are considered allowable costs for the purposes of a federally qualified health
center's cost report. The state department shall work with stakeholders to determine how services
provided by community health workers will be captured in federally qualified health centers' cost
reports.
(6) Costs associated with services provided by community health workers through a
rural health clinic, as defined in the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(2),
are considered allowable costs for the purposes of a rural health clinic's cost report. The state
department shall work with stakeholders to determine how services provided by community
health workers will be captured in rural health centers' cost reports.
(7) The state department shall consult with the Colorado department of public health and
environment in promulgating rules concerning the voluntary competency-based community
health worker registry managed by the Colorado department of public health and environment
and any additional criteria or standards that may be necessary.
(8) For purposes of medicaid reimbursement, a community health worker shall:
(a) Work under the supervision of a clinician or within a licensed or otherwise approved
and medicaid-enrolled health provider agency; and
(b) Meet the minimum qualifications and credentialing requirements of the voluntary
competency-based community health worker registry as defined in section 25-20.5-112.
(9) The state department shall ensure that reimbursement policies and federal authorities
for existing unlicensed health workers, such as peer support professionals, recovery
Colorado Revised Statutes 2023 Uncertified PrintoutPage 268 of 510
professionals, managed care navigation staff, and others, are aligned and incorporated with the
community health worker payment models.
(10) On or before January 31, 2026, the state department shall report on ways
community health workers are being utilized through the state medical assistance program and
include available data or any identified costs or savings associated with community health
worker services and considerations for the general assembly to expand community health worker
services in community-based organizations that are outside of the traditional health-care setting
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".
Source: L. 2023: Entire section added, (SB 23-002), ch. 157, p. 679, § 2, effective
August 7.
Cross references: For the legislative declaration in SB 23-002, see section 1 of chapter
157, Session Laws of Colorado 2023.
25.5-5-335. Continuous medical coverage for children and adults feasibility study -
federal authorization - rules - report - definition. (1) The state department shall study the
feasibility of extending continuous medical coverage for additional children and adults and how
to better meet the health-related social needs of medical assistance program recipients.
(2) At a minimum, the feasibility study must consider the costs; implementation factors,
including county workload, training, and administrative burdens on the counties, information
technology systems, upgrades, and associated costs; potential health benefits for individuals and
communities, including disadvantaged and marginalized groups; impacts of increased use of
preventive and high-value health services; administrative savings, including, but not limited to,
reducing or eliminating eligibility processing for populations during the continuous eligibility
period; reductions in administrative turnover and coverage loss; and, to the extent practicable,
social and economic impacts with respect to the following:
(a) Allowing an eligible child, as defined in this article 5 and articles 2, 3, 6, and 8 of
this title 25.5, including children eligible under sections 25.5-2-104 and 25.5-2-105, to remain
continuously eligible for medical assistance and the children's basic health plan for twenty-four
months after the last day of the month in which the child was enrolled;
(b) Allowing an eligible child, as defined in this article 5 and articles 2, 3, 6, and 8 of
this title 25.5, including children eligible under sections 25.5-2-104 and 25.5-2-105 who are less
than six years of age, to remain continuously eligible for medical assistance or the children's
basic health plan without regard to a change in household income until the child reaches six
years of age;
(c) Allowing an eligible adult to remain continuously eligible for medical assistance
without regard to income for twelve months and twenty-four months after the last day of the
month in which the adult was enrolled. For purposes of this subsection (2)(c), an "eligible adult"
includes a person eighteen years of age or older who:
(I) Has an income under thirty-three percent of the federal poverty line;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 269 of 510
(II) Is experiencing homelessness; or
(III) Has been in community corrections, is on parole, or has been released from another
carceral setting, including jail or federal prison. For purposes of this subsection (2)(c)(III),
continuous eligibility starts on the individual's medicaid approval date.
(d) Allowing an adult who is eligible for medical assistance at the time of enrollment to
remain continuously eligible for medical assistance without regard to income for twelve months
after the last day of the month in which the adult was enrolled.
(3) In addition to the study topics detailed in subsection (2) of this section, the feasibility
study must study how to best meet the health-related social needs of medical assistance program
recipients who are historically disadvantaged and underserved and must give consideration to
concerns related to housing and food security.
(4) In conducting the feasibility study pursuant to this section, the state department shall
take into consideration the efforts of other states to improve the health-related social needs of
medical assistance program recipients, including, but not limited to, housing and nutritional
needs, initiatives to pay for rental housing assistance for up to six months, the needs of perinatal
recipients, youth in or transitioning out of foster care, former foster care youth, people with
substance use disorders, high-risk infants and children, and the needs of low-income individuals
impacted by natural disasters, and the state department shall seek input from relevant
stakeholders. In conducting the stakeholder process, the state department shall:
(a) Engage directly with:
(I) Impacted individuals who are enrolled in medical assistance or the children's basic
health plan and whose coverage, or whose children's coverage, would be extended if legislation
were passed to extend continuous medical coverage for individuals pursuant to subsections
(2)(a) to (2)(d) of this section;
(II) Service providers, particularly those whose patients are predominantly medical
assistance program recipients or are uninsured;
(III) Advocacy organizations;
(IV) Counties;
(V) Organizations that assist with enrollment into the medical assistance programs and
the Colorado health exchange; and
(VI) Individuals working in or representing communities that are diverse with regard to
race, ethnicity, immigration status, age, ability, sexual orientation, gender identity, or geographic
region of the state and are affected by higher rates of health disparities and inequities;
(b) Publicly conduct stakeholder meetings, report on the outcomes of the meetings, and
publicize the reports in English as well as two other commonly spoken languages in Colorado;
(c) Include opportunities for participation in the stakeholder process outside of regular
work hours; and
(d) Hold at least three stakeholder meetings.
(5) On or before January 1, 2026, the state department shall submit a report detailing the
findings and recommendations from the feasibility study to the joint budget committee of the
senate and the house of representatives, or its successor committee, the governor, and to the
house of representatives public and behavioral health and human services committee and the
senate health and human services committee, or any successor committees. The state department
shall also make the report available to the public on the state department's website.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 270 of 510
(6) Nothing in this section prohibits or limits the state department's ability to amend any
approved federal authorization or to seek other federal permissions necessary to expand
continuous eligibility coverage to additional populations prior to the completion of the feasibility
study described in this section.
(7) (a) No later than April 1, 2024, the state department shall seek federal authorization
from the federal centers for medicare and medicaid services to provide continuous medical
coverage for eligible children and eligible adults described in subsections (7)(b) and (7)(c) of
this section, and to continue enrollment for individuals with no income, as described in
subsection (7)(d) of this section.
(b) For purposes of seeking federal authorization pursuant to subsection (7)(a) of this
section, an eligible child is as defined in this article 5 and articles 2, 3, 6, and 8 of this title 25.5,
including a child eligible pursuant to sections 25.5-2-104 and 25.5-2-105, and must be under
three years of age. An eligible child shall remain continuously eligible without regard to
household income until the eligible child reaches three years of age; except that a child is no
longer eligible and must be disenrolled from a medical assistance program if the state
department becomes aware that the child has moved out of the state, the state department or
county possesses facts indicating that the family has requested the child's voluntary
disenrollment, the state department determines eligibility was erroneously granted, or the child is
deceased.
(c) For purposes of seeking federal authorization pursuant to subsection (7)(a) of this
section, an eligible adult is limited to an adult who has been released from a Colorado
department of corrections facility after serving a sentence. An eligible adult shall remain
continuously eligible for medical assistance without regard to income for a period of twelve
months beginning on the date of the eligible adult's release; except that an adult is no longer
eligible and must be disenrolled from the medical assistance program if the state department
becomes aware that the adult has moved out of the state, the state department or county
possesses facts indicating that the adult has requested voluntary disenrollment, the state
department determines eligibility was erroneously granted, or the adult is deceased.
(d) To facilitate the renewal process for the medical assistance program for individuals
with no income, including those who are experiencing homelessness, the state department shall
seek federal authorization, to the extent allowable by the centers for medicare and medicaid
services, to complete the income determination for ex parte renewals without requesting
additional income information or documentation, if:
(I) An attestation of zero-dollar income was verified within the last twelve months at the
initial application or the previous renewal; and
(II) The state department has checked financial data sources in accordance with its
eligibility verification plan as required by the centers for medicare and medicaid services and no
information is received.
(e) Upon approval of the federal authorization sought pursuant to this subsection (7), the
state department shall implement the continuous eligibility coverage requirements pursuant to
this subsection (7) by January 1, 2026. In implementing the continuous eligibility requirement of
this section, the state department shall take all necessary steps to relieve the obligation of the
state department and counties to promptly evaluate information that does not affect eligibility for
continuous coverage cases under this section, unless required for program administration or as
approved by the federal authorization.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 271 of 510
(f) The continuous eligibility sought pursuant to this subsection (7) is dependent on the
receipt of federal financial participation, to the maximum extent allowed under federal law,
through federal authorization, state plan amendment, or otherwise, by the federal centers for
medicare and medicaid services.
(g) The state board may promulgate rules as necessary to implement the requirements of
this section.
Source: L. 2023: Entire section added, (HB 23-1300), ch. 302, p. 1810, § 2, effective
June 1.
Cross references: For the legislative declaration in HB 23-1300, see section 1 of chapter
302, Session Laws of Colorado 2023.
25.5-5-336. Prohibition on using the body mass index or ideal body weight - medical
necessity criteria. (1) (a) Beginning July 1, 2023, the state medical assistance program shall not
utilize the body mass index, ideal body weight, or any other standard requiring an achieved
weight when determining medical necessity or the appropriate level of care for an individual
diagnosed with an eating disorder, including but not limited to, bulimia nervosa, atypical
anorexia nervosa, binge-eating disorder, avoidant restrictive food intake disorder, and other
specified feeding and eating disorders as defined in the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders.
(b) Subsection (1)(a) of this section does not apply when determining medical necessity
or the appropriate level of care for an individual diagnosed with anorexia nervosa, restricting
subtype; however, body mass index, ideal body weight, or any other standard requiring an
achieved body weight must not be the determining factor when assessing medical necessity or
the appropriate level of care for an individual diagnosed with anorexia nervosa, restricting
subtype.
(2) The following factors, at a minimum, must be considered when determining medical
necessity or the appropriate level of care for an individual diagnosed with an eating disorder:
(a) The individual's eating behaviors;
(b) The individual's need for supervised meals and support interventions;
(c) Laboratory results, including but not limited to, the individual's heart rate, renal or
cardiovascular activity, and blood pressure;
(d) The recovery environment; and
(e) Co-occurring disorders the individual may have.
Source: L. 2023: Entire section added, (SB 23-176), ch. 275, p. 1626, § 2, effective May
30.
PART 4
STATEWIDE MANAGED CARE SYSTEM
25.5-5-401. Short title. This part 4 shall be known and may be cited as the "Statewide
Managed Care System".
Colorado Revised Statutes 2023 Uncertified PrintoutPage 272 of 510
Source: L. 2006: Entire article added with relocations, p. 1883, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-111 as it existed prior to 2006.
25.5-5-402. Statewide managed care system - rules - definitions - repeal. (1) The
state board shall adopt rules to implement a statewide managed care system for Colorado
medical assistance recipients pursuant to the provisions of this article 5 and articles 4 and 6 of
this title 25.5. The statewide managed care system shall be implemented to the extent possible.
(2) The statewide managed care system implemented pursuant to this article 5 does not
include:
(a) The services delivered under the residential child health-care program described in
section 25.5-6-903, except in those counties in which there is a written agreement between the
county department of human or social services, the designated and contracted MCE responsible
for community behavioral health care, and the state department;
(b) Long-term care services and the program of all-inclusive care for the elderly, as
described in section 25.5-5-412. For purposes of this subsection (2), "long-term care services"
means nursing facilities and home- and community-based services provided to eligible clients
who have been determined to be in need of such services pursuant to the "Colorado Medical
Assistance Act" and the state board's rules.
(3) The statewide managed care system must include a statewide system of community
behavioral health care that must:
(a) Address the economic, social, and personal costs to the state of Colorado and its
citizens of untreated behavioral health disorders, including mental health and substance use
disorders;
(b) Approach behavioral health disorders as treatable conditions not unlike other chronic
health issues that require a combination of behavioral change and medication or other treatment;
(c) Offer timely access through multiple points of entry to a full continuum of culturally
responsive behavioral health services, including prevention, early intervention, crisis response,
treatment, and recovery services, that support individuals living full, productive lives;
(c.5) Provide coordination of care for the full continuum of substance use disorder and
mental health treatment and recovery, including support for individuals transitioning between
levels of care;
(d) Feature a comprehensive and integrated system of quality behavioral health care that
is individualized and coordinated to meet individuals' changing needs;
(e) [Editor's note: This version of subsection (3)(e) is effective until July 1, 2024.] Be
paid for by the state department establishing capitated rates specifically for community mental
health services that account for a comprehensive continuum of needed services such as those
provided by community mental health centers as defined in section 27-66-101;
(e) [Editor's note: This version of subsection (3)(e) is effective July 1, 2024.] Be paid
for by the state department establishing capitated rates specifically for behavioral health services
that account for a comprehensive continuum of needed services such as those provided by
licensed behavioral health providers, including essential and comprehensive community
behavioral health providers, as defined in section 27-50-101;
(f) Make the behavioral health system's administrative processes, service delivery, and
funding more effective and efficient to improve outcomes for Colorado citizens;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 273 of 510
(g) In addition to network adequacy requirements determined by the state department,
require each MCE to offer an enrollee an initial or subsequent nonurgent care visit within a
reasonable period where medically necessary and at appropriate therapeutic intervals, as
determined by state board rule;
(h) Specify that the diagnosis of an intellectual or developmental disability, a
neurological or neurocognitive disorder, or a traumatic brain injury does not preclude an
individual from receiving a covered behavioral health service; and
(i) Require an MCE to cover all medically necessary covered treatments for covered
behavioral health diagnoses, regardless of any co-occurring conditions.
(3.5) (a) No later than July 1, 2023, the state department, in collaboration with the
behavioral health administration in the department of human services and other state agencies,
shall develop the universal contract as described in section 27-50-203.
(b) (I) For the 2022-23 state fiscal year, the general assembly shall appropriate three
million dollars from the behavioral and mental health cash fund, created in section 24-75-230, to
the state department for the development, implementation, and administration of the universal
contract.
(II) This subsection (3.5)(b) is repealed, effective July 1, 2024.
(4) The statewide managed care system must promote the utilization of the medical
home model of care for all enrolled members. The medical home model of care establishes a
focal point of care for comprehensive primary care and efficient coordination with specialty care
providers and other health-care systems. The medical home model has proven effective in
promoting early intervention and prevention, improving individuals' health, and reducing
health-care costs.
(5) The statewide managed care system builds upon the lessons learned from previous
managed care and community behavioral health-care programs in the state in order to reduce
barriers that may negatively impact medicaid recipient experience, medicaid recipient health,
and efficient use of state resources. The statewide managed care system is authorized to provide
services under a single MCE type or a combination of MCE types.
(6) (a) The state department is authorized to assign a medicaid recipient to a particular
MCE, consistent with federal requirements and rules promulgated by the state board.
(b) For a child or youth who obtains eligibility for services under the state's medicaid
program through a dependency and neglect action resulting in out-of-home placement pursuant
to article 3 of title 19 or a juvenile delinquency action resulting in out-of-home placement
pursuant to article 2.5 of title 19, the state department shall assign the child or youth to the MCE
covering the county with jurisdiction over the action. The state department shall only change the
assignment if the change is requested by the county with jurisdiction over the action or by the
child's or youth's legal guardian.
(7) The state department is authorized to enter into a contract with MCOs, PCCM
Entities, prepaid ambulatory health plans, and prepaid inpatient health plans, subject to the
receipt of any required federal authorizations and pursuant to the requirements of this section.
(7.5) (a) The state department shall offer to enter into a direct contract with the MCO
operated by or under the control of Denver health and hospital authority, created pursuant to
article 29 of title 25, until the MCO ceases to operate a medicaid managed care program or until
June 30, 2025, unless sooner reprocured. If the state department designates an MCO to manage
Colorado Revised Statutes 2023 Uncertified PrintoutPage 274 of 510
behavioral health services pursuant to this article 5, Denver health and hospital authority, or any
subsidiary thereof, shall collaborate with the MCO during the term of contract.
(b) The MCO operated by or under the control of Denver health and hospital authority
shall:
(I) Maintain adequate financials to ensure proper solvency as a risk manager;
(II) Accept rates determined by the state department, through standard methodologies, to
cover the population it is serving;
(III) Maintain service and quality metrics, as determined by the state department; and
(IV) Meet statewide managed care system standards and operate as part of the overall
managed care system.
(8) Waivers. The implementation of this part 4 is conditioned, to the extent applicable,
on the issuance of necessary waivers by the federal government. The provisions of this part 4
must be implemented to the extent authorized by federal waiver, if so required by federal law.
(9) Bidding. (a) The state department is authorized to institute a program for
competitive bidding pursuant to section 24-103-202 or 24-103-203 for MCEs seeking to provide,
arrange for, or otherwise be responsible for the provision of services to its enrollees. The state
department is authorized to award contracts to more than one offeror. The state department shall
use competitive bidding procedures to encourage competition and improve the quality of care
available to medicaid recipients over the long term that meets the requirements of this section
and section 25.5-5-406.1.
(b) (I) On or before January 1, 2023, in order to promote transparency and
accountability, the state department shall require each MCE that has twenty-five percent or more
ownership by providers of behavioral health services to comply with the following conflict of
interest policies:
(A) Providers who have ownership or board membership in an MCE shall not have
control, influence, or decision-making authority in the establishment of provider networks.
(B) Each MCE shall report quarterly the number of providers who applied to join the
network and were denied and a comparison of rate ranges for providers who have ownership or
board membership versus providers who do not.
(C) An employee of a contracted provider of an MCE shall not also be an employee of
the MCE unless the employee is a clinical officer or utilization management director of the
MCE. If the individual is also an employee of a provider that has board membership or
ownership in the MCE, the MCE shall develop policies, approved by the executive director of
the state department, to mitigate any conflict of interest the employee may have.
(D) An MCE's board shall not have more than fifty percent of contracted providers as
board members, and the MCE is encouraged to have a community member on the MCE's board.
(II) No later than July 1, 2025, the state department shall appropriately address perceived
or actual provider ownership and control of MCEs participating in the statewide managed care
system in the interest of transparency and accountability. In designing a competitive bidding
process, the state department shall incorporate community feedback and have a public process
related to governing requirements, including how to address conflicts of interest.
(III) As used in this subsection (9)(b):
(A) "Clinical officer" means a physician who provides the clinical vision for the MCE or
provides clinical direction to network management, quality improvement, utilization
management, or credentialing divisions.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 275 of 510
(B) "MCE" means a managed care entity responsible for the statewide system of
community behavioral health care, as described in section 25.5-5-402 (3), and is not owned,
operated by, or affiliated with an instrumentality, municipality, or political subdivision of the
state.
(C) "Ownership" means an individual who is a legal proprietor of an organization,
including a provider or individual who owns assets of an organization, or has a financial stake,
interest, or governance role in the MCE.
(D) "Utilization management director" means a licensed health-care professional with
behavioral health clinical experience who leads and develops the utilization management
program or manages the medical review and authorization process.
(10) An MCE that is contracting for a defined scope of services under a risk contract
shall certify the financial stability of the MCE pursuant to criteria established by the division of
insurance.
(11) The state department shall conduct a review of each MCE, in accordance with
federal requirements, prior to the implementation of a contract to assess the ability and capacity
of the MCE to satisfactorily perform the operational requirements of the contract.
(12) Graduate medical education. The state department shall continue the graduate
medical education, referred to in this subsection (12) as "GME", funding to teaching hospitals
that have graduate medical education expenses in their medicare cost report and are participating
as providers under one or more MCEs with a contract with the state department under this part 4.
GME funding for recipients enrolled in an MCE is excluded from the premiums paid to the MCE
and must be paid directly to the teaching hospital. The state board shall adopt rules to implement
this subsection (12) and establish the rate and method of reimbursement.
(13) Nothing in this part 4 creates an exemption from the applicable provisions of title
10.
(14) Nothing in this part 4 creates an entitlement to an MCE to contract with the state
department.
(15) On or before July 1, 2020, the state department shall include utilization
management guidelines for the MCEs in the state board's managed care rules.
(16) The state department shall provide information on its website specifying how the
public may request the network adequacy plan and quarterly network reports for an MCE. The
plan must include actions taken by the MCE to ensure that all necessary and covered primary
care, care coordination, and behavioral health services are provided to enrollees with reasonable
promptness. Such actions include, without limitation:
(a) Utilizing single case agreements with out-of-network providers when necessary; and
(b) Using financial incentives to increase network participation.
(17) If the state department receives a complaint from the office of the ombudsman for
behavioral health access to care established pursuant to part 3 of article 80 of title 27 that relates
to possible violations of subsection (3) of this section or the MHPAEA, the state department
shall examine the complaint, as requested by the office, and shall report to the office in a timely
manner any actions taken related to the complaint.
Source: L. 2006: Entire article added with relocations, p. 1883, § 7, effective July 1. L.
2008: (3) and (5) amended, p. 390, § 1, effective August 5. L. 2012: (6) added, (HB 12-1281),
ch. 246, p. 1187, § 3, effective June 4. L. 2018: Entire section amended with relocations, (HB
Colorado Revised Statutes 2023 Uncertified PrintoutPage 276 of 510
18-1431), ch. 313, p. 1877, § 1, effective August 8; IP(2) and (2)(a) amended, (HB 18-1328), ch.
184, p. 1244, § 6, effective June 7, 2019. L. 2019: (3)(e) amended and (3)(g), (3)(h), (3)(i), (15),
(16), and (17) added, (HB 19-1269), ch. 195, p. 2133, § 12, effective May 16; (7.5) added, (HB
19-1285), ch. 392, p. 3501, § 1, effective August 2. L. 2020: (6) amended, (HB 20-1237), ch.
271, p. 1319, § 1, effective July 11; (3)(c.5) added, (SB 20-007), ch. 286, p. 1391, § 7, effective
July 13. L. 2021: (6)(b) amended, (SB 21-059), ch. 136, p. 747, § 123, effective October 1. L.
2022: (9) amended, (SB 22-106), ch. 196, p. 1309, § 1, effective May 20; (3.5) added, (HB
22-1302), ch. 180, p. 1200, § 3, effective July 1; (3)(e) amended, (HB 22-1278), ch. 222, p.
1594, § 234, effective July 1, 2024.
Editor's note: (1) This section is similar to former § 26-4-113 as it existed prior to
2006.
(2) Section 10 of chapter 184 (HB 18-1328), Session Laws of Colorado 2018, provides
that section 6 of the act changing this section takes effect upon notice to the revisor of statutes
pursuant to § 25.5-5-306 (6) as enacted in section 2 of the act. For more information, see HB
18-1328. (L. 2018, p. 1247.) On August 14, 2019, the revisor of statutes received the notice
referred to in § 25.5-5-306 (6) that the federal department of health and human services
approved the waiver on June 7, 2019.
(3) Amendments to subsections IP(2) and (2)(a) by HB 18-1328 and HB 18-1431 were
harmonized, effective June 7, 2019.
(4) Provisions of this section are similar to provisions of former §§ 25.5-5-402,
25.5-5-404, 25.5-5-406, and 25.5-5-411, as they existed prior to 2018. For a detailed comparison
of this section, see the comparative tables located at the back of the index.
Cross references: (1) For the legislative declaration in HB 18-1328, see section 1 of
chapter 184, Session Laws of Colorado 2018. For the legislative declaration in HB 22-1302, see
section 1 of chapter 180, Session Laws of Colorado 2022.
(2) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB
19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
25.5-5-403. Definitions. As used in this part 4, unless the context otherwise requires:
(1) Repealed.
(2) "Essential community provider", referred to in this part 4 as an "ECP", means a
health-care provider that:
(a) Has historically served medically needy or medically indigent patients and that
demonstrates a commitment to serve low-income and medically indigent populations who
comprise 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 client's financial limitations.
(2.5) "Global payment" means a population-based payment mechanism that is
constructed on a per-member, per-month calculation. Global payments must account for
prospective local community or health system cost trends and value, as measured by quality and
satisfaction metrics, and incorporate community cost experience and reported encounter data to
the greatest extent possible to address regional variation and improve longitudinal performance.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 277 of 510
Risk adjustments, risk-sharing, and aligned payment incentives may be utilized to achieve
performance improvement. The rate calculations for global payment are exempt from the
provisions of section 25.5-5-408. An entity that uses global payment pursuant to section
25.5-5-402 shall meet the applicable financial solvency requirements of sections 25.5-5-402 (10)
and 25.5-5-408 (1)(f) and the essential community provider requirements of sections
25.5-5-406.1 (1)(f)(II) and 25.5-5-408 (1)(d).
(3) (a) "Managed care" means a health-care delivery system organized to manage costs,
utilization, and quality. Medicaid managed care provides for the delivery of medicaid health
benefits and additional services through contracted arrangements between state medicaid
agencies and MCEs.
(b) Nothing in this section shall be deemed to affect the benefits authorized for recipients
of the state medical assistance program.
(4) "Managed care entity", referred to in this part 4 as an "MCE", means an entity that
enters into a contract to provide services in the statewide managed care system, including
MCOs, prepaid inpatient health plans, prepaid ambulatory health plans, and PCCM Entities.
(5) "Managed care organization", referred to in this part 4 as an "MCO", means an entity
contracting with the state department that meets the definition of managed care organization as
defined in 42 CFR 438.2.
(5.5) "Medical home" means an appropriately qualified medical health-care practice that
verifiably ensures continuous access to comprehensive, accessible, and coordinated
community-based primary care. All medical homes may have, but are not limited to, the
following:
(a) Health maintenance and preventive care;
(b) Anticipatory guidance and health education;
(c) Acute and chronic illness care;
(d) Coordination of medications, specialists, and therapies;
(e) Provider participation in hospital care; and
(f) Mental health care, oral health care, and other related services, as appropriate.
(5.7) "MHPAEA" means the federal "Paul Wellstone and Pete Domenici Mental Health
Parity and Addiction Equity Act of 2008", Pub.L. 110-343, as amended, and all of its
implementing and related regulations.
(6) "Prepaid ambulatory health plan", referred to in this part 4 as a "PAHP", means an
entity contracting with the state department that meets the definition of prepaid ambulatory
health plan as defined in 42 CFR 438.2.
(7) "Prepaid inpatient health plan", referred to in this part 4 as "PIHP", means an entity
contracting with the state department that meets the definition of prepaid inpatient health plan as
defined in 42 CFR 438.2.
(7.5) "Primary care case management entity", referred to in this part 4 as a "PCCM
Entity", means an entity contracting with the state department that meets the definition of
primary care case management entity as defined in 42 CFR 438.2.
(8) "Primary care case manager", referred to in this part 4 as a "PCCM", means a
physician, a physician group practice, or other practitioner as identified by the state that meets
the definition of primary care case manager as defined in 42 CFR 438.2.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 278 of 510
Source: L. 2006: Entire article added with relocations, p. 1884, § 7, effective July 1. L.
2007: (1)(a) amended, p. 1354, § 3, effective May 29. L. 2008: Entire section amended, p. 390, §
2, effective August 5. L. 2012: (2.5) added, (HB 12-1281), ch. 246, p. 1187, § 4, effective June
4. L. 2018: (1) repealed, (2.5), (3)(a), (4), and (8) amended, and (5.5) and (7.5) added (HB
18-1431), ch. 313, p. 1881, § 2, effective August 8. L. 2019: (5.7) added, (HB 19-1269), ch. 195,
p. 2134, § 13, effective May 16.
Editor's note: This section is similar to former § 26-4-114 as it existed prior to 2006.
Cross references: (1) For additional definitions applicable to this part 4, see §
25.5-4-103.
(2) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB
19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
25.5-5-404. Selection of managed care entities. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1885, § 7, effective July 1. L.
2008: Entire section amended, p. 392, § 3, effective August 5. L. 2014: (1)(v) added, (HB
14-1211), ch. 253, p. 1011, § 2, effective January 1, 2015. L. 2018: Entire section repealed, (HB
18-1431), ch. 313, p. 1891, § 7, effective August 8.
Editor's note: (1) This section was similar to former § 26-4-115 as it existed prior to
2006.
(2) Provisions of this section were relocated to §§ 25.5-5-402 and 25.5-5-406.1 in 2018.
For a detailed comparison of this section, see the comparative tables located at the back of the
index.
25.5-5-405. Quality measurements. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1889, § 7, effective July 1. L.
2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, § 7, effective August 8.
Editor's note: This section was similar to former § 26-4-116 as it existed prior to 2006.
25.5-5-406. Required features of managed care system. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1889, § 7, effective July 1. L.
2008: Entire section amended, p. 396, § 4, effective August 5. L. 2012: (2) amended, (HB
12-1281), ch. 246, p. 1187, § 5, effective June 4. L. 2016: (1)(f)(I) amended, (HB 16-1081), ch.
22, p. 53, § 9, effective August 10. L. 2018: Entire section repealed, (HB 18-1431), ch. 313, p.
1891, § 7, effective August 8.
Editor's note: (1) This section was similar to former § 26-4-117 as it existed prior to
2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 279 of 510
(2) Provisions of this section were relocated to §§ 25.5-5-402 and 25.5-5-406.1 in 2018.
For a detailed comparison of this section, see the comparative tables located at the back of the
index.
25.5-5-406.1. Required features of statewide managed care system. (1) General
features. All medicaid managed care programs must contain the following general features, in
addition to others that the federal government, state department, and state board consider
necessary for the effective and cost-efficient operation of those programs:
(a) The MCE shall accept all enrollees that the state department assigns to the MCE in
the order in which they are assigned, without restriction, regardless of health status or need for
health-care services;
(b) The MCE shall not discriminate against enrolled members on the basis of race, color,
ethnic or national origin, ancestry, age, sex, gender, sexual orientation, gender identity, gender
expression, disability, religion, creed, or political beliefs, and shall not use any policy or practice
that has the effect of discriminating on the basis of race, color, ethnic or national origin,
ancestry, age, sex, gender, sexual orientation, gender identity, gender expression, disability,
religion, creed, or political beliefs;
(c) The MCE shall allow each enrolled member to choose his or her network provider to
the extent possible and appropriate;
(d) Notwithstanding any waivers authorized by the federal department of health and
human services, or any successor agency, each contract between the state department and an
MCE selected to participate in the statewide managed care system under this part 4 shall comply
with the requirements of 42 U.S.C. sec. 1396a (a)(23)(B);
(e) The MCE shall ensure access to care for all enrolled members in need of medically
necessary services covered in the contract;
(f) The MCE shall create, administer, and maintain a network of providers, building on
the current network of medicaid providers, to serve the health-care needs of its members. In
doing so, the MCE shall:
(I) Support providers in serving the medicaid population and implement value-based
payment methodologies for network providers that incentivize and reward providers for the
effective and efficient delivery of high-quality services to enrolled members;
(II) (A) Seek proposals from each ECP in a county in which the MCE is enrolling
recipients for those services that the MCE provides or intends to provide and that an ECP
provides or is capable of providing. The MCE shall consider such proposals in good faith and
shall, when deemed reasonable by the MCE based on the needs of its enrollees, contract with
ECPs. Each ECP shall be willing to negotiate on reasonably equitable terms with each MCE.
ECPs making proposals under this subsection (1)(f)(II) must be able to meet the contractual
requirements of the MCE. The requirements of this subsection (1)(f)(II) do not apply to an MCE
in areas in which the MCE operates entirely as a group health maintenance organization.
(B) In selecting MCEs, the state department shall not penalize an MCE for paying
cost-based reimbursement to federally qualified health centers as defined in the federal "Social
Security Act".
(III) Demonstrate that there are sufficient Indian health-care providers participating in
the provider network to ensure timely access to services available under the contract from such
providers for Indian enrollees who are eligible to receive services.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 280 of 510
(IV) Enter into single case agreements with willing providers of behavioral health
services enrolled in the medical assistance program when network development and access
standards established by the state department are not met and a member needs access to a
medically necessary behavioral health service covered under the scope of the MCE's contract
with the state department. The MCE:
(A) Shall consider any behavioral health provider enrolled in the medical assistance
program for a single case agreement if the MCE cannot provide a covered service through its
contracted provider network;
(B) Shall ensure all care coordination staff and staff who provide member and provider
support are trained in the single case agreement process;
(C) Can refuse to offer single case agreements based on factors of provider cost and
quality concerns;
(D) Shall offer both member and out-of-network providers assistance in navigating its
single case agreement process;
(E) Shall ensure the single case agreement process is executed within the standards and
timeliness requirements established by the state department;
(F) Shall not require providers that enter into a single case agreement to serve additional
members; and
(G) Shall complete single case agreements on a timeline that is informed by stakeholder
input.
(g) The MCE shall ensure that its contracted network providers are capable of serving all
members, including contracting with providers with specialized training and expertise across all
ages, levels of ability, gender identities, and cultural identities;
(h) The MCE shall meet the network adequacy standards, as established by the state
department, describing the maximum time and distance an enrolled member is expected to travel
in order to access the provider types covered under the state contract;
(i) The MCE shall meet, and require its network providers to meet, standards as
established by the state department for timely access to care and services, taking into account the
urgency of the need for services;
(j) (I) The MCE shall not interfere with appropriate medical care decisions rendered by
its contracted network providers;
(II) A prepaid inpatient health plan shall not require prior authorization for outpatient
psychotherapy services, as defined in the most recent version of the "Current Procedural
Terminology", as developed and copyrighted by the American Medical Association or its
successor entity;
(k) The MCE shall comply with the state department's transition of care policy to ensure
continued access to services during a transition from fee-for-service to an MCE or transition
from one MCE to another when an enrollee, in the absence of continued access to services,
would suffer serious detriment to his or her health or be at risk of hospitalization or
institutionalization;
(l) The MCE shall provide and facilitate the delivery of services in a culturally
competent manner to all members, including those with limited English proficiency, diverse
cultural and ethnic backgrounds, and disabilities, and regardless of gender, sexual orientation,
gender identity, or gender expression;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 281 of 510
(m) The MCE shall provide communications in a manner and format that may be easily
understood and is readily accessible by members;
(n) Grievances and appeals. (I) (A) Each MCE shall establish a grievance and appeal
system that complies with rules established by the state board and federal government.
(B) An enrollee is entitled to designate a representative, including but not limited to an
attorney, the ombudsman for medicaid managed care, a lay advocate, or the enrollee's physician,
to file and pursue a grievance or appeal on behalf of the enrollee. The procedure must allow for
the unencumbered participation of physicians.
(II) The MCE shall have an established grievance system that allows for client
expression of dissatisfaction at any time about any matter related to the MCE's contracted
services, other than an adverse benefit determination. The grievance system must provide timely
resolution of such matters in a manner consistent with the medical needs of the individual
recipient.
(III) (A) The MCE shall have an appeal system for review of any determination by the
MCE to deny a service authorization request or to authorize a service in an amount, duration, or
scope that is less than requested.
(B) Each MCE shall utilize an appeal process for expedited reviews that complies with
rules established by the state board. The appeal process for expedited reviews must provide a
means by which an enrollee may complain and seek resolution concerning any action or failure
to act in an emergency situation that immediately impacts the enrollee's access to quality
health-care services, treatments, or providers.
(C) The state department shall establish the position of ombudsman for medicaid
managed care. The ombudsman shall, if the enrollee requests, act as the enrollee's representative
in resolving appeals with the MCE. It is the intent of the general assembly that the ombudsman
for medicaid managed care be independent from the state department and selected through a
competitive bidding process. In the event the state department is unable to contract with an
independent ombudsman, an employee of the state department may serve as the ombudsman for
medicaid managed care. An enrollee whose appeal is not resolved to his or her satisfaction by a
procedure described in this subsection (1)(n), or whose appeal is deemed exhausted, is entitled to
request a state fair hearing by an independent hearing officer, further judicial review, or both, as
provided for by federal law and any state statute or rule.
(o) The MCE shall maintain and participate in an ongoing comprehensive quality
assessment and performance improvement program that must include but not be limited to the
following:
(I) Performance improvement projects designed to achieve significant improvement,
sustained over time, in clinical care and nonclinical care areas that are expected to have a
favorable effect on health outcomes and member satisfaction;
(II) The collection and submission of performance measurement data as required by the
state department;
(III) The implementation and maintenance of mechanisms to detect overutilization and
underutilization of services and to assess the quality and appropriateness of care furnished to its
members, including members with special health-care needs; and
(IV) Annual participation in an independent quality review and validation of
performance improvement projects, performance measures, and other contract requirements;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 282 of 510
(p) (I) The MCE shall administer a program integrity system to ensure compliance with
all requirements established by the federal government, state of Colorado, state department, and
state board that includes, but is not limited to:
(A) Procedures to detect and prevent fraud, waste, and abuse;
(B) Screening and disclosure processes to prevent relationships with individuals or
entities that are debarred, suspended, or otherwise excluded from participating in any federal
health-care program, procurement activities, or nonprocurement activities; and
(C) Treatment of recoveries of overpayment to providers;
(II) Prepaid inpatient health plans shall not retroactively recover provider payments if:
(A) A recipient was initially determined to be eligible for medical benefits pursuant to
section 25.5-4-205 when the provider has an eligibility guarantee number for the recipient; or
(B) The prepaid inpatient health plan makes an error processing the claim but the claim
is otherwise accurately submitted by the provider.
(III) (A) Prepaid inpatient health plans shall not retroactively recover provider payments
after twelve months from the date a claim was paid, except when medicare, commercial
insurance, or third-party liability is the primary payer for a claim; the claim is the subject of a
state or federal audit, including audits contractually required by the state department; the claim is
subject to a law enforcement investigation; the claim submitted is a duplicate; the claim is
fraudulent; the provider improperly bills the claim; or the claim is submitted with a billing code
or diagnosis code that inaccurately or incorrectly resulted in reimbursement or bypassed prior
authorization requirements.
(B) If a prepaid inpatient health plan retroactively recovers a provider payment that is
equal to one thousand dollars or more, the prepaid inpatient health plan shall work with the
provider to develop a payment plan if the provider requests a payment plan.
(q) Billing medicaid recipients. Notwithstanding any federal regulations or the general
prohibition of section 25.5-4-301 against providers billing medicaid recipients, a provider may
bill a medicaid recipient who is enrolled with a specific medicaid PCCM or MCE and, in
circumstances defined by the rules of the state board, receives care from a medical provider
outside that organization's network or without referral by the recipient's PCCM;
(r) Marketing. In marketing coverage to medicaid recipients, all MCEs shall comply
with all applicable provisions of title 10 regarding health plan marketing. The state board is
authorized to promulgate rules concerning the permissible marketing of medicaid managed care.
The purposes of such rules must include but not be limited to the avoidance of biased selection
among the choices available to medicaid recipients.
(s) Prescription drugs. All MCEs that have prescription drugs as a covered benefit shall
provide prescription drug coverage in accordance with the provisions of section 25.5-5-202
(1)(a) as part of a comprehensive health benefit and with respect to any formulary or other
access restrictions:
(I) The MCE shall supply participating providers who may prescribe prescription drugs
for MCE enrollees with a current copy of such formulary or other access restrictions, including
information about coverage, payment, or any requirement for prior authorization;
(II) The MCE shall provide to all medicaid recipients at periodic intervals, and prior to
and during enrollment upon request, clear and concise information about the prescription drug
program in language understandable to the medicaid recipients, including information about
Colorado Revised Statutes 2023 Uncertified PrintoutPage 283 of 510
such formulary or other access restrictions and procedures for gaining access to prescription
drugs, including off-formulary products; and
(III) The MCE shall follow state department policies for prescribing any prescription
drugs that are not covered under the MCE contract;
(t) Each MCE must include the following statements prominently in the enrollee
handbook, on the state department's website, and on the MCE's enrollment website:
(I) A statement indicating that the MCE is subject to the MHPAEA and that a denial,
restriction, or withholding of benefits for behavioral health services that are covered under the
medical assistance program could be a potential violation of that act; and
(II) A statement directing the enrollee to contact the office of the ombudsman for
behavioral health access to care established pursuant to part 3 of article 80 of title 27 if the
enrollee wants further assistance pursuing action regarding potential parity violations, which
statement must include the telephone number for the office and a link to the office's website.
Source: L. 2018: Entire section added with relocations, (HB 18-1431), ch. 313, p. 1882,
§ 3, effective August 8. L. 2019: (1)(t) added, (HB 19-1269), ch. 195, p. 2134, § 14, effective
May 16; (1)(o)(IV) amended, (SB 19-241), ch. 390, p. 3473, § 38, effective August 2. L. 2021:
(1)(b) and (1)(l) amended, (HB 21-1108), ch. 156, p. 896, § 40, effective September 7. L. 2022:
(1)(j) and (1)(p) amended, (SB 22-156), ch. 153, p. 978, § 1, effective January 1, 2023. L. 2023:
(1)(f)(IV) added, (HB 23-1200), ch. 429, p. 2522, § 1, effective August 7.
Editor's note: Provisions of this section are similar to provisions of former §§
25.5-5-404, 25.5-5-405, and 25.5-5-406, as they existed prior to 2018. For a detailed comparison
of this section, see the comparative tables located at the back of the index.
Cross references: (1) For the short title ("Behavioral Health Care Coverage
Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado
2019.
(2) For the legislative declaration in HB 21-1108, see section 1 of chapter 156, Session
Laws of Colorado 2021.
25.5-5-407. State department recommendations - primary care physician program.
(Repealed)
Source: L. 2006: Entire article added with relocations, p. 1893, § 7, effective July 1. L.
2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, § 7, effective August 8.
Editor's note: This section was similar to former § 26-4-118 as it existed prior to 2006.
25.5-5-407.5. Prepaid inpatient health plan agreements - rules. (Repealed)
Source: L. 2007: Entire section added, p. 1351, § 1, effective May 29. L. 2009: (1.5)
added, (SB 09-265), ch. 205, p. 936, § 3, effective May 1. L. 2010: (1.5) repealed, (HB
10-1382), ch. 217, p. 939, § 2, effective May 6. L. 2013: (2)(a) amended, (SB 13-044), ch. 54, p.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 284 of 510
180, § 1, effective March 22. L. 2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, §
7, effective August 8.
Editor's note: Subsection (2)(a) was relocated to § 25.5-5-408 (13) in 2018. For a
detailed comparison of this section, see the comparative tables located at the back of the index.
25.5-5-407.7. Disability care coordination organization - rules. (Repealed)
Source: L. 2007: Entire section added, p. 1352, § 1, effective May 29. L. 2008: Entire
section amended, p. 1909, § 109, effective August 5. L. 2013: Entire section repealed, (SB
13-276), ch. 256, p. 1353, § 9, effective May 23.
25.5-5-408. Capitation payments - availability of base data - adjustments - rate
calculation - capitation payment proposal - preference - assignment of medicaid recipients -
definition. (1) (a) The state department shall make capitation payments to MCEs based upon a
defined scope of services under a risk contract.
(b) A certification by a qualified actuary retained by the state department is conclusive
evidence that the state department has correctly calculated the direct health-care cost of
providing these same services on an actuarially equivalent Colorado medicaid population group.
(c) Except as otherwise provided in subsection (1)(d) of this section and where the state
department has instituted a program of competitive bidding provided in section 25.5-5-402 (9),
the state department may utilize a market rate set through the competitive bid process for a set of
defined services. The state department shall only use market rate bids that do not discriminate
and are adequate to assure quality and network sufficiency. A certification of a qualified actuary,
retained by the state department, to the appropriate lower limit is conclusive evidence of the state
department's compliance with the requirements of this subsection (1)(c). For the purposes of this
subsection (1), a "qualified actuary" means a person deemed as such under rules promulgated by
the commissioner of insurance.
(d) The state department shall reimburse a federally qualified health center, as defined in
the federal "Social Security Act", 42 U.S.C. sec. 1395x (aa)(4), for the total reasonable costs
incurred by the center in providing health-care services to all recipients of medical assistance.
(e) An MCE shall certify, as a condition of entering into a contract with the state
department, that the capitation payments set forth in the contract between the MCE and the state
department are sufficient to ensure the financial stability of the MCE with respect to delivery of
services to the medicaid recipients covered in the contract.
(f) (I) Except as provided in subsection (1)(f)(II) of this section, for capitation payments
effective on and after July 1, 2003, an MCE that is contracting for a defined scope of services
under a risk contract shall certify, through a qualified actuary retained by the MCE, that the
capitation payments set forth in the contract between the MCE and the state department comply
with all applicable federal and state requirements that govern the capitation payments. For
purposes of this subsection (1)(f)(I), a "qualified actuary" means a person deemed as such by
rule promulgated by the commissioner of insurance.
(II) An MCO providing services under the PACE program as described in section
25.5-5-412 shall certify that the capitation payments are in compliance with applicable federal
and state requirements that govern said capitation payments and that the capitation payments are
Colorado Revised Statutes 2023 Uncertified PrintoutPage 285 of 510
sufficient to ensure the financial viability of the MCO with respect to the delivery of services to
the PACE program participants covered in the contract.
(2) The state department shall develop capitation rates for MCEs contracting for a
defined scope of services under a risk contract that include risk adjustments, reinsurance, or
stop-loss funding methods. Payments to plans may vary when it is shown through diagnoses or
other relevant data that certain populations are expected to cost more or less than the capitated
population as a whole.
(3) The state board, in consultation with recognized medical authorities, shall develop a
definition of special needs populations that includes evidence of diagnosed or medically
confirmed health conditions. The state department shall develop a method for adjusting
payments to plans for such special needs populations when diagnoses or other relevant data
indicates these special needs populations would cost significantly more than similarly capitated
populations.
(4) Under no circumstances shall the risk adjustments, reinsurance, or stop-loss methods
developed by the state department pursuant to subsection (2) of this section cause the average
per capita medicaid payment to a plan to be greater than the projected medicaid expenditures for
treating medicaid enrollees of that plan under fee-for-service medicaid.
(5) The state department may develop quality incentive payments to recognize superior
quality of care or service provided by a managed care plan.
(6) Within two hundred ten days from the beginning of each fiscal year, the state
department, in cooperation with the MCEs, shall set a timeline for the rate-setting process for the
following fiscal year's rates and for the provision of base data to the MCEs that is used in the
calculation of the rates, which must include but not be limited to the information included in
subsection (7) of this section.
(7) The state department shall identify and make available to the MCEs the base data
used in the calculation of the direct health-care cost of providing these same services on an
actuarially equivalent Colorado medicaid population group. The state department shall consult
with the MCEs regarding any and all adjustments in the base data made to arrive at the capitation
payments.
(8) For capitation payments effective on and after July 1, 2003, the state department
shall recalculate the base calculation every three years. The three-year cycle for the recalculation
of the base calculation shall begin with capitation payments effective for fiscal year 2003-04. In
the years in which the base calculation is not recalculated, the state department shall annually
trend the base calculation after consulting with the MCEs. The state department shall take into
consideration when trending the base calculation any public policy changes that affect
reimbursement under the "Colorado Medical Assistance Act".
(9) The rate-setting process referenced in subsection (6) of this section must include a
time period after the MCEs have received the direct health-care cost of providing these same
services on an actuarially equivalent Colorado medicaid population group for each MCE to
submit to the state department the MCE's capitation payment proposal, which must not exceed
one hundred percent of the direct health-care cost of providing these same services on an
actuarially equivalent Colorado medicaid population group. The state department shall provide
to the MCEs the MCE's specific adjustments to be included in the calculation of the MCE's
proposal. Each MCE's capitation payment proposal must meet the requirements of subsections
(1)(e) and (1)(f) of this section and section 25.5-5-402 (10).
Colorado Revised Statutes 2023 Uncertified PrintoutPage 286 of 510
(10) For capitation payments effective on and after July 1, 2003, unless otherwise
required by federal law, the state department shall certify, through a qualified actuary retained by
the state department, that the capitation payments set forth in the contract between the state
department and the MCEs comply with all applicable federal and state requirements that govern
said capitation payments.
(11) Effective on and after July 1, 2003, the capitation payments certified by the
qualified actuary under subsection (10) of this section shall not be subject to any dispute
resolution process, including any such process set forth in any settlement agreement entered into
prior to July 1, 2002.
(12) Nothing in this section shall prevent, to the extent possible, an MCE that is also a
government-owned entity from using certified public expenditure or other federally recognized
financing mechanisms to provide the state share for the federal match to enhance capitation
payments up to or above the one hundred percent limit contained in subsection (9) of this
section. The state shall not be obligated to increase any general fund expenditures because of the
use of certified public expenditure or other federally recognized financing mechanism pursuant
to this subsection (12).
(13) A PIHP agreement may include a provision for a quality incentive payment that is
distributed to the contractor within a reasonable period of time, as specified in the contract,
following the end of each fiscal year if the contractor substantially exceeds predetermined
quality indicators. The quality indicators must be based upon broadly accepted measures of
performance adopted by rule of the state board and agreed upon at the outset of the contract
period, and must include, but need not be limited to, the health plan employers data and
information set measures. The quality incentive payment may be made proportional if the state
board establishes multiple quality measurements. The quality incentive payments must not
exceed the total cost savings created under the PIHP agreement, as determined by comparison of
the PIHP members with an actuarially equivalent fee-for-service population, and the quality
incentive payment must not exceed five percent of the total medicaid payments received by the
contractor during the performance period of the PIHP agreement.
Source: L. 2006: Entire article added with relocations, p. 1893, § 7, effective July 1. L.
2007: (1)(b) and (9) amended and (12) added, p. 1354, § 4, effective May 29. L. 2008: (1)(a),
(2), (6), (7), (8), (9), (10), and (12) amended, p. 400, § 5, effective August 5. L. 2009: (1)(a)
amended, (SB 09-265), ch. 205, p. 936, § 4, effective May 1. L. 2010: (1)(a)(II) repealed, (HB
10-1382), ch. 217, p. 939, § 3, effective May 6. L. 2018: (1) amended with relocations, (6), (7),
and (9) amended, and (13) added with relocations, (HB 18-1431), ch. 313, p. 1887, § 4, effective
August 8. L. 2020: (1)(d) amended, (SB 20-136), ch. 70, p. 289, § 28, effective September 14.
Editor's note: (1) This section is similar to former § 26-4-119 as it existed prior to
2006.
(2) Provisions of subsection (1) are similar to provisions of former § 25.5-5-404, as it
existed prior to 2018, and provisions of subsection (13) are similar to former § 25.5-5-407.5
(2)(a), as it existed prior to 2018. For a detailed comparison of this section, see the comparative
tables located at the back of the index.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 287 of 510
Cross references: For the legislative declaration in SB 20-136, see section 1 of chapter
70, Session Laws of Colorado 2020.
25.5-5-409. State department - privatization. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1896, § 7, effective July 1. L.
2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, § 7, effective August 8.
Editor's note: This section was similar to former § 26-4-120 as it existed prior to 2006.
25.5-5-410. Data collection for managed care programs.
(1) Repealed.
(2) The state department of human services, in conjunction with the state department,
shall continue its existing efforts, which include obtaining and considering consumer input, to
develop managed care systems for the developmentally disabled population and to consider a
pilot program for a certificate system to enable the developmentally disabled population to
purchase managed care services or fee-for-service care, including long-term care community
services. The department of human services shall not implement any managed care system for
developmentally disabled services without the express approval of the joint budget committee.
Any proposed implementation of fully capitated managed care in the developmental disabilities
community service system shall require legislative review.
(3) In addition to any other data collection and reporting requirements, each managed
care organization shall submit the following types of data to the state department or its agent:
(a) Medical access;
(b) Consumer outcomes based on statistics maintained on individual consumers as well
as the total consumer populations served;
(c) Consumer satisfaction;
(d) Consumer utilization;
(e) Health status of consumers; and
(f) Uncompensated care delivered.
Source: L. 2006: Entire article added with relocations, p. 1896, § 7, effective July 1. L.
2008: (1) amended, p. 402, § 6, effective August 5. L. 2016: (1) repealed and (2) amended, (HB
16-1081), ch. 22, p. 51, § 3, effective August 10.
Editor's note: This section is similar to former § 26-4-121 as it existed prior to 2006.
25.5-5-411. Medicaid community mental health services - legislative declaration -
administration - rules. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1897, § 7, effective July 1. L.
2007: (3) amended, p. 331, § 1, effective August 3. L. 2008: (1.5) added, p. 289, § 1, effective
April 3. L. 2009: (1.5)(c) added, (SB 09-265), ch. 205, p. 936, § 5, effective May 1. L. 2010:
(4)(c) repealed, (HB 10-1382), ch. 217, p. 940, § 4, effective May 6; entire section amended, (SB
10-153), ch. 295, p. 1372, § 3, effective May 26. L. 2018: Entire section repealed, (HB
Colorado Revised Statutes 2023 Uncertified PrintoutPage 288 of 510
18-1431), ch. 313, p. 1891, § 7, effective August 8; (4)(b) amended, (HB 18-1007), ch. 225, p.
1432, § 5, effective January 1, 2019; (4)(b) repealed, (HB 18-1431), ch. 313, p. 1893, § 13,
effective January 1, 2019.
Editor's note: (1) This section was similar to former § 26-4-123 as it existed prior to
2006.
(2) Provisions of this section were relocated to § 25.5-5-402 in 2018. For a detailed
comparison of this section, see the comparative tables located at the back of the index.
25.5-5-412. Program of all-inclusive care for the elderly - services - eligibility -
legislative declaration - rules - definitions. (1) (a) The general assembly hereby finds and
declares that it is the intent of this section to replicate the ON LOK program in San Francisco,
California, that has proven to be cost-effective at both the state and federal levels. The PACE
program is part of a national replication project authorized in section 9412(b)(2) of the federal
"Omnibus Budget Reconciliation Act of 1986", as amended. The general assembly finds that, by
coordinating an extensive array of medical and nonmedical services, the needs of the participants
will be met primarily in an outpatient environment in an adult day health center, in their homes,
or in an institutional setting. The general assembly finds that such a service delivery system will
enhance the quality of life for the participant and offers the potential to reduce and cap the costs
to Colorado of the medical needs of the participants, including hospital and nursing home
admissions.
(b) Repealed.
(2) The general assembly has determined on the recommendation of the state department
that the PACE program is cost-effective. As a result of such determination and after consultation
with the joint budget committee of the general assembly, application has been made to and
waivers have been obtained from the federal health care financing administration to implement
the PACE program as provided in this section. The general assembly, therefore, authorizes the
state department to implement the PACE program in accordance with this section. In connection
with the implementation of the program, the state department shall:
(a) Provide a system for reimbursement for services to the PACE program pursuant to
this section;
(b) Develop and implement a contract with any public, private, nonprofit, or for-profit
entity providing the PACE program, as permitted by federal law, that sets forth contractual
obligations for the PACE program as required by the state department, including but not limited
to reporting and monitoring of utilization of services and of the costs of the program, quality of
care, and a comprehensive assessment of the provider's fiscal soundness;
(c) Acknowledge that it is participating in the national PACE project as initiated by
congress;
(d) Be responsible for certifying the eligibility for services of all PACE program
participants.
(3) The general assembly declares that the purpose of this section is to provide services
that would foster the following goals:
(a) To maintain eligible persons at home as an alternative to long-term
institutionalization;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 289 of 510
(b) To provide optimum accessibility to various important social and health resources
that are available to assist eligible persons in maintaining independent living;
(c) To provide that eligible persons who are frail elderly but who have the capacity to
remain in an independent living situation have access to the appropriate social and health
services without which independent living would not be possible;
(d) To coordinate, integrate, and link such social and health services by removing
obstacles that impede or limit improvements in delivery of these services;
(e) To provide the most efficient and effective use of capitated funds in the delivery of
such social and health services.
(f) Repealed.
(4) Within the context of the PACE program, the state department may include any or all
of the services listed in sections 25.5-5-102, 25.5-5-103, 25.5-5-202, and 25.5-5-203, as
applicable.
(5) An eligible person may elect to receive services from the PACE program as
described in subsection (4) of this section. If such an election is made, the eligible person shall
not remain eligible for services or payment through the regular medicare or medicaid programs.
All services provided by said programs shall be provided through the PACE program in
accordance with this section. An eligible person may elect to disenroll from the PACE program
at any time.
(6) [Editor's note: This version of the introductory portion to subsection (6) is effective
until July 1, 2024.] The state department, in cooperation with the single entry point agencies
established in section 25.5-6-106, shall develop and implement a coordinated plan to provide
education about PACE program site operations under this section. The state board shall adopt
rules:
(6) [Editor's note: This version of the introductory portion to subsection (6) is effective
July 1, 2024.] The state department, in cooperation with the case management agencies
established in section 25.5-6-1703, shall develop and implement a coordinated plan to provide
education about PACE program site operations under this section. The state board shall adopt
rules:
(a) [Editor's note: This version of subsection (6)(a) is effective until July 1, 2024.] To
ensure that case managers and any other appropriate state department staff discuss the option and
potential benefits of participating in the PACE program with all eligible long-term care clients.
These rules shall require additional and on-going training of the single entry point agency case
managers in counties where a PACE program is operating. This training shall be provided by a
federally approved PACE provider. In addition, each single entry point agency may designate
case managers who have knowledge about the PACE program.
(a) [Editor's note: This version of subsection (6)(a) is effective July 1, 2024.] To ensure
that case managers and any other appropriate state department staff discuss the option and
potential benefits of participating in the PACE program with all eligible long-term care clients.
These rules must require additional and on-going training of the case management agency case
managers in counties where a PACE program is operating. This training must be provided by a
federally approved PACE provider. In addition, each case management agency may designate
case managers who have knowledge about the PACE program.
(b) To allow PACE providers to contract with an enrollment broker to include the PACE
program in its marketing materials to eligible long-term clients.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 290 of 510
(6.5) An eligible person who is enrolled in a managed care organization, an organization
contracted with the state department pursuant to part 4 of article 5 of this title, or other
risk-bearing entity may elect to withdraw from or terminate such enrollment and enroll in and
receive services through a PACE program. The state board's rules shall define how such election
is made. The effective date of an eligible person's election shall not be more than thirty days
after the eligible person's date of election.
(7) For purposes of this section:
(a) "Dually eligible person" means a person who is eligible for assistance or benefits
under both medicaid and medicare.
(b) "Eligible person" means a frail elderly individual who voluntarily enrolls in the
PACE program and whose gross income does not exceed three hundred percent of the current
federal supplemental security income benefit level, whose resources do not exceed the limit
established by the state department of human services for individuals receiving a mandatory
minimum state supplementation of SSI benefits pursuant to section 26-2-204, or in the case of a
person who is married, do not exceed the amount authorized in section 25.5-6-101, and for
whom a physician licensed pursuant to article 240 of title 12 certifies that such a program
provides an appropriate alternative to institutionalized care. "Eligible person" may also include a
dually eligible person.
(c) "Frail elderly" means an individual who meets functional eligibility requirements, as
established by the state department, for nursing home care and who is fifty-five years of age or
older.
(d) "Upper payment limit" means a federal upper payment limit on the amount of the
medicaid payment for which federal financial participation is available for a class of services and
a class of health-care providers, as specified in 42 CFR 447.
(8) Using a risk-based financing model, any public, private, nonprofit, or for-profit entity
providing the PACE program, as permitted by federal law, shall assume responsibility for all
costs generated by PACE program participants, and shall create and maintain a risk reserve fund
that will cover any cost overages for any participant. The PACE program is responsible for the
entire range of services in the consolidated service model, including hospital and nursing home
care, according to participant need as determined by the multidisciplinary team. Any public,
private, nonprofit, or for-profit entity providing the PACE program, as permitted by federal law,
is responsible for the full financial risk at the conclusion of the demonstration period and when
permanent waivers from the federal health care financing administration are granted. Specific
arrangements of the risk-based financing model shall be adopted and negotiated by the federal
health care financing administration, any public, private, nonprofit, or for-profit entity providing
the PACE program, as permitted by federal law, and the state department.
(9) Nothing in this section requires a PACE program site operator to hold a certificate of
authority as a health maintenance organization under part 4 of article 16 of title 10, C.R.S., for
purposes of the PACE program.
(10) (a) The state department shall perform a feasibility study, conditioned on the receipt
of sufficient gifts, grants, and donations, in order to identify viable communities that may
support a PACE program site. This study shall be completed on or before May 1, 2003.
(b) The state department, consistent with the results of the feasibility study, shall use its
best efforts to have in operation:
(I) One additional PACE program site by July 1, 2004;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 291 of 510
(II) A total of four additional PACE program sites by July 1, 2005; and
(III) A total of six additional PACE program sites by July 1, 2006.
(c) (I) No later than May 30, 2003, the executive director of the state department shall
submit to the joint budget committee of the general assembly and to the health and human
services committees of the house of representatives and the senate, or any successor committees,
a written report of the results of the feasibility study conducted under paragraph (a) of this
subsection (10).
(II) No later than January 1, 2007, the executive director of the state department shall
submit to the joint budget committee of the general assembly and to the health and human
services committees of the house of representatives and the senate, or any successor committees,
a final written report detailing the expansion of PACE program sites across the state.
(11) The state board shall promulgate such rules, pursuant to article 4 of title 24, C.R.S.,
as are necessary to implement this section.
(12) (a) The general assembly shall make appropriations to the state department to fund
services under this section provided at a monthly capitated rate. For the 2019-20 fiscal year, and
each fiscal year thereafter, the state department shall annually renegotiate, pursuant to the
provisions set forth in this subsection (12), a monthly capitated rate for the contracted services.
(b) The monthly capitated rate negotiated with the state department must be included in
the contract with the PACE organization and must be based upon a prospective monthly
capitation payment to a PACE organization for a medicaid participant enrolled in a PACE
program that is less than what would otherwise have been paid under the state medicaid plan if
the participant were not enrolled in the PACE program.
(c) In determining the monthly capitated rate, the state department, with the participation
of Colorado PACE organizations, shall develop an actuarially sound upper payment limit
methodology that complies with federal law relating to PACE organizations.
(d) Repealed.
(13) The state department may accept grants and donations from private sources for the
purpose of implementing this section.
(14) (a) No later than sixty days prior to the closing or effective date of a conversion of a
nonprofit PACE provider to a for-profit PACE provider, the nonprofit PACE provider shall:
(I) Transmit a conversion plan and written notice of the conversion to the attorney
general, which conversion plan must include, at a minimum:
(A) A copy of the results of an independent valuation of the fair market value of the
business that proposes to convert;
(B) A detailed explanation of the plans for distribution of the proceeds of the conversion,
including whether the proceeds will be distributed to a new nonprofit entity or to an existing
organization and, if to an existing nonprofit organization, which organization and the reasons for
selecting that organization, or, if to a new nonprofit organization, how the initial board of
directors will be selected;
(C) Information about any compensation, bonus, or inducement to any officers or
directors of the converting entity resulting from the conversion; and
(D) The PACE organization's audited financial statements for its three most recent fiscal
years for Colorado, and separately, for those operations outside of Colorado, for any such
operations that may be related to the conversion; and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 292 of 510
(II) Bear all costs associated with public oversight and review by the attorney general of
the conversion, including the retention of outside experts, if any.
(b) Within ten days after the receipt of the conversion plan, the attorney general shall
post the complete conversion plan on its website and receive public comments about the plan,
which shall also be posted as soon as practicable to the attorney general's website. Public
comment shall be received for a minimum of thirty days and available on the website for at least
the duration of the comment period.
(c) Nothing in this section shall be construed to affect the common law authority of the
attorney general.
(15) (a) No later than June 30, 2023, the state department, in conjunction with the
department of public health and environment, shall develop a regulatory plan to establish formal
oversight requirements for PACE entities. In developing the plan, the departments shall consider,
at a minimum:
(I) Input from executive agencies; any local governments within a PACE service area,
including cities and counties; aging and older adult advocacy organizations; PACE participants;
family members of PACE participants; disability advocacy organizations; urban PACE entities;
rural PACE entities; and PACE trade organizations;
(II) State department demographic data to determine the feasibility of potential or
existing PACE entities to establish or expand within a specific geographical area with an
established PACE program;
(III) Utilization, quality, and performance data of each PACE entity and associated
PACE entities;
(IV) Business continuity and solvency information of each PACE entity or associated
PACE entities;
(V) Measurable innovative practices of PACE entities;
(VI) Staffing practices of PACE entities;
(VII) Transportation data of each PACE entity, including the number of trips, travel
time, and pick-up and drop-off processes;
(VIII) Satisfaction and exit survey data of each PACE entity;
(IX) Audits, complaints, and grievances of each PACE entity;
(X) Current PACE oversight processes, including home health regulatory requirements
and licensure;
(XI) Any duplication of federal oversight processes;
(XII) Due process and appeal rights of PACE entities; and
(XIII) Citations, fines, and suspension remedies to ensure compliance with regulations to
protect the health, safety, and welfare of medicaid members.
(b) No later than March 1, 2024, the state department shall establish, administer, and
enforce minimum regulatory standards and rules for the PACE program, including for contracted
entities of the PACE program. The standards and rules must be sufficient to ensure the health,
safety, and welfare of PACE participants.
(c) The state department shall continually analyze the reimbursement methodology for
PACE entities and provide an update to the house of representatives public and behavioral health
and human services committee, the senate health and human services committee, and the joint
budget committee, or their successor committees, of any new methodology requirements that
Colorado Revised Statutes 2023 Uncertified PrintoutPage 293 of 510
incorporate encounter data and any associated cost to the state department in overseeing PACE
entities.
Source: L. 2006: Entire article added with relocations, p. 1898, § 7, effective July 1. L.
2008: (12) amended, p. 1749, § 1, effective June 2. L. 2009: (12) amended, (SB 09-265), ch.
205, p. 936, § 6, effective May 1. L. 2010: (12)(b) repealed, (HB 10-1382), ch. 217, p. 940, § 5,
effective May 6. L. 2012: (6) and (7) amended and (6.5) added, (SB 12-023), ch. 94, p. 308, § 1,
effective April 12. L. 2013: (3)(f) repealed, (HB 13-1300), ch. 316, p. 1690, § 81, effective
August 7. L. 2015: (1)(a), (2)(b), and (8) amended, (1)(b) repealed, and (14) added, (SB 15-137),
ch. 163, pp. 496, 498, §§ 1, 2, effective August 5. L. 2016: (7)(d) added and (12) amended, (SB
16-199), ch. 270, p. 1117, § 1, effective June 10. L. 2019: (12) amended, (SB 19-209), ch. 124,
p. 534, § 1, effective April 17; (7)(b) amended, (HB 19-1172), ch. 136, p. 1709, § 184, effective
October 1. L. 2021: IP(6) and (6)(a) amended, (HB 21-1187), ch. 83, p. 333, § 28, effective July
1, 2024. L. 2022: (15) added, (SB 22-203), ch. 450, p. 3168, § 1, effective August 10.
Editor's note: (1) This section is similar to former § 26-4-124 as it existed prior to
2006.
(2) Subsection (12)(d)(III) provided for the repeal of subsection (12)(d), effective July 1,
2020. (See L. 2019, p. 534.)
Cross references: For the federal laws creating the Program of All-Inclusive Care for the
Elderly (PACE), see section 9412 (b)(2) of the "Omnibus Budget Reconciliation Act of 1986",
Pub.L. 99-509, and section 4802 of the federal "Balanced Budget Act of 1997", Pub.L. 105-33,
codified at 42 U.S.C. secs. 1395 and 1396.
25.5-5-413. Direct contracting with providers - legislative declaration. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1902, § 7, effective July 1. L.
2018: Entire section repealed, (HB 18-1431), ch. 313, p. 1891, § 7, effective August 8.
Editor's note: This section was similar to former § 26-4-127 as it existed prior to 2006.
25.5-5-414. Telemedicine - legislative intent. (1) It is the intent of the general assembly
to recognize the practice of telemedicine as a legitimate means by which an individual may
receive medical services from a health-care provider without person-to-person contact with a
provider.
(2) Repealed.
(3) On or after January 1, 2002, face-to-face contact between a health-care provider and
a patient is not required under the statewide managed care system created in this part 4 for
services appropriately provided through telemedicine, subject to reimbursement policies
developed by the state department to compensate providers who provide health-care services
covered by the program created in section 25.5-4-104. Telemedicine services may only be used
in areas of the state where the technology necessary for the provision of telemedicine exists. The
audio and visual telemedicine system used must, at a minimum, have the capability to meet the
procedural definition of the most recent edition of the current procedural terminology that
Colorado Revised Statutes 2023 Uncertified PrintoutPage 294 of 510
represents the service provided through telemedicine. The telecommunications equipment must
be of a level of quality to adequately complete all necessary components to document the level
of service for the current procedural terminology fourth edition codes that are billed. If a
peripheral diagnostic scope is required to assess the patient, it must provide adequate resolution
or audio quality for decision-making.
(4) Repealed.
(5) The statewide managed care system is not required to pay for consultation provided
by a provider by telephone or facsimile machines.
(6) The state department may accept and expend gifts, grants, and donations from any
source to conduct the valuation of the cost-effectiveness and quality of health care provided
through telemedicine by those providers who are reimbursed for telemedicine services by the
statewide managed care system.
(7) Nothing in this section shall be construed to:
(a) Alter the scope of practice of any health-care provider; or
(b) Authorize the delivery of health-care services in a setting or manner not otherwise
authorized by law.
Source: L. 2006: Entire article added with relocations, p. 1903, § 7, effective July 1; (3)
amended and (7) added, p. 1547, § 4, effective July 1. L. 2018: (3), (5), and (6) amended and (4)
repealed, (HB 18-1431), ch. 313, p. 1889, § 5, effective August 8. L. 2019: (2) amended, (HB
19-1172), ch. 136, p. 1710, § 185, effective October 1. L. 2021: (2) repealed, (HB 21-1190), ch.
152, p. 875, § 4, effective May 18.
Editor's note: (1) This section is similar to former § 26-4-421 as it existed prior to
2006.
(2) (a) Amendments to section 26-4-421 (3) by Senate Bill 06-165 were harmonized
with subsection (3) as it appeared in Senate Bill 06-219.
(b) Subsection (7) was enacted as 26-4-421 (7) in Senate Bill 06-165 but was relocated
due to its harmonization with this section as it appeared in Senate Bill 06-219.
Cross references: For the legislative declaration contained in the 2006 act amending
subsection (3) and enacting subsection (7), see section 1 of chapter 312, Session Laws of
Colorado 2006.
25.5-5-415. Medicaid payment reform and innovation pilot program - legislative
declaration - creation - selection of payment projects - report - rules. (1) (a) The general
assembly finds that:
(I) Increasing health-care costs in Colorado's medicaid program creates challenges for
the state's budget. Further, the increasing health-care costs do not necessarily reflect
improvements in either health outcomes for patients or in patient satisfaction with the care
received;
(II) Moreover, the fee-for-service payment model may not support or align financially
with evolving care coordination and delivery systems;
(III) The reform of medicaid payment policies offers a significant opportunity for the
state to contain costs and improve quality;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 295 of 510
(IV) New payment methodologies, including global payments, have been developed to
respond to rising costs and the complexities of health-care delivery. Opportunities now exist to
explore, test, and implement such payment reforms in the medicaid program.
(V) The state department should explore how these new payment methodologies may
result in improved health outcomes and patient satisfaction and support the financial
sustainability of the medicaid program; and
(VI) The state department shall evaluate how successful payment projects could be
replicated and incorporated within the state department's statewide managed care system.
(b) Therefore, the general assembly declares that Colorado should build upon ongoing
reforms of health-care delivery in the medicaid program by implementing a pilot program within
the structure of the state department's statewide managed care system that encourages the use of
new and innovative payment methodologies, including global payments.
(2) (a) There is hereby created the medicaid payment reform and innovation pilot
program for purposes of fostering the use of innovative payment methodologies in the medicaid
program that are designed to provide greater value while ensuring good health outcomes and
client satisfaction.
(b) (I) The state department shall create a process for interested contractors of the state
department's statewide managed care system to submit payment projects for consideration under
the pilot program. Payment projects submitted pursuant to the pilot program may include, but
need not be limited to, global payments, risk adjustment, risk sharing, and aligned payment
incentives, including but not limited to gainsharing, to achieve improved quality and to control
costs.
(II) The design of the payment project or projects must address the client population of
the state department's statewide managed care system and be tailored to the region's health-care
needs and the resources of the state department's statewide managed care system.
(III) A contractor of the state department's statewide managed care system shall work in
coordination with the providers and MCEs contracted with the contractor of the state
department's statewide managed care system in developing the payment project or projects.
(c) (I) The state department shall review and select payment projects to be included in
the pilot program.
(II) For purposes of selecting payment projects for the pilot program, the state
department shall consider, at a minimum:
(A) The likely effect of the payment project on quality measures, health outcomes, and
client satisfaction;
(B) The potential of the payment project to reduce the state's medicaid expenditures;
(C) The state department's ability to ensure that inpatient and outpatient hospital
reimbursements are maximized up to the upper payment limits, as defined in 42 CFR 447.272
and 42 CFR 447.321 and calculated by the state department periodically;
(D) The client population served by the state department's statewide managed care
system and the particular health needs of the region;
(E) The business structure or structures likely to foster cooperation, coordination, and
alignment and the ability of the contractor of the state department's statewide managed care
system to implement the payment project, including the resources available to the contractor of
the state department's statewide managed care system and the technological infrastructure
required; and
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(F) The ability of the contractor of the state department's statewide managed care system
to coordinate among providers of physical health care, behavioral health care, oral health care,
and the system of long-term care services and supports.
(III) For payment projects not selected by the state department, the state department shall
respond to the contractor of the state department's statewide managed care system, in writing,
stating the reason or reasons why the payment project was not selected. The state department
shall send a copy of the response to the joint budget committee of the general assembly, the
health and human services committee of the senate, and the health, insurance, and environment
committee of the house of representatives, or any successor committees.
(d) (I) The payment projects selected for the program must be for a period of at least one
year and must not extend beyond the length of the contract with the contractor of the state
department's statewide managed care system. The provider contract must specify the payment
methodology utilized in the payment project.
(II) Repealed.
(III) MCEs participating in the pilot program are subject to the requirements of sections
25.5-5-402 (10) and 25.5-5-408 (1)(e) and (1)(f), as applicable.
(IV) Payments made to MCEs under the pilot program shall account for prospective,
local community or health system cost trends and values, as measured by quality and satisfaction
measures, and shall incorporate community cost experience and reported encounter data to the
extent possible to address regional variation and improve longitudinal performance.
(V) Notwithstanding any provisions of this section or state board rules to the contrary, it
is the intent of the general assembly that total payments, adjustments, and incentives will be
budget-neutral with respect to state expenditures. The state department shall not enter into a
contract with a provider pursuant to this section if the state department estimates that total
payments to the provider will be greater than without the contract.
(3) Pilot program participants shall provide data and information to the state department
and any designated evaluator concerning health outcomes, cost, provider participation and
satisfaction, client satisfaction, and any other data and information necessary to evaluate the
efficacy of the payment methodology.
(4) (a) The state department shall submit a report to the joint budget committee of the
general assembly, the health and human services committee of the senate, or any successor
committee, and the health and environment committee of the house of representatives, or any
successor committee, as follows:
(I) On or before February 1, 2013, concerning the design and implementation of the pilot
program, including a description of any payment projects received by the state department and
the time frame for implementation;
(II) On or before September 15, 2014, concerning the pilot program as implemented,
including but not limited to an analysis of the initial data and information concerning the
utilization of the payment methodology, quality measures, and the impact of the payment
methodology on health outcomes, cost, provider participation and satisfaction, and patient
satisfaction;
(III) On or before September 15, 2015, concerning the program as implemented,
including but not limited to an analysis of the data and information concerning the utilization of
the payment methodology, including an assessment of how the payment methodology drives
provider performance and participation and the impact of the payment methodology on quality
Colorado Revised Statutes 2023 Uncertified PrintoutPage 297 of 510
measures, health outcomes, cost, provider satisfaction, and patient satisfaction, comparing those
outcomes across patients utilizing existing state department data;
(IV) On or before April 15, 2017, and each April 15 that the program is being
implemented, concerning the program as implemented, including but not limited to an analysis
of the data and information concerning the utilization of the payment methodology, including an
assessment of how the payment methodology drives provider performance and participation and
the impact of the payment methodology on quality measures, health outcomes, cost, provider
satisfaction, and patient satisfaction, comparing those outcomes across patients utilizing existing
state department data. Specifically, the report must include:
(A) An evaluation of all current payment projects and whether the state department
intends to extend any current payment project into the next fiscal year;
(B) The state department's plans to incorporate any payment project into the larger
medicaid payment framework;
(C) A description of any payment project proposals received by the state department
since the prior year's report, and whether the state department intends to implement any new
payment projects in the upcoming fiscal year; and
(D) The results of the state department's evaluation of payment projects pursuant to
paragraph (a.5) of this subsection (4).
(a.5) The state department shall evaluate each payment project to determine:
(I) Whether the payment project offers the potential for better patient outcomes or
improved care and the impact of better outcomes and improved care on medicaid costs;
(II) Whether the payment project creates the opportunity for administrative efficiency in
the medicaid program;
(III) Whether the payment project is budget neutral or generates savings for the medicaid
program; and
(IV) Whether the payment project resulted in changes in provider participation in the
medicaid program, and the nature of those changes.
(b) For purposes of evaluating the pilot program and payment methodologies, the state
department may collaborate with a nonprofit entity or an institution of higher education to
analyze and verify data and information received from pilot participants and to evaluate quality
measures and the cost-effectiveness of the payment reforms.
(5) The state department shall seek any federal authorization necessary to implement the
pilot program.
(6) The state department may promulgate any rules necessary to implement the pilot
program.
Source: L. 2012: Entire section added, (HB 12-1281), ch. 246, p. 1182, § 2, effective
June 4. L. 2016: (1)(a)(V), (2)(c)(I), (2)(c)(III), (2)(d)(I), (4)(a)(II), and (4)(a)(III) amended and
(1)(a)(VI), (4)(a)(IV), and (4)(a.5) added, (HB 16-1407), ch. 152, p. 453, § 1, effective May 4. L.
2018: (1)(a)(VI), (1)(b), (2)(b), (2)(c)(II), (2)(c)(III), (2)(d)(I), and (2)(d)(III) amended and
(2)(d)(II) repealed, (HB 18-1431), ch. 313, p. 1889, § 6, effective August 8.
Editor's note: Subsection (2)(c)(II)(C) is similar to former § 25.5-5-402 (6)(b)(II), as it
existed prior to 2018. For a detailed comparison of this section, see the comparative tables
located at the back of the index.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 298 of 510
25.5-5-416. Report concerning efficient contracting in managed care - legislative
declaration - repeal. (Repealed)
Source: L. 2012: Entire section added, (HB 12-1281), ch. 246, p. 1186, § 2, effective
June 4.
Editor's note: Subsection (3) provided for the repeal of this section, effective July 1,
2013. (See L. 2012, p. 1186.)
25.5-5-417. Reducing unnecessary duplicative services in the accountable care
collaborative program - repeal. (Repealed)
Source: L. 2013: Entire section added, (HB 13-1196), ch. 201, p. 817, § 1, effective
August 7.
Editor's note: Subsection (4) provided for the repeal of this section, effective July 15,
2018. (See L. 2013, p. 817.)
25.5-5-418. Primary care provider sustainability fund - creation - use of fund. The
primary care provider sustainability fund is hereby created in the state treasury. The fund
consists of money transferred to the fund from the children's basic health plan trust created in
section 25.5-8-105 (1) pursuant to section 25.5-8-105 (8)(b) and any other money that the
general assembly may appropriate or transfer to 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.
Any unexpended and unencumbered money in the fund at the end of any fiscal year remains in
the fund and shall not be credited or transferred to the general fund or any other fund. Subject to
annual appropriation by the general assembly, the state department may expend money from the
fund for the purpose of increasing access to primary care through rate enhancements for primary
care office visits, preventive medicine visits, counseling and health-risk assessments,
immunization administration, health screening services, and newborn care, including neonatal
critical care. Money expended from the fund for the purposes of increasing access to primary
care through rate enhancements supplements and does not supplant general fund appropriations
for that purpose.
Source: L. 2016: Entire section added, (HB 16-1408), ch. 153, p. 468, § 18, effective
July 1.
25.5-5-419. Accountable care collaborative - reporting - rules. (1) In 2011, the state
department created the accountable care collaborative, also referred to in this title 25.5 as the
medicaid coordinated care system. The state department shall continue to provide care delivery
through the accountable care collaborative. The goals of the accountable care collaborative are to
improve member health and reduce costs in the medicaid program. To achieve these goals, the
state department's implementation of the accountable care collaborative must include, but need
not be limited to:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 299 of 510
(a) Establishing primary care medical homes for medicaid clients within the accountable
care collaborative;
(b) Providing regional care coordination and provider network support;
(c) Providing data to regional entities and providers to help manage client care;
(d) Integrating the delivery of behavioral health, including mental health and substance
use disorders, and physical health services for clients;
(e) Connecting primary care with specialty care and nonhealth community supports;
(f) Promoting member choice and engagement;
(g) Promoting telehealth and telemedicine;
(h) Utilizing innovative care models and provider payment models as part of the care
delivery system, including capitated managed care models within the broader accountable care
collaborative;
(i) Receiving feedback from affected stakeholder groups;
(j) Establishing a flexible structure that would allow for the efficient operation of the
accountable care collaborative to further include medicaid populations and services, including
long-term care services and supports; and
(k) Establishing a care delivery system and provider payment platform that can adapt to
changing federal financial participation models or funding levels.
(2) The state department shall facilitate transparency and collaboration in the
development, performance management, and evaluation of the accountable care collaborative
through the creation of stakeholder advisory committees.
(3) On or before December 1, 2017, and on or before December 1 each year thereafter,
the state department shall prepare and 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, concerning the
implementation of the accountable care collaborative. Notwithstanding the provisions of section
24-1-136 (11)(a)(I), the report required pursuant to this subsection (3) continues indefinitely. At
a minimum, the state department's report must include the following information concerning the
accountable care collaborative:
(a) The number of medicaid clients enrolled in the program;
(b) Performance results with an emphasis on member health impacts;
(c) Current administrative fees and costs for the program;
(d) Fiscal performance;
(e) A description of activities that promote access to services for medicaid members in
rural and frontier counties;
(f) A description of the state department's coordination with entities that authorize
long-term care services for medicaid clients;
(g) Information on any advisory committees created, including the participants, focus,
stakeholder feedback, and outcomes of the work of the advisory committees;
(h) Future areas of program focus and development, including, among others, a plan to
study the costs and benefits of further coverage of substance use disorder treatment; and
(i) Information concerning efforts to reduce medicaid waste and inefficiencies through
the accountable care collaborative, including:
(I) The specific efforts within the accountable care collaborative, including a summary
of technology-based efforts, to identify and implement best practices relating to cost
Colorado Revised Statutes 2023 Uncertified PrintoutPage 300 of 510
containment; reducing avoidable, duplicative, variable, and inappropriate uses of health-care
resources; and the outcome of those efforts, including cost savings, if known;
(II) Any statutes, policies, or procedures that prevent regional entities from realizing
efficiencies and reducing waste within the medicaid system; and
(III) Any other efforts by regional entities or the state department to ensure that those
who provide care for medicaid clients are aware of and actively participate in reducing waste
within the medicaid system.
(4) On or before December 1, 2017, 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, outlining the statutory changes needed to part 4 of this article 5 relating to the
statewide managed care system, as well as any other sections of the Colorado Revised Statutes,
in order to align Colorado law with the federal "Medicaid and CHIP Managed Care Final Rule",
CMS-2390-F.
(5) The state board shall promulgate rules implementing the accountable care
collaborative.
(6) The state department shall consider new technologies and business practices for
medical management reform that would reduce medical costs due to misuse, overuse, waste,
fraud, and abuse. Better drug management, especially of avoidable prescriptions and inefficient
use of specialty drugs, would allow the entire prescription drug cost continuum to be managed
more effectively to contain costs and achieve better patient outcomes. New technologies and
business practices for medical management reform may also benefit Colorado by providing a
more powerful medicaid enrollment platform that properly enrolls only those individuals who
are truly eligible for medicaid benefits.
Source: L. 2017: Entire section added, (HB 17-1353), ch. 231, p. 895, § 2, effective May
23.
25.5-5-420. Advancing care for exceptional kids. Within one hundred twenty days of
the enactment of the federal "Advancing Care for Exceptional Kids Act", subject to available
appropriations, the state department shall seek any federal approval necessary to fund, in
cooperation with hospitals that meet the specified requirements, the implementation of an
enhanced pediatric health home for children with complex medical conditions. Requirements for
participation by the state department, along with the requirement of an enhanced pediatric health
home, are stipulated by the "Advancing Care for Exceptional Kids Act" and shall be complied
with accordingly.
Source: L. 2017: Entire section added, (SB 17-267), ch. 267, p. 1466, § 21, effective
May 30.
Cross references: For the legislative declaration in SB 17-267, see section 1 of chapter
267, Session Laws of Colorado 2017.
25.5-5-421. Parity reporting - state department - public input. (1) The state
department shall require each MCE contracted with the state department to disclose all necessary
Colorado Revised Statutes 2023 Uncertified PrintoutPage 301 of 510
information in order for the state department, by June 1, 2020, and by each June 1 thereafter, to
submit a report to the health and insurance committee and the public health care and human
services committee of the house of representatives, or their successor committees, and to the
health and human services committee of the senate, or its successor committee, regarding
behavioral, mental health, and substance use disorder parity. The report must contain the
following information for the prior calendar year:
(a) A description of the process used to develop or select the medical necessity criteria
for behavioral, mental health, and substance use disorder benefits and the process used to
develop or select the medical necessity criteria for medical and surgical benefits;
(b) Identification of all nonquantitative treatment limitations that are applied to
behavioral, mental health, and substance use disorder benefits and to medical and surgical
benefits within each classification of benefits and a statement that the state is complying with 42
U.S.C. sec. 300gg-26 (a)(3)(A)(ii), as required by 42 U.S.C. sec. 1396u-2 (b)(8), prohibiting the
application of nonquantitative treatment limitations to behavioral, mental health, and substance
use disorder benefits that do not apply to medical and surgical benefits within any classification
of benefits;
(c) (I) The results of analyses demonstrating that, for the medical necessity criteria
described in subsection (1)(a) of this section and each nonquantitative treatment limitation
identified in subsection (1)(b) of this section, as written and in operation, the processes,
strategies, evidentiary standards, or other factors used in applying the medical necessity criteria
and each nonquantitative treatment limitation to benefits for behavioral, mental health, and
substance use disorders within each classification of benefits are comparable to, and are applied
no more stringently than, the processes, strategies, evidentiary standards, or other factors used in
applying the medical necessity criteria and each nonquantitative treatment limitation to medical
and surgical benefits within the corresponding classification of benefits.
(II) A report on the results of the analyses specified in this subsection (1)(c) must, at a
minimum:
(A) Identify the factors used to determine that a nonquantitative treatment limitation will
apply to a benefit, including factors that were considered but rejected;
(B) Identify and define the specific evidentiary standards used to define the factors and
any other evidence relied on in designing each nonquantitative treatment limitation;
(C) Provide the comparative analyses, including the results of the analyses, performed to
determine that the processes and strategies used to design each nonquantitative treatment
limitation, as written, and the written processes and strategies used to apply each nonquantitative
treatment limitation for benefits for behavioral, mental health, and substance use disorders are
comparable to, and are applied no more stringently than, the processes and strategies used to
design and apply each nonquantitative treatment limitation, as written, and the written processes
and strategies used to apply each nonquantitative treatment limitation for medical and surgical
benefits;
(D) Provide the comparative analyses, including the results of the analyses, performed to
determine that the processes and strategies used to apply each nonquantitative treatment
limitation, in operation, for benefits for behavioral, mental health, and substance use disorders
are comparable to, and are applied no more stringently than, the processes and strategies used to
apply each nonquantitative treatment limitation, in operation, for medical and surgical benefits;
and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 302 of 510
(E) Disclose the specific findings and conclusions that indicate that the state is in
compliance with this section and with the MHPAEA.
(2) By October 1, 2019, for purposes of obtaining meaningful public input during the
assessment process described in subsection (1) of this section, the state department shall seek
input from stakeholders who may have competency in benefit and delivery systems, utilization
management, managed care contracting, data and reporting, or compliance and audits. The state
department shall consider the input received in conducting the analyses and developing the
report pursuant to subsection (1) of this section.
(3) Notwithstanding section 24-1-136 (11)(a)(I), the reporting requirement specified in
this section continues indefinitely.
(4) The state department shall contract with an external quality review organization at
least annually to monitor MCEs' utilization management programs and policies, including those
that govern adverse determinations, to ensure compliance with the MHPAEA. The quality
review report must be readily available to the public.
Source: L. 2019: Entire section added, (HB 19-1269), ch. 195, p. 2134, § 15, effective
May 16.
Cross references: For the short title ("Behavioral Health Care Coverage Modernization
Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
25.5-5-422. Medication-assisted treatment - limitations on MCEs - definition. (1) As
used in this section, "FDA" means the food and drug administration in the United States
department of health and human services.
(2) Notwithstanding any provision of law to the contrary, beginning January 1, 2020,
each MCE that provides prescription drug benefits for the treatment of substance use disorders
shall:
(a) Not impose any prior authorization requirements on any prescription medication
approved by the FDA for the treatment of substance use disorders;
(b) Not impose any step therapy requirements as a prerequisite to authorizing coverage
for a prescription medication approved by the FDA for the treatment of substance use disorders;
and
(c) Not exclude coverage for any prescription medication approved by the FDA for the
treatment of substance use disorders and any associated counseling or wraparound services
solely on the grounds that the medications and services were court ordered.
Source: L. 2019: Entire section added, (HB 19-1269), ch. 195, p. 2136, § 15, effective
May 16.
Cross references: For the short title ("Behavioral Health Care Coverage Modernization
Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.
25.5-5-423. Independent review organization - review denial of residential and
inpatient substance use disorder treatment claims - contract. No later than July 1, 2023, the
state department shall contract with one or more independent review organizations to conduct
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external medical reviews requested for review by a medicaid provider when there is a denial or
reduction for residential or inpatient substance use disorder treatment and medicaid appeals
processes have been exhausted.
Source: L. 2021: Entire section added, (SB 21-137), ch. 362, p. 2364, § 9, effective June
28.
Cross references: For the short title ("Behavioral Health Recovery Act of 2021") and the
legislative declaration in SB 21-137, see sections 1 and 2 of chapter 362, Session Laws of
Colorado 2021.
25.5-5-424. Residential and inpatient substance use disorder treatment - MCE
standardized utilization management process - medical necessity - report. (1) On or before
October 1, 2021, the state department shall consult with the behavioral health administration in
the department of human services, residential treatment providers, and MCEs to develop
standardized utilization management processes to determine medical necessity for residential
and inpatient substance use disorder treatment. The processes must incorporate the most recent
edition of "The ASAM Criteria for Addictive, Substance-related, and Co-occurring Conditions"
and align with federal medicaid payment requirements.
(2) On or before January 1, 2022, the state department shall incorporate the standards
developed pursuant to subsection (1) of this section into existing MCE contracts, and each MCE
shall adhere to the standards when conducting utilization management for residential and
inpatient substance use disorder treatment.
(3) On or before January 1, 2022, each MCE's notice of an adverse benefit determination
must demonstrate how each dimension of the most recent edition of "The ASAM Criteria for
Addictive, Substance-related, and Co-occurring Conditions" was considered when determining
medical necessity.
(4) (a) Beginning October 1, 2021, and quarterly thereafter, the state department shall
collaborate with the behavioral health administration in the department of human services,
residential treatment providers, and MCEs to develop a report on the residential and inpatient
substance use disorder utilization management statistics. At a minimum, the report must include:
(I) The average length of an initial authorization and the average length of continued
authorizations for each MCE and provider disaggregated by level of residential care;
(II) Denials of initial authorizations reported for each MCE and provider and the reasons
for the denials; and
(III) The average response time for an initial authorization and continued authorization,
disaggregated by each MCE; level of residential care, including the percentage of extensions
granted to health-care providers to submit complete clinical documentation; retroactive
authorization requests; incomplete authorization requests; and the number of requests that met
and did not meet the state department's response time requirements.
(b) The state department shall make the report developed pursuant to subsection (4)(a) of
this section publicly available on the state department's website.
(c) Any information required to be reported pursuant to subsection (4)(a) of this section
may be aggregated as necessary to ensure confidentially pursuant to 42 CFR part 2.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 304 of 510
Source: L. 2021: Entire section added, (SB 21-137), ch. 362, p. 2365, § 10, effective
June 28. L. 2022: (1) and IP(4)(a) amended, (HB 22-1278), ch. 222, p. 1515, § 76, effective July
1.
Cross references: For the short title ("Behavioral Health Recovery Act of 2021") and the
legislative declaration in SB 21-137, see sections 1 and 2 of chapter 362, Session Laws of
Colorado 2021.
25.5-5-425. Audit of MCE denials for residential and inpatient substance use
disorder treatment authorization - report. (1) No later than July 1, 2022, the state department
shall contract with an independent third-party vendor to audit thirty-three percent of all denials
of authorization for inpatient and residential substance use disorder treatment for each MCE.
(2) Beginning December 1, 2022, and each December 1 thereafter, the state department
shall submit the results of the audit conducted pursuant to subsection (1) of this section and any
recommended changes to the residential and inpatient substance use disorder benefit to the house
of representatives health and insurance committee, the house of representatives public and
behavioral health and human services committee, the senate health and human services
committee, or their successor committees, and the joint budget committee.
Source: L. 2021: Entire section added, (SB 21-137), ch. 362, p. 2366, § 11, effective
June 28.
Cross references: For the short title ("Behavioral Health Recovery Act of 2021") and the
legislative declaration in SB 21-137, see sections 1 and 2 of chapter 362, Session Laws of
Colorado 2021.
PART 5
PRESCRIPTION DRUGS
25.5-5-500.3. Authorization to bill third party. As a condition of doing business in the
state, each provider is deemed to authorize the state department, or an independent contractor
retained by the state department, to bill a third party, as defined in section 25.5-4-209 (2)(g)(II),
on behalf of the provider if the third party is determined to be liable to pay for care pursuant to
sections 25.5-4-209 and 25.5-4-300.4.
Source: L. 2010: Entire section added, (SB 10-167), ch. 296, p. 1379, § 9, effective May
26.
Cross references: For the legislative declaration in SB 10-167, see section 1 of chapter
296, Session Laws of Colorado 2010.
25.5-5-501. Providers - drug reimbursement. (1) (a) As to drugs for which payment is
made, the state board's rules for payment must include the requirement that the generic
equivalent of a brand-name drug be prescribed if the generic equivalent is a therapeutic
Colorado Revised Statutes 2023 Uncertified PrintoutPage 305 of 510
equivalent to the brand-name drug, except when reimbursement to the state for a brand-name
drug makes the brand-name drug less expensive than the cost of the generic equivalent. The state
department shall grant an exception to this requirement if the patient has been stabilized on a
medication and the treating physician, or a pharmacist with the concurrence of the treating
physician, is of the opinion that a transition to the generic equivalent of the brand-name drug
would be unacceptably disruptive. The requirements of this subsection (1) do not apply to
medications for the treatment of behavioral or mental health disorders, cancer, epilepsy, or
human immunodeficiency virus and acquired immune deficiency syndrome.
(b) The provisions of this subsection (1) shall apply to fee-for-service and primary care
physician program recipients.
(2) It is the general assembly's intent that requiring the use of a generic equivalent of a
brand-name drug will produce savings within the state's medicaid program. The state
department, therefore, is authorized to use savings in the medical services premiums
appropriations to fund the administrative review process required by subsection (1) of this
section.
Source: L. 2006: Entire article added with relocations, p. 1904, § 7, effective July 1. L.
2013: (1)(a) amended, (HB 13-1266), ch. 217, p. 992, § 63, effective May 13. L. 2017: (1)(a)
amended, (SB 17-242), ch. 263, p. 1329, § 205, effective May 25.
Editor's note: This section is similar to former § 26-4-406 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017.
25.5-5-502. Unused medications - reuse - rules - definition. (1) As used in this section,
unless the context otherwise requires, "medication" means prescription medication that is not a
controlled substance.
(2) A pharmacist participating in the medical assistance program may accept unused
medication from a licensed facility, as defined in section 12-280-135 (1)(b), or a licensed
health-care provider for the purpose of dispensing the medication to another person. A
pharmacist shall reimburse the state department for the cost of medications that the state
department has paid to the pharmacist if medications are returned to a pharmacist and the
medications are available to be dispensed to another person. Medications shall only be available
to be dispensed to another person under this section if the medications are:
(a) Liquid and the vial is still sealed and properly stored;
(b) Individually packaged and the packaging has not been damaged; or
(c) In the original, unopened, sealed, and tamper-evident unit dose packaging.
(3) Medication dispensed pursuant to this section shall bear an expiration date that is
later than six months after the date the drug was donated.
(4) Any savings realized through reimbursements received pursuant to subsection (2) of
this section shall fund the administration of this section.
(5) The state board, in consultation with the state board of pharmacy, shall adopt rules
for the implementation of this section.
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Source: L. 2006: Entire article added with relocations, p. 1904, § 7, effective July 1. L.
2012: IP(2) amended, (HB 12-1311), ch. 281, p. 1621, § 76, effective July 1. L. 2019: IP(2)
amended, (HB 19-1172), ch. 136, p. 1710, § 186, effective October 1. L. 2021: (4) amended,
(SB 21-266), ch. 423, p. 2803, § 24, effective July 2.
Editor's note: This section is similar to former § 26-4-406.3 as it existed prior to 2006.
25.5-5-503. Prescription drug benefits - authorization - dual-eligible participation.
(1) The state department is authorized to ensure the participation of Colorado medical assistance
recipients, who are also eligible for medicare, in any federal prescription drug benefit enacted for
medicare recipients.
(2) Prescribed drugs shall not be a covered benefit under the medical assistance program
for a recipient who is eligible for a prescription drug benefit program under medicare; except
that, if a prescribed drug is not a covered Part D drug as defined in the "Medicare Prescription
Drug, Improvement, and Modernization Act of 2003", Pub.L. 108-173, the prescribed drug may
be a covered benefit if it is otherwise covered under the medical assistance program and federal
financial participation is available.
Source: L. 2006: Entire article added with relocations, p. 1905, § 7, effective July 1. L.
2007: (2) amended, p. 1631, § 1, effective July 1.
Editor's note: This section is similar to former § 26-4-406.5 as it existed prior to 2006.
Cross references: For additional information on the federal "Medicare Prescription
Drug, Improvement, and Modernization Act of 2003", see Pub.L. 108-173.
25.5-5-504. Providers of pharmaceutical services. (1) Consistent with the provisions
of section 25.5-4-401 (1), and consistent with subsections (2) and (3) of this section, and subject
to available appropriations, no provider of pharmaceutical services who meets the conditions
imposed by this article and articles 4 and 6 of this title and who complies with the terms and
conditions established by the state department and contracting health maintenance organizations
and prepaid health plans shall be excluded from contracting for the provision of pharmaceutical
services to recipients authorized in this article and articles 4 and 6 of this title.
(2) This provision shall not apply to a health maintenance organization or prepaid health
plan that enrolls less than forty percent of all the resident medicaid recipients in any county with
over one thousand medicaid recipients.
(3) The state board shall establish specifications in rules in order to provide criteria to
health maintenance organizations and prepaid health plans which ensure the accessibility and
quality of service to clients and the terms and conditions for pharmaceutical contracts.
Source: L. 2006: Entire article added with relocations, p. 1905, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-407 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 307 of 510
25.5-5-505. Prescribed drugs - mail order - rules. (1) (a) (I) The state board shall
adopt by rule a system to allow medical assistance recipients the option to receive through the
mail prescribed maintenance medications used to treat chronic medical conditions.
(II) The state board rules must include the definition of maintenance medications. The
rules may allow a medical assistance recipient to receive through the mail up to a three-month
supply, or the maximum allowed under federal law, of maintenance medications used to treat
chronic medical conditions.
(b) To the extent allowed by federal law, the state department shall require that a
medical assistance recipient receiving prescription medication through the mail pay the same
copayment amount as a medical assistance recipient receiving prescription medication through
any other method. The state department shall encourage medical assistance recipients who
choose to receive maintenance medications through the mail to use local retail pharmacies for
mail delivery.
(c) A pharmacy may provide maintenance medications through the mail to medical
assistance recipients in accordance with all applicable state and federal laws if the pharmacy is
enrolled as a provider with the state department and is registered with the state board of
pharmacy, created and existing pursuant to section 12-280-104.
(d) A nonresident prescription drug outlet doing business in this state shall provide a
means for recipients of state medical assistance who have third-party insurance with whom the
nonresident prescription drug outlet has a contractual relationship to receive their required
pharmacy benefits at a cost to the recipients of no more than the legally allowed state medical
assistance copayment. If a third-party insurance carrier's copayment or deductible for pharmacy
benefits is larger than the legally allowed state medical assistance copayment, the prescription
drug outlet may bill the state medical assistance program for the difference pursuant to state
medical assistance reimbursement rules.
(1.5) The state department shall publish on its website and include in the recipient
handbook the following information for recipients enrolled in fee-for-service medical assistance
programs:
(a) That a medical assistance recipient may use the pharmacy of his or her choice;
(b) That a medical assistance recipient may use a local retail pharmacy for mail delivery
of maintenance medications, if offered; and
(c) That the copayment amount for prescription medications is the same at any pharmacy
enrolled in the medical assistance program.
(2) The state department shall seek any federal authorization necessary to implement this
section.
Source: L. 2006: Entire article added with relocations, p. 1905, § 7, effective July 1. L.
2008: (1) amended, p. 890, § 1, effective May 20. L. 2009: (1)(a)(I)(B) amended, (SB 09-252),
ch. 271, p. 1228, § 1, effective May 18. L. 2016: (1) amended and (1.5) added, (SB 16-027), ch.
208, p. 745, § 1, effective August 10. L. 2019: (1)(c) amended, (HB 19-1172), ch. 136, p. 1710,
§ 187, effective October 1.
Editor's note: This section is similar to former § 26-4-407.5 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 308 of 510
25.5-5-506. Prescribed drugs - utilization review. (1) The state department shall
develop and implement a drug utilization review process to assure the appropriate utilization of
drugs by patients receiving medical assistance in the fee-for-service and primary care physician
programs. The review process shall include the monitoring of prescription information and shall
address at a minimum underutilization and overutilization of benefit drugs. Periodic reports of
findings and recommendations shall be forwarded to the state department.
(2) It is the general assembly's intent that the implementation of a drug utilization review
process for the fee-for-service and primary care physician programs will produce savings within
the state's medicaid program. The state department, therefore, is authorized to use savings in the
medical services premiums appropriations to fund the development and implementation of a
drug utilization review process for these programs, as required by subsection (1) of this section.
The state department may contract on a contingency basis for the development or
implementation of the review process required by subsection (1) of this section.
(3) (a) The state department shall implement drug utilization mechanisms, including, but
not limited to, prior authorization, to control costs in the medical assistance program associated
with prescribed drugs. The state board shall promulgate a rule that outlines a process in which
any interested party may be notified of and comment on the implementation of any prior
authorization for a class of prescribed drugs before the class is prior authorized.
(b) Repealed.
Source: L. 2006: Entire article added with relocations, p. 1906, § 7, effective July 1. L.
2016: (3)(b) repealed, (HB 16-1081), ch. 22, p. 51, § 4, effective August 10.
Editor's note: This section is similar to former § 26-4-408 as it existed prior to 2006.
25.5-5-507. Prescription drug information and technical assistance program - rules.
There is hereby created the prescription drug information and technical assistance program. The
program shall provide advice on the prudent use of prescription drugs to persons who receive
prescription drug benefits pursuant to this part 5. The state department shall contract with
licensed pharmacists for statewide medicaid pharmacy services and pharmacy consultations for
persons receiving prescription drug benefits pursuant to this part 5 regarding how each person
may, with the approval of the appropriate prescribing health-care provider, avoid dangerous drug
interactions, improve patient outcomes, and save the state money for the drugs prescribed. The
state department shall promulgate rules to establish and administer the program and to provide
incentive payments to pharmacists and physicians who participate in the program. The state
department shall design a calculation for savings under the program.
Source: L. 2007: Entire section added, p. 1631, § 2, effective July 1.
25.5-5-508. Electronic prescriptions - study - report - repeal. (Repealed)
Source: L. 2009: Entire section added, (HB 09-1073), ch. 282, p. 1286, § 1, effective
August 5.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 309 of 510
Editor's note: Subsection (4) provided for the repeal of this section, effective July 1,
2010. (See L. 2009, p. 1286.)
25.5-5-509. Substance use disorder - prescription drugs - opiate antagonist. (1)
Notwithstanding any provisions of this part 5 to the contrary, for the treatment of a substance use
disorder, in promulgating rules, and subject to any necessary federal authorization, the state
board shall authorize reimbursement for at least one federal food and drug
administration-approved ready-to-use opioid overdose reversal drug without prior authorization.
(2) (a) As used in this subsection (2), unless the context otherwise requires, "opiate
antagonist" has the same meaning as set forth in section 12-30-110 (7)(d).
(b) A hospital or emergency department shall receive reimbursement under the medical
assistance program for the cost of an opiate antagonist if, in accordance with section 12-30-110,
a prescriber, as defined in section 12-30-110 (7)(h), dispenses an opiate antagonist upon
discharge to a medical assistance recipient who is at risk of experiencing an opiate-related drug
overdose event or to a family member, friend, or other person in a position to assist a medical
assistance recipient who is at risk of experiencing an opiate-related drug overdose event.
(c) The state department shall seek federal financial participation for the cost of
reimbursement for the opiate antagonist, but shall provide reimbursement to the hospital or
emergency department for the opiate antagonist using state money until federal financial
participation is available.
Source: L. 2018: Entire section added (HB 18-1007), ch. 225, p. 1433, § 6, effective
January 1, 2019. L. 2022: Entire section amended (HB 22-1326), ch. 225, p. 1670, § 50,
effective July 1.
Cross references: For the legislative declaration in HB 22-1326 stating the purpose of,
and the provision directing legislative staff agencies to conduct, a post-enactment review
pursuant to § 2-2-1201 scheduled in 2024, 2025, and 2027, see sections 1 and 55 of chapter 225,
Session Laws of Colorado 2022. To obtain a copy of the review, once completed, go to
"Legislative Resources and Requirements" on the Colorado General Assembly's website.
25.5-5-510. Pharmacy reimbursement - substance use disorder - injections. If a
pharmacy has entered into a collaborative pharmacy practice agreement with one or more
physicians pursuant to section 12-280-602 to administer injectable antagonist medication for
medication-assisted treatment for substance use disorders, the pharmacy administering the drug
shall receive an enhanced dispensing fee that aligns with the administration fee paid to a
provider in a clinical setting.
Source: L. 2018: Entire section added, (HB 18-1007), ch. 225, p. 1433, § 7, effective
January 1, 2019. L. 2019: Entire section amended, (HB 19-1172), ch. 136, p. 1710, § 188,
effective October 1.
25.5-5-511. Reimbursement for pharmacists' services - legislative declaration. (1) (a)
The general assembly finds and declares that:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 310 of 510
(I) Pharmacists are highly trained and educated doctorate-level health-care professionals
specializing in the effective use of medications and their outcomes;
(II) Pharmacists provide health care throughout the entire health-care system, practicing
in community pharmacies, hospitals, provider clinic offices, and specialty areas;
(III) With ninety percent of Americans living within five miles of a pharmacy,
pharmacists are able to provide valuable public health services to communities and to provide
those services in novel ways, including during nontraditional hours and without appointments;
(IV) As part of an integrated team, pharmacists have been proven to lower the overall
cost of health care and improve long-term chronic disease outcomes; however, despite these
recognized benefits, pharmacists are not considered reimbursable medical providers;
(V) Further, pharmacists in integrated medical homes under the medical assistance
program are not supported by the same funding mechanisms as other providers, including rate
setting for federally qualified health centers or through fee-for-service billing;
(VI) Without the ability to generate revenue through direct reimbursement or new
value-based models, the services pharmacists provide are not sustainable;
(VII) Colorado has recognized that there is a shortage in primary care providers for
individuals enrolled in the medical assistance program; and
(VIII) Pharmacists can help address this shortage by providing certain primary care
services as a follow-up to physician care through collaborative practice models, including the
provision of chronic disease management.
(b) Therefore, the general assembly declares that the ability of pharmacists to generate
revenue for the same services provided by other health-care providers would be equitable, would
help fund staff and services in medical homes, and would alleviate barriers to access of care in
community settings.
(2) (a) A pharmacist is eligible to receive reimbursement under the medical assistance
program for medically necessary services authorized in part 6 of article 280 of title 12 that are
not duplicative of other pharmacist services or programs reimbursed under the medical
assistance program.
(b) The state department shall include the services reimbursed pursuant to subsection
(2)(a) of this section in the review of provider rates required pursuant to section 25.5-4-401.5.
(3) The state department shall request any federal authorization necessary to receive
federal financial participation under the medical assistance program.
Source: L. 2021: Entire section added, (HB 21-1275), ch. 470, p. 3377, § 1, effective
September 7.
25.5-5-512. Pharmacy benefit - mental health and substance use disorders -
legislative declaration. (1) (a) The general assembly finds and declares that:
(I) It is estimated that over one million Coloradans experience a mental health or
substance use disorder each year, yet less than half of the adult population in this state receives
the care it needs;
(II) It is well documented that access to appropriate treatments, including medication,
can lead to better outcomes for individuals dealing with these diagnoses;
(III) For this reason, policies that restrict access to medications lead to poorer outcomes
and increased health-care costs;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 311 of 510
(IV) Pharmacists also play an important role in improving access to treatments for
serious mental illness and substance use disorders; and
(V) The use of extended-release injectable medications for serious mental illness and
substance use disorders has research-proven clinical benefits compared to oral medications,
including medication adherence and significant delay and reduction in relapse, which decreases
criminal recidivism and emergency room visits for patients from vulnerable populations,
particularly those experiencing homelessness.
(b) Therefore, the general assembly declares that access to these treatments through a
pharmacy benefit under the medical assistance program will improve access to mental health
providers by allowing pharmacists to dispense, administer, and be reimbursed for these
important and effective medications.
(2) A pharmacist or pharmacy that dispenses or administers extended-release injectable
medications for the treatment of mental health or substance use disorders may seek
reimbursement for those medications under the medical assistance program either as a pharmacy
benefit or as a medical benefit.
Source: L. 2021: Entire section added, (HB 21-1275), ch. 470, p. 3377, § 1, effective
September 7.
25.5-5-513. Pharmacy benefits - prescription drugs - rebates - analysis. (1)
Beginning in 2023, the state department shall, in collaboration with the administrator of the
all-payer health claims database described in section 25.5-1-204, conduct an annual analysis of
the prescription drug rebates received in the previous calendar year, by health insurance carrier
and prescription drug tier. The analysis, using data from the all-payer health claims database and
other sources, must be completed on or before May 1 of each year.
(2) The state department shall make the analysis conducted in subsection (1) of this
section available to the public on an annual basis.
Source: L. 2022: Entire section added, (HB 22-1370), ch. 184, p. 1237, § 7, effective
August 10.
25.5-5-514. Prescription drugs used for treatment or prevention of HIV -
prohibition on utilization management - definition. (1) As used in this section, "HIV" means
human immunodeficiency virus.
(2) (a) Before July 1, 2027, the state department shall not restrict by prior authorization
or step therapy requirements any prescription drug approved by the federal food and drug
administration that is used for the treatment or prevention of HIV if a prescribing practitioner
licensed pursuant to title 12 has determined the prescription drug to be medically necessary for
the treatment or prevention of HIV for a recipient. Prescription drugs used for the treatment or
prevention of HIV include protease inhibitors, non-nucleoside reverse transcriptase inhibitors,
nucleoside reverse transcriptase inhibitors, antivirals, integrase inhibitors, long-acting
medications, and fusion inhibitors.
(b) Nothing in this subsection (2) prevents the state department from performing drug
utilization review that may be necessary for patient safety or for ensuring the prescribed use is
Colorado Revised Statutes 2023 Uncertified PrintoutPage 312 of 510
for a medically accepted indication, as required by section 1927 of the "Social Security Act of
1935".
Source: L. 2023: Entire section added, (SB 23-189), ch. 69, p. 260, § 9, effective April
14.
25.5-5-515. Pharmacy reimbursement - vaccine administration to children -
legislative declaration. (1) (a) The general assembly finds and declares that:
(I) Pharmacists are highly trained and educated, doctorate-level health-care professionals
specializing in the effective use of medications and their outcomes;
(II) Pharmacists provide health care throughout the entire health-care system, practicing
in community pharmacies, hospitals, provider clinic offices, and specialty areas;
(III) With ninety percent of Americans living within five miles of a pharmacy,
pharmacists are able to provide valuable public health services to communities and to provide
those services in novel ways, including during nontraditional hours and without appointments;
and
(IV) Convenient access to vaccines through a neighborhood pharmacy can help ensure
that more children receive their childhood vaccinations according to federal recommended
guidelines.
(b) Therefore, the general assembly declares that allowing reimbursement under the
medical assistance program to a pharmacist or pharmacy that dispenses or administers childhood
vaccinations is an important tool in ensuring the health of Colorado children through
immunization.
(2) Pursuant to the requirements set forth in subsection (3) of this section, a pharmacist
or pharmacy that dispenses or administers vaccinations to children under nineteen years of age
pursuant to the federal centers for disease control and prevention's guidelines pertaining to the
childhood immunization schedule may seek reimbursement for the dispensing or administration
of vaccines under the medical assistance program either as a pharmacy benefit or as a medical
benefit, as applicable.
(3) (a) To be eligible to receive reimbursement pursuant to subsection (2) of this section
for administering vaccines to children, a pharmacy or pharmacist must be enrolled in good
standing with the vaccines for children program administered by the department of public health
and environment.
(b) Until the department of public health and environment determines a framework for
participation by pharmacies and pharmacists in the vaccines for children program, nothing in this
section requires the department of public health and environment to enroll pharmacies receiving
reimbursement for the administration of vaccines through the medical assistance program as
vaccines for children providers.
(c) As used in this subsection (3), "vaccines for children program" means the federal
centers for disease control and prevention "vaccines for children program" administered by the
department of public health and environment, or any successor program.
Source: L. 2023: Entire section added, (SB 23-162), ch. 148, p. 630, § 4, effective
August 7.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 313 of 510
25.5-5-516. Serious mental illness - prescribed drugs. Notwithstanding any provisions
of this part 5 to the contrary, and subject to any necessary federal authorization, the state board
shall require a review for coverage of a new drug approved by the federal food and drug
administration for a serious mental illness within ninety days after the approval of the drug.
Source: L. 2023: Entire section added, (HB 23-1130), ch. 394, p. 2356, § 3, effective
August 7.
PART 6
PROGRAM FOR TEEN PREGNANCY
AND DROPOUT PREVENTION
25.5-5-601 to 25.5-5-605. (Repealed)
Editor's note: (1) This part 6 was added in 1995. For amendments to this part 6 prior to
its repeal in 2016, consult the 2015 Colorado Revised Statutes and the Colorado statutory
research explanatory note beginning on page vii in the front of this volume.
(2) Section 25.5-5-605 provided for the repeal of this part 6, effective September 1,
2016. (See L. 2011, p. 1458.)
PART 7
TELEMEDICINE PILOT PROGRAMS FOR
CHRONIC MEDICAL CONDITIONS
25.5-5-701 to 25.5-5-703. (Repealed)
Source: L. 2010: Entire part repealed, (HB 10-1322), ch. 29, p. 105, § 1, effective March
18.
Editor's note: This part 7 was added in 2006 and was not amended prior to its repeal in
2010. For the text of this part 7 prior to 2010, consult the 2009 Colorado Revised Statutes.
PART 8
CHILDREN AND YOUTH BEHAVIORAL
HEALTH SYSTEM IMPROVEMENTS
Cross references: For the legislative declaration in SB 19-195, see section 1 of chapter
190, Session Laws of Colorado 2019.
25.5-5-801. Legislative declaration. (1) The general assembly finds and declares that:
(a) In order to provide quality behavioral health services to families of children and
youth with behavioral health challenges, behavioral health services should be coordinated among
Colorado Revised Statutes 2023 Uncertified PrintoutPage 314 of 510
state departments and political subdivisions of the state and should be culturally competent,
cost-effective, and provided in the least restrictive settings;
(b) The behavioral health system and child- and youth-serving agencies are often
constrained by resource capacity and systemic barriers that can create difficulties in providing
appropriate and cost-effective interventions and services for children and youth;
(c) Children and youth with behavioral health challenges may require a multi-system
level of care that can lead to duplication and fragmentation of services. To avoid these problems,
keep families together, and support caregivers during a child's or youth's behavioral health
challenge, departments and political subdivisions of the state must collaborate with one another.
(d) The Colorado state innovation model, an initiative housed in the office of the
governor, has worked to integrate behavioral health and physical health, has made significant
progress advancing the use of alternative payment models, and has created infrastructure for
screening and innovative payment reforms. However, future work is needed to further expand
and improve integrated services for children and families, with a focus on early and upstream
interventions.
(2) The general assembly further finds and declares that, building upon work completed
by Colorado's trauma-informed system of care, Colorado must implement a model of
comprehensive system of care for families of children and youth with behavioral health
challenges.
Source: L. 2019: Entire part added, (SB 19-195), ch. 190, p. 2098, § 2, effective August
2.
25.5-5-802. Definitions. As used in this part 8, unless the context otherwise requires:
(1) "At risk of out-of-home placement" means a child or youth who is eligible for
medical assistance pursuant to articles 4, 5, and 6 of this title 25.5 and the child or youth:
(a) Has been diagnosed as having a mental health disorder, as defined in section
27-65-102 (11.5), or a behavioral health disorder; and
(b) May require a level of care that is provided in a residential child care facility,
inpatient psychiatric hospital, or other intensive care setting outside of the child's or youth's
home. "At risk of out-of-home placement" includes a child or youth who:
(I) Is entering the division of youth services; or
(II) Is at risk of child welfare involvement.
(2) "Behavioral health disorder" means a substance use disorder, mental health disorder,
or one or more substantial disorders of the cognitive, volitional, or emotional processes that
grossly impair judgment or capacity to recognize reality or to control behavior, including serious
emotional disturbances. "Behavioral health disorder" also includes those mental health disorders
listed in the most recent versions of the diagnostic statistical manual of mental health disorders,
the diagnostic classification of mental health and developmental disorders of infancy and early
childhood, and the international statistical classification of diseases and related health problems.
(3) "Behavioral health services" or "behavioral health system" means the child and youth
service system that encompasses prevention and promotion of emotional health, prevention and
treatment services for mental health and substance use conditions, and recovery support.
(4) "Child and youth" means a person who is twenty-six years of age or younger.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 315 of 510
(5) "Managed care entity" means an entity that enters into a contract to provide services
in the statewide managed care system pursuant to articles 4, 5, and 6 of this title 25.5.
(6) "Mental health professional" means an individual licensed as a mental health
professional pursuant to article 245 of title 12 or a professional person as defined in section
27-65-102 (17).
(7) "Out-of-home placement" means a child or youth who is eligible for medical
assistance pursuant to articles 4, 5, and 6 of this title 25.5 and the child or youth:
(a) Has been diagnosed as having a mental health disorder, as defined in section
27-65-102 (11.5), or a behavioral health disorder; and
(b) May require a level of care that is provided in a residential child care facility,
inpatient psychiatric hospital, or other intensive care setting outside of the child's or youth's
home. "Out-of-home placement" includes a child or youth who:
(I) Has entered the division of youth services; or
(II) Is at risk of child welfare involvement.
(8) "Wraparound" means a high-fidelity, individualized, family-centered,
strengths-based, and intensive care planning and management process used in the delivery of
behavioral health services for a child or youth with a behavioral health disorder, commonly
utilized as part of the system of care framework.
Source: L. 2019: Entire part added, (SB 19-195), ch. 190, p. 2098, § 2, effective August
2.
Cross references: For additional definitions applicable to this part 8, see § 25.5-4-103.
25.5-5-803. High-fidelity wraparound services for children and youth - federal
approval - reporting. (1) Subject to available appropriations, the state department shall seek
federal authorization from the federal centers for medicare and medicaid services to provide
wraparound services for eligible children and youth who are at risk of out-of-home placement or
in an out-of-home placement. Prior to seeking federal authorization, the state department shall
seek input from relevant stakeholders including counties, managed care entities participating in
the statewide managed care system, families of children and youth with behavioral health
disorders, communities that have previously implemented wraparound services, mental health
professionals, the behavioral health administration in the department of human services, and
other relevant departments. The state department shall consider tiered care coordination as an
approach when developing the wraparound model.
(2) Upon federal authorization, and subject to available appropriations, the state
department shall require managed care entities to implement wraparound services, which may be
contracted out to a third party. Subject to available appropriations, the state department shall
contract with the department of human services and the behavioral health administration in the
department of human services to ensure care coordinators and those responsible for
implementing wraparound services have adequate training and resources to support children and
youth who may have co-occurring diagnoses, including behavioral health disorders and physical
or intellectual or developmental disabilities. Attention must also be given to the geographic
diversity of the state in designing this program in rural communities.
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(3) Upon implementation of the wraparound services, the state department, the
department of human services, and the behavioral health administration in the department of
human services shall monitor and report the annual cost savings associated with eligible children
and youth receiving wraparound services to the public through the annual hearing, pursuant to
the "State Measurement for Accountable, Responsive, and Transparent (SMART) Government
Act", part 2 of article 7 of title 2. The state department shall require managed care entities to
report data on the utilization and effectiveness of wraparound services.
(4) Subject to available appropriations, the state department shall work collaboratively
with the department of human services, the behavioral health administration in the department of
human services, counties, and other departments, as appropriate, to develop and implement
wraparound services for children and youth at risk of out-of-home placement or in an
out-of-home placement. The behavioral health administration in the department of human
services shall oversee that the wraparound services are delivered with fidelity to the model. As
part of routine collaboration, and subject to available appropriations, the state department shall
develop a model of sustainable funding for wraparound services in consultation with the
department of human services and the behavioral health administration in the department of
human services. Wraparound services provided to eligible children and youth pursuant to this
section must be covered under the "Colorado Medical Assistance Act", articles 4, 5, and 6 of this
title 25.5, subject to available appropriations. The state department may use targeting criteria to
ramp up wraparound services as service capacity increases, or temporarily, as necessary, to meet
certain federal financial participation requirements.
Source: L. 2019: Entire part added, (SB 19-195), ch. 190, p. 2100, § 2, effective August
2. L. 2020: (1), (2), and (4) amended, (HB 20-1384), ch. 172, p. 789, § 2, effective June 29. L.
2022: Entire section amended, (HB 22-1278), ch. 222, p. 1516, § 77, effective July 1. L. 2023:
(1) amended, (HB 23-1236), ch. 206, p. 1054, § 15, effective May 16.
25.5-5-804. Integrated funding pilot. Subject to available appropriations, the state
department, in conjunction with the behavioral health administration in the department of human
services, counties, and other relevant departments, shall design and recommend a child and
youth behavioral health delivery system pilot program that addresses the challenges of
fragmentation and duplication of behavioral health services. The pilot program shall integrate
funding for behavioral health intervention and treatment services across the state to serve
children and youth with behavioral health disorders. To implement the provisions of this section,
the state department shall collaborate with the behavioral health administration in the department
of human services and other relevant stakeholders, including counties, managed care entities,
and families.
Source: L. 2019: Entire part added, (SB 19-195), ch. 190, p. 2101, § 2, effective August
2. L. 2020: Entire section amended, (HB 20-1384), ch. 172, p. 790, § 3, effective June 29. L.
2022: Entire section amended, (HB 22-1278), ch. 222, p. 1517, § 78, effective July 1.
ARTICLE 6
Colorado Medical Assistance Act -
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Long-term Care
Editor's note: This article was added with relocations in 2006 containing provisions of
some sections formerly located in article 4 of title 26. Former C.R.S. section numbers are shown
in editor's notes following those sections that were relocated. For a detailed comparison of this
article, see the comparative tables located in the back of the index.
Cross references: For definitions applicable to this article, see § 25.5-4-103.
Law reviews: For article, "Colorado Medicaid Home and Community-Based Services
and Least-Restrictive Environment", see 39 Colo. Law. 35 (May 2010).
PART 1
LONG-TERM CARE ADMINISTRATION
25.5-6-101. Spousal protection - protection of income and resources for community
spouse - definitions - amounts retained - responsibility of state department - right to
appeal. (1) As used in this section, unless the context otherwise requires:
(a) "Community spouse" means the spouse of a person who is in an institution or nursing
facility, the spouse of a person who is enrolled in the PACE program authorized pursuant to
section 25.5-5-412, or the spouse of a person who is receiving home- and community-based
services pursuant to this article.
(b) "Community spouse monthly income allowance" means the amount by which the
minimum monthly maintenance needs allowance exceeds the amount of monthly income that is
available to the community spouse.
(c) "Community spouse resource allowance" means the amount of assets, excluding the
value of the home and other exempt resources under federal law, that the community spouse
shall be allowed to retain and that shall not be available to cover an institutionalized spouse's
cost of care.
(d) (I) "Institutionalized spouse" means an individual who is in an institution or nursing
facility who is married to a spouse who is not in an institution or nursing facility.
(II) For purposes of this section, "institutionalized spouse" includes an individual who is
enrolled in the PACE program authorized pursuant to section 25.5-5-412 or is receiving home-
and community-based services pursuant to this article, and who is married to a spouse who is not
enrolled in the PACE program or receiving home- and community-based services.
(e) (I) (A) "Minimum monthly maintenance needs allowance" means an amount which is
equal to an applicable percent of the nonfarm income official poverty line (increased annually by
the consumer price index for all urban consumers), as defined by the federal office of
management and budget, for a family unit of two members.
(B) For the purposes of sub-subparagraph (A) of this subparagraph (I), the applicable
percent shall be: As of September 30, 1989, one hundred twenty-two percent; as of July 1, 1991,
one hundred thirty-three percent; as of July 1, 1992, one hundred fifty percent.
(II) Notwithstanding the provisions of subparagraph (I) of this paragraph (e), the
minimum monthly maintenance needs allowance may be increased on an individual basis if:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 318 of 510
(A) The community spouse has shelter and utilities expenses that exceed thirty percent
of the minimum monthly maintenance needs allowance; except that the total allowance shall not
exceed fifteen hundred dollars (increased annually by the consumer price index for all urban
consumers);
(B) Either spouse is responsible for a dependent family member, including children,
parents, or siblings who reside with the community spouse; or
(C) The community spouse has exceptional circumstances which would result in
significant financial duress.
(2) (a) In order to implement the medical assistance program in compliance with the
federal "Medicare Catastrophic Coverage Act of 1988", as amended, the state department shall
ensure, when an institutionalized spouse is eligible for medical assistance under this article and
articles 4 and 5 of this title, that the community spouse retain a community spouse monthly
income allowance but only to the extent that income of the institutionalized spouse is made
available to the community spouse.
(b) (I) The resources available to the married couple shall be calculated at the beginning
of a continuous period of institutionalization of the institutionalized spouse. The community
spouse shall retain the remainder of the couple's countable resources up to the federal maximum
resource allowance as a community spouse resources allowance. The institutionalized spouse
may keep an amount up to the amount of resources allowed under the federal medicaid program.
(II) Notwithstanding the provisions of subparagraph (I) of this paragraph (b), if either
spouse establishes that the community spouse resource allowance is inadequate to raise the
community spouse's income to the minimum monthly maintenance needs allowance, an amount
adequate to provide the minimum monthly maintenance needs allowance shall be substituted.
(3) The state board shall have the authority to promulgate any rules that are necessary to
implement the provisions of this section in accordance with the federal "Medicare Catastrophic
Coverage Act of 1988", as amended. The rules adopted by the state board shall include, as a
minimum, provisions regarding the following matters:
(a) The treatment of a married couple's income and resources before and after eligibility
for medical assistance is established, including the basis for dividing such income and resources
between the two parties;
(b) The process for appealing any determinations regarding income and resources that
are made pursuant to these rules.
Source: L. 2006: Entire article added with relocations, p. 1907, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-506 as it existed prior to 2006.
Cross references: For provisions of the federal "Medicare Catastrophic Coverage Act of
1988" referenced in this section, see section 303 of Pub.L. 100-360, codified at 42 U.S.C. sec.
1396r-5.
25.5-6-102. Court-approved trusts - transfer of property for persons seeking
medical assistance for nursing home care - undue hardship - legislative declaration. (1)
The general assembly hereby finds, determines, and declares that:
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(a) The state makes significant expenditures for nursing home care under the "Colorado
Medical Assistance Act";
(b) A large number of persons do not have enough income to afford nursing home care,
but have too much income to qualify for state medical assistance, a situation popularly referred
to as the "Utah gap";
(c) Some persons in the Utah gap, through innovative court-approved trust arrangements,
have become qualified for state medical assistance, thereby increasing state medical assistance
expenditures;
(d) It is therefore appropriate to enact state laws which limit such court-approved trusts
in a manner that is consistent with Title XIX of the federal "Social Security Act", 42 U.S.C. sec.
1396 et seq., as amended, and which provide that persons who qualify for assistance as a result
of the creation of such trusts shall be treated the same as any other recipient of medical
assistance for nursing home care;
(e) In enacting this section, the general assembly intends only to limit certain
court-approved trusts and court-approved transfers of property. It is not the general assembly's
intent to approve or disapprove of privately created trusts or private transfers of property made
under the same or similar circumstances.
(2) The county department shall verify that an applicant for medical assistance for
nursing home care, pursuant to the provisions of this title, meets applicable eligibility criteria for
assistance other than those set forth in subsection (3) of this section. Upon verification, for
eligibility purposes and in accordance with subsection (3) of this section, the county department
shall make a determination of the status of any court-approved trust established for or
court-approved transfer of property made by or for the applicant.
(3) (a) If a person who applies for medical assistance for nursing home care would be
deemed ineligible for assistance as a result of deeming a court-approved trust established for the
applicant as a medicaid qualifying trust or as a result of deeming property in the court-approved
trust as an improper transfer of assets, the person's application shall, nonetheless, be treated as a
case of undue hardship and the person shall be eligible for medical assistance for said care if the
establishment of the court-approved trust meets the following criteria:
(I) The applicant's monthly gross income from all sources, without reference to the
court-approved trust, exceeds the income eligibility standard for medical assistance then in effect
but is less than the average private pay rate for nursing home care for the geographic region in
which the applicant lives;
(II) The property used to fund the trust shall be limited to monthly unearned income
owned by the applicant, including any pension payment;
(III) The applicant and the state medical assistance program shall be the sole
beneficiaries of the trust. The entire corpus of the trust, or as much of the corpus as may be
distributed each month without violating federal requirements for federal financial participation,
shall be distributed each month for expenses related to the beneficiary's nursing home care that
are approved under the medical assistance program; except that an amount reasonably necessary
to maintain the existence of the trust and to comply with federal requirements may be retained in
the trust. Deductions may be distributed from the trust to the same extent deductions from the
income of a nursing home resident who is not a trust beneficiary are allowed under the medical
assistance program, which shall include the following:
(A) A monthly personal needs allowance;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 320 of 510
(B) Payments to the beneficiary's community spouse or dependent family members as
provided and in accordance with Title XIX of the federal "Social Security Act", 42 U.S.C. sec.
1396r-5, as amended, and section 25.5-6-101;
(C) Specified health insurance costs and special medical services provided under Title
XIX of the federal "Social Security Act", 42 U.S.C. sec. 1396a(r), as amended; and
(D) Any other deduction provided in the rules of the state department.
(IV) Upon the death of the beneficiary, a remainder interest in the corpus of the trust
shall pass to the state agency responsible for administering the state medical assistance program;
(V) The trust shall not be subject to modification by the beneficiary or the trustee unless
otherwise provided by this section or section 15-14-412.5, C.R.S.
(b) For the purposes of this subsection (3), "medicaid qualifying trust" shall have the
same meaning as set forth in Title XIX of the federal "Social Security Act", 42 U.S.C. sec.
1396a(k).
(4) The state board shall adopt rules as are necessary for the implementation of this
section and as are necessary to comply with federal law. In addition, the state department shall
amend the state medical assistance plan in a manner that is consistent with the provisions of this
section.
(5) This section shall take effect January 1, 1992, and shall apply to any court-approved
trust established for or court-approved transfer of property made by or for a protected person
applying for or receiving medical assistance for nursing home care pursuant to the provisions of
this title, on or after said date; except that a court-approved trust created before said date that
does not comply with this section shall be modified to comply with this section no later than July
1, 1992, before which time the court-approved trust or court-approved transfer of property to a
trust shall not render the protected person ineligible for medical assistance.
(6) The provisions of this section shall not apply if federal funds are not available for
persons who would qualify for medical assistance as a result of a court-approved trust that meets
the criteria set forth in this section.
(7) This section shall apply to trusts established or transfers of property made prior to
July 1, 1994. The provisions set forth in sections 15-14-412.6 to 15-14-412.9, C.R.S., and any
rules adopted by the state board pursuant to section 25.5-6-103 shall apply to trusts established
or property transferred on or after that date.
Source: L. 2006: Entire article added with relocations, p. 1908, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-506.5 as it existed prior to 2006.
25.5-6-103. Court-approved trusts - transfer of property for persons seeking
medical assistance - rule-making authority for trusts created on or after July 1, 1994 -
undue hardship. (1) The state board shall adopt such rules as are necessary with respect to
trusts established pursuant to sections 15-14-412.6 to 15-14-412.9. The state board shall adopt
rules that address, but need not be limited to, the following:
(a) The definition, including any limitations, of permissible distributions from trusts,
taking federal guidelines into consideration;
(b) Reasonable financial reimbursement or incentives to the state department, county
departments of human or social services, and any other designated agencies for the efforts and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 321 of 510
expenses in monitoring trusts, and where necessary, for the recovery of trust property that has
been improperly distributed or otherwise expended.
(2) The state board shall comply with Title XIX of the federal "Social Security Act", 42
U.S.C. sec. 1396p (d)(5), as amended, which requires the state medicaid agency to establish
procedures, in accordance with standards specified by the secretary of the United States
department of health and human services, under which the state medicaid agency may waive the
application of the general rules for considering trust property in determining eligibility for
medical assistance if the applicant for medical assistance establishes that the application of the
general rules would work an undue hardship on the individual.
(3) The state department shall determine the feasibility of providing ongoing support of
dependents by using the trust corpus during the life of the person for whom a trust is created or
using the remainder of the trust after the death of the person for whom the trust was created. If
the state department determines that it is feasible to provide that support, the state department
shall seek a waiver from the federal government to permit the use of trust property for that
purpose.
Source: L. 2006: Entire article added with relocations, p. 1911, § 7, effective July 1. L.
2018: IP(1) and (1)(b) amended, (SB 18-092), ch. 38, p. 445, § 112, effective August 8.
Editor's note: This section is similar to former § 26-4-506.6 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 18-092, see section 1 of chapter
38, Session Laws of Colorado 2018.
25.5-6-104. Long-term care placements - comprehensive and uniform client
assessment instrument - report - legislative declaration - definitions - repeal. (1) (a) The
general assembly hereby finds, determines, and declares that there is an increasing strain on
long-term care services in the state; that the number of persons in need of long-term care
continues to grow; that community-based resources are not integrated into a centralized system
for referrals, assessment of needs, development of care plans, and case management; and that
persons in need of long-term care services have difficulty accessing and using the current
system, which is fragmented and which results in inappropriate placements.
(b) The general assembly further finds, determines, and declares that the state is in need
of a long-term care system that organizes each long-term care client's entry, assessment of need,
and service delivery into a single unified system; and that such system must include, at a
minimum, a locally established single entry point administered by a designated entity, a single
client assessment instrument and administrative process, targeted case management in order to
maximize existing federal, state, and local funding, case management, and an accountability
mechanism designed to assure that budget allocations are being effectively managed.
(c) The general assembly therefore concludes that it is appropriate to develop and
implement a comprehensive and uniform long-term care client assessment process and to study
the establishment of a single entry point system that provides for the coordination of access and
service delivery to long-term care clients at the local level, that is available to all persons in need
of long-term care, and that is well managed and cost-efficient.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 322 of 510
(2) As used in this section and in sections 25.5-6-105 to 25.5-6-107, unless the context
otherwise requires:
(a) "Activities of daily living" means the basic self-care activities, including eating,
bathing, dressing, transferring from bed to chair, bowel and bladder control, and independent
ambulation.
(b) "Case management services" means the assessment of a long-term care client's
needs, the development and implementation of a care plan for such client, the coordination and
monitoring of long-term care service delivery, the direct delivery of services as provided by this
article or by rules adopted by the state board pursuant to this article, the evaluation of service
effectiveness, and the reassessment of such client's needs, all of which shall be performed by a
single entry point as defined in paragraph (k) of this subsection (2).
(c) "Community-based" means services provided in an individual's home or in a
homelike setting. "Community-based" does not include a hospital, hospital unit, nursing facility,
or nursing home.
(d) "Comprehensive and uniform client assessment process" means a standard
procedure, which includes the use of a uniform assessment instrument, to measure a client's
functional capacity, to determine the social and medical needs of a current or potential client of
any long-term care program, and to target resources to the functionally impaired.
(e) "Continuum of care" means an organized system of long-term care, benefits, and
services to which a client has access and which enables a client to move from one level or type
of care to another without encountering gaps in or barriers to service.
(f) "Information and referral" means the provision of specific, accurate, and timely
public information about services available to aging and disabled adults in need of long-term
care and referral to alternative agencies, programs, and services based on client inquiries.
(g) "Instrumental activities of daily living" means home management and independent
living activities such as cooking, cleaning, using a telephone, shopping, doing laundry, providing
transportation, and managing money.
(h) "Long-term care" means those services designed to provide diagnostic, preventive,
therapeutic, rehabilitative, supportive, and maintenance services for individuals who have
chronic physical or mental impairments, or both, in a variety of institutional and noninstitutional
settings, including the home, with the goal of promoting the optimum level of physical, social,
and psychological functioning of the individuals.
(i) "Resource development" means the study, establishment, and implementation of
additional resources or services which will extend the capabilities of community long-term care
systems to better serve long-term care clients.
(j) "Screening" means a preliminary determination of need for long-term care services
and, on the basis of such determination, the making of an appropriate referral for a client
assessment in accordance with subsection (3) of this section or referral to another community
resource to assist clients who are not in need of long-term care services.
(k) "Single entry point" means the availability of a single access or entry point within a
local area where a current or potential long-term care client can obtain long-term care
information, screening, assessment of need, and referral to appropriate long-term care program
and case management services.
(3) (a) On or before July 1, 1991, the state department shall establish, by rule in
accordance with article 4 of title 24, C.R.S., a comprehensive and uniform client assessment
Colorado Revised Statutes 2023 Uncertified PrintoutPage 323 of 510
process for all individuals in need of long-term care, the purpose of which is to determine the
appropriate services and levels of care necessary to meet clients' needs, to analyze alternative
forms of care and the payment sources for such care, and to assist in the selection of long-term
care programs and services that meet clients' needs most cost-efficiently.
(b) Participation in the process shall be mandatory for clients of publicly funded
long-term care programs, including, but not limited to, the following:
(I) Nursing facilities;
(II) Home- and community-based services for the elderly, the blind, and the disabled;
(III) Alternative care facilities;
(IV) to (VI) (Deleted by amendment, L. 2008, p. 437, § 1, effective August 5, 2008.)
(VII) Home health services for long-term care clients; and
(VIII) Repealed.
(c) Private paying clients of long-term care programs may participate in the process for a
fee to be established by the state department and adopted through rules.
(d) The state department, through rules, shall develop and implement no later than July
1, 1991, a uniform long-term care client needs assessment instrument for all individuals needing
long-term care. The instrument shall be used as part of the comprehensive and uniform client
assessment process to be established in accordance with subsection (3)(a) of this section and
shall serve the following functions:
(I) To obtain information on each client's status in the following areas:
(A) Activities of daily living and instrumental activities of daily living;
(B) Physical health;
(C) Cognitive and emotional well-being;
(D) Social interaction and current support resources;
(II) To assess each client's physical environment in terms of meeting the client's needs;
(III) To obtain information on each client's payment sources, including obtaining
financial eligibility information for publicly funded long-term care programs;
(IV) To disclose the need for more intensive needs assessments in areas such as
nutrition, adult protection, dementia diseases and related disabilities, and mental health;
(V) To prioritize a client's need for care using criteria established by the state department
for specific publicly funded long-term care programs;
(VI) To serve as the functional assessment for the determinations of medical necessity.
(e) On and after July 1, 1991, no publicly funded client shall be placed in a long-term
care program unless such placement is in accordance with rules adopted by the state board in
implementing this section.
(4) Repealed.
(5) (a) On or before July 1, 2018, pursuant to the state department's ongoing stakeholder
process relating to eligibility determination for long-term services and supports pursuant to this
article, the state department shall select a needs assessment tool for persons receiving long-term
services and supports, including persons with intellectual and developmental disabilities who are
eligible for services pursuant to section 25.5-6-409. Once selected, the state department shall
begin assessing client needs using the needs assessment tool as soon as practicable.
(b) Pursuant to the state department's ongoing stakeholder process relating to eligibility
determination for long-term services and supports pursuant to this article, the state department
shall develop or select the needs assessment tool in collaboration with persons with intellectual
Colorado Revised Statutes 2023 Uncertified PrintoutPage 324 of 510
and developmental disabilities who receive services, legal guardians, case managers, and any
other stakeholders as determined by the state department.
(c) The needs assessment tool developed or selected by the state department must
include a reasonable reassessment process, set forth in state board rules, that allows a
reassessment to be completed within thirty days after receipt of a request for reassessment made
by a person with intellectual and developmental disabilities or his or her legal guardian.
(d) Repealed.
(6) This section is repealed, effective July 1, 2024.
Source: L. 2006: Entire article added with relocations, p. 1911, § 7, effective July 1. L.
2007: (4) added, p. 1393, § 2, effective May 30. L. 2008: (3)(b) amended, p. 437, § 1, effective
August 5. L. 2016: (5) added, (SB 16-192), ch. 256, p. 1051, § 1, effective June 8. L. 2018:
(3)(b)(VIII) repealed, (SB 18-093), ch. 62, p. 610, § 5, effective August 8; IP(3)(d) and
(3)(d)(IV) amended, (HB 18-1091), ch. 74, p. 643, § 4, effective August 8. L. 2021: (6) added by
revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
Editor's note: (1) This section is similar to former § 26-4-507 as it existed prior to
2006.
(2) Subsection (4)(c) provided for the repeal of subsection (4), effective July 1, 2008.
(See L. 2007, p. 1393.)
(3) Subsection (5)(d)(II) provided for the repeal of subsection (5)(d), effective July 1,
2019. (See L. 2016, p. 1051.)
Cross references: For the legislative declaration contained in the 2007 act enacting
subsection (4), see section 1 of chapter 328, Session Laws of Colorado 2007. For the legislative
declaration in SB 18-093, see section 1 of chapter 62, Session Laws of Colorado 2018.
25.5-6-105. Legislative declaration relating to implementation of single entry point
system - repeal. (1) The general assembly hereby finds, determines, and declares that:
(a) A study of a single entry point system in accordance with former section 26-4.5-404,
C.R.S., has been completed;
(b) The establishment of a single entry point system for the coordination of access to
existing services and service delivery for all long-term care clients at the local level can be
implemented in a cost-efficient manner;
(c) The implementation of a well-managed single entry point system will result in the
utilization of more appropriate services by long-term care clients over time and will provide
better information on the unmet service needs of clients; and
(d) The implementation of a statewide single entry point system is a comprehensive
undertaking and would be more conducive to a phased-in approach.
(2) The general assembly further finds, determines, and declares that it is appropriate to
develop and implement, through four phases, a single entry point system for the state and,
therefore, enacts sections 26-4-522 to 26-4-525, which were relocated to sections 25.5-6-106 and
25.5-6-107, respectively, in the 2006 recodification of this title, to provide for such development
and implementation.
(3) This section is repealed, effective July 1, 2024.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 325 of 510
Source: L. 2006: Entire article added with relocations, p. 1914, § 7, effective July 1. L.
2021: (3) added by revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
Editor's note: This section is similar to former § 26-4-521 as it existed prior to 2006.
25.5-6-106. Single entry point system - authorization - phases for implementation -
services provided - repeal. (1) Authorization. The state board is hereby authorized to adopt
rules providing for the establishment of a single entry point system that consists of single entry
point agencies throughout the state for the purpose of enabling persons eighteen years of age or
older in need of long-term care to access appropriate long-term care services.
(2) Single entry point agencies - service programs - functions. (a) A single entry
point agency must be an agency in a local community through which any person eighteen years
of age or older who is in need of long-term care can access needed long-term care services. A
single entry point agency may be a private, nonprofit organization; a county agency, including a
county department of human or social services; a county nursing service; an area agency on
aging; or a multicounty agency. Persons in need of specialized assistance such as services for
persons with intellectual and developmental disabilities or behavioral or mental health disorders
may be referred by a single entry point agency to programs under the department of human
services.
(b) The agency may serve private paying clients on a fee-for-service basis and shall
serve clients of publicly funded long-term care programs, including, but not limited to, the
following:
(I) Nursing facility care;
(II) Home- and community-based services for the elderly, blind, and disabled;
(III) Repealed.
(IV) Long-term home health care, including services provided by a PACE organization
providing a program of all-inclusive care for the elderly pursuant to section 25.5-5-412;
(V) Home care allowance;
(VI) Alternative care facilities;
(VII) Adult foster care;
(VIII) Certain in-home services available pursuant to the federal "Older Americans Act
of 1965", as amended; and
(IX) Home- and community-based services for persons with brain injury.
(c) The major functions of a single entry point shall include, but need not be limited to,
the following:
(I) Providing information;
(II) Screening and referral services;
(III) Assessing clients' needs in accordance with section 25.5-6-104;
(IV) Developing plans of care for clients;
(V) Determining payment sources available to clients for long-term care services;
(VI) Authorizing the provision of certain long-term care services, as designated by the
state department;
(VII) Determining eligibility for certain long-term care programs, as designated by the
state department;
(VIII) Delivering case management services as an administrative function;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 326 of 510
(IX) Targeting outreach efforts to those most at risk of institutionalization;
(IX.5) Informing eligible persons about the benefits of participating in the program of
all-inclusive care for the elderly provided by a PACE organization pursuant to section
25.5-5-412 as an alternative to enrollment in a managed care organization, an organization
contracted with the state department pursuant to part 4 of article 5 of this title, or other
risk-bearing entity;
(X) Identifying resource gaps and coordinating resource development;
(XI) Recovering overpayment of benefits in accordance with rules adopted by the state
board;
(XII) Maintaining fiscal accountability; and
(XIII) Rendering state certified services, as provided by state board rules, as a qualified
and state certified agency.
(3) State certification of a single entry point agency - quality assurance standards.
(a) Upon selection of a single entry point agency, the state department shall contract with an
agency for five years but shall recertify the agency annually based on an evaluation procedure
provided for in paragraph (b) of this subsection (3).
(b) The state board shall adopt rules for the establishment of a quality assurance program
for the purpose of monitoring the quality of services provided to clients and for recertifying
single entry point agencies. The rules shall provide for: Procedures to evaluate the quality of
services provided by the agency; an assessment of the agency's compliance with program
requirements, including compliance with case management standards, which standards shall be
adopted by the state department; an assessment of an agency's performance of administrative
functions, including reasonable costs per client, timely responses, managing programs in one
consolidated unit, on-site visits to clients, community coordination and outreach, and client
monitoring; a determination as to whether targeted populations are being identified and served;
and an evaluation concerning financial accountability.
(c) The state department shall monitor each single entry point agency in the state for
compliance with quality assurance standards adopted by the state and may provide for the
implementation of sanctions at any time for noncompliance. In addition, each county department
may enter into cooperative agreements or contracts with the single entry point agencies to assure
quality performance by the single entry point agency serving such county.
(d) Ongoing reimbursement to single entry points shall be contingent upon compliance
with quality assurance standards.
(e) State board rules adopted pursuant to this section must include the requirement that,
on and after January 1, 2019, prior to employment, a single entry point agency shall submit the
name of a person who will be providing direct care, as defined in section 26-3.1-101 (3.5), to an
at-risk adult, as defined in section 26-3.1-101 (1.5), as well as any other required identifying
information, to the department of human services for a check of the Colorado adult protective
services data system pursuant to section 26-3.1-111, to determine if the person is substantiated in
a case of mistreatment of an at-risk adult.
(4) This section is repealed, effective July 1, 2024.
Source: L. 2006: Entire article added with relocations, p. 1915, § 7, effective July 1. L.
2012: (2)(b)(IV) amended and (2)(c)(IX.5) added, (SB 12-023), ch. 94, p. 309, § 2, effective
April 12. L. 2017: (2)(a) amended, (SB 17-242), ch. 263, p. 1329, § 206, effective May 25;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 327 of 510
(3)(e) added, (HB 17-1284), ch. 272, p. 1505, § 11, effective May 31. L. 2018: (2)(b)(III)
repealed, (SB 18-093), ch. 62, p. 610, § 6, effective August 8. L. 2021: (4) added by revision,
(HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
Editor's note: This section is similar to former § 26-4-522 as it existed prior to 2006.
Cross references: (1) For the "Older Americans Act of 1965", see Pub.L. 89-73,
codified at 42 U.S.C. sec. 3001 et seq.
(2) For the legislative declaration in SB 17-242, see section 1 of chapter 263, Session
Laws of Colorado 2017. For the legislative declaration in SB 18-093, see section 1 of chapter 62,
Session Laws of Colorado 2018.
25.5-6-107. Financing of single entry point system - repeal. (1) The single entry point
system shall be financed with the following moneys:
(a) Federal financial participation moneys available for case management for home- and
community-based services pursuant to this article, and for administration of medical assistance
programs, pursuant to Title XIX of the federal "Social Security Act", as amended;
(b) The state's share or contribution for specific long-term care programs in accordance
with or pursuant to sections 26-1-122 and 26-2-114, C.R.S.;
(c) County contributions, as follows:
(I) The total for the fiscal year beginning July 1, 1990, and for each fiscal year
thereafter, which totals shall serve as the base for determining the contribution required in
subparagraph (II) of this paragraph (c), of the following: The counties' five percent contribution
for home care allowance and adult foster care services as required by section 26-1-122, C.R.S.
(II) The amount contributed from each county in accordance with subparagraph (I) of
this paragraph (c) after making an adjustment based on the percentage of an increase or decrease
per fiscal year in the service costs for clients of such county. However, in no case shall a county
be required under this subparagraph (II) to contribute more than a five percent increase in said
service costs.
(2) County contributions for client services made in accordance with subparagraph (I) of
paragraph (c) of subsection (1) of this section shall be expended only for clients of the county
providing said contribution.
(3) This section is repealed, effective July 1, 2024.
Source: L. 2006: Entire article added with relocations, p. 1917, § 7, effective July 1. L.
2021: (3) added by revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
Editor's note: This section is similar to former § 26-4-525 as it existed prior to 2006.
25.5-6-108. Legislative declaration - advisory committee - long-term care - report -
repeal. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1917, § 7, effective July 1.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 328 of 510
Editor's note: (1) This section was similar to former § 26-4-425 as it existed prior to
2006.
(2) Subsection (9) provided for the repeal of this section, effective July 1, 2007. (See L.
2006, p. 1917.)
25.5-6-108.5. Community long-term care studies - authority to implement -
alternative care facility report. (1) (a) Subject to the receipt of sufficient moneys pursuant to
paragraph (c) of this subsection (1), the state department shall contract for one or more studies of
the population of recipients receiving services under the home- and community-based waivers
authorized pursuant to this article. The state department shall make necessary data available to
the contractor, including but not limited to data on activities of daily living. In selecting a
contractor to perform any study conducted pursuant to this subsection (1), the state department is
not required to follow the competitive bidding requirements of the "Procurement Code", articles
101 to 112 of title 24, C.R.S. The state department shall provide copies of all studies conducted
pursuant to this subsection (1) to members of the health and human services committees of the
general assembly, or any successor committees, and to the members of the joint budget
committee.
(b) If a study conducted pursuant to this subsection (1) concludes that a program of
home- and community-based services would result in cost savings, the state department shall
seek any necessary federal authorization to implement the program. If federal authorization to
implement the program is obtained, the state department shall request, through the state budget
process, that the program be implemented. The state department shall report to the joint budget
committee annually concerning the amount of any savings realized from the program.
(c) The state department is authorized to seek and accept gifts, grants, or donations from
private and public sources for the purposes of this subsection (1); except that the state
department may not accept a gift, grant, or donation that is subject to conditions that are
inconsistent with this subsection (1) or any other law of the state. The state department shall
transmit all private and public moneys received through gifts, grants, or donations to the state
treasurer, who shall credit the same to the department of health care policy and financing cash
fund created in section 25.5-1-109.
(2) (a) Subject to the receipt of sufficient moneys, one of the studies contracted for
pursuant to subsection (1) of this section shall include research and analysis of:
(I) The number of recipients with incontinence, Alzheimer's disease, dementia, or other
diagnoses of a chronic incapacitating condition that severely limit their activities of daily living
who would benefit from receiving additional services through an alternative care facility thereby
avoiding nursing home placement;
(II) The actuarially sound rate for providing services for the recipients at an alternative
care facility;
(III) The amount of savings associated with providing services at an alternative care
facility;
(IV) Recommendations for utilization controls or program controls for a program to
provide services at an alternative care facility;
(V) The experiences of the program of all-inclusive care for the elderly, created pursuant
to section 25.5-5-412, with tiered rates for alternative care facilities, including cost savings or
cost avoidance;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 329 of 510
(VI) Other states' experiences with tiered rates for alternative care facilities, including
cost savings or cost avoidance; and
(VII) Recommendations for maintaining or improving quality of care.
(b) The study conducted pursuant to this subsection (2) shall be completed by January 1,
2012, and, if federal approval is obtained prior to final figure-setting for the fiscal year
commencing July 1, 2012, the state department shall submit a request through the budget process
for implementation of the approved changes for that fiscal year.
Source: L. 2010: Entire section added, (HB 10-1053), ch. 276, p. 1264, § 2, effective
May 26. L. 2011: (2)(b) amended, (HB 11-1242), ch. 271, p. 1231, § 2, effective July 1.
Cross references: For the legislative declaration in the 2010 act adding this section, see
section 1 of chapter 276, Session Laws of Colorado 2010.
25.5-6-109. Community long-term care - coordinated care pilot program - federal
authorization - rules - repeal. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1921, § 7, effective July 1. L.
2007: (1) and (7) amended, p. 2016, § 1, effective June 1. L. 2010: (2)(b) amended, (HB
10-1422), ch. 419, p. 2114, § 149, effective August 11.
Editor's note: (1) This section was similar to former § 26-4-426 as it existed prior to
2006.
(2) Subsection (7) provided for the repeal of this section, effective July 1, 2012. (See L.
2007, p. 2016.)
25.5-6-110. Private-public partnership education and information program
concerning long-term care insurance authorized. (1) The general assembly hereby declares
that:
(a) A large number of Coloradans are in need of long-term health care;
(b) The cost of long-term care, especially nursing home care, is significant;
(c) Many persons in need of long-term care are ineligible for state medical assistance
due to countable resources. When faced with the need for long-term care, such persons expend
such resources to pay for nursing home care.
(d) A person's resources may cover only a relatively short period of care, often resulting
in rendering such person impoverished, and after which time the person must rely on state
medical assistance;
(e) Expenditures for long-term care represent a significant portion of the state's medical
assistance budget;
(f) Unless Colorado implements new methods for financing long-term care, which
methods include participation by the private sector, the cost to the state for long-term care will
increase astronomically; and
(g) It is therefore appropriate to enact legislation that allows the state department, upon a
determination by the executive director of the state department that it is feasible, to design and
implement a private-public partnership for financing long-term care in this state.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 330 of 510
(2) The state department shall cooperate with the division of insurance in the department
of regulatory agencies in a private-public partnership for financing long-term care in this state
through the availability of long-term care insurance policies that result in a reduction of total
dependency on the medical assistance program to finance such care. It is the general assembly's
intent that such partnership shall be designed to encourage individuals to purchase long-term
care insurance, which, with respect to middle to higher income individuals, will have the result
of eliminating or delaying the individual's need for medical assistance.
(3) Under the partnership described in subsection (2) of this section, the division of
insurance shall implement statutory changes to article 19 of title 10, C.R.S., concerning
long-term care policies that the general assembly hereby declares are necessary to accomplish
the purpose of the partnership described in this section. In addition, the state department is
encouraged to implement a public education-awareness program based on recommendations
from an advisory committee that the executive director of the state department is hereby
authorized to establish.
(4) The state department is authorized to seek and accept funds, grants, or donations
from any private entity for implementing the public education-awareness program. In addition, if
necessary, the state department may assess a fee in connection with conducting any public
education-awareness training program or seminar. Any such fee collected shall be transmitted to
the state treasurer, who shall credit the same to the long-term care insurance fund, which fund is
hereby created. The moneys in the fund shall be subject to annual appropriation by the general
assembly for the sole purpose of public education-awareness training programs and seminars.
(5) In addition to administering the public education-awareness program under the
partnership, the state department shall seek a federal waiver from the requirement of section
13612 of the federal "Omnibus Budget Reconciliation Act of 1993" (OBRA), Public Law
103-66, that prevents the state department from granting medical assistance applicants a full or
partial resource exemption in determining eligibility for medical assistance and an exemption
from estate recovery requirements.
(6) The state department, if funds are available, shall contract with a public or private
entity to conduct an evaluation of the public education-awareness program on or before
December 1, 2000.
(7) With respect to a policyholder who has allowed his or her private long-term care
insurance policy to lapse, if the person is found to be eligible for the medical assistance program,
the state department is authorized to pay the premium for a reinstated policy pursuant to section
10-19-107 (2), C.R.S., if the state department finds that to do so is feasible and cost-efficient.
Source: L. 2006: Entire article added with relocations, p. 1922, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-506.7 as it existed prior to 2006.
25.5-6-111. Pilot program for coordinated care for people with a disability - fund -
repeal. (Repealed)
Source: L. 2006: Entire section added, p. 1115, § 1, effective May 25. L. 2013: (1), (2),
(3), (5), (6), and (7) repealed and (4) amended, (SB 13-276), ch. 256, p. 1350, §§ 1, 2, effective
May 23.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 331 of 510
Editor's note: (1) This section was enacted as 26-4-537 in Senate Bill 06-128 but was
relocated due to its harmonization with this article as it appeared in Senate Bill 06-219.
(2) Subsection (4)(b) provided for the repeal of subsection (4), effective July 1, 2014.
(See L. 2013, p. 1350.)
25.5-6-112. Plan of financial operation - purpose - approval - financial audits - rules
- repeal. (Repealed)
Source: L. 2007: Entire section added, p. 1352, § 2, effective May 29. L. 2013: Entire
section repealed, (SB 13-276), ch. 256, p. 1353, § 10, effective May 23.
25.5-6-113. Health home - integrated services - legislative declaration - contracting -
definitions. (1) (a) The general assembly hereby finds and declares that:
(I) The state demography office in the department of local affairs estimates that between
2005 and 2015, the portion of Colorado's population that is over sixty-five years of age will
increase by more than twenty-three percent;
(II) This drastic increase in the population that is over sixty-five years of age is driven by
the aging "baby boomer" generation and will result in a parallel increase in a demand for
community long-term care services;
(III) Older adults, persons with disabilities, and their families need quality health-care
coverage and choice and flexibility in accessing community long-term care services that support
their independence and ability to live in the least restrictive environment;
(IV) Research has shown that older adults suffer from higher rates of depression, have a
higher risk of suicide, and have an increased misuse of prescription and illicit drugs, making the
need for behavioral health-care services essential to long-term care services;
(V) Coloradans deserve to have access to the proper level of health care;
(VI) The state needs a long-term care delivery system that addresses the needs of older
adults, persons with disabilities, and their families, and health-care coverage and coordination
should not be fragmented or difficult to access; instead, it should be integrated to meet the needs
of older adults, persons with disabilities, and their families;
(VII) A community long-term care system should be integrated, person-centered, and
provide maximum service delivery and make efficient use of available public funds; and
(VIII) The system must ensure a comprehensive approach to long-term care that
addresses the different demographic and geographic challenges in the state and the various
long-term care services and supports that clients need.
(b) Therefore, the general assembly declares that a comprehensive approach to long-term
care requires that programs and policies integrating and coordinating care under the medicaid
program be flexible and allow for full participation by providers of long-term care services to
ensure quality of care for clients and efficient use of limited resources.
(2) As used in this section, unless the context otherwise requires:
(a) "Dually eligible person" means a person who is eligible for assistance or benefits
under both medicaid and medicare.
(b) "Health home" means a provider or group of providers that operate in coordination
with a team of health-care professionals that shall include primary care providers selected by an
eligible individual with chronic conditions to provide health home services, as the term is
Colorado Revised Statutes 2023 Uncertified PrintoutPage 332 of 510
defined in section 2703 of the federal "Patient Protection and Affordable Care Act", 42 U.S.C.
sec. 1396w-4.
(3) (a) In determining the structure of health homes for chronic conditions for purposes
of the federal "Patient Protection and Affordable Care Act", 42 U.S.C. sec. 1396w-4, and state
plan amendments to the medicaid program, the state department shall include, to the extent
permitted under federal law, provisions allowing providers of long-term care services and
supports to participate as health homes or as part of a health home that provides:
(I) Comprehensive care management;
(II) Care coordination and health promotion;
(III) Comprehensive transitional care;
(IV) Patient and family support;
(V) Referral to community and social support services; and
(VI) The use of health information technology to link services, as is feasible and
appropriate.
(b) [Editor's note: This version of subsection (3)(b) is effective until July 1, 2024.] The
health home may consist of a multi-disciplinary team, including primary care management
providers, behavioral health-care providers, case managers, and providers of long-term care
services and supports, including but not limited to single entry point agencies, nursing homes,
alternative care facilities, day programs for the elderly, home care agencies, community mental
health centers, hospice and palliative care centers, and community centered boards.
(b) [Editor's note: This version of subsection (3)(b) is effective July 1, 2024.] The
health home may consist of a multi-disciplinary team, including primary care management
providers, behavioral health-care providers, case managers, and providers of long-term services
and supports, including but not limited to case management agencies, as defined in section
25.5-6-1702, nursing homes, alternative care facilities, day programs for the elderly, home care
agencies, community mental health centers, and hospice and palliative care centers.
(4) To the extent provided under federal law, in integrating dually eligible persons,
persons with chronic conditions, or persons needing long-term care services and supports in an
organization with which the state department contracts pursuant to part 4 of article 5 of this title,
the state department shall permit providers of long-term services and supports to contract as
health homes or to provide some or all of the services provided by the organization contracted
with the state department, which services may include, but need not be limited to, navigation of
primary, specialty, or long-term care supports.
(5) Dually eligible clients may voluntarily elect to participate in a recognized medicare
coordinated care system and may voluntarily elect to participate in the state department's
medicaid coordinated care system.
Source: L. 2012: Entire section added, (SB 12-127), ch. 132, p. 453, § 1, effective April
23. L. 2021: (3)(b) amended, (HB 21-1187), ch. 83, p. 333, § 29, effective July 1, 2024.
25.5-6-114. Alternative care facilities - reimbursement programs - legislative
declaration - report - repeal. (Repealed)
Source: L. 2012: Entire section added, (SB 12-128), ch. 275, p. 1452, § 1, effective
August 8.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 333 of 510
Editor's note: Subsection (5) provided for the repeal of this section, effective July 1,
2015. (See L. 2012, p. 1452.)
25.5-6-115. Notification of federal immigration consequences. The state department
shall consult with stakeholders, including people with lived experience, immigrants rights
advocates, health-care advocates, and immigration lawyers, to provide clear and accurate
information and referrals regarding current public charge policies.
Source: L. 2022: Entire section added, (HB 22-1289), ch. 399, p. 2844, § 19, effective
June 7.
Cross references: For the legislative declaration in HB 22-1289, see section 1 of chapter
399, Session Laws of Colorado 2022.
25.5-6-116. Community placement transformation - creation - report - repeal. (1)
The state department shall undertake efforts to transform the state department's process for
clients attempting to receive long-term care in the community.
(2) In order to affirm Colorado's commitment to the United States supreme court's
decision in Olmstead v. L.C., 527 U.S. 581 (1999), and to the federal "Americans with
Disabilities Act of 1990", 42 U.S.C. sec. 12101 et seq., as amended, and respond to the United
States department of justice's letter of findings, dated March 3, 2022, concerning the
investigation of Colorado's use of nursing facilities to serve adults with physical disabilities, the
general assembly shall appropriate money to the state department in order to advance community
placement and integration for individuals with disabilities.
(3) No later than January 2023, and January 2024, the state department shall report to the
joint budget committee, the house of representatives public and behavioral health and human
services committee, and the senate health and human services committee, or their successor
committees, as part of its "State Measurement for Accountable, Responsive, and Transparent
(SMART) Government Act" hearing required by section 2-7-203. At a minimum, the report must
include an analysis and recommendations on the following:
(a) The state department's work and strategic planning regarding fulfilling Colorado's
commitment to the Olmstead decision to ensure community living;
(b) Programmatic decisions, analysis, and policy changes in accordance with the federal
"Americans with Disabilities Act of 1990", 42 U.S.C. sec. 12101 et seq., as amended; and
(c) Information regarding the state department's coordination, programmatic or medicaid
benefit changes, implementation of quality oversight strategies, and metrics around community
integration.
(4) This section is repealed, effective July 1, 2025.
Source: L. 2022: Entire section added, (HB 22-1302), ch. 180, p. 1200, § 4, effective
May 27.
Cross references: For the legislative declaration in HB 22-1302, see section 1 of chapter
180, Session Laws of Colorado 2022.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 334 of 510
PART 2
NURSING FACILITIES
25.5-6-201. Special definitions relating to nursing facility reimbursement. As used in
this part 2, unless the context otherwise requires:
(1) "Acquisition cost" means the actual allowable cost to the owners of a capital-related
asset or any improvement thereto as determined in accordance with generally accepted
accounting principles.
(2) "Actual cost" or "cost" means the audited cost of providing services.
(3) "Administration and general services costs" means costs in the following categories:
(a) Advertising, recruitment, and public relations, to the extent that such costs are
necessary, reasonable, and patient-related;
(b) Travel and training of facility staff, unless the travel includes residents of the facility
or the training is for the facility staff described in paragraph (a) of subsection (15) of this
section; and
(c) All other costs that are not direct or indirect health-care services, raw food costs, or
capital-related assets.
(4) "Appraised value" means the determination by a qualified appraiser who is a member
of an institute of real estate appraisers, or its equivalent, of the depreciated cost of replacement
of a capital-related asset to its current owner. The depreciated replacement appraisal must be
based on a nationally recognized valuation system determined by the state department. The
depreciated cost of replacement appraisal must be redetermined at least every four years by new
appraisals of the nursing facilities. The new appraisals must be based upon rules promulgated by
the state board.
(5) "Array of facility providers" means a listing in order from lowest per diem cost
facility to highest for that category of costs or rates, as may be applicable, of all
medicaid-participating nursing facility providers in the state.
(6) (a) "Base value" means:
(I) For the fiscal year 1986-87 and every fourth year thereafter, the appraised value of a
capital-related asset;
(II) For each year in which an appraisal is not done pursuant to subparagraph (I) of this
paragraph (a), the most recent appraisal together with fifty percent of any increase or decrease
each year since the last appraisal, as reflected in the index.
(b) For the fiscal year 1985-86, the base value shall not exceed twenty-five thousand
dollars per licensed bed at any participating facility, and, for each succeeding fiscal year, the
base value shall not exceed the previous year's limitation adjusted by any increase or decrease in
the index.
(c) An improvement to a capital-related asset, which is an addition to that asset, as
defined by rules adopted by the state board, shall increase the base value by the acquisition cost
of the improvement.
(7) "Capital-related asset" means the land, buildings, and fixed equipment of a
participating facility.
(8) "Case-mix" means a relative score or weight assigned for a given group of residents
based upon their levels of resources, consumption, and needs.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 335 of 510
(9) "Case-mix adjusted direct health-care services costs" means those costs comprising
the compensation, salaries, bonuses, workers' compensation, employer-contributed taxes, and
other employment benefits attributable to a nursing facility provider's direct care nursing staff
whether employed directly or as contract employees, including but not limited to registered
nurses, licensed practical nurses, and nurses' aides.
(9.5) "Case-mix group" means the system determined by the state department for
grouping a nursing facility's residents according to their clinical and functional status as
identified from data supplied by the facility's minimum data set as published by the United
States department of health and human services.
(10) "Case-mix index" means a numeric score assigned to each nursing facility resident
based upon a resident's physical and mental condition that reflects the amount of relative
resources required to provide care to that resident.
(11) "Case-mix neutral" means the direct health-care costs of all facilities adjusted to a
common case-mix.
(12) "Case-mix reimbursement" means a payment system that reimburses each facility
according to the resource consumption in treating its case-mix of medicaid residents, which
case-mix may include such factors as the age, health status, resource utilization, and diagnoses of
the facility's medicaid residents as further specified in this section.
(13) "Class I facility" means a private for-profit or not-for-profit nursing facility
provider or a facility provider operated by the state of Colorado, a county, a city and county, or
special district that provides general skilled nursing facility care to residents who require
twenty-four-hour nursing care and services due to their ages, infirmity, or health-care conditions,
including residents who are behaviorally challenged by virtue of a severe behavioral or mental
health disorder.
(14) "Direct health-care services costs" means those costs subject to case-mix adjusted
direct health-care services costs.
(15) "Direct or indirect health-care services costs" means the costs incurred for patient
support services, including the following:
(a) Salaries, payroll taxes, workers' compensation payments, training, and other
employee benefits for registered nurses, licensed practical nurses, aides, medical records
librarians, social workers, and activity personnel;
(b) Nonprescription drugs ordered by a physician;
(c) Consultant fees for nursing, medical records, patient activities, social workers,
pharmacies, physicians, and therapies;
(d) Purchases, rentals, and costs incurred to operate, maintain, or repair health-care
equipment;
(e) Supplies for nurses, medical records personnel, social workers, activity personnel,
and therapy personnel;
(f) Medical director fees;
(g) Therapies and other medically related services, including the following:
(I) Utilization review;
(II) Dental care, when required by federal law;
(III) Audiology;
(IV) Psychology;
(V) Physical therapy;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 336 of 510
(VI) Recreational therapy;
(VII) Occupational therapy; and
(VIII) Speech therapy;
(h) Other patient support services determined and defined by the state board pursuant to
rule;
(i) Raw food costs that do not include the costs of equipment, staff, or other costs
associated with meal preparation;
(j) Malpractice insurance;
(k) Depreciation and interest for major health-care equipment, such as equipment
purchased for the sole purpose of providing care to facility residents; and
(l) Photocopying related to health-care purposes such as medical records of patients.
(15.5) "Eligible nursing facility provider" means a nursing facility, as defined in section
25.5-4-103.
(16) "Facility population distribution" means the number of Colorado nursing facility
residents who are classified into each case-mix group as of a specific point in time.
(17) "Fair rental allowance" means the product obtained by multiplying the base value of
a capital-related asset by the rental rate.
(18) "Improvement" means the addition to a capital-related asset of land, buildings, or
fixed equipment.
(19) "Index" means the RSMeans construction systems cost index or an equivalent index
that is based upon a survey of prices of common building materials and wage rates for nursing
home construction.
(20) "Index maximization" means classifying a resident who could be assigned to more
than one category to the category with the highest case-mix index.
(20.5) Repealed.
(21) "Median per diem cost" means the average daily cost of care and services per
patient for the nursing facility provider that represents the middle of all of the arrayed facilities
participating as providers or as the number of arrayed facilities may dictate, the mean of the two
middle providers.
(22) "Minimum data set" means a set of screening, clinical, and functional status
elements that are used in the assessment of a nursing facility provider's residents under the
federal medicare and medicaid programs.
(23) "Normalization ratio" means the statewide average case-mix index divided by the
facility's cost report period case-mix index.
(24) "Normalized" means multiplying the nursing facility provider's per diem case-mix
adjusted direct health-care services cost by its case-mix index normalization ratio for the purpose
of making the per diem cost comparable among facilities based upon a common case-mix in
order to determine the maximum allowable reimbursement limitation.
(25) "Nursing facility provider" means a facility provider that meets the state nursing
home licensing standards established pursuant to section 25-1.5-103 (1)(a), C.R.S., and is
maintained primarily for the care and treatment of inpatients under the direction of a physician.
(26) "Nursing salary ratios" means the relative difference in hourly wages of registered
nurses, licensed practical nurses, and nurses' aides.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 337 of 510
(27) "Nursing weights" means numeric scores assigned to each category of the case-mix
groups that measure the relative amount of resources required to provide nursing care to a
nursing facility provider's residents.
(28) "Occupancy-imputed days" means the use of a predetermined number for patient
days rather than actual patients days in computing per diem cost.
(29) "Per diem cost" means the daily cost of care and services per patient for a nursing
facility provider.
(30) "Per diem rate" means the daily dollar amount of reimbursement that the state
department shall pay a nursing facility provider per patient.
(31) "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.
(32) "Raw food" means the products and substances, including but not limited to
nutritional supplements, that are consumed by residents.
(33) "Rental rate" means the average annualized composite rate for United States
treasury bonds issued for periods of ten years and longer plus two percent. The rental rate shall
not exceed ten and three-quarters percent nor fall below eight and one-quarter percent.
(34) Repealed.
(35) "Statewide average per diem rate" means the average daily dollar amount of the per
patient payments to all medicaid-participating facility providers in the state.
(36) "Supplemental medicaid payment" means a lump sum payment that is made in
addition to a provider's per diem rate. A supplemental medicaid payment is calculated on an
annual basis using historical data and paid as a fixed monthly amount with no retroactive
adjustment.
(37) "Wage enhancement supplemental payment" means a supplemental payment to an
eligible nursing facility provider that is subject to available appropriations and not a rate
enhancement.
Source: L. 2006: Entire article added with relocations, p. 1924, § 7, effective July 1. L.
2008: Entire section R&RE, p. 1773, § 2, effective July 1. L. 2009: (36) added, (SB 09-263), ch.
203, p. 914, § 1, effective May 1. L. 2017: (13) amended, (SB 17-242), ch. 263, p. 1329, § 207,
effective May 25. L. 2019: (15.5) and (20.5) added, (HB 19-1210), ch. 320, p. 2976, § 6,
effective January 1, 2020. L. 2021: (4), (16), and (27) amended, (9.5) added, and (34) repealed,
(HB 21-1227), ch. 192, p. 1015, § 2, effective September 7. L. 2022: (15.5) amended, (20.5)
repealed, and (37) added, (HB 22-1333), ch. 140, p. 930, § 1, effective August 10.
Editor's note: This section is similar to former § 26-4-502 as it existed prior to 2006.
Cross references: For the legislative declaration contained in the 2008 act repealing and
reenacting this section, see section 1 of chapter 383, Session Laws of Colorado 2008. For the
legislative declaration in SB 17-242, see section 1 of chapter 263, Session Laws of Colorado
2017. For the legislative declaration in HB 19-1210, see section 1 of chapter 320, Session Laws
of Colorado 2019.
25.5-6-202. Providers - nursing facility provider reimbursement - exemption - rules
- repeal. (1) (a) (I) Subject to available appropriations, for the purpose of reimbursing a
Colorado Revised Statutes 2023 Uncertified PrintoutPage 338 of 510
medicaid-certified class I nursing facility provider a per diem rate for the cost of direct and
indirect health-care services and raw food, the state department shall establish an annually
readjusted schedule to pay each nursing facility provider the actual amount of the costs. The
payment shall not exceed one hundred twenty-five percent of the median cost of direct and
indirect health-care services and raw food as determined by an array of all facility providers;
except that, for state veteran nursing homes, the payment shall not exceed one hundred thirty
percent of the median cost.
(II) For the fiscal year commencing July 1, 2009, and for each fiscal year thereafter, any
increase in the direct and indirect health-care services and raw food costs shall not exceed eight
percent per year. The calculation of the eight percent per year limitation for rates effective on
July 1, 2009, shall be based on the direct and indirect health-care services and raw food costs in
the as-filed facility's cost reports up to and including June 30, 2009. For the purposes of
calculating the eight-percent limitation for rates effective after July 1, 2009, the limitation shall
be determined and indexed from the direct and indirect health-care services and raw food costs
as reported and audited for the rates effective July 1, 2009.
(b) In computing per diem cost, each nursing facility provider shall annually submit cost
reports, and actual days of care shall be counted, not occupancy-imputed days of care. In
addition, in determining the median cost, the cost of direct health care shall be case-mix neutral.
The cost reports used by the state department to establish the per diem cost shall be those filed
with the state department during the period ending December 31 of the prior year following
implementation of this subsection (1) and for each succeeding year. The state department shall
redetermine the median per diem cost based upon the most recent cost reports filed during the
period ending December 31 of the prior year.
(2) The state department shall further adjust and, subject to available appropriations, pay
the per diem rate to the nursing facility provider for the cost of direct health-care services based
upon the acuity or case-mix of the nursing facility provider residents in order to provide for the
resource utilization of its residents. The state department shall determine this adjustment in
accordance with each resident's status as identified and reported by the nursing facility provider
on its federal medicare and medicaid minimum data set assessment. The state department shall
establish a case-mix index for each nursing facility provider according to the case-mix group
determined by the state department. The state department shall calculate nursing weights based
upon standard nursing time studies and weighted by facility population distribution and
Colorado-specific nursing salary ratios. The state department shall determine an average
case-mix index for each nursing facility provider's medicaid residents on a quarterly basis.
(3) (a) Subject to available appropriations, for the purpose of reimbursing a
medicaid-certified class I nursing facility provider a per diem rate for the cost of its
administrative and general services, the state department shall establish an annually readjusted
schedule to pay each nursing facility provider a reasonable price for the costs, which reasonable
price shall be a percentage of the median per diem cost of administrative and general services as
determined by an array of all nursing facility providers. For facilities of sixty licensed beds or
fewer, the reasonable price shall be one hundred ten percent of the median per diem cost for all
class I facilities. For facilities of sixty-one licensed beds and more, the reasonable price shall be
one hundred five percent of the median per diem cost for all class I facilities.
(b) In computing per diem cost, each nursing facility provider shall annually submit cost
reports to the state department, and actual days of care shall be counted, not occupancy-imputed
Colorado Revised Statutes 2023 Uncertified PrintoutPage 339 of 510
days of care. The cost reports used to establish this median per diem cost shall be those filed
during the period ending December 31 of the prior year following implementation of this
subsection (3), and, for each succeeding fourth year, the state department shall redetermine the
median per diem cost based upon the most recent cost reports filed during the period ending
December 31 of the prior year.
(c) Repealed.
(4) In addition to the reimbursement components paid pursuant to subsections (1) to (3)
of this section, a per diem rate constituting a fair rental allowance for capital-related assets shall
be paid to each nursing facility provider as a rental rate based upon the nursing facility's
appraised value.
(5) Subject to available appropriations and the priority of the uses of the provider fees as
established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid
pursuant to subsections (1) to (4) of this section, the state department shall make a supplemental
medicaid payment based upon performance to those nursing facility providers that provide
services that result in better care and higher quality of life for their residents. The state
department shall determine the payment amount based upon performance measures established
in rules adopted by the state board in the domains of quality of life, quality of care, and facility
management. Beginning July 1, 2024, the payment must not be less than twelve percent of total
provider fee payments and must be adjusted for fiscal years 2024-25 and 2025-26. No later than
July 1, 2026, the payment must not be less than fifteen percent of total provider fee payments
and must be annually adjusted thereafter. During each state fiscal year, the state department may
discontinue the supplemental medicaid payment established pursuant to this subsection (5) to
any nursing facility provider that fails to comply with the established performance measures
during the state fiscal year, and the state department may initiate the supplemental medicaid
payment established pursuant to this subsection (5) to any provider that comes into compliance
with the established performance measures during the state fiscal year.
(6) Subject to available appropriations and the priority of the uses of the provider fees as
established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid
pursuant to subsections (1) to (5) of this section, the state department shall make a supplemental
medicaid payment to nursing facility providers that serve residents:
(a) Who have severe mental health conditions that are classified at a level II by the
medicaid program's preadmission screening and resident review assessment tool. The state
department shall compute this payment annually as of July 1, 2009, and each July 1 thereafter,
and it must not be less than two percent of the statewide average per diem rate for the combined
rate components determined pursuant to subsections (1) to (4) of this section. Beginning July 1,
2023, the state department shall annually adjust the rate to ensure access to care for residents
who have severe mental health conditions.
(b) With severe dementia diseases and related disabilities or acquired brain injury. The
state department shall calculate the payment based upon the resident's cognitive assessment
established in rules adopted by the state board. The state department shall compute this payment
annually as of July 1, 2009, and each July 1 thereafter, and it must not be less than one percent of
the statewide average per diem rate for the combined rate components determined pursuant to
subsections (1) to (4) of this section. Beginning July 1, 2023, the state department shall annually
adjust the rate to ensure access to care for residents with severe dementia diseases and related
disabilities or acquired brain injury.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 340 of 510
(7) Subject to available moneys and the priority of the uses of the provider fees as
established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid
pursuant to subsections (1) to (6) of this section, the state department shall pay a nursing facility
provider a supplemental medicaid payment for care and services rendered to medicaid residents
to offset payment of the provider fee assessed under the provisions of section 25.5-6-203. The
state department shall compute this payment annually, as of July 1, 2009, and each July 1
thereafter.
(8) (Deleted by amendment, L. 2009, (SB 09-263), ch. 203, p. 912, § 2, effective May 1,
2009.)
(9) (a) The per diem amount paid for direct and indirect health-care services and
administrative and general services costs shall include an allowance for inflation in the costs for
each category using a nationally recognized service that includes the federal government's
forecasts for the prospective medicare reimbursement rates recommended to the United States
congress. Amounts contained in cost reports used to determine the per diem amount paid for
each category shall be adjusted by the percentage change in this allowance measured from the
midpoint of the reporting period of each cost report to the midpoint of the payment-setting
period.
(b) (I) Except for changes in the number of patient days, the state department shall
establish the general fund share of the aggregate statewide average of the per diem rate net of
patient payment pursuant to subsections (1) to (4) of this section. The state's share of the
reimbursement rate components pursuant to subsections (1) to (4) of this section may be funded
through the provider fee assessed pursuant to section 25.5-6-203 and any associated federal
funds. Any provider fee used as the state's share and all federal funds must be excluded from the
calculation of the general fund share. For the fiscal year commencing July 1, 2009, and for each
fiscal year thereafter, the state department shall calculate the general fund share of the aggregate
statewide average per diem rate net of patient payment pursuant to subsections (1) to (4) of this
section using the rates that were effective on July 1 of that fiscal year; except that:
(A) For fiscal year 2023-24, the state department shall increase the aggregate statewide
average of the per diem rate by at least ten percent;
(B) For fiscal year 2024-25, the state department shall increase the aggregate statewide
average of the per diem rate by at least three percent;
(C) For fiscal year 2025-26, the state department shall increase the aggregate statewide
average of the per diem rate by at least one and one-half percent; and
(D) Beginning in fiscal year 2026-27, and for each fiscal year thereafter, the state
department shall establish the aggregate statewide average of the per diem rate.
(I.5) When increasing the aggregate statewide average of the per diem rate for fiscal
years 2023 through 2027, the reimbursement rate for a class I nursing facility that operates
efficiently and economically must be reasonable and adequate to meet the nursing home's costs
in order to provide care and services in conformity with applicable state and federal laws,
regulations, and quality and safety standards, and must be based on the most recent audited and
finalized cost and utilization data available.
(II) If the aggregate statewide average per diem rate net of patient payment pursuant to
subsections (1) to (4) of this section exceeds the general fund share, the amount of the average
statewide per diem rate that exceeds the general fund share shall be paid as a supplemental
medicaid payment using the provider fee established under section 25.5-6-203. Subject to the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 341 of 510
priority of the uses of the provider fee established under section 25.5-6-203 (2)(b), if the
provider fee is insufficient to fully fund the supplemental medicaid payment, the supplemental
medicaid payment shall be reduced to all providers proportionately.
(III) to (V) Repealed.
(VI) Notwithstanding any other provision of law, for the fiscal year commencing July 1,
2013, and each fiscal year thereafter, the general fund portion of the per diem rate pursuant to
subsections (1) to (4) of this section shall be reduced by one and one-half percent. The state
department may, but is not required to, increase the supplemental medicaid payment pursuant to
subparagraph (II) of this paragraph (b) due to this reduction; except that the provider fee shall
not exceed the amount specified in section 25.5-6-203 (1)(a)(II).
(VII) Notwithstanding any other provision of law to the contrary, for the 2020-21 and
2021-22 fiscal years, the general fund portion of the per diem rate pursuant to subsections (1) to
(4) of this section is limited to an annual increase of two percent.
(b.3) (I) For the fiscal year commencing July 1, 2009, and for each fiscal year thereafter,
if the provider fee established under section 25.5-6-203 is insufficient to fully fund the
supplemental medicaid payments established under subsections (5) to (7) of this section, subject
to the priority of the uses of the provider fee established pursuant to section 25.5-6-203 (2)(b),
the state department may suspend or reduce the supplemental medicaid payment subject to the
uses of the provider fee established under section 25.5-6-203.
(II) If it is determined by the state department that the case-mix reimbursement includes
a factor for nursing facility providers that serve residents with severe dementia diseases and
related disabilities or acquired brain injury, the state department may eliminate the supplemental
medicaid payment to those providers that serve residents with severe dementia diseases and
related disabilities or acquired brain injury.
(b.5) Notwithstanding any other provision of law or any federal law that temporarily
increases the federal matching participation rate for any fiscal year, payments to nursing facility
providers from the general fund share of the aggregate statewide average of the per diem rate
shall be calculated based on a fifty-percent federal match.
(b.7) Repealed.
(c) (I) The general assembly finds that the historical growth in nursing facility provider
rates has significantly exceeded the rate of inflation. These increases have been caused in part by
the inclusion of medicare costs in medicaid cost reports. The state of Colorado has an interest in
limiting these exceptional increases in medicaid nursing facility provider rates by removing
medicare costs from the medicaid nursing facility provider rates and by imposing a ceiling on the
medicare part A ancillary costs that are included in calculating medicaid nursing facility rates.
No later than July 1, 2023, the state department shall initiate a process to remove medicare costs
from the provider rate setting by July 1, 2026. The state board shall promulgate rules
establishing the specific methodology used for removing medicare costs.
(II) Repealed.
(III) The specific methodology for calculating the limitations and cost-reporting
requirements described in this paragraph (c) shall be established by rules promulgated by the
state board.
(d) The reimbursement rate components pursuant to subsections (5) to (7) of this section
shall be funded entirely through the provider fee assessed pursuant to the provisions of section
Colorado Revised Statutes 2023 Uncertified PrintoutPage 342 of 510
25.5-6-203 and any associated federal funds. No general fund moneys shall be used to pay for
the reimbursement rate components established pursuant to subsections (5) to (7) of this section.
(10) The state board shall promulgate rules pursuant to the "State Administrative
Procedure Act", article 4 of title 24, C.R.S.,to implement this section, including establishing
uniform accounting, reporting, and payment procedures consistent with this section, to determine
a nursing facility provider's costs and payments to the provider.
(11) (Deleted by amendment, L. 2009, (SB 09-263), ch. 203, p. 912, § 2, effective May
1, 2009.)
(12) The state department may exempt facilities with five or fewer medicaid beds from
the methodology described in this section and instead require the facilities to be reimbursed at
the statewide average rate.
(13) (a) As a condition of receiving medicaid funds, the state department may require a
nursing facility to submit any documentation necessary to ensure the state's interest in
transparency, stability, and sound fiscal stewardship, including, but not limited to:
(I) Annual audited financial statements, prepared by an independent accountant, for a
facility, management company, and any related party conducting business with a
medicaid-certified nursing facility, including audited and consolidated financial statements for
any parent company that accepts, or whose subsidiaries accept, medicaid payments from the
state of Colorado;
(II) Details on transactions between related parties or entities that have common
ownership; and
(III) Ownership interest in real estate, management companies, facility operators, and all
related parties.
(b) The state department shall determine the format for the documentation provided by
each nursing facility.
(c) The state board shall establish by rule any penalties for noncompliance with the
financial reporting required pursuant to this subsection (13).
(d) The costs associated with the financial reporting required pursuant to this subsection
(13), including any audit costs incurred by a nursing facility, are an allowable expense on the
medicaid cost report and must be incorporated as a component of the overall reimbursement
methodology.
(14) The general assembly finds that the inflexible nature of statutorily fixed
reimbursement rates is not in the best interest of the state of Colorado. Therefore, the state
department shall develop and implement a transition plan to regulate nursing facility
reimbursement aimed at improving the health and safety of residents, promoting innovation and
improved infection control efforts, improving access to care, and promoting innovation in
Colorado nursing facilities. As part of this process, the state department shall:
(a) No later than July 1, 2026, define "nursing home reimbursement" through rules
promulgated by the state board and provide payments to nursing facilities consistent with the
promulgated rules;
(b) Engage with stakeholders regularly to seek input on any proposed methodology
changes and ensure the methodology is reasonable and adequate to meet the costs of an
efficiently and economically operated nursing facility that provides care and services in
conformity with applicable state and federal laws, regulations, and quality and safety standards
based on the most recent audit and finalized cost and utilization data available; and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 343 of 510
(c) From November 1, 2023, to November 1, 2026, submit an annual report to the joint
budget committee of the general assembly regarding the implementation progress described in
this subsection (14), including, at a minimum:
(I) Records of stakeholder engagement;
(II) Conclusions drawn from financial oversight activities;
(III) Issues regarding payment equity and access to care coordination; and
(IV) Expected budgetary impacts of any methodology change.
(15) (a) Each nursing facility that receives medicaid funds shall develop and submit a
plan to the state department that meets state department standards and demonstrates how the
nursing facility will:
(I) Improve the health and safety of the nursing facility's residents, including infection
control and staffing;
(II) Increase access to care;
(III) Improve financial sustainability, including opportunities for diversification of
business lines and stabilization of revenue streams; and
(IV) Promote innovation to meet the emerging needs of individuals with disabilities and
aging and older adults.
(b) The state board shall promulgate rules implementing this subsection (15).
(16) Subsections (1) to (9) of this section and this subsection (16) are repealed, effective
July 1, 2026.
Source: L. 2006: Entire article added with relocations, p. 1925, § 7, effective July 1. L.
2008: Entire section R&RE, p. 1777, § 3, effective July 1. L. 2009: (1)(a), (3), (5), (6), (7), (8),
(9)(b), and (11) amended and (9)(b.3), (9)(b.5), and (9)(b.7) added, (SB 09-263), ch. 203, p. 912,
§ 2, effective May 1. L. 2010: (9)(b)(III) added, (HB 10-1324), ch. 14, p. 69, § 1, effective
March 1; (9)(b)(III) and (9)(b.7)(II) amended, (HB 10-1379), ch. 214, p. 930, §§ 1, 2, effective
May 6. L. 2011: (9)(b)(IV) added, (SB 11-215), ch. 148, p. 514, § 1, effective May 5. L. 2012:
(9)(b)(V) added, (HB 12-1340), ch. 154, p. 552, § 1, effective May 3. L. 2013: (9)(b)(III) and
(9)(b)(IV) repealed, (9)(b)(V) amended, and (9)(b)(VI) added, (HB 13-1152), ch. 162, p. 520, §
1, effective May 3. L. 2018: IP(6), (6)(b), and (9)(b.3)(II) amended, (HB 18-1091), ch. 74, p.
643, § 5, effective August 8. L. 2020: (9)(b)(VII) added, (HB 20-1362), ch. 203, p. 1005, § 1,
effective June 30. L. 2021: (2) amended and (12) added, (HB 21-1227), ch. 192, p. 1016, § 3,
effective September 7. L. 2023: (5), (6), (9)(b)(I), and (9)(c)(I) amended, (9)(b)(I.5), (13), (14),
(15), and (16) added, and (9)(c)(II) repealed, (HB 23-1228), ch. 278, p. 1643, § 1, effective May
30.
Editor's note: (1) This section is similar to former § 26-4-502.5 as it existed prior to
2006.
(2) Subsection (9)(b.7)(III) provided for the repeal of subsection (9)(b.7), effective July
1, 2011. (See L. 2009, p. 912.)
(3) Subsection (9)(b)(V)(B) provided for the repeal of subsection (9)(b)(V), effective
July 1, 2014. (See L. 2012, p. 552.)
(4) Subsection (3)(c)(III) provided for the repeal of subsection (3)(c), effective July 1,
2015. (See L. 2009, p. 912.)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 344 of 510
Cross references: For the legislative declaration contained in the 2008 act repealing and
reenacting this section, see section 1 of chapter 383, Session Laws of Colorado 2008.
25.5-6-203. Nursing facilities - provider fees - federal waiver - fund created - rules -
repeal. (1) (a) (I) Beginning with the fiscal year commencing July 1, 2008, and each fiscal year
thereafter, the state department shall charge and collect provider fees on health-care items or
services provided by nursing facility providers for the purpose of obtaining federal financial
participation under the state's medical assistance program as described in articles 4 to 6 of this
title. As specified by the priority of the uses of the provider fee in paragraph (b) of subsection (2)
of this section, the provider fees shall be used to sustain or increase reimbursement for providing
medical care under the state's medical assistance program for nursing facility providers.
(II) For the fiscal years commencing July 1, 2009, and July 1, 2010, the provider fee
shall not exceed seven dollars and fifty cents per nonmedicare-resident day. For the fiscal year
commencing July 1, 2011, and each fiscal year thereafter, the provider fee shall not exceed
twelve dollars per nonmedicare-resident day plus inflation based on the national skilled nursing
facility market basket index as determined by the secretary of the department of health and
human services pursuant to 42 U.S.C. sec. 1395yy (e)(5) or any successor index.
(III) In calculating the amount of the provider fee portion of the supplemental medicaid
payments established under section 25.5-6-202 (5), the state department may include an
additional amount of up to five percent of the provider fee portion of said supplemental medicaid
payments to initiate the payment to any provider who complies with the established performance
measures during the state fiscal year.
(b) The provider fees shall be charged on a nonmedicare-resident day basis and shall be
based upon the aggregate gross or net revenue, as prescribed by the state department, of all
nursing facility providers subject to the provider fee. The state department may exempt revenue
categories from the gross or net revenue calculation and the collection of the provider fee from
nursing facility providers, as authorized by federal law.
(c) (I) In accordance with the redistributive method set forth in 42 CFR 433.68 (e)(1)
and (e)(2), the state department shall seek a waiver from the broad-based provider fees
requirement or the uniform provider fees requirement, or both, to exclude nursing facility
providers from the provider fee. The state department shall exempt the following nursing facility
providers to obtain federal approval and minimize the financial impact on nursing facility
providers:
(A) A facility operated as a continuing care retirement community that provides a
continuum of services by one operational entity providing independent living services, assisted
living services, and skilled nursing care on a single, contiguous campus. Assisted living services
include an assisted living residence as defined in section 25-27-102 or that provides assisted
living services on-site, twenty-four hours per day, seven days per week.
(B) A skilled nursing facility owned and operated by the state;
(C) A nursing facility that is a distinct part of a facility that is licensed as a general acute
care hospital; and
(D) A facility that has forty-five or fewer licensed beds.
(II) No later than July 1, 2026, the state department shall promulgate rules maintaining
the exemptions identified in this subsection (1)(c) in order to minimize the financial impact on
nursing facility providers.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 345 of 510
(III) This subsection (1)(c) is repealed, effective July 1, 2028.
(d) The state department may lower the amount of the provider fee charged to certain
nursing facility providers to meet the requirements of 42 CFR 433.68 (e) and to obtain federal
approval.
(e) The imposition and collection of a provider fee shall be prohibited without the
federal government's approval of a state medicaid plan amendment authorizing federal financial
participation for the provider fees. The state department may alter the method prescribed in this
section to the extent necessary to meet the federal requirements and to obtain federal approval.
(f) If the provider fee required by this subsection (1) is not approved by the federal
government, notwithstanding any other provision of this section, the state department shall not
implement the assessment or collection of the provider fee from nursing facility providers.
(g) The state department shall establish a schedule to assess and collect the provider fee
on a monthly basis. The state board shall establish rules so that provider fee payments from a
nursing facility provider and the state department's supplemental medicaid payments to the
nursing facility are due as nearly simultaneously as feasible; except that the state department's
supplemental medicaid payments to the nursing facility shall be due no more than fifteen days
after the provider fee payment is received from the nursing facility. The state department shall
require each nursing facility provider to report annually its total number of days of care provided
to nonmedicare residents.
(h) The state department shall not assess or collect the provider fee until state medicaid
plan amendments adopting the medicaid reimbursement system for the state's class I nursing
facility providers, pursuant to section 25.5-6-202, including the waiver with respect to the
provider fees pursuant to this section, have been approved by the federal government.
(i) The state board shall promulgate any rules pursuant to the "State Administrative
Procedure Act", article 4 of title 24, C.R.S., necessary for the administration and implementation
of this section.
(j) A nursing facility provider shall not include any amount of the provider fee as a
separate line item in its billing statements.
(2) (a) All provider fees collected pursuant to this section by the state department shall
be transmitted to the state treasurer, who shall credit the same to the medicaid nursing facility
cash fund, which fund is hereby created and referred to in this section as the "fund".
(b) (I) All moneys in the fund shall be subject to federal matching as authorized under
federal law and subject to annual appropriation by the general assembly for the purpose of
paying the administrative costs of implementing section 25.5-6-202 and this section, to satisfy
settlements or judgments resulting from nursing facility provider reimbursement appeals, and to
pay the supplemental medicaid payments to offset payment of the provider fee established under
section 25.5-6-202 (7).
(II) Following the payment of the amounts described in subparagraph (I) of this
paragraph (b), the moneys remaining in the fund shall be subject to federal matching as
authorized under federal law and subject to annual appropriation by the general assembly for the
purpose of paying the supplemental medicaid payments for acuity or case-mix of residents
established under section 25.5-6-202 (2).
(III) (A) Except as provided in sub-subparagraph (B) of this subparagraph (III), after the
payment of the amounts described in subparagraphs (I) and (II) of this paragraph (b), the moneys
remaining in the fund shall be subject to federal matching as authorized under federal law and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 346 of 510
subject to annual appropriation by the general assembly for the purpose of paying the
supplemental medicaid payments for higher quality performance established under section
25.5-6-202 (5).
(B) Notwithstanding any other provision of this paragraph (b), the supplemental
medicaid payments established pursuant to section 25.5-6-202 (5) shall not be less than ten
percent of the supplemental medicaid payments established under section 25.5-6-202 (7) in the
prior state fiscal year.
(IV) Following the payment of the amounts described in subsections (2)(b)(I) to
(2)(b)(III) of this section, the money remaining in the fund shall be subject to federal matching
as authorized under federal law and subject to annual appropriation by the general assembly for
the purpose of paying the supplemental medicaid payments established under section 25.5-6-202
(6) for residents who have moderately to very severe mental health conditions, dementia diseases
and related disabilities, or acquired brain injury.
(V) Following the payment of the amounts described in subparagraphs (I) to (IV) of this
paragraph (b), the moneys remaining in the fund shall be subject to federal matching as
authorized under federal law and subject to annual appropriation by the general assembly for the
purpose of paying the supplemental medicaid payments for the amount by which the average
statewide per diem rate exceeds the general fund share established under section 25.5-6-202
(9)(b)(II).
(VI) Any moneys in the fund not expended for the purposes specified in this section may
be invested by the state treasurer as provided by law. All interest and income derived from the
investment and deposit of moneys in the fund shall be credited to the fund. Any unexpended and
unencumbered moneys remaining in the fund at the end of any fiscal year shall remain in the
fund and shall not be credited or transferred to the general fund or any other fund but may be
appropriated by the general assembly to pay nursing facility providers in future fiscal years.
(VII) (A) Notwithstanding any other provision of this subsection (2)(b), for state
medicaid expenditures 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, are still available only, and regardless of when this
federal money is made available, money in the fund may be used to offset general fund
expenditures in the medicaid program in an equivalent amount that would have been in excess of
the fifty percent federal financial participation generated by increased reimbursements and
payments appropriated for use in subsections (2)(b)(I) to (2)(b)(V) of this section pursuant to the
federal"Families First Coronavirus Response Act", Pub.L. 116-127, or any amendment thereto,
or any other federal law that increases federal financial participation above the federal financial
participation percentage in effect prior to the increase in federal financial participation provided
through the federal"Families First Coronavirus Response Act". The state treasurer shall transfer
such amount to the general fund for the state medicaid program.
(B) This subsection (2)(b)(VII) is repealed, effective December 31, 2024.
Source: L. 2006: Entire article added with relocations, p. 1926, § 7, effective July 1. L.
2008: Entire section R&RE, p. 1781, § 4, effective July 1. L. 2009: (1)(a), (1)(g), and (2)(b)
amended and (1)(j) added, (SB 09-263), ch. 203, p. 918, § 3, effective May 1; (1)(c)(I) amended,
(SB 09-292), ch. 369, p. 1975, § 98, effective August 5. L. 2010: (2)(b)(II.7) added, (HB
10-1324), ch. 14, p. 69, § 2, effective March 1. L. 2011: (1)(a)(II) and (2) amended, (SB
Colorado Revised Statutes 2023 Uncertified PrintoutPage 347 of 510
11-125), ch. 208, p. 900, § 1, effective August 10. L. 2013: (1)(c)(I) and (1)(g) amended, (HB
13-1199), ch. 63, p. 209, § 2, effective March 22. L. 2014: (2)(b)(I) amended, (SB 14-143), ch.
191, p. 712, § 1, effective May 15. L. 2018: (2)(b)(IV) amended, (HB 18-1091), ch. 74, p. 644, §
6, effective August 8. L. 2020: (2)(b)(VII) added, (HB 20-1385), ch. 173, p. 797, § 3, effective
June 29. L. 2021: (2)(b)(VII) amended, (SB 21-213), ch. 88, p. 365, § 3, effective May 4. L.
2023: (1)(c) amended, (HB 23-1228), ch. 278, p. 1647, § 2, effective May 30.
Editor's note: This section is similar to former § 26-4-503 as it existed prior to 2006.
Cross references: For the legislative declaration contained in the 2008 act amending this
section, see section 1 of chapter 383, Session Laws of Colorado 2008. For the legislative
declaration in the 2013 act amending subsections (1)(c)(I) and (1)(g), see section 1 of chapter 63,
Session Laws of Colorado 2013.
25.5-6-204. Providers - reimbursement - intermediate care facility for individuals
with intellectual disabilities - reimbursement - maximum allowable. (1) (a) For the purpose
of making payments to intermediate care facilities for individuals with intellectual disabilities,
the state department shall establish a price schedule to be readjusted every twelve months, that
shall reimburse, subject to available appropriations, each provider, as nearly as possible, for its
actual or reasonable cost of services rendered, whichever is less, its case-mix adjusted direct
health-care services costs as defined in section 25.5-6-201 (9), and a fair rental allowance for
capital-related assets as defined in section 25.5-6-201 (7). The state board shall adopt rules,
including uniform accounting or reporting procedures, in order to determine the actual or
reasonable cost of services and case-mix adjusted direct health-care services costs and the
reimbursement therefor. The provisions of this paragraph (a) shall not apply to state-operated
intermediate care facilities for individuals with intellectual disabilities.
(b) State-operated intermediate care facilities for individuals with intellectual disabilities
shall be reimbursed based on the actual costs of administration, property, including
capital-related assets, and room and board, and the actual costs of providing health-care services,
and such costs shall be projected by such facilities and submitted to the state department by July
1 of each year for the ensuing twelve-month period. Reimbursement to state-operated
intermediate care facilities for individuals with intellectual disabilities shall be adjusted
retrospectively at the close of each twelve-month period. The state board shall adopt rules to be
effective by June 30, 1988, implementing the provisions of this paragraph (b). In the
implementation of such rules, the state department shall ensure, by the establishment of classes
of facilities, that the reimbursement to private, nonprofit, or proprietary state-operated
intermediate care facilities for individuals with intellectual disabilities, as defined in section
25.5-10-202, is not adversely impacted.
(c) (I) Beginning in fiscal year 2013-14, and for each fiscal year thereafter, the state
department is authorized to charge both privately owned intermediate care facilities for
individuals with intellectual disabilities and state-operated intermediate care facilities for
individuals with intellectual disabilities a service fee for the purposes of maintaining the quality
and continuity of services provided by intermediate care facilities for individuals with
intellectual disabilities. The service fee charged by the state department pursuant to this
paragraph (c) will be assessed pursuant to rules adopted by the state board but must not exceed
Colorado Revised Statutes 2023 Uncertified PrintoutPage 348 of 510
five percent of the total costs incurred by all intermediate care facilities for the fiscal year in
which the service fee is charged. The state board shall adopt rules consistent with federal law in
order to implement the provisions of this paragraph (c).
(II) The moneys collected in each fiscal year pursuant to subparagraph (I) of this
paragraph (c) shall be transmitted by the state department to the state treasurer, who shall credit
the same to the service fee fund, which fund is hereby created and referred to in this paragraph
(c) as the "fund". The moneys in the fund shall be subject to annual appropriation by the general
assembly to the state department to be used toward the state match for the federal financial
participation to reimburse intermediate care facilities for individuals with intellectual disabilities
pursuant to this section. Any unexpended and unencumbered moneys remaining in the fund at
the end of any fiscal year shall remain in the fund and not be credited or transferred to the
general fund or any other fund.
(2) (a) In addition to the actual or reasonable costs and the reimbursement therefor, the
state department shall, subject to available appropriations, include an allowance equal to the
change in the national bureau of labor statistics consumer price index from the preceding year to
compensate for fluctuating costs. This amount shall be determined every twelve months when
the statewide average cost is determined by adjusting for inflation. The provider's allowable cost
shall be multiplied by the change in the consumer price index measured from the midpoint of the
provider's cost report period to the midpoint of the provider's rate period. This allowance is
applied to all costs, including case-mix adjusted direct health-care services costs as defined in
section 25.5-6-201 (9), less interest, up to the reasonable cost established and will be allowed to
proprietary, nonprofit, and tax-supported homes; except that the allowance shall not be applied
to the costs of state-operated intermediate facilities for individuals with intellectual disabilities.
(b) (I) The state board shall adopt rules to:
(A) Determine and pay to privately owned intermediate care facilities for individuals
with intellectual disabilities a reasonable share of the amount by which the reasonable costs of
the categories of administration, property, and room and board, excluding food costs, exceed the
actual cost in these categories only. The reasonable share shall be defined as twenty-five percent
of the amount in the categories for each facility, not to exceed twelve percent of the reasonable
cost.
(B) (Deleted by amendment, L. 2008, p. 1783, § 5, effective July 1, 2008.)
(II) (Deleted by amendment, L. 2008, p. 1783, § 5, effective July 1, 2008.)
(c) to (e) (Deleted by amendment, L. 2008, p. 1783, § 5, effective July 1, 2008.)
(3) to (5) (Deleted by amendment, L. 2008, p. 1783, § 5, effective July 1, 2008.)
(6) and (7) Repealed.
Source: L. 2006: (5)(b) amended and (6) added, p. 1615, §§ 4, 3, effective June 2; entire
article added with relocations, p. 1927, § 7, effective July 1. L. 2007: (7) added, p. 1802, § 2,
effective July 1. L. 2008: (1)(a) and (2) to (5) amended, p. 1783, § 5, effective July 1. L. 2013:
Entire section amended, (SB 13-167), ch. 394, p. 2290, § 3, effective June 5; (1)(b), (1)(c)(I),
and (1)(c)(II) amended, (HB 13-1314), ch. 323, p. 1809, § 46, effective March 1, 2014.
Editor's note: (1) This section is similar to former § 26-4-410 as it existed prior to
2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 349 of 510
(2) (a) Amendments to section 26-4-410 (5)(b) by Senate Bill 06-131 were harmonized
with subsection (5)(b) as it appeared in Senate Bill 06-219.
(b) Subsection (6) was enacted as § 26-4-410 (6) in Senate Bill 06-131 but was relocated
due to its harmonization with this section as it appeared in Senate Bill 06-219.
(3) Subsection (6)(c) provided for the repeal of subsection (6), effective July 1, 2007.
(See L. 2006, p. 1615.)
(4) Subsection (7)(c) provided for the repeal of subsection (7), effective July 1, 2008.
(See L. 2007, p. 1802.)
(5) Amendments to this subsections (1)(b), (1)(c)(I), and (1)(c)(II) by House Bill
13-1314 and Senate Bill 13-167 were harmonized.
Cross references: For the legislative declaration contained in the 2006 act amending
subsection (5)(b) and enacting subsection (6), see section 1 of chapter 324, Session Laws of
Colorado 2006. For the legislative declaration contained in the 2008 act amending subsections
(1)(a) and (2) to (5), see section 1 of chapter 383, Session Laws of Colorado 2008.
25.5-6-205. Collection of penalties assessed against nursing facilities - creation of
cash fund. (1) (a) The state department shall assess, enforce, and collect any civil penalties that
are recommended by the department of public health and environment pursuant to the authority
granted under section 25-1-107.5, C.R.S.
(b) Prior to the denial of medicaid payments or the assessment of a civil money penalty
against a nursing facility, the nursing facility shall be offered by the state department an
opportunity for a hearing in accordance with the provisions of section 24-4-105, C.R.S.
Enforcement and collection of the denial of medicaid payments or civil money penalty shall
occur following the decision reached at such hearing.
(2) In conjunction with the authority granted under subsection (1) of this section, the
state board shall promulgate rules that:
(a) Provide any nursing facility assessed a civil penalty the opportunity to appeal such
assessment;
(b) Govern the procedures for such appeals, including the right of a nursing facility to
thirty days' notice prior to the collection of any civil money penalty; and
(c) Are otherwise necessary to implement this section.
(3) (a) Any civil penalties collected by the state department pursuant to this section shall
be transmitted to the state treasurer, who shall credit the same to the nursing home penalty cash
fund, which fund is hereby created.
(b) (I) On and after July 1, 2021, the money in the fund is subject to annual appropriation
by the general assembly to the state department and the department of public health and
environment for the purposes set forth in section 25-1-107.5. Pursuant to section 25-1-107.5
(4)(b)(II)(B), the money in the fund is continuously appropriated to the state department and the
department of public health and environment for the purpose of emergency funding needs.
(II) Such moneys shall be used in the manner prescribed in section 25-1-107.5, C.R.S.,
and the rules promulgated thereunder.
(c) All interest derived from the deposit and investment of moneys in the fund shall be
credited to the fund.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 350 of 510
(d) At the end of any fiscal year, all unexpended and unencumbered moneys remaining
in the fund shall remain therein and shall not be credited or transferred to the general fund or any
other fund.
Source: L. 2006: Entire article added with relocations, p. 1933, § 7, effective July 1. L.
2021: (3)(b)(I) amended, (SB 21-128), ch. 302, p. 1817, § 2, effective June 23.
Editor's note: This section is similar to former § 26-4-505 as it existed prior to 2006.
25.5-6-206. Personal needs benefits - amount - patient personal needs trust fund
required - funeral and final disposition expenses - penalty for illegal retention and use. (1)
The state department, pursuant to its rules, may include in medical care benefits provided under
this article 6 and articles 4 and 5 of this title 25.5 reasonable amounts for the personal needs of
any recipient receiving nursing facility services or intermediate care facilities for individuals
with intellectual disabilities, if the recipient is not otherwise eligible for the amounts from other
categories of public assistance, but the amounts for personal needs must not be less than the
minimum amount provided for in subsection (2) of this section. Payments for funeral and final
disposition expenses upon the death of a recipient may be provided under rules of the state
department in the same manner as provided to recipients of public assistance as defined by
section 26-2-103 (8).
(2) (a) The basic minimum amount payable pursuant to subsection (1) of this section for
personal needs to any recipient admitted to a nursing facility or intermediate care facility for
individuals with intellectual disabilities is seventy-five dollars monthly; except that,
commencing January 1, 2015, and each January 1 thereafter, the basic minimum amount shall
increase annually by the same percentage applied to the general fund share of the aggregate
statewide average of the per diem net of patient payment pursuant to section 25.5-6-202
(9)(b)(I). Commencing with the fiscal year beginning July 1, 2014, and each fiscal year
thereafter, the reduction to patient payments received by nursing facilities resulting from an
increase in the basic minimum amount shall be funded in full by general fund and applicable
federal funds.
(b) On and after October 1, 1992, the basic minimum amount payable pursuant to
subsection (1) of this section for personal needs shall be ninety dollars for the following persons:
(I) A medical assistance recipient who receives a non-service connected disability
pension from the United States veterans administration, has no spouse or dependent child, and is
admitted to or is residing in a nursing facility; and
(II) A medical assistance recipient who is a surviving spouse of a person who received a
non-service connected disability pension from the United States veterans administration, has no
dependent child, and is admitted to or is residing in a nursing facility.
(3) (a) All personal needs funds shall be held in trust by the nursing facility or
intermediate care facility for individuals with intellectual disabilities, or its designated trustee,
separate and apart from any other funds of the facility. The facility shall deposit any personal
needs funds of a resident in an amount of fifty or more dollars in an interest-bearing checking
account or accounts or savings account or any combination thereof established to protect and
separate the personal needs funds of the patients. Any interest earned on a resident's personal
needs funds shall be credited to such account or accounts. In the event residents' personal needs
Colorado Revised Statutes 2023 Uncertified PrintoutPage 351 of 510
funds are maintained in a pooled account, separate accountings shall be made for each resident's
share of the pooled account. Any personal needs funds of a resident in an amount less than fifty
dollars shall be maintained in a non-interest-bearing account, an interest-bearing account, or a
petty cash fund.
(b) At all times, the principal and all income derived from said principal in the patient
personal needs trust fund shall remain the property of the participating patients, and the facility
or its designated trustee is bound by all of the duties imposed by law upon fiduciaries in the
handling of such fund. Those duties include but are not limited to providing notice to a resident
when the resident's personal needs account accumulates two hundred dollars less than the federal
supplemental security income resource limit for one person.
(c) The facility or its designated trustee shall post a surety bond in an amount to assure
the security of all personal needs funds deposited in the patient personal needs trust fund or shall
otherwise demonstrate to the satisfaction of the state department that the security of residents'
personal needs funds is assured.
(d) Within sixty days after a resident's death, the facility shall transfer the resident's
personal needs funds and a final accounting of the funds to the person responsible for settling the
resident's estate or, if there is none, to the resident's heirs in accordance with the provisions of
title 15, C.R.S. Within fifteen days after receiving the funds, the executor, administrator, or other
appropriate representative of the resident's estate shall provide written notice to the state
department regarding the receipt of the funds. Upon receipt of the notice, the state department
may bring an action to recover the funds pursuant to the provisions of this article and articles 4
and 5 of this title.
(4) The state department shall establish rules concerning the establishment of a patient
personal needs trust fund and procedures for the maintenance of a system of accounting for
expenditures of each patient's personal needs funds. The facility shall use an accounting system
that assures a complete and separate accounting of residents' personal needs funds based on
generally accepted accounting principles and that precludes the commingling of a resident's
personal needs funds with the facility's funds or the funds of any other person other than the
personal needs funds of another resident. These rules shall provide that the nursing facility or
intermediate care facility for individuals with intellectual disabilities shall maintain complete
records of all receipts and expenditures involving the patient personal needs trust fund, that all
expenditures shall be approved by the patient, legal custodian, guardian, or conservator prior to
an expenditure, and that each patient or such patient's legal custodian, guardian, or conservator
shall be given at least a quarterly accounting of the receipts and expenditures of such funds. In
addition, the rules shall require that the person who maintains the patient personal needs trust
fund for the facility and who is responsible for the deposit of moneys into such trust fund shall
deposit any personal needs funds received from a patient or from the state department no later
than sixty days after the receipt of such moneys.
(5) All patient personal needs trust funds shall be subject to audit by the state
department. A record of a patient's personal needs trust fund shall be kept by the facility for a
period of three years from the date of the patient's discharge from the facility or until such
records have been audited by the state department, whichever occurs later.
(6) Any overpayment of personal needs funds to a nursing facility or an intermediate
care facility for individuals with intellectual disabilities by the state department due to the
omission, error, fraud, or defalcation of the nursing facility or intermediate care facility for
Colorado Revised Statutes 2023 Uncertified PrintoutPage 352 of 510
individuals with intellectual disabilities or any shortage in an audited patient personal needs trust
fund shall be recoverable by the state on behalf of the recipient in the same manner and
following the same procedures as specified in section 25.5-4-301 (2) for an overpayment to a
provider.
(7) Nothing in this section shall prevent a nursing facility or intermediate care facility for
individuals with intellectual disabilities patient from excluding himself or herself from
participation in the patient personal needs trust fund.
(8) (a) It is unlawful for any person to knowingly fail to deposit personal needs funds
received from a patient or from the state department for a patient's personal needs into the
patients' personal needs trust fund within sixty days after the receipt of such moneys or to
knowingly apply, spend, commit, pledge, or otherwise use a patient personal needs trust fund, or
any other moneys paid by a patient or the state department for patient personal needs, for any
purpose other than the personal needs of the patient to purchase necessary clothing, incidentals,
or other items of personal needs that are not reimbursed by any federal or state program. Deposit
or use of personal needs funds, including the use of a petty cash fund for personal needs
purposes, is not a violation of this section if such deposit or use is in substantial compliance with
applicable rules of the state department. Sums later ordered repaid to the patients' personal needs
trust fund as a result of an audit adjustment related to simple accounting errors such as data entry
errors, mathematical errors, or posting errors or a dispute related to a proration of patient
payment is not a violation of this section.
(b) Any person who knowingly violates any of the provisions of this subsection (8) by
failing to deposit personal needs funds within sixty days after the receipt of such moneys
commits the crime of unlawful retention of patient personal needs funds. Any person who
violates any of the provisions of this subsection (8) by applying, spending, committing, pledging,
or otherwise using a patient personal needs trust fund for any purpose other than the purposes
permitted by this subsection (8) commits the crime of unlawful use of a patient personal needs
trust fund.
(c) Unlawful retention of patient personal needs funds is:
(I) A petty offense if the amount is less than three hundred dollars;
(II) A class 2 misdemeanor if the amount is three hundred dollars or more but less than
one thousand dollars;
(III) A class 1 misdemeanor if the amount is one thousand dollars or more but less than
two thousand dollars;
(IV) A class 6 felony if the amount is two thousand dollars or more but less than five
thousand dollars;
(V) A class 5 felony if the amount is five thousand dollars or more but less than twenty
thousand dollars;
(VI) A class 4 felony if the amount is twenty thousand dollars or more but less than one
hundred thousand dollars;
(VII) A class 3 felony if the amount is one hundred thousand dollars or more but less
than one million dollars; and
(VIII) A class 2 felony if the amount is one million dollars or more.
(d) Unlawful use of a patient personal needs trust fund is:
(I) A petty offense if the amount is less than three hundred dollars;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 353 of 510
(II) A class 2 misdemeanor if the amount is three hundred dollars or more but less than
one thousand dollars;
(III) A class 1 misdemeanor if the amount is one thousand dollars or more but less than
two thousand dollars;
(IV) A class 6 felony if the amount is two thousand dollars or more but less than five
thousand dollars;
(V) A class 5 felony if the amount is five thousand dollars or more but less than twenty
thousand dollars;
(VI) A class 4 felony if the amount is twenty thousand dollars or more but less than one
hundred thousand dollars;
(VII) A class 3 felony if the amount is one hundred thousand dollars or more but less
than one million dollars; and
(VIII) A class 2 felony if the amount is one million dollars or more.
(e) Any person who is convicted of violating this subsection (8) may not own or operate
a nursing facility that receives medical assistance pursuant to this article or article 4 or 5 of this
title. For the purposes of this paragraph (e), "convicted" means the entry of a plea of guilty,
including a plea of guilty entered pursuant to a deferred sentence under section 18-1.3-102,
C.R.S., the entry of a plea of no contest accepted by the court, or the entry of a verdict of guilty
by a judge or jury.
Source: L. 2006: Entire article added with relocations, p. 1934, § 7, effective July 1. L.
2012: (8)(a) and (8)(d) amended, (HB 12-1310), ch. 20, p. 1400, § 20, effective June 7. L. 2013:
(1), (2)(a), (3)(a), (4), (6), and (7) amended, (SB 13-167), ch. 394, p. 2292, § 4, effective June 5.
L. 2014: (2)(a) amended, (SB 14-130), ch. 338, p. 1504, § 1, effective July 1. L. 2021: (1)
amended, (SB 21-006), ch. 123, p. 497, § 25, effective September 7; (8)(c) and (8)(d) amended,
(SB 21-271), ch. 462, p. 3241, § 483, effective March 1, 2022.
Editor's note: This section is similar to former § 26-4-504 as it existed prior to 2006.
25.5-6-207. Class I nursing facility reimbursement rates - study - report - repeal.
(Repealed)
Source: L. 2006: Entire section added, p. 1614, § 2, effective June 2. L. 2007: (1) and
(3) amended, p. 1802, § 1, effective June 1. L. 2008: Entire section repealed, p. 1788, § 6,
effective July 1.
Editor's note: This section was enacted as § 26-4-410.1 in Senate Bill 06-131. Section 6
of the bill provided for the renumbering of that section. (See L. 2006, p. 1616.)
Cross references: For the legislative declaration contained in the 2008 act repealing this
section, see section 1 of chapter 383, Session Laws of Colorado 2008.
25.5-6-208. Nursing facility provider reimbursement - rules - definition - repeal. (1)
(a) Subject to available appropriations and federal matching funds, the executive director shall,
Colorado Revised Statutes 2023 Uncertified PrintoutPage 354 of 510
by rule, establish a process for providing a wage enhancement supplemental payment to eligible
nursing home providers that pay their employees a wage of at least fifteen dollars per hour.
(b) The rules must provide:
(I) That wage enhancement supplemental payments are available to any eligible nursing
facility provider;
(II) The form and manner in which an eligible nursing facility provider must attest to the
state department that the wage for all employees is fifteen dollars or more per hour;
(III) The timing for the distribution of the wage enhancement supplemental payment;
and
(IV) The calculation methodology for determining the wage enhancement supplemental
payment for each eligible nursing facility provider.
(2) and (3) (Deleted by amendment, L. 2022.)
(4) A wage enhancement supplemental payment made pursuant to this section is in
effect as long as the statewide minimum wage is less than fifteen dollars per hour as set forth in
section 15 of article XVIII of the state constitution.
(5) (Deleted by amendment, L. 2022.)
(6) Payments received under this section shall offset costs reported on the med-13 cost
report when calculating nursing facility provider per diem reimbursement under 10 CCR 2505.
(7) This section is repealed, effective July 1, 2026.
Source: L. 2019: Entire section added, (HB 19-1210), ch. 320, p. 2976, § 7, effective
January 1, 2020. L. 2022: Entire section amended, (HB 22-1333), ch. 140, p. 931, § 2, effective
August 10. L. 2023: (7) added, (HB 23-1228), ch. 278, p. 1648, § 3, effective May 30.
Cross references: For the legislative declaration in HB 19-1210, see section 1 of chapter
320, Session Laws of Colorado 2019.
25.5-6-209. Establishment of nursing facility provider demonstration of need -
criteria - rules. (1) The state department, in making any medicaid certification determination,
shall encourage an appropriate allocation of public health-care resources and the development of
alternative or substitute methods of delivering health-care services so that adequate long-term
care services are made reasonably available to every qualified recipient within the state at the
appropriate level of care, at the lowest reasonable aggregate cost, and in the least restrictive
setting. Medicaid certification determinations shall be made in accordance with Olmstead v.
L.C., 527 U.S. 581 (1999).
(2) The state department shall develop, analyze, and enforce a demonstration of need to
determine the viability of and required need for each new nursing facility provider seeking
medicaid certification. The requirement does not apply to a nursing facility provider certified
prior to June 30, 2021.
(3) In order to determine a valid demonstration of need, the state department shall, at a
minimum, consider:
(a) State demography office data illustrating the present or impending need within the
requesting nursing facility's geographic area;
(b) Quality and performance data of the requesting nursing facility or associated nursing
facilities;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 355 of 510
(c) Business continuity and solvency information of the requesting nursing facility or
associated nursing facilities;
(d) Input from the department of public health and environment; the department of local
affairs; the department of regulatory agencies; the department of labor and employment; and any
local governments, including cities and counties; and
(e) Measurable innovative practices of the requesting nursing facility.
(4) No later than June 30, 2022, the state board shall promulgate rules pursuant to the
"State Administrative Procedure Act", article 4 of title 24, addressing the establishment of
criteria to be used in determining a nursing facility provider's medicaid certification. The state
board shall publicly consider and gather input on the demonstration of need criteria prior to
promulgating rules. The state department shall consider input from, at a minimum:
(a) Disability advocacy organizations;
(b) Urban nursing facility providers;
(c) Rural nursing facility providers;
(d) Aging and older adult advocacy organizations; and
(e) Nursing facility trade organizations.
Source: L. 2021: Entire section added, (HB 21-1227), ch. 192, p. 1014, § 1, effective
September 7.
25.5-6-210. Additional supplemental payments - nursing facilities - funding
methodology - reporting requirement - rules - repeal. (1) Notwithstanding any other
provision of law to the contrary and subject to available appropriations, for the purposes of
reimbursing a medicaid-certified class I nursing facility provider, the state department shall issue
additional supplemental payments to nursing facility providers that meet the requirements
outlined in this section and the state department's subsequent regulation as follows:
(a) and (b) Repealed.
(c) A payment to a nursing facility with disproportionately high medicaid utilization or
geographically critical to ensuring access to care. In determining qualifying facilities for this
payment, the state department shall consider any access to care impacts to individuals not
covered by medicaid, including, but not limited to, veterans administration beneficiaries,
individuals without health-care coverage, and individuals pending medicaid coverage.
(d) A payment to a nursing facility admitting compassionate release individuals from the
department of corrections who need additional services to ensure access to care.
(2) The state department shall establish reporting and result tracking requirements
necessary to administer the funding outlined in this section. The state department may deny or
recoup funding from nursing facility providers that are noncompliant with reporting
requirements or if funding is used for purposes outside the intent of supporting and stabilizing
nursing facility providers that are medicaid providers.
(3) The state department shall evaluate provider outcomes, including changes in
capacity, associated with the payment of supplemental money to nursing facility providers. The
state department shall utilize nursing facility providers' financial statements and labor and wage
records to evaluate the results of payments.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 356 of 510
(4) (a) The state department shall pursue federal matching funds. If federal matching
funds are unavailable for any reason, payments outlined in this section may be reduced or
restricted, subject to available funding.
(b) For the purposes of federal upper payment limit calculations, the state department
shall pursue federal matching funds for payments made pursuant to this section but only after
securing federal matching funds for payments outlined in sections 25.5-6-203 (2) and
25.5-6-208.
(5) (a) Supplemental payments made to nursing facility providers pursuant to this section
must be determined based on the most recent available data.
(b) Pursuant to rules promulgated by the state department, payments received pursuant
to this section must be reported as revenue on the annual cost report when calculating nursing
facility provider per diem reimbursement as directed by the state department.
(6) to (9) Repealed.
(10) This section is repealed, effective July 1, 2026.
Source: L. 2022: Entire section added, (HB 22-1247), ch. 139, p. 926, § 1, effective
April 25. L. 2023: (1)(a), (1)(b), (6), (7), (8), and (9) repealed, (1)(c) and (1)(d) added, and (10)
amended, (HB 23-1228), ch. 278, p. 1648, § 4, effective May 30.
PART 3
HOME- AND COMMUNITY-BASED SERVICES
FOR THE ELDERLY, BLIND, AND DISABLED
25.5-6-301. Short title. This part 3 shall be known and may be cited as the "Home- and
Community-based Services for the Elderly, Blind, and Disabled Act".
Source: L. 2006: Entire article added with relocations, p. 1937, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-601 as it existed prior to 2006.
25.5-6-302. Legislative declaration. The general assembly hereby finds and declares
that it is the purpose of this part 3 to provide, under a federal waiver of statutory requirements,
for an array of home- and community-based services to eligible elderly, blind, and disabled
individuals as an alternative to nursing facility placement.
Source: L. 2006: Entire article added with relocations, p. 1937, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-602 as it existed prior to 2006.
25.5-6-303. Definitions - repeal. As used in this part 3, unless the context otherwise
requires:
(1) "Adult day care facility" means a facility which meets all applicable state and federal
requirements and is certified by the state to provide adult day care services to eligible persons.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 357 of 510
(2) "Adult day care services" means health and social services provided on a less than
twenty-four-hour basis to eligible persons in state-certified adult day care facilities.
(3) "Alternative care facility" means a residential facility which provides alternative care
services and protective oversight to eligible persons, which meets applicable state and federal
requirements, and which is state-certified.
(4) "Alternative care services" means a package of personal care and homemaker
services provided in a state-certified alternative care facility.
(5) [Editor's note: This version of subsection (5) is effective until July 1, 2024.] (a)
"Case management agency" means agencies providing services on and before July 1, 1995, for
home- and community-based programs for the elderly, blind, and disabled shall be terminated
July 1, 1995, and case management functions shall thereafter be performed in accordance with
this article 6.
(b) "Case management agency", for counties participating in the single entry point
system pursuant to this article before July 1, 1995, and for all counties on and after said date,
means a public or private, nonprofit or for profit agency that meets all applicable state and
federal requirements and is certified by the state department to provide case management
functions reimbursable under this article and articles 4 and 5 of this title, within a geographic
area of the state consisting of one or more counties. Such functions shall be provided by the
agency under a contract executed with the state department or other state designated agency. The
state department shall establish procedures for the designation, certification, and decertification
of case management agencies and requirements for performance and staffing of the agencies.
Such procedures and requirements shall be set forth in rules promulgated by the state board or
shall be included in the contracts executed by the state department.
(5) [Editor's note: This version of subsection (5) is effective July 1, 2024.] (a) "Case
management agency" means agencies providing services on and before July 1, 1995, for home-
and community-based programs for the elderly, blind, and disabled shall be terminated July 1,
1995, and case management functions shall thereafter be performed in accordance with this
article 6.
(b) "Case management agency" has the same meaning as set forth in section 25.5-6-1702
(2).
(6) [Editor's note: This version of subsection (6) is effective until July 1, 2024.] "Case
management services" means functions performed by a case management agency, including: The
assessment of a client's needs, the development and implementation of a case plan for the client,
the coordination and monitoring of service delivery, the direct delivery of services as provided
by parts 3 to 12 of this article or by rules adopted by the state board, the evaluation of service
effectiveness, and the reassessment of the client's needs. Case management services shall be
reimbursed as an administrative expense.
(6) [Editor's note: This version of subsection (6) is effective July 1, 2024.] "Case
management services" has the same meeting as set forth in section 25.5-6-1702 (3).
(7) [Editor's note: This version of subsection (7) is effective until July 1, 2024.] "Case
plan" means a coordinated plan for the provision of long-term-care services in a setting other
than a nursing home, developed and managed by a case management agency, in coordination
with the client, his family or guardian and physician, and other providers of care.
(7) [Editor's note: This version of subsection (7) is effective July 1, 2024.] "Case plan"
means a coordinated plan for the provision of long-term-care services in a setting other than a
Colorado Revised Statutes 2023 Uncertified PrintoutPage 358 of 510
nursing home, developed and managed by a case management agency, in coordination with the
client, the client's family or guardian, the client's physician, and other providers of care.
(8) (a) "Electronic monitoring provider" means an entity that meets applicable state,
federal, and local requirements and is certified to provide electronic monitoring services.
(b) This subsection (8) is repealed, effective July 1, 2025.
(9) (a) "Electronic monitoring services" means electronic equipment or adaptations or
other remote supports that are related to an eligible person's disability and enable the person to
remain at home.
(b) This subsection (9) is repealed, effective July 1, 2025.
(10) (a) "Homemaker agency" means any agency that meets applicable state and federal
requirements and is state-certified to provide homemaker services.
(b) This subsection (10) is repealed, effective July 1, 2025.
(11) (a) "Homemaker services" means general household activities that are provided by
state-certified agencies to maintain a healthy and safe home environment for eligible persons.
(b) This subsection (11) is repealed, effective July 1, 2025.
(12) "Home modification provider" means an entity that meets applicable state, federal,
and local requirements and is certified to provide home modification services.
(13) "Home modification services" means home installations or adaptations that are
related to the eligible person's physical impairment and enable the person to remain at home.
(14) "Medications administration" means the administration or monitoring of
medications provided in a manner consistent with part 3 of article 1.5 of title 25, C.R.S., under
the authority and direction of the state department, as part of the "alternative care services", as
defined in subsection (4) of this section, as provided in an "alternative care facility", as defined
in subsection (3) of this section.
(15) "Nonmedical transportation provider" means an entity that meets applicable state
and federal requirements and is certified to provide nonmedical transportation services.
(16) "Nonmedical transportation services" means transportation of eligible persons to
services such as, but not limited to, adult day care services, which enable the person to remain at
home.
(17) (a) "Personal care agency" means any agency that meets state and federal
requirements and is state-certified to provide personal care services.
(b) This subsection (17) is repealed, effective July 1, 2025.
(18) (a) "Personal care services" means services to meet an eligible person's physical
requirements and functional needs, when such services do not require the supervision of a nurse.
(b) This subsection (18) is repealed, effective July 1, 2025.
(19) "Respite care provider" means a facility or agency that meets all applicable state
and federal requirements and is state-certified to provide respite care services.
(20) "Respite care services" means services of a short-term nature provided to a client, in
the home or in a facility approved by the state department, in order to temporarily relieve the
family or other home providers from the care and maintenance of such client, including room
and board, maintenance, personal care, and other related services.
(21) Repealed.
Source: L. 2006: Entire article added with relocations, p. 1938, § 7, effective July 1. L.
2015: (21) amended, (SB 15-240), ch. 139, p. 423, § 4, effective July 1. L. 2016: (21) amended,
Colorado Revised Statutes 2023 Uncertified PrintoutPage 359 of 510
(SB 16-093), ch. 54, p. 132, § 4, effective July 1. L. 2018: IP amended and (21) repealed, (HB
18-1326), ch. 183, p. 1239, § 2, effective July 1; IP and (5)(a) amended, (SB 18-093), ch. 62, p.
610, § 7, effective August 8. L. 2021: (9) amended, (SB 21-210), ch. 78, p. 303, § 1, effective
April 30; (5), (6), and (7) amended, (HB 21-1187), ch. 83, p. 333, § 30, effective July 1, 2024. L.
2023: (8)(b), (9)(b), (10)(b), (11)(b), (17)(b), and (18)(b) added by revision, (SB 23-289), ch.
270, pp. 1606, 1611 §§ 3, 19.
Editor's note: (1) This section is similar to former § 26-4-603 as it existed prior to
2006.
(2) The introductory portion to this section was amended in HB 18-1326. Those
amendments were superseded by the amendment of the introductory portion to this section in SB
18-093, effective August 8, 2018.
Cross references: (1) For additional definitions applicable to this part 3, see §
25.5-4-103.
(2) For the legislative declaration in SB 18-093, see section 1 of chapter 62, Session
Laws of Colorado 2018.
25.5-6-304. Administration. The provisions of this part 3 shall be administered by the
state department.
Source: L. 2006: Entire article added with relocations, p. 1940, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-604 as it existed prior to 2006.
25.5-6-305. Provision of services for elderly and blind individuals and individuals
with disabilities. The provision of the services set forth in this part 3 shall be subject to the
availability of federal matching medicaid funds, pursuant to Title XIX of the federal "Social
Security Act", as amended, for payment of the costs for administration and costs for the
provision of such services.
Source: L. 2006: Entire article added with relocations, p. 1940, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-605 as it existed prior to 2006.
25.5-6-306. Eligible groups. (1) Home- and community-based services under this part 3
shall be offered only to persons:
(a) Who are elderly, blind, or physically disabled; and
(b) Who are in need of the level of care available in a nursing home; and
(c) Who are categorically eligible for medical assistance, or whose gross income does
not exceed three hundred percent of the current federal supplemental security income benefit
level, and whose resources do not exceed the limit established for individuals receiving a
mandatory minimum state supplementation of supplemental security income benefits or, in the
case of a person who is married, do not exceed the amount authorized in section 25.5-6-101.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 360 of 510
(2) A long-term-care eligible person receiving home- and community-based services
shall remain eligible for the services specified in sections 25.5-5-102, 25.5-5-103, 25.5-5-202,
and 25.5-5-203, as applicable.
Source: L. 2006: Entire article added with relocations, p. 1940, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-606 as it existed prior to 2006.
25.5-6-307. Services for the elderly, blind, and disabled. (1) [Editor's note: This
version of subsection (1) is effective until July 1, 2025.] Subject to the provisions of this part 3,
home- and community-based services for the elderly, blind, and disabled include only the
following services:
(a) Adult day care;
(b) Alternative care services;
(c) Electronic monitoring services;
(d) Home modification services;
(e) Homemaker services;
(f) Nonmedical transportation services;
(g) Personal care services;
(h) Respite care services;
(i) Repealed.
(j) Services provided under the consumer-directed care service model, part 11 of this
article;
(k) In-home support services provided pursuant to part 12 of this article.
(1) [Editor's note: This version of subsection (1) is effective July 1, 2025.] Subject to
the provisions of this part 3, home- and community-based services for the elderly, blind, and
disabled include only the following services:
(a) Adult day care;
(b) Alternative care services;
(c) (Deleted by amendment, L. 2023.)
(d) Home modification services;
(e) (Deleted by amendment, L. 2023.)
(f) Nonmedical transportation services;
(g) (Deleted by amendment, L. 2023.)
(h) Respite care services;
(i) Repealed.
(j) (Deleted by amendment, L. 2023.)
(k) (Deleted by amendment, L. 2023.)
(2) All providers of home- and community-based services for the elderly, blind, and
disabled may be separately certified to provide other services, if otherwise qualified.
(3) A case management agency may be certified to provide the services described in
subsection (1) of this section, if otherwise qualified as a provider under the state medical
assistance program.
(4) (a) The case management agency, in coordination with the eligible person, the
person's family or guardian, and the person's physician, shall include in each case plan a process
Colorado Revised Statutes 2023 Uncertified PrintoutPage 361 of 510
by which the eligible person may receive necessary care, which may include respite care, if the
eligible person's family or service provider is unavailable due to an emergency situation or to
unforeseen circumstances. The eligible person and the person's family or guardian shall be duly
informed by the case management agency of these alternative care provisions at the time the case
plan is initiated.
(b) The requirements of this subsection (4) shall not apply if the eligible person is
residing in an alternative care facility.
(5) (a) No later than January 2024, the state department shall submit a report to the
senate health and human services committee, the house of representatives public and behavioral
health and human services committee, and the house of representatives health and insurance
committee, or any successor committees, as part of its "State Measurement for Accountable,
Responsive, and Transparent (SMART) Government Act" presentation required by section
2-7-203. At a minimum, the report must identify:
(I) A reimbursement system with a goal to incentivize and increase transportation
provider participation;
(II) How the state department will ensure compliance with applicable federal laws and
waiver requirements;
(III) A system of common reporting to ensure a recipient does not exceed the medicaid
benefit in a multi-provider scenario; and
(IV) Best practices based on what other states have done to allow transportation network
companies to provide nonmedical transportation services for individuals receiving services,
including but not limited to, reimbursement rates; driver compensation; and integration with
programs that provide nonmedical transportation services.
(b) In developing the report, the state department shall engage in a stakeholder process
that includes individuals with intellectual and developmental disabilities and their families,
individuals with disabilities, and transportation network companies. The report may be
developed in conjunction with the reporting requirement in sections 25.5-6-409 (6), 25.5-6-606
(9), 25.5-6-704 (8), and 25.5-6-1303 (9).
(c) (I) Upon completion of the report described in subsection (5)(a) of this section, the
state department shall analyze and review each operational transportation network company, as
defined in section 40-10.1-602 (3). The state department shall verify each transportation network
company's viability to ensure the health, safety, welfare, cost effectiveness, and capability in
expanding nonmedical transportation services for individuals receiving services pursuant to this
section and comply with all rules promulgated pursuant to subsection (5)(e)(I) of this section.
(II) No later than July 1, 2024, the state department shall authorize verified
transportation network companies to provide nonmedical transportation services if the state
department finds the transportation network company viable under federal requirements and
within budgetary constraints.
(III) For the purposes of this subsection (5)(c), "verify" means a transportation network
company meets all requirements resulting from the report described in subsection (5)(a) of this
section.
(d) The state department may seek any necessary federal authorization for the
implementation of this subsection (5).
(e) (I) The state department shall promulgate any necessary rules to ensure transportation
network companies comply with federal and state oversight requirements and shall include all
Colorado Revised Statutes 2023 Uncertified PrintoutPage 362 of 510
relevant stakeholders, including medicaid recipients, transportation network companies, current
providers and drivers for nonmedical transportation services, and other interested parties in the
development of such requirements.
(II) Pursuant to section 40-10.1-105 (1)(l), transportation network companies are not
subject to regulation by the public utilities commission when providing nonmedical
transportation services pursuant to this section and are instead subject to rules promulgated by
the state department pursuant to this subsection (5)(e).
(f) This subsection (5) does not apply to a provider authorized to provide transportation
services pursuant to part 8 of article 1 of title 25.5 prior to August 10, 2022.
Source: L. 2006: Entire article added with relocations, p. 1940, § 7, effective July 1. L.
2014: IP(1) amended and (1)(k) added, (HB 14-1357), ch. 254, p. 1015, § 4, effective March 1,
2015. L. 2018: (1)(i) repealed, (HB 18-1326), ch. 183, p. 1240, § 3, effective July 1. L. 2022: (5)
added, (HB 22-1114), ch. 396, p. 2815, § 2, effective August 10. L. 2023: (1) amended, (SB
23-289), ch. 270, p. 1607, § 4, effective July 1, 2025.
Editor's note: This section is similar to former § 26-4-607 as it existed prior to 2006.
Cross references: For the legislative declaration in HB 22-1114, see section 1 of chapter
396, Session Laws of Colorado 2022.
25.5-6-308. Cost of services. Home- and community-based services for the elderly,
blind, and disabled shall meet aggregate federal waiver budget neutrality requirements.
Source: L. 2006: Entire article added with relocations, p. 1941, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-607.5 as it existed prior to 2006.
25.5-6-309. Special provisions - post-eligibility treatment of income. Persons who
receive services under this part 3 shall pay to the state department, or designated agent or
provider, all income remaining after application of federally allowed maintenance and medical
deductions or shall pay the cost of home- and community-based services rendered, whichever is
less.
Source: L. 2006: Entire article added with relocations, p. 1941, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-608 as it existed prior to 2006.
25.5-6-310. Special provisions - personal care services provided by a family - repeal.
(1) A member of an eligible person's family, other than the person's spouse, may be employed to
provide personal care services to such person.
(2) The maximum reimbursement for the services provided by a member of the person's
family per year for each client shall not exceed the equivalent of four hundred forty-four service
units per year for a member of the eligible person's family.
(3) This section is repealed, effective July 1, 2025.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 363 of 510
Source: L. 2006: Entire article added with relocations, p. 1942, § 7, effective July 1. L.
2023: (3) added by revision, (SB 23-289), ch. 270, pp. 1607, 1611 §§ 5, 19.
Editor's note: This section is similar to former § 26-4-609 as it existed prior to 2006.
25.5-6-311. Duties of state department. (1) The state department shall:
(a) Seek and utilize any available federal, state, or private funds which are available for
carrying out the purposes of this part 3, including but not limited to medicaid funds, pursuant to
Title XIX of the federal "Social Security Act", as amended;
(b) Provide a system for reimbursement for services provided pursuant to this part 3,
which system shall encourage cost containment.
Source: L. 2006: Entire article added with relocations, p. 1942, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-610 as it existed prior to 2006.
25.5-6-312. Gifts - grants. The state department, acting for and on behalf of the state,
may receive and accept title to any grant or gift from any source, including the federal
government, and all grants, grants-in-aid, and gifts shall be deposited with the state treasurer,
who shall credit the same to the general fund, and such moneys shall be appropriated to the state
department to carry out the purposes of this article and articles 4 and 5 of this title.
Source: L. 2006: Entire article added with relocations, p. 1942, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-611 as it existed prior to 2006.
25.5-6-313. Rules - federal authorization. (1) Pursuant to article 4 of title 24, C.R.S.,
the state board shall adopt rules for the administration of this part 3.
(1.5) The rules adopted by the state board pursuant to subsection (1) of this section shall
include the following provisions concerning adult day care facilities:
(a) A definition of a restricted environment and a restrictive egress alert device;
(b) Parameters governing how the restrictive egress alert device shall be used and tested
and the staff roles regarding the use and oversight of the device; and
(c) Parameters governing a restricted environment, including but not limited to staffing
and training requirements; appropriateness of placement; assessment; participant's rights; records
and reporting requirements; building requirements including grounds and fire safety; restrictive
egress alert systems and devices; fencing or other enclosures; and the application process to offer
a restricted environment.
(2) The state department is authorized to seek any necessary federal authorization to
implement the provisions of this part 3.
Source: L. 2006: Entire article added with relocations, p. 1942, § 7, effective July 1. L.
2010: (1.5) added, (HB 10-1053), ch. 276, p. 1267, § 4, effective May 26.
Editor's note: This section is similar to former § 26-4-612 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 364 of 510
Cross references: For the legislative declaration in the 2010 act adding subsection (1.5),
see section 1 of chapter 1267, Session Laws of Colorado 2010.
25.5-6-314. Training for staff providing direct-care services to clients with dementia
- rules - definitions. (1) As used in this section:
(a) "Covered facility" means a nursing care facility or an assisted living residence
licensed by the department of public health and environment pursuant to section 25-1.5-103
(1)(a).
(b) "Dementia diseases and related disabilities" has the same meaning as set forth in
section 25-1-502 (2.5).
(c) "Direct-care staff member" means a staff member caring for the physical, emotional,
or mental health needs of clients of an adult day care facility and whose work involves regular
contact with clients who are living with dementia diseases and related disabilities.
(d) "Staff member" means an individual, other than a volunteer, who is employed by an
adult day care facility.
(2) By July 1, 2024, the state board shall adopt rules requiring all direct-care staff
members to obtain dementia training pursuant to curriculum prescribed or approved by the state
department in collaboration with stakeholders that is consistent with the rules adopted pursuant
to this subsection (2). The rules must specify the following, at a minimum:
(a) The date on which the dementia training requirement is effective;
(b) The length and frequency of the dementia training, which must be competency-based
and must require all direct-care staff to obtain:
(I) At least four hours of initial dementia training, which must be completed as follows:
(A) For all direct-care staff members hired by or who start providing direct-care services
at an adult day care facility on or after the effective date of the dementia training requirement
specified in the rules, unless an exception established pursuant to subsection (2)(e) of this section
applies, the training must be completed within one hundred twenty days after the start of
employment or the provision of direct-care services, as applicable; and
(B) For all direct-care staff members hired by or providing direct-care services at an
adult day care facility before the effective date of the dementia training requirement specified in
the rules, unless an exception established pursuant to subsection (2)(e) of this section applies, the
training must be completed within one hundred twenty days after the effective date of the
dementia training requirement specified in the rules; and
(II) At least two hours of continuing education on dementia topics every two years. The
continuing education must include current information on best practices in the treatment and care
of persons living with dementia diseases and related disabilities.
(c) The content of the initial dementia training, which must be culturally competent and
include the following topics:
(I) Dementia diseases and related disabilities;
(II) Person-centered care;
(III) Care planning;
(IV) Activities of daily living; and
(V) Dementia-related behaviors and communication;
(d) The method of demonstrating completion of the required dementia training and
continuing education and of exempting a direct-care staff member from the required dementia
Colorado Revised Statutes 2023 Uncertified PrintoutPage 365 of 510
training if the direct-care staff member moves to a different adult day care facility than the adult
day care facility through which the direct-care staff member received the training or moves to a
covered facility after receiving the training through an adult day care facility;
(e) An exception to the initial dementia training requirements for:
(I) A direct-care staff member hired by or who starts providing direct-care services at an
adult day care facility on or after the effective date of the dementia training requirement
specified in the rules who has:
(A) Completed an equivalent dementia training program within the twenty-four months
immediately preceding the effective date of the dementia training requirement specified in the
rules; and
(B) Provided proof of satisfactory completion of the training program; and
(II) A direct-care staff member hired by or providing direct-care services at an adult day
care facility before the effective date of the dementia training requirement specified in the rules
who has:
(A) Received equivalent training, as defined in the rules, within the twenty-four months
immediately preceding the effective date of the dementia training requirement specified in the
rules; and
(B) Provided proof of satisfactory completion of the training program;
(f) Minimum requirements for individuals conducting the dementia training;
(g) A process for the state department to verify compliance with this section and the
rules adopted by the state board pursuant to this section; and
(h) Any other matters the state board deems necessary to implement this section.
Source: L. 2022: Entire section added, (SB 22-079), ch. 282, p. 2029, § 3, effective
August 10.
Cross references: For the legislative declaration in SB 22-079, see section 1 of chapter
282, Session Laws of Colorado 2022.
PART 4
HOME- AND COMMUNITY-BASED SERVICES FOR
PERSONS WITH INTELLECTUAL AND DEVELOPMENTAL
DISABILITIES
25.5-6-401. Short title. This part 4 shall be known and may be cited as the "Home- and
Community-based Services for Persons with Developmental Disabilities Act".
Source: L. 2006: Entire article added with relocations, p. 1942, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-621 as it existed prior to 2006.
25.5-6-402. Legislative declaration - Prader-Willi syndrome. (1) The general
assembly finds and declares that it is the purpose of this part 4 to provide services for persons
with intellectual and developmental disabilities that would foster the following goals:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 366 of 510
(a) To maintain eligible persons in the most appropriate settings possible and to
minimize admissions to institutions;
(b) To recognize the unique services requirements of persons with developmental
disabilities;
(c) To provide optimum accessibility to various important social, habilitative, remedial,
residential, and health services that are available to assist in maintaining eligible persons in the
least restrictive settings;
(d) To provide eligible persons who have the capacity to remain outside an institutional
setting access to appropriate social, habilitative, remedial, residential, and health services,
without which institutionalization would be necessary;
(e) To provide the most efficient and effective use of funds in the delivery of these
social, habilitative, remedial, residential, and health services to eligible persons;
(f) To coordinate, integrate, and link these social, habilitative, remedial, residential, and
health services into existing community-based service delivery systems for persons with
developmental disabilities, to avoid unnecessary and expensive duplication of services;
(g) To allow the state substantial flexibility in organizing and administering the delivery
of social, habilitative, remedial, residential, and health services to eligible citizens.
(2) The general assembly intends that the state department and the department of human
services shall cooperate to the maximum extent possible in designing, implementing, and
administering the programs authorized under this part 4.
(3) Nothing in this part 4 shall be construed to disqualify persons from receiving any
benefits to which they would otherwise be eligible under parts 1 and 2 of article 5 of this title, or
under Title XIX of the federal "Social Security Act", as amended, by reason of being designated
as a person with developmental disabilities.
(4) The general assembly further finds and declares that:
(a) Repealed.
(b) Because Prader-Willi syndrome is a genetic disorder, individuals either have it or
they do not. Further, because there is not currently a cure, individuals who have Prader-Willi
syndrome will have it for life.
(c) This disorder affects members of every culture, religion, economic class, race, and
social order;
(d) The most critical hallmark of Prader-Willi syndrome is overeating. Individuals with
Prader-Willi syndrome cannot tell when they are full and will continue to eat without stopping,
leading to a ruptured stomach and even death. Other symptoms include significant
developmental and cognitive delays, skin picking, sleep problems, obsessive-compulsive
behaviors, hypothyroidism, hypogonadism, and low muscle tone.
(e) Repealed.
Source: L. 2006: Entire article added with relocations, p. 1942, § 7, effective July 1. L.
2018: IP(1) amended and (4) added, (SB 18-074), ch. 98, p. 769, § 1, effective August 8. L.
2023: (4)(a) and (4)(e) repealed and (4)(d) amended, (HB 23-1040), ch. 41, p. 160, § 1, effective
March 31.
Editor's note: This section is similar to former § 26-4-622 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 367 of 510
25.5-6-403. Definitions. As used in this part 4, unless the context otherwise requires:
(1) [Editor's note: This version of subsection (1) is effective until July 1, 2024.]
"Developmentally disabled person" means a person with an intellectual and developmental
disability as defined in subsection (3.3)(a) of this section.
(1) [Editor's note: This version of subsection (1) is effective July 1, 2024.] "Case
management agency" has the same meaning as set forth in section 25.5-6-1702 (2).
(2) (a) "Eligible person" means a person with developmental disabilities:
(I) Who meets the definition of categorically needy as defined in section 25.5-4-103 (4);
(II) Who is in need of the level of care available in an intermediate care facility for
individuals with intellectual disabilities;
(III) Whose gross income does not exceed three hundred percent of the current federal
supplemental security income benefits level or other applicable standard provided in federal
regulations construing the federal "Social Security Act", as amended, and whose resources do
not exceed the limit established for individuals receiving a mandatory minimum state
supplementation of supplemental security income benefits or, in the case of a person who is
married, do not exceed the amount authorized in section 25.5-6-101; and
(IV) For whom it is determined that provision of such services is necessary to avoid
placement in an intermediate care facility for individuals with intellectual disabilities.
(b) The amount of parental income and resources that shall be attributable to a child's
gross income for purposes of eligibility under paragraph (a) of this subsection (2) shall be set
forth in rules promulgated by the state board of human services created in section 26-1-107,
C.R.S.
(2.5) [Editor's note: This subsection (2.5) is effective July 1, 2024.] "Entity" has the
same meaning as set forth in section 25.5-6-1702 (8).
(3) "In-home services" means those services described in section 25.5-10-205 provided
to support persons living with their family.
(3.3) (a) "Intellectual and developmental disability" means a disability that manifests
before the person reaches twenty-two years of age, that constitutes a substantial disability to the
affected person, and that is attributable to an intellectual and developmental disability or related
conditions, including Prader-Willi syndrome, cerebral palsy, epilepsy, autism, or other
neurological conditions when those conditions result in impairment of general intellectual
functioning or adaptive behavior similar to that of a person with an intellectual and
developmental disability. Unless otherwise specifically stated, the federal definition of
"developmental disability" found in 42 U.S.C. sec. 15002 (8) does not apply.
(b) [Editor's note: This version of subsection (3.3)(b) is effective until July 1, 2024.]
"Person with an intellectual and developmental disability" or "youth with an intellectual and
developmental disability" means a person or youth determined by a community-centered board
to have an intellectual and developmental disability and shall include a child with a
developmental delay.
(b) [Editor's note: This version of subsection (3.3)(b) is effective July 1, 2024.] "Person
with an intellectual and developmental disability" or "youth with an intellectual and
developmental disability" means a person or youth determined by a case management agency to
have an intellectual and developmental disability and includes a child with a developmental
delay.
(c) "Child with a developmental delay" means:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 368 of 510
(I) A person less than five years of age with delayed development as defined by rule of
the state board; or
(II) A person less than five years of age who is at risk of having an intellectual and
developmental disability as defined by rule of the state board.
(4) [Editor's note: This version of subsection (4) is effective until July 1, 2024.] "Plan
of care" means a coordinated plan of care for provision of services in other than a nursing
facility or institutional setting, developed and managed, subject to review and approval pursuant
to section 25.5-6-404, by a community centered board for persons with developmental
disabilities. This plan of care shall fully identify the services to be provided to eligible persons.
Prior to the provision of those services, a physician may be required to review an assessment
document to insure that it adequately describes the medical needs of the eligible person.
(4) [Editor's note: This version of subsection (4) is effective July 1, 2024.] "Plan of
care" means a coordinated plan of care for provision of services in other than a nursing facility
or institutional setting, developed and managed, subject to review and approval pursuant to
section 25.5-6-404, by a case management agency for persons with intellectual and
developmental disabilities. This plan of care shall fully identify the services to be provided to
eligible persons. Prior to the provision of those services, a physician may be required to review
an assessment document to insure that it adequately describes the medical needs of the eligible
person.
(5) (a) "Services for persons with intellectual and developmental disabilities" means
those services:
(I) Approved for reimbursement by the federal government; and
(II) Necessary to prevent a person, eligible for services under subsection (2) of this
section, from being subjected to placement in an intermediate care facility for individuals with
intellectual disabilities.
(b) "Services for persons with intellectual and developmental disabilities" includes, but
is not limited to, social, habilitative, remedial, residential, health services, and services provided
under the consumer-directed care service model, part 11 of this article, which shall include the
selection, from a list of qualified entities, of an organization of the eligible person's choice to
provide financial management services for the eligible person.
Source: L. 2006: Entire article added with relocations, p. 1943, § 7, effective July 1. L.
2013: (2)(a)(II), (2)(a)(IV), and (5)(a)(II) amended, (SB 13-167), ch. 394, p. 2294, § 5, effective
June 5; (1), (3), IP(5)(a), (5)(a)(II), and (5)(b) amended, (HB 13-1314), ch. 323, p. 1810, § 47,
effective March 1, 2014. L. 2014: (3.3) added, (HB 14-1368), ch. 304, p. 1288, § 1, effective
May 31. L. 2018: (1), (3.3)(a), and (3.3)(c)(II) amended, (SB 18-074), ch. 98, p. 770, § 2,
effective August 8; (3.3)(a) amended, (SB 18-096), ch. 44, p. 474, § 15, effective August 8. L.
2019: (3.3)(a) amended, (SB 19-241), ch. 390, p. 3473, § 40, effective August 2. L. 2021: (1),
(3.3)(b), and (4) amended and (2.5) added, (HB 21-1187), ch. 83, p. 334, § 31, effective July 1,
2024.
Editor's note: (1) This section is similar to former § 26-4-623 as it existed prior to
2006.
(2) Amendments to subsection (3.3)(a) by SB 18-074 and SB 18-096 were harmonized.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 369 of 510
Cross references: (1) For additional definitions applicable to this part 4, see §
25.5-4-103.
(2) For the legislative declaration in SB 18-096, see section 1 of chapter 44, Session
Laws of Colorado 2018.
25.5-6-404. Duties of the department of health care policy and financing and the
department of human services. (1) The state department and the department of human services
shall provide a system of reimbursement for services provided pursuant to this part 4 that
encourages the most cost-effective provision of services.
(2) The state department and the department of human services shall, subject to
appropriation, utilize any available federal, state, local, or private funds, including but not
limited to, medicaid funds available under Title XIX of the federal "Social Security Act", as
amended, such as medicaid home- and community-based waivers, to carry out the purposes of
this part 4.
(3) The state department may contract with the department of human services to certify
agencies providing services under this part 4 as eligible medicaid providers, to adopt fiscal and
administrative procedures, to review plans of care, to set rates, and to make and implement
recommendations regarding the scope, duration, and content of programs and the eligibility of
persons for specific services provided pursuant to this part 4, and to fulfill any other
responsibilities necessary to implement this part 4 that are consistent with the single state agency
designation set out in section 25.5-4-104.
(4) The executive director and the state board shall promulgate such rules regarding this
part 4 as are necessary to fulfill the obligations of the state department as the single state agency
to administer medical assistance programs in accordance with Title XIX of the federal "Social
Security Act", as amended. Such rules may include, but shall not be limited to, determination of
the level of care requirements for long-term care, patient payment requirements, clients' rights,
medicaid eligibility, and appeal rights associated with these requirements.
(5) The state board of human services, created in section 26-1-107, C.R.S., shall
promulgate such rules as are necessary to implement the provisions of this part 4 and to fulfill
the responsibilities and duties set out in article 10.5 of title 27, C.R.S. Such rules shall be
promulgated pursuant to section 24-4-103, C.R.S.
(6) In the event that a direct conflict arises between the rules of the state department
promulgated pursuant to subsection (4) of this section and the rules of the department of human
services promulgated pursuant to subsection (5) of this section, regarding implementation of this
part 4, the rules of the state department shall control.
Source: L. 2006: Entire article added with relocations, p. 1944, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-624 as it existed prior to 2006.
25.5-6-405. Relationship to other programs. The provisions of part 3 of this article are
separate and distinct from the provisions of this part 4. Therefore, the definitions and restrictions
embodied in part 3 of this article shall not apply to services and programs provided pursuant to
this part 4.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 370 of 510
Source: L. 2006: Entire article added with relocations, p. 1945, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-625 as it existed prior to 2006.
25.5-6-406. Appropriations - reimbursement for services - direct support
professionals - legislative declaration - definitions - repeal. (1) To carry out duties and
obligations pursuant to this part 4 and for the administration and provision of services to eligible
persons, all medicaid funds appropriated pursuant to Title XIX of the federal "Social Security
Act", as amended, for the provision of care for persons with developmental disabilities and all
other funds otherwise appropriated by the general assembly as additional sources of program
funding are available for the placement of eligible persons either in intermediate care facilities
for persons with intellectual disabilities or alternatives to such placements.
(2) (a) (I) The general assembly finds and declares that:
(A) Colorado's system of home- and community-based services that supports Coloradans
with intellectual and developmental disabilities has grown to serve more than twelve thousand
persons and their families;
(B) Costs associated with providing these services continue to rise with growth in
demand, inflation, increased regulation, rising minimum wages, rising health-care costs, and
other economic factors;
(C) Reimbursement rates have not kept pace with these rising costs, resulting in reduced
access to services for Coloradans with intellectual and developmental disabilities;
(D) Colorado needs significant initial investments to address the most urgent issues
concerning services for persons with intellectual and developmental disabilities, as well as future
long-term planning to address the growing strain on the system;
(E) One of the most urgent issues is the workforce crisis among direct support
professionals, characterized by chronically low wages, limited benefits, and lack of career
advancement opportunities for these critical workers;
(F) Colorado is experiencing a workforce crisis among direct support professionals
because reimbursement rates cannot support the compensation needed to match the high level of
responsibility required in these jobs;
(G) Agencies that serve people with intellectual and developmental disabilities
increasingly struggle to recruit and retain direct support professionals to meet the demand for
services; and
(H) High turnover among direct support professionals results in reduced continuity of
services for persons with intellectual and developmental disabilities.
(II) Therefore, as an initial investment, Colorado's reimbursement rates should be
increased to allow for direct support professional compensation that better reflects market
realities and the high level of responsibility required in these jobs.
(b) As used in this subsection (2), unless the context otherwise requires:
(I) "Compensation" means any form of monetary payment, including bonuses,
employer-paid health and other insurance programs, paid time off, payroll taxes, and all other
fixed and variable benefits conferred on or received by a direct support professional.
(II) "Direct support professional" means a worker who assists or supervises a worker to
assist a person with intellectual and developmental disabilities to lead a fulfilling life in the
community through a diverse range of services, including helping the person get ready in the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 371 of 510
morning, take medication, go to work or find work, and participate in social activities. "Direct
support professional" includes all workers categorized as program direct support professionals
and excludes workers categorized as administrative, as defined in standards established by the
Financial Accounting Standards Board.
(c) The state department shall immediately seek a six and one-half percent increase in
the reimbursement rate for the following services delivered through the home- and
community-based services for persons with developmental disabilities, supported living services,
and children's extensive supports waivers:
(I) Group residential services and supports;
(II) Individual residential services and supports;
(III) Specialized habilitation;
(IV) Respite;
(V) (A) Homemaker basic;
(B) This subsection (2)(c)(V) is repealed, effective July 1, 2025.
(VI) Homemaker enhanced;
(VII) (A) Personal care;
(B) This subsection (2)(c)(VII) is repealed, effective July 1, 2025.
(VIII) Prevocational services;
(IX) Behavioral line staff;
(X) Community connector;
(XI) Supported community connections;
(XII) Mentorship;
(XIII) Supported employment - job development; and
(XIV) Supported employment - job coaching.
(d) The state department shall implement a corresponding increase in service plan
authorization limits to account for this increase in reimbursement rates.
(e) [Editor's note: This version of subsection (2)(e) is effective until July 1, 2024.]
Service agencies shall use one hundred percent of the funding resulting from the increase in the
reimbursement rate pursuant to subsection (2)(c) of this section to increase compensation for
direct support professionals above the rate of compensation that direct support professionals are
receiving as of June 30, 2018. This requirement applies to funds billed by community-centered
boards in their role as organized health-care delivery systems. Service agencies shall not use
funding resulting from the reimbursement rate increase for general and administrative expenses,
such as chief executive officer salaries, human resources, information technology, oversight,
business management, general record keeping, budgeting and finance, and other activities not
identifiable to a single program.
(e) [Editor's note: This version of subsection (2)(e) is effective July 1, 2024.] Service
agencies shall use one hundred percent of the funding resulting from the increase in the
reimbursement rate pursuant to subsection (2)(c) of this section to increase compensation for
direct support professionals above the rate of compensation that direct support professionals are
receiving as of June 30, 2018. This requirement applies to funds billed by case management
agencies and entities in their role as organized health-care delivery systems, as defined in 42
CFR 447.10 (b). Service agencies shall not use funding resulting from the reimbursement rate
increase for general and administrative expenses, such as chief executive officer salaries, human
Colorado Revised Statutes 2023 Uncertified PrintoutPage 372 of 510
resources, information technology, oversight, business management, general record keeping,
budgeting and finance, and other activities not identifiable to a single program.
(f) (I) For the 2018-19 through 2020-21 fiscal years, service agencies shall track how
they used the funding resulting from the increase in the reimbursement rate pursuant to
subsection (2)(c) of this section using a reporting tool developed by the state department in
collaboration with service agencies. On or before December 31, 2019, service agencies shall
submit the report to the state department demonstrating how the funding was used to increase
direct support professional compensation for the 2018-19 fiscal year. The state department shall
have ongoing discretion to request information from service agencies demonstrating how they
maintained increases in compensation for direct support professionals beyond the three-year
tracking period.
(II) Service agencies shall maintain all books, documents, papers, accounting records,
and other evidence required to support the tracking of payroll information for increased
compensation to direct support professionals pursuant to subsection (2)(f)(I) of this section for at
least three years from the end of each respective fiscal year. Service agencies shall make the
information and materials available for inspection by the state department or its designees at all
reasonable times.
(g) If a service agency does not use one hundred percent of the funding resulting from
the increase in the reimbursement rate pursuant to subsection (2)(c) of this section to increase
compensation for direct support professionals, the state department may recoup part or all of the
funding resulting from the increase in the reimbursement rate.
(h) If the state department determines that the service agency did not use the funding
resulting from the increase in the reimbursement rate pursuant to subsection (2)(c) of this section
as required, within one year after the end of each fiscal year described in subsection (2)(f)(I) of
this section, the state department shall notify the service agency in writing of the state
department's intention to recoup funds pursuant to subsection (2)(g) of this section.
(i) The service agency has forty-five days after receiving notice of the determination
under subsection (2)(h) of this section to:
(I) Challenge the determination of the state department;
(II) Provide additional information to the state department demonstrating compliance; or
(III) Submit a plan of correction to the state department.
(j) The state department shall notify the service agency in writing of its final
determination after affording the service agency the opportunity to take the actions specified in
subsection (2)(i) of this section.
(k) The state department shall recoup from a service agency one hundred percent of the
funding resulting from the increase in the reimbursement rate pursuant to subsection (2)(c) of
this section that the service agency received but did not use for compensation for direct support
professionals if:
(I) The service agency fails to respond to a notice of determination of the state
department within the time provided in subsection (2)(i) of this section;
(II) The service agency is unable to provide documentation of compliance; or
(III) The state department does not accept the plan of correction submitted by the service
agency pursuant to subsection (2)(i) of this section.
(l) The state department shall participate in the national core indicators staff stability
survey.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 373 of 510
(m) Once the state department determines that a sufficient quantity and quality of data
exists to determine the impact and outcomes, if any, attributed to the increase in the
reimbursement rate pursuant to subsection (2)(c) of this section on persons with intellectual and
developmental disabilities, the state department shall include in its annual report concerning the
waiting list for services and supports for persons with intellectual and developmental disabilities,
required pursuant to section 25.5-10-207.5, information from the national core indicators data, or
another comparable source, concerning in what ways outcomes for persons with intellectual and
developmental disabilities changed as a result of the increase in reimbursement rates pursuant to
subsection (2)(c) of this section. The report must include, if available, multiyear personal
outcome data specific to Colorado and comparisons to other states, as appropriate, as well as
data from the national core indicators staff stability survey.
Source: L. 2006: Entire article added with relocations, p. 1945, § 7, effective July 1. L.
2013: Entire section amended, (SB 13-167), ch. 394, p. 2294, § 6, effective June 5. L. 2018:
Entire section amended, (HB 18-1407), ch. 248, p. 1527, § 2, effective May 24. L. 2020: (2)(f)
and (2)(h) amended, (HB 20-1363), ch. 204, p. 1007, § 1, effective June 30. L. 2021: (2)(e)
amended, (HB 21-1187), ch. 83, p. 334, § 32, effective July 1, 2024. L. 2023: (2)(c)(V)(B) and
(2)(c)(VII)(B) added by revision, (SB 23-289), ch. 270, pp. 1607, 1611 §§ 6, 19.
Editor's note: This section is similar to former § 26-4-626 as it existed prior to 2006.
Cross references: For the legislative declaration in HB 18-1407, see section 1 of chapter
248, Session Laws of Colorado 2018.
25.5-6-407. Gifts - grants. The state department and the department of human services,
acting on behalf of the state, may receive and accept title to gifts or grants from any source,
including the federal government. Both departments shall deposit all grants, grants-in-aid, and
gifts with the state treasurer, who shall credit them to the general fund. These moneys shall
remain available for appropriation to either department to carry out the purposes of this part 4.
Source: L. 2006: Entire article added with relocations, p. 1946, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-627 as it existed prior to 2006.
25.5-6-408. Eligibility - fees. (1) Subject to the availability of federal financial
participation, services shall be provided to eligible persons pursuant to this part 4.
(2) Any eligible person who accepts and receives services pursuant to this part 4 shall
pay to the state department, or to an agent designated by the state department, an amount
determined pursuant to federal regulations construing the federal "Social Security Act", as
amended, concerning the application of patient income to the cost of services.
Source: L. 2006: Entire article added with relocations, p. 1946, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-628 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 374 of 510
25.5-6-409. Services for persons with intellectual and developmental disabilities. (1)
A program to provide home- and community-based services to persons with intellectual and
developmental disabilities who are in need of the level of care available in an intermediate care
facility for individuals with intellectual disabilities is hereby established pursuant to the federal
"Social Security Act", as amended. This program shall provide for the social, habilitative,
remedial, residential, health, and other needs of persons with intellectual and developmental
disabilities to avoid placement in an intermediate care facility for individuals with intellectual
disabilities.
(2) [Editor's note: This version of subsection (2) is effective until July 1, 2024.]
Services for persons with developmental disabilities provided through this program shall be
delivered under the provisions of a statewide services plan, in the form of home- and
community-based services waivers or model waivers, developed by the state department and the
department of human services and approved by the federal centers for medicare and medicaid
services, or any successor agency. This plan shall include the specific services to be offered, a
plan for the delivery of such services through community centered boards or other service
agencies approved pursuant to article 10.5 of title 27, C.R.S., utilizing where appropriate the
provision of in-home services, the expected costs of such services, the expected benefits of
providing those services, and the administrative provisions which shall govern the
implementation of the plan. The plan shall provide for all necessary safeguards to ensure the
health and welfare of any eligible persons. The average per capita expenditure for services under
this plan shall not exceed the average per capita expenditure the department of human services or
the state department would have made for services otherwise available without this plan.
(2) [Editor's note: This version of subsection (2) is effective July 1, 2024.] Services for
persons with intellectual and developmental disabilities provided through this program must be
delivered under the provisions of a statewide services plan, in the form of home- and
community-based services waivers or model waivers, developed by the state department and the
department of human services and approved by the federal centers for medicare and medicaid
services, or any successor agency. This plan must include the specific services to be offered, a
plan for the delivery of such services through case management agencies or other service
agencies approved pursuant to this article 6 or article 10.5 of title 27 utilizing where appropriate
the provision of in-home services, the expected costs of such services, the expected benefits of
providing those services, and the administrative provisions which shall govern the
implementation of the plan. The plan must provide for all necessary safeguards to ensure the
health and welfare of any eligible persons. The average per capita expenditure for services under
this plan must not exceed the average per capita expenditure the department of human services
or the state department would have made for services otherwise available without this plan.
(3) The plan shall utilize existing community-based services programs to the maximum
extent possible and shall coordinate all available forms of assistance for the eligible person.
(4) Any services for persons with intellectual and developmental disabilities provided
through this program shall be set forth in a plan of care developed and managed by a
community-centered board and subject to review and approval pursuant to section 25.5-6-404.
The plan of care shall:
(a) Be based on the particular services needs of the eligible person;
(b) Describe the services necessary to avoid institutionalization; and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 375 of 510
(c) (I) Include a process by which the person who is receiving services may receive
necessary care for medical purposes, which may include respite care, if the person's service
provider is unavailable due to an emergency situation or to unforeseen circumstances. The
person who is receiving services and the person's family or guardian shall be duly informed by
the community centered board of these alternative care provisions at the time the plan of care is
initiated.
(II) Nothing in this paragraph (c) requires a community centered board to provide
services set forth in a plan of care that the community centered board is not otherwise required to
provide to the person receiving services, only that the plan of care include a contingency for such
services.
(d) This subsection (4) is repealed, effective July 1, 2024.
(5) (a) No later than January 2024, the state department shall submit a report to the
senate health and human services committee, the house of representatives public and behavioral
health and human services committee, and the house of representatives health and insurance
committee, or any successor committees, as part of its "State Measurement for Accountable,
Responsive, and Transparent (SMART) Government Act" presentation required by section
2-7-203. At a minimum, the report must identify:
(I) A reimbursement system with a goal to incentivize and increase transportation
provider participation;
(II) How the state department will ensure compliance with applicable federal laws and
waiver requirements;
(III) A system of common reporting to ensure a recipient does not exceed the medicaid
benefit in a multi-provider scenario; and
(IV) Best practices based on what other states have done to allow transportation network
companies to provide nonmedical transportation services for individuals receiving services,
including but not limited to, reimbursement rates; driver compensation; and integration with
programs that provide nonmedical transportation services.
(b) In developing the report, the state department shall engage in a stakeholder process
that includes individuals with intellectual and developmental disabilities and their families,
individuals with disabilities, and transportation network companies. The report may be
developed in conjunction with the reporting requirement in sections 25.5-6-307 (6), 25.5-6-606
(9), 25.5-6-704 (8), and 25.5-6-1303 (9).
(c) (I) Upon completion of the report described in subsection (5)(a) of this section, the
state department shall analyze and review each operational transportation network company, as
defined in section 40-10.1-602 (3). The state department shall verify each transportation network
company's viability to ensure the health, safety, welfare, cost effectiveness, and capability in
expanding nonmedical transportation services for individuals receiving services pursuant to this
section and comply with all rules promulgated pursuant to subsection (5)(e)(I) of this section.
(II) No later than July 1, 2024, the state department shall authorize verified
transportation network companies to provide nonmedical transportation services if the state
department finds the transportation network company viable under federal requirements and
within budgetary constraints.
(III) For the purposes of this subsection (5)(c), "verify" means a transportation network
company meets all requirements resulting from the report described in subsection (5)(a) of this
section.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 376 of 510
(d) The state department may seek any necessary federal authorization for the
implementation of this subsection (5).
(e) (I) The state department shall promulgate any necessary rules to ensure transportation
network companies comply with federal and state oversight requirements and shall include all
relevant stakeholders, including medicaid recipients, transportation network companies, current
providers and drivers for nonmedical transportation services, and other interested parties in the
development of such requirements.
(II) Pursuant to section 40-10.1-105 (1)(l), transportation network companies are not
subject to regulation by the public utilities commission when providing nonmedical
transportation services pursuant to this section and are instead subject to rules promulgated by
the state department pursuant to this subsection (5)(e).
(f) This subsection (5) does not apply to a provider authorized to provide transportation
services pursuant to part 8 of article 1 of title 25.5 prior to August 10, 2022.
Source: L. 2006: Entire article added with relocations, p. 1946, § 7, effective July 1. L.
2013: (1) amended, (SB 13-167), ch. 394, p. 2294, § 7, effective June 5; (1) and IP(4) amended,
(HB 13-1314), ch. 323, p. 1811, § 48, effective March 1, 2014. L. 2021: (2) amended, (HB
21-1187), ch. 83, p. 335, § 33, effective July 1, 2024; (4)(d) added by revision, (HB 21-1187),
ch. 83, pp. 335, 354, §§ 33, 70. L. 2022: (5) added, (HB 22-1114), ch. 396, p. 2817, § 3,
effective August 10.
Editor's note: (1) This section is similar to former § 26-4-629 as it existed prior to
2006.
(2) Amendments to subsection (1) by Senate Bill 13-167 and House Bill 13-1314 were
harmonized.
Cross references: For the legislative declaration in HB 22-1114, see section 1 of chapter
396, Session Laws of Colorado 2022.
25.5-6-409.3. Consolidated waiver - intellectual and developmental disabilities -
conflict-free case management - legislative declaration - repeal. (1) (a) The general assembly
declares that it is the intent of the general assembly that moneys appropriated for services for
individuals with intellectual and developmental disabilities be spent in the most effective
manner, thereby enabling the greatest number of eligible individuals to receive the services that
they need in the amounts needed so that they may live successfully in the community. Therefore,
the general assembly finds that the best mechanism for providing adequate services for
individuals with intellectual and developmental disabilities is to have a single consolidated
medicaid waiver for home- and community-based individuals with intellectual and
developmental disabilities.
(b) Further, the general assembly acknowledges the rights of individuals to make choices
regarding their case managers and service providers. Therefore, the general assembly believes
there exists the need to ensure conflict-free case management services within the medicaid
waivers for persons with intellectual and developmental disabilities.
(2) The state department shall establish a redesigned medicaid waiver for home- and
community-based services for adults with intellectual and developmental disabilities, effective
Colorado Revised Statutes 2023 Uncertified PrintoutPage 377 of 510
July 1, 2016, or as soon as the federal centers for medicare and medicaid services approves the
redesigned waiver.
(3) The redesigned waiver must include flexible service definitions, provide access to
services and supports when and where they are needed, offer services and supports based on the
individual's needs and preferences, and incorporate the following principles:
(a) Freedom of choice over living arrangements and social, community, and recreational
opportunities;
(b) Individual authority over supports and services;
(c) Support to organize resources in ways that are meaningful to the individual receiving
services;
(d) Health and safety assurances;
(e) Opportunity for community contribution; and
(f) Responsible use of public dollars.
(3.3) (a) The state department's administration of the redesigned waiver shall include:
(I) A functional eligibility and needs assessment tool used for the redesigned waiver that
aligns with the recommendations of the community living advisory group and that is fully
integrated with the assessment process for all clients receiving long-term services and supports;
(II) An assessment process that is person-centered, demonstrates inter-rater reliability, is
norm referenced for people with intellectual and developmental disabilities, and includes the
following principles and goals:
(A) Maximum personal control;
(B) System transparency; and
(C) Support needed to achieve key service outcomes, including health and welfare,
improving quality of life, increasing independence, and supporting employment and community
integration; and
(III) A service payment system that ensures fair distribution of available resources and
that is efficient, transparent, and equitable for both providers and consumers.
(b) As part of the state department's fiscal year 2016-17 budget request to the joint
budget committee, the state department shall include a justification for the continued use of the
supports intensity scale assessment. If the joint budget committee concludes that the justification
is insufficient to continue the use of the supports intensity scale assessment, the state department
shall present a plan to the joint budget committee for the transition to a different assessment tool
that meets the principles and goals set forth in subparagraph (II) of paragraph (a) of this
subsection (3.3), as well as a timeline for transition to the new assessment tool that comports
with the time frame set forth in subsection (2) of this section for the administration of the single
consolidated medicaid waiver.
(3.5) The redesigned waiver must ensure continuity of support, including residential
services, for eligible individuals enrolled in the home- and community-based services waivers
serving adults with intellectual and developmental disabilities who were receiving services as of
January 1, 2016, and who have maintained waiver eligibility.
(4) The state department shall notify the joint budget committee no later than June 1,
2016, if the federal centers for medicare and medicaid services has not approved a single
consolidated medicaid waiver for home- and community-based services for adults with
intellectual and developmental disabilities. If the state department has not received approval
from the federal centers for medicare and medicaid services by July 1, 2016, the joint budget
Colorado Revised Statutes 2023 Uncertified PrintoutPage 378 of 510
committee shall establish a notification and review process relating to the status of the pending
waiver consolidation process.
(5) No later than July 1, 2016, the state department, with input from community-centered
boards, single entry point agencies, and other stakeholders, shall develop a plan for the delivery
of conflict-free case management services that complies with the federal regulations relating to
person-centered planning. The plan must include a reasonable timeline for implementation of the
plan. The state department may hire a consultant to assist with plan development. During the
budget process for the 2016-17 legislative session, the state department shall report to the joint
budget committee on the development of the plan and any statutory changes required to
implement the plan.
(6) This section is repealed, effective July 1, 2024.
Source: L. 2015: Entire section added, (HB 15-1318), ch. 304, p. 1248, § 1, effective
August 5. L. 2021: (6) added by revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70. L.
2023: (2) and (4) amended, (HB 23-1301), ch. 303, p. 1832, § 52, effective August 7.
25.5-6-409.5. Transition plan for youth with intellectual and developmental
disabilities to adult services - legislative declaration - report - rules - cash fund. (1) The
general assembly finds and declares that:
(a) Youth with intellectual and developmental disabilities who are eighteen to twenty
years of age are currently served through the county child welfare system; and
(b) The home- and community-based services program for persons with intellectual and
developmental disabilities is better designed to meet the complex needs of these youth.
(2) Therefore, the general assembly declares that, in order to have a person-centered
system, youth with intellectual and developmental disabilities who are eighteen years of age and
older who are currently being served through child welfare services must be transitioned to the
home- and community-based services program for persons with intellectual and developmental
disabilities and a plan developed for the ongoing transition of such youth when they turn
eighteen years of age, except in extenuating circumstances when the court or interdisciplinary
team determines that it is not in the best interest of the youth to transition.
(3) (a) On or before June 30, 2014, each county department of human or social services
shall identify youth with intellectual and developmental disabilities who are receiving services
through the child welfare system in that county and who:
(I) Are twenty years of age or older as of June 30, 2014;
(II) Are nineteen years of age or older but younger than twenty-one years of age as of
June 30, 2014;
(III) Are eighteen years of age or older but younger than twenty years of age as of June
30, 2014; and
(IV) Will become eighteen years of age on or after June 30, 2014, and before January 1,
2015.
(b) On or before October 1, 2014, and as necessary thereafter, each county department of
human or social services shall identify youth with intellectual and developmental disabilities
who are receiving services through the child welfare system in that county and who will become
eighteen years of age within the following six months.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 379 of 510
(c) Each county department of human or social services shall develop a plan to transition
youth identified pursuant to paragraphs (a) and (b) of this subsection (3) to adult services for
persons with intellectual and developmental disabilities. The transition plan must meet the
criteria set forth in subsection (4) of this section and any rules promulgated by the state board to
implement this section. Each county's plan must provide for:
(I) Youth described in paragraph (a) of this subsection (3) to be transitioned as soon as
possible but in no case later than January 1, 2016; and
(II) Youth described in subparagraph (IV) of paragraph (a) of this subsection (3) or
paragraph (b) of this subsection (3) to be transitioned as soon as possible based on individual
needs but in no case earlier than their eighteenth birthday.
(d) The requirement to transition youth as set forth in subsection (3)(c) of this section
does not apply to youth currently serving a sentence in the division of youth services or to youth
under a court order in a juvenile delinquency case, unless the court approves the transition by
written court order.
(4) For each youth with intellectual and developmental disabilities who is going to be
transitioned to adult services for persons with intellectual and developmental disabilities
pursuant to subsection (3) of this section, the county department of human or social services that
is currently providing services to the youth through its child welfare system shall develop a
transition plan for that youth. The transition plan must, at a minimum:
(a) [Editor's note: This version of subsection (4)(a) is effective until July 1, 2024.]
Include the department-prescribed assessment provided by the community-centered board that is
performed as soon as possible for those youth who are being transitioned pursuant to subsection
(3) of this section and at seventeen and a half years of age for those youth who are being
transitioned pursuant to subparagraph (IV) of paragraph (a) of subsection (3) of this section or
paragraph (b) of subsection (3) of this section. In all instances, the assessment must be
completed within six months of a youth's transition to adult services.
(a) [Editor's note: This version of subsection (4)(a) is effective July 1, 2024.] Include
the department-prescribed assessment provided by the case management agency, as defined in
section 25.5-6-1702 that is performed as soon as possible for those youth who are being
transitioned pursuant to subsection (3) of this section and at seventeen and a half years of age for
those youth who are being transitioned pursuant to subsection (3)(a)(IV) or (3)(b) of this section.
In all instances, the assessment must be completed within six months of a youth's transition to
adult services.
(b) Provide for the social, habilitative, remedial, residential, educational, health, and
other needs of the youth who is being transitioned; and
(c) Address any legal needs concerning guardianship of the youth who is being
transitioned.
(5) In all instances, the involved parties and the county department of human or social
services shall consider and place precedence on the best interest of the youth prior to the
transition process, as set forth in sections 19-3-205 and 19-3-213, C.R.S.
(6) [Editor's note: This version of subsection (6) is effective until July 1, 2024.] It is
the intent of the general assembly that county child welfare systems and community-centered
boards collaborate to ensure minimal disruption for youth during the transition process.
(6) [Editor's note: This version of subsection (6) is effective July 1, 2024.] It is the
intent of the general assembly that county child welfare systems and case management agencies,
Colorado Revised Statutes 2023 Uncertified PrintoutPage 380 of 510
as defined in section 25.5-6-1702, collaborate to ensure minimal disruption for youth during the
transition process.
(7) The medical services board and the state board of human services may promulgate
rules as necessary and appropriate for the implementation of this section.
(8) The department shall submit a report to the joint budget committee on or before
January 1, 2015, and on or before January 1, 2016, on the status of the youth being transitioned.
The report must include, at a minimum:
(a) The number of youth transitioned to date by county;
(b) The needs assessment of the youth who have been transitioned; and
(c) The type of adult residential locations of the youth who have been transitioned.
(9) Repealed.
Source: L. 2014: Entire section added, (HB 14-1368), ch. 304, p. 1289, § 2, effective
May 31. L. 2017: (3)(d) amended, (HB 17-1329), ch. 381, p. 1983, § 60, effective June 6. L.
2021: (4)(a) and (6) amended, (HB 21-1187), ch. 83, p. 336, § 34, effective July 1, 2024.
Editor's note: Subsection (9)(b) provided for the repeal of subsection (9), effective July
1, 2016. (See L. 2014, p. 1289.)
25.5-6-410. Qualification for federal funding. Nothing in this part 4 shall prevent the
state department or the department of human services from complying with federal requirements
in order for the state of Colorado to qualify for federal funds under Title XIX of the federal
"Social Security Act", as amended.
Source: L. 2006: Entire article added with relocations, p. 1947, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-630 as it existed prior to 2006.
25.5-6-411. Personal needs trust fund required. All personal needs funds shall be held
in trust by a residential facility authorized to provide services pursuant to this part 4, or its
designated trustee, separate and apart from any other funds of the facility, in a checking account
or savings account or any combination thereof established to protect and separate the personal
needs funds of the clients. At all times, the principal and all income derived from said principal
in the personal needs trust fund shall remain the property of the participating clients, and the
facility or its designated trustee is bound by all of the duties imposed by law upon fiduciaries in
the handling of such fund including accounting for all expenditures from the fund.
Source: L. 2006: Entire article added with relocations, p. 1947, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-631 as it existed prior to 2006.
25.5-6-412. Cross-system response for behavioral health crises pilot program -
legislative declaration - creation - criteria - recommendations - fund - repeal. (Repealed)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 381 of 510
Source: L. 2015: Entire section added, (HB 15-1368), ch. 308, p. 1258, § 1, effective
June 5. L. 2017: IP(3) and (3)(e) amended, (SB 17-242), ch. 263, p. 1329, § 208, effective May
25.
Editor's note: Subsection (9) provided for the repeal of this section, effective July 1,
2019. (See L. 2015, p. 1258.)
25.5-6-413. Elimination of subminimum wage - transition plan for individuals with
disabilities - waiver - legislative declaration - definition. (1) The general assembly finds and
declares that:
(a) The payment of subminimum wages is an economic justice issue for individuals with
disabilities, impacting their ability to earn wages equal to their peers without disabilities and
devaluing their contributions based on their disabilities;
(b) Service enhancements and public policy changes are needed to address these
systemic barriers and assist individuals in subminimum wage jobs to pursue competitive
integrated employment; and
(c) The elimination of subminimum wage employment, along with the implementation
of critical service enhancements and policy changes, is essential to promoting economic justice
for, and the enhanced self-sufficiency of, individuals with disabilities while ensuring that
individuals currently working in subminimum wage jobs can successfully transition to
competitive integrated employment, supported employment, or integrated community activities
related to each individual's employment goals.
(2) (a) The state department shall seek federal approval, with an effective date on or
before July 1, 2023, to add the following medicaid waiver services for adults with intellectual
and developmental disabilities to assist them with pursuing competitive integrated employment:
(I) Support to provide line-of-sight supervision on the job as a less intensive and less
expensive alternative to individual job coaching, when appropriate; and
(II) Ongoing benefits counseling to assist such adults in earning higher incomes while
retaining necessary supports.
(b) The state department shall collaborate with stakeholders to develop service coverage
standards, reimbursement rates, and limitations on the services described in subsection (2)(a) of
this section.
(3) The state department shall seek federal approval, with an effective date on or before
July 1, 2023, to remove the following services from the service plan authorization limits to
ensure access to employment supports:
(a) Job coaching, individual; and
(b) Job development, individual.
(4) The state department shall collaborate with stakeholders to publish clarifying
guidance regarding allowable activities under services described in subsection (3) of this section.
(5) As used in this section, "competitive integrated employment" has the same meaning
as set forth in section 8-84-301 (3).
Source: L. 2021: Entire section added, (SB 21-039), ch. 380, p. 2548, § 6, effective July
1.
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PART 5
HOME- AND COMMUNITY-BASED SERVICES FOR
PERSONS WITH HEALTH COMPLEXES RELATED TO
ACQUIRED IMMUNE DEFICIENCY SYNDROME
25.5-6-501 to 25.5-6-508. (Repealed)
Source: L. 2018: Entire part repealed, (SB 18-093), ch. 62, p. 610, § 2, effective August
8.
Editor's note: This part 5 was added in 2006. For amendments to this part 5 prior to its
repeal in 2018, consult the 2017 Colorado Revised Statutes and the Colorado statutory research
explanatory note beginning on page vii in the front of this volume.
Cross references: For the legislative declaration in SB 18-093, see section 1 of chapter
62, Session Laws of Colorado 2018.
PART 6
HOME- AND COMMUNITY-BASED SERVICES FOR
PERSONS WITH MAJOR MENTAL HEALTH DISORDERS
25.5-6-601. Short title. The short title of this part 6 is the "Home- and Community-based
Services for Persons with Major Mental Health Disorders Act".
Source: L. 2006: Entire article added with relocations, p. 1951, § 7, effective July 1. L.
2018: Entire section amended, (SB 18-091), ch. 35, p. 388, § 27, effective August 8.
Editor's note: This section is similar to former § 26-4-671 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 18-091, see section 1 of chapter
35, Session Laws of Colorado 2018.
25.5-6-602. Legislative declaration - no entitlement created. (1) The general assembly
finds and declares that the purpose of this part 6 is to provide, under federal authorization and
subject to available appropriations, home- and community-based services for persons with major
mental health disorders.
(2) Nothing in this part 6 shall be construed to establish that eligible persons as defined
in section 25.5-6-603 (1) are entitled to receive services from the state department or the
department of human services. The provision of any services pursuant to this part 6 shall be
subject to federal waiver authorization and available appropriations.
Source: L. 2006: Entire article added with relocations, p. 1951, § 7, effective July 1. L.
2018: (1) amended, (SB 18-091), ch. 35, p. 388, § 28, effective August 8.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 383 of 510
Editor's note: This section is similar to former § 26-4-672 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 18-091, see section 1 of chapter
35, Session Laws of Colorado 2018.
25.5-6-603. Definitions. As used in this part 6, unless the context otherwise requires:
(1) "Eligible person" means a person:
(a) Who has a primary diagnosis of a major mental health disorder, as such term is
defined in the diagnostic and statistical manual of mental disorders used by the mental health
profession, and includes schizophrenic, paranoid, major affective, and schizoaffective disorders,
and atypical psychosis, but does not include dementia diseases and related disabilities;
(b) Who is in need of the level of care available in a nursing facility;
(c) Who is categorically eligible for medical assistance, or whose gross income does not
exceed three hundred percent of the current federal supplemental security income benefit level,
and whose resources do not exceed the limit established for individuals receiving a mandatory
minimum state supplementation of supplemental security income benefits or, in the case of a
person who is married, do not exceed the amount authorized in section 25.5-6-101.
Source: L. 2006: Entire article added with relocations, p. 1951, § 7, effective July 1. L.
2017: (1)(a) amended, (SB 17-242), ch. 263, p. 1330, § 209, effective May 25. L. 2018: (1)(a)
amended, (HB 18-1091), ch. 74, p. 644, § 7, effective August 8.
Editor's note: This section is similar to former § 26-4-673 as it existed prior to 2006.
Cross references: (1) For additional definitions applicable to this part 6, see §
25.5-4-103.
(2) For the legislative declaration in SB 17-242, see section 1 of chapter 263, Session
Laws of Colorado 2017.
25.5-6-604. Cost of services. Home- and community-based services for persons with
major mental health disorders must meet aggregate federal waiver budget neutrality
requirements.
Source: L. 2006: Entire article added with relocations, p. 1952, § 7, effective July 1. L.
2018: Entire section amended, (SB 18-091), ch. 35, p. 389, § 29, effective August 8.
Editor's note: This section is similar to former § 26-4-673.5 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 18-091, see section 1 of chapter
35, Session Laws of Colorado 2018.
25.5-6-605. Relationship to single entry point for long-term care - repeal. (1) The
home- and community-based services program for persons with major mental health disorders
must not be considered a publicly funded long-term care program for the purposes of sections
25.5-6-105 to 25.5-6-107, concerning the single entry point system, unless and until the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 384 of 510
departments of health care policy and financing and human services provide in the memorandum
of understanding between the departments for the inclusion of the program in the single entry
point system.
(2) This section is repealed, effective July 1, 2024.
Source: L. 2006: Entire article added with relocations, p. 1952, § 7, effective July 1. L.
2018: Entire section amended, (SB 18-091), ch. 35, p. 389, § 30, effective August 8. L. 2021: (2)
added by revision, (HB 21-1187), ch. 83, pp. 353, 354 §§ 69, 70.
Editor's note: This section is similar to former § 26-4-674 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 18-091, see section 1 of chapter
35, Session Laws of Colorado 2018.
25.5-6-606. Implementation of program for persons with mental health disorders
authorized - federal waiver - duties of the department of health care policy and financing
and the department of human services - rules. (1) [Editor's note: This version of subsection
(1) is effective until July 1, 2025.] The state department is authorized to seek any necessary
waiver from the federal government to develop and implement a home- and community-based
services program for persons with major mental health disorders. The program must be designed
to provide home- and community-based services to eligible persons. Eligibility may be limited to
persons who meet the level of services provided in a nursing facility, and services for eligible
persons may be established in state board rules to the extent such eligibility criteria and services
are authorized or required by federal waiver. The program must include services provided under
the consumer-directed care service model, part 11 of this article 6.
(1) [Editor's note: This version of subsection (1) is effective July 1, 2025.] The state
department is authorized to seek any necessary waiver from the federal government to develop
and implement a home- and community-based services program for persons with major mental
health disorders. The program must be designed to provide home- and community-based
services to eligible persons. Eligibility may be limited to persons who meet the level of services
provided in a nursing facility, and services for eligible persons may be established in state board
rules to the extent such eligibility criteria and services are authorized or required by federal
waiver.
(2) The state department and the department of human services shall provide a system of
reimbursement for services provided pursuant to this part 6 that encourages the most
cost-effective provision of services.
(3) The state department and the department of human services shall, subject to
appropriation, use available federal, state, local, or private funds, including but not limited to
medicaid funds available under Title XIX of the federal "Social Security Act", as amended, to
carry out the purposes of this part 6.
(4) The state department may include in the memorandum of understanding with the
department of human services provisions that allow the department of human services to certify
agencies as medicaid providers for the purposes of this part 6, to adopt fiscal and administrative
procedures, to review plans of care, to recommend reimbursement rates, to make
recommendations regarding the scope, duration, and content of programs and the eligibility of
Colorado Revised Statutes 2023 Uncertified PrintoutPage 385 of 510
persons for specific services provided pursuant to this part 6, and to fulfill any other
responsibilities necessary to implement this part 6. However, the provisions shall be consistent
with the designation of the state department as the single state agency in section 25.5-4-104.
(5) The executive director and the state board shall promulgate such rules regarding this
part 6 as are necessary to fulfill the obligations of the state department as the single state agency
to administer medical assistance programs in accordance with Title XIX of the federal "Social
Security Act", as amended.
(6) The department of human services shall promulgate such rules as are necessary to
perform its function pursuant to this part 6. Such rules shall be promulgated in accordance with
section 24-4-103, C.R.S., and shall be consistent with the rules of the executive director and the
state board.
(7) In the event a direct conflict arises between the rules of the state department
promulgated pursuant to subsection (5) of this section and the rules of the department of human
services promulgated pursuant to subsection (6) of this section, regarding implementation of this
part 6, the rules of the state department shall control.
(8) (a) No later than January 2024, the state department shall submit a report to the
senate health and human services committee, the house of representatives public and behavioral
health and human services committee, and the house of representatives health and insurance
committee, or any successor committees, as part of its "State Measurement for Accountable,
Responsive, and Transparent (SMART) Government Act" presentation required by section
2-7-203. At a minimum, the report must identify:
(I) A reimbursement system with a goal to incentivize and increase transportation
provider participation;
(II) How the state department will ensure compliance with applicable federal laws and
waiver requirements;
(III) A system of common reporting to ensure a recipient does not exceed the medicaid
benefit in a multi-provider scenario; and
(IV) Best practices based on what other states have done to allow transportation network
companies to provide nonmedical transportation services for individuals receiving services,
including but not limited to, reimbursement rates; driver compensation; and integration with
programs that provide nonmedical transportation services.
(b) In developing the report, the state department shall engage in a stakeholder process
that includes individuals with intellectual and developmental disabilities and their families,
individuals with disabilities, and transportation network companies. The report may be
developed in conjunction with the reporting requirement in sections 25.5-6-307(6), 25.5-6-409
(6), 25.5-6-704 (8), and 25.5-6-1303 (9).
(c) (I) Upon completion of the report described in subsection (8)(a) of this section, the
state department shall analyze and review each operational transportation network company, as
defined in section 40-10.1-602 (3). The state department shall verify each transportation network
company's viability to ensure the health, safety, welfare, cost effectiveness, and capability in
expanding nonmedical transportation services for individuals receiving services pursuant to this
section and comply with all rules promulgated pursuant to subsection (8)(e)(I) of this section.
(II) No later than July 1, 2024, the state department shall authorize verified
transportation network companies to provide nonmedical transportation services if the state
Colorado Revised Statutes 2023 Uncertified PrintoutPage 386 of 510
department finds the transportation network company viable under federal requirements and
within budgetary constraints.
(III) For the purposes of this subsection (8)(c), "verify" means a transportation network
company meets all requirements resulting from the report described in subsection (8)(a) of this
section.
(d) The state department may seek any necessary federal authorization for the
implementation of this subsection (8).
(e) (I) The state department shall promulgate any necessary rules to ensure transportation
network companies comply with federal and state oversight requirements and shall include all
relevant stakeholders, including medicaid recipients, transportation network companies, current
providers and drivers for nonmedical transportation services, and other interested parties in the
development of such requirements.
(II) Pursuant to section 40-10.1-105 (1)(l), transportation network companies are not
subject to regulation by the public utilities commission when providing nonmedical
transportation services pursuant to this section and are instead subject to rules promulgated by
the state department pursuant to this subsection (8)(e).
(f) This subsection (8) does not apply to a provider authorized to provide transportation
services pursuant to part 8 of article 1 of title 25.5 prior to August 10, 2022.
Source: L. 2006: Entire article added with relocations, p. 1952, § 7, effective July 1. L.
2018: (1) amended, (SB 18-091), ch. 35, p. 389, § 31, effective August 8. L. 2022: (8) added,
(HB 22-1114), ch. 396, p. 2818, § 4, effective August 10. L. 2023: (1) amended, (SB 23-289),
ch. 270, p. 1608, § 7, effective July 1, 2025.
Editor's note: This section is similar to former § 26-4-675 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 18-091, see section 1 of chapter
35, Session Laws of Colorado 2018. For the legislative declaration in HB 22-1114, see section 1
of chapter 396, Session Laws of Colorado 2022.
25.5-6-607. Implementation of part contingent upon receipt of federal waiver -
repeal of part. (1) The implementation of this part 6 is conditioned upon the issuance of
necessary waivers by the federal government and available appropriations. The provisions of this
part 6 shall be implemented to the extent authorized by federal waiver. The state department
shall propose legislation that conforms with the waiver provisions no later than the next regular
legislative session following the issuance of the waiver.
(2) Provisions of this part 6 that are approved by the federal government and are
authorized by federal waiver shall remain in effect only for so long as specified in the federal
waiver, unless otherwise extended by the federal government. The state department shall provide
written notice to the revisor of statutes of the final termination date of the waiver, and this part 6
shall be repealed, effective July 1 of the year in which the waiver is terminated.
Source: L. 2006: Entire article added with relocations, p. 1953, § 7, effective July 1.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 387 of 510
Editor's note: (1) This section is similar to former § 26-4-676 as it existed prior to
2006.
(2) As of publication date, the revisor of statutes has not received the notice referred to
in subsection (2).
PART 7
HOME- AND COMMUNITY-BASED SERVICES
FOR PERSONS WITH BRAIN INJURY
25.5-6-701. Short title. This part 7 shall be known and may be cited as the "Home- and
Community-based Services for Persons with Brain Injury Act".
Source: L. 2006: Entire article added with relocations, p. 1953, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-681 as it existed prior to 2006.
25.5-6-702. Legislative declaration - no entitlement created. (1) The general assembly
hereby finds and declares that the purpose of this part 7 is to provide, under federal authorization
and subject to available appropriations, home- and community-based services for persons with
brain injury.
(2) Nothing in this part 7 shall be construed to establish that eligible persons as defined
in section 25.5-6-703 (4) are entitled to receive services from the state department. The provision
of any services pursuant to this part 7 shall be subject to federal waiver authorization and
available appropriations.
Source: L. 2006: Entire article added with relocations, p. 1953, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-682 as it existed prior to 2006.
25.5-6-703. Definitions - repeal. As used in this part 7, unless the context otherwise
requires:
(1) "Adult day care" means health and social services furnished two or more hours per
day on a regularly scheduled basis for one or more days per week in an outpatient setting and for
the purpose of ensuring the optimal functioning of the recipient.
(2) "Behavioral programming" means an individualized plan that sets forth strategies to
decrease a recipient's maladaptive behaviors that interfere with the recipient's ability to remain in
the community. Behavioral programming includes a complete assessment of maladaptive
behaviors of the recipient, the development and implementation of a structured behavioral
intervention plan, continuous training and supervision of caregivers and behavioral aides, and
periodic reassessment of the individualized plan.
(3) "Brain injury" means an injury to the brain arising from external forces including, but
not limited to, toxic chemical reactions, anoxia, near drownings, closed or open head injuries,
and focal brain injuries.
(4) "Eligible person" means a person:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 388 of 510
(a) Who has a diagnosis of brain injury, as such term is defined in subsection (3) of this
section;
(b) Who is in need of the level of care available in a hospital, rehabilitation hospital,
hospital in lieu of a nursing facility, or is in need of specialized care provided in a nursing
facility in lieu of a hospital;
(c) Who is categorically eligible for medical assistance, or has a gross income that does
not exceed three hundred percent of the current federal supplemental security income benefit
level and resources that do not exceed the limit established for individuals receiving a mandatory
minimum state supplementation of supplemental security income benefits or, in the case of a
person who is married, do not exceed the amount authorized in section 25.5-6-101; and
(d) For whom the cost of services would not exceed the average cost of hospital care.
(5) "Independent living skills training" means skills and therapies that are directed at the
development and maintenance of community living skills and community integration.
Independent living skills include supervision or training with respect to or assistance with
self-care, communication skills, socialization, sensory and motor development, reducing
maladaptive behavior, community living and mobility, and therapeutic recreation.
(6) (a) "Personal care services" means assistance with eating, bathing, dressing, personal
hygiene, and activities of daily living. Personal care services include assistance with the
preparation of meals, but not the cost of the meals, and homemaker services that are necessary
for the health and safety of the recipient.
(b) This subsection (6) is repealed, effective July 1, 2025.
(7) "Structured day treatment" means structured, nonresidential therapeutic treatment
services that are directed at the development and maintenance of community living skills and are
provided two or more hours per day on a regularly scheduled basis for one or more days per
week. Day treatment services include supervision and specific training that allows a recipient to
function at the recipient's maximum potential. The services include, but are not limited to, social
skills training that allows for reintegration into the community, sensory and motor development
services, and services aimed at reducing maladaptive behavior.
(8) "Supported living" means assistance or support designed to maximize or maintain
independence and self-direction on a supportive care campus. Supported living services consist
of structured interventions designed to provide:
(a) Protective oversight and supervision;
(b) Behavioral management and cognitive supports;
(c) Interpersonal and social skills development;
(d) Improved household management skills to support independence and community
integration; and
(e) Medical management.
(9) "Supportive care campus" means a residential campus that provides supported living
services.
(10) "Transitional living" means a nonmedical residential program that provides training
and twenty-four-hour supervision to a recipient that will enhance the recipient's ability to live
more independently.
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Source: L. 2006: Entire article added with relocations, p. 1954, § 7, effective July 1. L.
2014: (10) amended, (SB 14-160), ch. 153, p. 531, § 1, effective May 9. L. 2023: (6)(b) added
by revision, (SB 23-289), ch. 270, pp. 1608, 1611 §§ 8, 19.
Editor's note: This section is similar to former § 26-4-683 as it existed prior to 2006.
Cross references: For additional definitions applicable to this part 7, see § 25.5-4-103.
25.5-6-704. Implementation of home- and community-based services program for
persons with brain injury authorized - federal waiver - duties of the department - rules -
repeal. (1) (a) The state department is hereby authorized to seek any necessary waiver from the
federal government to develop and implement a home- and community-based services program
for persons with brain injury. The state department shall design the program to provide home-
and community-based services to eligible persons. Eligibility shall be limited to persons who
meet the level of services provided in a hospital, rehabilitation hospital, hospital in lieu of
nursing facility care, or who are in need of specialized care provided in a nursing facility in lieu
of a hospital.
(b) The state department shall seek any necessary amendments to the current federal
waiver for the home- and community-based services program for persons with brain injury to
allow supported living, as defined in section 25.5-6-703 (8), to be provided to eligible persons on
a supportive care campus.
(2) Services for eligible persons may be established in department rules to the extent
authorized or required by federal waiver, but must include at least the following:
(a) Independent living skills training, as indicated in the eligible person's plan of care,
and provided by local agencies determined by the department to be qualified to provide the
services;
(b) Residential care including, but not limited to:
(I) Transitional living;
(II) Respite care;
(III) Supported living;
(c) (I) Personal care services;
(II) This subsection (2)(c) is repealed, effective July 1, 2025.
(d) Assisted transportation;
(e) Counseling and training including treatment for substance use disorders and family
counseling;
(f) Environmental modification services;
(g) Day care, which may include physical, occupational, and speech therapies as
indicated in the eligible person's plan of care;
(h) Structured day treatment, which may include physical, occupational, speech, and
cognitive therapies if deemed necessary by the eligible person's case manager and as indicated in
the person's plan of care. Structured day treatment services are for individuals who may benefit
from continued rehabilitation and reintegration into the community.
(i) Behavioral programming that may be provided in or outside an eligible person's
residence;
(j) Assistive technology;
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(k) (I) Services provided under the consumer-directed care service model, part 11 of this
article.
(II) This subsection (2)(k) is repealed, effective July 1, 2025.
(3) The case manager, in coordination with the eligible person and the person's family or
guardian, shall include in each plan of care a process by which the eligible person may receive
necessary care, which may include respite care, if the eligible person's family or service provider
is unavailable due to an emergency situation or to unforeseen circumstances. The eligible person
and the person's family or guardian shall be duly informed by the case manager of these
alternative care provisions at the time the plan of care is initiated.
(4) (a) The department shall provide a system of reimbursement for services provided
pursuant to this part 7 that encourages the most cost-effective provision of services.
(b) A member of an eligible person's family, other than the person's spouse or a parent of
a minor, may be employed to provide personal care services to such person. The maximum
reimbursement for the services provided by a member of the person's family per year for an
eligible person shall not exceed the equivalent of four hundred forty-four service units per year
for a member of the eligible person's family. Standards that apply to other providers who provide
personal care services apply to a family member who provides these services. In addition, a
registered nurse shall supervise a family member in providing services to the extent indicated in
the eligible person's plan of care.
(5) The state department shall, subject to appropriation, use available federal, state,
local, or private funds including, but not limited to, medicaid funds available under Title XIX of
the federal "Social Security Act", as amended, to carry out the purposes of this part 7.
(6) The state board shall adopt rules concerning the certification of agencies as medicaid
providers for the purposes of this part 7, fiscal and administrative procedures, procedures for
reviewing plans of care, reimbursement rates, and the scope, duration, and content of programs
and the eligibility for specific services provided pursuant to this part 7. The state board shall
adopt such rules as are necessary to fulfill the obligations of the state department as the single
state agency to administer medical assistance programs in accordance with Title XIX of the
federal "Social Security Act", as amended.
(7) (a) No later than January 2024, the state department shall submit a report to the
senate health and human services committee, the house of representatives public and behavioral
health and human services committee, and the house of representatives health and insurance
committee, or any successor committees, as part of its "State Measurement for Accountable,
Responsive, and Transparent (SMART) Government Act" presentation required by section
2-7-203. At a minimum, the report must identify:
(I) A reimbursement system with a goal to incentivize and increase transportation
provider participation;
(II) How the state department will ensure compliance with applicable federal laws and
waiver requirements;
(III) A system of common reporting to ensure a recipient does not exceed the medicaid
benefit in a multi-provider scenario; and
(IV) Best practices based on what other states have done to allow transportation network
companies to provide nonmedical transportation services for individuals receiving services,
including but not limited to, reimbursement rates; driver compensation; and integration with
programs that provide nonmedical transportation services.
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(b) In developing the report, the state department shall engage in a stakeholder process
that includes individuals with intellectual and developmental disabilities and their families,
individuals with disabilities, and transportation network companies. The report may be
developed in conjunction with the reporting requirement in sections 25.5-6-307 (6), 25.5-6-409
(6), 25.5-6-606 (9), and 25.5-6-1303 (9).
(c) (I) Upon completion of the report described in subsection (7)(a) of this section, the
state department shall analyze and review each operational transportation network company, as
defined in section 40-10.1-602 (3). The state department shall verify each transportation network
company's viability to ensure the health, safety, welfare, cost effectiveness, and capability in
expanding nonmedical transportation services for individuals receiving services pursuant to this
section and comply with all rules promulgated pursuant to subsection (7)(e)(I) of this section.
(II) No later than July 1, 2024, the state department shall authorize verified
transportation network companies to provide nonmedical transportation services if the state
department finds the transportation network company viable under federal requirements and
within budgetary constraints.
(III) For the purposes of this subsection (7)(c), "verify" means a transportation network
company meets all requirements resulting from the report described in subsection (7)(a) of this
section.
(d) The state department may seek any necessary federal authorization for the
implementation of this subsection (7).
(e) (I) The state department shall promulgate any necessary rules to ensure transportation
network companies comply with federal and state oversight requirements and shall include all
relevant stakeholders, including medicaid recipients, transportation network companies, current
providers and drivers for nonmedical transportation services, and other interested parties in the
development of such requirements.
(II) Pursuant to section 40-10.1-105 (1)(l), transportation network companies are not
subject to regulation by the public utilities commission when providing nonmedical
transportation services pursuant to this section and are instead subject to rules promulgated by
the state department pursuant to this subsection (7)(e).
(f) This subsection (7) does not apply to a provider authorized to provide transportation
services pursuant to part 8 of article 1 of title 25.5 prior to August 10, 2022.
Source: L. 2006: Entire article added with relocations, p. 1955, § 7, effective July 1. L.
2017: IP(2) and (2)(e) amended, (SB 17-242), ch. 263, p. 1330, § 210, effective May 25. L.
2022: (7) added, (HB 22-1114), ch. 396, p. 2820, § 5, effective August 10. L. 2023: (2)(c)(II)
and (2)(k)(II) added by revision, (SB 23-289), ch. 270, pp. 1608, 1611 §§ 9, 19.
Editor's note: This section is similar to former § 26-4-684 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 17-242, see section 1 of chapter
263, Session Laws of Colorado 2017. For the legislative declaration in HB 22-1114, see section
1 of chapter 396, Session Laws of Colorado 2022.
25.5-6-705. Implementation of part contingent upon receipt of federal waiver -
repeal of part. (1) (a) The implementation of this part 7 is conditioned upon the issuance of
Colorado Revised Statutes 2023 Uncertified PrintoutPage 392 of 510
necessary waivers by the federal government and available appropriations. The provisions of this
part 7 shall be implemented to the extent authorized by federal waiver. The state department
shall propose legislation that conforms with the waiver provisions no later than the next regular
legislative session following the issuance of the waiver.
(b) The implementation of the provisions of this part 7 relating to services provided on a
supportive care campus are conditioned upon the approval of necessary waiver amendments by
the federal government. The provisions of this part 7 relating to supported living shall be
implemented to the extent authorized by federal waiver and in accordance with applicable
federal requirements.
(2) Provisions of this part 7 that are approved by the federal government and are
authorized by federal waiver shall remain in effect only for so long as specified in the federal
waiver, unless otherwise extended by the federal government. The state department shall provide
written notice to the revisor of statutes of the final termination date of the waiver, and this part 7
shall be repealed, effective July 1 of the year in which the waiver is terminated.
Source: L. 2006: Entire article added with relocations, p. 1957, § 7, effective July 1.
Editor's note: (1) This section is similar to former § 26-4-685 as it existed prior to
2006.
(2) As of publication date, the revisor of statutes has not received the notice referred to
in subsection (2).
25.5-6-706. Rate structure - rules - quality assurance. (1) (a) The state board, by rule,
shall set tiered per diem rates for services provided on a supportive care campus under this part
7. When structuring the tiered per diem rates, the state board shall consider the medical and
cognitive needs of eligible persons being served on the supportive care campus.
(b) The maximum per diem rate for the services provided on a supportive care campus
shall not exceed the total per diem cost of comparable populations either in institutions or in
other community-based settings.
(2) The state board shall adopt rules necessary for quality assurance, which shall include
certification of supportive care campuses.
Source: L. 2006: Entire article added with relocations, p. 1958, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-686 as it existed prior to 2006.
PART 8
HOME- AND COMMUNITY-BASED SERVICES
FOR CHILDREN WITH AUTISM
25.5-6-801 25.5-6-806. (Repealed)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 393 of 510
Editor's note: This part 8 was added in 2006. For amendments to this part 8 prior to its
repeal in 2023, consult the 2022 Colorado Revised Statutes and the Colorado statutory research
explanatory note beginning on page vii in the front of this volume.
PART 9
HOME- AND COMMUNITY-BASED SERVICE
PROGRAMS FOR CHILDREN
25.5-6-901. Disabled children care program - eligibility criteria - documentation
requirements - report to the general assembly. (1) The general assembly hereby finds and
declares that a program shall be established by the state department to provide services not
otherwise available to eligible disabled children outside the confines of an acute care hospital or
nursing facility. Such program shall be known as the "disabled children care program" and shall
be designed to safely provide services to eligible disabled children in a home- or
community-based setting at a cost to the medicaid program equal to or less than the medicaid
cost of inpatient hospital or nursing facility care.
(2) (a) The state department is authorized to seek a waiver from the federal department
of health and human services to qualify for federal financial participation in the disabled children
care program. Application for such waiver is contingent upon a finding that continuation of the
disabled children care program results in less expenditures from the general fund than if such
program were terminated.
(b) If federal financial participation is secured, eligibility for participation in the program
and the number of children to be served under the program shall be in accordance with federal
regulations.
(3) (a) "Eligible disabled children" means any children eighteen years of age and under
who:
(I) Have medical needs which would qualify them, pursuant to state department criteria,
for institutionalization or place them at risk for institutionalization in any one of the following:
An acute care hospital or a nursing facility; and
(II) Have gross incomes which do not exceed three hundred percent of the current
federal supplemental security income benefit level. The amount of parental or spousal income
and resources which shall be attributable to a child's gross income for purposes of eligibility
shall be set forth in rules promulgated by the state board and shall be in relation to the parent's or
spouse's financial responsibility for such child; and
(III) Are not receiving services from any of the alternatives to long-term care waiver
programs established under this title.
(b) "Home care services" means all services available under sections 25.5-5-102,
25.5-5-103, 25.5-5-202, and 25.5-5-203 that may be received in a noninstitutional setting.
(4) (a) The state department shall require the following documentation on each applicant
for the program:
(I) An assessment by the disabled child's attending physician of the child's medical,
functional, and social status and a determination by such physician that the quality of care which
can be provided in the noninstitutional setting is equal to or exceeds the quality of care the child
could receive in an acute care hospital or nursing facility;
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(II) An analysis of the cost of services for the disabled child in an institutional setting as
compared to the cost of such services in a noninstitutional setting;
(III) An assessment of the caregiver's ability to provide the needed services to the
disabled child in a noninstitutional setting and an assessment of such caregiver's social history.
(b) The information required under paragraph (a) of this subsection (4) shall be collected
and reviewed by the state department at least every six months for disabled children who enter
the disabled children care program in order to ensure that the quality of noninstitutional care
continues to equal or exceed such care in an institutional setting and that the costs for care under
the program are less than the costs for such care in an institution. When the disabled child is
found to no longer qualify for institutionalization or be at risk for institutionalization pursuant to
state department criteria, the child shall no longer be eligible for the disabled children care
program.
Source: L. 2006: Entire article added with relocations, p. 1960, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-509 as it existed prior to 2006.
25.5-6-902. Children's personal assistance services and family support program -
repeal. (1) The general assembly finds that many families who attempt to care for severely
disabled or terminally ill children at home often are burdened with the excessive financial and
personal costs of providing continuous care. Private insurance companies rarely support
essential, long-term custodial services and often establish monetary limits that are well below the
levels required by these disabled children. When coverage is available, care is frequently
provided in a medical model that is marginally appropriate to the needs of the children and the
family and usually more expensive to the payer. The resulting pressures often contribute to
family disintegration and increased dependency on public programs. The general assembly finds
that it is in the best interests of the citizens of the state to encourage the preservation of families
with children with disabilities.
(2) As used in this section, unless the context otherwise requires, "eligible disabled
children" means children eighteen years of age or younger:
(a) Who have medical needs that, pursuant to state department rules, would qualify them
for institutionalization or place them at risk of institutionalization in an acute care hospital or
nursing facility;
(b) Who have gross incomes, including the amount of parental income and resources to
be attributed to the child's gross income according to rules to be promulgated by the state board,
that do not exceed three hundred percent of the current federal supplemental security income
benefit level;
(c) Who are not receiving long-term services from any alternative waiver program
established under this title;
(d) For whom a licensed physician or an advanced practice registered nurse has certified
that in-home care is an appropriate way to meet the child's needs; and
(e) For whom the cost of care outside of the institution is no higher than the estimated
medicaid cost of appropriate institutional care.
(3) There is hereby established in the state department the children's personal assistance
services and family support waiver program, referred to in this section as the "program", to
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provide services to eligible disabled children in their homes rather than in the confines of an
acute care hospital or nursing facility. The number of children enrolled in this program or any
other model 200 program shall not exceed the state department's ability to cover the costs of the
programs within the annual appropriations for this program and any other model 200 program.
(4) Priority for participation in the program shall be given first to children who are on
the waiting list for other model 200 programs and secondly to children whose parents will return
to work if appropriate care for their disabled child is provided under the program. Spaces in the
program shall also be available to children who were already covered by medicaid but who were
rendered temporarily ineligible for a period of not more than three months due to a periodic or
cyclical peak in their parents' income.
(5) The state board shall adopt rules to govern the program consistent with any federal
waivers including, but not limited to, rules concerning:
(a) Services that are reimbursable under this section including, but not limited to:
(I) Respite care, to the degree its additional cost is offset by collection of a parental
copayment;
(II) Case management; and
(III) Medically necessary professional or community services beyond those specified in
section 25.5-5-102 or 25.5-5-202, to the degree that they provide a cost-effective and medically
appropriate alternative to covered services;
(b) Provider selection and certification;
(c) Documentation for assessment and recertification;
(d) (I) Case management agency selection and responsibility; and
(II) This subsection (5)(d) is repealed, effective July 1, 2024.
(e) Reimbursement.
(6) The case management agency, in coordination with the eligible disabled child's
family and the child's physician, shall include in each case plan a process by which the eligible
disabled child may receive necessary care, which may include respite care, if the eligible
disabled child's family or care provider is unavailable due to an emergency situation or to
unforeseen circumstances. The eligible disabled child's family shall be duly informed by the case
management agency of these alternative care provisions at the time the case plan is initiated.
(7) If the state department finds it cost-effective and all necessary federal waivers are
obtained, parents of eligible disabled children may be authorized to hire and manage care
providers from certified medicaid agencies. Case management agencies shall work with parents
to develop the skills necessary for ongoing care management.
(8) The state department is authorized to seek waivers from the federal government to
qualify for federal financial participation in the program.
(9) The state department is authorized to charge and collect copayments from parents for
services rendered.
(10) The state department is directed to study the advisability of setting an upper limit on
parental income for participation in this program and other children's medicaid waiver programs.
Source: L. 2006: Entire article added with relocations, p. 1962, § 7, effective July 1. L.
2008: (2)(d) amended, p. 134, § 22, effective January 1, 2009. L. 2021: (5)(d)(II) added by
revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
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Editor's note: This section is similar to former § 26-4-509.2 as it existed prior to 2006.
25.5-6-903. Residential child health-care program - waiver - home- and
community-based services - rules. (1) Subject to federal authorization, the state department
shall implement a program for medicaid-eligible children with intellectual and developmental
disabilities, as defined in section 25.5-10-202, with significant behavioral support needs who are
at risk of institutionalization. The state board shall establish, by rule, the type of services
provided pursuant to the program, to the extent the services are cost-efficient, and the recipient
eligibility criteria that may include, but are not limited to, a medical necessity determination and
a financial eligibility determination.
(2) The state department may limit the number of participants in the program in
accordance with any federal waiver obtained by the state department to implement this section.
(3) The state board shall promulgate rules as necessary for the implementation and
administration of the program, including but not limited to rules regarding program services;
eligibility criteria, including financial eligibility criteria; and reimbursement of providers.
(4) This section will take effect if the federal department of health and human services
approves a redesigned children's habilitation residential program waiver for medicaid-eligible
children with intellectual and developmental disabilities, as defined in section 25.5-10-202, who
have complex behavioral support needs, pursuant to House Bill 18-1328, as enacted in 2018. The
executive director of the state department shall notify the revisor of statutes in writing of the date
on which the condition specified in this section has occurred by e-mailing the notice to
revisorofstatutes.ga@state.co.us. This section takes effect, effective upon the date identified in
the notice that the federal department of health and human services approved the waiver or, if the
notice does not specify that date, upon the date of the notice to the revisor of statutes.
Source: L. 2018: Entire section added, (HB 18-1328), ch. 184, p. 1243, § 3, effective
June 7, 2019.
Editor's note: Section 10 of chapter 184 (HB 18-1328), Session Laws of Colorado 2018,
provides that section 3 of the act adding this section takes effect upon notice to the revisor of
statutes pursuant to § 25.5-5-306 (6) as enacted in section 2 of the act. For more information, see
HB 18-1328. (L. 2018, p. 1247.) On August 14, 2019, the revisor of statutes received the notice
referred to in subsection (4) and § 25.5-5-306 (6) that the federal department of health and
human services approved the waiver on June 7, 2019.
Cross references: For the legislative declaration in HB 18-1328, see section 1 of chapter
184, Session Laws of Colorado 2018.
PART 10
CONSUMER-DIRECTED ATTENDANT SUPPORT
FOR PERSONS WITH DISABILITIES
25.5-6-1001 to 25.5-6-1004. (Repealed)
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Editor's note: (1) This article was added with relocations in 2006, and this part 10 was
subsequently repealed in 2009. For amendments to this part 10 prior to its repeal in 2009, consult
the Colorado statutory research explanatory note beginning on page vii in the front of this
volume and the editor's note following the article heading.
(2) Section 25.5-6-1004 provided for the repeal of this part 10, effective July 1, 2009.
(See L. 2006, p. 1967.)
PART 11
CONSUMER-DIRECTED CARE
25.5-6-1101. Definitions. As used in this part 11, unless the context otherwise requires:
(1) "Attendant support" means any action to assist an eligible person in accomplishing
activities of daily living, instrumental activities of daily living, and habilitative and
health-related tasks. Such activities include, but are not limited to, personal care services,
household services, cognitive services, mobility services, and health-related tasks.
(2) "Authorized representative" means an individual designated by the eligible person,
by the parent of a minor, or by the legal guardian of the eligible person if the eligible person
cannot demonstrate sound judgment to his or her primary care physician, who has the judgment
and ability to assist the eligible person in acquiring and utilizing services under this part 11. The
extent of the authorized representative's involvement shall be determined upon designation.
(3) "Consumer-directed" means that an eligible person receives a direct payment through
a voucher and employs, trains, and in other ways manages the person who provides his or her
attendant support. The direct payment through a voucher that is received by an eligible person to
pay for attendant support shall not be counted as income for purposes of determining eligibility
for medicaid and other state programs that use income to determine eligibility.
(4) [Editor's note: This version of subsection (4) is effective until July 1, 2025.]
"Eligible person" means a person who is eligible to receive services under parts 3 to 12 of this
article or any other home- and community-based service waiver for which the state department
has federal waiver authority.
(4) [Editor's note: This version of subsection (4) is effective July 1, 2025.] "Eligible
person" means a person who is eligible to receive services pursuant to part 19 of this article 6.
(5) "Primary care physician" means a physician who is the primary provider of physician
services to the eligible person or who is familiar with the eligible person's needs and capabilities.
(6) [Editor's note: This version of subsection (6) is effective until July 1, 2025.]
"Qualified services" means services provided under the eligible person's applicable waiver
program and attendant support.
(6) [Editor's note: This version of subsection (6) is effective July 1, 2025.] "Qualified
services" means services provided under the eligible person's community first choice option.
Source: L. 2006: Entire article added with relocations, p. 1967, § 7, effective July 1. L.
2023: (4) and (6) amended, (SB 23-289), ch. 270, p. 1608, § 10, effective July 1, 2025.
Editor's note: This section is similar to former § 26-4-1301 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 398 of 510
Cross references: For additional definitions applicable to this part 11, see § 25.5-4-103.
25.5-6-1102. Service model - consumer-directed care - repeal. (1) The state
department shall implement a consumer-directed care service model that allows eligible persons
to receive a direct payment through a voucher to purchase qualified services. The state
department is authorized to seek any federal waivers or waiver amendments that may be
necessary to implement this part 11. The state department shall design and implement the
consumer-directed care service model with input from consumers of home- and
community-based services or their authorized representatives. An eligible person shall not be
required to disenroll from the person's waiver program in order to receive qualified services
through the consumer-directed care service model.
(2) In order to qualify and to remain eligible for the consumer-directed care service
model authorized by this section, a person shall:
(a) [Editor's note: This version of subsection (2)(a) is effective until July 1, 2025.] Be
eligible for home- and community-based services under parts 3 to 12 of this article or any other
home- and community-based service waiver for which the state department has federal waiver
authority;
(a) [Editor's note: This version of subsection (2)(a) is effective July 1, 2025.] Be
eligible for community first choice services pursuant to part 19 of this article 6;
(b) Be willing to participate;
(c) Obtain a statement from his or her primary care physician or advanced practice
registered nurse indicating that the person has sound judgment and the ability to direct his or her
care or has an authorized representative;
(d) Demonstrate the ability to handle the financial aspects of self-directed care or has an
authorized representative who is able to handle the financial aspects of the eligible person's care;
and
(e) Meet any other qualifications established by the state board by rule.
(3) [Editor's note: This version of subsection (3) is effective until July 1, 2024.] The
voucher issued to the eligible person under this part 11 shall be based on the eligible person's
historical utilization of home- and community-based services under parts 3 to 12 of this article,
the single entry point agency's care plan, or any approved resource allocation process as
determined by the state department and the department of human services for the eligible person.
(3) [Editor's note: This version of subsection (3) is effective July 1, 2024, until July 1,
2025.] The voucher issued to the eligible person pursuant to this part 11 must be based on the
eligible person's historical utilization of home- and community-based services pursuant to parts 3
to 12 of this article 6, the case management agency's care plan, or any approved resource
allocation process as determined by the state department and the department of human services
for the eligible person.
(3) [Editor's note: This version of subsection (3) is effective July 1, 2025.] The
allocation issued to the eligible person pursuant to this part 11 must be based on the eligible
person's historical utilization of home- and community-based services pursuant to parts 3 to 12
of this article 6, the case management agency's care plan, or any approved resource allocation
process as determined by the state department and the department of human services for the
eligible person.
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(4) While an eligible person is participating in the consumer-directed care service model
established in this part 11, that person shall be ineligible to receive a home care allowance as
provided in section 26-2-122.3 (1)(b), C.R.S.
(5) The state department shall develop the accountability requirements necessary to
safeguard the use of public dollars, to promote effective and efficient delivery of services, and to
monitor the safety and welfare of eligible persons under this part 11.
(6) The state board shall adopt rules as necessary for the implementation and
administration of the consumer-directed care service model authorized by this part 11. Such
rules shall include a provision allowing an eligible person to designate a family member or
authorized representative to be responsible for managing the financial matters associated with
the consumer-directed care or to direct the eligible person's care. The designee shall not receive
reimbursement for managing the financial matters associated with the eligible person's care or
for directing the eligible person's care.
(7) Sections 12-255-104 (7), (8.5), and (11), 12-255-125 (1), and 12-255-214 (1)(b) shall
not apply to a person who is directly employed by an individual participating in the
consumer-directed care service model pursuant to this section and who is acting within the scope
and course of such employment. However, such person may not represent himself or herself to
the public as a licensed nurse, a certified nurse aide, a licensed practical or professional nurse, a
registered nurse, or a registered professional nurse. This exclusion shall not apply to any person
who has had his or her license as a nurse or certification as a nurse aide suspended or revoked or
his or her application for such license or certification denied.
(8) (a) Section 25.5-6-310 does not apply to a family member of an eligible person who
provides consumer-directed care services to the eligible person pursuant to this part 11.
(b) This subsection (8) is repealed, effective July 1, 2025.
(9) A person who has been designated as an authorized representative under this part 11
shall submit an affidavit, which shall become part of the eligible person's file, stating that:
(a) He or she is at least eighteen years of age;
(b) He or she has known the eligible person for at least two years;
(c) He or she has not been convicted of any crime involving exploitation, abuse, or
assault on another person; and
(d) He or she does not have a mental, emotional, or physical condition that could result
in harm to the eligible person.
Source: L. 2006: Entire article added with relocations, p. 1968, § 7, effective July 1. L.
2008: (2)(c) amended, p. 134, § 24, effective January 1, 2009. L. 2019: (7) amended, (HB
19-1172), ch. 136, p. 1710, § 189, effective October 1. L. 2020: (7) amended, (HB 20-1183), ch.
157, p. 703, § 61, effective July 1. L. 2021: (3) amended, (HB 21-1187), ch. 83, p. 336, § 36,
effective July 1, 2024. L. 2023: (2)(a) and (3) amended, (SB 23-289), ch. 270, p. 1609, § 11,
effective July 1, 2025; (8)(b) added by revision, (SB 23-289), ch. 270, pp. 1609, 1611, §§ 11, 19.
Editor's note: (1) This section is similar to former § 26-4-1302 as it existed prior to
2006.
(2) Senate Bill 23-289 amended subsection (3) as it will become effective July 1, 2024.
(See L. 2021, p. 336.). Senate Bill 23-289 takes effect July 1, 2025.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 400 of 510
25.5-6-1103. Reporting. (1) The state department shall provide a report to the joint
budget committee of the general assembly and the health and human services committees of the
house of representatives and the senate, or any successor committees, by October 1, 2006, that
includes, but is not limited to, the following:
(a) The number of elderly persons participating in the consumer-directed care program;
(b) The cost-effectiveness of the consumer-directed care program;
(c) Feedback from consumers and the state department concerning the progress and
success of the consumer-directed care program; and
(d) Any changes to the health status or health outcomes of the program participants.
Source: L. 2006: Entire article added with relocations, p. 1969, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-1303 as it existed prior to 2006.
PART 12
IN-HOME SUPPORT SERVICES
25.5-6-1201. Legislative declaration - repeal. (1) The general assembly finds that there
may be a more effective way to deliver home- and community-based services to the elderly,
blind, and disabled; to disabled children; and to persons with spinal cord injuries, that allows for
more self-direction in their care and a cost savings to the state. The general assembly also finds
that every person that is currently receiving home- and community-based services does not need
the same level of supervision and care from a licensed health-care professional in order to meet
his or her care needs and remain living in the community. The general assembly, therefore,
declares that it is beneficial to the elderly, blind, and disabled clients of home- and
community-based services, to clients of the disabled children care program, and to clients
enrolled in the spinal cord injury waiver pilot program, for the state department to develop a
service that would allow these people to receive in-home support.
(2) The general assembly further finds that allowing clients more self-direction in their
care is a more effective way to deliver home- and community-based services to clients with
major mental health disorders and brain injuries, as well as to clients receiving home- and
community-based supportive living services and children's extensive support services. Therefore,
the general assembly declares that it is appropriate for the state department to develop a plan for
expanding the availability of in-home support services to include these clients.
(3) This section is repealed, effective July 1, 2025.
Source: L. 2006: Entire article added with relocations, p. 1970, § 7, effective July 1. L.
2014: Entire section amended, (HB 14-1358), ch. 255, p. 1017, § 2, effective August 6; entire
section amended, (HB 14-1357), ch. 254, p. 1013, § 1, effective March 1, 2015. L. 2018: (2)
amended, (SB 18-091), ch. 35, p. 389, § 32, effective August 8. L. 2023: (3) added by revision,
(SB 23-289), ch. 270, pp. 1609, 1611, §§ 12, 19.
Editor's note: (1) This section is similar to former § 26-4-1401 as it existed prior to
2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 401 of 510
(2) Amendments to this section by HB 14-1357 and HB 14-1358 were harmonized.
Cross references: For the legislative declaration in SB 18-091, see section 1 of chapter
35, Session Laws of Colorado 2018.
25.5-6-1202. Definitions. As used in this part 12, unless the context otherwise requires:
(1) "Attendant" means a person who is directly employed by an in-home support service
agency to provide, or a family member, including a spouse, providing, in-home support services
to eligible persons.
(2) "Authorized representative" means an individual designated by the eligible person
receiving services, or by the parent or guardian of the eligible person receiving services, if
appropriate, who has the judgment and ability to assist the eligible person receiving services in
acquiring and utilizing services under this part 12. The extent of the authorized representative's
involvement shall be determined upon designation. The authorized representative shall not be the
eligible person's service provider.
(3) "Eligible person" means any person who:
(a) [Editor's note: This version of subsection (3)(a) is effective until July 1, 2025.] Is
enrolled in a home- and community-based services waiver program pursuant to this article 6 for
which in-home support services are authorized pursuant to state and federal law;
(a) [Editor's note: This version of subsection (3)(a) is effective July 1, 2025.] Is enrolled
in community first choice services pursuant to part 19 of this article 6;
(b) Is willing to participate;
(c) Obtains a statement from his or her primary care physician indicating that the person
has sound judgment and the ability to direct his or her care, the eligible child's parent or guardian
has sound judgment and the ability to direct the eligible child's care, or the person has an
authorized representative; and
(d) Meets any other qualifications established by the state board by rule.
(4) [Editor's note: This version of subsection (4) is effective until July 1, 2025.] "Health
maintenance activities" means health-related tasks as defined in rule by the state board and
include, but are not limited to, catheter irrigation; administration of medication, enemas, and
suppositories; and wound care.
(4) [Editor's note: This version of subsection (4) is effective July 1, 2025.] "Health
maintenance activities" means routine and repetitive health-related tasks furnished to a member
in the community or in the member's home that is necessary for the health and normal bodily
functioning that a person with a disability is physically unable to carry out. "Health maintenance
activities" includes skilled tasks typically performed by a certified nursing assistant or a licensed
nurse that do not require the clinical assessment and judgment of a licensed nurse.
(5) "In-home support service agency" means an agency that is certified by the state
department and provides independent living core services as defined in section 8-85-102 (6),
C.R.S., and in-home support services.
(6) "In-home support services" means services that are provided in the home and in the
community by an attendant under the direction of the eligible person or the eligible person's
authorized representative including health maintenance activities and support for activities of
daily living or instrumental activities of daily living, and personal care services and homemaker
Colorado Revised Statutes 2023 Uncertified PrintoutPage 402 of 510
services as defined in rules promulgated by the medical services board pursuant to section
24-4-103, C.R.S.
Source: L. 2006: Entire article added with relocations, p. 1970, § 7, effective July 1. L.
2014: (3)(a) amended, (HB 14-1358), ch. 255, p. 1018, § 3, effective August 6; (1), (3)(a), and
(6) amended, (HB 14-1357), ch. 254, p. 1014, § 2, effective March 1, 2015. L. 2015: (5)
amended, (SB 15-240), ch. 139, p. 423, § 5, effective July 1. L. 2016: (5) amended, (SB 16-093),
ch. 54, p. 132, § 5, effective July 1. L. 2019: (3)(a) amended, (SB 19-164), ch. 371, p. 3386, § 3,
effective August 2. L. 2023: (3)(a) and (4) amended, (SB 23-289), ch. 270, p. 1610, § 13,
effective July 1, 2025.
Editor's note: This section is similar to former § 26-4-1402 as it existed prior to 2006.
Cross references: For additional definitions applicable to this part 12, see § 25.5-4-103.
25.5-6-1203. In-home support services - eligibility - licensure exclusion - in-home
support service agency responsibilities - rules - repeal. (1) [Editor's note: This version of
subsection (1) is effective until July 1, 2025.] The state department shall offer in-home support
services as an option for eligible persons who receive home- and community-based services.
In-home support services shall be provided to eligible persons. The state department shall seek
any federal authorization that may be necessary to implement this part 12. The state department
shall design and implement in-home support services with input from consumers of home- and
community-based services and independent living centers and home- and community-based
service providers.
(1) [Editor's note: This version of subsection (1) is effective July 1, 2025.] The state
department shall offer in-home support services as an option for eligible persons who receive
community first choice services. In-home support services must be provided to eligible persons.
The state department shall seek any federal authorization that may be necessary to implement
this part 12. The state department shall design and implement in-home support services with
input from consumers of community first choice services and independent living centers.
(1.5) Repealed.
(2) An eligible person receiving in-home support services or the eligible person's
authorized representative or parent or guardian shall be allowed to:
(a) Choose the eligible person's in-home support service agency or the eligible person's
attendant; and
(b) Direct the eligible person's care, including directly scheduling, managing, and
supervising the attendant, and determine the level of in-home support services agency support.
(3) Sections 12-255-104 (7), (8.5), and (11), 12-255-125 (1), and 12-255-214 (1)(b) shall
not apply to a person who is directly employed by an in-home support service agency to provide
in-home support services and who is acting within the scope and course of such employment or
is a family member providing in-home support services pursuant to this part 12. However, such
person may not represent himself or herself to the public as a licensed nurse, a certified nurse
aide, a licensed practical or professional nurse, a registered nurse, or a registered professional
nurse. This exclusion shall not apply to any person who has had his or her license as a nurse or
Colorado Revised Statutes 2023 Uncertified PrintoutPage 403 of 510
certification as a nurse aide suspended or revoked or his or her application for such license or
certification denied.
(4) (a) In-home support service agencies providing in-home support services shall
provide twenty-four-hour back-up services to their clients. In-home support service agencies
shall either contract with or have on staff a state licensed health-care professional, as defined by
the state board by rule, acting within the scope of the person's profession. The state board shall
promulgate rules setting forth the training requirements for attendants providing in-home support
services and the oversight and monitoring responsibilities of the state licensed health-care
professional that is either contracting with or is on staff with the in-home support service agency.
The state board rules must allow the eligible person or the eligible person's authorized
representative, parent of a minor, or guardian to determine, in conjunction with the in-home
support services agency, the amount of oversight needed in connection with the eligible person's
in-home support services.
(b) The state board shall promulgate rules that establish how an in-home support service
agency can discontinue a client under this part 12. The rules shall establish that a client can only
be involuntarily discontinued when equivalent care in the community has been secured or that a
client can be discontinued after exhibiting documented prohibited behavior involving attendants,
including abuse of attendants, and that dispute resolution has failed. The determination of
whether an in-home support service agency has made adequate attempts at resolution shall be
made by the state department.
(5) [Editor's note: This version of subsection (5) is effective until July 1, 2024.] The
single entry point agencies established in section 25.5-6-106 shall be responsible for determining
a person's eligibility for in-home support services; except that for eligible disabled children the
state department shall designate the entity that will determine the child's eligibility. The state
board shall promulgate rules specifying the single entry point agencies' responsibilities under
this part 12. At a minimum, these rules shall require that case managers discuss the option and
potential benefits of in-home support services with all eligible long-term care clients.
(5) [Editor's note: This version of subsection (5) is effective July 1, 2024.] The case
management agencies established in section 25.5-6-1703 shall be responsible for determining a
person's eligibility for in-home support services; except that for eligible disabled children the
state department shall designate the entity that will determine the child's eligibility. The state
board shall promulgate rules specifying the case management agencies' responsibilities pursuant
to this part 12. At a minimum, these rules must require that case managers discuss the option and
potential benefits of in-home support services with all eligible long-term care clients.
(6) (a) Section 25.5-6-310 does not apply to a family member of an eligible person who
provides in-home support services to the eligible person pursuant to this part 12. The state board
shall promulgate rules, as necessary, to establish limits on reimbursement to family members.
(b) This subsection (6) is repealed, effective July 1, 2025.
(7) In administering the provision of in-home support services pursuant to this part 12,
the state department shall:
(a) Implement a system for the routine and accurate monitoring of the number of persons
receiving in-home support services; and
(b) [Editor's note: This version of the introductory portion to subsection (7)(b) is
effective until July 1, 2024.] Provide comprehensive, periodic training for all single entry point
agencies in the state, which training shall include, at a minimum:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 404 of 510
(b) [Editor's note: This version of the introductory portion to subsection (7)(b) is
effective July 1, 2024.] Provide comprehensive, periodic training for all case management
agencies in the state, which training shall include, at a minimum:
(I) The current eligibility requirements for the receipt of in-home support services; and
(II) The location of, and contact information for, the in-home support service agencies
providing in-home support services in the state.
Source: L. 2006: Entire article added with relocations, p. 1971, § 7, effective July 1. L.
2011: (7) added, (SB 11-105), ch. 277, p. 1244, § 1, effective June 2. L. 2014: (1.5) added and
(2), (4)(a), and (6) amended, (HB 14-1357), ch. 254, p. 1014, § 3, effective March 1, 2015. L.
2019: (1.5) repealed, (SB 19-164), ch. 371, p. 3386, § 4, effective August 2; (3) amended, (HB
19-1172), ch. 136, p. 1711, § 190, effective October 1. L. 2020: (3) amended, (HB 20-1183), ch.
157, p. 703, § 62, effective July 1. L. 2021: (5) and (7)(b) amended, (HB 21-1187), ch. 83, p.
337, § 37, effective July 1, 2024. L. 2023: (1) amended, (SB 23-289), ch. 270, p. 1610, § 14,
effective July 1, 2025; (6)(b) added by revision, (SB 23-289), ch. 270, pp. 1610, 1611 §§ 14, 19.
Editor's note: This section is similar to former § 26-4-1403 as it existed prior to 2006.
25.5-6-1204. Provision of services - duties of state department - gifts - grants. (1)
The provision of the in-home support services set forth in this part 12 shall be subject to the
availability of federal matching medicaid funds, pursuant to Title XIX of the federal "Social
Security Act", as amended, for payment of the costs for administration and the costs for the
provision of such services.
(2) The state department shall seek and utilize any available federal, state, or private
funds that are available for carrying out the purposes of this part 12, including but not limited to
medicaid funds, pursuant to Title XIX of the federal "Social Security Act", as amended.
(3) The executive director of the state department is authorized to accept and expend on
behalf of the state any grants or gifts from any public or private source for the purpose of
implementing this part 12.
Source: L. 2006: Entire article added with relocations, p. 1972, § 7, effective July 1.
Editor's note: This section is similar to former § 26-4-1404 as it existed prior to 2006.
25.5-6-1205. Accountability - rate structure - rules. (1) The state department shall
develop the accountability requirements necessary to safeguard the use of public dollars and to
promote effective and efficient service delivery under this part 12.
(2) The state board, by rule, shall set a separate rate structure for in-home support
services provided under this part 12.
(3) The state board shall adopt rules as necessary for the implementation and
administration of the in-home support services authorized by this part 12. At a minimum, the
rules shall include certification of in-home support service agencies and standards of care for the
provision of services under this part 12.
Source: L. 2006: Entire article added with relocations, p. 1972, § 7, effective July 1.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 405 of 510
Editor's note: This section is similar to former § 26-4-1405 as it existed prior to 2006.
25.5-6-1206. Report - repeal. (1) The state department shall report annually to the joint
budget committee of the general assembly and the health and human services committee of the
senate, or any successor committee, and the health and environment committee of the house of
representatives, or any successor committee, on the implementation of in-home support services.
At a minimum the report shall include the cost-effectiveness of providing in-home support
services to the elderly, blind, and disabled and to eligible disabled children, the number of
persons receiving such services, and any strategies and resources that are available or that are
necessary to assist more persons in staying in their homes through the use of in-home support
services.
(2) This section is repealed, effective July 1, 2025.
Source: L. 2006: Entire article added with relocations, p. 1973, § 7, effective July 1. L.
2011: Entire section amended, (SB 11-105), ch. 277, p. 1244, § 2, effective June 2. L. 2023: (2)
added by revision, (SB 23-289), ch. 270, pp. 1610, 1611 §§ 15, 19.
Editor's note: This section is similar to former § 26-4-1406 as it existed prior to 2006.
25.5-6-1207. Repeal of part. This part 12 is repealed, effective September 1, 2028. Prior
to such repeal, in-home support services established under this part 12 shall be reviewed as
provided for in section 24-34-104.
Source: L. 2006: Entire article added with relocations, p. 1973, § 7, effective July 1. L.
2008: Entire section amended, p. 323, § 3, effective April 7. L. 2011: Entire section amended,
(SB 11-105), ch. 277, p. 1245, § 3, effective June 2. L. 2014: Entire section amended, (HB
14-1358), ch. 255, p. 1018, § 4, effective August 6. L. 2019: Entire section amended, (SB
19-164), ch. 371, p. 3385, § 1, effective August 2.
Editor's note: This section is similar to former § 26-4-1407 as it existed prior to 2006.
25.5-6-1208. Conditional repeal of part. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1973, § 7, effective July 1. L.
2011: Entire section repealed, (SB 11-105), ch. 277, p. 1245, § 4, effective June 2; entire section
repealed, (HB 11-1303), ch. 264, p. 1169, § 69, effective August 10.
Editor's note: This section is similar to former § 26-4-1408 as it existed prior to 2006.
PART 13
COMPLEMENTARY AND ALTERNATIVE MEDICINE
FOR A PERSON WITH A SPINAL CORD INJURY
25.5-6-1301. Legislative declaration. (1) The general assembly finds that:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 406 of 510
(a) A person with a spinal cord injury could benefit from complementary and alternative
medicine such as chiropractic care, massage therapy, or acupuncture; and
(b) Complementary and alternative medicine could improve the quality of life and help
reduce the need for continuous or more expensive procedures, medications, and hospitalizations
for a person with a spinal cord injury and could allow a person with a spinal cord injury to be
employed.
Source: L. 2009: Entire part added, (HB 09-1047), ch. 395, p. 2128 § 1, effective August
5. L. 2015: Entire section amended, (SB 15-011), ch. 333, p. 1354, § 1, effective June 5.
25.5-6-1302. Definitions. As used in this part 13, unless the context otherwise requires:
(1) "Complementary or alternative medicine" means a form of diverse health-care
services not provided for under this article or article 4 or 5 of this title prior to August 5, 2009,
but authorized by the rules of the state board adopted pursuant to section 25.5-6-1303 (4). The
medicine is limited to chiropractic care, massage therapy, and acupuncture performed by
licensed or certified providers.
(2) "Eligible person with a disability" means a person with a disability who meets the
eligibility criteria specified in section 25.5-6-1303 (2)(b).
(3) "Pilot program" means the pilot program authorized pursuant to section 25.5-6-1303
to allow an eligible person with a disability to receive complementary and alternative medicine.
Source: L. 2009: Entire part added, (HB 09-1047), ch. 395, p. 2128, § 1, effective
August 5. L. 2015: (1) and (3) amended, (SB 15-011), ch. 333, p. 1354, § 2, effective June 5.
Cross references: For additional definitions applicable to this part 13, see § 25.5-4-103.
25.5-6-1303. Pilot program - complementary or alternative medicine - rules. (1) (a)
The general assembly authorizes the state department to implement a pilot program that would
allow an eligible person with a disability to receive complementary or alternative medicine to the
extent authorized by federal waiver. The pilot program may begin no later than January 1, 2012.
The state department shall design and implement the pilot program with input from an advisory
committee that must include, but need not be limited to, persons with spinal cord injuries who
are receiving complementary or alternative medicine. The state department may seek any federal
waivers that may be necessary to implement this part 13.
(b) Subject to available funds, it is the intent of the general assembly that the state
department enroll every eligible person that applies for the waiver and that an eligible person is
not placed on a waiting list for services.
(2) (a) The purpose of the pilot program is to expand the choice of therapies available to
eligible persons with disabilities, to study the success of complementary and alternative
medicine, and to produce an overall cost savings for the state compared to the estimated
expenditures that would have otherwise been spent for the same persons with spinal cord injuries
absent the pilot program.
(b) In order to qualify and to remain eligible for the pilot program authorized by this
section, a person shall:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 407 of 510
(I) Be diagnosed with a primary condition of a spinal cord injury, multiple sclerosis, a
brain injury, spina bifida, muscular dystrophy, or cerebral palsy, with the total inability for
independent ambulation directly resulting from one of these diagnoses;
(II) Be willing to participate in the pilot program;
(III) Demonstrate a current need, as further defined in rule by the state board, for
complementary or alternative medicine; and
(IV) Be eligible for medicaid, including but not limited to persons who meet the
functional level of care and financial criteria described in rules promulgated by the state board
relating to long-term care services.
(c) The state department shall implement subsection (2)(b) of this section no later than
July 1, 2022.
(d) The pilot program is available to all eligible individuals in Colorado.
(3) The state department shall develop the accountability requirements for the pilot
program necessary to safeguard the use of public moneys and to promote effective and efficient
service delivery.
(4) The state board shall adopt rules as necessary for the implementation and
administration of the pilot program.
(5) The state department shall cause to be conducted an independent evaluation of the
pilot program to be completed no later than January 1, 2025. The state department shall provide
a report of the evaluation 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 report on the evaluation must include the following:
(a) The number of eligible persons with disabilities participating in the pilot program;
(b) The cost-effectiveness of the pilot program;
(c) Feedback from consumers and the state department concerning the progress and
success of the pilot program;
(d) Any changes to the health status or health outcomes of the persons participating in
the pilot program;
(e) Other information relevant to the success and problems of the pilot program; and
(f) Recommendations concerning the feasibility of continuing the pilot program beyond
the pilot stage and changes, if any, that are needed.
(6) Repealed.
(7) Unless the state department receives sufficient appropriations, the state department is
not required to seek federal approval or implement the pilot program.
(8) (a) No later than January 2024, the state department shall submit a report to the
senate health and human services committee, the house of representatives public and behavioral
health and human services committee, and the house of representatives health and insurance
committee, or any successor committees, as part of its "State Measurement for Accountable,
Responsive, and Transparent (SMART) Government Act" presentation required by section
2-7-203. At a minimum, the report must identify:
(I) A reimbursement system with a goal to incentivize and increase transportation
provider participation;
(II) How the state department will ensure compliance with applicable federal laws and
waiver requirements;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 408 of 510
(III) A system of common reporting to ensure a recipient does not exceed the medicaid
benefit in a multi-provider scenario; and
(IV) Best practices based on what other states have done to allow transportation network
companies to provide nonmedical transportation services for individuals receiving services,
including but not limited to, reimbursement rates; driver compensation; and integration with
programs that provide nonmedical transportation services.
(b) In developing the report, the state department shall engage in a stakeholder process
that includes individuals with intellectual and developmental disabilities and their families,
individuals with disabilities, and transportation network companies. The report may be
developed in conjunction with the reporting requirement in sections 25.5-6-307 (6), 25.5-6-409
(6), 25.5-6-606 (9), and 25.5-6-704 (8).
(c) (I) Upon completion of the report described in subsection (8)(a) of this section, the
state department shall analyze and review each operational transportation network company, as
defined in section 40-10.1-602 (3). The state department shall verify each transportation network
company's viability to ensure the health, safety, welfare, cost effectiveness, and capability in
expanding nonmedical transportation services for individuals receiving services pursuant to this
section and comply with all rules promulgated pursuant to subsection (8)(e)(I) of this section.
(II) No later than July 1, 2024, the state department shall authorize verified
transportation network companies to provide nonmedical transportation services if the state
department finds the transportation network company viable under federal requirements and
within budgetary constraints.
(III) For the purposes of this subsection (8)(c), "verify" means a transportation network
company meets all requirements resulting from the report described in subsection (8)(a) of this
section.
(d) The state department may seek any necessary federal authorization for the
implementation of this subsection (8).
(e) (I) The state department shall promulgate any necessary rules to ensure transportation
network companies comply with federal and state oversight requirements and shall include all
relevant stakeholders, including medicaid recipients, transportation network companies, current
providers and drivers for nonmedical transportation services, and other interested parties in the
development of such requirements.
(II) Pursuant to section 40-10.1-105 (1)(l), transportation network companies are not
subject to regulation by the public utilities commission when providing nonmedical
transportation services pursuant to this section and are instead subject to rules promulgated by
the state department pursuant to this subsection (8)(e).
(f) This subsection (8) does not apply to a provider authorized to provide transportation
services pursuant to part 8 of article 1 of title 25.5 prior to August 10, 2022.
Source: L. 2009: Entire part added, (HB 09-1047), ch. 395, p. 2129, § 1, effective
August 5. L. 2015: (1), (2)(a), (2)(b)(III), (5), and (7) amended and (6) repealed, (SB 15-011),
ch. 333, p. 1355, § 3, effective June 5. L. 2019: IP(5) amended, (SB 19-197), ch. 335, p. 3089, §
1, effective May 29. L. 2021: (1)(a) and (2)(b) amended and (2)(c) and (2)(d) added, (SB
21-038), ch. 404, p. 2684, § 1, effective September 7. L. 2022: (8) added, (HB 22-1114), ch.
396, p. 2821, § 6, effective August 10.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 409 of 510
Cross references: For the legislative declaration in HB 22-1114, see section 1 of chapter
396, Session Laws of Colorado 2022.
25.5-6-1304. Repeal of part. This part 13 is repealed, effective September 1, 2025.
Source: L. 2009: Entire part added, (HB 09-1047), ch. 395, p. 2130, § 1, effective
August 5. L. 2015: Entire section amended, (SB 15-011), ch. 333, p. 1356, § 4, effective June 5.
L. 2019: Entire section amended, (SB 19-197), ch. 335, p. 3089, § 2, effective May 29.
PART 14
MEDICAID BUY-IN
Cross references: For the "Ticket to Work and Work Incentives Improvement Act of
1999", see Pub.L. 106-170, codified at 42 U.S.C. sec. 1320b-19.
25.5-6-1401. Legislative declaration. The general assembly hereby declares its support
for the full employment of people with disabilities. It is the general assembly's intent to enact
this part 14 for the purpose of allowing an individual with disabilities to purchase medicaid
coverage that will enable the individual to maintain employment without losing his or her
medicaid benefits.
Source: L. 2008: Entire part added, p. 2197, § 1, effective July 1.
25.5-6-1402. Definitions. As used in this part 14, unless the context otherwise requires:
(1) "Basic coverage group" means the category of eligibility under the federal "Ticket to
Work and Work Incentives Improvement Act of 1999", Pub.L. 106-170, that provides an
opportunity to buy into medicaid consistent with the federal "Social Security Act", 42 U.S.C.
sec. 1396a (a)(10)(A)(ii)(XV), as amended, for each worker with disabilities who is at least
sixteen years of age but less than sixty-five years of age and who, except for earnings, would be
eligible for the supplemental security income program. A person who is eligible under the basic
coverage group may also be a home- and community-based services waiver recipient.
(2) "Family" means an individual, the individual's spouse, and any dependent child of
the individual.
(3) "Health insurance" means surgical, medical, hospital, major medical, or other health
service coverage, including a self-insured health plan, but does not include hospital indemnity
policies or ancillary coverages such as income continuation, loss of time, or accident benefits.
(4) "Medicaid buy-in program" means a program that gives each person with disabilities
the opportunity to buy into medicaid if the person meets the eligibility criteria specified in
section 25.5-6-1404.
(5) "Medical improvement group" means the category of eligibility under the federal
"Ticket to Work and Work Incentives Improvement Act of 1999", Pub.L. 106-170, that provides
an opportunity to buy into medicaid consistent with the federal "Social Security Act", 42 U.S.C.
sec. 1496a (a)(10)(A)(ii)(XV), as amended, for each worker with a medically improved
disability who is at least sixteen years of age but less than sixty-five years of age and who was
Colorado Revised Statutes 2023 Uncertified PrintoutPage 410 of 510
previously in the basic coverage group and is no longer eligible for the basic coverage group due
to medical improvement. A person who is eligible under the medical improvement group may
also be a home- and community-based services waiver recipient.
(6) "Work incentives eligibility group" means the category of eligibility under the
federal "Balanced Budget Act of 1997", Pub.L. 105-33, 111, as amended, for individuals with a
disability who, except for assets or income, would be eligible for the supplemental security
income program. This eligibility applies to individuals who are sixty-five years of age or older.
Source: L. 2008: Entire part added, p. 2197, § 1, effective July 1. L. 2020: (6) added,
(SB 20-033), ch. 237, p. 1150, § 1, effective July 6.
Cross references: For additional definitions applicable to this part 14, see § 25.5-4-103.
25.5-6-1403. Waivers and amendments.
(1) Repealed.
(2) If approved by the joint budget committee and subject to available appropriations,
the state department shall submit to the federal centers for medicare and medicaid services an
amendment to the state medical assistance plan, and shall request any necessary waivers from
the secretary of the federal department of health and human services, to permit the state
department to expand medical assistance eligibility as provided in this part 14 for the purpose of
implementing a medicaid buy-in program for people with disabilities who are in the basic
coverage group or the medical improvement group. In addition, the state department shall apply
to the secretary of the federal department of health and human services for a medicaid
infrastructure grant, if available, to develop and implement the federal "Ticket to Work and
Work Incentives Improvement Act of 1999", Pub.L. 106-170.
(3) If the state medical assistance plan amendment and all necessary waivers are
approved, the state department shall implement the medicaid buy-in program provided in this
part 14 not later than three months after receiving full federal approval, whichever is later.
(4) The state department shall seek federal authorization to implement a medicaid buy-in
program for adults who are eligible to receive home- and community-based services pursuant to
the supported living services waiver; the developmental disabilities waiver or its successor, part
4 of this article 6; the persons with brain injury waiver, part 7 of this article 6; and the spinal
cord injury waiver pilot program, part 13 of this article 6. The state department shall prepare and
submit any requests necessary for federal approval not later than January 1, 2023, and shall
implement the medicaid buy-in program pursuant to this subsection (4) not later than three
months after receiving federal approval.
(5) (a) Except as provided in subsection (5)(b) of this section:
(I) The state department shall seek federal authorization through an amendment to the
state medical assistance plan to implement the federal "Balanced Budget Act of 1997", Pub.L.
105-33, 111, as amended, which provides individuals an opportunity to buy into medicaid
consistent with the federal "Social Security Act", 42 U.S.C. sec. 1396a (a)(10)(A)(ii)(XIII), as
amended, to permit the state department to provide medical assistance eligibility to individuals
in the work incentives eligibility group, age sixty-five and older, after they are no longer eligible
under the federal "Ticket to Work and Work Incentives Improvement Act of 1999", Pub.L.
106-170.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 411 of 510
(II) In addition to submitting an amendment to the state medical assistance plan pursuant
to subsection (5)(a)(I) of this section, the state department shall submit a state plan amendment
pursuant to section 1902(r)(2) of the federal "Social Security Act" to use less restrictive income
and resource methodologies to match the income, household, and asset levels of the medicaid
buy-in program for implementation no later than July 1, 2022.
(b) The state department shall not prepare and submit the amendments to the state
medical assistance plan pursuant to this subsection (5) if there are insufficient revenues from the
healthcare affordability and sustainability fee cash fund, created in section 25.5-4-402.4, for the
administrative expenses associated with preparing and submitting the state plan amendments. If
there are insufficient revenues from the healthcare affordability and sustainability fee cash fund,
the state department may accept and expend gifts, grants, or donations for this purpose.
Source: L. 2008: Entire part added, p. 2198, § 1, effective July 1. L. 2009: (2) amended,
(HB 09-1293), ch. 152, p. 649, § 7, effective July 1. L. 2016: (4) added, (HB 16-1321), ch. 344,
p. 1398, § 1, effective June 10; (1) repealed and (2) amended, (HB 16-1081), ch. 22, p. 52, § 7,
effective August 10. L. 2020: (5) added, (SB 20-033), ch. 237, p. 1150, § 2, effective July 6. L.
2021: (4) amended, (SB 21-039), ch. 380, p. 2549, § 7, effective July 1.
25.5-6-1404. Medicaid buy-in program - eligibility - premiums - medicaid buy-in
fund - report - rules - repeal. (1) Eligibility. An individual is eligible for and shall receive
medicaid provided in this part 14 through a medicaid buy-in program without losing eligibility
for medicaid if all of the following conditions are met:
(a) The individual meets the requirements for the basic coverage group or the individual
was previously in the basic coverage group and now meets the requirements for the medical
improvement group or the individual was previously in the basic coverage group and now meets
the requirements for the work incentives eligibility group, if a state plan amendment for the work
incentives eligibility group has been submitted and approved pursuant to section 25.5-6-1403
(5);
(b) The individual maintains premium payments calculated by the state department in
accordance with subsection (3) of this section, unless the individual is exempted from premium
payments under rules promulgated by the state board; and
(c) The individual meets all other requirements established by rule of the state board.
(2) There is no income or asset limitation for a participant in the medicaid buy-in
program. In addition, there is no income or asset limitation for an individual who participates in
the medicaid buy-in program and also receives home- and community-based services.
(3) Premiums. (a) An individual who is eligible for and receives medicaid under
subsection (1) of this section shall pay a premium pursuant to a payment schedule established by
the state department. The amount of the premium shall be determined from a sliding-fee scale
adopted by rule of the state board that is based on a percentage of the individual's income
adjusted for family size and on any impairment-related work expenses; except that, consistent
with federal law, if the amount of the individual's adjusted gross income exceeds seventy-five
thousand dollars, the individual shall be responsible for paying one hundred percent of the
premium. The rules shall specify the amount of unearned income the state department shall
disregard in calculating the individual's income.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 412 of 510
(b) The rules setting the premiums and the sliding-fee scale shall be based on an
actuarial study of the disabled population in this state. The state department may solicit and
accept federal grants to cover the costs of the actuarial study. Moneys received through any
grants and any premiums shall be credited to the medicaid buy-in cash fund, which fund is
hereby created in the state treasury. Moneys in the fund shall be appropriated by the general
assembly and expended by the state department for the purpose of conducting implementation
activities as determined by the state department, including conducting the actuarial study.
Premiums shall be credited to the fund for the purpose of offsetting program costs.
(c) Within three years after implementation of the medicaid buy-in program pursuant to
this part 14, the state department shall submit a report on the effectiveness of the program to the
health and human services committees of the general assembly, or any successor committees,
and the joint budget committee of the general assembly.
(4) Repealed.
(5) Medicare. If federal financial participation is available, subject to available
appropriations, the state department may pay medicare part A and part B premiums for
individuals who are eligible for medicare and for medicaid under subsection (1) of this section.
(6) (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 (1)(a), (1)(b), and (3)(a) of this
section establishing coverage group requirements and requiring payment of premiums in order to
maintain eligibility for the medicaid buy-in program are suspended until the last day of the
twelfth month following the end of the declared federal public health emergency as a result of
the coronavirus disease 2019, known as "COVID-19".
(b) The state board may adopt rules to implement this subsection (6) 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 (6) is repealed, effective June 1, 2024.
Source: L. 2008: Entire part added, p. 2199, § 1, effective July 1. L. 2020: (1)(a)
amended and (4) repealed, (SB 20-033), ch. 237, p. 1151, § 3, effective July 6. L. 2022: (3)(a)
amended, (SB 22-212), ch. 421, p. 2990, § 105, effective August 10. L. 2023: (6) added, (SB
23-182), ch. 118, p. 431, § 4, effective April 27.
25.5-6-1405. Rule-making authority. (1) The state board shall promulgate rules
necessary to implement and administer the medicaid buy-in program created in this part 14,
including the establishment of appropriate premium and cost-sharing charges on a sliding-fee
scale based on income. The premiums and cost-sharing charges shall be based upon an actuarial
study of the disabled population in this state.
(2) Any rules adopted by the state board must be consistent with the federal "Ticket to
Work and Work Incentives Improvement Act of 1999", Pub.L. 106-170, and the "Balanced
Budget Act of 1997", Pub.L. 105-33, 111, as amended.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 413 of 510
Source: L. 2008: Entire part added, p. 2200, § 1, effective July 1. L. 2020: (2) amended,
(SB 20-033), ch. 237, p. 1152, § 4, effective July 6.
25.5-6-1406. Availability of federal financial assistance under medical assistance.
Notwithstanding any other provision of law, this part 14 shall be implemented only if, and to the
extent that, the state department determines that federal financial participation is available under
the medicaid program.
Source: L. 2008: Entire part added, p. 2200, § 1, effective July 1.
PART 15
TRANSITION SERVICES
25.5-6-1501. Community transition services and supports - legislative declaration -
rules. (1) The general assembly finds and declares that:
(a) Federally required assessments indicate that more persons living in institutional
settings expressed an interest in transitioning to home- or community-based settings than
currently have transitions available to them;
(b) Federally required surveys indicate these persons report a higher quality of life after
transitioning to home- and community-based settings, and those successful transitions often
result in cost savings to the state;
(c) In order to ensure a successful transition, such persons will need ongoing services
and supports after the transition; and
(d) Some persons transitioning out of an institution will need assistance with finding and
paying for housing that may be provided by vouchers from the department of local affairs.
(2) (a) The state department shall implement community transition services and supports
that allow eligible persons to receive services to support a successful transition from an
institutional setting to a home- or community-based setting. The state department may seek any
state plan amendments or federal waivers or waiver amendments that may be necessary to
implement this part 15.
(b) With input from consumers of home- and community-based services, the state
department shall design and implement community transition services and supports for eligible
persons who are preparing to transition or have recently transitioned from an institutional setting.
(c) An eligible person is not required to leave an institutional setting if, while exploring
the option to transition, the person decides to remain in his or her current living situation. If an
eligible person does transition, the person may choose between state plan benefits and waiver
services for which he or she is eligible to ensure a successful transition.
(3) In order to qualify and to remain eligible for the community transition services and
supports authorized by this part 15, a person shall:
(a) Be eligible for home- and community-based services under parts 3 to 12 of this
article 6 or any other home- and community-based service waiver for which the state department
has federal waiver authority;
(b) Be willing to participate and have expressed an interest in moving to a home- or
community-based setting;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 414 of 510
(c) Reside in a nursing home or other institutional setting;
(d) Obtain medicaid eligibility prior to discharging from the institutional setting and
prior to accessing community transition services needed to assist the person with planning and
preparing for the transition;
(e) Work with a case management agency to determine and enroll in the additional
home- and community-based services needed for a successful transition;
(f) Transition to a home- or community-based setting that complies with federal and
state rules; and
(g) Meet any other qualifications established by the state board by rule.
(4) The services provided to the eligible person under this part 15 must be based on the
eligible person's community living goals, assessed needs, and support plan, or any approved
resource allocation process as determined by the state department for the eligible person.
(5) The state department shall develop the accountability requirements necessary to
safeguard the use of public dollars, to promote effective and efficient delivery of services, and to
monitor the safety and welfare of persons receiving services pursuant to this part 15.
(6) The state board shall adopt rules as necessary for the implementation and
administration of the community transition services and supports authorized by this part 15,
including establishing limits on the units of service per eligible person to fit within available
appropriations.
(7) A person who has been designated as a legal guardian must be involved in the
decision-making related to the feasibility of a transition to a home- or community-based setting
and the choice of services and supports that may be needed to support a successful transition.
(8) Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or before
November 1, 2019, and each November 1 thereafter, the state department shall submit an annual
report to the health and human services committee of the senate, the public health care and
human services committee of the house of representatives, and the joint budget committee, or
any successor committees, on the effectiveness of providing the services and supports required
by this part 15. The report must include:
(a) An evaluation of the cost-effectiveness of the services; and
(b) For each year of the program, the number of persons who:
(I) Requested services;
(II) Received services;
(III) Transitioned from an institutional setting to a home- or community-based setting;
and
(IV) Transitioned from an institutional setting but later returned to an institutional
setting.
Source: L. 2018: Entire part added, (HB 18-1326), ch. 183, p. 1237, § 1, effective July 1.
PART 16
HOME CARE EMPLOYEES'
COMPENSATION AND TRAINING
25.5-6-1601. Definitions. As used in this part 16, unless the context otherwise requires:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 415 of 510
(1) "Compensation" has the meaning set forth in section 25.5-6-406 (2)(b)(I).
(2) [Editor's note: This version of subsection (2) is effective until July 1, 2025.] "Health
maintenance activities" has the meaning set forth in section 25.5-6-1202 (4).
(2) [Editor's note: This version of subsection (2) is effective July 1, 2025.] "Health
maintenance activities" has the meaning set forth in section 25.5-6-1901 (2).
(3) "Home care agency" has the meaning set forth in section 25-27.5-102 (3).
(4) [Editor's note: This version of subsection (4) is effective until July 1, 2025.]
"Homemaker services" has the meaning set forth in section 25.5-6-303 (11).
(4) [Editor's note: This version of subsection (4) is effective July 1, 2025.] "Homemaker
services" has the meaning as set forth in section 25.5-6-1901 (3).
(5) "In-home support service agency" has the meaning set forth in section 25.5-6-1202
(5).
(6) "In-home support services" has the meaning set forth in section 25.5-6-1202 (6);
except that the term does not include health maintenance activities.
(7) "Personal care services" has the meaning set forth in section 25-27.5-102 (6).
Source: L. 2019: Entire part added, (SB 19-238), ch. 319, p. 2964, § 1, effective May 28.
L. 2023: (2) and (4) amended, (SB 23-289), ch. 270, p. 1611, § 16, effective July 1, 2025.
Cross references: For additional definitions applicable to this part 16, see § 25.5-4-103.
25.5-6-1602. State department to request increase in reimbursement rate for certain
services. (1) Not more than ninety days after May 28, 2019, the state department shall request
from the federal government an increase of eight and one-tenth percent in the reimbursement
rate for the following services delivered to consumers through the home- and community-based
services waivers:
(a) Homemaker;
(b) Homemaker enhanced; and
(c) Personal care.
(2) For the 2019-20 fiscal year, each home care agency shall pay one hundred percent of
the funding that results from the rate increase described in subsection (1) of this section as
compensation for employees who provide personal care services, homemaker services, and
in-home support services to consumers. This compensation shall be provided in addition to the
rate of compensation that the employee was receiving as of June 30, 2019. For an employee who
was hired after June 30, 2019, the home care agency shall use the lowest compensation paid to
an employee of similar functions and duties as of June 30, 2019, as the base compensation to
which the increase is applied.
(3) Within sixty days after the request described in subsection (1) of this section is
approved, each home care agency shall provide written notification to each nonadministrative
employee of the agency who provides personal care services, homemaker services, or in-home
support services of the compensation they are entitled to pursuant to subsection (2) of this
section.
Source: L. 2019: Entire part added, (SB 19-238), ch. 319, p. 2965, § 1, effective May 28.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 416 of 510
25.5-6-1603. Minimum wage - wage pass-through requirement for certain home
care agencies - applicability - reports - recovery. (1) This section applies to each home care
agency that receives reimbursement pursuant to the "Colorado Medical Assistance Act" for the
provision of personal care services, homemaker services, or in-home support services.
(2) On and after July 1, 2020, the hourly minimum wage for persons who provide
personal care services, homemaker services, or in-home support services for which a home care
agency may receive reimbursement pursuant to the "Colorado Medical Assistance Act" is twelve
dollars and forty-one cents per hour.
(3) For any increase to the reimbursement rates for personal care services, homemaker
services, or in-home support services that takes effect during the 2020-21 fiscal year, home care
agencies shall use eighty-five percent of the funding resulting from the increase to increase
compensation for nonadministrative employees above the rate of compensation that
nonadministrative employees are receiving as of June 30, 2020. Home care agencies may use
any remaining funding resulting from the reimbursement rate increase for general and
administrative expenses, such as chief executive officer salaries, human resources, information
technology, oversight, business management, general record keeping, budgeting and finance, and
other activities not identifiable to a single program.
(4) (a) Each home care agency shall track and report how it used any funding resulting
from the increase in the reimbursement rate pursuant to this section or section 25.5-6-1602 using
a reporting tool developed by the state department. On or before December 31, 2020, each home
care agency shall submit the report to the state department demonstrating how the funding was
used to increase compensation for the 2019-20 fiscal year. On or before December 31, 2021,
each home care agency shall report to the state department how the funding was used to increase
or, in the event that there is no reimbursement rate increase, maintain each employee's
compensation for the 2020-21 fiscal year. The state department has ongoing discretion to request
information from a home care agency demonstrating how it maintained increases in
compensation for nonadministrative employees beyond the reporting period.
(b) Each home care agency shall maintain all books, documents, papers, accounting
records, and other evidence required to support the reporting of payroll information for increased
compensation to nonadministrative employees pursuant to subsection (4)(a) of this section for at
least three years from the reporting deadlines described in subsection (4)(a) of this section for
each respective fiscal year. Each home care agency shall make the information and materials
available for inspection by the state department or its designees at all reasonable times.
(5) (a) The state department may recoup part or all of the funding resulting from the
increase in the reimbursement rate described in this section or section 25.5-6-1602 if the state
department determines that a home care agency:
(I) Did not use one hundred percent of any funding resulting from the rate increase to
increase compensation for nonadministrative employees, as required by section 25.5-6-1602 (2);
(II) Did not use eighty-five percent of the funding resulting from the rate increase to
increase compensation for nonadministrative employees, as required by subsection (3) of this
section; or
(III) Failed to track and report how it used any funds resulting from the increase in the
reimbursement rate as required by subsection (4) of this section.
(b) If the state department makes a determination described in subsection (5)(a) of this
section, the state department shall notify the home care agency in writing of the state
Colorado Revised Statutes 2023 Uncertified PrintoutPage 417 of 510
department's intention to recoup funds pursuant to subsection (5)(a) of this section. A home care
agency has forty-five days after receiving such notice to:
(I) Challenge the determination of the state department;
(II) Provide additional information to the state department demonstrating compliance; or
(III) Submit a plan of correction to the state department.
(c) The state department shall notify a home care agency in writing of its final
determination after affording the home care agency the opportunity to take one of the actions
specified in subsection (5)(b) of this section.
(d) The state department shall recoup from a home care agency any funding resulting
from the increase in the reimbursement rate pursuant to this section or section 25.5-6-1602 that
the home care agency received but did not use for compensation for nonadministrative
employees if:
(I) The home care agency fails to respond to a notice of determination of the state
department within the time provided in subsection (5)(b) of this section;
(II) The home care agency is unable to provide documentation of compliance; or
(III) The state department does not accept the plan of correction submitted by the home
care agency pursuant to subsection (5)(b)(III) of this section.
Source: L. 2019: Entire part added, (SB 19-238), ch. 319, p. 2965, § 1, effective May 28.
25.5-6-1604. Training for home care agency employees - process for reviewing and
enforcing training requirements. (1) On or before January 1, 2020, the state department and
the department of public health and environment, in consultation with stakeholders, shall
establish a process for reviewing and enforcing initial and ongoing training requirements for
persons who provide personal care services, homemaker services, and in-home support services
for which a home care agency may receive reimbursement pursuant to the "Colorado Medical
Assistance Act", as such requirements are set forth in this section and in rules promulgated by
the state board. The stakeholders must include, but are not limited to:
(a) One or more consumer advocacy organizations;
(b) One or more personal care workers;
(c) One or more worker organizations;
(d) One or more home care agencies;
(e) One or more disability advocacy organizations;
(f) One or more senior advocacy organizations; and
(g) One or more children's advocacy organizations.
(2) The stakeholders with whom the departments consult pursuant to subsection (1) of
this section shall discuss and advise the departments concerning the manner in which
nonadministrative employees will be notified of the compensation increases and minimum wage
described in sections 25.5-6-1602 and 25.5-6-1603.
Source: L. 2019: Entire part added, (SB 19-238), ch. 319, p. 2967, § 1, effective May 28.
25.5-6-1605. Exemptions. (1) Notwithstanding any provision of this part 16 to the
contrary, this part 16 does not apply to services provided under:
(a) The consumer-directed attendant support services model; or
Colorado Revised Statutes 2023 Uncertified PrintoutPage 418 of 510
(b) The pediatric personal care benefit.
Source: L. 2019: Entire part added, (SB 19-238), ch. 319, p. 2968, § 1, effective May 28.
PART 17
CASE MANAGEMENT SERVICES FOR LONG-TERM
SERVICES AND SUPPORTS
25.5-6-1701. Legislative declaration. The general assembly finds and declares that there
is a need to ensure a high-performing statewide case management system exists that serves all
populations of people who qualify for long-term services and supports. The case management
system includes, but is not limited to, intake and eligibility screening and determination,
outreach, and other administrative activities and case management services. The five key
outcomes of the statewide case management system must include federal compliance, quality,
simplicity, stability, and accountability.
Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 313, § 1, effective
September 7.
25.5-6-1702. Definitions. As used in this part 17, unless the context otherwise requires:
(1) "Authorized representative" means a person designated by the member receiving
services, or by the parent or guardian of the member receiving services, if appropriate, to assist
the member in acquiring or utilizing long-term services and supports pursuant to this article 6
and article 10 of this title 25.5. The extent of the authorized representative's involvement must be
determined upon designation.
(2) "Case management agency" means a public or private not-for-profit or for-profit
organization contracted with the state of Colorado to provide case management services and
activities.
(3) "Case management services" means the assessment of an individual's need for
long-term services and supports; the development and implementation of a person-centered
support plan for the member; the coordination, monitoring, and delivery of long-term services
and supports; the evaluation of service effectiveness; and the reassessment of the member's
needs, all of which must be performed by a case management agency or an entity.
(4) "Case manager" means a person who provides case management services and
activities pursuant to this article 6 and article 10 of this title 25.5 for members receiving
long-term services and supports.
(5) "Community-centered board" means a private for-profit or not-for-profit
organization that is an administrator of locally generated funding pursuant to section
25.5-10-206 (6) and acts as a resource for persons with an intellectual and developmental
disability or a child with a developmental delay.
(6) "Conflict-free case management" means case management services and activities
provided to a member enrolled in a home- and community-based services waiver by an entity
other than the entity providing direct long-term services and supports, except as otherwise
Colorado Revised Statutes 2023 Uncertified PrintoutPage 419 of 510
allowed pursuant to 42 CFR 441.301 (c)(1)(vi). Service providers, case management agencies,
and entities are responsible for ensuring employees meet the requirements of this article 6.
(7) "Defined service area" means the geographical area determined by the state
department to be served by a case management agency.
(8) "Entity" means a public or private not-for-profit or for-profit organization, which
may include a community-centered board, that has a contract or agreement with the state of
Colorado to perform specific functions.
(9) "Intellectual and developmental disability" has the same meaning as set forth in
section 25.5-6-403 (3.3)(a).
(10) "Long-term services and supports" means the services and supports used by
members of all ages with functional limitations and chronic illnesses who need assistance to
perform routine daily activities.
(11) "Member" means any person enrolled in the state medical assistance program,
articles 4, 5, and 6 of this title 25.5, or the children's basic health plan, article 8 of this title 25.5.
(12) "Person-centered support plan" means a long-term services and supports plan that is
directed by the member, or the member's legal guardian, and prepared by the case manager to
identify the supports needed for the member to achieve personally identified goals and is based
on respecting and valuing member preferences, strengths, and contributions.
(13) "Person with an intellectual and developmental disability" has the same meaning as
set forth in section 25.5-6-403 (3.3)(b).
(14) "Service provider" means an agency or individual certified by the state department
and enrolled to provide one or more long-term services and supports.
(15) "Waiting list" has the same meaning as set forth in section 25.5-10-202 (38).
Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 313, § 1, effective
September 7.
25.5-6-1703. Case management system - defined service areas - case management
services - only willing and qualified provider exemption - rules. (1) No later than July 1,
2024, the state board shall adopt rules providing for the establishment of a case management
system that consists of case management agencies throughout the state for the purpose of
enabling individuals in need of long-term care to access appropriate long-term services and
supports. Members in need of specialized assistance may be referred to other services outside of
long-term services and supports, as necessary for additional care coordination.
(2) No later than December 31, 2021, the state department shall work with stakeholders
to develop a timeline for the implementation of this part 17.
(3) (a) No later than December 31, 2022, the state department shall issue a competitive
solicitation in order to select case management agencies pursuant to subsection (1) of this
section. The competitive solicitation must include a reimbursement structure developed through
a fiscal analysis.
(b) No later than January 31, 2023, the state department shall provide an update on the
status of the implementation of this part 17 to the joint budget committee of the general
assembly as part of its annual presentation to that committee.
(4) The state department shall utilize a stakeholder process to identify defined service
areas for case management agencies across the state.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 420 of 510
(5) A case management agency may provide case management services to private paying
individuals on a fee-for-service basis and shall provide case management services to members of
publicly funded long-term services and supports programs, including but not limited to programs
created pursuant to this article 6 and article 10 of this title 25.5.
(6) Where applicable, the state department is authorized to seek a federal exemption
from conflict-free case management requirements for defined service areas within the state
where the only willing and qualified entity to provide case management services is also the only
willing and qualified entity to provide home- and community-based services in that defined
service area.
(7) The state board shall utilize a stakeholder process when promulgating rules to
implement this section.
Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 315, § 1, effective
September 7.
25.5-6-1704. Intellectual and developmental disability determination - functional
eligibility determination - rules. (1) Intellectual and developmental disability
determination. Any person may request an evaluation to determine whether the person has a
developmental delay or an intellectual and developmental disability and is eligible to receive
long-term services and supports pursuant to this article 6 and article 10 of this title 25.5. The
person must request a developmental delay determination or intellectual and developmental
disabilities determination from the case management agency or the entity in the defined service
area where the person resides.
(2) Functional eligibility determination. Pursuant to the contract with the state
department, a case management agency shall determine whether a person is eligible to receive
long-term services and supports pursuant to this article 6 and article 10 of this title 25.5. A case
management agency or an entity shall develop a person-centered support plan for persons
eligible for long-term services and supports for home- and community-based services and state
general-funded programs.
(3) The state board shall promulgate rules pursuant to article 4 of title 24 setting forth the
procedure and criteria for determination of eligibility and person-centered support plan
development. The procedure and criteria must be uniform in nature and applied throughout the
state in a consistent manner.
(4) Subject to available appropriations pursuant to section 25.5-10-206 and to the
capacity of a service provider, the person must be provided options for long-term services and
supports within the defined service area that can appropriately meet the person's identified needs,
pursuant to this section.
Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 316, § 1, effective
September 7.
25.5-6-1705. Person-centered support plan. (1) Each member receiving services shall
have a person-centered support plan, or a similar plan specified by the state department,
developed and managed by a case management agency or an entity, and subject to review and
approval pursuant to section 25.5-6-404. The person-centered support plan shall:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 421 of 510
(a) Be based on the particular service needs of the member receiving services;
(b) Describe the services necessary to avoid institutionalization;
(c) Ensure the member receives services in the setting of the member's choice; and
(d) Identify the supports needed for the member to achieve personally identified goals.
(2) Pursuant to this section, the person-centered support plan for each member receiving
services must be reviewed at least annually and modified as necessary or appropriate.
(3) A person-centered support plan is not required for a person with an intellectual and
developmental disability or a developmental delay who is eligible for long-term services and
supports and who is on a waiting list for enrollment into a program funded pursuant to article 10
of this title 25.5. Each case management agency shall provide information and referral services
to each member on the waiting list for enrollment in a program at the time of the member's
eligibility and annually thereafter, regarding long-term services and supports that are relevant to
persons and are commonly used by persons with intellectual and developmental disabilities and a
developmental delay as provided by rules promulgated by the state board. The criteria for
information and referral must be uniform in nature and applied throughout the state in a
consistent manner.
Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 316, § 1, effective
September 7.
25.5-6-1706. Termination of long-term services and supports for member receiving
services. (1) A member receiving long-term services and supports pursuant to this article 6 or
article 10 of this title 25.5 must be terminated from long-term services and supports upon a
determination, made pursuant to the person-centered support planning process, that the
long-term services and supports are no longer necessary. Prior to the effective date of the
termination, notification of termination must be given to the member receiving services, the
parents or guardian of a minor receiving services, and the person's legal guardian or other legal
representative when applicable. A member terminated from services pursuant to this subsection
(1) has a right to challenge the termination in accordance with state department rules.
(2) When a member receiving services notifies the case management agency that the
member no longer wishes to receive long-term services and supports, the member must be
terminated from long-term services and supports unless the member is subject to a petition to
impose a legal disability or to remove a legal right, filed pursuant to section 25.5-10-216, or the
member has a legal guardian or other legal representative appointed affecting the member's
ability to voluntarily terminate long-term services and supports. The parents of a minor who is
receiving long-term services and supports and the minor's guardian must be notified of the
minor's wish to terminate long-term services and supports, but no minor's long-term services and
supports will be terminated without the consent of the minor's parent or legal guardian.
Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 317, § 1, effective
September 7.
25.5-6-1707. Records and confidentiality of information. (1) A record for each
member receiving services must be diligently maintained by the case management agency or the
entity. The record must include, but not be limited to, information pertaining to the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 422 of 510
determination of eligibility for services and the person-centered support plan. The record is not a
public record for purposes of the "Colorado Open Records Act", part 2 of article 72 of title 24.
(2) Except as otherwise provided by law, all information obtained and any records
prepared in the course of determining eligibility or providing long-term services and supports
pursuant to this article 6 or article 10 of this title 25.5 are confidential and subject to the
evidentiary privileges established by law. The disclosure of this information and these records in
any manner is permitted only:
(a) To the applicant or member receiving services, to the parents of a minor receiving
services, to the member's legal guardian, or to any person authorized by the member receiving
services;
(b) In communications between qualified professional personnel, including the board of
directors or governing body of the case management agency and service agencies providing
services to the member, to the extent necessary for the acquisition, provision, oversight, or
referral of long-term services and supports;
(c) To the extent necessary to make claims for aid, insurance, or medical assistance to
which a member receiving services may be entitled, or to access long-term services and supports
pursuant to the person-centered support plan;
(d) For the purposes of evaluation, gathering statistics, or research when no identifying
information concerning a person or family is disclosed. Identifying information is information
which could reasonably be expected to identify a specific person and includes, but is not limited
to, name, address, telephone number, social security number, medicaid number, household
number, and photograph.
(e) To the court when necessary to implement the provisions of this article 6 or article 10
of this title 25.5;
(f) To persons authorized by a court order issued after a hearing, notice of which was
given to the member, parents or legal guardian, where appropriate, and the custodian of the
information;
(g) To safeguard the health and safety of an at-risk member by coordinating appropriate
services and medical supports;
(h) To the agency designated pursuant to 45 CFR 1326.20 as the protection and
advocacy system for Colorado when:
(I) The protection and advocacy system receives a complaint from or on behalf of a
member receiving services; and
(II) The person does not have a legal guardian or the state or the designee of the state is
the legal guardian of the person; and
(i) To the state department or the state department's designees as deemed necessary by
the executive director to fulfill the duties prescribed by this article 6 or article 10 of this title
25.5.
(3) Nothing in this section limits a member receiving services access to the member's
records.
(4) Nothing in this section interferes with the protections afforded to a person under the
federal "Health Insurance Portability and Accountability Act of 1996", 42 U.S.C. sec. 1320d, and
the federal "Family Educational Rights and Privacy Act of 1974", 20 U.S.C. sec. 1232g.
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Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 318, § 1, effective
September 7.
25.5-6-1708. Performance audits - Colorado local government audit law - public
disclosure of board administration and operations. (1) The state auditor may conduct or
cause to be conducted a performance audit that includes each case management agency or each
entity that receives more than seventy-five percent of its funding on an annual basis from the
federal, the state, or a local government or from any combination of governmental entities to
determine whether the board of directors or the governing body is effectively and efficiently
fulfilling its statutory obligations. A case management agency or an entity becomes subject to
the audit requirement under this subsection (1) at the time the case management agency or the
entity initially satisfies the seventy-five percent funding requirement for any one year regardless
of whether or not the funding level decreases below seventy-five percent in any subsequent year.
The state auditor shall submit a written report and recommendations on each audit conducted
pursuant to this subsection (1) and shall present the report and recommendations to the
legislative audit committee created in section 2-3-101 (1). The state auditor shall pay the costs of
any performance audit conducted pursuant to this section.
(2) Each case management agency and each entity is subject to the requirements of the
"Colorado Local Government Audit Law", part 6 of article 1 of title 29.
(3) In connection with the board of directors or the governing body of each case
management agency or each entity, in addition to any other requirements applicable to the
operation of the board of directors or the governing body pursuant to this section or as required
elsewhere by law:
(a) The case management agency or the entity shall post the date, time, and location of
each regularly scheduled meeting of the board of directors or the governing body on the website
of the case management agency or the entity not less than fourteen business days before the
meeting. The case management agency or the entity shall post the date, time, and location of any
special or emergency meeting of the board of directors or the governing body on the website of
the case management agency or the entity not less than twenty-four hours before the meeting.
(b) Each case management agency or each entity shall post the agenda for each meeting
of the board of directors or the governing body on the website of the case management agency or
the entity not less than seven business days before the meeting. The case management agency or
the entity shall post the agenda of any special or emergency meeting of the board of directors or
the governing body on the website of the case management agency or the entity not less than
twenty-four hours before the meeting. Each meeting of the board of directors or the governing
body must allow for public comment, and the agenda must reflect this requirement. Public
comment must be reasonably permitted during the board's or the governing body's meeting to
accommodate community needs. Any documents related to functions of the case management
agency or the entity to be distributed at a meeting of the board of directors or the governing body
that are available for public dissemination at the time the agenda is posted must also be posted
on the website of the case management agency or the entity at the time the agenda is posted.
Written copies of the documents must be made available for public dissemination at the board of
directors' or the governing body's meeting; except that the posting requirement specified in this
subsection (3)(b) does not apply to any document, or any portion of a document, the disclosure
of which requires the approval of the board of directors or the governing body and which
Colorado Revised Statutes 2023 Uncertified PrintoutPage 424 of 510
approval has not been obtained at the time the agenda is posted or any other document, or any
portion of a document, containing any information that is legally prohibited from being disclosed
to the public pursuant to the privacy requirements specified in the federal "Health Insurance
Portability and Accountability Act of 1996", 42 U.S.C. sec. 1320d, any document that has been
or will be discussed by the board of directors or the governing body meeting in executive
session, or any other document the disclosure of which is otherwise prohibited by law.
(c) Each case management agency and each entity shall provide a direct e-mail address
to each member of the board of directors or the governing body on the website of the case
management agency or the entity. The e-mail address selected must specify the name of the
individual board or governing body member and make reference to the particular case
management agency or entity for which the board or governing body member serves as a
member of the board of directors or the governing body. An e-mail that is sent to a member of
the board of directors or the governing body of a case management agency or an entity must not
be filtered by the case management agency or the entity through an employee of the case
management agency or the entity before it is sent to the board or governing body member.
(d) The board of directors or the governing body of each case management agency or
each entity shall present the financial statements of the organization for the approval of the board
of directors or the governing body at each regularly scheduled meeting of the board of directors
or the governing body. The financial statements must reflect accurate and current financial
information and be prepared using generally accepted accounting principles. Where exigent
circumstances are present that materially affect the preparation of the financial statements on a
monthly basis, the statements may be presented for the approval of the board of directors or the
governing body at the next regularly scheduled meeting of the board of directors or the
governing body but not less than at least once each quarter of the calendar year.
(e) Each case management agency and each entity shall require the person or
organization that performs financial audits of the case management agency or the entity to
present and discuss the results of the audit to the board of directors or the governing body not
less than once each year at a regularly scheduled meeting of the board of directors or the
governing body;
(f) Each case management agency and each entity shall provide to the incoming
members of the board of directors or the governing body training in such topics as the duties of a
board or governing body member, the financial and fiduciary responsibilities assumed by board
or governing body members, the intellectual and developmental disability and long-term services
and supports system in the state, the overall business functions of the case management agency
or the entity, and any other matters that will, in the determination of the case management
agency or the entity, allow the board or governing body member to better understand and fulfill
the board or governing body member's obligations to the board of directors or the governing
body and the case management agency or the entity and the role played by the case management
agency or the entity in the state in connection with the delivery of services for members
receiving services pursuant to this article 6 and article 10 of this title 25.5; and
(g) Each case management agency and each entity shall post on the website of the case
management agency or the entity the minutes of each meeting of its board of directors or its
governing body as the minutes are approved by the board of directors or the governing body.
Each case management agency and each entity shall also post on the website of the case
management agency or the entity any additional documents that were distributed to the board or
Colorado Revised Statutes 2023 Uncertified PrintoutPage 425 of 510
governing body at the meeting that were not, as of that date, already posted on the website of the
case management agency or the entity unless the public distribution of the documents, or any
portion of the documents, is otherwise prohibited pursuant to the privacy requirements specified
in the federal "Health Insurance Portability and Accountability Act of 1996", 42 U.S.C. sec.
1320d, or as otherwise prohibited by law. Minutes of special meetings of the board of directors
or the governing body must be posted on the website of the case management agency or the
entity after approval by the board of directors or the governing body at the board's or governing
body's next regular meeting.
(4) With respect to financial information concerning the case management agency or the
entity, each case management agency or each entity shall:
(a) Post the following on the website of the case management agency or the entity in a
place that allows access to the public in a clear, accessible, easily operated, and uncomplicated
manner:
(I) Each completed financial audit undertaken of the case management agency or the
entity not later than thirty days following acceptance by the organization's board of directors or
governing body of the audit. Any case management agency or any entity that is not required to
have an annual audit of financial statements shall post a detailed account of the agency's or
entity's assets, liabilities, revenue, losses and gains, expenses, investing activities, property and
equipment, and any other relevant financial disclosures required by the state department.
(II) The most current form 990 the case management agency or the entity has filed with
the federal internal revenue service not later than thirty days following filing of the form with the
federal internal revenue service. Any case management agency or any entity that is not required
to prepare and file a form 990 shall disclose and post the for-profit equivalent federal internal
revenue services tax form that includes the total number of individuals employed, all
executive-level employee salaries and other compensation, and employee benefits, as required
by the state department.
(b) Make the following information available upon reasonable request not later than five
business days after the request is made:
(I) The annual budget of the case management agency or the entity for each calendar or
fiscal year, as applicable, not later than thirty days after final approval of the budget by the board
of directors or the governing body of the case management agency or the entity;
(II) An annual summary of all revenues and expenditures of the case management
agency or the entity that have been appropriated by the state department that is calculated by
September 30 of each year for the prior year, as applicable; and
(III) A description of the policies and procedures the case management agency or the
entity follows to track, manage, and report its financial resources and transactions, which
policies and procedures are also known and may be referred to as its "financial controls".
(5) Any contract that each case management agency or each entity enters into with either
the state department or the department of human services, created in section 26-1-105, must be
posted on the website of the case management agency or the entity in a place that allows access
to the public in a clear, accessible, easily operated, and uncomplicated manner not later than
thirty days following approval of the contract by the board of directors or the governing body of
the case management agency or the entity.
(6) This section does not apply to a county agency, including a county department of
human or social services, a county nursing service, an area agency on aging, or a multicounty
Colorado Revised Statutes 2023 Uncertified PrintoutPage 426 of 510
agency acting as a case management agency that already has existing or duplicative audit and
transparency requirements.
Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 319, § 1, effective
September 7.
25.5-6-1709. Community-centered board designation - rules. The state department
shall develop a process to designate local or regional organizations as community-centered
boards. The state department shall promulgate rules outlining the designation process no later
than July 1, 2024. Any contracts or agreements entered into pursuant to this section are exempt
from the "Procurement Code", articles 101 to 112 of title 24.
Source: L. 2021: Entire part added, (HB 21-1187), ch. 83, p. 323, § 1, effective
September 7.
PART 18
COLORADO MEDICAL ASSISTANCE PROGRAM
REQUIREMENTS FOR DISBURSEMENT OF
FEDERAL FUNDS UNDER THE
FEDERAL "AMERICAN RESCUE PLAN ACT OF 2021"
25.5-6-1801. Legislative declaration. (1) The general assembly finds and declares that
Colorado has a long-standing commitment to serving older adults and people with disabilities
through home- and community-based services that enable them to stay in their homes in their
communities.
(2) Therefore, the general assembly declares that Colorado is committed to maximizing
the impact of the one-time, ten-percentage-point increase in the federal matching rate for
medicaid home- and community-based services, as outlined in section 9817 of the federal
"American Rescue Plan Act of 2021", to implement or supplement the implementation of one or
more activities to enhance, expand, and strengthen medicaid-funded home- and
community-based services.
Source: L. 2021: Entire part added, (SB 21-286), ch. 395, p. 2621, § 1, effective June 30.
25.5-6-1802. Definitions. As used in this part 18, unless the context otherwise requires:
(1) "American Rescue Plan Act" means the federal "American Rescue Plan Act of
2021", Pub.L. 117-2, as amended.
(2) "Home- and community-based services" means any of the following:
(a) Home health-care services authorized pursuant to paragraph (7) of section 1905(a) of
the "Social Security Act", 42 U.S.C. 1396d(a);
(b) Personal care services authorized pursuant to paragraph (24) of section 1905(a) of
the "Social Security Act", 42 U.S.C. 1396d(a);
(c) PACE services authorized pursuant to paragraph (26) of section 1905(a) of the
"Social Security Act", 42 U.S.C. 1396d(a);
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(d) Home- and community-based services authorized pursuant to subsections (b), (c), (i),
(j), and (k) of section 1915 of the "Social Security Act", 42 U.S.C. 1396n; services authorized
pursuant to a waiver under section 1115 of the "Social Security Act", 42 U.S.C. 1315; and
services through coverage authorized under section 1937 of the "Social Security Act", 42 U.S.C.
1396u-7;
(e) Case management services authorized under section 1905(a)(19) of the "Social
Security Act", 42 U.S.C. 1396d(a)(19), and section 1915(g) of the "Social Security Act", 42
U.S.C. 1396n(g);
(f) Rehabilitative services, including those related to behavioral health, described in
section 1905(a)(13) of the "Social Security Act", 42 U.S.C. 1396d(a)(13); and
(g) Such other services specified by the United States secretary of health and human
services.
(3) "Social Security Act" means the federal "Social Security Act", as amended.
Source: L. 2021: Entire part added, (SB 21-286), ch. 395, p. 2622, § 1, effective June 30.
25.5-6-1803. Development of spending plan. (1) In accordance with federal guidance
issued by the federal centers for medicare and medicaid services regarding the implementation of
section 9817 of the "American Rescue Plan Act", the state department shall develop a proposed
spending plan using the enhanced funding, which plan may include but is not limited to the
following components:
(a) Consideration of methods to maximize federal financial participation;
(b) Incorporation of feedback from medical assistance recipients, advocates, and
providers for the services for which the "American Rescue Plan Act" provides additional federal
financial participation;
(c) Expedition of the response and recovery for medical assistance recipients, providers,
and other relevant organizations most significantly impacted by the COVID-19 pandemic.
Response and recovery efforts may include but are not limited to:
(I) One-time provider rate increases to support organizations and the direct-care workers
impacted by COVID-19;
(II) One-time payments to support infection control; and
(III) Tribal grants to increase access to and use of home- and community-based services
on tribal lands;
(d) Advancement and acceleration of existing and newly identified system reform
efforts. Advancement and acceleration efforts may include but are not limited to:
(I) Support for local organizations and stakeholders to plan and prepare for the
implementation of case management redesign efforts;
(II) Analysis and development of recommendations to better stabilize existing rural
providers and to expand provider access in rural communities;
(III) Analysis and development of recommendations for new models of care for
investment and innovation;
(IV) Development of pay for performance programs;
(V) Improvement of provider certification oversight;
(VI) Development of acuity tools for long-term home health;
(VII) Development of training to align with 988 mobile dispatch;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 428 of 510
(VIII) Analysis and development of recommendations for implementing behavioral
health peer supports for day services serving people experiencing homelessness;
(IX) Development of transition support services for people with complex behavioral
needs;
(X) Provider capacity-building to serve people with high-intensity needs;
(XI) Development of provider cultural and disability competency training; and
(XII) Home- and community-based services through the community first choice option,
section 1915(k) of the "Social Security Act", 42 U.S.C. 1396n;
(e) Investment in infrastructure and technology innovation that has a long-term benefit to
the system and the people of Colorado, including integration with other statewide and local
efforts. Investments may include but are not limited to:
(I) Comprehensive training for case managers and providers;
(II) System enhancements to support streamlined eligibility;
(III) Member and family material on case management, care coordination, and home-
and community-based services;
(IV) Expanding recipient access to technology and technology literacy training;
(V) Capital funding for IT infrastructure to purchase devices to support the
implementation of the care and case management tool; and
(VI) Telemedicine and telehealth one-time payments to support equipment for service
delivery; and
(f) Development and stabilization of the direct-care workforce. Efforts may include but
are not limited to:
(I) The analysis of nationwide efforts to strengthen the direct-care workforce;
(II) Development of a strategic plan to stabilize the direct-care workforce, including
plans for rural sustainability;
(III) Consideration of direct-care worker wage sustainability through increased rates and
potential wage pass-through programs;
(IV) Development of training programs focusing on additional career pathways; and
(V) Creation of structure around recruitment, retention, and public awareness of
direct-care work.
(2) The state department shall continue to engage stakeholders for input concerning
prioritization of the use of the enhanced funding from the "American Rescue Plan Act".
Source: L. 2021: Entire part added, (SB 21-286), ch. 395, p. 2622, § 1, effective June 30.
25.5-6-1804. Spending plan - approval by joint budget committee - reporting. (1) (a)
As soon as practicable after receiving federal guidance, the state department shall submit a
proposed spending plan for expenditures pursuant to this part 18 to the joint budget committee
for the committee's rejection or approval. If a proposed spending plan is rejected, the state
department shall resubmit a new plan as soon as possible. The joint budget committee may make
recommendations for modifications to the spending plan. The state department shall not
implement the spending plan unless the joint budget committee approves the spending plan.
(b) The state department shall identify in the plan the data, research, and evidence used
to determine the spending plan in a manner consistent with the instructions published by the
office of state planning and budgeting pursuant to section 24-37-302 (1)(a).
Colorado Revised Statutes 2023 Uncertified PrintoutPage 429 of 510
(c) The spending plan must incorporate any available federal funds.
(d) The state department shall not include provisions in the spending plan or implement
provisions of the spending plan that are not eligible for funding pursuant to federal guidance
relating to the "American Rescue Plan Act".
(2) Commencing November 1, 2021, and occurring quarterly thereafter, the state
department shall report to the joint budget committee concerning the status of expenditures
pursuant to this part 18.
(3) The reports must include:
(a) The scope, intended impact, and amount of money disbursed from the money
received pursuant to the "American Rescue Plan Act";
(b) A description of how the state department incorporated stakeholder feedback into
plans for the disbursement of money; and
(c) An update as to the total amount of money disbursed from the money received
pursuant to the "American Rescue Plan Act", the remaining amount of money, and the projected
amount of anticipated federal financial participation.
Source: L. 2021: Entire part added, (SB 21-286), ch. 395, p. 2624, § 1, effective June 30.
25.5-6-1805. Home- and community-based services improvement fund - creation -
transfer - expenditures. (1) The home- and community-based services improvement fund,
referred to in this section as the "fund", is created in the state treasury. The fund consists of
money transferred to the fund pursuant to subsection (2) of this section.
(2) (a) On June 30, 2021, the state treasurer shall transfer two hundred sixty million
seven hundred thirty thousand ninety-nine dollars from the general fund to the fund.
(b) (I) If the general fund savings due to the enhanced federal match under section 9817
of the "American Rescue Plan Act" is greater than the amount transferred to the fund under
subsection (2)(a) of this section, then the state department shall notify the state treasurer of the
amount by which the savings exceeded the transfer. The state treasurer shall transfer this amount
of money from the general fund to the fund.
(II) If the general fund savings due to the enhanced federal match under section 9817 of
the "American Rescue Plan Act" is less than the amount transferred to the fund under subsection
(2)(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 of money
from to the fund to the general fund.
(3) The state treasurer shall credit all interest and income derived from the deposit and
investment of money in the fund to the general fund.
(4) (a) Money in the fund is appropriated to the state department for the fiscal year
commencing on July 1, 2021, for the expenditures identified in the spending plan approved by
the joint budget committee pursuant to section 25.5-6-1804; except that the spending authority
conferred by this subsection (4)(a) expires if a supplemental appropriation bill that appropriates
money from the fund to the state department is enacted.
(b) During the next legislative session, the joint budget committee shall introduce a
supplemental appropriation bill with the specific expenditures authorized under subsection (4)(a)
of this section.
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(5) For fiscal years commencing on and after July 1, 2021, money in the fund is subject
to annual appropriation to enhance, expand, and strengthen medicaid home- and
community-based services pursuant to section 9817 of the "American Rescue Plan Act".
(6) The state department may use the money in the fund for reasonable and necessary
administrative costs associated with implementing this part 18.
Source: L. 2021: Entire part added, (SB 21-286), ch. 395, p. 2625, § 1, effective June 30.
25.5-6-1806. Repeal of part. This part 18 is repealed, effective July 1, 2025.
Source: L. 2021: Entire part added, (SB 21-286), ch. 395, p. 2626, § 1, effective June 30.
PART 19
COMMUNITY FIRST CHOICE
25.5-6-1901. Definitions. As used in this part 19, unless the context otherwise requires:
(1) "Electronic monitoring" means the installation, purchase, or rental of electronic
monitoring devices that enable an individual to secure help in the event of an emergency;
provide the individual reminders about medical appointments, treatment, or medication
schedules; are required because of the individual's illness, impairment, or disability; and include
personal emergency response systems and medication reminders through an automated
medication dispensing system.
(2) "Health maintenance activities" means routine and repetitive health-related tasks
furnished to a member in the community or in the member's home that are necessary for the
health and normal bodily functioning that a person with a disability is physically unable to carry
out. "Health maintenance activities" includes skilled tasks typically performed by a certified
nursing assistant or a licensed nurse that do not require the clinical assessment and judgment of a
licensed nurse.
(3) "Homemaker services" means general household activities provided by an attendant
in a member's home to maintain a healthy and safe environment for the member through
hands-on assistance, supervision, or cueing. "Homemaker services" must only be provided in the
member's primary living space and multiple attendants shall not be reimbursed for duplicating
such services.
(4) "Personal care services" means services that are furnished to a member to meet the
member's physical, maintenance, and supportive needs through hands-on assistance, supervision,
or cueing that do not require a nurse's supervision or physician's order.
Source: L. 2023: Entire part added, (SB 23-289), ch. 270, p. 1603, § 1, effective May 25.
25.5-6-1902. Community first choice option - covered services - state plan
amendment. (1) No later than July 1, 2025, the state department shall seek federal authorization
through an amendment to the state medical assistance plan to implement the community first
choice option.
(2) At a minimum, the state plan amendment must provide for, but is not limited to:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 431 of 510
(a) The following services:
(I) Personal care services;
(II) Homemaker services;
(III) Health maintenance activities;
(IV) Electronic monitoring services; and
(V) Voluntary training on how to select, manage, and dismiss an attendant; and
(b) The delivery of covered services, if applicable, through:
(I) In-home support services;
(II) Consumer-directed services and supports; and
(III) Licensed home care services.
Source: L. 2023: Entire part added, (SB 23-289), ch. 270, p. 1604, § 1, effective May 25.
25.5-6-1903. Permissible services and supports. (1) The state department may provide
permissible services and supports that are linked to an assessed need or goal in the individual's
person-centered service plan. Permissible services and supports may include, but are not limited
to, the following:
(a) Expenditures for transition costs, such as rent and utility deposits, first month's rent
and utilities, bedding, basic kitchen supplies, and other necessities linked to an assessed need for
an individual to transition from a nursing facility, institution for behavioral or mental health
disorders, or intermediate care facility for individuals with intellectual disabilities, to a home-
and community-based setting where the individual resides; and
(b) Expenditures relating to a need identified in an individual's person-centered service
plan that increases an individual's independence or substitutes for human assistance, to the extent
that would otherwise be made for human assistance.
Source: L. 2023: Entire part added, (SB 23-289), ch. 270, p. 1604, § 1, effective May 25.
25.5-6-1904. Maintenance of effort. In implementing the community first choice option,
the state department shall ensure continuity of support for eligible individuals who were
receiving services as of July 1, 2025, and who have maintained eligibility in the state medical
assistance program since that date.
Source: L. 2023: Entire part added, (SB 23-289), ch. 270, p. 1605, § 1, effective May 25.
25.5-6-1905. Eligibility. (1) To be eligible for the community first choice option, an
individual must:
(a) Be eligible for the state medical assistance program;
(b) Be in an eligibility group under the state medical assistance program that includes
nursing facility services, or if in an eligibility group that does not include nursing facility
services, have an income that is at or below one hundred fifty percent of the federal poverty
level. The state department shall determine whether an individual is at or below one hundred
fifty percent of the federal poverty level on an annual basis by applying the same methodologies
that apply under the state medical assistance program, including the same less restrictive
Colorado Revised Statutes 2023 Uncertified PrintoutPage 432 of 510
resource methodologies described in the federal "Social Security Act", 42 U.S.C. sec. 1902
(r)(2).
(c) (I) Receive an annual determination that in the absence of the home- and
community-based attendant services and supports provided pursuant to the community first
choice option, the individual would require the level of care furnished in a hospital, a nursing
facility, an intermediate care facility to an individual with intellectual disabilities, an institution
providing inpatient psychiatric services to an individual under twenty-one years of age, or an
institution for behavioral or mental health disorders for an individual sixty-five years of age or
older if the cost could be reimbursed under the state medical assistance program.
(II) The state department may, at its discretion, permanently waive the annual
determination for an individual if the state department:
(A) Determines there is no reasonable expectation of improvement or significant change
in the individual's condition because of the severity of a chronic condition or the degree of
impairment of functional capacity; and
(B) Retains documentation of the reason for waiving the individual's annual
determination requirement.
(2) For the purposes of meeting the requirements of subsection (1)(b) of this section, an
individual who qualifies for medical assistance pursuant to the special home- and
community-based waiver eligibility group defined in the federal "Social Security Act", 42 U.S.C.
sec. 1902 (a)(10)(A)(ii)(VI), shall meet all the requirements in 42 U.S.C. sec. 1915(c) and
receive at least one home- and community-based waiver service per month.
(3) Individuals receiving services through the community first choice option must not be
precluded from receiving other home- and community-based long-term care services and
supports through other state medical assistance program waivers, grants, or demonstration
authorities.
Source: L. 2023: Entire part added, (SB 23-289), ch. 270, p. 1605, § 1, effective May 25.
CHILDREN'S BASIC HEALTH PLAN
ARTICLE 8
Children's Basic Health Plan
Editor's note: This article was added with relocations in 2006 containing provisions of
some sections formerly located in article 19 of title 26. Former C.R.S. section numbers are
shown in editor's notes following those sections that were relocated. For a detailed comparison
of this article, see the comparative tables located in the back of the index.
25.5-8-101. Short title. This article shall be known and may be cited as the "Children's
Basic Health Plan Act".
Source: L. 2006: Entire article added with relocations, p. 1973, § 7, effective July 1.
Editor's note: This section is similar to former § 26-19-101 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 433 of 510
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) 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.
(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;
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 434 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1973, § 7, effective July 1.
Editor's note: This section is similar to former § 26-19-102 as it existed prior to 2006.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 435 of 510
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
(b) Waives charges or charges for services on a sliding scale based on income and does
not restrict access or services because of a client'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.
Source: L. 2006: Entire article added with relocations, p. 1975, § 7, effective July 1. L.
2007: (4) amended, p. 149, § 10, effective March 22. L. 2008: (4)(a) amended, p. 2019, § 1,
effective March 1, 2009; (4)(b) amended, p. 2019, § 2, effective October 1, 2009. L. 2009: (4)(a)
and (4)(b) amended, (SB 09-211), ch. 2, pp. 3, 4, § § 1, 2, 3, effective February 26; (4) amended,
(HB 09-1293), ch. 152, p. 650, § 8, effective July 1; (4)(b) amended, (SB 09-292), ch. 369, p.
1985, § 130, effective August 5. L. 2010: (4)(a)(I), (4)(a)(II), (4)(a)(III)(A), (4)(a)(III)(B),
(4)(b)(I), (4)(b)(II), (4)(b)(III)(A), and (4)(b)(III)(B) amended, (HB 10-1422), ch. 419, p. 2114, §
150, effective August 11. L. 2017: IP, (4)(a)(II), and (4)(b)(II) amended, (SB 17-267), ch. 267,
p. 1466, § 22, effective July 1. L. 2022: (4)(a)(I), (4)(a)(II), (4)(b)(I), and (4)(b)(II) amended,
(SB 22-052), ch. 43, p. 217, § 4, effective March 24; (4)(a)(I) and (4)(b)(I) amended, (HB
22-1289), ch. 399, p. 2844, § 20, effective June 7.
Editor's note: (1) This section is similar to former § 26-19-103 as it existed prior to
2006.
(2) Subsection (4)(a)(III)(C) and (4)(b)(III)(C) provided for the repeal of subsection
(4)(a)(III) and (4)(b)(III), respectively, effective the July 1 following the revisor of statutes'
Colorado Revised Statutes 2023 Uncertified PrintoutPage 436 of 510
receipt of the notice required pursuant to subsection (4)(a)(III)(B) and (4)(b)(III)(B). (See L.
2010, p. 2114.) The revisor of statutes received said notice dated February 17, 2017.
(3) Section 34 of chapter 267 (SB 17-267), Session Laws of Colorado 2017, provides
that the section of the act changing this section does not take effect if the centers for medicare
and medicaid services determine that the amendments do not comply with federal law. For more
information, see SB 17-267. (L. 2017, p. 1478.) The executive director of the department of
health care policy and financing did not notify the revisor of statutes by June 1, 2017, of such
determination; therefore, the amendments to this section took effect July 1, 2017.
(4) Amendments to subsections (4)(a)(I) and (4)(b)(I) by HB 22-1289 and SB 22-052
were harmonized.
Cross references: For the legislative declaration in SB 17-267, see section 1 of chapter
267, Session Laws of Colorado 2017. For the legislative declaration in HB 22-1289, see section
1 of chapter 399, Session Laws of Colorado 2022.
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.
Source: L. 2006: Entire article added with relocations, p. 1976, § 7, effective July 1.
Editor's note: This section is similar to former § 26-19-104 as it existed prior to 2006.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 437 of 510
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.
Source: L. 2006: (3) amended, p. 1040, § 10, effective May 25; entire article added with
relocations, p. 1976, § 7, effective July 1. L. 2007: (1), (2), and (3) amended, p. 150, § 11,
effective March 22; (3)(b) amended, p. 892, § 5, effective July 1. L. 2008: (2) amended, p. 2020,
§ 3, effective June 3. L. 2009: (1), (2), and (3) amended, (SB 09-210), ch. 124, p. 531, § 5,
effective April 16; (3) amended, (SB 09-269), ch. 333, p. 1768, § 9, effective June 1. L. 2011:
(1) and (2)(a) amended and (8) added, (SB 11-008), ch. 100, p. 293, § 3, effective September 1.
L. 2012: (3)(b) amended, (HB 12-1247), ch. 53, p. 197, § 7, effective March 22. L. 2015: (1)
and (2)(a) amended and (4), (5)(b), and (5)(c) repealed, (SB 15-264), ch. 259, p. 962, § 79,
effective August 5. L. 2016: (3)(a) and (8) amended and (3)(b) repealed, (HB 16-1408), ch. 153,
pp. 469, 472, § § 20, 26, effective July 1; (6) amended, (HB 16-1081), ch. 22, p. 53, § 10,
effective August 10.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 438 of 510
Editor's note: (1) This section is similar to former § 26-19-105 as it existed prior to
2006.
(2) Subsection (3) was originally numbered as § 26-19-105 (2.5), and the amendments to
it in House Bill 06-1310 were harmonized with subsection (3) as it appeared in Senate Bill
06-219.
(3) Amendments to subsection (3) by Senate Bill 09-210 and Senate Bill 09-269 were
harmonized.
25.5-8-106. Annual savings report. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1977, § 7, effective July 1. L.
2016: Entire section repealed, (HB 16-1081), ch. 22, p. 52, § 8, effective August 10.
Editor's note: This section was similar to former § 26-19-106 as it existed prior to 2006.
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 subparagraphs (I) and (II) of this paragraph (a)
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 recipients 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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 439 of 510
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;
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 440 of 510
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.
(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.
Source: L. 2006: (1)(a)(I) amended, p. 1505, § 51, effective June 1; entire article added
with relocations, p. 1978, § 7, effective July 1; (1)(a)(I) amended, p. 1078, § 6, effective January
1, 2007. L. 2008: (2)(a)(III) added, p. 2020, § 4, effective January 1, 2009. L. 2009: (1)(a)(IV)
added, (SB 09-244), ch. 391, p. 2118, § 5, effective July 1, 2010. L. 2010: (1)(b) amended, (HB
10-1422), ch. 419, p. 2115, § 151, effective August 11. L. 2013: (1)(a)(I) amended, (HB
13-1266), ch. 217, p. 993, § 64, effective May 13; (5) amended, (SB 13-222), ch. 350, p. 2033, §
5, effective May 28. L. 2019: IP(1) and (1)(a)(II) amended, (HB 19-1038), ch. 116, p. 491, § 2,
effective April 16. L. 2022: (1)(a)(V) and (1)(i) added and (1)(b) repealed, (HB 22-1289), ch.
399, p. 2845, § 21, effective June 7.
Editor's note: (1) This section is similar to former § 26-19-107 as it existed prior to
2006.
(2) Amendments to section 26-19-107 (1)(a)(I) by House Bill 06-1391 were harmonized
with subsection (1)(a)(I) as it appeared in Senate Bill 06-219. Amendments to section 26-19-107
(1)(a)(I) by Senate Bill 06-036 were further harmonized with subsection (1)(a)(I), effective
January 1, 2007.
Cross references: For the legislative declaration contained in the 2006 act amending
subsection (1)(a)(I), see § 1 of chapter 236, Session Laws of Colorado 2006. For the legislative
declaration contained in the 2009 act adding subsection (1)(a)(IV), see § 1 of chapter 391,
Session Laws of Colorado 2009. For the legislative declaration in the 2013 act amending
Colorado Revised Statutes 2023 Uncertified PrintoutPage 441 of 510
subsection (5), see section 1 of chapter 350, Session Laws of Colorado 2013. For the legislative
declaration in HB 19-1038, see section 1 of chapter 116, Session Laws of Colorado 2019. For
the legislative declaration in HB 22-1289, see section 1 of chapter 399, Session Laws of
Colorado 2022.
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.
Source: L. 2006: Entire article added with relocations, p. 1980, § 7, effective July 1. L.
2007: (5) added, p. 465, § 3, effective July 1. L. 2008: (4)(a) amended, p. 459, § 2, effective
April 14. L. 2010: (4)(a) amended, (HB 10-1422), ch. 419, p. 2115, § 152, effective August 11.
Editor's note: This section is similar to former § 26-19-108 as it existed prior to 2006.
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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 442 of 510
(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 recipient's income eligibility at
reenrollment through federally approved electronic data sources. If a recipient meets all
eligibility requirements, a recipient remains enrolled in the plan. The department shall also allow
a recipient to provide income information more recent than the records of federally approved
electronic data sources.
(III) If the state department determines that a recipient was not eligible for medical
benefits solely based upon the recipient's income after the recipient 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 recipient, and the county department is not responsible for any federal
error rate sanctions resulting from such 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.
(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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 443 of 510
(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.
(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.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 444 of 510
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 June 1, 2024.
(b) The state board may adopt rules to implement this subsection (8) to ensure that the
state department can resume routine operations by June 1, 2024, 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 June 1, 2024.
Source: L. 2006: (5)(a) amended, p. 1121, § 1, effective May 25; entire article added
with relocations, p. 1981, § 7, effective July 1. L. 2007: (5)(a)(I) and (5)(a)(II)(A) amended, p.
151, § 12, effective March 22; (3), IP(4), and (4)(b) amended, p. 1493, § 6, effective January 1,
2008. L. 2008: (4.5) added, p. 2026, § 2, effective June 3; (5)(a)(I) amended, p. 2020, § 5,
effective October 1, 2009. L. 2009: (4.5)(c) added, (HB 09-1020), ch. 298, p. 1596, § 2,
effective May 21; (6) added, (HB 09-1353), ch. 360, p. 1870, § 3, effective July 1, 2010. L.
2012: (4.5)(a)(I), (4.5)(a)(II), and (4.5)(a)(III) amended, (HB 12-1120), ch. 27, p. 109, § 26,
effective June 1. L. 2013: (1) amended, (SB 13-008), ch. 78, p. 251, § 1, effective March 29. L.
2014: (4)(a) and (4.5)(a) amended and (4)(b) repealed, (SB 14-067), ch. 12, p. 114, § 8, effective
February 27. L. 2021: (5.5) added, (SB 21-194), ch. 434, p. 2871, § 8, effective September 7. L.
2022: (5.5)(a) and (6) amended and (7) added, (HB 22-1289), ch. 399, p. 2846, § 22, effective
June 7. L. 2023: (8) added, (SB 23-182), ch. 118, p. 432, § 5, effective April 27.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 445 of 510
Editor's note: (1) This section is similar to former § 26-19-109 as it existed prior to
2006.
(2) Amendments to section 26-19-109 (5)(a) by Senate Bill 06-135 were harmonized
with subsection (5)(a) as it appeared in Senate Bill 06-219.
(3) Subsection (5)(a)(II)(B) provided for the repeal of subsection (5)(a)(II), effective
July 1, 2007. (See L. 2006, pp. 1121, 1981.)
(4) Subsection (4.5)(b)(II) provided for the repeal of subsection (4.5)(b), effective July 1,
2009. (See L. 2008, p. 2026.)
(5) The effective date for amendments to subsections (4.5)(a)(I), (4.5)(a)(II), and
(4.5)(a)(III) by House Bill 12-1120 (chapter 27, Session Laws of Colorado 2012) was changed
from August 8, 2012, to June 1, 2012, by House Bill 12S-1002 (First Extraordinary Session,
chapter 2, p. 2432, Session Laws of Colorado 2012.)
Cross references: For the legislative declaration contained in the 2007 act amending
subsections (3) and (4)(b) and the introductory portion to subsection (4), see section 1 of chapter
347, Session Laws of Colorado 2007. For the legislative declaration in HB 22-1289, see section
1 of chapter 399, Session Laws of Colorado 2022.
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;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 446 of 510
(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.
Source: L. 2022: Entire section added, (HB 22-1289), ch. 399, p. 2847, § 23, effective
June 7.
Cross references: For the legislative declaration in HB 22-1289, see section 1 of chapter
399, Session Laws of Colorado 2022.
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.
Source: L. 2015: Entire section added, (HB 15-1309), ch. 326, p. 1335, § 9, effective
August 5. L. 2019: (2) amended, (HB 19-1172), ch. 136, p. 1711, § 191, effective October 1. L.
2021: (2)(b) amended, (SB 21-102), ch. 31, p. 130, § 11, effective September 1.
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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 447 of 510
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 recipients 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
such proposals in good faith and shall, when deemed reasonable by the managed care
organization based on the needs of its enrollees, contract with essential community providers.
Each essential community provider shall be willing to negotiate on reasonably equitable terms
with each managed care organization. Essential community providers making proposals under
this subsection (4) shall be able to meet the contractual requirements of the managed care
organization. The requirement of this subsection (4) shall 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 enrollees regarding
failure to provide covered services or efforts to obtain payment, other than authorized
copayments, for covered services directly from eligible recipients.
(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
Colorado Revised Statutes 2023 Uncertified PrintoutPage 448 of 510
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 enrollees 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 this opportunity is
afforded eligible recipients. In geographic regions served by more than one participating
managed care plan, the department shall endeavor to establish a uniform period for such
opportunity.
(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.
Source: L. 2006: Entire article added with relocations, p. 1982, § 7, effective July 1. L.
2008: (2) amended, p. 1603, § 32, effective May 29. L. 2009: (10) amended, (SB 09-265), ch.
205, p. 936, § 7, effective May 1. L. 2010: (10)(b) repealed, (HB 10-1382), ch. 217, p. 940, § 6,
effective May 6. L. 2013: (1) amended, (HB 13-1266), ch. 217, p. 993, § 65, effective May 13.
L. 2021: (2) amended, (HB 21-1108), ch. 156, p. 897, § 41, effective September 7.
Editor's note: This section is similar to former § 26-19-110 as it existed prior to 2006.
Cross references: (1) For the legislative declaration contained in the 2008 act amending
subsection (2), see section 1 of chapter 341, Session Laws of Colorado 2008.
(2) For the definition of "federally qualified health centers" in the federal Social Security
Act, see 42 U.S.C. sec. 1395x.
(3) For the legislative declaration in HB 21-1108, see section 1 of chapter 156, Session
Laws of Colorado 2021.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 449 of 510
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.
Source: L. 2006: Entire article added with relocations, p. 1984, § 7, effective July 1. L.
2018: (1)(a)(II) amended, (SB 18-092), ch. 38, p. 446, § 113, effective August 8. L. 2022: (3)
added, (SB 22-235), ch. 409, p. 2895, § 4, effective June 7.
Editor's note: This section is similar to former § 26-19-111 as it existed prior to 2006.
Cross references: For the legislative declaration in SB 18-092, see section 1 of chapter
38, Session Laws of Colorado 2018.
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.
Source: L. 2006: Entire article added with relocations, p. 1985, § 7, effective July 1.
Editor's note: This section is similar to former § 26-19-112 as it existed prior to 2006.
25.5-8-113. Reports by contractors to medical services board. (Repealed)
Source: L. 2006: Entire article added with relocations, p. 1985, § 7, effective July 1. L.
2016: Entire section repealed, (HB 16-1081), ch. 22, p. 52, § 5, effective August 10.
Editor's note: This section was similar to former § 26-19-113 as it existed prior to 2006.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 450 of 510
ARTICLE 10
Community Living
Editor's note: This article was added with relocations in 2013. Former C.R.S. section
numbers are shown in editor's notes following those sections that were relocated. For a detailed
comparison of this article, see the comparative tables located in the back of the index.
PART 1
OFFICE OF COMMUNITY LIVING
25.5-10-101. Office of community living - creation - transfer of duties and functions
- rules - legislative declaration. (1) There is created in the state department the office of
community living, referred to in this article 10 as the "office". The office is a type 2 entity, as
defined in section 24-1-105. The head of the office is the director of community living appointed
by the executive director in accordance with section 13 of article XII of the state constitution.
The director of community living reports directly to the executive director.
(2) (a) On and after March 1, 2014, the powers, duties, and functions of the department
of health care policy and financing include the powers, duties, and functions relating to the
programs, services, and supports contained in this article 10 that were formerly vested in the
department of human services. Such powers, duties, and functions are allocated to the division of
intellectual and developmental disabilities of the office, which division is created in part 2 of this
article 10.
(b) (I) By March 1, 2014, all positions of employment in the department of human
services related to the administration of community-based long-term services and supports are
transferred to the division of intellectual and developmental disabilities of the office and become
employment positions therein.
(II) All employees in positions transferred to the division of intellectual and
developmental disabilities are considered employees of the division of intellectual and
developmental disabilities of the office. Such employees retain all rights under the state
personnel system and to retirement benefits pursuant to the laws of this state, and their services
shall be deemed to have been continuous.
(c) By March 1, 2014, all items of property, real and personal, including office furniture
and fixtures, books, documents, and records of the department of human services related to the
administration of community-based long-term services and supports are transferred to the
division of intellectual and developmental disabilities of the office and become the property
thereof.
(d) On and after March 1, 2014, whenever the executive director of the department of
human services or the department of human services is referred to or designated by any contract
or other document in connection with the powers, duties, and functions transferred to the
department of health care policy and financing, the reference or designation shall be deemed to
apply to the department of health care policy and financing. All contracts entered into by the
executive director of the department of human services prior to March 1, 2014, in connection
with the powers, duties, and functions transferred to the department of health care policy and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 451 of 510
financing are hereby validated, with the executive director of the department of health care
policy and financing succeeding to all the rights and obligations of such contracts.
(3) All rules and orders of the department of human services, the executive director of
the department of human services, and the state board of human services in connection with the
programs transferred to the department of health care policy and financing shall continue to be
effective until revised, amended, repealed, or nullified pursuant to law.
(4) Repealed.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1742, §
1, effective July 1. L. 2022: (1) and (2)(a) amended, (SB 22-162), ch. 469, p. 3372, § 61,
effective August 10.
Editor's note: Subsection (4)(b) provided for the repeal of subsection (4), effective July
1, 2014. (See L. 2013, p. 1742.)
Cross references: For the short title ("Debbie Haskins 'Administrative Organization Act
of 1968' Modernization Act") in SB 22-162, see section 1 of chapter 469, Session Laws of
Colorado 2022.
25.5-10-102. Transition planning - task force - legislative declaration - report -
definitions - repeal. (Repealed)
Source: L. 2018: Entire section added, (SB 18-231), ch. 331, p. 1990, § 1, effective May
30.
Editor's note: Subsection (5) provided for the repeal of this section, effective September
1, 2019. (See L. 2018, p. 1990.)
PART 2
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
25.5-10-201. Legislative declaration. (1) In recognition of the varied, extensive, and
substantial needs of persons with intellectual and developmental disabilities, including the urgent
need to enhance the development of children with intellectual and developmental disabilities, the
general assembly, subject to available appropriations and subject to the existence of appropriate
services and supports with available resources, hereby declares that the purposes of this article
are:
(a) To provide appropriate services and supports to persons with intellectual and
developmental disabilities throughout their lifetimes regardless of their age or degree of
disability;
(b) To prohibit deprivation of liberty of persons with intellectual and developmental
disabilities, except when such deprivation is for the purpose of providing services and supports
which constitute the least restrictive available alternative adequate to meet the person's needs,
and to ensure that these services and supports afford due process protections;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 452 of 510
(c) To ensure the fullest measure of privacy, dignity, rights, and privileges to persons
with intellectual and developmental disabilities;
(d) To ensure the provision of services and supports to all persons with intellectual and
developmental disabilities on a statewide basis;
(e) To enable persons with intellectual and developmental disabilities to remain with
their families and in the community of their choice, to minimize the likelihood of out-of-home
placement, and to enhance the capacity of families to meet the needs of children with intellectual
and developmental disabilities;
(f) To provide community services and supports for persons with intellectual and
developmental disabilities which reflect typical patterns of everyday living;
(g) To encourage state and local agencies to provide a wide array of innovative and
cost-effective services and supports for persons with intellectual and developmental disabilities;
(h) To ensure that persons with intellectual and developmental disabilities receive
services and supports which encourage and build on existing social networks and natural sources
of support, and result in increased interdependence, contribution to, and inclusion in community
life; and
(i) To recognize the efficacy of early intervention services and supports in minimizing
developmental delays and reducing the future education costs to our society.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1744, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-101 as it existed prior to 2013.
25.5-10-202. Definitions - repeal. As used in this article 10, unless the context otherwise
requires:
(1) "Abuse" means any of the following acts or omissions committed against a person
with an intellectual and developmental disability:
(a) The nonaccidental infliction of physical pain or injury, as demonstrated by, but not
limited to, substantial or multiple skin bruising, bleeding, malnutrition, dehydration, burns, bone
fractures, poisoning, subdural hematoma, soft tissue swelling, or suffocation;
(b) Confinement or restraint that is unreasonable under generally accepted caretaking
standards; or
(c) Unlawful sexual behavior as defined in section 16-22-102 (9).
(1.3) "Authorized representative" means a person designated by the person receiving
services, or by the parent or guardian of the person receiving services, if appropriate, to assist the
person receiving services in acquiring or utilizing services or supports pursuant to this article.
The extent of the authorized representative's involvement shall be determined upon designation.
(1.6) "Caretaker" means a person who:
(a) Is responsible for the care of a person with an intellectual and developmental
disability as a result of a family or legal relationship;
(b) Has assumed responsibility for the care of a person with an intellectual and
developmental disability; or
(c) Is paid to provide care, services, or oversight of services to a person with an
intellectual and developmental disability.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 453 of 510
(1.8) (a) "Caretaker neglect" means neglect that occurs when adequate food, clothing,
shelter, psychological care, physical care, medical care, habilitation, supervision, or other
treatment necessary for the health and safety of a person with an intellectual and developmental
disability is not secured for a person with an intellectual and developmental disability or is not
provided by a caretaker in a timely manner and with the degree of care that a reasonable person
in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence,
or intimidation to create a hostile or fearful environment for an at-risk adult with an intellectual
and developmental disability.
(b) Notwithstanding the provisions of paragraph (a) of this subsection (1.8), the
withholding, withdrawing, or refusing of any medication, any medical procedure or device, or
any treatment, including but not limited to resuscitation, cardiac pacing, mechanical ventilation,
dialysis, artificial nutrition and hydration, any medication or medical procedure or device, in
accordance with any valid medical directive or order, or as described in a palliative plan of care,
shall not be deemed caretaker neglect.
(c) As used in this subsection (1.8), "medical directive or order" includes a medical
durable power of attorney, a declaration as to medical treatment executed pursuant to section
15-18-104, C.R.S., a medical order for scope of treatment form executed pursuant to article 18.7
of title 15, C.R.S., and a CPR directive executed pursuant to article 18.6 of title 15, C.R.S.
(1.9) [Editor's note: This version of subsection (1.9) is effective until July 1, 2024.]
"Case management agency" means a public or private not-for-profit or for-profit agency that
meets all applicable state and federal requirements and is certified by the state department to
provide case management services pursuant to section 25.5-10-209.5. The case management
agency shall provide case management services pursuant to a contract with the state department.
(1.9) [Editor's note: This version of subsection (1.9) is effective July 1, 2024.] "Case
management agency" has the same meaning as set forth in section 25.5-6-1702 (2).
(2) [Editor's note: This version of subsection (2) is effective until July 1, 2024.] "Case
management services" means the following:
(a) Repealed.
(b) Service and support coordination; and
(c) The monitoring of all services and supports delivered pursuant to the individualized
plan and the evaluation of results identified in the individualized plan.
(2) [Editor's note: This version of subsection (2) is effective July 1, 2024.] "Case
management services" has the same meaning as set forth in section 25.5-6-1702 (3).
(3) [Editor's note: This version of subsection (3) is effective until July 1, 2024.] "Case
manager" means a person who assists with case management services and supports provided
pursuant to this article for persons with intellectual and developmental disabilities.
(3) [Editor's note: This version of subsection (3) is effective July 1, 2024.] "Case
manager" has the same meaning as set forth in section 25.5-6-1702 (4).
(4) (a) "Community-centered board" means a private corporation, for-profit or
not-for-profit, that is designated pursuant to section 25.5-10-209.
(b) This subsection (4) is repealed, effective July 1, 2024.
(5) "Community residential home" means a group living situation accommodating at
least four but no more than eight persons, which is licensed by the state and in which services
and supports are provided to persons with intellectual and developmental disabilities.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 454 of 510
(5.5) "Competitive integrated employment" has the same meaning as set forth in section
8-84-301, C.R.S.
(5.7) [Editor's note: This version of subsection (5.7) is effective until July 1, 2024.]
"Conflict-free case management" means, pursuant to 42 CFR 441.301 (c)(1)(VI), case
management services provided to a person with an intellectual and developmental disability
enrolled in a home- and community-based services waiver that are provided by a case
management agency that is not the same agency that provides services and supports to that
person. Service agencies and case management agencies are responsible for ensuring persons
who are employed by the agency meet the requirements of this article 10.
(5.7) [Editor's note: This version of subsection (5.7) is effective July 1, 2024.]
"Conflict-free case management" has the same meaning as set forth in section 25.5-6-1702 (6).
(6) "Consent" means an informed assent that is expressed in writing and freely given.
Consent shall always be preceded by the following:
(a) A fair explanation of the procedures to be followed, including an identification of
procedures that are experimental;
(b) A description of the attendant discomforts and risks;
(c) A description of the expected benefits;
(d) A disclosure of appropriate alternative procedures together with an explanation of the
respective benefits, discomforts, and risks;
(e) An offer to answer any inquiries concerning procedures;
(f) An instruction that the person giving consent is free to withdraw consent and to
discontinue participation in the project or activity at any time; and
(g) A statement that withholding or withdrawal of consent shall not prejudice future
provision of appropriate services and supports to persons.
(7) "Contribution" means the benefits gained by the household or community in which a
person lives as the result of the person engaging in meaningful activities, including but not
limited to income-producing work, volunteer work, continuing education, and participation in
community activities.
(8) "Court" means a district court of the state of Colorado or the probate court in the
appropriate jurisdiction.
(9) [Editor's note: This version of subsection (9) is effective until July 1, 2024.]
"Designated service area" means the geographical area specified by the executive director to be
served by a designated community-centered board.
(9) [Editor's note: This version of subsection (9) is effective July 1, 2024.] "Defined
service area" has the same meaning as set forth in section 25.5-6-1702 (7).
(10) "Developmental disabilities professional" has the same meaning as "intellectual and
developmental disabilities professional" as set forth in subsection (25) of this section.
(11) (a) "Developmental disability" has the same meaning as "intellectual and
developmental disability" as set forth in paragraph (a) of subsection (26) of this section.
(b) "Person with a developmental disability" or "individual with a developmental
disability" has the same meaning as "person with an intellectual and developmental disability" as
set forth in paragraph (b) of subsection (26) of this section.
(c) "Child with a developmental delay" has the same meaning as set forth in paragraph
(c) of subsection (26) of this section.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 455 of 510
(12) "Division" means the division of intellectual and developmental disabilities, created
in this part 2.
(13) "Early intervention services and supports" has the same meaning as set forth in
section 27-10.5-102, C.R.S.
(13.5) "Eligible for home- and community-based services" means a "person with an
intellectual and developmental disability", as defined in section 25.5-6-403, who meets the
definition of an "eligible person", as defined in section 25.5-6-403.
(14) [Editor's note: This version of subsection (14) is effective until July 1, 2024.]
"Eligible for supports and services" refers to any person with an intellectual and developmental
disability as determined by a community-centered board pursuant to section 25.5-10-211.
(14) [Editor's note: This version of subsection (14) is effective July 1, 2024.] "Eligible
for supports and services" refers to any person with an intellectual and developmental disability
as determined by a case management agency pursuant to section 25.5-6-1704.
(15) "Enrolled" means that a person with an intellectual and developmental disability
who is eligible for supports and services has been authorized, as defined by rules promulgated by
the state board, to participate in the program funded pursuant to this section.
(15.3) [Editor's note: This subsection (15.3) is effective July 1, 2024.] "Entity" has the
same meaning as set forth in section 25.5-6-1702 (8).
(15.5) "Exploitation" means an act or omission that:
(a) Uses deception, harassment, intimidation, or undue influence to permanently or
temporarily deprive a person with an intellectual and developmental disability of the use, benefit,
or possession of any thing of value;
(b) Employs the services of a third party for the profit or advantage of the person or
another person to the detriment of the person with an intellectual and developmental disability;
(c) Forces, compels, coerces, or entices a person with an intellectual and developmental
disability to perform services for the profit or advantage of the person or another person against
the will of the person with an intellectual and developmental disability; or
(d) Misuses the property of a person with an intellectual and developmental disability in
a manner that adversely affects the person with an intellectual and developmental disability's
ability to receive health care or health-care benefits or to pay bills for basic needs or obligations.
(16) (a) "Family" means the interdependent group of persons that consists of:
(I) A parent, child, sibling, grandparent, aunt, uncle, spouse, or any combination thereof
and a family member with an intellectual and developmental disability;
(II) An adoptive parent of and a family member with an intellectual and developmental
disability;
(III) One or more persons to whom legal custody of a person with an intellectual and
developmental disability has been given by a court and in whose home such person resides; or
(IV) Any other family unit as may be defined in rules developed pursuant to section
25.5-10-306.
(b) State board rules must define the families that are eligible to receive services and
supports pursuant to this article, and rules of the state board of human services must define the
families that are eligible to receive services and supports pursuant to article 10.5 of title 27,
C.R.S.
(17) "Family caregiver" means a family member of the person with an intellectual and
developmental disability who provides care to the person with an intellectual and developmental
Colorado Revised Statutes 2023 Uncertified PrintoutPage 456 of 510
disability in the family home, who meets the requirements for a qualified family caregiver, as
established by rule of the state board, and who is working through a program-approved service
agency, as established by rule of the state board.
(18) "Gastrostomy tube" means a tube that has been surgically inserted into the stomach
through the abdominal wall, or a tube that has been inserted through the nasal passage into the
stomach, or both.
(18.5) "Harmful act" means an act committed against a person with an intellectual and
developmental disability by a person with a relationship to the person with an intellectual and
developmental disability when such act is not defined as abuse, caretaker neglect, or exploitation
but causes harm to the health, safety, or welfare of a person with an intellectual and
developmental disability.
(19) "Human rights committee" means a third-party mechanism to adequately safeguard
the legal rights of persons receiving services by participating in the granting of informed
consent, monitoring the suspension of rights of persons receiving services, monitoring
behavioral development programs in which persons with intellectual and developmental
disabilities are involved, monitoring the use of psychotropic medication by persons with
intellectual and developmental disabilities, and reviewing investigations of allegations of
mistreatment of persons with intellectual and developmental disabilities who are receiving
services or supports under this article.
(20) "IDEA" has the same meaning as set forth in section 27-10.5-102, C.R.S.
(21) "Inclusion" means:
(a) The use by persons with intellectual and developmental disabilities of the same
community resources that are used by and available to other persons;
(b) The participation by persons with intellectual and developmental disabilities in the
same community activities in which persons without intellectual and developmental disabilities
participate. Participation includes regular contact with persons without intellectual and
developmental disabilities.
(c) Vocational experiences for persons with intellectual and developmental disabilities in
community settings that offer opportunities to associate with other persons who do not have
intellectual and developmental disabilities; and
(d) Living in homes that are in residential neighborhoods and in proximity to community
resources.
(22) "Independent residential support services" means a community living situation,
defined by rule of the state board, in which services and supports are provided to no more than
three persons with intellectual and developmental disabilities and for which a state license is not
required.
(23) "Individualized family service plan" or "IFSP" has the same meaning as set forth in
section 27-10.5-102, C.R.S.
(24) (a) "Individualized plan" means a written plan designed by an interdisciplinary team
for the purpose of identifying:
(I) The needs and preferences of the person or family receiving services;
(II) The specific services and supports appropriate to meet those needs and preferences;
(III) The projected date for initiation of services and supports; and
(IV) The anticipated results to be achieved by receiving the services and supports.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 457 of 510
(b) [Editor's note: This version of subsection (24)(b) is effective until July 1, 2024.]
Every individualized plan must include a statement of agreement with the plan, signed by the
person receiving services or other such person legally authorized to sign on behalf of the person
and by a representative of the community-centered board or case management agency.
(b) [Editor's note: This version of subsection (24)(b) is effective July 1, 2024.] Every
individualized plan must include a statement of agreement with the plan, signed by the person
receiving services or other such person legally authorized to sign on behalf of the person and by
a representative of the case management agency.
(c) Any other service or support plan designated by the state department that meets all of
the requirements of an individualized plan is considered to be an individualized plan pursuant to
this article.
(d) (I) Every individualized plan that includes the provision of respite care for medical
purposes, pursuant to section 25.5-10-205, shall include a process by which the person receiving
services and supports may receive necessary care if the person's family or caregiver is
unavailable due to an emergency situation or unforeseen circumstances. The family or caregiver
must be duly informed by the interdisciplinary team of these alternative care provisions at the
time the individualized plan is initiated.
(II) Nothing in this paragraph (d) requires the provision of respite care. However, any
individual plan that includes the provision of respite care for medical purposes must contain a
contingency plan.
(25) "Intellectual and developmental disabilities professional" means a person who has
professional training and experience in the intellectual and developmental disabilities field, as
defined by rule of the state board.
(26) (a) "Intellectual and developmental disability" means a disability that manifests
before the person reaches twenty-two years of age, that constitutes a substantial disability to the
affected person, and that is attributable to an intellectual and developmental disability or related
conditions, including Prader-Willi syndrome, cerebral palsy, epilepsy, autism, or other
neurological conditions when the condition or conditions result in impairment of general
intellectual functioning or adaptive behavior similar to that of a person with an intellectual and
developmental disability. Unless otherwise specifically stated, the federal definition of
"developmental disability" found in 42 U.S.C. sec. 15002 (8) does not apply.
(b) [Editor's note: This version of subsection (26)(b) is effective until July 1, 2024.]
"Person with an intellectual and developmental disability" means a person determined by a
community-centered board to have an intellectual and developmental disability and includes a
child with a developmental delay.
(b) [Editor's note: This version of subsection (26)(b) is effective July 1, 2024.] "Person
with an intellectual and developmental disability" means a person determined by a case
management agency to have an intellectual and developmental disability and includes a child
with a developmental delay.
(c) "Child with a developmental delay" means:
(I) A person less than five years of age with delayed development as defined by rule of
the state board; or
(II) A person less than five years of age who is at risk of having an intellectual and
developmental disability as defined by rule of the state board.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 458 of 510
(27) "Interdependence" means those multiple interactive relationships that are necessary
to create a sense of belonging and support between and among people that are mutually sought,
sustained over time, and beneficial to those involved.
(28) [Editor's note: This version of subsection (28) is effective until July 1, 2024.]
"Interdisciplinary team" means a group of people convened by a designated community-centered
board or by a case management agency that includes the person receiving services; the parents or
guardian of a minor; a guardian or an authorized representative, as appropriate; the person who
coordinates the provisions of services and supports; and others chosen by the person receiving
services, who are assembled to work in a cooperative manner to develop or review the
individualized plan.
(28) [Editor's note: This version of subsection (28) is effective July 1, 2024.]
"Interdisciplinary team" means a group of people convened by a designated case management
agency that includes the person receiving services; the parents or guardian of a minor; a guardian
or an authorized representative, as appropriate; the person who coordinates the provisions of
long-term services and supports; and others chosen by the person receiving services, who are
assembled to work in a cooperative manner to develop or review the individualized plan.
(29) [Editor's note: This version of subsection (29) is effective until July 1, 2024.]
"Least restrictive environment" means an environment that represents the least departure from
the typical patterns of living and that effectively meets the needs and preferences of the person
receiving services. "Least restrictive environment" may include, but need not be limited to,
receiving services from a community-centered board, service agency, case management agency,
or a family caregiver in the family home.
(29) [Editor's note: This version of subsection (29) is effective July 1, 2024.] "Least
restrictive environment" means an environment that represents the least departure from the
typical patterns of living and that effectively meets the needs and preferences of the person
receiving services. "Least restrictive environment" may include, but need not be limited to,
receiving services from a service agency, a case management agency, or a family caregiver in
the family home.
(29.5) "Mistreated" or "mistreatment" means:
(a) Abuse;
(b) Caretaker neglect;
(c) Exploitation; or
(d) A harmful act.
(e) Repealed.
(30) "Office" means the office of community living created in part 1 of this article.
(31) "Person receiving services" means a person with an intellectual and developmental
disability who is enrolled in a program funded pursuant to this article.
(32) "Program" means a specific group of services or supports as defined by rules
promulgated by the state board and for which funding is available pursuant to this article to a
person with an intellectual and developmental disability who is eligible for supports and
services.
(33) "Regional center" has the same meaning as set forth in section 27-10.5-102, C.R.S.
(34) "Service agency" means a person or any publicly or privately operated program,
organization, or business providing services or supports for persons with intellectual and
developmental disabilities.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 459 of 510
(35) "Service and support coordination" means planning, locating, facilitating access to,
coordinating, and reviewing all aspects of needed services, supports, and resources that are
provided in cooperation with the person receiving services, the person's family, as appropriate,
the family of a child with a developmental delay, and the involved public or private agencies.
Planning includes the development or review of an existing individualized plan. "Service and
support coordination" also includes the reassessment of the needs and preferences of the person
receiving services or the needs of the family of the person, with maximum participation of the
person receiving services and the person's parents, guardian, or authorized representative, as
appropriate.
(36) "Services and supports" or "supports and services" means one or more of the
following: Education, training, independent or supported living assistance, therapies,
identification of natural supports, and other activities provided:
(a) To enable persons with intellectual and developmental disabilities to make
responsible choices, exert greater control over their lives, experience presence and inclusion in
their communities, develop their competencies and talents, maintain relationships, foster a sense
of belonging, and experience personal security and self-respect;
(b) To enhance child development and healthy parent-child and family interaction for
eligible persons and their families; and
(c) To enable families, who choose or desire to maintain a family member with an
intellectual and developmental disability at home, to obtain support and to enjoy a typical
lifestyle.
(37) "Sterilization" means any surgical or other medical procedure that has as its primary
purpose to render a person permanently incapable of reproduction.
(37.5) "Undue influence" means the use of influence to take advantage of a person with
an intellectual and developmental disability's vulnerable state of mind, neediness, pain, or
emotional distress.
(38) "Waiting list" means the list of persons with intellectual and developmental
disabilities who are waiting for enrollment into a program provided pursuant to this article.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1745, §
1, effective March 1, 2014. L. 2016: (1) and (19) amended and (1.3), (1.6), (1.8), (15.5), (29.5),
and (37.5) added, (HB 16-1394), ch. 172, p. 562, § 14, effective July 1; (5.5) added, (SB
16-077), ch. 360, p. 1505, § 4, effective July 1. L. 2017: IP, (4), (14), (24)(b), (28), (29), and
IP(36) amended, (1.9), (5.7), and (13.5) added, and (2)(a) repealed, (HB 17-1343), ch. 320, p.
1721, § 1, effective June 5. L. 2018: (26) amended, (SB 18-074), ch. 98, p. 770, § 3, effective
August 8; (26)(a) amended, (SB 18-096), ch. 44, p. 474, § 16, effective August 8. L. 2019:
(26)(a) amended, (SB 19-241), ch. 390, p. 3474, § 41, effective August 2. L. 2020: (1)(c),
IP(15.5), (29.5)(c), and (29.5)(d) amended, (18.5) added, and (29.5)(e) repealed, (HB 20-1302),
ch. 265, p. 1275, § 10, effective September 14. L. 2021: (1.9), (2), (3), (5.7), (9), (14), (24)(b),
(26)(b), (28), and (29) amended and (15.3) added, (HB 21-1187), ch. 83, p. 337, § 38, effective
July 1, 2024; (4)(b) added by revision, (HB 21-1187), ch. 83, pp. 335, 354, §§ 38, 70.
Editor's note: (1) This section is similar to former § 27-10.5-102 as it existed prior to
2013.
(2) Amendments to subsection (26)(a) by SB 18-074 and SB 18-096 were harmonized.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 460 of 510
Cross references: For the legislative declaration in SB 16-077, see section 1 of chapter
360, Session Laws of Colorado 2016. For the legislative declaration in SB 18-096, see section 1
of chapter 44, Session Laws of Colorado 2018.
25.5-10-203. Division of intellectual and developmental disabilities - creation -
functions - reporting - legislative declaration. (1) (a) The general assembly finds and declares
that:
(I) An effective system of community-based services and supports is essential to enable
children and adults with intellectual and developmental disabilities to live in their communities;
(II) The demand for high-quality intellectual and developmental disabilities services is
expected to grow; and
(III) Persons with intellectual and developmental disabilities need a system that
promotes self-direction of services and self-determination and that is designed to improve
personal outcomes.
(b) (I) The general assembly further finds and declares that state agencies should be
organized in a manner that allows for improved delivery of long-term services and supports for
persons and providers; and
(II) The transfer pursuant to part 1 of this article of the powers, duties, and functions
relating to the programs, services, and supports for persons with intellectual and developmental
disabilities to the office for administration by the division of intellectual and developmental
disabilities, created in this section, is an initial step in the process of redesigning Colorado's
long-term care system.
(2) There is created in the office the division of intellectual and developmental
disabilities. The division is a type 2 entity, as defined in section 24-1-105.
(3) The division shall administer the programs, services, and supports for persons with
intellectual and developmental disabilities contained in this article.
(4) Because of the unique goal of the division in administering lifelong programs,
services, and supports for persons with intellectual and developmental disabilities, as part of its
annual briefing to the joint budget committee, the state department shall allow sufficient briefing
time devoted solely to issues relating to the division and its administration of the programs,
services, and supports contained in this article.
(5) Repealed.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1751, §
1, effective March 1, 2014. L. 2022: (2) amended, (SB 22-162), ch. 469, p. 3372, § 62, effective
August 10.
Editor's note: Subsection (5)(b) provided for the repeal of subsection (5), effective July
1, 2015. (See L. 2013, p. 1751.)
Cross references: For the short title ("Debbie Haskins 'Administrative Organization Act
of 1968' Modernization Act") in SB 22-162, see section 1 of chapter 469, Session Laws of
Colorado 2022.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 461 of 510
25.5-10-204. Duties of the executive director - state board rules - definitions - repeal.
(1) In order to implement the provisions of this article 10, the executive director shall, subject to
available appropriations, carry out the following duties:
(a) [Editor's note: This version of subsection (1)(a) is effective until July 1, 2024.]
Conduct monitoring and review activities that include community-centered boards, service
agencies, and case management agencies;
(a) [Editor's note: This version of subsection (1)(a) is effective July 1, 2024.] Conduct
monitoring and review activities that include case management agencies and service agencies;
(b) [Editor's note: This version of subsection (1)(b) is effective until July 1, 2024.]
Provide or obtain training and technical assistance through community-centered boards, service
agencies, and case management agencies in order to improve the quality of services and supports
provided to persons with intellectual and developmental disabilities;
(b) [Editor's note: This version of subsection (1)(b) is effective July 1, 2024.] Provide
or obtain training and technical assistance through case management agencies and service
agencies in order to improve the quality of long-term services and supports provided to persons
with intellectual and developmental disabilities;
(c) [Editor's note: This version of introductory portion to subsection (1)(c) is effective
until July 1, 2024.] Prepare and transmit annually to the governor and the joint budget
committee of the general assembly, in the form and manner prescribed pursuant to section
24-1-136, C.R.S., a report detailing the following information, as available and appropriate, that
is broken down into designated service areas as well as provided in an overall statewide format:
(c) [Editor's note: This version of the introductory portion to subsection (1)(c) is
effective July 1, 2024.] Prepare and transmit annually to the governor and the joint budget
committee of the general assembly, in the form and manner prescribed pursuant to section
24-1-136, a report detailing the following information, as available and appropriate, that is
broken down into defined service areas as well as provided in an overall statewide format:
(I) The total number of persons receiving services pursuant to this article;
(II) The types of services and supports provided;
(III) The costs of services and supports regardless of funding source;
(IV) An evaluation of the quality of the services and supports rendered;
(V) An evaluation of the effectiveness of the services and supports rendered in
implementing the individualized plans of persons receiving services;
(VI) The numbers, types, and resolution of appeals that were heard by the state
department arising from disputes specified in section 25.5-10-212; and
(VII) The number of persons determined to be eligible to receive services and supports
who are not receiving services or supports pursuant to this article along with an analysis of the
reasons they are not receiving services and supports;
(d) [Editor's note: This version of subsection (1)(d) is effective until July 1, 2024.]
Designate a community-centered board in each designated service area in the state;
(d) [Editor's note: This version of subsection (1)(d) is effective July 1, 2024.]
Designate a case management agency in each defined service area in the state;
(e) Implement the provision of home- and community-based services to eligible persons
with intellectual and developmental disabilities and pursue other medicaid-funded services
determined by the state department to be appropriate for persons with intellectual and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 462 of 510
developmental disabilities, pursuant to part 4 of article 6 of this title and subject to available
appropriations;
(f) Promote effective coordination with agencies serving persons with intellectual and
developmental disabilities in order to improve continuity of services and supports for persons
facing life transitions from toddler to preschool, school to adult life, and work to retirement; and
(g) Facilitate employment first policies and practices by:
(I) Developing practices that reflect a presumption that all persons with disabilities are
capable of working in competitive integrated employment if they choose to do so, and ensuring
that options for competitive integrated employment with appropriate supports are explored
before consideration of segregated activities;
(II) Providing state department input and assistance to the employment first advisory
partnership described in section 8-84-303, C.R.S., in carrying out its duties;
(III) Establishing annual reporting of the following data, reported by county, for
individuals eligible for supported employment services, including but not limited to home- and
community-based waiver services:
(A) The number of individuals employed in group employment, the sector of
employment, the mean wage per hour earned, and the mean hours worked per week;
(B) The number of individuals employed in competitive integrated employment, the
sector of employment, the mean wage per hour earned, and the mean hours worked per week;
(C) The number of individuals employed and served in prevocational services, the sector
of employment, the mean wage per hour earned, the mean hours worked per week, and the mean
service hours per week;
(D) The number of individuals served in community-based nonwork and the mean
service hours per week;
(E) The number of individuals served in specialized habilitation services and the mean
service hours per week;
(F) The number of individuals employed or served, as applicable, in any other
employment services or day services model, the sector of employment, and the mean wage per
hour worked, mean hours worked per week, or the service hours per week, as applicable;
(G) The number of individuals eligible for employment services, regardless of whether
the individual is utilizing employment services; and
(H) The number of individuals served earning less than minimum wage.
(IV) Maintaining Colorado's membership in the state employment leadership network
that was founded as a joint partnership between the national association of state directors of
developmental disabilities services and the institute for community inclusion at the university of
Massachusetts Boston or another similar organization that facilitates collaboration with other
states to share effective solutions to increase employment outcomes for persons with disabilities;
and
(V) Presenting the reports and recommendations of the employment first advisory
partnership to the state department's legislative committee of reference pursuant to section
8-84-303 (7), C.R.S.
(2) The state board shall adopt such rules, in accordance with section 24-4-103, as are
necessary to carry out the provisions and purposes of this article 10, including but not limited to
the following subjects:
(a) Standards for services and supports, including preparation of individualized plans;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 463 of 510
(b) (I) The designation of community-centered boards and the organization of those
entities, including standards of organization, staff qualifications, and other factors necessary to
ensure program integrity;
(II) This subsection (2)(b) is repealed, effective July 1, 2024.
(c) Purchase of services and supports and financial administration;
(d) Procedures for resolving disputes over eligibility determination and the modification,
denial, or termination of services;
(e) Eligibility determination, the criteria for determination, and admission to the
program;
(f) Systems of quality assurance and data collection;
(g) The rights of a person receiving services;
(h) Confidentiality of records of a person receiving services;
(i) Designation of authorized representatives and delineation of their rights and duties
pursuant to this article;
(j) (I) The establishment of guidelines and procedures for authorization of persons for
administration of nutrition and fluids through gastrostomy tubes.
(II) The state department shall require that a service agency providing residential or day
program services or supports have a staff member qualified pursuant to subparagraph (III) of this
paragraph (j) on duty at any time the facility administers said nutrition and fluids through
gastrostomy tubes, and that the facility maintain a written record of each nutrient or fluid
administered to each person receiving services, including the time and the amount of the nutrient
or fluid.
(III) A person who is not otherwise authorized by law to administer nutrition and fluids
through gastrostomy tubes is allowed to perform the duties only under the supervision of a
licensed nurse, a licensed certified midwife, or a licensed physician. A person who administers
nutrition and fluids in compliance with this subsection (2)(j) is exempt from the licensing
requirements of the "Colorado Medical Practice Act", article 240 of title 12, and the "Nurse and
Nurse Aide Practice Act", article 255 of title 12. Nothing in this subsection (2)(j) shall be
deemed to authorize the administration of medications through gastrostomy tubes. A person
administering medications through gastrostomy tubes is subject to the requirements of part 3 of
article 1.5 of title 25.
(IV) As used in this subsection (2)(j):
(A) "Administration" means assisting a person in the ingestion of nutrition or fluids
according to the direction and supervision of a licensed nurse, a licensed certified midwife, or a
licensed physician.
(B) "Certified midwife" has the same meaning as set forth in section 12-255-104 (3.2).
(k) (I) No later than July 1, 2019, the state board, in conjunction with the department of
labor and employment, shall require a nationally recognized supported employment training
certificate or nationally recognized supported employment certification for all vendors of
supported employment services, including supported employment professionals who provide
individual competitive integrated employment outcomes, and excluding those professionals
exclusively providing group or other congregate services. The state board's rules must include
time frames for compliance with the training or certification requirement for existing staff and
for newly hired staff and requirements for supervision of newly hired staff until the staff member
has completed the training or certification. The time frames established in the state board's rules
Colorado Revised Statutes 2023 Uncertified PrintoutPage 464 of 510
must provide for training to be completed over a five-year period, subject to the availability of
appropriations for reimbursement of vendors pursuant to subsection (2)(k)(II) of this section.
(II) The training or certification requirement in subsection (2)(k)(I) of this section is
contingent upon appropriations to the department of health care policy and financing for
reimbursement to vendors of supported employment services for the cost of training and
certification. The state board shall adopt rules for administering the reimbursement to vendors,
which reimbursement must be three hundred dollars for each certification exam and twelve
hundred dollars for each training program certificate, which includes reimbursement for both the
cost of the training and wages paid to employees during training. The state board may increase
the fixed reimbursement amount over time based on increases in the cost of the exam and
employee wages.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1752, §
1, effective March 1, 2014. L. 2016: (1)(e) and (1)(f) amended and (1)(g) added, (SB 16-077),
ch. 360, p. 1505, § 5, effective July 1. L. 2017: IP(1), (1)(a), and (1)(b) amended, (HB 17-1343),
ch. 320, p. 1722, § 2, effective June 5. L. 2018: (1)(g)(III) and IP(2) amended and (2)(k) added,
(SB 18-145), ch. 215, p. 1370, § 3, effective August 8. L. 2019: (2)(j)(III) amended, (HB
19-1172), ch. 136, p. 1711, § 192, effective October 1. L. 2020: (2)(j)(III) amended, (HB
20-1183), ch. 157, p. 704, § 63, effective July 1. L. 2021: (1)(a), (1)(b), IP(1)(c), and (1)(d)
amended, (HB 21-1187), ch. 83, p. 339, § 39, effective July 1, 2024; (2)(b)(II) added by revision,
(HB 21-1187), ch. 83, pp. 339, 354, §§ 39, 70. L. 2023: (2)(j)(III) and (2)(j)(IV) amended, (SB
23-167), ch. 261, p. 1550, § 63, effective May 25.
Editor's note: This section is similar to former § 27-10.5-103 as it existed prior to 2013.
Cross references: For the legislative declaration in SB 16-077, see section 1 of chapter
360, Session Laws of Colorado 2016. For the legislative declaration in SB 18-145, see section 1
of chapter 215, Session Laws of Colorado 2018.
25.5-10-205. Community-centered boards and service agencies - local public
procurement units. [Editor's note: This version of this section is effective until July 1, 2024.]
For purposes of entering into a cooperative purchasing agreement pursuant to section
24-110-201, C.R.S., a nonprofit community-centered board or a nonprofit service agency may be
certified as a local public procurement unit as provided in section 24-110-207.5, C.R.S.
25.5-10-205. Case management agencies - local public procurement units. [Editor's
note: This version of this section is effective July 1, 2024.] For purposes of entering into a
cooperative purchasing agreement pursuant to section 24-110-201, a nonprofit case management
agency or a nonprofit service agency may be certified as a local public procurement unit as
provided in section 24-110-207.5.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1754, §
1, effective March 1, 2014. L. 2021: Entire section amended, (HB 21-1187), ch. 83, p. 339, § 40,
effective July 1, 2024.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 465 of 510
Editor's note: This section is similar to former § 27-10.5-103.5 as it existed prior to
2013.
25.5-10-206. Authorized long-term services and supports - conditions of funding -
purchase of services and supports - adult protective services data system check - boards of
county commissioners - appropriation. (1) [Editor's note: This version of the introductory
portion to subsection (1) is effective until July 1, 2024.] Subject to annual appropriations by the
general assembly, the state department shall provide or purchase, pursuant to subsection (4) of
this section, authorized services and supports from community-centered boards, case
management agencies, or service agencies for persons who have been determined to be eligible
for such services and supports pursuant to section 25.5-10-211 and as specified in the eligible
person's individualized plan. Those services and supports may include, but need not be limited
to, the following:
(1) [Editor's note: This version of the introductory portion to subsection (1) is effective
July 1, 2024.] Subject to annual appropriations by the general assembly, the state department
shall provide or purchase, pursuant to subsection (4) of this section, authorized long-term
services and supports from case management agencies or service agencies for persons who have
been determined to be eligible for such long-term services and supports pursuant to section
25.5-6-1704 and as specified in the eligible person's individualized plan. Those long-term
services and supports may include, but need not be limited to, the following:
(a) Family support services, including an array of supportive services provided to the
person receiving services and the person's family, that enable the family to maintain the person
in the family home, thereby preventing or delaying the need for out-of-home placement that is
unwanted by the person or the family, pursuant to section 25.5-10-301;
(b) Case management services;
(c) Respite care services, including temporary care of a person with an intellectual and
developmental disability to offer relief to the person's family or caregiver or to allow the family
or caregiver to deal with emergency situations or to engage in personal, social, or routine
activities and tasks that otherwise may be neglected, postponed, or curtailed due to the demands
of supporting a person who has an intellectual and developmental disability;
(d) Day services and supports that offer opportunities for persons with intellectual and
developmental disabilities to experience and actively participate in valued adult roles in the
community. These services and supports will enable persons receiving services to access and
participate in community activities, such as work, recreation, higher education, and senior citizen
activities. Day services may also include the administration of nutrition or fluids through
gastrostomy tubes, if administered by a person authorized pursuant to section 25.5-10-204 (2)(j)
and supervised by a licensed nurse or physician.
(e) Residential services and supports, including an array of training, learning,
experiential, and support activities provided in living alternatives designed to meet the individual
needs and preferences of persons receiving services and may include the administration of
nutrition or fluids through gastrostomy tubes, if administered by a person authorized pursuant to
section 25.5-10-204 (2)(j) and supervised by a licensed nurse or physician; and
(f) Ancillary services, including activities that are secondary but integral to the provision
of the services and supports specified in this subsection (1).
Colorado Revised Statutes 2023 Uncertified PrintoutPage 466 of 510
(2) [Editor's note: This version of subsection (2) is effective until July 1, 2024.]
Service agencies, community-centered boards, and case management agencies receiving funds
pursuant to subsection (1) of this section shall comply with all of the provisions of this article 10
and the rules promulgated thereunder.
(2) [Editor's note: This version of subsection (2) is effective July 1, 2024.] Service
agencies and case management agencies receiving funds pursuant to subsection (1) of this
section shall comply with all of the provisions of this article 10 and the rules promulgated
thereunder.
(3) [Editor's note: This version of subsection (3) is effective until July 1, 2024.] Case
management services must be purchased from the community-centered board designated
pursuant to section 25.5-10-209 or the case management agency, except as otherwise provided in
subsection (4) of this section.
(3) [Editor's note: This version of subsection (3) is effective July 1, 2024.] Case
management services must be purchased from the case management agency, except as otherwise
provided in subsection (4) of this section.
(4) (a) [Editor's note: This version of the introductory portion to subsection (4)(a) is
effective until July 1, 2024.] The state department may purchase services and supports directly
from service agencies and case management services from case management agencies if:
(4) (a) [Editor's note: This version of the introductory portion to subsection (4)(a) is
effective July 1, 2024.] The state department may purchase long-term services and supports
directly from service agencies and case management services from case management agencies if:
(I) Required by the federal requirements for the state to qualify for federal funds under
Title XIX of the federal "Social Security Act", as amended, including programs authorized
pursuant to part 4 of article 6 of this title; or
(II) [Editor's note: This version of subsection (4)(a)(II) is effective until July 1, 2024.]
The executive director has determined that a service or support provided or purchased by a
designated community-centered board does not meet established standards and the continuation
of purchase of the service or support through the community-centered board is not in the best
interests of the persons receiving services.
(II) [Editor's note: This version of subsection (4)(a)(II) is effective July 1, 2024.] The
executive director has determined that a long-term service or support provided or purchased by a
case management agency does not meet established standards and the continuation of purchase
of the long-term service or support through the case management agency is not in the best
interests of the persons receiving services.
(b) (I) [Editor's note: This version of subsection (4)(b)(I) is effective until July 1,
2024.] The state department shall only purchase services and supports directly from those
community-centered boards, case management agencies, or service agencies that meet
established standards.
(b) (I) [Editor's note: This version of subsection (4)(b)(I) is effective July 1, 2024.] The
state department shall only purchase long-term services and supports directly from those case
management agencies or service agencies that meet established standards.
(II) The standards referenced in subsection (4)(b)(I) of this section must include a
requirement that, on and after January 1, 2019, prior to employment, the name of a person who
will be providing direct care, as defined in section 26-3.1-101 (3.5), to an at-risk adult, as
defined in section 26-3.1-101 (1.5), as well as any other required identifying information, is
Colorado Revised Statutes 2023 Uncertified PrintoutPage 467 of 510
submitted to the department of human services for a check of the Colorado adult protective
services data system pursuant to section 26-3.1-111, to determine if the person is substantiated in
a case of mistreatment of an at-risk adult.
(c) The state department may purchase services and supports, including service and
support coordination, from a family caregiver if the executive director has determined that the
provision of a service or support by a family caregiver in the family home would provide the
person receiving the service or support with the least restrictive environment.
(d) Nothing in this section shall be construed to prohibit the provision of services and
supports, including case management services, directly by the department of human services
through regional centers, for persons receiving services in regional centers.
(e) Nothing in this section shall be construed to require the provision of services and
supports, including case management services, directly by the state department.
(5) [Editor's note: This version of subsection (5) is effective until July 1, 2024.]
Governmental units, including but not limited to counties, municipalities, school districts, health
service districts, and state institutions of higher education, are authorized at their own expense to
furnish money, materials, or services and supports to persons with intellectual and
developmental disabilities, or to purchase services and supports for such persons through
designated community-centered boards, case management agencies, or service agencies, so long
as no conditions or requirements imposed as a result of the provision or purchase conflict with
the provisions of this article 10 or the rules promulgated thereunder.
(5) [Editor's note: This version of subsection (5) is effective July 1, 2024.]
Governmental units, including but not limited to counties, municipalities, school districts, health
service districts, and state institutions of higher education, are authorized at their own expense to
furnish money, materials, or long-term services and supports to persons with intellectual and
developmental disabilities, or to purchase long-term services and supports for such persons
through designated case management agencies or service agencies, so long as no conditions or
requirements imposed as a result of the provision or purchase conflict with the provisions of this
article 10 or the rules promulgated thereunder.
(6) Boards of county commissioners may levy up to one mill for the purpose of
purchasing services and supports for persons with intellectual and developmental disabilities. To
the extent authorized by federal law, and subject to annual appropriation by the general
assembly, and pursuant to rules established by the state board, a county may transfer the revenue
raised pursuant to the mill levy to the state department to receive matching federal funds to
provide medicaid-approved waiver services to persons with intellectual and developmental
disabilities.
(7) (a) Each year the general assembly shall appropriate moneys to the state department
to provide or purchase services and supports for persons with intellectual and developmental
disabilities pursuant to this section. Unless specifically provided otherwise, services and supports
shall be purchased on the basis of state funding less any federal or cash funds received for
general operating expenses from any other state or federal source, less funds available to a
person receiving residential services or supports after such person receives an allowance for
personal needs or for meeting other obligations imposed by federal or state law, and less the
required local school district funds specified in paragraph (b) of this subsection (7). The yearly
appropriation, when combined with all other sources of funds, shall in no case exceed one
hundred percent of the approved program costs as determined by the general assembly.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 468 of 510
(b) [Editor's note: This version of subsection (7)(b) is effective until July 1, 2024.]
Each school district shall pay to the community-centered board providing programs attended by
a student with an intellectual and developmental disability, who is domiciled in the school
district and may be counted in the district's pupil enrollment, an amount at least equal to the
district's per pupil revenues as determined pursuant to the "Public School Finance Act of 1994",
article 54 of title 22, C.R.S. This subsection (7) applies to students who are less than twenty-two
years of age.
(b) [Editor's note: This version of subsection (7)(b) is effective July 1, 2024.] Each
school district shall pay to the case management agency purchasing programs attended by a
student with an intellectual and developmental disability, who is domiciled in the school district
and may be counted in the district's pupil enrollment, an amount at least equal to the district's per
pupil revenues as determined pursuant to the "Public School Finance Act of 1994", article 54 of
title 22. This subsection (7) applies to students who are less than twenty-two years of age.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1754, §
1, effective March 1, 2014. L. 2017: (4)(b) amended, (HB 17-1284), ch. 272, p. 1505, § 12,
effective May 31; IP(1), (2), (3), IP(4)(a), (4)(b), and (5) amended, (HB 17-1343), ch. 320, p.
1723, § 3, effective June 5. L. 2021: IP(1), (2), (3), IP(4)(a), (4)(a)(II), (4)(b)(I), (5), and (7)(b)
amended, (HB 21-1187), ch. 83, p. 339, § 41, effective July 1, 2024.
Editor's note: (1) This section is similar to former § 27-10.5-104 as it existed prior to
2013.
(2) Amendments to subsection (4)(b) by HB 17-1284 and HB 17-1343 were harmonized.
25.5-10-207. Long-term services and supports - waiting list reduction - cash fund -
repeal. (Repealed)
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1757, §
1, effective March 1, 2014. L. 2014: (1.5), (2), and (3) amended and (3.5) added, (HB 14-1252),
ch. 18, p. 135, § 1, effective March 1; (2) repealed, (HB 14-1051), ch. 33, p. 184, § 1, effective
August 6. L. 2015: (6) added, (SB 15-168), ch. 16, p. 40, § 1, effective March 13. L. 2016: (7)
added, (SB 16-196), ch. 226, p. 866, § 4, effective June 6; (3)(b) and (3)(c) amended and (3)(d)
added, (SB 16-192), ch. 256, p. 1052, § 2, effective June 8. L. 2017: IP(3), (3)(c), and (3)(d)
amended and (3)(e), (8), and (9) added, (HB 17-1343), ch. 320, p. 1724, § 4, effective June 5. L.
2021: (3)(c) and (3)(e) amended, (HB 21-1187), ch. 83, p. 340, § 42, effective July 1, 2024;
(3)(d)(II) added by revision, (HB21-1187), ch. 83, pp. 340, 354, §§ 42, 70.
Editor's note: Subsection (9)(a) provided for the repeal of this section, effective July 1,
2022. (See L. 2017, p. 1724.)
25.5-10-207.5. Strategic plan for long- term services and supports - joint hearing -
appropriation - reporting - legislative declaration - rules. (1) (a) The general assembly finds
that:
(I) Colorado has a long commitment to supporting persons with intellectual and
developmental disabilities in communities of their choosing;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 469 of 510
(II) Coloradans with intellectual and developmental disabilities who are eligible for state
services and supports should be able to access services and supports in a timely manner to allow
them to benefit from those services and supports and lead lives that build on their independence;
(III) Providing early and timely access to services and supports for persons with
intellectual and developmental disabilities is an excellent and cost-effective investment that
results in substantial future savings;
(IV) The presence of a waiting list as long as fifteen years for essential services and
supports contradicts Colorado's commitment to supporting persons in the least restrictive
environment of their choosing;
(V) Colorado must have accurate data concerning the need for services and supports for
persons with intellectual and developmental disabilities and their families and must regularly
forecast this data to ensure that effective policy and programs are directed to meet these needs;
(VI) The waiting list includes persons with intellectual and developmental disabilities
who are at risk of experiencing a crisis due to the advanced age, reduced capacity, and illness of
their caregivers;
(VII) After a lifetime of providing continuous support, these caregivers deserve the
comfort of knowing that their loved one will have needed services and supports; and
(VIII) Persons with intellectual and developmental disabilities and their caregivers
should not have to experience a crisis before getting needed assistance, as each crisis puts undue
hardship and strain on the person and caregiver, and the services system.
(b) Therefore, the general assembly declares that Colorado is committed to developing a
strategic plan to ensure that Coloradans with intellectual and developmental disabilities and their
families will be able to access the services and supports they need and want at the time that they
need and want those services and supports.
(2) [Editor's note: This version of subsection (2) is effective until July 1, 2024.] During
each regular session of the general assembly, the joint budget committee and the health and
human services committees of the senate and the house of representatives, or any successor
committees, shall hold a joint hearing and take public testimony on the status of the waiting lists
for persons with intellectual and developmental disabilities who are waiting for enrollment into a
home- and community-based services program or a program provided pursuant to this article 10
and the availability of general fund money to reduce the number of persons on the waiting lists
and the amount of time eligible persons wait for such services. Notwithstanding the provisions of
section 24-1-136 (11)(a)(I), the state department shall present testimony, including the
information provided in the report pursuant to subsection (3) of this section, as well as
information concerning the ongoing implementation of the strategic plan required pursuant to
subsection (4) of this section, including any revisions to the strategic plan. Additionally, the state
department, community-centered boards, and providers shall report on the use and effectiveness
of any money appropriated in the preceding state fiscal year for increasing system capacity. The
goal of the hearing is to propose an appropriation from the general fund to the intellectual and
developmental disabilities services cash fund.
(2) [Editor's note: This version of subsection (2) is effective July 1, 2024.] During each
regular session of the general assembly, the joint budget committee and the health and human
services committees of the senate and the house of representatives, or any successor committees,
shall hold a joint hearing and take public testimony on the status of the waiting lists for persons
with intellectual and developmental disabilities who are waiting for enrollment into a home- and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 470 of 510
community-based services program or a program provided pursuant to this article 10 and the
availability of general fund money to reduce the number of persons on the waiting lists and the
amount of time eligible persons wait for such services. Notwithstanding the provisions of section
24-1-136 (11)(a)(I), the state department shall present testimony, including the information
provided in the report pursuant to subsection (3) of this section, as well as information
concerning the ongoing implementation of the strategic plan required pursuant to subsection (4)
of this section, including any revisions to the strategic plan. Additionally, the state department,
case management agencies, and providers shall report on the use and effectiveness of any money
appropriated in the preceding state fiscal year for increasing system capacity. The goal of the
hearing is to propose an appropriation from the general fund to the intellectual and
developmental disabilities services cash fund.
(3) (a) Notwithstanding the provisions of section 24-1-136 (11)(a)(I), on or before
November 1, 2014, and November 1 of each year thereafter, in accordance with section 24-1-136
(9), the state department shall report to the general assembly the total number of persons with
intellectual and developmental disabilities who are waiting at the time of the report for
enrollment into a home- and community-based services program or a program provided pursuant
to this article 10. The report must also include information concerning the ongoing
implementation of the strategic plan required pursuant to subsection (4) of this section, including
any revisions to the strategic plan.
(b) The information reported pursuant to paragraph (a) of this subsection (3) relating to
persons with intellectual and developmental disabilities who are waiting for enrollment into a
home- and community-based services program or a program provided pursuant to this article
shall be disaggregated by:
(I) The specific medicaid waiver program or other intellectual and developmental
disabilities program, service, or support;
(II) The persons who need services immediately but who are not currently receiving
services;
(III) The persons who need services immediately who are currently receiving some
services; and
(IV) The persons who are eligible for services but who do not need services at this time.
(4) (a) [Editor's note: This version of subsection (4)(a) is effective until July 1, 2024.]
On or before November 1, 2014, the state department shall develop, in consultation with
intellectual and developmental disability system stakeholders, a comprehensive strategic plan
including administrative procedures and adequate funding to enroll eligible persons with
intellectual and developmental disabilities into home- and community-based services programs
and programs provided pursuant to this article at the time those persons choose to enroll in the
programs or need the services or supports. As part of developing the strategic plan, the state
department shall review the statutory definition of "waiting list" set forth in section 25.5-10-202
and make recommendations concerning amendments to the definition. In engaging stakeholders,
the state department shall include both persons and families receiving services, as well as
persons and families waiting for enrollment into programs, services, or supports. These persons
and families shall include, at a minimum, persons and families who reside in each
community-centered, board-designated service area within the state. In developing the strategic
plan, the state department shall review relevant recommendations from the community living
advisory group created in the office pursuant to the governor's executive order D 2012-027, as
Colorado Revised Statutes 2023 Uncertified PrintoutPage 471 of 510
well as other relevant information. The strategic plan shall include specific recommendations
and annual benchmarks for achieving this enrollment goal by July 1, 2020, including
recommendations relating to increasing system capacity. The state department shall review the
strategic plan annually and revise the plan as needed to meet the enrollment goal. Nothing in this
section precludes the state department from considering changes in the structure of the state's
intellectual and developmental disabilities programs, including medicaid waiver modification.
(4) (a) [Editor's note: This version of subsection (4)(a) is effective July 1, 2024.] On or
before November 1, 2014, the state department shall develop, in consultation with intellectual
and developmental disability system stakeholders, a comprehensive strategic plan including
administrative procedures and adequate funding to enroll eligible persons with intellectual and
developmental disabilities into home- and community-based services programs and programs
provided pursuant to this article 10 at the time those persons choose to enroll in the programs or
need the services or supports. As part of developing the strategic plan, the state department shall
review the statutory definition of "waiting list" set forth in section 25.5-10-202 and make
recommendations concerning amendments to the definition. In engaging stakeholders, the state
department shall include both persons and families receiving services, as well as persons and
families waiting for enrollment into programs, services, or supports. These persons and families
must include, at a minimum, persons and families who reside in each defined service area within
the state. In developing the strategic plan, the state department shall review relevant
recommendations from the community living advisory group created in the office pursuant to the
governor's executive order D 2012-027, as well as other relevant information. The strategic plan
must include specific recommendations and annual benchmarks for achieving this enrollment
goal by July 1, 2020, including recommendations relating to increasing system capacity. The
state department shall review the strategic plan annually and revise the plan as needed to meet
the enrollment goal. Nothing in this section precludes the state department from considering
changes in the structure of the state's intellectual and developmental disabilities programs,
including medicaid waiver modification.
(b) The state department shall submit the strategic plan to the general assembly in
accordance with section 24-1-136 (9), C.R.S., and shall present the strategic plan to the joint
budget committee on or before December 1, 2014.
(5) In its annual submission of the state department's budget request to the joint budget
committee, the governor's office of state planning and budgeting shall reference the number of
persons who are waiting at the time of the November 1 report for enrollment into a home- and
community-based services program or a program provided pursuant to this article and shall
indicate to the joint budget committee those budget requests related specifically to achieving the
enrollment goal set forth in the strategic plan required pursuant to this section.
(6) (a) Subject to the availability of reserve capacity enrollment, a person with an
intellectual and developmental disability who is on the waiting list for services and who is at risk
of experiencing an emergency due to any of the criteria included in subsection (6)(b) of this
section and who meets other applicable criteria for enrollment established by the state board
shall be offered enrollment into the home- and community-based services developmental
disabilities waiver using a person-centered transition process.
(b) No later than June 1, 2019, the state board shall promulgate rules regarding the
criteria for reserve capacity enrollments for those persons described in subsection (6)(a) of this
section, which criteria must include but is not limited to:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 472 of 510
(I) The age of the custodial parent or caregiver;
(II) The loss of the custodial parent or caregiver;
(III) Incapacitation of the custodial parent or caregiver;
(IV) Any life-threatening or serious persistent illness of the custodial parent or caregiver;
and
(V) A threat to health or safety that the custodial parent or caregiver places on the person
with intellectual and developmental disabilities.
(c) As part of the rule-making process for reserve capacity enrollment pursuant to
subsection (6)(b) of this section, the state board shall solicit feedback from persons with
intellectual and developmental disabilities and family members of persons with intellectual and
developmental disabilities.
(7) During the state fiscal year beginning July 1, 2018, the state department shall initiate
three hundred nonemergency enrollments from the waiting list for the home- and
community-based services developmental disabilities waiver.
(8) Beginning July 2018, and continuing monthly thereafter, the state department shall
include in its monthly premiums, expenditures, and caseload report the number of persons who
were moved off the developmental disabilities waiting list, specifying the enrollments initiated
under the order of selection and the enrollments initiated under the reserve capacity criteria.
Source: L. 2014: Entire section added, (HB 14-1051), ch. 33, p. 184, § 2, effective
August 6. L. 2017: (2) and (3)(a) amended, (HB 17-1060), ch. 6, p. 17, § 10, effective November
2. L. 2018: (1)(a)(IV) amended and (1)(a)(VI), (1)(a)(VII), (1)(a)(VIII), (6), (7), and (8) added,
(HB 18-1407), ch. 248, p. 1531, § 3, effective May 24. L. 2021: (2) and (4)(a) amended, (HB
21-1187), ch. 83, p. 341, § 43, effective July 1, 2024.
Editor's note: Subsection (2) is similar to former § 25.5-10-207 (2) as it existed prior to
2014.
Cross references: For the legislative declaration in HB 18-1407, see section 1 of chapter
248, Session Laws of Colorado 2018.
25.5-10-208. Service agencies and case management agencies - money - rules -
repeal. (1) A service agency and a case management agency shall comply with the requirements
set forth in this article 10 and the rules promulgated thereunder.
(2) [Editor's note: This version of the introductory portion to subsection (2) is effective
until July 1, 2024.] The state board shall promulgate rules to implement the purchase of services
and supports from a community-centered board, service agency, case management agency, or
family caregiver. The rules must include, but need not be limited to:
(2) [Editor's note: This version the introductory portion to subsection (2) is effective
July 1, 2024.] The state board shall promulgate rules to implement the purchase of long-term
services and supports from a service agency, case management agency, or family caregiver. The
rules must include, but need not be limited to:
(a) Terms and conditions necessary to promote the effective delivery of services and
supports, including those services and supports delivered by a family caregiver;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 473 of 510
(b) [Editor's note: This version of subsection (2)(b) is effective until July 1, 2024.]
Procedures for obtaining an annual audit of designated community-centered boards, case
management agencies, and service agencies to provide financial information deemed necessary
by the state department to establish costs of services and supports and to ensure proper
management of money received pursuant to section 25.5-10-206;
(b) [Editor's note: This version of subsection (2)(b) is effective July 1, 2024.]
Procedures for obtaining an annual audit of case management agencies and service agencies to
provide financial information deemed necessary by the state department to establish costs of
long-term services and supports and to ensure proper management of money received pursuant
to section 25.5-10-206;
(c) (I) Delineation of a system to resolve contractual disputes between the state
department and designated community-centered boards, service agencies, or case management
agencies, and between designated community-centered boards and service agencies, including
the contesting of any rates that the designated community-centered boards charge to service
agencies based upon a percentage of the rates that service agencies charge for services and
supports;
(II) This subsection (2)(c) is repealed, effective July 1, 2024.
(d) [Editor's note: This version of subsection (2)(d) is effective until July 1, 2024.]
Specification of which services and supports are to be reimbursed by the state department and
secondarily by the community-centered board, the source of reimbursement, actual service or
support costs, incentives, and program service objectives that affect reimbursement;
(d) [Editor's note: This version of subsection (2)(d) is effective July 1, 2024.]
Specification of which long-term services and supports are to be reimbursed by the state
department and secondarily by the case management agency, the source of reimbursement,
actual long-term service or support costs, incentives, and program service objectives that affect
reimbursement;
(e) The methods of coordinating the purchase of services and supports, including but not
limited to service and support coordination, with other federal, state, and local programs that
provide funding for authorized services and supports; and
(f) [Editor's note: This version of subsection (2)(f) is effective until July 1, 2024.]
Criteria for and limitations on any rates that designated community-centered boards charge to
service agencies based upon a percentage of the rates that service agencies charge for services
and supports.
(f) [Editor's note: This version of subsection (2)(f) is effective July 1, 2024.] Criteria
for and limitations on any rates that case management agencies charge to service agencies based
upon a percentage of the rates that service agencies charge for long-term services and supports.
(3) [Editor's note: This version of subsection (3) is effective until July 1, 2024.] Any
incorporated service agency that is registered in Colorado as a foreign corporation shall organize
a local advisory board consisting of persons who reside within the designated service area. Such
advisory board shall be representative of the community at large and persons receiving services
and their families.
(3) [Editor's note: This version of subsection (3) is effective July 1, 2024.] Any
incorporated service agency that is registered in Colorado as a foreign corporation shall organize
a local advisory board consisting of persons who reside within the defined service area. The
Colorado Revised Statutes 2023 Uncertified PrintoutPage 474 of 510
advisory board shall be representative of the community at large and persons receiving services
and their families.
(4) [Editor's note: This version of subsection (4) is effective until July 1, 2024.] Upon a
determination by the executive director that services or supports have not been provided in
accordance with the program or financial administration standards specified in this article 10 and
the rules promulgated thereunder, the executive director may reduce, suspend, or withhold
payment to a designated community-centered board, case management agency, service agency
under contract with a designated community-centered board, or service agency from which the
state department purchased services or supports directly. When the executive director decides to
reduce, suspend, or withhold payment, the executive director shall specify the reasons therefor
and the actions that are necessary to bring the designated community-centered board, case
management agency, or service agency into compliance.
(4) [Editor's note: This version of subsection (4) is effective July 1, 2024.] Upon a
determination by the executive director that services or supports have not been provided in
accordance with the program or financial administration standards specified in this article 10 and
the rules promulgated thereunder, the executive director may reduce, suspend, or withhold
payment to a case management agency or service agency under contract with a case management
agency, or service agency from which the state department purchased long-term services or
supports directly. When the executive director decides to reduce, suspend, or withhold payment,
the executive director shall specify the reasons therefor and the actions that are necessary to
bring the case management agency or service agency into compliance.
(5) Nothing in this article or in any rules promulgated pursuant thereto and no actions
taken by the executive director pursuant to this article shall be construed to affect the obtaining
of funds from local authorities, including those funds obtained from a mill levy assessed by a
county or municipality for the purpose of purchasing services or supports for persons with
intellectual and developmental disabilities, or to require that such funds from local authorities be
used to supplant state or federal funds available for purchasing services and supports for persons
with developmental disabilities.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1758, §
1, effective March 1, 2014. L. 2017: (1), IP(2), (2)(b), (2)(c), and (4) amended, (HB 17-1343),
ch. 320, p. 1724, § 5, effective June 5. L. 2021: IP(2), (2)(b), (2)(d), (2)(f), (3), and (4) amended,
(HB 21-1187), ch. 83, p. 342, § 44, effective July 1, 2024; (2)(c)(II) added by revision, (HB
21-1187), ch. 83, pp. 342, 354, §§ 44, 70.
Editor's note: This section is similar to former § 27-10.5-104.5 as it existed prior to
2013.
25.5-10-209. Community-centered boards - designation - purchase of services and
supports - performance audits - Colorado local government audit law - public disclosure of
board administration and operations - repeal. (1) In order to be designated as the
community-centered board in a particular designated service area, a private for-profit or
not-for-profit corporation shall annually apply for such designation to the state department in the
form and manner specified by the executive director. Designation shall be based on the
following factors:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 475 of 510
(a) Utilization of existing service agencies or existing social networks or natural sources
of support in the designated service area;
(b) Encouragement of competition among service agencies within the designated service
area to provide newly identified services or supports, the variety of service agencies available to
the person receiving services within the designated service area, and the demonstrated effort to
purchase new or expanded services or supports from service agencies other than those affiliated
with the community-centered board;
(c) Utilization of state-funded services and supports administered at the local level,
including but not limited to public education, social services, public health, and rehabilitation
programs;
(d) Quality of services and supports provided directly or by contract for persons with
intellectual and developmental disabilities;
(e) The establishment of new services and supports for the prevention of
institutionalization, the support of deinstitutionalization, and a commitment to innovative,
effective, and inclusive services and supports for persons with intellectual and developmental
disabilities; and
(f) The willingness of the applicant to pursue authorized services and supports from all
eligible persons within the designated service area.
(2) Once a community-centered board has been designated pursuant to this section, it
shall, subject to available appropriations:
(a) Be under the control and direction of a board of directors or trustees composed of one
or more persons from each of the following categories:
(I) Interested persons representing the community at large;
(II) Family members of persons with intellectual and developmental disabilities who are
receiving services or supports; and
(III) Persons with intellectual and developmental disabilities who are receiving services
or supports;
(b) Adopt by-law provisions to ensure that:
(I) Members of the governing board are prohibited from voting on issues in which they
have a conflict of interest;
(II) Staff members of the community-centered board and employees or board members
of service agencies may not serve on the governing board;
(III) Staff members of the community-centered board and employees or board members
of service agencies are prohibited from voting in elections for members of the governing board;
and
(IV) Board meetings must be scheduled after adequate notice and must be open to the
public; except that, by vote of a two-thirds majority of members present, the board may elect to
address the following matters in executive session:
(A) The purchase, acquisition, lease, transfer, or sale of any real, personal, or other
property interest;
(B) Conferences with an attorney for the purpose of receiving legal advice on specific
legal questions;
(C) Matters required to be kept confidential by federal or state law or rules;
(D) Specialized details of security arrangements or investigations;
(E) Determining positions relative to matters that may be subject to negotiations;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 476 of 510
(F) Developing strategy for negotiations and instructing negotiators; and
(G) Personnel matters;
(c) Determine the needs of eligible persons within the community-centered board
designated service area and prepare and implement a long-range plan and annual updates to that
plan for the development and coordination of services and supports to address those needs. The
needs determination and designated service area plans or annual update shall be submitted to the
state department.
(d) Determine eligibility and develop an individualized plan for each person who
receives services or supports pursuant to section 25.5-10-211; except that, for a child from birth
through two years of age, eligibility determination and development of an individualized family
service plan are made pursuant to the provisions of part 4 of article 3 of title 26.5;
(e) Provide case management services and periodic reviews pursuant to section
25.5-10-211, for persons receiving services and families with children with intellectual and
developmental disabilities or delays;
(f) Obtain or provide early intervention services and supports pursuant to the provisions
of part 4 of article 3 of title 26.5;
(g) Take steps to notify eligible persons, and their families as appropriate, regarding the
availability of services and supports; and
(h) Establish a human rights committee. The human rights committee is composed, to
the extent possible, of two professional persons trained in the application of behavior
development techniques and three representatives of persons receiving services, their parents,
legal guardians, or authorized representatives. An employee or board member of a service
agency within the community-centered board's designated service area shall not serve as a
member of the human rights committee.
(3) The executive director shall review each designated community-centered board
program to ensure that the program complies with the requirements and standards set forth in
this article and the rules promulgated thereunder.
(4) The state auditor shall conduct or cause to be conducted a performance audit that
includes each community-centered board that receives more than seventy-five percent of its
funding on an annual basis from the federal, the state, or a local government or from any
combination of such governmental entities to determine whether such board is effectively and
efficiently fulfilling its statutory obligations. A community-centered board becomes subject to
the audit requirement under this subsection (4) at such time as the board initially satisfies the
seventy-five percent funding requirement for any one year regardless of whether or not the
funding level decreases below seventy-five percent in any subsequent year. Any performance
audit that is required to be conducted under this subsection (4) must be completed in the first
five-year period following August 10, 2016. Thereafter, a performance audit may be conducted
of such community-centered boards described in this subsection (4) if requested by the state
auditor in the exercise of his or her discretion. The state auditor shall submit a written report and
recommendations on each audit conducted under this subsection (4) and shall present the report
and recommendations to the legislative audit committee created in section 2-3-101 (1), C.R.S.
The state auditor shall pay the costs of any performance audit conducted pursuant to this section.
(5) Each community-centered board is subject to the requirements of the "Colorado
Local Government Audit Law", part 6 of article 1 of title 29, C.R.S.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 477 of 510
(6) In connection with the board of directors of each community-centered board, in
addition to any other requirements applicable to the operation of the board of directors pursuant
to this section or as required elsewhere by law:
(a) The community-centered board shall post the date, time, and location of each
regularly scheduled meeting of its board of directors on the website of the community-centered
board not less than fourteen business days prior to the date of the meeting. The
community-centered board shall post on the website of the community-centered board the date,
time, and location of any special or emergency meeting of the board of directors not less than
twenty-four hours before the meeting.
(b) Each community-centered board shall post the agenda for each meeting of its board
of directors on the website of the community-centered board not less than seven business days
prior to the date of the meeting. The community-centered board shall post on the website of the
community-centered board the agenda of any special or emergency meeting of the board of
directors not less than twenty-four hours before the meeting. Each meeting of the board must
allow for public comment, and the agenda must reflect this requirement. Public comment must
be reasonably permitted during the board meeting to accommodate community needs. Any
documents related to functions of the community-centered board to be distributed at a meeting of
the board of directors that are available for public dissemination at the time the agenda is posted
must also be posted on the website of the community-centered board at the time the agenda is
posted, and written copies of such documents must be made available for public dissemination at
the board meeting; except that, the posting requirement specified in this paragraph (b) does not
apply to any document, or any portion of such document, the disclosure of which requires the
approval of the board of directors and which approval has not been obtained as of the time the
agenda is posted or any other document, or any portion of such document, containing any
information that is legally prohibited from being disclosed to the public pursuant to the privacy
requirements specified in the health insurance portability and accountability act, any document
that has been or will be discussed by the board of directors meeting in executive session, or any
other document the disclosure of which is otherwise prohibited by law.
(c) Each community-centered board shall provide a direct e-mail address to each
member of its board of directors on the website of the community-centered board. The e-mail
address selected must specify the name of the individual board member and make reference to
the particular community-centered board for which he or she serves as a member of the board of
directors. An e-mail that is sent to a member of the board of directors of a community-centered
board shall not be filtered by the community-centered board through an employee of the
community-centered board before it is sent to the member of the board of directors.
(d) The board of directors of each community-centered board shall present the financial
statements of the corporation for the approval of the board at each regularly scheduled meeting
of the board of directors. The financial statements must reflect accurate and current financial
information and be prepared using generally accepted accounting principles. Where exigent
circumstances are present that materially affect the preparation of the financial statements on a
monthly basis, such statements may be presented for the approval of the board of directors at the
next regularly scheduled meeting of the board but not less than at least once each quarter of the
calendar year.
(e) Each community-centered board shall require the person or entity that performs
financial audits of the community-centered board to present and discuss the results of the audit to
Colorado Revised Statutes 2023 Uncertified PrintoutPage 478 of 510
the board of directors not less than once each year at a regularly scheduled meeting of the board
of directors.
(f) Each community-centered board shall provide to the incoming members of its board
of directors training in such topics as the duties of a board member, the financial and fiduciary
responsibilities assumed by board members, the intellectual and developmental disability system
in the state, the overall business functions of the community-centered board, and any other
matters that will, in the determination of the community-centered board, allow the board member
to better understand and fulfill his or her obligations to the board of directors and the
community-centered board and the role played by community-centered boards in the state in
connection with the delivery of services for persons with intellectual and developmental
disabilities.
(g) Each community-centered board shall post on the website of the community-centered
board the minutes of each meeting of its board of directors as such minutes are approved by the
board of directors. Each community-centered board shall also post on the website of the
community-centered board any additional documents that were distributed to the board at such
meeting that were not, as of that date, already posted on the website of the community-centered
board unless the public distribution of such documents, or any portion of such documents, is
otherwise prohibited pursuant to the privacy requirements specified in the health insurance
portability and accountability act or as otherwise prohibited by law. Minutes of special meetings
of the board of directors must be posted after approval by the board of the same at the board's
next regular meeting.
(7) With respect to financial information concerning the community-centered board,
each community-centered board shall:
(a) Post the following on the website of the community-centered board in a place on the
website that allows access to the public in a clear, accessible, easily operated, and uncomplicated
manner:
(I) Each completed financial audit undertaken of the community-centered board not later
than thirty days following acceptance by the corporation's board of directors of the audit; and
(II) The most current form 990 the community-centered board has filed with the federal
internal revenue service not later than thirty days following filing of the form with the internal
revenue service.
(b) Make the following information available upon reasonable request not later than five
business days after the request is made:
(I) The annual budget of the community-centered board for each calendar or fiscal year,
as applicable, not later than thirty days after final approval of the budget by the board of
directors of the community-centered board;
(II) An annual summary of all revenues and expenditures of the community-centered
board as have been appropriated by the state concerning capacity building, family support
services, state general fund supported living services, and state general fund early intervention
that is calculated by September 30 of each year for the prior year, as applicable; and
(III) A description of the policies and procedures it follows to track, manage, and report
its financial resources and transactions, which policies and procedures are also known and may
be referred to as its "financial controls".
(8) Any contract that each community-centered board enters into on or after August 10,
2016, with either the department of health care policy and financing created in section
Colorado Revised Statutes 2023 Uncertified PrintoutPage 479 of 510
25.5-1-104 (1) or the department of human services created in section 26-1-105, C.R.S., must be
posted on the website of the community-centered board in a place on the website that allows
access to the public in a clear, accessible, easily operated, and uncomplicated manner not later
than thirty days following approval of the contract by the board of directors of the
community-centered board.
(9) This section is repealed, effective July 1, 2024.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1760, §
1, effective March 1, 2014. L. 2016: (4), (5), (6), (7), and (8) added, (SB 16-038), ch. 199, p.
702, § 2, effective August 10. L. 2017: (2)(e) amended, (HB 17-1343), ch. 320, p. 1725, § 6,
effective June 5. L. 2021: (9) added by revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
L. 2022: (2)(d) and (2)(f) amended, (HB 22-1295), ch. 123, p. 848, § 77, effective July 1.
Editor's note: This section is similar to former § 27-10.5-105 as it existed prior to 2013.
Cross references: (1) For the federal "Health Insurance Portability and Accountability
Act of 1996", (HIPAA), see 42 U.S.C. sec. 1320d et seq.
(2) For the legislative declaration in SB 16-038, see section 1 of chapter 199, Session
Laws of Colorado 2016.
25.5-10-209.3. Cross-system behavioral health crisis response - comprehensive care
coordination and treatment model - training - legislative declaration. (1) (a) The general
assembly declares that persons with intellectual and developmental disabilities and co-occurring
behavioral health diagnoses and needs:
(I) Experience limited access to appropriate treatment, including crisis intervention,
stabilization, and prevention, and such individuals who live in rural areas of Colorado are
particularly impacted by this limited access to appropriate treatment;
(II) Deserve to live, work, play, and thrive in their communities;
(III) Require a heightened level of care;
(IV) Require evidence-based treatment to help lead full lives within their communities;
and
(V) Experience significant gaps in care, including a lack of access to appropriate
treatment.
(b) Therefore, as a preliminary measure to close these gaps in care, the general assembly
finds that the state must invest in extensive, expanded training using a comprehensive model of
care that is available via teleconference. The training must be available for up to thirty
individuals across the state in order to adequately address the limited access to treatment in rural
areas.
(2) (a) As soon as possible, the state department shall obtain a vendor to provide
extensive statewide training to professional persons who work with persons with intellectual and
developmental disabilities and co-occurring behavioral health needs.
(b) A qualified vendor must:
(I) Utilize a comprehensive care coordination and treatment model that is
evidence-based;
(II) Be able to show demonstrated success in multiple states;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 480 of 510
(III) Have experience with rural issues;
(IV) Have at least ten years of experience working with professionals who work with
individuals with intellectual and developmental disabilities;
(V) Maintain a national database that involves the standardized collection, analysis, and
reporting of outcomes associated with the impact of the training on the individuals being served;
and
(VI) Be able to provide the training statewide using teleconference technology.
(3) (a) No later than sixty calendar days after a vendor is obtained pursuant to subsection
(2)(a) of this section, case management agencies, mental health centers, and other
program-approved service agencies in the state shall nominate one provider in their geographic
service area to be trained in the comprehensive care coordination and treatment model designed
and provided by the vendor selected pursuant to subsection (2) of this section. Up to twenty
providers may be selected for training pursuant to this subsection (3)(a). Selected providers must
have a clinical background and prior experience working with the intellectual and developmental
disabilities population. If more than twenty providers are nominated through this process, the
state department shall make final selections, giving preference to providers in underserved areas.
(b) The state department shall coordinate with case management agencies in underserved
areas of the state to select an additional ten providers to be trained in the comprehensive care
coordination and treatment model.
(4) Participating providers shall complete the training provided no later than one
calendar year after a provider is nominated pursuant to subsection (3)(a) of this section.
(5) The state department shall reimburse participating providers at the provider's current
pay rate for time spent in training.
Source: L. 2021: Entire section added, (HB 21-1166), ch. 234, p. 1233, § 1, effective
June 15. L. 2022: (2)(a), (3)(a), and (4) amended, (HB 22-1189), ch. 15, p. 126, § 1, effective
August 10.
25.5-10-209.5. Case management agencies - certification - purchase of services and
supports - rules - repeal. (1) In order to be certified as a case management agency, a public or
private for-profit or not-for-profit agency shall apply for certification to the state department in
the form and manner specified by the executive director. The state board shall promulgate rules
for certification and decertification of case management agencies.
(2) Once certified pursuant to this section, a case management agency shall, subject to
available appropriations:
(a) Determine the needs of a person enrolled in home- and community-based services
who selects the case management agency; and
(b) Provide case management services and periodic reviews pursuant to section
25.5-10-211.
(3) The executive director or his or her designee shall review each case management
agency to ensure that the agency complies with the requirements and standards set forth in this
article 10 and the rules promulgated pursuant to this article 10.
(4) The state board shall promulgate rules to ensure that:
(a) Each enrolled person with an intellectual and developmental disability has access to
case management services;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 481 of 510
(b) A person who is enrolled in home- and community-based services and other
programs, as defined in section 25.5-10-202, is not required to have multiple case managers; and
(c) There is an established process for a person to select the case management agency of
his or her choice.
(5) The state board shall begin promulgating rules for case management agencies on
June 5, 2017.
(6) This section is repealed, effective July 1, 2024.
Source: L. 2017: Entire section added, (HB 17-1343), ch. 320, p. 1725, § 7, effective
June 5. L. 2021: (6) added by revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
25.5-10-210. Revocation of designation - repeal. (1) The executive director may
revoke the designation of a community-centered board upon a finding that the
community-centered board is in violation of the provisions of this article and the rules
promulgated thereunder. Such revocation shall conform to the provisions and procedures
specified in article 4 of title 24, C.R.S., and shall be made only after a hearing is provided as
specified in that article.
(2) Once a designation has been revoked pursuant to subsection (1) of this section, the
executive director may designate a service agency to perform the case management services of
the designated community-centered board pending designation of a new community-centered
board.
(3) This section is repealed, effective July 1, 2024.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1762, §
1, effective March 1, 2014. L. 2021: (3) added by revision, (HB 21-1187), ch. 83, pp. 353, 354,
§§ 69, 70.
Editor's note: This section is similar to former § 27-10.5-105.5 as it existed prior to
2013.
25.5-10-211. Eligibility determination - individualized plan - periodic review - rules -
repeal. (1) (a) Any person may request an evaluation to determine whether he or she has an
intellectual and developmental disability and is eligible to receive services and supports pursuant
to this article 10. The person must apply for eligibility determination to the designated
community-centered board in the designated service area where the person resides.
(b) Pursuant to the contract with the state department, designated community-centered
boards shall determine whether a person is eligible to receive services and supports pursuant to
this article 10. For persons eligible for services and supports other than home- and
community-based services, the designated community-centered board shall develop an
individualized plan for him or her as part of his or her enrollment into a program.
(c) For a person eligible for and authorized to receive home- and community-based
services, designated community-centered boards shall refer the person to a third-party entity for
selection of a case management agency.
(2) (a) Following intake and assessment, pursuant to subsection (2)(b) of this section, the
designated community-centered board or the case management agency chosen by the person
Colorado Revised Statutes 2023 Uncertified PrintoutPage 482 of 510
shall develop an individualized plan as provided by rules promulgated by the state board. The
designated community-centered board shall develop an individualized family service plan for a
child with disabilities from birth through two years of age pursuant to section 26.5-3-403.
(b) (I) The case management agency shall develop an individualized plan for persons
enrolled in home- and community-based services.
(II) The designated community-centered board shall develop an individualized plan for
persons eligible for other programs, as defined in section 25.5-10-202, and for a child with
disabilities from birth through two years of age pursuant to section 26.5-3-403.
(2.5) The state board shall promulgate rules pursuant to article 4 of title 24 setting forth
the procedure and criteria for determination of eligibility and individualized plan development.
The procedure and criteria must be uniform in nature and applied throughout the state in a
consistent manner. The procedure and criteria established by the state board must conform with
the provisions of section 25.5-10-211.5 relating to conflict-free case management.
(3) Subject to available appropriations pursuant to section 25.5-10-206 and to the
capacity of an individual service agency, the person with an intellectual and developmental
disability must be provided options for services and supports within the designated service area
that can appropriately meet the person's identified needs, as identified pursuant to subsection (2)
of this section, and may select the case management agency and service agency from which to
receive services or supports.
(4) (a) Each person receiving services must receive periodic and adequate reviews to
ascertain whether the services and supports specified in the person's individualized plan have
been provided, determine the appropriateness of current services and supports, identify whether
the outcomes specified in the person's individualized plan have been achieved, and modify and
revise current services or supports to meet the identified needs and preferences of the person
receiving services. The designated community-centered board shall develop modifications or
revisions to the individualized family service plan for a child with disabilities from birth through
two years of age pursuant to section 26.5-3-403.
(b) In order to accurately review the services and supports being provided, the
community-centered board or regional center may make cognitive, physical, medical,
behavioral, social, vocational, educational, or other necessary types of evaluations of a person
receiving services. An intellectual and developmental disabilities professional shall supervise the
reviews. The person receiving services, the parents or guardian of a minor, or the guardian of the
person receiving services, and the authorized representative of the person receiving services may
attend and shall receive adequate advance notice of the reviews. Parental or legal guardian
consent must be obtained prior to administering evaluations for program review to minors. The
results of a review must be given to the person receiving services and to the person's parent, or
guardian, as appropriate, and must be made a part of the person's record.
(c) A person's individualized plan must be reviewed at least annually; except that an
individualized family service plan for a child with disabilities from birth through two years of
age must be reviewed as required pursuant to part 4 of article 3 of title 26.5.
(5) An individualized plan is not required for a person with intellectual and
developmental disabilities who is eligible for supports and services and who is on a waiting list
for enrollment into a program funded pursuant to this article. Each community-centered board
shall provide information and referral services to each person on the waiting list for enrollment
in a program, at the time of his or her eligibility and annually thereafter, regarding services and
Colorado Revised Statutes 2023 Uncertified PrintoutPage 483 of 510
supports that are relevant to persons and are commonly used by persons with intellectual and
developmental disabilities as provided by rules promulgated by the state board. The criteria for
information and referral shall be uniform in nature and applied throughout the state in a
consistent manner.
(6) This section is repealed, effective July 1, 2024.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1762, §
1, effective March 1, 2014. L. 2017: (1), (2), and (3) amended and (2.5) added, (HB 17-1343),
ch. 320, p. 1726, § 8, effective June 5. L. 2021: (6) added by revision, (HB 21-1187), ch. 83, pp.
353, 354, §§ 69, 70. L. 2022: (2)(a), (2)(b)(II), (4)(a), and (4)(c) amended, (HB 22-1295), ch.
123, p. 849, § 78, effective July 1.
Editor's note: This section is similar to former § 27-10.5-106 as it existed prior to 2013.
25.5-10-211.5. Conflict-free case management - implementation - legislative
declaration - definition - repeal. (1) The general assembly acknowledges the rights of
individuals to make choices regarding their case management agency and service agency.
Therefore, the general assembly believes there exists the need to ensure conflict-free case
management services within the medicaid waivers for persons with intellectual and
developmental disabilities.
(2) As used in this section, unless the context otherwise requires, "rural
community-centered board" means a community-centered board comprised primarily of counties
designated by the state office of rural health as a rural or frontier county.
(3) A conflict-free case management system shall be implemented in Colorado as
follows:
(a) No later than July 1, 2017, the state department shall determine the options for
community-centered boards to become compliant with conflict-free case management;
(b) No later than January 1, 2018, the state department shall publish guidance on the
components of a business continuity plan;
(c) No later than July 1, 2018, each community-centered board shall submit a business
continuity plan to the state department based on the best option for the community-centered
board pursuant to subsection (3)(a) of this section;
(d) Once a community-centered board has submitted its business continuity plan, on or
before June 30, 2019, the state department shall complete an analysis of the adequacy of the
continuity plan, unreimbursed transition costs, and community impacts of the transition to
conflict-free case management;
(e) No later than June 30, 2020, a community-centered board shall complete any
necessary changes to its business operation that are required to implement its business continuity
plan;
(f) No later than June 30, 2021, at least twenty-five percent of clients receiving home-
and community-based services must be served through a system of conflict-free case
management; and
(g) No later than June 30, 2022, all clients receiving home- and community-based
services must be served through a system of conflict-free case management.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 484 of 510
(4) Rural-based services - exemption. (a) The state department is authorized to seek a
federal exemption from conflict-free case management requirements for geographic areas within
the state where the only willing and qualified entity to provide case management services is also
the only willing and qualified entity to provide home- and community-based services in that
geographic area.
(b) A rural community-centered board must initially notify the state department in
writing, no later than July 1, 2017, to request that the state department seek a federal exemption
for its designated service area, as defined in section 25.5-10-202. Upon receipt of the notice, the
state department shall evaluate case management service provider capacity, and, if the state
department determines that it is supported, the state department shall seek a federal exemption
for its designated service area within a reasonable period of time.
(c) Upon notification of federal approval or denial of a federal exemption from
conflict-free case management requirements, the rural community-centered board shall submit a
business continuity plan and commence any necessary changes to its business operation pursuant
to subsection (3)(e) of this section.
(d) The state board shall promulgate rules for the provision of services and supports,
including services and supports coordination, when there are multiple agencies operating in a
specified geographic area.
(e) If the state department has not received notification by July 1, 2019, regarding
approval or denial for a federal exemption from conflict-free case management requirements, the
state board shall promulgate rules for the provision of services and supports, including services
and supports coordination, for designated service areas where a federal exemption from
conflict-free case management is pending.
(f) In order to ensure stability, client choice, and access to services in rural communities,
the state board shall promulgate rules, as permitted under federal law, that allow a qualified
entity to provide both case management services and home- and community-based services to
the same individual if there is insufficient choice or capacity among existing service agencies or
case management agencies serving a designated service area of a rural community-centered
board.
(5) The state board shall amend its rules consistent with changes in federal law as set
forth in 42 CFR (c)(1)(VI), including changes relating to allowable exemptions.
(6) This section is repealed, effective July 1, 2024.
Source: L. 2017: Entire section added, (HB 17-1343), ch. 320, p. 1727, § 9, effective
June 5. L. 2021: (6) added by revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
25.5-10-212. Procedure for resolving disputes over eligibility, modification of
services or supports, and termination of services or supports. (1) Every state or local service
agency receiving state money pursuant to section 25.5-10-206 shall adopt a procedure for the
resolution of disputes arising between the service agency and any recipient of, or applicant for,
services or supports authorized pursuant to section 25.5-10-206. Procedures for the resolution of
disputes regarding early intervention services must comply with IDEA and with part 4 of article
3 of title 26.5. The procedures must be consistent with rules promulgated by the state board
pursuant to article 4 of title 24 and must apply to the following disputes:
(a) A contested decision that the applicant is not eligible for services or supports;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 485 of 510
(b) A contested decision to provide, modify, reduce, or deny services or supports set
forth in the individualized plan or individualized family service plan of the person receiving
services;
(c) A contested decision to terminate services or supports;
(d) A contested decision that the person receiving services is no longer eligible for
services or supports.
(2) The state board shall promulgate rules pursuant to article 4 of title 24, C.R.S., setting
forth procedures for the resolution of disputes specified in subsection (1) of this section that
must:
(a) Require that all applicants for services and supports and the parents or guardian of a
minor, the guardian, or an authorized representative be informed orally and in writing, in their
native language, of the dispute resolution procedures at the time of application, at the time the
individualized plan is developed, and any time changes in the plan are contemplated;
(b) Require that a service agency keep a written record of all proceedings specified
pursuant to this section;
(c) Require that no person receiving services be terminated from such services or
supports during the resolution process;
(d) Require that utilizing the dispute resolution procedure must not prejudice the future
provision of appropriate services or supports to persons; and
(e) Require that the intended action not occur until after reasonable notice has been
provided to the person, the parents or guardian of a minor, the guardian, or an authorized
representative, along with an opportunity to utilize the resolution process, except in emergency
situations, as determined by the state department.
(3) The resolution process need not conform to the requirements of section 24-4-105,
C.R.S., as long as the rules adopted by the state board include provisions specifically setting
forth procedures, time frames, notice, an opportunity to be heard and to present evidence, and the
opportunity for impartial review of the decision in dispute by the executive director or designee,
if the resolution process has failed.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1764, §
1, effective March 1, 2014. L. 2022: IP(1) amended, (HB 22-1295), ch. 123, p. 849, § 79,
effective July 1.
Editor's note: This section is similar to former § 27-10.5-107 as it existed prior to 2013.
25.5-10-213. Discharge - repeal. (1) A person receiving services must be discharged
from services or supports upon a determination, made pursuant to the individualized planning
process, that the services or supports are no longer appropriate. At least ten days prior to
effectuation of the discharge, notification of discharge must be given to the person receiving
services, the parents or guardian of such a person who is a minor, and the person's legal guardian
and authorized representative when applicable.
(2) When a person receiving services notifies a service agency that the person no longer
wishes to receive a service or support, the person must be discharged from the service or support
unless the person is subject to a petition to impose a legal disability or to remove a legal right,
filed pursuant to section 25.5-10-216, or for whom a legal guardian has been appointed, affecting
Colorado Revised Statutes 2023 Uncertified PrintoutPage 486 of 510
the person's ability to voluntarily terminate services or supports. The parents of the person
receiving services who is a minor and such person's guardian must be notified of the person's
wish to terminate services or supports, but no minor will be discharged without the consent of
the parent or legal guardian.
(3) This section is repealed, effective July 1, 2024.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1765, §
1, effective March 1, 2014. L. 2021: (3) added by revision, (HB 21-1187), ch. 83, pp. 353, 354,
§§ 69, 70.
Editor's note: This section is similar to former § 27-10.5-108 as it existed prior to 2013.
25.5-10-214. Community residential home - licenses - rules. (1) The department of
public health and environment and the state department shall implement a system of joint
licensure and certification of community residential homes. Independent residential support
services provided by the state department do not require licensure by the department of public
health and environment.
(2) (a) The department of public health and environment and the state department shall
develop standards for the licensure and certification of community residential homes. The
standards shall include health, life, and fire safety, as well as standards to ensure the effective
delivery of services and supports to residents; except that any community residential home must
comply with local codes.
(b) (I) The state department or the state board of health, as appropriate, shall adopt the
standards by rule and shall specify the responsibilities of each department in the program.
Surveys undertaken to ensure compliance with these standards shall, as appropriate, be
undertaken as joint surveys by the departments.
(II) If a service agency operates a community residential home and provides personal
care services, as defined in section 25-27.5-102, C.R.S., the department of public health and
environment or the state department, as appropriate, is responsible for surveying those services
provided by the service agency, which survey shall be conducted simultaneously with the survey
of the community residential home.
(3) Any community residential home applying for a license or certification on or after
January 1, 1986, shall accommodate at least four but no more than eight persons with intellectual
and developmental disabilities. All licenses and certificates issued by the department of public
health and environment or the state department shall bear the date of issuance and shall be valid
for not more than a twenty-four-month period.
(4) The issuance, suspension, revocation, modification, renewal, or denial of a license or
certification shall be governed by the provisions of section 24-4-104, C.R.S. The failure of a
community residential home to comply with the provisions of this article and the rules
promulgated thereunder, or any local fire, safety, and health codes shall be sufficient grounds for
the department of public health and environment or the state department to deny, suspend,
revoke, or modify the community residential home's license or certification.
(5) The state department and the state board of health shall promulgate such rules as are
necessary to implement this section, pursuant to the provisions specified in article 4 of title 24,
C.R.S. The rules shall include, but shall not be limited to, the following:
Colorado Revised Statutes 2023 Uncertified PrintoutPage 487 of 510
(a) Requirements concerning the distance between the location of community residential
homes and factors to be considered in waiving such requirements for existing community
residential homes;
(b) Procedures to secure the health and safety of persons receiving services or supports
residing in a community residential home in the event the community residential home closes or
its license is denied, suspended, or revoked pursuant to this section; and
(c) Prohibiting the cultivation, use, or consumption of retail marijuana on the premises
of a community residential home.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1765, §
1, effective March 1, 2014.
Editor's note: (1) This section is similar to former § 27-10.5-109 as it existed prior to
2013.
(2) Subsection (5)(c) was numbered as § 27-10.5-109 (6)(d) in Senate Bill 13-283 (see
L. 2013, p. 1896). That provision was harmonized with subsection (5)(c) as it appears in House
Bill 13-1314, effective March 1, 2014.
25.5-10-215. Compliance with local government zoning regulations - notice to local
governments - provisional licensure. (1) The state department shall require any community
residential home seeking licensure pursuant to section 25.5-10-214 to comply with any
applicable zoning regulations of the municipality, city and county, or county where the home is
situated. Failure to comply with applicable zoning regulations shall constitute grounds for the
denial of a license to a home; except that nothing in this section shall be construed to supersede
the provisions of sections 30-28-115 (2), 31-23-301 (4), and 31-23-303 (2), C.R.S.
(2) The state department shall ensure that timely written notice is provided to the
municipality, city and county, or county where a community residential home is situated,
including the address of the home and the population and number of persons to be served by the
home, when any of the following occurs:
(a) An application for a license to operate a community residential home pursuant to
section 25.5-10-214 is made;
(b) A license is granted to a community residential home pursuant to section
25.5-10-214;
(c) A change in the license of a community residential home occurs; or
(d) The license of a community residential home is revoked or otherwise terminated for
any reason.
(3) In the event of a zoning or other delay or dispute between a community residential
home and the municipality, city and county, or county where the home is situated, the state
department may grant a provisional license to the home for up to one hundred twenty days
pending resolution of the delay or dispute.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1767, §
1, effective March 1, 2014.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 488 of 510
Editor's note: This section is similar to former § 27-10.5-109.5 as it existed prior to
2013.
25.5-10-216. Imposition of legal disability - removal of legal right. (1) Any interested
person may petition the court to impose a legal disability on or to remove a legal right from a
person with an intellectual and developmental disability as defined in section 25.5-10-202. The
petition must set forth the disability to be imposed or the legal right to be removed and the
reasons therefor. The petition may affect the right to contract, the right to determine place of
abode or provisions of services and supports, the right to operate a motor vehicle, and other
similar rights.
(2) (a) Prior to granting the petition, the court must find:
(I) That the person subject to the petition has been determined to be a person with an
intellectual and developmental disability pursuant to the provisions of this article; and
(II) That the requested disability or removal is both necessary and desirable to
implement the individualized plan developed for the person receiving services or supports under
the supervision of an intellectual and developmental disabilities professional and the
interdisciplinary team. Such professional must have an understanding of the rights of persons
receiving services as set forth in sections 25.5-10-218 to 25.5-10-229. Such plan must be
submitted to the court and must be signed by the intellectual and developmental disabilities
professional.
(b) When a petition filed pursuant to subsection (1) of this section seeks to impose a
disability or to remove a legal right, related to the selection of place of abode by the person with
an intellectual and developmental disability, the court must also find:
(I) That, based on the recent overt actions or omissions of the person subject to the
petition, and because of the presence of an intellectual and developmental disability, without the
relief requested in the petition such person poses a probable threat of serious physical harm to
such person or others or is unable to care for such person's own needs to the extent that such
person's own life or safety is seriously threatened; and
(II) That the place of abode requested in the petition is the least restrictive residential
setting that is appropriate for the individual needs of the person with an intellectual and
developmental disability.
(3) Within six months after a legal disability has been imposed or a legal right has been
removed, the court shall hold a hearing to review its order and either reaffirm the findings made
pursuant to subsection (2) of this section and continue the legal disability or removal or remove
the legal disability or restore the legal rights to the person subject to the petition. The court may
remove a legal disability from or restore a legal right to a person without a hearing upon the
filing of a motion requesting such relief containing affidavits in support of the motion signed by
all of the parties.
(4) Any interested person may move that the court remove a legal disability or restore a
legal right. If such motion is contested, it must be served on the person whose rights are affected
and upon the party who filed the original petition if the person is not the moving party.
(5) The following procedures must apply to any proceedings instituted pursuant to this
section:
(a) When a petition is filed pursuant to subsection (1) of this section, the person subject
to the petition shall be advised by the court of such person's right to retain and consult with an
Colorado Revised Statutes 2023 Uncertified PrintoutPage 489 of 510
attorney at any time, and that if such person cannot afford to pay an attorney, one will be
appointed by the court without cost. Attorney fees for court-appointed counsel shall be paid by
the court.
(b) Upon the request of an indigent respondent or such respondent's attorney, the court
shall appoint one or more intellectual and developmental disabilities professionals of the
respondent's choice to assist the respondent in the preparation of the respondent's case. The court
shall pay the fees for such intellectual and developmental disabilities professionals.
(c) The court may issue a temporary order imposing a legal disability or removing a
legal right, pending a hearing, for a period not to exceed ten days, based upon the standards
required for issuance of a temporary restraining order. No individualized plan shall be required
by the court to support the issuance of such order.
(d) The burden of proof is at all times upon the party seeking imposition of a disability
or removal of a legal right or opposing removal of a disability or restoration of a legal right, and
the standard of proof is by clear and convincing evidence.
(e) Except as otherwise provided in this subsection (5), all proceedings must be held in
conformance with the Colorado rules of civil procedure, but no costs must be assessed against
the respondent.
(6) In order to provide representation to eligible persons as provided in this section, the
judicial department may pay moneys, out of appropriations made therefor by the general
assembly, directly to appointed counsel or intellectual and developmental disabilities
professionals on a case-by-case basis or, on behalf of the state, to contract with individual
attorneys, legal partnerships, legal professional corporations, public interest law firms, or
nonprofit legal services corporations to provide legal representation for an agreed-upon lump
sum.
(7) A person shall not be admitted to a regional center, as defined in section
27-10.5-102, C.R.S., without a court order issued pursuant to this section except in an emergency
or for the purpose of temporary respite care.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1767, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-110 as it existed prior to 2013.
25.5-10-217. Conduct of court proceedings. All court proceedings arising under section
25.5-10-216 shall be conducted by the district attorney of the county where the proceeding is
held or by a qualified attorney acting for the district attorney appointed by the district court for
that purpose; except that, in any county or in any city and county having a population exceeding
one hundred thousand persons, the proceedings shall be conducted by the county attorney or by a
qualified attorney acting for the county attorney appointed by the district court. In any case in
which there has been a change of venue to a county other than the county of residence of the
respondent or the county in which the proceeding was commenced, the county from which the
proceeding was transferred shall either reimburse the county in which the proceeding was held
for the reasonable costs incurred in conducting the proceeding or conduct the proceeding itself
using its own personnel and resources, including its own district or county attorney, as the case
may be.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 490 of 510
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1769, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-111 as it existed prior to 2013.
25.5-10-218. Persons' rights. (1) Unless a person's rights are modified by court order, a
person with an intellectual and developmental disability has the same legal rights and
responsibilities guaranteed to all other persons under the federal and state constitutions and
federal and state laws. No otherwise qualified person, by reason of having an intellectual and
developmental disability, may be excluded from participation in, denied the benefits of, or
subjected to discrimination under any program or activity which receives public funds.
(2) The receipt of services and supports pursuant to this article does not deprive any
person of any other rights, benefits, or privileges or cause the person to be declared legally
incompetent.
(3) [Editor's note: This version of subsection (3) is effective until July 1, 2024.] The
rights of any person receiving services which are specified in this article may be suspended to
protect the person receiving services from endangering such person, others, or property. Such
rights may be suspended only by the intellectual and developmental disabilities professional with
subsequent review by the interdisciplinary team and by the human rights committee in order to
provide specific services or supports to the person receiving services, which will promote the
least restriction on the person's rights. Such person's legal rights may be removed by a court
pursuant to section 25.5-10-216.
(3) [Editor's note: This version of subsection (3) is effective July 1, 2024.] The rights
of any person receiving services which are specified in this article 10 may be modified to protect
the person receiving services from endangering the person, others, or property. The rights may
be modified only with the informed consent of the person receiving services or the person's
legally authorized representative and with subsequent review by the person receiving services,
the person's legally authorized representative, the person's interdisciplinary team, and by the
human rights committee in order to provide specific services or supports to the person receiving
services, which will promote the least restriction on the person's rights. The person's legal rights
may be removed by a court pursuant to section 25.5-10-216.
(4) None of the rights established pursuant to this article shall be construed to interfere
with the rights and privileges of parents regarding their minor child.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1770, §
1, effective March 1, 2014. L. 2021: (3) amended, (HB 21-1187), ch. 83, p. 343, § 45, effective
July 1, 2024.
Editor's note: This section is similar to former § 27-10.5-112 as it existed prior to 2013.
25.5-10-219. Right to individualized plan or individualized family service plan -
repeal. (1) Each person receiving services must have an individualized plan, an individualized
family service plan, or a similar plan specified by the state department that qualifies as an
individualized plan that is developed by the person's interdisciplinary team. The individualized
Colorado Revised Statutes 2023 Uncertified PrintoutPage 491 of 510
family service plan for a child with disabilities from birth through two years of age shall be
developed in compliance with part 4 of article 3 of title 26.5.
(2) Pursuant to section 25.5-10-211, the individualized plan for each person who
receives services or supports shall be reviewed at least annually and modified as necessary or
appropriate; except that an individualized family service plan for a child with disabilities from
birth through two years of age shall be reviewed as required pursuant to part 4 of article 3 of title
26.5. A review consists of, but is not limited to, the determination by the interdisciplinary team
as to whether the needs and preferences of the person receiving services or supports are
accurately reflected in the plan, whether the services and supports provided pursuant to the plan
are appropriate to meet the person's needs and preferences, and what actions are necessary for
the plan to be achieved.
(3) This section is repealed, effective July 1, 2024.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1770, §
1, effective March 1, 2014. L. 2021: (3) added by revision, (HB 21-1187), ch. 83, pp. 353, 354,
§§ 69, 70. L. 2022: (1) and (2) amended, (HB 22-1295), ch. 123, p. 850, § 80, effective July 1.
Editor's note: This section is similar to former § 27-10.5-113 as it existed prior to 2013.
25.5-10-220. Right to medical care and treatment. (1) Each person receiving services
must have access to appropriate dental and medical care and treatment for any physical ailments
and for the prevention of any illness or disability.
(2) No medication for which a prescription is required shall be administered without the
written order of a physician. A physician shall conduct a review of all prescriptions and other
orders for medications in order to determine the appropriateness of the person's medication
regimen annually, or more often, if required by law.
(3) All service agencies which administer medication shall require that notation of the
medication of a person receiving services be kept in the person's medical records. All
medications must be administered pursuant to part 3 of article 1.5 of title 25, C.R.S.
(4) Persons receiving services must have a right to be free from unnecessary or excessive
medication. The service agency's records must state the effects of psychoactive medication if
administered to the person receiving services. When dosages of such are changed or other
psychoactive medications are prescribed, a notation must be made in such person's record
concerning the effect of the new medication or new dosages and the behavior changes, if any,
which occur.
(5) Medication must not be used for the convenience of the staff, for punishment, as a
substitute for a treatment program, or in quantities that interfere with the treatment program of
the person receiving services.
(6) Only appropriately trained staff shall be allowed to administer medications.
(7) The executive director has the power to direct the administration or monitoring of
medications to persons receiving services and supports in centers for persons with intellectual
and developmental disabilities pursuant to section 25-1.5-301 (2)(h), C.R.S.
(8) No person receiving services may be subjected to any experimental research or
hazardous treatment procedures without the consent of such person, if the person is over
eighteen years of age and is able to give such consent, or of the person's parent, if the person is
Colorado Revised Statutes 2023 Uncertified PrintoutPage 492 of 510
under eighteen years of age, or of the person's legal guardian. Such consent may be given only
after consultation with the interdisciplinary team and an intellectual and developmental
disabilities professional not affiliated with the facility or community residential home in which
the person receiving services resides. However, no such person of any age may be subjected to
experimental research or hazardous treatment procedures if said person implicitly or expressly
objects to such procedure.
(9) No person receiving services may have any organs removed for the purpose of
transplantation without the consent of such person, if the person is over eighteen years of age
and is able to give such consent. If the person's ability to give consent to the medical procedure
is challenged by the physician, the same procedures as those set forth in section 25.5-10-232
shall be followed. Consent for the removal of organs for transplantation may be given by the
parents of a person receiving services, if the person is under eighteen years of age, or by the
person's legal guardian. Such consent may be given only after consultation with the
interdisciplinary team and an intellectual and developmental disabilities professional not
affiliated with the facility or community residential home in which the person receiving services
resides. However, no person receiving services of any age may be a donor of an organ if the
person implicitly or expressly objects to such procedure.
(10) (a) As used in subsections (8) and (9) of this section, consent also requires that the
person whose consent is sought has been adequately and effectively informed as to the:
(I) Method of experimental research, hazardous treatment, or transplantation;
(II) Nature and consequence of such procedures; and
(III) Risks, benefits, and purposes of such procedures.
(b) The consent of any person may be revoked at any time.
(11) Subsections (8), (9), and (10) of this section do not apply when a physician renders
emergency medical care or treatment to any resident.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1771, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-114 as it existed prior to 2013.
25.5-10-221. Right to humane treatment. (1) Corporal punishment of persons with an
intellectual and developmental disability is not permitted.
(2) All service agencies shall prohibit mistreatment, exploitation, neglect, or abuse in
any form of any person receiving services.
(3) Service agencies shall provide every person receiving services with a humane
physical environment.
(4) Each person receiving services must be attended to by qualified staff in numbers
sufficient to provide appropriate services and supports.
(5) Seclusion, defined as the placement of a person receiving services alone in a closed
room for the purpose of punishment, is prohibited.
(6) "Time out" procedures, defined as separation from other persons receiving services
and group activities, may be employed under close and direct professional supervision, as
defined by rule by the state board, and only as a technique in behavior-shaping programs.
Behavior-shaping programs utilizing a "time out" procedure may be implemented only when it
Colorado Revised Statutes 2023 Uncertified PrintoutPage 493 of 510
incorporates a positive approach designed to result in the acquisition of adaptive behaviors. Such
behavior programs may only be implemented following the completion of a comprehensive
functional analysis, when alternative nonrestrictive procedures have been proven to be
ineffective, and only with the informed consent of the person, parents, or legal guardian. Such
behavior programs may be implemented only following the review and approval process defined
in rules. Behavior development programs must be developed in conjunction with the
interdisciplinary team and implemented only following review by the human rights committee.
Behavior development programs involving the use of the procedure in a "time out room" are
prohibited.
(7) Behavior development programs involving the use of aversive or noxious stimuli are
prohibited.
(8) Physical restraint, defined as the use of manual methods intended to restrict the
movement or normal functioning of a portion of a person's body through direct contact by staff,
may be employed only when necessary to protect the person receiving services from injury to
self or others. Physical restraint may not be employed as punishment, for the convenience of
staff, or as a substitute for a program of services and supports. Physical guidance or prompting
techniques of short duration such as those employed in training techniques are not considered
physical restraint. Physical restraint may be applied only if alternative techniques have failed and
only if such restraint imposed the least possible restriction consistent with its purpose. If
physical restraint is used in an emergency or on a continuing basis its use shall be reviewed by
the interdisciplinary team and the human rights committee in accordance with the rules of the
state board.
(9) The use of a mechanical restraint, defined as the use of mechanical devices intended
to restrict the movement or normal functioning of a portion of a person's body, is subject to
special review and oversight, as defined in rules. Use of mechanical restraints may be applied
only in an emergency if alternative techniques have failed and in conjunction with a behavior
development program. Mechanical restraints must be designed and used so as not to cause
physical injury to the person receiving services and so as to cause the least possible discomfort.
The use of mechanical restraints shall be reviewed by the human rights committee. The use of
posey vests, straight jackets, ankle and wrist restraints, and other devices defined in rules is
prohibited.
(10) A record must be maintained of all physical injuries to any person receiving
services, all incidents of mistreatment, exploitation, neglect, or abuse, and all uses of physical or
mechanical restraint. All records are subject to review by the human rights committee.
(11) Behavior development programs must be supervised by an intellectual and
developmental disabilities professional having specific knowledge and skills to develop and
implement positive behavioral intervention strategies.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1772, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-115 as it existed prior to 2013.
25.5-10-222. Right to religious belief, practice, and worship. No person receiving
services is required to perform any act or be subject to any procedure whatsoever which is
Colorado Revised Statutes 2023 Uncertified PrintoutPage 494 of 510
contrary to the person's religious belief, and each such person has the right to practice such
religious belief and be accorded the opportunity for religious worship. Provisions for religious
worship must be made available to all persons receiving services on a nondiscriminatory basis.
No such person shall be coerced into engaging in or refraining from any religious activity,
practice, or belief.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1773, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-116 as it existed prior to 2013.
25.5-10-223. Rights to communications and visits. (1) Each person receiving services
has the right to communicate freely and privately with others of the person's own choosing.
(2) Each person receiving services has the right to receive and send sealed, unopened
correspondence. No such person's incoming or outgoing correspondence shall be opened,
delayed, held, or censored by any person.
(3) Each person receiving services shall have the right to receive and send packages. No
such person's outgoing packages shall be opened, delayed, held, or censored by any person.
(4) Each person receiving services must have reasonable access to telephones, both to
make and to receive calls in privacy, and must be afforded reasonable and frequent opportunities
to meet with visitors.
(5) All service agencies shall ensure that persons receiving services have suitable
opportunities for interaction with persons of their choice. Nothing in this section will limit the
protections provided under article 3.1 of title 26, C.R.S.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1774, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-117 as it existed prior to 2013.
25.5-10-224. Right to fair employment practices. (1) No person receiving services
shall be required to perform labor; except that persons receiving services may voluntarily engage
in such labor if the labor is compensated in accordance with applicable minimum wage laws.
(2) No person receiving services shall be involved in the physical care, care and
treatment, training, or supervision of other persons receiving services unless such person has
volunteered, has been specifically trained in the necessary skills, and has the judgment required
for such activities, is adequately supervised, and is reimbursed in accordance with the applicable
minimum wage laws.
(3) Each person receiving services may perform vocational training tasks, subject to a
presumption that an assignment longer than three months to any task is not a training task, if the
specific task or any change in task assignment is an integral part of such person's individualized
plan. If such person performs vocational training tasks for which the service agency is receiving
compensation from any outside source, the person shall be compensated in accordance with the
applicable minimum wage laws.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 495 of 510
(4) Each person receiving services may voluntarily engage in labor for which the service
agency would otherwise have to pay an employee if the specific labor or any change in labor is
an integral part of such person's individualized plan and the person is compensated in accordance
with the applicable minimum wage laws.
(5) Each person receiving services may be required to perform tasks of a personal
housekeeping nature or tasks oriented to improving community living skills in accordance with
the person's individualized plan.
(6) Payment to persons receiving services pursuant to this section shall not be collected
by the service agency to offset the costs of providing services and supports to such person.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1774, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-118 as it existed prior to 2013.
25.5-10-225. Right to vote. Each person receiving services who is eligible to vote
according to law has the right to vote in all primary and general elections. As necessary, all
service agencies shall assist such persons to register to vote, to obtain mail ballots, to comply
with other requirements that are prerequisite to voting, and to vote.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1775, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-119 as it existed prior to 2013.
25.5-10-226. Records and confidentiality of information pertaining to eligible
persons or their families - repeal. (1) A record for each person receiving services shall be
diligently maintained by the community-centered board. The record must include, but not be
limited to, information pertaining to the determination of eligibility for services and the
individualized plan. The record is not a public record.
(2) Except as otherwise provided by law, all information obtained and any records
prepared in the course of determining eligibility or providing services and supports pursuant to
this article are confidential and subject to the evidentiary privileges established by law. The
disclosure of this information and these records in any manner shall be permitted only:
(a) To the applicant or person receiving services, to the parents of a minor, to such
person's legal guardian, and to any person authorized by the above named person;
(b) In communications between qualified professional personnel, including the board of
directors of community-centered boards and service agencies providing services to persons with
intellectual and developmental disabilities, to the extent necessary for the acquisition, provision,
oversight, or referral of services and supports;
(c) To the extent necessary to make claims for aid, insurance, or medical assistance to
which a person receiving services may be entitled, or to access services and supports pursuant to
the individualized plan;
(d) For the purposes of evaluation, gathering statistics, or research when no identifying
information concerning an individual person or family is disclosed. Identifying information is
Colorado Revised Statutes 2023 Uncertified PrintoutPage 496 of 510
information which could reasonably be expected to identify a specific person and includes, but is
not limited to, name, address, telephone number, social security number, medicaid number,
household number, and photograph.
(e) To the court when necessary to implement the provisions of this article;
(f) To persons authorized by an order of court issued after a hearing, notice of which was
given to the person, parents or legal guardian, where appropriate, and the custodian of the
information;
(g) To the agency designated pursuant to 42 U.S.C. sec. 6012 as the protection and
advocacy system for Colorado when:
(I) A complaint has been received by the protection and advocacy system from or on
behalf of a person with an intellectual and developmental disability; and
(II) Such person does not have a legal guardian or the state or the designee of the state is
the legal guardian of such person;
(h) To the state department or its designees as deemed necessary by the executive
director to fulfill the duties prescribed by this article.
(3) Nothing in this section shall be construed to limit access by a person receiving
services to such person's records.
(4) Nothing in this section shall be construed to interfere with the protections afforded to
a person under the federal "Health Insurance Portability and Accountability Act of 1996", 42
U.S.C. sec. 1320d, and the federal "Family Educational Rights and Privacy Act of 1974", 20
U.S.C. sec. 1232g.
(5) This section is repealed, effective July 1, 2024.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1775, §
1, effective March 1, 2014. L. 2017: (4) amended, (SB 17-294), ch. 264, p. 1409, § 93, effective
May 25. L. 2021: (5) added by revision, (HB 21-1187), ch. 83, pp. 353, 354, §§ 69, 70.
Editor's note: This section is similar to former § 27-10.5-120 as it existed prior to 2013.
25.5-10-227. Right to personal property. (1) Each person receiving services has the
right to the possession and use of such person's own clothing and personal effects. If the service
agency holds any of such person's personal effects for any reason, such retention shall be
promptly recorded in such person's record and the reason for retention shall also be recorded.
(2) Upon the request of a person receiving services, a service agency may hold money or
funds belonging to the person receiving services, received by such person, or received by the
service agency for such person. All such money or funds shall be held by the service agency as
trustee for the person receiving services. Upon request, an accounting shall be rendered by the
service agency.
(3) Upon request, a person receiving services is entitled to receive reasonable amounts of
such person's money or funds held in trust.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1776, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-121 as it existed prior to 2013.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 497 of 510
25.5-10-228. Right to influence policy. The persons receiving services of a service
agency are entitled to establish a committee to hear the views and represent the interests of all
such persons served by the agency and to attempt to influence the policies of the agency to the
extent that they influence provision of services and supports.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1776, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-122 as it existed prior to 2013.
25.5-10-229. Right to notification. Each person receiving services has the right to read
or have explained, in each person's or family's native language, any rules adopted by the service
agency and pertaining to such person's activities.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1777, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-123 as it existed prior to 2013.
25.5-10-230. Discrimination. No person who has received services or supports under
any provision of this article shall be discriminated against because of such status. For purposes
of this section, "discrimination" means the giving of any unfavorable weight to the fact that a
person has received such services or supports.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1777, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-124 as it existed prior to 2013.
25.5-10-231. Sterilization rights. (1) It is the intent of the general assembly that the
procedures set forth in the following subsections be utilized when sterilization is being
considered for the primary purpose of rendering the person incapable of reproduction.
(2) Any person with an intellectual and developmental disability over eighteen years of
age who has given informed consent has the right to be sterilized, subject to the following:
(a) Prior to the procedure, competency to give informed consent and assurance that such
consent is voluntarily and freely given shall be evaluated by the following:
(I) A psychiatrist, psychologist, or physician who does not provide services or supports
to the person and who has consulted with and interviewed the person with an intellectual and
developmental disability; and
(II) An intellectual and developmental disabilities professional who does not provide
services or supports in which said person participates, and who has consulted with and
interviewed the person with an intellectual and developmental disability.
(b) The professionals who conducted the evaluation pursuant to paragraph (a) of this
subsection (2) shall consult with the physician who is to perform the operation concerning each
professional's opinion in regard to the informed consent of the person requesting the sterilization.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 498 of 510
(3) Any person with an intellectual and developmental disability whose capacity to give
an informed consent is challenged by the intellectual and developmental disabilities professional
or the physician may file a petition with the court to declare competency to give consent
pursuant to the procedures set forth in section 25.5-10-232.
(4) No person with an intellectual and developmental disability who is over eighteen
years of age and has the capacity to participate in the decision-making process regarding
sterilization shall be sterilized in the absence of the person's informed consent. No minor may be
sterilized without a court order pursuant to section 25.5-10-233.
(5) Sterilization conducted pursuant to this section shall be legal. Consent given by any
person pursuant to subsection (2) of this section is not revocable after sterilization, and no person
shall be liable for acting pursuant to such consent.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1777, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-128 as it existed prior to 2013.
25.5-10-232. Competency to give consent to sterilization. (1) If the competency of the
person with an intellectual and developmental disability to give consent to sterilization is
disputed by the intellectual and developmental disabilities professional, the psychiatrist or
psychologist, or physician, said person may file a petition for declaration of competency to give
consent to sterilization with the court. Upon the filing of a petition which shows that said person
is over eighteen years of age and desires to give consent to sterilization, the court shall
immediately set a hearing to determine the person's competency to give such consent. For the
purpose of determining competency, the court shall appoint two or more independent
professional persons with expertise in the field of intellectual and developmental disabilities who
do not provide services and supports to said person to examine said person and to present their
findings as to said person's competency to give consent to sterilization at the competency
hearing.
(2) If the court determines that the person has given consent to sterilization and is
competent to give such consent, the court may order that the sterilization be performed unless
the person withdraws consent to sterilization prior to the sterilization being performed. If the
court determines that the person is incompetent to give consent to sterilization, the court shall
order that no sterilization be performed without further court proceedings pursuant to section
25.5-10-233.
(3) Determination of competency in these proceedings is specific to the ability to give
consent to sterilization and does not determine legal competency for any other purpose.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1778, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-129 as it existed prior to 2013.
25.5-10-233. Court-ordered sterilization. (1) A person with an intellectual and
developmental disability who has been determined to be incompetent to give consent, the
Colorado Revised Statutes 2023 Uncertified PrintoutPage 499 of 510
person's legal guardian, or the parents of a minor with an intellectual and developmental
disability, may petition the court to hold a hearing to determine whether said person should be
ordered to be sterilized. The petition shall set forth the following:
(a) The name, age, and residence of the person to be sterilized;
(b) The name, address, and relation to said person of the petitioner;
(c) The names and addresses of any parents, spouse, legal guardian, or custodian of said
person;
(d) The mental condition of the person to be sterilized;
(e) A statement that the sterilization is medically necessary to preserve the life or
physical or mental health of the person, including a short and plain description of the reasons
behind the determination of medical necessity;
(f) A statement that other less intrusive measures were considered and the reasons
behind the determination that less intrusive means would not protect the interests of the person.
(2) Upon petition to the court, the court shall appoint an attorney who will represent the
interests of the person with an intellectual and developmental disability and one or more experts
in the intellectual and developmental disability field to examine the person and to give testimony
at the hearing regarding the person's mental and physical status and other relevant matters.
(3) The hearing on the petition must be held promptly. The person with an intellectual
and developmental disability must be represented by an attorney and must have the opportunity
to present testimony and to cross-examine witnesses.
(4) Copies of the petition and notices of the time and place of the hearing shall be
mailed, not less than ten days prior to the hearing, to the person with an intellectual and
developmental disability, that person's attorney, a parent or next of kin, and legal guardian or
custodian.
(5) Reasonable fees and costs incurred pursuant to this section shall be paid by the court
for a person who is indigent.
(6) Prior to ordering sterilization, the court must find:
(a) That the person lacks the capacity to effectively participate in the decision-making
process regarding sterilization or is a minor with an intellectual and developmental disability;
(b) That the court has heard from the person regarding that person's desires, if possible,
and the court has considered the desires of the person;
(c) That the person lacks the capacity to make a decision regarding sterilization and that
the person's capacity to make such a decision is unlikely to improve in the future;
(d) That the person is capable of reproduction and is likely to engage in activities at the
present or in the near future which could result in pregnancy;
(e) By clear and convincing evidence, that the sterilization is medically necessary to
preserve the life or physical or mental health of the person, including a short and plain
description of the reasons behind the determination of medical necessity;
(f) That other less intrusive measures were considered and the reasons behind the
determination that less intrusive means would not protect the interests of the person.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1778, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-130 as it existed prior to 2013.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 500 of 510
25.5-10-234. Confidentiality of sterilization proceedings. All records, hearings, and
proceedings pursuant to sections 25.5-10-231 to 25.5-10-233 are strictly confidential unless
requested to be open to the public by the person with an intellectual and developmental disability
or the person's legal guardian.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1779, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-131 as it existed prior to 2013.
25.5-10-235. Limitations on sterilization. (1) Consent to sterilization shall be made
neither a condition for release from any institution nor a condition for the exercise of any right,
privilege, or freedom.
(2) Nothing in this article requires any hospital or any person to participate in any
sterilization, nor shall any hospital or any person be civilly or criminally liable for refusing to
participate in any sterilization.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1779, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-132 as it existed prior to 2013.
25.5-10-236. Civil action and attorney fees. A violation of any provision of this article
gives rise to a civil cause of action by the person adversely affected by such violation, and any
judgment may include plaintiff's reasonable attorney fees.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1780, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-134 as it existed prior to 2013.
25.5-10-237. Terminology. (1) Whenever the terms "insane", "insanity", "mentally or
mental incompetent", "mental incompetency", or "of unsound mind" are used in the laws of the
state of Colorado, they shall be deemed to refer to the insane, as defined in section 16-8-101,
C.R.S., or to a person with an intellectual and developmental disability, as defined in section
25.5-10-202, as the context of the particular law requires.
(2) Whenever the term "mentally deficient person" is used in the laws of the state of
Colorado, it shall be deemed to mean and be included with the term "person with an intellectual
and developmental disability", as defined in section 25.5-10-202.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1780, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-135 as it existed prior to 2013.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 501 of 510
25.5-10-238. Federal funds. The state department is authorized to accept, on behalf of
the state, any grants of federal funds made available for any purposes consistent with the
provisions of this article. The executive director of the state department, with the approval of the
governor, shall have power to direct the disposition of any such grants so accepted in conformity
with the terms and conditions under which they are given.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1780, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-137 as it existed prior to 2013.
25.5-10-239. Evaluations to determine whether a defendant is mentally retarded or
has an intellectual and developmental disability for purposes of class 1 felony trials. Upon
request of the court, the executive director, or his or her designee, shall recommend specific
professionals who are qualified to perform an evaluation to determine whether a defendant is
mentally retarded or is a defendant with an intellectual and developmental disability, as defined
in section 18-1.3-1101. A recommended professional must be licensed as a psychologist in the
state of Colorado and must have experience in and demonstrated competence in determination
and evaluation of persons with intellectual and developmental disabilities. The executive director
shall convene a panel of not fewer than three persons with expertise in intellectual and
developmental disabilities to assess the qualifications of licensed psychologists and make
recommendations to the executive director or his or her designee.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1780, §
1, effective March 1, 2014. L. 2018: Entire section amended, (SB 18-096), ch. 44, p. 474, § 17,
effective August 8.
Editor's note: This section is similar to former § 27-10.5-139 as it existed prior to 2013.
Cross references: For the legislative declaration in SB 18-096, see section 1 of chapter
44, Session Laws of Colorado 2018.
25.5-10-240. Retaliation prohibited. [Editor's note: This version of this section is
effective until July 1, 2024.] No person shall be discriminated against because he or she has
made a complaint, testified, assisted, or participated in any manner in an investigation,
proceeding, or hearing pursuant to this article, including the dispute resolution procedures in
section 25.5-10-212 and section 27-10.5-107, C.R.S. A service agency, including the state
department and any community-centered board, shall not coerce, intimidate, threaten, or
interfere with any person in the exercise or enjoyment of any right pursuant to this article, or on
account of his or her having exercised or enjoyed any right pursuant to this article, or on account
of his or her having aided or encouraged any other person in the exercise or enjoyment of any
right pursuant to this article.
25.5-10-240. Retaliation prohibited. [Editor's note: This version of this section is
effective July 1, 2024.] No person shall be discriminated against because the person has made a
Colorado Revised Statutes 2023 Uncertified PrintoutPage 502 of 510
complaint, testified, assisted, or participated in any manner in an investigation, proceeding, or
hearing pursuant to this article 10, including the dispute resolution procedures in section
25.5-10-212 and section 27-10.5-107. A service agency, including the state department and any
case management agency, shall not coerce, intimidate, threaten, or interfere with any person in
the exercise or enjoyment of any right pursuant to this article 10, or on account of the person
having exercised or enjoyed any right pursuant to this article 10, or on account of the person
having aided or encouraged any other person in the exercise or enjoyment of any right pursuant
to this article 10.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1780, §
1, effective March 1, 2014. L. 2021: Entire section amended, (HB 21-1187), ch. 83, p. 343, § 46,
effective July 1, 2024.
Editor's note: This section is similar to former § 27-10.5-141 as it existed prior to 2013.
25.5-10-241. Host home provider stakeholder collaboration - report. (1) No later
than September 1, 2023, the state department shall engage in a stakeholder process, which must
include but is not limited to equitable representation among program-approved service agencies,
case management agencies, host home providers under contract with a provider agency,
individuals with lived experiences, and advocacy groups that represent the disability community,
to address concerns and identify viable solutions related to individuals who receive long-term
services and supports pursuant to this article 10. At a minimum, the stakeholder process must
address:
(a) The timeline, process, and procedure for reporting and resolving a grievance or
complaint by an individual receiving long-term services and supports, including regular
notifications to the individual about the grievance and complaint procedure and process, the right
to an appeal, how an individual can easily access information related to the process and
procedure, and how to report retaliation;
(b) The process by which a host home provider under contract with a provider agency
that is convicted of abuse or neglect may be determined ineligible to continue providing services
and supports; and
(c) Consistency of contract language between program-approved service agencies and
host home providers under contract with a provider agency.
(2) No later than January 2025, the state department shall report as part of its "SMART
Act" hearing required by section 2-7-203 on the stakeholder process described in subsection (1)
of this section, including identifying any administrative resources needed to address the concerns
and solutions identified during the stakeholder process.
Source: L. 2023: Entire section added, (HB 23-1197), ch. 281, p. 1659, § 2, effective
May 30.
Cross references: For the legislative declaration in HB 23-1197, see section 1 of chapter
281, Session Laws of Colorado 2023.
PART 3
Colorado Revised Statutes 2023 Uncertified PrintoutPage 503 of 510
FAMILY SUPPORT SERVICES
25.5-10-301. Legislative declaration. (1) It is the intent of the general assembly that the
service delivery system for persons with intellectual and developmental disabilities emphasize
community living for persons with intellectual and developmental disabilities and provide
supports to persons that enable them to enjoy typical lifestyles. One way to accomplish this is to
recognize that families are the greatest resource available to persons who have an intellectual
and developmental disability and that families must be supported in their role as primary care
givers. The general assembly finds that supporting families in their effort to provide supports for
their family members at home is more efficient, cost-effective, and humane than maintaining
persons with intellectual and developmental disabilities in out-of-home residential settings. In
recognition of the importance of families, the general assembly states that the following
principles should be used as guidelines in developing programs to support a family that has a
child with disabilities:
(a) Families of persons with intellectual and developmental disabilities are best able to
determine their own needs and preferences and should be empowered to make decisions
concerning necessary, desirable, and appropriate services and supports;
(b) Families must receive the services and supports necessary to care for their children at
home;
(c) Family support must be responsive to the needs of the entire family unit;
(d) Family support must be sensitive to the unique strengths and needs of individual
families;
(e) Family support must build on existing social networks and natural sources of
support;
(f) Family support is needed throughout the life span of the person who has a disability;
(g) Family support must encourage the inclusion of people with intellectual and
developmental disabilities within the community;
(h) Family support services must be flexible enough to accommodate unique needs of
families as they evolve over time;
(i) Family support services must be consistent with the cultural preferences and
orientations of individual families;
(j) Family support services should be comprehensive and coordinated across the
numerous agencies likely to provide resources, supports, or services to families;
(k) Family support services should be based on the principles of sharing ordinary places,
developing meaningful relationships, learning things that are useful, making choices, as well as
increasing the status and enhancing the reputation of people served;
(l) Supports should be developed by the state that are necessary, desirable, and
appropriate to support families;
(m) Intellectual and developmental disabilities programs and policies must enhance the
development of the person with an intellectual and developmental disability and the family;
(n) State programs should provide sufficient services and supports to enable families to
keep their family members with intellectual and developmental disabilities at home;
Colorado Revised Statutes 2023 Uncertified PrintoutPage 504 of 510
(o) A comprehensive, coordinated system of supports to families effectively uses
existing resources and minimizes gaps in supports to families and persons in all areas of the
state;
(p) Services and supports provided through the family support program must be closely
coordinated with early intervention services and must foster collaboration and cooperation with
all agencies providing services and supports to infants and preschool children; and
(q) Any rights, entitlements, services, or supports created by this part 3 are not to be
considered a limitation, modification, or infringement on any existing rights, entitlements,
services, or supports, otherwise expressly provided by this article.
(2) In addition, the general assembly recognizes that the state department has for several
years developed and maintained a family resource service program that provides support
services to families of children with intellectual and developmental disabilities who are at risk of
out-of-home placement. Because of the success of this program the general assembly
recommends that this valuable program be continued and expanded so that more families in this
state are able to receive appropriate services, supports, and assistance needed to stabilize the
family unit. In recognition of the basic goal to support families, on an individual family basis, in
maintaining a person with an intellectual and developmental disability at home and in
recognition of the principles stated in subsection (1) of this section, the general assembly
declares that its purpose in enacting this part 3 is to create, subject to annual appropriation, a
comprehensive statewide family support service program.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1781, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-401 as it existed prior to 2013.
25.5-10-302. Purpose. The purpose of the family support services program created in
this part 3 is to provide support to families in their role as primary care givers for a family
member with an intellectual and developmental disability.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1782, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-402 as it existed prior to 2013.
25.5-10-303. Administration - duties of department. (1) Subject to annual
appropriation by the general assembly, the state department shall administer the family support
services program and shall coordinate family support services with other existing services
provided to families and individuals. Family support services must be provided in a manner that
develops comprehensive, responsive, and flexible support to families in their role as the primary
care givers for a family member with an intellectual and developmental disability.
(2) [Editor's note: This version of subsection (2) is effective until July 1, 2024.] The
state department may contract with community-centered boards and other service providers
approved by the state department to provide family support services in accordance with this part
3. Programs developed shall be flexible in order to address individual family needs.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 505 of 510
(2) [Editor's note: This version of subsection (2) is effective July 1, 2024.] The state
department may contract with case management agencies or entities approved by the state
department to provide family support services in accordance with this part 3. Programs
developed shall be flexible in order to address individual family needs.
(3) In administering the family support services program, the state department shall have
the following duties:
(a) To design the program;
(b) [Editor's note: This version of subsection (3)(b) is effective until July 1, 2024.] To
pursue a family support model 200 waiver for approval by the federal health care financing
administration in order to utilize medicaid funds for the provision of family support services,
implemented subject to appropriation;
(b) [Editor's note: This version of subsection (3)(b) is effective July 1, 2024.] To
pursue a family support model 200 waiver for approval by the federal centers for medicare and
medicaid services in order to utilize medicaid funds for the provision of family support services,
implemented subject to appropriation;
(c) [Editor's note: This version of subsection (3)(c) is effective until July 1, 2024.] To
develop rules to be promulgated by the state board pursuant to section 25.5-10-306, with
consultation from service providers, including representatives of families of persons with
intellectual and developmental disabilities;
(c) [Editor's note: This version of subsection (3)(c) is effective July 1, 2024.] To
develop rules to be promulgated by the state board pursuant to section 25.5-10-306, with
consultation from service agencies, including representatives of families of persons with
intellectual and developmental disabilities;
(d) To allocate funds;
(e) [Editor's note: This version of subsection (3)(e) is effective until July 1, 2024.] To
coordinate training and provide technical assistance to community-centered boards and service
providers;
(e) [Editor's note: This version of subsection (3)(e) is effective July 1, 2024.] To
coordinate training and provide technical assistance to case management agencies or entities
approved to provide family support services;
(f) To monitor and evaluate the program;
(g) To coordinate contracts, expenditures, and billing of the program; and
(h) To recommend changes in the program.
(4) [Editor's note: This version of subsection (4) is effective until July 1, 2024.]
Subject to annual appropriation by the general assembly, out of the appropriation to the state
department for community programs in the general appropriation act, the state department is
authorized to use up to seven percent of such appropriation allocated for family support services
to pay for administrative costs within the state department and the community-centered boards.
(4) [Editor's note: This version of subsection (4) is effective July 1, 2024.] Subject to
annual appropriation by the general assembly, out of the appropriation to the state department for
community programs in the general appropriation act, the state department is authorized to use
up to seven percent of such appropriation allocated for family support services to pay for
administrative costs within the state department and the service agency.
(5) The state department shall take any necessary action relating to the termination and
wind up of the Colorado family support loan fund as created in section 25.5-10-402 prior to its
Colorado Revised Statutes 2023 Uncertified PrintoutPage 506 of 510
repeal. The state department shall receive payments relating to outstanding loans made from the
Colorado family support loan fund as created in section 25.5-10-402 prior to its repeal, which
payments shall be transferred to the state treasurer and credited to the family support services
fund created in section 25.5-10-303.5.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1783, §
1, effective March 1, 2014. L. 2017: (5) added, (HB 17-1078), ch. 27, p. 82, § 4, effective July 1.
L. 2021: (2), (3)(b), (3)(c), (3)(e), and (4) amended, (HB 21-1187), ch. 83, p. 343, § 47, effective
July 1, 2024.
Editor's note: This section is similar to former § 27-10.5-404 as it existed prior to 2013.
25.5-10-304. Family support councils. (1) [Editor's note: This version of subsection
(1) is effective until July 1, 2024.] The state department shall ensure that each
community-centered board establishes a family support council in each community-centered
board designated service area. The family support councils shall consist of professionals,
interested citizens, family members of persons with an intellectual and developmental disability,
and persons with an intellectual and developmental disability with a majority of the council
being made up of family members.
(1) [Editor's note: This version of subsection (1) is effective July 1, 2024.] The state
department shall ensure that each case management agency or service agency approved to
provide family support services establishes a family support council in each defined service area.
The family support councils must consist of professionals, interested citizens, family members of
persons with an intellectual and developmental disability, and persons with an intellectual and
developmental disability with a majority of the council being made up of family members.
(2) The family support council shall:
(a) [Editor's note: This version of subsection (2)(a) is effective until July 1, 2024.]
Provide direction and assistance to the community-centered board in the development of a
family support plan for the designated service area;
(a) [Editor's note: This version of subsection (2)(a) is effective July 1, 2024.] Provide
direction and assistance to the case management agency in the development of a family support
plan for the defined service area;
(b) Make recommendations regarding other family supports or services not specifically
listed in this part 3;
(c) Monitor the implementation of the supports or services provided pursuant to the plan;
and
(d) Provide a written report to the state department of its involvement in the duties
specified in this subsection (2).
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1783, §
1, effective March 1, 2014. L. 2021: (1) and (2)(a) amended, (HB 21-1187), ch. 83, p. 344, § 48,
effective July 1, 2024.
Editor's note: This section is similar to former § 27-10.5-405 as it existed prior to 2013.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 507 of 510
25.5-10-305. Authorized family support services. (1) The family support services
included in this program include, but are not limited to, family support grants, family support
services coordination, information and referral, educational materials, emergency and outreach
services, and other person- and family-centered assistance services such as:
(a) Medical and dental expenses not covered by medical or health insurance or other
programs;
(b) Insurance expenses;
(c) Respite;
(d) Mobility aids; adaptive equipment; assistive technology, including the cost of
therapies essential for a child's development, as prescribed by a physician or specialized
therapist; and home adaptations;
(e) Home health services and therapies;
(f) Family counseling, training, and support groups;
(g) Recreation and leisure needs;
(h) Transportation;
(i) Special diets, clothing, materials, and equipment; and
(j) Homemaker services.
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1784, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-406 as it existed prior to 2013.
25.5-10-305.5. Family support services fund - creation. (1) The family support
services fund, referred to in this section as the "fund", is hereby created in the state treasury. The
fund consists of money transferred to the fund from the Colorado family support loan fund as
created in section 25.5-10-402 prior to its repeal, payments relating to outstanding loans made
from the Colorado family support loan fund as created in section 25.5-10-402 prior to its repeal,
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) Subject to annual appropriation by the general assembly, the state department may
expend money from the fund for necessary expenditures relating to the administration of
outstanding loans made from the Colorado family support loan fund as created in section
25.5-10-402 prior to its repeal, and to provide family support services pursuant to this part 3.
Source: L. 2017: Entire section added, (HB 17-1078), ch. 27, p. 81, § 3, effective July 1.
25.5-10-306. Rules. (1) The state board shall develop rules concerning:
(a) Further definition of services and supports to be provided by the family support
services program described in this part 3;
(b) The requirements for eligibility for services and supports;
(c) The manner of providing services and supports; and
(d) The size, makeup, and duties of family support councils.
Colorado Revised Statutes 2023 Uncertified PrintoutPage 508 of 510
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1784, §
1, effective March 1, 2014.
Editor's note: This section is similar to former § 27-10.5-407 as it existed prior to 2013.
PART 4
COLORADO FAMILY SUPPORT LOAN FUND
25.5-10-401. Legislative declaration. (Repealed)
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1785, §
1, effective March 1, 2014. L. 2017: Entire section repealed, (HB 17-1078), ch. 27, p. 81, § 1,
effective July 1.
Editor's note: This section was similar to former § 27-10.5-501 as it existed prior to
2013.
25.5-10-402. Colorado family support loan fund - creation - loans to families -
repeal. (Repealed)
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1785, §
1, effective March 1, 2014. L. 2017: (6) added, (HB 17-1078), ch. 27, p. 81, § 2, effective July 1.
Editor's note: (1) This section was similar to former § 27-10.5-502 as it existed prior to
2013.
(2) Subsection (6)(a) provided for the repeal of this section, effective July 1, 2017. (See
L. 2017, p. 81.)
25.5-10-403. Duties relating to the fund. (Repealed)
Source: L. 2013: Entire article added with relocations, (HB 13-1314), ch. 323, p. 1786, §
1, effective March 1, 2014. L. 2017: Entire section repealed, (HB 17-1078), ch. 27, p. 81, § 1,
effective July 1.
Editor's note: This section was similar to former § 27-10.5-503 as it existed prior to
2013.
ARTICLE 11
Health Care Cost Savings Act
25.5-11-101 to 25.5-11-106. (Repealed)
Colorado Revised Statutes 2023 Uncertified PrintoutPage 509 of 510
Source: L. 2019: Entire article added, (HB 19-1176), ch. 381, p. 3424, § 2, effective
May 31.
Editor's note: Section 25.5-11-106 provided for the repeal of this article, effective
September 1, 2022. (See L. 2019, p. 3428.)
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