Colorado § 25-3-121 - Health-care facilities - emergency and nonemergency services - required disclosures - balance billing - unfair or deceptive trade practice - rules - definitions.

§ 25-3-121. Health-care facilities - emergency and nonemergency services - required disclosures - balance billing - unfair or deceptive trade practice - rules - definitions.

(1) On and after January 1, 2020, health-care facilities shall develop and provide disclosures to consumers about the potential effects of receiving emergency or nonemergency services from an out-of-network provider providing services at an in-network facility or emergency services at an out-of-network facility. The disclosures must comply with the rules adopted pursuant to subsection (2) of this section.

(2) The state board of health, in consultation with the commissioner of insurance and the applicable regulators of health-care providers in the division of professions and occupations in the department of regulatory agencies, shall adopt rules that specify the requirements for health-care facilities to develop and provide consumer disclosures in accordance with this section. The state board of health 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) Receipt of the disclosure 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.

(3.5) (a) An out-of-network facility may balance bill a covered person for services other than ancillary services if:

(I) The out-of-network facility provides written notice that the facility 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 facility is located. The notice must state:

(A) If applicable, that the facility 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 not a participating 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 at an out-of-network facility 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 facility 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 at the out-of-network facility 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) The notice and consent required by this subsection (3.5) must include the date on which the covered person received the written notice and the date and the time at which the consent form was signed. The out-of-network facility shall provide a signed copy of the consent form to the covered person through regular or electronic mail.

(c) An out-of-network facility 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.

(d) An out-of-network facility shall not balance bill a covered person, as defined in section 10-16-102 (15), for services if the provisions of section 10-16-705 (4.5)(c)(II) apply.

(3.7) A violation of this section is an unfair or deceptive trade practice pursuant to section 6-1-105 (1)(rrr).

(4) As used in this section and section 25-3-122:

(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.

(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 facility" means a health-care facility that is not a participating provider.

(h) "Participating provider" has the same meaning as set forth in section 10-16-102 (46).

Source: L. 2019: Entire section added, (HB 19-1174), ch. 171, p. 1992, § 6, effective January 1, 2020. L. 2022: (2), IP(4), (4)(a), (4)(c), (4)(d), (4)(f), and (4)(g) amended and (3.5), (4)(a.3), (4)(a.5), (4)(c.5), and (4)(h) added, (HB 22-1284), ch. 446, p. 3147, § 5, effective August 10. L. 2023: (3.7) added, (SB 23-093), ch. 152, p. 649, § 11, effective May 4. L. 2024: (3.5)(d) added, (SB 24-093), ch. 41, p. 149, § 3, effective January 1, 2025. L. 2026: (3.7) amended, (HB 26-1426), ch. 334, p. 2027, § 99, effective August 12.