HB 25-1213

House Bill 25-1213 updates Colorado's Medicaid program in several ways. It relaxes some construction requirements for assisted living facilities, allows the state healthcare enterprise to receive public funds, and mandates that managed care organizations pay providers within a year when rates are updated starting January 1, 2026. The bill also requires managed care entities to report their medical loss ratios annually, which will be published by the state department on its website for transparency. Additionally, it removes signature requirements from doctors certifying certain therapy services and ensures continuity of care during transitions in home-based or community-based services. Since the bill has been signed into law, these changes are now official and will begin to take effect as specified.

Official Summary

The act exempts an assisted living residence that has not undergone new construction or major renovations from complying with the facility guideline institute guidelines. The department of health care policy and financing (state department) must establish a process for reviewing and updating the general billing manual on an annual basis and ensure that the general billing manual includes all necessary CPT codes or links to the state department's list of CPT codes. The act allows the Colorado healthcare affordability and sustainability enterprise to receive public funds. Beginning January 1, 2026, for claims that must be reprocessed as a result of updating the provider rates, the act requires a managed care organization to issue payment to a contracted provider within one year after the provider rate is updated. The state department must notify the managed care organizations of changes to the provider rates within 60 days of changing the provider rates. The act requires the state department to include in each new contract with, or renewal of a contract with, a managed care entity (MCE) a provision requiring the MCE to submit to the state department, on an annual basis, the amount the MCE is paid and the MCE's medical loss ratio. The state department is required to publish this information, as well as historical medical loss ratio data for each MCE, and publish on an annual basis audit findings regarding an MCE's most recently completed medical loss ratio audit on the state department's website. The act prohibits the state department from imposing signature requirements on a physician or practitioner certifying a medicaid member's (member) plan of care that involves physical therapy, occupational therapy, or speech therapy. The act requires that for members receiving home- and community-based services, if a service the member receives is discontinued or no longer a covered service, the state department must confirm the timeline for the continuity of treatment with the federal centers for medicare and medicaid during the transition period of the benefit or service being discontinued and must communicate that timeline to the member impacted by the benefit or service being discontinued. (Note: This summary applies to this bill as enacted.)

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