C.R.S. tit. 6, art. 18 — Health-Care Coverage Cooperatives - Provider Networks | Colorado Revised Statutes (2024 edition) — Colorado

C.R.S. § 6-18-301 Legislative declaration

6-18-301. Legislative declaration. (1) The general assembly hereby finds, determines, and declares that the rapidly changing health-care market provides unique opportunities for health-care providers to organize themselves into new forms of collaborative systems to deliver high quality health care at competitive market prices to cooperatives and other purchasers. This part 3 is enacted to encourage such collaborative arrangements and to further market-based competition among health-care providers. (2) The general assembly further recognizes that in order to achieve the most effective use of resources and medical technology to respond to changing market conditions, providers who would otherwise be competitors with each other will need to horizontally integrate in order to develop collaborative arrangements to guarantee an adequate number of providers to service the market and to vertically integrate in order to guarantee that those who receive services will have a continuum of care as appropriate to their care needs. (3) The general assembly also recognizes that to effect such new forms of collaborative systems and integration of providers to service the market will require an analysis of existing methods of providing services, contracting, collaborating, and networking among providers and the extent and type of regulatory oversight of licensed provider networks or licensed individual providers which is appropriate to protect the public.

C.R.S. § 6-18-301.5 Definitions

6-18-301.5. Definitions. As used in this part 3, unless the context otherwise requires: (1) "Licensed provider network" or "licensed individual provider" means a provider network or individual provider that is authorized to transact insurance business pursuant to title 10, C.R.S. (2) "Provider" means a state-licensed, state-certified, or state-authorized facility or a practitioner delivering health-care services to individuals. (3) "Provider network" means a group of health-care providers formed to provide health-care services to individuals.

C.R.S. § 6-18-302 Creation of provider networks - requirements

6-18-302. Creation of provider networks - requirements. (1) (a) Providers are hereby authorized to conduct business collaboratively as provider networks. Such networks are entities existing on or before July 1, 1994, that meet the definition of a provider network or may be created as any lawful entity under title 7, C.R.S., or as otherwise allowed by law. Provider networks existing on or before July 1, 1994, and provider networks created on and after July 1, 1994, conducting business pursuant to this part 3, in addition to the matters otherwise required, shall be subject to this article. (b) (I) Except as provided in subparagraph (II) of this paragraph (b), if a provider network or individual provider organized on or after July 1, 1994, or organized prior to said date, proposes or is engaged in the transaction of insurance business, as defined in section 10-3-903, C.R.S., or the activities of a health maintenance organization as defined in section 10-16-102 (35), C.R.S., such provider network or individual provider must hold a certificate of authority from the commissioner of insurance to do business as an insurance company under title 10, C.R.S., or to establish a health maintenance organization under section 10-16-402, C.R.S. (II) The fact that a provider network or individual provider has a capitated contract or other agreement with a carrier, pursuant to which the provider network or individual provider shares some of the risk of providing services to groups or individuals covered under a health-care coverage plan issued by a carrier, shall not, in and of itself, be grounds for a determination by the commissioner of insurance that the provider network or individual provider is engaged in the transaction of insurance business. (III) The commissioner of insurance, in consultation with providers and other appropriate persons, shall evaluate the need for specific legislation or rules for the licensure of provider networks and individual providers and, if determined appropriate, shall make recommendations thereon to the general assembly and governor and shall adopt such rules that are specific to licensed provider networks and licensed individual providers as provided in section 10-1-108 (13), C.R.S. A licensed provider network or licensed individual provider shall be subject to applicable provisions of title 10, C.R.S., except as otherwise provided in statute or rule adopted pursuant to section 10-1-108 (13), C.R.S. (IV) Every licensed provider network that conducts insurance business in the state of Colorado shall: (A) Obtain from the commissioner of insurance, before the start of business, a certificate of authority authorizing the provider network to conduct business in the state of Colorado; (B) Maintain its principal and home office in the state of Colorado, maintain such books and records in this state, and maintain principal banking relationships with a bank chartered by the state of Colorado or a member bank of the federal reserve system; (C) Hold at least one board of directors' meeting each year in the state of Colorado; (D) Include in the provider network's management and administrative agreements, for essential insurance services, a provision that allows the commissioner reasonable access to examine such books and records; and (E) For purposes of this paragraph (b), substantially perform in the state of Colorado the essential functions of the licensed provider network's principal and home office, including, but not limited to, the provision and administration of health-care services, the issuance of health-care plans, the maintenance of health-care provider relations, and the provision of consumer information and services. For purposes of this paragraph (b), substantially perform in the state of Colorado the essential functions of the licensed provider network's principal and home office, including, but not limited to, the provision and administration of health-care services, the issuance of health-care plans, the maintenance of health-care provider relations, and the provision of consumer information and services. (2) If applicable, a network organized on and after July 1, 1994, is organized when the articles of organization are filed by the secretary of state or, if a delayed effective date is specified in the articles as filed with the secretary of state and a certificate of withdrawal is not filed, on such delayed effective date. The existence of the network begins upon organization. (3) If applicable, each provider network shall file a report pursuant to section 7-136-107, C.R.S., and pay a fee to the secretary of state which shall be determined and collected pursuant to section 24-21-104 (3), C.R.S., in lieu of all franchise or corporation license taxes. (4) A provider network or individual provider may request that specified information submitted to the division of insurance be kept confidential because it is a trade secret as defined in section 7-74-102 (4), C.R.S. The division shall honor such request unless the commissioner determines that the information is already public knowledge or that its confidentiality would be contrary to the public interest or the provider subsequently authorized the commissioner to release such information.

C.R.S. § 6-18-303 Effect on scope of practice - limited exception to prohibitions on corporate practice of licensed health-care providers

6-18-303. Effect on scope of practice - limited exception to prohibitions on corporate practice of licensed health-care providers. (1) Except as provided in subsection (2) of this section, the fact that an entity or provider is a member of a provider network shall not exempt such entity or provider from any licensure or regulatory statute, nor shall any scope of practice of any provider be expanded, reduced, or otherwise modified by virtue of membership in or affiliation with any provider network. (2) Any provision of article 200, 215, or 290 of title 12, or any of the provisions of articles 220, 240, 245, 255 to 285, 295, and 300 of title 12, prohibiting the practice of any licensed or certificated health-care profession as the partner, agent, or employee of or in joint venture with a person who does not hold a license or certificate to practice such profession within this state shall not apply to professional practice if a professional is participating in a provider network organized pursuant to this part 3 and: (a) The partnership, agency, employment, or joint venture is evidenced by a written agreement containing language to the effect that the relationship created by the agreement may not affect the exercise of the licensed or certified professional's independent judgment in the practice of the profession; (b) The licensed or certificated professional's independent judgment in the practice of such profession is in fact unaffected by the relationship; and (c) The licensed professional is not required to exclusively refer any patient to a particular provider or supplier or take any other action the licensed professional determines not to be in the patient's best interest.

C.R.S. § 6-18-304 Competitive behavior - restraints of trade prohibited

6-18-304. Competitive behavior - restraints of trade prohibited. Organization or operation as a provider network is authorized under this article for the purpose of more cost-effective delivery of health-care services, and shall not be construed as permitting any such collaborative system or any member of such provider network to act in a concerted way to restrain trade or otherwise engage in practices which are otherwise prohibited by federal or state antitrust law.