(1)
Newborn children. (a) All group and individual sickness and accident insurance policies and
all service or indemnity contracts issued by any entity subject to part 3 or 4 of this article shall
provide coverage for a dependent newborn child of the insured or subscriber from the moment of
birth.
(b) (I) Coverage for a hospital stay for a newborn following a normal vaginal delivery
shall not be limited to less than forty-eight hours. If forty-eight hours following delivery falls
after 8 p.m., coverage shall continue until 8 a.m. the following morning.
(II) Coverage for a hospital stay for a newborn following a cesarean section shall not be
limited to less than ninety-six hours. If ninety-six hours following the cesarean section falls after
8 p.m., coverage shall continue until 8 a.m. the following morning.
(III) The provisions of subparagraphs (I) and (II) of this paragraph (b) shall not apply in
any case in which the decision to discharge the newborn prior to the minimum length of stay
otherwise required under subparagraphs (I) and (II) of this paragraph (b) is made by an attending
provider with the agreement of the mother.
(IV) Nothing in this paragraph (b) shall be construed to require a mother who is a
participant or beneficiary to give birth in a hospital or to stay in the hospital for a fixed period of
time after the birth of her child.
(V) Nothing in this paragraph (b) shall be construed as preventing a carrier from
imposing deductibles, coinsurance, or other cost sharing in relation to benefits for hospital
lengths of stay in connection with childbirth for a mother or newborn child under the plan;
except that such coinsurance or other cost sharing for any portion of a period within a hospital
length of stay required under subparagraphs (I) and (II) of this paragraph (b) may not be greater
than such coinsurance or cost sharing for any other sickness, injury, disease, or condition that is
otherwise covered under the policy or contract.
(c) (I) Except as provided for cleft lip and cleft palate coverage in sub-subparagraph (A)
of subparagraph (II) of this paragraph (c) and for inherited enzymatic disorders caused by single
gene defects involved in the metabolism of amino, organic, and fatty acids and for which
medically standard methods of diagnosis, treatment, and monitoring exist pursuant to sub-
subparagraph (A) of subparagraph (III) of this paragraph (c), the benefits available to newborn
children shall consist of coverage of injury or sickness, including all medically necessary care
and treatment of medically diagnosed congenital defects and birth abnormalities for the first
thirty-one days of the newborn's life, notwithstanding policy limitations and exclusions
applicable to other conditions or procedures covered by the policy. Except as provided in sub-
subparagraph (C) of subparagraph (II) of this paragraph (c), such coverage shall be subject to
copayment, deductible, and aggregate dollar policy maximums that are no higher than are
generally applicable under the policy to all other sicknesses, diseases, and conditions otherwise
covered under the policy.
(II) (A) With regard to newborn children born with cleft lip or cleft palate or both, there
shall be no age limit on benefits for such conditions, and care and treatment shall include to the
extent medically necessary: Oral and facial surgery, surgical management, and follow-up care by
plastic surgeons and oral surgeons; prosthetic treatment such as obturators, speech appliances,
and feeding appliances; medically necessary orthodontic treatment; medically necessary
prosthodontic treatment; habilitative speech therapy; otolaryngology treatment; and audiological
assessments and treatment.
(B) Cleft lip, cleft palate, or any condition or illness which is related to or developed as a
result of the cleft lip or cleft palate shall be considered to be compensable for coverage under the
provisions of sub-subparagraph (A) of this subparagraph (II).
(C) If a dental insurance policy, a contract for dental insurance, or an enrollee coverage
contract issued pursuant to this article is in effect at the time of the birth, or is purchased after the
birth, of a child with cleft lip or cleft palate or both, it shall provide fully for any orthodontics or
dental care needed as a result of the cleft lip or cleft palate or both. Such policy or contract may
contain the same copayment provisions for the coverage of cleft lip or cleft palate or both as
apply to other conditions or procedures covered by the policy or contract.
(III) (A) Coverage for inherited enzymatic disorders caused by single gene defects
involved in the metabolism of amino, organic, and fatty acids as well as severe protein allergic
conditions includes, without limitation, the following diagnosed conditions: Phenylketonuria;
maternal phenylketonuria; maple syrup urine disease; tyrosinemia; homocystinuria; histidinemia;
urea cycle disorders; hyperlysinemia; glutaric acidemias; methylmalonic acidemia; propionic
acidemia; immunoglobulin E and nonimmunoglobulin E-mediated allergies to multiple food
proteins; severe food protein induced enterocolitis syndrome; eosinophilic disorders as
evidenced by the results of a biopsy; and impaired absorption of nutrients caused by disorders
affecting the absorptive surface, function, length, and motility of the gastrointestinal tract.
Covered care and treatment of such conditions shall include, to the extent medically necessary,
medical foods for home use for which a physician who is a participating provider has issued a
written, oral, or electronic prescription.
(B) There is no age limit on benefits for inherited enzymatic disorders specified in sub-
subparagraph (A) of this paragraph (III) except for phenylketonuria. The maximum age to
receive benefits for phenylketonuria is twenty-one years of age; except that the maximum age to
receive benefits for phenylketonuria for women who are of child-bearing age is thirty-five years
of age.
(C) As used in this subparagraph (III), "medical foods" means prescription metabolic
formulas and their modular counterparts and amino acid-based elemental formulas, obtained
through a pharmacy, that are specifically designated and manufactured for the treatment of
inherited enzymatic disorders caused by single gene defects involved in the metabolism of
amino, organic, and fatty acids and for severe allergic conditions, if diagnosed by a board-
certified allergist or board-certified gastroenterologist, for which medically standard methods of
diagnosis, treatment, and monitoring exist. Such formulas are specifically processed or
formulated to be deficient in one or more nutrients. The formulas for severe food allergies
contain only singular form elemental amino acids. The formulas are to be consumed or
administered enterally either via tube or oral route under the direction of a physician who is a
participating provider. This sub-subparagraph (C) shall not be construed to apply to cystic
fibrosis patients or lactose- or soy-intolerant patients.
(D) Coverage of medical foods, as provided under this subparagraph (III), shall only
apply to insurance plans that include an approved pharmacy benefit and shall not apply to
alternative medicines. Such coverage shall only be available through participating pharmacy
providers. Nothing in this subparagraph (III) shall be construed as preventing a carrier from
imposing deductibles, coinsurance, or other cost-sharing methods.
(d) If payment of a specific premium is required to provide coverage for a child, the
policy may require that notification of birth of the newborn child and payment of the required
premium must be furnished to the insurer or other entity within thirty-one days after the date of
birth in order to have the coverage continue beyond such thirty-one-day period.
(e) The requirements of this section shall apply to all individual sickness and accident
policies issued on and after July 1, 1975, and to all blanket and group sickness and accident
policies issued, renewed, or reinstated on and after July 1, 1975, and to all subscriber or enrollee
coverage contracts delivered or issued for delivery in this state on and after July 1, 1975.
(f) (I) Any contract of a prepaid dental plan of an entity subject to the provisions of part
5 of this article applied for that provides family coverage shall, as to such coverage of
individuals in the family, also provide that the benefits applicable for children shall be payable
with respect to a newly born child of the insured from the instant of such child's birth to the same
extent that such coverage applies to other individuals in the family. If payment of a specific
premium or capitation amount is required to provide coverage for a child, the contract may
require that notification of birth of a newly born child and payment of the required premium or
capitation amount shall be furnished to the organization within thirty-one days after the date of
birth in order to have the coverage continue beyond the thirty-one-day period.
(II) The coverage for newborn children shall include any orthodontics or dental care
needed as the result of the child being born with a cleft lip or cleft palate or both. The contract
providing such coverage may contain the same copayment provisions as apply to other
conditions or procedures covered by the contract.
(g) The health-care service plan issued by an entity subject to the provisions of part 4 of
this article may provide that the benefits required pursuant to this subsection (1) shall be covered
benefits only if the services are rendered by a provider who is designated by and affiliated with
the health maintenance organization.
(1.3) Early intervention services. (a) As used in this subsection (1.3), unless the
context otherwise requires:
(I) "Division" means the unit within the department of human services that is responsible
for developmental disabilities services.
(II) "Early intervention services" means services as defined by the division in
accordance with part C that are authorized through an eligible child's IFSP but that exclude
nonemergency medical transportation; respite care; service coordination, as defined in 34 CFR
303.12 (d)(11); and assistive technology, unless assistive technology is covered under the
applicable insurance policy or service or indemnity contract as durable medical equipment.
(III) "Eligible child" means an infant or toddler, from birth through two years of age,
who is an eligible dependent and who, as defined by the department pursuant to section 26.5-3-
402 (11), has significant delays in development or has a diagnosed physical or mental condition
that has a high probability of resulting in significant delays in development or who is eligible for
services pursuant to section 27-10.5-102 (11)(c).
(IV) "Individualized family service plan" or "IFSP" means a written plan developed
pursuant to 20 U.S.C. sec. 1436 and 34 CFR 303.340 that authorizes early intervention services
to an eligible child and the child's family. An IFSP shall serve as the individualized plan,
pursuant to section 27-10.5-102 (20)(c), C.R.S., for an eligible child from birth through two
years of age.
(V) "Part C" means the early intervention program for infants and toddlers who are
eligible for services under part C of the federal "Individuals with Disabilities Education Act", 20
U.S.C. sec. 1400 et seq.
(VI) "Qualified early intervention service provider" or "qualified provider" means a
person or agency, as defined by the division in accordance with part C, who provides early
intervention services and is listed on the registry of early intervention service providers pursuant
to section 26.5-3-408 (1).
(b) (I) All individual and group sickness and accident insurance policies or contracts
issued or renewed by an entity subject to part 2 of this article on or after January 1, 2008, and all
service or indemnity contracts issued or renewed by an entity subject to part 3 or 4 of this article
on or after January 1, 2008, that include dependent coverage shall provide coverage for early
intervention services delivered by a qualified early intervention service provider to an eligible
child. Early intervention services specified in an eligible child's IFSP shall qualify as meeting the
standard for medically necessary health-care services as used by private health insurance plans.
(II) (A) The coverage required by this subsection (1.3) must be available annually to an
eligible child from birth up to the child's third birthday for early intervention services for each
dependent child per calendar or policy year. The commissioner shall specify, by rule, the extent
of the coverage for early intervention services required by this subsection (1.3), which, except
for grandfathered health benefit plans, must require coverage of a number of early intervention
services or visits that is actuarially equivalent to the dollar limit of the benefit as it existed prior
to May 13, 2013.
(B) For grandfathered health benefit plans, the coverage required by this subsection (1.3)
per calendar or policy year for early intervention services for each eligible dependent child from
birth up to the child's third birthday is limited to six thousand three hundred sixty-one dollars,
including case management costs. Effective January 1, 2014, and each January 1 thereafter, the
commissioner shall annually adjust the dollar limit for early intervention services coverage based
on the Denver-Aurora-Lakewood consumer price index or, if applicable, its predecessor or
successor index for the state fiscal year that ends in the immediately preceding calendar year, or
by an additional amount equal to the increase by the general assembly in the annual appropriated
rate to serve one child for one fiscal year in the state-funded early intervention program if that
increase is more than the consumer price index increase.
(III) Except as provided in paragraph (d) of this subsection (1.3), the coverage shall not
be subject to deductibles or copayments, and any benefits paid under the coverage required by
this subsection (1.3) shall not be applied to an annual or lifetime maximum benefit contained in
the policy or contract. Unless the carrier agrees prior to the provision of early intervention
services, a carrier shall not be required to pay a reimbursement rate for early intervention
services provided by a nonparticipating provider that exceeds the reimbursement rate allowed for
comparable early intervention services provided by a participating provider.
(IV) Any limit on the amount of coverage for early intervention services specified by the
commissioner by rule pursuant to sub-subparagraph (A) of subparagraph (II) of this paragraph
(b) or, for grandfathered health benefit plans, specified in sub-subparagraph (B) of subparagraph
(II) of this paragraph (b) shall not apply to:
(A) Rehabilitation or therapeutic services that are necessary as the result of an acute
medical condition or post-surgical rehabilitation;
(B) Services provided to a child who is not participating in part C and services that are
not provided pursuant to an IFSP. However, such services shall be covered at the level specified
in paragraph (b) of subsection (1.7) of this section.
(c) This subsection (1.3) shall not apply to the following:
(I) Short-term, accident, fixed indemnity, or specified disease policies, disability income
contracts, limited benefit health insurance, as defined by the commissioner by rule, credit
disability insurance, or a medicare supplement policy as defined in section 10-18-101 (4);
(II) Workers' compensation or similar insurance;
(III) Automobile medical payment insurance or insurance under which benefits are
payable with or without regard to fault and required by law to be contained in any liability
insurance policy or equivalent self-insurance.
(d) (I) The coverage required by this subsection (1.3) may be offered through a high
deductible plan that would qualify for a health savings account pursuant to 26 U.S.C. sec. 223;
except that a carrier may apply deductible amounts for the required coverage if it is not
considered by the United States department of treasury to be preventive or to have an acceptable
deductible amount.
(II) If a high deductible plan that would qualify for a health savings account pursuant to
26 U.S.C. sec. 223 requires a deductible or copayment amount for the coverage required by this
subsection (1.3), the deductible or copayment amount may be paid by the state as determined by
rules adopted by the commissioner in accordance with article 4 of title 24, C.R.S., in
consultation with the division of insurance.
(d.5) (I) Upon notice from the department of early childhood pursuant to section 26.5-3-
409 (1) that a child is eligible for early intervention services, the carrier shall submit payment of
benefits for the eligible child in accordance with this subsection (1.3)(d.5)(I) and section 26.5-3-
409 (1). If the eligible child is covered by a grandfathered health benefit plan, the carrier shall
submit payment in the amount specified in subsection (1.3)(b)(II)(B) of this section, as adjusted
annually pursuant to said subsection. If the eligible child is covered by any other policy or
contract subject to this subsection (1.3), the carrier shall submit payment in an amount that
equals the approximate value of the number of early intervention services or visits specified by
the commissioner pursuant to subsection (1.3)(b)(II)(A) of this section.
(II) Qualified early intervention service providers that receive reimbursement in
accordance with this paragraph (d.5) shall accept the reimbursement as payment in full for
services provided under this subsection (1.3) and shall not seek additional reimbursement from
either the covered person or the carrier.
(e) Within ninety days after the division determines that a child is no longer an eligible
child for purposes of this subsection (1.3), the division shall notify the carrier that the child is no
longer eligible and that the carrier is no longer required to provide the coverage required by this
subsection (1.3) for that child.
(f) Use of available coverage under this subsection (1.3) for the cost of early intervention
services is mandatory, consistent with the requirements of part C. An eligible child must fully
utilize available coverage under this subsection (1.3) prior to accessing state general funds or
federal part C funds. A carrier shall not terminate or fail to renew health coverage on the basis
that an eligible child has accessed or will be accessing early intervention services under this
subsection (1.3).
(g) Early intervention services shall be provided as specified in the eligible child's IFSP,
and such services shall not duplicate or replace treatment for autism spectrum disorders provided
in accordance with subsection (1.4) of this section. Services for the treatment of autism spectrum
disorders provided in accordance with subsection (1.4) of this section shall be considered the
primary service to an eligible child, and early intervention services provided under this
subsection (1.3) shall supplement, but not replace, services provided under subsection (1.4) of
this section.
(1.4) Autism spectrum disorders. (a) As used in this subsection (1.4), unless the
context otherwise requires:
(I) "Applied behavior analysis" means the use of behavior analytic methods and research
findings to change socially important behaviors in meaningful ways.
(II) "Autism services provider" means any person who provides direct services to a
person with autism spectrum disorder, is licensed, certified, or registered by the applicable state
licensing board or by a nationally recognized organization, and meets one of the following:
(A) Has a doctoral degree with a specialty in psychiatry, medicine, or clinical
psychology, is actively licensed by the Colorado medical board, and has at least one year of
direct experience in behavioral therapies that are consistent with best practice and research on
effectiveness for people with autism spectrum disorders;
(B) Has a doctoral degree in one of the behavioral or health sciences and has completed
one year of experience in behavioral therapies that are consistent with best practice and research
on effectiveness for people with autism spectrum disorders;
(C) Has a master's degree or higher in behavioral sciences and is nationally certified as a
"board certified behavior analyst" or certified by a similar nationally recognized organization;
(D) Has a master's degree or higher in one of the behavior or health sciences, is
credentialed as a related services provider, and has completed one year of direct supervised
experience in behavioral therapies that are consistent with best practice and research on
effectiveness for people with autism spectrum disorders. For the purposes of this sub-
subparagraph (D), "related services provider" means a physical therapist, occupational therapist,
or speech therapist.
(E) Has a baccalaureate degree or higher in behavioral sciences and is nationally
certified as a "board certified associate behavior analyst" by the behavior analyst certification
board or by a similar nationally recognized organization; or
(F) Is nationally registered as a "registered behavior technician" by the behavior analyst
certification board or by a similar nationally recognized organization and provides direct
services to a person with an autism spectrum disorder under the supervision of an autism
services provider described in sub-subparagraph (A), (B), (C), (D), or (E) of this subparagraph
(II).
(III) "Autism spectrum disorders" or "ASD":
(A) Has the same meaning as set forth in the most recent edition of the Diagnostic and
Statistical Manual of Mental Disorders in effect at the time of the diagnosis; and
(B) Includes the following disorders, as defined in the most recent edition of the
Diagnostic and Statistical Manual of Mental Disorders in effect at the time of the diagnosis:
Autistic disorder, Asperger's disorder, and atypical autism as a diagnosis within pervasive
developmental disorder not otherwise specified.
(IV) "Health benefit plan", does not include:
(A) Short-term limited duration health insurance policies; or
(B) Individual grandfathered health benefit plans.
(V) "Individualized education program" shall have the same meaning as provided in
section 22-20-103, C.R.S.
(VI) "Individualized family service plan" shall have the same meaning as provided in
section 27-10.5-102, C.R.S.
(VII) "Individualized plan" has the same meaning as provided in section 25.5-10-202,
C.R.S.
(VIII) "Pharmacy care" means medications prescribed by a physician licensed by the
Colorado medical board under the "Colorado Medical Practice Act", article 240 of title 12.
(IX) "Psychiatric care" means direct or consultative services provided by a psychiatrist
licensed by the Colorado medical board under the "Colorado Medical Practice Act", article 240
of title 12.
(X) "Psychological care" means direct or consultative services provided by a
psychologist licensed by the state board of psychologist examiners pursuant to part 3 of article
245 of title 12 or a social worker licensed by the state board of social work examiners pursuant
to part 4 of article 245 of title 12.
(XI) "Therapeutic care" means services provided by a speech therapist; an occupational
therapist or occupational therapy assistant licensed to practice occupational therapy pursuant to
article 270 of title 12; a physical therapist licensed to practice physical therapy pursuant to
article 285 of title 12; or an autism services provider. "Therapeutic care" includes, but is not
limited to, speech, occupational, and applied behavior analytic and physical therapies.
(XII) "Treatment for autism spectrum disorders" shall be for treatments that are
medically necessary. The treatments listed in this subparagraph (XII) are not considered
experimental or investigational and are considered appropriate, effective, or efficient for the
treatment of autism. "Treatment for autism spectrum disorders" shall include the following, as
medically necessary:
(A) Evaluation and assessment services;
(B) Behavior training and behavior management and applied behavior analysis,
including but not limited to consultations, direct care, supervision, or treatment, or any
combination thereof, for autism spectrum disorders provided by autism services providers;
(C) Habilitative or rehabilitative care, including, but not limited to, occupational therapy,
physical therapy, or speech therapy, or any combination of those therapies. For a person who is
also covered under subsection (1.7) of this section, the level of benefits for occupational therapy,
physical therapy, or speech therapy shall exceed the limit of twenty visits for each therapy if
such therapy is medically necessary to treat autism spectrum disorders under this subsection
(1.4).
(D) Pharmacy care and medication, if covered by the health benefit plan;
(E) Psychiatric care;
(F) Psychological care, including family counseling; and
(G) Therapeutic care.
(XIII) "Treatment plan" means a plan developed for an individual by an autism services
provider and prescribed by a licensed physician or a licensed psychologist pursuant to a
comprehensive evaluation or reevaluation for an individual consisting of the individual's
diagnosis; proposed treatment by type, frequency, and anticipated treatment; the anticipated
outcomes stated as goals; and the frequency by which the treatment plan will be updated. The
treatment plan shall be developed in accordance with the patient-centered medical home as
defined in section 25.5-1-103 (5.5), C.R.S.
(b) (I) All health benefit plans issued or renewed in this state must provide coverage for
the assessment, diagnosis, and treatment of autism spectrum disorders for a child pursuant to this
subsection (1.4).
(II) Nothing in this subsection (1.4):
(A) Requires or permits a carrier to reduce benefits provided for autism spectrum
disorders if a health benefit plan already provides coverage that exceeds the requirements of this
subsection (1.4) and rules adopted by the commissioner;
(B) Prevents a carrier from increasing benefits provided for autism spectrum disorders;
or
(C) Limits coverage for physical or mental health benefits covered under a health benefit
plan.
(c) Treatment for autism spectrum disorders shall be prescribed or ordered by a licensed
physician or licensed psychologist.
(d) A health benefit plan offered to residents of this state providing basic health-care
services that is delivered, issued for delivery, or renewed in this state shall not exclude autism
spectrum disorders or impose additional requirements for authorization of services that operate
to exclude coverage for the assessment, diagnosis, and treatment of autism spectrum disorders.
(e) Except as otherwise provided in paragraph (b) of this subsection (1.4), the coverage
required under this subsection (1.4) shall not be subject to dollar limits, deductibles, or
coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or
coinsurance provisions that apply to physical illness generally under the health benefit plan. The
benefits of this subsection (1.4) shall be in addition to any benefits provided for in subsections
(1.3) and (1.7) of this section.
(f) Benefits provided by a carrier on behalf of a covered individual for any care,
treatment, intervention, service, or item, the provision of which was for the treatment of a health
condition not diagnosed as an autism spectrum disorder, shall not be applied toward any
maximum benefit amount established under this subsection (1.4).
(g) A carrier may not deny or refuse to provide otherwise covered services, refuse to
issue, renew, or reissue, or otherwise restrict or terminate coverage under a health benefit plan
because the individual or his or her covered dependent is diagnosed with an autism spectrum
disorder or due to the individual's or dependent's utilization of services for which benefits are
mandated by this subsection (1.4).
(h) Any review of a treatment plan or any appeal of a decision regarding treatment shall
be subject to the rules of the commissioner on prompt investigation of health plan claims
involving utilization review and denial of benefits.
(i) Nothing in this subsection (1.4) shall be construed as affecting any obligation to
provide services to an individual under an individualized family service plan, an individualized
education program, or an individualized plan. The services required to be covered by this
subsection (1.4) shall be in addition to any services provided to an individual under an
individualized family service plan, an individualized education program, or an individualized
plan.
(j) Coverage under this subsection (1.4) is subject to all terms, conditions, definitions,
restrictions, exclusions, limitations, and utilization review of health-care services that apply to
any other coverage under the health benefit plan, including the treatment under the health benefit
plan of services performed by participating and nonparticipating providers.
(1.5) (Deleted by amendment, L. 2009, (HB 09-1204), ch. 344, p. 1802, § 2, effective
January 1, 2010.)
(1.7) Therapies for congenital defects and birth abnormalities. (a) After the first
thirty-one days of life, policy limitations and exclusions that are generally applicable under the
policy may apply; except that all individual and group health benefit plans shall provide
medically necessary physical, occupational, and speech therapy for the care and treatment of
congenital defects and birth abnormalities for a covered child from the child's third birthday to
the child's sixth birthday.
(b) The level of benefits required in paragraph (a) of this subsection (1.7) shall be the
greater of the number of such visits provided under the policy or plan or twenty therapy visits
per year each for physical therapy, occupational therapy, and speech therapy. Said therapy visits
shall be distributed as medically appropriate throughout the yearly term of the policy or yearly
term of the enrollee coverage contract, without regard to whether the condition is acute or
chronic and without regard to whether the purpose of the therapy is to maintain or to improve
functional capacity.
(c) Repealed.
(d) The health-care service plan issued by an entity subject to the provisions of part 4 of
this article may provide that the benefits required pursuant to this subsection (1.7) shall be
covered benefits only if the services are rendered by a provider who is designated by and
affiliated with the health maintenance organization.
(2) Complications of pregnancy and childbirth. (a) Any sickness and accident
insurance policy providing indemnity for disability due to sickness issued by an entity subject to
the provisions of part 2 of this article and any individual or group service or indemnity contract
issued by an entity subject to part 3 of this article shall provide coverage for a sickness or disease
which is a complication of pregnancy or childbirth in the same manner as any other similar
sickness or disease is otherwise covered under the policy or contract. Any sickness and accident
insurance policy providing indemnity for disability due to accident shall provide coverage for an
accident which occurs during the course of pregnancy or childbirth in the same manner as any
other similar accident is covered under the policy.
(b) Any sickness and accident insurance policy providing coverage for sickness on an
expense-incurred basis shall provide coverage for a sickness or disease which is a complication
of pregnancy or childbirth in the same manner as any other similar sickness or disease is
otherwise covered under the policy.
(3) Maternity coverage. (a) (I) (A) All group sickness and accident insurance policies
providing coverage within the state and issued to an employer by an entity subject to part 2 of
this article 16, all group health service contracts issued by an entity subject to part 3 or 4 of this
article 16 and issued to an employer, all individual sickness and accident insurance policies
issued by an entity subject to part 2 of this article 16, and all individual health-care or indemnity
contracts issued by an entity subject to part 3 or 4 of this article 16, except supplemental policies
covering a specified disease or other limited benefit, must insure against the expense of normal
pregnancy and childbirth or provide coverage for maternity care and provide coverage for
contraception in the same manner as any other sickness, injury, disease, or condition is otherwise
covered under the policy or contract; except that coverage for contraception must be consistent
with the requirements in section 10-16-104.2.
(B) Individual sickness and accident insurance policies or contracts may exclude
coverage for pregnancy and delivery expenses on the grounds that pregnancy was a preexisting
condition; except that the exclusion for a pregnancy as a preexisting condition under the policy
or contract does not apply for any subsequent pregnancies. Group sickness and accident
insurance policies or contracts must not exclude coverage for pregnancy and delivery expenses
on the grounds that pregnancy was a preexisting condition.
(II) Coverage for a hospital stay following a normal vaginal delivery shall not be limited
to less than forty-eight hours. If forty-eight hours following delivery falls after 8 p.m., coverage
shall continue until 8 a.m. the following morning.
(III) Coverage for a hospital stay following a cesarean section shall not be limited to less
than ninety-six hours. If ninety-six hours following the cesarean section falls after 8 p.m.,
coverage shall continue until 8 a.m. the following morning.
(IV) The provisions of subparagraphs (II) and (III) of this paragraph (a) shall not apply
in any case in which the decision to discharge prior to the minimum length of stay otherwise
required under subparagraphs (II) and (III) of this paragraph (a) is made by an attending provider
with the agreement of the mother.
(V) Nothing in this paragraph (a) shall be construed to require a mother who is a
participant or beneficiary to give birth in a hospital or to stay in the hospital for a fixed period of
time after the birth of her child.
(VI) Nothing in this paragraph (a) shall be construed as preventing a carrier from
imposing deductibles, coinsurance, or other cost sharing in relation to benefits for hospital
lengths of stay in connection with childbirth for a mother or newborn child under the plan;
except that such coinsurance or other cost sharing for any portion of a period within a hospital
length of stay required under subparagraphs (II) and (III) of this paragraph (a) may not be greater
than such coinsurance or cost sharing for any other sickness, injury, disease, or condition that is
otherwise covered under the policy or contract.
(b) The requirement in paragraph (a) of this subsection (3) shall not apply to policies or
contracts purchased by employers who employ any number of full-time or part-time employees
in fewer than fifteen full-time employee positions or to employers who employ any number of
full-time or part-time employees for not more than six consecutive months each year on a
seasonal basis if such coverage as required in paragraph (a) of this subsection (3) is provided by
the employer in one of the following methods:
(I) Self-insurance. All employers who elect under this subparagraph (I) to utilize self-
insurance for providing this benefit shall provide written notice to affected employees and to the
health insurance carrier of its choice to self-insure.
(II) A policy purchased from an insurance company authorized to do business in this
state which meets all of the requirements of the division of insurance for that purpose;
(III) A contract issued by an entity subject to the provisions of part 3 or 4 of this article;
(IV) A combination of the methods of obtaining insurance authorized in subparagraphs
(I) to (III) of this paragraph (b).
(c) An entity authorized under the provisions of part 3 or 4 of this article to issue service
or indemnity-type contracts shall offer coverage for maternity care to both married and
unmarried women in individual, nonfamily contracts and shall offer the same coverage and the
same payment of costs for maternity benefits to unmarried women that it offers to married
women.
(d) A carrier offering a health benefit plan in the state shall reimburse participating
providers who provide covered health-care services related to labor and delivery within the
scope of the provider's practice in a manner that:
(I) Promotes high-quality, cost-effective, and evidence-based care;
(II) Promotes high-value, evidence-based payment models; and
(III) Prevents risk in subsequent pregnancies.
(e) Doula services - rules - definitions. (I) As used in this subsection (3)(e), unless the
context otherwise requires:
(A) "Billing guidance" means guidance from the department of health care policy and
financing concerning coverage and billing for doula services after consideration of the findings
and recommendations for doula services resulting from the stakeholder process required
pursuant to section 25.5-4-506.
(B) "Doula" means a trained birth companion who provides personal, nonmedical
support to pregnant and postpartum people and their families prior to childbirth, during labor and
delivery, and during the postpartum period and who has the qualifications and training required
by the state.
(C) "Doula services" means services provided by a doula.
(D) "Medical assistance program" means the "Colorado Medical Assistance Act",
articles 4, 5, and 6 of title 25.5.
(II) In the large group market, maternity coverage pursuant to this subsection (3) must
include coverage for doula services, to the extent practicable, for the same scope and duration of
coverage that is included in the department of health care policy and financing's request
submitted pursuant to section 25.5-4-506 for federal authorization for doula services under the
medical assistance program. The benefit may include the same qualifications for individuals
providing doula services as recommended in the billing guidance for individuals providing doula
services under the medical assistance program.
(III) Except as provided in subsection (3)(e)(VI) of this section, in the individual and
small group markets, maternity coverage pursuant to this subsection (3) must include coverage
for doula services if the services are within the doula's area of professional competence and the
doula services are:
(A) Currently reimbursed when rendered by any other health-care providers; or
(B) Covered as part of the maternity essential health benefit.
(IV) This subsection (3)(e) applies to, and the division shall implement the requirements
of this subsection (3)(e) for, large employer health benefit plans issued or renewed in this state
on or after July 1, 2025, or twelve months after the date on which the department of health care
policy and financing submits its request pursuant to section 25.5-4-506 for federal authorization
for doula services under the medical assistance program, whichever is later.
(V) With respect to individual and small group health benefit plans, the division shall:
(A) Review the actuarial review conducted pursuant to section 10-16-155.5 and submit
to the federal department of health and human services the division's determination as to whether
the benefit specified in this subsection (3)(e) is in addition to essential health benefits and would
be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and
(B) Request that the federal department of health and human services confirm the
division's determination within sixty days after receipt of the division's request and submission
of its determination.
(VI) This subsection (3)(e) applies to, and the division shall implement the requirements
of this subsection (3)(e) for, individual and small group health benefit plans issued or renewed in
this state upon the earlier of:
(A) Twelve months after the federal department of health and human services confirms
the division's determination or otherwise informs the division that the coverage specified in this
subsection (3)(e) does not constitute an additional benefit that requires defrayal by the state
pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or
(B) The passage of more than three hundred sixty-five days since the division submitted
its determination and request for confirmation pursuant to subsection (3)(e)(V) of this section,
and the federal department of health and human services has failed to respond to the request
within that period, in which case the division shall consider the federal department's
unreasonable delay a preclusion from requiring defrayal by the state.
(VII) The commissioner may promulgate rules as necessary to implement this subsection
(3).
(4) (Deleted by amendment, L. 2009, (HB 09-1204), ch. 344, p. 1802, § 2, effective
January 1, 2010.)
(5) Repealed.
(5.5) Behavioral, mental health, and substance use disorders. (a) (I) Every health
benefit plan subject to part 2, 3, or 4 of this article 16, except those described in section 10-16-
102 (32)(b), must provide coverage:
(A) For the prevention of, screening for, and treatment of behavioral, mental health, and
substance use disorders that is no less extensive than the coverage provided for any physical
illness and that complies with the requirements of the MHPAEA; and
(B) At a minimum, for the treatment of substance use disorders in accordance with the
American Society of Addiction Medicine criteria for placement, medical necessity, and
utilization management determinations as set forth in the most recent edition of "The ASAM
Criteria for Addictive, Substance-related, and Co-occurring Conditions"; except that the
commissioner may identify by rule, in consultation with the department of health care policy and
financing and the behavioral health administration in the department of human services, an
alternate nationally recognized and evidence-based substance-use-disorder-specific criteria for
placement, medical necessity, or utilization management, if the American Society of Addiction
Medicine criteria are no longer available or relevant or do not follow best practices for substance
use disorder treatment.
(II) (Deleted by amendment, L. 2013.)
(III) (A) Except as provided in subsections (5.5)(a)(III)(B) and (5.5)(a)(III)(C) of this
section, any preauthorization or utilization review mechanism used in the determination to
provide the coverage required by this subsection (5.5)(a) must be the same as, or no more
restrictive than, that used in the determination to provide coverage for a physical illness. The
commissioner shall adopt rules as necessary to implement and administer this subsection (5.5).
(B) A health benefit plan subject to this subsection (5.5) must provide coverage without
prior authorization for a five-day supply of at least one of the FDA-approved drugs for the
treatment of opioid dependence; except that this requirement is limited to a first request within a
twelve-month period.
(C) A health benefit plan subject to this subsection (5.5) must provide coverage for at
least one opiate antagonist, as defined in section 12-30-110 (7)(d).
(IV) In the event of a concurrent review for a claim for coverage of services for the
prevention of, screening for, and treatment of behavioral, mental health, and substance use
disorders, the service continues to be a covered service until the carrier notifies the covered
person of the determination on the claim.
(V) A carrier offering a health benefit plan subject to the requirements of this subsection
(5.5) shall:
(A) Comply with the nonquantitative treatment limitation requirements specified in 45
CFR 146.136 (c)(4), or any successor regulation, regarding any limitations that are not expressed
numerically but otherwise limit the scope or duration of benefits for treatment, which, in
addition to the limitations and examples listed in 45 CFR 146.136 (c)(4)(ii) and (c)(4)(iii), or any
successor regulation, and 78 FR 68246, include the methods by which the carrier establishes and
maintains its provider networks pursuant to section 10-16-704 and responds to deficiencies in the
ability of its networks to provide timely access to care;
(B) Comply with the financial requirements and quantitative treatment limitations
specified in 45 CFR 146.136 (c)(2) and (c)(3), or any successor regulation;
(C) Not apply any nonquantitative treatment limitations to benefits for behavioral,
mental health, and substance use disorders that are not applied to medical and surgical benefits
within the same classification of benefits;
(D) Establish procedures to authorize treatment with a nonparticipating provider if a
covered service is not available within established time and distance standards and within a
reasonable period after a service is requested, and with the same coinsurance, deductible, or
copayment requirements as would apply if the services were provided by a participating
provider, and at no greater cost to the covered person than if the services were obtained at or
from a participating provider; and
(E) If a covered person obtains a covered service from a nonparticipating provider
because the covered service is not available within established time and distance standards,
reimburse treatment or services for behavioral, mental health, or substance use disorders
required to be covered pursuant to this subsection (5.5) that are provided by a nonparticipating
provider using the same methodology the carrier uses to reimburse covered medical services
provided by nonparticipating providers and, upon request, provide evidence of the methodology
to the covered person or provider.
(b) The commissioner may adopt rules as necessary to ensure that this subsection (5.5) is
implemented and administered in compliance with federal law and shall adopt rules to establish
reasonable time periods for visits with a provider for treatment of a behavioral, mental health, or
substance use disorder after an initial visit with a provider.
(c) A carrier offering a managed care plan that does not cover services provided by an
out-of-network provider may provide that the benefits required by this subsection (5.5) are
covered benefits if the services are rendered by a provider who is designated by and affiliated
with the managed care plan only if the same requirement applies for services for a physical
illness.
(d) As used in this subsection (5.5), "behavioral, mental health, and substance use
disorder":
(I) Means a condition or disorder, regardless of etiology, that may be the result of a
combination of genetic and environmental factors and that falls under any of the diagnostic
categories listed in the mental disorders section of the most recent version of:
(A) The International Statistical Classification of Diseases and Related Health Problems;
(B) The Diagnostic and Statistical Manual of Mental Disorders; or
(C) The Diagnostic Classification of Mental Health and Developmental Disorders of
Infancy and Early Childhood; and
(II) Includes autism spectrum disorders, as defined in subsection (1.4)(a)(III) of this
section.
(6) Dependent children. (a) No entity subject to the provisions of this article or section
607 (1) of the federal "Employee Retirement Income Security Act of 1974", as amended, shall
refuse to accept and honor an otherwise valid claim for a covered benefit that is filed by either
parent of a covered child, or by the state department of human services in the case of an
assignment under section 26-13-106, C.R.S., who submits valid copies of medical bills. A claim
submitted by a custodial parent who is not the insured under a policy issued by an entity subject
to the provisions of this article or section 607 (1) of the federal "Employee Retirement Income
Security Act of 1974", as amended, shall be deemed a valid assignment of benefits for payment
to the health-care provider.
(b) An entity described in subsection (6)(a) of this section must not refuse to provide
coverage for a dependent child under the health plan of the child's parent for the sole reason that:
(I) The child does not live in the home of the parent applying for the policy; or
(II) The child does not live in the insurer's service area, notwithstanding any other
provision of law restricting enrollment to the persons who reside in an insurer's service area; or
(III) The child's parents were not married at the time of his or her birth; or
(IV) The child is not claimed as a dependent on the child's parent's federal or state
income tax return.
(c) When a dependent child is enrolled in a health insurance plan of a parent with whom
the child resides less than fifty percent of the time, the entity described in paragraph (a) of this
subsection (6) shall:
(I) Provide to the dependent child's parent with whom the child resides the majority of
the time information that is necessary for the dependent child to obtain medical benefits and
services;
(II) Allow the parent described in subparagraph (I) of this paragraph (c), the health-care
provider with such parent's approval, or the state to submit claims for covered services without
the approval of the other parent;
(III) Make payments directly to the parent described in subparagraph (I) of this
paragraph (c), the health-care provider, or the state medical assistance agency on claims
submitted pursuant to subparagraph (II) of this paragraph (c).
(d) Whenever a parent of a dependent child with whom the child resides less than fifty
percent of the time is subject to a court or an administrative order to provide health-care
coverage for the dependent child, and such parent is eligible for family health-care coverage
through the parent's employment, the entity described in paragraph (a) of this subsection (6)
shall:
(I) Permit such parent to enroll the dependent child under the family coverage plan,
regardless of any enrollment season restriction;
(II) Enroll the dependent child upon application for enrollment by the parent with whom
the child resides the majority of the time, the state medical assistance agency, or the state child
support enforcement agency or a delegate child support enforcement unit if the parent with
whom the child resides less than fifty percent of the time is enrolled in a family coverage plan
but fails to enroll the dependent child, regardless of any enrollment restrictions;
(III) Not cancel or revoke enrollment of the dependent child, or eliminate coverage for
the dependent child, unless the insurer is provided with satisfactory written proof that:
(A) The court or administrative order for health-care coverage is no longer in effect; or
(B) The child is or will be enrolled in a comparable plan through another insurer, which
enrollment takes effect no later than the effective date of the cancellation or revocation of
enrollment or the elimination of coverage.
(e) An entity described in paragraph (a) of this subsection (6) shall not impose on the
state medical assistance agency that is assigned the right to recover medical costs on behalf of a
medical assistance recipient any requirement that is not imposed on or applicable to other agents
or assignees.
(6.5) Adopted child - dependent coverage. (a) Whenever an entity described in
paragraph (a) of subsection (6) of this section offers coverage for dependent children under a
health plan, the entity shall provide benefits to a child placed for adoption with an enrollee,
policyholder, or subscriber under the same terms and conditions that apply to a natural
dependent of an enrollee, policyholder, or subscriber, regardless of whether adoption of the child
is final.
(b) An entity described in paragraph (a) of subsection (6) of this section shall not deny or
restrict coverage to an adopted child of an enrollee, policyholder, or subscriber or a child placed
for adoption with an enrollee, policyholder, or subscriber on the basis of a preexisting condition
if the child would otherwise be eligible for enrollment or coverage and the adoption or
placement occurs while the adoptive parent or parent with whom the child is placed is enrolled
in the plan.
(c) For the purposes of this subsection (6.5), unless the context otherwise requires:
(I) "Child" means a person who has not attained eighteen years of age.
(II) "Placed for adoption" means circumstances under which a person assumes or retains
a legal obligation to partially or totally support a child in anticipation of the child's adoption. A
placement terminates at the time such legal obligation terminates.
(6.7) Medical assistance recipients - denial of coverage - liability to state. (a) No
entity subject to the provisions of this article, article 8 of this title, or section 607 (1) of the
federal "Employee Retirement Income Security Act of 1974", as amended, shall refuse to enroll
a person for the sole reason that the person is a medical assistance recipient for whom coverage
is sought pursuant to section 25.5-4-210, C.R.S., or refuse to accept and honor an otherwise valid
claim for a covered benefit which is filed in the case of an assignment under the provisions of
articles 4, 5, and 6 of title 25.5, C.R.S.
(b) An entity subject to this subsection (6.7) that is liable as a third party for the medical
costs of a medical assistance recipient or that recovers or may recover medical costs from a third
party who is liable to a medical assistance recipient for medical costs is liable to the state
pursuant to section 25.5-4-301 (4), C.R.S.
(c) The state is deemed to have acquired the rights as an assignee of the medical
assistance recipient to any payment by a third party for medical costs.
(7) Repealed.
(8) Availability of hospice care coverage. (a) As used in this subsection (8), unless the
context otherwise requires:
(I) "Home health services" means home health services as defined in section 25.5-4-103
(7), C.R.S., which are provided by a home health agency certified by the department of public
health and environment.
(II) "Hospice care" means hospice services provided to a terminally ill individual by a
hospice care program, licensed and regulated by the department of public health and
environment pursuant to sections 25-1.5-103 (1)(a)(I) and 25-3-101, C.R.S., or by others under
arrangements made by such hospice care program.
(b) Notwithstanding any other provision of the law to the contrary, no individual or
group policy of sickness and accident insurance issued by an insurer subject to the provisions of
part 2 of this article and no plan issued by an entity subject to the provisions of part 3 of this
article which provides hospital, surgical, or major medical coverage on an expense incurred basis
shall be sold in this state unless a policyholder under such policy or plan is offered the
opportunity to purchase coverage for benefits for the costs of home health services and hospice
care which have been recommended by a physician as medically necessary. Nothing in this
paragraph (b) shall require an insurer to offer coverages for which premiums would not cover
expected benefits. This paragraph (b) shall not apply to any insurance policy, plan, contract, or
certificate which provides coverage exclusively for disability loss of income, dental services,
optical services, hospital confinement indemnity, accident only, or prescription drug services.
(c) The insurer or entity may adopt standards and criteria for eligibility to be applied to
home health services programs and hospice care programs consistent with standards established
in rules and regulations of the department of public health and environment.
(d) The commissioner, in consultation with the department of public health and
environment, may establish by rule and regulation requirements for standard policy and plan
provisions which state clearly and completely the criteria for and extent of insured coverage for
home health services and hospice care. Such provisions shall be designed to facilitate prompt
and informed decisions regarding patient placement and discharge.
(9) Repealed.
(10) Prostate cancer screening. (a) All individual and all group sickness and accident
insurance policies, except supplemental policies covering a specified disease or other limited
benefit, which are delivered or issued for delivery within the state by an entity subject to the
provisions of part 2 of this article and all individual and group health-care service or indemnity
contracts issued by an entity subject to the provisions of part 3 or 4 of this article, as well as any
other group health-care coverage offered to residents of this state, shall provide coverage for
annual screening for the early detection of prostate cancer in men over the age of fifty years and
in men over the age of forty years who are in high-risk categories, which coverage by entities
subject to part 2 or 3 of this article shall not be subject to policy deductibles. Such coverage shall
be the lesser of sixty-five dollars per prostate cancer screening or the actual charge for such
screening. Such benefit shall in no way diminish or limit diagnostic benefits otherwise allowable
under a policy. This coverage shall be provided according to the following guidelines:
(I) The screening shall be performed by a qualified medical professional, including
without limitation a urologist, internist, general practitioner, doctor of osteopathy, nurse
practitioner, or physician assistant.
(II) The screening shall consist, at a minimum, of the following tests:
(A) A prostate-specific antigen ("PSA") blood test;
(B) Digital rectal examination.
(III) At least one screening per year shall be covered for any man fifty years of age or
older.
(IV) At least one screening per year shall be covered for any man from forty to fifty
years of age who is at increased risk of developing prostate cancer as determined by the man's
physician for an entity subject to part 2 or 3 of this article, or as determined by a participating
physician for an entity subject to part 4 of this article.
(b) The requirements of this subsection (10) shall apply to all individual sickness and
accident insurance policies and health-care service or indemnity contracts issued on or after
January 1, 1996, and to all group accident and sickness policies and group health-care service or
indemnity contracts issued, renewed, or reinstated on or after January 1, 1996.
(c) For purposes of this subsection (10), "sickness and accident insurance policy" does
not include short-term, accident, fixed indemnity, specified disease policies or disability income
contracts, and limited benefit or credit disability insurance, or such other insurance as defined in
section 10-18-101 (3) or by the commissioner. The term also does not include insurance arising
out of the "Workers' Compensation Act of Colorado", articles 40 to 47 of title 8, C.R.S., or other
similar law, automobile medical payment insurance, or insurance under which benefits are
payable with or without regard to fault and which is required by law to be contained in any
liability insurance policy or equivalent self-insurance.
(d) The health-care service plan issued by an entity subject to the provisions of part 4 of
this article may provide that the benefits provided pursuant to this subsection (10) shall be
covered benefits only if the services are rendered by a provider who is designated by and
affiliated with the health maintenance organization.
(11) Repealed.
(12) Hospitalization and general anesthesia for dental procedures for dependent
children. (a) All individual and all group sickness and accident insurance policies that are
delivered or issued for delivery within the state by an entity subject to part 2 of this article and
all individual and group heaExcerpt shown. Open the full section in Lexace.
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