Colorado

SUMMARY

Colorado is a state to watch on healthcare transparency and costs. In the 2017 legislative term, Colorado was very active especially in terms of healthcare cost legislation. Colorado has a working All-Payer Claims Database, which calls itself “the most comprehensive source of health claims data from public and private payers in Colorado.” Indeed, Colorado’s APCD includes a full scope of providers and paid amounts, and has an easily accessible website for consumers. In the enforcement realm, the state has not been too active. It has allowed a few recent sales of non-profit hospitals on the grounds that they complied with the state’s statutory requirements. 

 

LEGISLATION/REGULATION

Legislative Calendar

Colorado’s current regular legislative session runs from 1/10/2018 – 5/10/2018.

 

Recent Legislative Developments

Healthcare Transparency

2018 HB 1009 DIABETES DRUG PRICING TRANSPARENCY ACT 2018: Require drug manufacturers to submit reports to the state board of health for diabetes products when the price increases relative to the increase in the medical component of the consumer price index. Information to be reported includes market analysis, research, production and marketing costs among other information. There are financial penalties for failure to comply. Active – Referred to Health, Insurance, and Environment Committee
HB 1260 PRESCRIPTION DRUG PRICE TRANSPARENCY: requires health insurers, starting in 2019, to submit to the commissioner of insurance (commissioner), as part of the health care cost reporting requirement, information regarding prescription drugs covered under their health insurance plans that were dispensed in the preceding calendar year; and prescription drug manufacturers, on or after July 1, 2018, to notify state purchasers, health insurers, and pharmacy benefit management firms when the manufacturer increases the price of certain prescription drugs by more than 10% or when the manufacturer introduces a new specialty drug in the commercial market. Active -Referred to Appropriations Committee on 3/8/18.
HB 1284 DISCLOSURE OF PRESCRIPTION COSTS AT PHARMACIES: prohibits a pharmacy or pharmacist from, or penalizing a pharmacy or pharmacist for, providing a covered person information on the amount of the covered person’s cost share for the covered person’s prescription drug and the clinical efficacy of any more affordable alternative drugs that are therapeutically equivalent; or requires a pharmacy to charge or collect a copayment from a covered person that exceeds the total submitted charges by the network pharmacy. Active –Introduced on 3/8/18.
HB 1207 HOSPITAL FINANCIAL TRANSPARENCY MEASURES: requires the department of health care policy and financing (department), in consultation with the Colorado healthcare affordability and sustainability enterprise board, to develop and prepare an annual report detailing uncompensated hospital costs and the different categories of expenditures made by general hospitals in the state. Active –Referred to Health, Insurance, and Environment Committee on 3/8/18.
SB 136 HEALTH INSURANCE PRODUCER FEES AND FEE DISCLOSURE: allows an insurance producer or broker advising a client on individual health benefit plans to charge the client a fee if the producer or broker does not receive a commission related to the individual health benefit plan selected by the client and if the producer or broker discloses in writing the fee to the client. Active –Referred to Finance Committee on 2/13/18.
2017 SB 65 TRANSPARENCY IN DIRECT PAY HEALTH CARE PRICES: The bill creates the ‘Transparency in Health Care Prices Act’, which requires health care professionals and health care facilities to make available to the public the health care prices they assess directly for common health care services they provide. Additionally, the act prohibits health insurers, government agencies, or other persons or entities from penalizing a health care recipient, provider, facility, employer, or other person or entity who pays directly for health care services or otherwise exercises rights under or complies with the act. The bill takes effect January 1, 2018. Passed – Signed by Governor on 4/6/17.
HB 1236 HEALTH CARE POLICY AND FINANCING ANNUAL REPORT ON HOSPITAL EXPENDITURES: The department of health care policy and financing (department), in consultation with the hospital provider fee oversight and advisory board, shall prepare an annual report detailing uncompensated hospital costs and the different categories of expenditures made by general hospitals in the state. The hospital expenditure report shall include, but not be limited to: a description of the analysis methods and definitions of report components; uncompensated care costs; and the percentage that different categories of expenses contribute to overall expenses of hospitals. Inactive – Passed House on 3/29, died in Senate Committee on State, Veterans, & Military Affairs.
2015 SB074

 

TRANSPARENCY IN HEALTH CARE PRICES ACT: would have required health care providers to make available to the public, in a single document, electronically or on their websites, the health care prices for (at a minimum) the 15 most common health care services they provide.In addition health care facilities would have been required to make available to the public, in a single document, electronically or on their websites the: (1) 50 most-used, diagnosis-related group codes or other codes for in-patient health care services used by the facility for billing and (2) 25 most-used outpatient CPT or health care services procedure codes used for billing. Inactive — Died.

 

Healthcare Cost

2018 SB 152 PROHIBIT PRICE GOUGING ON PRESCRIPTION DRUGS: Prohibits a pharmaceutical manufacturer or wholesaler from price gouging on sales of essential off-patent or generic drugs; makes the practice of price gouging a deceptive trade practice under the ‘Colorado Consumer Protection Act’; and requires the state board of pharmacy and the executive director of the department of health care policy and financing to report suspected price gouging to the attorney general. The attorney general is authorized to seek subpoenas and file lawsuits with the appropriate district courts.  Active Introduced on 1/29/18.
HB 1205 FINANCIAL RELIEF DEFRAY INDIVIDUAL HEALTH PLAN COSTS: Concerning a financial relief program to provide financial assistance to an individual earning a household income of not more than five hundred percent of the federal poverty line of which the individual spends more than twenty percent on health insurance premiums for individual health insurance purchased through the Colorado health benefit exchange. Active –Referred to Appropriations Committee on 3/8/18.
HB 1112 CONCERNING COVERED HEALTH CARE SERVICES PROVIDED BY A PHARMACIST: The bill requires a health benefit plan to provide coverage for health care services provided by a pharmacist if: 1) The services are provided within a health professional shortage area; and 2) The health benefit plan provides coverage for the same services provided by a licensed physician or advanced practice nurse Passed – Signed by Governor on 4/9/18.
SB 80  WHOLESALE CANADIAN DRUG IMPORTATION PROGRAM:  creates the Colorado Wholesale Importation of Prescription Drugs Act’, under which the department of health care policy and financing (department) must design a program to import prescription pharmaceuticals from Canada for sale to Colorado consumers.  Active – Referred to Veterans, & Military Affairs Committee on 1/12/18. 
2017 SB 267 SUSTAINABILITY OF RURAL COLORADO: Section 16 of the bill repeals the existing hospital provider fee program, effective July 1, 2017, and section 17 creates a new Colorado healthcare affordability and sustainability enterprise (CHASE) within the department of health care policy and financing (HCPF), effective July 1, 2017, to charge and collect a healthcare affordability and sustainability fee that functions similarly to the repealed hospital provider fee. Passed – Signed by Governor on 5/20/17.
SB 300

 

HIGH RISK HEALTH CARE COVERAGE PROGRAM: Concerning the authority of the commissioner of insurance to implement programs to address the rising costs of providing health care coverage to high-risk individuals in the state, and, in connection therewith, directing the commissioner to study issues related to the implementation of such programs. Passed – Signed on 5/10/17.
HB 1115

DIRECT PRIMARY HEALTH CARE SERVICES: The bill establishes parameters under which a direct primary care agreement (agreement) may be implemented. Direct primary care patients pay a monthly fee —it’s usually between $25 and $80, depending on factors like the patient’s age — in exchange for access to primary care services like consultations, lab work and clinical visits without insurance copays or deductibles. An agreement may be entered into between a direct primary health care provider (provider) and a patient for the payment of a periodic fee and for a specified period of time. The provider must be a licensed, registered, or certified individual or entity authorized to provide primary care services.

The bill establishes that the agreement is not the business of insurance or the practice of underwriting and does not fall under regulation of the division of insurance. The bill outlines the conditions under which a provider may discontinue care to a patient.

Passed – Signed by Governor on 4/24/17.
2017 HB 1353

IMPLEMENT MEDICAID DELIVERY AND PAYMENTS INITIATIVE: Authorizes the department of health care policy and financing (department) to implement performance-based payments for medicaid providers. Furthermore, the bill codifies the Accountable Care Collaborative (ACC), the primary Medicaid delivery system in Colorado.

The bill defines the goals of the ACC and HCPF’s implementation of the ACC, including, in part, establishing primary care medical homes for Medicaid clients, providing regional coordination and accountability, and integrating physical and behavioral health care delivery. The medical services board is required to promulgate rules implementing the ACC.

Passed – Signed by Governor on 5/23/17.

 

Healthcare Markets

2018 HB 1097

PATIENT CHOICE OF PHARMACY: Prohibits a carrier that offers or issues a health benefit plan that covers pharmaceutical services, including prescription drug coverage, or a pharmacy benefit management firm managing those benefits for a carrier, from limiting or restricting a covered person’s ability to select a pharmacy or pharmacist of the covered person’s choice if certain conditions are met; and imposing a copayment, fee, or other cost-sharing requirement for selecting a pharmacy of the covered person’s choosing.

Active –Referred to Health, Insurance, and Environment Committee on 2/15/18.
SB 80

WHOLESALE CANADIAN DRUG IMPORTATION PROGRAM: The department of health care policy and financing (department) must design a program to import prescription pharmaceuticals from Canada for sale to Colorado consumers. The program design must ensure both drug safety and cost savings for Colorado consumers.

Active – Referred to State, Veterans, and Military Affairs Committee on 1/31/18.
2017 SB 57

COLORADO HEALTH CARE AFFORDABILITY AND SUSTAINABILITY ENTERPRISE: The bill creates the Colorado healthcare affordability and sustainability enterprise (enterprise) as a type 2 agency and government-owned business within the department of health care policy and financing (HCPF) for the purpose of participating in the implementation and administration of a state Colorado healthcare affordability and sustainability program (program) on and after July 1, 2017, and creates a board consisting of 13 members appointed by the governor with the advice and consent of the senate to govern the enterprise.

The business purpose of the enterprise is, in exchange for the payment of a new healthcare affordability and sustainability fee (fee) by hospitals to the enterprise, to administer the program and thereby support hospitals that provide uncompensated medical services to uninsured patients and participate in publicly funded health insurance programs.

Inactive – Died in Committee.

 

Key Statutes

We compile state statutes relate to healthcare price and competition, including healthcare transparency, markets, and costs. For a complete listing of all health related statutes visit the State Health Practice Database for Research.

 

Transparency in Healthcare

  • R.S.A § 25.5-1-204: Established Colorado’s All-Payer Claims Database, which calls itself “the most comprehensive source of health claims data from public and private payers in Colorado.”
  • S.A. § 25-3-1278: The hospital report card act provides that the executive director shall approve a comprehensive hospital information system to provide for the collection, compilation, coordination, analysis, indexing, and utilization data.

 

Insurance Code Provisions

  • R.S.A. § 10-16-111 requires that non-profit hospitals, medical-surgery, and health services corporations file an annual statement with the Insurance Commissioner containing fee amounts and other information.

 

  • R.S.A. § 10-16-133 requires that the Insurance Commissioner maintain a consumer guide on its website containing information submitted by carriers to the Division of Insurance, as well as a complaint form that allows consumers to file complaints against insurers. It also requires that any licensed insurance producer who negotiates applications for insurance on behalf of a health insurance company disclose the receipt of commissions from the insurer.

 

  • R.S.A. § 10-16-134 requires that each carrier submit by March 1, annually, to the Division of Insurance its average reimbursement rates for either statewide or by geographic area, for the average inpatient day or for the 25 most common inpatient procedures based on the most commonly reported diagnostic-related groups, and that the DOI post those rates to the its website.

 

  • S.A § 10-16-145: A carrier shall not require a covered person to undergo step therapy, and shall provide coverage for the drug prescribed by the covered person’s health care provider as long as the prescribed drug is on the carrier’s prescription drug formulary, when the patient has tried the step-therapy required prescription drugs while under his or her current or previous health insurance or health benefit plan, and such prescription drugs were discontinued due to lack of efficiency or effectiveness.

 

Health Code Provisions

  • B. 10-1332 created the Medical Clean Claims Transparency and Uniformity Act, which required the executive director of the department of health care policy and financing (department) to establish a task force by November 30, 2010, to develop a standardized set of payment rules and claim edits to be used by payers and health care providers in Colorado. Status, passed, Amended C.R.S.A. §25-37-101.

 

  • R.S.A. § 25-3-705 requires that the Insurance Commissioner work with the Colorado Hospital Association to develop a consumer friendly resource for hospital charges. As part of that effort, each hospital in the state must submit a report to the Hospital Association containing charge information for the 25 most common inpatient diagnostic-related groups. The Commissioner will work with the Hospital Association to incorporate the information into a website accessible to consumers.

 

Controlling Healthcare Costs to Consumers

  • As of February 2014, the Colorado Division of Insurance will study healthcare costs in the state in response to concern about higher premiums in certain areas of the state. The Division of Insurance explained that it needed new data to justify rate changes to HHS for 2015.

 

FY 2017-2018 BUDGET

Budgets are set for a fiscal year. The fiscal year is the 12‐month period beginning on July 1 and ending June 30 of the following year. The FY 2017-2018 Budget passed in May 2017. To view Colorado’s FY 2017-2018 spending on Medicaid and health spending, click here.

 

LITIGATION/ENFORCEMENT

  • Colorado Attorney General John W. Suthers has allowed three recent transactions involving non-profit hospitals to proceed without further review under the Hospital Transfer Act, R.S § 6-19-101, et seq., which requires nonprofit hospitals, when sold to for-profit entities, to use the sale proceeds toward a similar charitable activity.

 

  • On August 1, 2014, the AG announced that his office had issued an opinion under the Hospital Transfer Act relating to the proposed transaction between the Sisters of Charity of Leavenworth Health System Inc. (d/b/a SCL Health), Saint Joseph Hospital Inc., and National Jewish Health. This matter was noticed on July 10, 2014. The Attorney General’s office determined that the transaction meets the relevant criteria of the Act and may proceed without further review by the Attorney General.

 

  • On June 28, 2013,
the AG announced that his office had issued an opinion under the Hospital Transfer Act relating to the proposed transaction between the Lutheran Hospital Association of San Luis Valley doing business as San Luis Valley Regional Medical Center and Conejos County Hospital Corporation. This matter was noticed on June 24, 2013.

 

  • On October 1, 2012 the AG announced that his office had issued an opinion under the Hospital Transfer Act relating to the proposed transaction between Community First Foundation and Sisters of Charity of Leavenworth Health System, Inc. regarding the Exempla healthcare system. This matter was noticed on July 31, 2012. The Attorney General’s office determined that the transaction had met the relevant criteria of the Act and may proceed without further review by the Attorney General.

 

KEY RESOURCES

Colorado State General Assembly

Colorado State Legislative Council

Colorado Office of the Attorney General

CIVHC: Colorado’s All Payer Claims Database