House Bill 25-1002 Revised

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.

• 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), (5.5)(b) 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),

• Page 2, Line 5(5.5)(c.5), and (5.5)(e) 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, medical necessity, and utilization management determinations

• Page 3, Line 3as set forth in the most recent edition of "The ASAM Criteria:

• Page 3, Line 4Treatment Criteria for Addictive, Substance-related, and Co-occurring

• Page 3, Line 5Conditions"; except that the commissioner may identify by rule, in

• Page 3, Line 6consultation with the department of health care policy and financing and

• Page 3, Line 7the behavioral health administration in the department of human services,

• Page 3, Line 8an alternate nationally recognized and evidence-based

• Page 3, Line 9substance-use-disorder-specific not-for-profit utilization review

• Page 3, Line 10criteria that is consistent with generally accepted standards of

• Page 3, Line 11substance use disorder care for placement, medical necessity, or

• Page 3, Line 12utilization management review, if the American Society of Addiction

• Page 3, Line 13Medicine criteria are no longer available or relevant or do not follow best

• Page 3, Line 14practices for substance use disorder treatment; and

• Page 3, Line 16(C)  For medically necessary treatment of covered

• Page 3, Line 17behavioral, mental health, and substance use disorder benefits,

• Page 3, Line 18including services that are consistent with criteria, guidelines,

• Page 3, Line 19or consensus recommendations from nationally recognized

• Page 3, Line 20not-for-profit clinical specialty associations of the relevant

• Page 3, Line 21behavioral, mental health, or substance use disorder specialty.

• Page 3, Line 22(I.5) (A)  All utilization review and utilization review

• Page 3, Line 23criteria must be consistent with current generally accepted

• Page 3, Line 24standards of behavioral, mental health, and substance use

• Page 3, Line 25disorder care.

• Page 3, Line 27(B)  In conducting utilization review of covered services

• Page 4, Line 1for the diagnosis, prevention, and treatment of behavioral or

• Page 4, Line 2mental health disorders, a health benefit plan shall apply the

• Page 4, Line 3criteria and guidelines set forth in the most recent version of

• Page 4, Line 4the treatment criteria developed by unaffiliated nationally

• Page 4, Line 5recognized not-for-profit clinical specialty associations of the

• Page 4, Line 6relevant behavioral or mental health disorders. In conducting

• Page 4, Line 7utilization review of covered services for the diagnosis,

• Page 4, Line 8prevention, and treatment of substance use disorders, a health

• Page 4, Line 9benefit plan shall apply the criteria specified in subsection

• Page 4, Line 10(5.5)(a)(I)(B) of this section.

• Page 4, Line 11(C)  In conducting utilization review relating to service

• Page 4, Line 12intensity, level of care placement, or any other patient care

• Page 4, Line 13decisions that are within the scope of the sources specified in

• Page 4, Line 14subsections (5.5)(a)(I)(B) and (5.5)(a)(I.5)(B) of this section, a

• Page 4, Line 15health benefit plan shall not apply different, additional,

• Page 4, Line 16conflicting, or more restrictive utilization review criteria than

• Page 4, Line 17the criteria set forth in those sources. If the requested service

• Page 4, Line 18intensity or level of care placement is inconsistent with the

• Page 4, Line 19health benefit plan's assessment using the relevant criteria, as

• Page 4, Line 20part of any adverse benefit determination, the health benefit

• Page 4, Line 21plan shall provide full detail of its assessment and the relevant

• Page 4, Line 22criteria used in the assessment to the provider and the covered

• Page 4, Line 23person.

• Page 4, Line 24(D)  In conducting utilization review that is outside the

• Page 4, Line 25scope of the criteria specified in subsections (5.5)(a)(I)(B) and

• Page 4, Line 26(5.5)(a)(I.5)(B) of this section or related to advancements in

• Page 4, Line 27technology or types of levels of care that are not addressed in

• Page 5, Line 1the most recent versions of the sources specified in those

• Page 5, Line 2subsections, a health benefit plan shall conduct utilization

• Page 5, Line 3review in accordance with subsection (5.5)(a)(I.5)(A) of this

• Page 5, Line 4section. If a health benefit plan purchases or licenses utilization

• Page 5, Line 5review criteria pursuant to this subsection (5.5)(a)(I.5)(D), the

• Page 5, Line 6health benefit plan shall verify and document before use that

• Page 5, Line 7the criteria comply with the requirements of subsection

• Page 5, Line 8(5.5)(a)(I.5)(A) of this section.

• Page 5, Line 9(E)  A health benefit plan must not limit benefits or

• Page 5, Line 10coverage for chronic behavioral, mental health, or substance

• Page 5, Line 11use disorders to short-term symptom reduction at any

• Page 5, Line 12level-of-care placement.

• Page 5, Line 13(V)  A carrier offering a health benefit plan subject to the

• Page 5, Line 14requirements of this subsection (5.5) shall:

• Page 5, Line 15(A)  Comply with the nonquantitative treatment limitation

• Page 5, Line 16requirements specified in 45 CFR 146.136 (c)(4) 45 CFR 146.136 or 29

• Page 5, Line 17CFR 2590.712, or any successor regulation, regarding any limitations that

• Page 5, Line 18are not expressed numerically but otherwise limit the scope or duration

• Page 5, Line 19of benefits for treatment, which, in addition to the limitations and

• Page 5, Line 20examples listed in 45 CFR 146.136 (c)(4)(ii) and (c)(4)(iii) (c)(4)(vi) or

• Page 5, Line 2129 CFR 2590.712 (c)(4)(ii) and (c)(4)(vi), or any successor regulation,

• Page 5, Line 22and 78 FR 68246 78 Fed. Reg. 68246 (November 13, 2013) and 89 Fed.

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

• Page 5, Line 24carrier establishes and maintains its provider networks pursuant to section

• Page 5, Line 2510-16-704 and responds to deficiencies in the ability of its networks to

• Page 5, Line 26provide timely access to care;

• Page 5, Line 27(B)  Comply with the financial requirements and quantitative

• Page 6, Line 1treatment limitations specified in 45 CFR 146.136 (c)(2) and (c)(3) or any

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

• Page 6, Line 3(D)  Establish procedures to authorize medically necessary

• Page 6, Line 4treatment with a an appropriate nonparticipating provider and to

• Page 6, Line 5provide services to make available the covered service if a

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

• Page 6, Line 7standards, and within a reasonable period, after a service is requested, and

• Page 6, Line 8with the same coinsurance, deductible, or copayment requirements,

• Page 6, Line 9accruing to in-network annual cost-sharing limits, as would

• Page 6, Line 10apply if the services were provided by a participating provider, and at no

• Page 6, Line 11greater cost to the covered person than if the services were obtained at or

• Page 6, Line 12from a participating provider; and

• Page 6, Line 13(F)  Not reverse or alter a determination of medical

• Page 6, Line 14necessity made pursuant to this subsection (5.5), including

• Page 6, Line 15downgrading or bundling the coding of a claim, through a

• Page 6, Line 16review or audit of a claim, except in cases of fraud or where the

• Page 6, Line 17covered person did not have a valid policy when the service was

• Page 6, Line 18provided.

• Page 6, Line 19(VI)  If a health benefit plan provides any benefits for a

• Page 6, Line 20mental health condition or substance use disorder in any

• Page 6, Line 21classification of benefits, it must provide meaningful benefits

• Page 6, Line 22for that mental health condition or substance use disorder in

• Page 6, Line 23every classification in which medical or surgical benefits are

• Page 6, Line 24provided. Whether the benefits provided are meaningful benefits

• Page 6, Line 25is determined in comparison to the benefits provided for medical

• Page 6, Line 26conditions and surgical procedures in the classification and

• Page 6, Line 27requires, at a minimum, coverage of benefits for that condition

• Page 7, Line 1or disorder in each classification in which the health benefit

• Page 7, Line 2plan provides benefits for one or more medical conditions or

• Page 7, Line 3surgical procedures. A health benefit plan does not provide

• Page 7, Line 4meaningful benefits unless it provides benefits for a core

• Page 7, Line 5treatment for that condition or disorder in each classification

• Page 7, Line 6in which the health benefit plan provides benefits for a core

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

• Page 7, Line 8procedures. A core treatment for a condition or disorder is a

• Page 7, Line 9standard treatment or course of treatment, therapy, service,

• Page 7, Line 10or intervention indicated by generally accepted standards of

• Page 7, Line 11behavioral, mental health, and substance use disorder care. If

• Page 7, Line 12there is no core treatment for a covered mental health

• Page 7, Line 13condition or substance use disorder with respect to a

• Page 7, Line 14classification, the health benefit plan is not required to provide

• Page 7, Line 15benefits for a core treatment for such condition or disorder in

• Page 7, Line 16that classification, but must provide benefits for such condition

• Page 7, Line 17or disorder in every classification in which medical or surgical

• Page 7, Line 18benefits are provided.

• Page 7, Line 19(b)  The commissioner:

• Page 7, Line 20(I)  May adopt rules as necessary to ensure that this subsection

• Page 7, Line 21(5.5) is implemented and compliantly administered; in compliance with

• Page 7, Line 22federal law and shall adopt rules to establish reasonable time periods for

• Page 7, Line 23visits with a provider for treatment of a behavioral, mental health, or

• Page 7, Line 24substance use disorder after an initial visit with a provider.

• Page 7, Line 25(II)  May adopt rules to establish carrier utilization

• Page 7, Line 26review compliance in accordance withsubsection (5.5)(a)(I.5)of

• Page 7, Line 27this section;

• Page 8, Line 1(III)  May adopt rules as necessary to specify data testing

• Page 8, Line 2requirements to determine plan design and application of parity

• Page 8, Line 3compliance for nonquantitative treatment limitations using

• Page 8, Line 4outcomes data;

• Page 8, Line 5(IV)  May adopt rules to set standard definitions for

• Page 8, Line 6coverage requirements, including processes, strategies,

• Page 8, Line 7evidentiary standards, and other factors;

• Page 8, Line 8(V)  May adopt rules to establish specific timelines for

• Page 8, Line 9carrier compliance to provide comparative analysis information

• Page 8, Line 10to the division for review, including the effect of a carrier's

• Page 8, Line 11lack of sufficient comparative analyses to demonstrate

• Page 8, Line 12compliance; and

• Page 8, Line 13(V)  May adopt rules to establish reasonable time periods

• Page 8, Line 14and documentation of such time periods for visits with a

• Page 8, Line 15provider for treatment of a behavioral, mental health, or

• Page 8, Line 16substance use disorder after an initial visit with a provider.

• Page 8, Line 17(c.3)  This subsection (5.5) applies to any individual, entity,

• Page 8, Line 18or contracting provider that performs utilization review

• Page 8, Line 19functions on behalf of a health benefit plan.

• Page 8, Line 20(c.5)  A carrier offering a health benefit plan shall not

• Page 8, Line 21adopt, impose, or enforce terms in its policies or provider

• Page 8, Line 22agreement, in writing or in operation, that undermine, alter, or

• Page 8, Line 23conflict with the requirements of this subsection (5.5).

• Page 8, Line 24(d)  As used in this subsection (5.5):

• Page 8, Line 25(I)  "Appropriate nonparticipating provider" means a

• Page 8, Line 26provider who is accessible and has the training and experience

• Page 8, Line 27necessary to provide age-appropriate, medically necessary

• Page 9, Line 1treatment of a behavioral, mental health, or substance use

• Page 9, Line 2disorder.

• Page 9, Line 3(II)  "Behavioral, mental health, and substance use disorder":

• Page 9, Line 4(I)  (A)  Means a condition or disorder, regardless of etiology, that

• Page 9, Line 5may be the result of a combination of genetic and environmental factors

• Page 9, Line 6and that falls under any of the diagnostic categories listed in the mental

• Page 9, Line 7disorders section of the most recent version of

• Page 9, Line 8(A)   the "International Statistical Classification of Diseases and

• Page 9, Line 9Related Health Problems",

• Page 9, Line 10(B)   the "Diagnostic and Statistical Manual of Mental Disorders",

• Page 9, Line 11or

• Page 9, Line 12(C)   the "Diagnostic Classification of Mental Health and

• Page 9, Line 13Developmental Disorders of Infancy and Early Childhood"; and

• Page 9, Line 14(II)  (B)  Includes autism spectrum disorders, as defined in

• Page 9, Line 15subsection (1.4)(a)(III) of this section.

• Page 9, Line 16(III)  "Generally accepted standards of behavioral,

• Page 9, Line 17mental health, and substance use disorder care" means

• Page 9, Line 18standards of care and clinical practice that are generally

• Page 9, Line 19recognized by health-care providers practicing in relevant

• Page 9, Line 20clinical specialties such as psychiatry, psychology, clinical

• Page 9, Line 21social work, psychiatric nursing, addiction medicine and

• Page 9, Line 22counseling, and behavioral health treatment. Valid,

• Page 9, Line 23evidence-based sources reflecting generally accepted

• Page 9, Line 24standards of behavioral, mental health, and substance use

• Page 9, Line 25disorder care include peer-reviewed scientific studies and

• Page 9, Line 26medical literature; clinical practice guidelines and

• Page 9, Line 27recommendations of nonprofit health-care provider

• Page 10, Line 1professional associations, specialty societies, and federal

• Page 10, Line 2government agencies; and drug labeling approved by the FDA.

• Page 10, Line 3(IV)  "Medically necessary treatment" means a service or

• Page 10, Line 4product addressing the specific needs of a patient for the

• Page 10, Line 5purpose of screening, preventing, diagnosing, managing, or

• Page 10, Line 6treating a behavioral, mental health, or substance use disorder

• Page 10, Line 7or its symptoms, including minimizing the progression of the

• Page 10, Line 8disorder, in a manner that is:

• Page 10, Line 9(A)  In accordance with the generally accepted standards

• Page 10, Line 10of behavioral, mental health, and substance use disorder care;

• Page 10, Line 11(B)  Clinically appropriate in terms of type, frequency,

• Page 10, Line 12extent, site, and duration; and

• Page 10, Line 13(C)  Not primarily for the economic benefit of the insurer

• Page 10, Line 14or purchaser or for the convenience of the covered person,

• Page 10, Line 15treating physician, or other health-care provider.

• Page 10, Line 16(V)  "Utilization review" means prospectively,

• Page 10, Line 17retrospectively, or concurrently reviewing and approving,

• Page 10, Line 18modifying, delaying, or denying requests by health-care

• Page 10, Line 19providers, covered persons, or their authorized representatives

• Page 10, Line 20for coverage, based in whole or in part on medical necessity, or

• Page 10, Line 21for out-of-network services required pursuant to subsection

• Page 10, Line 22(5.5)(a)(V)(D) of this section.

• Page 10, Line 23(VI)  "Utilization review criteria" means an evaluation of

• Page 10, Line 24the necessity, appropriateness, and efficiency of the use of

• Page 10, Line 25health-care services, procedures, and facilities, including

• Page 10, Line 26out-of-network services required pursuant to subsection

• Page 10, Line 27(5.5)(a)(V)(D) of this section. "Utilization review criteria" does

• Page 11, Line 1not include an independent medical examination provided for in

• Page 11, Line 2any policy.

• Page 11, Line 3(e) (I)  This subsection (5.5)does not expand coverage

• Page 11, Line 4requirements beyond the state essential health benefits

• Page 11, Line 5benchmark plan as required pursuant to 45 CFR 156.111.

• Page 11, Line 6(II)  If an exclusion for behavioral health, mental health,

• Page 11, Line 7or substance use disorder services is not permitted under the

• Page 11, Line 8MHPAEA, coverage for these services must meet the

• Page 11, Line 9requirements ofthis subsection (5.5).

• Page 11, Line 10SECTION 2.  Act subject to petition - effective date. This act

• Page 11, Line 11takes effect January 1, 2026; except that, if a referendum petition is filed

• Page 11, Line 12pursuant to section 1 (3) of article V of the state constitution against this

• Page 11, Line 13act or an item, section, or part of this act within the ninety-day period

• Page 11, Line 14after final adjournment of the general assembly, then the act, item,

• Page 11, Line 15section, or part will not take effect unless approved by the people at the

• Page 11, Line 16general election to be held in November 2026 and, in such case, will take

• Page 11, Line 17effect on the date of the official declaration of the vote thereon by the

• Page 11, Line 18governor.