SB 17

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SENATE BILL 26-017
BY SENATOR(S) Daugherty and Bright, Cutter, Exum, Hinrichsen, Kipp,
Marchman, Roberts, Snyder, Wallace, Coleman;
also REPRESENTATIVE(S) Stewart R. and Gonzalez R., Bacon, Duran,
Lieder, Lindsay, Rutinel, Stewart K.
CONCERNING CHANGES TO OUT-OF-NETWORK HEALTH-CARE SERVICES
        DISPUTE RESOLUTION PROCESSES FOR HEALTH INSURANCE CARRIERS.
Be it enacted by the General Assembly of the State of Colorado:
        SECTION 1. In Colorado Revised Statutes, 10-16-704, amend (13)
as follows:
       10-16-704. Network adequacy - required disclosures - balance
billing - rules - legislative declaration - definitions.
        ( 13) (a) (I) THE GENERAL ASSEMBLY FINDS AND DECLARES THAT:
        (A)       UNDER       CURRENT        STATE      LAW,     PROVIDERS        RESOLVE
OUT-OF-NETWORK REIMBURSEMENT DISPUTES THROUGH AN INDIVIDUAL,
CLAIM-BY-CLAIM ARBITRATION PROCESS THAT, FOR SOME PROVIDERS WITH
SMALLER REIMBURSEMENT AMOUNTS BEING DISPUTED, IS PROHIBITIVELY
Capital letters or bold & italic numbers indicate new material added to existing law; dashes
through words or numbers indicate deletions from existing law and such material is not part of
the act.
EXPENSIVE AND ADMINISTRATIVELY BURDENSOME;
      (B) BECAUSE THE COST OF ARBITRATION EXCEEDS THE AMOUNT OF
THE UNDERPAID CLAIM, THIS PROCESS PARTICULARLY IMPACTS SMALLER
PROVIDER GROUPS;
      (C) THE DIVISION HAS AN ESTABLISHED COMPLAINT PROCESS THAT
ALLOWS PROVIDERS TO SUBMIT COMPLAINTS TO ENSURE THAT PAYMENT
REQUIREMENTS ARE MET BY CARRIERS. THIS ESTAB LI SHED COMPLAINT
PROCESS REQUIRES THE RESOLUTION OF CLAIMS WITHIN THIRTY DAYS AFTER
THE COMPLAINT CONTAINING THE CLAIMS HAS BEEN FILED IF THERE ARE ONE
HUNDRED OR FEWER CLAIMS SUBMITTED ON THE COMPLAINT FORM AND
ALLOWS FOR ADDITIONAL TIME WHEN THERE ARE MORE THAN ONE HUNDRED
CLAIMS SUBMITTED ON THE COMPLAINT FORM. HOWEVER, THE COMPLAINT
PROCESS DOES NOT ENSURE PROMPT PAYMENT TO PROVIDERS OF MONEY
OWED WHEN CARRIERS ARE DEEMED TO HAVE VIOLATED PAYMENT
REQUIREMENTS.
      (D) TOIMPROVEFAIRNESSINTHEHEALTH-INSURANCEMARKET, THE
DIVISION'S EXISTING OVERSIGHT AND ENFORCEMENT AUTHORITY OF CARRIER
PAYMENTS TO PROVIDERS SHOULD BE AUGMENTED TO COMPEL PROMPT
PAYMENT FROM CARRIERS WHEN UNDERPAYMENT IS IDENTIFIED IN THE
COMPLAINT PROCESS, THEREBY PROVIDING A MORE EFFECTIVE PATHWAY FOR
PROVIDERS TO CHALLENGE UNDERPAYMENT; AND
      (E) CARRIERS ARE NOT REQUIRED TO DISCLOSE WHEN A PATIENT'S
HEALTH BENEFIT PLAN IS GOVERNED BY STATE LAW, SO THE PROVIDER IS
UNABLE TO DETERMINE IN WHICH JURISDICTION THE PROVIDER MAY APPEAL.
      (II)    THE GENERAL ASSEMBLY THEREFORE INTENDS FOR THIS
SUBSECTION (13) TO:
      (A)     STREAMLINE OUT-OF-NETWORK DISPUTE RESOLUTIONS BY
GRANTING THE DIVISION ADDITIONAL ENFORCEMENT AUTHORITY WITHIN ITS
OUT-OF-NETWORK COMPLAINT PROCESS, INCLUDING A REQUIREMENT TO
COMPEL PROMPT PAYMENT FROM CARRIERS WHEN UNDERPAYMENT IS
IDENTIFIED;
      (B) REQUIRE JURISDICTIONAL TRANSPARENCY BY MANDATING THAT
CARRIERS CLEARLY STATE ON A REMITTANCE ADVICE WHEN A HEALTH
PAGE 2-SENATE BILL 26-017
BENEFIT PLAN IS REGULATED BY STATE LAW; AND
       (C) EMPOWER DATA-DRIVEN ENFORCEMENT BY REQUIRING CARRIERS
TO DISCLOSE THE  SPECIFIC METHODOLOGIES USED TO DETERMINE
OUT-OF-NETWORK REIMBURSEMENT AND BY GRANTING THE COMMISSIONER
AUTHORITY TO ORDER CORRECTIVE PAYMENTS AND IMPOSE FINES FOR
NONCOMPLIANCE.
        W (b) When a carrier makes a payment to a provider or a
health-care facility pursuant to subsection (3)(d) or (5.5)(b) of this section,
the provider or the facility may request, and the commissioner shall collect,
data from the carrier to evaluate the carrier's compliance in paying the
highest rate required. The information requested may PROVIDED MUST
include the methodology for determining the carrier's median in-network
rate or AND reimbursement for each service in the same geographic area.
DATA SUBMITTED BY A CARRIER PURSUANT TO THIS SUBSECTION ( 13 )(b) IS
PROPRIETARY, A TRADE SECRET, AND CONFIDENTIAL PURSUANT TO SECTION
24-72-204 (3)(a)(IV).
       (b) Repealed.
       (c) BEGINNING JANUARY 1, 2027, WHEN A CARRIER MAKES A
PAYMENT TO A PROVIDER OR A HEALTH-CARE FACILITY PURSUANT TO
SUBSECTION (3)(d) OR (5.5)(b) OF THIS SECTION, THE CARRIER SHALL
PROVIDE A REMITTANCE ADVICE THAT IDENTIFIES WHEN THE HEALTH
BENEFIT PLAN THE CARRIER IS MAKING THE PAYMENT PURSUANT TO IS
REGULATED BY THE STATE AND THAT THE PAYMENT WAS MADE PURSUANT
TO SUBSECTION (3)(d) OR (5.5)(b) OF THIS SECTION.
       (d) A CARRIER SHALL PROVIDE THE CARRIER'S MEDIAN IN-NETWORK
REIMBURSEMENT RATE FOR OUT-OF-NETWORK CLAIMS ON EACH REMITTANCE
ADVICE.
        SECTION 2. Act subject to petition - effective date -
applicability. (1) This act takes effect at 12:01 a.m. on the day following
the expiration of the ninety-day period after final adjournment of the
general assembly (August 12, 2026, if adjournment sine die is on May 13,
2026); except that, if a referendum petition is filed pursuant to section 1 (3)
of article V of the state constitution against this act or an item, section, or
part of this act within such period, then the act, item, section, or part will
PAGE 3-SENATE BILL 26-017
not take effect unless approved by the people at the general election to be
held in November 2026 and, in such case, will take effect on the date of the
official declaration of the vote thereon by the governor.
       (2) This act applies to payments owed by health insurance carriers
on or after the applicable effective date of this act.
James Rashad Coleman, Sr.
PRESIDENT OF  SPEAKER OF THE HOUSE
THE SENATE  OF REPRESENTATIVES
                                           v~~ly
Es r van Mourik
SECRETARY OF  CHIEF CLERK OF THE HOUSE
THE SENATE  OF REPRESENTATIVES
       APPROVED O'\       To~ Yb~ 1-f>'i¼-- UJu, o.,+ lL;oor~
                                    (Date and Time)
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