Federal No Surprises Act / Colorado Out-of-Network Billing
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
- anesthesiology,
- pathology
- radiology,
- neonatology;
- 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.
For Colorado Consumers
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.
Resources
- 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
Other Agencies:
- Providers with questions regarding the NSA, please contact the DORA Division of Professions and Occupations at dora_dpo_licensing@state.co.us.
- Facilities with question regarding the NSA, please contact the Department of Public Health and Environment at cdphe_hfemsdpolicy@state.co.us.
For Health Care Providers and Insurance Companies
Out-of-Network Health Care Provider Reimbursement Regulations
Out-of-Network Health Care Carrier Regulations
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 15, 2023
- HB19-1174 CO APCD 60th Percentile Allowed Amounts for Professionals - Issued December 15, 2023
- HB19-1174 CO APCD 50th Percentile Allowed Amounts for Emergency Services - Issued December 15, 2023
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
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 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
For Carriers - Out of Network Data Reporting
The Division repealed Regulation 4-2-74 due to the recent passage of Senate Bill 24-135, signed by Governor Polis on March 22, 2024, which eliminated the requirement carriers to annual submit information to the Division concerning the use of out-of-network providers and out-of-network facilities and the impact on premium affordability for consumers.