House Bill 25-1002 Engrossed

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. For all service intensity

• Page 4, Line 18and level of care placement decisions, the health benefit plan

• Page 4, Line 19must authorize placement at the service intensity and level of

• Page 4, Line 20care consistent with the assessment of the covered person using

• Page 4, Line 21the relevant patient placement criteria specified in subsections

• Page 4, Line 22(5.5)(a)(I)(B) and (5.5)(a)(I.5)(B) of this section. If there is a

• Page 4, Line 23disagreement, as part of the adverse benefit determination, the

• Page 4, Line 24health benefit plan must provide full detail of its assessment

• Page 4, Line 25and the relevant criteria used in the assessment to the provider

• Page 4, Line 26and the covered person.

• Page 4, Line 27(D)  In conducting utilization review that is outside the

• Page 5, Line 1scope of the criteria specified in subsections (5.5)(a)(I)(B) and

• Page 5, Line 2(5.5)(a)(I.5)(B) of this section or related to advancements in

• Page 5, Line 3technology or types of levels of care that are not addressed in

• Page 5, Line 4the most recent versions of the sources specified in those

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

• Page 5, Line 6review in accordance with subsection (5.5)(a)(I.5)(A) of this

• Page 5, Line 7section. If a health benefit plan purchases or licenses utilization

• Page 5, Line 8review criteria pursuant to this subsection (5.5)(a)(I.5)(D), the

• Page 5, Line 9health benefit plan shall verify and document before use that

• Page 5, Line 10the criteria comply with the requirements of subsection

• Page 5, Line 11(5.5)(a)(I.5)(A) of this section.

• Page 5, Line 12(E)  A health benefit plan must not limit benefits or

• Page 5, Line 13coverage for chronic behavioral, mental health, or substance

• Page 5, Line 14use disorders to short-term symptom reduction at any

• Page 5, Line 15level-of-care placement.

• Page 5, Line 16(V)  A carrier offering a health benefit plan subject to the

• Page 5, Line 17requirements of this subsection (5.5) shall:

• Page 5, Line 18(A)  Comply with the nonquantitative treatment limitation

• Page 5, Line 19requirements specified in 45 CFR 146.136 (c)(4) 45 CFR 146.136 or 29

• Page 5, Line 20CFR 2590.712, or any successor regulation, regarding any limitations that

• Page 5, Line 21are not expressed numerically but otherwise limit the scope or duration

• Page 5, Line 22of benefits for treatment, which, in addition to the limitations and

• Page 5, Line 23examples listed in 45 CFR 146.136 (c)(4)(ii) and (c)(4)(iii) (c)(4)(vi) or

• Page 5, Line 2429 CFR 2590.712 (c)(4)(ii) and (c)(4)(vi), or any successor regulation,

• Page 5, Line 25and 78 FR 68246 78 Fed. Reg. 68246 (November 13, 2013) and 89 Fed.

• Page 5, Line 26Reg. 77586 (September 23, 2024), include the methods by which the

• Page 5, Line 27carrier establishes and maintains its provider networks pursuant to section

• Page 6, Line 110-16-704 and responds to deficiencies in the ability of its networks to

• Page 6, Line 2provide timely access to care;

• Page 6, Line 3(B)  Comply with the financial requirements and quantitative

• Page 6, Line 4treatment limitations specified in 45 CFR 146.136 (c)(2) and (c)(3) or any

• Page 6, Line 5successor regulation or 29 CFR 2590.712 (c)(2) and (c)(3);

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

• Page 6, Line 7treatment with a an appropriate nonparticipating provider and to

• Page 6, Line 8provide services to make available the covered service if a

• Page 6, Line 9covered service is not available within established time and distance

• Page 6, Line 10standards, and within a reasonable period, after a service is requested, and

• Page 6, Line 11with the same coinsurance, deductible, or copayment requirements,

• Page 6, Line 12accruing to in-network annual cost-sharing limits, as would

• Page 6, Line 13apply if the services were provided by a participating provider, and at no

• Page 6, Line 14greater cost to the covered person than if the services were obtained at or

• Page 6, Line 15from a participating provider; and

• Page 6, Line 16(F)  Not reverse or alter a determination of medical

• Page 6, Line 17necessity made pursuant to this subsection (5.5), including

• Page 6, Line 18downgrading or bundling the coding of a claim, through a

• Page 6, Line 19review or audit of a claim, except in cases of fraud or where the

• Page 6, Line 20covered person did not have a valid policy when the service was

• Page 6, Line 21provided.

• Page 6, Line 22(VI)  If a health benefit plan provides any benefits for a

• Page 6, Line 23mental health condition or substance use disorder in any

• Page 6, Line 24classification of benefits, it must provide meaningful benefits

• Page 6, Line 25for that mental health condition or substance use disorder in

• Page 6, Line 26every classification in which medical or surgical benefits are

• Page 6, Line 27provided. Whether the benefits provided are meaningful benefits

• Page 7, Line 1is determined in comparison to the benefits provided for medical

• Page 7, Line 2conditions and surgical procedures in the classification and

• Page 7, Line 3requires, at a minimum, coverage of benefits for that condition

• Page 7, Line 4or disorder in each classification in which the health benefit

• Page 7, Line 5plan provides benefits for one or more medical conditions or

• Page 7, Line 6surgical procedures. A health benefit plan does not provide

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

• Page 7, Line 8treatment for that condition or disorder in each classification

• Page 7, Line 9in which the health benefit plan provides benefits for a core

• Page 7, Line 10treatment for one or more medical conditions or surgical

• Page 7, Line 11procedures. A core treatment for a condition or disorder is a

• Page 7, Line 12standard treatment or course of treatment, therapy, service,

• Page 7, Line 13or intervention indicated by generally accepted standards of

• Page 7, Line 14behavioral, mental health, and substance use disorder care. If

• Page 7, Line 15there is no core treatment for a covered mental health

• Page 7, Line 16condition or substance use disorder with respect to a

• Page 7, Line 17classification, the health benefit plan is not required to provide

• Page 7, Line 18benefits for a core treatment for such condition or disorder in

• Page 7, Line 19that classification, but must provide benefits for such condition

• Page 7, Line 20or disorder in every classification in which medical or surgical

• Page 7, Line 21benefits are provided.

• Page 7, Line 22(b)  The commissioner:

• Page 7, Line 23(I)  May adopt rules as necessary to ensure that this subsection

• Page 7, Line 24(5.5) is implemented and compliantly administered; in compliance with

• Page 7, Line 25federal law and shall adopt rules to establish reasonable time periods for

• Page 7, Line 26visits with a provider for treatment of a behavioral, mental health, or

• Page 7, Line 27substance use disorder after an initial visit with a provider.

• Page 8, Line 1(II)  May adopt rules to establish carrier utilization

• Page 8, Line 2review compliance in accordance with subsections (5.5)(a)(I.5)(B)

• Page 8, Line 3and (5.5)(a)(I.5)(C) of this section;

• Page 8, Line 4(III)  May adopt rules as necessary to specify data testing

• Page 8, Line 5requirements to determine plan design and application of parity

• Page 8, Line 6compliance for nonquantitative treatment limitations using

• Page 8, Line 7outcomes data;

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

• Page 8, Line 9coverage requirements, including processes, strategies,

• Page 8, Line 10evidentiary standards, and other factors;

• Page 8, Line 11(V)  May adopt rules to establish specific timelines for

• Page 8, Line 12carrier compliance to provide comparative analysis information

• Page 8, Line 13to the division for review, including the effect of a carrier's

• Page 8, Line 14lack of sufficient comparative analyses to demonstrate

• Page 8, Line 15compliance; and

• Page 8, Line 16(V)  May adopt rules to establish reasonable time periods

• Page 8, Line 17and documentation of such time periods for visits with a

• Page 8, Line 18provider for treatment of a behavioral, mental health, or

• Page 8, Line 19substance use disorder after an initial visit with a provider.

• Page 8, Line 20(c.3)  This subsection (5.5) applies to any individual, entity,

• Page 8, Line 21or contracting provider that performs utilization review

• Page 8, Line 22functions on behalf of a health benefit plan.

• Page 8, Line 23(c.5)  A carrier offering a health benefit plan shall not

• Page 8, Line 24adopt, impose, or enforce terms in its policies or provider

• Page 8, Line 25agreement, in writing or in operation, that undermine, alter, or

• Page 8, Line 26conflict with the requirements of this subsection (5.5).

• Page 8, Line 27(d)  As used in this subsection (5.5):

• Page 9, Line 1(I)  "Appropriate nonparticipating provider" means a

• Page 9, Line 2provider who is accessible and has the training and experience

• Page 9, Line 3necessary to provide age-appropriate, medically necessary

• Page 9, Line 4treatment of a behavioral, mental health, or substance use

• Page 9, Line 5disorder.

• Page 9, Line 6(II)  "Behavioral, mental health, and substance use disorder":

• Page 9, Line 7(I)  (A)  Means a condition or disorder, regardless of etiology, that

• Page 9, Line 8may be the result of a combination of genetic and environmental factors

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

• Page 9, Line 10disorders section of the most recent version of

• Page 9, Line 11(A)   the "International Statistical Classification of Diseases and

• Page 9, Line 12Related Health Problems",

• Page 9, Line 13(B)   the "Diagnostic and Statistical Manual of Mental Disorders",

• Page 9, Line 14or

• Page 9, Line 15(C)   the "Diagnostic Classification of Mental Health and

• Page 9, Line 16Developmental Disorders of Infancy and Early Childhood"; and

• Page 9, Line 17(II)  (B)  Includes autism spectrum disorders, as defined in

• Page 9, Line 18subsection (1.4)(a)(III) of this section.

• Page 9, Line 19(III)  "Generally accepted standards of behavioral,

• Page 9, Line 20mental health, and substance use disorder care" means

• Page 9, Line 21standards of care and clinical practice that are generally

• Page 9, Line 22recognized by health-care providers practicing in relevant

• Page 9, Line 23clinical specialties such as psychiatry, psychology, clinical

• Page 9, Line 24social work, psychiatric nursing, addiction medicine and

• Page 9, Line 25counseling, and behavioral health treatment. Valid,

• Page 9, Line 26evidence-based sources reflecting generally accepted

• Page 9, Line 27standards of behavioral, mental health, and substance use

• Page 10, Line 1disorder care include peer-reviewed scientific studies and

• Page 10, Line 2medical literature; clinical practice guidelines and

• Page 10, Line 3recommendations of nonprofit health-care provider

• Page 10, Line 4professional associations, specialty societies, and federal

• Page 10, Line 5government agencies; and drug labeling approved by the FDA.

• Page 10, Line 6(IV)  "Medically necessary treatment" means a service or

• Page 10, Line 7product addressing the specific needs of a patient for the

• Page 10, Line 8purpose of screening, preventing, diagnosing, managing, or

• Page 10, Line 9treating a behavioral, mental health, or substance use disorder

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

• Page 10, Line 11disorder, in a manner that is:

• Page 10, Line 12(A)  In accordance with the generally accepted standards

• Page 10, Line 13of behavioral, mental health, and substance use disorder care;

• Page 10, Line 14(B)  Clinically appropriate in terms of type, frequency,

• Page 10, Line 15extent, site, and duration; and

• Page 10, Line 16(C)  Not primarily for the economic benefit of the insurer

• Page 10, Line 17or purchaser or for the convenience of the covered person,

• Page 10, Line 18treating physician, or other health-care provider.

• Page 10, Line 19(V)  "Utilization review" means prospectively,

• Page 10, Line 20retrospectively, or concurrently reviewing and approving,

• Page 10, Line 21modifying, delaying, or denying requests by health-care

• Page 10, Line 22providers, covered persons, or their authorized representatives

• Page 10, Line 23for coverage, based in whole or in part on medical necessity, or

• Page 10, Line 24for out-of-network services required pursuant to subsection

• Page 10, Line 25(5.5)(a)(V)(D) of this section.

• Page 10, Line 26(VI)  "Utilization review criteria" means an evaluation of

• Page 10, Line 27the necessity, appropriateness, and efficiency of the use of

• Page 11, Line 1health-care services, procedures, and facilities, including

• Page 11, Line 2out-of-network services required pursuant to subsection

• Page 11, Line 3(5.5)(a)(V)(D) of this section. "Utilization review criteria" does

• Page 11, Line 4not include an independent medical examination provided for in

• Page 11, Line 5any policy.

• Page 11, Line 6(e) (I)  Subsection (5.5)(d) of this section does not expand

• Page 11, Line 7coverage requirements beyond the state essential health

• Page 11, Line 8benefits benchmark plan as required pursuant to 45 CFR 156.111.

• Page 11, Line 9(II)  If an exclusion for behavioral health, mental health,

• Page 11, Line 10or substance use disorder services is not permitted under the

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

• Page 11, Line 12requirements of subsection (5.5)(d) of this section.

• Page 11, Line 13SECTION 2.  Act subject to petition - effective date. This act

• Page 11, Line 14takes effect January 1, 2026; except that, if a referendum petition is filed

• Page 11, Line 15pursuant to section 1 (3) of article V of the state constitution against this

• Page 11, Line 16act or an item, section, or part of this act within the ninety-day period

• Page 11, Line 17after final adjournment of the general assembly, then the act, item,

• Page 11, Line 18section, or part will not take effect unless approved by the people at the

• Page 11, Line 19general election to be held in November 2026 and, in such case, will take

• Page 11, Line 20effect on the date of the official declaration of the vote thereon by the

• Page 11, Line 21governor.