HOUSE BILL 971122
BY REPRESENTATIVES Morrison, Tool, Gordon, Kaufman, Schwarz, Grossman, Lawrence, Leyba, Udall, and Veiga;
also SENATORS Hopper and Weddig.
CONCERNING CONSUMER PROTECTION STANDARDS FOR THE
OPERATION OF MANAGED CARE PLANS.
Be it enacted by the General Assembly of the State
of Colorado:
SECTION 1. 1016102,
Colorado Revised Statutes, 1994 Repl. Vol., as amended, is amended
BY THE ADDITION OF THE FOLLOWING NEW SUBSECTIONS to read:
1016102. Definitions.
As used in this article, unless the context otherwise requires:
(27.5) "NETWORK" MEANS A GROUP
OF PARTICIPATING PROVIDERS PROVIDING SERVICES TO A MANAGED CARE
PLAN. FOR THE PURPOSES OF PART 7 OF THIS ARTICLE, ANY SUBDIVISION
OR SUBGROUPING OF A NETWORK IS CONSIDERED A NETWORK IF COVERED
INDIVIDUALS ARE RESTRICTED TO THE SUBDIVISION OR SUBGROUPING FOR
COVERED BENEFITS UNDER THE MANAGED CARE PLAN.
(28.5) "PARTICIPATING PROVIDER"
MEANS A PROVIDER THAT, UNDER A CONTRACT WITH A CARRIER OR WITH
ITS CONTRACTOR OR SUBCONTRACTOR, HAS AGREED TO PROVIDE HEALTH
CARE SERVICES TO COVERED PERSONS WITH AN EXPECTATION OF RECEIVING
PAYMENT, OTHER THAN COINSURANCE, COPAYMENTS, OR DEDUCTIBLES, DIRECTLY
OR INDIRECTLY FROM THE CARRIER.
SECTION 2. Article 16 of title 10, Colorado Revised Statutes, 1994 Repl. Vol., as amended, is amended BY THE ADDITION OF A NEW PART to read:
PART 7
CONSUMER PROTECTION STANDARDS ACT FOR THE
OPERATION OF MANAGED CARE PLANS
1016701. Short title.
THIS PART 7 SHALL BE KNOWN AND MAY BE CITED AS THE "CONSUMER
PROTECTION STANDARDS ACT FOR THE OPERATION OF MANAGED CARE PLANS".
1016702. Legislative declaration.
(1) THE GENERAL ASSEMBLY HEREBY FINDS, DETERMINES,
AND DECLARES THAT THE PURPOSES OF THIS PART 7 ARE:
(a) TO INCORPORATE CONSUMER PROTECTIONS
IN THE CREATION AND MAINTENANCE OF PROVIDER NETWORKS BY CARRIERS;
(b) TO ESTABLISH STANDARDS TO ASSURE THE
ADEQUACY, ACCESSIBILITY, AND QUALITY OF HEALTH CARE SERVICES OFFERED
UNDER A MANAGED CARE PLAN; AND
(c) TO ESTABLISH REQUIREMENTS FOR WRITTEN
AGREEMENTS BETWEEN CARRIERS OFFERING MANAGED CARE PLANS AND PARTICIPATING
PROVIDERS REGARDING THE STANDARDS, TERMS, AND PROVISIONS UNDER
WHICH THE PARTICIPATING PROVIDER WILL PROVIDE SERVICES TO COVERED
PERSONS.
1016703. Applicability.
THIS PART 7 APPLIES TO ALL MANAGED CARE PLANS, EXCEPT FOR WORKERS'
COMPENSATION AND AUTOMOBILE INSURANCE CONTRACTS, THAT ARE ISSUED,
RENEWED, EXTENDED, OR MODIFIED ON OR AFTER JANUARY 1, 1998.
1016704. Network adequacy.
(1) A CARRIER PROVIDING A MANAGED CARE PLAN SHALL MAINTAIN
A NETWORK THAT IS SUFFICIENT IN NUMBERS AND TYPES OF PROVIDERS
TO ASSURE THAT ALL COVERED BENEFITS TO COVERED PERSONS WILL BE
ACCESSIBLE WITHOUT UNREASONABLE DELAY. IN THE CASE OF EMERGENCY
SERVICES, COVERED PERSONS SHALL HAVE ACCESS TO HEALTH CARE SERVICES
TWENTYFOUR HOURS PER DAY, SEVEN DAYS PER WEEK. SUFFICIENCY
SHALL BE DETERMINED IN ACCORDANCE WITH THE REQUIREMENTS OF THIS
SECTION AND MAY BE ESTABLISHED BY REFERENCE TO ANY REASONABLE
CRITERIA USED BY THE CARRIER, INCLUDING BUT NOT LIMITED TO:
(a) PROVIDERCOVERED PERSON RATIOS
BY SPECIALTY;
(b) PRIMARY CARE PROVIDERCOVERED
PERSON RATIOS;
(c) GEOGRAPHIC ACCESSIBILITY;
(d) WAITING TIMES FOR APPOINTMENTS WITH PARTICIPATING
PROVIDERS;
(e) HOURS OF OPERATION; AND
(f) THE VOLUME OF TECHNOLOGICAL AND SPECIALTY
SERVICES AVAILABLE TO SERVE THE NEEDS OF COVERED PERSONS REQUIRING
COVERED TECHNOLOGICALLY ADVANCED OR SPECIALTY CARE.
(2) IN ANY CASE WHERE THE CARRIER HAS
NO PARTICIPATING PROVIDERS TO PROVIDE A COVERED BENEFIT, THE CARRIER
SHALL ARRANGE FOR A REFERRAL TO A PROVIDER WITH THE NECESSARY
EXPERTISE AND ENSURE THAT THE COVERED PERSON OBTAINS THE COVERED
BENEFIT AT NO GREATER COST TO THE COVERED PERSON THAN IF THE BENEFIT
WERE OBTAINED FROM PARTICIPATING PROVIDERS.
(3) WHEN A COVERED PERSON RECEIVES SERVICES
OR TREATMENT IN ACCORDANCE WITH PLAN PROVISIONS AT A NETWORK FACILITY,
THE BENEFIT LEVEL FOR ALL COVERED SERVICES AND TREATMENT RECEIVED
THROUGH THE FACILITY SHALL BE THE INNETWORK BENEFIT.
(4) WHEN A TREATMENT OR PROCEDURE HAS
BEEN PREAUTHORIZED BY THE PLAN, BENEFITS CANNOT BE RETROSPECTIVELY
DENIED EXCEPT FOR FRAUD AND ABUSE. IF A HEALTH CARRIER PROVIDES
PREAUTHORIZATION FOR TREATMENT OR PROCEDURES THAT ARE NOT COVERED
BENEFITS UNDER THE PLAN, THE CARRIER SHALL PROVIDE THE BENEFITS
AS AUTHORIZED WITH NO PENALTY TO THE COVERED PERSON.
(5) A MANAGED CARE PLAN SHALL NOT DENY
BENEFITS FOR EMERGENCY SERVICES PREVIOUSLY RENDERED, BASED UPON
THE COVERED PERSON'S FAILURE TO PROVIDE SUBSEQUENT NOTIFICATION
IN ACCORDANCE WITH PLAN PROVISIONS, WHERE THE COVERED PERSON'S
MEDICAL CONDITION PREVENTED TIMELY NOTIFICATION.
(6) THE CARRIER SHALL ESTABLISH AND MAINTAIN
ADEQUATE ARRANGEMENTS TO ENSURE REASONABLE PROXIMITY OF PARTICIPATING
PROVIDERS TO COVERED PERSONS AND SHALL ONLY MARKET A NETWORK PLAN
IN A GEOGRAPHIC AREA WHERE NETWORK PROVIDERS ARE ACCESSIBLE WITHOUT
UNREASONABLE DELAY. IN DETERMINING WHETHER A HEALTH CARRIER HAS
COMPLIED WITH THIS SUBSECTION (6), CONSIDERATION SHALL BE GIVEN
TO THE RELATIVE AVAILABILITY OF HEALTH CARE PROVIDERS IN THE SERVICE
AREA UNDER CONSIDERATION.
(7) A CARRIER SHALL MONITOR, ON AN ONGOING
BASIS, THE CAPACITY AND LEGAL AUTHORITY OF THE PARTICIPATING PROVIDERS
AND FACILITIES WITH WHICH IT CONTRACTS TO FURNISH ALL COVERED
BENEFITS TO COVERED PERSONS.
(8) NO MANAGED CARE PLAN SHALL DENY OR
RESTRICT INNETWORK COVERED BENEFITS TO A COVERED PERSON
SOLELY BECAUSE THE COVERED PERSON OBTAINED TREATMENT OUTSIDE THE
NETWORK. THIS PROTECTION SHALL BE DISCLOSED IN WRITING TO THE
COVERED PERSON. NOTHING IN THIS SUBSECTION (8) SHALL BE CONSTRUED
TO REQUIRE A MANAGED CARE PLAN TO PAY FOR ANY BENEFIT OBTAINED
OUTSIDE THE PLAN'S NETWORK UNLESS THE CONTRACT OR CERTIFICATE
PROVIDES FOR THAT OUTOFNETWORK BENEFIT.
(9) BEGINNING JANUARY 1, 1998, A CARRIER
SHALL MAINTAIN AND MAKE AVAILABLE UPON REQUEST OF THE COMMISSIONER,
THE EXECUTIVE DIRECTOR OF THE DEPARTMENT OF PUBLIC HEALTH AND
ENVIRONMENT, OR THE EXECUTIVE DIRECTOR OF THE DEPARTMENT OF HEALTH
CARE POLICY AND FINANCING, IN A MANNER AND FORM THAT REFLECTS
THE REQUIREMENTS SPECIFIED IN PARAGRAPHS (a) TO (k) OF THIS SUBSECTION
(9), AN ACCESS PLAN FOR EACH MANAGED CARE NETWORK THAT THE CARRIER
OFFERS IN THIS STATE. THE CARRIER SHALL MAKE THE ACCESS PLANS,
ABSENT CONFIDENTIAL INFORMATION AS SPECIFIED IN SECTION 2472204
(3), C.R.S., AVAILABLE ON ITS BUSINESS PREMISES AND SHALL PROVIDE
THEM TO ANY INTERESTED PARTY UPON REQUEST. IN ADDITION, ALL HEALTH
BENEFIT PLANS AND MARKETING MATERIALS SHALL CLEARLY DISCLOSE THE
EXISTENCE AND AVAILABILITY OF THE ACCESS PLAN. ALL RIGHTS AND
RESPONSIBILITIES OF THE COVERED PERSON UNDER THE HEALTH BENEFIT
PLAN, HOWEVER, SHALL BE INCLUDED IN THE CONTRACT PROVISIONS, REGARDLESS
OF WHETHER OR NOT SUCH PROVISIONS ARE ALSO SPECIFIED IN THE ACCESS
PLAN. THE CARRIER SHALL PREPARE AN ACCESS PLAN PRIOR TO OFFERING
A NEW MANAGED CARE NETWORK AND SHALL UPDATE AN EXISTING ACCESS
PLAN WHENEVER THE CARRIER MAKES ANY MATERIAL CHANGE TO AN EXISTING
MANAGED CARE NETWORK, BUT NOT LESS THAN ANNUALLY. THE ACCESS PLAN
SHALL DESCRIBE OR CONTAIN AT LEAST THE FOLLOWING:
(a) THE CARRIER'S NETWORK, WHICH SHALL
DEMONSTRATE THE FOLLOWING:
(I) AN ADEQUATE NUMBER OF ACCESSIBLE ACUTE
CARE HOSPITAL SERVICES, WITHIN A REASONABLE DISTANCE OR TRAVEL
TIME, OR BOTH;
(II) AN ADEQUATE NUMBER OF ACCESSIBLE
PRIMARY CARE PROVIDERS, WITHIN A REASONABLE DISTANCE OR TRAVEL
TIME, OR BOTH; AND
(III) AN ADEQUATE NUMBER OF ACCESSIBLE
SPECIALISTS AND SUBSPECIALISTS, WITHIN A REASONABLE DISTANCE
OR TRAVEL TIME, OR BOTH;
(b) THE CARRIER'S PROCEDURES FOR MAKING
REFERRALS WITHIN AND OUTSIDE ITS NETWORK THAT, AT A MINIMUM, MUST
INCLUDE THE FOLLOWING:
(I) A COMPREHENSIVE LISTING, MADE AVAILABLE
TO COVERED PERSONS AND PRIMARY CARE PROVIDERS, OF THE PLAN'S NETWORK
PARTICIPATING PROVIDERS AND FACILITIES;
(II) A PROVISION THAT REFERRAL OPTIONS
CANNOT BE RESTRICTED TO LESS THAN ALL PROVIDERS IN THE NETWORK
THAT ARE QUALIFIED TO PROVIDE COVERED SPECIALTY SERVICES;
(III) TIMELY REFERRALS FOR ACCESS TO SPECIALTY
CARE;
(IV) A PROCESS FOR EXPEDITING THE REFERRAL
PROCESS WHEN INDICATED BY MEDICAL CONDITION;
(V) A PROVISION THAT REFERRALS APPROVED
BY THE PLAN CANNOT BE RETROSPECTIVELY DENIED EXCEPT FOR FRAUD
OR ABUSE.
(c) THE CARRIER'S PROCESS FOR MONITORING
AND ASSURING ON AN ONGOING BASIS THE SUFFICIENCY OF THE NETWORK
TO MEET THE HEALTH CARE NEEDS OF POPULATIONS THAT ENROLL IN MANAGED
CARE PLANS;
(d) THE CARRIER'S QUALITY ASSURANCE STANDARDS,
ADEQUATE TO IDENTIFY, EVALUATE, AND REMEDY PROBLEMS RELATING TO
ACCESS, CONTINUITY, AND QUALITY OF CARE;
(e) THE CARRIER'S EFFORTS TO ADDRESS THE
NEEDS OF COVERED PERSONS WITH LIMITED ENGLISH PROFICIENCY AND
ILLITERACY, WITH DIVERSE CULTURAL AND ETHNIC BACKGROUNDS, AND
WITH PHYSICAL AND MENTAL DISABILITIES;
(f) THE CARRIER'S METHODS FOR DETERMINING
THE HEALTH CARE NEEDS OF COVERED PERSONS, TRACKING AND ASSESSING
CLINICAL OUTCOMES FROM NETWORK SERVICES, AND EVALUATING CONSUMER
SATISFACTION WITH SERVICES PROVIDED;
(g) THE CARRIER'S METHOD FOR INFORMING
COVERED PERSONS OF THE PLAN'S SERVICES AND FEATURES, INCLUDING
BUT NOT LIMITED TO THE FOLLOWING:
(I) THE PLAN'S GRIEVANCE PROCEDURES, WHICH
SHALL BE IN CONFORMANCE WITH DIVISION RULES CONCERNING PROMPT
INVESTIGATION OF HEALTH CLAIMS INVOLVING UTILIZATION REVIEW AND
GRIEVANCE PROCEDURES;
(II) THE EXTENT TO WHICH SPECIALTY MEDICAL
SERVICES, INCLUDING PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND
REHABILITATION SERVICES ARE AVAILABLE;
(III) THE PLAN'S PROCESS FOR CHOOSING
AND CHANGING NETWORK PROVIDERS; AND
(IV) THE PLAN'S PROCEDURES FOR PROVIDING
AND APPROVING EMERGENCY AND MEDICAL CARE;
(h) THE CARRIER'S SYSTEM FOR ENSURING
THE COORDINATION AND CONTINUITY OF CARE FOR COVERED PERSONS REFERRED
TO SPECIALTY PROVIDERS;
(i) THE CARRIER'S PROCESS FOR ENABLING
COVERED PERSONS TO CHANGE PRIMARY CARE PROFESSIONALS;
(j) THE CARRIER'S PROPOSED PLAN FOR PROVIDING
CONTINUITY OF CARE IN THE EVENT OF CONTRACT TERMINATION BETWEEN
THE CARRIER AND ANY OF ITS PARTICIPATING PROVIDERS OR IN THE EVENT
OF THE CARRIER'S INSOLVENCY OR OTHER INABILITY TO CONTINUE OPERATIONS.
THE DESCRIPTION SHALL EXPLAIN HOW COVERED PERSONS WILL BE NOTIFIED
OF THE CONTRACT TERMINATION OR THE CARRIER'S INSOLVENCY OR OTHER
CESSATION OF OPERATIONS AND TRANSFERRED TO OTHER PROVIDERS IN
A TIMELY MANNER; AND
(k) ANY OTHER INFORMATION REQUIRED BY
THE COMMISSIONER TO DETERMINE COMPLIANCE WITH THE PROVISIONS OF
THIS PART 7.
1016705. Requirements for
carriers and participating providers. (1) IN
ADDITION TO ANY OTHER APPLICABLE REQUIREMENTS OF THIS PART 7,
A CARRIER OFFERING A MANAGED CARE PLAN SHALL SATISFY ALL THE REQUIREMENTS
OF THIS SECTION.
(2) A CARRIER SHALL MAINTAIN A MECHANISM
BY WHICH PROVIDERS CAN ACCESS INFORMATION ON THE COVERED HEALTH
SERVICES FOR WHICH THE PROVIDER IS RESPONSIBLE, INCLUDING ANY
LIMITATIONS OR CONDITIONS ON SERVICES.
(3) EVERY CONTRACT BETWEEN A CARRIER AND
A PARTICIPATING PROVIDER SHALL SET FORTH A HOLD HARMLESS PROVISION
SPECIFYING THAT COVERED PERSONS SHALL, IN NO CIRCUMSTANCES, BE
LIABLE FOR MONEY OWED TO PARTICIPATING PROVIDERS BY THE PLAN AND
THAT IN NO EVENT SHALL A PARTICIPATING PROVIDER COLLECT OR ATTEMPT
TO COLLECT FROM A COVERED PERSON ANY MONEY OWED TO THE PROVIDER
BY THE CARRIER. NOTHING IN THIS SECTION SHALL PROHIBIT A PARTICIPATING
PROVIDER FROM COLLECTING COINSURANCE, DEDUCTIBLES, OR COPAYMENTS
AS SPECIFICALLY PROVIDED IN THE COVERED PERSON'S CONTRACT WITH
THE MANAGED CARE PLAN.
(4) (a) EVERY CONTRACT BETWEEN A
CARRIER AND A PARTICIPATING PROVIDER SHALL INCLUDE PROVISIONS
FOR CONTINUITY OF CARE AS SPECIFIED IN THIS SUBSECTION (4).
(b) EACH MANAGED CARE PLAN SHALL ALLOW
COVERED PERSONS TO CONTINUE RECEIVING CARE FOR SIXTY DAYS FROM
THE DATE A PARTICIPATING PROVIDER IS TERMINATED BY THE PLAN WITHOUT
CAUSE WHEN PROPER NOTICE AS SPECIFIED IN SUBSECTION (7) OF THIS
SECTION HAS NOT BEEN PROVIDED TO THE COVERED PERSON.
(c) IN THE CIRCUMSTANCE THAT COVERAGE
IS TERMINATED FOR ANY REASON OTHER THAN NONPAYMENT OF THE PREMIUM,
FRAUD, OR ABUSE, EVERY MANAGED CARE PLAN SHALL PROVIDE FOR CONTINUED
CARE FOR COVERED PERSONS BEING TREATED AT AN INPATIENT FACILITY
UNTIL THE PATIENT IS DISCHARGED.
(5) (a) EXCEPT AS PROVIDED FOR IN
PARAGRAPH (b) OF THIS SUBSECTION (5), NOTWITHSTANDING ANY CONTRACTUAL
PROVISION TO THE CONTRARY, A CARRIER THAT HAS ENTERED INTO CONTRACTS
WITH ONE OR MORE CONTRACTORS OR SUBCONTRACTORS OR THEIR INTERMEDIARIES
TO PROVIDE COVERED HEALTH CARE SERVICES TO COVERED PERSONS OF
THE CARRIER UNDER ANY MANAGED CARE PLAN SHALL, IN THE EVENT OF
NONPAYMENT BY, OR INSOLVENCY OF, SUCH CONTRACTORS OR SUBCONTRACTORS
OR THEIR INTERMEDIARIES, REMAIN RESPONSIBLE FOR THE PAYMENT OF
ALL PARTICIPATING PROVIDERS THAT HAVE PROVIDED COVERED HEALTH
CARE SERVICES TO COVERED PERSONS OF THE CARRIER PURSUANT TO ONE
OR MORE CONTRACTS WITH SUCH CONTRACTORS OR SUBCONTRACTORS OR THEIR
INTERMEDIARIES. ANY CONTRACTING PROVIDER THAT PROVIDES COVERED
HEALTH CARE SERVICES TO COVERED PERSONS OF THE CARRIER UNDER A
MANAGED CARE CONTRACT SHALL, IN THE EVENT OF NONPAYMENT FOR SUCH
SERVICES, HAVE LEGAL STANDING TO ENFORCE THE MANAGED CARE CONTRACT
AGAINST THE CARRIER AND RECEIVE PAYMENT FOR SUCH SERVICES. IN
THE EVENT OF THE INSOLVENCY OF A CARRIER, PARTICIPATING PROVIDER
CLAIMS FOR UNPAID SERVICES SHALL BE A CLASS 6 CLAIM UNDER SECTION
10-3-541 (1) (f).
(b) A CARRIER MAY APPLY TO THE COMMISSIONER
FOR THE USE OF AN ALTERNATIVE MECHANISM TO ENSURE THAT ALL PARTICIPATING
PROVIDERS THAT HAVE PROVIDED COVERED HEALTH CARE SERVICES TO COVERED
PERSONS OF THE CARRIER PURSUANT TO ONE OR MORE CONTRACTS WITH
SUCH CONTRACTORS OR SUBCONTRACTORS OR THEIR INTERMEDIARIES RECEIVE
PAYMENT DUE. IF APPROVAL IS GRANTED, SAID CARRIER SHALL BE EXEMPT
FROM THE REQUIREMENTS OF PARAGRAPH (a) OF THIS SUBSECTION (5).
(6) A CARRIER SHALL NOTIFY PARTICIPATING
PROVIDERS OF THE PROVIDERS' RESPONSIBILITIES WITH RESPECT TO THE
CARRIER'S APPLICABLE ADMINISTRATIVE POLICIES AND PROGRAMS, INCLUDING
BUT NOT LIMITED TO, PAYMENT TERMS, UTILIZATION REVIEW, QUALITY
ASSESSMENT AND IMPROVEMENT PROGRAMS, CREDENTIALING, GRIEVANCE
PROCEDURES, DATA REPORTING REQUIREMENTS, CONFIDENTIALITY REQUIREMENTS,
AND ANY APPLICABLE FEDERAL OR STATE PROGRAMS.
(7) A CARRIER AND PARTICIPATING PROVIDER
SHALL PROVIDE AT LEAST SIXTY DAYS WRITTEN NOTICE TO EACH OTHER
BEFORE TERMINATING THE CONTRACT WITHOUT CAUSE. THE CARRIER SHALL
MAKE A GOOD FAITH EFFORT TO PROVIDE WRITTEN NOTICE OF TERMINATION
WITHIN FIFTEEN WORKING DAYS AFTER RECEIPT OF OR ISSUANCE OF A
NOTICE OF TERMINATION TO ALL COVERED PERSONS THAT ARE PATIENTS
SEEN ON A REGULAR BASIS BY THE PROVIDER WHOSE CONTRACT IS TERMINATING,
REGARDLESS OF WHETHER THE TERMINATION WAS FOR CAUSE OR WITHOUT
CAUSE. WHERE A CONTRACT TERMINATION INVOLVES A PRIMARY CARE PROVIDER,
ALL COVERED PERSONS THAT ARE PATIENTS OF THAT PRIMARY CARE PROVIDER
SHALL ALSO BE NOTIFIED. WITHIN FIVE WORKING DAYS AFTER THE DATE
THAT THE PROVIDER EITHER GIVES OR RECEIVES NOTICE OF TERMINATION,
THE PROVIDER SHALL SUPPLY THE CARRIER WITH A LIST OF THOSE PATIENTS
OF THE PROVIDER THAT ARE COVERED BY A PLAN OF THE CARRIER.
(8) THE RIGHTS AND RESPONSIBILITIES UNDER
A CONTRACT BETWEEN A CARRIER AND A PARTICIPATING PROVIDER SHALL
NOT BE ASSIGNED OR DELEGATED BY THE PROVIDER WITHOUT THE PRIOR
WRITTEN CONSENT OF THE CARRIER, AND ANY SUBCONTRACTS SHALL COMPLY
WITH THE REQUIREMENTS OF THIS PART 7.
(9) A CARRIER'S CONTRACT WITH PARTICIPATING
PROVIDERS SHALL INCLUDE A PROVISION THAT PARTICIPATING PROVIDERS
DO NOT DISCRIMINATE, WITH RESPECT TO THE PROVISION OF MEDICALLY
NECESSARY COVERED BENEFITS, AGAINST COVERED PERSONS THAT ARE PARTICIPANTS
IN A PUBLICLY FINANCED PROGRAM.
(10) A CARRIER SHALL NOTIFY THE PARTICIPATING
PROVIDERS OF THEIR OBLIGATIONS, IF ANY, TO COLLECT APPLICABLE
COINSURANCE, COPAYMENTS, OR DEDUCTIBLES FROM COVERED PERSONS PURSUANT
TO THE EVIDENCE OF COVERAGE OR OF THE PROVIDERS' OBLIGATIONS,
IF ANY, TO NOTIFY COVERED PERSONS OF THEIR PERSONAL FINANCIAL
OBLIGATIONS FOR NONCOVERED SERVICES.
(11) A CARRIER SHALL NOT PENALIZE A PROVIDER
BECAUSE THE PARTICIPATING PROVIDER, IN GOOD FAITH, REPORTS TO
STATE OR FEDERAL AUTHORITIES ANY ACT OR PRACTICE BY THE CARRIER
THAT JEOPARDIZES PATIENT HEALTH OR WELFARE, OR BECAUSE THE PARTICIPATING
PROVIDER DISCUSSES THE FINANCIAL INCENTIVES OR FINANCIAL ARRANGEMENTS
BETWEEN THE PROVIDER AND THE MANAGED CARE PLAN.
(12) A CARRIER SHALL ESTABLISH A MECHANISM
BY WHICH THE PARTICIPATING PROVIDERS MAY DETERMINE, AT THE TIME
SERVICES ARE PROVIDED, WHETHER OR NOT A PERSON IS COVERED BY THE
CARRIER.
(13) A CARRIER SHALL ESTABLISH PROCEDURES
FOR RESOLUTION OF ADMINISTRATIVE, PAYMENT, OR OTHER DISPUTES BETWEEN
PROVIDERS AND THE CARRIER.
(14) EVERY CONTRACT BETWEEN A CARRIER
AND A PARTICIPATING PROVIDER FOR A MANAGED CARE PLAN THAT REQUIRES
PREAUTHORIZATION FOR PARTICULAR SERVICES, TREATMENTS, OR PROCEDURES
SHALL INCLUDE A PROVISION THAT CLEARLY STATES THAT THE SOLE RESPONSIBILITY
FOR OBTAINING ANY NECESSARY PREAUTHORIZATION RESTS WITH THE PARTICIPATING
PROVIDER THAT RECOMMENDS OR ORDERS SAID SERVICES, TREATMENTS,
OR PROCEDURES, NOT WITH THE COVERED PERSON.
(15) A CONTRACT BETWEEN A CARRIER AND
A PARTICIPATING PROVIDER SHALL NOT CONTAIN DEFINITIONS OR OTHER
PROVISIONS THAT CONFLICT WITH THE DEFINITIONS OR PROVISIONS CONTAINED
IN THE MANAGED CARE PLAN OR THIS PART 7.
1016706. Intermediaries.
(1) IN ADDITION TO ANY OTHER APPLICABLE REQUIREMENTS
OF THIS PART 7, A CONTRACT BETWEEN A CARRIER AND AN INTERMEDIARY
SHALL SATISFY ALL THE REQUIREMENTS OF THIS SECTION.
(2) INTERMEDIARIES AND PARTICIPATING PROVIDERS
WITH WHOM THEY CONTRACT SHALL COMPLY WITH ALL THE APPLICABLE REQUIREMENTS
OF SECTION 1016705.
(3) THE RESPONSIBILITY TO ENSURE THAT
PARTICIPATING PROVIDERS HAVE THE CAPACITY AND LEGAL AUTHORITY
TO FURNISH COVERED BENEFITS SHALL BE RETAINED BY THE CARRIER.
(4) A CARRIER SHALL HAVE THE RIGHT TO
APPROVE OR DISAPPROVE PARTICIPATION STATUS OF A SUBCONTRACTED
PROVIDER IN ITS OWN OR A CONTRACTED NETWORK FOR THE PURPOSE OF
DELIVERING COVERED BENEFITS TO THE CARRIER'S COVERED PERSONS.
(5) A CARRIER SHALL MAINTAIN COPIES OF
ALL INTERMEDIARY HEALTH CARE SUBCONTRACTS.
(6) IF APPLICABLE, AN INTERMEDIARY SHALL
TRANSMIT UTILIZATION DOCUMENTATION AND CLAIMS PAID DOCUMENTATION
TO THE CARRIER. THE CARRIER SHALL MONITOR THE TIMELINESS AND APPROPRIATENESS
OF PAYMENTS MADE TO PARTICIPATING PROVIDERS AND HEALTH CARE SERVICES
RECEIVED BY COVERED PERSONS.
(7) IF APPLICABLE, AN INTERMEDIARY SHALL
MAINTAIN BOOKS, RECORDS, FINANCIAL INFORMATION, AND DOCUMENTATION
OF SERVICES PROVIDED TO COVERED PERSONS AT THE INTERMEDIARY'S
PLACE OF BUSINESS IN THIS STATE.
(8) AN INTERMEDIARY SHALL ALLOW THE COMMISSIONER
ACCESS TO THE INTERMEDIARY'S BOOKS, RECORDS, FINANCIAL INFORMATION,
AND ANY DOCUMENTATION OF SERVICES PROVIDED TO COVERED PERSONS
AS NECESSARY TO DETERMINE COMPLIANCE WITH THIS PART 7.
(9) A CARRIER SHALL HAVE THE RIGHT, IN
THE EVENT OF THE INTERMEDIARY'S INSOLVENCY, TO REQUIRE THE ASSIGNMENT
TO THE CARRIER OF THE PROVISIONS OF A PARTICIPATING PROVIDER'S
CONTRACT ADDRESSING THE PROVIDER'S OBLIGATION TO FURNISH COVERED
SERVICES.
1016707. Enforcement.
(1) IF IT IS DETERMINED THAT A CARRIER HAS NOT CONTRACTED
WITH ENOUGH PARTICIPATING PROVIDERS TO ASSURE THAT COVERED PERSONS
HAVE ACCESSIBLE HEALTH CARE SERVICES IN A GEOGRAPHIC AREA, THAT
A CARRIER'S ACCESS PLAN DOES NOT ASSURE REASONABLE ACCESS TO COVERED
BENEFITS, THAT A CARRIER HAS ENTERED INTO A CONTRACT THAT DOES
NOT COMPLY WITH THIS PART 7, OR THAT A CARRIER HAS NOT COMPLIED
WITH A PROVISION OF THIS PART 7, THE COMMISSIONER MAY INSTITUTE
A CORRECTIVE ACTION THAT SHALL BE FOLLOWED BY THE CARRIER OR MAY
USE ANY OF THE COMMISSIONER'S OTHER ENFORCEMENT POWERS TO OBTAIN
THE CARRIER'S COMPLIANCE WITH THIS PART 7.
(2) THE COMMISSIONER SHALL NOT ACT TO
ARBITRATE, MEDIATE, OR SETTLE DISPUTES BETWEEN A MANAGED CARE
PLAN AND A PROVIDER CONCERNING A PROVIDER'S INCLUSION OR TERMINATION
FROM THE NETWORK.
1016708. Rulemaking
authority of commissioner. THE COMMISSIONER
MAY PROMULGATE RULES AS NECESSARY FOR CARRYING OUT THE COMMISSIONER'S
DUTIES UNDER THIS PART 7.
SECTION 3. 1016401
(4), Colorado Revised Statutes, 1994 Repl. Vol., is amended BY
THE ADDITION OF A NEW PARAGRAPH to read:
1016401. Establishment
of health maintenance organizations. (4) Each
application for a certificate of authority shall be verified by
an officer or authorized representative of the applicant, shall
be in a form prescribed by the commissioner, and shall set forth
or be accompanied by the following:
(p) AN ACCESS PLAN FOR EACH SEPARATE NETWORK
OF THE HEALTH MAINTENANCE ORGANIZATION AS SPECIFIED IN SECTION
1016704 (9). TO THE EXTENT THAT THE INFORMATION IN
THE ACCESS PLAN CONTAINS THE REQUIRED INFORMATION SPECIFIED IN
PARAGRAPHS (e), (f), (k), (l), (m), AND (n) OF THIS SUBSECTION
(4), THE HEALTH MAINTENANCE ORGANIZATION SHALL BE DEEMED TO BE
IN COMPLIANCE WITH SAID PARAGRAPHS.
SECTION 4. 1031104
(1), Colorado Revised Statutes, 1994 Repl. Vol., as amended, is
amended BY THE ADDITION OF A NEW PARAGRAPH to read:
1031104. Unfair methods
of competition and unfair or deceptive acts or practices.
(1) The following are defined as unfair methods of
competition and unfair or deceptive acts or practices in the business
of insurance:
(y) VIOLATING ANY PROVISION OF THE "CONSUMER PROTECTION STANDARDS ACT FOR THE OPERATION OF MANAGED CARE PLANS", PART 7 OF ARTICLE 16 OF THIS TITLE BY THOSE SUBJECT TO SAID PART 7.
SECTION 5. Effective date. This
act shall take effect July 1, 1997.
SECTION 6. Safety
clause. The general assembly hereby finds, determines, and
declares that this act is necessary for the immediate preservation
of the public peace, health, and safety.
____________________________ ____________________________
Charles E. Berry Tom Norton
SPEAKER OF THE HOUSE PRESIDENT OF
OF REPRESENTATIVES THE SENATE
____________________________ ____________________________
Judith M. Rodrigue Joan M. Albi
CHIEF CLERK OF THE HOUSE SECRETARY OF
OF REPRESENTATIVES THE SENATE
APPROVED________________________________________
_________________________________________
Roy Romer
GOVERNOR OF THE STATE OF COLORADO