As used in this part 13, unless the context otherwise requires:
(1) Advisory board means the board established in section 10-16-1307.
(2) Critical access hospital means a hospital that is federally certified or undergoing federal certification as a critical access hospital pursuant to 42 CFR 485, subpart F.
(3) (a) Equivalent rate means, for a hospital that is part of a pediatric specialty hospital system where over ninety percent of the hospital system's population served is under eighteen years of age and that has a level one pediatric trauma center, the payment rate determined by the medicaid fee schedule for the hospital from the most recent year for which a complete set of hospital financial data is publicly available as of May 10, 2023, multiplied by a conversion factor equal to the ratio of the statewide payment-to-cost ratio for medicare to the hospital's specific payment-to-cost ratio for the most recent set of publicly available hospital financial data as of May 10, 2023, which is 1.52.
(b) In any given year, the rate in subsection (3)(a) of this section must be adjusted annually for cumulative inflation by a factor equal to the average percentage increase in the medicare inpatient and outpatient prospective payment systems over the previous three years.
(c) For any health-care service without an existing medicare reimbursement rate and for services that have low volume statewide relative to other medicare services, including pediatric or obstetric services, an equivalent rate means a rate set by rule of the commissioner after consultation with a statewide association of hospitals, physicians, other providers, and the department of health care policy and financing. The equivalent rate must utilize the ratio of medicaid payment rates to existing medicare payment rates whenever possible.
(4) Essential access hospital means a critical access hospital or general hospital located in a rural area with twenty-five or fewer licensed beds.
(5) Essential community provider has the same meaning as set forth in section 25.5-8-103 (6).
(6) General hospital means a hospital licensed as a general hospital by the Colorado department of public health and environment.
(7) Health-care coverage cooperative has the same meaning as set forth in section 10-16-1002 (2).
(8) Health-care provider means a health-care professional registered, certified, or licensed pursuant to title 12 or a health facility licensed or certified pursuant to section 25-1.5-103.
(9) Health system means a corporation or other organization that owns, contains, or operates three or more hospitals.
(10) Medical inflation means the annual percentage change in the medical care index component of the United States department of labor's bureau of labor statistics consumer price index for medical care services and medical care commodities for the Denver-Aurora-Lakewood area, or its applicable predecessor or successor index, based on the average change in the medical care index over the previous three years.
(11) (a) Medicare reimbursement rate means the facility-specific reimbursement rate for a particular health-care service provided under the Health Insurance for the Aged Act, Title XVIII of the federal Social Security Act, 42 U.S.C. sec. 1395 et seq., as amended.
(b) For a hospital that is reimbursed through the medicare prospective payments systems rate for a critical access hospital, medicare reimbursement rate means the rate based on allowable costs as reported in medicare cost reports and the historical cost-to-charge ratios for the specific hospital.
(12) Public benefit corporation means a public benefit corporation formed pursuant to part 5 of article 101 of title 7 that may be organized and operated by the exchange pursuant to section 10-22-106 (3).
(13) Small group market means the market for small group sickness and accident insurance.
(14) Standardized plan means the standardized health benefit plan designed by rule of the commissioner pursuant to section 10-16-1304.
Source: L. 2021: Entire part added, (HB 21-1232), ch. 241, p. 1279, � 1, effective June 16. L. 2023: (3)(a) and (10) amended, (HB 23-1224), ch. 159, p. 689, � 1, effective May 10.
10-16-1304. Standardized health benefit plan - established - components - rules - independent analysis - repeal. (1) On or before January 1, 2022, the commissioner shall establish, by rule, a standardized health benefit plan to be offered by carriers in this state in the individual and small group markets. The standardized plan must:
(a) Offer health-care coverage at the bronze, silver, and gold levels of coverage as described in section 10-16-103.4;
(b) Include, at a minimum, pediatric and other essential health benefits;
(c) Be offered through the exchange and in the individual market through the public benefit corporation;
(d) Be a standardized benefit design that:
(I) Is created through a stakeholder engagement process that includes physicians, health-care industry and consumer representatives, individuals who represent health-care workers or who work in health care, and individuals working in or representing communities that are diverse with regard to race, ethnicity, immigration status, age, ability, sexual orientation, gender identity, or geographic regions of the state and that are affected by higher rates of health disparities and inequities;
(II) Has a defined benefit design and cost-sharing that improves access and affordability; and
(III) Is designed to improve racial health equity and decrease racial health disparities through a variety of means, which are identified collaboratively with consumer stakeholders, including:
(A) Improving perinatal health-care coverage; and
(B) Providing first-dollar, predeductible coverage for certain high-value services, such as primary and behavioral health care;
(e) Be actuarially sound and allow a carrier to continue to meet the financial requirements in article 3 of this title 10;
(f) Comply with the federal act, including the risk adjustment requirements under 45 CFR 153, and this article 16; and
(g) Have a network that is:
(I) Culturally responsive and, to the greatest extent possible, reflects the diversity of its enrollees in terms of race, ethnicity, gender identity, and sexual orientation in the area that the network exists; and
(II) No more narrow than the most restrictive network the carrier is offering for nonstandardized plans in the individual market for the metal tier for that rating area.
(2) (a) In developing the network for the standardized plan pursuant to subsection (1)(g) of this section, each carrier shall:
(I) Include as part of its network access plan a description of the carrier's efforts to construct diverse, culturally responsive networks that are well-positioned to address health equity and reduce health disparities; and
(II) Include a majority of the essential community providers in the service area in its network.
(b) If a carrier is unable to achieve the network adequacy requirements in subsection (1)(g) of this section, the carrier shall file an action plan with the division that describes the carrier's efforts to achieve the requirements in subsection (1)(g) of this section.
(c) The commissioner shall promulgate rules regarding the network adequacy requirements in subsection (1)(g) of this section and the action plan in subsection (2)(b) of this section.
(3) (a) The standardized plan must be offered in a manner that allows consumers to easily compare the standardized plans offered by each carrier.
(b) The exchange, in collaboration with the commissioner and after a stakeholder engagement process with consumers, producers, and carriers, shall develop a format for displaying the standardized plans on the exchange in a manner that allows for standardized plans to be easily identified and compared.
(4) The commissioner may update the standardized plan annually by rule through the stakeholder process described in subsection (1)(d)(I) of this section.
(5) The commissioner shall contract with an independent third party to conduct an analysis of the impact of this section on health plan enrollment, health insurance affordability, and health equity. To the extent available, the analysis must include disaggregated data by race, ethnicity, immigration status, sexual orientation, gender identity, age, and ability. If the data is not available, the analysis must note such unavailability. The analysis must include information concerning total out-of-pocket health-care spending. The analysis must be completed on or before January 1, 2026.
(6) (a) The commissioner shall collaborate with the exchange concerning the survey required in section 10-22-114, which survey addresses consumers' experience.
(b) This subsection (6) is repealed, effective July 1, 2026.
(7) The commissioner is not required to comply with the Procurement Code, articles 101 to 112 of title 24, for the purposes of this section.
Source: L. 2021: Entire part added, (HB 21-1232), ch. 241, p. 1281, � 1, effective June 16. L. 2023: (3) amended, (HB 23-1224), ch. 159, p. 690, � 2, effective May 10.
10-16-1305. Standardized health benefit plan - carriers required to offer - premium rates - rules. (1) Beginning January 1, 2023, a carrier that offers:
(a) An individual health benefit plan in Colorado is required to offer the standardized plan in the individual market in each county where the carrier offers an individual health benefit plan and shall offer the standardized plan throughout the entire county; and
(b) A small group health benefit plan in Colorado is required to offer the standardized plan in the small group market in each county where the carrier offers a small group health benefit plan and shall offer the standardized plan throughout the entire county.
(2) (a) (I) In the individual market, for the plan year beginning January 1, 2023, and in the small group market, beginning January 1, 2023, each carrier shall offer the standardized plan at a premium rate that is at least five percent less than the premium rate for health benefit plans that the carrier offered in the 2021 calendar year, as adjusted for medical inflation, in the individual and small group markets. The commissioner shall calculate the premium rate reduction based on the rates charged in the same county in which the carrier offered health benefit plans in the individual and small group markets in 2021 prior to the application of the Colorado reinsurance program pursuant to part 11 of this article 16.
(II) For carriers offering the standardized plan in the 2023 plan year in a county in which the carrier did not offer a health benefit plan in the individual or small group market in the 2021 calendar year, each carrier that offers the standardized plan shall offer the standardized plan:
(A) In the individual market at a premium rate that is at least five percent less than the average premium rate for individual health benefit plans offered in that county in 2021, calculated based on the average premium rate for individual health benefit plans offered in that county, as adjusted for medical inflation, prior to the application of the Colorado reinsurance program pursuant to part 11 of this article 16; and
(B) In the small group market at a premium rate that is at least five percent less than the average premium rate for small group plans offered in that county in 2021, as adjusted for medical inflation.
(b) (I) In the individual market, for the plan year beginning January 1, 2024, and in the small group market, beginning January 1, 2024, each carrier shall offer the standardized plan at a premium rate that is at least ten percent less than the premium rate for health benefit plans that the carrier offered in the 2021 calendar year, as adjusted for medical inflation, in the individual and small group markets. The commissioner shall calculate the premium rate reduction based on the rates charged in the same county in which the carrier offered health benefit plans in the individual and small group markets in 2021 prior to the application of the Colorado reinsurance program pursuant to part 11 of this article 16.
(II) For carriers offering the standardized plan in the 2024 plan year in a county in which the carrier did not offer a health benefit plan in the individual or small group market in the 2021 calendar year, each carrier that offers the standardized plan shall offer the standardized plan:
(A) In the individual market at a premium rate that is at least ten percent less than the average premium rate for individual plans offered in that county in 2021, calculated based on the average premium rate for individual plans offered in that county, as adjusted for medical inflation, prior to the application of the Colorado reinsurance program pursuant to part 11 of this article 16; and
(B) In the small group market at a premium rate that is at least ten percent less than the average premium rate for small group plans offered in that county in 2021, as adjusted for medical inflation.
(c) (I) In the individual market, for the plan year beginning January 1, 2025, and in the small group market, beginning January 1, 2025, each carrier shall offer the standardized plan at a premium rate that is at least fifteen percent less than the premium rate for health benefit plans that the carrier offered in the 2021 calendar year, as adjusted for medical inflation, in the individual and small group markets. The commissioner shall calculate the premium rate reduction based on the rates charged in the same county in which the carrier offered health benefit plans in the individual and small group markets in 2021 prior to the application of the Colorado reinsurance program pursuant to part 11 of this article 16.
(II) For carriers offering the standardized plan in the 2025 plan year in a county in which the carrier did not offer a health benefit plan in the individual or small group market in the 2021 calendar year, each carrier that offers the standardized plan shall offer the standardized plan:
(A) In the individual market at a premium rate that is at least fifteen percent less than the average premium rate for individual plans offered in that county in 2021, calculated based on the average premium rate for individual plans offered in that county, as adjusted for medical inflation, prior to the application of the Colorado reinsurance program pursuant to part 11 of this article 16; and
(B) In the small group market at a premium rate that is at least fifteen percent less than the average premium rate for small group plans offered in that county in 2021, as adjusted for medical inflation.
(d) For the plan year beginning on or after January 1, 2026, and each year thereafter, each carrier and health-care coverage cooperative shall limit any annual percentage increase in the premium rate for the standardized plan in both the individual and small group markets to a rate that is no more than medical inflation, relative to the previous year.
(3) The premium rate requirements in subsections (2)(a), (2)(b), and (2)(c) of this section for the standardized plan offered in the individual and small group markets must account for policy adjustments adopted consistent with the requirements in section 10-16-107 (8) to prevent people with low and moderate incomes from experiencing net increases in premium costs, such as adopting the induced demand factors utilized as part of the federal risk adjustment program under 42 U.S.C. sec. 18063.
(4) The commissions paid to insurance producers for the sale of the standardized plan must be comparable to the average commissions paid for the sale of other plans offered in the individual and small group markets.
Source: L. 2021: Entire part added, (HB 21-1232), ch. 241, p. 1283, � 1, effective June 16.