State Law

Code of Colorado Regs-3 CCR 702-4

07/31/2023 Colorado Regulation 4-2-67

Concerning Carrier Disclosures for Emergency and Non-Emergency Out-of-Network Services

OON-Payment Issues

Section 1 Authority

This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§10-1-109(1), 10-16-109, 10-16-704(12)(b) and 10-16-708, C.R.S.

Section 2 Scope and Purpose

The purpose of this regulation is to establish requirements for carriers to provide disclosures concerning a covered person’s financial responsibility for emergency and non-emergency services rendered by out-ofnetwork providers pursuant to HB 19-1174.

Section 3 Applicability

This regulation applies to carriers offering individual, small group and large group health benefit plans whose members may receive services from out-of-network providers on or after January 1, 2020, which are subject to the requirements of §§ 10-16-704(3) and 10-16-704(5.5), C.R.S. This regulation replaces Colorado Emergency Regulation 19-E-07 in its entirety.

Section 4 Definitions

A. “Carrier” shall have the same meaning as found at § 10-16-102(8), C.R.S.

B. “Covered person” shall have the same meaning as found at § 10-16-102(15), C.R.S.

C. “Emergency services” shall have the same meaning as found at § 10-16-704(5.5)(e)(II), C.R.S.

D. “Health care services” shall have the same meaning as found at § 10-16-102(33), C.R.S.

E. “Out-of-network provider” means, for the purposes of this regulation, a provider in this state that has not entered into a contract with a carrier or with its contractor or subcontractor to provide health care services to covered persons.

F. “Participating provider” shall have the same meaning as found at § 10-16-102(46), C.R.S.

G. “Preauthorization” means, for the purposes of this regulation, a pre-service or pre-treatment confirmation provided by a carrier, at the request of a covered person and/or his or her healthcare provider, indicating that the service(s) and/or treatment(s) being considered by the covered person will be covered by his or her health plan.

H. “Prior authorization” shall have the same meaning as found at § 10-16-112.5(7)(d), C.R.S.

I. “Provider” shall have the same meaning as found at § 10-16-102(56), C.R.S.

Section 5 Disclosure Requirements

A. When a covered person has incurred a claim for emergency or non-emergency health care
services from an out-of-network provider, and which is subject to the requirements of §§ 10-16-704(3) and 10-16-704(5.5), C.R.S., the carrier shall provide the disclosure contained in Appendix A as a separate document with any explanation of benefits form (EOB) that is provided to the covered person related to the payment and/or denial of an incurred claim subject to this regulation.

B. A description of the covered person’s protections required by §§ 10-16-704(3) and 10-16-
704(5.5), C.R.S., shall be provided:

1. In the covered person’s health plan documents;

2. In communications approving, in whole or in part, requests for preauthorization of
covered services; and

3. In communications approving, in whole or in part, covered services where a prior
authorization is required by the carrier.

C. The disclosure contained in Appendix A of this regulation shall be made available on a carrier’s public website in a clear and conspicuous manner.

D. Carriers shall make the disclosure contained in Appendix A of this regulation available in
languages other than English upon request to the carrier.

Section 6 Severability

If any provision of this regulation or the application of it to any person or circumstances is for any reason held to be invalid, the remainder of this regulation shall not be affected.

Section 7 Enforcement

Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.

Section 8 Effective Date

This regulation shall become effective April 15, 2020.

Section 9 History

Emergency regulation effective December 20, 2019.
Regulation effective April 15, 2020.

Appendix A: Emergency and Non-emergency Services Disclosure

[CARRIER LOGO] Surprise Billing — Know your rights

Beginning January 1, 2020, Colorado state law protects you from ”surprise billing”. This is sometimes
called “balance billing” and it may happen when you receive covered services, other than ambulance
services, from an out-of-network provider in Colorado. This law does not apply to all health plans and
may not apply to out-of-network providers located outside of Colorado. Check to see if you have a
“CO-DOI” on your ID card; if not, this law may not apply to your health plan.

What is surprise/balance billing and when does it happen?

You are responsible for the cost-sharing amounts required by your health plan, including copayments,
deductibles and/or coinsurance. If you are seen by a provider or use services in a hospital or other type of
facility that are not in your health plan’s network, you may have to pay additional costs associated with
that care. These providers or services at hospitals and other facilities are sometimes referred to as “outof-network”.

Out-of-network hospitals, facilities or providers often bill you the difference between what [Carrier]
decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called
‘surprise’ or ‘balance’ billing.

When you CANNOT be balance-billed:

Emergency Services

When you receive services for emergency medical care, usually the most you can be billed for emergency
services is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or
coinsurance. You cannot be balanced-billed for any other amount. This includes both the emergency
facility and any providers you may see for emergency care.

Non-emergency services at an In-Network or Out-of-Network Facility

The hospital or facility must tell you if you are at an out-of-network location or at an in-network location
that is using out-of-network providers. It must also tell you what types of services may be provided by any
out-of-network provider.

You have the right to request that in-network providers perform all covered medical services. However,
you may have to receive medical services from an out-of-network provider if an in-network provider is not
available. When this happens, the most you can be billed for covered services is your in-network costsharing amount (copayments, deductibles, and/or coinsurance). These providers cannot balance bill you.

Additional Protections

• [Carrier] will pay out-of-network providers and facilities directly. Again, you are only responsible
for paying your in-network cost-sharing for covered services.

• [Carrier] will count any amount you pay for emergency services or certain out-of-network services(described above) toward your in-network deductible and out-of-pocket limit.

• Your provider, hospital, or facility must refund any amount you overpay within 60 days of you
reporting the overpayment to them.

• A provider, hospital, or other type of facility cannot ask you to limit or give up these rights.

If you receive services from an out-of-network provider, hospital or facility in any OTHER
situation, you may still be balance billed, or you may be responsible for the entire bill. If you
intentionally receive non-emergency services from an out-of-network provider or facility, you may
also be balance billed.

If you do receive a bill for amounts other than your copayments, deductible, and/or coinsurance, please
contact us at the number on your ID card, or the Division of Insurance at 303-894-7490 or 1-800-930-

Ambulance Information: You may be balance billed for emergency ambulance services you receive if
the ambulance service provider is a publicly funded fire agency, but state law against balance billing does
apply to private companies that are not publicly funded fire agencies. Non-emergency ambulance
services, such as ambulance transport between hospitals, are not subject to the state law against balance
billing, so if you receive such services and they are not a service covered by [Carrier], you may receive a
balance bill