Colorado law protects consumers from surprise medical bills.
Coloradans are protected from certain surprise medical bills under both state and federal law when a covered individual receives:
- Most emergency services;
- Non-emergency services from an out-of-network provider at an in-network facility, such as a hospital;
- Service from a private ground ambulance provider (not from a fire department or government entity); and
- Service from an out-of-network air ambulance service provider.
Colorado law and the federal No Surprises Act ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.
If you want to learn more about the federal No Surprises Act, please visit the No Surprises Act website (from the Center for Medicare & Medicaid Services) to see fact sheets on what No Surprises Act rules cover, as well as additional details about consumer protections.
What are surprise medical bills?
If you have health insurance and get care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the entire out-of-network cost. This can leave you with higher costs than if you got care from an in-network provider or facility.
In the past, in addition to any out-of-network cost-sharing you might owe (like coinsurance or copayments), the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid. This is called “balance billing.”
An unexpected balance bill from an out-of-network provider is called a surprise medical bill.
Out-of-network providers and facilities may ask you to waive your balance billing protections, you do NOT have consent to out-of-network care. If you choose an out-of-network provider, the provider must give you information in advance about what your share of the costs will be and you must provide written consent to the higher costs.
You can never be asked to waive your surprise billing protections for services related to:
- emergency medicine
- services provided by assistant surgeons, hospitalists, intensivists;
- diagnostic services including radiology and laboratory services; and
- services provided by an out-of-network provider if there is no in-network provider who can provide the service at the facility.
Colorado law includes provisions for how health insurance carriers will reimburse providers (doctors, hospitals and other health care providers) for out-of-network emergency and non-emergency care.
Recording of NSA Overview Webinar - January 26, 2023
For Colorado Consumers
What should I pay?
If you go to an in-network facility only have to pay for in-network cost sharing.
If you are taken to a non-contracted medical facility for emergency services, you are only required to pay the in-network cost share.
Consumers should contact their health plan if they have questions about their in-network cost sharing.
What should I do if I get a surprise medical bill?
If you get a surprise bill for more than your in-network cost share, first file a grievance/complaint with your health plan and include a copy of the bill. Your health plan will review your grievance and should tell the provider to stop billing you. If you do not agree with your health plan’s response or they are not taking immediate action to fix the problem, contact our Consumer Services Division for assistance.
Colorado surprise billing law (HB22-1284) applies to plans regulated by the Colorado Division of Insurance. The federal No Surprises Act (Pub L. 116-260) applies to self-funded plans regulated by the U.S. Department of Labor.
If you receive a surprise bill and have questions about which law is applicable, contact our Consumer Services Division for assistance.
303-894-7490 / 800-930-3745 (outside the Denver Metro area) DORA_Insurance@state.co.us
Monday - Friday, 8:00 a.m. - 5:00 p.m.
- To learn more about the federal No Surprises Act, visit the Centers for Medicare & Medicaid Services website: Overview of rules & fact sheets.
- No Surprises: Health Insurance Terms You Should Know
- No Surprises: Understanding your rights against surprise medical bills
- Providers with questions regarding the NSA, please contact the DORA Division of Professions and Occupations at email@example.com.
- Facilities with question regarding the NSA, please contact the Department of Public Health and Environment at firstname.lastname@example.org.
For Health Care Providers and Insurance Companies
Out-of-Network Health Care Provider Reimbursement Regulations
Regulation 4-2-65- Concerning the Establishment of a Carrier Payment Arbitration Program for Out-of-Network Provider
Regulation 4-2-66 - Concerning the Payment Methodology for Non-contracted Service Agencies that Provide Emergency Ambulance Services
Regulation 4-2-79 Concerning the Requirements for Provider Data Requests and Carrier Responses Confirming Out-of-Network Payment Methodology Utilization
Out-of-Network Health Care Carrier Regulations
Regulation 4-2-67- Concerning Carrier Disclosures for Emergency and Non-emergency Out-of-Network Services
Regulation 4-2-74 - Concerning Data Reporting Requirements for Carriers' Out-of-Network Reimbursements
Regulation 4-2-88 - Concerning Gag Clauses in Individual and Group Health Benefit Plans
Regulation 4-2-89 - Compensation Disclosures for Health Insurance Carriers
Out-of-Network Arbitration Program Main Page
Apply to be Arbitrator for the Out-of-Network Arbitration Program - The Division is currently not accepting applications for additional arbitrators
List of Qualified Arbitrators and Fees for the Out-of-Network Payment Arbitration Program
Out-of-Network APCD Reimbursement Datasets
December 20, 2022
- HB19-1174 CO APCD 60th Percentile Allowed Amounts for Professionals - Issued December 20, 2022
- HB19-1174 CO APCD 50th Percentile Allowed Amounts for Emergency Services - Issued December 20, 2022
CO APCD Professional, Anesthesia, and Emergency Room Fee Schedule Overview and Methods (Data issued 12.2022)
December 21, 2021
- HB19-1174 CO APCD 60th Percentile Allowed Amounts for Professionals - Issued December 21, 2021
- HB19-1174 CO APCD 50th Percentile Allowed Amounts for Emergency Services
- HB19-1174 2020-2021 CO APCD 50th Percentile Allowed Amounts for COVID Services
CO APCD Professional, Anesthesia, and Emergency Room Fee Schedule Overview and Methods (Data issued 12.2021)
CO APCD COVID Fee Schedule Overview and Methods (Data issued 12.2021)
December 18, 2020
- HB19-1174 CO APCD 60th Percentile Allowed Amounts for Professionals - Issued December 18, 2020
- HB19-1774 CO APCD 50th Percentile Allowed Amounts for Emergency Services
CO APCD Support for HB 19-1174 (2019 Service Dates)
October 21, 2020
- HB 19-1174 Re-issued CO APCD Reimbursement Dataset - 60th Percentile Allowed Amounts for Out-of-Network Professionals - Includes Anesthesiology - Reissued October 21, 2020
- HB 19-1174 Re-issued CO APCD Reimbursement Dataset - 50th Percentile Allowed Amounts for Out-of-Network Emergency Services - Reissued October 21, 2020
CO APCD Calculated Allowed Amounts to Support Implementation of House Bill 19-1174 - October 2020 Update
- CO APCD Out of Network Fee Schedule FAQs, January 2023 - CIVHC's Colorado All Payer Claims Database (CO APCD) is specifically identified in the bill as a data source for the implementation of HB19-1174.
For Carriers - Out of Network Data Reporting
Deadline for data reporting March 1, 2023
Regulation 4-2-74 requires that all applicable health insurance carriers report data to the Commissioner of Insurance on the use of out-of-network providers and facilities, as well as the impact on premium affordability. To facilitate carrier submissions of these data the Division of Insurance has created a data reporting template. It is suggested that carriers download the template, fill it out, and email it to all of the following Division staff:
- Deb Judy (Debra.Judy@state.co.us)
- Jill Mullen (Jill.Mullen@state.co.us)
Out-of-Network Carrier Data Reporting Template
Any questions about the data reporting template itself, reporting requirements, or issues reporting the required data by the deadlines listed in statute can be directed to the same Division staff listed above.
*Note: template revised 2.11.22 with edit regarding data collection on contracted ambulance service providers in tab D., cell E19