Concerning Network Adequacy and Continuity of Care Requirements for ACA-Compliant Health Benefit Plans
This entire regulation falls under the category “Network Adequacy.” See the hold text below to see the section of the regulation falling under other categories.
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), and 10-16-708, C.R.S.
Section 2 Scope and Purpose
The purpose of this regulation is to provide carriers offering ACA-compliant health benefit plans with the continuity of care requirements for health benefit plans as they relate to network adequacy. These standards shall serve as the measurable requirements used by the Division to evaluate carrier compliance with network adequacy continuity of care requirements.
Section 3 Applicability
This regulation applies to all carriers offering ACA-compliant individual and/or group health benefit plans subject to the individual, small group, and/or large group laws of Colorado. This regulation excludes individual short-term policies as defined in § 10-16-102(60), C.R.S.
Section 4 Definitions
A. “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.
Continuity of Care Post-Contract
B. “Active course of treatment” means, for the purposes of this regulation:
1. An ongoing course of treatment for a life threatening condition;
2. An ongoing course of treatment for a serious acute health condition, chronic health condition, or life limiting illness;
3. The second or third trimester of pregnancy through the postpartum period; or
4. An ongoing course of treatment for a health condition, whether physical health, mental health, behavioral health, or substance abuse disorder, for which a treating physician or health care provider attests that discontinuing care by that physician or health care provider would worsen the condition or interfere with anticipated outcomes.
C. “Covered person” shall have the same meaning as found at § 10-16-102(15), C.R.S.
D. “Health condition” means, for the purposes of this regulation, an illness, injury, impairment, or condition of a physical, behavioral, or mental health nature, or that involves substance abuse.
E. “Life threatening health condition” means, for the purpose of this regulation, a disease or health condition for which likelihood of death is probable unless the course of the disease or health condition is interrupted.
F. “Network” shall have the same meaning as found at § 10-16-102(45), C.R.S.
G. “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 non-physician primary care provider.
H. “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) and physician assistants and nurse practitioners supervised by, or collaborating with, a primary care physician.
I. “Serious acute health condition, chronic health condition, or life limiting illness” means, for the purpose of this regulation, a disease or health condition requiring complex on going care which the covered person is currently receiving, including, but not limited to, chemotherapy, post operative visits or radiation therapy.
Section 5 Network Adequacy Continuity of Care Requirements
Carriers shall ensure sufficient continuity of care provisions for their policyholders. Carriers shall include their processes on continuity of care provisions in their network access plans.
A. A carrier and participating provider shall provide at least sixty (60) days written notice to each other before a provider is removed or leaves the network without cause.
B. When a primary care provider is being removed, leaving the network, or is being non renewed, all covered persons who are patients of that primary care provider shall be notified by the carrier, in writing, prior to termination. When the provider gives or receives the notice in accordance with Section 5.A. of this regulation, the provider shall supply the carrier with a list of those patients of the provider that are covered by a plan of the carrier. The carrier shall supply the provider with a list of the provider’s patients that are covered by the carrier.
C. Irrespective of whether it is for cause or without cause or due to non renewal of a contract, the carrier shall make a good faith effort to provide both written notice of a provider’s removal, leaving, or non renewal from the network, and the provider information contained in Section 5.F. of this regulation, within fifteen (15) working days of receipt or issuance of a notice provided in accordance with Section 5.A. of this regulation. This notice shall be provided to all covered persons who are identified as patients by the provider, are on a carrier’s patient list for that provider, or who have been seen by the provider being removed or leaving the network within the previous twelve (12) months.
D. A covered person must have been undergoing treatment, or have been seen at least once in the previous twelve (12) months, by the provider being removed or leaving the network for that covered person to be considered in an active course of treatment.
E. A carrier shall establish reasonable procedures to transition the covered person who is in an active course of treatment to a participating provider in a manner that provides for continuity of care when a covered person’s provider leaves or is removed from the network.
F. A carrier shall make available to the covered person a list of available participating providers who are accepting new patients in the same geographic area and specialty provider type, or a referral to a provider if there is no participating provider available, who is of the same provider or specialty type. The carrier shall provide information about how the covered person may request continuity of care as required by this regulation.
Continuity of Care Post-Contract
G. A carrier’s transition procedures shall provide that:
1. A carrier shall review requests for continuity of care made by the covered person or the covered person’s authorized representative;
2. Requests for continuity of care shall be reviewed by the carrier’s Medical Director after consultation with the treating provider. This requirement applies to:
a. Patients who meet the applicable criteria listed in Section 5 of this regulation; and
b. Who are under the care of a provider who has not been removed or leaving the network for cause;
3. Any decisions made with respect to a request for continuity of care shall be subject to the health benefit plan’s internal and external grievance and appeal processes in accordance with applicable state and federal laws and regulations;
4. The continuity of care period for covered persons who are in their second or third trimester of pregnancy shall extend through the postpartum period; and
5. The continuity of care period for covered persons who are undergoing an active course of treatment shall extend to the earlier of:
a. The termination of the course of treatment by the covered person or the treating provider;
b. Ninety (90) days after the effective date of the provider’s departure or termination from the network, unless the carrier’s Medical Director determines that a longer period is necessary;
c. The date that care is successfully transitioned to a participating provider;
d. Benefit limitations under the plan are met or exceeded; or
e. The care is no longer medically necessary.
H. In addition to the provisions of Section 5.G. of this regulation, a continuity of care request may only be granted when the provider departing or terminated from the network:
1. Agrees in writing to accept the same payment from and abide by the same terms and conditions with respect to the carrier for that patient as provided in the original provider contract, or by the new payment and terms agreed upon and executed between the provider and the carrier; and
2. Agrees in writing not to seek any payment from the covered person for any amount for which the covered person would not have been responsible if the provider were still a participating provider.
I. The obligation to hold the patient harmless for services rendered in the provider’s capacity as a participating provider survives the termination of the provider contract. The hold harmless obligation does not apply to services rendered after the termination of the provider contract, except to the extent that the in-network relationship is extended to provide continuity of care.
Section 6 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 7 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 8 Effective Date
This amended regulation shall be effective on July 1, 2018.
Section 9 History
New regulation effective January 1, 2017.
Amended regulation effective July 1, 2018.