DEPARTMENT OF REGULATORY AGENCIES
Division of Insurance
3 CCR 702-4
LIFE, ACCIDENT AND HEALTH
Amended Regulation 4-2-42
CONCERNING ESSENTIAL HEALTH BENEFITS
Section 1 Authority
Section 2 Scope and Purpose
Section 3 Applicability
Section 4 Definitions
Section 5 Essential Health Benefits
Section 6 Preventive Services Requirements
Section 7 Incorporation by Reference
Section 8 Severability
Section 9 Enforcement
Section 10 Effective Date
Section 11 History
Section 1 Authority
This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§ 10-1-108(7), 10-1-109, 10-16-103.4 and 10-16-109, C.R.S.
Section 2 Scope and Purpose
The purpose of this regulation is to establish rules for the required inclusion of the essential health benefits in individual and small group health benefit plans in accordance with Article 16 of Title 10 of the Colorado Revised Statutes, and the Patient Protection and Affordable Care Act of 2010, Pub. L. No. 111-148, 124 Stat. 119 (2010) and the Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010), together referred to as the “Affordable Care Act” (ACA).
Section 3 Applicability
This regulation shall apply to all carriers offering individual and small group health benefit plans subject to the individual and group laws of Colorado and the requirements of the ACA. The requirements of this regulation do not apply to grandfathered health benefit plans.
Section 4 Definitions
A. “Actuarial value” and “AV” means, for the purposes of this regulation, the percentage of total average costs for covered benefits that a plan will cover, with calculations based on the provision of essential health benefits to a standard population.
B. “AV calculator” means, for the purposes of this regulation, the publicly available actuarial value (AV) calculator developed by the U.S. Department of Health and Human Services (HHS) and available electronically on the Center for Consumer Information & Insurance Oversight (CCIIO) website.
C. "Carrier" shall have the same meaning as found at § 10-16-102(8), C.R.S.
D. “Catastrophic plan” shall have the same meaning as found at § 10-16-102(10), C.R.S.
E. “Essential health benefits” and “EHB” shall have the same meaning as found at § 10-16-102(22), C.R.S.
F. “Essential health benefits package” shall have the same meaning as found at § 10-16-102(23), C.R.S.
G. “Exchange” shall have the same meaning as found at § 10-16-102(26), C.R.S.
H. “Federal law” shall have the same meaning as found at § 10-16-102(29), C.R.S.
I. “Grandfathered health benefit plan” shall have the same meaning as found at § 10-16-102(31), C.R.S.
J. “Habilitative services” means, for the purposes of this regulation, services that help a person retain, learn or improve skills and functioning for daily living that are offered in parity with, and in addition to, any rehabilitative services offered in Colorado’s EHB benchmark plan.
K. “Health benefit plan” shall have the same meaning as found at § 10-16-102(32), C.R.S.
L. “Premium adjustment percentage” means, for purposes of this regulation, the percentage (if any) by which the average per capita premium for health insurance coverage for the preceding calendar year exceeds such average per capita premium for health insurance, as published in the annual HHS “Notice of benefits and payment parameters.”
Section 5 Essential Health Benefits
A. Carriers offering non-grandfathered individual and small group health benefit plans inside or outside of the Exchange must include the essential health benefits package.
1. Carriers must provide benefits that are substantially equal to Colorado’s EHB-benchmark plan in the following thirteen (13) categories:
a. Ambulatory patient services, which must include, at a minimum:
(1) Primary care to treat an illness or injury;
(2) Specialist visits;
(3) Outpatient surgery;
(4) Chemotherapy services;
(5) Radiation therapy;
(6) Home infusion therapy;
(7) Home health care;
(8) Outpatient diagnostic laboratory, x-ray, and pathology services;
(9) Sterilization;
(10) Treatment of cleft palate and cleft lip conditions; and
(11) Oral anti-cancer medications.
b. Emergency services, which must include, at a minimum:
(1) Emergency room – facility and professional services;
(2) Ambulance services; and
(3) Urgent care treatment services.
c. Hospitalization services, which must include:
(1) Inpatient medical and surgical care;
(2) Organ and tissue transplants (transplants may be limited to specified organs);
(3) Chemotherapy services;
(4) Radiation services;
(5) Anesthesia services; and
(6) Hospice care.
d. Laboratory and radiology services, which must include:
(1) Laboratory tests, x-ray, and pathology services; and
(2) Imaging and diagnostics, such as MRIs, CT scans, and PET scans.
e. Maternity and newborn care services, including state and federally required benefits for hospital stays in connection with childbirth, which must include:
(1) Pre-natal and postnatal care;
(2) Delivery and inpatient maternity services; and
(3) Newborn well child care.
f. Mental health, substance abuse disorders, and behavioral health treatment services rendered on an inpatient or outpatient basis, which must include:
(1) Benefits for treating alcoholism and drug dependency, including partial hospitalization and/or inpatient treatment outside of a hospital to the extent provided under the medical or surgical benefit;
(2) Benefits for mental health services, including partial hospitalization and/or inpatient treatment outside of a hospital to the extent provided under the medical or surgical benefit;
(3) Behavioral health treatment;
(4) Benefits for biologically based mental illness and mental disorder treatment that are no less extensive than the coverage provided for a physical illness, pursuant to § 10-16-104(5.5), C.R.S.; and
(5) Outpatient hospital and physician services.
g. Pediatric services, which must include:
(1) Preventive care services;
(2) Immunizations;
(3) One (1) comprehensive routine eye exam per year, to age nineteen (19),
(4) Prescribed vision hardware, such as eyeglasses, lenses, or contact lenses, no less than one pair or one set every two (2) years for plans issued and renewed on or after January 1, 2017, to age nineteen (19);
(5) Routine hearing exams to age nineteen (19);
(6) Hearing aids to age eighteen (18), pursuant to § 10-16-104(19), C.R.S.; and
(7) Children’s dental anesthesia, pursuant to § 10-16-104(12), C.R.S.
h. Prescription drugs, which must include:
(1) Retail services;
(2) Mail services (home delivery);
(3) All contraceptive methods approved by the Food and Drug Administration (FDA); and
(4) To meet the EHB requirement for prescription drug benefits, carriers must offer coverage that includes at least the greater of:
(a) One (1) drug in every United States Pharmacopeia (USP) category and class; or
(b) The same number of prescription drugs in each category and class as the EHB-benchmark plan.
i. All preventive services required by state and/or federal mandate, which are not subject to deductibles, copayments, or coinsurance, include, but are not limited to:
(1) Services related to contraception, including, but not limited to FDA-approved methods, and including the services related to follow-up and management of side effects, counseling for continued adherence, and device removal; and
(2) Age-appropriate immunizations and vaccines for children, adolescents, and adults in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP).
j. Rehabilitative and habilitative services and devices, which must include:
(1) No less than twenty (20) visits per calendar year, per therapy, for physical, speech, and occupational therapy for:
(a) Habilitative services; and
(b) Rehabilitative services.
Habilitative and rehabilitative service visits are cumulative, such that a carrier must provide, at a minimum, no less than sixty (60) visits for habilitative services, and no less than sixty (60) visits for rehabilitative services per calendar year.
(2) Cardiac rehabilitation services;
(3) Pulmonary rehabilitation services;
(4) Durable medical equipment;
(5) Arm and leg prosthetics;
(6) Inpatient and outpatient habilitative services;
(7) No less than one hundred (100) days of skilled nursing services annually;
(8) No less than two (2) months of inpatient rehabilitation annually, and no less than sixty (60) days;
(9) Autism spectrum disorder services; and
(10) Physical, occupational, and speech therapy for congenital defects for children up to age six (6), as required by § 10-16-104(1.7), C.R.S.
k. Medically necessary bariatric surgery services, for plans issued and renewed on or after January 1, 2017.
l. Infertility services, for plans issued and renewed on or after January 1, 2017, which must include:
(1) X-ray and laboratory procedures;
(2) Services for diagnosis and treatment of involuntary infertility; and
(3) Artificial insemination.
m. Chiropractic care, up to twenty (20) visits per year, at a minimum, for plans issued and renewed on or after January 1, 2017, which must include:
(1) Diagnosis and evaluation; and
(2) Medically necessary lab and x-ray services required for chiropractic services and musculoskeletal disorders.
2. Carriers seeking to include pediatric dental EHB coverage within a health benefit plan, or carriers offering a stand-alone pediatric dental plan that meets EHB requirements, must include the following eligible services, subject to plan benefit limitations, in order to meet the EHB requirements for pediatric dental coverage:
a. Diagnostic and preventive procedures, which must include:
(1) Oral exams and evaluations;
(2) Full mouth, intra-oral, and panoramic x-rays;
(3) Bitewing x-rays;
(4) Routine cleanings;
(5) Fluoride treatments;
(6) Space maintainers;
(7) Sealants; and
(8) Palliative treatment.
b. Basic restorative services, which must include:
(1) Amalgam fillings;
(2) Resin and composite filings;
(3) Crowns;
(4) Pin retention; and
(5) Sedative fillings.
c. Oral surgery, consisting of extractions.
d. Endodontics, consisting of:
(1) Surgical services; and
(2) Root canal therapy.
e. Medically necessary orthodontia and medically necessary prosthodontics for the treatment of cleft lip and cleft palate.
f. Implants, denture repair and realignment, dentures and bridges, non-medically necessary orthodontia, and periodontics are not considered a part of the pediatric dental EHB.
3. Carriers must limit cost-sharing for EHB coverage in accordance with state and federal law.
a. Cost-sharing (or maximum out-of-pocket limits) for individual and small group plans must not exceed the annual out-of-pocket limit set by federal law. For managed care plans, out-of-network deductibles and out-of-pocket maximums do not count toward these cost sharing limits.
b. Cost sharing limits for individual and small group plans may not be increased beyond the annual premium adjustment percentage for individuals, and no more than twice the individual amount for family plans. Increases in annual deductibles must be in multiples of fifty (50) dollars, and if not, must be rounded to the next lowest multiple of fifty (50) dollars.
c. Cost-sharing (or maximum out-of-pocket limits) for stand-alone pediatric dental plans must not exceed the annual out-of-pocket limit set by federal law. For managed care plans, out-of-network deductibles and out-of-pocket maximums do not count toward these cost sharing limits.
d. The Division will annually publish the federally established annual premium adjustment percentages and annual out-of-pocket limits for medical and dental plans, as determined by HHS.
4. Carriers must offer health benefit plans that meet state and federally defined levels of coverage.
a. In order to be a qualified health plan for purposes of sale on the Exchange, a carrier must meet the federal standards found in 45 CFR § 156.200(c)(1), which require a carrier to offer at least one (1) silver plan and at least one (1) gold plan for purchase in each region in which it offers health benefit plans.
b. Carriers must offer plans that meet at least one (1) of the following metal tiers of coverage:
(1) Bronze level: benefits actuarially equivalent to sixty percent (60%) of the full actuarial value of the benefits provided under the plan;
(2) Silver level: benefits actuarially equivalent to seventy percent (70%) of the full actuarial value of the benefits provided under the plan;
(3) Gold level: benefits actuarially equivalent to eighty percent (80%) of the full actuarial value of the benefits provided under the plan; or
(4) Platinum level: benefits actuarially equivalent to ninety (90%) of the full actuarial value of the benefits provided under the plan.
c. Carriers are allowed a de minimis range of +/- two percentage (2%) points for each metal tier.
d. Carriers offering health benefit plans at any of the levels of coverage listed in Section 5.A.4.b. of this regulation must offer child-only plans at that same level.
e. Carriers may offer a catastrophic plan that does not provide a bronze, silver, gold, or platinum level of coverage to certain qualified individuals.
5. Benefits that are excluded from EHB, even though they may be covered by the EHB-benchmark plan, include:
a. Routine non-pediatric dental services;
b. Routine non-pediatric eye exam services;
c. Long-term/custodial nursing home care benefits; and
d. Non-medically necessary orthodontia.
6. Although the EHB-benchmark plan provides coverage for abortion services, no health benefit plan must cover such services as part of the requirement to cover EHB.
7. Carriers offering stand-alone non-pediatric dental plans that are offered in conjunction with a health benefit plan, or are offered as a stand-alone policy, need not comply with the requirements of Section 5.A.2. of this regulation.
B. Carriers must use actuarial value (AV) to determine the level of coverage of a health benefit plan. The AV is the percentage of total average costs for covered benefits that a plan will cover, and must be calculated based on the provision of EHB to a standard population.
1. For standard plan designs, carriers must use the AV calculator developed by HHS to determine AV.
2. Carriers offering plans with benefit designs that cannot be accommodated by the AV calculator may alternatively:
a. Decide how to adjust the plan’s benefit design (for calculation purposes only) to fit the parameters of the calculator, and have a member of the American Academy of Actuaries certify that the methodology to fit the parameters of the AV calculator was in accordance with generally accepted actuarial principles and methodologies; or
b. Use the AV calculator for the plan design provisions that correspond to the parameters of the calculator, and have a member of the American Academy of Actuaries calculate appropriate adjustments to the AV as determined by the AV calculator for the plan design features that deviate substantially, in accordance with generally accepted actuarial principles and methodologies.
C. Substitution of Benefits
1. Carriers are permitted to substitute EHB if the following conditions are met:
a. The substituted benefit must be actuarially equivalent to the benefit that is being replaced. Carriers must submit evidence of actuarial equivalence that is: