Colorado Medicaid Access to Primary Care Services

Second Regular Session Seventy-fifth General Assembly STATE OF COLORADO REENGROSSED This Version Includes All Amendments Adopted in the House of Introduction HOUSE BILL 26-1096 LLS NO. 26-0044.01 Chelsea Princell x4335 HOUSE SPONSORSHIP Johnson and Feret, Bradley, Garcia Sander, Gonzalez R., Keltie, Weinberg, Winter T.

SENATE SPONSORSHIP Rich, House Committees Senate Committees Health & Human Services A BILL FOR AN ACT COLORADO MEDICAID MEMBERS.

The bill prohibits the department of health care policy and financing (department) from denying a medicaid member (member) the ability to purchase primary care services or enter into a direct primary care agreement. A member who purchases direct primary care services from a direct primary health-care provider or enters into a direct primary care agreement must sign a document acknowledging that the direct Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.

Capital letters or bold & italic numbers indicate new material to be added to existing law. Dashes through the words or numbers indicate deletions from existing law.

February 23, 2026 (Note: This summary applies to this bill as introduced and does not reflect any amendments that may be subsequently adopted. If this bill passes third reading in the house of introduction, a bill summary that applies to the reengrossed version of this bill will be available at http://www.leg.state.co.us/billsummaries.) HOUSE Bill Summary 3rd Reading Unamended CONCERNING ACCESS TO DIRECT PRIMARY CARE SERVICES FOR HOUSE Amended 2nd Reading February 20, 2026 primary health-care provider is enrolled in the Colorado medical assistance program only as an ordering, prescribing, and referring provider; that the direct primary health-care provider does not accept medicaid payments for the services rendered; that the member cannot submit a claim for medicaid reimbursement for the services rendered by the direct primary health-care provider; and that the member retains the right to receive primary care services from a primary care provider who is enrolled in the Colorado medical assistance program.

Be it enacted by the General Assembly of the State of Colorado:

SECTION 1. Legislative declaration. (1) The general assembly finds that:

(a) The public policy of the state of Colorado promotes access to medical care for all Colorado citizens by encouraging innovative, cost-saving arrangements;

(b) Direct primary health-care providers use a model of health-care delivery based on a periodic fee for a specified period of time, rather than a fee-for-service arrangement financed through health insurance;

(c) Direct primary care services represent an option that can improve access to affordable primary care services, increasing the health and well-being of patients;

(d) Although direct primary care services are not reimbursable by medicaid, a medicaid member who utilizes a direct primary health-care provider is still able to use their medicaid benefits for services not provided by the medicaid member's direct primary health-care provider;

and

(e) Patients in Colorado, including those on medicaid, have the right to choose the providers that best fit their unique health needs and have the ability to access health-care providers that are closer to home, when available. Access to timely and appropriate primary care is a crucial component of ensuring the health and well-being of our communities, particularly in rural and frontier areas where access to clinics, providers, and other resources may be limited.

(2) Therefore, the general assembly declares that Coloradans enrolled in medicaid must have the option to access direct primary health-care providers, and direct primary health-care providers must be allowed to opt-in to providing services to medicaid patients.

SECTION 2. In Colorado Revised Statutes, 6-23-101, amend the introductory portion; and add (2.5) as follows:

6-23-101. Definitions.

As used in this section ARTICLE 23, UNLESS THE CONTEXT OTHERWISE REQUIRES:

"MEMBER" HAS THE MEANING SET FORTH IN SECTION

SECTION 3. In Colorado Revised Statutes, add 6-23-106 as follows: 6-23-106. Direct primary care - medicaid members - federal authorization - report - definition - repeal.

(1) AS USED IN THIS SECTION, UNLESS THE CONTEXT OTHERWISE REQUIRES, "ORDERING, PRESCRIBING, OR REFERRING PROVIDER" MEANS A PHYSICIAN OR AN ELIGIBLE NON-PHYSICIAN PRACTITIONER ENROLLED IN THE COLORADO MEDICAL ASSISTANCE PROGRAM WHO ORDERS TESTS, SERVICES, OR MEDICATIONS FOR A MEMBER BUT DOES NOT BILL THE COLORADO MEDICAL ASSISTANCE PROGRAM FOR THE SERVICES DIRECTLY.

(2) THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING SHALL NOT PROHIBIT A MEMBER FROM PURCHASING PRIMARY CARE SERVICES OR ENTERING INTO A DIRECT PRIMARY CARE AGREEMENT.

A DIRECT PRIMARY HEALTH-CARE PROVIDER SHALL NOT SUBMIT A FEE-FOR-SERVICE CLAIM FOR PRIMARY CARE SERVICES RENDERED TO MEDICAID FOR REIMBURSEMENT.

(4) A MEMBER WHO PURCHASES PRIMARY CARE SERVICES FROM A DIRECT PRIMARY HEALTH-CARE PROVIDER OR ENTERS INTO A DIRECT PRIMARY CARE AGREEMENT WITH A DIRECT PRIMARY HEALTH-CARE PROVIDER MUST SIGN A DOCUMENT PROVIDED BY THE DIRECT PRIMARY HEALTH-CARE PROVIDER ACKNOWLEDGING THE FOLLOWING:

(a) THE DIRECT PRIMARY HEALTH-CARE PROVIDER IS ENROLLED IN THE COLORADO MEDICAL ASSISTANCE PROGRAM ONLY AS AN ORDERING, PRESCRIBING, AND REFERRING PROVIDER AND THE DIRECT PRIMARY HEALTH-CARE PROVIDER DOES NOT ACCEPT MEDICAID PAYMENTS FOR THE SERVICES RENDERED;

(b) THE MEMBER MAY NOT SUBMIT A CLAIM FOR MEDICAID REIMBURSEMENT FOR PRIMARY CARE SERVICES RENDERED BY THE DIRECT PRIMARY HEALTH-CARE PROVIDER PURSUANT TO THE DIRECT PURCHASE OF PRIMARY CARE SERVICES OR AS A RESULT OF THE DIRECT PRIMARY CARE AGREEMENT ENTERED INTO BETWEEN THE DIRECT PRIMARY HEALTH-CARE PROVIDER AND THE MEMBER; AND

(c) THE MEMBER RETAINS THE RIGHT TO RECEIVE PRIMARY CARE SERVICES FROM A PRIMARY CARE PROVIDER WHO IS ENROLLED IN THE COLORADO MEDICAL ASSISTANCE PROGRAM.

(5) A DIRECT PRIMARY HEALTH-CARE PROVIDER WHO PROVIDES PRIMARY CARE SERVICES TO A MEMBER WHO DIRECTLY PURCHASES PRIMARY CARE SERVICES FROM THE DIRECT PRIMARY HEALTH-CARE PROVIDER OR AS A RESULT OF THE DIRECT PRIMARY CARE AGREEMENT ENTERED INTO BETWEEN THE DIRECT PRIMARY HEALTH-CARE PROVIDER AND THE MEMBER MUST ENROLL IN THE COLORADO MEDICAL ASSISTANCE PROGRAM AS AN ORDERING, PRESCRIBING, OR REFERRING PROVIDER TO ENSURE ORDERS, PRESCRIPTIONS, AND REFERRALS FOR MEMBERS ARE ACCEPTED AND PROCESSED APPROPRIATELY THROUGH THE COLORADO MEDICAL ASSISTANCE PROGRAM.

(6) THE DEPARTMENT OF HEALTH CARE POLICY AND FINANCING SHALL SEEK ANY FEDERAL AUTHORIZATION NECESSARY TO IMPLEMENT THIS SECTION.

(7) (a) ON OR BEFORE NOVEMBER 15, 2028, A DIRECT PRIMARY HEALTH-CARE PROVIDER WHO PROVIDES PRIMARY CARE SERVICES TO A MEMBER SHALL SUBMIT TO THE STATE DEPARTMENT:

(I) THE NUMBER OF MEMBERS THE DIRECT PRIMARY HEALTH-CARE PROVIDER HAS SERVED FROM AUGUST 12, 2026, TO NOVEMBER 1, 2028;

AND

(II) WHETHER THE DIRECT PRIMARY HEALTH-CARE PROVIDER WAS ENROLLED IN THE COLORADO MEDICAL ASSISTANCE PROGRAM AND DISENROLLED IN THE BETWEEN AUGUST 12, 2026, AND NOVEMBER 1, 2028, AND STARTED PROVIDING DIRECT PRIMARY CARE SERVICES TO MEMBERS DURING THAT TIME.

COLORADO MEDICAL ASSISTANCE PROGRAM

(b) ON OR BEFORE JANUARY 1, 2029, THE STATE DEPARTMENT SHALL INCLUDE AS PART OF ITS "SMART ACT" PRESENTATION REQUIRED BY SECTION 2-7-203 INFORMATION THAT IS READILY AVAILABLE ON:

(I) THE NUMBER OF MEMBERS SERVED BY DIRECT PRIMARY HEALTH-CARE PROVIDERS AS REPORTED BY THE DIRECT PRIMARY HEALTH-CARE PROVIDERS PURSUANT TO SUBSECTION (7)(a) OF THIS SECTION;

(II) THE NUMBER OF PRIMARY CARE PROVIDERS WHO WERE ENROLLED IN THE COLORADO MEDICAL ASSISTANCE PROGRAM AND REPORTED TO THE STATE DEPARTMENT PURSUANT TO SUBSECTION (7)(a) THAT THEY DISENROLLED IN THE COLORADO MEDICAL ASSISTANCE PROGRAM BETWEEN AUGUST 12, 2026, AND NOVEMBER 1, 2028;

(III) THE NUMBER OF PRIMARY CARE PROVIDERS WHO WERE ENROLLED IN THE COLORADO MEDICAL ASSISTANCE PROGRAM BEFORE AUGUST 12, 2026; AND

(IV) THE NUMBER OF PRIMARY CARE PROVIDERS WHO WERE ENROLLED IN THE COLORADO MEDICAL ASSISTANCE PROGRAM AFTER NOVEMBER 1, 2028.

SECTION 4. In Colorado Revised Statutes, 25.5-4-301, amend (1)(a)(III)(B) as follows:

25.5-4-301. Recoveries - overpayments - penalties - interest - adjustments - liens - review or audit procedures - cash fund - rules - definitions - repeal.

(1) (a) (III) (B) A member may enter into a written agreement with a third party or provider, INCLUDING A DIRECT PRIMARY CARE AGREEMENT, AS DEFINED IN SECTION 6-23-101, under which the member agrees to pay for items provided or services rendered that are outside of the network or plan protocols, INCLUDING DIRECT PRIMARY CARE RETAINER PAYMENTS MADE ON BEHALF OF THE MEMBER. The member's agreement to be personally liable for nonemergency, nonreimbursable items must be recorded on forms approved by the state board and signed and dated by both the member and the provider in advance of the services being rendered.

SECTION 5. Act subject to petition - effective date. This act takes effect at 12:01 a.m. on the day following the expiration of the ninety-day period after final adjournment of the general assembly (August 12, 2026, if adjournment sine die is on May 13, 2026); except that, if a referendum petition is filed pursuant to section 1 (3) of article V of the state constitution against this act or an item, section, or part of this act within such period, then the act, item, section, or part will not take effect unless approved by the people at the general election to be held in November 2026 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.