(1) A carrier offering an individual or group health benefit plan shall not require any individual, as a condition of enrollment or continued enrollment under the plan, to pay a premium or, for group plans, a contribution that is greater than the premium or contribution for a similarly situated individual enrolled in the plan on the basis of any health-status-related factor in relation to the individual or to an individual enrolled under the plan as a dependent of the individual.
(2) The prohibition in subsection (1) of this section does not:
(a) Restrict the amount that a carrier may charge an employer for coverage under a group health benefit plan; or
(b) Prevent a carrier from establishing premium discounts or rebates or modifying otherwise applicable copayments, coinsurance, or deductibles in return for adherence to programs of health promotion and disease prevention if otherwise allowed by state or federal law.
(3) Repealed.
(4) A small employer carrier may impose a premium surcharge of up to thirty-five percent above the modified community rate on a small employer group whose small group insurance has been discontinued because of nonpayment of premiums or fraud. The small employer carrier may impose the premium surcharge when the small business group reapplies for coverage in the small group market. A small employer carrier may require the increased premium to apply to the small business group for up to twelve months.
Source: L. 2013: Entire section added with relocations, (HB 13-1266), ch. 217, p. 934, � 9, effective May 13. L. 2016: (2)(b) amended, (SB 16-189), ch. 210, p. 756, � 14, effective June 6. L. 2017: (3) repealed, (SB 17-249), ch. 283, p. 1549, � 19, effective June 1.
Editor's note: Subsections (1) and (2) are similar to former � 10-16-107 (6); subsections (3)(a), (3)(b), and (3)(c) are similar to former � 10-16-105 (13)(a); subsection (3)(d) is similar to former � 10-16-105 (13)(d); and subsection (4) is similar to former � 10-16-105 (14)(a), as those sections existed prior to 2013.
10-16-105.7. Health benefit plan open enrollment periods - special enrollment periods - rules. (1) (a) A carrier offering an individual health benefit plan in this state shall permit an individual to purchase an individual health benefit plan during the initial and annual open enrollment periods.
(b) The initial open enrollment period begins October 1, 2013, and extends through March 31, 2014.
(c) For benefit years beginning on or after January 1, 2015, the annual open enrollment period begins October 15 and extends through December 7 of the preceding calendar year.
(d) For purposes of this subsection (1), the benefit year for health benefit plans purchased during the initial and annual enrollment periods is a calendar year.
(e) The commissioner shall establish rules in accordance with federal law for the implementation of this subsection (1).
(2) (a) A carrier offering a group health benefit plan in this state shall permit an employer to purchase a group health benefit plan at any point during the year.
(b) In the case of health benefit plans offered in the small group market, a carrier may decline to offer coverage to a small employer that is unable to comply with a material plan provision relating to employer contribution or group participation rules, as required by section 10-16-105 (3)(b), and that carrier may limit the availability of coverage for a group it has declined to an enrollment period that begins November 15 and ends December 15 of each year or begins and ends on dates set by the commissioner by rule.
(c) The coverage is effective consistent with the dates determined by the commissioner by rule.
(3) (a) (I) A carrier offering an individual health benefit plan in this state shall establish special enrollment periods during which an individual for whom a triggering event has occurred may enroll in an individual health benefit plan offered by the carrier.
(II) A triggering event occurs when:
(A) An individual involuntarily loses existing creditable coverage for any reason other than fraud, misrepresentation, or failure to pay a premium;
(B) An individual gains a dependent or becomes a dependent through marriage, civil union, birth, adoption, or placement for adoption or by entering into a designated beneficiary agreement pursuant to article 22 of title 15, C.R.S.;
(C) An individual's enrollment or nonenrollment in a health benefit plan is unintentional, inadvertent, or erroneous and is the result of an error, misrepresentation, or inaction of the carrier, producer, or exchange established pursuant to article 22 of this title;
(D) An individual adequately demonstrates to the commissioner that the health benefit plan in which the individual is enrolled has substantially violated a material provision of its contract in relation to the individual;
(E) The exchange established pursuant to article 22 of this title determines an individual to be newly eligible or newly ineligible for the federal advance payment tax credit or cost-sharing reductions available through the exchange pursuant to federal law;
(F) An individual gains access to other creditable coverage as a result of a permanent change of residence;
(F.5) An uninsured individual was included in the calculation of family size as defined in the federal Internal Revenue Code of 1986, 26 U.S.C. sec. 36B (d)(1), as amended, by a tax filer who filed an income tax return for the prior calendar year by the April 15 tax deadline, and the exchange notifies the individual based on information provided through the Colorado affordable health care coverage easy enrollment program created in section 10-22-113 that the individual qualifies for a subsidized health benefit plan;
(G) Any other event or circumstance occurs as set forth in rules of the commissioner defining triggering events; or
(H) Beginning January 1, 2024, an individual who does not have existing creditable coverage receives certification from a health-care provider acting within the provider's scope of practice that the individual is pregnant. Coverage is deemed effective as of the first month in which the individual receives certification of the pregnancy, unless the individual elects to have coverage effective on the first day of the month following the date that the individual makes a plan selection. Any person or entity enrolling an individual in coverage pursuant to this special enrollment period shall provide a notice, developed by the department through a stakeholder process, to the individual regarding the individual's option to begin coverage either prospectively or retroactively and the financial and tax implications of those options. The notice must be in, at a minimum, English and Spanish.
(III) For the purposes of subsection (3)(a)(II)(F.5) of this section, a carrier is not required to further verify that an individual is eligible for a special enrollment period.
(b) (I) A carrier offering a group health benefit plan in this state shall establish special enrollment periods during which an individual for whom a qualifying event has occurred may enroll in a group health benefit plan offered by the carrier.
(II) A qualifying event occurs when:
(A) An individual loses coverage under a health benefit plan due to the death of a covered employee; the termination or reduction in number of hours of the covered employee's employment; or the covered employee becoming eligible for benefits under Title XVIII of the federal Social Security Act, as amended;
(B) An individual loses coverage under a health benefit plan due to the divorce or legal separation of the covered employee from the covered employee's spouse or partner in a civil union;
(C) An individual becomes a dependent of a covered person through marriage, civil union, birth, adoption, or placement for adoption, by entering into a designated beneficiary agreement pursuant to article 22 of title 15, C.R.S., or pursuant to a court or administrative order mandating that the individual be covered;
(D) An individual loses other creditable coverage due to the termination of his or her employment or eligibility for the coverage; reduction in number of hours of employment; involuntary termination of coverage; or reduction or elimination of his or her employer's contributions toward the coverage;
(E) An individual loses eligibility under the Colorado Medical Assistance Act, articles 4 to 6 of title 25.5, C.R.S., or the children's basic health plan, article 8 of title 25.5, C.R.S.; or
(F) Any other event or circumstance occurs as set forth in rules of the commissioner defining qualifying events.
(c) The commissioner shall adopt rules in accordance with federal law for the implementation of this section. The commissioner may adopt rules to allow individuals enrolled in a health benefit plan through an exchange established under article 22 of this title to enroll in or change from one health benefit plan to another under circumstances specified in the rules.
Source: L. 2013: Entire section added, (HB 13-1266), ch. 217, p. 936, � 10, effective May 13. L. 2020: (3)(a)(II)(F) amended and (3)(a)(II)(F.5) and (3)(a)(III) added, (HB 20-1236), ch. 236, p. 1143, � 1, effective September 14. L. 2022: (3)(a)(II)(H) added, (HB 22-1289), ch. 399, p. 2835, � 4, effective June 7.
Cross references: For the legislative declaration in HB 22-1289, see section 1 of chapter 399, Session Laws of Colorado 2022.
10-16-105.9. Health benefit plan - carrier insolvency - covered persons - deductible amounts - rules - definition. (1) As used in this section:
(a) Out-of-pocket expenses means expenses paid toward a health benefit plan:
(I) Deductible for medical services and prescription drugs that were credited under the covered person's health benefit plan; and
(II) Out-of-pocket maximum for medical services and prescription drugs that were credited under the person's health benefit plan, including any coinsurance amounts.
(b) Out-of-pocket expenses does not include premium payments made for a health benefit plan.
(2) For individual health benefit plans, if a covered person has paid any out-of-pocket expenses for services covered by a health benefit plan in a given plan year, and the carrier that provides the health benefit plan to the covered person exits the health insurance market and can no longer provide health insurance benefits to that person during the same plan year, a carrier of a new health benefit plan that covers the person during the same plan year shall credit all of the out-of-pocket expenses paid by the covered person to the new health benefit plan.
(3) If a covered person's out-of-pocket expenses credited to the new health benefit plan in accordance with subsection (2) of this section for coverage under the original health benefit plan are greater than the amount of out-of-pocket expenses required by the new health benefit plan, the new carrier is not required to apply the amount in excess to the new health benefit plan.
(4) The commissioner shall promulgate rules to implement this section that include protocols for each carrier to follow when crediting out-of-pocket expenses paid by a covered person to a new health benefit plan and protocols for the division to follow to ensure that the necessary data to determine the amount of the out-of-pocket expenses credit for each new member is delivered to each carrier in a timely and accurate manner by the commissioner. The commissioner shall collect the necessary data from the carriers for the division's determination of the amount of the out-of-pocket expense credits. The protocols must be based on the out-of-pocket maximum amounts, as described in section 10-16-161, from the division. The commissioner shall consult with the exchange to develop the protocols.
(5) The new health benefit plan is required only to credit out-of-pocket expenses toward the deductible and the out-of-pocket maximum, which are reported by the previous health benefit plan, the health benefit plan's conservatorship, or the division in a time and manner determined by the commissioner.
(6) (a) The new carrier may file a claim for the amount of the credited out-of-pocket expenses as a result of this section with the estate of the original health benefit plan carrier.
(b) (I) A carrier may recoup, over a reasonable length of time, a sum equal to the amount of out-of-pocket expenses credited to covered persons, in accordance with this section. The amount must be reasonably calculated to recoup these expenses and is subject to review by the commissioner. An amount recouped is not considered a premium for any other purpose, including the computations of gross premium tax or an agent's commission.
(II) A carrier that imposes a surcharge to recoup the amount of out-of-pocket expenses credited pursuant to this section must include the amount of the surcharge as part of the carrier's rate filing pursuant to section 10-16-107 (1). The carrier must show the surcharge in the rate filing as a separate component of the rate and shall include supporting documentation.
(7) A carrier shall not file a claim for the amount of the increase in claims liability due to this section with the estate of the original health benefit plan if the carrier has recouped costs for out-of-pocket expenses credited to covered persons in accordance with subsection (6)(b) of this section.
(8) Subject to approval by the commissioner, a carrier is not required to credit all of the out-of-pocket expenses paid by the covered person to the new health benefit plan in accordance with subsection (2) of this section if doing so would cause the carrier to become insolvent.
Source: L. 2024: Entire section added, (HB 24-1258), ch. 335, p. 2272, � 1, effective January 1, 2025.