Colorado medical-plan questions test the national plan designs (HMO, PPO, EPO, POS, indemnity, HSAs and FSAs, all covered in the shared guide) plus a layer of Colorado statutes in C.R.S. Title 10, Article 16. This page covers the Colorado layer: the marketplace, renewability and termination rules, mandated benefits, cost-sharing caps, prompt-pay deadlines and appeals.

Connect for Health Colorado and essential health benefits

• Connect for Health Colorado is the state's health insurance marketplace. The General Assembly created it in 2011 as a public, nonprofit entity for individuals and small employers (C.R.S. 10-22-104).
• Individual and small-group plans (other than grandfathered plans) must include the essential health benefits package (10-16-103.4(1)).
• Metal levels by actuarial value: bronze 60%, silver 70%, gold 80%, platinum 90% (10-16-103.4(2)).
• Premiums may not vary by any health-status-related factor (10-16-105.6(1)).
• Child-only plans must be offered on a guaranteed-issue basis to applicants under 21 during open enrollment (10-16-105(1)(a)(II)).
• Special enrollment: 60 days after a triggering event (Reg. 4-2-43). Since January 1, 2024, a provider's certification of pregnancy is a triggering event for someone without creditable coverage (10-16-105.7(3)(a)(II)(H)).

Renewal, grace and termination

• Guaranteed renewability: plans renew at the policyholder's option. A carrier may refuse only for listed reasons such as nonpayment or fraud or intentional misrepresentation (10-16-105.1).
• Discontinuing a product: at least 90 days' notice, plus an offer of the carrier's other plans. Leaving the market entirely: 180 days' notice.
• Grace periods (10-16-140): three months for enrollees receiving a federal premium subsidy, and 31 days for everyone else.
• Termination (10-16-222): no retroactive termination except for fraud or intentional misrepresentation. Other terminations require 30 days' advance notice.

Colorado mandated benefits

• Newborns are covered from the moment of birth. The policy may require notice of the birth and payment of any added premium within 31 days (10-16-104(1)).
• Adopted children are covered from placement, on the same terms as natural children, whether or not the adoption is final (10-16-104(6.5)).
• A dependent child can't be refused coverage just because the child doesn't live with the parent who is applying (10-16-104(6)(b)).
• Maternity: complications of pregnancy are covered like any other illness. Group policies may not exclude pregnancy as preexisting. The hospital stay may not be limited to under 48 hours after a vaginal delivery or 96 hours after a cesarean, unless provider and mother agree to an earlier discharge (10-16-104(2), (3)).
• Diabetes: equipment, supplies and self-management training are covered (10-16-104(13)).
• Prostate screening: annually for men over 50, and over 40 if high risk. The deductible does not apply (10-16-104(10)).
• Home health and hospice: must be offered to the policyholder (10-16-104(8)(b)).
• Insulin: cost-sharing is capped at $100 for a 30-day supply of all covered insulin combined (10-16-151(2)).
• Recreational activities: a claim can't be excluded solely because the injury came from casual, nonprofessional motorcycling, snowmobiling, off-highway riding, skiing or snowboarding (10-3-1104(1)(h)(XVI)).

Claims, prompt pay and appeals

• Clean claims: resolve within 30 calendar days if filed electronically, or 45 days if filed on paper. All other claims: pay, deny or settle within 90 days (10-16-106.5(4)).
• Late payment: 10% annual interest on the amount finally allowed. From the 91st day, a 20% penalty applies (10-16-106.5(5)).
• Utilization review: decide urgent requests within 72 hours (10-16-113).
• Appeals: a denial goes through internal review, with an optional voluntary second level, then external review. External review must be requested within four months of the final internal denial (10-16-113, 10-16-113.5).
• Carriers provide the federal summary of benefits and coverage. The commissioner may require a supplemental plan description (10-16-108.5(11)).

Fair marketing and producer pay

• Carriers and producers may not steer individuals or small employers away from applying because of health status, claims experience, industry, occupation or location (10-16-108.5(2)).
• Producer commissions can't vary on those factors. A uniform percentage of premium is allowed.
• Denials must be in writing with the reason. A violation is an unfair practice.
• Commission disclosure: producers disclose their commission and standard compensation schedule when the sale is finalized (10-16-133(5)(a), Reg. 1-2-17). The rule excludes Medicare Advantage, Part D, travel, disability income, credit and LTC.
• A producer may charge an advice fee only if taking no commission and disclosing the fee in writing (10-16-133(5)(b)).

Exam traps

• Grace period: three months for subsidized marketplace enrollees, 31 days otherwise. Don't mix them up.
• Notice periods: 90 days to discontinue one product, 180 days to leave the market, 30 days for other terminations.
• Prompt pay: 30 days electronic, 45 days paper, 90 days non-clean. 10% interest, 20% penalty from day 91.
• Insulin cap: $100 per 30 days covers all insulin combined, not each prescription.