3 CCR 702-4
DEPARTMENT OF REGULATORY AGENCIES Division of Insurance LIFE, ACCIDENT AND HEALTH , Series 4-2 3 CCR 702-4 Series 4-2 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ Regulation 4-2-1 REPLACEMENT OF INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Appendix A Notice of Replacement Section 1 Authority This amended regulation is promulgated under the authority of § § 10-1-109 and 10-3-1110, C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to reduce the opportunity for misrepresentation and other unfair practices and methods of competition in the business of insurance. The scope of this regulation includes persons covered by an individual health care coverage plan offered by a health maintenance organization and individual accident and sickness insurance policies or plans, who are considering replacement of their coverage Section 3 Applicability This regulation shall apply to individual accident and sickness insurance and a health care coverage plan offered by a health maintenance organization (except Medicare supplement insurance, conversion to an individual or family policy from a group, blanket or group type policy, or any other insurance that is covered by a separate state statute).
Section 4 Definitions A. “Accident and sickness insurance” means a policy, plan, contract, agreement, statement of coverage, rider or endorsement that provides accident or sickness benefits or medical, surgical or hospital benefits, whether on an indemnity, reimbursement, service or prepaid basis, except when issued in connection with another kind of insurance other than life and except disability, waiver of premium and double indemnity benefits included in life insurance and annuity contracts. An accident and sickness insurance policy does not include a Medicare supplement insurance policy, or any other type of accident and sickness insurance with advertising guidelines covered by a separate statute. For the purposes of this regulation, accident and sickness insurance includes health coverage plans issued by health maintenance organizations as defined in § 10-16- 102(22.5), C.R.S.
B “Direct response” means a solicitation through a sponsoring or endorsing entity or individually solely through mail, telephone, the Internet or other mass communication media. Section 5 Rules A. Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has accident and sickness insurance in force or whether accident and sickness insurance is intended to replace or be in addition to any other accident and sickness insurance presently in force. A supplementary application or other form to be signed by the applicant and producer containing such questions and statements may be used.
B. Producers shall list any other accident and sickness insurance they have sold to the applicant.
C. In the case of a direct response carrier, a copy of the application or supplemental form, signed by the applicant, and acknowledged by the insurer, shall be returned to the applicant by the insurer upon delivery of the policy.
D. Upon determining that a sale will involve replacement of accident and sickness insurance, other than a direct response issuer, or its producer, shall furnish the applicant, prior to issuance or delivery of the accident and sickness insurance policy or contract, a notice regarding replacement of accident and sickness insurance. One (1) copy of such notice signed by the applicant and producer, except where the coverage is old without a producer, shall be provided to the applicant and an additional signed copy shall be retained by the issuer. A direct response issuer shall deliver to the applicant, at the time of issuance of the policy, The Notice to Applicant Regarding Replacement of Accident and Sickness Insurance, located in Appendix A of this regulation.
E. The Notice to Applicant Regarding Replacement of Accident and Sickness Insurance (Appendix A) required by Subsection D above for an issuer, shall be provided in the format prescribed and adopted by the Commissioner of Insurance.
F. Paragraphs 1 and 2, contained in such Notice to the Applicant Regarding Replacement of Accident and Sickness Insurance, (applicable to preexisting conditions), in Appendix A, may be deleted by the issuer if the replacement does not involve the application of a new preexisting condition limitation.
G. Failure to comply with the requirements of this Section 5 constitutes an unfair method of competition and an unfair or deceptive act or practice in the business of insurance which is prohibited under § 10-3-1104, C.R.S.
Section 6 Severability If any provisions of this regulation or the application thereof to any person or circumstances are for any reason held to be invalid, the remainder of the regulation shall not be affected in any way. Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders and/or suspension or revocation of certificates of authority. Among others, the penalties provided for in §10- 3-1108, C.R.S. may be applied.
Section 8 Effective Date This regulation is effective May 1, 2010.
Section 9 History Originally issued as Regulation 74-2, effective March 15, 1974. Amended December 22, 1975, effective January 1, 1976.
Amended effective January 14, 1977.
Amended effective January 14, 1977.
Renumbered on June 1, 1992.
Repealed and Repromulgated in full, effective February 1, 2001. Amended Regulation 4-2-1, effective May 1, 2010.
Appendix A NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE [Insurance Carrier name and address] According to (your application) (the information furnished by you), you intend to lapse or otherwise terminate your present policy and replace it with a policy to be issued by [Insurance Carrier Name]. Your new policy will provide [Number days of free look period, if any] days within which you may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find the purchase of this accident and sickness coverage is a wise decision you should evaluate the need for other accident and sickness coverage you have that may duplicate this policy.
STATEMENT TO APPLICANT BY ISSUER OR PRODUCER:
I have reviewed your current accident and sickness insurance coverage. To the best of my knowledge, this accident and sickness policy will not duplicate your existing coverage because you intend to terminate your existing coverage. The replacement policy is being purchased for the following reason(s) (check one):
1. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of claim for benefits under the new policy, whereas a similar claim may have been payable under your present policy.
2. State law provides that your replacement policy or contract may not contain new preexisting conditions, waiting periods, elimination periods or probationary periods. The issuer will waive any time periods applicable to preexisting conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.
3. If, you wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy has never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded. [If the policy or contract is guaranteed issued this paragraph need not appear].
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
_________________________________________ (Signature of Producer or Other Representative)* [Typed Name and Address of Issuer or Producer] __________________________________________ (Applicants Signature)
___________________________________________ (Date)
*Signature not required for direct response sales Regulation 4-2-2 HOSPITAL INDEMNITY AND DISABILITY INCOME POLICIES Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is issued based upon the authority granted the commissioner under § § 10-1-109 and 10- 16-109, C.R.S.
Section 2 Scope and Purpose This regulation prohibits insurers from refusing to pay benefits under certain contracts because of hospitalization in government hospitals.
Section 3 Applicability This regulation applies to all hospital, indemnity and disability income policies, contracts, riders, endorsements, etc., which provide benefits because of hospitalization or disability originating out of hospitalization hereinafter referred to as hospital indemnity and disability income policies. It does not apply to hospital expense policies.
Section 4 Definitions For the purposes of this regulation:
A. "Disability income policy" means a policy that provides periodic payments to replace income lost when the insured is unable to work as the result of a sickness or injury.
B. "Government hospital" means any hospital under governmental control whether federal, state, county or city. It includes Veterans Administration hospitals.
C. "Hospital indemnity policy" means a policy that provides a stated daily, weekly or monthly payment while the insured is hospitalized, regardless of expenses incurred and regardless of whether or not other insurance is in force. The insured can use the daily, weekly or monthly benefit as (s)he chooses, for hospital or other expenses.
Section 5 Rules All hospital indemnity and disability income policies delivered or issued for delivery in the State of Colorado which provide benefits predicated on hospitalization will not in any way deny such benefits on the basis that such hospitalization was in a government hospital. Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected. Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspension or revocation of certificates of authority. Among others, the penalties provided in § 10-3-1108, C.R.S., may be applied.
Section 8 Effective Date This regulation is effective July 1, 2010.
Section 9 History Originally issued as Regulation 74-4, effective July 1, 1974. Renumbered as Regulation 4-2-2, effective June 1, 1992. Repealed and Repromulgated in full, effective January 1, 2001. Amended Regulation 4-2-2, effective July 1, 2010.
Regulation 4-2-3 ADVERTISEMENTS OF ACCIDENT AND SICKNESS INSURANCE Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Method of Disclosure of Required Information Section 6 Form and Content of Advertisements Section 7 Advertisement of Benefits Payable, Losses Covered or Premiums Payable Section 8 Necessity for Disclosing Policy Provisions Relating to Renewability, Cancellability and Termination Section 9 Standards for Marketing Section 10 Testimonials or Endorsements by Third Parties Section 11 Use of Statistics Section 12 Identification of Plan or Number of Policies Section 13 Disparaging Comparisons and Statements Section 14 Jurisdictional Licensing and Status of Insurer Section 15 Identity of Insurer Section 16 Group or Quasi-Group Implications Section 17 Introductory, Initial or Special Offers Section 18 Statements about an Insurer Section 19 Severability Section 20 Enforcement Procedures Section 21 Enforcement Section 22 Effective Date Section 23 History Section 1 Authority This regulation is promulgated under the authority of § § 10-1-109 and 10-3-1110, C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to establish minimum criteria to assure proper and accurate description and to protect prospective purchasers with respect to the advertisement of accident and sickness insurance in the same manner as the regulation governing advertisements of Medicare supplement insurance. This regulation assures the clear and truthful disclosure of the benefits, limitations and exclusions of policies sold as accident and sickness insurance by the establishment of standards of conduct in the advertising of accident and sickness insurance in a manner that prevents unfair, deceptive and misleading advertising and is conducive to accurate presentation and description to the insurance- buying public through the advertising media and material used by insurance producers and companies. Section 3 Applicability A. This regulation shall apply to any accident and sickness insurance “advertisement,” as that term is defined, intended for presentation, distribution or dissemination in this State when such presentation, distribution or dissemination is made either directly or indirectly by or on behalf of an insurer, producer or solicitor, as those terms are defined in the Insurance Code of this state and this regulation.
B. Every insurer shall establish and at all times maintain a system of control over the content, form and method of dissemination of all advertisements of its policies. All of the insurer's advertisements, regardless of by whom written, created, designed or presented, shall be the responsibility of the insurer whose policies are advertised.
C. Advertising materials that are reproduced in quantity shall be identified by form numbers or other identifying means. The identification shall be sufficient to distinguish an advertisement from any other advertising materials, policies, applications or other materials used by the insurer. Section 4 Definitions A. “Accident and sickness insurance policy” means, a policy, plan, certificate, contract, agreement, statement of coverage, rider or endorsement that provides accident or sickness benefits or medical, surgical or hospital benefits, whether on an indemnity, reimbursement, service or prepaid basis, except when issued in connection with another kind of insurance other than life and except disability, waiver of premium and double indemnity benefits included in life insurance and annuity contracts.
B. “Advertisement” means printed and published material, audio visual material, and descriptive literature of an insurer used in direct mail, newspapers, magazines, radio scripts, TV scripts, web sites and other Internet displays or communications, other forms of electronic communications, billboards and similar displays.
C. “Certificate” means a statement of the coverage and provisions of a group accident and sickness insurance policy, which has been delivered or issued for delivery in this state and includes riders, endorsements and enrollment forms, if attached.
D. “Exception” means any provision in a policy whereby coverage for a specified hazard is entirely eliminated; it is a statement of a risk not assumed under the policy.
E. “Institutional advertisement” means an advertisement having as its sole purpose the promotion of the reader’s, viewer’s or listener’s interest in the concept of accident and sickness insurance, or the promotion of the insurer as a seller of accident and sickness insurance. Carriers are required to comply with Section 15A of the regulation, clearly identifying the name of the carrier.
F. “Invitation to contract” means an advertisement that is neither an “invitation to inquire” nor an “institutional advertisement.”
G. “Invitation to inquire” means an advertisement having as its objective the creation of a desire to inquire further about accident and sickness insurance and that is limited to a brief description of the loss for which benefits are payable, but may contain: the dollar amount of benefits payable and the period of time during which benefits are payable.
H. “Lead-generating device” means any communication directed to the public that, regardless of form, content or stated purpose, is intended to result in the compilation or qualification of a list containing names and other personal information to be used to solicit residents of this state for the purchase of accident and sickness insurance.
I. “Limitation” means a provision that restricts coverage under the policy other than an exception or a reduction.
J. “Limited benefit health coverage” means a health policy, contract, or certificate offered or marketed as supplemental health insurance that pays specified amounts according to a schedule of benefits to defray the costs of care, services, deductibles, copayments, or coinsurance amounts not covered by a health benefit plan. “Limited benefit health insurance” does not include short-term hospital and medical expense policies, contracts or certificates, or catastrophic health policies, contracts, or certificates. Such non-supplemental plans are included under the term “health benefit plan” as defined in Section 10-16-102(21)(b), C.R.S.
K. “Prominently” or “conspicuously” means that the information to be disclosed “prominently” or “conspicuously” will be presented in a manner that is noticeably set apart from other information or images in the advertisement.
L. “Reduction” means a provision that reduces the amount of the benefit; a risk of loss is assumed but payment upon the occurrence of the loss is limited to some amount or period less than would be otherwise payable had the reduction not been used.
Section 5 Method of Disclosure of Required Information All information, exceptions, limitations, reductions and other restrictions required to be disclosed by this regulation shall be set out conspicuously and in close conjunction to the statements to which the information relates or under appropriate captions of such prominence that it shall not be minimized, rendered obscure or presented in an ambiguous fashion or intermingled with the context of the advertisements so as to be confusing or misleading. This regulation permits, but is not limited to, the use of either of the following methods of disclosure:
A. Disclosure in the description of the related benefits or in a paragraph set out in close conjunction with the description of policy benefits; or B. Disclosure not in conjunction with the provisions describing policy benefits but under appropriate captions of such prominence that the information shall not be minimized, rendered obscure or otherwise made to appear unimportant. The phrase “under appropriate captions” means that the title must be accurately descriptive of the captioned material. Appropriate captions include the following: “Exceptions,” “Exclusions,” “Conditions Not Covered,” and “Exceptions and Reductions.” The use of captions such as the following are prohibited because they do not provide adequate notice of the significance of the material: “Extent of Coverage,” “Only these Exclusions,” or “Minimum Limitations.”
Section 6 Format and Content of Advertisements A. The format and content of an advertisement of an accident and sickness insurance policy shall be sufficiently complete and clear to avoid deception or the capacity or tendency to mislead or deceive. Format means the arrangement of the text and the captions.
B. Distinctly different advertisements are required for publication in different media, such as newspapers or magazines of general circulation as compared to scholarly, technical or business journals and newspapers. Where an advertisement consists of more than one piece of material, each piece of material must, independent of all other pieces of material, conform to the disclosure requirements of this regulation.
C. Whether an advertisement has a capacity or tendency to mislead or deceive shall be determined by the commissioner from the overall impression that the advertisement may be reasonably expected to create within the segment of the public to which it is directed.
D. Advertisements shall be truthful and not misleading in fact or in implication. Words or phrases, the meaning of which is clear only by implication or by familiarity with insurance terminology, shall not be used.
E. An insurer shall clearly identify its accident and sickness insurance policy as an insurance policy. A policy trade name shall be followed by the words “insurance policy” or similar words clearly identifying the fact that an insurance policy or health benefits product (in the case of health maintenance organizations, prepaid health plans and other direct service organizations) is being offered.
F. An insurer, producer, solicitor or other person shall not solicit a resident of this state for the purchase of accident and sickness insurance in connection with or as the result of the use of advertisement by the person or any other persons, where the advertisement:
G. An insurer, producer, solicitor or other person shall not solicit residents of this state for the purchase of accident and sickness insurance through the use of a true or fictitious name that is deceptive or misleading with regard to the status, character or proprietary or representative capacity of the person or the true purpose of the advertisement.
Section 7 Advertisements of Benefits Payable, Losses Covered or Premiums Payable A. Covered Benefits.
This paragraph 6 does not apply to individual major medical expense coverage, individual basic medical expense coverage, or disability income insurance.
B. Exceptions, Reductions and Limitations
C. Preexisting Conditions
Or substantially the following statement:
“I understand that the policy applied for will not pay benefits for any loss incurred during the first [insert number] [years, months] after the issue date on account of disease or physical condition that I now have or have had in the past.” Section 8 Necessity for Disclosing Policy Provisions Relating to Renewability, Cancellability and Termination
A. An advertisement that is an invitation to contract shall disclose the provisions relating to renewability, cancellability and termination, and any modification of benefits, losses covered, or premiums because of age or for other reasons, in a manner that shall not minimize or render obscure the qualifying conditions.
B. Advertisements of cancellable accident and sickness insurance policies shall state that the company may cancel or renew the contract using language substantially similar to the following: “This policy is renewable at the option of the company,” or “The company has the right to refuse renewal of this policy,” or “Renewable at the option of the insurer,” or “This policy can be cancelled by the company at any time.”
C. Advertisements of insurance policies that are guaranteed renewable, cancellable or renewable at the option of the company shall disclose that the insurer has the right to increase premium rates if the policy so provides.
D. Qualifying conditions that constitute limitations on the permanent nature of the coverage shall be disclosed in advertisements of insurance policies that are guaranteed renewable, cancelable or renewable at the option of the company. Examples of qualifying conditions are (1) age limits, (2) reservation of a right to increase premiums, and (3) the establishment of aggregate limits.
Section 9 Standards for Marketing A. An insurer, directly or through its producers or solicitors, shall:
B. The following acts and practices are prohibited:
Section 10 Testimonials or Endorsements by Third Parties A. Testimonials and/or endorsements used in advertisements shall be genuine, represent the current opinion of the author, be applicable to the policy advertised and be accurately reproduced. The insurer, in using a testimonial or endorsement, makes as its own all of the statements contained in it, and the advertisement, including the statement, is subject to all of the provisions of this regulation. When a testimonial or endorsement is used more than one year after it was originally given, a confirmation must be obtained.
B. A person shall be deemed a “spokesperson” if the person making the testimonial or endorsement:
C. Any person or agency acting as a spokesperson, as defined in the preceding paragraph, who performs any of the following acts in an advertisement shall be considered soliciting an insurance product, and such person or agency shall be a licensed insurance producer or agency pursuant to the Colorado Insurance Laws:
D. The fact of a financial interest or the proprietary or representative capacity of a spokesperson shall be disclosed in an advertisement and shall be accomplished in the introductory portion of the testimonial or endorsement in the same form and with equal prominence. If a spokesperson is directly or indirectly compensated for making a testimonial or endorsement, the fact shall be disclosed in the advertisement by language substantially such as follows: “Paid Endorsement.” The requirement of this disclosure may be fulfilled by use of the phrase “Paid Endorsement” or words of similar import in a type style and size at least equal to that used for the spokesperson’s name or the body of the testimonial or endorsement, whichever is larger. In the case of television or radio advertising, the required disclosure shall be accomplished in the introductory portion of the advertisement and shall be given prominence.
E. The disclosure requirements of this regulation shall not apply where the sole financial interest or compensation of a spokesperson, for all testimonials or endorsements made on behalf of the insurer, consists of the payment of union scale wages required by union rules, and if the payment is actually the scale for TV or radio performances.
F. An advertisement shall not state or imply that an insurer or an accident and sickness insurance policy has been approved or endorsed by any individual, group of individuals, society, association or other organizations, unless that is the fact, and unless any proprietary relationship between an organization and the insurer is disclosed. If the entity making the endorsement or testimonial has been formed by the insurer or is owned or controlled by the insurer or the person or persons who own or control the insurer, the fact shall be disclosed in the advertisement. If the insurer or an officer of the insurer formed or controls the association, or holds any policy-making position in the association, that fact must be disclosed.
G. When a testimonial refers to benefits received under an accident and sickness insurance policy, the specific claim data, including claim number, date of loss and other pertinent information shall be retained by the insurer for inspection for a period of four (4) years or until the filing of the next regular report of examination of the insurer, whichever is the longer period of time. The use of testimonials that do not correctly reflect the present practices of the insurer or that are not applicable to the policy or benefit being advertised is not permissible. Section 11 Use of Statistics A. An advertisement relating to the dollar amounts of claims paid, the number of persons insured, or similar statistical information relating to an insurer or policy shall not use irrelevant facts, and shall not be used unless it accurately reflects all of the current and relevant facts. The advertisement shall not imply that the statistics are derived from the policy advertised unless that is the fact, and when applicable to other policies or plans, shall specifically so state.
B. An advertisement shall not represent or imply that claim settlements by the insurer are “liberal” or “generous,” or use words of similar import, or that claim settlements are or will be beyond the actual terms of the contract. An unusual amount paid for a unique claim for the policy advertised is misleading and shall not be used.
C. The source of any statistics used in an advertisement shall be identified in the advertisement. Section 12 Identification of Plan or Number of Policies A. An advertisement that uses the word “plan” without prominently identifying it as an accident and sickness insurance policy is prohibited.
B. When a choice of the amount of benefits is referred to, an advertisement that is an invitation to contract shall disclose that the amount of benefits provided depends upon the plan selected and that the premium will vary with the amount of the benefits selected.
C. When an advertisement that is an invitation to contract refers to various benefits that may be contained in two (2) or more policies, other than group master policies, the advertisement shall disclose that the benefits are provided only though a combination of policies. Section 13 Disparaging Comparisons and Statements An advertisement shall not directly or indirectly make unfair or incomplete comparisons of policies or benefits or comparisons of non-comparable policies of other insurers, and shall not disparage competitors, their policies, services or business methods, and shall not disparage or unfairly minimize competing methods of marketing insurance.
A. An advertisement shall not contain statements such as “no red tape” or “here is all you do to receive benefits.”
B. Advertisements that state or imply that competing insurance coverages customarily contain certain exceptions, reductions or limitations not contained in the advertised policies are prohibited unless the exceptions, reductions or limitations are contained in a substantial majority of the competing coverages.
C. Advertisements that state or imply that an insurer’s premiums are lower or that its loss ratios are higher because its organizational structure differs from that of competing insurers are prohibited. Section 14 Jurisdictional Licensing and Status of Insurer A. An advertisement that is intended to be seen or heard beyond the limits of the jurisdiction in which the insurer is licensed shall not imply licensing beyond those limits.
B. An advertisement shall not create the impression directly or indirectly that the insurer, its financial condition or status, or the payment of its claims, or the merits, desirability, or advisability of its policy forms or kinds of plans of insurance are approved, endorsed or accredited by any division or agency of this state or the federal government. Terms such as “official” or words of similar import, used to describe any policy or application form are prohibited because of the potential for deceiving or misleading the public.
C. An advertisement shall not imply that approval, endorsement or accreditation of policy forms or advertising has been granted by any division or agency of the state or federal government. Approval of either policy forms or advertising shall not be used by an insurer to imply or state that a governmental agency has endorsed or recommended the insurer, its policies, advertising or its financial condition.
Section 15 Identity of Insurer A. The name of the actual insurer shall be stated in all of its advertisements. The form number or numbers of the policy advertised shall be stated in an advertisement that is an invitation to contract. An advertisement shall not use a trade name, an insurance group designation, name of the parent company of the insurer, name of a particular division of the insurer, service mark, slogan, symbol or other device that without disclosing the name of the actual insurer, would have the capacity and tendency to mislead or deceive as to the true identity of the insurer.
B. An advertisement shall not use any combination of words, symbols, or physical materials that by their content, phraseology, shape, color or other characteristics are so similar to combination of words, symbols or physical materials used by agencies of the federal government or of this state, or otherwise appear to be of such a nature that it tends to confuse or mislead prospective insureds into believing that the solicitation is in some manner connected with an agency of the municipal, state or federal government.
C. Advertisements, envelopes or stationery that employ words, letters, initials, symbols or other devices that are similar to those used in governmental agencies or by other insurers are not permitted if they may lead the public to believe:
D. An advertisement shall not use the name of a state or political subdivision of a state in a policy name or description.
E. An advertisement in the form of envelopes or stationery of any kind may not use any name, service mark, slogan, symbol or any device in a manner that implies that the insurer or the policy advertised, or that any producer who may call upon the consumer in response to the advertisement, is connected with a governmental agency, such as the Social Security Administration.
F. An advertisement may not incorporate the word “Medicare” in the title of the plan or policy being advertised unless, wherever it appears, the word is qualified by language differentiating it from Medicare. The advertisement, however, shall not use the phrase “[ ] Medicare Department of the [ ] Insurance Company,” or language of similar import.
G. An advertisement may not imply that the reader may lose a right or privilege or benefit under federal, state or local law if he or she fails to respond to the advertisement.
H. The use of letters, initials or symbols of the corporate name or trademark that would have the tendency or capacity to mislead or deceive the public as to the true identity of the insurer is prohibited unless the true, correct and complete name of the insurer is in close conjunction and in the same size type as the letters, initials or symbols of the corporate name or trademark.
I. The use of the name of an agency or “[ ] Underwriters” or “[ ] Plan” in type, size and location so as to have the capacity and tendency to mislead or deceive as to the true identity of the insurer is prohibited.
J. The use of an address so as to mislead or deceive as to true identity of the insurer, its location or licensing status is prohibited.
K. An insurer shall not use, in the trade name of its insurance policy, any terminology or words so similar to the name of a governmental agency or governmental program as to have the tendency to confuse, deceive or mislead the prospective purchaser.
L. Advertisements used by producers or solicitors of an insurer shall have prior written approval of the insurer before they may be used.
M. A producer who makes contact with a consumer, as a result of acquiring that consumer’s name from a lead-generating device, shall disclose that fact in the initial contact with the consumer. A producer or insurer may not use names produced from lead-generating devices that do not comply with the requirements of this regulation.
Section 16 Group or Quasi-Group Implications A. An advertisement of a particular policy shall not state or imply that prospective insureds become group or quasi-group members covered under a group policy and as members, enjoy special rates or underwriting privileges, unless that is the fact.
B. This regulation prohibits the solicitations of a particular class, such as governmental employees, by use of advertisements which state or imply that their occupational status entitles them to reduced rates on a group or other basis when, in fact, the policy being advertised is sold only on an individual basis at regular rates.
C. Advertisements that indicate that a particular coverage or policy is exclusively for “preferred risks” or a particular segment of the population or that a particular segment of the population is an acceptable risk, when the distinctions are not maintained in the issuance of policies, are prohibited.
D. An advertisement to join an association, trust or discretionary group that is also an invitation to contract for insurance coverage shall clearly disclose that the applicant will be purchasing both membership in the association, trust or discretionary group and insurance coverage. The insurer shall solicit insurance coverage on a separate and distinct application that requires a separate signature. The separate and distinct applications required need not be on separate documents or contained in a separate mailing. The insurance program shall be presented so as not to conceal the fact that the prospective members are purchasing insurance as well as applying for membership, if that is the case. Similarly, it is prohibited to use terms such as “enroll” or “join” to imply group or blanket insurance coverage when that is not the fact. Advertisements for group or franchise group plans that provide a common benefit or a common combination of benefits shall not imply that the insurance coverage is tailored or designed specifically for that group, unless that is the fact.
Section 17 Introductory, Initial or Special Offers A. An advertisement of an individual policy shall not directly or by implication represent that a contract or combination of contracts is an introductory, initial or special offer, or that applicants will receive substantial advantages not available at a later date, or that the offer is available only to a specified group of individuals, unless that is the fact. An advertisement shall not contain phrases describing an enrollment period as “special,” “limited,” or similar words or phrases when the insurer uses the enrollment periods as the usual method of marketing accident and sickness insurance.
B. An advertisement shall not offer a policy that utilizes a reduced initial premium rate in a manner that overemphasizes the availability and the amount of the initial reduced premium. When an insurer charges an initial premium that differs in amount from the amount of the renewal premium payable on the same mode, the advertisement shall not display the amount of the reduced initial premium either more frequently or more prominently than the renewal premium, and both the initial reduced premium and the renewal premium must be stated in juxtaposition in each portion of the advertisement where the initial reduced premium appears.
C. Special awards, such as a “safe drivers’ award,” shall not be used in connection with advertisements of accident and sickness insurance.
Section 18 Statements about an Insurer An advertisement shall not contain statements that are untrue in fact, or by implication misleading, with respect to the assets, corporate structure, financial standing, age or relative position of the insurer in the insurance business. An advertisement shall not contain a recommendation by any commercial rating system unless it clearly indicates the purpose of the recommendation and the limitations of the scope and extent of the recommendations.
Section 19 Severability If any provisions of this regulation or the application thereof to any person or circumstances are for any reason held to be invalid, the remainder of the regulation shall not be affected in any way. Section 20 Enforcement Procedures Each insurer shall maintain at its home or principal office a complete file containing every printed, published or prepared advertisement of its individual policies and typical printed, published or prepared advertisements of its blanket, franchise and group policies hereafter disseminated in this or any other state, whether or not licensed in an other state, with a notation attached to each advertisement that indicates the manner and extent of distribution and the form number of any policy advertised. The file shall be subject to regular and periodical inspection by the commissioner. All of these advertisements shall be maintained in a file for a period of either four (4) years or until the filing of the next regular report on examination of the insurer, whichever is the longer period of time. Section 21 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of all applicable sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws, which include the imposition of fines and suspension or revocation of license. Failure to comply with the requirements of this regulation constitutes an unfair method of competition and an unfair or deceptive act or practice in the business of insurance which is prohibited under § 10-3-1104, C.R.S.
Section 22 Effective Date This regulation is effective May 1, 2010.
Section 23 History Originally issued as Regulation 75-2, effective December 22, 1975. Renumbered as Regulation 4-2-3, effective June 1, 1992. Amended Regulation, effective July 1, 1993.
Repealed and Repromulgated in full, effective February 1, 2001. Amended Regulation, effective August 1, 2001.
Amended Regulation, effective February 1, 2003.
Amended Regulation, effective May 1, 2010.
Regulation 4-2-5 HOSPITAL DEFINITION Section 1 Authority Section 2 Purpose Section 3 Scope Section 4 Definitions Section 5 Enforcement Section 6 Severability Section 7 Effective Date Section 8 History Section 1 Authority This amended regulation is promulgated under the authority of §10-1-109 C.R.S. Section 2 Purpose The purpose of this regulation is to standardize the definition of “hospital” used in sickness and accident insurance policy forms in this state to ensure the adequate provision of inpatient health care services. Section 3 Scope This regulation shall apply to all entities marketing or selling policies of sickness and accident insurance within the State of Colorado which provide coverage for inpatient health care services at a hospital; except this regulation does not include a Medicare supplement insurance policies and a waiver of premium or double indemnity benefit included in a life insurance policy or annuity contract. Section 4 Definition “Hospital” means a hospital currently licensed or certified by the department of public health and environment pursuant to the department's authority under section 25-1-107 (1) (l). This definition shall not be construed to create coverage for any health care service that is not otherwise covered under the terms of the sickness and accident insurance policy.
Section 5 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any applicable sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws, which include the imposition of fines and/or suspension or revocation of license. Section 6 Severability If any provisions of this regulation or the application thereof to any person or circumstances are for any reason held to be invalid, the remainder of the regulation shall not be affected in any way. Section 7 Effective Date This regulation is repealed effective May 1, 2010.
Section 8 History Originally issued as Regulation 76-6, effective January 14, 1977. Renumbered as Colorado Regulation 4-2-5 on June 1, 1992. Amended Regulation effective March 1, 1994.
Amended Regulation effective January 1, 2001.
Repealed Regulation effective May 1, 2010.
Regulation 4-2-6 CONCERNING THE DEFINITION OF THE TERM “COMPLICATIONS OF PREGNANCY”
Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This amended regulation is promulgated under the authority granted to the Commissioner of Insurance under § § 10-1-109, 10-16-109 and 10-3-1110, C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to standardize the definition of the term “complications of pregnancy” as used in sickness and accident insurance policies covering residents of this state consistent with the commonly perceived connotation of this term by the general public. Section 3 Applicability This regulation shall apply to all entities marketing or selling policies of sickness and accident insurance within the State of Colorado; except that this regulation will not apply to Medicare supplement insurance policies and a waiver of premium or double indemnity benefit included in a life insurance policy or annuity contract.
Section 4 Definitions For the purposes of this regulation "complications of pregnancy" shall mean:
A. Conditions (when the pregnancy is not terminated) whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, and similar medical and surgical conditions of comparable severity, but shall not include false labor, occasional spotting, physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy;
B. Non-elective cesarean section, ectopic pregnancy, which is terminated, and spontaneous termination of pregnancy, which occurs during a period of gestation in which a viable birth is not possible. Section 5 Rules All insurers marketing sickness and accident insurance policies, as defined in this regulation, delivered or issued for delivery in the State of Colorado shall use in each insurance policy or certificate of insurance a definition of the complications of pregnancy no more restrictive than that required by this regulation. Section 6 Severability If any provisions of this regulation or the application thereof to any person or circumstances are for any reason held to be invalid, the remainder of the regulation shall not be affected in any way. Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines issuance of cease and desist orders, and/or suspensions or revocation of certificates of authority. Among others, the penalties provided in § 10-3-1108, C.R.S. may be applied.
Section 8 Effective Date This amended regulation shall become effective March 2, 2010. Section 9 History Originally issued as Regulation 78-16, effective June 30, 1979. Amended Regulation 78-16, effective October 1, 1983.
Renumbered as Regulation 4-2-6, effective June 1, 1992. Amended effective November 1, 2000.
Regulation amended, effective March 2, 2010.
Regulation 4-2-8 CONCERNING REQUIRED HEALTH INSURANCE BENEFITS FOR HOME HEALTH SERVICES AND HOSPICE CARE Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Requirements for Home Health Services Section 5 Requirements for Hospice Care Section 6 Additional Requirements for Home Health Services Section 7 Severability Section 8 Enforcement Section 9 Effective Date Section 10 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance, under the authority of § § 10-1-109 and 10-16-104(8)(d), C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to establish requirements for standard policy provisions, which state clearly and completely the criteria for and extent of coverage for home health services and hospice care and to facilitate prompt and informed decisions regarding patient placement and discharge. Section 3 Applicability The requirements of this regulation shall apply to:
A. Insurers subject to the provisions of Part 2 of Article 16 of Title 10, C.R.S. and non-profit hospital, medical surgical, and health service corporations subject to the provisions of Part 3 of Article 16 of Title 10, C.R.S., which provide: hospital, surgical or major medical coverage on an expense incurred basis, except as noted in paragraph B below, issued on or after the effective date hereof and to all such policies renewed after said date, unless the insurer certifies in writing to the Commissioner of Insurance that it no longer issues the type of policy being renewed. "Renewed" or "renewal" means to continue coverage for an additional policy period upon expiration of the current policy period of a policy.
B. This regulation does not apply to the following:
Section 4 Requirements for Home Health Services A. Definitions.
B. General Policy Provisions Pertaining to Home Health Care.
C. Benefits for Home Health Care Services.
D. Limitations and Exclusions.
A. Definitions.
B. General Provisions Pertaining to Hospice Care.
C. Benefits for Hospice Care Services.
D. Limitations and Exclusions.
Section 6 Additional Requirements for Home Health Care Services and Hospice Care A. The offer to a policyholder to purchase home health care and hospice care coverage must be in writing, either by means of a prominent statement or question on the application for the policy or on a separate form.
B. Nothing in this regulation shall prohibit the insurer from offering a higher level of benefits than required herein.
Section 7 Severability If any provision of this regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision shall not be affected thereby.
Section 8 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspension or revocation of license. Amount others, the penalties provided for in § 10-3-1108, C.R.S. may be applied. Section 9 Effective Date The effective date of this regulation is March 2, 2011. Section 10 History Originally issued as Colorado Regulation 85-6, effective Oct 1, 1985. Amended October 1, 1986.
Renumbered as Colorado Regulation 4-2-8, July 1, 1992.
Amended August 1, 1993.
Amended February 1, 1994.
Amended February 1, 2001.
Amended regulation, effective March 2, 2011.
Regulation 4-2-9 CONCERNING NON-DISCRIMINATORY TREATMENT OF ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS) AND HUMAN IMMUNODEFICIENCY VIRUS (HIV) RELATED ILLNESS BY LIFE AND HEALTH CARRIERS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Incorporated Materials Section 8 Enforcement Section 9 Effective Date Section 10 History Appendix A FDA Licensed/Approved HIV Tests Section 1 Authority This amended regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109, 10-3-1104.5(3)(d)(II) and 10-3-1110, C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to establish standards that will assure non-discriminatory treatment with respect to AIDS and HIV infection in underwriting practices, policy forms and benefit provisions utilized by entities subject to the provisions of this regulation. It also establishes what HIV/AIDS medical tests, permitted under § 10-3-1104.5, C.R.S., are considered medically reliable for underwriting decisions. Section 3 Applicability This regulation applies to all entities that provide life or a policy of sickness and accident insurance in this state including a franchise insurance plan, a fraternal benefit society, a health maintenance organization, a nonprofit hospital and health service corporation, a sickness and accident company, a life or annuity company, and any other entity providing a life policy, annuity, or a policy of sickness and accident insurance subject to the insurance laws and regulations of Colorado. Section 4 Definitions A. “Insurance coverage” shall mean life insurance policies and policies of sickness and accident insurance.
B. “Person” shall have the meaning in § 10-3-1104.5(2)(f), C.R.S.
C. “Policy of sickness and accident insurance” shall have the meaning in §10-16-102(30), C.R.S. Section 5 Rules A. No person, their agent or employee shall make any inquiry or investigation to determine an insurance applicant’s sexual orientation.
B. Sexual orientation may not be used in the underwriting process or in the determination of insurability.
C. Insurance support organizations shall be directed by insurers to not investigate, directly or indirectly, the sexual orientation of an applicant or a beneficiary. All persons shall give written notice to their agents and employees who conduct investigations of applicants for insurance coverage, that they shall not investigate, either directly or indirectly, the sexual orientation of an applicant or beneficiary.
D. No question shall be used which is designed to establish the sexual orientation of the applicant.
E. Questions relating to the applicant having or having been diagnosed as having AIDS or HIV infection are permissible if they are designed solely to establish the existence of the condition. For example, straightforward questions on applications are acceptable, such as, “Have you had or been told by a member of the medical profession that you have AIDS or HIV infection?” or “Have you received treatment from a member of the medical profession for AIDS or HIV infection?” are acceptable.
F. Questions relating to medical and other factual matters intending to reveal the possible existence of a medical condition are permissible if they are not used as a proxy to establish the sexual orientation of the applicant, and the applicant has been given an opportunity to provide an explanation for any affirmative answers given in the application. For example: “Have you had chronic cough, significant weight loss, chronic fatigue, diarrhea, enlarged glands?” These types of questions should be related to a finite period of time preceding completion of the application and should be specific. Such questions should provide the applicant the opportunity to give a detailed explanation.
G. Persons may not use an applicant’s marital status, living arrangements, occupation, gender, medical history, beneficiary designation, or zip code or other territorial classification to establish, or aid in establishing, the applicant’s sexual orientation.
H. For the purpose of rating an applicant for health and life insurance, a person may impose territorial rates only if the rates are based on sound actuarial principles or are related to actual or reasonably anticipated experience.
I. No adverse underwriting decision shall be made because medical records or any investigation or report indicates that the applicant has demonstrated AIDS or HIV infection related concerns by seeking counseling from health care professionals. Neither shall an adverse underwriting decision be made on the basis of such AIDS or HIV infection related concerns unless a medical test which is a reliable predictor of infection, as defined in subsection J of this section, has been administered. This subsection does not apply to an applicant seeking treatment and/or diagnosis.
J. Reliable predictors of infection are delineated in § 10-3-1104.5 (3)(d)(I), C.R.S. Pursuant to § 10-3-
K. To be used for issuing or underwriting a policy, a test described in subsection J of this section must have been licensed by the U.S. Food and Drug Administration as of the effective date of this regulation. A list of such tests is attached as Appendix A.
L. If a specific test licensed by the U.S. Food and Drug Administration indicates the presence of the HIV infection or medical condition indicative of the HIV infection, the person shall, before relying on a single test result to deny or limit coverage or to rate the coverage, follow the U.S. Food and Drug Administration confirmation protocols licensed as of the effective date of this regulation and shall use any applicable confirmatory tests or series of tests licensed as of the effective date of this regulation by the U.S. Food and Drug Administration to confirm the indication. The confirmation protocols and applicable follow-up test regimens are attached as Appendix A.
M. If an applicant is required to take an AIDS or HIV infection test in connection with an application for life or health insurance, the use of such test must be revealed to the applicant and his or her written consent obtained. Test results shall be strictly confidential medical information. However, this regulation is not intended nor should it be interpreted as prohibiting reporting HIV infection to state and local departments of health as provided in § § 25-4-1402 and 25-4-1403, C.R.S.
N. Persons subject to this regulation may include questions on applications as to whether or not the applicant has tested positive on an AIDS or HIV infection test. However, in the event of an affirmative response, no adverse underwriting decisions shall be made on the basis of such response unless it can be determined that the test protocols in subsections J and K of this section above, have been followed.
O. Insurance coverage which excludes or limits coverages for expenses related to the treatment of AIDS and HIV related illness or complications of AIDS, e.g., opportunistic infection resulting from AIDS, shall not be issued for use in Colorado, except to the extent that such exclusions or limitations are consistent with the exclusions or limitations applicable to other covered illnesses or conditions covered by the policy or certificate.
Section 6 Severability If any provision of this regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 7 Incorporated Materials The Morbidity and Mortality Weekly Report, Volume 95, March 1, 1996 published by U.S. Department of Public Health and Human Services, Center for Disease Control and Prevention shall mean Morbidity and Mortality Weekly Report, Volume 95, March 1, 1996 as published on the effective date of this regulation and does not include later amendments to or editions of Morbidity and Mortality Weekly Report, Volume 95, March 1, 1996. A copy of the Morbidity and Mortality Weekly Report, Volume 95, March 1, 1996 may be examined during regular business hours at the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado, 80202. A Certified copy of Morbidity and Mortality Weekly Report, Volume 95, March 1, 1996 may be requested from Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333. A charge for certification or copies may apply. A copy of the Morbidity and Mortality Weekly Report, Volume 95, March 1, 1996 may be examined at any state publications depository library.
Section 8 Enforcement Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.
Section 9 Effective Date This regulation as amended is effective July 1, 2012.
Section 10 History Originally issued as Regulation 87-2, effective January 1, 1988. Renumbered as Regulation 4-2-9, effective June 1, 1992. Amended Section IV(J), effective February 1, 1995.
Amended Regulation, effective March 2, 1999.
Amended Regulation, effective May 1, 2010.
Amended Regulation, effective July 1, 2012.
Appendix A FDA Licensed/Approved HIV Tests for Colorado Regulation 4-2-9 Published as of 7/22/2011 Human Immunodeficiency Virus Type 1 (Anti-HIV-1 Assay)
GS rLAV EIA HIV-1 EIA Serum / Plasma Fluorognost HIV-1 IFA HIV-1 IFA Serum / Plasma Cambridge Biotech HIV- HIV-1 WB Serum / Plasma 1 Western Blot Kit GS HIV-1 Western Blot HIV-1 WB Serum / Plasma Avioq HIV-1 Microelisa HIV-1 EIA Serum, Plasma, Dried System blood spot, Oral Fluid HIVAB HIV-1 EIA HIV-1 EIA Dried Blood Spot Maxim Biotech HIV-1 HIV-1 EIA Urine Urine EIA INSTI™ HIV-1 Antibody HIV-1 Rapid Immunoassay Plasma / Whole Blood Test Kit (veni-puncture and fingerstick)
Reveal Rapid HIV-1 HIV-1 Rapid Immunoassay Serum / Plasma Antibody Test15 Uni-Gold Recombigen HIV-1 Rapid Immunoassay Serum / Plasma / Whole HIV Blood (venipuncture and fingerstick)
GS HIV-1 Western Blot HIV-1 WB Dried Blood Spot Fluorognost HIV-1 IFA HIV-1 IFA Dried Blood Spot OraSure HIV-1 Western HIV-1 WB Oral Fluid Blot Kit Cambridge Biotech HIV- HIV-1 WB Urine 1 Western Blot Kit Human Immunodeficiency Virus Type 1 (HIV-1 Nucleic Acid Assay) - see Multiplex Assays also, below Tradename(s) (Labeling Infec-tious Agent Format Current Sample may be out of date)
Human HIV-1 PCR Plasma Immunodeficiency Virus, Type 1 (HIV-1) Reverse Transcription (RT)
Polymerase Chain Reaction (PCR) Assay UltraQual HIV-1 RT-PCR HIV-1 PCR Plasma Assay COBAS Ampliscreen HIV-1 PCR Plasma/ Cadaveric serum HIV-1 Test or plasma APTIMA HIV-1 RNA HIV-1 HIV-1 Nucleic Acid Plasma/ Serum Qualitative Assay (TMA)
Abbott RealTime HIV-1 HIV-1 PCR Plasma Amplification Kit Roche Amplicor HIV-1 HIV-1 PCR Plasma Monitor Test COBAS HIV-1 PCR Plasma AmpliPrep/COBAS TaqMan HIV-1 Test Versant HIV-1 RNA 3.0 HIV-1 Signal amplification Plasma (bDNA) nucleic acid probe ViroSeq HIV-1 HIV-1 HIV-1 Genotyping Plasma Genotyping System with the 3700 Genetic Analyzer Trugene HIV-1 HIV-1 HIV-1 Genotyping Plasma Genotyping Kit and Open Gene DNA Sequencing System Anti-HIV-1 Testing Service Tradename(s) (Labeling Infec-tious Agent Format Current Sample may be out of date)
Home Access HIV-1 Test HIV-1 Dried Blood Spot Dried Blood Spot System Collection Device Anti-HIV-1 Oral Specimen Collection Device Tradename(s) (Labeling Infec-tious Agent Format Current Sample may be out of date)
OraSure HIV-1 Oral HIV-1 Oral Specimen Collection Oral Fluid Specimen Collection Device Device Human Immunodeficiency Virus Type 2 (Anti-HIV-2 Assay)
Tradename(s) (Labeling Infec-tious Agent Format Current Sample may be out of date)
GS HIV-2 EIA HIV-2 EIA Serum / Plasma Human Immunodeficiency Virus Types 1 & 2 (Anti-HIV-1/2 Assay) Tradename(s) (Labeling Infec-tious Agent Format Current Sample may be out of date)
Abbott HIVAB HIV- HIV-1, HIV-2 EIA Serum / Plasma / 1/HIV-2 (rDNA) EIA Cadaveric Serum ABBOTT PRISM HIV O HIV-1, HIV-2 Chemi-luminescent Plasma / Serum/ Plus assay Immunoassay (ChLIA) Cadaveric Serum GS HIV-1/HIV-2 Plus O HIV-1, HIV-2 EIA Serum / Plasma / EIA Cadaveric Serum ADVIA Centaur HIV HIV-1, HIV-2 Microparticle Chemi- Plasma/Serum 1/O/2 Enhanced luminometric ReadyPack Reagents Immunoassay Ortho VITROS HIV- HIV-1, HIV-2 EIA Plasma/Serum 1/HIV-2 Multispot HIV-1/HIV-2 HIV-1, HIV-2 Rapid Immunoassay Plasma / Serum Rapid Test SURE CHECK HIV 1/2 HIV-1, HIV-2 Rapid Immunoassay Fingerstick & venous ASSAY whole blood, serum, plasma HIV 1/2 STAT-PAK HIV-1, HIV-2 Rapid Immunoassay Fingerstick & venous ASSAY whole blood, serum, plasma OraQuick ADVANCE HIV-1, HIV-2 Rapid Immunoassay Whole Blood, Plasma, Rapid HIV-1/2 Antibody Oral Fluid Test OraQuick ADVANCE HIV-1, HIV-2 Rapid Immunoassay oral fluid, plasma, venous Rapid HIV-1/2 Antibody whole blood Test Human Immunodeficiency Virus Types 1 & 2 (Anti-HIV-1/2 Assay) and Anti- HIV-1 (HIV-1 Antigen Assay)
Tradename(s) (Labeling Infec-tious Agent Format Current Sample may be out of date)
ARCHITECT HIV HIV-1, HIV-2 Chemi-luminescent Plasma / Serum Ag/Ab Combo Microparticle Immunoassay (CMIA)
Bio-Rad GS HIV Ag/Ab HIV-1, HIV-2 EIA Plasma / Serum Combo EIA Human T-Lymphotropic Virus Types I & II (Anti-HTLV-I/II Assay) Tradename(s) (Labeling Infec-tious Agent Format Current Sample may be out of date)
Abbott HTLV-I/HTLV-II HTLV-1, HTLV-2 EIA Serum / Plasma EIA ABBOTT PRISM HTLV- HTLV-1, HTLV-2 Chemi-luminescent Serum / Plasma I/HTLV-II Immunoassay (ChLIA)
Regulation 4-2-10 REPORTING REQUIREMENTS FOR MULTIPLE EMPLOYER WELFARE ARRANGEMENTS (MEWAS)
Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Filing Requirements of MEWAs Section 6 Authorized Insurance Arrangements Section 7 Producer Responsibilities Section 8 Continuing Compliance Section 9 Severability Section 10 Enforcement Section 11 Effective Date Section 12 History Section 1 Authority This regulation is promulgated under the authority of §10-1-109, C.R.S. Section 2 Scope and Purpose This regulation is intended to: (1) clarify the information to be filed under the provisions of §10-3-903.5(7) (c), C.R.S. by Multiple Employer Welfare Arrangements (MEWAs) claiming exempt status from formal licensing requirements; and (2) clarify the responsibilities of licensed producers, Section 3 Applicability This regulation applies to all multiple employer welfare arrangements subject to §10-3–903.5, C.R.S Section 4 Definitions A. "Fully insured" means an arrangement where a licensed entity is liable to pay all health care benefits, less any contractual deductibles, coinsurance or copayments to be made by the enrollee. The liability of the licensed entity for payment of the covered services or benefits is directly to the individual employee, member or dependent(s) receiving the health care services or benefits. The contract issuance claims payment and administration and all other insurance related functions remain the ultimate responsibility of the licensed entity.
B. "Health plan" is an arrangement such as a fund, trust, plan, program or other funding mechanism that provides health care benefits.
C. "Licensed entity" means a licensed insurance company; health maintenance organization; or nonprofit hospital, medical-surgical, and health service corporation having a certificate of authority to transact business in this state.
D. "Producer" means a licensed person as defined by Article 2 of Title 10.
E. "Substantial compliance" means that each benefit provided to an individual covered by a MEWA complies with the essential requirements of each mandated benefit. Section 5 Filing Requirements of MEWAs A filing under this regulation by a MEWA is solely for the purpose of providing the information required to the Commissioner in order to demonstrate if a MEWA complies with the requirements of §10-3-903.5(c) (7), C.R.S. Determination of compliance or noncompliance will be provided in writing to the MEWA. The following information is required to be filed in order to meet the filing requirements of §10-3-903.5(7) (c), C.R.S. and for the Division of Insurance to make a determination regarding the qualification of a MEWA seeking exemption from licensure requirements.
A. Evidence that the MEWA has existed continuously since January 1, 1983.
B. A copy of the sponsor association's organizational documents, membership criteria, ownership and a summary of the activities and benefits, other than health plan coverage, provided to its membership.
C. A copy of the most recent financial report, which includes at a minimum, a balance sheet, income statement, cash flow report and a detailed listing of assets, as of the MEWA's most recent fiscal year end. The financial report must disclose and support the required five percent (5%) unallocated reserve level.
D. The method of marketing and enrolling eligible participants.
E. Actuarial information that must be prepared and signed by a qualified actuary as indicated by §10-7- 114(1)(e), C.R.S. This information must include:
F. A copy of the products offered along with a summary of benefits and a comparison of how each benefit is in substantial compliance with the state's mandated benefit provisions.
G. Such other relevant information as the Commissioner may request in order to evaluate the financial, actuarial and benefits of the health plan.
H. A copy of an audited annual financial report within 150 days of the MEWA's fiscal year end. Items A and B above are only required to be filed once, unless materially altered. Items C through G will be required to be filed annually within sixty (60) days following the fiscal year end of the MEWA. Item H shall be filed annually as indicated.
Section 6 Authorized Insurance Arrangements Qualifying health plans that are not subject to licensure as an insurer under Colorado law are plans that are:
A. Fully insured;
B. Established and maintained by a single employer;
C. Established and subject to a collectively bargained agreement pursuant to §10-3-903.5(7)(b)(II), C.R.S.;
D. Established by a government entity, pursuant to §10-3-903.5(7)(b)(I), C.R.S.; or E. Determined to be in compliance with §10-3-905.3(7)(c), C.R.S. and Section 5 of this regulation. Pursuant to Colorado law, health plans sold to residents of Colorado are subject to Colorado law even if the master policy is issued and delivered outside of Colorado. Section 7 Producer Responsibilities No producer may solicit, advertise, market, accept an application, or place coverage for a person who resides in this state with a MEWA unless the producer first verifies that the MEWA complies with the requirements of this regulation and the provisions of §10-3-903.5, C.R.S. This is accomplished by the producer acquiring a copy of the Division's correspondence determining that the MEWA is in compliance with this regulation and the provisions of §10-3-903.5(7)(c), C.R.S. Lack of knowledge regarding the compliance of any organization or health plan is not a defense to a violation of this regulation. Any producer involved in the solicitation or sale of health plans through unauthorized insurers or MEWAs which are found not to be in compliance with the provisions of §10-3- 903.5, C.R.S. and this regulation are subject to discipline or action including fines, suspension or revocation of their license.
Section 8 Continuing Compliance In the event that a MEWA ceases to qualify under Section 6 of this regulation, it will be transacting the business of insurance in the State of Colorado without a license and subject to the procedures of Parts 9 and 10 of Article 3 of Title 10, C.R.S. and the provisions of the State Administrative Procedure Act, Part 4 of Title 24, C.R.S. as applicable. Any insurer that may have issued a contract to a health plan is not exempt from the liability under its contract solely due to the unauthorized status of a health plan. Section 9 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 10 Enforcement Noncompliance with this regulation may result in the imposition of any sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance or cease and desist orders, and/or suspensions or revocations of license, subject to the requirements of due process.
Section 11 Effective Date This amended regulation shall be effective August 1, 2012. Section 12 History Regulation 4-2-10, effective July 1, 1994 Amended regulation effective October 2, 2006 Amended regulation effective August 1, 2012 Regulation 4-2-11 RATE FILING SUBMISSIONS FOR HEALTH INSURANCE Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 General Rate Filing Requirements Section 6 Actuarial Memorandum Section 7 Additional Rate Filing Requirement by Line of Business Section 8 Prohibited Rating Practices Section 9 Severability Section 10 Enforcement Section 11 Effective Date Section 12 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109, 10-3-1110, 10 16-107, 10-16-109, and 10-18-105(2), C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to ensure that health insurance rates are not excessive, inadequate or unfairly discriminatory, by establishing the requirements for rate filings. Section 3 Applicability This regulation applies to all carriers, as defined in Section 4.C, operating in the State of Colorado. This regulation concerns all health insurance rate filings, including, but not limited to, comprehensive health insurance, long-term care, supplemental health, limited benefit health, prepaid dental, limited service licensed provider networks, disability, Medicare supplement, Health Maintenance Organization (HMO) coverages and stop loss carriers for employers with self insured health plans. Section 4 Definitions A. "Administrative ratio" means, for purposes of this regulation, the ratio of actual total administrative expenses, not including policyholder dividends, to the value of the actual earned premiums, not reduced by policyholder dividends, over the specified period, which is typically a calendar year.
B. "Benefits ratio" means, for purposes of this regulation, the ratio of policy benefits, not including policyholder dividends, to the value of the earned premiums, not reduced by policyholder dividends, over the entire period for which rates are computed to provide coverage. Note: active life reserves do not represent claim payments, but provide for timing differences. Benefits ratio calculations must be displayed without the inclusion of active life reserves.
C. "Carrier" means, for purposes of this regulation, a carrier as defined in § 10-16-102(8), C.R.S., and includes, but is not limited to, licensed property and casualty insurance companies; licensed life and health insurance companies; non-profit hospital, medical-surgical, and health service corporations; HMOs; prepaid dental companies; and limited service licensed provider networks.
D. "Covered lives" means, for purposes of this regulation, the number of members, subscribers and dependents.
E. "Dividends" means, for purposes of this regulation, both policyholder and stockholder dividends.
F. "Excessive rates" means, for purposes of this regulation, rates that are likely to produce a long run profit that is unreasonably high for the insurance provided or if the rates include a provision for expenses that is unreasonably high in relation to the services rendered. In determining if the rate is excessive, the Commissioner may consider profits, dividends, annual rate reports, annual financial statements, subrogation funds credited, investment income or losses, unearned premium reserve, reserve for losses, surpluses, executive salaries, expected benefits ratios, and any other appropriate actuarial factors as determined by accepted actuarial standards of practice. The Commissioner may require the submission of whatever relevant information the Commissioner deems necessary in determining whether to approve or disapprove a rate filing.
G. "File and use" is a filing procedure that requires rates and rating data to be filed with the Division of Insurance (Division) concurrent with or prior to distribution, release to producers, collection of premium, advertising, or any other use of the rates. Under no circumstance shall the carrier provide insurance coverage under the rates until on or after the proposed implementation date. Carriers may bill members but not require the member remit premium prior to the proposed implementation date of the rate change.
H. "Filing date" means, for purposes of this regulation, the date that the rate filing is received at the Division.
I. "Health coverage plan" shall have the same meaning as defined in § 10-16-102(22.5), C.R.S.
J. "Implementation date" means, for purposes of this regulation, the date that the filed or approved rates can be charged to an individual or group.
K. "Inadequate rates" means, for purposes of this regulation, rates that are clearly insufficient to sustain projected losses and expenses, or if the use of such rates, if continued, will tend to create a monopoly in the marketplace. In determining if the rate is inadequate, the Commissioner may consider profits, dividends, annual rate reports, annual financial statements, subrogation funds credited, investment income or losses, unearned premium reserve, reserve for losses, surpluses, executive salaries, expected benefits ratios, and any other appropriate actuarial factors as determined by accepted actuarial standards of practice. The Commissioner may require the submission of whatever relevant information the Commissioner deems necessary in determining whether to approve or disapprove a rate filing.
L. "Indemnity benefits" means, for the purpose of the twenty percent (20%) limitation imposed on HMOs, the following benefits: out-of-area services, supplemental benefits (such as vision and dental provided on a non-contractual fee-for-service basis) and point-of-service benefits. It does not include any benefits provided by an HMO for which there exists a hold harmless agreement between the providers and the HMO.
M. "Lifetime loss ratio":
N. "Non-developed rates" are rates that are established by agreement with a governmental entity through a bidding process or by some other means and include, but are not limited to: rates for Medicare, Title XVIII of the federal "Social Security Act;" Medicaid, Title XIX of the federal "Social Security Act;" and the State Children’s Health Insurance Program (SCHIP), Title XXI of the federal "Social Security Act."
O. "On-rate-level premium" is the premium that would have been generated if the present rates had been in effect during the entire period under consideration.
P. "Premium" means, for purposes of this regulation, the amount of money paid by the insured member, subscriber, or policyholder as a condition of receiving health care coverage. The premium paid normally reflects such factors as the carrier’s expectation of the insured’s future claim costs and the insured’s share of the carrier’s claims settlement, operational and administrative expenses, and the carrier’s cost of capital. This amount is net of any adjustments, discounts, allowances or other inducements permitted by the health care coverage contract.
Q. "Prior approval" is a filing procedure that requires a rate change to be affirmatively approved by the Commissioner prior to distribution, release to agents, collections of premium, advertising, or any other use of the rate. Under no circumstances shall the carrier provide insurance coverage under the rates until on or after the proposed implementation date specified in the rate filing. After the rate filing has been approved by the Commissioner, carriers may bill members but not require the member remit premium prior to the proposed implementation date of the rate change.
R. "Qualified actuary" is a person who meets the qualifications in Colorado Insurance Regulation 1-1-1.
S. "Rate" means, for purposes of this regulation, the amount of money a carrier charges as a condition of providing health care coverage. The rate charged normally reflects such factors as the carrier’s expectation of the insured’s future claim costs, and the insured’s share of the carrier’s claim settlement, operational and administrative expenses, and cost of capital. This amount is net of any adjustments, discounts, allowances or other inducements permitted by the health care coverage contract.
T. "Rate filing" means, for purposes of this regulation, a filing that contains all of the items required in this regulation, and
U. "Rate increase" shall have the same meaning as defined in § 10-16-102(36.5), C.R.S., and includes an increase in any current rate or factor used to calculate premium rates for new or existing policyholders or certificateholders.
V. "Renewed." A health coverage plan shall be deemed renewed upon the occurrence of the earliest of: the annual anniversary date of issue; or the date on which premium rates can be or are changed according to the terms of the plan; or the date on which benefits can be or are changed according to the terms of the plan. If the health care coverage contract specifically allows for a change in premiums or benefits due to changes in state or federal requirements and a change in the health coverage plan premiums or benefits that is solely due to changes in state or federal requirements is not considered a renewal in the health care coverage contract, then such a change will not be considered a renewal for the purposes of this regulation.
W. "Retention" means, for the purposes of this regulation, the sum of all non-claim expenses including investment income from unearned premium reserves, contract or policy reserves, reserves from incurred losses, and reserves from incurred but not reported losses as percentage of total premium (or 100% minus the lifetime loss ratio, for products priced on a lifetime loss ratio standard).
X. "Trend" or "trending" means any procedure for projecting losses to the average date of loss, or of projecting premium or exposures to the average date of writing.
Y. "Trend factors" means, for purposes of this regulation, rates or rating factors which vary over time or due to the duration that the insured has been covered under the policy or certificate, and that reflect any of the components of medical or insurance trend assumptions used in pricing. Medical trend includes changes in unit costs of medical services or procedures, medical provider price changes, changes in utilization (other than due to advancing age), medical cost shifting, and new medical procedures and technology. Insurance trend includes the effect of underwriting wearoff, deductible leveraging, and antiselection resulting from rate increases and discontinuance of new sales. Underwriting wearoff means the gradual increase from initial low expected claims that result from underwriting selection to higher expected claims for later (ultimate) durations. Underwriting wearoff does not apply to guaranteed issue products. Trend factors include inflation factors, durational factors and the Index Rate for small group business.
Z. "Unfairly discriminatory rates" means, for purposes of this regulation, charging different rates for the same benefits provided to individuals, or groups, with like expectations of loss; or if after allowing for practical limitations, differences in rates fail to reflect equitably the differences in expected losses and expenses. A rate is not unfairly discriminatory solely if different premiums result for policyholders with like loss exposures but different expenses, or like expenses but different loss exposures, so long as the rate reflects the differences with reasonable accuracy.
AA. "Use of the rates" means, for purposes of this regulation, the distribution of rates or factors to calculate the premium amount for a specific policy or certificate holder including advertising, distributing rates or premiums to agents, and disclosing premium quotes. It does not include releasing information about the proposed rating change to other government entities or disclosing general information about the rate change to the public.
AB. "Wellness and prevention program" for the purposes of this regulation, shall have the same meaning as provided under § 10-16-136(7)(b), C.R.S.
Section 5 General Rate Filing Requirements All rate filings shall be submitted electronically by licensed entities. Failure to supply the information required in Sections 5, 6 and 7 of this regulation will render the filing incomplete. Incomplete filings are not reviewed for substantive content. All filings that are not returned or disapproved on or before the 30th calendar day after receipt will be considered complete. Filings may be reviewed for substantive content, and if reviewed, any deficiency will be identified and communicated to the filing carrier on or before the 45th calendar day after receipt. Correction of any deficiency, including deficiencies identified after the 45th calendar day, will be required on a prospective basis, and no penalty will be applied for a non-willful violation identified in this manner. Nothing in this regulation shall render a rate filing subject to prior approval by the Commissioner that is not otherwise subject to prior approval as provided by statute.
A. General Requirements
B. Required Forms and Actuarial Certification
Section 6 Actuarial Memorandum The rate filing must contain an actuarial memorandum, either signed by, or prepared under the supervision of, a qualified actuary, containing, at a minimum, the following sections in the designated order shown below or an alternate template supplied by the Division:
A. Summary: A brief written summary of the filing including, but not limited to, the following:
B. Assumption, Acquisition or Merger: The memorandum must state whether or not the products included in the rate filing were part of an assumption, acquisition or merger of policies from/with another carrier. If so, then the memorandum must include the full name of the carrier/carriers from which the policies were assumed, acquired or merged, and the closing date of assumption, acquisition or merger.
C. Rating Period: The memorandum must identify the period for which the rates will be effective. At a minimum, the proposed implementation date of the rates must be provided. If the length of the rating period is not clearly identified, it will be assumed to be for twelve months, starting from the proposed implementation date.
D. Underwriting: The memorandum must include a brief description of the extent to which this product will be underwritten, if a new product, or the changes, if any, to the underwriting standards, if an existing product. The memorandum should include the expected impact on the claim costs by duration and in total. The carrier shall state separately the effects of different types of underwriting: medical, financial or other. An example of an acceptable brief description is: "This policy form is subject to limited underwriting with yes/no questions. The expected impact is: duration 1 = .15; duration 2 = .05; duration 3 = .03 decrease in claim costs." Underwriting rate ups are considered rating factors and need to be filed and supported – see paragraph Q, "Other Factors", in this section.
E. Effect of Law Changes: The memorandum should identify, quantify, and adequately support any changes to the rates, expenses, and/or medical costs that result from changes in law(s) or regulation(s), including federal, state or local. All applicable benefit mandates should be listed, including those with no rating impact. This quantification must include the effect of specific mandated benefits and anticipated changes both individually by benefit, as well as for all benefits combined.
F. Rate History: The memorandum must include a chart showing the rate changes implemented including the implementation date of each rate change in at least the three years immediately prior to the date of the filing. This chart must contain the following information: the filing number (State or SERFF tracking number), the implementation date of each rate change, average increase or decrease, minimum and maximum increase and cumulative rate change for the past 12 months. The cumulative effect of all rate filings, submitted in the prior year, on renewal rates should be specified. The rate history should be provided on both a Colorado basis, as well as an average nationwide basis, if applicable.
G. Coordination of Benefits: Each rate filing must reflect actual loss experience net of any savings associated with coordination of benefits and/or subrogation.
H. Relation of Benefits to Premium: The memorandum must adequately support the reasonableness of the relationship of the projected benefits to projected earned premiums for the rating period. This relationship will be presumed to be reasonable if the carrier complies with the following:
Comprehensive Major 80% Medical (Small Group)
Comprehensive Major 85% Medical (Large Group)
Specified or Dread 60% Disease Limited Benefit Plans 60% Disability Income 60% Dental/Vision 60% Stop Loss 60% Short Term Limited 60% Duration Health Insurance
I. Lifetime Loss Ratio: The memorandum must state whether or not the product was priced initially using a lifetime loss ratio standard. If the product was priced using a lifetime loss ratio standard, then any subsequent rate change request must be based on the same lifetime loss ratio standard unless there has been a material change in assumptions used to price the product including changes in regulations covering the product. Changes to the lifetime loss ratio must be identified and clearly supported. The lifetime loss ratio standard shall consider the effects of investment income. Any subsequent rate change request shall consider the variance in the expected benefits ratios over the duration of the policy. The rate filing must include the average policy duration in years as of the endpoint of the experience period and the expected benefits ratio, as originally priced, for each year of the experience period. The rate filing must also include a chart showing actual and expected benefits ratios for both the experience and rating periods. For each year of the experience period the chart must show the actual and expected benefits ratios, and the ratio of these two benefits ratios. For each year of the rating period, the chart must show the projected and expected benefits ratios, and the ratio of these two benefits ratios. It is expected that the carrier is pricing these products to achieve a benefits ratio greater than or equal to the expected benefits ratio for the rating period.
J. Provision for Profit and Contingencies: The memorandum must identify the percentage of the provision for profit and contingencies, and how this provision is included in the final rate. If material, investment income from unearned premium reserves, reserves from incurred losses, and reserves from incurred but not reported losses must be considered in the ratemaking process. Detailed support must be provided for any proposed load in excess of 7% after federal income tax.
K. Complete Explanation as to How the Proposed Rates were Determined: The memorandum must contain a section with a complete explanation as to how the proposed rates were determined, including all underlying rating assumptions, with detailed support for each assumption. The Division may return a rate filing if adequate support for each rating assumption is not provided. This explanation may be on an aggregate expected loss basis or as a per-member-per-month
L. Trend: This section must describe the trend assumptions used in pricing. These assumptions must each be separately discussed, adequately supported, and also be appropriate for the specific line of business, product design, benefit configuration, and time period. Any and all factors affecting the projection of future claims must be presented and adequately supported. The trend assumptions shall be, if practical, separately quantified into two categories, medical and insurance, as defined below:
M. Credibility: The Colorado standard for fully credible data is 2,000 life years and 2,000 claims. Both standards must be met within a maximum of three years, if the proposed rates are based on claims experience.
N. Data Requirements: The memorandum must, at a minimum, include earned premium, incurred claims, actual benefits ratio, number of claims, average covered lives and number of policyholders submitted on a Colorado-only basis for at least 3 years. National or other relevant data shall also be provided in order to support the rates, if the Colorado data is not fully credible. Any rate filing involving an existing product is required to provide this information. This includes, but is not limited to: changes in rates; rating factors; rating methodology; trend; new benefit options; or new plan designs for an existing product. If the filing is to introduce a new product to Colorado, nationwide experience must be provided for this product, if available. If no experience for the new product is available, experience for a comparable product must be provided, if available. Rates must be supported by the most recent data available, with as much weight as possible placed upon the Colorado experience. The experience period must include consecutive data no older than six months prior to the filing date. The loss data must be on an incurred basis, including both the accrued and unaccrued portions of the liability and reserve (e.g., case, bulk and IBNR reserves) as of the valuation date. Premiums and/or exposure data must be stated on both an actual and on-rate-level basis. Capitation payments should be considered as claim or loss payments. The carrier should also provide information about how the number of claims was calculated.
O. Side-by-Side Comparison: Each memorandum must include a "side-by-side comparison" identifying any proposed change(s) in rates. This comparison should include three columns: the first containing the current rate, rating factor, or rating variable; the second containing the proposed rate, rating factor, or rating variable; and the third containing the percentage increase or decrease of each proposed change(s). If the proposed rating factor(s) are new, the memorandum must specifically so state, and provide detailed support for each of the factors.
P. Benefits Ratio Projections: The memorandum must contain a section projecting the benefits ratio, over the rating period, both with and without the requested rate change. For products priced using a lifetime loss ratio standard, such as long-term care, Medicare supplement and long term disability, the projections should include a timeframe as to when the lifetime loss ratio will be achieved.
Q. Other Factors: The memorandum must clearly display or clearly reference all other rating factors and definitions, including the area factors, age factors, gender factors, etc., and support for each of these factors in a new rate filing. The same level of support for changes to any of these factors must be included in renewal rate filings. In addition, the Commissioner expects each carrier to review each of these rating factors at least every five years and provide detailed support for the continued use of each of these factors in a rate filing. Gender factors shall not vary for individual health care coverage effective on or after January 1, 2011. See Section 8.C of this regulation. Note: this requirement does not apply to Medicare supplement coverage.
R. Rating manuals and underwriting guidelines: A rating manual and the underwriting guidelines that affect the calculation of the rates must be submitted to the Division for each new product. All changes to the rating manual and/or underwriting guidelines must be filed with the Division in an appropriate rate filing. Rating manuals and underwriting guidelines based on an accept or reject basis are not required to be filed.
Section 7 Additional Rate Filing Requirement by Line of Business The following subsections set forth the requirements by separate lines of business, which must be complied in addition to the above general requirements:
A. Individual: Renewal rates for individual health insurance plans shall not be affected by the health status or claims experience of the individual insured. A "claims experience factor," or any other part of the renewal rate calculation, which is based in whole or in part upon the health status or claims experience of the individual insured is prohibited.
B. Wellness and Prevention Programs: A carrier offering an individual health coverage plan or a small group plan in this state may offer incentives or rewards to encourage the individual or small group and other covered persons under the plan to participate in wellness and prevention programs, pursuant to §10-16-136, C.R.S., and shall be subject to the following:
C. Small Employer Group Health Benefit Plans: The provisions of § § 10-16-105 and 10-16-107, C.R.S., and Colorado Insurance Regulations 4-6-5, 4-6-7, and 4-6-8, shall apply to the filing of rates for small employer health benefit plans.
D. Large Group Health Coverage Plans: Large group health coverage plan contracts are considered to be a negotiated agreement between a sophisticated purchaser and seller. Certain rating variables may vary due to the final results of each negotiation. Each large group rate filing must contain the ranges for these negotiated rating variables, an explanation of the method used to apply these rating variables, and a discussion of the need for the filed ranges. A new rate filing is required whenever a rating variable or a range for a rating variable changes. Each filing should also contain an example of how the large group health rates are calculated. While the final rate charged the large group may differ from the initial quote, all rating variables must be on file with the Division.
E. Valid Multi-State Association Groups: Pursuant to § 10-16-107(6), C.R.S., any health benefit plan issued or renewing on or after May 1, 2010, for any valid multi-state association under § 10-16- 214(2), C.R.S., shall not use any health status-related factor in determining the premium or contribution for any enrolled individual and/or their dependent. However, the prohibition in this subsection shall not be construed to prevent the carrier from establishing premium discounts or rebates or modifying otherwise applicable copayments, coinsurance, or deductibles in return for adherence to programs of health promotion or disease prevention if otherwise allowed by state or federal law.
F. Medicare Supplement: A Medicare supplement policy is defined in § 10-18-101(4), C.R.S., and regulated pursuant to Colorado Insurance Regulation 4 3-1 and § § 10-18-101 to 109, C.R.S. If the requirements of both Colorado Insurance Regulation 4-3-1 and this regulation are not met, the filing will be considered incomplete and returned to the carrier. Medicare supplement filings require prior approval. (The requirements for the actuarial certification for Medicare supplement rate filings can be found in Section 14.H of Colorado Insurance Regulation 4-3-1. Rating requirements can be found in Sections 10.E, 13 and 14.F – J).
G. Long-Term Care: Long-term care insurance is defined in § 10-19-103(5), C.R.S., and regulated pursuant to Colorado Insurance Regulation 4-4-1 and § § 10-19-101 to 115, C.R.S. If the requirements of both Colorado Insurance Regulation 4-4-1 and this regulation are not met, the filing will be considered incomplete and returned to the carrier. The filing must also:
H. Disability Income: The filing must demonstrate that investment income has been considered in the development of the rate.
I. Health Maintenance Organization (HMO): The rates for all HMO point-of-service (POS) benefits must be separately determined and supported. The actuarial memorandum supporting any rate filing for a policy which includes POS or other indemnity benefits must include a statement that all indemnity benefits are not expected to exceed twenty percent (20%) of the net medical and hospital expenses incurred. HMOs that exceed the 20% limitation in the prior calendar year may be prohibited from offering a point-of-service plan for new issues until compliance can be demonstrated.
J. Limited Service Licensed Provider Network (LSLPN): Rates and premiums for products issued by an LSLPN are to be determined on a fixed prepayment basis. Therefore, no LSLPN product may be issued on a cost-plus or retrospective rating basis.
Section 8 Prohibited Rating Practices The Commissioner has determined that certain rating activities lead to excessive, inadequate or unfairly discriminatory rates, and are unfair methods of competition and/or unfair or deceptive acts or practices in the business of insurance. Therefore, in accordance with § § 10-16-107, 10-16-109, and 10-3-1110(1), C.R.S., the following are prohibited:
A. Attained age premium schedules where the slope by age is substantially different from the slope of the ultimate claim cost curve. However, this requirement is not intended to prohibit use of a premium schedule which provides for attained age premiums to a specific age followed by a level premium, or the use of reasonable step rating;
B. The use of premium modalization factors which implicitly or explicitly increase the premium to the consumer by any amount other than those amounts necessary to offset reasonable increases in actual operating expenses that are associated with the increased number of billings and/or the loss of interest income;
C. For individual health coverage plans other than Medicare supplement, rates shall not vary due to the gender of the individual policyholder, enrollee, subscriber, or member for rates effective on or after January 1, 2011, pursuant to 10-16-107(1.5)(b), C.R.S; and, D. For individual health insurance plans, other than Medicare supplement, the use of any rating factors based upon zip codes which fail to equitably adjust for different expectations of loss. It is the expectation of the Commissioner that areas of the state with like expectations of loss must be treated in a similar manner. Also, policyholders utilizing the same provider groups should be rated in a like manner. The use of zip codes in determining rating factors can result in inequities. Unless different rating factors can be justified based upon different provider groups or other actuarially sound reasons, the following guidelines shall be followed whenever zip codes are used in determining a carrier’s rating factors:
If a carrier uses area rating factors which are based in whole or in part upon the zip code, and does not follow these guidelines, the carrier may be found to have rates that are unfairly discriminatory. The Commissioner would prefer that a carrier use federal MSA’s, rather than zip codes, in their rating structure. The Commissioner expects carriers to review the appropriateness of area factors at least every five years and provide detailed support for the continued use of the factors in rate filings and upon request.
Section 9 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected. Section 10 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of certificates of authority. Among others, the penalties provided in § § 10-3-1108, 10-16-107, 10-16-107.1, and 10-16-216.5, C.R.S., may be applied.
Section 11 Effective date This regulation is amended effective January 1, 2012.
Section 12 History Regulation 4-2-11, effective November 1, 1992.
Regulation Repealed and Re-promulgated, effective February 1, 1999. Regulation amended effective January 1, 2001.
Regulation amended effective December 1, 2005.
Regulation amended effective December 1, 2007.
Emergency Regulation 08-E-4 was effective July 1, 2008. Regulation amended effective October 1, 2008.
Regulation amended effective February 1, 2009.
Regulation amended effective July 1, 2009.
Regulation amended effective January 1, 2010.
Regulation 4-2-11 amended, effective May 1, 2010.
Regulation 4-2-11 amended, effective January 1, 2011.
Regulation 4-2-11 amended, effective January 1, 2012.
Regulation 4-2-13 Repealed in Full [eff. 01/01/2010] Regulation 4-2-15 REQUIRED PROVISIONS IN CARRIER CONTRACTS WITH PROVIDERS, CARRIER CONTRACTS WITH INTERMEDIARIES NEGOTIATING ON BEHALF OF PROVIDERS, AND CARRIER CONTRACTS WITH INTERMEDIARIES CONDUCTING UTILIZATION REVIEWS Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109, 10-16-121(5) , and 10-16-708, C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to describe the entities subject to the provisions of Sections 10-16-121, and 10-16-705, C.R.S., which concerns required provisions in insurance carrier’s contracts with health care providers and intermediaries, and to establish how those entities shall meet the requirements of the above sections.
Section 3 Applicability The provisions of this regulation shall apply to all contracts that concern the delivery, provision, payment or offering of care or services covered by a managed care plan that are entered into between a carrier and a provider or its representative, or between a carrier and an intermediary. Section 4 Definitions As used in this regulation, and unless the context requires otherwise:
A. “Carrier” is defined in § 10-16-102(8), C.R.S.
B. “Intermediary” is defined in § 10-16-102(25.5), C.R.S.
C. “Managed care plan” is defined in § 10-16-102(26.5), C.R.S.
D. “Utilization management” is defined in §10-16-1002(10), C.R.S.
E. “Utilization review” is defined in § 10-16-112(1)(b), C.R.S. Section 5 Rules A. Every contract between a carrier that has covered lives in Colorado and a provider or its representative that concerns the delivery, provision, payment or offering of care or services covered by a managed care plan that is issued, renewed, amended or extended shall contain provisions substantially similar to the following:
B. Every contract between a carrier and an intermediary that concerns the delivery, provision, payment or offering of care or services covered by a managed care plan that is issued, renewed, amended or extended shall contain a provision requiring that the underlying contract authorizing the intermediary to negotiate and execute contracts with carriers, on behalf of providers, contain provisions substantially similar to the following:
C. Any contract entered into by a carrier with one or more intermediaries to conduct utilization management, utilization reviews, provider credentialing, administration of health insurance benefits, setting or negotiation of reimbursement rates, payment to providers, network development, or disease management programs , when issued, renewed, amended or extended shall contain provisions requiring the intermediary to:
Amended regulation effective December 1, 2009.
Regulation 4-2-16 WOMEN'S ACCESS TO OBSTETRICIANS, GYNECOLOGISTS AND CERTIFIED NURSE MIDWIVES UNDER MANAGED CARE PLANS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is promulgated pursuant to § § 10-1-109 and 10-16-107(5)(b), C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to set forth guidelines for carrier compliance with the provisions of § 10- 16-107(5), C.R.S., concerning women's access to obstetricians, gynecologists, and certified nurse midwives in managed care plans.
Section 3 Applicability The provisions of this regulation shall apply to all carriers offering managed care plans that provide coverage for reproductive health or gynecological care. Section 4 Definitions A. "Carrier" shall have the same meaning as set forth in § 10-16-102(8), C.R.S.
B. "Managed care plan" shall have the same meaning as set forth in § 10-16-102(26.5), C.R.S. Examples of managed care plans include but are not limited to: preferred provider organization
C. " Reproductive health and gynecological care" means care for both the normal and abnormal processes of the female reproductive system, including medical and surgical management of disorders, pregnancy and childbirth, and related preventive care. Section 5 Rules A. A managed care plan that provides coverage for reproductive health or gynecological care shall not be issued or renewed unless such plan either provides a woman covered under the plan direct access to an obstetrician, gynecologist, or certified nurse midwife, participating and available under the plan, for her reproductive or gynecological care or has referral procedures in place that comply with this regulation.
B. A managed care plan will be considered to have provided "direct access" to an obstetrician, gynecologist, or certified nurse midwife for reproductive and gynecological care only if a woman covered under the plan has the option of selecting a participating obstetrician, gynecologist or certified nurse midwife who is available under the plan as her primary care provider, or:
C. Notwithstanding any other provision in law, a managed care plan that does not provide direct access pursuant to subsection B. shall have procedures in place to ensure that a woman covered under the plan who requests a referral to, or preauthorization of care provided by, an obstetrician, gynecologist or certified nurse midwife participating and available under the plan for her reproductive and gynecological care shall not have such referral or preauthorization withheld. Such procedures shall be in writing, shall be provided upon request and at no charge to the Division of Insurance, a covered person, or a participating provider, and shall make provision for the following:
D. If the managed care plan requires the designation of a primary care provider, the carrier shall inform each covered person that there is no requirement to obtain an authorization or referral for obstetrical or gynecological care by a participating obstetrician, gynecologist, or certified nurse midwife.
E. All carriers subject to subsection C. shall keep a log on file of all denied requests for referrals to, and denials of preauthorizations of care provided by, an obstetrician, gynecologist, or certified nurse midwife who is participating and available under the plan that have been appealed. The log shall indicate the date of each request, the reason for each denial, and the final outcome of each appeal. The log of denied requests that have been appealed shall not include patient identifying information. The log shall be made available upon request to the Division of Insurance.
F. Nothing in this regulation shall be construed to require a carrier to make or approve a referral to an obstetrician, gynecologist, or certified nurse midwife who is not a participating provider under the plan. Also, nothing in this regulation shall be construed to require a carrier to include in its plan of coverage specific obstetrical or gynecological services except to the extent otherwise required by law or regulation.
Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 7 Enforcement Non-compliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of license. Section 8 Effective Date This amended regulation is effective on March 1, 2012.
Section 9 History Originally effective December 30, 1996 for health coverage plans issued or renewed on or after January 31, 1997.
Amended March 1, 2000 to include access to certified nurse midwives. Amended regulation effective March 1, 2012.
Regulation 4-2-17 PROMPT INVESTIGATION OF HEALTH CLAIMS INVOLVING UTILIZATION REVIEW AND DENIAL OF BENEFITS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Compliance Requirements Section 6 Standard Utilization Review Section 7 Expedited Utilization Review Section 8 Emergency Services Section 9 Peer-to-Peer Conversation Section 10 First Level Review Section 11 Voluntary Second Level Review Section 12 Expedited Review of an Adverse Determination Section 13 Severability Section 14 Enforcement Section 15 Effective Date Section 16 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § §10-1-109, 10-3-1110, 10-16-109, and 10-16-113, subsections (2) and (3)(b), C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to set forth guidelines for carrier compliance with the provisions of § §10- 3-1104(1)(h), 10-16-409(1)(a), and 10-16-113, C.R.S., in situations involving utilization review and certain denials of benefits for treatment, as described herein. Among other things, §10-3-1104(1)(h), C.R.S., requires carriers to adopt and implement reasonable standards for the prompt investigation of claims arising from health coverage plans; promptly provide a reasonable explanation of the basis in the health coverage plan in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement; and refrain from denying a claim without conducting a reasonable investigation based upon all available information.
This regulation is designed to provide minimum standards for handling appeals and grievances involving utilization review determinations, and certain denials of benefits for treatments excluded by health coverage plans.
Section 3 Applicability The provisions of this regulation shall apply to all health coverage plans, but shall not apply to automobile medical payment policies, worker’s compensation policies or property and casualty insurance. Where a decision concerning a claim is not based on utilization review, a carrier is not required to use the specific procedures outlined in this regulation. However, this regulation shall apply to a carrier’s denial of a benefit because the treatment is excluded by the health coverage plan if the covered person presents evidence from a medical professional that there is a reasonable medical basis that the contractual exclusion does not apply. Nothing in this regulation shall be construed to supplant any appeal or due process rights that a person may have under federal or state law.
Section 4 Definitions A. “Adverse determination” means a determination by a health carrier or its designee that a request for a benefit has been reviewed and, based upon the information provided, does not meet the health carrier’s requirement for medical necessity, or is determined to be experimental or investigational, and is therefore denied, reduced, or terminated. An adverse determination also includes a denial for a benefit excluded by a health coverage plan for which the claimant is able to present evidence from a medical professional that there is a reasonable medical basis that the contractual exclusion does not apply to the denied benefit.
B. “Ambulatory review” means utilization review of health care services performed or provided in an outpatient setting.
C. “Carrier” as defined in §10-16-102(8), C.R.S.
D. “Case management” means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.
E. “Clinical peer” means a physician or other health care professional who holds a non-restricted license in a state of the United States and in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.
F. “Complaint” means a written communication primarily expressing a grievance.
G. “Covered person” as defined in §10-16-102(13.5), C.R.S.
H. “Date of receipt of a notice” for purposes of this regulation means the date that shall be calculated to be no less than three calendar days after the date the notice is postmarked by the carrier.
I. “Designated representative” means:
J. “Discharge planning” means the formal process for determining, prior to discharge from a facility or service, the coordination and management of the care that a patient receives following discharge from a facility or service.
K. “Emergency medical condition” means the sudden, and at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.
L. “Grievance” means a circumstance regarded as a cause for protest, including the protest of an adverse determination.
M. “Health care professional” means a physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with state law.
N. “Health coverage plan” as defined in §10-16-102(22.5), C.R.S.
O. “Life or limb threatening emergency” means any event that a prudent lay person would believe threatens his or her life or limb in such a manner that a need for immediate medical care is created to prevent death or serious impairment of health.
P. “Medical professional” means an individual licensed pursuant to the “Colorado Medical Practice Act” , article 36 of title 12, C.R.S., or, for dental plans only, a dentist licensed pursuant to the “Dental Practice Law of Colorado” , article 35 of title 12, C.R.S., acting within his or her scope of practice.
Q. “Prospective review” means utilization review conducted prior to an admission or course of treatment.
R. “Provider” shall have the same meaning as defined in §10-16-102(36), C.R.S.
S. “Retrospective review” means any utilization review that is not prospective review, but does not include the review of a claim that is limited to veracity of documentation or accuracy of coding.
T. “Second opinion” means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health service to assess the clinical necessity and appropriateness of the initial proposed health service.
U. “Stabilized” means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result or occur before an individual can be transferred.
V. “Urgent care request” means:
W. “Utilization review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review. For the purposes of this regulation, utilization review shall also include reviews for the purpose of determining coverage based on whether or not a procedure or treatment is considered experimental or investigational in a given circumstance, and reviews of a covered person's medical circumstances when necessary to determine if an exclusion applies in a given situation. Section 5 Compliance Requirements A. A health carrier that does not use a procedure for investigating claims involving utilization review that is consistent with this regulation shall be deemed not to be in compliance with the requirement under the unfair competition and deceptive practice insurance statutes of Colorado that a carrier refrain from denying a claim without conducting a reasonable investigation based upon all available information. ( §10-3-1104(1)(h)(IV), C.R.S.)
B. A health carrier that uses standards in the review of claims involving utilization review that are not in compliance with the rules contained in this regulation shall be deemed not to be in compliance with the requirement under the unfair competition and deceptive practice insurance statutes of Colorado that a carrier use reasonable standards for the prompt investigation of claims. ( §10-3- 1104(1)(h)(III), C.R.S.)
C. A health carrier that does not investigate claims involving utilization review within the time frames set out in this regulation shall be deemed not to be in compliance with the requirement under the unfair competition and deceptive practice insurance statutes of Colorado that a carrier promptly investigate claims. ( §10-3-1104(1)(h)(II), C.R.S.)
D. A health carrier that does not follow the procedures for explaining the basis of a utilization review decision set forth in this regulation shall be deemed not to be in compliance with the requirement under the unfair competition and deceptive practice insurance statutes of Colorado that a carrier promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim. ( §10-3-1104(1)(h)(XIV), C.R.S.) E. A health carrier that does not allow an appeal, consistent with the procedures set forth in this regulation, of a benefit denial for a treatment excluded by the health coverage plan when the covered person presents evidence from a medical professional that there is a reasonable medical basis that the contractual exclusion does not apply shall be deemed not to be in compliance with the requirement under the unfair competition and deceptive practice insurance statutes of Colorado that a carrier refrain from denying a claim without conducting a reasonable investigation based upon all available information. ( §10-3-1104(1)(h)(IV), C.R.S.) Section 6 Standard Utilization Review A. A health carrier shall maintain written procedures pursuant to this section for making utilization review decisions and for notifying covered persons of its decisions. For purposes of this section, "covered person" includes the designated representative of a covered person.
B. Prospective review determinations.
C. Retrospective review determinations.
D. Calculation of time periods.
E. Requirements for adverse determination notifications.
Section 7 Expedited Utilization Review A. Procedures.
B. Urgent care requests.
C. Concurrent urgent care review requests.
D. For purposes of calculating the time periods within which a determination is required to be made under subsection B. or C., the time period within which the determination is required to be made shall begin on the date the request is filed with the health carrier in accordance with the health carrier’s procedures established for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.
E. Adverse determination notification requirements.
F. The requirements of section 7 apply to all written requests involving utilization review received by the health carrier which are submitted by a covered person, the covered person’s designated representative, or provider requesting a determination of coverage for a specific health care service or treatment for a specific member.
Section 8 Emergency Services A. A health carrier shall not deny a claim for emergency services necessary to screen and stabilize a covered person on the grounds that an emergency medical condition did not actually exist if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life or limb threatening emergency existed. Under these same circumstances, a claim for emergency services necessary to screen and stabilize a covered person shall not be denied for failure by the covered person or the emergency service provider to secure prior authorization. With respect to care obtained from a non-contracting provider within the service area of a managed care plan, a health carrier shall not deny a claim for emergency services necessary to screen and stabilize a covered person and shall not require prior authorization of the services if a prudent layperson would have reasonably believed that use of a contracting provider would result in a delay that would worsen the emergency, or if a provision of federal, state or local law requires the use of a specific provider.
B. Health maintenance organizations shall also comply with the life or limb threatening emergency coverage provisions of §10-16-407(2), C.R.S., in reviewing claims for emergency services necessary to screen and stabilize a covered person.
Section 9 Peer-to-Peer Conversation A. In a case involving a prospective review determination, a health carrier shall give the provider rendering the service an opportunity to request on behalf of the covered person a peer-to-peer conversation regarding an adverse determination by the reviewer making the adverse determination. Such a request may be made either orally or in writing.
B. The peer-to-peer conversation shall occur within five (5) days of the receipt of the request and shall be conducted between the provider rendering the service and the reviewer who made the adverse determination or a clinical peer designated by the reviewer if the reviewer who made the adverse determination cannot be available within five (5) days.
C. If the peer-to-peer conversation does not resolve the difference of opinion, the adverse determination may be appealed by the covered person. A peer-to-peer conversation is not a prerequisite to a first level review or an expedited review of an adverse determination.
D. For the purposes of §10-3-1104(1)(i), C.R.S., and Colorado Insurance Regulation 6-2-1 concerning complaints and complaint records, a request for a peer-to-peer conversation shall not be considered a complaint.
Section 10 First Level Review A. A health carrier shall establish written procedures for the review of an adverse determination that does not involve an urgent care request. The procedures shall specify whether a first level review request must be in writing or may be submitted orally. The procedures shall also allow the covered person to identify providers to whom the health carrier shall send a copy of the review decision.
B. A first level review shall be available to, and may be initiated by, the covered person. For purposes of this section, “covered person” includes the designated representative of a covered person.
C. Pursuant to §10-3-1104(1)(i), C.R.S., all written requests for a first level review must be entered into the carrier’s complaint record.
D. Within 180 days after the date of receipt of a notice of an adverse determination sent pursuant to section 6 or 7 or after the receipt of notification of a benefit denied due to a contractual exclusion, a covered person may file a grievance with the health carrier requesting a first level review of the adverse determination. In order to secure a first level review after the receipt of the notification of a benefit denied due to a contractual exclusion, the covered person must be able to provide evidence from a medical professional that there is a reasonable medical basis that the exclusion does not apply. If the deadline for filing a request ends on a weekend or holiday, the deadline shall be extended to the next business day.
E. Conduct of first level reviews.
F. Covered person’s rights.
G. Notification requirements.
H. For purposes of calculating the time periods within which a determination is required to be made and notice provided under subsection G., the time period shall begin on the date the grievance requesting the review is filed with the health carrier in accordance with the health carrier’s procedures for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.
I. The decision issued pursuant to subsection G. shall set forth in a manner calculated to be understood by the covered person:
J. A first level review decision involving an adverse determination issued pursuant to subsection G. shall include, in addition to the requirements of subsection I.:
A. A carrier shall establish a voluntary review process to give those covered persons who are dissatisfied with the first level review decision the option to request a voluntary second level review, at which the covered person has the right to appear in person or by telephone conference at the review meeting before a health care professional (reviewer) or, if offered by the health carrier, a review panel of health care professionals, selected by the carrier. The procedures shall allow the covered person to identify providers to whom the health carrier shall send a copy of the second level review decision. The purpose of the voluntary review process is to give the covered person the opportunity to explain their grievance and to provide any relevant evidence in support of their claim for benefits.
B. For purposes of this section, "covered person" includes the designated representative of a covered person.
C. A complaint record entry shall be made for all voluntary second level reviews, pursuant to §10-3- 1104(1)(i), C.R.S., and Colorado Insurance Regulation 6-2-1.
D. Within thirty (30) days after the date of receipt of a notice of an adverse determination, a covered person may file a request with the carrier requesting a voluntary second level review of the adverse determination. If the deadline for filing a request ends on a weekend or holiday, the deadline shall be extended to the next business day.
E. The covered person’s right to a fair review shall not be made conditional on the covered person’s appearance at the review.
F. Procedures.
G. A health carrier's procedures for conducting a voluntary second level review shall include the following:
H. A decision issued pursuant to subsection G. shall include:
A. A health carrier shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination. A health carrier shall also provide an expedited review to a request for a benefit for a covered person who has received emergency services but has not been discharged from a facility. The procedures shall allow a covered person to request an expedited review under this section orally or in writing. The procedures shall also allow the covered person to identify providers to whom the health carrier shall send a copy of the review decision.
B. An expedited review shall be available to, and may be initiated by, the covered person or the provider acting on behalf of the covered person. For purposes of this section, "covered person" includes the designated representative of a covered person.
C. Pursuant to §10-3-1104(1)(i), C.R.S., all written requests for an expedited review must be entered into the carrier’s complaint record.
D. Expedited appeal evaluations.
E. Covered person’s rights.
F. In an expedited review, all necessary information, including the health carrier's decision, shall be transmitted between the health carrier and the covered person or the provider acting on behalf of the covered person by telephone, facsimile or similar expeditious method available.
G. In an expedited review, a health carrier shall make a decision and notify the covered person or the provider acting on the covered person's behalf as expeditiously as the covered person's medical condition requires, but in no event more than seventy-two (72) hours after the review is commenced. If the expedited review is a concurrent review determination, the service shall be continued without liability to the covered person until the covered person has been notified of the determination.
H. A health carrier shall provide written confirmation of its decision concerning an expedited review within three (3) days of providing notification of that decision, if the initial notification was not in writing.
I. In the case of an adverse determination, the written decision shall contain the provisions specified in sections 10.I. and 10.J. of this regulation.
J. For purposes of calculating the time periods within which a decision is required to be made under subsection G., the time period within which the decision is required to be made shall begin on the date the request is filed with the health carrier in accordance with the health carrier’s procedures for filing a request without regard to whether all of the information necessary to make the determination accompanies the filing.
K. In any case where the expedited review process does not resolve a difference of opinion between the health carrier and the covered person or the provider acting on behalf of the covered person, the covered person or the provider acting on behalf of the covered person may request a voluntary second level appeal or request an independent external review.
L. A health carrier shall not provide an expedited review for retrospective adverse determinations. Section 13 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected. Section 14 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspension or revocation of licenses or certificates of authority. Among others, the penalties provided for in §10-3-1108, C.R.S., may be applied.
Section 15 Effective Date This amended regulation is effective on November 1, 2010. Section 16 History Originally promulgated effective July 1, 1997.
Amended effective April 1, 2000.
Amended effective April 1, 2004 to comply with ERISA claims/appeals procedures. Amended effective October 1, 2004, to correct internal references and to provide clarification with respect to the expedited appeal.
Emergency Regulation 05-E-5 effective January 1, 2006.
Amended effective February 1, 2006.
Amended regulation effective November 1, 2010.
Regulation 4-2-18 CONCERNING THE METHOD OF CREDITING AND CERTIFYING CREDITABLE COVERAGE FOR PRE-EXISTING CONDITIONS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Incorporated Materials Section 8 Enforcement Section 9 Effective Date Section 10 History Section 1 Authority This regulation is promulgated under the authority of § § 10-1-109(1), 10-16-109, and 10-16-118(1)(b), C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to establish the method health coverage plans must use to credit and certify creditable coverage for purposes of limiting pre-existing condition exclusion periods, as required by § 10-16-118(1) (b) , C.R.S.
Section 3 Applicability This amended regulation shall apply to all certificates of creditable coverage issued on or after March 1, 2012.
Section 4 Definitions A. "Individual", as used in this regulation, means a person age nineteen years and older.
B. "Significant break in coverage" means a period of consecutive days during all of which the individual does not have any creditable coverage, except that neither a waiting period nor an affiliation period is taken into account in determining a significant break in coverage. For plans subject to the jurisdiction of the Colorado Division of Insurance (Division ), a significant break in coverage consists of more than ninety (90) consecutive days. For all other plans (i.e. , those not subject to the jurisdiction of the Division, a significant break in coverage may consist of as few as sixty- three (63) days.
C. "Student health plan" means a health benefit plan that covers the students of an educational institution.
Section 5 Rules A. Application of federal laws concerning creditable coverage.
B. Colorado law concerning creditable coverage.
C. Maximum six (6) month pre-existing condition exclusion period for group health benefit plans. Colorado law prohibits group health benefit plans from imposing a pre-existing condition limitation period that exceeds six (6) months, except with respect to late enrollees as provided for in § 10- 16-118(1)(c), C.R.S. All references in the federal regulations to twelve (12) month pre-existing condition limitations for group health benefit plans are not applicable in Colorado.
D. Student health benefit plans are considered group health benefit plans. Colorado law considers student health benefit plans to be group plans. As such, student health benefit plans shall comply with the group health benefit plan provisions of Colorado law including those related to pre-existing condition limitations.
E. Treatment of late enrollees.
Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected and shall remain in full force and effect.
Section 7 Incorporated Materials The following are hereby incorporated by reference as written on or before the effective date of this regulation. This rule does not include later amendments to or editions of the incorporated material. A copy of these references may be examined at any state publications depository library. For additional information regarding how to obtain a copy please contact the Colorado Division of Insurance, 1560 Broadway Suite 850, Denver, CO 80202.
A. Title 45 of the Code of Federal Regulations, section 146.113(a) (3) , (b) and (c) ;
B. Title 45 of the Code of Federal Regulations, section 146.115; and C. Title 45 of the Code of Federal Regulations, section 148-124(b) . Section 8 Enforcement Non-compliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of license. Section 9 Effective Date This amended regulation is effective on March 1, 2012.
Section 10 History Originally issued as Emergency Regulation 97-E-6, effective July 31, 1997. Issued as Regulation 4-2-18, effective October 30, 1997. Amended, effective November 1, 1999.
Amended, effective October 1, 2004.
Amended regulation effective March 1, 2012.
Regulation 4-2-19 CONCERNING INDIVIDUAL HEALTH BENEFIT PLANS ISSUED TO SELF- EMPLOYED BUSINESS GROUPS OF ONE Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is promulgated pursuant to § § 10-1-109(1), 10-16-105.2(1)(c)(I) and (3), 10-16-108.5(8), and 10-16-109, C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to establish and implement rules concerning health benefit plans marketed and/or newly issued to self-employed business groups of one. In some cases such plans are exempt from Colorado’s small group guarantee issue laws, pursuant to § 10-16-105.2(1)(c), (d) and (3), C.R.S.
Section 3 Applicability This amended regulation shall apply to individual health benefit plans marketed and/or newly issued to self-employed business groups of one.
Section 4 Definitions A. “Self-employed business group of one” means, pursuant to § 10-16-105(1)(c)(I), C.R.S., that type of business group of one that includes only a self-employed person who has no employees, or a sole proprietor who is not offering or sponsoring health care coverage to his or her employees.
B. “Health benefit plan” shall have the same meaning as defined in § 10-16-102(21)(a), which includes high deductible health savings account (HSA) plans.
Section 5 Rules A. An individual health benefit plan marketed and/or newly issued, to a self-employed business group of one, together with the dependents of the self-employed business group of one, shall be regulated as an individual health benefit plan instead of a small group health plan if the carrier issuing such policy, the policy itself, and the application for coverage meet all the following conditions:
B. Material failure by a carrier or its representative to comply with the requirements of subsection A of Section 5 of this regulation will result in individual health benefit plans sold to self-employed business groups of one becoming subject to Colorado’s small group laws.
Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected. Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of certificates of authority. Among others, the penalties provided in § 10-3-1108, C.R.S., may be applied.
Section 8 Effective Date This amended regulation is effective on May 1, 2010.
Section 9 History Original regulation effective November 1, 1997.
Amended regulation hearing September 8, 1999; effective November 1, 1999. Amended regulation effective January 1, 2002.
Amended regulation effective October 1, 2004 Amended regulation 4-2-19, effective May 1, 2010.
Regulation 4-2-20 CONCERNING THE COLORADO SUPPLEMENT TO THE SUMMARY OF BENEFITS AND COVERAGE FORM Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Incorporated Materials Section 8 Enforcement Section 9 Effective Date Section 10 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109, 10-16-108.5(11)(b), and 10-16-109, C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to coordinate the requirements of § 10-16-108.5(11), C.R.S. and certain provisions of the Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stat. 119 (2010) and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010), together referred to as the “Affordable Care Act” (ACA). This regulation also sets out procedures for carriers to make available a Colorado Supplement to the Summary of Benefits and Coverage Form for each policy, contract, and plan of health benefits that either covers a Colorado resident or is marketed to a Colorado resident or such resident's employer. Section 3 Applicability This regulation shall apply to all carriers offering or providing health benefit plan coverage or Medicare supplemental coverage on and after January 1, 2013.
Section 4 Definitions A. “Carrier” shall have the same meaning as in § 10-16-102(8), C.R.S.
B. “Glossary” means the form required by the Affordable Care Act as described in the final rule published on February 14, 2012 in Volume 77, No. 30 of the Federal Register (77 FR 8668, Summary of Benefits and Coverage and Uniform Glossary).
C. “Health benefit plan” shall have the same meaning as § 10-16-102(21), C.R.S.
D. “Summary of Benefits and Coverage” means the form required by the Affordable Care Act as described in the final rule published on February 14, 2012 in Volume 77, No. 30 of the Federal Register (77 FR 8668, Summary of Benefits and Coverage and Uniform Glossary). Section 5 Rules A. All carriers offering or providing health benefit plan coverage shall make available to a producer or consumer through electronic means or paper copy, along with a Summary of Benefits and Coverage form, a completed copy of the Colorado Supplement to the Summary of Benefits and Coverage Form shown in Appendix A for each policy or contract for a health benefit plan that either covers a Colorado resident or is selected by a Colorado resident or such resident’s employer for which the employee or participant is eligible.
B. Carriers marketing or providing a Medicare supplemental plan shall meet the requirement of § 10-16- 108.5(11)(a), C.R.S., by making available for each such plan a Medicare supplement outline of coverage as prescribed in Colorado Insurance Regulation 4-3-1, 3 CCR 702-4.
C. Carriers shall use the exact format found in Appendix A for the Colorado Supplement to the Summary of Benefits and Coverage Form. All boxes must be filled in. Carriers may modify box dimensions, reduce margins, or use a portrait rather than a landscape page layout format. A carrier may also add its logo to the form and print the form in color or black and white. Pursuant to § 10-3-1104(1), C.R.S., in completing the form, carriers shall not misrepresent the benefits, advantages, conditions, or terms of the policy.
D. Carriers shall follow the directions for completing the Colorado Supplement to the Summary of Benefits and Coverage Form found in Appendix B of this regulation.
E. Carriers shall provide a Colorado Supplement to the Summary of Benefits and Coverage Form that is specific with respect to the particular policy provisions of the policy as follows:
F. Anti-duplication rule.
G. A carrier shall develop a separate Colorado Supplement to the Summary of Benefits and Coverage Form for each of its health benefit plans.
H. The Colorado Supplement to the Summary of Benefits and Coverage Form should not include attachments, except that a carrier may:
J. A carrier shall make a list of policy exclusions available immediately upon request, but in no event more than seven (7) business days after the request, for each of its health benefit plans.
K. The Colorado Supplement to the Summary of Benefits and Coverage Forms developed for each health benefit plan shall be in standard, easy-to-read type sizes and fonts, of no less than 12 points.
Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 7 Incorporated Materials The relevant portions of the final rule published on February 14, 2012 in Volume 77, No. 30 of the Federal Register (77 FR 8668, Summary of Benefits and Coverage and Uniform Glossary) as published on the effective date of this regulation are incorporated by reference. Later amendments to this final rule are not included. Volume 77, No. 30 of the Federal Register may be examined during regular business hours at the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado 80202. Section 8 Enforcement Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.
Section 9 Effective Date This regulation is effective on September 1, 2012.
Section 10 History New regulation effective November 15, 1997.
Amended Sections 1, 2, 3, 4, 7, Appendix A, and Appendix B effective September 30, 1998. Amended regulation effective January 1, 2004.
Amended regulation effective: January 1, 2005.
Amended regulation effective July 1, 2007.
Repealed and repromulgated effective September 1, 2012. Appendix A Colorado Supplement to the Summary of Benefits and Coverage Form _______________________________________ Name of Carrier _______________________________________ Name of Plan _______________________________________ Policy Type TYPE OF COVERAGE
covered? 3. Areas of Colorado .
where plan is available.
SUPPLEMENTAL INFORMATION REGARDING BENEFITS Important Note : The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. It provides additional information meant to supplement the Summary of Benefits of Coverage you have received for this plan. This plan may exclude coverage for certain treatments, diagnoses, or services not specifically noted. Consult the actual policy to determine the exact terms and conditions of coverage.
screenings are covered? LIMITATIONS AND EXCLUSIONS 7. Period during which .
pre-existing conditions are not covered for covered persons age 19 and older.
define a “pre-existing condition” ? 9. Exclusionary Riders. .
Can an individual’s specific, pre-existing condition be entirely excluded from the policy? USING THE PLAN . IN-NETWORK OUT-OF-NETWORK 10. If the provider . .
charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference? 11. Does the plan have a . .
binding arbitration clause? Questions: Call 1-800-[insert carrier’s customer service number] or visit us at www.[insert carrier’s web address].
If you are not satisfied with the resolution of your complaint or grievance, contact: Colorado Division of Insurance Consumer Affairs Section 1560 Broadway, Suite 850, Denver, CO 80202 Call: 303-894-7490 (in-state, toll-free: 800-930-3745)
Appendix B Directions for Filling Out the Colorado Supplement to the Summary of Benefits and Coverage Form TOP OF FORM Carrier and plan names : Fill in the complete carrier name on the first line and the name of the plan on the second line. Plans may also include the following information, if they wish to do so, either at the top of the form, at the bottom of the page, or at the end of the document: carrier logo, group identification number, class or division, and effective date.
Policy Type : Select one of the following choices only: (1) “Individual Policy” , (2) “Small Employer Group Policy” , (3) “Large Employer Group Policy” , (4) “Association Group Policy” , or (5) “Short-term Limited Duration Policy” .
TYPE OF COVERAGE Question 1: Type of Plan . Enter type of plan. Select one of the following choices only: (1) “Medical expense policy” , (2) “Preferred provider organization (PPO)” , (3) “Health maintenance organization (HMO)” , (4) “Point of service (POS)” (i.e., an HMO plan with some out-of-network benefits), or (5) “Limited service licensed provider network (LSLPN) plan” . Question 2: Coverage for Out-of-Network Care . Indicate if out-of-network care is covered. Select one of the following choices only: (1) “Only for emergency care” ; (2) “Only for emergency and urgent care” ; (3) “Only for specified services; patient pays more for such out-of-network care” [e.g., POS plans]; (4) “Yes, but patient pays more for out-of-network care.” [e.g., PPO]; or (5) “Yes; plan makes no distinction between in-network and out-of-network care.” [e.g., traditional indemnity plans]. For HMOs that are marketing to small employers or employees of small employers outside of its geographic service area, the following statement must be added in bold, 10 point font caps: “INTERESTED POLICYHOLDERS, CERTIFICATE HOLDERS, AND ENROLLES ARE HEREBY GIVEN NOTICE THAT THIS SMALL GROUP POLICY REQUIRES THAT AN INSURED TRAVEL OUTSIDE OF THE GEOGRAPHIC AREA TO RECEIVE COVERED HEALTH BENEFITS.” Question 3: Where Plan Is Available . Indicate where the plan itself is available. This question does not concern the residence of the potential enrollee. Select one of the following choices only: (1) “Plan is available throughout Colorado” ; (2) “Plan is available only in the following areas: [fill in]” ; or (3) “Plan is available throughout Colorado except in the following areas: [fill in].” A note should be added if the plan is marketed to employers or employees located over state or county lines. SUPPLEMENTAL INFORMATION REGARDING BENEFITS Question 4: Deductible Period . Describe whether the deductible period is “Calendar Year” (January 1 through December 31) or “Benefit Year” (i.e., based on a benefit year beginning on the policy’s anniversary date) or if the deductible is based on other requirements such as a “Per Accident or Sickness” .
Question 5: Annual Deductible Type . For a non-HSA qualified plan, insert “Individual/Family” in the first column and provide the corresponding information in the “What this means.” column. For an HSA- qualified plan, insert “Single Coverage/Non-single Coverage” and provide the corresponding information in the “What this means.” column.
Question 6: What cancer screenings are covered? Provide a list of covered cancer screenings. LIMITATIONS AND EXCLUSIONS Question 7: Pre-existing Condition Exclusion Period for covered persons age 19 and older. Select one of the following choices only: (1) “____ [insert the length of the limitation period] months for all pre-existing conditions.” ; (2) “____ [insert the length of the limitation period] months for selected pre-existing conditions only; no pre-existing condition limitation for all other conditions. See policy for details.” ; (3) “Not applicable; plan does not impose limitation periods for pre-existing conditions.” ; (4) “This individual short-term health benefit plan does not cover pre-existing conditions.” Note: For group plans (except business groups of one) the limitation period may not exceed six (6) months; for business groups of one the limitation period may not exceed 12 months. Carriers are reminded that Colorado law governs allowable pre-existing periods for all health benefit plans. Question 8: Definition of a Pre-existing Condition . Enter the definition of a pre-existing condition under this policy. Select one of the following choices only: (1) “Not applicable. Plan does not exclude coverage for pre-existing conditions.” ; (2) for group plans: “A pre-existing condition is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the last ___ [insert a number not to exceed 12 for business groups of one and not to exceed 6 for all other group plans] months immediately preceding the date of enrollment or, if earlier, the first day of the waiting period; except that pre-existing condition exclusions may not be imposed on children under 19, special enrollees, or for pregnancy.” ; (3) for individual plans: “A pre-existing condition is an injury, sickness or pregnancy for which a person, 19 or older, incurred charges, received medical treatment, consulted a health care professional, or took prescription drugs within ___ [insert a number not to exceed 12] months immediately preceding the effective date of coverage.” ; or (4) for individual short-term health benefit plans: “A pre- existing condition is an injury, sickness or pregnancy for which a person incurred charges, received medical treatment, consulted a health care professional, or took prescription drugs within ___ [insert a number not to exceed 12] months immediately preceding the effective date of coverage.” Question 9: Exclusionary Riders . All group carriers must enter “No” . Depending on the policy, individual carriers should enter “Yes” or “No.”
USING THE PLAN Question 10: General Directions . If the plan has separate in-network and out-of-network benefits, use two columns and label them “In-network” and “Out-of-network.” If the plan does not make such a distinction (e.g., a traditional indemnity plan), replace two columns with a single column labeled “Using the Plan.” Question 10: Provider Charges . In each column, select one of the following choices only: (1) “Yes” or (2) “No.” If the answer is “Yes” , a carrier may expand on the answer to note exceptions to this requirement. Question 11: Binding Arbitration . Indicate, with a “Yes” or “No” , if the plan has binding arbitration. QUESTIONS’ FOOTER Questions : Carrier must insert the appropriate telephone number and website information. Regulation 4-2-21 EXTERNAL REVIEW OF BENEFIT DENIALS OF HEALTH COVERAGE PLANS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Notice and Disclosure of Right to External Review Section 6 Request for External Review Section 7 Exhaustion of Internal Appeal Process Section 8 Standard External Review Section 9 Expedited External Review Section 10 Binding Nature of External Review Decisions Section 11 Approval of Independent External Review Entities Section 12 Minimum Qualifications for Independent External Review Entities Section 13 External Review Record Requirements Section 14 Funding of External Review Section 15 Severability Section 16 Enforcement Section 17 Effective Date Section 18 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109, 10-16-109, 10-16-113(3)(b) and 10-16-113.5(4)(d), C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to provide standards for the external review process set forth in § 10-16- 113.5, C.R.S., including the approval of independent external review entities. It is being amended to facilitate the implementation of certain provisions of the Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stat. 119 (2010) and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010), together referred to as the “Affordable Care Act” (ACA).
Section 3 Applicability The provisions of this regulation shall apply to all health coverage plans that base coverage decisions in whole or in part based on utilization reviews as defined in this regulation. This regulation shall not apply to automobile medical payment policies, worker’s compensation policies or property and casualty contracts. Where a decision concerning a claim is in no way based on utilization review, a carrier is not required to use the specific procedures outlined in this regulation, except this regulation shall apply to a carrier’s denial of a benefit because the treatment is excluded by the health coverage plan if the covered person presents evidence from a medical professional that there is a reasonable medical basis that the contractual exclusion does not apply. This regulation also applies to carriers offering wellness and prevention programs that offer any incentive or reward for satisfying a standard related to a health risk factor. Nothing in this regulation shall be construed to supplant any appeal or due process rights that a person may have under federal or state law.
Section 4 Definitions A. “Ambulatory review” means utilization review of health care services performed or provided in an outpatient setting.
B. “Carrier” as defined in § 10-16-102(8), C.R.S.
C. “Carrier’s adverse determination” means an adverse determination, as defined in Colorado Insurance Regulation 4-2-17, involving a covered benefit that has been upheld by a carrier at the completion or exhaustion of at least one of the carrier’s internal appeal processes as set forth in Colorado Insurance Regulation 4-2-17. It also includes a carrier’s denial of a request for an alternate standard or a waiver of a standard that would otherwise be applicable to an individual under a wellness and prevention program that offers incentives or rewards for satisfaction of a standard related to a health risk factor.
D. “Case management” means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted or other health conditions.
E. “Certification,” as used in the definition of "utilization review," means a determination by a carrier that an admission, availability of care, continued stay or other health care service has been reviewed and, based on the information provided, satisfies the carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness or efficiency.
F. “Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols and practice guidelines used by a carrier to determine the necessity and appropriateness of health care services.
G. “Concurrent review” means utilization review conducted during a patient’s hospital stay or course of treatment.
H. “Covered benefits” or “benefits,” means those health care services to which a covered person is entitled under the terms of a health coverage plan.
I. “Covered person” as defined in § 10-16-102(13.5), C.R.S.
J. “Designated representative” means:
K. “Discharge planning” means the formal process for determining, prior to discharge from a facility or service, the coordination and management of the care that a patient receives following discharge from a facility or service.
L. “Disability” shall mean, with respect to a covered person, a physical or mental impairment that substantially limits one or more of the major life activities of such covered person, in accordance with the Americans with Disabilities Act of 1990, 42 U.S.C. § 12101.
M. “Facility” means an institution providing health care services, or a health care setting, including but not limited to, hospitals and other licensed inpatient centers, ambulatory surgical or treatment centers, skilled nursing centers, residential treatment centers, diagnostic, laboratory and imaging centers, and rehabilitation and other therapeutic health settings.
N. “Health care professional” means a physician or other health care practitioner licensed, accredited or certified to perform specified health services consistent with state law.
O. “Health care services” means services for the diagnosis, prevention, maintenance, treatment, cure or relief of a health condition, illness, injury or disease.
P. “Health coverage plan” as defined in § 10-16-102(22.5), C.R.S.
Q. “Prospective review” means utilization review conducted prior to an admission or a course of treatment.
R. “Protected health information” means health information:
S. “Retrospective review” means utilization review conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding or adjudication for payment.
T. “Second opinion” means an opportunity or requirement to obtain a clinical evaluation by a provider other than the one originally making a recommendation for a proposed health service to assess the clinical necessity and appropriateness of the initial proposed health service.
U. “Utilization review” means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review. For the purposes of this regulation, utilization review shall also include reviews for the purpose of determining coverage based on whether or not a procedure or treatment is considered experimental or investigational in a given circumstance, and reviews of a covered person's medical circumstances when necessary to determine if an exclusion applies in a given situation. Section 5 Notice and Disclosure of Right to External Review A. Notification requirements.
B. Disclosure requirements.
C. There is no minimum dollar amount for a claim to be eligible for an external review. Section 6 Request for External Review A. Within four (4) months after the date of receipt of a notice of a carrier’s adverse determination following the completion or exhaustion of the first level review or within sixty (60) calendar days after the date of receipt of a notice of a carrier’s adverse determination following the completion of a voluntary second level review, a covered person or the covered person’s designated representative may file a request for an external review with the carrier. For purposes of this subsection A., the date of receipt shall be calculated to be no less than three (3) calendar days after the date the notice is postmarked by the carrier. If the deadline for filing a request ends on a weekend or holiday, the deadline shall be extended to the next business day.
B. All requests for external review shall be made in writing to the carrier and must include a completed external review request form as specified by the Division of Insurance.
C. A covered person or a covered person's designated representative requesting an expedited external review must include a request for an expedited review in the written request described in subsection A. of this section 6.
D. All requests for external review shall include a signed consent form, authorizing the carrier to disclose protected health information, including medical records, concerning the covered person that is pertinent to the external review.
E. A request for external review submitted by the covered person or the covered person's designated representative may include new information, if significantly different from information provided or considered during the internal review process, for consideration by the carrier and the independent external review entity.
F. A carrier’s denial of a request for a standard external review, including but not limited to a de minimis error, shall be made in writing and include the specific reasons for the denial and shall provide information about appealing the denial of the request with the Division of Insurance. A copy of the denial shall be sent to the Division of Insurance at the same time it is sent to the covered person or, if applicable, the covered person’s designated representative.
G. A carrier’s denial of a request for an expedited external review, including but not limited to a de minimis error, shall be made in writing and transmitted electronically or by facsimile or any other available expeditious method. It shall include the specific reasons for the denial and shall provide information about appealing the denial of the request with the Division of Insurance. A copy of the denial shall be sent to the Division of Insurance at the same time it is sent to the covered person or, if applicable, the covered person’s designated representative. Section 7 Exhaustion of Internal Appeal Process A. A request for an external review pursuant to section 8 or 9 of this regulation may be made after the covered person has received the carrier’s decision following the first level or voluntary second level review of an adverse determination as set forth in Colorado Insurance Regulation 4-2-17.
B. A request for an external review pursuant to section 8 or 9 of this regulation may be made if the carrier fails to comply with any of the requirements of section 10 of Colorado Insurance Regulation 4-2- 17.
C. A request for an external review pursuant to section 9 of this regulation may be made concurrent to an expedited request for a first level review in accordance with the requirements set forth in Colorado Insurance Regulation 4-2-17.
D. A carrier’s denial of a request for an alternate standard or a waiver of a standard that would otherwise be applicable to an individual under a wellness and prevention program that offers incentives or rewards for satisfaction of a standard related to a health risk factor is not subject to the internal appeal process requirements set forth in Colorado Insurance Regulation 4-2-17. Section 8 Standard External Review A. Carrier requirements.
B. Division of Insurance requirements.
C. Carrier requirements to provide documents and information.
D. The independent external review entity shall review all of the information and documents received pursuant to subsection C. of this section 8.
E. Carrier’s reconsideration of its adverse determination.
F. In addition to the documents and information provided pursuant to subsection C. of this section 8, the independent external review entity, to the extent the documents or information are available, shall review the following:
G. The independent external review entity shall base its determination on an objective review of relevant medical and scientific evidence.
H. Independent external review entity notice requirements.
Section 9 Expedited External Review A. Request requirements.
B. Division of Insurance requirements.
C. In reaching a decision, the independent external review entity is not bound by any decisions or conclusions reached during the carrier’s utilization review process or the carrier’s internal appeal process as set forth in Colorado Insurance Regulation 4-2-17.
D. Immediately upon receipt of the notification pursuant to subsection B., the carrier shall provide or transmit all necessary documents and information, as described in section 8.C.1., considered in making its adverse determination to the independent external review entity electronically or by telephone or facsimile or any other available expeditious method.
E. In addition to the documents and information provided or transmitted pursuant to subsection D. of this section 9, the independent external review entity, to the extent the information or documents are available, shall consider the following in reaching a decision:
F. The independent external review entity shall base its determination on an objective review of relevant medical and scientific evidence.
G. Independent external review entity notice requirements.
H. An expedited external review may not be provided for retrospective adverse determinations.
I. A carrier’s denial of a request for an alternate standard or a waiver of a standard that would otherwise be applicable to an individual under a wellness and prevention program that offers incentives or rewards for satisfaction of a standard related to a health risk factor is not eligible for an expedited external review.
Section 10 Binding Nature of External Review Decisions A. An external review decision is binding on the carrier and the covered person except to the extent the carrier and covered person have other remedies available under federal or state law; however, the determination of the expert reviewer will create a rebuttable presumption in any subsequent action.
B. A covered person or the covered person’s designated representative may not file a subsequent request for external review involving the same carrier’s adverse determination for which the covered person has already received an external review decision pursuant to this regulation. Section 11 Approval of Independent External Review Entities A. The Commissioner shall approve independent external review entities eligible to be assigned to conduct external reviews under this regulation to ensure that an independent external review entity satisfies the minimum qualifications established under section 12 of this regulation.
B. Application shall be made on a form specified by the Commissioner for approving independent external review entities to conduct external reviews.
C. Any independent external review entity wishing to be approved to conduct external reviews under this regulation shall submit a completed application form, including any documentation or information necessary for the Commissioner to determine if the independent external review entity satisfies the minimum qualifications established under section 12 of this regulation.
D. Expiration of approval.
E. The Commissioner shall maintain and update, as necessary, a list of approved independent external review entities.
F. The Commissioner may rely on the accreditation status of an applicant independent external review entity as demonstration of fulfillment of any or all requirements of this section. Section 12 Minimum Qualifications for Independent External Review Entities A. To be approved under section 11 of this regulation to conduct external reviews, an independent external review entity shall meet the requirements of § 10-16-113.5(4), C.R.S., and shall:
B. The independent external review entity shall be accredited as an independent review organization by a nationally recognized private accrediting organization.
C. All expert reviewers assigned by an independent external review entity to conduct external reviews shall be physicians or other appropriate health care providers who meet the minimum qualifications and conflict of interest requirements described in § 10-16-113.5(2)(c), C.R.S. Section 13 External Review Record Requirements A. An independent external review entity assigned pursuant to section 8 or 9 of this regulation to conduct an external review shall maintain written records in the aggregate and by carrier on all requests for external review for which it conducted an external review for the Division of Insurance during a calendar year. The independent external review entity shall retain the written records required pursuant to this subsection for at least three (3) years.
B. Each carrier shall maintain written records in the aggregate and for each type (i.e., indemnity, preferred provider organization (PPO), health maintenance organization (HMO), and point-of- service (POS)) of health coverage plan offered by the carrier on all requests for external review that are filed with the carrier. The carrier shall retain the written records required pursuant to this subsection for at least three (3) years.
Section 14 Funding of External Review The carrier against which a request for a standard external review or an expedited external review is filed shall pay the cost, consistent with the fee schedule the independent external review entity filed with the Commissioner, to the independent external review entity for conducting the external review. In the case of a carrier reversing a denial which is the subject of an external review after assignment of the review to independent external review entity, but prior to assignment of an expert reviewer, the carrier shall pay an administrative fee to the independent external review entity. Charges for the independent external review, when denial is reversed by the carrier prior to review completion but after assignment to an expert reviewer, shall be the full cost.
Section 15 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected. Section 16 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspension or revocation of licenses or certificates of authority. Among others, the penalties provided for in § 10-3-1108, C.R.S., may be applied.
Section 17 Effective Date This amended regulation shall be effective on September 1, 2011. Section 18 History Originally promulgated with an effective date of April 1, 2000 for the approval process for independent expert review entities and an effective date of June 1, 2000 for the external review process. Amended effective October 1, 2003 to delete reporting requirements since the Division of Insurance already tracks external review information.
Amended effective October 1, 2004, to clarify the options available after a covered person receives a final adverse determination.
Amended effective February 1, 2006.
Amended effective November 1, 2010.
Amended effective September 1, 2011.
Regulation 4-2-22 INSURER ASSESSMENTS FOR COVERCOLORADO Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Annual Report of Lives Section 6 Determination of Amount of Special Fee Assessment to Each Insurer Section 7 Notice and Collection of the Assessed Special Fees Section 8 Deferral of or Credit Against Special Fees Section 9 Severability Section 10 Enforcement Section 11 Effective Date Section 12 History Section 1 Authority This regulation is promulgated under the authority of § § 10-1-109, 10-8-520, and 10-8-530(1.5), C.R.S. Section 2 Scope and Purpose CoverColorado was created by legislation in 1990 to provide access to health insurance for those Colorado residents who are termed “high risk” because they are unable to obtain health insurance or unable to obtain health insurance except at prohibitive rates or with restrictive exclusions. In order to keep up with the rising medical care costs for eligible individuals, § 10-8-530(1.5), C.R.S. was enacted to permit CoverColorado to assess special fees against certain insurers in Colorado, as necessary, to pay projected administrative expenses and losses of the program. Such special fees will be used to supplement premiums and other sources of funding, as set forth in § 10-8-530(1), C.R.S., received by the program.
The purpose of this regulation is to establish the procedures for the assessment of special fees for the CoverColorado program.
Section 3 Applicability This regulation shall apply to insurers that are assessed special fees by CoverColorado. Section 4 Definitions For the purposes of this regulation, the following terms shall have the meanings set forth below:
A. “Benefit design weighted average” means the average actuarial value of the benefits provided under all plans issued in Colorado by the insurer during the previous year, weighted by enrollment in each plan.
B. “CoverColorado” is the Colorado program which provides health insurance for those individuals who are termed “high risk” because they are unable to obtain health insurance or are unable to obtain health insurance except at prohibitive rates or with restrictive exclusions. The program is described in §10-8-501 et seq., C.R.S.
C. “Eligible Individual” is either:
D. “Group health plan” has the same meaning as set forth in §10-16-105.5(1)(a), C.R.S.
E. “Higher level health benefit plan design” means a health plan benefit design for which the actuarial value of the benefits is at least one hundred percent (100%) but not greater than one hundred twenty percent (120%) of the benefit design weighted average.
F. “Insurer” is any entity that provides group or individual health benefit plans, as that phrase is defined in §10-16-102(21), C.R.S., and is subject to state insurance regulation in this state, as well as any entity, including a property and casualty insurance company, that, directly or indirectly, provides stop-loss or excess loss insurance to a self-insured group health plan.
G. “Lower level health benefit plan design” means a health benefit plan design for which the actuarial value of the benefits is at least eighty-five percent (85%) but not greater than ninety-nine percent (99%) of the benefit design weighted average.
H. “Total funding for the program” means the amount needed in a given calendar year to fund projected claims, administrative expenses, reserves for claims incurred but not reported, and amounts need to ensure that CoverColorado maintains a surplus equal to five percent (5%) of the projected annual claims of the program.
I. “Unexpected growth” means an increase in program enrollment or claims expenses in a calendar year of more than one hundred fifteen percent (115%) of the amount of the projected growth in program enrollment or claims expenses of that calendar year. Section 5 Annual Report of Lives A. On March 1 of each year, each insurer shall report to CoverColorado, on the prescribed form:
B. The Annual Report of Lives shall not include any employees, retired employees or individual policyholders or subscribers who receive health benefits through Medicare, Medicaid, the Children’s Basic Health Plan (pursuant to article 8 of title 25.5, C.R.S.), or the Federal Employees Health Benefit Plan.
C. Insurers providing stop-loss, excess loss or reinsurance are permitted to exclude from their Annual Report of Lives those employees/retired employees or individual policyholders/subscribers who have been counted by the primary carrier or primary reinsurer. Section 6 Determination of Amount of Special Fee Assessment to Each Insurer A. For calendar year 2009 and thereafter, CoverColorado shall, on an annual basis and by August 1 of the preceding calendar year, determine the amount of special fees needed to pay twenty-five (25%) of the total funding for the program. The total funding for the program for any calendar year shall be determined by the board based on the incurred claims and administrative expenses of the program in the immediately preceding calendar year, the expected annual program growth, existing cash balances and interest earned thereon, and other actuarial considerations of the program. The projections shall not include any costs related to any dependent coverage offered by CoverColorado.
B. The amount of special fees needed by CoverColorado pursuant to subsection 6.A. shall be assessed in an equitable manner upon insurers, as follows:
C. In no event shall CoverColorado increase the amount of special fees to be collected from insurers in any calendar year because of unexpected growth during that calendar year. If CoverColorado’s incurred administrative expenses or losses exceed the amounts collected through special fees and other sources in any calendar year, the amount needed to pay for such excess expenses and losses shall be requested from the Colorado Unclaimed Property Trust Fund in accordance with § 10-8-530(1)(d), C.R.S.
Section 7 Notice and Collection of the Assessed Special Fees A. Each insurer shall receive written notice of the special fee to be paid by such insurer in a calendar year no later than August 15 of the preceding calendar year. Each notice of a special fee shall include:
B. Each insurer shall pay the special fees to CoverColorado in four installments, with the first installment due on March 31, the second installment due on June 30, the third installment due on September 30, and the fourth installment due on December 31 of each calendar year.
C. CoverColorado, or its designated agent, shall collect all assessed special fees and deposit the fees into the accounts specifically maintained by the CoverColorado board for this purpose. Any amounts not immediately needed to pay the expenses and losses for eligible individuals shall be invested by the board in accordance with the investment guidelines adopted by the board and filed with the Division of Insurance as part of CoverColorado’s plan of operations.
D. If the special fees collected in any calendar year exceed the amount actually needed, the excess shall be invested by the board in accordance with the investment guidelines adopted by the board and filed with the Division of Insurance as a part of CoverColorado’s plan of operations and shall, in accordance with subsection 6.A. above, be included as funds held by CoverColorado when the next projections are made.
E. In the event that any insurer fails to pay its special fee as assessed by CoverColorado, CoverColorado shall send one notice of nonpayment thirty (30) days after March 31, June 30, September 30, or December 31. If CoverColorado has not received payment of all amounts due from an insurer within thirty (30) days after the date of the notice of nonpayment, CoverColorado shall report same to the commissioner.
F. An insurer receiving a certificate of authority to do business in the State of Colorado market on or after the date of issuance by CoverColorado of a special fee assessment notice shall receive notice of the special fee at the time of licensure and shall be liable for a prorated amount of the special fee due and owing in the calendar year of licensure. Thereafter, a new insurer shall be liable for the special fee in the normal course of the assessment process.
G. Any insurer withdrawing from the Colorado market after a special fee assessment notice has been issued shall be liable for a prorated amount of the assessment owing in that calendar year and shall not be liable for any assessment owing thereafter. The date of withdrawal shall be the date on which the last contract or policy of the insurer in Colorado expires, is terminated by the insurer in accordance with Colorado insurance laws or is voluntarily terminated by the policyholder/subscriber, whichever is sooner. Any insurer discontinuing a type of health coverage (e.g. small group coverage) in the Colorado market shall be liable in the calendar year of discontinuation for a prorated amount of the assessment due an owing in that calendar year, and the amount of assessment due and owing shall be calculated pursuant to subsection 6.B., regardless of any reduction in the number of employees and retired employees or individual policyholders or subscribers in that calendar year by reason of the discontinuation. Section 8 Deferral of or Credit Against Special Fees A. Any insurer that believes that the payment of special fees would endanger its financial ability to fulfill its contractual obligations to its insureds may submit, no later than October 1 of the year preceding the calendar year for which payment is due, a written request for deferral of the payment of its assessed special fees to the commissioner, with a copy sent to CoverColorado. The written request for deferral shall be accompanied by certified copies of statutory annual and quarterly statements and any other documents necessary to demonstrate the claimed adverse financial position. Based on the Division of Insurance’s risk-based capital guidelines, the commissioner may defer, in whole or in part, payment of the special fees owing for the coming the calendar year. The commissioner’s determination regarding deferral shall be made no later than November 1 (e.g.within thirty (30) days of receipt of a written request for deferral), with written notice of the determination sent to CoverColorado. The insurer receiving the deferment shall remain liable to CoverColorado for the deferred amount, and the deferred amount shall be incrementally reassessed to the insurer over such period as is deemed reasonable by CoverColorado, in consultation with the commissioner and the insurer, but in no event longer than three (3) years.
B. In the event a special fee assessed against an insurer is deferred, in whole or in part, the amount by which the special fee is deferred may be assessed against the other insurers in a manner consistent with the basis for assessments set forth in section 6 above ( the resulting additional special fees shall be called “excess special fees” ). Written notice of excess special fees shall be sent to all insurers no later than January 1 of the calendar year of payment. Such excess special fees amount shall be included by the insurer in its March 31 payment of previously assessed special fees to CoverColorado. As the deferred assessment is repaid in subsequent assessments by the deferring insurer, as provided in subsection 8.A. above, each insurer that paid such excess special fees shall receive a pro rata credit for its share of previously paid excess special fees.
C. An insurer shall be entitled to a credit, in the amount set forth in subsection 8.D. below, against special fees assessed (exclusive of excess special fees) if it meets any of the following criteria and has enrolled the required number of individuals in the health benefit plans described during the previous twelve-month period:
The two different plans shall meet one of the criteria set forth in subsections 8.C.1(a) and (b) above.
D. Under any of the criteria in subsections 8.C.1., 8.C.2. or 8.C.3. above, the insurer shall be entitled to a credit against any special fee assessment due and owing in a calendar year equal to three percent (3%) for enrolling the following number of individuals in the above-described plans during the preceding twelve-month period:
E. Any insurer that believes that it is entitled to a credit shall submit a written request for credit, along with supporting documentation satisfactory to the commissioner, of compliance with subsections 8.C.1., 8 C.2. or 8.C.3. above no later than March 1 of the calendar year in which any assessment is due and owing.
F. The commissioner shall make a determination regarding a credit within sixty (60) days of submission of a written request. All credits will be reported by the commissioner to CoverColorado. Section 9 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 10 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the suspension or revocation of the certificate of authority to transact insurance business in this state of any insurer which fails to pay a special fee assessment.
Section 11 Effective Date This amended regulation shall become effective on January 1, 2010. Section 12 History New regulation effective on January 1, 2002.
Amended, effective July 1, 2002 Amended, effective September 1, 2008.
Amended, effective January 1, 2010.
Regulation 4-2-23 Procedure for Provider-Carrier Dispute Resolution Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is promulgated pursuant to § § 10-1-109, 10-3-1110, 10-16-109, and 10-16-708, C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to establish procedures for resolution of provider-carrier disputes, as required by § 10-16-705(13), C.R.S.
Section 3 Applicability The provisions of this regulation shall apply to all carriers when they are providing health care services through managed care plans, except workers’ compensation and auto insurance contracts. Section 4 Definitions A. "Necessary information" consists of the following:
B. "Participating provider" shall have the same definition as in § 10-16-102(28.5), C.R.S. and includes any provider that enters into an agreement with a carrier for the provision of a particular health care service or services to a particular insured or insureds.
C. "Provider-carrier dispute" means an administrative, payment or other dispute between a participating provider and a carrier that does not involve a utilization review analysis and does not include routine provider inquiries that the carrier resolves in a timely fashion through existing informal processes.
D. "Provider-carrier dispute log" means a record of provider dispute resolution requests received by the carrier and maintained on a calendar year basis by the carrier.
E. "Provider representative" means a person designated by a provider in writing, including other providers or an association of providers, to represent the provider’s interest during the dispute resolution process.
F. "Utilization review" means a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings. Techniques include, without limitation, ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review. For the purposes of this regulation, utilization review shall also include reviews for the purpose of determining coverage based on whether or not a procedure or treatment is considered experimental or investigational in a given circumstance, and reviews of a covered person's medical circumstances when necessary to determine if an exclusion applies in a given situation. Section 5 Rules A. A carrier shall maintain written procedures for provider-carrier disputes. The procedures shall specify that requests for resolution of provider-carrier disputes must be in writing. All written requests for provider-carrier dispute resolution must be entered into a carrier’s provider-carrier dispute log. The log shall be made available to the Commissioner within a reasonable time, upon request.
B. A carrier shall make a determination of a provider dispute resolution request within forty-five (45) calendar days of receipt of all necessary information. Where the carrier does not receive all necessary information to make a decision, the carrier shall request in writing within thirty (30) calendar days of receipt of the request the additional information needed. The carrier shall allow thirty (30) calendar days from the date of the request to receive the requested information. If the provider does not respond within the thirty (30) day timeframe, the carrier shall close the request without further review. Further consideration of the closed provider dispute resolution request must begin with a new request by the provider.
C. Notification requirements.
D. A carrier shall offer the provider the opportunity to designate a provider representative in the dispute resolution process. The carrier shall allow the provider or the provider’s representative the opportunity to present the rationale for the dispute resolution request in person. In cases where the provider determines that a face-to-face meeting is not practical, the carrier shall offer the provider the opportunity to utilize alternative methods such as teleconference or videoconference to present the rationale for the dispute resolution request. The carrier may require appropriate confidentiality agreements from representatives as a condition to participating in the dispute resolution process. The parties may mutually agree in writing to extend the timeframes beyond the forty-five (45) days from receipt of all necessary information timeframe established by this regulation.
E. A carrier shall provide notification of the determination to the provider. In the event the determination is not in favor of the provider, the written notification shall include the principal reasons for the determination. The written notification shall contain:
F. All requirements in this regulation concerning written notification may be met by electronic means, including e-mail or facsimile, as long as confirmation of the transmission can be shown.
G. Nothing in this regulation shall be construed to supersede contract provisions that do not directly conflict with the terms of this regulation. For example, after a final determination is made by the carrier in accordance with the requirements set forth in this regulation, any further consideration of the request shall be handled in accordance with the contract provisions between the carrier and the provider, i.e., the request may be subject to mandatory arbitration as stated in the contract.
Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected and shall remain in full force and effect.
Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any sanctions made available in Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspension or revocation certificate of authority. Among others, the penalties provided for in § § 10-3-1108 and 10-3-1110(2), C.R.S., may be applied. Failure of a carrier to employ the procedures outlined in this regulation constitutes an unfair or deceptive act in the business of insurance under § 10-3-1104(1)(h)(IV), C.R.S. Section 8 Effective Date This regulation is effective on January 1, 2012.
Section 9 History New regulation, effective August 1, 2002.
Amended regulation effective September 1, 2011.
Amended regulation effective January 1, 2012.
Regulation 4-2-24 CONCERNING CLEAN CLAIM REQUIREMENTS FOR HEALTH CARRIERS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Rules Section 5 Required Elements Section 6 Additional Information Section 7 Severability Section 8 Enforcement Section 9 Effective Date Section 10 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-16-106.3(2), 10-16-109, and 10-1-109, C.R.S.
Section 2 Scope and Purpose This regulation provides a uniform list of required elements to be included on a specified uniform claim form in order to be considered a "clean claim".
Section 3 Applicability This regulation applies to any entity that provides health coverage in this state including a fraternal benefit society, a health maintenance organization, a nonprofit hospital and health service corporation, a sickness and accident insurance company, and any other entity providing a plan of health insurance or health benefits subject to Article 16 of the insurance laws of Colorado. Section 4 Rules A. Clean claims, as defined in § 10-16-106.5(2), C.R.S., shall be submitted on the appropriate uniform claim form (the American Dental Association Dental Claim Form, the CMS 1500, or the CMS 1450) and include all the required elements as specified in Section 5 of this regulation.
B. A carrier shall process clean claims within the time frames specified in statute.
C. A carrier shall pay interest pursuant to § 10-16-106.5(5), C.R.S., when clean claims are not processed within the specified timeframes.
D. When all of the information or documentation necessary to resolve the claim is initially provided with the appropriate claim form that includes all of the required elements as specified in Section 5 of this regulation, the claim shall be considered a clean claim and processed within the timeframes specified in statute.
Section 5 Required Elements A. The following fields of the American Dental Association Dental Claim Form (2006 version) must be completed before a claim can be considered a "clean claim" (See Attachment I):
B. The following fields of the CMS 1500 Claim Form must be completed before a claim can be considered a "clean claim" (See Attachment II):
C. The following fields of the CMS 1450 (UB-04) Claim Form must be completed before a claim can be considered a "clean claim" (see Attachment III):
28 Field 56: National Provider ID (NPI);
A. A claim with all required fields completed is not considered "clean" if additional information is needed in order to adjudicate the claim. Carriers may request additional information only if the carrier’s claim liability cannot be determined with the existing information on the claim form and the information requested is likely to allow a determination of liability to be made. When additional information is required, the carrier shall make the specific request in writing within thirty (30) calendar days after receipt of the claim form. If information is being requested from a party other than the billing provider, the provider shall be notified that additional information is needed to adjudicate the claim. The specific information required shall be requested within thirty (30) calendar days after receipt of the claim form and identified for the provider upon request.
B. Additional information requested must be related to information in the required fields of the claim forms. This applies even though the genesis of the request may be from other sources, e.g., if the carrier has other information that indicates the information in a required field is incorrect, such as previous claims that indicate the treatment was for work-related injuries when the claim form indicates otherwise. Requests for additional information to determine if the treatment is medically necessary or if a pre-existing condition limitation applies would be related to the fields specifying the services provided.
C. A carrier is not permitted to request additional information for the purpose of determining medical necessity when the claim form has all required fields correctly completed and the services were preauthorized pursuant to § 10-16-704(4), C.R.S.
D. The following circumstances are those for which additional information is generally required by most health carriers:
E. If a managed care plan requires medical or other records on all claims for particular types of services/procedures or diagnosis codes, the carrier must clearly disclose such requirements in the provider contract, provider manual, or provider manual updates. If a carrier contracts with an intermediary, the carrier shall be responsible for making sure the intermediary provides such disclosure to contracted providers in a timely manner.
F. When requesting medical records, carriers must identify the particular component(s) of the medical record being requested or indicate the specific reason for the request, e.g., progress reports for most recent three months, or records to establish the medical necessity of the treatment provided. The records requested must be related to the service/procedure of the claim and limited to the minimum amount of information necessary. Requests for "all medical records" are not specific enough and would not be an appropriate request for claim adjudication.
G. Medical information requested from institutional providers shall be limited to the following:
Section 7 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected and shall remain in full force and effect.
Section 8 Enforcement Non-compliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws, which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of license. Section 9 Effective Date This regulation is effective June 1, 2012.
Section 10 History Emergency Regulation 02-E-7, effective July 2, 2002.
Temporary Regulation 02-T-7, effective October 1, 2002. Regulation 4-2-24 effective February 1, 2003.
Amended Regulation 4-2-24 effective February 1, 2008.
Amended Regulation effective June 1, 2012.
Attachments Regulation 4-2-25 Repealed in Full [Eff. 04/01/2009] Regulation 4-2-26 Repealed in Full [Eff. 11/01/2010] Regulation 4-2-27 PROCEDURES FOR REASONABLE MODIFICATIONS TO INDIVIDUAL AND SMALL GROUP HEALTH BENEFIT PLANS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Notice and Disclosure of Reasonable Modifications Section 7 Severability Section 8 Enforcement Section 9 Effective Date Section 10 History Section 1 Authority This regulation is promulgated under the authority of § § 10-1-109, 10-16-109, and 10 16 201.5(8)(b), C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to establish procedures for the submission of reasonable modifications to individual and small group health benefit plans, as outlined in § 10-16-201.5(8), C.R.S. Section 3 Applicability This regulation applies to any carrier intending on making reasonable modifications to an individual or small group health benefit plan.
Section 4 Definitions “Reasonable modification” : An alteration to the benefits of a health benefit plan that is fair and reasonable under the circumstances. The Division of Insurance (Division) determines if a modification is fair and reasonable.
Section 5 Rules A. General Requirements
All changes to the rates must be filed separately in accordance with all rating laws and regulations once the Division and the carrier have resolved all issues.
B. Specific Requirements Removal of an existing benefit is generally not considered to be a reasonable modification. However, the Division may determine, on a case-by-case basis, if the removal of an existing benefit is reasonable after reviewing the supporting documentation. Section 6 Notice and Disclosure of Reasonable Modifications The policyholder notification shall be provided no later than ninety (90) days prior to renewal of each policyholder’s benefit plan. It shall provide the policyholder an opportunity to purchase any other health benefit plan offered by the carrier in that specific market. A copy of this notification must be provided to the Division as part of the benefit modification filing. Section 7 Severability If any provision of this regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision shall not be affected thereby.
Section 8 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist order, and/or suspensions or revocation of license. Among others, the penalties provided for in § 10-3-1108, C.R.S may be applied. Section 9 Effective Date This regulation shall become effective on May 1, 2010.
Section 10 History Regulation 4-2-27 effective January 1, 2005.
Amended regulation 4-2-27, effective May 1, 2010.
Regulation 4-2-28 CONCERNING THE PAYMENT OF EARLY INTERVENTION SERVICES FOR CHILDREN ELIGIBLE FOR BENEFITS UNDER PART C OF THE FEDERAL “INDIVIDUALS WITH DISABILITIES EDUCATION ACT”
Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Incorporated Materials Section 9 Effective Date Section 10 History Section 1 Authority This regulation is being promulgated and adopted by the Commissioner of Insurance under the authority of § §10-1-109 and 27-10.5-704(2), C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to provide health carriers the guidance necessary to implement House Bill 1237 enacted in 2009 by the Colorado General Assembly to facilitate the payment of early intervention services by private insurance sources. It replaces Emergency Regulation 09-E-01 in its entirety. Section 3 Applicability This amended regulation applies to all individual and group sickness and accident insurance policies and all service or indemnity contracts issued or renewed on or after October 1, 2009 by entities subject to Part 2, Part 3 and Part 4 of Article 16 of Title 10 of the Colorado Revised Statutes, which provide coverage for health care services.
Section 4 Definitions A. “Carrier” shall have the same meaning as set forth in §10-16-102(8), C.R.S.
B. “Case management services” are the service coordination activities as defined in 34 CFR 303.23.
C. “Certified early intervention service broker” or “broker” means a community centered board or other entity designated by the Colorado Department of Human Services to perform the specified duties and functions in a particular designated service area and may include the Division for Developmental Disabilities acting as the broker for any service area until another broker has been designated.
D. “Division for Developmental Disabilities” is a division of the Colorado Department of Human Services.
E. “Early intervention services” shall have the same meaning as set forth in §10-16-104(1.3)(a)(II), C.R.S., and include a monthly case management service fee.
F. “Eligible child” shall have the same meaning as set forth in §10-16-104(1.3)(a)(III), C.R.S.
G. “Health benefit plan” shall have the same meaning as set forth in §10-16-102(21), C.R.S.
H. “Individualized family service plan” or “IFSP” shall have the same meaning as set forth in §10-16- 104(1.3)(a)(IV), C.R.S.
I. "Limited benefit health insurance" means a health policy, contract or certificate offered or marketed on an individual or group basis as supplemental health insurance that pays specified amounts according to a schedule of benefits to defray the costs of care, services, deductibles, copayments or coinsurance amounts not covered by a health benefit plan. “Limited benefit health insurance” does not include short-term limited duration health insurance policies, contracts or certificates; high deductible plans; or catastrophic health policies, contracts or certificates. Such non- supplemental plans are included under the term “health benefit plan” .
J. “Registry” means a listing of early intervention service providers established by the designated area’s certified early intervention service broker. The broker may provide early intervention services directly or may subcontract the provision of services to other qualified providers in the registry. Section 5 Rules A. Eligible early intervention services specified in the eligible child’s IFSP shall be considered to meet the carrier’s test of medically necessary services. Therefore, carriers shall arrange for the payment of claims for early intervention services provided to an eligible child received from qualified early intervention service providers listed in the registry.
B. The certified early intervention service broker will notify the carrier within ten (10) days of determining that a child, up to age three, is eligible for early intervention services. This notification will include, at a minimum:
C. Subject to paragraphs 1, 2 and 3 of this subsection C., carriers shall pay benefits into the trust established by the Colorado Department of Human Services (CDHS) as provided in §27-10.5- 709(1), C.R.S., within 30 days of receipt of an invoice issued by CDHS, as follows:
D. Carrier payment guidelines.
E. The Division for Developmental Disabilities will notify the carrier within 90 days if a child is no longer eligible for early intervention services.
F. Short-term, accident, fixed indemnity, specified disease policies, disability income contracts, limited benefit health insurance plans, credit disability insurance and Medicare supplement policies are not required to provided the benefits set forth in §10-16-104(1.3), C.R.S.
G. The carrier shall return requests for verification of eligibility of coverage of the eligible child to the certified early intervention service broker within five (5) business days of receipt. Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of certificates of authority. Among others, the penalties provided for in §10-3-1108, C.R.S., may be applied.
Section 8 Incorporated Materials The following is hereby incorporated by reference as written on or before the effective date of this regulation:
This rule does not include later amendments to or editions of the incorporated material. A copy of this reference may be examined at any state publications depository library. For additional information regarding how to obtain a copy, please contact the Rulemaking Coordinator, Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202.
Section 9 Effective Date This regulation shall become effective on October 1, 2009. Section 10 History Emergency regulation 07-E-3 is effective December 3, 2007. New regulation effective March 1, 2008.
Emergency regulation 09-E-01 is effective June 15, 2009. Amended regulation effective October 1, 2009.
Regulation 4-2-29 CONCERNING THE RULES FOR STANDARDIZED CARDS ISSUED TO PERSONS COVERED BY HEALTH BENEFIT PLANS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is being promulgated pursuant to the authority granted to the Commissioner of Insurance in §10-1-109, C.R.S. and is adopted by the Commissioner of Insurance pursuant to the requirement in §10-16-135, C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to provide health carriers the guidance necessary to implement Senate Bill 135 enacted in 2008 by the Colorado General Assembly and effective on July 1, 2009. Section 3 Applicability This regulation applies to all individual and group health benefit plans issued or renewed on or after July 1, 2009 by entities subject to Part 2, Part 3 and Part 4 of Article 16 of Title 10 of the Colorado Revised Statutes, and to any person enrolling in an existing plan on or after July 1, 2009. Section 4 Definitions A. “Carrier” shall have the same meaning as set forth in §10-16-102(8), C.R.S.
B. “Clear and conspicuous” as used in this regulation means that the placement of the required information will be set apart from other information listed to allow it to be easily located on the card.
C. “Health benefit plan” shall have the same meaning as set forth in §10-16-102(21), C.R.S.
D. "Limited benefit health insurance" means a health policy, contract or certificate offered or marketed on an individual or group basis as supplemental health insurance that pays specified amounts according to a schedule of benefits to defray the costs of care, services, deductibles, copayments or coinsurance amounts not covered by a health benefit plan. “Limited benefit health insurance” does not include short-term limited duration health insurance policies, contracts or certificates; high deductible plans; or catastrophic health policies, contracts or certificates. Such non- supplemental plans are included under the term “health benefit plan” .
E. “Short-term health benefit plans” shall have the same meaning as §10-16-102(21)(b), CRS, subparagraphs (I) and (II).
Section 5 Rules A. The requirements of this regulation shall apply to identification cards issued to persons covered under health benefit plans. These requirements do not apply to identification cards issued to persons covered by limited benefit health insurance plans.
B. The card size shall be approximately 2.125 inches by 3.370 inches, which is consistent with standard- sized credit cards, and shall be either made of plastic, or laminated. Cards issued in connection with coverage provided by short-term health benefit plans do not have to be made of plastic or be laminated.
C. The colors used for the card and font shall be legible and conducive to black and white photocopying.
D. The following information shall appear on the front side of the identification card, in no less than 8 point font:
E. The following information shall appear on either the front or reverse side of the identification card at the carrier’s discretion, in no less than 8 point font:
F. The card may include other information at the carrier’s discretion.
G. Carriers may utilize commonly-known abbreviations or acronyms for the purposes of displaying the information required by paragraph 6. of subsection D., such as:
H. Carriers choosing to utilize commonly known abbreviations or acronyms in accordance with subsection G. shall provide an explanation of the abbreviations and/or acronyms displayed on the card in the information provided when the card is sent to the covered person. Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of certificates of authority. Among others, the penalties provided for in §10-3-1108, C.R.S., may be applied.
Section 8 Effective Date This regulation shall become effective on July 1, 2009. Section 9 History New regulation effective October 1, 2008.
Amended effective July 1, 2009.
Regulation 4-2-30 CONCERNING THE RULES FOR COMPLYING WITH MANDATED COVERAGE OF HEARING AIDS AND PROSTHETICS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is being promulgated pursuant to the authority granted to the Commissioner of Insurance in §10-1-109, C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to provide health carriers the guidance necessary to implement Senate Bill 57 enacted in 2008 by the Colorado General Assembly and effective on January 1, 2009. In addition, it is to clarify the coverage mandated for prosthetics by §10-16-104(14), C.R.S. This regulation replaces Emergency Regulation 08-E-11 in its entirety.
Section 3 Applicability This regulation applies to all individual and group health benefit plans issued or renewed on or after January 1, 2009 by entities subject to Part 2, Part 3 and Part 4 of Article 16 of Title 10 of the Colorado Revised Statutes.
Section 4 Definitions A. “Carrier” shall have the same meaning as set forth in §10-16-102(8), C.R.S.
B. “Health benefit plan” shall have the same meaning as set forth in §10-16-102(21), C.R.S.
C. “Hearing aid” shall have the same meaning as set forth in §10-16-102(24.7), C.R.S.
D. "Limited benefit health insurance" means a health policy, contract or certificate offered or marketed on an individual or group basis as supplemental health insurance that pays specified amounts according to a schedule of benefits to defray the costs of care, services, deductibles, copayments or coinsurance amounts not covered by a health benefit plan. “Limited benefit health insurance” does not include short-term limited duration health insurance policies, contracts or certificates; high deductible plans; or catastrophic health policies, contracts or certificates. Such non- supplemental plans are included under the term “health benefit plan” .
E. “Minor child” shall have the same meaning as set forth in §10-16-102(27.3), C.R.S. Section 5 Rules A. Hearing aids.
B. For the purposes of §10-16-104(14), C.R.S., prosthetics do not meet the traditional definition of durable medical equipment; therefore, any benefits paid for prosthetics in accordance with the coverage mandated by Colorado law shall not be used to exhaust a health benefit plan’s annual or lifetime durable medical equipment maximum, if any.
Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of certificates of authority. Among others, the penalties provided for in §10-3-1108, C.R.S., may be applied.
Section 8 Effective Date This regulation shall become effective on February 1, 2009. Section 9 History 1. Emergency Regulation 08-E-11 is effective January 1, 2009.
2. New regulation is effective February 1, 2009.
Regulation 4-2-31 ANNUAL HEALTH REPORTING AND DATA RETENTION REQUIREMENTS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Hospital Reimbursement Rate Record Retention and Report Section 6 Annual Cost Report Section 7 Incorporated Materials Section 8 Severability Section 9 Enforcement Section 10 Effective Date Section 11 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109, 10-3-109, 10-16-111(4), and 10-16-134, C.R.S. Section 2 Scope and Purpose The purpose of this regulation is to define uniform reporting, filing and data retention requirements for the hospital reimbursement rate report and the Annual Cost Report. Section 3 Applicability This regulation applies to all carriers, as defined in Section 4(B) of this regulation, operating in the state of Colorado with written health premium in the data year. This includes, but is not limited to carriers operating with the following types of business: comprehensive health insurance, Health Maintenance Organization (HMO) coverage, supplemental health, limited service licensed provider network business, long-term care, disability income, accident-only, specified or dread disease, hospital indemnity, vision only, dental only, other limited-medical payment plans, Medicare supplement and excess loss insurance (pursuant to § 10-16-119, C.R.S.).
Reporting of information is waived for the following lines of business for each report:
A. Hospital Reimbursement Rate Report Limited medical-payment plans (including disability income, accident only, specified or dread disease, hospital indemnity, vision only, and dental only), Medicare, Medicaid, long term care, and Medicare supplement insurance.
B. Annual Cost Report Third party administration for fully self-funded plans, undeveloped rates that involve Medicare and Medicaid and Medicare Part D.
Section 4 Definitions A. "Average Reimbursement Rate" is the average of all reimbursement rates that a carrier paid, by MS- DRG code, to only hospitals/facilities reporting to the Colorado Hospital Association during the previous calendar year including both in-network and out-of-network facilities.
B. "Carrier" means any entity that provides health coverage in this state including a franchise insurance plan, a fraternal benefit society, a health maintenance organization, a non-profit hospital and health service corporation, a sickness and accident insurance company, and any other entity providing a plan of health insurance or health benefits subject to the insurance laws and regulations of Colorado.
C. "Diagnostic Related Group" means, for purposes of this regulation, the classification assigned to an inpatient hospital service claim based on the patient's age and sex, the principal and secondary diagnoses, the procedures performed, and the discharge status.
D. "Dividends" means, for purposes of this regulation, both policyholder and stockholder dividends.
E. "MS-DRG" (Medicare Severity Diagnosis Related Group) is a code within a system developed for Medicare as part of their payment system to classify each hospital case into one of approximately 500 groups that is published in the Federal Register Vol. 77, No. 92.
F. "Premium" means, for purposes of this regulation, the amount of money paid by the insured as a condition of receiving health care coverage. The premium paid normally reflects such factors as the carrier’s expectation of the insured’s future claim costs and the insured’s share of the carrier’s claims settlement, operational and administrative expenses, and the carrier’s cost of capital. This amount is net of any adjustments, discounts, allowances or other inducements permitted by the health care coverage contract.
G. "Reimbursement rate" means the amount, by MS-DRG code, that a carrier paid for a procedure at a facility or hospital, plus any expected deductible, copayment, and/or coinsurance. It is important that only the entire hospital/facility reimbursement be included in this rate, not just the carrier’s portion. Provider reimbursement charges should be excluded from this total. Private room, personal item and other charges that are generally the responsibility of the policyholder should also be excluded.
H. "Trend," for the purposes of this regulation, means the rate of increase in costs for the reporting period.
I. "Stop Loss" means Individual or group policies providing coverage to a health plan, a self-insured employer plan, or a medical provider providing coverage to insure against the risk that any one claim or an entire plan's losses will exceed a specified dollar amount. Section 5 Hospital Reimbursement Rate Record Retention and Report A. The Division will annually publish on its website or communicate directly to carriers the list of MS-DRG codes associated with the twenty-five most common inpatient procedures performed in Colorado for the previous reporting year. This will include more than twenty-five MS-DRG codes, as there are multiple codes for different levels of severity in many of the identified procedures.
B. Pursuant to the Health Care Transparency Act, § 10-16-134, C.R.S., each carrier shall report to the Division the average reimbursement rates and number of procedures on a statewide basis for the twenty-five most common inpatient procedures performed in Colorado at hospitals/facilities reporting to the Colorado Hospital Association. This information shall be filed electronically using the Division of Insurance website in a format made available by the Division.
C. Timing and Submission: The required data shall be filed on or before March 1 of each year. Pursuant to § 10-3-109, C.R.S., failure to file this report by March 1 may result in a late penalty not to exceed $100 per day and any applicable surcharges. Reports not containing all of the information specified in this section may be subject to a fine for an incomplete report.
D. Each entity subject to the Health Care Transparency Act shall:
Section 6 Annual Cost Report A. Pursuant to § 10-16-111(4)(a), C.R.S., companies subject to this regulation shall file an Annual Cost Report as described in this section. This report must comply with the requirements of this section and must contain the information specified in Subsection C of this section and shall be filed electronically via a form provided on the Division of Insurance’s website www.dora.state.co.us/insurance .
B. Timing and Submission: All Annual Cost Reports shall be filed electronically in a format made available by the Division of Insurance via the Division’s website on or before June 1 of each year. Failure to file this report by June 1 will result in a late penalty not to exceed $100 per day. Reports not containing complete and accurate information specified in Subsection C of this section may be subject to a fine for an incomplete report.
C. Annual Cost Reports filed by companies identified in Section 3 must contain, where applicable, all of the information in this subsection. For every company the report shall include the following information from the previous calendar year.
D. The information provided in Subsection C of this section shall be provided on a Colorado only basis, with the exception of executive salaries which is defined in Subsection C(4)(a) of this section. A carrier licensed in multiple jurisdictions may satisfy the requirements of Subsection C of this section by filing the Colorado-allocated portion of national data if the actual Colorado only data is not otherwise available. The methods of allocation that should be used, if necessary, will be provided by the Division prior to the release of the report for completion.
E. If any of the items listed in Subsection C of this section are not applicable to the carrier, the carrier shall indicate in the filing which items are not applicable and the reason why such items are not applicable.
F. The information provided to the Division of Insurance in Subsection C of this section will be aggregated for all carriers and will be published on the Division of Insurance’s website, www.dora.state.co.us/insurance .
Section 7 Incorporated Materials The MS-DRG is incorporated by reference, but this rule does not cover amendments to this law or model act that were promulgated later than the effective date of this rule. A copy of the MS-DRG codes may be examined at any state publications depository library. For additional information regarding how relevant portions of the these codes can be obtained or examined, contact the Director of Market Regulation, Colorado Division of Insurance, 1560 Broadway, Ste 850, Denver, CO 80202. The Federal Register Vol. 77, No. 92 published by Centers for Medicare & Medicaid Services shall mean Federal Register Vol. 77, No. 92 as published on the effective date of this regulation and does not include later amendments to or editions of Federal Register Vol. 77, No. 92. A copy of the Federal Register Vol. 77, No. 92 may be examined during regular business hours at the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado, 80202. A Certified copy of the Federal Register Vol. 77, No. 92 may be requested from Center for Medicare & Medicaid Services, Baltimore Headquarters telephone number 877-267-2323. A charge for certification or copies may apply. A copy may also be obtained online at http://www.gpo.gov/fdsys/pkg/FR-2012-05-11/pdf/2012-9985.pdf. Section 8 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected. Section 9 Enforcement Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.
Section 10 Effective Date This regulation shall become effective on December 1, 2012. Section 11 History New Regulation 4-2-31, Effective January 1, 2010.
Amended Regulation, Effective August 1, 2011.
Amended Regulation, Effective December 1, 2012.
Regulation 4-2-32 STANDARDIZED ELECTRONIC IDENTIFICATION AND COMMUNICATIONSYSTEMS GUIDELINES FOR HEALTH BENEFIT PLANS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Incorporated Materials Section 8 Enforcement Section 9 Effective Date Section 10 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109 and 10-16-135, C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to define the standardized electronic identification and communication systems to be used by carriers and providers of health benefit plans in Colorado, as required by § 10-16- 135, C.R.S. It is being amended to change the compliance date to ensure that an unnecessary burden is not placed on health carriers doing business in Colorado by requiring they comply with CORE guidelines on a date earlier than the date required by the federal government. Section 3 Applicability This regulation applies to all health benefit plan providers and carriers operating in the state of Colorado. Deadlines imposed in this regulation may be extended by the Commissioner under the circumstances listed in subsection 5.F. of this regulation.
Section 4 Definitions A. "Carrier" shall have the same meaning as in § 10-16-102(8), C.R.S.
B. "CORE" means the Committee on Operating Rules for Information Exchange.
C. "CORE Phase I certified" means having followed all CORE certification guidelines and received a Phase I certification seal.
D. "CORE Phase II certified" means having followed all CORE certification guidelines and received a Phase II certification seal.
E. "Health benefit plan" shall have the same meaning as in § 10-16-102(21), C.R.S.
F. "Provider" shall have the same meaning as in § 10-16-102(36), C.R.S.
G. "HIPAA" means Health Insurance Portability and Accountability Act of 1996. Section 5 Rules A. All carriers licensed in this state as of January 1, 2013, shall be able to show the ability of their systems to allow real time data exchange including benefits eligibility, coverage determinations, and other appropriate provider-carrier transactions and interoperability following all CORE guidelines for data formats and system requirements.
B. Carriers licensed in this state after January 1, 2013, if not already having systems that allow real time data exchange including benefits eligibility, coverage determinations, and other appropriate provider-carrier transactions following all CORE guidelines, shall, within sixty (60) days of becoming licensed adjust their systems to follow all CORE guidelines for data formats and system requirements.
C. CORE Phase I certification shall be accepted as evidence of compliance with subsections 5.A. and 5.B. Those carriers using CORE certification to comply with the provisions of this rule shall be required to become CORE Phase II certified within one (1) year of completing certification for CORE Phase I.
D. All carriers and providers shall uniformly use the Council for Affordable Quality Healthcare-developed CORE data content and infrastructure rules in the exchange of HIPAA compliant healthcare information and infrastructure improvements.
E. When installing new operating systems after December 31, 2012, all carriers are required to use CORE certified systems for communications, those systems which meet CORE certification standards, or contract with a vendor who has applied by January 1, 2013 to be CORE certified.
F. Notwithstanding the above requirements, those systems used solely for internal integrated systems between a carrier and a provider group may be granted an exemption from this requirement so long as CORE certification standards of systems that provide information exchange functionality for carrier interactions related to consumers, out of network providers, and non-dedicated providers is maintained. No exemption exists until the Commissioner has reviewed a written request for exemption and has made a written finding that the exemption is granted.
G. A carrier or provider located in a rural area of the state, as determined by the Commissioner, may apply to the Commissioner for, and the Commissioner may grant, an extension of any of the deadlines imposed by this section if meeting a particular deadline would impose a financial hardship on the rural carrier or provider. The Commissioner may require the rural carrier or provider to submit documentation supporting the financial hardship claim. Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 7 Incorporated Materials A. The “CORE Phase I Eligibility and Benefits Operating Rules Manual” published by the Council for Affordable Quality Healthcare shall mean “CORE Phase I Eligibility and Benefits Operating Rules Manual” as published on the effective date of this regulation. It does not include later amendments to or editions of “CORE Phase I Eligibility and Benefits Operating Rules Manual” . A copy of the “CORE Phase I Eligibility and Benefits Operating Rules Manual” may be examined at any state publications depository library. For additional information regarding how the “CORE Phase I Eligibility and Benefits Operating Rules Manual” may be obtained or examined, contact the Rulemaking Coordinator, Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado, 80202.
B. The “CORE Phase II Policies and Operating Rules” published by the Council for Affordable Quality Healthcare shall mean “CORE Phase II Policies and Operating Rules” as published on the effective date of this regulation. It does not include later amendments to or editions of “CORE Phase II Policies and Operating Rules” . A copy of the “CORE Phase II Policies and Operating Rules” may be examined at any state publications depository library. For additional information regarding how the “CORE Phase II Policies and Operating Rules” may be obtained or examined, contact the Rulemaking Coordinator, Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado, 80202.
Section 8 Enforcement Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.
Section 9 Effective Date This regulation shall become effective on July 1, 2012. Section 10 History New regulation effective October 1, 2010.
Amended regulation effective July 1, 2012.
Regulation 4-2-33 MANDATORY OPEN ENROLLMENT PERIODS FOR CARRIERS ISSUING CHILD- ONLY PLANS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109, 10-16-104.4, and 10-16-108.5, C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to facilitate the implementation of SB11-128 and certain provisions of the Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stat. 119 (2010) and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010), together referred to as the "Affordable Care Act" (ACA). It replaces Emergency Regulation E-11-03 in its entirety.
Section 3 Applicability This regulation applies to carriers that issue child-only plans on or after September 1, 2011. Section 4 Definitions A. "Carrier" shall have the same meaning as defined in § 10-16-102(8), C.R.S.
B. "Child-only plan" shall mean an individual health benefit plan that is issued on or after September 1, 2011, that provides coverage to an individual under the age of nineteen (19). A "child-only plan" does not include coverage provided to a dependent under an individual or group health benefit plan.
C. "Qualifying Event" shall include birth, adoption, marriage, dissolution of marriage, loss of employer- sponsored insurance, loss of eligibility under the Colorado Medical Assistance Act in Parts 4, 5, and 6 of Title 25.5 of the Colorado Revised Statutes, loss of eligibility under the Children’s Basic Health Plan in Article 8 of Title 25.5 of the Colorado Revised Statues, entry of a valid court or administrative order mandating the child be covered, or involuntary loss of other existing coverage for any reason other than fraud, misrepresentation or failure to pay premium. Section 5 Rules A. Enrollment Only Allowed During Certain Periods.
B. Twice Yearly Open Enrollment Periods for New Applicants.
C. As a condition of issuing coverage in the individual health market, a carrier shall have an approved child-only plan available to be issued pursuant to § 10-16-104.4 and this regulation.
D. A carrier may cancel coverage for a dependent in the individual market if the parent subscriber cancels his or her individual coverage. The carrier shall allow the dependent to apply for a child- only plan during the next open enrollment period with no surcharge.
E. A carrier may deny coverage to an applicant for enrollment in a child-only plan if other creditable coverage as defined in § 10-16-102(13.7), C.R.S., is available. For purposes of this subsection E., creditable coverage does not include eligibility for a high-risk pool insurance plan, including but not limited to CoverColorado and Getting US Covered, but creditable coverage does include current enrollment in a high-risk pool insurance plan.
F. A carrier may impose a surcharge for up to twelve (12) months on an individual who enrolls in a child- only plan if the individual was previously enrolled in a child-only plan, subsequently dropped the coverage, and the lapse in coverage is greater than sixty-three (63) days. The surcharge may be up to an additional fifty percent (50%) of the amount that would be charged for the same child demonstrating continuous coverage.
G. Annual Report.
Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected and shall remain in full force and effect.
Section 7 Enforcement Noncompliance with this Regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, refund of excess premiums plus interest, restitution, issuance of cease and desist orders, and/or suspensions or revocation of license or certificate of authority. Among others, the penalties provided for in § 10-3-1108, C.R.S. may be applied. Section 8 Effective Date This regulation shall become effective on September 1, 2011. Section 9 History Emergency Regulation E-11-01 effective September 23, 2010. New Regulation 4-2-33 effective January 1, 2011.
Emergency Regulation E-11-03 effective May 3, 2011.
Amended Regulation effective September 1, 2011.
Regulation 4-2-34 SECTION NAMES AND THE PLACEMENT OF THOSE SECTIONS IN POLICY FORMS BY HEALTH CARRIERS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109, and 10-16-137(2), C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to set forth the standardized format for section names and placement of those section names in policy forms issued by health carriers. Section 3 Applicability The requirements and provisions of this regulation apply to health benefit plans, limited benefit health insurance, dental and vision policies issued or delivered on or after January 1, 2012. This regulation does not apply to Medicare Supplement or disability income insurance. Section 4 Definitions A. "Health benefit plans" for the purposes of this regulation, shall have the same meaning as provided under § 10-16-102(21), C.R.S.
B. "Health carriers" for the purposes of this regulation, shall have the same meaning as provided under § 10-16-102(8), C.R.S.
C. "Limited benefit health insurance" means a health policy, contract or certificate offered or marketed as supplemental health insurance that pays specified amounts according to a schedule of benefits to defray the costs of care, services, deductibles, copayments or coinsurance amounts not covered by a health benefit plan. "Limited benefit health insurance" does not include short-term limited duration health insurance policies, contracts or certificates; or catastrophic health policies, contracts or certificates. Such non-supplemental plans are included under the term "health benefit plan" as defined in § 10-16-102(21), C.R.S.
Section 5 Rules Health carriers shall use the following section names in the listed order, for health benefit plans, limited benefit health insurance, dental and vision policy forms:
A. Section Names
B. Carriers may continue to use existing forms and instead publish a table of contents or directory which cross-references the proposed standards section names with those used in carrier’s current forms.
Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected. Section 7 Enforcement Noncompliance with this Regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist orders, and/or suspensions or revocation of license. Among others, the penalties provided for in § 10-3-1108, C.R.S. may be applied. Section 8 Effective Date This regulation is new and shall become effective on October 1, 2011. Section 9 History New regulation effective October 1, 2011.
Regulation 4-2-35 REQUIRED INFORMATION FOR CARRIERS TO PROVIDE ON EXPLANATION OF BENEFITS FORMS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109 and 10-16-137(2), C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to set forth the minimum required information for health carriers to provide on an explanation of benefits form sent to covered persons or providers. Section 3 Applicability The requirements and provisions of this regulation apply to health benefit plans, limited benefit health insurance, and dental plans issued or delivered on or after January 1, 2012. This regulation does not apply to Medicare Supplement or disability income insurance. Section 4 Definitions A. "Health benefit plans" for the purposes of this regulation, shall have the same meaning as provided under § 10-16-102(21), C.R.S.
B. "Health carriers" for the purposes of this regulation, shall have the same meaning as provided under § 10-16-102(8), C.R.S.
C. "Limited benefit health insurance" for the purposes of this regulation, means a health policy, contract or certificate marketed as supplemental health insurance that pays specified amounts according to a schedule of benefits to defray the costs of care, services, deductibles, copayments or coinsurance amounts not covered by a health benefit plan. "Limited benefit health insurance" does not include short-term limited duration health insurance policies, contracts of certificates; or catastrophic health policies, contracts or certificates. Such non-supplemental plans are included under the term "health benefit plan" as defined in § 10-16-102(21), C.R.S. Section 5 Rules Health carriers shall include the following information on an explanation of benefits (EOB) form sent to covered persons or providers:
A. Name of member.
B. Relationship of member to subscriber.
C. Subscriber/member’s claim number.
D. Name of subscriber.
E. Provider name and whether the provider is in or out of network.
F. Date of service.
G. Type of service (emergency, inpatient, outpatient, etc.).
H. Denial information (with enough specificity to enable the member/subscriber to determine the reason for the denial). Additionally, a notice will need to go out with the denial: "Notice: The diagnosis and treatment codes (and their meaning) related to the service that is the subject of this Explanation of Benefits (EOB) are available upon request made to the carrier." I. Carrier contact information.
J. Explanation of appeal rights (Can be an attachment to EOB).
K. Notice "THIS IS NOT A BILL".
L. Claim payment calculation.
M. Subscriber/member’s financial liability.
N. Status of policy deductible, out-of pocket amount, and policy maximums.
Section 8 Effective Date This regulation is effective October 1, 2011.
Section 9 History New Regulation effective October 1, 2011.
Regulation 4-2-36 PRESCREENING QUESTIONAIRE FOR INDIVIDUAL HEALTH BENEFIT PLANS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Rules Section 5 Severability Section 6 Enforcement Section 7 Effective Date Section 8 History Appendix A Prescreening Questionnaire Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109 and 10-16-107.2(2)(c)(III), C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to implement a prescreening questionnaire for use by carriers marketing and issuing individual health benefit plans.
Section 3 Applicability The requirements and provisions of this regulation apply to carriers issuing individual health benefit plans on or after January 1, 2012. Child-only policies are guaranteed issued pursuant to state and federal law and therefore this questionnaire shall not be used in connection with the issuance of child-only policies. Section 4 Rules The prescreening questionnaire provided in Appendix A, is not part of an application, and is required to be used by all carriers issuing individual health benefit plans. Section 5 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected. Section 6 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist order, and/or suspensions or revocations of certificates of authority. Among others, the penalties provided in § 10-3-1108, C.R.S., may be applied.
Section 7 Effective Date This regulation shall become effective on October 1, 2011. Section 8 History New regulation effective October 1, 2011.
Appendix A, Prescreening Questionnaire Regulation 4-2-37 REQUIRED INFORMATION FOR CARRIERS TO OBTAIN ON ALL FULL-LENGTH APPICATIONS FOR INDIVIDUAL HEALTH BENEFIT PLANS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109 and 10-16-105.2(1.5), C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to establish a standard affidavit form to be used upon application for an individual health benefit plan when a small employer intends on reimbursing an employee for any portion of the premium. It replaces Emergency Regulation E-11-04 in its entirety. Section 3 Applicability The requirements of this regulation apply to all carriers issuing individual health benefit plans. It applies to all applications received by the carrier on or after September 1, 2011. It does not apply to applications for limited benefit health insurance plans or to applications for short-term health benefit plans. Section 4 Definitions A. "Carrier" for the purposes of this regulation, shall have the same meaning as provided under § 10-16- 102(8), C.R.S.
B. "Health benefit plan" for the purposes of this regulation, shall have the same meaning as provided under § 10-16-102(21), C.R.S.
C. "Limited benefit health insurance" for the purposes of this regulation, means a health policy, contract or certificate marketed as supplemental health insurance that pays specified amounts according to a schedule of benefits to defray the costs of care, services, deductibles, copayments or coinsurance amounts not covered by a health benefit plan. "Limited benefit health insurance" does not include short-term limited duration health insurance policies, contracts of certificates; or catastrophic health policies, contracts or certificates. Such non-supplemental plans are included under the term "health benefit plan" as defined in § 10-16-102(21), C.R.S.
D. "Short-term health benefit plans" shall have the same meaning as §10-16-102(21)(b), C.R.S., subparagraphs (I) and (II).
Section 5 Rules A. All full-length applications for individual health benefit plans must contain the questions provided in Appendix A either as part of the application or as supplemental form with a separate applicant signature.
B. If an applicant for an individual health benefit plan is required to submit an affidavit executed by the employer, the affidavit that must be used is attached in Appendix B.
New regulation effective September 1, 2011.
Appendix A: Required questions for full-length applications for individual health benefit plans.
1. Will an employer of fifty (50) or fewer eligible employees be paying for or reimbursing an employee through wage adjustment or a health reimbursement arrangement for any portion of the premium on the policy being applied for? ____ Yes ____ No If you answered "yes", please continue. If you answered "no", you may stop.
2. Did the employer have a small group health benefit plan providing coverage to any employee in the twelve months prior to the date of this application? ____ Yes ____ No 3. If the answer to both questions 1 and 2 is "yes", the applicant may not be issued an individual policy with the premiums, or portion thereof, paid or reimbursed by the employer. If the answer to question 1 is "yes" and the answer to question 2 is "no", the applicant must submit a signed affidavit from the employer certifying that the employer has not had a small group health benefit plan providing coverage to any employee in the previous twelve (12) months. The affidavit form to be executed by the employer is attached. The submission of this affidavit does not guarantee that the individual policy you are applying for will be issued by the carrier. Appendix B: Form of Affidavit Employer’s Name: ______________________________________ Employer’s Address: ______________________________________ ______________________________________ The undersigned officer or principal of the employer identified above certifies that:
1. The employer is a small employer as defined in § 10-16-102(40), C.R.S., with fifty (50) or fewer eligible employees;
2. The employer has not had in place a small group health benefit plan for the twelve (12) months prior to the execution of this affidavit.
3. A false certification may cause the rescission of the employee’s individual insurance policy and subject the employer to penalties for perjury and liability to the employee. Signed: ________________________________ Printed Name: ________________________________ Position: ________________________________ Date: ________________________________ Regulation 4-2-38 CONTRACEPTIVE BENEFITS Section 1 Authority Section 2 Scope and Purpose Section 3 Applicability Section 4 Definitions Section 5 Rules Section 6 Severability Section 7 Enforcement Section 8 Effective Date Section 9 History Section 1 Authority This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of § § 10-1-109 and 10-16-104(3)(a)(I) C.R.S.
Section 2 Scope and Purpose The purpose of this regulation is to implement Colorado insurance law and ensure carriers are providing coverage for contraception in policies in the same manner as any other sickness, injury, disease or condition is otherwise covered under the policy or contract. Section 3 Applicability The requirements and provisions of this regulation apply to all group sickness and accident insurance policies and health service contracts issued to an employer and all individual sickness and accident, health care or indemnity contracts under parts 2, 3 or 4 of Title 10. This regulation does not apply to supplemental policies covering a specified disease or other limited benefits under § 10-16-102(21)(b), C.R.S.
Section 4 Definitions For purposes of this regulation, the following terms are defined:
A. "Contraceptive" or "contraception" means a medically acceptable drug, device, or procedure used to prevent pregnancy in accordance with § 2-4-401, C.R.S.
B. "Emergency contraception" means a drug approved by the federal food and drug administration that prevents pregnancy after sexual intercourse, including but not limited to oral contraceptive pills; except that "emergency contraception" shall not include RU-486, mifepristone, or any other drug or device that induces a medical abortion, in accordance with § 25-3-110, C.R.S.
C. "Prescription drug" shall have the same meaning as defined in § 12-22-102(30), C.R.S. Section 5 Rules All group sickness and accident insurance policies and health service contracts issued to an employer and all individual sickness and accident insurance, health care or indemnity contracts shall provide contraceptive benefits in the same manner as any other sickness, injury, disease or condition is otherwise covered under the policy or contract.
A. Policies or contracts with prescription drug benefits shall cover prescription contraceptive drugs in the same manner as other prescription drugs are covered under the policy or contract. However, over-the-counter contraceptive drugs or devices for which a prescription is not required and which are not otherwise covered under the policy or contract, are not required to be covered.
B. Voluntary sterilization procedures are covered as a health care service as defined in § 10-16-102(22), C.R.S., in the same manner as any other sickness, injury, disease or condition is otherwise covered under the policy or contract.
C. Hormone injections for contraception shall be covered in the same manner as hormone injections for any other sickness, injury, disease or condition.
D. Emergency contraception is covered in the same manner as any other drug or device for any other sickness, injury, disease or condition is otherwise covered under the policy or contract.
E. The drugs RU-486, mifepristone, or any other drug or device that induces a medical abortion are not contraceptives or emergency contraceptives within the definitions of such terms and are not required to be covered under a contraceptive benefit.
F. Intrauterine devices (IUDs), subdermal implants, and the insertion, management and removal of such devices are covered in the same manner as health care services as defined in § 10-16-102(22), C.R.S. and devices as defined in § 12-22-102(8), C.R.S. to treat any other sickness, injury, disease or condition are otherwise covered under the policy or contract. Section 6 Severability If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected. Section 7 Enforcement Noncompliance with this regulation may result, after proper notice and hearing, in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance or other laws which include the imposition of fines, issuance of cease and desist order, and/or suspensions or revocations of certificates of authority. Among others, the penalties provided in § 10-3-1108, C.R.S., may be applied.
Section 8 Effective Date This regulation shall become effective on January 1, 2012. Section 9 History New regulation effective January 1, 2012.
_________________________________________________________________________ Editor’s Notes 3 CCR 702-4 has been divided into smaller sections for ease of use. Versions prior to 09/01/2011 and rule history are located in the first section, 3 CCR 702-4. Prior versions can be accessed from the History link that appears above the text in 3 CCR 702-4. To view versions effective after 09/01/2011, select the desired part of the rule, for example 3 CCR 702-4 Series 4-1, or 3 CCR 702-4 Series 4-6. History [For history of this section, see Editor’s Notes in the first section, 3 CCR 702-4]