First Regular Session Seventieth General Assembly STATE OF COLORADO INTRODUCED LLS NO. 15-0363.03 Kristen Forrestal x4217SENATE BILL 15-259 SENATE SPONSORSHIP Aguilar, HOUSE SPONSORSHIP Lontine, Senate Committees House Committees Business, Labor, & Technology A BILL FOR AN ACT Concerning out-of-network health care provider charges. 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 requires a health care provider who provides out-of-network covered services at an in-network facility or emergency services to: Submit a claim for the entire cost of the services to the covered person's health insurance carrier; Not collect payment from the covered person except for a deductible, copayment, or coinsurance; and Not balance bill the covered person but instead submit a demand for the remaining amount of the bill to the health insurance carrier and attempt to negotiate payment, if necessary. The bill requires a health insurance carrier to provide written notice of the covered person's out-of-network obligations. The health care facility must inform the covered person about the legal protections against balance billing. A failure to provide disclosure is a deceptive trade practice. Be it enacted by the General Assembly of the State of Colorado: SECTION 1. In Colorado Revised Statutes, add article 21 to title 6 as follows: ARTICLE 21 Notification of Out-of-network Provider 6-21-101. Providing billing for out-of-network services - billing dispute settlements. (1) If a health care provider provides out-of-network covered services to a covered person at an in-network facility or provides out-of-network covered emergency services to a covered person: (a) The out-of-network provider shall submit a claim for the entire cost of the services rendered to the covered person's carrier; (b) The out-of-network provider shall not collect any payment from the covered person, except for applicable deductible, copayment, or coinsurance allowed by the carrier for the covered services; and (c) (I) If the out-of-network provider wishes to collect any amount in excess of the carrier's average in-network rate for the relevant geographic area, the provider may not balance bill the covered person for covered services. Instead, the out-of-network provider shall submit a demand for any remaining amount billed for the out-of-network covered service to the covered person's carrier, and the carrier shall pay the demanded amount or attempt to negotiate the remaining balance billed by the out-of-network health care provider. (II) As part of its demand for payment from a carrier, the out-of-network provider shall submit proof that it either disclosed to the covered person that it was an out-of-network provider or that, due to the nature of the services, providing the disclosure was reasonably impracticable. The disclosure does not waive a covered person's rights and protections under this section and 10-16-704, C.R.S. (2) The carrier, the health care facility, and the health care provider shall hold the covered person harmless for additional charges from out-of-network providers for care provided as described in subsection (1) of this section and section 10-16-704, C.R.S. (3) (a) For each of its in-network plans, a carrier shall develop and provide to each covered person a written disclosure or notice in plain language that describes the covered person's out-of-network obligations. When the carrier receives a bill for a covered person for services described in section 10-16-704, C.R.S., or this section, the carrier shall notify the covered person in writing of the protections in this section. (b) Prior to receiving services or treatment in accordance with the health plan provisions at an in-network facility, the facility shall inform the covered person in plain language of the protections against balance billing in subsection (1) of this section and section 10-16-704, C.R.S., and that all services, treatment, and charges by the facility and all health care providers will be provided at an in-network rate. (c) When providing an emergency service, a facility shall disclose in writing at the time of admission, to the extent practicable, the covered person's protections against balance billing in subsection (1) of this section and in section 10-16-704, C.R.S. (d) If a health care provider does not participate in the network of a covered person's health care plan, the health care provider shall: (I) Before providing non-emergency services, inform the person in writing that the person is seeking services at an out-of-network facility and that the amount or estimated amount of the charges to be billed to the person are available upon request; (II) Upon request of a covered person, disclose in writing the amount or estimated amount the health care provider will bill the covered person absent unforeseen medical circumstances that might arise. The health care provider may not bill the covered person for out-of-network services unless the person has chosen in writing, at or before the time the procedure or treatment is scheduled, to use the out-of-network facility. (4) If a health care provider, in the course of the provider's business, waives any deductible, copayment, or coinsurance owed by a person for services obtained, except as allowed under subsections 18-13-119 (5), (6), and (8), C.R.S., or routinely fails to provide disclosure to covered persons as required in paragraph (c) of subsection (1) of this section, the health care provider thereby engages in a deceptive trade practice as defined by section 6-1-105 and forfeits any right to any reimbursement it would otherwise be owed on behalf of the covered person, and the amount forfeited shall be deemed the amount of damages resulting from these practices. (5) For purposes of this section: (a) "Carrier" has the same meaning as set forth in section 10-16-102 (8), C.R.S. (b) (I) "Emergency services", with respect to an emergency medical condition, means: (A) A medical screening examination that is within the capability of an emergency department, including ancillary services routinely available to emergency departments to evaluate the emergency medical conditions; and (B) Within the capabilities of the staff and facilities available at the emergency department, further medical examination and treatment as required to stabilize the patient to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of an individual from a facility, or with respect to an emergency medical condition. (II) For the purpose of this paragraph (b), "emergency medical condition" means a medical condition that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect, in the absence of immediate medical attention, to result in: (A) Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; (B) Serious impairment to bodily functions; or (C) Serious dysfunction of any bodily organ or part. (6) If any provision of this article or the application thereof to any person or circumstance is held invalid, such invalidity does not affect other provisions or applications of this article that can be given effect without the invalid provision or application, and to this end the provisions of this article are declared to be severable. SECTION 2. In Colorado Revised Statutes, 6-1-105, add (1) (hhh) as follows: 6-1-105. Deceptive trade practices. (1) A person engages in a deceptive trade practice when, in the course of the person's business, vocation, or occupation, the person: (hhh) Violates section 6-21-101. SECTION 3. Act subject to petition - effective date. This act takes effect January 1, 2016; 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 2016 and, in such case, will take effect on the date of the official declaration of the vote thereon by the governor.