Colo. Rev. Stat. § 25.5-5-402

Current through 11/5/2024 election

Section 25.5-5-402 - Statewide managed care system - rules - definitions

(1) The state board shall adopt rules to implement a statewide managed care system for Colorado medical assistance members pursuant to the provisions of this article 5 and articles 4 and 6 of this title 25.5. The statewide managed care system shall be implemented to the extent possible.

(2) The statewide managed care system implemented pursuant to this article 5 does not include:

(a) The services delivered under the residential child health-care program described in section 25.5-6-903, except in those counties in which there is a written agreement between the county department of human or social services, the designated and contracted MCE responsible for community behavioral health care, and the state department;

(b) Long-term care services and the program of all-inclusive care for the elderly, as described in section 25.5-5-412. For purposes of this subsection (2), "long-term care services" means nursing facilities and home- and community-based services provided to eligible members who have been determined to be in need of such services pursuant to the "Colorado Medical Assistance Act" and the state board's rules.

(3) The statewide managed care system must include a statewide system of community behavioral health care that must:

(a) Address the economic, social, and personal costs to the state of Colorado and its citizens of untreated behavioral health disorders, including mental health and substance use disorders;

(b) Approach behavioral health disorders as treatable conditions not unlike other chronic health issues that require a combination of behavioral change and medication or other treatment;

(c) Offer timely access through multiple points of entry to a full continuum of culturally responsive behavioral health services, including prevention, early intervention, crisis response, treatment, and recovery services, that support individuals living full, productive lives;

(c.5) Provide coordination of care for the full continuum of substance use disorder and mental health treatment and recovery, including support for individuals transitioning between levels of care;

(d) Feature a comprehensive and integrated system of quality behavioral health care that is individualized and coordinated to meet individuals' changing needs;

(e) Be paid for by the state department establishing capitated rates specifically for behavioral health services that account for a comprehensive continuum of needed services such as those provided by licensed behavioral health providers, including essential and comprehensive community behavioral health providers, as defined in section 27-50-101;

(f) Make the behavioral health system's administrative processes, service delivery, and funding more effective and efficient to improve outcomes for Colorado citizens;

(g) In addition to network adequacy requirements determined by the state department, require each MCE to offer an enrollee an initial or subsequent nonurgent care visit within a reasonable period where medically necessary and at appropriate therapeutic intervals, as determined by state board rule;

(h) Specify that the diagnosis of an intellectual or developmental disability, a neurological or neurocognitive disorder, or a traumatic brain injury does not preclude an individual from receiving a covered behavioral health service; and

(i) Require an MCE to cover all medically necessary covered treatments for covered behavioral health diagnoses, regardless of any co-occurring conditions.

(3.5)

(a) No later than July 1, 2023, the state department, in collaboration with the behavioral health administration in the department of human services and other state agencies, shall develop the universal contract as described in section 27-50-203.

(b) Repealed.

(4) The statewide managed care system must promote the utilization of the medical home model of care for all enrolled members. The medical home model of care establishes a focal point of care for comprehensive primary care and efficient coordination with specialty care providers and other health-care systems. The medical home model has proven effective in promoting early intervention and prevention, improving individuals' health, and reducing health-care costs.

(5) The statewide managed care system builds upon the lessons learned from previous managed care and community behavioral health-care programs in the state in order to reduce barriers that may negatively impact medicaid member experience, medicaid member health, and efficient use of state resources. The statewide managed care system is authorized to provide services under a single MCE type or a combination of MCE types.

(6)

(a) The state department is authorized to assign a medicaid member to a particular MCE, consistent with federal requirements and rules promulgated by the state board.

(b) For a child or youth who obtains eligibility for services under the state's medicaid program through a dependency and neglect action resulting in out-of-home placement pursuant to article 3 of title 19 or a juvenile delinquency action resulting in out-of-home placement pursuant to article 2.5 of title 19, the state department shall assign the child or youth to the MCE covering the county with jurisdiction over the action. The state department shall only change the assignment if the change is requested by the county with jurisdiction over the action or by the child's or youth's legal guardian.

(7) The state department is authorized to enter into a contract with MCOs, PCCM Entities, prepaid ambulatory health plans, and prepaid inpatient health plans, subject to the receipt of any required federal authorizations and pursuant to the requirements of this section.

(7.5)

(a) The state department shall offer to enter into a direct contract for physical health-care services with the MCO operated by or under the control of Denver health and hospital authority, created pursuant to article 29 of title 25, from July 1, 2025, until June 30, 2032, as long as the MCO meets all MCO criteria required by the state department. If the state department designates an MCE other than the MCO operated by or under the control of Denver health and hospital authority to manage behavioral health-care services pursuant to this article 5, Denver health and hospital authority, or any subsidiary, shall collaborate with the MCE during the term of contract.

(b) The MCO operated by or under the control of Denver health and hospital authority shall:

(I) Maintain adequate financials to ensure proper solvency as a risk manager;

(II) Accept rates determined by the state department, through standard methodologies, to cover the population it is serving. Rates paid by the MCO to contracted providers must not be higher than the state department's medicaid fee-for-service rates unless the provider enters into a quality incentive agreement with the MCO.

(III) Maintain service and quality metrics, as determined by the state department; and

(IV) Meet statewide managed care system standards and operate as part of the overall managed care system.

(8)Waivers. The implementation of this part 4 is conditioned, to the extent applicable, on the issuance of necessary waivers by the federal government. The provisions of this part 4 must be implemented to the extent authorized by federal waiver, if so required by federal law.

(9)Bidding.

(a) The state department is authorized to institute a program for competitive bidding pursuant to section 24-103-202 or 24-103-203 for MCEs seeking to provide, arrange for, or otherwise be responsible for the provision of services to its members. The state department is authorized to award contracts to more than one offeror. The state department shall use competitive bidding procedures to encourage competition and improve the quality of care available to medicaid members over the long term that meets the requirements of this section and section 25.5-5-406.1.

(b)

(I) On or before January 1, 2023, in order to promote transparency and accountability, the state department shall require each MCE that has twenty-five percent or more ownership by providers of behavioral health services to comply with the following conflict of interest policies:

(A) Providers who have ownership or board membership in an MCE shall not have control, influence, or decision-making authority in the establishment of provider networks.

(B) Each MCE shall report quarterly the number of providers who applied to join the network and were denied and a comparison of rate ranges for providers who have ownership or board membership versus providers who do not.

(C) An employee of a contracted provider of an MCE shall not also be an employee of the MCE unless the employee is a clinical officer or utilization management director of the MCE. If the individual is also an employee of a provider that has board membership or ownership in the MCE, the MCE shall develop policies, approved by the executive director of the state department, to mitigate any conflict of interest the employee may have.

(D) An MCE's board shall not have more than fifty percent of contracted providers as board members, and the MCE is encouraged to have a community member on the MCE's board.

(II) No later than July 1, 2025, the state department shall appropriately address perceived or actual provider ownership and control of MCEs participating in the statewide managed care system in the interest of transparency and accountability. In designing a competitive bidding process, the state department shall incorporate community feedback and have a public process related to governing requirements, including how to address conflicts of interest.

(III) As used in this subsection (9)(b):

(A) "Clinical officer" means a physician who provides the clinical vision for the MCE or provides clinical direction to network management, quality improvement, utilization management, or credentialing divisions.

(B) "MCE" means a managed care entity responsible for the statewide system of community behavioral health care, as described in section 25.5-5-402 (3), and is not owned, operated by, or affiliated with an instrumentality, municipality, or political subdivision of the state.

(C) "Ownership" means an individual who is a legal proprietor of an organization, including a provider or individual who owns assets of an organization, or has a financial stake, interest, or governance role in the MCE.

(D) "Utilization management director" means a licensed health-care professional with behavioral health clinical experience who leads and develops the utilization management program or manages the medical review and authorization process.

(10) An MCE that is contracting for a defined scope of services under a risk contract shall certify the financial stability of the MCE pursuant to criteria established by the division of insurance.

(11) The state department shall conduct a review of each MCE, in accordance with federal requirements, prior to the implementation of a contract to assess the ability and capacity of the MCE to satisfactorily perform the operational requirements of the contract.

(12)Graduate medical education. The state department shall continue the graduate medical education, referred to in this subsection (12) as "GME", funding to teaching hospitals that have graduate medical education expenses in their medicare cost report and are participating as providers under one or more MCEs with a contract with the state department under this part 4. GME funding for members enrolled in an MCE is excluded from the premiums paid to the MCE and must be paid directly to the teaching hospital. The state board shall adopt rules to implement this subsection (12) and establish the rate and method of reimbursement.

(13) Nothing in this part 4 creates an exemption from the applicable provisions of title 10.

(14) Nothing in this part 4 creates an entitlement to an MCE to contract with the state department.

(15) On or before July 1, 2020, the state department shall include utilization management guidelines for the MCEs in the state board's managed care rules.

(16) The state department shall provide information on its website specifying how the public may request the network adequacy plan and quarterly network reports for an MCE. The plan must include actions taken by the MCE to ensure that all necessary and covered primary care, care coordination, and behavioral health services are provided to enrollees with reasonable promptness. Such actions include, without limitation:

(a) Utilizing single case agreements with out-of-network providers when necessary; and

(b) Using financial incentives to increase network participation.

(17) If the state department receives a complaint from the office of the ombudsman for behavioral health access to care established pursuant to part 3 of article 80 of title 27 that relates to possible violations of subsection (3) of this section or the MHPAEA, the state department shall examine the complaint, as requested by the office, and shall report to the office in a timely manner any actions taken related to the complaint.

C.R.S. § 25.5-5-402

Amended by 2024 Ch. 152,§ 56, eff. 8/7/2024.

Amended by 2024 Ch. 46,§ 2, eff. 4/4/2024.

Amended by 2022 Ch. 222, § 234, eff. 7/1/2024.

Amended by 2022 Ch. 180, § 3, eff. 5/25/2022.

Amended by 2022 Ch. 196, § 1, eff. 5/20/2022.

Amended by 2021 Ch. 136, § 123, eff. 10/1/2021.

Amended by 2020 Ch. 286, § 7, eff. 7/13/2020.

Amended by 2020 Ch. 271, § 1, eff. 7/11/2020.

Amended by 2019 Ch. 392, § 1, eff. 8/2/2019.

Amended by 2019 Ch. 195, § 12, eff. 5/16/2019.

Amended by 2018 Ch. 184, § 6, eff. 6/6/2019.

Amended by 2018 Ch. 313, § 1, eff. 8/8/2018.

L. 2006: Entire article added with relocations, p. 1883, § 7, effective July 1. L. 2008: (3) and (5) amended, p. 390, § 1, effective August 5. L. 2012: (6) added, (HB 12-1281), ch. 1187, p. 1187, § 3, effective June 4. L. 2018: Entire section amended with relocations, (HB 18-1431), ch. 1877, p. 1877, § 1, effective August 8; IP(2) and (2)(a) amended, (HB 18-1328), ch. 1244, p. 1244, § 6, effective 6/7/2019. L. 2019: (3)(e) amended and (3)(g), (3)(h), (3)(i), (15), (16), and (17) added, (HB 19-1269), ch. 2133, p. 2133, § 12, effective May 16; (7.5) added, (HB 19-1285), ch. 3501, p. 3501, § 1, effective August 2. L. 2020: (6) amended, (HB 20-1237), ch. 1319, p. 1319, § 1, effective July 11; (3)(c.5) added, (SB 20-007), ch. 1391, p. 1391, § 7, effective July 13. L. 2021: (6)(b) amended, (SB 21-059), ch. 747, p. 747, § 123, effective October 1.

(1) This section is similar to former § 26-4-113 as it existed prior to 2006.

(2) Section 10 of chapter 184 (HB 18-1328), Session Laws of Colorado 2018, provides that section 6 of the act changing this section takes effect upon notice to the revisor of statutes pursuant to § 25.5-5-306 (6) as enacted in section 2 of the act. For more information, see HB 18-1328. (L. 2018, p. 1247.) On August 14, 2019, the revisor of statutes received the notice referred to in § 25.5-5-306 (6) that the federal department of health and human services approved the waiver on June 7, 2019.

(3) Amendments to subsections IP(2) and (2)(a) by HB 18-1328 and HB 18-1431 were harmonized, effective June 7, 2019.

(4) Provisions of this section are similar to provisions of former §§ 25.5-5-402, 25.5-5-404, 25.5-5-406, and 25.5-5-411, as they existed prior to 2018.

(5) Subsection (3.5)(b)(II) provided for the repeal of subsection (3.5)(b), effective July 1, 2024. (See L. 2022, p. 1200.)

2024 Ch. 152, was passed without a safety clause. See Colo. Const. art. V, § 1(3).

(1) For the legislative declaration in HB 18-1328, see section 1 of chapter 184, Session Laws of Colorado 2018. For the legislative declaration in HB 22-1302, see section 1 of chapter 180, Session Laws of Colorado 2022. For the legislative declaration in HB 24-1086, see section 1 of chapter 46, Session Laws of Colorado 2024. (2) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.