(1) (a) A carrier
subject to part 2, 3, 4, or 5 of this article 16 shall not establish rates for any
sickness, accident, or health insurance policy, contract, certificate, or other
evidence of coverage or dental coverage plan, as defined in section 10-16-165 (1)(b),
issued or delivered to any policyholder, enrollee, subscriber, or member in Colorado
that are excessive, inadequate, or unfairly discriminatory. To assure compliance
with the requirements of this section that rates are not excessive in relation to
benefits, the commissioner shall promulgate rules to require rate filings and, as
part of the rules, may require the submission of adequate documentation and
supporting information, including actuarial opinions or certifications and set
expected benefits ratios. The carrier shall submit expected rate increases to the
commissioner at least sixty days prior to the proposed implementation of the rates.
If the commissioner does not approve or disapprove the rate filings within a sixty-day period, the carrier may implement and reasonably rely upon the rates on the
condition that the commissioner may require correction of any deficiencies in the
rate filing upon later review if the rate the carrier charged is excessive, inadequate,
or unfairly discriminatory. A prospective rate adjustment is the sole remedy for rate
deficiencies pursuant to this subsection (1). If the commissioner finds deficiencies in
the rate filing after a sixty-day period, the commissioner shall provide notice to the
carrier, and the carrier shall correct the rate on a prospective basis.
(b) The commissioner may review expected rate filing increases filed with
the commissioner and shall disapprove the rate increase and require the carrier to
resubmit for approval if any of the provisions of subsection (3) of this section apply.
Rate filings that do not involve a requested rate increase, or that involve a
requested rate increase of less than five percent for dental insurance, do not
require preapproval, and the carrier may implement the rate upon filing with the
commissioner.
(c) The filing requirements of this subsection (1) do not apply to
nondeveloped rates, including rates for medicaid, medicare, and the children's
basic health plan, as defined by the commissioner.
(d) If the carrier fails to supply the information required by this section, the
filing is incomplete. The commissioner shall make a determination of completeness
no later than thirty days following submission of the filing for review. All filings not
returned on or before the thirtieth day after receipt are considered complete.
(e) The commissioner may review filings for substantive content and, if
reviewed, shall identify and communicate to the filing carrier, on or before the
forty-fifth day after receipt, any deficiency in the filing. The carrier shall apply a
correction of a deficiency, including a deficiency identified after the forty-fifth day,
on a prospective basis, and the commissioner shall not assess a penalty against the
carrier if the violation identified was not willful.
(f) Carriers shall file rate filings for insurance regulated under parts 1 to 5 of
this article 16 electronically in a format made available by the division, unless
exempted by rule for an emergency situation as determined by the commissioner.
The division shall post on its website a rate filing summary for insurance regulated
under parts 1 to 5 of this article 16 in order to provide notice to the public.
(g) This section does not:
(I) Limit the right of the public to inspect a rate filing and any supporting
information pursuant to part 2 of article 72 of title 24, C.R.S.; or
(II) Impair the commissioner's ability to review rates and determine whether
the rates are excessive, inadequate, or unfairly discriminatory.
(2) (a) (I) Rates for an individual health coverage plan issued or delivered to
any policyholder, enrollee, subscriber, or member in Colorado by an insurer subject
to part 2 of this article 16 or an entity subject to part 3, 4, or 5 of this article 16 shall
not be excessive, inadequate, or unfairly discriminatory to assure compliance with
the requirements of this section that rates are not excessive in relation to benefits.
Rates are excessive if they are likely to produce a long run profit that is
unreasonably high for the insurance provided or if expenses are unreasonably high
in relation to services rendered. In determining if rates are excessive, the
commissioner may consider:
(A) The expected filed rates in relation to the actual rates charged;
(B) Whether the carrier's products are affordable; and
(C) Whether the carrier has implemented effective strategies to enhance the
affordability of its products.
(II) Rates are not inadequate unless clearly insufficient to sustain projected
losses and expenses, or the use of the rates, if continued, will tend to create a
monopoly in the market.
(III) Rates are unfairly discriminatory if, after allowing for practical
limitations, price differentials fail to reflect equitably the differences in expected
losses and expenses.
(b) Notwithstanding any other provision of this article 16, a carrier subject to
part 2, 3, 4, or 5 of this article 16 shall not vary the premium rate for an individual
health coverage plan due to the gender of the individual policyholder, enrollee,
subscriber, or member. Any premium rate based on the gender of the individual
policyholder, enrollee, subscriber, or member is unfairly discriminatory and is not
allowed.
(3) (a) The commissioner shall disapprove the requested rate increase if any
of the following apply:
(I) The benefits provided are not reasonable in relation to the premiums
charged;
(II) The requested rate increase contains a provision or provisions that are
excessive, inadequate, unfairly discriminatory, or otherwise do not comply with the
provisions of this title;
(III) The requested rate increase is excessive or inadequate. In determining if
the rate is excessive or inadequate, the commissioner may consider profits,
dividends, annual rate reports, annual financial statements, subrogation funds
credited, investment income or losses, unearned premium reserve and reserve for
losses, surpluses, executive salaries, expected benefits ratios, any factors in
section 10-16-111, and any other appropriate actuarial factors as determined by
current actuarial standards of practice.
(IV) The actuarial reasons and data based upon Colorado claims experience
and data, when available, do not justify the necessity for the requested rate
increase;
(V) The rate filing is incomplete;
(VI) The rate filing fails to demonstrate compliance with the MHPAEA. The
commissioner shall adopt rules to establish the process and timeline for carriers to
demonstrate compliance with the MHPAEA in establishing their rates.
(VII) The rate filing reflects a cost shift between the standardized plan, as
defined in section 10-16-1303 (14), offered by the carrier and the health benefit plan
for which rate approval is being sought. The commissioner may consider the total
cost of health care in making this determination.
(b) In determining whether to approve or disapprove a rate filing, the
commissioner may consider, without limitation, the expected benefits ratio for a
health benefit plan or any other cost category determined appropriate by the
commissioner. If the carrier achieves a benefits ratio of eighty-five percent or
higher for large group insurance, eighty percent for small group insurance, and
eighty percent for individual insurance, the commissioner may expedite the review
of the approval process for the carrier.
(c) The commissioner shall adopt rules that establish the benefits ratio for
carriers to use for rate filing purposes for health benefit plans, other than
grandfathered health benefit plans. The rules must include, as supplemental
criteria that will be considered during review, requirements for carriers to provide
information on activities to improve health-care quality as set forth under the
authority of section 2718 of the federal Public Health Service Act, as amended,
and in 45 CFR 158.150 and expenditures related to health information technology
and meaningful use as set forth in 45 CFR 158.151.
(3.5) The commissioner shall promulgate rules establishing affordability
standards. These standards must include appropriate targets for carrier
investments in primary care. In developing these standards, the commissioner shall
consider the recommendations of the primary care payment reform collaborative
created in section 10-16-150.
(4) The commissioner may require the submission of any relevant information
the commissioner deems necessary in determining whether to approve or
disapprove a filing made pursuant to this section.
(5) (a) (I) With respect to the premium rates charged by a carrier offering an
individual or small employer health benefit plan, the carrier shall develop its
premium rates based on, and vary the premium rates with respect to the particular
plan or coverage only by the following case characteristics:
(A) Whether the plan or coverage covers an individual or family;
(B) Geographic rating area, established in accordance with federal law;
(C) Age, except that the rate must not vary by more than three to one for
adults; and
(D) Tobacco use, except that the rate must not vary by more than one and
one-fifteenth to one.
(II) The carrier shall not vary a premium rate with respect to any particular
individual or small employer health benefit plan by any factor other than the factors
described in subparagraph (I) of this paragraph (a).
(III) With respect to family coverage under an individual or small employer
health benefit plan, the carrier shall apply the rating variations permitted under
sub-subparagraphs (C) and (D) of subparagraph (I) of this paragraph (a) based on
the portion of the premium that is attributable to each family member covered
under the plan in accordance with rules of the commissioner.
(b) The carrier shall not adjust the premium charged with respect to any
particular individual or small employer health benefit plan more frequently than
annually; except that the carrier may change the premium rates to reflect:
(I) With respect to a small employer health benefit plan, changes to the
enrollment of the small employer;
(II) Changes to the family composition of the policyholder or employee;
(III) With respect to an individual health benefit plan, changes in geographic
rating area of the policyholder, as provided in sub-subparagraph (B) of
subparagraph (I) of paragraph (a) of this subsection (5);
(IV) Changes in tobacco use, as provided in sub-subparagraph (D) of
subparagraph (I) of paragraph (a) of this subsection (5);
(V) Changes to the health benefit plan requested by the policyholder or
small employer; or
(VI) Other changes required by federal law or regulations or otherwise
expressly permitted by state law or commissioner rule.
(c) (I) A carrier shall consider all individuals in all individual health benefit
plans, other than grandfathered health benefit plans, offered by the carrier,
including those individuals who do not enroll in the plans through an exchange
established under article 22 of this title, to be members of a single risk pool.
(II) A carrier shall consider all covered persons in all small employer health
benefit plans, other than grandfathered health benefit plans, offered by the carrier,
including those covered persons who do not enroll in the plans through an
exchange established under article 22 of this title, to be members of a single risk
pool.
(d) Any individual who does not qualify for a lower rate based on tobacco use
may be offered the option of participating in a bona fide wellness program, as
defined under the federal Health Insurance Portability and Accountability Act of
1996, as amended. A carrier may allow any individual who participates in a bona
fide wellness program the lower rate. The carrier shall disclose the availability of a
tobacco rating adjustment and any bona fide wellness program to each potential
insured. The provisions of this paragraph (d) are applicable only if allowed under
federal law.
(e) The commissioner may adopt rules to implement and administer this
subsection (5) and to assure that rating practices used by carriers are consistent
with the purposes of this article.
(f) A carrier shall make a reasonable disclosure, as part of its solicitation and
sales materials, of all of the following:
(I) How premium rates are established;
(II) The provisions of the coverage concerning the carrier's right to change
premium rates, the factors that may affect changes in premium rates, and the
frequency with which the carrier may change premium rates; and
(III) (A) With respect to individual health benefit plans, a listing of and
descriptive information about, including benefits and premiums, all individual health
benefit plans offered by the carrier and the availability of the plans for which the
individual is qualified; and
(B) With respect to small employer health benefit plans, a listing of and
descriptive information about, including benefits and premiums, all small employer
health benefit plans for which the small employer is qualified.
(g) (I) Each carrier shall maintain at its principal place of business a complete
and detailed description of its rating practices, including information and
documentation that demonstrate that its rating methods and practices are based
upon commonly accepted actuarial assumptions and are in accordance with sound
actuarial principles.
(II) Each carrier shall annually file with the commissioner, on or before March
15, an actuarial certification certifying that the carrier is in compliance with this
article and that the rating methods of the carrier are actuarially sound. The
certification must be in a form and manner and must contain information as
specified by the commissioner. The carrier shall retain a copy of the certification at
its principal place of business.
(III) (A) A carrier shall make the information and documentation described in
subparagraph (I) of this paragraph (g) available to the commissioner upon request.
(B) Except in cases of violations of this section, the information is considered
proprietary and trade secret information and is not subject to disclosure by the
commissioner to persons outside of the division except as agreed to by the carrier
or as ordered by a court of competent jurisdiction.
(6) (a) The carrier shall use the applicable index rate for the premium rate for
all of the carrier's individual and small group health benefit plans and shall adjust
the applicable index rate for total expected market-wide payments and charges
under the risk adjustment and reinsurance programs in the state, subject only to
the adjustments permitted in federal and state law. The commissioner may
establish, by rule, the components and adjustments that carriers are able to use
and make to the index rate.
(b) A carrier shall treat all health benefit plans issued or renewed in the
same calendar month as having the same rating period.
(c) For the purposes of this subsection (6), a health benefit plan that contains
a restricted network provision is not similar coverage to a health benefit plan that
does not contain a restricted network provision if the restriction of benefits to
network providers results in substantial differences in claim costs.
(7) Starting in 2021, as part of the rate filing required pursuant to this
section, each carrier shall provide to the commissioner, in a form and manner
determined by the commissioner, information concerning the utilization of out-of-network providers and facilities and the aggregate cost savings as a result of the
implementation of section 10-16-704 (3)(d)(I) and (5.5)(b)(I).
(8) (a) The commissioner may adopt rules designed to:
(I) Maximize the purchasing power of exchange consumers whose household
income is up to four hundred percent of the federal poverty line; and
(II) Assure premium pricing that complies with the requirements in the
federal act for modified community rating.
(b) In adopting these rules, the commissioner may consider the results of the
evaluation and study of the reinsurance program conducted pursuant to section 10-16-1104 (2).