Colorado.gov

Life, Accident and Health

Managed Care - Answers to Consumer Questions

Q	What happens if my preferred provider organization (PPO) insurance plan or my health maintenance organization (HMO) doesn't have a qualified provider for a particular covered service that I need? Can I go to any provider without penalty?
A	No, but the health plan must arrange for a referral to a qualified provider and ensure that you will not have to pay more than if you had been treated by an in-network provider.
Q	I just found out my doctor is no longer a part of my health plan's network and I'm 8 months pregnant! I don't want to have to change doctors at this point. Do I have any options?
A	Insurance law requires a 60-day notice when a provider terminates or is terminated from a network and a good faith effort on the part of the carrier to provide adequate notice to covered persons. Without the required notice, health plans must make arrangements for continued care with the doctor for up to 60 days.
Q	I've been preauthorized by my health plan for surgery at a network hospital. What happens if the anesthesiologist happens not to be in the network? Will I have to pay out-network coinsurance for his charges?
A	No. All covered benefits provided at an in-network facility should be provided at the in-network benefit level.
Q	Can my appointed primary care physician (PCP) or other provider be terminated from my managed care plan prior to expiration of my contract?
A	Yes. There is no law prohibiting a provider or managed care plan from terminating their contract with one another at any time with at least 60 days notice. Colorado law does, however, requires that proper notice be given. If not, the provider must continue providing coverage for up to 60 days after termination of the contract.
Q	What are my options if one of my providers elects to leave or is terminated?
A	If you are in an exclusive provider arrangement contact your managed care plan to arrange for a new PCP or specialty provider. If your plan provides out of network benefits for your particular care you can elect to continue with the previous provider at the out-network benefit level.
Q	What if my plan does not pay my network provider. Am I responsible for any payment?
A	No. Colorado law requires all contracts between providers and managed care plans to contain provisions wherein the provider is prohibited from billing the enrollee when payment for which the plan is responsible is not made. This does not include an enrollee's payment of co-payments, coinsurance or deductibles.
Q	My current physician is not associated with the managed care plan offered by my employer. He has attempted to enter into a contract with the plan, but to date the plan has elected not to include him as part of their network. Is there anything that can be done to force the plan to enter into a contract with my physician?
A	No. Nothing in Colorado law requires a managed care plan to contract with "any willing provider". This is a contract negotiation issue between the provider and the managed care plan.

original 02/2007, updated 01/2012