Types of coverage

Maternity

Group accident and health policies issued in Colorado to an employer must cover normal pregnancy and childbirth expenses. Coverage for expenses must be provided in the same manner as for any other sickness, injury, disease, or condition covered under the policy.

Mental health

Group policies that cover mental illness must provide benefits for at least 45 days of inpatient care or 90 days of partial hospitalization in a psychiatric hospital in any 12-month period. Policies must also cover no less than 20 outpatient visits or no less than $1,000 paid for outpatient visits in any 12-month period Copayment for these benefits cannot exceed 50%

Handicapped dependents

Handicapped children are not subject to an age limitation and are covered until they become self- supportive.

Cancellation by the insured

If an insured changes occupation to a less hazardous one than stated in the policy, the insured can, upon written request, either: Cancel policy and receive a refund of the unearned premium Reduce the premium accordingly and refund prorated unearned premium from the date of change

Fair Marketing Standards

If an insurer denies coverage to a small employer on the basis of the health status or claims experience of the small employer, the insurer must offer the small employer the opportunity to purchase a basic or standard health benefit plan.

Group Coverage

In Colorado, a group health certificate of insurance must contain a summary of policy features and benefits.

Genetic screening information

It is illegal for insurers to use the results of a proposed insured's genetic screening to: underwrite a policy; determine whether to issue an insurance policy or to cancel; refuse to issue or renew, or limit benefits of a policy.

Home health care

Long-term care policies must pay for "at-home" care at the same daily amount as paid for a nursing home if the insured meets the qualifications for nursing home care.

Colorado Long-Term Care Partnership Program

Partnership policies permit individuals to protect assets from spend-down requirements under the state's Medicaid program.

Pre-existing conditions

Pre-existing conditions (conditions for which medical advice, diagnosis, care or treatment was recommended or received in the six months prior to the effective date of enrollment) may be excluded for a maximum of 6 months.

Pre-existing conditions/group coverage

Pre-existing conditions are health issues that existed, were treated, or diagnosed within 6 months prior to employment. An enrollee for a health benefit plan may be excluded for up to 12 months (18 months for late enrollees). A late enrollee is an individual who elects coverage after the initial eligibility period.

Rating factors

Small employer insurers must apply consistent rating factors with all small employers. The insurer must not use case characteristics other than age, geographic area, and family composition. • A small employer carrier may apply an increase or decrease of up to 15% rating adjustment to individuals related to tobacco use

Wellness programs

The Colorado general assembly has enacted rules to encourage carriers to offer flexible benefits that encourage wellness, prevention, and healthy lifestyles. Participation in wellness/prevention program must not be made a condition of coverage The incentive for the wellness and prevention program must not exceed 20% of the cost of employee-only coverage or 20% of the cost of the coverage in which an employee and dependents are enrolled Services for wellness/programs include, but not limited to : health screenings, disease management, tobacco cessation programs, nurse-on-call programs, and fitness center memberships or facilities

Physical exams and autopsies

The insurer has the right to examine the insured during the claim process and to make an autopsy when death is involved and where it is not forbidden by law.

Intoxicants and narcotics

The insurer shall not be liable for any loss sustained or contracted in consequence of the insured's being intoxicated or under the influence of narcotics unless administered on the advice of a physician.

Illegal occupation

The insurer shall not be liable for any loss to which a contributing cause was the insured's commission of or attempt to commit a felony or to which a contributing cause was the insured's being engaged in an illegal occupation.

Participation requirements

The requirements an insurer uses to determine whether to provide coverage to a small employer must be applied uniformly among all small employers applying

Unpaid premiums

Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted from such payment.

Free look

A 30-day free look period is required for long-term care policies.

Termination

A carrier may not retroactively terminate a policy except for fraud or intentional misrepresentation For any termination other than for fraud or intentional misrepresentation, the carrier must give the policyholder at least 30 days' advance notice

Preexisting condition limitation

A carrier offering an individual or small employer health benefit plan in this state must not impose any preexisting condition exclusion with respect to cover age under the plan.

Leasing Companies

A carrier writing health coverage for an employee leasing company must ensure that any health benefit plan sold to the company that covers at least 50 employees complies with all the provisions of Colorado law that apply to large employer health plans.

Incontestable period

A long-term care policy is incontestable after it has been in force for a period of 2 years. Only fraudulent misstatements in the application may be used to void the policy or deny any claim at this point.

Policy summary

A producer must provide a Policy Summary when delivering a long-term care policy to a policyholder

Definition of small employer

A small employer is defined as a person or business that, on at least 50% of the working days in the preceding calendar year, employed no more than 50 persons, most of whom were employed in Colorado. • An eligible employee is considered an employee who has a regular work week of at least 24 hours

Guaranteed renewability

A small group health plan must be renewable for all eligible employees and dependents at the option of the small employer.

Home health coverage

All accident and health policies issued in Colorado that provide major medical services must offer policyholders the opportunity to purchase home health care coverage.

Colorado Supplement

All carriers of health benefit plans are required to make available a Summary of Benefits and Coverage form and a completed copy of the Colorado Supplement to the Summary of Benefits and Coverage form for every policy, contract, and plan. The Colorado Supplement to the Summary of Benefits and Coverage form contains additional information about deductibles, covered cancer screenings, balanced billing, and binding arbitration clauses Upon request, the Colorado Supplement to the Summary of Benefits and Coverage Form must be provided within 7 business days

Coverage of adopted children

All individual and group health plans must provide coverage to the insured's adopted children on the same basis as other dependents.

Inflation protection

All insurers issuing long-term care insurance policies on an indemnity basis, must offer, as an optional benefit, an inflation protection adjustment which provides for automatic future increases in the level of benefits without evidence of insurability. Adjustments must be at a level which provides reasonable protection from future increases in the costs of care for which benefits are provided.

Conversion of coverage

An employee whose insurance under a group plan that has been terminated can convert to an individual plan with the same insurer without evidence of insurability Employee must have been covered under the group plan for a period of at least 3 months Application for a conversion policy and first premium payment must be made within 31 days after termination of insurance The converted policy will not exclude, as a pre-existing condition, any condition covered by the group policy

Commission disclosure

An insurance producer who solicits or negotiates an application for health care insurance on behalf of a carrier must disclose to the person purchasing the plan that the insurance producer will receive a commission from the carrier.

Material misrepresentation

An insurer can deny a claim under a long-term care insurance policy for any material misrepresentation made by the insured if it has been in effect for less than 6 months.

Outline of coverage

An outline of coverage is required and provides a very brief description of the important features of the policy. It is considered a summary of coverage.

Conformity with state statutes

Any provision of this policy which, on the date of issue, is in conflict with the statutes of the state in which the insured resides at the date of issue is understood to be amended to conform to such statutes.

Continuation of coverage

Continuation of group health coverage is only available to those employees who were covered under a group plan for a minimum period of three months prior to the date of termination. 36 Continuation of coverage of a group Hospital, Surgical, and Major Medical Policy must include hospital expenses The eligible employee can elect continuation of coverage for at least 60 days and up to 18 months after termination, as long as the premiums are paid by the employee. No more than 102% of the full group rate will be charged to that employee Continuation payments need to start being paid by the employee within 31 days of termination to be eligible for continuation coverage Continuation coverage is not required to include dental, vision, or prescription drug benefits

Relation of earnings to income

Disability payments shall not exceed the average monthly earnings of the insured at the time disability begins or for the two years prior to the disability.

Genetic testing

Discrimination based on genetic information is prohibited.

Guaranteed issue

Every small employer insurer must actively offer to small employers the choice of a basic health benefit plan or a standard health benefit plan.

Medical examinations and lab tests including HIV

For underwriting an individual policy, insurers may require proposed insureds to undergo an HIV test, but only in conjunction with other medical tests. The basis for requiring an HIV test cannot be the proposed insured's sexual orientation. The insurer must obtain written consent from the proposed insured in order to conduct the HIV test.

Pre-existing conditions, replacement policies

When replacing an individual health policy in Colorado, the required replacement notice to the applicant must include notice that pre-existing conditions may not be covered. An individual's waiting period for pre-existing conditions is reduced when he or she has "creditable coverage." Creditable coverage is previous coverage under another group or individual health plan when there has not been a break in coverage of 63 days. The 63-day period begins when the individual's previous coverage ended. It ends when coverage under your plan begins, or, if earlier, when your group's waiting period for eligibility begins.

Long-Term Care

is designed to provide coverage for diagnostic, preventive, therapeutic, rehabilitative, maintenance, or personal care services in a setting other than an acute care unit of a hospital. Long-term care insurance is any policy designed to provide coverage for at least 12 consecutive months for each covered person on an expense-incurred, indemnity, prepaid, or other basis

Notice to buyer

must be on the first page of each long-term care policy delivered in. It explains that some long-term care costs may not be covered.

Contingent

or additional compensation (such as renewal commission) is not considered standard compensation and does not need to be disclosed