Section 1 Authority

This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§ 10-1-109(1), 10-16-109, 10-16-704(1.5), 10-16-708, 10-16-1304(2)(c), and 10-16-1312, C.R.S.

Section 2 Scope and Purpose

The purpose of this regulation is to provide carriers offering ACA-compliant health benefit plans with standards and guidance on Colorado filing requirements for health benefit plan network access plan filings and requirements for Colorado Option Standardized Plans as specified in Colorado Insurance Regulation 4-2-80. These standards shall serve as the measurable requirements used by the Division to evaluate the adequacy of carrier network access plan filings.

Section 3 Applicability

This regulation applies to all carriers offering ACA-compliant individual, group health benefit plans and/or student health insurance coverage subject to the individual, small group, and/or large group laws of Colorado. This regulation excludes individual short-term limited duration health insurance policies as defined in § 10-16-102(60), C.R.S.

Section 4 Definitions

A. “ACA” or means, for the purposes of this regulation, The Patient Protection and Affordable Care Act, Pub. L. 111-148 and the Health Care and Education Reconciliation Act of 2010, Pub. L. 111-152.

B. “Carrier” shall have the same meaning as found at § 10-16-102(8), C.R.S.

C. “Covered person” shall have the same meaning as found at § 10-16-102(15), C.R.S.

D. “Emergency medical condition” shall have the same meaning as found at § 10-16-704(19)(d), C.R.S.

E. “Emergency services” shall have the same meaning as found at § 10-16-704(19)(e)(I), C.R.S.

F. “Enrollment” means, for the purposes of this regulation, the number of covered persons enrolled in a specific health plan or network.

G. “Essential community provider” and “ECP”, mean, for the purpose of this regulation, a provider, including health care providers defined in § 25.5-5-403(2), C.R.S., § 25.5-8-103(6), C.R.S., and at 45 C.F.R. § 156.235(c), that serves predominantly low-income, medically underserved individuals.

H. “Health benefit plan” shall have the same meaning as found at § 10-16-102(32), C.R.S.

I. “Health maintenance organization” shall have the same meaning as found at § 10-16-102(35), C.R.S.

J. “Managed care plan” shall have the same meaning as found at § 10-16-102(43), C.R.S.

K. “Material change” means, for the purposes of this regulation, changes in the carrier’s network of providers or type of providers available in the network to provide health care services or specialty health care services to covered persons that may render the carrier’s network non-compliant with one or more network adequacy standards. Types of changes that could be considered material include:

1. A significant reduction in the number of primary or specialty care for physical health, mental health, behavioral health, or substance use disorder providers available in a network;

2. A reduction in a specific type of provider such that a specific covered service is no longer available;

3. A change to the tiered, multi-tiered, layered or multi-level network plan structure; and

4. A change in inclusion of a major health system that causes the network to be significantly different from what the covered person initially purchased.

L. “Mental health, behavioral health, and substance abuse disorder care” means, for the purposes of this regulation, health care services for a behavioral, mental health, and substance use disorder as defined by section § 10-16-104(5.5)(d), C.R.S., provided by mental health, behavioral health, and substance use disorder care providers.

M. “Mental health, behavioral health, and substance abuse disorder care providers” for the purposes of this regulation, and for the purposes of network adequacy measurements, means a provider offering health care services for a behavioral, mental health, and substance use disorder as defined by section 10-16-104(5.5)(d), C.R.S., and includes but is not limited to psychiatrists, psychologists, psychotherapists, licensed clinical social workers, psychiatric practice nurses, licensed addiction counselors, opioid treatment programs, inpatient and residential behavioral health facilities, licensed marriage and family counselors, and licensed professional counselors.

N. “Network” shall have the same meaning as found at § 10-16-102(45), C.R.S.

O. “Primary care” means, for the purposes of this regulation, health care services for a range of common physical, mental or behavioral health conditions provided by a physician or nonphysician primary care provider.

P. “Primary care provider” or “PCP” means, for the purposes of this regulation, a participating health care professional designated by the carrier to supervise, coordinate or provide initial care or continuing care to a covered person, and who may be required by the carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person. For the purposes of network adequacy measurements, PCPs for adults and children include physicians (pediatrics, general practice, family medicine, internal medicine, geriatrics, obstetrics/gynecology), physician assistants, and nurse practitioners supervised by, or collaborating with, a primary care physician.

Q. SERFF means, for the purposes of this regulation, the NAIC System for Electronic Rate and Form Filings.

R. “Specialist” means, for the purposes of this regulation, a physician or non-physician health care professional who:

1. Focuses on a specific area of physical health, mental health, behavioral health or substance use disorder for a group of patients; and

2. Has successfully completed required training and is recognized by the state in which they practice to provide specialty care. “Specialist” includes a subspecialist who has additional training and recognition above and
beyond his or her specialty training.

S. “Standardized plan” shall have the same meaning as found in § 10-16-1303(14) C.R.S.

T. “Telehealth” shall have the same meaning as found in § 10-16-123(4)(e), C.R.S. Section 5 Network Access Plan Standards A. Network access plans are used by carriers to describe their policies and procedures for maintaining and ensuring that their networks are sufficient and consistent with state and federal requirements. These plans, along with other documents, are filed with the Division annually and are available upon request to consumers. Carriers shall submit current network access plans to the Division through SERFF with the annual network adequacy form filing specified in Colorado Insurance Regulation 4-2-53.

B. Carriers shall file, maintain, and make available on their website, an access plan for each network that the carrier offers in Colorado.

C. Carriers shall prepare an access plan prior to offering a new network plan, and shall notify the Division of any material change to any existing network plan within fifteen (15) business days after the change occurs, including a reasonable timeframe, pursuant to § 10-16-704(2.5), C.R.S., within which it will file an update to an existing access plan.

D. Carriers shall make the access plans, absent confidential information pursuant to § 24-72-204, C.R.S., available and shall provide them to any interested party upon request.

E. All health benefit plan form documents and marketing materials of a carrier shall clearly disclose the existence and availability of the access plan.

F. All rights and responsibilities of the covered person shall be included in the policy provisions, regardless of whether or not such provisions are also specified in the access plan.

G. Carriers shall prepare and file an access plan prior to offering a new network, and shall update an existing access plan whenever the carrier makes any material change to an existing network.

H. An access plan submitted by a carrier offering a health benefit plan that is a managed care plan shall demonstrate that the carrier meets all requirements in Section 6.

Section 6 Network Access Plan Reporting Requirements

The carrier shall address the following in the network access plan for each network offered by the carrier:

A. Establishing that the carrier’s network has an adequate number of providers and facilities within a reasonable distance, as defined in Colorado Insurance Regulation 4-2-53;

B. The specific provider and facility types that will be measured and reported by the carrier. Those provider and facility types include, but are not limited to, the following:

1. Acute care hospital services;

2. Primary care providers (PCP);

3. Providers who may be available through the use of telehealth;

4. Pharmacy providers, within a reasonable distance and/or delivery time, and can include retail and/or mail-order pharmacy providers; and

5. Other provider and facility types;

C. The carrier’s documented quantifiable and measureable process for monitoring and assuring the sufficiency of the network in order to meet the health care needs of populations enrolled in its managed care plans on an ongoing basis;

D. Information regarding how a carrier builds its provider network, including a description of the network and the criteria used to select and/or tier providers;

E. The carrier’s quality assurance standards which must be adequate to identify, evaluate, and remedy problems relating to access, continuity, and quality of care;

F. The carrier’s process and communication to consumers to assure that a covered person is able to obtain a covered benefit, at the in-network benefit level, from a non-participating provider should the carrier’s network prove to not be sufficient within the appointment wait time and distance standards required by Colorado Insurance Regulation 4-2-53, Section 6;

G. The carrier’s process to ensure that covered services or treatment rendered at a network facility, including ancillary services or treatment rendered by an out-of-network provider performing the services or treatment at a network facility, shall be covered at no greater cost to the covered person than if the services or treatment were obtained from an in-network provider; and

H. The carrier’s process for monitoring access to physician specialist services for emergency room care, anesthesiology, radiology, hospitalist care, pathology, and laboratory services at its participating facilities.

I. For Colorado Option Standardized Plan networks, all Network Access Plan reporting requirements listed in Colorado Insurance Regulation 4-2-80, Section 7.

Section 7 Network Access Plan Procedures for Referrals

The network access plan for each network offered by the carrier shall include procedures for making referrals both within its networks and outside of its networks pursuant to § 10-16-704(9)(b), C.R.S., and shall include the following:

A. A comprehensive listing, made available to covered persons and primary care providers, of the carrier’s network of participating providers and facilities;

B. A provision that referral options cannot be restricted to less than all providers in the network that are qualified to provide covered specialty services; except that a health maintenance organization may offer variable deductibles, coinsurance and/or copayments to encourage the selection of certain providers;

C. Timely referrals for access to specialty care;

D. A process for expediting the referral process when indicated by the covered persons medical condition;

E. A provision that referrals approved by the carrier cannot be retrospectively denied except for fraud or abuse;

F. A provision that referrals approved by the carrier cannot be changed after the preauthorization is provided unless there is evidence of fraud or abuse; and

G. The carrier’s process for covered persons to access services outside the network when necessary.

Section 8 Network Access Plan Disclosures and Notices

A. In the network access plan for each network offered, a carrier shall explain its method for informing covered persons of the plan’s services and features through disclosures and notices to policyholders.

B. Required disclosures to covered persons, pursuant to § 10-16-704(9), C.R.S., shall include:

1. The carrier’s grievance procedures, which shall be in conformance with Division regulations concerning prompt investigation of health claims involving utilization review and grievance procedures;

2. The extent to which specialty medical services, including but not limited to physical therapy, occupational therapy, and rehabilitation services are available;

3. The carrier’s procedures for providing and approving emergency and non-emergency medical care;

4. The carrier’s process for choosing and changing network providers;

5. The carrier’s documented process to address the needs, including access and accessibility of services, of covered persons with limited English proficiency and illiteracy, with diverse cultural and ethnic backgrounds, and with physical or mental disabilities;

6. The carrier’s documented process to identify the potential needs of special populations;
and

7. The carrier’s methods for assessing the health care needs of covered persons, tracking and assessing clinical outcomes from network services, assessing needs on an on-going basis, assessing the needs of diverse populations, and evaluating consumer satisfaction with services provided.

Section 9 Network Access Plans and Coordination and Continuity of Care

A. A carrier shall address its process for ensuring the coordination and continuity of care for its covered persons in the network access plan, pursuant to § 10-16-704(9)(h) and (j), C.R.S., for each network offered by the carrier.

B. The process for ensuring the coordination and continuity of care shall include, but is not limited to, the following:

1. The carrier’s documented process for ensuring the coordination and continuity of care for covered persons referred to specialty providers;

2. The carrier’s documented process for ensuring the coordination and continuity of care for covered persons using ancillary services, including social services and other community resources;

3. The carrier’s documented process for ensuring appropriate discharge planning;

4. The carrier’s process for enabling covered persons to change primary care providers;

5. The carrier’s proposed plan and process for providing continuity of care in the event of contract termination between the carrier and any of its participating providers or in the event of the carrier’s insolvency or other inability to continue operations. The proposed plan and process shall include an explanation of how covered persons shall be notified in the case of a provider contract termination, the carrier’s insolvency, or of any other cessation of operations, as well as how policyholders impacted by such events will be transferred to other providers in a timely manner; and

6. A carrier shall file and make available upon request the fact that the carrier has a “hold harmless” provision in its provider contracts, prohibiting contracted providers from balance-billing covered in compliance with § 10-16-705(3), C.R.S.

Section 10 Annual Network Access Plan Reporting and Attestations

A. Network access plans shall be submitted in network adequacy form filings in SERFF for each network offered, including networks for Colorado Option Standardized Plans. The data provided in the network access plans shall be specific to each network in a carrier’s service area.

B. For networks including Colorado Option plans, in addition to the reporting requirements in this regulation, network access plan attestations and requirements in Colorado Insurance Regulation 4-2-80 shall be submitted in network adequacy filings in SERFF. C. The following attestations shall be made on the “Carrier Network Adequacy Summary and Attestation Template” submitted with the form filing in SERFF.

1. Carrier attests that each of its managed care health benefit plans will maintain a provider network(s) that is sufficient in number and types of providers, including providers that specialize in mental health, behavioral health, and substance use care services, to assure that the services will be accessible without unreasonable delay.

2. Carrier attests that each of its managed care health benefit plans include in its provider network(s) a sufficient number and geographic distribution of essential community providers (ECPs), where available, to ensure reasonable and timely access to a broad range of such providers for low-income, medically underserved individuals in their service areas.

3. If the carrier does not immediately meet network adequacy standards, the carrier will include an attestation adequately addressing how it plans to meet network adequacy standards specified in section 5 of this regulation. Such changes shall be implemented and filed by the carrier in accordance with the reasonable schedule established by the
carrier and reviewed by the Division.

Section 11 Severability

If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of this regulation shall not be affected.

Section 12 Incorporated Materials

45 C.F.R. § 156.235(c) published by the Government Printing Office shall mean 45 C.F.R. § 156.235(c) as published on the effective date of this regulation and does not include later amendments to or editions of 45 C.F.R. § 156.235(c). A copy of 45 C.F.R. § 156.235(c) may be examined during regular business hours at the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, Colorado, 80202. A certified copy of 45 C.F.R. § 156.235(c) may be requested from the Colorado Division of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202. A charge for certification or copies may apply. A copy may also be obtained online at www.ecfr.gov.

Section 13 Enforcement

Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.

Section 14 Effective Date

This amended regulation shall be effective on June 30, 2023.

Section 15 History

New regulation effective January 1, 2017.
Amended regulation effective on July 1, 2018.
Amended regulation effective June 30, 2023.

This section was updated on July 24, 2023.