Back in January, I told you about the No Surprises Act, a law created by Congress last year tucked away deep inside the 2,123 page Consolidated Appropriations Act.
Under the No Surprises Act, if, other than as a matter of personal choice, you receive services from a health care provider (facility or doctor) not a part of your health plan’s network, you will only be required to pay what you would have been charged if the provider was in the network. You’ll still be responsible for your normal co-pays and deductibles, but no more. The act also creates an arbitration process whereby your health insurance plan and an out-of-network health care provider who treated you can duke it out to determine what the provider will be paid. You, however, are out of the middle of this dispute.
The federal No Surprises Act doesn’t go into effect until Jan. 1 of next year. But, you should know that Colorado has its own no surprises law, which is already in effect. Like the federal law, the Colorado law is lengthy and detailed; if you tried to figure out what it does and doesn’t do by just reading the bill that created it — HB19-1174 — you would come away confused (with, however, a new appreciation for how complicated health insurance has become).
To help out here, the most important parts of the Colorado law go like this. If you end up in a health care facility because of a true emergency, even though the facility and/or the doctors who work there are not part of your health plan’s network, you will only be required to pay what you would have paid if the facility and/or the doctors were a part of your network, meaning your co-pays and deductibles. Thus, the next time you’re injured in a car accident, you won’t need to comparison shop for emergency room services. (How ambulance companies fit into this scenario, however, is not entirely clear and you might still want to comparison shop for an ambulance.)
The second big protection coming out of the Colorado law is that, if you receive care at a medical facility in your health plan’s network but some or all of the doctors who treat you there are not in the network, your charges will again be limited to what you would be required to pay if all the doctors were in the network.
Since the Colorado law, like the federal law, will generate payment disputes between non-network providers (who want to be paid more) and health insurance plans (who want to pay less), the Colorado law, like the federal law, sets up an alternative dispute resolution process that, after several intermediate steps, ends up with arbitration.
Importantly, the Colorado law also creates disclosure requirements on the part of providers and health insurance plans obligating them to answer questions health plan members/prospective patients might have about a health plan’s network, and what happens if a non-network provider shows up on the stage. The Colorado law encourages prospective patients to ask questions about charges and insurance coverage, and get answers, before they receive health care services.
The Colorado Division of Insurance website — doi. colorado.gov/health-insurance — provides basic information about out-of-network billing, and that agency is set up to answer questions and process complaints. Another good resource is the Colorado Consumer Health Initiative (cohealthinitiative.org), a nonprofit organization whose staff members have spent much time in the trenches of health care and are knowledgeable about the Colorado no surprises act.
A word of caution. The Colorado law only governs health plans regulated by the Colorado Division of Insurance. If your plan is one of these, somewhere on your health insurance ID card you should see “CO-DOI.”
Jim Flynn is with the Colorado Springs firm of Flynn & Wright LLC. You can contact him at firstname.lastname@example.org.