C.R.S. Section 25.5-6-202
Providers

  • nursing facility provider reimbursement
  • exemption
  • rules
  • repeal
(1)(a)(I) Subject to available appropriations, for the purpose of reimbursing a medicaid-certified class I nursing facility provider a per diem rate for the cost of direct and indirect health-care services and raw food, the state department shall establish an annually readjusted schedule to pay each nursing facility provider the actual amount of the costs. The payment shall not exceed one hundred twenty-five percent of the median cost of direct and indirect health-care services and raw food as determined by an array of all facility providers; except that, for state veteran nursing homes, the payment shall not exceed one hundred thirty percent of the median cost.

(II)

For the fiscal year commencing July 1, 2009, and for each fiscal year thereafter, any increase in the direct and indirect health-care services and raw food costs shall not exceed eight percent per year. The calculation of the eight percent per year limitation for rates effective on July 1, 2009, shall be based on the direct and indirect health-care services and raw food costs in the as-filed facility’s cost reports up to and including June 30, 2009. For the purposes of calculating the eight-percent limitation for rates effective after July 1, 2009, the limitation shall be determined and indexed from the direct and indirect health-care services and raw food costs as reported and audited for the rates effective July 1, 2009.

(b)

In computing per diem cost, each nursing facility provider shall annually submit cost reports, and actual days of care shall be counted, not occupancy-imputed days of care. In addition, in determining the median cost, the cost of direct health care shall be case-mix neutral. The cost reports used by the state department to establish the per diem cost shall be those filed with the state department during the period ending December 31 of the prior year following implementation of this subsection (1) and for each succeeding year. The state department shall redetermine the median per diem cost based upon the most recent cost reports filed during the period ending December 31 of the prior year.

(2)

The state department shall further adjust and, subject to available appropriations, pay the per diem rate to the nursing facility provider for the cost of direct health-care services based upon the acuity or case-mix of the nursing facility provider residents in order to provide for the resource utilization of its residents. The state department shall determine this adjustment in accordance with each resident’s status as identified and reported by the nursing facility provider on its federal medicare and medicaid minimum data set assessment. The state department shall establish a case-mix index for each nursing facility provider according to the case-mix group determined by the state department. The state department shall calculate nursing weights based upon standard nursing time studies and weighted by facility population distribution and Colorado-specific nursing salary ratios. The state department shall determine an average case-mix index for each nursing facility provider’s medicaid residents on a quarterly basis.

(3)

Intentionally left blank —Ed.

(a)

Subject to available appropriations, for the purpose of reimbursing a medicaid-certified class I nursing facility provider a per diem rate for the cost of its administrative and general services, the state department shall establish an annually readjusted schedule to pay each nursing facility provider a reasonable price for the costs, which reasonable price shall be a percentage of the median per diem cost of administrative and general services as determined by an array of all nursing facility providers. For facilities of sixty licensed beds or fewer, the reasonable price shall be one hundred ten percent of the median per diem cost for all class I facilities. For facilities of sixty-one licensed beds and more, the reasonable price shall be one hundred five percent of the median per diem cost for all class I facilities.

(b)

In computing per diem cost, each nursing facility provider shall annually submit cost reports to the state department, and actual days of care shall be counted, not occupancy-imputed days of care. The cost reports used to establish this median per diem cost shall be those filed during the period ending December 31 of the prior year following implementation of this subsection (3), and, for each succeeding fourth year, the state department shall redetermine the median per diem cost based upon the most recent cost reports filed during the period ending December 31 of the prior year.

(c)

Repealed.

(4)

In addition to the reimbursement components paid pursuant to subsections (1) to (3) of this section, a per diem rate constituting a fair rental allowance for capital-related assets shall be paid to each nursing facility provider as a rental rate based upon the nursing facility’s appraised value.

(5)

Subject to available appropriations and the priority of the uses of the provider fees as established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid pursuant to subsections (1) to (4) of this section, the state department shall make a supplemental medicaid payment based upon performance to those nursing facility providers that provide services that result in better care and higher quality of life for their residents. The state department shall determine the payment amount based upon performance measures established in rules adopted by the state board in the domains of quality of life, quality of care, and facility management. Beginning July 1, 2024, the payment must not be less than twelve percent of total provider fee payments and must be adjusted for fiscal years 2024-25 and 2025-26. No later than July 1, 2026, the payment must not be less than fifteen percent of total provider fee payments and must be annually adjusted thereafter. During each state fiscal year, the state department may discontinue the supplemental medicaid payment established pursuant to this subsection (5) to any nursing facility provider that fails to comply with the established performance measures during the state fiscal year, and the state department may initiate the supplemental medicaid payment established pursuant to this subsection (5) to any provider that comes into compliance with the established performance measures during the state fiscal year.

(6)

Subject to available appropriations and the priority of the uses of the provider fees as established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid pursuant to subsections (1) to (5) of this section, the state department shall make a supplemental medicaid payment to nursing facility providers that serve residents:

(a)

Who have severe mental health conditions that are classified at a level II by the medicaid program’s preadmission screening and resident review assessment tool. The state department shall compute this payment annually as of July 1, 2009, and each July 1 thereafter, and it must not be less than two percent of the statewide average per diem rate for the combined rate components determined pursuant to subsections (1) to (4) of this section. Beginning July 1, 2023, the state department shall annually adjust the rate to ensure access to care for residents who have severe mental health conditions.

(b)

With severe dementia diseases and related disabilities or acquired brain injury. The state department shall calculate the payment based upon the resident’s cognitive assessment established in rules adopted by the state board. The state department shall compute this payment annually as of July 1, 2009, and each July 1 thereafter, and it must not be less than one percent of the statewide average per diem rate for the combined rate components determined pursuant to subsections (1) to (4) of this section. Beginning July 1, 2023, the state department shall annually adjust the rate to ensure access to care for residents with severe dementia diseases and related disabilities or acquired brain injury.

(7)

Subject to available moneys and the priority of the uses of the provider fees as established in section 25.5-6-203 (2)(b), in addition to the reimbursement rate components paid pursuant to subsections (1) to (6) of this section, the state department shall pay a nursing facility provider a supplemental medicaid payment for care and services rendered to medicaid residents to offset payment of the provider fee assessed under the provisions of section 25.5-6-203. The state department shall compute this payment annually, as of July 1, 2009, and each July 1 thereafter.
(8)(Deleted by amendment, L. 2009, (SB 09-263), ch. 203, p. 912, § 2, effective May 1, 2009.)(9)(a) The per diem amount paid for direct and indirect health-care services and administrative and general services costs shall include an allowance for inflation in the costs for each category using a nationally recognized service that includes the federal government’s forecasts for the prospective medicare reimbursement rates recommended to the United States congress. Amounts contained in cost reports used to determine the per diem amount paid for each category shall be adjusted by the percentage change in this allowance measured from the midpoint of the reporting period of each cost report to the midpoint of the payment-setting period.

(b)

Intentionally left blank —Ed.

(I)

Except for changes in the number of patient days, the state department shall establish the general fund share of the aggregate statewide average of the per diem rate net of patient payment pursuant to subsections (1) to (4) of this section. The state’s share of the reimbursement rate components pursuant to subsections (1) to (4) of this section may be funded through the provider fee assessed pursuant to section 25.5-6-203 and any associated federal funds. Any provider fee used as the state’s share and all federal funds must be excluded from the calculation of the general fund share. For the fiscal year commencing July 1, 2009, and for each fiscal year thereafter, the state department shall calculate the general fund share of the aggregate statewide average per diem rate net of patient payment pursuant to subsections (1) to (4) of this section using the rates that were effective on July 1 of that fiscal year; except that:

(A)

For fiscal year 2023-24, the state department shall increase the aggregate statewide average of the per diem rate by at least ten percent;

(B)

For fiscal year 2024-25, the state department shall increase the aggregate statewide average of the per diem rate by at least three percent;

(C)

For fiscal year 2025-26, the state department shall increase the aggregate statewide average of the per diem rate by at least one and one-half percent; and

(D)

Beginning in fiscal year 2026-27, and for each fiscal year thereafter, the state department shall establish the aggregate statewide average of the per diem rate.

(I.5)

When increasing the aggregate statewide average of the per diem rate for fiscal years 2023 through 2027, the reimbursement rate for a class I nursing facility that operates efficiently and economically must be reasonable and adequate to meet the nursing home’s costs in order to provide care and services in conformity with applicable state and federal laws, regulations, and quality and safety standards, and must be based on the most recent audited and finalized cost and utilization data available.

(II)

If the aggregate statewide average per diem rate net of patient payment pursuant to subsections (1) to (4) of this section exceeds the general fund share, the amount of the average statewide per diem rate that exceeds the general fund share shall be paid as a supplemental medicaid payment using the provider fee established under section 25.5-6-203. Subject to the priority of the uses of the provider fee established under section 25.5-6-203 (2)(b), if the provider fee is insufficient to fully fund the supplemental medicaid payment, the supplemental medicaid payment shall be reduced to all providers proportionately.

(III)

to (V) Repealed.

(VI)

Notwithstanding any other provision of law, for the fiscal year commencing July 1, 2013, and each fiscal year thereafter, the general fund portion of the per diem rate pursuant to subsections (1) to (4) of this section shall be reduced by one and one-half percent. The state department may, but is not required to, increase the supplemental medicaid payment pursuant to subparagraph (II) of this paragraph (b) due to this reduction; except that the provider fee shall not exceed the amount specified in section 25.5-6-203 (1)(a)(II).

(VII)

Notwithstanding any other provision of law to the contrary, for the 2020-21 and 2021-22 fiscal years, the general fund portion of the per diem rate pursuant to subsections (1) to (4) of this section is limited to an annual increase of two percent.

(b.3)

Intentionally left blank —Ed.

(I)

For the fiscal year commencing July 1, 2009, and for each fiscal year thereafter, if the provider fee established under section 25.5-6-203 is insufficient to fully fund the supplemental medicaid payments established under subsections (5) to (7) of this section, subject to the priority of the uses of the provider fee established pursuant to section 25.5-6-203 (2)(b), the state department may suspend or reduce the supplemental medicaid payment subject to the uses of the provider fee established under section 25.5-6-203.

(II)

If it is determined by the state department that the case-mix reimbursement includes a factor for nursing facility providers that serve residents with severe dementia diseases and related disabilities or acquired brain injury, the state department may eliminate the supplemental medicaid payment to those providers that serve residents with severe dementia diseases and related disabilities or acquired brain injury.

(b.5)

Notwithstanding any other provision of law or any federal law that temporarily increases the federal matching participation rate for any fiscal year, payments to nursing facility providers from the general fund share of the aggregate statewide average of the per diem rate shall be calculated based on a fifty-percent federal match.

(b.7)

Repealed.

(c)

Intentionally left blank —Ed.

(I)

The general assembly finds that the historical growth in nursing facility provider rates has significantly exceeded the rate of inflation. These increases have been caused in part by the inclusion of medicare costs in medicaid cost reports. The state of Colorado has an interest in limiting these exceptional increases in medicaid nursing facility provider rates by removing medicare costs from the medicaid nursing facility provider rates and by imposing a ceiling on the medicare part A ancillary costs that are included in calculating medicaid nursing facility rates. No later than July 1, 2023, the state department shall initiate a process to remove medicare costs from the provider rate setting by July 1, 2026. The state board shall promulgate rules establishing the specific methodology used for removing medicare costs.

(II)

Repealed.

(III)

The specific methodology for calculating the limitations and cost-reporting requirements described in this paragraph (c) shall be established by rules promulgated by the state board.

(d)

The reimbursement rate components pursuant to subsections (5) to (7) of this section shall be funded entirely through the provider fee assessed pursuant to the provisions of section 25.5-6-203 and any associated federal funds. No general fund moneys shall be used to pay for the reimbursement rate components established pursuant to subsections (5) to (7) of this section.

(10)

The state board shall promulgate rules pursuant to the “State Administrative Procedure Act”, article 4 of title 24, C.R.S.,to implement this section, including establishing uniform accounting, reporting, and payment procedures consistent with this section, to determine a nursing facility provider’s costs and payments to the provider.
(11)(Deleted by amendment, L. 2009, (SB 09-263), ch. 203, p. 912, § 2, effective May 1, 2009.)(12) The state department may exempt facilities with five or fewer medicaid beds from the methodology described in this section and instead require the facilities to be reimbursed at the statewide average rate.

(13)

Intentionally left blank —Ed.

(a)

As a condition of receiving medicaid funds, the state department may require a nursing facility to submit any documentation necessary to ensure the state’s interest in transparency, stability, and sound fiscal stewardship, including, but not limited to:

(I)

Annual audited financial statements, prepared by an independent accountant, for a facility, management company, and any related party conducting business with a medicaid-certified nursing facility, including audited and consolidated financial statements for any parent company that accepts, or whose subsidiaries accept, medicaid payments from the state of Colorado;

(II)

Details on transactions between related parties or entities that have common ownership; and

(III)

Ownership interest in real estate, management companies, facility operators, and all related parties.

(b)

The state department shall determine the format for the documentation provided by each nursing facility.

(c)

The state board shall establish by rule any penalties for noncompliance with the financial reporting required pursuant to this subsection (13).

(d)

The costs associated with the financial reporting required pursuant to this subsection (13), including any audit costs incurred by a nursing facility, are an allowable expense on the medicaid cost report and must be incorporated as a component of the overall reimbursement methodology.

(14)

The general assembly finds that the inflexible nature of statutorily fixed reimbursement rates is not in the best interest of the state of Colorado. Therefore, the state department shall develop and implement a transition plan to regulate nursing facility reimbursement aimed at improving the health and safety of residents, promoting innovation and improved infection control efforts, improving access to care, and promoting innovation in Colorado nursing facilities. As part of this process, the state department shall:

(a)

No later than July 1, 2026, define “nursing home reimbursement” through rules promulgated by the state board and provide payments to nursing facilities consistent with the promulgated rules;

(b)

Engage with stakeholders regularly to seek input on any proposed methodology changes and ensure the methodology is reasonable and adequate to meet the costs of an efficiently and economically operated nursing facility that provides care and services in conformity with applicable state and federal laws, regulations, and quality and safety standards based on the most recent audit and finalized cost and utilization data available; and

(c)

From November 1, 2023, to November 1, 2026, submit an annual report to the joint budget committee of the general assembly regarding the implementation progress described in this subsection (14), including, at a minimum:

(I)

Records of stakeholder engagement;

(II)

Conclusions drawn from financial oversight activities;

(III)

Issues regarding payment equity and access to care coordination; and

(IV)

Expected budgetary impacts of any methodology change.

(15)

Intentionally left blank —Ed.

(a)

Each nursing facility that receives medicaid funds shall develop and submit a plan to the state department that meets state department standards and demonstrates how the nursing facility will:

(I)

Improve the health and safety of the nursing facility’s residents, including infection control and staffing;

(II)

Increase access to care;

(III)

Improve financial sustainability, including opportunities for diversification of business lines and stabilization of revenue streams; and

(IV)

Promote innovation to meet the emerging needs of individuals with disabilities and aging and older adults.

(b)

The state board shall promulgate rules implementing this subsection (15).

(16)

Subsections (1) to (9) of this section and this subsection (16) are repealed, effective July 1, 2026.

Source: Section 25.5-6-202 — Providers - nursing facility provider reimbursement - exemption - rules - repeal, https://leg.­colorado.­gov/sites/default/files/images/olls/crs2023-title-25.­5.­pdf (accessed Oct. 20, 2023).

25.5‑6‑101
Spousal protection - protection of income and resources for community spouse - definitions - amounts retained - responsibility of state department - right to appeal 25.5‑6‑102
Court-approved trusts - transfer of property for persons seeking medical assistance for nursing home care - undue hardship - legislative declaration 25.5‑6‑103
Court-approved trusts - transfer of property for persons seeking medical assistance - rule-making authority for trusts created on or after July 1, 1994 - undue hardship 25.5‑6‑104
Long-term care placements - comprehensive and uniform client assessment instrument - report - legislative declaration - definitions - repeal 25.5‑6‑105
Legislative declaration relating to implementation of single entry point system - repeal 25.5‑6‑106
Single entry point system - authorization - phases for implementation - services provided - repeal 25.5‑6‑107
Financing of single entry point system - repeal 25.5‑6‑108.5
Community long-term care studies - authority to implement - alternative care facility report 25.5‑6‑110
Private-public partnership education and information program concerning long-term care insurance authorized 25.5‑6‑113
Health home - integrated services - legislative declaration - contracting - definitions 25.5‑6‑115
Notification of federal immigration consequences 25.5‑6‑116
Community placement transformation - creation - report - repeal 25.5‑6‑201
Special definitions relating to nursing facility reimbursement 25.5‑6‑202
Providers - nursing facility provider reimbursement - exemption - rules - repeal 25.5‑6‑203
Nursing facilities - provider fees - federal waiver - fund created - rules - repeal 25.5‑6‑204
Providers - reimbursement - intermediate care facility for individuals with intellectual disabilities - reimbursement - maximum allowable 25.5‑6‑205
Collection of penalties assessed against nursing facilities - creation of cash fund 25.5‑6‑206
Personal needs benefits - amount - patient personal needs trust fund required - funeral and final disposition expenses - penalty for illegal retention and use 25.5‑6‑208
Nursing facility provider reimbursement - rules - definition - repeal 25.5‑6‑209
Establishment of nursing facility provider demonstration of need - criteria - rules 25.5‑6‑210
Additional supplemental payments - nursing facilities - funding methodology - reporting requirement - rules - repeal 25.5‑6‑301
Short title 25.5‑6‑302
Legislative declaration 25.5‑6‑303
Definitions - repeal 25.5‑6‑304
Administration 25.5‑6‑305
Provision of services for elderly and blind individuals and individuals with disabilities 25.5‑6‑306
Eligible groups 25.5‑6‑307
Services for the elderly, blind, and disabled 25.5‑6‑308
Cost of services 25.5‑6‑309
Special provisions - post-eligibility treatment of income 25.5‑6‑310
Special provisions - personal care services provided by a family - repeal 25.5‑6‑311
Duties of state department 25.5‑6‑312
Gifts - grants 25.5‑6‑313
Rules - federal authorization 25.5‑6‑314
Training for staff providing direct-care services to clients with dementia - rules - definitions 25.5‑6‑401
Short title 25.5‑6‑402
Legislative declaration - Prader-Willi syndrome 25.5‑6‑403
Definitions 25.5‑6‑404
Duties of the department of health care policy and financing and the department of human services 25.5‑6‑405
Relationship to other programs 25.5‑6‑406
Appropriations - reimbursement for services - direct support professionals - legislative declaration - definitions - repeal 25.5‑6‑407
Gifts - grants 25.5‑6‑408
Eligibility - fees 25.5‑6‑409
Services for persons with intellectual and developmental disabilities 25.5‑6‑409.3
Consolidated waiver - intellectual and developmental disabilities - conflict-free case management - legislative declaration - repeal 25.5‑6‑409.5
Transition plan for youth with intellectual and developmental disabilities to adult services - legislative declaration - report - rules - cash fund 25.5‑6‑410
Qualification for federal funding 25.5‑6‑411
Personal needs trust fund required 25.5‑6‑413
Elimination of subminimum wage - transition plan for individuals with disabilities - waiver - legislative declaration - definition 25.5‑6‑601
Short title 25.5‑6‑602
Legislative declaration - no entitlement created 25.5‑6‑603
Definitions 25.5‑6‑604
Cost of services 25.5‑6‑605
Relationship to single entry point for long-term care - repeal 25.5‑6‑606
Implementation of program for persons with mental health disorders authorized - federal waiver - duties of the department of health care policy and financing and the department of human services - rules 25.5‑6‑607
Implementation of part contingent upon receipt of federal waiver - repeal of part 25.5‑6‑701
Short title 25.5‑6‑702
Legislative declaration - no entitlement created 25.5‑6‑703
Definitions - repeal 25.5‑6‑704
Implementation of home- and community-based services program for persons with brain injury authorized - federal waiver - duties of the department - rules - repeal 25.5‑6‑705
Implementation of part contingent upon receipt of federal waiver - repeal of part 25.5‑6‑706
Rate structure - rules - quality assurance 25.5‑6‑901
Disabled children care program - eligibility criteria - documentation requirements - report to the general assembly 25.5‑6‑902
Children’s personal assistance services and family support program - repeal 25.5‑6‑903
Residential child health-care program - waiver - home- and community-based services - rules 25.5‑6‑1101
Definitions 25.5‑6‑1102
Service model - consumer-directed care - repeal 25.5‑6‑1103
Reporting 25.5‑6‑1201
Legislative declaration - repeal 25.5‑6‑1202
Definitions 25.5‑6‑1203
In-home support services - eligibility - licensure exclusion - in-home support service agency responsibilities - rules - repeal 25.5‑6‑1204
Provision of services - duties of state department - gifts - grants 25.5‑6‑1205
Accountability - rate structure - rules 25.5‑6‑1206
Report - repeal 25.5‑6‑1207
Repeal of part 25.5‑6‑1301
Legislative declaration 25.5‑6‑1302
Definitions 25.5‑6‑1303
Pilot program - complementary or alternative medicine - rules 25.5‑6‑1304
Repeal of part 25.5‑6‑1401
Legislative declaration 25.5‑6‑1402
Definitions 25.5‑6‑1403
Waivers and amendments 25.5‑6‑1404
Medicaid buy-in program - eligibility - premiums - medicaid buy-in fund - report - rules - repeal 25.5‑6‑1405
Rule-making authority 25.5‑6‑1406
Availability of federal financial assistance under medical assistance 25.5‑6‑1501
Community transition services and supports - legislative declaration - rules 25.5‑6‑1601
Definitions 25.5‑6‑1602
State department to request increase in reimbursement rate for certain services 25.5‑6‑1603
Minimum wage - wage pass-through requirement for certain home care agencies - applicability - reports - recovery 25.5‑6‑1604
Training for home care agency employees - process for reviewing and enforcing training requirements 25.5‑6‑1605
Exemptions 25.5‑6‑1701
Legislative declaration 25.5‑6‑1702
Definitions 25.5‑6‑1703
Case management system - defined service areas - case management services - only willing and qualified provider exemption - rules 25.5‑6‑1704
Intellectual and developmental disability determination - functional eligibility determination - rules 25.5‑6‑1705
Person-centered support plan 25.5‑6‑1706
Termination of long-term services and supports for member receiving services 25.5‑6‑1707
Records and confidentiality of information 25.5‑6‑1708
Performance audits - Colorado local government audit law - public disclosure of board administration and operations 25.5‑6‑1709
Community-centered board designation - rules 25.5‑6‑1801
Legislative declaration 25.5‑6‑1802
Definitions 25.5‑6‑1803
Development of spending plan 25.5‑6‑1804
Spending plan - approval by joint budget committee - reporting 25.5‑6‑1805
Home- and community-based services improvement fund - creation - transfer - expenditures 25.5‑6‑1806
Repeal of part 25.5‑6‑1901
Definitions 25.5‑6‑1902
Community first choice option - covered services - state plan amendment 25.5‑6‑1903
Permissible services and supports 25.5‑6‑1904
Maintenance of effort 25.5‑6‑1905
Eligibility
Green check means up to date. Up to date

Current through Fall 2024

§ 25.5-6-202’s source at colorado​.gov