This entire regulation falls under the category “Continuity of Care Post-Contract.”  See the bold text below for the language falling under “termination.”

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, 10-16-705 and 10-16-708, C.R.S.

Section 2 Scope and Purpose

The purpose of this regulation is to provide carriers offering ACA-compliant health benefit plans with the continuity of care requirements for health benefit plans. Continuity of care protections apply when a provider leaves or is terminated from a plans network; a Medicaid enrollee transfers to a commercial plan;
or an enrollee’s coverage is not renewed because the carrier is no longer offering any health benefit plans for which the individual is eligible.

Section 3 Applicability

This regulation applies to all carriers offering ACA-compliant individual and/or group health benefit plans subject to the individual, small group, and/or large group laws of Colorado. This regulation excludes individual short-term policies as defined in § 10-16-102(60), C.R.S.

Section 4 Definitions

A. “ACA” means, for the purposes of this regulation, The Patient Protection and Affordable Care Act, Pub. L. 111-148 and the Health Care and Education Reconciliation Act of 2010, Pub. L. 111-152.

B. “Active course of treatment” means, for the purposes of this regulation:

1. An ongoing course of treatment for a life-threatening condition;

2. An ongoing course of treatment for a serious acute health condition, chronic health condition, or life-limiting illness;

3. the entire pregnancy through the postpartum period;

4. An ongoing course of treatment for a health condition, whether physical health, mental health, behavioral health, or substance use disorder, for which a treating physician or health care provider attests that discontinuing care by that physician or health care provider would worsen the condition or interfere with anticipated outcomes;

5. Inpatient care; or

6. Scheduled to undergo non elective surgery, including the receipt of post operative care with respect to the surgery.

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

D. “Health condition” means, for the purposes of this regulation, an illness, injury, impairment, or condition of a physical, behavioral, or mental health nature, or that involves substance abuse.

E. “Life-threatening health condition” means, for the purpose of this regulation, a disease or health condition for which likelihood of death is probable unless the course of the disease or health condition is interrupted.

F. “Network” shall have the same meaning as found at § 10-16-102(45), C.R.S.

G. “Primary care” means, for the purposes of this regulation, health care services for a range of common physical, mental or behavioral health conditions provided by a physician or non-physician primary care provider.

H. “Primary care provider” or “PCP” means, for the purposes of this regulation, a participating health care professional designated by the carrier to supervise, coordinate or provide initial care or continuing care to a covered person, and who may be required by the carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person. For the purposes of network adequacy measurements, PCPs for adults and children include physicians (pediatrics, general practice, family medicine, internal medicine, geriatrics, obstetrics/gynecology) and physician assistants and nurse practitioners supervised by, or collaborating with, a primary care physician.

I. “Serious acute health condition, chronic health condition, or life-limiting illness” means, for the purpose of this regulation, a disease or health condition requiring complex on-going care which the covered person is currently receiving, including, but not limited to, chemotherapy, post-operative visits or radiation therapy.

J. “Transferring enrollee” shall have the same meaning as found at § 10-16-705(4.5)(a)(IV), C.R.S.

Section 5 Continuity of Care Requirements

Termination

Carriers shall ensure sufficient continuity of care provisions for their policyholders. Carriers shall include their processes on continuity of care provisions in their network access plans, as required by Insurance Regulation 4-2-54, Section 9.

A. A carrier and participating provider shall provide at least sixty (60) days written notice to each other before a provider is removed or leaves the network without cause.

B. When a primary care provider is being removed, leaving the network, or is being non-renewed. All covered persons who are patients of that primary care provider shall be notified by the carrier, in writing, by first class mail and by electronic mail, prior to termination. When the provider gives or receives the notice in accordance with Section 5.A. of this regulation, the provider shall supply the carrier with a list of those patients of the provider that are covered by a plan of the carrier. The carrier shall supply the provider with a list of the provider’s patients that are covered by the carrier.

C. Notice to policyholders:

1. For covered persons, irrespective of whether it is for cause or without cause or due to non-renewal of a contract, the carrier shall make a good faith effort to provide both written notice of a provider’s removal, leaving, or non-renewal from the network, and the provider information contained in Section 5.F. of this regulation, within fifteen (15) working days of receipt or issuance of a notice provided in accordance with Section 5.A. of this regulation. This notice shall be provided to all covered persons who are identified as patients by the provider, are on a carrier’s patient list for that provider, or who have been seen by the
provider being removed or leaving the network within the previous twelve (12) months. This notice shall be provided by first class mail, and by electronic mail, when possible.

2. For transferring enrollees, the carrier shall notify the transferring enrollee, in plain language, by first-class mail, and by electronic mail, when possible, at the time of enrollment, that the enrollee may request continued transition care from an out-of-network provider. The transferring enrollee or enrollee’s provider must notify the carrier of the need for continued transitional care within thirty (30) days after the transferring enrollees effective date of coverage. The carrier shall make a good faith effort to provide the provider information contained in Section 5.F. of this regulation, within fifteen (15) working
days of receipt of a request for care.

D. A covered person must have been undergoing treatment, or have been seen at least once in the previous twelve (12) months, by the provider being removed or leaving the network for that covered person to be considered in an active course of treatment. A transferring enrollee must have been undergoing treatment or have been seen at least once in the previous twelve (12) months by the out-of-network provider.

E. A carrier shall establish reasonable procedures to transition the covered person or transferring enrollee who is in an active course of treatment to a participating provider in a manner that provides for continuity of care when a covered person’s provider leaves or is removed from the network or when a transferring enrollee enrolls in the carrier’s network.

F. A carrier shall make available to the covered person or transferring enrollee a list of available participating providers who are accepting new patients in the same geographic area and specialty provider type, or a referral to a provider if there is no participating provider available, who is of the same provider or specialty type. The carrier shall provide information about how the covered person or transferring enrollee may request continuity of care as required by this regulation.

G. A carrier’s transition procedures shall provide that:

1. A carrier shall review requests for continuity of care made by the covered person or transferring enrollee or the covered person’s or transferring enrollee’s authorized representative and ensure a timely transfer, without a gap in coverage, after the continuity of care period.

2. The continuity of care period shall extend through the entire pregnancy and postpartum period.

3. The continuity of care period for covered persons and transferring enrollees who are undergoing an active course of treatment shall extend to the earlier of:

a. The termination of the course of treatment by the covered person or transferring enrollee or the treating provider;

b. Ninety (90) days after the effective date of the provider’s departure or termination from the network, unless the carrier’s Medical Director determines that a longer period is necessary;

c. The date that care is successfully transitioned to a participating provider;

d. Benefit limitations under the plan are met or exceeded; or

e. The care is no longer medically necessary.

H. For the duration of the continuity of care period, in addition to the provisions of Section 5.G. of this regulation, a continuity of care request may only occur when the provider departing or terminated from the network:

1. Agrees in writing to accept the same payment from and abide by the same terms and conditions with respect to the carrier for that patient as provided in the original provider contract, or by the new payment and terms agreed upon and executed between the provider and the carrier; and

2. Agrees in writing not to seek any payment from the covered person for any amount for which the covered person would not have been responsible if the provider were still a participating provider.

I. The obligation to hold the patient harmless for services rendered in the provider’s capacity as a participating provider survives the termination of the provider contract. The hold harmless obligation does not apply to services rendered after the termination of the provider contract, except to the extent that the in-network relationship is extended to provide continuity of care.

J. For the duration of the continuity of care period, in addition to the provisions of Section 5.G of this regulation, a continuity of care request from a transferring enrollee may only occur when the out-of-network provider:

1. Agrees in writing to accept the carrier’s standard in-network reimbursement rate and adhere to the carriers’ terms and conditions, quality of care standard and protocols, referral process, and reporting standards that apply to comparable in-network providers; and

2. Agrees in writing not to seek any payment from the covered person for any amount for which the covered person would not have been responsible if the provider were an in-network provider.

Section 6 Severability

If any provision of this regulation or the application of it to any person or circumstance 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 amended regulation shall be effective on January 1, 2025.

Section 9 History

New regulation effective January 1, 2017.
Amended regulation effective July 1, 2018.
Amended regulation effective January 1, 2025.

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