Colo. Rev. Stat. § 25.5-8-109

Current through 11/5/2024 election

Section 25.5-8-109 - Eligibility - children - pregnant women - rules - repeal

(1) To be eligible for a subsidy, a child must not be insured by a comparable health plan through an employer.

(2) If one child from a family is enrolled in the plan, all children must be enrolled, unless the other children have alternative health insurance coverage.

(3) The department may establish procedures such that children with family incomes that exceed the percent of the federal poverty guidelines specified in section 25.5-8-103 (4)(a) may enroll in the plan, but are not eligible for subsidies from the department.

(4) A child whose family income does not exceed the applicable level specified in section 25.5-8-103 (4)(a) shall be presumptively eligible for the plan. Children who are determined to be eligible for the plan shall remain eligible for twelve months subsequent to the last day of the month in which they were enrolled; except that a child shall no longer be eligible for the plan and shall be disenrolled from the plan if the department becomes aware of or is notified that any of the following has occurred:

(a) The child has moved out of the state; or

(b) Repealed.

(c) The child has been enrolled in a commercial health insurance plan during the twelve-month period following enrollment in the plan under this article.

(4.5)

(a)

(I) To the extent authorized by federal law, the department shall require an applicant to state only the applicant's family income and shall notify the applicant that the applicant's family income will be verified by federally approved electronic data sources. The department shall allow an applicant to provide income information more recent than the records of the federally approved electronic data sources.

(II) The department shall annually verify the member's income eligibility at reenrollment through federally approved electronic data sources. If a Member meets all eligibility requirements, a Member remains enrolled in the plan. The department shall also allow a Member to provide income information more recent than the records of federally approved electronic data sources.

(III) If the state department determines that a Member was not eligible for medical benefits solely based upon the member's income after the Member had been determined to be eligible based upon information verified through federally approved electronic data sources, the state department shall not pursue recovery from a county department for the cost of medical services provided to the Member, and the county department is not responsible for any federal error rate sanctions resulting from the determination.

(IV) Notwithstanding any other provision in this paragraph (a), for applications that contain self-employment income, the state department shall not implement this paragraph (a) until it can verify self-employment income through federally approved electronic data sources as authorized by rules of the state department and federal law.

(V) The county department, state department, or other entity designated by the state department to make the eligibility determination shall automatically transfer to the state insurance marketplace through a system interface the application data and verifications of a child or pregnant woman who is determined ineligible for medical assistance benefits pursuant to this section.

(VI) The state department may seek federal authorization to not require additional verification during a member's eligibility reenrollment process if information about the member's income is not verified through a federally approved electronic data source. The state department may use the information on file or the information that was originally collected during the application process to determine whether the member is eligible for reenrollment. Notwithstanding this subsection (4.5)(a)(VI) to the contrary, the state department shall require additional income verification if information about a member's income is not verified through a federally approved electronic data source for two or more consecutive years or as specified through federal authorization.

(VII) The state department may seek federal authorization to not require additional verification during a member's eligibility reenrollment process if information about the member's assets is not verified through a federally approved electronic data source in a reasonable time, as determined by the state department. The state department may complete the member's eligibility reenrollment process without any additional verification of the member's assets if there has been no change in the member's assets since the initial verification during the application process or as specified through federal authorization.

(VIII) The state department may seek federal authorization to delay a member's procedural termination during the reenrollment process to allow the member to continue receiving necessary services during the reenrollment process. The state department may apply this delay in procedural termination to a specific population or as specified through federal authorization.

(IX) The state department may seek federal authorization to allow an applicant's or member's eligibility for reenrollment to be based on financial findings from the supplemental nutrition assistance program established pursuant to part 3 of article 2 of title 26, the temporary assistance for needy families program established pursuant to part 7 of article 2 of title 26, and other means-tested benefit programs administered through the Colorado benefits management system. the state department may apply financial eligibility for medicaid to individuals whose gross income program and assets for applicable means-tested benefit programs are below applicable medicaid limits, regardless of differences in household composition and income-counting rules between programs or as specified through federal authorization.

(X) Subject to available appropriations and upon receiving necessary federal authorization, the state department may implement subsections (4.5)(a)(VI), (4.5)(a)(VII), (4.5)(a)(VIII), and (4.5)(a)(IX) of this section.

(b) Repealed.

(c) Subject to the provisions and requirements of section 25.5-4-205 (3)(e), the department shall establish a process so that an enrollee or the parent or guardian of an enrollee may apply for reenrollment either over the telephone or through the internet.

(5)

(a)

(I) A pregnant woman whose family income does not exceed the applicable level specified in section 25.5-8-103 (4)(b) shall be presumptively eligible for the plan. Once determined eligible for the plan, a pregnant woman shall be considered to be continuously eligible throughout the pregnancy and for the sixty days following the pregnancy, even if the woman's eligibility would otherwise terminate during such period due to an increase in income. Upon birth, a child born to a woman eligible for the plan shall be eligible for the plan and shall be automatically enrolled in the plan in accordance with the eligibility requirements for children specified in subsection (4) of this section.

(II) Repealed.

(b)

(I) Under the plan, prenatal and postpartum primary health-care providers shall implement policies regarding the integration of evidence-based tobacco use treatments into the regular health-care delivery system, including, but not limited to:

(A) Assessment of tobacco use and exposure to second-hand smoke;

(B) Education on the dangers of tobacco use during pregnancy and postpartum;

(C) Referrals to appropriate cessation services.

(II) Health-care providers may coordinate the implementation of such policies with the tobacco education, prevention, and cessation programs established in section 25-3.5-804, C.R.S.

(c) The addition of coverage under the plan for pregnant women shall only be implemented if the department obtains a waiver from the federal department of health and human services.

(d) Enrollment of a pregnant woman in the plan shall be limited based upon annual appropriations made out of the trust by the general assembly as described in section 25.5-8-105 and any grants and donations. The general assembly shall annually establish maximum enrollment figures for pregnant women in the plan. The department shall not exceed the enrollment caps regardless of whether the funding comes from annual appropriations or grants and donations.

(5.5)

(a) Subject to the receipt of federal financial participation, to the maximum extent allowed under federal law, a person who was eligible for the plan while pregnant and who remains eligible for the plan for the sixty days following the pregnancy remains continuously eligible for all services under the plan for the twelve-month postpartum period.

(b) The department shall seek any plan amendment necessary to implement a twelve-month postpartum benefit pursuant to this subsection (5.5) and shall implement the benefit only upon receipt of federal authorization and financial participation, and no later than July 1, 2022.

(c) If permissible under federal law, an eligible individual within the postpartum period may resume coverage under the plan upon implementation of this section.

(6)

(a) Notwithstanding any other provision of law, but subject to the receipt of federal financial participation, the department shall provide benefits pursuant to this article 8 to a pregnant person who is lawfully residing, as defined in section 25.5-4-103 (10), and a child less than nineteen years of age, who is lawfully residing, so long as such pregnant person or child meets eligibility criteria other than those related to citizenship or immigration status.

(7)

(a) Beginning no later than January 1, 2025, notwithstanding any other provision of law, the department shall provide benefits pursuant to this article 8 to a pregnant person who is not a citizen and is not eligible pursuant to subsection (6) of this section, so long as the pregnant person meets the eligibility criteria other than those related to citizenship or immigration status. Eligibility pursuant to this section extends continuously through the twelve-month postpartum period, so long as eligibility remains in effect pursuant to subsection (5.5)(a) of this section.

(b) The department shall seek any necessary federal approvals to maximize any available federal financial participation in implementing this subsection (7).

(c)

(I) During its 2024 presentation to the joint budget committee of the general assembly and in its presentation to the health and human services committee of the senate and the health and insurance committee of the house of representatives, or any successor committees, at the hearing held pursuant to section 2-7-203 (2)(a) of the "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act", the state department shall report on its plans and progress in implementing the coverage expansion created pursuant to this subsection (7).

(II) Beginning January 1, 2026, and continuing every January thereafter, the state department, in its presentation to the joint budget committee of the general assembly and in its presentation to the health and human services committee of the senate and the health and insurance committee of the house of representatives, or any successor committees, at the hearing held pursuant to section 2-7-203 (2)(a) of the "State Measurement for Accountable, Responsive, and Transparent (SMART) Government Act", shall report on the cost savings and health improvements associated with the coverage expansion created pursuant to this subsection (7).

(d) This subsection (7) constitutes state authority within the meaning of 8 U.S.C. sec. 1621 (d), as that law existed on January 1, 2022.

(8)

(a) To ensure that the state department maintains access to state and federal funding provided by the federal "Families First Coronavirus Response Act", Pub.L. 116-127, and the federal "Consolidated Appropriations Act, 2023", subsections (4) and (4.5)(a)(II) of this section requiring the state department to disenroll an individual enrolled in the children's basic health plan due to the annual verification of income, as authorized by the centers for medicare and medicaid services, are suspended until January 1, 2025.

(b) The state board may adopt rules to implement this subsection (8) to ensure that the state department can resume routine operations that follow guidance issued by the federal centers for medicare and medicaid services, including terminations of eligibility, the processing of eligibility renewals, and the transition between medical assistance and children's basic health plan eligibility categories.

(c) This subsection (8) is repealed, effective January 1, 2025.

C.R.S. § 25.5-8-109

Amended by 2024 Ch. 152,§ 99, eff. 8/7/2024.

Amended by 2024 Ch. 77,§ 5, eff. 4/18/2024.

Amended by 2023 Ch. 118,§ 5, eff. 4/27/2023.

Amended by 2022 Ch. 399, § 22, eff. 6/7/2022.

Amended by 2021 Ch. 434, § 8, eff. 9/7/2021.

L. 2006: (5)(a) amended, p. 1121, § 1, effective May 25; entire article added with relocations, p. 1981, § 7, effective July 1. L. 2007: (5)(a)(I) and (5)(a)(II)(A) amended, p. 151, § 12, effective March 22; (3), IP(4), and (4)(b) amended, p. 1493, § 6, effective 1/1/2008. L. 2008: (4.5) added, p. 2026, § 2, effective June 3; (5)(a)(I) amended, p. 2020, § 5, effective 10/1/2009. L. 2009: (4.5)(c) added, (HB 09 -1020), ch. 298, p. 1596, § 2, effective May 21; (6) added, (HB 09 -1353), ch. 360, p. 1870, § 3, effective 7/1/2010. L. 2012: (4.5)(a)(I), (4.5)(a)(II), and (4.5)(a)(III) amended, (HB 12-1120), ch. 27, p. 109, § 26, effective June 1. L. 2013: (1) amended, (SB 13-008), ch. 78, p. 251, § 1, effective March 29. L. 2014: (4)(a) and (4.5)(a) amended and (4)(b) repealed, (SB 14-067), ch. 12, p. 114, § 8, effective February 27.

(1) This section is similar to former § 26-19-109 as it existed prior to 2006.

(2) Amendments to section 26-19-109(5)(a) by Senate Bill 06-135 were harmonized with subsection (5)(a) as it appeared in Senate Bill 06-219.

(3) Subsection (5)(a)(II)(B) provided for the repeal of subsection (5)(a)(II), effective July 1, 2007. (See L. 2006, pp. 1121, 1981.)

(4) Subsection (4.5)(b)(II) provided for the repeal of subsection (4.5)(b), effective July 1, 2009. (See L. 2008, p. 2026.)

(5) The effective date for amendments to subsections (4.5)(a)(I), (4.5)(a)(II), and (4.5)(a)(III) by House Bill 12-1120 (chapter 27, Session Laws of Colorado 2012) was changed from August 8, 2012, to June 1, 2012, by House Bill 12S-1002 (First Extraordinary Session, chapter 2, p. 2432, Session Laws of Colorado 2012.)

2024 Ch. 152, was passed without a safety clause. See Colo. Const. art. V, § 1(3).

For the legislative declaration contained in the 2007 act amending subsections (3) and (4)(b) and the introductory portion to subsection (4), see section 1 of chapter 347, Session Laws of Colorado 2007.