2023 Colorado Revised Statutes › Title 10 - INSURANCE (§§ 10-1-101 — 10-23-110) › HEALTH CARE COVERAGE (§§ 10-16-101 — 10-16.5-101) › Article 16 - HEALTH-CARE COVERAGE (§§ 10-16-101 — 10-16-1506) › Part 1 - GENERAL PROVISIONS (§§ 10-16-101 — 10-16-169) › Section 10-16-139 - Access to care - rules - definitions

(1)
Access to obstetricians and gynecologists.
A health benefit plan that is delivered, issued, renewed, or reinstated in this state on or after January 1, 2014, that provides coverage for reproductive health or gynecological care shall not be delivered, issued, renewed, or reinstated unless the plan provides a woman covered by the plan direct access to an obstetrician, a gynecologist, a physician assistant authorized under section
12-240-107 (6)
, an advanced practice registered nurse who is a certified nurse midwife pursuant to section
12-255-111
, or a certified midwife licensed pursuant to section
12-255-111.5
, participating and available under the plan for her reproductive health care or gynecological care.
(2)
Eye care services.
(a)
A health coverage plan or managed care plan that provides coverage for eye care services shall not be issued or renewed after January 1, 2001, by any entity subject to part 2, 3, or 4 of this article unless the health coverage plan or managed care plan:
(I)
Provides a covered person direct access to any eye care provider participating and available under the plan or through its eye care services intermediary for eye care services;
(II)
Ensures that all eye care providers on a health coverage plan or managed care plan are annually included on any publicly accessible list of participating providers for the health coverage plan or managed care plan; and
(III)
Allows each eye care provider on a health coverage plan or managed care plan panel to furnish covered eye care services to covered persons without discrimination between classes of eye care providers and to provide the services as permitted by their license.
(b)
A carrier offering a health coverage plan or managed care plan shall not:
(I)
Impose a deductible or coinsurance for eye care services that is greater than the deductible or coinsurance imposed for other medical services under the health coverage plan or managed care plan;
(II)
Require an eye care provider to hold hospital privileges as a condition of participation as a provider under the health coverage plan or managed care plan, unless an eye care provider is licensed pursuant to article
240
of title
12
; or
(III)
Impose penalties upon primary care providers as a result of the direct access provisions of this section.
(c)
This subsection (2) does not:
(I)
Create coverage for any health-care service that is not otherwise covered under the terms of the health coverage plan or managed care plan;
(II)
Require a health coverage plan or managed care plan to include as a participating provider every willing provider or health professional who meets the terms and conditions of the health coverage plan or managed care plan;
(III)
Prevent a covered person from seeking eye care services from the covered person's primary care provider in accordance with the terms of the covered person's health coverage plan or managed care plan;
(IV)
Increase or decrease the scope of the practice of optometry as defined in section
12-275-103
;
(V)
Require eye care services to be provided in a hospital or similar medical facility; or
(VI)
Prohibit a health coverage plan or managed care plan from requiring a covered person to receive a referral or prior authorization from a primary care provider for any subsequent surgical procedures.
(d)
As used in this subsection (2), unless the context otherwise requires:
(I)
"Eye care provider" means a participating provider who is an optometrist licensed to practice optometry pursuant to article
275
of title
12
or an ophthalmologist licensed to practice medicine pursuant to article
240
of title
12
.
(II)
"Eye care services" means those health-care services related to the examination, diagnosis, treatment, and management of conditions and diseases of the eye and related structures that a health coverage plan or managed care plan is obligated to pay, reimburse, arrange, or provide for covered persons or organizations as specified by a health coverage plan or managed care plan, excluding those health-care services rendered in conjunction with a routine vision examination or the filling of prescriptions for corrective eyewear.
(3)
Treatment of intractable pain.
(a)
A service or indemnity contract issued or renewed on or after January 1, 1998, by any entity subject to part 2, 3, or 4 of this article 16 shall disclose in the contract and in information on coverage presented to consumers whether the health coverage plan or managed care plan provides coverage for treatment of intractable pain. If the contract is silent on coverage of intractable pain, the contract is presumed to offer coverage for the treatment of intractable pain. If the contract is silent or if the plan specifically includes coverage for the treatment of intractable pain, the plan shall provide access to the treatment for any individual covered by the plan either:
(I)
By a primary care physician or physician assistant authorized under section
12-240-107 (6)
, so long as the physician or physician assistant has demonstrated interest and documented experience in pain management and has a practice that includes up-to-date pain treatment;
(II)
By providing direct access to a pain management specialist located within this state and participating in and available under the plan; or
(III)
By having procedures in place that ensure that, if the individual requests a timely referral for intractable pain management to a pain management specialist participating in and available under the plan, the carrier shall not unreasonably deny the request for referral.
(b)
The commissioner may promulgate rules to implement and administer this subsection (3) that include the following issues:
(I)
What constitutes a timely referral;
(II)
Circumstances, practices, policies, contract provisions, or actions that constitute an undue or unreasonable interference with the ability of an individual to secure a referral or reauthorization for continuing care;
(III)
The process for issuing a denial of a request, including the means by which an individual may receive notice of a denial and the reasons for the denial in writing;
(IV)
Actions that constitute improper penalties imposed upon a primary care physician or physician assistant authorized under section
12-240-107 (6)
as a result of referrals made pursuant to this section; and
(V)
Such other issues as the commissioner deems necessary.
(c)
For purposes of this subsection (3), "intractable pain" means a pain state in which the cause of the pain cannot be removed and for which, in the generally accepted course of medical practice, relief or cure of the cause of the pain is impossible or has not been found after reasonable efforts, including evaluation by the attending physician or physician assistant authorized under section
12-240-107 (6)
and one or more physicians specializing in the treatment of the area, system, or organ of the body perceived as the source of the pain.
(4)
Access to pediatric care.
(a)
If a carrier offering an individual or small employer health benefit plan requires or provides for the designation of a participating primary health-care professional, the carrier shall permit the parent or legal guardian of each covered person who is a child to designate any participating physician or physician assistant authorized under section
12-240-107 (6)
who specializes in pediatrics as the child's primary health-care professional if the pediatrician or physician assistant is available to accept the child.
(b)
The provisions of paragraph (a) of this subsection (4) do not waive any exclusions of coverage under the terms and conditions of the health benefit plan with respect to coverage of pediatric care.
(5)
Annual behavioral health screenings.
A health benefit plan that is issued or renewed in this state on or after January 1, 2020, that provides coverage for an annual physical examination as a preventive health-care service pursuant to section
10-16-104 (18)
shall include coverage and reimbursement for behavioral health screenings using a validated screening tool for behavioral health, which coverage and reimbursement is no less extensive than the coverage and reimbursement for the annual physical examination.
Amended by 2023 Ch. 261,§ 52, eff. 5/25/2023.
Amended by 2019 Ch. 136, § 50, eff. 10/1/2019.
Amended by 2019 Ch. 195, § 8, eff. 5/16/2019.
Amended by 2016 Ch. 204, § 6, eff. 8/10/2016.
Added with amended and relocated provisions by 2013 Ch. 217, § 25, eff. 5/13/2013.
Subsections (1), (2), and (3) are similar to former § 10-16-107 (5)(a), (5.5), and (7), respectively, as they existed prior to 2013.
(1) For the legislative declaration in SB 16-158, see section 1 of chapter 204, Session Laws of Colorado 2016. (2) For the short title ("Behavioral Health Care Coverage Modernization Act") in HB 19-1269, see section 1 of chapter 195, Session Laws of Colorado 2019.