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, 10-16-146, 10-16-1304(2)(c), and 10-16-1312, C.R.S.

Section 2 Scope and Purpose

The purpose of this regulation is to establish standards and requirements for carrier ACA-compliant health benefit plan provider directories. These standards shall serve as the measurable requirements used by the Division to evaluate the adequacy of carrier provider directories.

Section 3 Applicability

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

Section 4 Definitions

A. Affordable Care Act, “ACA” 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., and shall include a carrier’s designee.

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

D. “Essential community provider” or “ECP” means, 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.

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

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

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

H. “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.

I. “Primary care provider” or “PCP” means, for the purposes of this regulation, a participating healthcare 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) and physician assistants and nurse practitioners supervised by, or collaborating with, a primary care physician.

J. “Provider” shall have the same meaning as found at § 10-16-102(56).

K. “Provider directory” means, for the purposes of this regulation, a comprehensive listing, produced and maintained by the carrier, or it’s designee, made available to covered persons, the public, and primary care providers, of the plan’s participating providers and facilities in each of the carrier’s networks.

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

M. “Specialty care” means, for the purposes of this regulation, health care services that are not primary care and focus on a specific area of physical, mental, or behavioral health, or a specific group of patients.

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

Section 5 Provider Directories

A. Provider directories shall be maintained by the carrier. Screen shots of the provider directory must be filed in SERFF in the annual network adequacy form filing.

B. Provider directories maintained by the carriers shall meet all of the following requirements:

1. A carrier shall post electronically a current and accurate provider directory for each of its networks, with the information and search functions as described in Appendix A, no less than monthly;

2. When making the provider directory available electronically, the carrier shall ensure that the general public is able to view all of the current providers for a network through a clearly identifiable link or tab without requiring an individual to create or access an account or requiring the entry of a policy or contract number. The carrier shall include on the public electronic provider directory notice that the directory is available in the 15 most .common languages spoken by individuals with limited English proficiency in Colorado;

3. The carrier shall include a disclosure in the provider directory of the carrier’s response protocols as specified in Section 11, and a disclosure of the date of the most recent update for electronic directories, or the date of printing for printed directories. This disclosure shall state that the information included in the provider directory is accurate, to
the best of the carrier’s knowledge, as of the date of updating/printing, and that covered persons or prospective covered persons should consult the carrier’s electronic provider directory on its website, or call the carrier’s customer service telephone number, to obtain current provider directory information;

4. A carrier shall provide a print copy of the requested pertinent portion of the current provider directory with the information described in Appendix A, Item 3, to a covered person within five (5) business days of the request;

5. A carrier shall provide information on how to file a complaint with the Division or with the carrier related to the accuracy of the provider directory and/or the provider experience:

6. A carrier shall include, in both the electronic and print versions of the provider directory, the following general information for each of its provider networks:

a. A description of the criteria the carrier has used to build its provider network;

b. If applicable, a description of the criteria the carrier has used to tier providers;

c. If applicable, a description of how the carrier designates the different provider tiers or levels in the network and identifies (e.g., by name, symbols or grouping) which tier or level the following are placed in:

(1) Each specific provider;

(2) Each specific hospital; and

(3) Each specific other type of facility in the network.

d. A note that an authorization or referral may be required to access some providers; and

e. A description of available translation and interpreter services in languages other than English for individuals with limited English proficiency, and how to access them.

7. A carrier shall make it clear, in both its electronic and print directories, which provider directory applies to a particular managed care network plan, such as including the specific name of the managed care network plan as marketed and issued in this state;

8. The carrier shall include, in both its electronic and print directories, customer service contact information by electronic means such as email, text or social media and, telephone number and an electronic link that covered persons or the general public may use to notify the carrier of inaccurate provider directory information;

9. For the items of information required in a provider directory pursuant to Appendix A pertaining to a health care professional, a hospital or a facility other than a hospital, the carrier shall make available, through the provider directory, the source of the information and any limitations;

10. A provider directory, whether in electronic or print format, shall accommodate the communication needs of individuals with disabilities, and include a link to or information regarding available assistance for persons with limited English proficiency. A provider directory shall also be available in Spanish; and

11. The carrier shall respond as soon as practicable and, in no case later than one business day after receiving a request from a covered person through a telephone call or electronic, web-based, or Internet-based means, on whether a provider or facility has a contractual relationship to furnish items and services under the covered person’s plan.  The carrier shall retain the communication in the covered person’s file for at least two years following the response.

Section 6 Requirements for Provider Directory Updates and Audits

A. The carrier shall update each electronic network provider directory at least monthly. Current provider directories shall be made available to the Commissioner, upon request. The carrier shall update the provider directory within two business days of receiving updated information from a provider or facility:

1. When the provider or facility begins a network agreement with a plan or with a carrier with respect to certain coverage;

2. When the provider or facility terminates a network agreement with a plan or with an issuer with respect to certain coverage; and

3. When there are material changes to the content of provider directory information of the provider or facility.

B. No less frequently than quarterly, the carrier shall audit at least twenty percent (20%) of the providers contained in its provider directories for accuracy and update that provider directory based upon its findings.

C. Audits shall be conducted such that all entries in a provider directory will be audited at least once every eighteen (18) months. Documentation of the process and findings of all audits and the information required by this regulation shall be retained for no less than thirty-six (36) months and shall be made available to the Commissioner upon request.

Section 7 Materially Inaccurate Information in Provider Directories

A. A covered person who has demonstrated that he or she reasonably relied upon materially inaccurate information contained in a carrier’s provider directory and received services from what the covered person believed to be an in-network provider. The covered person will only be required to pay the amount that he or she would have paid, had the services been delivered by an in-network provider under the carrier’s network plan.

B. A covered person will be considered to have demonstrated that he or she reasonably relied upon a carrier’s provider directory if a covered person has confirmed that a provider is contained in a carrier’s provider directory at the time the appointment was made.

C. Carriers shall maintain an archive of all provider directory updates for a period of at least one hundred and eighty (180) days which must be provided to the Commissioner upon request.

Section 8 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 9 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 10 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 11 Effective Date

This amended regulation shall be effective on July 15, 2023.

Section 12 History

New regulation effective January 1, 2017

Amended regulation effective July 1, 2018

Amended regulation effective July 15, 2023.

Appendix A – Provider Directory Contents

Provider directory filings made on or after the date of this regulation will be required to meet the following requirements.

1. The carrier shall make available through an electronic provider directory, for each network, the following information in a searchable format. Specific requirements for fields and searchability criteria are defined in the network adequacy filing instructions provided annually by the Division.

A. For health care professionals:

(1) Name;

(2) Gender;

(3) Participating office location(s);

(4) Accessibility of the provider’s office and examination rooms for persons with disabilities;

(5) If the provider offers extended and weekend hours;

(6) Specialty, if applicable;

(7) Medical group affiliations, if applicable;

(8) Participating facility affiliations, if applicable;

(9) Languages spoken other than English, if applicable;

(10) Tiers and network plans to which the provider belongs, if applicable; and

(11) Whether accepting new patients.

B. For hospitals:

(1) Hospital name;

(2) Hospital type (i.e. acute, rehabilitation, children’s, cancer);

(3) Participating hospital location; and

(4) Hospital accreditation status.

C. For facilities, other than hospitals, by type:

(1) Facility name;

(2) Facility type;

(3) Types of services performed;

(4) If the facility is an ECP; and

(5) Participating facility location(s).

2. For the electronic provider directories, for each network, a health carrier shall make available the following, non-searchable, information in addition to all of the information available under item 1. above:

A. For health care professionals:
(1) Contact information (telephone number(s), and if available, e-mail addresses, website URLs, etc.);

(2) Board certification(s); and

B. For hospitals and facilities other than hospitals: Telephone number(s), e-mail addresses, website URLs, etc., if applicable.

3. The carrier shall make available in print, upon request, the following provider directory information
for the applicable network:

A. For health care professionals:

(1) Name;

(2) Contact information (telephone number(s), and if available, e-mail addresses, website URLs, etc.);

(3) Participating office location(s);

(4) Specialty, if applicable;

(5) Languages spoken other than English, if applicable; and

(6) Whether accepting new patients.

B. For hospitals:

(1) Hospital name;

(2) Hospital type (i.e. acute, rehabilitation, children’s, cancer); and

(3) Participating hospital location and telephone number.

C. For facilities, other than hospitals, by type:

(1) Facility name;

(2) Facility type;

(3) Types of services performed;

(4) If the facility is an ECP; and

(5) Participating facility location(s), telephone number(s), e-mail addresses, website URLs, if applicable.

Updated on July 23, 2023.