2016 Colorado Revised Statutes
Title 18 - Criminal Code
Article 13 - Miscellaneous Offenses
§ 18-13-119. Health care providers - abuse of health insurance
(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 payor, as payment in full for services rendered, the amount the third-party payor covers; or
(b) Submits a fee to a third-party payor 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 class 1 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 payor, as payment in full for services rendered, the amount the third-party payor covers shall be presumed to be engaged in waiving the deductible or copayment as a regular business practice.
(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.
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