The act requires the department of health care policy and financing, in coordination with the department of human services and the department of early childhood (state departments), to contract with a single county department of human or social services to administer a centralized member integrity service to conduct fraud investigations concerning eligibility for medicaid, the children's basic health plan, the supplemental nutrition assistance program, the Colorado child care assistance program, temporary assistance for needy families, and adult financial programs (public assistance programs), and benefit overpayments. The act creates the centralized member integrity service cash fund consisting of money recouped from member fraud investigations. The centralized member integrity service must be operational and utilized on July 1, 2027. On or before February 1, 2027, the act requires the state departments to establish aligned requirements for county departments of human or social services (county departments) to comply with through a performance-based contract established between the state departments and each county department. Prior to February 1, 2027, the state departments shall draft templates of the performance-based contract with the county departments for review and comment. On or before July 1, 2027, the state departments shall enter into a performance-based contract with each county department. The performance-based contract must establish requirements for the state departments and county departments to comply with in administering public assistance programs and establish corrective action protocols that are consistently utilized by the state departments. On or before September 1, 2026, the act requires the state departments to work together, and in consultation with the county departments, to establish a continuous quality improvement process to review data reported to the state departments by the county departments. The state departments must annually submit a report to the joint budget committee that includes an update on the continuous quality improvement process and data on the impact of the continuous quality improvement process. Beginning January 2027, and monthly thereafter, the state departments must establish a single, shared online dashboard used to publish county-level and statewide performance data for the public assistance programs on a monthly basis. This data must be published on each of the state department's website's in a publicly accessible format. Beginning July 1, 2028, the state departments must oversee a streamlined public benefits delivery model that consists of up to 12 cohorts of counties in the state that will coordinate public assistance program eligibility and distribute case processing work. The state departments shall enter into performance-based contracts with each cohort for administering a new public benefits delivery model to ensure public assistance programs are administered consistently and uniformly across the state. On or before July 1, 2026, the state departments must contract with a third-party contractor to help the state departments and county departments develop and implement a plan for transitioning to the new public benefits delivery model. The act establishes an implementation work group comprised of representatives of counties, the governor's office, the state departments, and nongovernmental organizations, to work with the third-party contractor to develop and implement the transition plan. The transition plan must be delivered to the joint budget committee by January 1, 2027. The act establishes the state cross-departmental policy alignment team to align the policies of the public assistance programs to improve service delivery and outcomes for recipients of public assistance benefits. The act makes a household eligible for fuel assistance payments if the household has not received low-income energy assistance program assistance in the previous 12 months and if it is eligible for the standard utility allowance under federal law. The act requires the department of health care policy and financing to certify to the department of revenue information regarding persons who are obligated to the state for overpayment of medicaid benefits and sets forth the process for distributing money withheld from a person's tax refund owed for overpayment of benefits. To implement the act, it includes appropriations from the general fund and various cash funds to the department of health care policy and financing, the department of human services, and the department of early childhood. The act appropriates money to the office of the governor for use by the office of information technology and to the department of law from reappropriated money received by other departments. The act decreases the appropriation from the federal child care development funds made in the annual general appropriation act for the 2026-27 state fiscal year to the department of early childhood for intrastate child care assistance program redistribution by $222,598.(Note: This summary applies to this bill as enacted.)
The act caps at $400 the amount that a health-care entity or health-care provider may charge for a record request made by a patient's attorney or the attorney of the patient's personal representative pursuant to an authorization in compliance with the federal 'Health Insurance Portability and Accountability Act of 1996', a valid subpoena, or a valid court order, if the requested record exceeds 664 pages. The health-care entity or health-care provider may charge a reasonable fee above the cap if the record request requires the health-care facility or health-care provider to segregate, withhold, or redact protected health information in order to comply with applicable law or the scope or limitations of the authorization in compliance with the federal 'Health Insurance Portability and Accountability Act of 1996', a valid subpoena, or a valid court order. Beginning January 1, 2028, and every even-numbered year thereafter, the act requires the $400 limit to be adjusted for inflation. The act requires the requested medical records to be delivered in electronic format if the requestor requests electronic format, the original records are stored in electronic format, and the records are readily producible in electronic format. The act requires the health-care facility or health-care provider to provide the requestor with an invoice for the records provided in response to the record request within 30 days of receiving the request, and the health-care facility or health-care provider must provide the records upon payment of the invoice. If the health-care facility or health-care provider is unable to comply with the request for records within 30 days after the request, the health-care facility or health-care provider must send written notice of a 30-day extension to the requestor. The health-care facility or health-care provider must provide the records to the requestor at no cost if the records were not provided within 30 days or without written notice of an extension, unless the delay is due to a force majeure event. In the case of a force majeure event, the health-care facility or health-care provider must provide written notice to the requestor within 5 business days of becoming aware of the force majeure event. The 30-day time frame to respond to a request for records commences upon resolution of the force majeure event.(Note: This summary applies to this bill as enacted.)
The act:Authorizes the health insurance affordability enterprise (enterprise), on or after January 1, 2027, to issue revenue bonds of up to $100 million to fund enterprise programs, secured by the enterprise's revenues, and require the enterprise to pay bond obligations before allocating revenues for enterprise programs;Allows the enterprise to invest specified money in the health insurance affordability cash fund (cash fund) without regard to otherwise applicable requirements for such investments and to contract with private professional fund managers to advise on investment strategies;Modifies the allocation of enterprise revenue among authorized purposes and allows the enterprise to reallocate unexpended amounts for specified purposes;Directs the enterprise to require qualified individuals who are enrolled in state-subsidized individual health coverage plans eligible for subsidies from the enterprise to pay premiums established in rules adopted by the commissioner, in consultation with the health insurance affordability board (board);Requires the enterprise to adjust the statewide average premium reduction under the reinsurance program to 18% and to reduce the amount of bonds issued to account for the reduced costs for the reinsurance program;Directs the board, in recommending parameters for implementing subsidies for state-subsidized individual health coverage plans, to recommend coverage that prioritizes enrollment stability and customer predictability; when seeking input on its recommendations regarding plans, coverage, and the number of eligible slots, to enable feedback in at least English and Spanish and in other languages upon request; and to indicate how it incorporated such feedback into its final recommendations;Directs the enterprise to conduct or contract a third party to conduct a study to evaluate the feasibility of restructuring the enterprise programs to increase health insurance affordability and maximize enrollment in health insurance plans;Requires the enterprise to submit 3 written reports and make one in-person presentation to the joint budget committee each year regarding the status of the cash fund and, as part of its in-person presentation in January 2027, to provide an analysis of the effects of changing the statewide average premium reduction under the reinsurance program to 15% and of creating a tiered, income-based, structure for premium assistance for individuals who purchase insurance on the Colorado health benefit exchange (exchange);Repeals the tax credit for contributions to the exchange and replaces it with a tax credit for contributions to the enterprise; andDirects the state treasurer to transfer $40 million from the marijuana tax cash fund to the cash fund by June 30, 2026, reduces to $60 million the designation of money in the marijuana tax cash fund as the state emergency reserve for the 2025-26 and 2026-27 state fiscal years, and increases by $40 million the value of the capitol annex building for purposes of the state emergency reserve for the 2025-26 and 2026-27 state fiscal years.(Note: This summary applies to this bill as enacted.)
Currently, the 'Workers' Compensation Act of Colorado' provides that certain cancers contracted by firefighters are considered occupational diseases presumed to have been a result of the firefighters' employment. A firefighter's employer or an insurer may rebut this presumption by showing by a preponderance of the medical evidence that the cancer did not occur on the job. The act expands the types of cancer that are considered occupational diseases and strengthens the rebuttable presumption to require an employer to show clear and convincing evidence that the cancer did not occur on the job. The act exempts firefighters who are employed by the state.(Note: This summary applies to this bill as enacted.)
Beginning on January 1, 2028, a health insurance carrier (carrier) of an individual or group health benefit plan in Colorado (plan) shall, when calculating a covered person's contribution to an out-of-pocket maximum or cost-sharing requirement under the plan, account for and credit to the covered person's contribution an out-of-pocket expense that the covered person incurs by purchasing a prescription drug directly from a pharmacy or direct-to-consumer platform (contribution credit). The carrier shall apply the contribution credit to the out-of-pocket maximum or cost-sharing requirement that is applicable in the plan year in which the out-of-pocket expense was incurred. To receive a contribution credit, a covered person must provide to the carrier proof of payment for a direct purchase of a prescription drug, such as an itemized receipt or pharmacy record, within 90 days after making the purchase (proof of payment). The carrier may request additional information or documentation if the proof of payment is insufficient or incomplete. The carrier shall not apply a contribution credit in the following circumstances:For an amount of a covered person's out-of-pocket expense incurred by the direct purchase of a prescription drug that is greater than the amount the covered person would have incurred if they had obtained the same prescription drug in the same plan year from an in-network pharmacy and pursuant to the terms of their plan;If the covered person does not provide proof of payment;If the covered person incurred the out-of-pocket expense by purchasing a prescription drug that is not covered under the formulary of the covered person's plan, unless the carrier grants an exception; orIf the covered person does not comply with the carrier's utilization management processes, including prior authorization and step therapy protocols required under the covered person's plan.(Note: This summary applies to this bill as enacted.)
The act limits the benefits pregnant women and children with a certain family household income and citizen or immigration status are eligible for under the state medical assistance program and the medical assistance program. Eligible pregnant women and children are subject to the following limitations on benefits:Beginning July 1, 2026, there is an annual cap on dental services in the amount of $1,100;Beginning January 1, 2027, behavioral health services offered must be provided on a fee-for-service basis only;Beginning January 1, 2027, services offered through the accountable care collaborative are no longer covered; andBeginning January 1, 2027, managed care services through the medical assistance program are no longer covered. Beginning January 1, 2027, children under 19 years old whose family household income does not exceed 260% of the federal poverty line, adjusted for family size, and who are not eligible for the medical assistance program due to their immigration status, are not eligible for home- and community-based services, community first choice, long-term home health, private duty nursing, hospice care, and nursing home care unless those children already receive those services on or before December 31, 2026. Beginning January 1, 2027, the act caps enrollment of children in the state medical assistance program at 25,000 children if either enrollment exceeds 25,000 or the expenditures for a fiscal quarter exceeds one-quarter of the appropriation for state medical assistance plus 5% to account for seasonality fluctuations. If one of the conditions is met, the enrollment cap begins on the first day of the month following 60 days after the department of health care policy and financing (state department) determines that the condition was met. The act repeals provisions requiring the state department to develop an outreach and enrollment strategy for enrolling eligible groups into new coverage options and repeals the state children's basic health plan. The act appropriates $3,378,166 from the general fund to the state department to implement the act and reduces appropriations to the state department by $14,202,723 if certain conditions are met.(Note: This summary applies to this bill as enacted.)
Section 2 of the act repeals a requirement that health-care profession regulators adopt rules that require each licensed health-care provider, as a condition of renewing, reactivating, or reinstating a license, to complete up to 4 credit hours of training per licensing cycle in order to demonstrate competency regarding topics related to prescribing drugs and treatment. Section 3 authorizes the Colorado dental board to adopt rules that require every dentist, dental therapist, and dental hygienist, as a condition of renewing, reactivating, or reinstating a license, to complete up to 4 credit hours of training per licensing cycle regarding topics related to prescribing drugs and treatment. Section 4 requires a licensed veterinarian to complete at least 1 hour of training per renewal period regarding topics related to prescribing drugs and treatment. Section 5 changes the frequency at which specific health-care facilities are required to apply for a license issued by the department of public health and environment from annually to every 2 years. Under current law, a health-care facility is required to screen each uninsured patient for eligibility for public health insurance programs and discounted care (screening) utilizing a single uniform application developed by the department of health care policy and financing (state department). Sections 6 through 11 change this requirement by:Changing the method used to conduct the screening from a uniform application to use of a third-party resource, such as a major credit bureau, or use of a uniform screening questionnaire (questionnaire) developed by the state department;Allowing a health-care facility the option of screening a patient for eligibility for the health-care facility's financial assistance program;Requiring a health-care facility to provide specified notifications upon completion of the screening;Creating an application for discounted care (application) for use by a health-care facility upon completion of the screening through which additional information is requested from a patient to determine whether the patient qualifies or is likely to qualify for public health-care coverage or discounted care;Requiring a health-care facility to provide specified notice and appeal rights to a patient upon completion and review of the application; andRequiring the state department to adopt rules regarding the questionnaire and application. Section 11 also narrows state department review requirements of health-care facilities' and licensed health-care professionals' billing for patients who are indigent. The act prohibits the state department from making changes to regulatory documents or imposing new requirements unless the changes or new requirements are adopted by rule by specified dates and are subject to stakeholder engagement. Section 12 requires the state department to establish by rule the content and format of the information each hospital must provide to the state department for a hospital transparency report at least 30 days prior to the hospital's fiscal year. The act changes the deadline for a hospital to submit to the state department an annual audited financial statement from 120 days to 150 days after the end of the hospital's fiscal year. Current law requires that each hospital has a minimum of 15 days to review the hospital transparency report; the act specifies that the review period is 15 business days and requires that a statewide hospital association must also have a minimum of 15 business days to review the report.(Note: This summary applies to this bill as enacted.)
The bill prohibits a person, health-care provider, or mental health professional from knowingly performing surgery on, or prescribing, administering, or providing hormones or puberty blockers to, a minor for the purpose of altering the minor's biological sex characteristics, or providing mental health therapy, counseling, or referrals that promote or affirm a minor's belief that the minor was born in the wrong body or that the minor needs medical intervention to address distress related to the minor's biological sex (prohibited interventions). The bill prohibits the state from investigating or penalizing a minor's parent, or terminating the parent's rights, for refusing to consent to a prohibited intervention for the minor. A public school, health-care provider, or a governmental entity is prohibited from withholding information from a minor's parent regarding the minor's express desire to transition the minor's biological sex. The bill prohibits state or federal funding, medicaid reimbursement, and health insurance coverage from being used to pay for a prohibited intervention. A person who, as a minor, was subjected to a prohibited intervention may bring a civil action within 20 years after attaining the age of 18 years against the person, health-care provider, or mental health professional who performed or provided the prohibited intervention. The bill requires a regulator to revoke a health-care provider's or mental health professional's license for performing or providing a prohibited intervention. A person who knowingly performs or provides a prohibited intervention commits a class 5 felony, and the court is required to sentence the person to the maximum term of imprisonment and impose the maximum fine.(Note: This summary applies to this bill as introduced.)
The bill requires all health benefit plans in the state and the medicaid program to provide coverage for hormone replacement therapy, as prescribed by licensed physicians, for women who are experiencing menopause or perimenopause. Coverage for hormone replacement therapy will be implemented for all large employer health benefit plans issued or renewed in this state on or after January 1, 2027. Coverage for hormone replacement therapy will be implemented for all individual and small group health benefit plans issued or renewed in this state on or after January 1, 2028, as long as the state is not required to defray the cost of the coverage of the hormone replacement therapy. The state medicaid program is required to provide hormone replacement therapy beginning on July 1, 2027.(Note: This summary applies to this bill as introduced.)
On and after January 1, 2027, when determining coverage for health-care services, the act requires entities that use an artificial intelligence system (AI system) for the purpose of conducting utilization review of health-care services, including health insurance companies (carriers), pharmacy benefit managers, private utilization review organizations, behavioral health administrative services organizations, and managed care entities (entities), ensure that the AI system complies with certain requirements specified in the act. Specifically, an entity shall ensure that the AI system:Makes determinations based on medical or clinical history, the patient's individual clinical circumstances, and other relevant clinical factors specified in the act, with denial of coverage reviewed by a licensed clinician or physician or other competent regulated professional who is competent to evaluate the specific clinical issues and review the health benefit plan's terms of coverage (competent regulated professional);Does not base its determination solely on group data without reference to the individual's data;Is not used in any way that discriminates against individuals in violation of other state or federal laws and is fairly and equitably applied, including in accordance with regulations and guidance issued by the federal department of health and human services; andIs periodically reviewed to ensure the AI systems outcomes are accurate and reliable and that an individual's health data is not used beyond its intended or stated purpose. Entities that use AI systems shall disclose to the division of insurance, the department of human services, or the department of health care policy and financing, as applicable, the utilization review functions for which the AI system will be used and the points in the utilization review process when it will be used, the process for human oversight of adverse coverage determinations, and the process for maintaining audit information to ensure that the use of the AI system complies with the requirements in the act. The AI system may be used to assist in utilization review, including expedited approvals. A carrier's denial of coverage for a service based in whole or in part on medical necessity shall not be issued solely on the output of an AI system without human review by a licensed clinician or physician or other competent regulated professional. Further, the act prohibits a carrier and a payer of services under the 'Colorado Medical Assistance Act' and the 'Children's Basic Health Plan Act' from paying for psychotherapy services that are provided directly to a client and that are conducted by an AI system.(Note: This summary applies to this bill as enacted.)
