3 Colo. Code Regs. § 702-2-1-9-3

Current through Register Vol. 47, No. 7, April 10, 2024

Section 3 CCR 702-2-1-9-3 - Definitions

A. "Capitation" means, for the purpose of this regulation, an arrangement whereby the amount of money paid to the provider network is based upon the agreement to provide certain health care services to covered persons, and does not vary on the basis of the number or type of services actually rendered.

B. "Carrier" shall have the same meaning as found at § 10-16-102(8) C.R.S.

C. "Covered person" shall have the same meaning as found at § 10-16-102(15), C.R.S.

D. "Employee assistance program" shall mean, for the purpose of this regulation, a worksite-focused program designed to assist:

1. Work organizations in addressing productivity issues; and

2. Employee clients in identifying and resolving personal concerns (including, but not limited to health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal issues that may affect job performance.

E. "Health care coverage plan" shall have the same meaning as found at § 10-16-102(34), C.R.S.

F. "Home health care services" shall mean, for the purpose of this regulation, the following services when provided to a covered person in his/her place of residence:

1. Skilled nursing services; home health aide services;

2. Provision of medical supplies, equipment, and appliances suitable for use in the home; and

3. Physical therapy, speech and hearing therapy, or occupational therapy.

G. "Incidental services" means, for the purpose of this regulation, fees only for x-rays, laboratory services, medications, and other services as approved by the commissioner.

H. "Inpatient hospital services" means, for the purpose of this regulation, services provided by a licensed hospital to anyone requiring twenty-four (24) hours or more of continuous care in the facility.

I. "Limited service licensed provider network" or "LSLPN" means, for the purpose of this regulation, a provider network that offers to contract directly with a consumer(s) (e.g., individual, group, employer, etc.) or their representative(s), to provide health care services restricted to:

1. A narrowly defined health specialty (e.g., substance abuse, radiology, mental health, pediatrics, pharmacology, etc.), or

2. Services narrowly limited to a single type of licensed health facility (e.g., inpatient hospital, birth center, long term care facility, hospice, etc.), or

3. Home health care services delivered in the covered person's residence only.

J. "Limited service licensed provider network health coverage plan" or "LSLPN health coverage plan" means, for the purpose of this regulation, a contract, policy, certificate, or agreement entered into or issued by an LSLPN that agrees to assume the risk for specific, limited health care expenses and/or provide delivery of such services.

K. "Producer" shall have the same meaning as found at § 10-2-103(6), C.R.S.

L. "Provider network" shall have the same meaning as found at § 6-18-301.5(3), C.R.S.

M. "Risk assumption" or "risk sharing" means, for the purpose of this regulation, a transaction whereby the chance of loss, including the expenses for the delivery of service, with respect to the health care of a person, is transferred to or shared with another entity (e.g., carrier, including an LSLPN), in return for a consideration. Examples include but are not limited to, full or partial capitation agreements, withholds, risk corridors, and indemnity agreements. For the purposes of this regulation, fee-for-service, per diem payments, diagnostic-related group payment agreements, and employee assistance programs (EAPS) are not considered to be risk assumption or risk sharing arrangements.

N. "Risk based capital" or "RBC" is a formula which quantifies the assets, liabilities, size and risk profile of a regulated entity in order to determine the minimum amount of capital and surplus required to be maintained by a company. The RBC formula provides an elastic means of setting the capital and surplus requirement, in which the degree of risk taken by the entity is the primary determinant.

3 CCR 702-2-1-9-3

38 CR 03, February 10, 2015, effective 3/15/2015

39 CR 01, January 10, 2016, effective 2/1/2016

39 CR 22, November 25, 2016, effective 1/1/2017

39 CR 23, December 10, 2016, effective 1/1/2017

40 CR 05, March 10, 2017, effective 4/1/2017

40 CR 09, May 10, 2017, effective 6/1/2017

40 CR 17, September 10, 2017, effective 10/1/2017

45 CR 09, May 10, 2022, effective 5/30/2022

46 CR 04, February 25, 2023, effective 3/17/2023