C.R.S. § 10-3-1713 — CO Code / Title 10 / Article 3 / Part 17 / Section 10-3-1713
10-3-1713. Shareholder appraisal rights
Status: in_force

10-3-1713. Shareholder appraisal rights. If a dividing insurer does not survive a division, a shareholder of the dividing insurer is entitled to appraisal rights and to obtain payment of the fair value of the shareholder's shares in the same manner and to the extent provided for a corporation as a party to a merger pursuant to section 7-113-102.
C.R.S. § 10-19-103 — CO Code / Title 10 / Article 19 / Section 10-19-103
10-19-103. Definitions
Status: repealed

10-19-103. Definitions. As used in this article 19, unless the context otherwise requires:

(1) "Applicant" means:

(a) In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits; and

(b) In the case of a group long-term care insurance policy, the proposed certificate holder.

(1.5) Repealed.

(2) "Certificate" means any certificate issued under a group long-term care insurance policy, which policy has been delivered or issued for delivery in this state.

(3) "Commissioner" means the commissioner of insurance.

(3.5) "Dementia diseases and related disabilities" has the same meaning set forth in section 10-16-102 (16.5).

(4) "Group long-term care insurance" means a long-term care insurance policy which is delivered or issued for delivery in this state and issued to one of the following:

(a) One or more employers or labor organizations, or to a trust or to the trustees of a fund established by one or more employers or labor organizations, or a combination thereof, for employees or former employees or a combination thereof or for members or former members or a combination thereof, of the labor organizations;

(b) Any professional, trade, or occupational association for its members or former or retired members, or combination thereof, if such association:

(I) Is composed of individuals all of whom are or were actively engaged in the same profession, trade, or occupation; and

(II) Has been maintained in good faith for purposes other than obtaining insurance;

(c) (I) An association or a trust or the trustee of a fund established, created, or maintained for the benefit of members of one or more associations. Prior to advertising, marketing, or offering such policy within this state, the association or the insurer of the association shall file evidence with the commissioner that the association has at the outset a minimum of one hundred persons and has been organized and maintained in good faith for purposes other than that of obtaining insurance, has been in active existence for at least one year, and has a constitution and bylaws which provide that:

(A) The association holds regular meetings not less than annually to further purposes of the members;

(B) Except for credit unions, the association collects dues or solicits contributions from members; and

(C) The members have voting privileges and representation on the governing board and committees.

(II) Thirty days after such filing, the association will be deemed to satisfy such organizational requirements, unless the commissioner makes a finding that the association does not satisfy those organizational requirements.

(d) A group other than as described in paragraph (a), (b), or (c) of this subsection (4), subject to a finding by the commissioner that:

(I) The issuance of the group policy is not contrary to the best interest of the public;

(II) The issuance of the group policy would result in economies of acquisition or administration; and

(III) The benefits are reasonable in relation to the premiums charged.

(5) "Long-term care insurance" means any insurance policy or rider advertised, marketed, offered, or designed to provide coverage for not less than twelve consecutive months for each covered person on an expense-incurred, indemnity, prepaid, or other basis for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services provided in a setting other than an acute care unit of a hospital. "Long-term care insurance" includes group and individual annuities and life insurance policies or riders that provide directly or that supplement long-term care insurance. The term shall also include qualified long-term care insurance contracts. This term does not include life insurance policies that accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention, or permanent institutional confinement and that provide the option of a lump-sum payment for those benefits and in which neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care. "Long-term care insurance" also includes a policy or rider that provides for payment of benefits based upon cognitive impairment or the loss of functional capacity. Long-term care insurance may be issued by insurers, fraternal benefit societies, nonprofit hospital, medical-surgical, and health service corporations, prepaid health plans, health maintenance organizations, or any similar organizations to the extent they are otherwise authorized to issue life or health insurance. "Long-term health-care insurance" shall not include any insurance policy that is offered primarily to provide basic medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset protection coverage, accident-only coverage, specified disease or specified accident coverage, or limited-benefit health coverage. Notwithstanding any other provisions contained herein, any product advertised, marketed, or offered as long-term care insurance shall be subject to the provisions of this article.

(6) "Policy" means any policy, contract, subscriber agreement, rider, or endorsement delivered or issued for delivery in this state by an insurer, fraternal benefit society, nonprofit hospital, medical-surgical, or health service corporation, prepaid health plan, health maintenance organization, or any similar organization.

(7) Repealed.

(8) (a) "Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract" means an individual or group insurance contract that meets the requirements of 26 U.S.C. sec. 7702B (b) of the federal "Internal Revenue Code of 1986", as amended, as follows:

(I) The only insurance protection provided under the contract is coverage of qualified long-term care services. A contract shall not fail to satisfy the requirements of this subparagraph (I) by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.

(II) The contract does not pay or reimburse expenses incurred for services or items to the extent that the expenses are reimbursable under Title XVIII of the federal "Social Security Act", as added by the "Social Security Amendments of 1965", Pub.L. 89-97, as amended, or would be so reimbursable but for the application of a deductible or coinsurance amount. The requirements of this subparagraph (II) do not apply to expenses that are reimbursable under said Title XVIII only as a secondary payer. A contract shall not fail to satisfy the requirements of this subparagraph (II) by reason of payments being made on a per diem or other periodic basis without regard to the expenses incurred during the period to which the payments relate.

(III) The contract is guaranteed renewable, within the meaning of 26 U.S.C. sec. 7702B (b)(1)(C) of the federal "Internal Revenue Code of 1986", as amended;

(IV) The contract does not provide for a cash surrender value or other money that can be paid, assigned, pledged as collateral for a loan, or borrowed except as provided in subparagraph (V) of this paragraph (a);

(V) All refunds of premiums and all policyholder dividends or similar amounts under the contract are to be applied as a reduction in future premiums or to increase future benefits; except that a cash refund may be issued in the event of death of the insured or a complete surrender or cancellation of the contract, so long as the refund does not exceed the aggregate premiums paid under the contract;

(VI) The contract meets the consumer protection provisions set forth in 26 U.S.C. sec. 7702B (g) of the federal "Internal Revenue Code of 1986", as amended.

(b) "Qualified long-term care insurance contract" or "federally tax-qualified long-term care insurance contract" also means the portion of a life insurance contract that provides long-term care insurance coverage by rider or as part of the contract and that satisfies the requirements of 26 U.S.C. sec. 7702B (b) and (e) of the federal "Internal Revenue Code of 1986", as amended.
C.R.S. § 10-3-414 — CO Code / Title 10 / Article 3 / Part 4 / Section 10-3-414
10-3-414. Nondisclosure of reports and evidence during period of direct supervision or con
Status: in_force

10-3-414. Nondisclosure of reports and evidence during period of direct supervision or conservatorship. Any other provision of law notwithstanding, the commissioner shall not divulge to the public any examination report, results of investigation, or other information received by the division of insurance on, about, or relating to any insurance company which would be detrimental to the efforts of rehabilitation of that company under this part 4.
C.R.S. § 10-14-402 — CO Code / Title 10 / Article 14 / Part 4 / Section 10-14-402
10-14-402. Beneficiaries
Status: in_force

10-14-402. Beneficiaries. (1) The owner of a benefit contract shall have the right at all times to change the beneficiary in accordance with the governing documents of the society unless the owner waives this right by specifically requesting in writing that the beneficiary designation be irrevocable. A society may, through its governing documents, limit the scope of beneficiary designations and shall provide that no revocable beneficiary shall have or obtain any vested interest in the proceeds of any certificate until the certificate has become due and payable in conformity with the provisions of the benefit contract.

(2) A society may make provision for the payment of funeral benefits to the extent of such portion of any payment under a certificate as might reasonably appear to be due to any person equitably entitled thereto by reason of having incurred expense occasioned by the burial of the member. The portion so paid shall not exceed the sum of one thousand dollars.

(3) If at the death of any person insured under a benefit contract there is no lawful beneficiary to whom the proceeds shall be payable, the amount of such benefit, except to the extent that funeral benefits may be paid as provided in subsection (2) of this section, shall be payable to the estate of the deceased insured the same as other property not exempt; except that, if the owner of the certificate is other than the insured, such proceeds shall be payable to such owner.
C.R.S. § 10-16-112.5 — CO Code / Title 10 / Article 16 / Part 1 / Section 10-16-112.5
10-16-112.5. Prior authorization for health-care services - disclosures and notice - determin
Status: in_force

10-16-112.5. Prior authorization for health-care services - disclosures and notice - determination deadlines - criteria - limits and exceptions - enforcement - definitions - rules. (1) Applicability. (a) On or after January 1, 2020, a carrier or, if a carrier contracts with a private utilization review organization to perform prior authorization for health-care services, the organization shall use the prior authorization process and comply with the requirements specified in this section. Except as otherwise specified in this section, this section applies to prior authorization requests for health-care services, excluding requests for drug benefits pursuant to section 10-16-124.5.

(b) This section does not apply to:

(I) A health maintenance organization with respect to managed care plans that provide a majority of covered professional services through a single contracted medical group;

(II) A nonprofit health maintenance organization operated by or under the control of the Denver health and hospital authority created by article 29 of title 25 or any subsidiary of the authority; or

(III) Carriers, organizations, and medical benefits subject to the "Workers' Compensation Act of Colorado", articles 40 to 47 of title 8.

(2) Disclosure of requirements - notice of changes - rules. (a) [Editor's note: For the applicability of this subsection (2)(a) on or after January 1, 2026, see the editor's note following this section.] (I) A carrier shall post current prior authorization requirements and restrictions, including written, clinical criteria, on the carrier's public-facing website in a readily accessible, standardized, searchable format. The prior authorization requirements must be described in detail and in clear and easily understandable language.

(II) If a carrier contracts with a private utilization review organization to perform prior authorization for health-care services, the organization shall provide its prior authorization requirements and restrictions, as required by this subsection (2), to the carrier with which the organization contracted, and that carrier shall post the organization's prior authorization requirements and restrictions on its public-facing website in the manner required by subsection (2)(a)(I) of this section.

(b) If a carrier or organization intends to implement a new prior authorization requirement or restriction or to amend an existing requirement or restriction, the carrier or organization shall:

(I) Notify any participating providers of the new or amended requirement or restriction in the manner and within the time specified in section 25-37-102 (9)(c) or 25-37-104 (1), as applicable; and

(II) Update the prior authorization information posted on the carrier's website pursuant to subsection (2)(a) of this section to reflect the new or amended prior authorization requirement or restriction before implementing the new or amended requirement or restriction.

(c) [Editor's note: For the applicability of this subsection (2)(c) on or after January 1, 2026, see the editor's note following this section.] (I) A carrier shall post, on a public-facing portion of its website, data regarding approvals and denials of prior authorization requests, including requests for drug benefits pursuant to section 10-16-124.5, in a readily accessible, standardized, searchable format and that include the following:

(A) The total number of prior authorization requests received in the immediately preceding calendar year in each of the following categories of services: Medical procedures, diagnostic tests and diagnostic images, prescription drugs, and all other categories of health-care services or drug benefits for which a prior authorization request was received;

(B) The total number of prior authorization requests that were approved in each of the categories specified in subsection (2)(c)(I)(A) of this section;

(B.5) The total number of prior authorization requests for which an adverse determination was issued and the service was denied in each of the categories specified in subsection (2)(c)(I)(A) of this section;

(C) The reason for the denial in each of the categories specified in subsection (2)(c)(I)(A) of this section, with the denial reasons sorted by categories defined by rule; and

(D) In each of the categories specified in subsection (2)(c)(I)(A) of this section, the total number of adverse determinations that were appealed and whether the determination was upheld or reversed on appeal.

(II) An organization or PBM that provides prior authorization for a carrier shall provide the data specified in subsection (2)(c)(I) of this section to the carrier with which the organization or PBM contracted, and the carrier shall post the organization's or PBM's data on its public-facing website in the manner required by subsection (2)(c)(I) of this section.

(III) Carriers and organizations shall use the data specified in this subsection (2)(c) to refine and improve their utilization management programs. Carriers and organizations shall review the list of medical procedures, diagnostic tests and diagnostic images, prescription drugs, and other health-care services for which the carrier or organization requires prior authorization at least annually and shall eliminate the prior authorization requirements for those procedures, diagnostic tests and diagnostic images, prescription drugs, or other health-care services for which prior authorization neither promotes health-care quality or equity nor substantially reduces health-care spending. Each carrier and organization shall annually attest to the commissioner that it has completed the review required by this subsection (2)(c)(III) and has eliminated prior authorization requirements consistent with the requirements of this subsection (2)(c)(III).

(IV) A carrier shall post, on a public-facing portion of its website, in a readily accessible, standardized, searchable format, data on the number of exemptions from prior authorization requirements or alternatives to prior authorization requirements provided pursuant to a program adopted by the carrier, organization, or PBM pursuant to subsection (4)(b)(II) of this section or section 10-16-124.5 (5.5), as applicable. The carrier shall include the following data:

(A) The number of providers offered an exemption or alternative program, including their specialty areas;

(B) The number and categorized types of exemptions or alternative programs offered to providers; and

(C) The prescription drug, diagnostic test, procedure, or other health-care service for which an exemption or alternative program was offered.

(V) The commissioner shall adopt rules to:

(A) Implement subsections (2)(c)(I) and (2)(c)(IV) of this section to ensure that the data fields required to be posted pursuant to subsections (2)(c)(I) and (2)(c)(IV) of this section are presented consistently by carriers; and

(B) Define categories of prior authorization request denials for purposes of subsection (2)(c)(I)(C) of this section.

(3) Nonurgent and urgent health-care services - timely determination - notice of determination - deemed approved. (a) Except as provided in subsection (3)(b) of this section, a prior authorization request is deemed granted if a carrier or organization fails to:

(I) [Editor's note: For the applicability of this subsection (3)(a)(I) on or after January 1, 2026, see the editor's note following this section.] (A) Notify the provider and covered person, within five business days after receipt of the request, that the request is approved, denied, or incomplete and indicate: If denied, what relevant alternative services or treatments may be a covered benefit or are required before approval of the denied service or treatment or, if incomplete, the specific additional information, consistent with criteria posted pursuant to subsection (2)(a) of this section, that is required to process the request; or

(B) Notify the provider and covered person, within five business days after receiving the additional information required by the carrier or organization pursuant to subsection (3)(a)(I)(A) of this section, that the request is approved or denied and, if denied, indicate what relevant alternative services or treatments may be a covered benefit or are required before approval of the denied service or treatment; and

(II) For a prior authorization request for urgent health-care services:

(A) Notify the provider and covered person, within two business days but not longer than seventy-two hours after receipt of the request, that the request is approved, denied, or incomplete and, if incomplete, indicate the specific additional information, consistent with criteria posted pursuant to subsection (2)(a) of this section, that is required to process the request; or

(B) Notify the provider and covered person, within two business days but not longer than seventy-two hours after receiving the additional information required by the carrier or organization pursuant to subsection (3)(a)(II)(A) of this section, that the request is approved or denied.

(b) If a carrier or organization notifies the provider and covered person pursuant to subsection (3)(a)(I)(A) or (3)(a)(II)(A) of this section that a prior authorization request is incomplete and that additional information is required, the provider shall submit the additional information within two business days after receipt of the notice from the carrier or organization. If the provider fails to submit the required additional information within two business days after receipt of the notice, the request is not deemed granted pursuant to subsection (3)(a) of this section. After receipt of the required additional information, the carrier or organization shall respond to the prior authorization request in accordance with subsection (3)(a)(I)(B) of this section or, for a prior authorization request for urgent health-care services, subsection (3)(a)(II)(B) of this section.

(c) (I) When notifying the provider of the determination on a prior authorization request, the carrier or organization shall provide a unique prior authorization number attributable to that request and the particular health-care service that is the subject of the request.

(II) [Editor's note: For the applicability of this subsection (3)(c)(II) on or after January 1, 2026, see the editor's note following this section.] If the carrier or organization denies a prior authorization request based on a ground specified in section 10-16-113 (3)(a), the notification is subject to the requirements of section 10-16-113 (3)(a) and commissioner rules adopted pursuant to that section and must:

(A) Include information concerning whether the carrier or organization requires an alternative treatment, test, procedure, or medication and what alternative services or treatments would be approved as a covered benefit under the health benefit plan; or

(B) In the case of the denial of a prior authorization request for a prescription drug, specify which prescription drugs and dosages in the same class as the prescription drug for which the prior authorization request was denied are covered prescription drugs under the health benefit plan.

(III) [Editor's note: For the applicability of this subsection (3)(c)(III) on or after January 1, 2026, see the editor's note following this section.] A carrier's, organization's, or pharmacy benefit manager's compliance with subsection (3)(c)(II) of this section does not constitute the practice of medicine.

(d) This subsection (3) does not apply to prior authorization requests for drug benefits that are subject to section 10-16-124.5; except that subsection (3)(c)(II) of this section applies to prior authorization requests for drug benefits.

(3.5) [Editor's note: For the applicability of this subsection (3.5) on or after January 1, 2026, see the editor's note following this section.] (a) Starting January 1, 2027, a carrier or organization shall have, maintain, and use a prior authorization application programming interface that automates the prior authorization process to enable a provider to:

(I) Determine whether prior authorization is required for a health-care service;

(II) Identify prior authorization information and documentation requirements; and

(III) Facilitate the exchange of prior authorization requests and determinations from the provider's electronic health records or practice management systems through secure electronic transmission.

(b) A carrier's or organization's application programming interface must meet the most recent standards and implementation specifications adopted by the secretary of the United States department of health and human services as specified in 45 CFR 170.215 (a).

(c) If a provider submits a prior authorization request through the carrier's or organization's application programming interface, the carrier or organization shall accept and respond to the request through the interface.

(4) Criteria, limits, and exceptions - program. (a) Carriers and organizations shall:

(I) Use prior authorization criteria that are current, clinically based, aligned with other quality initiatives of the carrier or organization, and aligned with other carriers' and organizations' prior authorization criteria for the same health-care services;

(II) Ensure that prior authorization requests are reviewed by appropriate providers; and

(III) Make eligibility, benefit coverage, and medical policy determinations as part of the prior authorization process.

(b) [Editor's note: For the applicability of this subsection (4)(b) on or after January 1, 2026, see the editor's note following this section.] (I) Carriers and organizations shall consider limiting the use of prior authorization to providers whose prescribing or ordering patterns differ significantly from the patterns of their peers after adjusting for patient mix and other relevant factors and present opportunities for improvement in adherence to the carrier's or organization's prior authorization requirements.

(II) No later than January 1, 2026, a carrier or an organization shall adopt a program, developed in consultation with providers participating with the carrier, to eliminate or substantially modify prior authorization requirements in a manner that removes the administrative burden for qualified providers, as defined under the program, and their patients for certain health-care services and related benefits based on any of the following:

(A) The performance of providers with respect to adherence to nationally recognized, evidence-based medical guidelines, appropriateness, efficiency, and other quality criteria; and

(B) Provider specialty, experience, or other objective factors; except that eligibility for the program must not be limited by provider specialty.

(III) A program developed pursuant to subsection (4)(b)(II) of this section:

(A) Must not require qualified providers to request participation in the program; and

(B) May include limiting the use of prior authorization to providers whose prescribing or ordering patterns differ significantly from the patterns of their peers after adjusting for patient mix and other relevant factors and in order to present those providers with opportunities for improvement in adherence to the carrier's or organization's prior authorization requirements.

(IV) At least annually, a carrier or an organization shall:

(A) Reexamine a provider's prescribing or ordering patterns;

(B) Reevaluate the provider's status for exemption from prior authorization requirements or for inclusion in the program developed pursuant to subsection (4)(b)(II) of this section; and

(C) Notify the provider of the provider's status for exemption or inclusion in the program.

(V) A program developed pursuant to subsection (4)(b)(II) of this section must include procedures for a provider to request:

(A) An expedited, informal resolution of a carrier's or an organization's failure or refusal to include the provider in the program; and

(B) If the matter is not resolved through informal resolution, binding arbitration as specified in subsection (4)(b)(VI) of this section.

(VI) If a provider requests binding arbitration pursuant to the procedures a carrier or an organization develops under subsection (4)(b)(V)(B) of this section, the following provisions govern the arbitration procedure:

(A) The provider and carrier or organization shall jointly select an arbitrator from the list of arbitrators approved pursuant to section 10-16-704 (15)(b). Neither the provider nor the carrier or organization is required to notify the division of the arbitration or of the selected arbitrator.

(B) The selected arbitrator shall determine the provider's eligibility to participate in the carrier's or organization's program based on the program criteria developed pursuant to subsection (4)(b)(II) of this section;

(C) Within thirty days after the date the arbitrator accepts the matter, the provider and the carrier or organization shall submit to the arbitrator written materials in support of their respective positions;

(D) The arbitrator may render a decision based on the written materials submitted pursuant to subsection (4)(b)(VI)(C) of this section or may schedule a hearing, lasting not longer than one day, for the provider and carrier or organization to present evidence;

(E) Within thirty days after the date the arbitrator receives the written materials or, if a hearing is conducted, the date of the hearing, the arbitrator shall issue a written decision stating whether the provider is eligible for the program; and

(F) If the arbitrator overturns the carrier's or organization's failure or refusal to include the provider in the program, the carrier or organization shall pay the arbitrator's fees and costs, and if the arbitrator affirms the carrier's or organization's failure or refusal to include the provider in the program, the provider shall pay the arbitrator's fees and costs.

(c) [Editor's note: For the applicability of this subsection (4)(c) on or after January 1, 2026, see the editor's note following this section.] (I) When a carrier or an organization approves a prior authorization request for a surgical procedure for which prior authorization is required, the carrier or organization shall not deny a claim for an additional or a related health-care procedure identified during the authorized surgical procedure if:

(A) The provider, while providing the approved surgical procedure to treat the covered person, determines, in accordance with generally accepted standards of medical practice, that providing a related health-care procedure, instead of or in addition to the approved surgical procedure, is medically necessary as part of the treatment of the covered person and that, in the provider's clinical judgment, to interrupt or delay the provision of care to the covered person in order to obtain prior authorization for the additional or related health-care procedure would not be medically advisable;

(B) The additional or related health-care procedure is a covered benefit under the covered person's health benefit plan;

(C) The additional or related health-care procedure is not experimental or investigational;

(D) After completing the additional or related health-care procedure and before submitting a claim for payment, the provider notifies the carrier or organization that the provider performed the additional or related health-care procedure and includes in the notice the information required under the carrier's or organization's current prior authorization requirements posted in accordance with subsection (2)(a)(I) of this section; and

(E) The provider is compliant with the carrier's or organization's post-service claims process, including submission of the claim within the carrier's or organization's required timeline for claims submissions.

(II) When a provider provides an additional or a related health-care procedure as described in this subsection (4)(c), the carrier or organization shall not deny the claim for the initial surgical procedure for which the carrier or organization approved a prior authorization request on the basis that the provider provided the additional or related health-care procedure.

(5) Duration of approval. (a) [Editor's note: For the applicability of this subsection (5)(a) on or after January 1, 2026, see the editor's note following this section.] Upon approval by the carrier or organization, a prior authorization is valid for at least one calendar year after the date of approval and continues for the duration of the authorized course of treatment. Except as provided in subsection (5)(b) of this section, once approved, a carrier or an organization shall not retroactively deny the prior authorization request for a health-care service.

(b) If there is a change in coverage of or approval criteria for a previously approved health-care service, the change in coverage or approval criteria does not affect a covered person who received prior authorization before the effective date of the change for the remainder of the covered person's plan year.

(c) Subsections (5)(a) and (5)(b) of this section do not apply if:

(I) The prior authorization approval was based on fraud;

(II) The provider never performed the services that were requested for prior authorization;

(III) The service provided did not align with the service that was authorized;

(IV) The person receiving the service no longer had coverage under the health coverage plan on or before the date the service was delivered; or

(V) The covered person's benefit maximums were reached on or before the date the service was delivered.

(6) Rules - enforcement. [Editor's note: For the applicability of this subsection (6) on or after January 1, 2026, see the editor's note following this section.] (a) The commissioner may adopt rules as necessary to implement this section.

(b) The commissioner may enforce the requirements of this section and impose a penalty or other remedy against a person that violates this section.

(7) Definitions. As used in this section:

(a) "Approval" means a determination by a carrier or organization that a health-care service has been reviewed and, based on the information provided, satisfies the carrier's or organization's requirements for medical necessity and appropriateness and that payment will be made for that health-care service.

(b) "Clinical criteria" means the written policies, written screening procedures, drug formularies or lists of covered drugs, determination rules, determination abstracts, clinical protocols, practice guidelines, medical protocols, and other criteria or rationale used by the carrier or organization to determine the necessity and appropriateness of health-care services.

(c) "Medical necessity" means a determination by the carrier that a prudent provider would provide a particular covered health-care service to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or symptom in a manner that is:

(I) In accordance with generally accepted standards of medical practice and approved by the FDA or other required agency;

(II) Clinically appropriate in terms of type, frequency, extent, service site, and level and duration of service;

(III) Known to be effective in improving health, as proven by scientific evidence;

(IV) The most appropriate supply, setting, or level of service that can be safely provided given the patient's condition and that cannot be omitted;

(V) Not experimental or investigational;

(VI) Not more costly than an alternative drug, service, service site, or supply that is not contraindicated for the patient's condition or safety and is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of an illness, injury, disease, or symptom; and

(VII) Not primarily for the economic benefit of carriers and purchasers or for the convenience of the patient, treating provider, or other provider.

(d) "Prior authorization" means the process by which a carrier or organization determines the medical necessity and appropriateness of otherwise covered health-care services prior to the rendering of the services. "Prior authorization" includes preadmission review, pretreatment review, utilization review, and case management and a carrier's or organization's requirement that a covered person or provider notify the carrier or organization prior to receiving or providing a health-care service.

(e) [Editor's note: For the applicability of this subsection (7)(e) on or after January 1, 2026, see the editor's note following this section.] "Private utilization review organization" or "organization" means a private utilization review organization, as defined in section 10-16-112 (1)(a), that has a contract with and performs prior authorization on behalf of a carrier.

(f) "Urgent health-care service" means a health-care service that, in the opinion of the provider based on the covered person's medical condition, if subjected to the prior authorization time period for a nonurgent health-care service, could:

(I) Seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function;

(II) For a person with a physical or mental disability, create an imminent and substantial limitation on the person's existing ability to live independently; or

(III) Subject the covered person to severe pain that cannot be adequately managed without the particular health-care service.
C.R.S. § 10-16-1405 — CO Code / Title 10 / Article 16 / Part 14 / Section 10-16-1405
10-16-1405. Colorado prescription drug affordability review board - reports from carriers an
Status: in_force

10-16-1405. Colorado prescription drug affordability review board - reports from carriers and pharmacy benefit management firms required - confidential materials. (1) Beginning in the 2022 calendar year, for all prescription drugs dispensed at a pharmacy in this state and paid for by a carrier pursuant to a health benefit plan issued under part 2, 3, or 4 of this article 16 during the immediately preceding calendar year, including brand-name drugs, authorized generic drugs, biological products, and biosimilar drugs:

(a) Each carrier and each pharmacy benefit management firm acting on behalf of a carrier shall report to the all-payer health claims database the following information:

(I) The top fifteen prescription drugs by volume, calculated by unit, for which the carrier paid;

(II) The fifteen costliest prescription drugs for which the carrier paid, as determined by total annual plan spending;

(III) The fifteen prescription drugs paid for by the carrier that accounted for the highest increase in total annual plan spending when compared with the total annual plan spending for the same prescription drugs in the year immediately preceding the year for which the information is reported;

(IV) The fifteen prescription drugs that caused the greatest increases in the carrier's premiums;

(V) The fifteen prescription drugs for which the carrier paid most frequently and for which the carrier received a rebate from manufacturers;

(VI) The fifteen prescription drugs for which the carrier received the highest rebates, as determined by percentages of the price of the prescription drug;

(VII) The fifteen prescription drugs for which the carrier received the largest rebates;

(VIII) The total spending for each of the following categories of prescription drugs:

(A) Brand-name drugs purchased from retail pharmacies;

(B) Authorized generic drugs purchased from retail pharmacies;

(C) Brand-name drugs purchased from mail-order pharmacies;

(D) Authorized generic drugs purchased from mail-order pharmacies;

(E) Prescription drugs dispensed by a practitioner in accordance with section 12-280-120 (6);

(F) Prescription drugs administered in an inpatient hospital setting; and

(G) Prescription drugs administered in an outpatient hospital setting; and

(IX) The total spending for the prescription drugs described in subsection (1)(a)(VIII) of this section paid for by a carrier pursuant to a health benefit plan issued under part 2, 3, or 4 of this article 16 during the immediately preceding calendar year for each of the following market sectors:

(A) Individual;

(B) Small employer; and

(C) Large employer.

(b) If the all-payer health claims database does not collect and maintain the data that is required to be reported to the database pursuant to subsection (1)(a) of this section, the administrator of the all-payer health claims database shall amend the requirements regarding the data to be submitted to the database pursuant to section 25.5-1-204 (5) to include the data required by subsection (1)(a) of this section during the next update of such requirements, but no later than June 1, 2022.

(2) The administrator of the all-payer health claims database shall provide to the commissioner, in a form and manner determined by the commissioner, the information that is reported to the database by carriers and pharmacy benefit management firms pursuant to subsection (1)(a) of this section.

(3) (a) Except as provided in subsection (3)(b) of this section, the commissioner shall:

(I) Post the information reported by carriers and pharmacy benefit management firms pursuant to this section on the division's website; and

(II) Provide the information reported by carriers and pharmacy benefit management firms pursuant to this section to the board, in a form and manner prescribed by the board.

(b) If a carrier or pharmacy benefit management firm claims that information submitted pursuant to this section is confidential or proprietary, the commissioner shall review the information and redact specific items that the carrier or pharmacy benefit management firm demonstrates to be confidential or proprietary. The commissioner shall not disclose redacted items to any person; except that the commissioner may disclose redacted items:

(I) As may be required pursuant to the "Colorado Open Records Act", part 2 of article 72 of title 24; and

(II) To employees of the division, as necessary.

(4) The requirement in this section to report information relating to the cost of prescription drugs is intended to create transparency in prescription drug pricing and does not:

(a) Prohibit a manufacturer of a prescription drug from making pricing decisions about its prescription drugs; or

(b) Prohibit purchasers, both public and private, or pharmacy benefit management firms from negotiating discounts and rebates consistent with existing state and federal law.
C.R.S. § 10-3-1110 — CO Code / Title 10 / Article 3 / Part 11 / Section 10-3-1110
10-3-1110. Rules
Status: in_force

10-3-1110. Rules. (1) The commissioner may, after notice and hearing, as provided in article 4 of title 24, C.R.S., promulgate reasonable rules and regulations as are necessary or proper to identify specific methods of competition or acts or practices which are prohibited by sections 10-3-1104 and 10-3-1105.

(2) The commissioner may, after notice and hearing, as provided in article 4 of title 24, C.R.S., promulgate rules with respect to the payment of benefits under group and individual contracts of property or casualty coverage, issued by organizations authorized to do business in this state under the provisions of article 4 of this title; except that, to the extent that a provision of this subsection (2) conflicts with section 10-4-642, as enacted by Senate Bill 04-125, enacted at the second regular session of the sixty-fourth general assembly, the provisions of said section 10-4-642 shall govern. Such rules may establish a penalty payable to the claimant on benefit payments that are delayed more than sixty days after a valid and complete filing of the claim unless there is a reasonable dispute between the parties concerning such claim. Such penalty shall not exceed twenty dollars on claims of less than one hundred dollars or interest at a rate of eight percent annually on claims above one hundred dollars. In addition to such penalties payable to the claimant, the commissioner, after notice and hearing, may assess a civil penalty against any insurer of one hundred dollars per day for each day benefit payments are delayed more than sixty days after a valid and complete filing of the claim unless there is a reasonable dispute between the parties concerning such claim.

(3) (Deleted by amendment, L. 99, p. 1142, § 2, effective January 1, 2000.)
C.R.S. § 10-4-1703 — CO Code / Title 10 / Article 4 / Part 17 / Section 10-4-1703
10-4-1703. License - application - restrictions
Status: in_force

10-4-1703. License - application - restrictions. (1) (a) Before being issued a limited lines self-storage insurance producer license, a person must submit an application for a limited lines self-storage license in accordance with section 10-2-404; except that the applicant is not required to provide the information specified in section 10-2-404 (2).

(b) A supervising entity is responsible for compliance with this part 17. If a self-storage retailer has more than one supervising entity, the commissioner may hold all supervising entities responsible for a violation of this part 17 in accordance with section 10-4-1709. If a self-storage retailer derives more than fifty percent of its revenue from the sale of limited lines self-storage insurance, the self-storage retailer shall provide the location of the self-storage retailer's home office and the name, residential address, and other information required by the commissioner for all officers, directors, and shareholders of record having beneficial ownership of ten percent or more of any class of the self-storage retailer's securities registered under federal securities laws. For purposes of this section:

(I) A supervising entity is not required to be an officer, partner, or director of the self-storage retailer; and

(II) The applicant for a limited lines self-storage insurance producer license pursuant to this part 17 is exempt from the requirements of section 10-2-406.

(c) By July 1, 2018, a person engaged in the sale, solicitation, or negotiation of self-storage insurance before August 9, 2017, shall either apply for a limited lines self-storage insurance producer license or cease engaging in the sale of self-storage insurance. To sell, solicit, or negotiate self-storage insurance on or after July 1, 2018, a person must first obtain a limited lines self-storage insurance producer license. A limited lines self-storage insurance producer license application must be accompanied by a fee prescribed by the commissioner in accordance with section 10-2-413. A limited lines self-storage insurance producer license must be renewed as set forth in section 10-2-408.

(2) A supervising entity may sell, solicit, or negotiate, or offer to sell, solicit, or negotiate, self-storage insurance only in connection with, and incidental to, the rental of a self-storage space in a self-service storage facility. The self-storage insurance may provide coverage only for damage or loss to the personal property of the occupant contained in the self-storage space.
C.R.S. § 10-4-116 — CO Code / Title 10 / Article 4 / Part 1 / Section 10-4-116
10-4-116. Use of credit information
Status: in_force

10-4-116. Use of credit information. (1) An insurer that offers personal lines of property and casualty insurance shall not:

(a) Use an insurance score that is calculated using income, gender, address, United States postal zip code, ethnic group, religion, marital status, or nationality of the consumer;

(b) Deny, cancel, or fail to renew a policy of personal lines of property and casualty insurance on the basis of credit information, without consideration of any other applicable underwriting factor that is independent of credit information prohibited pursuant to paragraph (a) of this subsection (1);

(c) Base an insured's renewal rates for personal lines of property and casualty insurance upon credit information, without consideration of any other applicable factor independent of credit information;

(d) Take an adverse action against a consumer because he or she does not have a credit card account, without consideration of any other applicable factor independent of credit information;

(e) Consider an absence of credit information or an inability to calculate an insurance score in underwriting or rating personal lines of property and casualty insurance issued in this state, unless the insurer does one of the following:

(I) Treats the consumer in a manner otherwise approved by the commissioner, if the insurer presents information that such an absence or inability relates to the risk for the insurer;

(II) Treats the consumer as if he or she had neutral credit information, as defined by the insurer; or

(III) Excludes the use of credit information as a factor and uses only other underwriting criteria;

(f) Take an adverse action against a consumer based on credit information, unless the insurer obtains and uses a credit report issued or an insurance score calculated within ninety days before the date the policy is first written or renewal is issued;

(g) Use credit information unless, not later than every thirty-six months following the last time that the insurer obtained current information for the consumer, the insurer recalculates the consumer's insurance score or obtains an updated credit report. Notwithstanding any provision of this section to the contrary, an insurer:

(I) At annual renewal, upon the request of a consumer or the consumer's agent, shall reunderwrite and rerate the policy based upon a current credit report or insurance score. An insurer may recalculate the insurance score or obtain the updated credit report of a consumer more frequently than once during a twelve-month period.

(II) May obtain current credit information upon a renewal before the thirty-sixth month of coverage, if obtaining current credit information is consistent with the insurer's underwriting guidelines;

(III) Notwithstanding subparagraph (I) of this paragraph (g), need not obtain current credit information for an insured if one of the following situations apply:

(A) The insurer is treating the insured in a manner otherwise approved by the commissioner;

(B) The insured is in the most-favorably-priced tier of the insurer, within a group of affiliated insurers; except that the insurer may order a credit report if ordering the credit report is consistent with its underwriting guidelines;

(C) Credit was not used for underwriting or rating the insured when the insured's initial policy of insurance was written; except that an insurer may use credit for underwriting or rating the insured upon renewal if the use of credit is consistent with its underwriting guidelines; or

(D) The insurer reevaluates the insured beginning no later than thirty-six months after inception and thereafter based upon other underwriting or rating factors, excluding credit information.

(h) Use the following as a negative factor in an insurance scoring methodology or in reviewing credit information for the purpose of underwriting or rating a policy of personal lines of property and casualty insurance:

(I) Credit inquiries not initiated by the consumer or inquiries requested by the consumer for his or her own credit information;

(II) Inquiries relating to insurance coverage, if so identified on a consumer's credit report;

(III) Collection accounts with a medical industry code, if so identified on the consumer's credit report;

(IV) Multiple lender inquiries, if coded by the consumer reporting agency on the consumer's credit report as being from the motor vehicle lending industry and made within thirty days after one another, unless only one inquiry is considered;

(V) Multiple lender inquiries, if coded by the consumer reporting agency on the consumer's credit report as being from the home mortgage industry and made within thirty days of one another, unless only one inquiry is considered;

(VI) Identity theft that may be sufficiently and independently corroborated;

(VII) Credit information adversely impacted by a dissolution of marriage or by the credit information of a former spouse.

(2) If it is determined through the dispute resolution process as set forth in the federal "Fair Credit Reporting Act", 15 U.S.C. sec. 1681i (a)(5), that the credit information of a current insured was incorrect or incomplete and if the insurer receives notice of a determination from either the consumer reporting agency or from the insured, the insurer shall reunderwrite and rerate the consumer within thirty days after receiving the notice. After reunderwriting or rerating the insured, the insurer shall make any adjustments necessary, consistent with its underwriting and rating guidelines. If an insurer determines that the insured has overpaid a premium, the insurer shall refund to the insured the amount of overpayment calculated back to the shorter of either the last twelve months of coverage or the actual policy period.

(3) (a) If an insurer offering personal lines of property and casualty coverage uses credit information in underwriting or rating a consumer, the insurer or the producer shall disclose, either on the insurance application or at the time the insurance application is taken, that it may obtain credit information in connection with such application. The disclosure shall be either in writing or in the same medium as the application for insurance is taken. The insurer may provide the disclosure statement required pursuant to this subsection (3) to an insured on a renewal policy, if the consumer has previously been provided a copy of the disclosure statement.

(b) Use of the following disclosure statement shall constitute compliance with the provisions of this subsection (3); except that an insurer may use different terms or phrases to communicate the same meaning:

In connection with this application for insurance, we may review your credit report or obtain or use a credit-based insurance score based on the information contained in that credit report. We may use a third party in connection with the development of your insurance score.

(4) If an insurer takes an adverse action based upon credit information, the insurer shall meet the notice requirements of this subsection (4). Specifically, an insurer shall:

(a) Provide notification to the consumer that an adverse action has been taken, in accordance with the requirements of the federal "Fair Credit Reporting Act", 15 U.S.C. sec. 1681m (a); and

(b) Provide notification to the consumer explaining the reason for the adverse action. The reasons shall be provided in sufficiently clear and specific language so that a person may identify the basis for the insurer's decision to take adverse action. The notification shall include a description of up to four factors that were the primary influences of the adverse action. The use of generalized terms such as "poor credit history", "poor credit rating", or "poor insurance score" does not meet the explanation requirements of this subsection (4). Standardized credit explanations provided by consumer reporting agencies or other third-party vendors are deemed to comply with this subsection (4).

(5) An insurer that uses insurance scores to underwrite and rate risk shall file its scoring models or other scoring processes with the commissioner. A third party may file scoring models on behalf of an insurer. A filing that includes insurance scoring may include loss experience justifying the use of credit information. The insurer may request that information requested pursuant to this subsection (5) not be open to public inspection or considered an open record pursuant to article 72 of title 24, C.R.S.

(6) An insurer shall indemnify, defend, and hold a producer harmless against all liability, fees, and costs arising out of or relating to the actions, errors, or omissions of the producer who obtains or uses credit information or insurance scores for an insurer, so long as the producer follows the instructions of or procedures established by the insurer and complies with any applicable law or rule. Nothing in this section shall be construed to provide a consumer or insured with a cause of action that does not exist in the absence of this section.

(7) (a) A consumer reporting agency shall not provide or sell data or lists that include information that, in whole or in part, was submitted in conjunction with an insurance inquiry about a consumer's credit information or a request for a credit report or insurance score. Information that may not be provided or sold includes, but is not limited to, the expiration dates of an insurance policy or other information that may identify periods in which a consumer's insurance may expire and the terms and conditions of the consumer's insurance coverage.

(b) The restrictions provided in paragraph (a) of this subsection (7) shall not apply to data or lists the consumer reporting agency supplies to the insurance producer from whom information was received, the insurer on behalf of whom the producer acted, or such insurer's affiliates or holding companies.

(c) Nothing in this subsection (7) shall be construed to restrict an insurer from being able to obtain a claims history report or a motor vehicle report.

(8) For the purposes of this section, unless the context otherwise requires:

(a) "Adverse action" means a denial or cancellation of, an increase in any charge for, or a reduction or other unfavorable change in the terms of coverage or amount of any insurance existing or applied for in connection with the underwriting of personal lines of property and casualty insurance coverages.

(b) "Affiliate" means a company that controls, is controlled by, or is under common control with another insurer.

(c) "Applicant" means a person who has applied to be covered under a policy of personal lines of property and casualty insurance.

(d) "Beneficiary or claimant" includes an insured person and a third-party claimant.

(e) "Consumer" means an insured whose credit information is used or whose insurance score is calculated in the underwriting or rating of personal lines of property and casualty insurance or an application for personal lines of property and casualty insurance coverage.

(f) "Consumer reporting agency" shall have the same meaning as in section 5-16-103 (6).

(g) "Credit information" means credit-related information derived from a credit report itself or provided on an application for personal lines of property and casualty insurance. Information that is not credit-related shall not be considered "credit information" regardless of whether it is contained in a credit report or in an application or is used to calculate an insurance score.

(h) "Credit report" means a written, oral, or other communication of information by a consumer reporting agency bearing on a consumer's creditworthiness, credit standing, or credit capacity that is used or expected to be used or collected in whole or in part for the purpose of serving as a factor to determine personal lines of property and casualty insurance premiums, eligibility for coverage, or tier placement.

(i) "Insurance score" means a number or rating that is derived from an algorithm, computer application, model, or other process that is based in whole or in part on credit information for the purpose of predicting the future insurance loss exposure of an individual applicant or insured.
C.R.S. § 10-1-130 — CO Code / Title 10 / Article 1 / Part 1 / Section 10-1-130
10-1-130. Availability of sickness, health, and accident insurance
Status: repealed

10-1-130. Availability of sickness, health, and accident insurance. (1) The commissioner shall assess the availability of sickness, health, and accident insurance in Colorado with a view to identifying specific groups of persons to whom such coverage is unavailable by virtue of cost, preexisting condition, or other circumstances.

(2) Repealed.
C.R.S. § 10-16-104 — CO Code / Title 10 / Article 16 / Part 1 / Section 10-16-104
10-16-104. Mandatory coverage provisions - definitions - rules - applicability
Status: repealed

10-16-104. Mandatory coverage provisions - definitions - rules - applicability. (1) Newborn children. (a) All group and individual sickness and accident insurance policies and all service or indemnity contracts issued by any entity subject to part 3 or 4 of this article shall provide coverage for a dependent newborn child of the insured or subscriber from the moment of birth.

(b) (I) Coverage for a hospital stay for a newborn following a normal vaginal delivery shall not be limited to less than forty-eight hours. If forty-eight hours following delivery falls after 8 p.m., coverage shall continue until 8 a.m. the following morning.

(II) Coverage for a hospital stay for a newborn following a cesarean section shall not be limited to less than ninety-six hours. If ninety-six hours following the cesarean section falls after 8 p.m., coverage shall continue until 8 a.m. the following morning.

(III) The provisions of subparagraphs (I) and (II) of this paragraph (b) shall not apply in any case in which the decision to discharge the newborn prior to the minimum length of stay otherwise required under subparagraphs (I) and (II) of this paragraph (b) is made by an attending provider with the agreement of the mother.

(IV) Nothing in this paragraph (b) shall be construed to require a mother who is a participant or beneficiary to give birth in a hospital or to stay in the hospital for a fixed period of time after the birth of her child.

(V) Nothing in this paragraph (b) shall be construed as preventing a carrier from imposing deductibles, coinsurance, or other cost sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or newborn child under the plan; except that such coinsurance or other cost sharing for any portion of a period within a hospital length of stay required under subparagraphs (I) and (II) of this paragraph (b) may not be greater than such coinsurance or cost sharing for any other sickness, injury, disease, or condition that is otherwise covered under the policy or contract.

(c) (I) Except as provided for cleft lip and cleft palate coverage in sub-subparagraph (A) of subparagraph (II) of this paragraph (c) 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 pursuant to sub-subparagraph (A) of subparagraph (III) of this paragraph (c), the benefits available to newborn children shall 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 thirty-one days of the newborn's life, notwithstanding policy limitations and exclusions applicable to other conditions or procedures covered by the policy. Except as provided in sub-subparagraph (C) of subparagraph (II) of this paragraph (c), such coverage shall be subject to copayment, deductible, and aggregate dollar policy maximums that are no higher than are generally applicable under the policy to all other sicknesses, diseases, and conditions otherwise covered under the policy.

(II) (A) With regard to newborn children born with cleft lip or cleft palate or both, there shall be no age limit on benefits for such conditions, and care and treatment shall 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.

(B) Cleft lip, cleft palate, or any condition or illness which is related to or developed as a result of the cleft lip or cleft palate shall be considered to be compensable for coverage under the provisions of sub-subparagraph (A) of this subparagraph (II).

(C) If a dental insurance policy, a contract for dental insurance, or an enrollee coverage contract issued pursuant to this article 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 shall provide fully for any orthodontics or dental care needed as a result of the cleft lip or cleft palate or both. Such policy or contract may contain the same copayment provisions for the coverage of cleft lip or cleft palate or both as apply to other conditions or procedures covered by the policy or contract.

(III) (A) Coverage for inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic, and fatty acids as well as severe protein allergic conditions includes, without limitation, the following diagnosed conditions: Phenylketonuria; maternal phenylketonuria; maple syrup urine disease; tyrosinemia; homocystinuria; histidinemia; urea cycle disorders; hyperlysinemia; glutaric acidemias; methylmalonic acidemia; propionic acidemia; immunoglobulin E and nonimmunoglobulin E-mediated allergies to multiple food proteins; severe food protein induced enterocolitis syndrome; eosinophilic disorders as evidenced by the results of a biopsy; and impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, and motility of the gastrointestinal tract. Covered care and treatment of such conditions shall include, 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.

(B) There is no age limit on benefits for inherited enzymatic disorders specified in sub-subparagraph (A) of this paragraph (III) except for phenylketonuria. The maximum age to receive benefits for phenylketonuria is twenty-one years of age; except that the maximum age to receive benefits for phenylketonuria for women who are of child-bearing age is thirty-five years of age.

(C) As used in this subparagraph (III), "medical foods" means prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas, 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 of amino, organic, and fatty acids and for severe allergic conditions, if diagnosed by a board-certified allergist or board-certified gastroenterologist, 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. The formulas for severe food allergies contain only singular form elemental amino acids. The formulas 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 sub-subparagraph (C) shall not be construed to apply to cystic fibrosis patients or lactose- or soy-intolerant patients.

(D) Coverage of medical foods, as provided under this subparagraph (III), shall only apply to insurance plans that include an approved pharmacy benefit and shall not apply to alternative medicines. Such coverage shall only be available through participating pharmacy providers. Nothing in this subparagraph (III) shall be construed as preventing a carrier from imposing deductibles, coinsurance, or other cost-sharing methods.

(d) If payment of a specific premium is required to provide coverage for a child, the policy may require that notification of birth of the newborn child and payment of the required premium must be furnished to the insurer or other entity within thirty-one days after the date of birth in order to have the coverage continue beyond such thirty-one-day period.

(e) The requirements of this section shall apply to all individual sickness and accident policies issued on and after July 1, 1975, and to all blanket and group sickness and accident policies issued, renewed, or reinstated on and after July 1, 1975, and to all subscriber or enrollee coverage contracts delivered or issued for delivery in this state on and after July 1, 1975.

(f) (I) Any contract of a prepaid dental plan of an entity subject to the provisions of part 5 of this article applied for that provides family coverage shall, as to such coverage of individuals in the family, also provide that the benefits applicable for children shall be payable with respect to a newly born child of the insured from the instant of such child's birth to the same extent that such coverage applies to other individuals in the family. If payment of a specific premium or capitation amount is required to provide coverage for a child, the contract may require that notification of birth of a newly born child and payment of the required premium or capitation amount shall be furnished to the organization within thirty-one days after the date of birth in order to have the coverage continue beyond the thirty-one-day period.

(II) The coverage for newborn children shall include any orthodontics or dental care needed as the result of the child being born with a cleft lip or cleft palate or both. The contract providing such coverage may contain the same copayment provisions as apply to other conditions or procedures covered by the contract.

(g) The health-care service plan issued by an entity subject to the provisions of part 4 of this article may provide that the benefits required pursuant to this subsection (1) shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization.

(1.3) Early intervention services. (a) As used in this subsection (1.3), unless the context otherwise requires:

(I) "Division" means the unit within the department of human services that is responsible for developmental disabilities services.

(II) "Early intervention services" means services as defined by the division in accordance with part C that are authorized through an eligible child's IFSP but that exclude nonemergency medical transportation; respite care; service coordination, as defined in 34 CFR 303.12 (d)(11); and assistive technology, unless assistive technology is covered under the applicable insurance policy or service or indemnity contract as durable medical equipment.

(III) "Eligible child" means an infant or toddler, from birth through two years of age, who is an eligible dependent and who, as defined by the department pursuant to section 26.5-3-402 (11), has significant delays in development or has a diagnosed physical or mental condition that has a high probability of resulting in significant delays in development or who is eligible for services pursuant to section 27-10.5-102 (11)(c).

(IV) "Individualized family service plan" or "IFSP" means a written plan developed pursuant to 20 U.S.C. sec. 1436 and 34 CFR 303.340 that authorizes early intervention services to an eligible child and the child's family. An IFSP shall serve as the individualized plan, pursuant to section 27-10.5-102 (20)(c), C.R.S., for an eligible child from birth through two years of age.

(V) "Part C" means the early intervention program for infants and toddlers who are eligible for services under part C of the federal "Individuals with Disabilities Education Act", 20 U.S.C. sec. 1400 et seq.

(VI) "Qualified early intervention service provider" or "qualified provider" means a person or agency, as defined by the division in accordance with part C, who provides early intervention services and is listed on the registry of early intervention service providers pursuant to section 26.5-3-408 (1).

(b) (I) All individual and group sickness and accident insurance policies or contracts issued or renewed by an entity subject to part 2 of this article on or after January 1, 2008, and all service or indemnity contracts issued or renewed by an entity subject to part 3 or 4 of this article on or after January 1, 2008, that include dependent coverage shall provide coverage for early intervention services delivered by a qualified early intervention service provider to an eligible child. Early intervention services specified in an eligible child's IFSP shall qualify as meeting the standard for medically necessary health-care services as used by private health insurance plans.

(II) (A) The coverage required by this subsection (1.3) must be available annually to an eligible child from birth up to the child's third birthday for early intervention services for each dependent child per calendar or policy year. The commissioner shall specify, by rule, the extent of the coverage for early intervention services required by this subsection (1.3), which, except for grandfathered health benefit plans, must require coverage of a number of early intervention services or visits that is actuarially equivalent to the dollar limit of the benefit as it existed prior to May 13, 2013.

(B) For grandfathered health benefit plans, the coverage required by this subsection (1.3) per calendar or policy year for early intervention services for each eligible dependent child from birth up to the child's third birthday is limited to six thousand three hundred sixty-one dollars, including case management costs. Effective January 1, 2014, and each January 1 thereafter, the commissioner shall annually adjust the dollar limit for early intervention services coverage based on the Denver-Aurora-Lakewood consumer price index or, if applicable, its predecessor or successor index for the state fiscal year that ends in the immediately preceding calendar year, or by an additional amount equal to the increase by the general assembly in the annual appropriated rate to serve one child for one fiscal year in the state-funded early intervention program if that increase is more than the consumer price index increase.

(III) Except as provided in paragraph (d) of this subsection (1.3), the coverage shall not be subject to deductibles or copayments, and any benefits paid under the coverage required by this subsection (1.3) shall not be applied to an annual or lifetime maximum benefit contained in the policy or contract. Unless the carrier agrees prior to the provision of early intervention services, a carrier shall not be required to pay a reimbursement rate for early intervention services provided by a nonparticipating provider that exceeds the reimbursement rate allowed for comparable early intervention services provided by a participating provider.

(IV) Any limit on the amount of coverage for early intervention services specified by the commissioner by rule pursuant to sub-subparagraph (A) of subparagraph (II) of this paragraph (b) or, for grandfathered health benefit plans, specified in sub-subparagraph (B) of subparagraph (II) of this paragraph (b) shall not apply to:

(A) Rehabilitation or therapeutic services that are necessary as the result of an acute medical condition or post-surgical rehabilitation;

(B) Services provided to a child who is not participating in part C and services that are not provided pursuant to an IFSP. However, such services shall be covered at the level specified in paragraph (b) of subsection (1.7) of this section.

(c) This subsection (1.3) shall not apply to the following:

(I) Short-term, accident, fixed indemnity, or specified disease policies, disability income contracts, limited benefit health insurance, as defined by the commissioner by rule, credit disability insurance, or a medicare supplement policy as defined in section 10-18-101 (4);

(II) Workers' compensation or similar insurance;

(III) Automobile medical payment insurance or insurance under which benefits are payable with or without regard to fault and required by law to be contained in any liability insurance policy or equivalent self-insurance.

(d) (I) The coverage required by this subsection (1.3) may be offered through a high deductible plan that would qualify for a health savings account pursuant to 26 U.S.C. sec. 223; except that a carrier may apply deductible amounts for the required coverage if it is not considered by the United States department of treasury to be preventive or to have an acceptable deductible amount.

(II) If a high deductible plan that would qualify for a health savings account pursuant to 26 U.S.C. sec. 223 requires a deductible or copayment amount for the coverage required by this subsection (1.3), the deductible or copayment amount may be paid by the state as determined by rules adopted by the commissioner in accordance with article 4 of title 24, C.R.S., in consultation with the division of insurance.

(d.5) (I) Upon notice from the department of early childhood pursuant to section 26.5-3-409 (1) that a child is eligible for early intervention services, the carrier shall submit payment of benefits for the eligible child in accordance with this subsection (1.3)(d.5)(I) and section 26.5-3-409 (1). If the eligible child is covered by a grandfathered health benefit plan, the carrier shall submit payment in the amount specified in subsection (1.3)(b)(II)(B) of this section, as adjusted annually pursuant to said subsection. If the eligible child is covered by any other policy or contract subject to this subsection (1.3), the carrier shall submit payment in an amount that equals the approximate value of the number of early intervention services or visits specified by the commissioner pursuant to subsection (1.3)(b)(II)(A) of this section.

(II) Qualified early intervention service providers that receive reimbursement in accordance with this paragraph (d.5) shall accept the reimbursement as payment in full for services provided under this subsection (1.3) and shall not seek additional reimbursement from either the covered person or the carrier.

(e) Within ninety days after the division determines that a child is no longer an eligible child for purposes of this subsection (1.3), the division shall notify the carrier that the child is no longer eligible and that the carrier is no longer required to provide the coverage required by this subsection (1.3) for that child.

(f) Use of available coverage under this subsection (1.3) for the cost of early intervention services is mandatory, consistent with the requirements of part C. An eligible child must fully utilize available coverage under this subsection (1.3) prior to accessing state general funds or federal part C funds. A carrier shall not terminate or fail to renew health coverage on the basis that an eligible child has accessed or will be accessing early intervention services under this subsection (1.3).

(g) Early intervention services shall be provided as specified in the eligible child's IFSP, and such services shall not duplicate or replace treatment for autism spectrum disorders provided in accordance with subsection (1.4) of this section. Services for the treatment of autism spectrum disorders provided in accordance with subsection (1.4) of this section shall be considered the primary service to an eligible child, and early intervention services provided under this subsection (1.3) shall supplement, but not replace, services provided under subsection (1.4) of this section.

(1.4) Autism spectrum disorders. (a) As used in this subsection (1.4), unless the context otherwise requires:

(I) "Applied behavior analysis" means the use of behavior analytic methods and research findings to change socially important behaviors in meaningful ways.

(II) "Autism services provider" means any person who provides direct services to a person with autism spectrum disorder, is licensed, certified, or registered by the applicable state licensing board or by a nationally recognized organization, and meets one of the following:

(A) Has a doctoral degree with a specialty in psychiatry, medicine, or clinical psychology, is actively licensed by the Colorado medical board, and has at least one year of direct experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism spectrum disorders;

(B) Has a doctoral degree in one of the behavioral or health sciences and has completed one year of experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism spectrum disorders;

(C) Has a master's degree or higher in behavioral sciences and is nationally certified as a "board certified behavior analyst" or certified by a similar nationally recognized organization;

(D) Has a master's degree or higher in one of the behavior or health sciences, is credentialed as a related services provider, and has completed one year of direct supervised experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism spectrum disorders. For the purposes of this sub-subparagraph (D), "related services provider" means a physical therapist, occupational therapist, or speech therapist.

(E) Has a baccalaureate degree or higher in behavioral sciences and is nationally certified as a "board certified associate behavior analyst" by the behavior analyst certification board or by a similar nationally recognized organization; or

(F) Is nationally registered as a "registered behavior technician" by the behavior analyst certification board or by a similar nationally recognized organization and provides direct services to a person with an autism spectrum disorder under the supervision of an autism services provider described in sub-subparagraph (A), (B), (C), (D), or (E) of this subparagraph (II).

(III) "Autism spectrum disorders" or "ASD":

(A) Has the same meaning as set forth in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders in effect at the time of the diagnosis; and

(B) Includes the following disorders, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders in effect at the time of the diagnosis: Autistic disorder, Asperger's disorder, and atypical autism as a diagnosis within pervasive developmental disorder not otherwise specified.

(IV) "Health benefit plan", does not include:

(A) Short-term limited duration health insurance policies; or

(B) Individual grandfathered health benefit plans.

(V) "Individualized education program" shall have the same meaning as provided in section 22-20-103, C.R.S.

(VI) "Individualized family service plan" shall have the same meaning as provided in section 27-10.5-102, C.R.S.

(VII) "Individualized plan" has the same meaning as provided in section 25.5-10-202, C.R.S.

(VIII) "Pharmacy care" means medications prescribed by a physician licensed by the Colorado medical board under the "Colorado Medical Practice Act", article 240 of title 12.

(IX) "Psychiatric care" means direct or consultative services provided by a psychiatrist licensed by the Colorado medical board under the "Colorado Medical Practice Act", article 240 of title 12.

(X) "Psychological care" means direct or consultative services provided by a psychologist licensed by the state board of psychologist examiners pursuant to part 3 of article 245 of title 12 or a social worker licensed by the state board of social work examiners pursuant to part 4 of article 245 of title 12.

(XI) "Therapeutic care" means services provided by a speech therapist; an occupational therapist or occupational therapy assistant licensed to practice occupational therapy pursuant to article 270 of title 12; a physical therapist licensed to practice physical therapy pursuant to article 285 of title 12; or an autism services provider. "Therapeutic care" includes, but is not limited to, speech, occupational, and applied behavior analytic and physical therapies.

(XII) "Treatment for autism spectrum disorders" shall be for treatments that are medically necessary. The treatments listed in this subparagraph (XII) are not considered experimental or investigational and are considered appropriate, effective, or efficient for the treatment of autism. "Treatment for autism spectrum disorders" shall include the following, as medically necessary:

(A) Evaluation and assessment services;

(B) Behavior training and behavior management and applied behavior analysis, including but not limited to consultations, direct care, supervision, or treatment, or any combination thereof, for autism spectrum disorders provided by autism services providers;

(C) Habilitative or rehabilitative care, including, but not limited to, occupational therapy, physical therapy, or speech therapy, or any combination of those therapies. For a person who is also covered under subsection (1.7) of this section, the level of benefits for occupational therapy, physical therapy, or speech therapy shall exceed the limit of twenty visits for each therapy if such therapy is medically necessary to treat autism spectrum disorders under this subsection (1.4).

(D) Pharmacy care and medication, if covered by the health benefit plan;

(E) Psychiatric care;

(F) Psychological care, including family counseling; and

(G) Therapeutic care.

(XIII) "Treatment plan" means a plan developed for an individual by an autism services provider and prescribed by a licensed physician or a licensed psychologist pursuant to a comprehensive evaluation or reevaluation for an individual consisting of the individual's diagnosis; proposed treatment by type, frequency, and anticipated treatment; the anticipated outcomes stated as goals; and the frequency by which the treatment plan will be updated. The treatment plan shall be developed in accordance with the patient-centered medical home as defined in section 25.5-1-103 (5.5), C.R.S.

(b) (I) All health benefit plans issued or renewed in this state must provide coverage for the assessment, diagnosis, and treatment of autism spectrum disorders for a child pursuant to this subsection (1.4).

(II) Nothing in this subsection (1.4):

(A) Requires or permits a carrier to reduce benefits provided for autism spectrum disorders if a health benefit plan already provides coverage that exceeds the requirements of this subsection (1.4) and rules adopted by the commissioner;

(B) Prevents a carrier from increasing benefits provided for autism spectrum disorders; or

(C) Limits coverage for physical or mental health benefits covered under a health benefit plan.

(c) Treatment for autism spectrum disorders shall be prescribed or ordered by a licensed physician or licensed psychologist.

(d) A health benefit plan offered to residents of this state providing basic health-care services that is delivered, issued for delivery, or renewed in this state shall not exclude autism spectrum disorders or impose additional requirements for authorization of services that operate to exclude coverage for the assessment, diagnosis, and treatment of autism spectrum disorders.

(e) Except as otherwise provided in paragraph (b) of this subsection (1.4), the coverage required under this subsection (1.4) shall not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the health benefit plan. The benefits of this subsection (1.4) shall be in addition to any benefits provided for in subsections (1.3) and (1.7) of this section.

(f) Benefits provided by a carrier on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition not diagnosed as an autism spectrum disorder, shall not be applied toward any maximum benefit amount established under this subsection (1.4).

(g) A carrier may not deny or refuse to provide otherwise covered services, refuse to issue, renew, or reissue, or otherwise restrict or terminate coverage under a health benefit plan because the individual or his or her covered dependent is diagnosed with an autism spectrum disorder or due to the individual's or dependent's utilization of services for which benefits are mandated by this subsection (1.4).

(h) Any review of a treatment plan or any appeal of a decision regarding treatment shall be subject to the rules of the commissioner on prompt investigation of health plan claims involving utilization review and denial of benefits.

(i) Nothing in this subsection (1.4) shall be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized plan. The services required to be covered by this subsection (1.4) shall be in addition to any services provided to an individual under an individualized family service plan, an individualized education program, or an individualized plan.

(j) Coverage under this subsection (1.4) is subject to all terms, conditions, definitions, restrictions, exclusions, limitations, and utilization review of health-care services that apply to any other coverage under the health benefit plan, including the treatment under the health benefit plan of services performed by participating and nonparticipating providers.

(1.5) (Deleted by amendment, L. 2009, (HB 09-1204), ch. 344, p. 1802, § 2, effective January 1, 2010.)

(1.7) Therapies for congenital defects and birth abnormalities. (a) After the first thirty-one days of life, policy limitations and exclusions that are generally applicable under the policy may apply; except that all individual and group health benefit plans shall provide medically necessary physical, occupational, and speech therapy for the care and treatment of congenital defects and birth abnormalities for a covered child from the child's third birthday to the child's sixth birthday.

(b) The level of benefits required in paragraph (a) of this subsection (1.7) shall be the greater of the number of such visits provided under the policy or plan or twenty therapy visits per year each for physical therapy, occupational therapy, and speech therapy. Said therapy visits shall be distributed as medically appropriate throughout the yearly term of the policy or yearly term of the enrollee coverage contract, without regard to whether the condition is acute or chronic and without regard to whether the purpose of the therapy is to maintain or to improve functional capacity.

(c) Repealed.

(d) The health-care service plan issued by an entity subject to the provisions of part 4 of this article may provide that the benefits required pursuant to this subsection (1.7) shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization.

(2) Complications of pregnancy and childbirth. (a) Any sickness and accident insurance policy providing indemnity for disability due to sickness issued by an entity subject to the provisions of part 2 of this article and any individual or group service or indemnity contract issued by an entity subject to part 3 of this article shall provide coverage for a sickness or disease which 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 shall provide coverage for an accident which occurs during the course of pregnancy or childbirth in the same manner as any other similar accident is covered under the policy.

(b) Any sickness and accident insurance policy providing coverage for sickness on an expense-incurred basis shall provide coverage for a sickness or disease which is a complication of pregnancy or childbirth in the same manner as any other similar sickness or disease is otherwise covered under the policy.

(3) Maternity coverage. (a) (I) (A) All group sickness and accident insurance policies providing coverage within the state and issued to an employer by an entity subject to part 2 of this article 16, all group health service contracts issued by an entity subject to part 3 or 4 of this article 16 and issued to an employer, all individual sickness and accident insurance policies issued by an entity subject to part 2 of this article 16, and all individual health-care or indemnity contracts issued by an entity subject to part 3 or 4 of this article 16, except supplemental policies covering a specified disease or other limited benefit, must insure against the expense of normal pregnancy and childbirth or provide coverage for maternity care and provide coverage for contraception in the same manner as any other sickness, injury, disease, or condition is otherwise covered under the policy or contract; except that coverage for contraception must be consistent with the requirements in section 10-16-104.2.

(B) Individual sickness and accident insurance policies or contracts may exclude coverage for pregnancy and delivery expenses on the grounds that pregnancy was a preexisting condition; except that the exclusion for a pregnancy as a preexisting condition under the policy or contract does not apply for any subsequent pregnancies. Group sickness and accident insurance policies or contracts must not exclude coverage for pregnancy and delivery expenses on the grounds that pregnancy was a preexisting condition.

(II) Coverage for a hospital stay following a normal vaginal delivery shall not be limited to less than forty-eight hours. If forty-eight hours following delivery falls after 8 p.m., coverage shall continue until 8 a.m. the following morning.

(III) Coverage for a hospital stay following a cesarean section shall not be limited to less than ninety-six hours. If ninety-six hours following the cesarean section falls after 8 p.m., coverage shall continue until 8 a.m. the following morning.

(IV) The provisions of subparagraphs (II) and (III) of this paragraph (a) shall not apply in any case in which the decision to discharge prior to the minimum length of stay otherwise required under subparagraphs (II) and (III) of this paragraph (a) is made by an attending provider with the agreement of the mother.

(V) Nothing in this paragraph (a) shall be construed to require a mother who is a participant or beneficiary to give birth in a hospital or to stay in the hospital for a fixed period of time after the birth of her child.

(VI) Nothing in this paragraph (a) shall be construed as preventing a carrier from imposing deductibles, coinsurance, or other cost sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or newborn child under the plan; except that such coinsurance or other cost sharing for any portion of a period within a hospital length of stay required under subparagraphs (II) and (III) of this paragraph (a) may not be greater than such coinsurance or cost sharing for any other sickness, injury, disease, or condition that is otherwise covered under the policy or contract.

(b) The requirement in paragraph (a) of this subsection (3) shall not apply to policies or contracts purchased by employers who employ any number of full-time or part-time employees in fewer than fifteen 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 as required in paragraph (a) of this subsection (3) is provided by the employer in one of the following methods:

(I) Self-insurance. All employers who elect under this subparagraph (I) to utilize self-insurance for providing this benefit shall provide written notice to affected employees and to the health insurance carrier of its choice to self-insure.

(II) A policy purchased from an insurance company authorized to do business in this state which meets all of the requirements of the division of insurance for that purpose;

(III) A contract issued by an entity subject to the provisions of part 3 or 4 of this article;

(IV) A combination of the methods of obtaining insurance authorized in subparagraphs (I) to (III) of this paragraph (b).

(c) An entity authorized under the provisions of part 3 or 4 of this article to issue service or indemnity-type contracts shall offer coverage for maternity care to both married and unmarried women in individual, nonfamily contracts and shall offer the same coverage and the same payment of costs for maternity benefits to unmarried women that it offers to married women.

(d) A carrier offering a health benefit plan in the state shall reimburse participating providers who provide covered health-care services related to labor and delivery within the scope of the provider's practice in a manner that:

(I) Promotes high-quality, cost-effective, and evidence-based care;

(II) Promotes high-value, evidence-based payment models; and

(III) Prevents risk in subsequent pregnancies.

(e) Doula services - rules - definitions. (I) As used in this subsection (3)(e), unless the context otherwise requires:

(A) "Billing guidance" means guidance from the department of health care policy and financing concerning coverage and billing for doula services after consideration of the findings and recommendations for doula services resulting from the stakeholder process required pursuant to section 25.5-4-506.

(B) "Doula" means a trained birth companion who provides personal, nonmedical support to pregnant and postpartum people and their families prior to childbirth, during labor and delivery, and during the postpartum period and who has the qualifications and training required by the state.

(C) "Doula services" means services provided by a doula.

(D) "Medical assistance program" means the "Colorado Medical Assistance Act", articles 4, 5, and 6 of title 25.5.

(II) In the large group market, maternity coverage pursuant to this subsection (3) must include coverage for doula services, to the extent practicable, for the same scope and duration of coverage that is included in the department of health care policy and financing's request submitted pursuant to section 25.5-4-506 for federal authorization for doula services under the medical assistance program. The benefit may include the same qualifications for individuals providing doula services as recommended in the billing guidance for individuals providing doula services under the medical assistance program.

(III) Except as provided in subsection (3)(e)(VI) of this section, in the individual and small group markets, maternity coverage pursuant to this subsection (3) must include coverage for doula services if the services are within the doula's area of professional competence and the doula services are:

(A) Currently reimbursed when rendered by any other health-care providers; or

(B) Covered as part of the maternity essential health benefit.

(IV) This subsection (3)(e) applies to, and the division shall implement the requirements of this subsection (3)(e) for, large employer health benefit plans issued or renewed in this state on or after July 1, 2025, or twelve months after the date on which the department of health care policy and financing submits its request pursuant to section 25.5-4-506 for federal authorization for doula services under the medical assistance program, whichever is later.

(V) With respect to individual and small group health benefit plans, the division shall:

(A) Review the actuarial review conducted pursuant to section 10-16-155.5 and submit to the federal department of health and human services the division's determination as to whether the benefit specified in this subsection (3)(e) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and

(B) Request that the federal department of health and human services confirm the division's determination within sixty days after receipt of the division's request and submission of its determination.

(VI) This subsection (3)(e) applies to, and the division shall implement the requirements of this subsection (3)(e) for, individual and small group health benefit plans issued or renewed in this state upon the earlier of:

(A) Twelve months after the federal department of health and human services confirms the division's determination or otherwise informs the division that the coverage specified in this subsection (3)(e) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or

(B) The passage of more than three hundred sixty-five days since the division submitted its determination and request for confirmation pursuant to subsection (3)(e)(V) of this section, and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department's unreasonable delay a preclusion from requiring defrayal by the state.

(VII) The commissioner may promulgate rules as necessary to implement this subsection (3).

(4) (Deleted by amendment, L. 2009, (HB 09-1204), ch. 344, p. 1802, § 2, effective January 1, 2010.)

(5) Repealed.

(5.5) Behavioral, mental health, and substance use disorders. (a) (I) Every health benefit plan subject to part 2, 3, or 4 of this article 16, except those described in section 10-16-102 (32)(b), must provide coverage:

(A) For the prevention of, screening for, and treatment of behavioral, mental health, and substance use disorders that is no less extensive than the coverage provided for any physical illness and that complies with the requirements of the MHPAEA; and

(B) At a minimum, for the treatment of substance use disorders in accordance with the American Society of Addiction Medicine criteria for placement, medical necessity, and utilization management determinations as set forth in the most recent edition of "The ASAM Criteria for Addictive, Substance-related, and Co-occurring Conditions"; except that the commissioner may identify by rule, in consultation with the department of health care policy and financing and the behavioral health administration in the department of human services, an alternate nationally recognized and evidence-based substance-use-disorder-specific criteria for placement, medical necessity, or utilization management, if the American Society of Addiction Medicine criteria are no longer available or relevant or do not follow best practices for substance use disorder treatment.

(II) (Deleted by amendment, L. 2013.)

(III) (A) Except as provided in subsections (5.5)(a)(III)(B) and (5.5)(a)(III)(C) of this section, any preauthorization or utilization review mechanism used in the determination to provide the coverage required by this subsection (5.5)(a) must be the same as, or no more restrictive than, that used in the determination to provide coverage for a physical illness. The commissioner shall adopt rules as necessary to implement and administer this subsection (5.5).

(B) A health benefit plan subject to this subsection (5.5) must provide coverage without prior authorization for a five-day supply of at least one of the FDA-approved drugs for the treatment of opioid dependence; except that this requirement is limited to a first request within a twelve-month period.

(C) A health benefit plan subject to this subsection (5.5) must provide coverage for at least one opiate antagonist, as defined in section 12-30-110 (7)(d).

(IV) In the event of a concurrent review for a claim for coverage of services for the prevention of, screening for, and treatment of behavioral, mental health, and substance use disorders, the service continues to be a covered service until the carrier notifies the covered person of the determination on the claim.

(V) A carrier offering a health benefit plan subject to the requirements of this subsection (5.5) shall:

(A) Comply with the nonquantitative treatment limitation requirements specified in 45 CFR 146.136 (c)(4), or any successor regulation, regarding any limitations that are not expressed numerically but otherwise limit the scope or duration of benefits for treatment, which, in addition to the limitations and examples listed in 45 CFR 146.136 (c)(4)(ii) and (c)(4)(iii), or any successor regulation, and 78 FR 68246, include the methods by which the carrier establishes and maintains its provider networks pursuant to section 10-16-704 and responds to deficiencies in the ability of its networks to provide timely access to care;

(B) Comply with the financial requirements and quantitative treatment limitations specified in 45 CFR 146.136 (c)(2) and (c)(3), or any successor regulation;

(C) Not apply any nonquantitative treatment limitations to benefits for behavioral, mental health, and substance use disorders that are not applied to medical and surgical benefits within the same classification of benefits;

(D) Establish procedures to authorize treatment with a nonparticipating provider if a covered service is not available within established time and distance standards and within a reasonable period after a service is requested, and with the same coinsurance, deductible, or copayment requirements as would apply if the services were provided by a participating provider, and at no greater cost to the covered person than if the services were obtained at or from a participating provider; and

(E) If a covered person obtains a covered service from a nonparticipating provider because the covered service is not available within established time and distance standards, reimburse treatment or services for behavioral, mental health, or substance use disorders required to be covered pursuant to this subsection (5.5) that are provided by a nonparticipating provider using the same methodology the carrier uses to reimburse covered medical services provided by nonparticipating providers and, upon request, provide evidence of the methodology to the covered person or provider.

(b) The commissioner may adopt rules as necessary to ensure that this subsection (5.5) is implemented and administered in compliance with federal law and shall adopt rules to establish reasonable time periods for visits with a provider for treatment of a behavioral, mental health, or substance use disorder after an initial visit with a provider.

(c) A carrier offering a managed care plan that does not cover services provided by an out-of-network provider may provide that the benefits required by this subsection (5.5) are covered benefits if the services are rendered by a provider who is designated by and affiliated with the managed care plan only if the same requirement applies for services for a physical illness.

(d) As used in this subsection (5.5), "behavioral, mental health, and substance use disorder":

(I) Means a condition or disorder, regardless of etiology, that may be the result of a combination of genetic and environmental factors and that falls under any of the diagnostic categories listed in the mental disorders section of the most recent version of:

(A) The International Statistical Classification of Diseases and Related Health Problems;

(B) The Diagnostic and Statistical Manual of Mental Disorders; or

(C) The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood; and

(II) Includes autism spectrum disorders, as defined in subsection (1.4)(a)(III) of this section.

(6) Dependent children. (a) No entity subject to the provisions of this article or section 607 (1) of the federal "Employee Retirement Income Security Act of 1974", as amended, shall refuse to accept and honor an otherwise valid claim for a covered benefit that is filed by either parent of a covered child, or by the state department of human services in the case of an assignment under section 26-13-106, C.R.S., who submits valid copies of medical bills. A claim submitted by a custodial parent who is not the insured under a policy issued by an entity subject to the provisions of this article or section 607 (1) of the federal "Employee Retirement Income Security Act of 1974", as amended, shall be deemed a valid assignment of benefits for payment to the health-care provider.

(b) An entity described in subsection (6)(a) of this section must not refuse to provide coverage for a dependent child under the health plan of the child's parent for the sole reason that:

(I) The child does not live in the home of the parent applying for the policy; or

(II) The child does not live in the insurer's service area, notwithstanding any other provision of law restricting enrollment to the persons who reside in an insurer's service area; or

(III) The child's parents were not married at the time of his or her birth; or

(IV) The child is not claimed as a dependent on the child's parent's federal or state income tax return.

(c) When a dependent child is enrolled in a health insurance plan of a parent with whom the child resides less than fifty percent of the time, the entity described in paragraph (a) of this subsection (6) shall:

(I) Provide to the dependent child's parent with whom the child resides the majority of the time information that is necessary for the dependent child to obtain medical benefits and services;

(II) Allow the parent described in subparagraph (I) of this paragraph (c), the health-care provider with such parent's approval, or the state to submit claims for covered services without the approval of the other parent;

(III) Make payments directly to the parent described in subparagraph (I) of this paragraph (c), the health-care provider, or the state medical assistance agency on claims submitted pursuant to subparagraph (II) of this paragraph (c).

(d) Whenever a parent of a dependent child with whom the child resides less than fifty percent of the time is subject to a court or an administrative order to provide health-care coverage for the dependent child, and such parent is eligible for family health-care coverage through the parent's employment, the entity described in paragraph (a) of this subsection (6) shall:

(I) Permit such parent to enroll the dependent child under the family coverage plan, regardless of any enrollment season restriction;

(II) Enroll the dependent child upon application for enrollment by the parent with whom the child resides the majority of the time, the state medical assistance agency, or the state child support enforcement agency or a delegate child support enforcement unit if the parent with whom the child resides less than fifty percent of the time is enrolled in a family coverage plan but fails to enroll the dependent child, regardless of any enrollment restrictions;

(III) Not cancel or revoke enrollment of the dependent child, or eliminate coverage for the dependent child, unless the insurer is provided with satisfactory written proof that:

(A) The court or administrative order for health-care coverage is no longer in effect; or

(B) The child is or will be enrolled in a comparable plan through another insurer, which enrollment takes effect no later than the effective date of the cancellation or revocation of enrollment or the elimination of coverage.

(e) An entity described in paragraph (a) of this subsection (6) shall not impose on the state medical assistance agency that is assigned the right to recover medical costs on behalf of a medical assistance recipient any requirement that is not imposed on or applicable to other agents or assignees.

(6.5) Adopted child - dependent coverage. (a) Whenever an entity described in paragraph (a) of subsection (6) of this section offers coverage for dependent children under a health plan, the entity shall provide benefits 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.

(b) An entity described in paragraph (a) of subsection (6) of this section shall not deny or restrict coverage to an adopted child of an enrollee, policyholder, or subscriber or a child placed for adoption with an enrollee, policyholder, or subscriber on the basis of a preexisting condition if the child would otherwise be eligible for enrollment or coverage and the adoption or placement occurs while the adoptive parent or parent with whom the child is placed is enrolled in the plan.

(c) For the purposes of this subsection (6.5), unless the context otherwise requires:

(I) "Child" means a person who has not attained eighteen years of age.

(II) "Placed for adoption" means circumstances under which a person assumes or retains a legal obligation to partially or totally support a child in anticipation of the child's adoption. A placement terminates at the time such legal obligation terminates.

(6.7) Medical assistance recipients - denial of coverage - liability to state. (a) No entity subject to the provisions of this article, article 8 of this title, or section 607 (1) of the federal "Employee Retirement Income Security Act of 1974", as amended, shall refuse to enroll a person for the sole reason that the person is a medical assistance recipient for whom coverage is sought pursuant to section 25.5-4-210, C.R.S., or refuse to accept and honor an otherwise valid claim for a covered benefit which is filed in the case of an assignment under the provisions of articles 4, 5, and 6 of title 25.5, C.R.S.

(b) An entity subject to this subsection (6.7) that is liable as a third party for the medical costs of a medical assistance recipient or that recovers or may recover medical costs from a third party who is liable to a medical assistance recipient for medical costs is liable to the state pursuant to section 25.5-4-301 (4), C.R.S.

(c) The state is deemed to have acquired the rights as an assignee of the medical assistance recipient to any payment by a third party for medical costs.

(7) Repealed.

(8) Availability of hospice care coverage. (a) As used in this subsection (8), unless the context otherwise requires:

(I) "Home health services" means home health services as defined in section 25.5-4-103 (7), C.R.S., which are provided by a home health agency certified by the department of public health and environment.

(II) "Hospice care" means hospice services provided to a terminally ill individual by a hospice care program, licensed and regulated by the department of public health and environment pursuant to sections 25-1.5-103 (1)(a)(I) and 25-3-101, C.R.S., or by others under arrangements made by such hospice care program.

(b) Notwithstanding any other provision of the law to the contrary, no individual or group policy of sickness and accident insurance issued by an insurer subject to the provisions of part 2 of this article and no plan issued by an entity subject to the provisions of part 3 of this article which provides hospital, surgical, or major medical coverage on an expense incurred basis shall be sold in this state unless a policyholder under such policy or plan is offered the opportunity to purchase coverage for benefits for the costs of home health services and hospice care which have been recommended by a physician as medically necessary. Nothing in this paragraph (b) shall require an insurer to offer coverages for which premiums would not cover expected benefits. This paragraph (b) shall not apply to any insurance policy, plan, contract, or certificate which provides coverage exclusively for disability loss of income, dental services, optical services, hospital confinement indemnity, accident only, or prescription drug services.

(c) The insurer or entity may adopt standards and criteria for eligibility to be applied to home health services programs and hospice care programs consistent with standards established in rules and regulations of the department of public health and environment.

(d) The commissioner, in consultation with the department of public health and environment, may establish by rule and regulation requirements for standard policy and plan provisions which state clearly and completely the criteria for and extent of insured coverage for home health services and hospice care. Such provisions shall be designed to facilitate prompt and informed decisions regarding patient placement and discharge.

(9) Repealed.

(10) Prostate cancer screening. (a) All individual and all group sickness and accident insurance policies, except supplemental policies covering a specified disease or other limited benefit, which are delivered or issued for delivery within the state by an entity subject to the provisions of part 2 of this article and all individual and 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 this state, shall provide coverage for annual screening for the early detection of prostate cancer in men over the age of fifty years and in men over the age of forty years who are in high-risk categories, which coverage by entities subject to part 2 or 3 of this article shall not be subject to policy deductibles. Such coverage shall be the lesser of sixty-five dollars per prostate cancer screening or the actual charge for such screening. Such benefit shall in no way diminish or limit diagnostic benefits otherwise allowable under a policy. This coverage shall be provided according to the following guidelines:

(I) The screening shall be performed by a qualified medical professional, including without limitation a urologist, internist, general practitioner, doctor of osteopathy, nurse practitioner, or physician assistant.

(II) The screening shall consist, at a minimum, of the following tests:

(A) A prostate-specific antigen ("PSA") blood test;

(B) Digital rectal examination.

(III) At least one screening per year shall be covered for any man fifty years of age or older.

(IV) At least one screening per year shall be covered for any man from forty to fifty years of age who is at increased risk of developing prostate cancer as determined by the man's physician for an entity subject to part 2 or 3 of this article, or as determined by a participating physician for an entity subject to part 4 of this article.

(b) The requirements of this subsection (10) shall apply to all individual sickness and accident insurance policies and health-care service or indemnity contracts issued on or after January 1, 1996, and to all group accident and sickness policies and group health-care service or indemnity contracts issued, renewed, or reinstated on or after January 1, 1996.

(c) For purposes of this subsection (10), "sickness and accident insurance policy" does not include short-term, accident, fixed indemnity, specified disease policies or disability income contracts, and limited benefit or credit disability insurance, or such other insurance as defined in section 10-18-101 (3) or by the commissioner. The term also does not include insurance arising out of the "Workers' Compensation Act of Colorado", articles 40 to 47 of title 8, C.R.S., or other similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and which is required by law to be contained in any liability insurance policy or equivalent self-insurance.

(d) The health-care service plan issued by an entity subject to the provisions of part 4 of this article may provide that the benefits provided pursuant to this subsection (10) shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization.

(11) Repealed.

(12) Hospitalization and general anesthesia for dental procedures for dependent children. (a) All individual and all group sickness and accident insurance policies that are delivered or issued for delivery within the state by an entity subject to part 2 of this article and all individual and group health-care service or indemnity contracts issued by an entity subject to part 3 or 4 of this article, except supplemental policies that cover a specific disease or other limited benefit, must provide coverages for general anesthesia, when rendered in a hospital, outpatient surgical facility, or other facility licensed pursuant to section 25-3-101, C.R.S., and for associated hospital or facility charges for dental care provided to a dependent child, as dependent is defined in section 10-16-102 (17), of a covered person. Such dependent child shall, in the treating dentist's opinion, satisfy one or more of the following criteria:

(I) The child has a physical, mental, or medically compromising condition; or

(II) The child has dental needs for which local anesthesia is ineffective because of acute infection, anatomic variations, or allergy; or

(III) The child is an extremely uncooperative, unmanageable, anxious, or uncommunicative child or adolescent with dental needs deemed sufficiently important that dental care cannot be deferred; or

(IV) The child has sustained extensive orofacial and dental trauma.

(b) A carrier may:

(I) Require prior authorization for general anesthesia and outpatient surgical facilities or hospitalization for dental care procedures in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions; and

(II) Require that if coverage is provided through a managed care plan, the benefits mandated pursuant to this subsection (12) shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the carrier; and

(III) Restrict coverage to include anesthesia provided by an anesthesia provider only during procedures performed by an educationally qualified specialist in pediatric dentistry or other dentist educationally qualified in a recognized dental specialty for which hospital privileges are granted or who is certified by virtue of completion of an accredited program of post-graduate hospital training to be granted hospital privileges.

(c) The provisions of this subsection (12) shall not apply to treatment rendered for temporal mandibular joint (TMJ) disorders.

(13) Diabetes. (a) Any health benefit plan, except supplemental policies covering a specified disease or other limited benefit, that provides hospital, surgical, or medical expense insurance shall provide coverage for diabetes that shall include equipment, supplies, and outpatient self-management training and education, including medical nutrition therapy if prescribed by a health-care provider licensed to prescribe such items pursuant to Colorado law, and, if coverage is provided through a managed care plan, such qualified provider shall be a participating provider in such managed care plan.

(b) Diabetes outpatient self-management training and education when prescribed shall be provided by a certified, registered, or licensed health-care professional with expertise in diabetes.

(c) The benefits provided in this subsection (13) are subject to the same annual deductibles or copayments established for all other covered benefits within a given policy.

(d) Private third-party payors shall not reduce or eliminate coverage due to the requirements of this subsection (13).

(14) Prosthetic devices. (a) Any health benefit plan, except supplemental policies covering a specified disease or other limited benefit, that provides hospital, surgical, or medical expense insurance shall provide coverage for benefits for prosthetic devices that equal those benefits provided for under federal laws for health insurance for the aged and disabled pursuant to 42 U.S.C. secs. 1395k, 1395l, and 1395m and 42 CFR 414.202, 414.210, 414.228, and 410.100, as applicable to this subsection (14).

(b) As used in this subsection (14), "prosthetic device" means an artificial device to replace, in whole or in part, an arm or leg.

(c) A health benefit plan may require prior authorization for prosthetic devices in the same manner that prior authorization is required for any other covered benefit.

(d) (I) Except as provided in subsection (14)(d)(II) of this section, covered benefits are limited to the most appropriate prosthetic device models that adequately meet the medical needs of the covered person as determined by the covered person's treating physician.

(II) With respect to a covered person, covered benefits include an additional prosthetic device or devices if the treating physician determines that the additional prosthetic device or devices are necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports.

(III) The division shall submit to the federal department of health and human services:

(A) A determination as to whether the benefit specified in subsection (14)(d)(II) of this section is in addition to an essential health benefit that requires the state to defray the cost pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and

(B) A request that the federal department confirm the division's determination within sixty days after receiving the division's submission.

(IV) Subsection (14)(d)(II) of this section applies to, and the division shall implement the requirements for, large employer policies and contracts issued or renewed on or after January 1, 2025. Subsection (14)(d)(II) of this section applies to, and the division shall implement the requirements for, individual and small group policies and contracts issued on or after January 1, 2025, if:

(A) The division receives confirmation or any other notification from the federal department of health and human services that the coverage specified in subsection (14)(d)(II) of this section does not constitute an additional benefit that requires the state to defray the cost pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or

(B) The federal department of health and human services fails to respond to the request submitted by the division pursuant to subsection (14)(d)(III) of this section within three hundred sixty-five days after submission of the request, in which case the division shall consider the federal department's unreasonable delay a confirmation that the coverage specified in subsection (14)(d)(II) of this section does not require the state to defray the cost pursuant to 42 U.S.C. sec. 18031 (d)(3)(B).

(e) Repairs and replacements of prosthetic devices are also covered, subject to copayments and deductibles, unless necessitated by misuse or loss.

(f) A carrier may require that, if coverage is provided through a managed care plan, the benefits mandated pursuant to this subsection (14) shall be covered benefits only if the prosthetic devices are provided by a vendor and prosthetic services are rendered by a provider who contracts with or is designated by the carrier, to the extent that a carrier provides in-network and out-of-network services, the coverage for the prosthetic device shall be offered no less extensively.

(15) and (16) Repealed.

(17) Cervical cancer vaccines. (a) 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 the state by an entity subject to the provisions of part 2 of this article and all individual and 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 this state, 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 United States department of health and human services.

(b) The requirements of this subsection (17) shall apply to all individual sickness and accident insurance policies and health-care service or indemnity contracts issued on or after January 1, 2008, and 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.

(c) For purposes of this subsection (17), "sickness and accident insurance policy" does not include short-term, accident, fixed indemnity, specified disease policies or disability income contracts, and limited benefit or credit disability insurance, or such other insurance as described in section 10-18-101 (3) or by the commissioner. The term also does not include insurance arising out of the "Workers' Compensation Act of Colorado", articles 40 to 47 of title 8, C.R.S., or other similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and which is required by law to be contained in a liability insurance policy or equivalent self-insurance.

(d) The health-care service plan issued by an entity subject to the provisions of part 4 of this article may provide that the benefits provided pursuant to this subsection (17) shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization.

(18) Prevention health-care services - rules - defintions. (a) (I) The following policies and contracts that are issued or renewed in this state must provide coverage for the total cost of the preventive health-care services specified in subsections (18)(b), (18)(b.3), and (18)(b.7) of this section:

(A) 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 the state by an entity subject to part 2 of this article;

(B) All individual and group health-care service or indemnity contracts issued by an entity subject to part 3 or 4 of this article; and

(C) Any other individual or group health-care coverage offered to residents of this state.

(II) Repealed.

(III) (A) Except as provided in subsection (18)(a)(III)(B) of this section, coverage required by this subsection (18) is not subject to policy deductibles, copayments, or coinsurance.

(B) For purposes of grandfathered health benefit plans, coverage required by this subsection (18) is not subject to policy deductibles or coinsurance. Copayments may apply as required by the grandfathered health benefit plan.

(b) The coverage required by this subsection (18) must include coverage for the following preventive health-care services, in accordance with the A or B recommendations of the task force, recommendations established by the ACIP, or preventive care and screening as provided for in the comprehensive guidelines, as applicable:

(I) Unhealthy alcohol use screening for adults, depression screening for adolescents and adults, and perinatal maternal counseling for persons at risk. The services specified in this section may be provided by a primary care provider, behavioral health-care provider, as defined in section 25-1.5-502 (1.3), or mental health professional licensed or certified pursuant to article 245 of title 12.

(II) Cervical cancer screening;

(III) Repealed.

(IV) Cholesterol screening for lipid disorders;

(V) (A) Colorectal cancer screening coverage for tests for the early detection of colorectal cancer and adenomatous polyps.

(B) In addition to covered persons eligible for colorectal cancer screening coverage in accordance with the A or B recommendations of the task force, colorectal cancer screening coverage required by this subparagraph (V) shall also be provided to covered persons who are at high risk for colorectal cancer, including covered persons who have a family medical history of colorectal cancer; a prior occurrence of cancer or precursor neoplastic polyps; a prior occurrence of a chronic digestive disease condition, such as inflammatory bowel disease, Crohn's disease, or ulcerative colitis; or other predisposing factors as determined by the provider.

(VI) Child health supervision services and childhood immunizations pursuant to the schedule established by the ACIP;

(VII) Influenza vaccinations pursuant to the schedule established by the ACIP;

(VIII) Pneumococcal vaccinations pursuant to the schedule established by the ACIP;

(IX) Tobacco use screening of adults and tobacco cessation interventions by primary care providers; and

(X) (A) Any other preventive services included in the A or B recommendation of the task force or required by federal law; any other recommendations established by the ACIP; or any other preventive care and screening, as provided for in the comprehensive guidelines.

(B) This subsection (18)(b)(X) does not apply to grandfathered health benefit plans.

(XI) (A) Counseling, prevention, and screening for a sexually transmitted infection, as defined in section 25-4-402 (10); except that the coverage under this subsection (18)(b)(XI) must be provided to all covered persons regardless of the covered person's gender.

(B) The division shall submit to the federal department of health and human services its determination as to whether the benefit specified in this subsection (18)(b)(XI) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B) and a request that the federal department confirm the division's determination within sixty days after receipt of the division's request and submission of its determination.

(C) This subsection (18)(b)(XI) applies to large employer policies or contracts issued or renewed on or after January 1, 2022, and to individual and small group policies and contracts issued on or after January 1, 2023, and the division shall implement the requirements of this subsection (18)(b)(XI) if the division receives confirmation from the federal department of health and human services that the coverage specified in this subsection (18)(b)(XI) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); the federal department of health and human services has otherwise informed the division that the coverage does not require state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or more than three hundred sixty-five days have passed since the division submitted its determination and request for confirmation that the coverage specified in this subsection (18)(b)(XI) is not an additional benefit that requires state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B), and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department's unreasonable delay a preclusion from requiring defrayal by the state.

(b.3) For health benefit plans issued or renewed on or after January 1, 2025, if counseling, prevention, and screening for a sexually transmitted infection, as required in subsection (18)(b)(XI) of this section, are covered services, the health benefit plan must provide the coverage without cost sharing, regardless of the covered person's gender, and the coverage must include, consistent with task force requirements, coverage for HIV prevention drugs and services necessary for initiation and continued use of HIV prevention drugs, including office visits, testing, vaccinations, and monitoring services.

(b.5) (I) The coverage required by this subsection (18) must include a preventive breast cancer screening study that is within appropriate use guidelines as determined by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities, for the actual cost of an annual breast cancer screening using the noninvasive imaging modality appropriate for the covered person's breast health needs, as determined by the covered person's provider.

(II) (A) For any breast imaging performed after the breast cancer screening study, whether it is diagnostic breast imaging for further evaluation or supplemental breast imaging within the same calendar year based on factors including a high lifetime risk for breast cancer or high breast density, the noninvasive imaging modality or modalities used must be the same as, or comparable to, the modality or modalities used for the breast cancer screening study.

(B) If the noninvasive imaging modality is recommended by the covered person's provider and the breast imaging is within appropriate use guidelines as determined by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities, the covered person is not responsible for any cost-sharing amounts.

(C) If the covered person receives more than one breast imaging that is in excess of what is recommended by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities, in a given calendar year or contract year, the other benefit provisions in the policy or contract apply with respect to the additional breast imaging.

(III) Benefits for preventive breast cancer screening studies and breast imaging are determined on a calendar year or a contract year basis. The preventive and diagnostic coverages provided pursuant to this subsection (18)(b.5) do not diminish or limit diagnostic benefits otherwise allowable under a policy or contract.

(IV) Notwithstanding the other coverage provisions of this subsection (18)(b.5), a policy or contract subject to this subsection (18) must cover an annual breast cancer screening using the appropriate noninvasive imaging modality or combination of modalities recognized by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities, for all individuals possessing at least one risk factor for breast cancer, including:

(A) A family history of breast cancer;

(B) Being forty years of age or older; or

(C) An increased lifetime risk of breast cancer determined by a risk factor model such as Tyrer-Cuzick, BRCAPRO, or GAIL or by other clinically appropriate risk assessment models.

(b.7) (I) For large employer policies and contracts issued or renewed on or after January 1, 2022, and for individual and small group policies and contracts issued or renewed on or after January 1, 2023, the coverage required by this subsection (18) must include an annual mental health wellness examination of up to sixty minutes that is performed by a qualified mental health-care provider. The coverage for an annual mental health wellness examination must be no less extensive than the coverage provided for a physical examination and must comply with the requirements of the MHPAEA.

(II) The division shall conduct an actuarial study to determine the effect, if any, the coverage required by this subsection (18)(b.7) has on premiums.

(III) Within one hundred twenty days after July 6, 2021, the division shall submit to the federal department of health and human services:

(A) Its determination as to whether the coverage specified in this subsection (18)(b.7) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and

(B) A request that the federal department confirm the division's determination within sixty days after receipt of the division's request and submission of its determination.

(IV) This subsection (18)(b.7) applies to large employer policies or contracts issued or renewed on or after January 1, 2022, and to individual and small group policies and contracts issued on or after January 1, 2023, and the division shall implement the requirements of this subsection (18)(b.7), if:

(A) The division receives confirmation from the federal department of health and human services that the coverage specified in this subsection (18)(b.7) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B);

(B) The federal department of health and human services has informed the division that the coverage does not require state defrayal; or

(C) More than three hundred sixty-five days have passed since the division submitted its determination and request for confirmation that the coverage specified in this subsection (18)(b.7) is not an additional benefit that requires state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B), and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department's unreasonable delay a preclusion from requiring defrayal by the state.

(c) As used in this subsection (18):

(I) "ACIP" means the advisory committee on immunization practices to the centers for disease control and prevention in the federal department of health and human services, or any successor entity.

(II) "A recommendation" means a recommendation adopted by the task force that strongly recommends that clinicians provide a preventive health-care service because the task force found there is a high certainty that the net benefit of the preventive health-care service is substantial.

(III) "B recommendation" means a recommendation adopted by the task force that recommends that clinicians provide a preventive health-care service because the task force found there is a high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

(III.5) "Breast cancer screening study" and "breast imaging" mean:

(A) A mammogram, with or without a clinical exam, for individuals at average risk;

(B) A mammogram, using a noninvasive imaging modality or modalities, as recommended by the medical provider; or

(C) A mammogram, with or without a clinical exam, and medically recommended subsequent noninvasive imaging modality or modalities that fall within appropriate use guidelines as determined by the American College of Radiology, the National Comprehensive Cancer Network, or their successor entities, for the early detection of breast cancer for individuals at average risk who have an incomplete mammogram result or for individuals at high risk.

(III.6) "Comprehensive guidelines" means the following comprehensive guidelines supported by the health resources and services administration in the United States department of health and human services:

(A) Preventive care and screening for women; and

(B) Evidence-informed preventive care and screening for infants, children, and adolescents.

(III.7) "Mental health wellness examination" means an examination that seeks to identify any behavioral or mental health needs and appropriate resources for treatment. The examination may include:

(A) Observation; a behavioral health screening; education and consultation on healthy lifestyle changes; referrals to ongoing treatment, mental health services, and other necessary supports; and discussion of potential options for medication; and

(B) Age-appropriate screenings or observations to understand a covered person's mental health history, personal history, and mental or cognitive state and, when appropriate, relevant adult input through screenings, interviews, and questions.

(III.9) "Qualified mental health-care provider" means:

(A) A physician licensed to practice medicine pursuant to article 240 of title 12 who has specific board certification or training in psychiatry or other mental or behavioral health-care areas;

(B) A physician assistant licensed pursuant to article 240 of title 12 who has training in psychiatry or mental health;

(C) A psychologist licensed pursuant to part 3 of article 245 of title 12;

(D) A clinical social worker licensed pursuant to part 4 of article 245 of title 12;

(E) A marriage and family therapist licensed pursuant to part 5 of article 245 of title 12;

(F) A professional counselor licensed pursuant to part 6 of article 245 of title 12;

(G) An addiction counselor licensed pursuant to part 8 of article 245 of title 12; or

(H) An advanced practice registered nurse, as defined in section 12-255-104 (1), with specific training in psychiatric nursing.

(IV) "Task force" means the U.S. preventive services task force, or any successor organization, sponsored by the agency for healthcare research and quality, the health services research arm of the federal department of health and human services.

(d) The health-care service plan issued by an entity subject to part 4 of this article may provide that the benefits provided pursuant to this subsection (18) shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization.

(e) (I) A carrier shall reimburse a pharmacist employed by an in-network pharmacy for prescribing and dispensing HIV prevention drugs to a covered person. A carrier shall provide a pharmacist who prescribes and dispenses HIV prevention drugs to a covered person pursuant to section 12-280-125.7 an adequate consultative fee or, if medical billing is not available, an enhanced dispensing fee, that is equivalent or that is provided to a physician or advanced practice registered nurse.

(II) This subsection (18)(e) does not apply to an integrated health-care delivery system that dispenses a majority of prescription drugs through integrated pharmacies.

(f) The commissioner may promulgate rules as necessary to implement this subsection (18).

(18.1) Contraception. (a) Policies or contracts described in subsection (18)(a)(I) of this section issued or renewed in this state must provide coverage for the total cost of contraception, as defined in section 2-4-401 (1.5).

(b) The coverage required by this subsection (18.1) is not subject to policy deductibles, copayments, or coinsurance.

(c) This subsection (18.1) does not apply to grandfathered health benefit plans.

(d) (I) The division shall submit to the federal department of health and human services:

(A) Its determination as to whether the benefit specified in this subsection (18.1) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and

(B) A request that the federal department confirm the division's determination within sixty days after receipt of the division's request and submission of its determination.

(II) This subsection (18.1) applies to large employer policies or contracts issued or renewed on or after January 1, 2022, and to individual and small group policies and contracts issued on or after January 1, 2023, and the division shall implement the requirements of this subsection (18.1), if:

(A) The division receives confirmation from the federal department of health and human services that the coverage specified in this subsection (18.1) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B);

(B) The federal department of health and human services has otherwise informed the division that the coverage does not require state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or

(C) More than three hundred sixty-five days have passed since the division submitted its determination and request for confirmation that the coverage specified in this subsection (18.1) is not an additional benefit that requires state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B), and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department's unreasonable delay a preclusion from requiring defrayal by the state.

(19) Hearing aids for children - legislative declaration. (a) The general assembly hereby finds and determines that the language development of children with partial or total hearing loss may be impaired due to the hearing loss. Children learn the concept of spoken language through auditory stimuli, and the language skills of children who have hearing loss improve when they are provided with hearing aids and access to visual language upon the discovery of hearing loss. The general assembly therefore declares that providing hearing aids to children with hearing loss will reduce the costs borne by the state, including special education, alternative treatments that would otherwise be necessary if a hearing aid were not provided, and other costs associated with such hearing loss.

(b) Any health benefit plan that provides hospital, surgical, or medical expense insurance, except supplemental policies covering a specified disease or other limited benefit, must provide coverage for hearing aids for minor children who have a hearing loss that has been verified by a physician licensed pursuant to article 240 of title 12 and by an audiologist licensed pursuant to article 210 of title 12. The hearing aids must be medically appropriate to meet the needs of the child according to accepted professional standards. Coverage must include the purchase of the following:

(I) Initial hearing aids and replacement hearing aids not more frequently than every five years;

(II) A new hearing aid when alterations to the existing hearing aid cannot adequately meet the needs of the child;

(III) Services and supplies including, but not limited to, the initial assessment, fitting, adjustments, and auditory training that is provided according to accepted professional standards.

(c) The benefits accorded pursuant to this subsection (19) shall be subject to the same annual deductible or copayment established for all other covered benefits within the insured's policy and utilization review as provided in sections 10-16-112, 10-16-113, and 10-16-113.5. The benefits shall also be subject to part 7 of this article.

(d) Health benefit plans issued by an entity subject to this part 1 may provide that the benefits required pursuant to this section shall be covered benefits only if the services are deemed medically necessary.

(20) Clinical trials and studies. (a) All individual and group health benefit plans shall provide coverage for routine patient care costs that a policy or certificate holder, or his or her dependent, receives during a clinical trial if:

(I) The covered person's treating physician, who is providing covered health-care services to the person under the health benefit plan contract, recommends participation in the clinical trial after determining that participation in the clinical trial has the potential to provide a therapeutic health benefit to the covered person;

(II) The clinical trial or study is approved under the September 19, 2000, medicare national coverage decision regarding clinical trials, as amended;

(III) The patient care is provided by a certified, registered, or licensed health-care provider practicing within the scope of his or her practice and the facility and personnel providing the treatment have the experience and training to provide the treatment in a competent manner;

(IV) Prior to participation in a clinical trial or study, the covered person has signed a statement of consent indicating that the covered person has been informed of the procedure to be undertaken, alternative methods of treatment, the general nature and extent of the risks associated with participation in the clinical trial or study, the coverage provided by an individual or group health benefit plan will be consistent with the coverage provided in the covered person's health benefit plan, and all out-of-network rates will apply; and

(V) The covered person suffers from a condition that is disabling, progressive, or life-threatening.

(b) The coverage required pursuant to paragraph (a) of this subsection (20) does not include:

(I) Any portion of the clinical trial or study that is paid for by a government or a biotechnical, pharmaceutical, or medical industry;

(II) Coverage for any drug or device that is paid for by the manufacturer, distributor, or provider of the drug or device;

(III) Extraneous expenses related to participation in the clinical trial or study including, but not limited to, travel, housing, and other expenses that a participant or person accompanying a participant may incur;

(IV) An item or service that is provided solely to satisfy a need for data collection or analysis that is not directly related to the clinical management of the participant;

(V) Costs for the management of research relating to the clinical trial or study; or

(VI) Health-care services that, except for the fact that they are being provided in a clinical trial, are otherwise specifically excluded from coverage under the covered person's health plan.

(c) Nothing in this subsection (20) shall:

(I) Preclude a carrier from asserting the right to seek reimbursement from the entity conducting the clinical trial or study for expenses arising from complications caused by a drug or device used in the clinical trial or study;

(II) Be interpreted to provide a private cause of action against a carrier for damages arising as a result of compliance with this section.

(d) For the purposes of this section:

(I) "Clinical trial" means an experiment in which a drug or device is administered to, dispensed to, or used by one or more human subjects. An experiment may include the use of a combination of drugs as well as the use of a drug in combination with an alternative therapy or dietary supplement.

(II) "Routine patient care cost" means all items and services that are a benefit under a health coverage plan that would be covered if the covered person were not involved in either the experimental or the control arms of a clinical trial; except the investigational item or service, itself; items and services provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; items and services customarily provided by the research sponsors free of charge for any enrollee in the trial; routine costs in clinical trials that include items or services that are typically provided absent a clinical trial; items or services required solely for the provision of the investigational items or services, the clinically appropriate monitoring of the effects of the item of service, or the prevention of complications; and items or services needed for reasonable and necessary care arising from the provision of an investigational item or service, including the diagnosis or treatment of complications.

(21) Oral anticancer medication. (a) Any health benefit plan that provides coverage for cancer chemotherapy treatment shall provide coverage for prescribed, orally administered anticancer medication that has been approved by the FDA and is used to kill or slow the growth of cancerous cells. The orally administered medication shall be provided at a cost to the covered person not to exceed the coinsurance percentage or the copayment amount as is applied to an intravenously administered or an injected cancer medication prescribed for the same purpose. A medication provided pursuant to this subsection (21) shall be prescribed only upon a finding that it is medically necessary by the treating physician for the purpose of killing or slowing the growth of cancerous cells in a manner that is in accordance with nationally accepted standards of medical practice, clinically appropriate in terms of type, frequency, extent site, and duration, and not primarily for the convenience of the patient, physician, or other health-care provider. This subsection (21) does not require the use of orally administered medications as a replacement for other cancer medications. Nothing in this subsection (21) prohibits coverage for oral generic medications in a health benefit plan. Nothing in this subsection (21) prohibits a carrier from applying an appropriate formulary or other clinical management to any medication described in this subsection (21). For the purposes of this subsection (21), the treating physician for a patient covered under a health maintenance organization's health benefit plan shall be a physician who is designated by and affiliated with the health maintenance organization.

(b) A carrier shall not achieve compliance with this subsection (21) by imposing an increase in patient out-of-pocket costs with respect to anticancer medications used to kill or slow the growth of cancerous cells covered under a policy beyond the modifications permitted pursuant to section 10-16-105.1 (5).

(22) Prescription eye drop refill coverage. (a) Any health benefit plan, except supplemental policies covering a specified disease or other limited benefit, that provides coverage for prescription eye drops shall provide coverage for:

(I) A renewal of prescription eye drops if:

(A) The renewal is requested by the insured at least twenty-one days for a thirty-day supply of eye drops, forty-two days for a sixty-day supply of eye drops, or sixty-three days for a ninety-day supply of eye drops, from the later of the date that the original prescription was distributed to the insured or the date that the last renewal of the prescription was distributed to the insured; and

(B) The original prescription states that additional quantities are needed and the renewal requested by the insured does not exceed the number of additional quantities needed; and

(II) One additional bottle of prescription eye drops if:

(A) A bottle is requested by the insured or the health-care provider at the time the original prescription is filled; and

(B) The original prescription states that one additional bottle is needed by the insured for use in a day care center, school, or adult day program. The additional bottle is limited to one bottle every three months.

(b) The prescription eye drop benefits covered under this subsection (22) are subject to the same annual deductibles, copayment, or coinsurance established for all other prescription drug benefits under the health benefit plan.

(23) Infertility diagnosis and treatment - fertility preservation services. (a) Except as provided in subsection (23)(e) of this section and subject to subsection (23)(f) of this section, all individual and group health benefit plans issued or renewed in this state shall provide coverage for the diagnosis of and treatment for infertility and standard fertility preservation services.

(b) The coverage required by this subsection (23) includes three completed oocyte retrievals with unlimited embryo transfers in accordance with the guidelines of the ASRM, using single embryo transfer when recommended and medically appropriate.

(c) The health benefit plan shall not impose:

(I) Any exclusions, limitations, or other restrictions on coverage of fertility medications that are different from the exclusions, limitations, or other restrictions imposed on any other prescription medications covered under the health benefit plan; or

(II) Deductibles, copayments, coinsurance, benefit maximums, waiting periods, or other limitations on coverage for the diagnosis of and treatment for infertility and standard fertility preservation services, except as otherwise specified in this subsection (23), that are different from deductibles, copayments, coinsurance, benefit maximums, waiting periods, or other limitations imposed on benefits for services covered under the health benefit plan that are not related to infertility.

(d) The commissioner shall adopt rules consistent with and as are necessary to implement this subsection (23).

(e) A religious employer may request and a carrier subject to this subsection (23) shall grant an exclusion from the coverage required under this subsection (23) in a health benefit plan if the required coverage conflicts with the religious organization's bona fide religious beliefs and practices. A religious employer that obtains an exclusion under this subsection (23)(e) shall provide its employees reasonable and timely notice of the exclusion of the coverage described in this subsection (23) from the health benefit plan the religious employer offers to its employees.

(f) (I) This subsection (23) applies to, and the division shall implement the requirements of this subsection (23) for, large employer health benefit plans issued or renewed in this state on or after January 1, 2023.

(II) This subsection (23) applies to, and the division shall implement the requirements of this subsection (23) for, individual and small group health benefit plans issued or renewed in this state twelve months after the federal department of health and human services determines that the coverage specified in this subsection (23) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B).

(g) As used in this subsection (23):

(I) "ACOG" means the American College of Obstetricians and Gynecologists or its successor organization.

(II) "ASCO" means the American Society of Clinical Oncology or its successor organization.

(III) "ASRM" means the American Society for Reproductive Medicine or its successor organization.

(IV) "Diagnosis of and treatment for infertility" means the procedures and medications recommended by a licensed physician that are consistent with established, published, or approved medical practices or professional guidelines from ACOG or ASRM for diagnosing and treating infertility.

(V) "Failure to impregnate or conceive" means the failure to establish a clinical pregnancy after twelve months of regular, unprotected sexual intercourse or therapeutic donor insemination for a woman under the age of thirty-five, or after six months of regular, unprotected sexual intercourse or therapeutic donor insemination for a woman thirty-five years of age or older. Conception resulting in a miscarriage does not restart the twelve-month or six-month clock to qualify as having infertility.

(VI) "Infertility" means a disease or condition characterized by:

(A) The failure to impregnate or conceive;

(B) A person's inability to reproduce either as an individual or with the person's partner; or

(C) A licensed physician's findings based on a patient's medical, sexual, and reproductive history, age, physical findings, or diagnostic testing.

(VII) "Licensed physician" means a person licensed by the Colorado medical board pursuant to article 240 of title 12 to practice medicine in this state.

(VIII) "Standard fertility preservation services" means procedures and services that are consistent with established medical practices or professional guidelines published by ASRM or ASCO for a person who has a medical condition or is expected to undergo medication therapy, surgery, radiation, chemotherapy, or other medical treatment that is recognized by medical professionals to cause a risk of impairment to fertility.

(24) Living organ donation - rules - definitions. (a) (I) All individual and group health benefit plans issued or renewed in this state on and after January 1, 2022, shall provide coverage for health-care services related to living organ donation for a covered person who is a living organ donor.

(II) The health benefit plan shall not impose any deductibles, copayments, coinsurance, benefit maximums, waiting periods, or other limitations on coverage for health-care services related to living organ donation.

(III) The commissioner shall adopt rules consistent with and as are necessary to implement this subsection (24).

(b) As used in this subsection (24):

(I) "Health-care services related to living organ donation" means an organ donation recovery operation and all services required before and after the operation.

(II) "Living organ donor" means a living individual who has donated all or part of an organ.

(III) "Organ donation recovery operation" means a procedure to recover an organ from a living organ donor.

(25) Nonpharmacological alternative treatment to opioids. (a) A health benefit plan issued or renewed on or after January 1, 2023, must align cost-sharing amounts for nonpharmacological treatment for a patient with a pain diagnosis where an opioid might be prescribed, which must include a cost-sharing amount for each visit not to exceed the cost-sharing amount for a primary care visit for nonpreventive services for a minimum of six physical therapy visits, six occupational therapy visits, six chiropractic visits, and six acupuncture visits.

(b) At the time of a covered person's initial visit for treatment, a physical therapist, occupational therapist, chiropractor, or acupuncturist shall notify the covered person's carrier that the covered person has started treatment with the provider.

(c) (I) The division shall submit to the federal department of health and human services:

(A) Its determination as to whether the benefit specified in this subsection (25) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and

(B) A request that the federal department confirm the division's determination within sixty days after receipt of the division's request and submission of its determination.

(II) This subsection (25) applies to large employer policies or contracts issued or renewed on or after January 1, 2022, and to individual and small group policies and contracts issued on or after January 1, 2023, and the division shall implement the requirements of this subsection (25), if:

(A) The division receives confirmation from the federal department of health and human services that the coverage specified in this subsection (25) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B);

(B) The federal department of health and human services has otherwise informed the division that the coverage does not require state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or

(C) More than three hundred sixty-five days have passed since the division submitted its determination and request for confirmation that the coverage specified in this subsection (25) is not an additional benefit that requires state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B), and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department's unreasonable delay a preclusion from requiring defrayal by the state.

(d) The division shall conduct an actuarial study to determine the effect, if any, the cost-sharing benefit required by this subsection (25) has on premiums.

(26) Abortion care - rules - definition. (a) Except as provided in subsections (26)(d) and (26)(g) of this section and subject to the provisions of subsections (26)(e) and (26)(f) of this section, all individual and group health benefit plans issued or renewed in this state shall provide coverage for the total cost of abortion care.

(b) The coverage required pursuant to this subsection (26) is not subject to policy deductibles, copayments, or coinsurance; except that copayments may apply as required by a grandfathered health benefit plan.

(c) The commissioner shall adopt rules consistent with and as are necessary to implement this subsection (26).

(d) An employer is not obligated to provide the coverage required by this subsection (26) if:

(I) Providing the coverage conflicts with the employer's sincerely held religious beliefs; or

(II) The employer is a public entity prohibited by section 50 of article V of the state constitution from using public funds to pay for induced abortions.

(e) This subsection (26) applies to, and the division shall implement the requirements of this subsection (26) for, large employer health benefit plans issued or renewed in this state on or after January 1, 2025; except that copayments may apply as required by a grandfathered large employer health benefit plan.

(f) With respect to individual and small group health benefit plans:

(I) The division shall submit to the federal department of health and human services:

(A) The division's determination as to whether the benefit specified in this subsection (26) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and

(B) A request that the federal department of health and human services confirm the division's determination within sixty days after receipt of the division's request for confirmation of the determination.

(II) This subsection (26) applies to, and the division shall implement the requirements of this subsection (26) for, individual and small group health benefit plans issued or renewed in this state upon the earlier of:

(A) Twelve months after the federal department of health and human services confirms that the coverage specified in this subsection (26) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B);

(B) Twelve months after the federal department of health and human services otherwise informs the division that the coverage in this subsection (26) does not require state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or

(C) The passage of more than three hundred sixty-five days since the division submitted its determination and request for confirmation pursuant to subsection (26)(f)(I) of this section, and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department's unreasonable delay a preclusion from requiring defrayal by the state.

(g) The provisions of this subsection (26) do not apply to a high deductible health benefit plan pursuant to 26 U.S.C. sec. 223, as amended, issued or renewed in this state until an eligible insured's deductible has been met, unless allowed pursuant to federal law.

(h) As used in this subsection (26), "abortion care" has the same meaning as "abortion", as defined in section 25-6-402 (1).

(27) Pediatric acute-onset neuropsychiatric syndrome (PANS) and pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) - rules - definitions. (a) As used in this subsection (27), unless the context otherwise requires:

(I) "PANDAS" means pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections.

(II) "PANS" means pediatric acute-onset neuropsychiatric syndrome.

(b) (I) Except as provided in subsection (27)(g)(III) of this section and to the extent that such coverage is not in addition to benefits provided pursuant to the benchmark plan, all individual and group health benefit plans issued or renewed in this state shall provide the prophylaxis, diagnosis, and treatment of PANS and PANDAS.

(II) Coverage for PANS and PANDAS must adhere to the treatment recommendations developed by a consortium of medical professionals convened to research, identify, and publish clinical practice guidelines and evidence-based standards for the diagnosis and treatment of PANS and PANDAS.

(III) The coverage required pursuant to this subsection (27) includes treatments and therapies prescribed or ordered by the treating health-care provider, including:

(A) Antibiotics;

(B) Medication and psychological and behavioral therapies to manage neuropsychiatric symptoms;

(C) Immunomodulating medicines;

(D) Plasma exchange; and

(E) Intravenous immunoglobulin therapy.

(c) Coverage for PANS and PANDAS must include up to six immunomodulatory courses of intravenous immunoglobulin therapy for the treatment of PANS and PANDAS when the following conditions have been met:

(I) Clinically appropriate trials, which may be done concurrently, of two or more less intensive treatments:

(A) Were not effective;

(B) Were not tolerated; or

(C) Did not result in sustained improvement in symptoms, as measured by a lack of clinically meaningful improvement on a validated instrument directed at the patient's primary symptom complex; and

(II) The patient's treating health-care provider recommends the treatment or therapy or the treatment or therapy is recommended by a pediatric or, for an adolescent patient, an adult subspecialist, after consultation with the treating health-care provider.

(d) The carrier may require that the patient be clinically reevaluated at three-month intervals.

(e) For billing and diagnostic purposes, PANS and PANDAS shall be coded as autoimmune encephalitis until the American Medical Association and the federal centers for medicare and medicaid services create and assign a specific code or codes for PANS and PANDAS. After the creation of the code or codes, PANS and PANDAS may be coded as autoimmune encephalitis, PANS, or PANDAS. If PANS or PANDAS becomes known by a different common name, it may be coded under that name, and this section applies to that disorder or syndrome.

(f) The carrier shall not:

(I) Impose deductibles, copayments, coinsurance, or other limitations on coverage for PANS or PANDAS that are different from deductibles, copayments, coinsurance, or other limitations imposed on benefits for services covered under the health benefit plan that are not related to PANS or PANDAS;

(II) Deny or delay coverage for PANS or PANDAS treatments or therapies because the covered person previously received treatment or therapy, including the same or similar treatment or therapy, for PANS or PANDAS or because the covered person was diagnosed with or received treatment or therapy for the condition under a different diagnostic name, including autoimmune encephalitis;

(III) Delay timely determination of prior authorization requests for treatments or therapies or fail to expedite requests for urgent health-care services; or

(IV) Limit coverage of immunomodulating therapies for PANS or PANDAS in a manner that is inconsistent with the treatment recommendations made pursuant to subsection (27)(b)(II) of this section and shall not require a trial of therapies that treat only neuropsychiatric symptoms before authorizing coverage of immunomodulating therapies pursuant to this section.

(g) (I) The division shall submit to the federal department of health and human services:

(A) Its determination as to whether the benefit specified in this subsection (27) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and

(B) A request that the federal department of health and human services confirm the division's determination within sixty days after receipt of the division's request and submission of its determination.

(II) This subsection (27) applies to, and the division shall implement the requirements of this subsection (27) for, large employer health benefit plans issued or renewed in this state on or after January 1, 2025.

(III) This subsection (27) applies to, and the division shall implement the requirements of this subsection (27) for, individual and small group health benefit plans issued or renewed in this state on or after January 1, 2026, if:

(A) The division receives confirmation from the federal department of health and human services that the coverage specified in this subsection (27) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B);

(B) The federal department of health and human services has otherwise informed the division that the coverage does not require state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or

(C) More than three hundred sixty-five days have passed since the division submitted its determination and request for confirmation that the coverage specified in this subsection (27) is not an additional benefit that requires state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B), and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department of health and human services' unreasonable delay a preclusion from requiring defrayal by the state.

(h) The commissioner shall adopt rules consistent with and as are necessary to implement this subsection (27).

(28) Biomarker testing - rules - definitions. (a) All large group health benefit plans and, to the extent that such coverage is not in addition to the benefits provided pursuant to the benchmark plan, all individual and small group health benefit plans shall provide coverage for biomarker testing pursuant to this subsection (28).

(b) Coverage must include biomarker testing for diagnosis, treatment, appropriate management, and ongoing monitoring of a covered person's disease or condition to guide treatment decisions when the test is supported by medical and scientific evidence, including:

(I) Labeled indications for an FDA-approved or FDA-cleared test;

(II) Indicated tests for an FDA-approved drug;

(III) Warnings and precautions on FDA-approved drug labels;

(IV) Centers for medicare and medicaid services national coverage determinations or medicare administrative contractor local coverage determinations; or

(V) Nationally recognized clinical practice guidelines, consensus statements, and peer-reviewed studies.

(c) The coverage required by this subsection (28) is subject to annual deductibles, copayments, or coinsurance requirements under the health benefit plan but is not subject to any annual or lifetime maximum benefit limit.

(d) The coverage required by this subsection (28) must be provided in a manner that limits unreasonable disruptions in care, including limiting the need for multiple biopsies or biospecimen samples.

(e) Nothing in this subsection (28) shall be construed to require coverage for biomarker testing for screening purposes.

(f) A carrier may require prior authorization for biomarker testing in the same manner that prior authorization is required for any other covered benefit and consistent with section 10-16-112.5.

(g) (I) Within one hundred twenty days after June 3, 2024, the division shall submit to the federal department of health and human services:

(A) A determination as to whether the benefit specified in this subsection (28) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and

(B) A request that the federal department of health and human services confirm the division's determination within sixty days after receipt of the division's request and submission of its determination.

(II) This subsection (28) applies to, and the division shall implement the provisions of this subsection (28) for, large employer health benefit plans issued or renewed in this state on or after January 1, 2025.

(III) This subsection (28) applies to, and the division shall implement the requirements of this subsection (28) for, individual and small group health benefit plans issued or renewed in this state twelve months after the earlier of the following:

(A) The division receives confirmation from the federal department of health and human services that the coverage specified in this subsection (28) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B);

(B) The federal department of health and human services has otherwise informed the division that the coverage does not require state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or

(C) More than three hundred sixty-five days have passed since the division submitted its determination and request for confirmation that the coverage specified in this subsection (28) is not an additional benefit that requires state defrayal pursuant to 42 U.S.C. sec. 18031 (d)(3)(B), and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department of health and human services' unreasonable delay a preclusion from requiring defrayal by the state.

(h) The commissioner shall implement this subsection (28) and shall adopt rules consistent with and as are necessary to implement this subsection (28).

(i) As used in this subsection (28):

(I) "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. "Biomarker" includes gene mutations, characteristics of genes, or protein expression.

(II) "Biomarker testing" means the analysis of a patient's tissue, blood, or other biospecimen for the presence of a biomarker. "Biomarker testing" includes single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing. "Biomarker testing" does not include direct-to-consumer genetic tests.

(III) "Consensus statements" means statements developed by an independent, multidisciplinary panel of experts utilizing a transparent methodology and reporting structure and with a conflict of interest policy. Consensus statements are developed for specific clinical circumstances and are based on the best available evidence for the purpose of optimizing the outcomes of clinical care.

(IV) "Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. Clinical practice guidelines:

(A) Establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options; and

(B) Include recommendations intended to optimize patient care.
C.R.S. § 10-16-107 — CO Code / Title 10 / Article 16 / Part 1 / Section 10-16-107
10-16-107. Rate filing regulation - benefits ratio - rules
Status: in_force

10-16-107. Rate filing regulation - benefits ratio - rules. (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).