Second Regular Session Sixty-eighth General Assembly STATE OF COLORADO INTRODUCED LLS NO. 12-0535.02 Kristen Forrestal x4217HOUSE BILL 12-1257 HOUSE SPONSORSHIP Kefalas, SENATE SPONSORSHIP Boyd, House Committees Senate Committees State, Veterans, & Military Affairs A BILL FOR AN ACT Concerning transparency in the delivery of health care services. Bill Summary (Note: This summary applies to this bill as introduced and does not reflect any amendments that may be subsequently adopted. If this bill passes third reading in the house of introduction, a bill summary that applies to the reengrossed version of this bill will be available at http://www.leg.state.co.us/billsummaries.) The bill clarifies that an intermediary between a health insurance carrier and health care provider is a "person or entity" for purposes of complying with health care contract disclosure requirements. Each health care provider who provides outpatient health care or treatment is required to disclose to a patient the right to request the nondiscounted charge for the care or treatment and, upon request, make that information available before the scheduling of care or treatment. Each health insurance carrier shall: Provide notice to covered persons advising them of the relationship with the third-party administrator, the policyholder, and the insurance carrier; Disclose to the covered person all charges, fees, and commissions paid to the third-party administrator; and Prohibit a third-party administrator from altering a health care provider's charges or adding charges to any of the insurance claims submitted by a health care provider. Each carrier must disclose to each covered person any charges for administrative costs that are in addition to the charges for the care or services provided by the health care provider. The bill makes technical corrections to the law concerning the contractual relationship with a third-party intermediary. Current law uses the term "intermediary" when the proper entity is "third-party administrator". Be it enacted by the General Assembly of the State of Colorado: SECTION 1. In Colorado Revised Statutes, 25-37-102, amend (12) as follows: 25-37-102. Definitions. As used in this article, unless the context otherwise requires: (12) "Person or entity" means a person or entity that has a primary business purpose of contracting with health care providers for the delivery of health care services. "Person or entity" also means an intermediary as defined in section 10-16-102 (25.5), C.R.S. SECTION 2. In Colorado Revised Statutes, add 6-20-102 as follows: 6-20-102. Health care provider disclosure of average charge - outpatient. (1) (a) Each health care provider shall disclose to a person seeking outpatient care or treatment his or her right to receive notice of the nondiscounted charge for any frequently performed outpatient procedure prior to scheduling the care or treatment; except that the nondiscounted charge for an emergency procedure need not be disclosed before the provision of emergency care or treatment. (b) When requested, the nondiscounted charge information must be made available to the person before scheduling the care or treatment. (2) For the purposes of this section, "health care provider" means any person licensed or certified pursuant to title 12, C.R.S., to deliver health care or services. SECTION 3. In Colorado Revised Statutes, 10-16-705, amend (6.5) and (10.5) (a); and add (6.7) and (17) as follows: 10-16-705. Requirements for carriers and participating providers. (6.5) A carrier that has entered into a contract with one or more intermediaries third-party administrators to conduct utilization management, utilization review, provider credentialing, administration of health insurance benefits, setting or negotiation of reimbursement rates, payment to providers, network development, or disease management programs shall require the intermediary third-party administrator to comply with the same standards, guidelines, medical policies, and benefit terms of the carrier. (6.7) (a) When the services of a third-party administrator are used, the carrier shall provide a written notice to covered persons advising them of the identity of, and relationship among, the third-party administrator, the policyholder, and the carrier. (b) The carrier shall disclose to the covered person all charges, fees, and commissions paid to the third-party administrator. (c) The carrier shall prohibit a third-party administrator from altering a health care provider's charges or adding charges to any of the insurance claims submitted by a health care provider. (10.5) (a) A carrier that has entered into a contract with one or more intermediaries third-party administrators to conduct utilization management, utilization review, provider credentialing, administration of health insurance benefits, setting or negotiation of reimbursement rates, payment to providers, network development, or disease management programs, shall require the intermediary third-party administrators to indicate the name of the intermediary third-party administrator and the name of the carrier for which it is conducting the work when making any payment to a health care provider on behalf of the carrier. (17) For the purposes of this section, a "third-party administrator" means a person who conducts utilization management, utilization review, provider credentialing, administration of health insurance benefits, setting or negotiation of reimbursement rates, payment to providers, network development, or disease management programs. SECTION 4. In Colorado Revised Statutes, 10-16-706, amend (5) as follows: 10-16-706. Intermediaries. (5) (a) A carrier shall maintain copies of all intermediary health care subcontracts. (b) A carrier shall disclose to each covered person any charges for administrative costs that are in addition to the charges for the care or service provided by the health care provider. SECTION 5. Act subject to petition - effective date. This act takes effect January 1, 2013; except that, if a referendum petition is filed pursuant to section 1 (3) of article V of the state constitution against this act or an item, section, or part of this act within the ninety-day period after final adjournment of the general assembly, then the act, item, section, or part will not take effect unless approved by the people at the general election to be held in November 2012 and, in such case, will take effect on January 1, 2013, or on the date of the official declaration of the vote thereon by the governor, whichever is later.