§ 18-13-119 — Health-care providers - abuse of health insurance

Colorado § 18-13-119

• Jurisdiction: Colorado
• Title 18: Criminal
• Art.: Miscellaneous Offenses

Text

(1) The
general assembly hereby finds, determines, and declares that:

(a) Business practices that have the effect of eliminating the need for actual
payment by the recipient of health care of required copayments and deductibles in
health benefit plans interfere with contractual obligations entered into between the
insured and the insurer relating to such payments;

(b) Such interference is not in the public interest when it is conducted as a
regular business practice because it has the effect of increasing health-care costs
by removing the incentive that copayments and deductibles create in making the
consumer a cost-conscious purchaser of health care; and

(c) Advertising of such practices may aggravate the adverse financial and
other impacts upon recipients of health care.

(2) Therefore, the general assembly declares that such business practices
are illegal and that violation thereof or the advertising thereof shall be grounds for
disciplinary actions. The general assembly further declares that nothing contained
in this section shall be construed to otherwise prohibit advertising by health-care
providers.

(3) Except as otherwise provided in subsections (5), (6), and (8) of this
section, if the effect is to eliminate the need for payment by the patient of any
required deductible or copayment applicable in the patient's health benefit plan, a
person who provides health care commits abuse of health insurance if the person
knowingly:

(a) Accepts from any third-party payer, as payment in full for services
rendered, the amount the third-party payer covers; or

(b) Submits a fee to a third-party payer which is higher than the fee he has
agreed to accept from the insured patient with the understanding of waiving the
required deductible or copayment.

(4) Abuse of health insurance is a petty offense.

(5) (a) Reimbursements made pursuant to articles 3 to 6 of title 25.5, C.R.S.,
federal medicare laws for inpatient hospitalization, and mental health services
purchased in accordance with article 66 of title 27, C.R.S., are exempt from the
provisions of this section.

(b) Health-care services are exempt from the provisions of this section if
such health-care services are provided:

(I) In accordance with a contract or agreement between an employer and an
employee or employees and the contract includes, as a part of an employee's salary
or employment benefits, terms that authorize a practice that would otherwise be
prohibited by subsection (3) of this section; or

(II) In accordance with a contract or agreement between a town, city, city
and county, or municipality or a special health assurance district pursuant to
section 31-15-302 (1), C.R.S., under terms that authorize a practice that would
otherwise be prohibited by subsection (3) of this section.

(6) (a) The waiver of any required deductible or copayment for charitable
purposes is exempt from the provisions of subsection (3) of this section if:

(I) The person who provides the health care determines that the services are
necessary for the immediate health and welfare of the patient; and

(II) The waiver is made on a case-by-case basis and the person who provides
the health care determines that payment of the deductible or copayment would
create a substantial financial hardship for the patient; and

(III) The waiver is not a regular business practice of the person who provides
the health care.

(b) Any person who provides health care and who waives the deductible or
copayment for more than one-fourth of his patients during any calendar year,
excluding patients covered by subsection (5) of this section, or who advertises
through newspapers, magazines, circulars, direct mail, directories, radio, television,
or otherwise that he will accept from any third-party payer, as payment in full for
services rendered, the amount the third-party payer covers shall be presumed to be
engaged in waiving the deductible or copayment as a regular business practice.

(7) Repealed.

(8) The waiver of a required deductible or copayment for health-care
services provided by a school-based health center, as defined in section 25-20.5-502, C.R.S., is exempt from the provisions of this section.

Legislative History

Source: L. 85: Entire section added, p. 680, � 1, effective July 1. L. 2001: (5)(b) amended, p. 1164, � 12, effective June 5. L. 2002: (7) added, p. 384, � 1, effective April 25. L. 2006: (7) repealed, p. 1493, � 22, effective June 1. L. 2010: (5)(a) amended, (SB 10-175), ch. 188, p. 787, � 33, effective April 29. L. 2011: IP(3) amended and (8) added, (HB 11-1019), ch. 27, p. 67, � 1, effective March 17; (5)(a) amended, (HB 11-1303), ch. 264, p. 1157, � 34, effective August 10. L. 2021: (4) amended, (SB 21-271), ch. 462, p. 3216, � 369, effective March 1, 2022.