Health Insurance Benefit Coverage Law Summaries
Colorado, Health Insurance Benefit Coverage Law Summaries
Colorado's mandated health care law is codified in the Colorado Revised Statutes at Title 10, Articles 3 and 16. Coordination of benefits provisions are located in the Colorado Code of Regulations.
DEFINITIONS
“Small employer” means any person, firm, corporation, partnership, or association that is actively engaged in business that, on at least 50 percent of its working days during the preceding calendar quarter, employed no more than 50 eligible employees, the majority of whom were employed within Colorado and that was not formed primarily for the purpose of purchasing insurance (Sec. 10-16-102, as amended by Ch. 111 (S. 141), L. 1999).
“Child health supervision services” means those preventive services and immunizations required to be provided in basic and standard health benefit plans to dependent children up to age 13. Such services must be provided by a physician or pursuant to a physician's supervision or by a primary health care provider who is a physician's assistant or registered nurse who has additional training in child health assessment and who is working in collaboration with a physician (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
“Enrollee” means an individual who is or has been enrolled in a health maintenance organization or an individual who is or has been enrolled in an individual or group prepaid dental care plan as a principal subscriber together with such individual's dependents who are entitled to dental care services under the plan solely because of their status as dependents of the principal subscriber (Sec. 10-16-102, as amended by Ch. 111 (S. 141, L. 1999).
“Utilization review” means an evaluation of the necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities, but does not include any independent medical examination provided for in any policy of insurance (Sec. 10-16-112).
PROCEDURES
ID cards.- An insured may require that an insurance company or insurer doing business in Colorado not display the Social Security number on his or her insurance identification card or proof of insurance card. If an insured makes the request, the insurance company or insurer must reissue the card without the insured's Social Security number. After January 1, 2006, upon issuance or renewal of an insurance policy, an insurance company or insurer doing business in Colorado must not issue an insurance identification card or proof of insurance card that displays an insured's Social Security number (Sec. 10-3-129, as added by H. 1311, L. 2004, effective August 4, 2004).
WHAT THE EMPLOYER MUST DO
Colorado does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.
Mental health coverage.- In the case of basic coverage benefits based upon either confinement as an inpatient or partial hospitalization in a hospital or psychiatric hospital licensed by the Department of Public Health and Environment, the period of confinement for which benefits are payable must be at least 45 days for inpatient care or 90 days for partial hospitalization in any one 12-month benefit period. For the purpose of computing the period for which benefits are payable, each two days of partial hospitalization care reduces by one day the 45 days available for inpatient care, and each day of inpatient care reduces by two days the 90 days available for partial hospitalization care. Each day of confinement as an inpatient or each two days of partial hospitalization reduces by one day the total days available for all other illnesses during any one 12-month benefit period (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Providers.- Mental health services performed by a registered professional nurse or licensed clinical social worker licensed to practice in Colorado must be reimbursed, whether or not such services are provided under the direct supervision of a physician or licensed psychologist (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Copayments/deductibles.- Copayment requirements for mental illness may not exceed a 50 percent copayment requirement, and deductibles may not differ from the deductible amount for any other condition or illness (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Parity.- Group health care policies must provide coverage for the treatment of biologically based mental illness that is no less extensive than the coverage provided for any other physical illness (Sec. 10-16-104(5.5), as added by Ch. 71 (H. 1192), L. 1997, effective January 1, 1998).
Outpatient services.- In the case of major medical coverage, benefits must cover outpatient services furnished by a comprehensive health care service corporation, a hospital, or a community mental health center or other mental health clinics approved by the Department of Human Services to furnish mental health services; or furnished by a registered professional nurse within the scope of his or her license; or furnished by a licensed clinical social worker within the scope of his or her license; or furnished by or under the supervision of a licensed physician or licensed psychologist (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Facilities.- No individual policy or group policy of sickness, health, or accident insurance or small group sickness and accident insurance delivered or issued for delivery to any person in Colorado that provides for coverage of mental illness or mental retardation, or both, may exclude or be construed to diminish benefits for the payment of the direct costs related to the treatment of mental illness or mental retardation, or both, that is provided by a state institution, including community clinics and centers for mental health and mental retardation services, if charges for such treatment are customarily charged to nonindigent patients by the state institution (Sec. 10-16-219).
Small employers.- The mandatory coverage provision for mental health coverage does not apply to any small employer who has not provided group sickness and accident insurance to employees after July 1, 1989, or to any small employer who has provided group sickness and accident insurance from a person or entity licensed as a provider of health care benefits that did not include mental health coverage after July 1, 1989. Any small employer who is not required to provide mental health coverage, however, must be offered the opportunity to purchase such coverage (Sec. 10-16-105, as amended by S. 54, L. 1997).
Court-ordered coverage.- A group health benefit plan delivered or issued for delivery within this state by an entity subject to the provisions of part 2, 3, or 4 of this article that provides coverage for mental health services shall provide coverage for mental health services regardless of whether the services are voluntary or court-ordered as a result of contact with the criminal justice or juvenile justice system. The health benefit plan shall be required to provide coverage only for benefits that are medically necessary and otherwise covered under the plan. Such coverage shall be subject to applicable in- or out-of-network copayment, deductible, and policy maximums and limitations. The court order for mental health services shall not mandate the type of mental health services or the length and frequency of treatment that is to be covered by the health benefit plan. The health benefit plan shall only be responsible for those benefits that are covered by the health benefit plan and not those that are court-ordered that exceed the scope of benefits as provided by the health plan. Determination of medically necessary mental health services shall be made by the health benefit plan based on the submitted clinical treatment plan from a provider who is designated by and affiliated with the health benefit plan. Health benefit plans issued by an entity subject to the provisions of part 4 of this article may provide that the benefits required pursuant to this section shall be covered benefits only if the services are deemed medically necessary and are rendered by a provider who is designated by and affiliated with the HMO (Sec. 10-16-104.8, as added by Ch. 52 (S. 5), L. 2006).
Dependent care coverage.- All group sickness and accident insurance policies providing coverage on an expense-incurred basis and all group service or indemnity contracts that provide coverage for a family member of the insured or subscriber must also provide, as to such family coverage, that the health insurance benefits applicable for children are payable with respect to a newborn child of the insured or subscriber from the moment of birth. The same applies for all individual sickness and accident insurance policies providing coverage on an expense-incurred basis and all individual service or indemnity contracts (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Dependent" means a spouse, an unmarried child under age 19, an unmarried child who is a full-time student under age 24 and who is financially dependent upon the parent, and an unmarried child of any age who is medically certified as disabled and dependent upon the parent (Sec. 10-16-102 (14)).
All sickness and accident insurance policies providing coverage within the state that offer dependent coverage shall offer to the parent, for an additional premium if applicable, the same dependent coverage for an unmarried child who is under age 25 and is not a dependent as defined above if the child has the same legal residence as the parent; or is financially dependent upon the parent. Additional premiums, if applicable, shall be paid by the parent or the policyholder, at the discretion of the policyholder (Sec. 10-16-104.3 as added by L. 2005, effective January 1, 2006).
Except as provided below for cleft lip and cleft palate coverage, and for inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic, and fatty acids and for which medically standard methods of diagnosis, treatment, and monitoring exist as described below, the benefits available to newborn children must consist of coverage of injury or sickness, including all medically necessary care and treatment of medically diagnosed congenital defects and birth abnormalities for the first 31 days of the newborn's life, notwithstanding policy limitations and exclusions applicable to other conditions or procedures covered by the policy (Sec. 10-16-104(1)(c)(I), as amended by H. 1156, L. 2001, effective January 1, 2002).
Coverage for inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic, and fatty acids must include, but is not limited to, the following diagnosed conditions: phenylketonuria; maternal phenylketonuria; maple syrup urine disease; tyrosinemia; homocystinuria; histidinemia; urea cycle disorders; hyperlysinemia; glutaric acidemias; methylmalonic acidemia; and propionic acidemia. Covered care and treatment of such conditions includes, to the extent medically necessary, medical foods for home use for which a physician who is a participating provider has issued a written, oral or electronic prescription (Sec. 10-16-104(1)(c)(III), as added by H. 1156, L. 2001, effective January 1, 2002).
There is no age limit on benefits for inherited enzymatic disorders specified just above except for phenylketonuria. The maximum age to receive benefits for phenylketonuria is 21; except that the maximum age to receive benefits for phenylketonuria for women who are of child-bearing age is 35 (Sec. 10-16-104(1)(c)(III), as added by H. 1156, L. 2001, effective January 1, 2002).
“Medical foods” means prescription metabolic formulas and their modular counterparts, obtained through a pharmacy, that are specifically designated and manufactured for the treatment of inherited enzymatic disorders caused by single gene defects involved in the metabolism or amino, organic, and fatty acids and for which medically standard methods of diagnosis, treatment, and monitoring exist. Such formulas are specifically processed or formulated to be deficient in one or more nutrients and are to be consumed or administered enterally either via tube or oral route under the direction of a physician who is a participating provider. This definition does not apply to cystic fibrosis patients or lactose-or soy-intolerant patients (Sec. 10-16-104(1)(c)(III), as added by H. 1156, L. 2001, effective January 1, 2002).
Coverage of medical foods only applies to insurance plans that include an approved pharmacy benefit and does not apply to alternative medicines. Such coverage is only available through participating pharmacy providers (Sec. 10-16-104(1)(c)(III), as added by H. 1156, L. 2001, effective January 1, 2002).
After the first 31 days of life, policy limitations and exclusions that are generally applicable under the policy may apply, except that all group health benefit plans must provide medically necessary physical, occupational and speech therapy for the care and treatment of congenital defects and birth abnormalities for covered children up to five years of age (Sec. 10-16-104(1.7), as added by Ch. 266 (H. 1088), L. 1999, effective January 1, 2000).
It is unlawful to refuse to provide coverage for a dependent child under the health plan of the child's parent for the sole reason that the child (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002):
does not live in the home of the parent applying for the policy; or
does not live in the insurer's service area, notwithstanding any other provision of law restricting enrollment to persons who reside in an insurer's service area; or
was born out of wedlock; or
is not claimed as a dependent on the federal or state income tax return of the child's parent.
Child health supervision services.- An individual, small group, or large group health benefit plan issued in Colorado or covering a Colorado resident that provides coverage for a family member of the insured or subscriber must, as to such family member's coverage, also provide that the health insurance benefits applicable to children include coverage for child health supervision services up to the age of 13. Each such plan must, at a minimum, provide benefits for preventive child health supervision services (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Benefits for child health supervision services must be exempt from a deductible or dollar limit provision in any individual, small group, or large group health benefit plan issued in Colorado or covering a Colorado resident, and such exemption must be explicitly stated in such a plan (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
A local government or political subdivision of Colorado is not required to offer to employees or dependents coverage for child health supervision services in any health benefit plan offered or made available to employees or dependents of the local government or political subdivision (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Child health supervision services need not be provided by multiple employer health trusts or multiple employer welfare arrangements (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Adoption.- When coverage is offered for dependent children under a health plan, benefits must also be provided to a child placed for adoption with an enrollee, policyholder, or subscriber under the same terms and conditions that apply to a natural dependent of an enrollee, policyholder, or subscriber, regardless of whether adoption of the child is final (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Cleft palate.- With regard to newborn children born with cleft lip or cleft palate or both, there may be no age limit on benefits for such conditions, and care and treatment must include to the extent medically necessary: oral and facial surgery, surgical management, and follow-up care by plastic surgeons and oral surgeons; prosthetic treatment such as obturators, speech appliances, and feeding appliances; medically necessary orthodontic treatment; medically necessary prosthodontic treatment; habilitative speech therapy; otolaryngology treatment; and audiological assessments and treatment (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
If a dental insurance policy, a contract for dental insurance, or an enrollee coverage contract is in effect at the time of the birth, or is purchased after the birth, of a child with cleft lip or cleft palate or both, it must provide fully for any orthodontics or dental care needed as a result of the cleft lip or cleft palate or both (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Immunization.- If coverage for pediatric vaccinations was provided on May 1, 1993, the level of the coverage in effect on that date may not be reduced (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Hearing aids.- Effective January 1, 2009, any health benefit plan that provides hospital, surgical, or medical expense insurance, except supplemental policies covering a specified disease or other limited benefit, shall provide coverage for hearing aids for minor children who have a hearing loss that has been verified by a physician, and by an audiologist. The hearing aids shall be medically appropriate to meet the needs of the child according to accepted professional standards. Coverage shall include the purchase of the following (Sec. 10-16-104(19)(b), as amended by S. 57, L. 2008):
Initial hearing aids and replacement hearing aids not more frequently than every five years;
A new hearing aid when alterations to the existing hearing aid cannot adequately meet the needs of the child;
Services and supplies including, but not limited to, the initial assessment, fitting, adjustments, and auditory training that is provided according to accepted professional standards.
Preventive colorectal cancer health care services.- The following policies and contracts delivered, issued, renewed, or reinstated on or after July 1, 2009, must provide coverage for the total cost of preventive health care services listed below. Coverage must not be subject to policy deductibles but coinsurance and copayments may apply. For managed care organizations that provide health care services directly to enrollees, deductibles, copayments and coinsurance and any other cost sharing may not exceed 10 percent of the required preventive care.
individual and group sickness and accident insurance policies, except supplemental policies covering a specified disease or limited benefit delivered or issued by an entity subject to Part 2 (sickness and accident insurance) of Article 16.
individual and group health care service or indemnity contracts issued by entities subject to Parts 3 (nonprofit corporations) or 4 (health maintenance organizations) of Article 16, and
any other individual or group health care coverage offered to state residents.
Basic health benefit plans issued under Secs. 16-16-105 (7.2)(b)(I), (7.2)(b)(III), or (7.2)(B)(IV) are excluded.
Covered services for colorectal cancer and adenomatous polyps include coverage for “A recommendation” and “B recommendation”tests for asymptomatic, average risk adults of 50 years or older and covered persons who are at high risk such as persons with a family medical history of colorectal cancer, a prior occurrence of cancer or precursor neoplastic polyps, a prior occasion of a chronic digestive disease condition including inflammatory bowel disease, Crohn's disease, or ulcerative colitis, or other predisposing factors determined by the provider (Sec. 10-16-104, as amended by H. 1410, L. 2008).
Substance abuse coverage.- Any other provision of law to the contrary notwithstanding, no hospitalization or medical benefits contract on a group basis may be sold in Colorado unless the policyholder under such contract or persons holding the master contract under such contract are offered the opportunity to purchase coverage for benefits for the treatment of and for conditions arising from alcoholism, which benefits are at least equal to the following minimum requirements (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002):
In the case of benefits that are based upon a person's confinement as an inpatient in an accredited or licensed hospital, or in any other public or private facility or portion thereof, that provides services especially for the treatment of alcoholics and that is licensed by the Department of Human Services for those services, such benefits must be not less than 45 days in any calendar year.
Each day of confinement as an inpatient reduces by one day the total days available for all other illnesses during any one 12-month-benefit period.
Each day of confinement as an inpatient reduces by one day the available days provided for mental health coverage (see above).
Copayment requirements for the treatment of alcoholism must not exceed a 50 percent copayment requirement, and deductible amounts must not differ from the deductible amount for any other condition or illness. Benefits will not be payable unless the patient having the coverage has completed the full continuum of care, including detoxification and rehabilitation (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Outpatient services.- Outpatient benefits must cover, to the extent of $500 over a 12-month period, services furnished by (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002):
an accredited or licensed hospital; or
any public or private facility or portion thereof providing services especially for the treatment of alcoholics that is licensed by the Department of Human Services for those purposes; or
any mental health facility approved as such by the Department of Human Services.
Court-ordered treatment coverage.- Effective January 1, 2003, group health benefit plans delivered or issued for delivery within Colorado that provide coverage for substance abuse treatment must provide coverage for such treatment regardless of whether the treatment is voluntary or court-ordered as a result of contact with the criminal justice or legal system (Sec. 10-16-104.7, as added by H. 1263, L. 2002, effective January 1, 2003).
Medical use of marijuana.- On November 7, 2000, Colorado voters approved an amendment to the state constitution authorizing the medical use of marijuana for persons suffering from debilitating medical conditions. The amendment does not, however, require health insurers to be liable for any claim for reimbursement for the medical use of marijuana (Amendment 20, effective December 28, 2000).
See also ¶6-2600 .
Recreational activities.- Health insurers may not deny coverage to an individual based solely on that individual's casual or nonprofessional participation in motorcycling, snowmobiling, off-road vehicle riding, or, effective January 1, 2003, skiing or snowboarding (Sec. 10-3-1104, as amended by S. 107, L. 2002, effective January 1, 2003).
Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, health maintenance organizations, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language, however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.
The following types of plans must specify how benefits will be coordinated: group insurance, group subscriber contracts, uninsured arrangements of group or group-type coverages, group or group-type coverage through a health maintenance organization (HMO), and other prepayment, group practice, and individual practice plans, group-type contracts available to a membership in a particular organization or group if the individual does not have a right to maintain or renew the policy independent of continued employment with an employer, group or group-type excess hospital indemnity benefits exceeding $100 per day, group or group-type or individual “no fault” and “fault” contracts, or Medicare or other governmental benefits. A plan does not include: individual or family insurance or subscriber contracts, individual HMO coverage, individual or family coverage through prepayment, group practice, or individual practice plans, group or group-type hospital indemnity benefits of $100 per day or less, school accident-type coverages, or a state plan under Medicaid (Code of Colorado Regulations 4-6-2, 3 CCR 702-4, 16 CR 7, 7-93 (formerly 86-3), as authorized by Colorado Revised Statutes Sec. 10-1-109).
Order of benefits.- The following priority applies when coordinating health benefit payments as Colorado adopts the NAIC model language by reference (Code of Colorado Regulations 4-6-2):
Employee/Dependent: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;
Dependent Child/Birthday Rule: For a dependent child covered by two health benefit plans, health maintenance organizations, or health insurance policies whose parents are not separated or divorced, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time. If only one plan specifies the birthday rule and the other plan specifies priority based on the gender of the parent, benefits will be paid first according to the order of benefits specified in the plan without the birthday rule;
Dependent Child/Divorced or Separated Parents: For a dependent child covered by two health benefit plans, health maintenance organizations, or health insurance policies whose parents are separated or divorced, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent. If the specific terms of the court decree state that the parents will share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child follow the order of benefit determination rules specified in the birthday rule;
Active/Inactive Employee: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored;
Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time;
Continuation Coverage: For an individual covered by two health benefit plans, health maintenance organizations, or health insurance policies, one of which is a COBRA continuation plan, benefits will be paid first by the plan that covers the individual as an employee, member, or subscriber or as the employee's dependent, second as a former employee or as the former employee's dependent, and third under the COBRA continuation coverage. If only one of the two plans specifies this rule, this standard is ignored; and
Excess Benefits: A complying plan may coordinate its benefits with a plan that is “excess” or “always secondary” or that uses an order of benefit determination provision that is inconsistent with that contained in this rule (called a noncomplying plan), on the following basis: if the complying plan is the primary plan, it must pay or provide its benefits on a primary basis. If the complying plan is the secondary plan, it must still pay or provide its benefits first, as the secondary plan. In such a situation, such payment is the limit of the complying plan's liability, except if the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within a reasonable time after it is requested to do so, the complying plan may assume that the benefits of the noncomplying plan are identical to its own and pay its benefits accordingly. The complying plan must adjust any payments it makes based on such assumption when information becomes available about the actual benefits of the noncomplying plan. If the noncomplying plan pays less in benefits than it would have if the noncomplying plan paid or provided its benefits as the primary plan, the complying plan must advance an amount equal to such difference.
Maintenance of benefits.- A plan that pays benefits on a secondary basis may reduce benefits payable so that the total benefits paid by all plans do not exceed allowable expenses (Code of Colorado Regulations 4-6-2).
Medicare coordination.- A group contract may not reduce benefits if a person is or could be covered under another plan, except for Part B of Medicare (Code of Colorado Regulations 4-6-2).
Providers.- Notwithstanding any provisions of any policy of sickness and accident insurance, whenever any such policy provides for reimbursement for any service that may be lawfully performed by a person licensed in Colorado for the practice of osteopathy, medicine, dentistry, optometry, psychology, chiropractic, or podiatry, reimbursement under such policy may not be denied when such service is rendered by a person so licensed. The licensed persons who may not be denied reimbursement include registered professional nurses and licensed clinical social workers (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Preexisting conditions.- A group health benefit plan that covers residents of Colorado may not deny, exclude, or limit benefits for a covered individual because of a preexisting condition for losses incurred more than six months following the date of enrollment of the individual in such plan or, if earlier, the first day of the waiting period for such enrollment. A group health benefit plan may impose a preexisting condition exclusion or limitation only if such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within six months immediately preceding the effective date of coverage. A group health benefit plan may not impose any preexisting condition exclusion in the case of a child that is adopted or placed for adoption before attaining 18 years of age, or relating to pregnancy (Sec. 10-16-118, as amended by S. 54, L. 1997, effective July 1, 1997).
A health maintenance organization that covers Colorado residents and that does not utilize preexisting condition limitations in any health benefit plan may impose an “affiliation period” that runs concurrently with any waiting period. An HMO may, in lieu of an affiliation period, use an alternative method to address adverse selection with the prior approval of the Commissioner of Insurance (Sec. 10-16-118, as amended by S. 54, L. 1997, effective July 1, 1997).
Except for waiting periods applicable to all new enrollees under a plan, a health coverage plan that covers Colorado residents must waive any affiliation period or time period applicable to a preexisting condition exclusion or limitation period for the period of time an individual was previously covered by creditable coverage if such creditable coverage was continuous to a date not more than 90 days prior to the effective date of the new coverage. The period of continuous coverage may not include any waiting period for the effective date of the new coverage (Sec. 10-16-118, as amended by S. 54, L. 1997, effective July 1, 1997).
A health coverage plan that covers Colorado residents will exclude coverage for late enrollees for the greater of 12 months or for no more than an 18-month preexisting condition exclusion. If both a period of exclusion from coverage and a preexisting condition exclusion are applicable to a late enrollee, the combined period may not exceed 18 months from the date the individual enrolls for coverage under the plan. HMOs that do not use preexisting condition exclusion periods in any of their plans may impose up to a three-month affiliation period in lieu of the 18-month preexisting condition period (Sec. 10-16-118, as amended by S. 54, L. 1997, effective July 1, 1997).
Mammograms.- All individual and all group sickness and accident insurance policies, except supplemental policies covering a specified disease or other limited benefit, that are delivered or issued for delivery within Colorado and all individual and group health care service or indemnity contracts, as well as any other group health care coverage provided to Colorado residents, must provide coverage for routine and certain diagnostic screening by low-dose mammography for the presence of breast cancer in adult women. Routine and diagnostic screenings must be provided on a contract year or a calendar year basis and are not subject to policy deductibles. Such coverages must be the lesser of $60 per mammography screening or the actual charge for such screening. The minimum benefit required must be adjusted to reflect increases and decreases in the consumer price index. This mandated mammography coverage must be provided according to the following guidelines (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002):
provision of a single baseline mammogram for women 35 to under 40 years of age;
screening not less than once every two calendar years or contract years for women 40 to under 50 years of age, as specified in the insured's policy or contract, but at least once each such calendar year or contract year for a woman with risk factors to breast cancer as determined by a physician;
annual screening, on a calendar year or contract year basis, for women who are 50 to 65 years of age.
Nurse-midwives.- Managed care plans must provide women with direct access to an advanced practice nurse who is a certified midwife for reproductive health and gynecological care (Sec. 10-16-107(5)(a) and (b)(I)).
Maternity benefits.- All group sickness and accident insurance policies providing coverage within Colorado and issued to an employer and all group health service contracts issued to an employer must insure against the expense of normal pregnancy and childbirth or provide coverage for maternity care therefor in the same manner as any other sickness, injury, disease or condition is otherwise covered under the policy or contract. Policies or contracts may not exclude coverage for pregnancy and delivery expenses on the grounds that pregnancy was a preexisting condition (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Exceptions.- The requirement to provide coverage for normal pregnancy and childbirth does not apply to policies or contracts purchased by employers who employ any number of full-time or part-time employees in fewer than 15 full-time employee positions or to employers who employ any number of full-time or part-time employees for not more than six consecutive months each year on a seasonal basis if such coverage is provided by the employer in one of the following methods (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002):
self-insurance (all employers who so elect to utilize self-insurance for providing this benefit must provide written notice to affected employees and to the health insurance carrier of its choice to self-insure);
a policy purchased from an insurance company authorized to do business in Colorado that meets all of the requirements of the Division of Insurance for that purpose;
a contract issued by a nonprofit hospital, medical-surgical or health service corporation, or by a health maintenance organization;
a combination of the methods of obtaining insurance authorized in items (1) through (3) above.
Coverage for maternity care must be offered on an equal basis to both married and unmarried women (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Complications of pregnancy and childbirth.- Any sickness and accident insurance policy providing indemnity for disability due to sickness or coverage for sickness on an expense-incurred basis and any individual or group service or indemnity contract must provide coverage for a sickness or disease that is a complication of pregnancy or childbirth in the same manner as any other similar sickness or disease is otherwise covered under the policy or contract. Any sickness and accident insurance policy providing indemnity for disability due to accident must provide coverage for an accident that occurs during the course of pregnancy or childbirth in the same manner as any other similar accident is covered under the policy (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Hospital stay.- Coverage for a hospital stay for a mother and her newborn following a normal vaginal delivery must not be limited to less than 48 hours. If 48 hours following delivery falls after 8:00 p.m., coverage must continue until 8:00 a.m. the following morning. Coverage for a hospital stay following a cesarean section must not be limited to less than 96 hours. If 96 hours following the cesarean section falls after 8:00 p.m., coverage must continue until 8:00 a.m. the following morning (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
These provisions do not apply in any case in which the decision to discharge prior to the minimum length of stay otherwise required is made by an attending provider with the agreement of the mother (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Domestic abuse victims.- Health insurers may not deny, refuse to issue, refuse to renew, refuse to reissue, cancel, or otherwise terminate an insurance policy or restrict coverage on any person solely because of that person's domestic abuse status (Sec. 10-3-1104.8, as added by S. 72, L. 1997, effective January 1, 1998).
Cervical cancer vaccinations.- Group sickness and accident insurance policies, except supplemental policies covering a specified disease or other limited benefit, that are delivered or issued for delivery within Colorado by an entity subject to the provisions of Part 2 of this article and all group health care service or indemnity contracts issued by an entity subject to the provisions of Part 3 or 4 of this article, as well as any other group health care coverage offered to residents of Colorado, shall provide coverage for the full cost of cervical cancer vaccination for all females for whom a vaccination is recommended by the advisory committee on immunization practices of the U.S. Department of Health and Human Services (Sec. 10-16-104(17)(a), as added by H. 1301, L. 2007).
The requirements of Sec. 10-16-104(17) shall apply to all group accident and sickness policies and group health care service or indemnity contracts issued, renewed, or reinstated on or after January 1, 2008 (Sec. 10-16-104(17)(b), as added by H. 1301, L. 2007).
Prostate cancer screening.- All group sickness and accident insurance policies, except supplemental policies covering a specified disease or other limited benefit, that are delivered or issued for delivery within Colorado and all individual and group health care service or indemnity contracts, as well as any other group health care coverage offered to Colorado residents, must provide coverage for annual screening for the early detection of prostate cancer in men over the age of 50 years and in men over the age of 40 years who are in high-risk categories. Coverage must be the lesser of $65 per prostate cancer screening or the actual charge for such screening. This benefit cannot diminish or limit diagnostic benefits otherwise allowable under a policy. This coverage must be provided according to the following guidelines (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002):
The screening must be performed by a qualified medical professional, including without limitation urologist, internist general practitioner, doctor of osteopathy, nurse practitioner or physician assistant.
The screening must consist, at a minimum, of the following tests: a prostate-specific antigen (“PSA” ) blood test and a digital rectal examination.
At least one screening per year must be covered for any man 50 years of age or older.
At least one screening per year must be covered for any man from 40 to 50 years of age who is at increased risk of developing prostate cancer as determined by a physician.
Orthotic and prosthetic devices.- Effective January 1, 2001, any health benefit plan, except supplemental policies covering a specified disease or other limited benefit, that provides hospital, surgical, or medical expense insurance must provide coverage for benefits for prosthetic devices that equal those benefits provided for under federal laws for health insurance for the aged and disabled (Sec. 10-16-104(14)(a), as added by H. 1478, L. 2000, effective January 1, 2001).
Home health care benefits.- Notwithstanding any other provision of the law to the contrary, no individual or group policy of sickness and accident insurance and no plan that provides hospital, surgical, or major medical coverage on an expense-incurred basis may be sold in Colorado unless a policyholder under such policy or plan is offered the opportunity to purchase coverage for benefits for the costs of home health services that have been recommended by a physician as medically necessary (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Exceptions.- This requirement does not apply to any insurance policy, plan, contract, or certificate that provides coverage exclusively for disability loss of income, dental services, optical services, hospital confinement indemnity, accident only, or prescription drug services (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Hospice services.- Notwithstanding any other provision of the law to the contrary, no individual or group policy of sickness and accident insurance and no plan that provides hospital, surgical, or major medical coverage on an expense-incurred basis may be sold in Colorado unless a policyholder under such policy or plan is offered the opportunity to purchase coverage for benefits for the costs of hospice care that have been recommended by a physician as medically necessary (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Exceptions.- This requirement does not apply to any insurance policy, plan, contract, or certificate that provides coverage exclusively for disability loss of income, dental services, optical services, hospital confinement indemnity, accident only, or prescription drug services (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
Autism.- Any sickness and accident insurance policy providing indemnity for disability due to sickness and any individual or group service or indemnity contracts that provide coverage for autism must provide such coverage in the same manner as for any other accident or sickness, other than mental illness, otherwise covered under such policy (Sec. 10-16-104.5).
Standing referrals.- Effective July 1, 1999, every contract between a carrier or entity that contracts with a carrier and a participating provider for a managed care plan that requires preauthorization for particular services, treatments or procedures must include a provision that allows a covered person to receive a standing referral, for medically necessary treatment, to a specialist or specialized treatment center participating in the carrier's network (Sec. 10-16-705(14), as amended by Ch. 111 (S. 141), L. 1999).
Utilization review.- To promote delivery of quality health care in a cost-effective manner, assure that utilization review agents adhere to reasonable standards, foster coordination and cooperation between health care providers and utilization review agents, improve communication among all parties, and ensure that medical records are kept confidential, Colorado requires utilization review agents to be certified annually and adhere to minimum standards (Sec. 10-16-112).
Beneficiaries.- Effective July 1, 2009, Colorado law will grant unmarried persons the right to designate each other as beneficiaries for health insurance and retirement benefits purposes (H. 1260, L. 2009).
NOTICE
Maternity benefits: Small employers.- Small employers who elect to utilize self-insurance for providing maternity benefits must provide written notice to affected employees and to the health insurance carrier of their choice to self-insure (Sec. 10-16-104, as amended by H. 1156, L. 2001, effective January 1, 2002).
<p>Maternity benefits: Small employers.— Small employers who elect to utilize self-insurance for providing maternity benefits must provide written notice to affect</p>
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