C.R.S. Section 25.5-4-401
Providers

  • payments
  • rules

(1)

Intentionally left blank —Ed.

(a)

The state department shall establish rules for the payment of providers under this article and articles 5 and 6 of this title. Within the limits of available funds, such rules shall provide reasonable compensation to such providers, but no provider shall, by this section or any other provision of this article or article 5 or 6 of this title, be deemed to have any vested right to act as a provider under this article and articles 5 and 6 of this title or to receive any payment in addition to or different from that which is currently payable on behalf of a recipient at the time the medical benefits are provided by said provider.

(b)

Intentionally left blank —Ed.

(I)

On and after July 1, 1992, the state department rules established for the payment of providers under this article and articles 5 and 6 of this title shall provide that services that are compensable under both Title XIX and Title XVIII of the social security act shall be paid at either the rate established under Title XIX or the rate established under Title XVIII, whichever is lower.

(II)

If any provision of this paragraph (b) is found to be in conflict with any federal law or regulation, such conflicting portion of this paragraph (b) is declared to be inoperative to the extent of the conflict.

(c)

The state department shall exercise its overexpenditure authority under section 24-75-109, C.R.S., and shall not intentionally interrupt the normal provider payment schedule unless notified jointly by the director of the office of state planning and budgeting and the state controller that there is the possibility that adequate cash will not be available to make payments to providers and for other state expenses. If it is determined that adequate cash is not available and the state department does interrupt the normal payment cycle, the state department shall notify the joint budget committee of the general assembly and any affected providers in writing of its decision to interrupt the normal payment schedule. Nothing in this paragraph (c) shall be interpreted to establish a right for any provider to be paid during any specific billing cycle.

(d)

Repealed.

(2)

As to all payments made pursuant to this article and articles 5 and 6 of this title, the state department rules for the payment of providers may include provisions that encourage the highest quality of medical benefits and the provision thereof at the least expense possible.

(3)

Intentionally left blank —Ed.

(a)

As used in this subsection (3), “capitated” means a method of payment by which a provider directly delivers or arranges for delivery of medical care benefits for a term established by contract with the state department based on a fixed rate of reimbursement per recipient.

(b)

Intentionally left blank —Ed.

(I)

In order to provide medical benefits under this article and articles 5 and 6 of this title on a capitated basis and subject to the condition imposed in subparagraph (II) of this paragraph (b), the state department is authorized to solicit negotiated contracts with providers based upon the requirements of this subsection (3). The state department may contract with one or more providers concerning the same medical services in a single geographic area.

(II)

The state department may award a contract to one or more providers pursuant to subparagraph (I) of this paragraph (b) when the executive director determines that such contract will reduce the costs of providing medical benefits under this article and articles 5 and 6 of this title.

(III)

The state department may define groups of recipients by geographic area or other categories and may require that all members of the defined group obtain medical services through one or more provider contracts entered into pursuant to this subsection (3).

(4)

Intentionally left blank —Ed.

(a)

The general assembly hereby finds, determines, and declares that access to health-care services would be improved and costs of health care would be restrained if the recipients of the medicaid program would choose a primary care physician through a managed care provider. For purposes of this subsection (4), “managed care provider” means either a primary care physician program, a health maintenance organization, or a prepaid health plan.

(b)

Subject to the provisions of paragraph (c) of this subsection (4), the executive director of the state department has the authority to require a recipient of the medicaid program to select a managed care provider and to assign a recipient to a managed care provider if the recipient has failed to make a selection within a reasonable time. To the extent possible, this requirement shall be implemented on a statewide basis.

(c)

The state department shall ensure the following:

(I)

A managed care provider shall establish and implement consumer friendly procedures and instructions for disenrollment and shall have adequate staff to explain issues concerning service delivery and disenrollment procedures to recipients, including staff to address the communications needs and requirements of recipients with disabilities.

(II)

All recipients shall be adequately informed about service delivery options available to them consistent with the provisions of this subparagraph (II). If a recipient does not respond to a state department request for selection of a delivery option within forty-five calendar days, the state department shall send a second notification to the recipient. If the recipient does not respond within twenty days of the date of the second notification, the state department shall ensure that the recipient remains with the recipient’s primary care physician, regardless of whether said primary care physician is enrolled in a health maintenance organization.

(5)

The state board may promulgate rules to provide for the implementation and administration of subsections (3) and (4) of this section.

(6)

The state department shall make good faith efforts to obtain a waiver or waivers from any requirements of Title XIX of the social security act which would prohibit the implementation of subsections (3) and (4) of this section. Such waiver or waivers shall be obtained from the federal department of health and human services, or any successor agency. If such waivers are not granted, the state department shall not act to implement or administer subsections (3) and (4) of this section to the extent that Title XIX prohibits it.

Source: Section 25.5-4-401 — Providers - payments - rules, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­5.­pdf (accessed Oct. 20, 2023).

25.5‑4‑101
Short title
25.5‑4‑102
Legislative declaration
25.5‑4‑103
Definitions
25.5‑4‑104
Program of medical assistance - single state agency
25.5‑4‑105
Federal requirements under Title XIX
25.5‑4‑106
Cooperation with federal government - grants-in-aid - cooperation with the state department of human services in delivery of services
25.5‑4‑107
Retaliation definition
25.5‑4‑201
Cash system of accounting - financial administration of medical services premiums - medical programs administered by department of human services - federal contributions - rules
25.5‑4‑203
Advisory council established
25.5‑4‑204
Automated medical assistance administration
25.5‑4‑205
Application - verification of eligibility - demonstration project - rules - repeal
25.5‑4‑205.5
Confined persons - suspension of benefits
25.5‑4‑206
Reimbursement to counties - costs of administration
25.5‑4‑207
Appeals - rules - applicability
25.5‑4‑208
County duties - transitional medicaid
25.5‑4‑209
Payments by third parties - copayments by recipients - review - appeal - children’s waiting list reduction fund - rules - repeal
25.5‑4‑210
Purchase of health insurance for recipients
25.5‑4‑211
Medicaid management information system - appropriation in annual general appropriation act - expenditure in next fiscal year
25.5‑4‑212
Medicaid client correspondence improvement process - legislative declaration - definition
25.5‑4‑213
Audit of medicaid client correspondence - definition
25.5‑4‑215
Study - benefits for persons on work release - repeal
25.5‑4‑216
Report on impact of hospital facility fees in Colorado - definitions - steering committee - repeal
25.5‑4‑300.4
Last resort for payment - legislative intent
25.5‑4‑300.7
Prevention of coding errors - prepayment review of claims
25.5‑4‑300.9
Explanation of benefits - medicaid recipients - legislative declaration
25.5‑4‑301
Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - repeal
25.5‑4‑302
Recovery of assets
25.5‑4‑303
State income tax refund intercept - garnishment of earning - failure to provide medical support for child
25.5‑4‑303.3
Provider fraud - attorney general report
25.5‑4‑303.5
Short title
25.5‑4‑304
Definitions
25.5‑4‑305
False medicaid claims - liability for certain acts
25.5‑4‑306
Civil actions for false medicaid claims
25.5‑4‑307
False medicaid claims procedures - statute of limitations
25.5‑4‑308
False medicaid claims jurisdiction
25.5‑4‑309
False medicaid claims civil investigation demands
25.5‑4‑310
Medicaid false claims report
25.5‑4‑401
Providers - payments - rules
25.5‑4‑401.2
Performance-based payments - reporting - repeal
25.5‑4‑401.5
Review of provider rates - advisory committee - recommendations - repeal
25.5‑4‑402
Providers - hospital reimbursement - hospital review program - rules
25.5‑4‑402.4
Hospitals - healthcare affordability and sustainability fee - legislative declaration - Colorado healthcare affordability and sustainability enterprise - federal waiver - fund created - rules - reports - repeal
25.5‑4‑402.5
Providers - state university teaching hospitals
25.5‑4‑402.8
Hospital transparency report - definitions
25.5‑4‑403
Providers - behavioral health safety net providers - reimbursement
25.5‑4‑403.1
Providers - community mental health centers - cost reporting
25.5‑4‑404
Payments for clinic services - restrictions on use
25.5‑4‑405
Mental health managed care service providers - requirements
25.5‑4‑406
Rate setting - medicaid residential treatment service providers - monitoring and auditing - report
25.5‑4‑407
Services by licensed psychologists without a doctor’s referral
25.5‑4‑408
Services provided by licensed psychologists - cost containment program
25.5‑4‑409
Authorization of services - nurse anesthetists - advanced practice registered nurses
25.5‑4‑410
Services of audiologists and speech pathologists without supervision
25.5‑4‑411
Authorization of services provided by dental hygienists
25.5‑4‑412
Family planning services - family-planning-related services - rules - definitions
25.5‑4‑413
Certain providers to inform patients of rights concerning advance medical directives
25.5‑4‑414
Providers - physicians - prohibition of certain referrals - definitions
25.5‑4‑415
No public funds for abortion - exception - definitions - repeal
25.5‑4‑416
Providers - medical equipment and supplies - requirements
25.5‑4‑417
Provider fee - medicaid providers - state plan amendment - rules - definitions
25.5‑4‑420
Providers to obtain unique NPI - service site - provider type - definitions
25.5‑4‑422
Cost control - legislative intent - use of technology - stakeholder feedback - reporting - rules
25.5‑4‑423
Targets for investments in primary care
25.5‑4‑425
Providers - health-care services related to labor and delivery - reimbursement
25.5‑4‑427
Supplemental state payment to the Denver health and hospital authority - repeal
25.5‑4‑428
Prior authorization for a step-therapy exception - rules - definition
25.5‑4‑429
Hospital and provider billing requirements - description of service provided - rules
25.5‑4‑430
Increasing access to behavioral health care for children and youth - directed payment authority - fee schedule rates
25.5‑4‑503
Waiver applications - authorization
25.5‑4‑505
Federal authorization related to persons involved in the criminal justice system - assessment - report - repeal
25.5‑4‑506
Coverage for doula services - stakeholder process - federal authorization - scholarship program - training - report - definitions - repeal
Green check means up to date. Up to date

Current through Fall 2024

§ 25.5-4-401’s source at colorado​.gov