A carrier offering an individual or small employer health benefit plan in this state shall not impose any preexisting condition exclusion with respect to coverage under the plan.
Source: L. 94: Entire section added, p. 1913, � 9, effective July 1. L. 97: Entire section amended, p. 639, � 7, effective July 1. L. 2002: (1)(a)(I) amended, p. 1284, � 3, effective January 1, 2003; (1)(a)(I) amended, p. 1293, � 5, effective January 1, 2003. L. 2013: Entire section R&RE, (HB 13-1266), ch. 217, p. 972, � 22, effective May 13.
Cross references: For the legislative declaration contained in the 1997 act amending this section, see section 1 of chapter 154, Session Laws of Colorado 1997.
10-16-119. Requirements for excess loss or stop-loss health insurance used in conjunction with self-insured employer benefit plans under the federal Employee Retirement Income Security Act - data collection 2013-18 - rules. (1) Any entity issuing excess loss insurance shall file all policy forms with the division and certify compliance with the provisions of this title.
(2) All excess loss insurance shall be issued to cover the employer's liability under the employer's self-insured obligation. Excess loss insurance shall meet the following requirements:
(a) The policy shall only be issued to insure an employer and not the employer's employees;
(b) Payment by the issuer of the insurance shall only be made to the employer and not the employees or providers;
(c) Commencing with policies issued or renewed on and after January 1, 2003, the minimum retention to the employer shall be no less than fifteen thousand dollars per person per plan year with a minimum one hundred twenty percent of expected claims aggregate.
(3) Repealed.
Source: L. 94: Entire section added, p. 1913, � 9, effective July 1. L. 2002: (2)(c) amended, p. 1293, � 6, effective January 1, 2003. L. 2013: (3) added, (HB 13-1290), ch. 339, p. 1975, � 1, effective July 1.
Editor's note: Subsection (3)(d) provided for the repeal of subsection (3), effective September 1, 2019. (See L. 2013, p. 1976.)
10-16-119.5. Stop-loss health insurance for small employers of not more than fifty employees - requirements - definitions - rules. (1) Notwithstanding section 10-16-119, the purpose of this section is to establish criteria for the issuance of stop-loss health insurance policies to any person, firm, corporation, partnership, or association actively engaged in business that employed an average of at least one but not more than fifty eligible employees on business days during the immediately preceding calendar year. This section does not impose any requirement or duty on any person other than an insurer offering stop-loss health insurance policies to any person, firm, corporation, partnership, or association actively engaged in business that employed an average of at least one but not more than fifty eligible employees on business days during the immediately preceding calendar year or treat any stop-loss health insurance policy as a direct policy of health insurance.
(2) An insurer shall not issue a stop-loss health insurance policy to any person, firm, corporation, partnership, or association actively engaged in business that employed an average of at least one but not more than fifty eligible employees on business days during the immediately preceding calendar year that:
(a) Has an annual attachment point for claims incurred per individual that is lower than twenty thousand dollars;
(b) Has an annual aggregate attachment point lower than the greater of:
(I) One hundred twenty percent of expected claims; or
(II) Twenty thousand dollars;
(c) Provides direct coverage of health-care expenses of an individual;
(d) Varies by individual within the group the annual attachment point for claims incurred per individual; or
(e) Excludes any employee or eligible dependent from the stop-loss health insurance coverage.
(3) The commissioner may, by rule, change the dollar amounts in subsection (2) of this section based upon changes in the medical components of the Denver-Aurora-Lakewood consumer price index or its applicable predecessor or successor index. Any change in these dollar amounts must be made at least six months prior to the effective date of the change.
(4) An insurer that issues one or more stop-loss health insurance policies to any person, firm, corporation, partnership, or association actively engaged in business that employed an average of at least one but not more than fifty eligible employees on business days during the immediately preceding calendar year shall file with the commissioner annually an actuarial certification certifying that the insurer is in compliance with this section. The certification must be in a form and manner and contain information as required by the commissioner.
(5) For each stop-loss health insurance policy delivered, issued for delivery, or entered into, the insurer shall prepare a separate exhibit to be given to the insured with the policy containing at least the following information:
(a) The complete costs for the stop-loss health insurance policy;
(b) The date on which the stop-loss health insurance policy takes effect and terminates, including renewability provisions;
(c) The aggregate attachment point and the specific attachment point for the stop-loss health insurance policy;
(d) Any limitations on coverage;
(e) An explanation of monthly accommodation and disclosure about any monthly accommodation features included in the stop-loss health insurance policy; and
(f) A description of terminal liability funding, including:
(I) Costs of processing claims before and after the termination of the policy; and
(II) Maximum claims liability to the employer.
(6) As used in this section:
(a) Actuarial certification means a written statement by a member of the American academy of actuaries, or by another individual acceptable to the commissioner, that an insurer is in compliance with this section, based upon the individual's examination and including a review of the appropriate records and the actuarial assumptions and methods used by the insurer in establishing attachment points and other applicable determinations in conjunction with the provision of stop-loss health insurance coverage.
(b) Attachment point means the claims amount incurred by an insured group beyond which the insurer incurs a liability for payment.
(c) Expected claims means the amount of claims that, in the absence of a stop-loss health insurance policy or other insurance, are projected to be incurred by an insured group through its health plan.
Source: L. 2013: Entire section added, (HB 13-1290), ch. 339, p. 1976, � 2, effective January 1, 2014. L. 2018: (3) amended, (HB 18-1375), ch. 274, p. 1695, � 4, effective May 29.
10-16-120. Legislative review of requirements for guaranteed issue of basic and standard health benefit plans. (Repealed)
Source: L. 94: Entire section added, p. 1913, � 9, effective July 1. L. 96: (1) amended, p. 1230, � 52, effective August 7. L. 97: (1) amended, p. 1478, � 25, effective June 3. L. 2001: (2) amended, p. 1167, � 2, effective July 1. L. 2006: Entire section repealed, p. 1077, � 4, effective July 1.
Cross references: For the legislative declaration contained in the 2006 act repealing this section, see section 1 of chapter 236, Session Laws of Colorado 2006.
10-16-121. Required contract provisions in contracts between carriers and providers - definitions. (1) A contract between a carrier and a provider or its representative concerning the delivery, provision, payment, or offering of care or services covered by a managed care plan must make provisions for the following requirements:
(a) The contract must contain a provision stating that neither the provider nor the carrier is prohibited from protesting or expressing disagreement with a medical decision, medical policy, or medical practice of the carrier or provider.
(b) (I) The contract must contain a provision that states the carrier may not take an adverse action against a provider because the provider expresses disagreement with a carrier's decision to deny or limit benefits to a covered person or because the provider assists the covered person to seek reconsideration of the carrier's decision or because a provider discusses with a current, former, or prospective patient any aspect of the patient's medical condition, any proposed treatments or treatment alternatives, whether covered by the plan or not, policy provisions of a plan, or a provider's personal recommendation regarding selection of a health plan based on the provider's personal knowledge of the health needs of such patients.
(II) The contract between a carrier and the provider must state that the carrier may not take an adverse action against a provider because the provider, acting in good faith:
(A) Communicates with a public official or other person concerning public policy issues related to health-care items or services;
(B) Files a complaint, makes a report, or comments to an appropriate governmental body regarding actions, policies, or practices of the carrier the provider believes might negatively affect the quality of, or access to, patient care;
(C) Provides testimony, evidence, opinion, or any other public activity in any forum concerning a violation or possible violation of any provision of this section;
(D) Reports what the provider believes to be a violation of law to an appropriate authority; or
(E) Participates in any investigation into a violation or possible violation of any provision of this section.
(c) Any contract providing for the performance of claims processing functions by an entity with which the carrier contracts must require such entity to comply with section 10-16-106.5 (3), (4), and (5).
(d) The contract must contain a provision that the provider shall not be subjected to financial disincentives based on the number of referrals made to participating providers in the health plan for covered benefits so long as the provider making the referral adheres to the carrier's or the carrier's intermediary's utilization review policies and procedures.
(e) The contract must contain a provision that states the carrier shall not take an adverse action against a provider or provide financial incentives or subject the provider to financial disincentives based solely on a patient satisfaction survey or other method of obtaining patient feedback relating to the patient's satisfaction with pain treatment.
(f) (I) A provision that prohibits the carrier from taking an adverse action against a provider or subjecting the provider to financial disincentives based solely on the provider's provision of, or assistance in the provision of, a legally protected health-care activity, as defined in section 12-30-121 (1)(d), in this state, so long as the care provided did not violate Colorado law.
(II) As used in this subsection (1)(f), adverse action means refusing or failing to pay a provider for otherwise covered services as defined in the applicable health benefit plan.
(2) Nothing in subsection (1) of this section shall be construed to prohibit a carrier from:
(a) Including in its provider contracts a provision that precludes a provider from making, publishing, disseminating, or circulating directly or indirectly or aiding, abetting, or encouraging the making, publishing, disseminating, or circulating of any oral or written statement or any pamphlet, circular, article, or literature that is false or maliciously critical of the carrier and calculated to injure such carrier; or
(b) Terminating a contract with a provider because such provider materially misrepresents the provisions, terms, or requirements of a carrier's products; or
(c) Terminating a contract with a provider pursuant to a contract provision that allows either party to the contract to terminate the contract without cause pursuant to specific notice requirements that are the same for both parties.
(3) Each contract between a carrier and an intermediary shall contain a provision requiring that the underlying contract authorizing the intermediary to negotiate and execute contracts with carriers, on behalf of the providers, shall comply with the requirements of subsection (1) of this section.
(4) The commissioner shall not act to arbitrate, mediate, or settle disputes between a carrier, its intermediaries, or a provider network arising under or by reason of a provider contract or its termination. Existing dispute resolution mechanisms available in contract law shall be used to resolve such disputes. Notwithstanding any provision of law to the contrary, the commissioner is not prohibited from enforcing the applicable provisions of this article.
(5) The commissioner shall, after notice and hearing, promulgate reasonable regulations as are necessary or proper to carry out the requirements of this section.
(6) No contract between a carrier and a provider or its representative or between a carrier and an intermediary that concerns the delivery, provision, payment, or offering of care or services covered by a managed care plan shall be issued, renewed, amended, or extended in this state after January 1, 1997, unless it complies with the requirements of this section.
(7) (a) A provider who is aggrieved by a violation of this section may bring an action for injunctive relief in a court of competent jurisdiction and may seek recovery of reasonable court costs. This section does not change the standards for obtaining injunctive relief.
(b) If a court deems an action frivolous, the court may award costs to the defendant.
(8) As used in this section:
(a) Adverse action means a decision by a carrier to terminate, deny, or otherwise condition a provider's participation in one or more provider networks, including a decision pertaining to participation in a narrow network or allocation within a tiered network.
(b) Narrow network means a reduced or selective provider network that is a subgroup or subdivision of a larger provider network and from which providers who participate in the larger network may be excluded.
(c) Tiered network means a provider network in which:
(I) Providers are assigned to, or placed in, different benefit tiers, as determined by tiering; and
(II) Patients receive benefits and pay the copayment, coinsurance, or deductible amounts that are associated with the benefit tier to which the provider from whom services were received is assigned.
(d) Tiering means a system that compares, rates, ranks, tiers, or classifies a provider's performance, quality of care, or cost of care against objective standards or against the practice or performance of other health-care providers. Tiering includes quality improvement programs, pay-for-performance programs, public reporting on health-care provider performance or ratings, and the use of tiered or narrowed networks.
Source: L. 96: Entire section added, p. 569, � 3, effective July 1. L. 99: (1)(c) added, p. 1142, � 3, effective January 1, 2000. L. 2000: (1)(d) added, p. 1064, � 2, effective August 2, 2000. L. 2003: (4) amended, p. 2494, � 2, effective June 5. L. 2017: (1) amended and (7) and (8) added, (HB 17-1173), ch. 120, p. 421, � 1, effective July 1. L. 2018: (1)(e) added, (HB 18-1007), ch. 225, p. 1431, � 2, effective January 1, 2019. L. 2023: (1)(f) added, (SB 23-188), ch. 68, p. 242, � 3, effective April 14.
Cross references: For the legislative declaration contained in the 1996 act enacting this section, see section 1 of chapter 122, Session Laws of Colorado 1996. For the legislative declaration contained in the 2000 act enacting subsection (1)(d), see section 1 of chapter 238, Session Laws of Colorado 2000. For the legislative declaration in SB 23-188, see section 1 of chapter 68, Session Laws of Colorado 2023.
10-16-121.3. Limitations on provisions in contracts between carriers and licensed health-care providers - methods of payment - fees - definitions. (1) As used in this section, unless the context otherwise requires:
(a) Billing service means a person or entity that contracts with a licensed health-care provider to:
(I) Process bills for health-care services provided by the licensed health-care provider; and
(II) Pursuant to the terms of the contract, submit bills, request reconsideration of payments, and receive payments or reimbursements for health-care services provided by the licensed health-care provider.
(b) Contract means a contract between a carrier and a licensed health-care provider for the provision of health-care services to covered persons under a health coverage plan issued by the carrier.
(c) Health-care electronic funds transfers and remittance advice transaction has the same meaning as defined in 45 CFR 162.1601 and incorporates the standards described in 45 CFR 162.1602.
(2) In a contract entered into, amended, or renewed on or after August 7, 2023, the carrier shall:
(a) Offer at least one method of payment to the licensed health-care provider that does not require an associated fee charged to the health-care provider; and
(b) Not restrict the method or form of payment to the licensed health-care provider so that the only acceptable payment method is a credit card payment.
(3) If a carrier initiates a payment to a licensed health-care provider using, or changes the payment method to, electronic funds transfer payments, including virtual credit card payments, the carrier shall:
(a) Notify the licensed health-care provider if any fee is associated with a particular payment method;
(b) Advise the licensed health-care provider of the available payment methods and provide clear instructions to the licensed health-care provider as to how to select an alternative payment method; and
(c) With each payment, remit an explanation of benefits.
(4) For any contract that is in effect on or before August 7, 2023, or that is entered into, amended, or renewed on or after August 7, 2023, a carrier that initiates a payment to a licensed health-care provider using, or changes the payment method to, a health-care electronic funds transfers and remittance advice transaction shall not charge a fee solely to transmit the payment to the licensed health-care provider unless the licensed health-care provider consents to the fee. A licensed health-care provider's billing service may charge a reasonable fee related to transaction management, data management, portal services, or other value-added services above and beyond the bank transmittal when transmitting an electronic funds transfer.
(5) The commissioner has the authority to enforce this section and impose a penalty or remedy against a person who violates this section.
Source: L. 2023: Entire section added, (HB 23-1116), ch. 59, p. 208, � 1, effective August 7.
10-16-121.5. Prohibited contract provisions in contracts between carriers and providers for dental services - definition. (1) A contract between a carrier and a dentist licensed to practice under article 220 of title 12 must not require, directly or indirectly, that a dentist who is a participating provider provide services to a covered person at a fee set by, or subject to the approval of, the carrier unless:
(a) The services are covered services under the person's policy; and
(b) The carrier provides payment for the services under the person's policy in an amount that is reasonable and not nominal or de minimis.
(2) The dentist may charge the covered person for noncovered items or services in any amount determined by the dentist and agreed to by the patient that is equal to, or less than, the usual and customary amount that the dentist charges individuals who do not have coverage for such items and services.
(3) If the commissioner determines that a carrier has not complied with this section, the commissioner shall institute a corrective action plan that the carrier shall follow or may use any of the commissioner's enforcement powers to obtain the carrier's compliance with this section.
(4) For purposes of this section, covered services means dental care services for which reimbursement is available under a covered person's plan contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other contractual limitations.
Source: L. 2017: Entire section added, (SB 17-190), ch. 147, p. 492, � 2, effective August 9. L. 2019: IP(1) amended, (HB 19-1172), ch. 136, p. 1654, � 45, effective October 1.
Cross references: For the legislative declaration in SB 17-190, see section 1 of chapter 147, Session Laws of Colorado 2017.
10-16-121.7. Prohibited contract provisions in contracts between carriers and eye care providers - definitions. (1) A carrier or entity that offers a vision care plan shall not require that an eye care provider with whom the carrier or entity contracts:
(a) Provide services or materials to a covered person at a fee set by, or subject to the approval of, the carrier or entity unless the services or materials are covered services or covered materials under the covered person's vision care plan and the amount of coverage is neither nominal nor de minimis;
(b) Charge a covered person for a noncovered service or noncovered materials in an amount less than the usual and customary amount that the eye care provider charges individuals who do not have coverage for such materials and services; or
(c) Participate, as a condition of participation in a vision care plan, in any of the carrier's or entity's other vision plan networks.
(2) A carrier or entity shall not change the terms of the contract between the carrier or entity and an eye care provider without communication with the eye care provider.
(3) If the commissioner determines that a carrier or entity has not complied with this section, the commissioner shall do one or both of the following:
(a) Institute a corrective action plan for the carrier to follow;
(b) Use any of the commissioner's enforcement powers to obtain the carrier's or entity's compliance with this section.
(4) For purposes of this section:
(a) Covered materials means materials for which reimbursement is available under a covered person's vision care plan, or for which reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other contractual limitations.
(b) Covered services means eye care provider services for which reimbursement is available under a covered person's vision care plan, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other contractual limitations.
(c) Eye care provider means:
(I) An optometrist licensed to practice under article 275 of title 12; or
(II) An ophthalmologist licensed to practice under article 240 of title 12.
(d) Materials means ophthalmic devices including lenses, devices containing lenses, artificial intraocular lenses, ophthalmic frames and other lens mounting apparatus, prisms, lens treatments and coatings, contact lenses, and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye.
(e) Usual and customary amount means an amount established pursuant to an appropriate methodology that is based on generally accepted industry standards and practices.
(f) Vision care plan means:
(I) A vision care insurance policy or contract that provides vision benefits to a covered person; and
(II) A vision discount plan that provides discounts to vision benefits to a covered person.
(5) This section does not apply to an entity offering a vision discount plan to the entity's members if the entity is not primarily engaged in the business of offering vision care plans.
Source: L. 2018: Entire section added, (HB 18-1012), ch. 79, p. 665, � 1, effective January 1, 2019. L. 2019: (4)(c) amended, (HB 19-1172), ch. 136, p. 1655, � 46, effective October 1.