Network Adequacy Standards and Reporting Requirements for ACA-Compliant Health Benefit Plans
Section 1 Authority
This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§ 10-1-109(1), 10-16-104(5.5)(b), 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 Affordable Care Act (ACA)-compliant health benefit plans with standards and guidance on Colorado filing requirements for health benefit plan network adequacy filings, and requirements for Colorado Option Standardized Plan as specified in Colorado Insurance Regulation 4-2-80, including the applicable requirements found in Section 10-16-104(5.5), C.R.S. These standards shall serve as the measurable requirements used by the Division to evaluate the adequacy of carrier networks.
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 includes student health insurance coverage. 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” 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. “Counties with Extreme Access Considerations” or “CEAC” means, for the purposes of this regulation, counties with a population density of less than ten (10) people per square mile, based on U.S. Census Bureau population and density estimates.
D. “Covered person” shall have the same meaning as found at § 10-16-102(15), C.R.S.
E. “Dentist” and “dental provider” means, for the purposes of this regulation, a dental provider who is skilled in and licensed to practice dentistry for patients in all age groups and is responsible for the diagnosis, treatment, management, and overall coordination of services to meet the patient’s oral health needs.
F. “Embedded” means, for the purposes of this regulation, dental benefits provided as part of a health benefit plan, which may or may not be subject to the same deductible, coinsurance, copayment and out-of-pocket maximum of the health benefit plan.
G. “Emergency services” shall have the same meaning as found in § 10-16-704(19)(e)(I), C.R.S.
H. “Enrollment” means, for the purposes of this regulation, the number of covered persons enrolled in a specific health plan or network.
I. “Essential community provider” or “ECP” means, for the purposes 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, J. “Health benefit plan” shall, for the purposes of this regulation, have the same meaning as found in § 10-16-102(32), C.R.S.
K. “Home health services” shall, for the purposes of this regulation, have the same meaning as found in § 25.5-4-103(7), C.R.S.
L. “Managed care plan” shall have the same meaning as found at § 10-16-102(43), C.R.S.
M. “Mental health, behavioral health, and substance use disorder care” means, for the purposes of this regulation, health care services for a behavioral, mental health, and substance use disorder as defined by § 10-16-104(5.5)(d), C.R.S., provided by mental health, behavioral health, and substance use disorder care providers.
N. “Mental health, behavioral health, and substance use 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 § 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.
O. “Network” shall have the same meaning as found at § 10-16-102(45), C.R.S.
P. “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.
Q. “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 includes physicians (pediatrics, general practice, family medicine, internal medicine, geriatrics,
obstetrician/gynecologist), physician assistants, and nurse practitioners supervised by, or collaborating with, a primary care physician.
R. “SERFF” means, for the purposes of this regulation, the NAIC System for Electronic Rate and Form Filings.
S. “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, mental health, behavioral health, substance use disorder care or 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.
T. “Standardized plan” shall have the same meaning as found in § 10-16-1303(14) C.R.S.
U. “Student health insurance coverage” shall have the same meaning as found in § 10-16-102(65), C.R.S.
V. “Substance use disorder care provider” for purposes of this regulation, means a provider offering health care services for a substance use disorder, including the recurring use of alcohol and/or drugs that causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities.
W. “Telehealth” shall have the same meaning as found in § 10-16-123(4)(e), C.R.S.
X. “Urgent care facility” means, for the purposes of this regulation, a facility or office that generally has extended hours, may or may not have a physician on the premises at all times, and is only able to treat minor illnesses and injuries. An urgent care facility does not typically have the facilities to handle an emergency condition, which includes life or limb threatening injuries or illnesses, as defined under emergency services.
Section 5 Reporting Requirements
A. Network adequacy filings shall be filed with the Division through SERFF prior to use and annually thereafter. Specific SERFF filing requirements are in Section 11.
B. The following four (4) measurement standards shall be used to evaluate a carrier’s network adequacy:
1. Compliance with network adequacy filing instructions published by the Division;
2. Compliance with network adequacy definitions contained in this regulation;
3. Compliance with the measurement details contained in this regulation; and
4. Compliance with the reporting methodologies contained in this regulation.
C. Attestations of adequate networks, for each network, including networks for Colorado Option Standardized Plans, shall be provided on the “Colorado Carrier Network Adequacy Summary and Attestation Form” submitted as part of the network adequacy form filing.
Section 6 Network Adequacy Standards
The following access to service and waiting time standards shall be met in order to comply with network adequacy requirements:
Note: A table shows specific access and waiting time standards for specific types of providers. The table could not be reproduced here because of formatting reasons.
Section 7 Availability Standards
A. “Provider to enrollee” ratios for different provider types shall be reported in the filed “Enrollment Document”. Carriers shall also report on the Enrollment Document in SERFF the total number of lives and counts for the following types of providers/facilities: PCPs, specialists, obstetricians, gynecologists, OBGYNs, pediatricians, behavioral health, mental health and substance abuse disorder providers and facilities, pharmacy, hospitals, and urgent care facilities.
B. The standards listed below shall be used to measure network adequacy, along with geographic access standards, in counties with “large metro, metro and micro” status, as defined in Appendix A, for the specific provider types listed in Section 7.D. of this regulation.
C. The carrier shall attest that it is compliant with the “provider to enrollee” ratios standards in Section 7.D. of this regulation D. The following “provider to enrollee” ratio availability standards shall be met in order to comply with
network adequacy requirements:
Note: A table shows specific provider-to-patient ratios for specific types of providers and geographic areas. The table could not be reproduced here because of formatting reasons.
Section 8 Geographic Access Standards
A. The carrier shall attest that at least one (1) of each of the providers and facilities listed below is available within the maximum road travel distance of any enrollee in each specific carrier’s network.
B. Geographic access standards may require that an enrollee cross county or state lines to reach a provider.
C. Network Adequacy Geographic Access Standards by Provider Type: Individual Provider Specialty
Note: An extensive table immediately follows “C.” above. The table could not be reproduced here because of formatting reasons.
Section 9 Essential Community Provider Standards
A. ACA-compliant individual and small group health benefit plans, including those with embedded dental benefits, are required to have a sufficient number and geographic distribution of essential community providers (ECPs), where available. ECP standards do not apply to large group health benefit plans or student health insurance coverage.
B. Carriers shall ensure the inclusion of a sufficient number of ECPs to ensure reasonable and timely access to a broad range of ECP providers for low-income, medically underserved individuals in their service areas.
C. There are four (4) ECP standards for carrier ECP submissions:
1. General ECP Standard. Carriers utilizing this standard shall demonstrate in their “Essential Community Provider/Network Adequacy Template” in SERFF that at least 35 percent (35%), as specified by Colorado and CMS, of available ECPs in each plan’s service area participate in the plan’s network. This standard applies to all carriers except
those who qualify for the alternate ECP standard.
2. Alternate ECP Standard. Carriers utilizing this standard shall demonstrate in their “Essential Community Provider/Network Adequacy Template” in SERFF, that they have the same number of ECPs as defined in the general ECP standard (calculated as 35 percent (35%) of the ECPs in the carrier’s service area), but the ECPs should be located
within Health Professional Shortage Areas (HPSAs) or five-digit ZIP codes in which 30 percent (30%) or more of the population falls below 200 percent (200%) of the federal poverty level (FPL). An alternate ECP standard carrier is one that provides a majority of covered professional services through physicians it employs or through a single
contracted medical group.
3. General ECP Standard for Colorado Option Standardized Plans Networks as specified in Colorado Insurance Regulation 4-2-80, as applicable.
4. Alternate ECP Standard for Colorado Option Standardized Plans Networks as specified in Colorado Insurance Regulation 4-2-80, as applicable.
Section 10 Network Adequacy Requirements for Plans with Embedded Dental Benefits
Health benefit plans that offer embedded dental coverage shall report all aspects of network adequacy required in Section 11 of this regulation for dental providers included in carrier networks. If the dental provider is not within the carrier’s medical network, the carrier shall include network adequacy reporting for the separate dental network(s) within the medical network adequacy filing. Network adequacy standards and reporting requirements for ACA-compliant stand-alone dental plans are specified in Colorado Insurance Regulation 4-2-57.
A. The carrier shall attest that at least one (1) dentist or dental provider listed below is available within the maximum road travel distance for each geographic type, as defined in Appendix A, for at least 90% of its enrollees in each Colorado county within the carrier’s service area:
Note: A table immediately follows “A” above. The table could not be reproduced here because of formatting reasons.
B. Geographic accessibility in some circumstances, may require that an enrollee cross county or state lines to reach an in-network provider.
Section 11 Requirements for Annual Network Adequacy Reporting for ACA-Compliant Individual, Small Group, and Large Group Health Benefit Plans, and Student Health Insurance Coverage Plans
Network adequacy reporting shall consist of network adequacy form and binder (if appropriate) filings submitted in SERFF. These filings shall be filed using the filing instructions for the appropriate ACA-compliant managed care plans in Sections 11.A and 11.B. Carriers shall report each network, including networks for Standardized Plans, if applicable, that provides managed care services for a carrier’s individual, small group, large group, and student health insurance coverage plans.
A. Network Adequacy Filings for ACA-Compliant Individual and Small Group Health Benefit Plans Network adequacy filings for networks associated with ACA-compliant individual and small group health benefit plans, including networks for Standardized Plans, shall be filed during the annual health benefit plan certification process, and shall consist of two (2) sections, the “Essential Community Providers/Network Adequacy” (ECP/NA) template filing in the Plan Management (Binder) section in SERFF, and a network adequacy form filing, filed with a SERFF “type of
insurance” (TOI) code NA01.004. Each network that is included in any of a carrier’s Binder filings, including networks for Standardized Plans, shall be included in the carrier’s ECP/NA template filing and in the carrier’s network adequacy form filing. Templates in SERFF and filing instructions specified on the Division’s website shall be used.
1. Elements of the Binder Filing
a. All carriers shall submit network provider and facility listings on the “Essential Community Provider/Network Adequacy” (ECP/NA) template in the Binder filing in SERFF for each network. All ECPs in each network, including networks for Standardized Plans, must be included in this template. The templates must be completed and filed as described in SERFF and in the Division filing instructions on the Division website.
b. The “ECP Write-in Worksheet”, if applicable, shall be filed on the “Supporting Documentation” tab of the Binder filing.
c. If a carrier does not meet the 35% ECP standard during the carrier binder validation or Division review process, the carrier shall submit a copy of the “Colorado ECP Justification Template” on the Supporting Documentation tab of
the Binder in SERFF.
d. If the carrier does not meet the Colorado Option Standardized Plans ECP standards as specified in Colorado Insurance Regulation 4-2-80, the carrier shall submit a copy of the “Colorado ECP Justification Template” on the Supporting Documentation tab of the Binder in SERFF.
2. Elements of the Network Adequacy Form Filing. The network adequacy form filing shall include the following items and attached on the “Supporting Documentation” tab.
a. Carriers shall submit network access plans for each network, including networks for Colorado Option Standardized Plans, pursuant to § 10-16-704(9), C.R.S., and each Colorado Option Standardized Plan network in accordance with Colorado Insurance Regulation 4-2-80. Network access plan standards and reporting requirements are provided in Colorado Insurance Regulations 4-2-54 and 4-2-80.
b. Carriers shall submit an “Enrollment Document” in SERFF containing separate spreadsheets (tabs) for each network. Counts used for this document shall be based on the projected enrollment of all members in the carrier’s individual, small group, and large group health benefit plans, and the student health insurance coverage plans utilizing that specific network.
c. The carrier shall provide screen shots from the provider directory(ies) showing:
(1) Master (entry) page of the carrier’s website, directing users to the provider directory(ies);
(2) Introduction screen of the provider directory;
(3) The directory’s general information, such as inclusion criteria, description of tiering (if applicable), customer service contact information, date of last revision(s), and directory disclosures;
(4) Simple search screen;
(5) A page of a provider directory produced from a search; and
(6) Detail screen for at least one (1) provider and one (1) facility.
d. The carrier shall submit the completed “Carrier Individual/Small Group Network Adequacy Summary and Attestation Form” in SERFF as described in Section 12.
B. Large Group Health Benefit Plans and Student Health Insurance Coverage Plans Network adequacy reporting for large group health benefit plans and/or student health insurance coverage plans shall be contained in network adequacy filings separate from individual and small group filings, submitted annually to the Division. The annual submittal date is at the carrier’s discretion.
Large group health benefit plans and student health insurance coverage plan network adequacy filings shall consist of one (1) or more network adequacy form filings, filed with SERFF “type of insurance” (TOI) code NA01.004. Each network (i.e. HMO, PPO, EPO, etc.) that is utilized by the carrier for large group health benefit plans or student health insurance coverage plans shall be reported in network adequacy form filings. Copies of the templates and filing instructions to be used for network adequacy filings for large group and student plans are in SERFF and on the
Division’s website. Requirements specified in Colorado Insurance Regulation 4-2-80 are not applicable to large group health benefit plans and student health insurance coverage plans. The form filing will include the following items, all attached on the “Supporting Documentation” tab:
1. Carriers shall submit network adequacy access plans for each network, pursuant to § 10- 16-704(9), C.R.S. and Colorado Insurance Regulation 4-2-54;
2. Carriers shall submit an “Enrollment Document” in SERFF containing separate spreadsheets (tabs) for each network. Counts used for this document shall be based on the projected enrollment of all members in the carrier’s large group health benefit plans or student health insurance coverage plans utilizing that specific network.
3. The carrier shall provide screen shots from the provider directory(ies) showing:
a. The master (entry) page of the carrier’s website, directing users to the provider directory(ies);
b. The introduction screen of the provider directory;
c. The directory’s general information, such as inclusion criteria, description of tiering (if applicable), customer service contact information, date of last revisions, and directory disclosures;
d. The simple search screen;
e. A page of a provider directory produced from the search; and
f. A detail screen for at least one (1) provider and one (1) facility.
3. All carriers must submit the “Network Provider Listing” and the “Network Facility Listing” for each network included in the network adequacy filing. For network adequacy filings that do not utilize a network reported for an individual or small group ACA plan in the last 12 months, the carrier shall submit a “Network Provider Listing” and a “Network Facility Listing.” Copies of the templates and instructions for completing the listing documents are
in SERFF and on the Division’s website. If the carrier uses a network in a filing that has been reported in a network adequacy filing for an individual or small group ACA plan within the last twelve (12) months, the provider and network facility listings need not be duplicated. In these cases, the carrier must identify the network name, filing number, and
date of the filing for each network that has already been reviewed on the “Carrier Large Group/Student Network Adequacy Summary and Attestation Form”.
4. The carrier shall submit the completed “Carrier Large Group/Student Network Adequacy Summary and Attestation Form” in SERFF as described in Section 12.
Section 12 Required Attestations
A. A carrier shall attest that each of its health benefit plans will maintain a provider network(s) that meets the standards contained in this regulation, and that each provider network is sufficient in number and types of providers, including providers that specialize in mental health and substance use services, to assure that the services will be accessible without unreasonable delay.
B. A carrier shall attest that each of its individual and/or small group 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 its service areas. This specific attestation is not applicable to networks only serving large group health benefit plans or student health insurance coverage plans.
C. In addition to the attestations required in subsections 12.A and 12.B, a carrier offering Standardized Plans shall attest that any network used for Standardized Plans meets the requirements of Section 8 of Colorado Insurance Regulation 4-2-80. This specific attestation does not apply to networks only serving large group health benefit plans or student health insurance coverage plans.
D. Each applicable attestation, including attestations for Colorado Option Standardized Plans network, shall be made on the applicable “Carrier Network Adequacy Summary and Attestation Form” submitted with the network adequacy form filing in SERFF. Network adequacy filings for individual and small group ACA-compliant plans shall include a completed, signed and dated “Carrier Individual/Small Group Network Adequacy Summary and Attestation Form.” Network adequacy filings for large group and student health insurance coverage ACA-compliant plans shall include a completed, signed and dated “Carrier Large Group/Student Network Adequacy Summary and Attestation Form.”
Section 13 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 14 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 15 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 16 Effective Date
This regulation shall be effective on June, 30, 2023.
Section 17 History
New regulation effective January 1, 2017
Amended regulation effective July 1, 2018.
Emergency regulation effective September 10, 2019.
Amended regulation effective January 1, 2020.
Amended regulation effective June, 30, 2023.
APPENDIX A – DESIGNATING COUNTY TYPES
The county type, Large Metro, Metro, Micro, Rural, or Counties with Extreme Access Considerations (CEAC), is a significant component of the network access criteria. CMS uses a county type designation methodology that is based upon the population size and density parameters of individual counties. Density parameters are foundationally based on approaches taken by the U.S. Census Bureau in its delineation of “urbanized areas” and “urban clusters”, and the Office of Management and Budget (OMB) in its delineation of “metropolitan” and “micropolitan”. A county must meet both the population and density thresholds for inclusion in a given designation. For example, a county with population greater than one million and a density greater than or equal to 1,000 persons per square mile (sq. mile) is designated
Large Metro. Any of the population-density combinations listed for a given county type may be met for inclusion within that county type (i.e., a county would be designated “Large Metro” if any of the three Large Metro population-density combinations listed in the following table are met; a county is designated as “Metro” if any of the five Metro population-density combinations listed in the table are met; etc.).
Note: An extensive table immediately follows. The table could not be reproduced here because of formatting reasons.
Updated on July 24, 2023.