A Bill for an Act
Page 1, Line 101Concerning changes to out-of-network health-care services
Page 1, Line 102dispute resolution processes for health insurance
Page 1, Line 103carriers.
Bill Summary
(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://leg.colorado.gov.)
The bill makes changes to the dispute resolution process between health insurance carriers (carriers) and out-of-network health-care providers (providers) by:
- Mandating that a carrier provide a remittance advice with each payment made to a provider;
- Establishing penalties that the division of insurance (division) may assess against a carrier that fails to properly reimburse a provider for services provided to a patient;
- Requiring a carrier to annually submit information to the division concerning patient use of out-of-network providers; and
- Requiring the division to produce an annual report regarding patient use of out-of-network providers and relevant arbitration data and statistics.
Page 2, Line 1Be it enacted by the General Assembly of the State of Colorado:
Page 2, Line 2SECTION 1. In Colorado Revised Statutes, 10-16-704, amend
Page 2, Line 3(13); and recreate and reenact, with amendments, (14) and (16) as
Page 2, Line 4follows:
Page 2, Line 510-16-704. Network adequacy - required disclosures - balance
Page 2, Line 6billing - rules - legislative declaration - definitions.
Page 2, Line 7(13) (a) (I) The general assembly finds and declares that:
Page 2, Line 8(A) Under current state law, providers resolve
Page 2, Line 9out-of-network reimbursement disputes through an individual,
Page 2, Line 10claim-by-claim arbitration process that is prohibitively
Page 2, Line 11expensive and administratively burdensome;
Page 2, Line 12(B) The current fragmented process creates de facto
Page 2, Line 13immunity for carriers to systemically underpay claims because
Page 2, Line 14the cost of a single arbitration often exceeds the amount of the
Page 2, Line 15disputed reimbursement, which practice particularly impacts
Page 2, Line 16smaller provider groups;
Page 2, Line 17(C) The division has an established complaint process that
Page 2, Line 18allows providers to submit complaints to ensure that payment
Page 2, Line 19requirements are met by carriers. This established complaint
Page 2, Line 20process requires the resolution of claims within thirty days
Page 3, Line 1after the complaint containing the claims has been filed if there
Page 3, Line 2are one hundred or fewer claims submitted on the complaint
Page 3, Line 3form and allows for additional time when there are more than
Page 3, Line 4one hundred claims submitted on the complaint form. However,
Page 3, Line 5the complaint process does not ensure prompt payment to
Page 3, Line 6providers of money owed when carriers are deemed to have
Page 3, Line 7violated payment requirements.
Page 3, Line 8(D) To improve fairness in the health-insurance market,
Page 3, Line 9the division's existing oversight and enforcement authority of
Page 3, Line 10carrier payments to providers should be augmented to compel
Page 3, Line 11prompt payment from carriers when underpayment is identified
Page 3, Line 12in the complaint process, thereby providing a more effective
Page 3, Line 13pathway for providers to challenge underpayment;
Page 3, Line 14(E) Effective dispute resolution is further hindered
Page 3, Line 15because carriers frequently fail to disclose whether a patient's
Page 3, Line 16health benefit plan is governed by state law or the "Employee
Page 3, Line 17Retirement Income Security Act of 1974", 29 U.S.C. sec. 1001 et
Page 3, Line 18seq., leaving providers unable to determine in which jurisdiction
Page 3, Line 19the provider may appeal; and
Page 3, Line 20(F) The division requires a clear statutory mandate to
Page 3, Line 21collect specific reimbursement methodology data and to
Page 3, Line 22reinstate formal reporting of out-of-network utilization in
Page 3, Line 23order to ensure that the transparency goals of this section are
Page 3, Line 24fully realized.
Page 3, Line 25(II) The general assembly therefore intends for this
Page 3, Line 26subsection (13) and subsections (14) and (16) of this section to:
Page 3, Line 27(A) Streamline out-of-network dispute resolutions by
Page 4, Line 1granting the division additional enforcement authority within
Page 4, Line 2its out-of-network complaint process, including a requirement
Page 4, Line 3to compel prompt payment from carriers when underpayment is
Page 4, Line 4identified;
Page 4, Line 5(B) Require jurisdictional transparency by mandating
Page 4, Line 6that carriers clearly state on a remittance advice whether a
Page 4, Line 7health benefit plan is regulated by state law or federal law;
Page 4, Line 8(C) Empower data-driven enforcement by requiring
Page 4, Line 9carriers to disclose the specific methodologies used to
Page 4, Line 10determine out-of-network reimbursement and by granting the
Page 4, Line 11commissioner authority to order corrective payments and
Page 4, Line 12impose fines for noncompliance; and
Page 4, Line 13(D) Restore public accountability by reinstating the
Page 4, Line 14requirement that the division publish an annual report on the
Page 4, Line 15implementation and impact of the state's out-of-network
Page 4, Line 16payment laws.
Page 4, Line 17
(a)Page 4, Line 18health-care facility pursuant to subsection (3)(d) or (5.5)(b) of this
Page 4, Line 19section, the provider or the facility may request, and the commissioner
Page 4, Line 20shall collect, data from the carrier to evaluate the carrier's compliance in
Page 4, Line 21paying the highest rate required. The information
requested mayPage 4, Line 22provided must include the methodology for determining the carrier's
Page 4, Line 23median in-network rate
orPage 4, Line 24same geographic area.
Page 4, Line 25
(b) Repealed.Page 4, Line 26(c) When a carrier makes a payment to a provider or a
Page 4, Line 27health-care facility pursuant to subsection (3)(d) or (5.5)(b) of
Page 5, Line 1this section, the carrier shall provide a remittance advice that
Page 5, Line 2identifies whether the health benefit plan the carrier is making
Page 5, Line 3the payment pursuant to is regulated by the state or the
Page 5, Line 4federal government.
Page 5, Line 5(d) If the commissioner finds, based on the information
Page 5, Line 6provided by the carrier pursuant to subsection (13)(b) of this
Page 5, Line 7section, that the carrier did not properly reimburse a provider
Page 5, Line 8for services provided to a covered person who has a health
Page 5, Line 9benefit plan issued and delivered in the state pursuant to
Page 5, Line 10subsection (3)(d) or (5.5)(b) of this section, the commissioner
Page 5, Line 11shall order the carrier to pay:
Page 5, Line 12(I) The provider in compliance with subsection (3)(d) or
Page 5, Line 13(5.5)(b) of this section;
Page 5, Line 14(II) Any additional amounts that may be due under section
Page 5, Line 1510-16-106.5; and
Page 5, Line 16(III) A fine that the commissioner assesses and in an
Page 5, Line 17amount that the commissioner deems appropriate based on the
Page 5, Line 18facts.
Page 5, Line 19(14) Beginning on January 1, 2027, and on or before
Page 5, Line 20January 1 of each year thereafter, each carrier shall submit
Page 5, Line 21information to the commissioner, in a form and manner
Page 5, Line 22determined by the commissioner, concerning the use of
Page 5, Line 23out-of-network providers and health-care facilities by covered
Page 5, Line 24persons and the impact on premium affordability for consumers.
Page 5, Line 25(16) Notwithstanding section 24-1-136 (11)(a)(I), on or
Page 5, Line 26before July 1, 2027, and on or before each July 1 thereafter, the
Page 5, Line 27commissioner shall produce a report that the commissioner
Page 6, Line 1posts on the division's website and submits to the health and
Page 6, Line 2human services committee of the senate and the health and
Page 6, Line 3human services committee of the house of representatives, or
Page 6, Line 4their successor committees. The report must summarize:
Page 6, Line 5(a) The information submitted to the commissioner
Page 6, Line 6pursuant to subsection (14) of this section; and
Page 6, Line 7(b) The number of complaints filed in the previous
Page 6, Line 8calendar year; the number of complaints settled, arbitrated,
Page 6, Line 9and dismissed in the previous calendar year; and a summary
Page 6, Line 10reflecting the number of complaints resolved in favor of the
Page 6, Line 11carrier or in favor of the provider or health-care facility. The
Page 6, Line 12report submitted pursuant to this subsection (16) must not
Page 6, Line 13include any information that specifically identifies the
Page 6, Line 14provider, health-care facility, carrier, or covered person
Page 6, Line 15involved in each decision.
Page 6, Line 16SECTION 2. Act subject to petition - effective date -
Page 6, Line 17applicability. (1) This act takes effect at 12:01 a.m. on the day following
Page 6, Line 18the expiration of the ninety-day period after final adjournment of the
Page 6, Line 19general assembly (August 12, 2026, if adjournment sine die is on May 13,
Page 6, Line 202026); except that, if a referendum petition is filed pursuant to section 1
Page 6, Line 21(3) of article V of the state constitution against this act or an item, section,
Page 6, Line 22or part of this act within such period, then the act, item, section, or part
Page 6, Line 23will not take effect unless approved by the people at the general election
Page 6, Line 24to be held in November 2026 and, in such case, will take effect on the
Page 6, Line 25date of the official declaration of the vote thereon by the governor.
Page 6, Line 26(2) This act applies to payments owed by health insurance carriers
Page 6, Line 27on or after the applicable effective date of this act.