The Colorado Department of Labor and Employment officially adopted rule updates for Rule 16: Utilization Standards and Rule 18: Medical Fee Schedule. These changes followed a rulemaking process that included stakeholder feedback and public meetings. The adopted changes are effective January 1, 2027.

Across both Rules, many definitions were added, updated, or deleted, which may impact the facilitation of care on multiple levels.

Changes from Rule 16: Utilization Standards include:

• Updated definitions for what constitute a federally qualified health center, home care agencies, inpatient rehabilitation facilities, advanced practice providers, rural health clinics, and more
• Clarifying language regarding out-of-state providers
• Clarifying language regarding prior authorizations, non-medical denials, and IMEs
• Modified language regarding acceptance of a complete medical bill by the payer
• Language clarifications regarding the retroactive review of bills, appeals, reconsiderations, corrected bills, and denied claims

Changes from Rule 18: Medical Fee Schedule include:

• Significant changes to DME, such as rental thresholds, when maintenance is separately payable, a new policy for the reimbursement of knee scooters, new language for hearing supplies, clarifying language for vision supplies, and more
• Updated rules for topical analgesics, compound medications, physician dispensing, OTC drugs, repackaged drugs
• Revised opioid prescribing guidance
• Revised language for home care services, including which require prior authorization
• New conversion factors for anesthesia, surgery, radiology, pathology, and medicine, physical medicine and rehabilitation, and evaluation and management
• Modified anesthesia time reporting
• Revised language regarding physical medicine and rehabilitation evaluation
• A condition where and APP maybe be paid 100% of the fee schedule
• New language regarding reduced or discontinued professional services
• Revised wound care language addressing negative pressure wound therapy
• Revised language for complementary medicine, such as yoga, qigong, and reiki
• Updated rules for telemedicine services that require prior authorization
• Updated language and thresholds for outlier reimbursement language services
• New reimbursement rules for rural health clinics