(1) Nonprofit hospital,
medical-surgical, and health service corporations. (a) All corporations subject to
the provisions of this part 1 and part 3 of this article doing business in this state on
July 1, 1967, or which may thereafter do business in this state, shall make and file
annually with the commissioner, on or before the first day of March of each year, a
statement under oath upon a form prescribed by the commissioner stating the
amount of all membership dues or subscriber fees collected in this state or from
residents thereof by the corporation making such statement during the year ending
the last day of December next preceding; the amounts actually paid during such
year for hospital, medical-surgical, and other health services for the subscribers or
members of the corporation, and the amounts placed in established reserves for
cases billed but not yet paid, unreported and unbilled cases, retroactive cost
adjustments, membership dues or fees paid in advance but not yet earned, and all
other liabilities and obligations required of domestic insurers which are consistent
with the responsibilities of such corporations. The annual statement made to the
commissioner pursuant to this subsection (1) shall at least include the substance of
that which is required by what is known as the convention blank form for hospital,
medical, and dental service or indemnity corporations adopted from year to year by
the national association of insurance commissioners, including any instructions,
procedures, and guidelines not in conflict with any provision of this title for
completing the convention blank form.
(b) In preparing the statements required by paragraph (a) of this subsection
(1), all insurance companies shall follow the instructions, procedures, and guidelines
of the national association of insurance commissioners. If the initial application of
any such instruction, procedure, or guideline would cause a reduction in the total
capital and surplus of a domestic insurer of ten percent or more or would cause the
capital and surplus of a domestic insurer to fall to or below the company action
level as defined by the commissioner by rule, such insurer may, within thirty days
after the effective date of such instruction, procedure, or guideline, file with the
commissioner a request to phase in the effect of the instruction, procedure, or
guideline over a period not to exceed three years or a time period approved by the
commissioner.
(c) Any request made pursuant to paragraph (b) of this subsection (1) shall
include a complete analysis, in a form prescribed by the commissioner, of the
impact upon the insurer making the request that is expected to result from
application of the subject instruction, procedure, or guideline and, if a phase-in is
requested, a description of the insurer's plan for the phase-in period. The
commissioner shall not deny a request for a phase-in except upon notice and the
opportunity for a hearing as provided in section 24-4-105, C.R.S.
(d) Any request for a hearing made pursuant to paragraph (c) of this
subsection (1) shall include a description of the basis on which relief is sought. Upon
receiving such a request, the commissioner shall postpone the effective date of the
subject instruction, procedure, or guideline pending the conclusion of the hearing
and the taking of final agency action thereon. The hearing shall commence within
sixty days after the commissioner receives the request and shall be conducted in
accordance with section 24-4-105, C.R.S.
(2) Health maintenance organizations. (a) Every health maintenance
organization shall annually, on or before March 1, file a report verified by at least
two principal officers with the commissioner covering the preceding calendar year.
(b) The report must be on forms prescribed by the commissioner and shall
include:
(I) A financial statement of the organization, including its balance sheet and
receipts and disbursements for the preceding year certified by an independent
public accountant;
(II) Any material changes in the information submitted pursuant to section
10-16-401 (3);
(III) The number of persons enrolled during the year, the number of enrollees
as of the end of the year, and the number of enrollments terminated during the
year;
(IV) A summary of information compiled pursuant to section 10-16-402
(1)(b)(III) in such form as required by the commissioner;
(V) Such other information relating to the performance of the health
maintenance organization as is necessary to enable the commissioner to carry out
the commissioner's duties under this part 1 and part 4 of this article.
(c) and (d) Repealed.
(e) Each health maintenance organization shall report to the commissioner
within five days of receipt or determination of a noncompliance order issued by the
United States department of health and human services. Each health maintenance
organization shall report to the commissioner within five days of receipt of
determination by the United States department of health and human services or the
health maintenance organization or a creditor or guarantor as to repayment
schedule of loans or modification of financial commitments. The report shall
include any determination for the ensuing twelve-month period. Upon providing
such report, the health maintenance organization shall submit a revised financial
statement recognizing the appropriate amounts as a direct liability.
(3) Prepaid dental care plan organizations. (a) Every prepaid dental care
plan organization subject to this part 1 and part 5 of this article shall file with the
commissioner annually, on or before March 1, a report verified by at least two
principal officers covering the preceding calendar year.
(b) Such report shall be on forms prescribed by the commissioner and shall
include:
(I) A financial statement of the organization, including its balance sheet and
receipts and disbursements for the preceding year certified by an independent
public accountant;
(II) Any material changes in the information submitted pursuant to section
10-16-503 (1);
(III) The number of persons enrolled during the year, the number of enrollees
as of the end of the year, and the number of enrollments terminated during the
year;
(IV) Statistics relating to the cost of its operations, the pattern of utilization
of its services, and the availability and accessibility of its services;
(V) Such other information relating to the performance of the organization as
is necessary to enable the commissioner to carry out the commissioner's duties
under this part 1 and part 5 of this article.
(4) Carriers. (a) On or before June 1 of each year, a carrier doing business in
this state that satisfies qualifications as determined by rule of the commissioner
shall submit to the commissioner, where applicable, the following cost information
for the previous calendar year:
(I) Medical trend itemized by medical provider price increases, utilization
changes, medical cost shifting, and new medical procedures and technology;
(II) Medical trend itemized by pharmaceutical price increases, utilization
changes, cost shifting, and the introductions of new brand and generic drugs;
(III) Dividends paid;
(IV) Executive salaries, stock options, or bonuses;
(V) Insurance producer commissions;
(VI) Payments to legal counsel;
(VII) Provision for profit and contingencies;
(VIII) Administrative expenditures with breakdowns for advertising or
marketing expenditures, paid lobbying expenditures, and staff salaries;
(IX) Expenditures for disease or case management programs or patient
education and other cost containment or quality improvement expenses;
(X) Charitable contributions;
(XI) Losses on investments or investment income;
(XII) Reserves on hand;
(XIII) The amount of surplus and the amount of surplus relative to the
carrier's risk-based capital requirement;
(XIV) Taxes itemized by category;
(XV) Administrative ratio;
(XVI) Actual benefits ratio;
(XVII) The number of lives insured under each benefit plan the carrier offers
to small employers;
(XVIII) The cost of providing or arranging health-care services; and
(XIX) A list of each intermediary with whom the carrier has a contractual
relationship.
(a.5) Repealed.
(b) A carrier licensed in multiple jurisdictions may satisfy the requirements
of paragraph (a) of this subsection (4) by filing the Colorado allocated portion of
national data if the actual data is not otherwise available.
(c) The commissioner shall aggregate the data submitted pursuant to
paragraph (a) of this subsection (4) for all carriers and publish the information on
the division's website. Notwithstanding section 24-1-136 (11)(a)(I), the commissioner
shall submit a report annually to the general assembly that analyzes the cost of
health care and the factors that drive the cost of health care on an individual and
group basis in this state.
(d) Notwithstanding section 24-1-136 (11)(a)(I), the commissioner shall report
annually to the general assembly regarding financial information on carriers that
includes, but is not limited to, benefits ratios, rate increases, and the reasons or
data tracked for cost increases, as applicable for health insurance provided
pursuant to this article.
(e) When promulgating rules pursuant to paragraph (a) of this subsection (4),
the commissioner shall ensure that at least ninety-two percent of the market share
reports cost information.