House Bill 25-1002 Introduced

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), 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 case management services to a covered person to assist

• Page 6, Line 5the person in finding an appropriate nonparticipating provider,

• Page 6, Line 6if a covered 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 administered in compliance with federal law;

• Page 7, Line 22and

• Page 7, Line 23(II)  Shall adopt rules to establish reasonable time periods for visits

• Page 7, Line 24with a provider for treatment of a behavioral, mental health, or substance

• Page 7, Line 25use disorder after an initial visit with a provider; and

• Page 7, Line 26(III)  May adopt rules as necessary to specify data testing

• Page 7, Line 27requirements to determine plan design and in-operation parity

• Page 8, Line 1compliance for nonquantitative treatment limitations,

• Page 8, Line 2including prior authorization, concurrent review, retrospective

• Page 8, Line 3review, credentialing standards, and reimbursement rates.

• Page 8, Line 4(c.3)  This subsection (5.5) applies to any individual, entity,

• Page 8, Line 5or contracting provider that performs utilization review

• Page 8, Line 6functions on behalf of a health benefit plan.

• Page 8, Line 7(c.5)  A carrier offering a health benefit plan shall not

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

• Page 8, Line 9agreement, in writing or in operation, that undermine, alter, or

• Page 8, Line 10conflict with the requirements of this subsection (5.5).

• Page 8, Line 11(d)  As used in this subsection (5.5):

• Page 8, Line 12(I)  "Appropriate nonparticipating provider" means a

• Page 8, Line 13provider who is accessible and has the training and experience

• Page 8, Line 14necessary to provide age-appropriate, medically necessary

• Page 8, Line 15treatment of a behavioral, mental health, or substance use

• Page 8, Line 16disorder.

• Page 8, Line 17(II)  "Behavioral, mental health, and substance use disorder":

• Page 8, Line 18(I)  (A)  Means a condition or disorder, regardless of etiology, that

• Page 8, Line 19may be the result of a combination of genetic and environmental factors

• Page 8, Line 20and that falls under any of the diagnostic categories listed in the mental

• Page 8, Line 21disorders section of the most recent version of

• Page 8, Line 22(A)   the "International Statistical Classification of Diseases and

• Page 8, Line 23Related Health Problems",

• Page 8, Line 24(B)   the "Diagnostic and Statistical Manual of Mental Disorders",

• Page 8, Line 25or

• Page 8, Line 26(C)   the "Diagnostic Classification of Mental Health and

• Page 8, Line 27Developmental Disorders of Infancy and Early Childhood"; and

• Page 9, Line 1(II)  (B)  Includes autism spectrum disorders, as defined in

• Page 9, Line 2subsection (1.4)(a)(III) of this section.

• Page 9, Line 3(III)  "Generally accepted standards of behavioral,

• Page 9, Line 4mental health, and substance use disorder care" means

• Page 9, Line 5standards of care and clinical practice that are generally

• Page 9, Line 6recognized by health-care providers practicing in relevant

• Page 9, Line 7clinical specialties such as psychiatry, psychology, clinical

• Page 9, Line 8sociology, addiction medicine and counseling, and behavioral

• Page 9, Line 9health treatment. Valid, evidence-based sources reflecting

• Page 9, Line 10generally accepted standards of behavioral, mental health,

• Page 9, Line 11and substance use disorder care include peer-reviewed scientific

• Page 9, Line 12studies and medical literature; clinical practice guidelines and

• Page 9, Line 13recommendations of nonprofit health-care provider

• Page 9, Line 14professional associations, specialty societies, and federal

• Page 9, Line 15government agencies; and drug labeling approved by the FDA.

• Page 9, Line 16(IV)  "Medically necessary treatment" means a service or

• Page 9, Line 17product addressing the specific needs of a patient for the

• Page 9, Line 18purpose of screening, preventing, diagnosing, managing, or

• Page 9, Line 19treating a behavioral, mental health, or substance use disorder

• Page 9, Line 20or its symptoms, including minimizing the progression of the

• Page 9, Line 21disorder, in a manner that is:

• Page 9, Line 22(A)  In accordance with the generally accepted standards

• Page 9, Line 23of behavioral, mental health, and substance use disorder care;

• Page 9, Line 24(B)  Clinically appropriate in terms of type, frequency,

• Page 9, Line 25extent, site, and duration; and

• Page 9, Line 26(C)  Not primarily for the economic benefit of the insurer

• Page 9, Line 27or purchaser or for the convenience of the covered person,

• Page 10, Line 1treating physician, or other health-care provider.

• Page 10, Line 2(V)  "Utilization review" means prospectively,

• Page 10, Line 3retrospectively, or concurrently reviewing and approving,

• Page 10, Line 4modifying, delaying, or denying requests by health-care

• Page 10, Line 5providers, covered persons, or their authorized representatives

• Page 10, Line 6for coverage, based in whole or in part on medical necessity, or

• Page 10, Line 7for out-of-network services required pursuant to subsection

• Page 10, Line 8(5.5)(a)(V)(D) of this section.

• Page 10, Line 9(VI)  "Utilization review criteria" means any criteria,

• Page 10, Line 10standards, protocols, or guidelines used by a health benefit

• Page 10, Line 11plan to conduct utilization review.

• Page 10, Line 12SECTION 2.  Act subject to petition - effective date. This act

• Page 10, Line 13takes effect at 12:01 a.m. on the day following the expiration of the

• Page 10, Line 14ninety-day period after final adjournment of the general assembly; except

• Page 10, Line 15that, if a referendum petition is filed pursuant to section 1 (3) of article V

• Page 10, Line 16of the state constitution against this act or an item, section, or part of this

• Page 10, Line 17act within such period, then the act, item, section, or part will not take

• Page 10, Line 18effect unless approved by the people at the general election to be held in

• Page 10, Line 19November 2026 and, in such case, will take effect on the date of the

• Page 10, Line 20official declaration of the vote thereon by the governor.