Federal "No Surprises" Act
The federal No Surprises Act will go into effect on January 1, 2022 and applies to self funded and fully insured plans. This new law will have some overlap with Colorado’s Out-of-Network Health Care Services law, put into place by HB19-1174. Know that the Division is working to evaluate the intersection between the state and federal laws. Both laws protect consumers from surprise out of network bills. If you receive a surprise bill and have questions about which law is applicable, contact our Consumer Services Division for assistance.
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.
House Bill 19-1174 was passed by the Colorado Legislature to help protect patients from surprise out-of-network bills
Surprise billing happens when a patient receives an unexpected balance bill after they receive care from an out-of-network provider or at an out-of-network facility, such as a hospital. It can happen for both emergency and non-emergency care. Typically, patients don’t know the provider or facility is out-of-network until they receive the bill.
Balance billing happens when a health care provider (a doctor, for example) bills a patient after the patient’s health insurance company has paid its share of the bill. The balance bill is for the difference between the provider’s charge and the price the insurance company set, after the patient has paid any copays, coinsurance, or deductibles.
The bill 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.
Legislation and FAQ: HB19-1174 - Out-of-Network Health Care Services
Out-of-Network Health Care Provider Reimbursement Regulations
Out-of-Network APCD Reimbursement Datasets
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
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
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, December 2021- 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 extended to March 15, 2022
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:
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
Out-of-Network Arbitration Program
Out-of-Network Arbitration Request Form [Fillable PDF]
Arbitration Decision and Reporting Form [Fillable PDF]