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Colorado Administrative Code
Department 700 - Department of Regulatory AgenciesDivision 702 - Division of InsuranceRule 3 CCR 702-4 - LIFE, ACCIDENT AND HEALTHSection 3 CCR 702-4 Series 4-2 - LIFE, ACCIDENT AND HEALTH, Series 4-2 Accident and Health (General)
Regulation Regulation 4-2-42 - CONCERNING ESSENTIAL HEALTH BENEFITS
Section 3 CCR 702-4-2-42-5 - Essential Health Benefits

3 Colo. Code Regs. § 702-4-2-42-5

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Current through Register Vol. 47, No. 24, December 25, 2024
Section 3 CCR 702-4-2-42-5 - Essential Health Benefits
A. Carriers offering non-grandfathered individual and small group health benefit plans inside or outside of the Exchange must include the essential health benefits package.
1. Carriers must provide benefits that are substantially equal to Colorado's EHB-benchmark plan in the following thirteen (13) categories:
a. Ambulatory patient services, which must include, at a minimum:
(1) Primary care to treat an illness or injury;
(2) Specialist visits;
(3) Outpatient surgery;
(4) Chemotherapy services;
(5) Radiation therapy;
(6) Home infusion therapy;
(7) Home health care;
(8) Outpatient diagnostic laboratory, x-ray, and pathology services;
(9) Sterilization;
(10) Treatment of cleft palate and cleft lip conditions; and
(11) Oral anti-cancer medications.
b. Emergency services, which must include, at a minimum:
(1) Emergency room - facility and professional services;
(2) Ambulance services; and
(3) Urgent care treatment services.
c. Hospitalization services, which must include:
(1) Inpatient medical and surgical care;
(2) Organ and tissue transplants (transplants may be limited to specified organs);
(3) Chemotherapy services;
(4) Radiation services;
(5) Anesthesia services; and
(6) Hospice care.
d. Laboratory and radiology services, which must include:
(1) Laboratory tests, x-ray, and pathology services; and
(2) Imaging and diagnostics, such as MRIs, CT scans, and PET scans.
e. Maternity and newborn care services, including state and federally required benefits for hospital stays in connection with childbirth, which must include:
(1) Pre-natal and postnatal care;
(2) Delivery and inpatient maternity services; and
(3) Newborn well child care.
f. Behavioral health, mental health, and substance use disorder treatment services, which are provided in a manner no less extensive than the coverage provided for any physical illness, pursuant to § 10-16-104 (5.5), C.R.S.
g. Pediatric services, which must include:
(1) Preventive care services;
(2) Immunizations;
(3) One (1) comprehensive routine eye exam per year, to age nineteen (19),
(4) Prescribed vision hardware, such as eyeglasses, lenses, or contact lenses, no less than one pair or one set every two (2) years for plans issued and renewed on or after January 1, 2017, to age nineteen (19);
(5) Routine hearing exams to age nineteen (19);
(6) Hearing aids to age eighteen (18), pursuant to § 10-16-104(19), C.R.S.; and
(7) Children's dental anesthesia, pursuant to § 10-16-104(12), C.R.S.
h. Prescription drugs, which must include:
(1) Retail services;
(2) Mail services (home delivery);
(3) All contraceptive methods approved by the Food and Drug Administration (FDA); and
(4) To meet the EHB requirement for prescription drug benefits, carriers must offer coverage that includes at least the greater of:
(a) One (1) drug in every United States Pharmacopeia (USP) category and class; or
(b) The same number of prescription drugs in each category and class as the EHB-benchmark plan.
i. All preventive services required by state and/or federal mandate, which are not subject to deductibles, copayments, or coinsurance, include, but are not limited to:
(1) Services related to contraception, including, but not limited to FDA-approved methods, and including the services related to follow-up and management of side effects, counseling for continued adherence, and device removal; and
(2) Age-appropriate immunizations and vaccines for children, adolescents, and adults in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP).
(3) Mental health wellness exam, at least one (1) visit per year for plans issued and renewed on or after January 1, 2023.
j. Rehabilitative and habilitative services and devices, which must include:
(1) No less than twenty (20) visits per calendar year, per therapy, for physical, speech, and occupational therapy for:
(a) Habilitative services; and
(b) Rehabilitative services.

Habilitative and rehabilitative service visits are cumulative, such that a carrier must provide, at a minimum, no less than sixty (60) visits for habilitative services, and no less than sixty (60) visits for rehabilitative services per calendar year.

(2) Cardiac rehabilitation services;
(3) Pulmonary rehabilitation services;
(4) Durable medical equipment;
(5) Arm and leg prosthetics;
(6) Inpatient and outpatient habilitative services;
(7) No less than one hundred (100) days of skilled nursing services annually;
(8) No less than two (2) months of inpatient rehabilitation annually, and no less than sixty (60) days;
(9) Autism spectrum disorder services; and
(10) Physical, occupational, and speech therapy for congenital defects for children up to age six (6), as required by § 10-16-104 (1.7), C.R.S.
k. Medically necessary bariatric surgery services, for plans issued and renewed on or after January 1, 2017.
l. Infertility services, for plans issued and renewed on or after January 1, 2017, which must include:
(1) X-ray and laboratory procedures;
(2) Services for diagnosis and treatment of involuntary infertility; and
(3) Artificial insemination.
m. Chiropractic care, up to twenty (20) visits per year, at a minimum, for plans issued and renewed on or after January 1, 2017, which must include:
(1) Diagnosis and evaluation; and
(2) Medically necessary lab and x-ray services required for chiropractic services and musculoskeletal disorders.
n. Acupuncture care, up to six (6) visits per year, at a minimum, for plans issued and renewed on or after January 1, 2023.
o. Medically necessary gender affirming care for gender dysphoria, for plans issued and renewed on or after January 1, 2023, which must include:
(1) Hormone therapy;
(2) Genital and non-genital surgical procedures;
(3) Blepharoplasty (eye and lid modification);
(4) Face/forehead and/or neck tightening;
(5) Facial bone remodeling for facial feminization;
(6) Genioplasty (chin width reduction);
(7) Rhytidectomy (cheek, chin, and neck);
(8) Cheek, chin, nose implants;
(9) Lip lift/augmentation;
(10) Mandibular angle augmentation/creation/reduction (jaw);
(11) Orbital recontouring;
(12) Rhinoplasty (nose reshaping);
(13) Laser or electrolysis hair removal; and
(14) Breast/Chest augmentation, reduction, construction.
2. Carriers seeking to include pediatric dental EHB coverage within a health benefit plan, or carriers offering a stand-alone pediatric dental plan that meets EHB requirements, must include the following eligible services, subject to plan benefit limitations, in order to meet the EHB requirements for pediatric dental coverage:
a. Diagnostic and preventive procedures, which must include:
(1) Oral exams and evaluations;
(2) Full mouth, intra-oral, and panoramic x-rays;
(3) Bitewing x-rays;
(4) Routine cleanings;
(5) Fluoride treatments;
(6) Space maintainers;
(7) Sealants; and
(8) Palliative treatment.
b. Basic restorative services, which must include:
(1) Amalgam fillings;
(2) Resin and composite filings;
(3) Crowns;
(4) Pin retention; and
(5) Sedative fillings.
c. Oral surgery, consisting of extractions.
d. Endodontics, consisting of:
(1) Surgical services; and
(2) Root canal therapy.
e. Medically necessary orthodontia and medically necessary prosthodontics for the treatment of cleft lip and cleft palate.
f. Implants, denture repair and realignment, dentures and bridges, non-medically necessary orthodontia, and periodontics are not considered a part of the pediatric dental EHB.
3. Benefits that are excluded from EHB, even though they may be covered by the EHB-benchmark plan, include:
a. Routine non-pediatric dental services;
b. Routine non-pediatric eye exam services;
c. Long-term/custodial nursing home care benefits; and
d. Non-medically necessary orthodontia.
4. Although the EHB-benchmark plan provides coverage for abortion services, no health benefit plan must cover such services as part of the requirement to cover EHB.
5. Carriers offering stand-alone non-pediatric dental plans that are offered in conjunction with a health benefit plan, or are offered as a stand-alone policy, need not comply with the requirements of Section 5.A.2. of this regulation.
6. Carrier compliance with the provision of EHBs shall include coverage of behavioral, mental health and substance use disorders that is in compliance with §§ 10-16-102 (43.5) and 10-16-104 (5.5), C.R.S., and all Colorado insurance regulations concerning mental health parity.
C. Drug/Formulary Review

Carriers must submit their formularies to the Division annually, by June 30 of each year. If a formulary changes by more than five percent (5%) in a calendar year, the carrier must submit a filing to the Division supporting that its formulary has the required number of drugs in each category to comply with the EHB requirement.

3 CCR 702-4-2-42-5

37 CR 11, June 10, 2014, effective 7/1/2014
37 CR 12, June 25, 2014, effective 7/15/2014
Colorado Register, Vol 37, No. 14. July 25, 2014, effective 8/15/2014
37 CR 23, December 10, 2014, effective 1/1/2015
38 CR 03, February 10, 2015, effective 3/15/2015
38 CR 06, March 25, 2015, effective 4/30/2015
38 CR 09, May 10, 2015, effective 6/1/2015
38 CR 13, July 10, 2015, effective 7/30/2015
38 CR 19, October 10, 2015, effective 11/1/2015
38 CR 21, November 10, 2015, effective 1/1/2016
38 CR 23, December 10, 2015, effective 1/1/2016
39 CR 01, January 10, 2016, effective 2/1/2016
39 CR 05, March 10, 2016, effective 4/1/2016
39 CR 08, April 25, 2016, effective 5/15/2016
39 CR 19, October 10, 2016, effective 11/1/2016
39 CR 20, October 25, 2016, effective 1/1/2017
39 CR 22, November 25, 2016, effective 1/1/2017
39 CR 23, December 10, 2016, effective 1/1/2017
39 CR 23, December 25, 2016, effective 1/1/2017
40 CR 03, February 10, 2017, effective 3/15/2017
40 CR 09, May 10, 2017, effective 6/1/2017
40 CR 15, August 10, 2017, effective 9/1/2017
40 CR 17, September 10, 2017, effective 10/1/2017
40 CR 21, November 10, 2017, effective 12/1/2017
41 CR 04, February 25, 2018, effective 4/1/2018
41 CR 05, March 10, 2018, effective 6/1/2018
41 CR 08, April 25, 2018, effective 6/1/2018
41 CR 09, May 10, 2018, effective 6/1/2018
41 CR 11, June 10, 2018, effective 7/1/2018
41 CR 15, August 10, 2018, effective 9/1/2018
41 CR 17, September 10, 2018, effective 10/1/2018
41 CR 18, September 25, 2018, effective 10/15/2018
41 CR 21, November 10, 2018, effective 12/1/2018
41 CR 23, December 10, 2018, effective 1/1/2019
42 CR 01, January 10, 2019, effective 2/1/2019
41 CR 19, October 10, 2018, effective 3/1/2019
42 CR 03, February 10, 2019, effective 4/1/2019
42 CR 04, February 25, 2019, effective 4/1/2019
42 CR 06, March 25, 2019, effective 6/1/2019
42 CR 08, April 10, 2019, effective 6/1/2019
42 CR 15, August 10, 2019, effective 9/1/2019
42 CR 17, September 10, 2019, effective 10/1/2019
43 CR 02, January 25, 2020, effective 12/20/2019
43 CR 02, January 25, 2020, effective 12/23/2019
42 CR 23, December 10, 2019, effective 1/1/2020
43 CR 01, January 10, 2020, effective 2/1/2020
42 CR 24, December 25, 2019, effective 2/2/2020
43 CR 06, March 25, 2020, effective 4/15/2020
43 CR 10, May 25, 2020, effective 8/1/2020
43 CR 14, July 25, 2020, effective 8/15/2020
43 CR 17, September 10, 2020, effective 10/1/2020
43 CR 18, September 25, 2020, effective 11/1/2020
43 CR 22, November 25, 2020, effective 12/15/2020
43 CR 24, December 25, 2020, effective 1/15/2021
44 CR 03, February 10, 2021, effective 3/15/2021
44 CR 08, April 25, 2021, effective 5/15/2021
44 CR 09, May 10, 2021, effective 6/1/2021
44 CR 10, May 25, 2021, effective 6/14/2021
44 CR 10, May 25, 2021, effective 6/15/2021
44 CR 13, July 10, 2021, effective 8/1/2021
44 CR 15, August 10, 2021, effective 9/1/2021
44 CR 19, October 10, 2021, effective 11/1/2021
44 CR 21, November 10, 2021, effective 12/1/2021
44 CR 23, December 10, 2021, effective 12/30/2021
44 CR 21, November 10, 2021, effective 1/1/2022
44 CR 23, December 10, 2021, effective 1/15/2022
44 CR 24, December 25, 2021, effective 1/15/2022
45 CR 03, February 10, 2022, effective 3/2/2022
45 CR 08, April 25, 2022, effective 5/30/2022
45 CR 09, May 10, 2022, effective 5/30/2022
45 CR 10, May 25, 2022, effective 6/14/2022
45 CR 11, June 10, 2022, effective 6/30/2022
45 CR 11, June 10, 2022, effective 7/15/2022
45 CR 19, October 10, 2022, effective 11/1/2022
45 CR 20, October 25, 2022, effective 11/14/2022
45 CR 21, November 10, 2022, effective 11/30/2022
45 CR 24, December 25, 2022, effective 1/14/2023
46 CR 01, January 10, 2023, effective 2/14/2023
46 CR 06, March 25, 2023, effective 2/15/2023
46 CR 03, February 10, 2022, effective 3/2/2023
46 CR 04, February 25, 2023, effective 3/17/2023
46 CR 05, March 10, 2023, effective 4/15/2023
46 CR 09, May 10, 2023, effective 5/30/2023
46 CR 09, May 10, 2023, effective 6/1/2023
46 CR 10, May 25, 2023, effective 6/15/2023
46 CR 11, June 10, 2023, effective 6/30/2023