Requirements for carriers and participating providers - definitions - rules

(b) Each carrier that issues a managed care plan shall allow covered persons to continue receiving care for up to ninety days after the date a carrier has provided notice to an individual enrolled in such plan pursuant to subsection (4)(d)(II)(A) of this section that the contract is terminated. The carrier shall provide the requisite coverage or continuing care to the covered person at the covered person's in-network benefit level cost-sharing amount during the period beginning on the date on which the notice of termination is given pursuant to subsection (4)(d)(II)(A) of this section and ending on the earlier of the ninety-day period beginning on such date or the date on which the covered person is no longer a continuing care patient with the provider or health-care facility.

(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 in-patient facility until the patient is discharged.

(d) (I) A carrier shall comply with the requirements of subsection (4)(d)(II) of this section if a participating provider, whether an individual provider or a facility, is treating a continuing care patient who is a covered person under the plan and if:

(A) The contract between the carrier and the participating provider is terminated due to the expiration or nonrenewal of the contract;

(B) The benefits provided under the managed care plan or the health insurance coverage, with respect to the provider or facility, are terminated due to the expiration or nonrenewal of the contract between the carrier and the provider or facility because of a change in the terms of the participation in the plan or coverage; or

(C) A contract between the group health plan and the carrier offering coverage in connection with the group health plan is terminated due to the expiration or nonrenewal of the contract, resulting in the loss of benefits under the plan with respect to the participating provider that is providing treatment or services to the covered person in compliance with the federal No Surprises Act.

(II) A carrier subject to this subsection (4)(d) shall:

(A) Notify each covered person who is receiving care from a provider or facility with whom a contract is terminated as described in subsection (4)(d)(I) of this section, at the time of the termination of the contract, that the patient has the right to elect continued transitional care from the treating provider or facility if the termination of the contract affects the status of the provider or facility as a participating provider;

(B) Provide the covered person with an opportunity to notify the managed care plan or carrier of the need for transitional care; and

(C) Permit the covered person to elect to continue to have benefits provided under the covered person's current plan or coverage under the same terms and conditions as would have applied and with respect to the same items and services as would have been covered had a termination described in subsection (4)(d)(I) of this section not occurred, with respect to the course of treatment furnished by the provider or facility relating to the covered person's status as a continuing care patient during the period beginning on the date on which the notice under subsection (4)(d)(II)(A) of this section is provided and ending on the ninety-first day after that date or the date on which the covered person is no longer a continuing care patient with respect to the provider or facility, whichever is earlier.

(III) As used in this subsection (4)(d):

(A) Continuing care patient means a covered person who, with respect to a provider or facility whose contract with the covered person's carrier is terminated: Is undergoing a course of treatment for a serious and complex medical condition, which course of treatment is provided by the provider or facility; is undergoing a course of inpatient care provided by the provider or facility; is pregnant and undergoing a course of treatment for the pregnancy provided by the provider or facility; is terminally ill as determined under section 1861 (dd)(3)(A) of the federal Social Security Act, as amended, and is receiving treatment for the illness from the provider or facility; or is scheduled to undergo nonelective surgery from the provider or facility, including the receipt of postoperative care from the provider or facility with respect to the surgery.

(B) Serious and complex medical condition means, in the case of acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm or, in the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially disabling, or congenital and requires specialized medical care over a prolonged period of time.

(C) Terminated, with respect to a contract, means the expiration or nonrenewal of the contract; except that terminated does not include a contract terminated for failure to meet applicable quality standards or for fraud.

(4.5) (a) As used in this subsection (4.5):

(I) Facility means a health-care facility licensed or certified pursuant to section 25-1.5-103.

(II) Medicaid means a medical assistance program established pursuant to the Colorado Medical Assistance Act, articles 4 to 6 of title 25.5.

(III) Serious and complex medical condition has the same meaning as set forth in subsection (4)(d)(III)(B) of this section.

(IV) Transferring enrollee means an individual who:

(A) Was enrolled in medicaid or the children's basic health plan but is no longer eligible for benefits through the program in which the individual was enrolled; or

(B) Was covered under a health benefit plan whose coverage has not been renewed because the carrier is no longer offering any health benefit plans that the individual is eligible for and is therefore enrolled in a new health benefit plan and who: Is undergoing a course of treatment for a serious and complex medical condition that is treated by the provider or facility; is undergoing a course of inpatient care provided by the provider or facility; is pregnant and undergoing a course of treatment for the pregnancy provided by the provider or facility; is terminally ill as determined under section 1861 (dd)(3)(A) of the federal Social Security Act, 42 U.S.C. sec. 1395x, as amended, and is receiving treatment for the illness from the provider or facility; or is scheduled to undergo nonelective surgery from the provider or facility, including the receipt of postoperative care from the provider or facility with respect to the surgery.

(b) A carrier shall allow a transferring enrollee to continue to receive treatment as an in-network benefit from an out-of-network provider or facility as follows:

(I) A transferring enrollee being treated by an out-of-network provider or facility may continue to receive treatment from that provider or facility until the current episode of treatment ends or until ninety days after the enrollee is covered by a new health benefit plan, whichever occurs first.

(II) A transferring enrollee who is pregnant and being treated by an out-of-network provider or facility may continue to receive treatment through the completion of postpartum care, beginning on the date of the enrollee's first day as a covered person under a new health benefit plan.

(c) (I) During the time periods covered under subsection (4.5)(b) of this section:

(A) A carrier shall reimburse the out-of-network provider or facility at the carrier's standard in-network reimbursement rate; and

(B) The carrier may require the out-of-network provider or facility to adhere to the carrier's terms and conditions, quality of care standards and protocols, referral process, and reporting standards that apply to comparable in-network providers or facilities in order for the out-of-network provider or facility to be eligible for reimbursement under subsection (4.5)(c)(I)(A) of this section.

(II) If an out-of-network provider or facility has been reimbursed pursuant to subsection (4.5)(c)(I)(A) of this section, the transferring enrollee shall not be balance billed.

(d) This subsection (4.5) does not require a provider or facility to continue to provide care for a transferring enrollee after the applicable time period in subsection (4)(b) of this section.

(e) A carrier subject to this subsection (4.5) shall:

(I) Notify the transferring enrollee, in plain language, at the time of enrollment that the enrollee has the right to elect continued transitional care from an out-of-network provider or facility if the enrollee is a transferring enrollee; and

(II) At the request of the transferring enrollee or the enrollee's provider, grant the transferring enrollee an opportunity to notify the carrier of the need for continued transitional care within one month after the transferring enrollee's effective date of coverage.

(f) (I) At the request of the transferring enrollee or provider, a new carrier shall accept a preauthorization for treatment from the previous carrier for coverage by the new carrier or from the department of health care policy and financing for:

(A) The procedures, treatment, medications, or services that are covered benefits under the new health benefit plan; and

(B) A period of ninety days or for the course of treatment, whichever is less, or until the completion of postpartum care.

(II) Subject to state and federal laws relating to the confidentiality of medical records, at the request and with the consent of an enrollee, a carrier shall provide a copy of the enrollee's preauthorization for treatment to the enrollee's new carrier within ten days after receipt of the request.

(III) After the applicable time period under subsection (4.5)(b) of this section has lapsed, the new carrier may elect to perform its own utilization review in order to:

(A) Reassess and make its own determination regarding the need for continued treatment; and

(B) Authorize any continued procedure, treatment, medication, or service deemed to be medically necessary.

(g) This subsection (4.5) does not require a carrier to provide benefits to an enrollee that are not otherwise covered benefits under the health benefit plan.

(h) The commissioner may adopt rules to implement this subsection (4.5).

(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.

(6.5) A carrier that has entered into a contract with one or more intermediaries to conduct utilization management, utilization review, provider credentialing, administration of health insurance benefits, setting or negotiation of reimbursement rates, payment to providers, network development, or disease management programs shall require the intermediary to comply with the same standards, guidelines, medical policies, and benefit terms of the carrier.

(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.

(9.5) If the health benefit plan provides coverage for a second opinion, the carrier and any entity that contracts with the carrier shall disclose the availability of the second opinion along with the health benefit description form.

(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.

(10.5) (a) A carrier that has entered into a contract with one or more intermediaries to conduct utilization management, utilization review, provider credentialing, administration of health insurance benefits, setting or negotiation of reimbursement rates, payment to providers, network development, or disease management programs, shall require the intermediary to indicate the name of the intermediary and the name of the carrier for which it is conducting the work when making any payment to a health-care provider on behalf of the carrier.

(b) (I) A violation of subsection (6.5) of this section or this subsection (10.5) is an unfair or deceptive act or practice in the business of insurance pursuant to section 10-3-1104.

(II) The commissioner may examine the actions of a carrier pursuant to subsection (6.5) of this section and this subsection (10.5) when conducting a market conduct analysis pursuant to part 2 of article 1 of this title.

(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.

(11.5) A carrier or entity that contracts with the carrier shall not penalize a primary care provider who makes a standing referral of a covered person to a specialist, nor shall the specialist treating the covered person be penalized, with actions that include but are not limited to disincentives or disaffiliation, except for violations of section 10-1-128.

(12) (a) A carrier shall establish one or more mechanisms by which the participating providers may determine, at the time services are provided, whether or not a person is covered by the carrier or is within the grace period established under section 10-16-140 (1), during which period a carrier may hold a claim for services pending receipt of full premium payment. If a carrier maintains only one mechanism, such mechanism shall not require electronic access.

(b) (I) Each carrier, regardless of the mechanism used, shall issue a verification code that the participating provider may use as proof of verification as required by section 10-16-704 (4.5)(f).

(II) In lieu of the requirements of this paragraph (b), for the purposes of verifying the carrier's communication to the provider pursuant to section 10-16-704

(4.5)(g) or (4.5)(h), a carrier may submit written confirmation to a provider within two business days.

(III) If a carrier provides electronic access as a mechanism to verify coverage, the carrier may, in lieu of the requirement to issue a verification code through such mechanism, accept as proof of verification a dated screen print from the carrier's electronic verification mechanism demonstrating that the member is eligible pursuant to section 10-16-704 (4.5)(g) or that the carrier is not required to pay for services pursuant to section 10-16-704 (4.5)(h).

(c) In lieu of the requirements of paragraph (b) of this subsection (12), a carrier may institute a policy providing that adjustments to claims related to eligibility will be made only if the carrier can demonstrate that the member did not appear as eligible on any of the carrier's verification mechanisms on the date of service.

(d) A carrier shall notify participating providers of the mechanisms available to verify eligibility and the carrier's intent with respect to the requirements of paragraphs (a), (b), and (c) of this subsection (12).

(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 or entity that contracts with a carrier and a participating provider for a managed care plan that requires preauthorization for particular services, treatments, or procedures shall include:

(a) 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; and

(b) A provision that allows a covered person to receive a standing referral for medically necessary treatment to a specialist or specialized treatment center participating in the carrier's network or participating in a subdivision or subgrouping of the carrier's network if the subdivision or subgrouping demonstrates network adequacy pursuant to section 10-16-704. The primary care provider for the covered person, in consultation with the specialist and covered person, shall determine that the covered person needs ongoing care from the specialist in order to make the standing referral. A time period for the standing referral of up to one year, or a longer period of time if authorized by the carrier or any entity that contracts with the carrier, shall be determined by the primary care provider in consultation with the specialist or specialized treatment center. The specialist or specialized treatment center shall refer the covered person back to the primary care provider for primary care. To be reimbursed by the carrier or entity contracting with a carrier, treatment provided by the specialist shall be for a covered person and must comply with provisions contained in the covered person's certificate or policy. The primary care physician shall record the reason, diagnosis, or treatment plan necessitating the standing referral.

(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.

(16) A provider who is not licensed to furnish health-care services in this state and who participates in a network shall be licensed in the state in which the provider practices and shall meet minimum statutory and regulatory standards for that professional practice applicable in this state.