e Health Tips

The administration, regulation and oversight of private family health insurance in Colorado is undertaken by the Colorado Department of Regulatory Agencies’ Division of Insurance. The current Commissioner is Marcy Morrison.

Colorado insurance law affords consumers a number of benefits when health insurance is involved. For example, private health insurance providers operating in Colorado must give a 60-day notice period when a healthcare provider is terminated from a managed care network, with insurance coverage continuing through this time. However, Colorado insurance law may not apply to employer healthcare plans if the employer’s headquarters are not located in Colorado.

Colorado law also protects consumers from unexpected out-of-pocket costs as a result of the non-payment of an insurer following a visit to an in-network provider. For example, if an insurer’s client visits an in-network provider and receives care, the in-network provider is not permitted to directly bill the patient for any costs involved should the insurer not pay the provider after it said it would. Note that this does not apply to any copay, coinsurance or deductibles involved – these are always the responsibility of the patient.

Private health insurers are required by Colorado law to ensure that they notify patients and healthcare providers of their determinations in relation to claims within 30 days of receiving a request for coverage of medical services already rendered. Private health insurers are not permitted to require patients to get prior authorization for coverage of emergency services if a life- or ‘limb-threatening’ situation has occurred. If a private health insurer denies a patient’s request for coverage under their plan, a written appeals procedure must be in place in the event that a patient wishes to challenge their insurer’s decision. A first level review of the decision may be requested within 180 days of receiving notification of the ‘adverse determination’ (claim rejection). The private health insurer is bound to make a decision and inform the patient about it within 30 days of receiving the first level review request. If this request is returned with a second negative decision, a second-level review may be requested within 30 days. Patients have the right to appear at the review meeting by teleconference or in person if possible.

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