§ 25.5-5-419. Accountable Care Collaborative – Reporting – Rules
In 2011, the state department created the accountable care collaborative, also referred to in this title 25.5 as the medicaid coordinated care system. The state department shall continue to provide care delivery through the accountable care collaborative. The goals of the accountable care collaborative are to improve member health and reduce costs in the medicaid […]
§ 25.5-5-420. Advancing Care for Exceptional Kids
Within one hundred twenty days of the enactment of the federal “Advancing Care for Exceptional Kids Act”, subject to available appropriations, the state department shall seek any federal approval necessary to fund, in cooperation with hospitals that meet the specified requirements, the implementation of an enhanced pediatric health home for children with complex medical conditions. […]
§ 25.5-5-421. Parity Reporting – State Department – Public Input
The state department shall require each MCE contracted with the state department to disclose all necessary information in order for the state department, by June 1, 2020, and by each June 1 thereafter, to submit a report to the health and insurance committee and the public health care and human services committee of the house […]
§ 25.5-5-422. Medication-Assisted Treatment – Limitations on Mces – Definition
As used in this section, “FDA” means the food and drug administration in the United States department of health and human services. Notwithstanding any provision of law to the contrary, beginning January 1, 2020, each MCE that provides prescription drug benefits for the treatment of substance use disorders shall: Not impose any prior authorization requirements […]
§ 25.5-5-423. Independent Review Organization – Review Denial of Residential and Inpatient Substance Use Disorder Treatment Claims – Contract
No later than July 1, 2023, the state department shall contract with one or more independent review organizations to conduct external medical reviews requested for review by a medicaid provider when there is a denial or reduction for residential or inpatient substance use disorder treatment and medicaid appeals processes have been exhausted. Source: L. 2021: […]
§ 25.5-5-424. Residential and Inpatient Substance Use Disorder Treatment – Mce Standardized Utilization Management Process – Medical Necessity – Report
On or before October 1, 2021, the state department shall consult with the office of behavioral health in the department of human services, residential treatment providers, and MCEs to develop standardized utilization management processes to determine medical necessity for residential and inpatient substance use disorder treatment. The processes must incorporate the most recent edition of […]
§ 25.5-5-425. Audit of Mce Denials for Residential and Inpatient Substance Use Disorder Treatment Authorization – Report
No later than July 1, 2022, the state department shall contract with an independent third-party vendor to audit thirty-three percent of all denials of authorization for inpatient and residential substance use disorder treatment for each MCE. Beginning December 1, 2022, and each December 1 thereafter, the state department shall submit the results of the audit […]
§ 25.5-5-500.3. Authorization to Bill Third Party
As a condition of doing business in the state, each provider is deemed to authorize the state department, or an independent contractor retained by the state department, to bill a third party, as defined in section 25.5-4-209 (2)(g)(II), on behalf of the provider if the third party is determined to be liable to pay for […]
§ 25.5-5-501. Providers – Drug Reimbursement
As to drugs for which payment is made, the state board’s rules for payment must include the requirement that the generic equivalent of a brand-name drug be prescribed if the generic equivalent is a therapeutic equivalent to the brand-name drug, except when reimbursement to the state for a brand-name drug makes the brand-name drug less […]
§ 25.5-5-502. Unused Medications – Reuse – Rules – Definition
As used in this section, unless the context otherwise requires, “medication” means prescription medication that is not a controlled substance. A pharmacist participating in the medical assistance program may accept unused medication from a licensed facility, as defined in section 12-280-135 (1)(b), or a licensed health-care provider for the purpose of dispensing the medication to […]