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
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
NEW (June 2021)- DRAFT PROPOSED REGULATION 4-2-7X
The Division is proposing the following new regulation regarding requirements for data request and carrier responses confirming-out-of-network payment methodology utilization. To obtain stakeholder feedback, the Division hosted a stakeholder meeting on June 22, 2021. A recording of the meeting and the draft proposed regulation can be found at the following links:
Out-of-Network APCD Reimbursement Datasets
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
- FAQ from Center for Improving Value in Health Care (CIVHC) (rev Dec 2020) - 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
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)
- Tara Smith (Tara.Smith@state.co.us)
- Leilani Russell (Leilani.Russell@state.co.us)
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.
Out-of-Network Arbitration Program
Out-of-Network Arbitration Request Form [Fillable PDF]
Arbitration Decision and Reporting Form [Fillable PDF]