2020 Colorado Revised Statutes
Title 25.5 - Health Care Policy And Financing
Article 4. Colorado Medical Assistance Act - General Medical Assistance
Section 25.5-4-209. Payments by third parties - copayments by recipients - review - appeal children's waiting list reduction fund.

(1) (a) Any recipient receiving benefits under this article or article 5 or 6 of this title who receives any supplemental income, available for medical purposes under rules of the state department, or who receives proceeds from sickness, accident, health, or casualty insurance shall apply the supplemental income or insurance proceeds to the cost of the benefits rendered, and the rules may require reports from providers of other payments received by them from or on behalf of recipients.

2. Subject to any limitations imposed by Title XIX and the requirements set forth insubsection (1)(c) of this section, a recipient must pay at the time of service a portion of the cost of any medical benefit rendered to the recipient or to the recipient's dependents pursuant to this article 4 or article 5 or 6 of this title 25.5, as determined by rules of the state department.

3. (I) Except as otherwise provided in subsection (1)(c)(II) of this section, on and after

January 1, 2018, for pharmacy and for hospital outpatient services, including urgent care centers and facilities and emergency services, the rules of the state department required by subsection (1)(b) of this section must require the recipient to pay:

1. For pharmacy, at least double the average amount paid by recipients in state fiscalyear 2015-16; or

2. For hospital outpatient services, at least double the amount required to be paid asspecified in the rules as of January 1, 2017.

(II) For both pharmacy and hospital outpatient services, the amount required to be paid by the recipient shall not exceed any specified maximum dollar amount allowed by federal law or regulations as of January 1, 2017.

(d) The state department shall evaluate options to exempt individuals who are qualified for institutional care but are instead enrolled in home- and community-based service waivers from the increased payment requirements specified in subsection (1)(c) of this section.

(2) (a) Notwithstanding the provisions of section 26-1-114, C.R.S., the state department is authorized to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services available, including the collection of sufficient information from individuals who are eligible for medical assistance to pursue claims against the third parties. The state department shall collect the information at the time of any determination or redetermination of eligibility for medical assistance. A knowing or willful failure of an individual to provide the information may result in the termination of the individual's eligibility for medical assistance.

(b) A third party, as a condition of doing business in the state, shall:

(I) (A) Provide on a monthly basis to the state department or its business associate eligibility records identifying all persons covered by the third party in a manner prescribed by rule to allow the state department or its business associate to perform an analysis and determine which persons are eligible for medical assistance;

(B) The eligibility record data elements provided by the third party shall be the minimum necessary to achieve a satisfactory data match. The third party shall provide, upon request of the state department or its business associate, additional data elements as needed to confirm eligibility matches as determined by the initial analysis, including, but not limited to, the name, address, and identifying number of the third party's plan.

2. Accept the state's right of recovery and the assignment to the state of any right of anindividual or other entity to payment from the third party for an item or service for which payment has been made under the medical assistance plan to the extent that such service is covered by the third party;

3. Respond to any inquiry by the state regarding a claim for payment for any healthcare item or service that is submitted not later than three years after the date of the provision of the health care item or service; and

4. Agree not to deny a claim submitted by the state solely on the basis of the date ofsubmission of the claim, the type or format of the claim form, or a failure to present proper documentation at the point of sale that is the basis of the claim, if:

1. The claim is submitted by the state within the three-year period beginning on thedate that the item or service is furnished; and

2. Any action by the state to enforce its rights with respect to the claim is commencedwithin six years after the state's submission of the claim.

3. The cost to a third party of providing data, including eligibility records, shall beborne by the state department.

4. A third party that provides data required by the state department, whether confidential or not, shall not be held liable for the provision of such data to the state department or for any use made thereof.

5. (I) The state department's business associate shall not use, transfer, extract, copy,revise, or store any data required to be provided to the state department and its business associate, including the eligibility records, social security numbers, coverage, nature of coverage, period provided, or any other data elements, for purposes other than:

1. The identification of persons eligible to receive medical assistance, as defined bysection 25.5-1-103 (5);

2. Cost avoidance;

3. The remuneration of the state department for services provided or paid for;

4. Any record retention requirements;

5. Audit requirements; and

6. Purposes related to litigation and testimony.

(II) The state department's business associate shall destroy all data once the functions specified in subparagraph (I) of this paragraph (e) have been accomplished.

(f) (I) A Colorado resident shall have a private right of action against the state department's business associate if the business associate negligently uses the data specified in paragraph (e) of this subsection (2) for purposes other than those stated in paragraph (e) of this subsection (2). The right of action shall be enforceable in the courts of Colorado and limited to the actual damages incurred by the individual bringing the action.

(II) A third party may bring an action on behalf of a Colorado resident for injunctive relief against the state department's business associate to prevent the business associate from intentionally using the data for purposes other than those specified in paragraph (e) of this subsection (2).

(g) As used in this section:

1. "Business associate" shall have the same meaning as provided in 45 CFR 160.103.

2. "Third party" means a health insurer, self-insured plan, group health plan as definedin 29 U.S.C. sec. 1167 (1), service benefit plan, managed care organization, pharmacy benefit manager, or other party that is, by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service.

(3) (a) The rights assigned by a recipient of medical assistance to the state department pursuant to section 25.5-4-205 (4) shall include the right to appeal an adverse coverage decision by a third party for which the medical assistance program may be responsible for payment, including but not limited to the internal and external reviews provided for in sections 10-16-113 and 10-16-113.5, C.R.S., and a third party's reasonable appeal procedure under state and federal law. The state department or the independent contractor retained pursuant to paragraph (b) of this subsection (3) shall review and, if necessary, may appeal at any level an adverse coverage decision, except an adverse coverage decision relating to medicare, Title XVIII of the federal "Social Security Act", as amended.

2. The state department shall enter into one or more agreements with an independentcontractor to pursue recoveries from third parties pursuant to paragraph (a) of this subsection (3). Any such agreement shall provide that the independent contractor's only compensation shall be a prudent and reasonable percentage of the amount recovered on behalf of the state department as determined by the state department.

3. (I) An independent contractor retained pursuant to paragraph (b) of this subsection(3) shall maintain a contemporaneous record of the hours of services provided and any costs incurred. When the matter is resolved, the independent contractor shall provide to the state department a statement of the hours of services provided, the amount of costs incurred, the total amount of the contingent fee, and the hourly rate for the services provided. The hourly rate for the services provided shall be determined by dividing the amount of the contingent fee, less the amount of costs incurred, by the number of hours of services provided by the independent contractor. The statement required by this subparagraph (I) shall be available for inspection and copying at reasonable times at the state department.

(II) Compliance with this paragraph (c) does not relieve a contracting attorney of any obligation or legal responsibility imposed by the Colorado rules of professional conduct or any provision of law.

4. Nothing in this subsection (3) shall be construed to authorize the denial of or delay ofpayment to a provider by the state department or the delay or interference with the provision of services to a medical assistance recipient.

5. Repealed.

(4) With respect to programs administered by the state department, the state department shall access available data from the public assistance reporting information system for the purpose of identifying persons who are receiving certain public benefits from other states. The state department shall ensure that duplicate benefits are not being paid improperly to persons identified pursuant to the public assistance reporting information system.

Source: L. 2006: Entire article added with relocations, p. 1826, § 7, effective July 1. L. 2008: (1)(a), (2), and (3)(a) amended, p. 1768, § 1, effective June 2. L. 2010: (4) added, (SB 10167), ch. 296, p. 1378, § 5, effective May 26; (3)(a) amended and (3)(e) added, (SB 10-002), ch. 366, p. 1727, § 4, effective June 7. L. 2017: (1)(b) amended and (1)(c) and (1)(d) added, (SB 17267), ch. 267, p. 1447, § 14, effective May 30.

Editor's note: (1) This section is similar to former § 26-4-518 as it existed prior to 2006.

(2) Subsection (3)(e)(IV) provided for the repeal of subsection (3)(e), effective July 1, 2013. (See L. 2010, p. 1727.)

Cross references: For the legislative declaration in SB 10-002, see section 1 of chapter 366, Session Laws of Colorado 2010. For the legislative declaration in SB 10-167, see section 1 of chapter 296, Session Laws of Colorado 2010. For the legislative declaration in SB 17-267, see section 1 of chapter 267, Session Laws of Colorado 2017.