C.R.S.
Section 12-30-112
Health-care providers
- required disclosures
- balance billing
- deceptive trade practice
- rules
- definitions
(1)
As used in this section and section 12-30-113:(a)
“Ancillary services” means:(I)
Diagnostic services, including radiology and laboratory services, unless excluded by rule of the secretary of the United States department of health and human services pursuant to 42 U.S.C. sec. 300gg-132 (b)(3);(II)
Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether or not provided by a physician or nonphysician provider, unless excluded by rule of the secretary of the United States department of health and human services pursuant to section 2799B-2 (b)(3) of the federal “No Surprises Act”;(III)
Items and services provided by assistant surgeons, hospitalists, and intensivists, unless excluded by rule of the secretary of the United States department of health and human services pursuant to section 2799B-2 (b)(3) of the federal “No Surprises Act”;(IV)
Items and services provided by an out-of-network provider if there is no in-network provider who can furnish the needed services at the facility; and(V)
Any other items and services provided by specialty providers as established by rule of the commissioner of insurance.(a.3)
“Balance bill” has the same meaning as set forth in section 10-16-704 (19)(c).(a.5)
“Carrier” has the same meaning as set forth in section 10-16-102 (8).(b)
“Covered person” has the same meaning as defined in section 10-16-102 (15).(c)
“Emergency services” has the same meaning as set forth in section 10-16-704 (19)(e).(c.5)
“Federal ’No Surprises Act’” means the federal “No Surprises Act”, Pub.L. 116-260, as amended.(d)
“Geographic area” has the same meaning as set forth in section 10-16-704 (19)(h).(e)
“Health benefit plan” has the same meaning as defined in section 10-16-102 (32).(f)
“Medicare reimbursement rate” has the same meaning as set forth in section 10-16-704 (19)(k).(g)
“Out-of-network provider” means a health-care provider that is not a participating provider.(h)
“Participating provider” has the same meaning as set forth in section 10-16-102 (46).(2)
On and after January 1, 2020, health-care providers shall develop and provide disclosures to consumers about the potential effects of receiving emergency or nonemergency services from an out-of-network provider. The disclosures must comply with the rules adopted pursuant to subsection (3) of this section.(3)
The regulator, in consultation with the commissioner of insurance and the state board of health created in section 25-1-103, shall adopt rules that specify the requirements for health-care providers to develop and provide consumer disclosures in accordance with this section. The regulator shall ensure that the rules, at a minimum, comply with the notice and consent requirements in subsection (3.5) of this section and the federal “No Surprises Act”.(3.5)
Intentionally left blank —Ed.(a)
An out-of-network provider may balance bill a covered person for post-stabilization services in accordance with section 10-16-704 and covered nonemergency services in an in-network facility that are not ancillary services if:(I)
The out-of-network provider provides written notice that the provider will balance bill a covered person at least seventy-two hours in advance of the date of service, if the appointment was scheduled at least seventy-two hours in advance, or at least three hours before the scheduled appointment, if the appointment was made less than seventy-two hours in advance, in either paper or electronic format as selected by the covered person. The notice must be available in the fifteen most common languages in the geographic region in which the out-of-network provider is located. The notice must state:(A)
If applicable, that the health-care provider is out of network with respect to the covered person’s health benefit plan;(B)
Effective upon the implementation date of the applicable federal rules, a good-faith estimate of the amount of the charges for which the covered person may be responsible;(C)
That the estimate or consent to treatment does not constitute a contract for services;(D)
If the facility is a participating provider and the health-care provider is an out-of-network provider, a list of participating providers at the facility who are able to provide the same services;(E)
Information about whether prior authorization or other care management limitations may be required in advance of receiving the requested services; and(F)
That consent to receive the services from an out-of-network provider is optional and that the covered person may seek services from a participating provider, in which case the cost-sharing responsibility of the covered person would not exceed the responsibility for in-network benefits under the covered person’s health benefit plan;(II)
The out-of-network provider obtains signed consent from the covered person that acknowledges that the covered person has been:(A)
Provided with written notice of the covered person’s financial responsibility, in the format and language selected by the covered person and within the applicable periods specified in subsection (3.5)(a)(I) of this section; and(B)
Provided written notice that the payment by the covered person for health-care services provided by the out-of-network provider may not accrue toward meeting any limitation that the health benefit plan places on cost sharing, including an explanation that the payment may not apply to an in-network deductible.(b)
If the notice in subsection (3.5)(a)(I) of this section is received within ten days before a scheduled service, the covered person may elect to use the out-of-network provider at the in-network benefit level, and the provider must be reimbursed for the services in accordance with section 10-16-704 (3)(d)(II).(c)
The notice and consent required by this subsection (3.5) must include the date and the time at which the covered person received the written notice and the date on which the consent form was signed. The out-of-network provider shall provide a signed copy of the consent form to the covered person through regular or electronic mail.(d)
An out-of-network provider that obtains a signed consent with respect to furnishing an item or service shall retain the signed consent for at least a seven-year period after the date on which such item or service is furnished.(4)
Receipt of the disclosures required by this section does not waive a consumer’s protections under section 10-16-704 (3) or (5.5) or the consumer’s right to benefits under the consumer’s health benefit plan at the in-network benefit level for all covered services and treatment received.(5)
This section does not apply to service agencies, as defined in section 25-3.5-103 (11.5), that are publicly funded fire agencies.(6)
A violation of this section is a deceptive trade practice pursuant to section 6-1-105 (1)(xxx).
Source:
Section 12-30-112 — Health-care providers - required disclosures - balance billing - deceptive trade practice - rules - definitions, https://leg.colorado.gov/sites/default/files/images/olls/crs2023-title-12.pdf (accessed Oct. 20, 2023).
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