As used in this article 16, unless the context
otherwise requires:
(1) Actuarial certification means a written statement by a member of the
American academy of actuaries or other individual acceptable to the commissioner
that a small employer carrier is in compliance with the provisions of part 10 of this
article, based upon the person's examination, including a review of the appropriate
records and of the actuarial assumptions and methods used by the small employer
carrier in establishing premium rates for applicable health benefit plans.
(2) Affiliate or affiliated means any entity or person that directly or
indirectly, through one or more intermediaries, controls or is controlled by, or is
under common control with, a specified entity or person.
(3) Affiliation period means a period of time, not to exceed two months,
during which a health maintenance organization does not collect premiums and
coverage issued is not yet effective.
(4) Basic health-care services means health-care services that an enrolled
population of a health maintenance organization organized pursuant to the
provisions of part 4 of this article might reasonably require in order to maintain
good health, including, at a minimum, emergency care, inpatient and outpatient
hospital services, physician services, outpatient medical services, and laboratory
and X-ray services.
(5) Benefits ratio means the ratio of the value of the actual benefits, not
including dividends, to the value of the actual premiums, not reduced by dividends,
over the entire period for which rates are computed to provide coverage. Benefits
ratio is also known as targeted loss ratio.
(6) Bona fide association means, with respect to health insurance coverage
offered in Colorado, an association that:
(a) Has been actively in existence for at least five years;
(b) Has been formed and maintained in good faith for purposes other than
obtaining insurance and does not condition membership on the purchase of
association-sponsored insurance;
(c) Does not condition membership in the association on any health-status-related factor relating to an individual, including an employee of an employer or a
dependent of an employee, and clearly so states in all membership and application
materials;
(d) Makes health insurance coverage offered through the association
available to all members regardless of any health-status-related factor relating to
the members or individuals eligible for coverage through a member and clearly so
states in all marketing and application materials;
(e) Does not make health insurance coverage offered through the
association available other than in connection with a member of the association and
clearly so states in all marketing and application materials; and
(f) Provides and annually updates information necessary for the
commissioner to determine whether or not an association meets the definition of a
bona fide association before qualifying as a bona fide association for the purposes
of this article.
(7) Bona fide volunteer:
(a) Has the meaning set forth in section 31-30-1202, C.R.S.;
(b) Means any volunteer member of a not-for-profit nongovernmental entity
that is organized to provide firefighting services, emergency medical services, or
ambulance services; and
(c) Means any volunteer member of a rescue unit as defined in section 25-3.5-103, C.R.S.
(8) 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 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 the insurance laws and rules of
Colorado.
(9) (a) Case characteristics means demographic characteristics that are
considered by the carrier in the determination of premium rates for individuals and
small employers.
(b) Case characteristics are limited to the following demographic
characteristics, as further defined and determined by the commissioner by rule:
(I) The age of covered individuals;
(II) Geographic location of the policyholder;
(III) Family size; and
(IV) Tobacco use.
(10) Catastrophic plan means an individual health benefit plan that does
not provide a bronze, silver, gold, or platinum level of coverage, as those coverage
levels are described in section 10-16-103.4, and is available only to individuals under
thirty years of age or who meet the eligibility requirements in federal law for
participation in a catastrophic plan.
(11) Child-only plan means a health benefit plan issued on or after April 29,
2011, that provides coverage to an individual under twenty-one years of age. A
child-only plan does not include coverage provided to a dependent under an
individual or group health benefit plan.
(12) Church plan has the same meaning as set forth in 29 U.S.C. sec. 1002
(33) of the federal Employee Retirement Income Security Act of 1974.
(13) Commissioner means the commissioner of insurance.
(14) Control has the same meaning as set forth in section 10-3-801 (3).
(15) Covered person means a person entitled to receive benefits or services
under a health coverage plan.
(16) Creditable coverage means benefits or coverage provided under:
(a) Medicare, the Colorado Medical Assistance Act, articles 4 to 6 of title
25.5, C.R.S., or the children's basic health plan established pursuant to article 8 of
title 25.5, C.R.S.;
(b) An employee welfare benefit plan or group health insurance or health
benefit plan;
(c) An individual health benefit plan;
(d) A state health benefits risk pool; or
(e) Chapter 55 of title 10 of the United States Code, a medical care program
of the federal Indian health service or of a tribal organization, a health plan offered
under chapter 89 of title 5, United States Code, a public health plan, or a health
benefit plan under section 5 (e) of the federal Peace Corps Act, 22 U.S.C. sec.
2504 (e).
(16.5) Dementia diseases and related disabilities is a condition where
mental ability declines and is severe enough to interfere with an individual's ability
to perform everyday tasks. Dementia diseases and related disabilities includes
Alzheimer's disease, mixed dementia, Lewy body dementia, vascular dementia,
frontotemporal dementia, and other types of dementia.
(17) Dependent means a spouse, a partner in a civil union, an unmarried
child under nineteen years of age, an unmarried child who is a full-time student
under twenty-four years of age 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. Dependent includes a designated beneficiary, as
defined in section 15-22-103 (1), C.R.S., if an employer elects to cover a designated
beneficiary as a dependent.
(17.5) EISA means the federal Employee Retirement Income Security Act
of 1974, 29 U.S.C. sec. 1001 et seq.
(18) (a) Eligible employee means a full-time employee in a bona fide
employer-employee relationship with an employer that has not been established for
the purpose of obtaining a small group plan. The term does not include:
(I) An employee who works on a temporary or substitute basis;
(II) An individual and his or her spouse or partner in a civil union with respect
to a trade or business, whether incorporated or unincorporated, that is wholly
owned by the individual or by the individual and his or her spouse or partner in a civil
union; or
(III) A partner in a partnership and his or her spouse or partner in a civil union
with respect to the partnership; except that a partner and his or her spouse or
partner in a civil union may participate in a small group plan established to cover
one or more eligible employees of the partnership who are not partners in the
partnership.
(b) Notwithstanding any provision of law to the contrary, an eligible
employee of a small employer who could also be considered a dependent of the
small employer must receive taxable income from the small employer in an amount
equivalent to minimum wage for working full-time on a permanent basis in order to
be considered an employee of the small employer.
(c) Nothing in this subsection (18) limits the employer's traditional ability to
set valid and acceptable standards for employee eligibility based on the terms and
conditions of employment, including a minimum weekly work requirement in excess
of thirty hours and eligibility based upon salaried versus hourly workers and
management versus nonmanagement employees.
(19) Emergency service provider means a local government, or an authority
formed by two or more local governments, that provides firefighting and fire
prevention services, emergency medical services, ambulance services, or search
and rescue services, or a not-for-profit nongovernmental entity organized for the
purpose of providing any of those services through the use of bona fide volunteers.
(20) Enrollee means:
(a) An individual who is or has been enrolled in a health maintenance
organization;
(b) An individual who is or has been enrolled in an individual or group prepaid
dental care plan as a principal subscriber and includes the individual's dependents
who are entitled to prepaid dental care services under the plan solely because of
their status as dependents of the principal subscriber; or
(c) An individual who is or has been enrolled in a health coverage plan.
(21) Enrollee coverage means a health coverage plan issued pursuant to
this article to an enrollee setting out the coverage to which the enrollee is entitled
under the health coverage plan.
(22) (a) Essential health benefits has the same meaning as set forth in
section 1302 (b) of the federal Patient Protection and Affordable Care Act, as
amended, Pub.L. 111-148;
(b) Essential health benefits includes:
(I) Ambulatory patient services;
(II) Emergency services;
(III) Hospitalization;
(IV) Laboratory services;
(V) Maternity and newborn care;
(VI) Behavioral, mental health, and substance use disorder services,
including behavioral health treatment;
(VII) Pediatric services, including oral and vision care;
(VIII) Prescription drugs;
(IX) Preventive and wellness services and chronic disease management; and
(X) Rehabilitative and habilitative services and devices.
(23) Essential health benefits package means the essential health benefits
package required under section 1302 (a) of the federal act and includes coverage
that:
(a) Provides for the essential health benefits;
(b) Limits cost sharing for this coverage in accordance with section 1302 (c)
of the federal act; and
(c) For individual and small employer health benefit plans, provides bronze,
silver, gold, or platinum levels of coverage described in section 1302 (d) of the
federal act, as specified in section 10-16-103.4.
(24) Established geographic service area means the entire state of
Colorado or, for plans that do not cover the entire state, any county within which the
carrier is authorized to have arrangements established with providers to provide
services.
(25) Evidence of coverage means any certificate, agreement, or contract
issued to an enrollee by a health maintenance organization setting out the coverage
to which the enrollee is or was entitled.
(26) Exchange means the Colorado health benefit exchange created in
article 22 of this title.
(27) Executive director means the executive director of the department of
public health and environment.
(27.5) FDA means the food and drug administration in the United States
department of health and human services, or any successor entity.
(28) Federal act means the federal Patient Protection and Affordable
Care Act, Pub.L. 111-148, as amended by the federal Health Care and Education
Reconciliation Act of 2010, Pub.L. 111-152, and as may be further amended,
including any federal regulations adopted under the federal act.
(29) Federal law includes the federal act, PHA, HIPAA, EISA, and any
federal regulation implementing these federal acts.
(30) Government plan has the same meaning as set forth in 29 U.S.C. sec.
1002 (32) of the federal Employee Retirement Income Security Act of 1974, and
as in any federal governmental plan.
(31) Grandfathered health benefit plan means a health benefit plan
provided to an individual or employer by a carrier on or before March 23, 2010, for
as long as it maintains that status in accordance with federal law and includes any
extension of coverage under an individual or employer health benefit plan that
existed on or before March 23, 2010, to a dependent of an individual enrolled in the
plan or to a new employee and his or her dependents who enroll in the employer
health benefit plan. This article, as it existed prior to May 13, 2013, applies to
grandfathered health benefit plans on and after May 13, 2013.
(32) (a) Health benefit plan means any hospital or medical expense policy
or certificate, hospital or medical service corporation contract, or health
maintenance organization subscriber contract or any other similar health contract
subject to the jurisdiction of the commissioner available for use, offered, or sold in
Colorado.
(b) Health benefit plan does not include:
(I) Accident only;
(II) Credit;
(III) Dental;
(IV) Vision;
(V) Medicare supplement;
(VI) Benefits for long-term care, home health care, community-based care, or
any combination thereof;
(VII) Disability income insurance;
(VIII) Liability insurance including general liability insurance and automobile
liability insurance;
(IX) Coverage for on-site medical clinics;
(X) Coverage issued as a supplement to liability insurance, workers'
compensation, or similar insurance;
(XI) Automobile medical payment insurance; or
(XII) Specified disease, hospital confinement indemnity, or limited benefit
health insurance if the types of coverage do not provide coordination of benefits
and are provided under separate policies or certificates.
(c) Solely with respect to section 10-16-118, health benefit plan excludes
individual short-term limited duration health insurance policies.
(33) Health-care services means any services included in or incidental to
the furnishing of medical, behavioral, mental health, or substance use disorder;
dental, or optometric care; hospitalization; or nursing home care to an individual, as
well as the furnishing to any person of any other services for the purpose of
preventing, alleviating, curing, or healing human physical illness or injury, or
behavioral, mental health, or substance use disorder. Health-care services
includes the rendering of the services through the use of telehealth, as defined in
section 10-16-123 (4)(e).
(34) Health coverage plan means a policy, contract, certificate, or
agreement entered into, offered, or issued by a carrier to provide, deliver, arrange
for, pay for, or reimburse any of the costs of health-care services.
(35) Health maintenance organization means any person who:
(a) Provides, either directly or through contractual or other arrangements
with others, health-care services to enrollees; and
(b) Provides, either directly or through contractual or other arrangements
with other persons, health-care services, including, at a minimum, emergency care,
inpatient and outpatient hospital services, physician services, outpatient medical
services, and laboratory and X-ray services; and
(c) Is responsible for the availability, accessibility, and quality of the health-care services provided or arranged.
(36) Health status means the determination by a carrier of the past,
present, or expected risk of an individual or the employer due to the health
conditions of the individual or the employees of the employer.
(37) Health-status-related factor means any of the following factors:
(a) Health status;
(b) Medical condition, including both physical illnesses and mental health
disorders;
(c) Claims experience;
(d) Receipt of health care;
(e) Medical history;
(f) Genetic information;
(g) Evidence of insurability, including conditions arising out of acts of
domestic violence; and
(h) Disability.
(38) Hearing aid means amplification technology that optimizes audibility
and listening skills in the environments commonly experienced by the patient,
including a wearable instrument or device designed to aid or compensate for
impaired human hearing. Hearing aid includes any parts or ear molds.
(38.3) HIPAA means the federal Health Insurance Portability and
Accountability Act of 1996, Pub.L. 104-191.
(38.5) HIV prevention drug means preexposure prophylaxis, post-exposure
prophylaxis, or other drugs approved by the FDA for the prevention of HIV infection.
(39) Index rate means the premium rate established for a market segment
based on the total combined claims costs for providing essential health benefits
within the single risk pool of that market segment.
(40) Intermediary means a person authorized by health-care providers to
negotiate and execute provider contracts with carriers on behalf of such providers.
(40.5) (a) [ Editor's note: This version of the introductory portion to
subsection (40.5)(a) is effective until January 1, 2026. ] Large employer means
any person, firm, corporation, partnership, or association that:
(40.5) (a) [ Editor's note: This version of the introductory portion to
subsection (40.5)(a) is effective January 1, 2026. ] Large employer means any
person that:
(I) Is actively engaged in business;
(II) [ Editor's note: This version of subsection (40.5)(a)(II) is effective until
January 1, 2026. ] Employed an average of more than one hundred eligible
employees on business days during the immediately preceding calendar year,
except as provided in subsection (40.5)(c) of this section; and
(II) [ Editor's note: This version of subsection (40.5)(a)(II) is effective January
1, 2026. ] Employed an average of more than fifty eligible employees on business
days during the immediately preceding calendar year, except as provided in
subsection (40.5)(c) of this section; and
(III) Was not formed primarily for the purpose of purchasing insurance.
(b) For purposes of determining whether an employer is a large employer,
the number of eligible employees is calculated using the method set forth in 26
U.S.C. sec. 4980H (c)(2)(E).
(c) In the case of an employer that was not in existence throughout the
preceding calendar quarter, the determination of whether the employer is a large
employer is based on the average number of employees that the employer is
reasonably expected to employ on business days in the current calendar year.
(d) The following employers are single employers for purposes of
determining the number of employees:
(I) A person or entity that is a single employer pursuant to 26 U.S.C. sec. 414
(b), (c), (m), or (o); and
(II) An employer and any predecessor employer.
(41) Licensed health-care provider has the same meaning as in section 10-4-601.
(42) Local government means any city, county, city and county, special
district, or other political subdivision of this state.
(43) Managed care plan means a policy, contract, certificate, or agreement
offered by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the
costs of health-care services through the covered person's use of health-care
providers managed by, owned by, under contract with, or employed by the carrier
because the carrier either requires the use of or creates incentives, including
financial incentives, for the covered person's use of those providers.
(43.5) MHPAEA means the federal Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008, Pub.L. 110-343, as
amended, and all of its implementing and related regulations.
(44) Minor child means any person under eighteen years of age.
(45) Network means a group of participating providers providing services
to a managed care plan. For the purposes of part 7 of this article, any subdivision or
subgrouping of a network is considered a network if covered individuals are
restricted to the subdivision or subgrouping for covered benefits under the
managed care plan.
(46) Participating provider means a provider, either within or outside of
Colorado, that, under a contract with a carrier or with its contractor or
subcontractor, has agreed to provide health-care services to covered persons with
an expectation of receiving payment, other than coinsurance, copayments, or
deductibles, directly or indirectly, from the carrier.
(47) Patient with diabetes means a person with elevated blood glucose
levels who has been diagnosed as having diabetes by an appropriately licensed
health-care professional.
(48) Person means any individual, partnership, association, trust, or
corporation and includes any hospital licensed or certified in this state, independent
practice association of physicians, or professional service corporation for the
practice of medicine.
(48.5) PHA means the federal Public Health Service Act, 42 U.S.C. sec.
201 et seq.
(49) (a) Pharmacy benefit management firm, pharmacy benefit manager,
or PBM means any entity doing business in this state that administers or manages
prescription drug benefits, including claims processing services and other
prescription drug or device services as defined in section 10-16-122.1, on behalf of
any carrier that provides prescription drug benefits to residents of this state, either
pursuant to a contract with the carrier or as an entity that is related to, associated
by common or other ownership with, or otherwise associated with the carrier.
(b) Pharmacy benefit management firm, pharmacy benefit manager, or
PBM does not include:
(I) A health-care facility licensed or certified by the department of public
health and environment pursuant to section 25-1.5-103 (1)(a);
(II) A provider;
(III) A consultant who only provides advice as to the selection or
performance of a pharmacy benefit management firm; or
(IV) A nonprofit health maintenance organization that offers managed care
plans that provide a majority of covered professional services through a single,
contracted medical group and that operates its own pharmacies.
(50) Policy of sickness and accident insurance means any policy or
contract of insurance against loss or expense resulting from the sickness of the
insured, the bodily injury or death of the insured by accident, or both.
(50.5) Post-exposure prophylaxis means a drug or drug combination that
meets the same clinical eligibility recommendations provided in CDC guidelines, as
defined in section 12-280-125.7.
(50.7) Preexposure prophylaxis means a drug or drug combination that
meets the same clinical eligibility recommendations provided in CDC guidelines, as
defined in section 12-280-125.7.
(51) Premium means all moneys paid as a condition of receiving coverage
from a carrier, including any fees or other contributions associated with the health
benefit plan.
(52) Prepaid dental care plan means any contractual arrangement through
an entity organized pursuant to part 5 of this article to provide, either directly or
through arrangements with others, dental care services to enrollees on a fixed
prepayment basis or as a benefit of the enrollees' participation or membership in
any other contract, agreement, or group.
(53) Prepaid dental care plan organization means any person who
undertakes to conduct one or more prepaid dental care plans providing only dental
care services.
(54) Prepaid dental care services means services included in the practice
of dentistry, as defined in article 220 of title 12, that are provided to enrollees under
a prepaid dental care plan.
(55) Producer means a person licensed by the division who solicits,
negotiates, effects, procures, delivers, renews, continues, services, or binds health
benefit plans and is licensed to conduct these activities in Colorado.
(56) Provider means any physician, dentist, optometrist, anesthesiologist,
hospital, X ray, laboratory and ambulance service, or other person who is licensed
or otherwise authorized in this state to furnish health-care services.
(57) Rate increase means an increase in the current rate.
(58) Rating period means the calendar period for which premium rates
established by a carrier are assumed to be in effect.
(59) Restricted network provision means any provision of an individual or
group health benefit plan that conditions the payment of benefits, in whole or in
part, on the use of health-care providers that have entered into a contractual
arrangement with the carrier to provide health-care services to covered individuals.
(59.5) Rural independent pharmacy means a prescription drug outlet that
is privately owned by at least one licensed pharmacist with no ownership interest
by or affiliation with a chain pharmacy or a publicly traded prescription drug outlet.
(60) Short-term limited duration health insurance policy or short-term
policy means a nonrenewable individual health benefit plan with a specified
duration of not more than six months that meets the following requirements:
(a) The policy is issued only to individuals who have not had more than one
short-term policy providing the same or similar nonrenewable coverage from any
carrier within the past twelve months and so states in all marketing materials,
application forms, and policy forms. An applicant is eligible for coverage if a short-term carrier includes in its application form the following:
Have you or any other person to be insured been covered under two or more
nonrenewable short-term policies during the past twelve months? If yes, then this
policy cannot be issued. You must wait six months from the date of your last such
policy to apply for a short-term policy.
(b) The policy contains the following disclosure in ten-point or larger, bold-faced type in all marketing materials, application forms, and policy forms:
This policy does not provide portability of prior coverage. As a result, any injury,
sickness, or pregnancy for which you have incurred charges, received medical
treatment, consulted a health-care professional, or taken prescription drugs
within twelve months before the effective date of this policy will not be covered
under this policy.
(61) (a) Repealed.
(b) [ Editor's note: This version of the introductory portion to subsection
(61)(b) is effective until January 1, 2026. ] Effective January 1, 2016, small
employer means any person, firm, corporation, partnership, or association that:
(b) [ Editor's note: This version of the introductory portion to subsection
(61)(b) is effective January 1, 2026. ] Small employer means any person that:
(I) Is actively engaged in business;
(II) [ Editor's note: This version of subsection (61)(b)(II) is effective until
January 1, 2026. ] Employed an average of at least one but not more than one
hundred eligible employees on business days during the immediately preceding
calendar year, except as provided in paragraph (e) of this subsection (61); and
(II) [ Editor's note: This version of subsection (61)(b)(II) is effective January 1,
2026. ] Employed an average of at least one but not more than fifty eligible
employees on business days during the immediately preceding calendar year,
except as provided in subsection (61)(e) of this section; and
(III) Was not formed primarily for the purpose of purchasing insurance.
(c) For purposes of determining whether an employer is a small employer,
the number of eligible employees is calculated using the method set forth in 26
U.S.C. sec. 4980h (c)(2)(E).
(d) In order to be classified as a small employer with more than one
employee when only one employee enrolls in the small employer's health benefit
plan, the small employer shall submit to the small employer carrier the two most
recent quarterly employment and tax statements substantiating that the employer
had two or more eligible employees. Such small employer group shall also meet the
participation requirements of the small employer carrier.
(e) In the case of an employer that was not in existence throughout the
preceding calendar quarter, the determination of whether the employer is a small
employer is based on the average number of employees that the employer is
reasonably expected to employ on business days in the current calendar year.
(f) The following employers are single employers for purposes of
determining the number of employees:
(I) A person or entity that is a single employer pursuant to 26 U.S.C. sec. 414
(b), (c), (m), or (o); and
(II) An employer and any predecessor employer.
(62) Small employer carrier means a carrier that offers health benefit
plans covering eligible employees of one or more small employers in this state.
(63) Small group sickness and accident insurance, small group plan, and
small group policy mean that form of group sickness and accident insurance
issued by an entity subject to part 2 of this article, that form of group service or
indemnity type contract issued by an entity organized pursuant to part 3 of this
article, or that form of policy issued by an entity organized pursuant to part 4 of this
article that provides coverage to small employers located in Colorado. These terms
include a bona fide association plan if such plan provides coverage to one or more
eligible employees of a small employer in Colorado.
(64) Standing referral means a referral by the covered person's primary
care provider to a specialist or specialized treatment center participating in the
carrier's network for ongoing treatment of a covered person.
(65) Student health insurance coverage means a type of individual health
insurance coverage that is provided pursuant to a written agreement between an
institution of higher education, as defined in the Higher Education Act of 1965,
and a health carrier and provided to students enrolled in that institution of higher
education and their dependents, that:
(a) Does not make health insurance coverage available other than in
connection with enrollment as a student, or as a dependent of a student, in the
institution of higher education;
(b) Does not condition eligibility for health insurance coverage on any health-status-related factor related to a student or a dependent of a student; and
(c) Meets any additional requirement that may be imposed by law.
(66) Targeted loss ratio means the ratio of expected policy benefits over
the entire future period for which the proposed rates are expected to provide
coverage to the expected earned premium over the same period. The anticipated
loss ratio shall be calculated on an incurred basis as the ratio of expected incurred
losses to expected earned premium.
(67) Uncovered expenditures means the costs of those health-care
services:
(a) That are covered under the health maintenance organization's health-care plans but are not guaranteed, insured, or assumed by a person or organization
other than the health maintenance organization; or
(b) For which a provider has not agreed to hold enrollees harmless if the
provider is not paid by the health maintenance organization.
(68) Valid multistate association means an association that has:
(a) Been in active existence for at least five years;
(b) Been organized and maintained in good faith for purposes other than to
obtain insurance;
(c) A minimum of five hundred members;
(d) A constitution, charter, or bylaws that provide for regular meetings, at
least annually, to further the purposes of the members;
(e) Collected dues or solicited contributions for members; and
(f) Provided the members with voting privileges and representation on the
governing board and committees.
(69) Waiting period means, with respect to a group health benefit plan and
an individual that is a potential participant or beneficiary in the plan, the period that
must pass with respect to the individual, as determined by the plan sponsor, before
the individual is eligible to be covered for benefits under the terms of the plan.