A Bill for an Act
Page 1, Line 101Concerning changes to the medical assistance program.
Bill Summary
(Note: This summary applies to this bill as introduced and does not reflect any amendments that may be subsequently adopted. If this bill passes third reading in the house of introduction, a bill summary that applies to the reengrossed version of this bill will be available at http://leg.colorado.gov.)
The bill exempts an assisted living residence with fewer than 19 beds that has not undergone new construction or renovations and that complies with the standards for assisted living residences from complying with facility guidelines adopted by the state board of health.
The bill requires the department of health care policy and financing (state department) to follow the standards set by the federal centers for medicare and medicaid when updating rules.
The state department must establish a process for reviewing and updating the general billing manual on an annual basis and ensure that the general billing manual includes all necessary CPT codes.
Beginning January 1, 2026, for claims that must be reprocessed as a result of updating the provider rates, the bill requires a managed care organization to issue payment to a contracted provider within one year after the provider rate is updated.
The bill requires the state department to include in each new contract with, or renewal of a contract with, a managed care entity (MCE) a provision requiring the MCE to submit to the state department, on an annual basis, the amount the MCE is paid and the MCE's medical loss ratio. The state department is required to publish this information on the state department's website on an annual basis.
The bill prohibits the state department from imposing signature requirements on a physician or practitioner certifying a medicaid member's (member) plan of care that involves physical therapy or occupational therapy.
The bill prevents a member receiving home- and community-based services from losing the services the member currently receives if the member's disability and need for services have not changed in the preceding 3 years.
Page 2, Line 1Be it enacted by the General Assembly of the State of Colorado:
Page 2, Line 2SECTION 1. In Colorado Revised Statutes, 10-16-1203, amend (12)(c) as follows:
Page 2, Line 310-16-1203. Definitions. As used in this part 12, unless the context otherwise requires:
Page 2, Line 4(12) "Qualified individual" means an individual, regardless of immigration status, who:
Page 2, Line 5(c) Is not eligible for the premium tax credit, medicaid, medicare,
Page 2, Line 6or the children's basic health plan, except for individuals eligible pursuant to section 25.5-5-201 (6) or section 25.5-8-109 (7).
Page 2, Line 7SECTION 2. In Colorado Revised Statutes, 25-27-104, add (3) as follows:
Page 2, Line 825-27-104. Minimum standards for assisted living residences
Page 2, Line 9- rules - definition. (3) (a) Rules adopted by the state board
Page 3, Line 1pursuant to subsection (1) of this section must exempt an
Page 3, Line 2assisted living residencefrom complying with the facility
Page 3, Line 3guideline institute (FGI) guidelines, except in the case of new
Page 3, Line 4construction or major renovations. An assisted living residence
Page 3, Line 5must still comply with all other fire and local building codes and the standards outlined in this section.
Page 3, Line 6(b) For purposes of subsection (3)(a) of this section, "major
Page 3, Line 7renovations" means additions to a building's structure or
Page 3, Line 8changes that affect the structural integrity of the building.
Page 3, Line 9Major renovations do not include changing the functional
Page 3, Line 10operation of a space if no construction is completed and the
Page 3, Line 11floor plan of the building remains the same. It also does not
Page 3, Line 12include adding beds to accommodate more residents or upgrades
Page 3, Line 13to the heating or cooling systems and electrical systems if those improvements do not require construction.
Page 3, Line 14SECTION 3. In Colorado Revised Statutes, add 25.5-1-135 as follows:
Page 3, Line 1525.5-1-135. Billing manual.Using existing resources
Page 3, Line 16allocated for billing manual reviews, the state department
Page 3, Line 17shall establish a process to review and update the general
Page 3, Line 18billing manual on an annual basis, which must ensure that the
Page 3, Line 19general billing manual includes all necessary CPT codes, or provides links to the state department's list of CPT codes.
Page 3, Line 21SECTION 4. In Colorado Revised Statutes, 25.5-4-402.4, amend
Page 3, Line 22(2)(f),(3)(d)(V),(3)(d)(VI), (3)(d)(VII),(4)(b) introductory portion,
Page 3, Line 23(4)(b)(II), (5)(a), (5)(b)(VI)(B), (6)(a)(I), (6)(b)(II), and (6)(c); amend as
Page 4, Line 1they will become effective July 1, 2025, (4)(a) introductory portion and
Page 4, Line 2(5)(b)(VI)(D); and add (2)(f.5),(3)(d)(VIII),(5)(b)(I.5), and (9) as follows:
Page 4, Line 325.5-4-402.4. Hospitals - healthcare affordability and
Page 4, Line 4sustainability fee - receipt of public funds - Colorado healthcare
Page 4, Line 5affordability and sustainability enterprise - federal waiver - fund
Page 4, Line 6created - reports - rules - legislative declaration - repeal.
Page 4, Line 7(2) Legislative declaration. The general assembly hereby finds and declares that:
Page 4, Line 8(f) Consistent with the determination of the Colorado supreme
Page 4, Line 9court in Nicholl v. E-470 Public Highway Authority, 896 P.2d 859 (Colo.
Page 4, Line 101995), that the power to impose taxes is inconsistent with enterprise status
Page 4, Line 11under section 20 of article X of the state constitution, it is the conclusion
Page 4, Line 12of the general assembly that the healthcare affordability and sustainability
Page 4, Line 13fee charged and collected by the Colorado healthcare affordability and
Page 4, Line 14sustainability enterprise is a fee, not a tax, because the fee is imposed for
Page 4, Line 15the specific purposes of allowing the enterprise to defray the costs of
Page 4, Line 16providing the business services specified in subsections (2)(d)(I) and
Page 4, Line 17(2)(d)(II) of this section to hospitals that pay the fee and is collected at
Page 4, Line 18rates that are reasonably calculated based on the benefits received by those hospitals;
andPage 4, Line 19(f.5) Transfers from governmental health-care providers
Page 4, Line 20to the enterprise through a mutually executed agreement, and
Page 4, Line 21as authorized by 42 CFR 433.51, are not "grants" under section 20 of article X of the state constitution because:
Page 4, Line 22(I) Participating providers receive federal funds and
Page 4, Line 23other business services as described in this section; and
Page 5, Line 1(II) Such transfers must be repaid if they are not utilized
Page 5, Line 2or approved, and thus do not meet the definition of "grant" set forth in section 24-77-102; and
Page 5, Line 3(3) Colorado healthcare affordability and sustainability enterprise. (d) The enterprise's primary powers and duties are:
Page 5, Line 5(V) To enter into agreements with the state department to the
Page 5, Line 6extent necessary to
collect andrevenuePage 5, Line 7(VI) To engage the services of private persons or entities serving
Page 5, Line 8as contractors, consultants, and legal counsel for professional and
Page 5, Line 9technical assistance and advice and to supply other services related to the
Page 5, Line 10conduct of the affairs of the enterprise, including the provision of
Page 5, Line 11additional business services to hospitals as specified in subsection (4)(a)(IV) of this section;
andPage 5, Line 12(VII) To adopt and amend or repeal policies for the regulation of
Page 5, Line 13its affairs and the conduct of its business consistent with the provisions of this section; and
Page 5, Line 14(VIII) To receive public funds as described in subsection (4) of this section.
Page 5, Line 15(4) Healthcare affordability and sustainability fee. (a) For the
Page 5, Line 16fiscal year commencing July 1, 2017, and for each fiscal year thereafter,
Page 5, Line 17the enterprise is authorized to charge and collect a healthcare affordability
Page 5, Line 18and sustainability fee, as described in 42 CFR 433.68 (b), or as
Page 5, Line 19otherwise in compliance with 42 CFR 433, on outpatient and inpatient
Page 5, Line 20services provided by all licensed or certified hospitals, referred to in this
Page 5, Line 21section as "hospitals", and receive public funds as described in 42
Page 6, Line 1CFR 433.51, for the purpose of obtaining federal financial participation
Page 6, Line 2under the state medical assistance program as described in this article 4
Page 6, Line 3and articles 5 and 6 of this title 25.5, referred to in this section as the
Page 6, Line 4"state medical assistance program", including disproportionate share
Page 6, Line 5hospital payments pursuant to 42 U.S.C. sec. 1396r-4. If the amount of
Page 6, Line 6healthcare affordability and sustainability fee revenue collected exceeds
Page 6, Line 7the federal net patient revenue-based limit on the amount of such fee
Page 6, Line 8revenue that may be collected, requiring repayment to the federal
Page 6, Line 9government of excess federal matching money received, hospitals that
Page 6, Line 10received such excess federal matching money are responsible for repaying
Page 6, Line 11the excess federal money and any associated federal penalties to the
Page 6, Line 12federal government. The enterprise shall use the healthcare affordability and sustainability fee revenue to:
Page 6, Line 13(b) The enterprise shall recommend for approval and
Page 6, Line 14establishment by the state board the amount of the healthcare affordability
Page 6, Line 15and sustainability fee that it intends to charge and collect and the
Page 6, Line 16amount of public funds that it intends to receive. The state board
Page 6, Line 17must establish the final amount of the fee by rules promulgated in
Page 6, Line 18accordance with article 4 of title 24. The state board shall not establish
Page 6, Line 19any amount that exceeds the federal limit for such fees or public funds.
Page 6, Line 20The state board may deviate from the recommendations of the enterprise,
Page 6, Line 21but shall express in writing the reasons for any deviations. In establishing
Page 6, Line 22the amount of the fee and in promulgating the rules governing the fee, the state board shall:
Page 6, Line 23(II) Establish the amount of the healthcare affordability and
Page 6, Line 24sustainability fee and public funds so that the amount collected from the
Page 6, Line 25fee, the amount received from public funds, and federal matching
Page 7, Line 1funds associated with the fee and public funds are sufficient to pay for
Page 7, Line 2the items described in subsection (4)(a) of this section, but nothing in this
Page 7, Line 3subsection (4)(b)(II) requires the state board to increase the healthcare
Page 7, Line 4affordability and sustainability fee or the amount of public
Page 7, Line 5funds to be received above the
amountPage 7, Line 6(5) Healthcare affordability and sustainability fee cash fund.
Page 7, Line 7(a) Any healthcare affordability and sustainability fee collected or
Page 7, Line 8public funds received pursuant to this section by the enterprise must be
Page 7, Line 9transmitted to the state treasurer, who shall credit the fee or public
Page 7, Line 10funds to the healthcare affordability and sustainability fee cash fund,
Page 7, Line 11which fund is hereby created and referred to in this section as the "fund".
Page 7, Line 12The state treasurer shall credit all interest and income derived from the
Page 7, Line 13deposit and investment of money in the fund to the fund. The state
Page 7, Line 14treasurer shall invest any money in the fund not expended for the
Page 7, Line 15purposes specified in subsection (5)(b) of this section as provided by law.
Page 7, Line 16Money in the fund shall not be transferred to any other fund and shall not
Page 7, Line 17be used for any purpose other than the purposes specified in this subsection (5) and in subsection (4) of this section.
Page 7, Line 18(b) All money in the fund is subject to federal matching as
Page 7, Line 19authorized under federal law and, subject to annual appropriation by the
Page 7, Line 20general assembly, shall be expended by the enterprise for the following purposes:
Page 7, Line 21(I.5) To maximize the inpatient and outpatient hospital reimbursements, as permitted in 42 CFR 438.6(c);
Page 7, Line 22(VI) To pay the enterprise's actual administrative costs of
Page 7, Line 23implementing and administering this section, including but not limited to the following costs:
Page 8, Line 1(B) The enterprise's actual costs related to implementing and
Page 8, Line 2maintaining the healthcare affordability and sustainability fee and
Page 8, Line 3receipt of public funds, including personal services, operating, and consulting expenses;
Page 8, Line 4(D) The enterprise's personal services and operating costs related
Page 8, Line 5to personnel, consulting services, and for review of hospital costs
Page 8, Line 6necessary to implement and administer the increases in inpatient and
Page 8, Line 7outpatient hospital payments made pursuant to
subsection (5)(b)(I)Page 8, Line 8subsections (5)(b)(I) and (5)(b)(I.5) of this section, disproportionate
Page 8, Line 9share hospital payments made pursuant to subsection (5)(b)(II) of this
Page 8, Line 10section, and quality incentive payments made pursuant to subsection (5)(b)(III) of this section;
Page 8, Line 11(6) Appropriations. (a) (I) Except as otherwise provided in
Page 8, Line 12subsection (6)(b)(I.5) or (6)(b)(I.7) of this section, the healthcare
Page 8, Line 13affordability and sustainability fee
isPage 8, Line 14supplement, not supplant, general fund appropriations to support hospital
Page 8, Line 15reimbursements. General fund appropriations for hospital reimbursements
Page 8, Line 16shall be maintained at the level of appropriations in the medical services
Page 8, Line 17premium line item made for the fiscal year commencing July 1, 2008;
Page 8, Line 18except that general fund appropriations for hospital reimbursements may
Page 8, Line 19be reduced if an index of appropriations to other providers shows that
Page 8, Line 20general fund appropriations are reduced for other providers. If the index
Page 8, Line 21shows that general fund appropriations are reduced for other providers,
Page 8, Line 22the general fund appropriations for hospital reimbursements shall not be
Page 8, Line 23reduced by a greater percentage than the reductions of appropriations for
Page 8, Line 24the other providers as shown by the index.
Page 9, Line 1(b) If the revenue from the healthcare affordability and
Page 9, Line 2sustainability fee is insufficient to fully fund all of the purposes described in subsection (5)(b) of this section:
Page 9, Line 3(II) The hospital provider reimbursement and quality incentive
Page 9, Line 4payment increases described in
subsections (5)(b)(I) to (5)(b)(III)Page 9, Line 5subsections (5)(b)(I), (5)(b)(II), and (5)(b)(III) of this section and the
Page 9, Line 6costs described in subsection (5)(b)(VI) of this section shall be fully
Page 9, Line 7funded using revenue from the healthcare affordability and sustainability
Page 9, Line 8fee and federal matching funds before any eligibility expansion is funded; and
Page 9, Line 9(c) Notwithstanding any other provision of this section, if, after
Page 9, Line 10receipt of authorization to receive federal matching funds for money in
Page 9, Line 11the fund, the authorization is withdrawn or changed so that federal
Page 9, Line 12matching funds are no longer available, the enterprise shall cease
Page 9, Line 13collecting the healthcare affordability and sustainability fee and
Page 9, Line 14receiving public funds and shall repay to the hospitals any money received by the fund that is not subject to federal matching funds.
Page 9, Line 15(9) State-directed payments program - funding and
Page 9, Line 16implementation.The enterprise, acting in concert with, or
Page 9, Line 17through an agreement with, the state department, if required by
Page 9, Line 18federal law, shall seek a state plan amendment or any federal
Page 9, Line 19authorization necessary to fund and, in cooperation with the
Page 9, Line 20state department and hospitals, support the implementation of
Page 9, Line 21a state-directed payment program in compliance with 42 CFR
Page 9, Line 22438.6(c) that complies with all federal requirements for
Page 9, Line 23financing of the non-federal share and shall support a total
Page 9, Line 24payment rate for each state-directed payment that does not
Page 10, Line 1exceed the average commercial rate and is distributed pursuant to the requirements of subsection (5) of this section.
Page 10, Line 2SECTION 5. In Colorado Revised Statutes, 25.5-5-402, add(7.3) as follows:
Page 10, Line 325.5-5-402. Statewide managed care system - rules -
Page 10, Line 4definitions.(7.3) (a) Beginning January 1, 2026, for a claim that
Page 10, Line 5must be reprocessed as a result of updating the provider rates,
Page 10, Line 6an MCO shall issue payment to the contracted provider within one year after the provider rate is updated.
Page 10, Line 7(b) The state department shall notify the MCOs of any
Page 10, Line 8change to the provider rates within sixty days of changing the provider rates.
Page 10, Line 9SECTION 6. In Colorado Revised Statutes, add 25.5-5-427 as follows:
Page 10, Line 1025.5-5-427. Managed care entities - disclosure of payment and
Page 10, Line 11medical loss ratio - definition. (1) The state department shall
Page 10, Line 12include in each new contract with, or renewal of a contract
Page 10, Line 13with, an MCE a provision requiring the MCE to submit to the
Page 10, Line 14state department, on an annual basis, the amount the MCE is paid for delivering services and the MCE's medical loss ratio.
Page 10, Line 15(2) The state department shall annually publish the following information on its website:
Page 10, Line 16(a) The information received pursuant to subsection (1) of this section;
Page 10, Line 17(b) Historicalmedicalloss ratio data for each MCE; and
Page 10, Line 18(c) Audit findings regarding an MCE's most recently
Page 10, Line 19completed medical loss ratio audit.
Page 11, Line 1(3) For purposes of subsection (1) of this section, "medical
Page 11, Line 2loss ratio" means the percentage of premium revenue that the
Page 11, Line 3MCE spends on health-care services and quality improvement activities.
Page 11, Line 4SECTION 7. In Colorado Revised Statutes, add 25.5-6-117 as follows:
Page 11, Line 525.5-6-117. Plan of care - rehabilitation therapy -
Page 11, Line 6requirements - definition. (1) As used in the section, unless the
Page 11, Line 7context otherwise requires, "plan of care" has the same meaning as set forth in section 25.5-6-403.
Page 11, Line 8(2) The state department shall not impose signature
Page 11, Line 9requirements beyond what is required by the federal centers for
Page 11, Line 10medicare and medicaid services pursuant to 42 CFR 409.43 on a
Page 11, Line 11physician or practitioner certifying a member's plan of care that
Page 11, Line 12involves physical therapy, occupational therapy, or speech therapy services.
Page 11, Line 13SECTION 8. In Colorado Revised Statutes, add 25.5-6-118 as follows:
Page 11, Line 1425.5-6-118. Long-term care for members with permanent
Page 11, Line 15disability. (1) For a member receiving services through a
Page 11, Line 16long-term care program pursuant to parts 3 to 10 of this article
Page 11, Line 176, if a service the member receives is discontinued or is no longer
Page 11, Line 18a covered service, the state department must confirm the
Page 11, Line 19timeline for continuity of treatment with the federal centers
Page 11, Line 20for medicare and medicaid during the transition period of the
Page 11, Line 21benefit or service being discontinued. Upon confirmation, the
Page 11, Line 22state department shall communicate the timeline to the member impacted by the benefit or service being discontinued.
Page 12, Line 1(2) This section applies to members who are functionally
Page 12, Line 2and financially eligible to receive long-term care services pursuant to parts 3 to 10 of this article 6.
Page 12, Line 3SECTION 9. In Colorado Revised Statutes, 25.5-6-2001, amend (2)(a), (2)(c)(II), (2)(c)(III), (3)(a), and(7)(b) as follows:
Page 12, Line 425.5-6-2001. System of care for children and youth - federal
Page 12, Line 5authorization - leadership and implementation team - report - rules
Page 12, Line 6- definition. (2) (a)
No later than November 1, 2024,Page 12, Line 7department shall convene a leadership team that is responsible for
thePage 12, Line 8
decision-making and oversightPage 12, Line 9development and operation of the system of care for children and youth who have complex behavioral health needs.
Page 12, Line 10(c) The leadership team has the following duties and responsibilities:
Page 12, Line 11(II) To
oversee and advisePage 12, Line 12(III) To
provide fiscal oversight of the state department'sPage 12, Line 13
development and oversight of the system of carePage 12, Line 14on the state department's fiscal development and oversight of the system of care.
Page 12, Line 15(3) (a)
No later than October 1, 2024,Page 12, Line 16convene an implementation team that shall create a plan utilizing the
Page 12, Line 17recommendations from the leadership team, as appropriate, to
Page 12, Line 18implement the system of care for children and youth who have complex behavioral health needs.
Page 12, Line 19(7) (b) Beginning January 2025, and each quarter thereafter, the
Page 13, Line 1state department shall report progress on the development and
Page 13, Line 2implementation of the system of care developed pursuant to this section
Page 13, Line 3to the joint budget committee, the implementation team, the
Page 13, Line 4leadership team, the senate health and human services
Page 13, Line 5committee, and the house of representatives health and human
Page 13, Line 6services committee. The report required by this subsection (7)(b)
Page 13, Line 7must include the rationale for any recommendation from the leadership team that the department elects not to implement.
Page 13, Line 8SECTION 10. Act subject to petition - effective date. This act
Page 13, Line 9takes effect at 12:01 a.m. on the day following the expiration of the
Page 13, Line 10ninety-day period after final adjournment of the general assembly; except
Page 13, Line 11that, if a referendum petition is filed pursuant to section 1 (3) of article V
Page 13, Line 12of the state constitution against this act or an item, section, or part of this
Page 13, Line 13act within such period, then the act, item, section, or part will not take
Page 13, Line 14effect unless approved by the people at the general election to be held in
Page 13, Line 15November 2026 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.