House Bill 25-1002 Preamended

A Bill for an Act

• Page 1, Line 101Concerning the determination of health benefits coverage

• Page 1, Line 102for mental health services.

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 clarifies that the health benefits coverage for the prevention of, screening for, and treatment of behavioral, mental health, and substance use disorders must be no less extensive than the coverage provided for any physical illness. The bill requires that every health benefit plan must provide coverage for:

• The placement, including admission, continued stay, transfer, and discharge of a covered person and determinations relating to mental health disorders in accordance with criteria developed by the American Academy of Child and Adolescent Psychiatry or the American Association for Community Psychiatry; and
• Medically necessary treatment of covered behavioral, mental health, and substance use disorder benefits, consistent with specified criteria.

The bill also specifies criteria to be used for utilization review, service intensity, the level of care for covered persons, and provider reimbursement.

• This Unofficial Version Includes Committee

• Amendments Not Yet Adopted on Second Reading

• Page 2, Line 1Be it enacted by the General Assembly of the State of Colorado:

• Page 2, Line 2SECTION 1.  In Colorado Revised Statutes, 10-16-104, amend

• Page 2, Line 3(5.5)(a)(I), (5.5)(a)(V)(A), (5.5)(a)(V)(B), (5.5)(a)(V)(D), and

• Page 2, Line 4(5.5)(d); and add (5.5)(a)(I.5), (5.5)(a)(V)(F), (5.5)(a)(VI), (5.5)(c.3), and

• Page 2, Line 5(5.5)(c.5) as follows:

• Page 2, Line 610-16-104.  Mandatory coverage provisions - definitions - rules

• Page 2, Line 7- applicability. (5.5)  Behavioral, mental health, and substance use

• Page 2, Line 8disorders - utilization review criteria - federal treatment limitation

• Page 2, Line 9requirements - meaningful benefits - rules - definitions. (a) (I)  Every

• Page 2, Line 10health benefit plan subject to part 2, 3, or 4 of this article 16, except those

• Page 2, Line 11described in section 10-16-102 (32)(b), must provide coverage:

• Page 2, Line 12(A)  For the prevention of, screening for, and treatment of

• Page 2, Line 13behavioral, mental health, and substance use disorders that is no less

• Page 2, Line 14extensive than the coverage provided for any physical illness, and that

• Page 2, Line 15complies with the requirements of the MHPAEA, and that does not

• Page 2, Line 16discriminate in its benefit design against individuals because of

• Page 2, Line 17their present or predicted behavioral, mental health, or

• Page 2, Line 18substance use disorder;

• Page 2, Line 19(B)  At a minimum, for the treatment of substance use disorders in

• Page 3, Line 1accordance with the American Society of Addiction Medicine criteria for

• Page 3, Line 2placement, including admission, continued stay, transfer, and

• Page 3, Line 3discharge of a covered person; medical necessity; and utilization

• Page 3, Line 4management determinations as set forth in the most recent edition of "The

• Page 3, Line 5ASAM Criteria: Treatment Criteria for Addictive, Substance-related,

• Page 3, Line 6and Co-occurring Conditions"; except that the commissioner may identify

• Page 3, Line 7by rule, in consultation with the department of health care policy and

• Page 3, Line 8financing and the behavioral health administration in the department of

• Page 3, Line 9human services, an alternate nationally recognized and evidence-based

• Page 3, Line 10substance-use-disorder-specific not-for-profit utilization review

• Page 3, Line 11criteria that is consistent with generally accepted standards of

• Page 3, Line 12substance use disorder care for placement, medical necessity, or

• Page 3, Line 13utilization management review, if the American Society of Addiction

• Page 3, Line 14Medicine criteria are no longer available or relevant or do not follow best

• Page 3, Line 15practices for substance use disorder treatment;

• Page 3, Line 16(C)  At a minimum, for placement, including admission,

• Page 3, Line 17continued stay, transfer, and discharge of a covered person,

• Page 3, Line 18determinations relating to mental health disorders in

• Page 3, Line 19accordance with the age-appropriate level-of-care or service

• Page 3, Line 20intensity criteria developed by the American Academy of Child

• Page 3, Line 21and Adolescent Psychiatry or the American Association for

• Page 3, Line 22Community Psychiatry as set forth in the most recent edition of

• Page 3, Line 23the "Level of Care Utilization System", the "Child and

• Page 3, Line 24Adolescent Level of Care / Service Intensity Utilization

• Page 3, Line 25System", and the "Early Childhood Service Intensity

• Page 3, Line 26Instrument"; except that the commissioner may identify by rule,

• Page 3, Line 27in consultation with the department of health care policy and

• Page 4, Line 1financing and the behavioral health administration in the

• Page 4, Line 2department of human services, alternate, age-appropriate

• Page 4, Line 3nationally recognized and evidence-based not-for-profit

• Page 4, Line 4mental-health-disorder-specific utilization review criteria that

• Page 4, Line 5are consistent with generally accepted standards of mental

• Page 4, Line 6health disorder care for patient placement, transfer, or

• Page 4, Line 7discharge determinations, if the criteria in this subsection

• Page 4, Line 8(5.5)(a)(I)(C) are no longer available or relevant or do not

• Page 4, Line 9follow best practices for mental health disorder treatment;

• Page 4, Line 10and

• Page 4, Line 11(D)  For medically necessary treatment of covered

• Page 4, Line 12behavioral, mental health, and substance use disorder benefits,

• Page 4, Line 13including services that are consistent with criteria, guidelines,

• Page 4, Line 14or consensus recommendations from nationally recognized

• Page 4, Line 15not-for-profit clinical specialty associations of the relevant

• Page 4, Line 16behavioral, mental health, or substance use disorder specialty.

• Page 4, Line 17(I.5) (A)  All utilization review and utilization review

• Page 4, Line 18criteria must be consistent with current generally accepted

• Page 4, Line 19standards of behavioral, mental health, and substance use

• Page 4, Line 20disorder care.

• Page 4, Line 21(B)  When a health-care provider has completed an

• Page 4, Line 22assessment concerning service intensity or level-of-care

• Page 4, Line 23placement, continued stay, or transfer or discharge using the

• Page 4, Line 24relevant criteria in subsection (5.5)(a)(I)(B) or (5.5)(a)(I)(C) of

• Page 4, Line 25this section, the health benefit plan must authorize placement

• Page 4, Line 26at the service intensity and level of care consistent with that

• Page 4, Line 27criteria and must not apply different, additional, conflicting, or

• Page 5, Line 1more restrictive criteria. If the assessed level of placement is

• Page 5, Line 2not available, the health benefit plan must authorize the next

• Page 5, Line 3higher level of care; if there is a disagreement with the

• Page 5, Line 4accuracy of the provider's assessment, as part of the adverse

• Page 5, Line 5benefit determination, the health benefit plan must provide full

• Page 5, Line 6detail of its assessment and the relevant criteria used in the

• Page 5, Line 7assessment to the provider and the covered person.

• Page 5, Line 8(C)  A health benefit plan must not limit benefits or

• Page 5, Line 9coverage for chronic behavioral, mental health, or substance

• Page 5, Line 10use disorders to short-term symptom reduction at any

• Page 5, Line 11level-of-care placement.

• Page 5, Line 12(V)  A carrier offering a health benefit plan subject to the

• Page 5, Line 13requirements of this subsection (5.5) shall:

• Page 5, Line 14(A)  Comply with the nonquantitative treatment limitation

• Page 5, Line 15requirements specified in 45 CFR 146.136 (c)(4) 45 CFR 146.136 or 29

• Page 5, Line 16CFR 2590.712, or any successor regulation, regarding any limitations that

• Page 5, Line 17are not expressed numerically but otherwise limit the scope or duration

• Page 5, Line 18of benefits for treatment, which, in addition to the limitations and

• Page 5, Line 19examples listed in 45 CFR 146.136 (c)(4)(ii) and (c)(4)(iii) (c)(4)(vi) or

• Page 5, Line 2029 CFR 2590.712 (c)(4)(ii) and (c)(4)(vi), or any successor regulation,

• Page 5, Line 21and 78 FR 68246 78 Fed. Reg. 68246 (November 13, 2013) and 89 Fed.

• Page 5, Line 22Reg. 77586 (September 23, 2024), include the methods by which the

• Page 5, Line 23carrier establishes and maintains its provider networks pursuant to section

• Page 5, Line 2410-16-704 and responds to deficiencies in the ability of its networks to

• Page 5, Line 25provide timely access to care;

• Page 5, Line 26(B)  Comply with the financial requirements and quantitative

• Page 5, Line 27treatment limitations specified in 45 CFR 146.136 (c)(2) and (c)(3) or any

• Page 6, Line 1successor regulation or 29 CFR 2590.712 (c)(2) and (c)(3);

• Page 6, Line 2(D)  Establish procedures to authorize medically necessary

• Page 6, Line 3treatment with a an appropriate nonparticipating provider and to

• Page 6, Line 4provide services to make available the covered service if a

• Page 6, Line 5covered service is not available within established time and distance

• Page 6, Line 6standards, and within a reasonable period, after a service is requested, and

• Page 6, Line 7with the same coinsurance, deductible, or copayment requirements,

• Page 6, Line 8accruing to in-network annual cost-sharing limits, as would

• Page 6, Line 9apply if the services were provided by a participating provider, and at no

• Page 6, Line 10greater cost to the covered person than if the services were obtained at or

• Page 6, Line 11from a participating provider; and

• Page 6, Line 12(F)  Not reverse or alter a determination of medical

• Page 6, Line 13necessity made pursuant to this subsection (5.5), including

• Page 6, Line 14downgrading or bundling the coding of a claim, through a

• Page 6, Line 15review or audit of a claim, except in cases of fraud or where the

• Page 6, Line 16covered person did not have a valid policy when the service was

• Page 6, Line 17provided.

• Page 6, Line 18(VI)  If a health benefit plan provides any benefits for a

• Page 6, Line 19mental health condition or substance use disorder in any

• Page 6, Line 20classification of benefits, it must provide meaningful benefits

• Page 6, Line 21for that mental health condition or substance use disorder in

• Page 6, Line 22every classification in which medical or surgical benefits are

• Page 6, Line 23provided. Whether the benefits provided are meaningful benefits

• Page 6, Line 24is determined in comparison to the benefits provided for medical

• Page 6, Line 25conditions and surgical procedures in the classification and

• Page 6, Line 26requires, at a minimum, coverage of benefits for that condition

• Page 6, Line 27or disorder in each classification in which the health benefit

• Page 7, Line 1plan provides benefits for one or more medical conditions or

• Page 7, Line 2surgical procedures. A health benefit plan does not provide

• Page 7, Line 3meaningful benefits unless it provides benefits for a core

• Page 7, Line 4treatment for that condition or disorder in each classification

• Page 7, Line 5in which the health benefit plan provides benefits for a core

• Page 7, Line 6treatment for one or more medical conditions or surgical

• Page 7, Line 7procedures. A core treatment for a condition or disorder is a

• Page 7, Line 8standard treatment or course of treatment, therapy, service,

• Page 7, Line 9or intervention indicated by generally accepted standards of

• Page 7, Line 10behavioral, mental health, and substance use disorder care. If

• Page 7, Line 11there is no core treatment for a covered mental health

• Page 7, Line 12condition or substance use disorder with respect to a

• Page 7, Line 13classification, the health benefit plan is not required to provide

• Page 7, Line 14benefits for a core treatment for such condition or disorder in

• Page 7, Line 15that classification, but must provide benefits for such condition

• Page 7, Line 16or disorder in every classification in which medical or surgical

• Page 7, Line 17benefits are provided.

• Page 7, Line 19(c.3)  This subsection (5.5) applies to any individual, entity,

• Page 7, Line 20or contracting provider that performs utilization review

• Page 7, Line 21functions on behalf of a health benefit plan.

• Page 7, Line 22(c.5)  A carrier offering a health benefit plan shall not

• Page 7, Line 23adopt, impose, or enforce terms in its policies or provider

• Page 7, Line 24agreement, in writing or in operation, that undermine, alter, or

• Page 7, Line 25conflict with the requirements of this subsection (5.5).

• Page 7, Line 26(d)  As used in this subsection (5.5):

• Page 7, Line 27(I)  "Appropriate nonparticipating provider" means a

• Page 8, Line 1provider who is accessible and has the training and experience

• Page 8, Line 2necessary to provide age-appropriate, medically necessary

• Page 8, Line 3treatment of a behavioral, mental health, or substance use

• Page 8, Line 4disorder.

• Page 8, Line 5(II)  "Behavioral, mental health, and substance use disorder":

• Page 8, Line 6(I)  (A)  Means a condition or disorder, regardless of etiology, that

• Page 8, Line 7may be the result of a combination of genetic and environmental factors

• Page 8, Line 8and that falls under any of the diagnostic categories listed in the mental

• Page 8, Line 9disorders section of the most recent version of

• Page 8, Line 10(A)   the "International Statistical Classification of Diseases and

• Page 8, Line 11Related Health Problems",

• Page 8, Line 12(B)   the "Diagnostic and Statistical Manual of Mental Disorders",

• Page 8, Line 13or

• Page 8, Line 14(C)   the "Diagnostic Classification of Mental Health and

• Page 8, Line 15Developmental Disorders of Infancy and Early Childhood"; and

• Page 8, Line 16(II)  (B)  Includes autism spectrum disorders, as defined in

• Page 8, Line 17subsection (1.4)(a)(III) of this section.

• Page 8, Line 18(III)  "Generally accepted standards of behavioral,

• Page 8, Line 19mental health, and substance use disorder care" means

• Page 8, Line 20standards of care and clinical practice that are generally

• Page 8, Line 21recognized by health-care providers practicing in relevant

• Page 8, Line 22clinical specialties such as psychiatry, psychology, clinical

• Page 8, Line 23social work, psychiatric nursing, addiction medicine and

• Page 8, Line 24counseling, and behavioral health treatment. Valid,

• Page 8, Line 25evidence-based sources reflecting generally accepted

• Page 8, Line 26standards of behavioral, mental health, and substance use

• Page 8, Line 27disorder care include peer-reviewed scientific studies and

• Page 9, Line 1medical literature; clinical practice guidelines and

• Page 9, Line 2recommendations of nonprofit health-care provider

• Page 9, Line 3professional associations, specialty societies, and federal

• Page 9, Line 4government agencies; and drug labeling approved by the FDA.

• Page 9, Line 5(IV)  "Medically necessary treatment" means a service or

• Page 9, Line 6product addressing the specific needs of a patient for the

• Page 9, Line 7purpose of screening, preventing, diagnosing, managing, or

• Page 9, Line 8treating a behavioral, mental health, or substance use disorder

• Page 9, Line 9or its symptoms, including minimizing the progression of the

• Page 9, Line 10disorder, in a manner that is:

• Page 9, Line 11(A)  In accordance with the generally accepted standards

• Page 9, Line 12of behavioral, mental health, and substance use disorder care;

• Page 9, Line 13(B)  Clinically appropriate in terms of type, frequency,

• Page 9, Line 14extent, site, and duration; and

• Page 9, Line 15(C)  Not primarily for the economic benefit of the insurer

• Page 9, Line 16or purchaser or for the convenience of the covered person,

• Page 9, Line 17treating physician, or other health-care provider.

• Page 9, Line 18(V)  "Utilization review" means prospectively,

• Page 9, Line 19retrospectively, or concurrently reviewing and approving,

• Page 9, Line 20modifying, delaying, or denying requests by health-care

• Page 9, Line 21providers, covered persons, or their authorized representatives

• Page 9, Line 22for coverage, based in whole or in part on medical necessity, or

• Page 9, Line 23for out-of-network services required pursuant to subsection

• Page 9, Line 24(5.5)(a)(V)(D) of this section.

• Page 9, Line 25(VI)  "Utilization review criteria" means an evaluation of

• Page 9, Line 26the necessity, appropriateness, and efficiency of the use of

• Page 9, Line 27health-care services, procedures, and facilities, including

• Page 10, Line 1out-of-network services required pursuant to subsection

• Page 10, Line 2(5.5)(a)(V)(D) of this section. "Utilization review criteria" does

• Page 10, Line 3not include an independent medical examination provided for in

• Page 10, Line 4any policy.

• Page 10, Line 5SECTION 2.  Act subject to petition - effective date. This act

• Page 10, Line 6takes effect January 1, 2026; except that, if a referendum petition is filed

• Page 10, Line 7pursuant to section 1 (3) of article V of the state constitution against this

• Page 10, Line 8act or an item, section, or part of this act within the ninety-day period

• Page 10, Line 9after final adjournment of the general assembly, then the act, item,

• Page 10, Line 10section, or part will not take effect unless approved by the people at the

• Page 10, Line 11general election to be held in November 2026 and, in such case, will take

• Page 10, Line 12effect on the date of the official declaration of the vote thereon by the

• Page 10, Line 13governor.