Colorado bills propose reforms to health care billing and payment


Boram Kim


Two health care bills that address medical billing and payment for Coloradans passed Third Reading in the Colorado House of Representatives on Monday and now head to the Senate.

House Bills 1284 and 1325 would eliminate “surprise” health insurance billing and institute alternative payment models for primary care providers, respectively.


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HB 1284 aligns state laws to conform with the federal No Surprises Act (NSA). Under that mandate, patients are protected from receiving surprise medical bills resulting from out-of-network care for emergency services and for certain scheduled services without prior patient consent.

NSA also guarantees patients the right to a good faith estimate of the cost of items and services that are expected for the specified care at least three days in advance.

Previously, health plans were not required to cover the entire out-of-network cost for care received at an in-network facility. This left consumers with higher costs, especially in emergency care situations where patients often have no choice in who provides the services.

The proposed bill would require all emergency health care services in Colorado, regardless of the facility at which they are provided, to be covered at the in-network benefit level.

“We should not have to mortgage our farms or houses or our lives because we went to the hospital, we went to the doctor, we did all the things we’re supposed to do. And then all of a sudden someone says, ‘Sorry, you were out of network when you were in your own community,’ those things really don’t work,” said Representative (R – Montrose) Marc Catlin, one of the sponsors of the bill, on the House floor on Friday.

Meanwhile, HB 1325 is part of a larger process of developing a multi-payer statewide alternative payment model (APM), with the goal of shifting health plan providers away from fee-for-service payments to value-based payments.

The statewide aligned health care APM is intended to reduce administrative burden for providers, increase health care value, and improve quality and health equity for consumers. 

“What we are really trying to do here is to say that the way that medicine is practiced now is not necessarily the way that medicine should always be practiced. We should really incentivize value and taking care of the whole person, not just having patient care be about a set of fees that are charged whenever you see a patient,” said Representative (D – Thornton) Yadira Caraveo, the bill’s primary sponsor, from the House floor on Friday.

Colorado Access, a locally based nonprofit health plan offering coverage across a continuum of health services, believes that the varying health care needs of each community across the state make implementing a “one size fits all” APM challenging.

“We’ve really worked directly with our provider network in these communities around these particular Medicaid and CHIP [Child Health Plan Plus] patients and the gaps in the care that those specific patients have, designing alternative payment model programs to drive to that specific need,” said Gretchen McGinnis, Senior Vice President of Healthcare Systems and Accountable Care at Colorado Access. “It’s a very regionally based program. This [includes] the upfront support in terms of financial support, but also the practice support teams that come in and do workflow redesign of the ongoing technical systems.”

McGinnis, who serves as Co-Chair on the Division of Insurance’s (DOI) Primary Care Payment Reform Collaborative Committee, is working with the Lieutenant Governor’s Office to develop recommendations on Colorado-specific, consensus-based APMs that could be used to advance alignment of payment approaches within the public and commercial markets.

She noted the increases to health care funding in the recently approved FY22-23 budget will provide a wealth of investment opportunities in primary and behavioral health care delivery over the next few years.

“What works well in an urban environment with lots of different kinds of transportation opportunities or good broadband access may be very different than what it looks like in our rural communities,” she said. “I’m hoping that we see a good focus on trial and error and evaluation, [and] a really good culture of learning from what doesn’t work … not an effort to squash failure of projects, but to really have some openness and transparency about what to build on for that next phase,” she said.