3 Colo. Code Regs. § 702-4-2-43-5

Current through Register Vol. 47, No. 24, December 25, 2024

Section 3 CCR 702-4-2-43-5 - Individual Enrollment Periods

A. Carriers offering individual health benefit plans must accept every eligible individual who applies for coverage, agrees to make the required premium payments, and to abide by the reasonable provisions of the plan, although carriers may choose to restrict enrollment to open or special enrollment periods.

B. Carriers offering individual health benefit plans must display continuously and prominently on their website:

1. Notice of open enrollment dates;

2. Notice of special enrollment for qualifying and triggering events;

3. Notice of the enrollment periods for each qualifying and triggering event; and

4. Instructions on how to enroll.

C. Open enrollment periods.

1. Pursuant to 45 C.F.R. § 155.410(e)(4)(i), the open enrollment period for plans effective on or after January 1 shall begin on November 1 of the prior year and extend through January 15 of the immediately following year.

2 Carriers must ensure that coverage is effective on January 1 for health benefit plans purchased on or before December 15 of the open enrollment period.

3. Individual health benefit plans purchased beginning December 16 through January 15 shall be effective no later than February 1 of the plan year.

4. The benefit year for individual health benefit plans purchased during the annual open enrollment period is a calendar year.

5. During open enrollment periods, carriers must offer guarantee-issue child-only health benefit plans to all applicants under the age of 21.

D. Special enrollment periods.

Carriers must establish special enrollment periods for individuals who experience triggering events, pursuant to § 10-16-105.7, C.R.S.

1. Following a triggering event, a carrier must provide a special enrollment period of sixty (60) days, except for individuals under Section 5.D.4.h.9 who will have a special enrollment period of up to twenty (20) months, beginning on April 1, 2023 through November 30, 2024.

2. When an individual is notified or becomes aware of a triggering event that will occur in the future, they may apply for enrollment in a new health benefit plan during the sixty (60) calendar days prior to the date of the triggering event, unless otherwise noted in Section 5.D.4., with coverage beginning no earlier than the day the triggering event occurs, to avoid a gap in coverage. The individual may be required to provide written documentation to support the date of the triggering event. The effective date of this enrollment must comply with the coverage effective dates found in Section 5.D.6. of this regulation.

3. When a qualified individual is notified or becomes aware of a triggering event that will occur in the future, they may apply for enrollment in a new health benefit plan during the sixty (60) calendar days prior to the date of the triggering event, with coverage beginning no earlier than the day the triggering event occurs, to avoid a gap in coverage. The individual may be required to provide written documentation to support the date of the triggering event. The effective date of this enrollment must comply with the coverage effective dates found in Section 5.D.6. of this regulation.

4. Triggering events are:

a. An individual or their dependent involuntarily losing existing creditable coverage for any reason other than fraud, misrepresentation, or failure to pay a premium. Such individual or dependent may apply for enrollment in a new health benefit plan during the sixty (60) calendar days before or after the effective date of the loss of coverage. Dependent coverage cannot be terminated, on the basis of age, before the end of the plan year in which the dependent attains age 26;

b. An individual or their dependent loses pregnancy-related Medicaid coverage. The date of the loss of coverage is the last day the consumer would have pregnancy-related Medicaid coverage;

c. When an Exchange enrollee loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by state law in the state in which the divorce or legal separation occurs, or if the Exchange enrollee, or their dependent, dies;

d. An individual or their dependent losing other coverage as described under Section 1902(a)(10)(C) of the Social Security Act (42 U.S.C. § 301 et seq.). Such individual or dependent may apply once during a calendar year for enrollment in a new health benefit plan during the sixty (60) calendar days before and after the effective date of the loss of coverage;

e. An individual gaining a dependent or becoming a dependent through marriage, civil union, birth, adoption, or placement for adoption, placement in foster care, through a child support order or other court order, or by entering into a designated beneficiary agreement if the carrier offers coverage to designated beneficiaries;

f. An individual's or their dependent's enrollment or non-enrollment in a health benefit plan that is unintentional, inadvertent or erroneous and is the result of an error, misrepresentation, or inaction of the carrier, producer, or the Exchange;

g. An individual or their dependent demonstrating 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 or their dependent;

h. A qualified individual who:

(1) Becomes newly eligible, or an Exchange enrollee who is newly eligible or ineligible, for the federal advance premium tax credit or has a change in eligibility for cost-sharing reductions available through the Exchange;

(2) Has a dependent enrolled in the same qualified health plan who is determined to be newly eligible or ineligible for the federal advance premium tax credit or has a change in eligibility for cost-sharing reductions available through the Exchange;

(3) Becomes newly eligible, or their dependent becomes newly eligible, for enrollment in a QHP through the Exchange because they have been released from incarceration;

(4) Was previously ineligible for federal premium tax credit solely because of a household income below one hundred percent (100%) of the Federal Poverty Level and who, during the same timeframe, was ineligible for Medicaid because they were living in a non-Medicaid expansion state, who either experiences a change in household income or moves to a different state resulting in the qualified individual becoming newly eligible for advance payments of the federal premium tax credit;

(5) Is enrolled, or has a dependent enrolled, in an eligible employer- sponsored plan and is determined to be newly eligible for the federal advance premium tax credit based in part on a finding that such individual is ineligible for coverage in an eligible employer-sponsored plan that provides minimum creditable coverage, including as a result of their employer discontinuing or changing coverage within the next sixty (60) days, provided the enrollee is able to terminate their existing coverage. This enrollee may apply for enrollment in a new health benefit plan during the sixty (60) calendar days before and after the effective date of the loss of coverage;

(6) Is found eligible for financial assistance for health coverage by Connect for Health Colorado, having indicated by the tax deadline on a Colorado Individual Income Tax Form that they are interested in learning more about free or reduced health coverage.

(7) Did not receive timely notice of an event that triggers eligibility for a special enrollment period, and otherwise was reasonably unaware that a triggering event described in Section 5.D.4 occurred, the Exchange must allow the individual, their dependent to select a new plan within sixty (60) days of the date that they knew, or reasonably should have known, of the occurrence of the triggering event; or

(8) Becomes eligible, or their dependent becomes eligible for the federal advance premium tax credit and whose household income is expected to be no greater than 150 percent of the federal poverty level, may enroll in a QHP or change from one QHP to another one time per month.

(9) Beginning April 1, 2023 through November 30, 2024, becomes ineligible under the Colorado Medical Assistance Act (C.R.S. § 25.5-4-101, et seq., C.R.S.) or a dependent becomes ineligible under the Child Health Plan Plus (CHP+) due to the provisions of the Consolidated Appropriations Act, 2023, Pub. L. No. 117-164.

i. An individual or their dependent gaining access to other creditable coverage as a result of a permanent change in residence;

j. A parent or legal guardian dis-enrolling a dependent, or a dependent becoming ineligible for the Child Health Plan Plus (CHP+);

k. An individual becoming ineligible under the Colorado Medical Assistance Act (C.R.S. § 25.5-4-101 et seq.);

l. An individual, who was not previously a citizen, a national, or a lawfully present individual, gaining such status;

m. An Indian, as defined by Section 4 of the Indian Health Care Improvement Act (25 U.S.C. § 1601 et seq.), or their dependent on the same application, may enroll in a qualified health plan or change from one qualified health plan to another one (1) time per month;

n. An individual or their dependent currently enrolled in an individual or group non-calendar year health benefit plan may apply for enrollment in a new health benefit plan during the sixty (60) calendar days prior to the effective date of the involuntary loss of coverage, which is the last day of the plan or policy year, or the sixty (60) calendar days after the effective date of the involuntary loss of coverage;

o. An individual who is a victim of domestic abuse or spousal abandonment, as defined by 26 C.F.R. § 1.36B-2(b)(2), including a dependent or unmarried victim within a household, who is enrolled in creditable coverage and seeks to enroll in coverage separate from the perpetrator of the abuse or abandonment;

p. An individual who is a dependent of a victim of domestic abuse or spousal abandonment, on the same application as the victim, may enroll in coverage at the same time as the victim;

q. An individual or their dependent who applies for coverage during the annual open enrollment period or due to a triggering event, and is assessed as potentially eligible for Medicaid or the Child Health Plan Plus (CHP+), and is determined ineligible for Medicaid or CHP+ either after open enrollment has ended or more than sixty (60) days after the triggering or qualifying event, or applies for coverage through a State Medicaid or CHP+ agency during the annual open enrollment period, and is determined ineligible for Medicaid or CHP+ after open enrollment has ended;

r. An individual, or their dependent, who has purchased an off-Exchange plan, adequately demonstrates to the Commissioner that a material error related to plan benefits, service area, or premium influenced the qualified individual's or enrollee's decision to purchase a QHP, including adequate demonstration by other individuals for the benefit of the individual or their dependent;

s. An individual, or their dependent, who has purchased an on-Exchange plan, adequately demonstrates to the Exchange that a material error related to plan benefits, service area, or premium influenced the qualified individual's or enrollee's decision to purchase a QHP, including adequate demonstration by other individuals for the benefit of the individual or their dependent;

t. An individual, or their dependent, adequately demonstrates to the Exchange, in accordance with 45 C.F.R. § 155.420(d)(9), that the individual meets other exceptional circumstances as the Exchange may provide;

u. An individual who has purchased a short-term limited duration health insurance policy in the past twelve (12) months and is unable, at the end of their policy term, to purchase another short-term policy from the same carrier due to that short-term policy carrier ceasing its sales of all short-term policies in Colorado on or after April 1, 2019. Such individuals may apply for enrollment in a new individual health benefit plan in accordance with Section 5.D.1. and 2. of this regulation, or during the sixty (60) calendar days after the effective date of this regulation; or

v. In the event, an individual, or their dependent, is enrolled in COBRA (Consolidated Omnibus Budget Reconciliation Act) continuation coverage for which an employer is paying all or part of the premiums, or for which a government entity is providing subsidies, and the employer completely ceases its contributions to the qualified individual's or dependent's COBRA continuation coverage or government subsidies completely cease. The triggering event is the last day of the period for which COBRA continuation coverage is paid for or subsidized, in whole or in part, by an employer or government entity.

w. Beginning January 1, 2024, an individual who does not have existing credible coverage receives written certification from a provider acting within the provider's scope of practice that the individual is pregnant.

x. An individual becomes eligible, or their dependent becomes eligible for financial assistance and whose household income is expected to be no greater than 150 percent of the federal poverty level can enroll at any month.

5. Special Enrollment Period Eligibility Verification and Prior Coverage Requirements

a. Carriers may establish a special enrollment period eligibility verification process to confirm that an individual applying for coverage through a special enrollment period is eligible for the requested special enrollment period. Carriers may delay the processing of an application or any enrollment documents or premium payments until after completion of verification of eligibility for the requested special enrollment period.

(1) For special enrollment period eligibility verification, carriers shall make the list of required documentation, relevant premium payment information, and the verification process and deadlines available on their website in a conspicuous manner, and encourage individuals to provide the required documentation with their request for a special enrollment.

(2) A carrier shall notify the applicant within fourteen (14) days of receipt of the application if the applicant did not provide sufficient documentation necessary to verify eligibility for the special enrollment period requested. The notice shall include information that a failure to provide the documentation will result in a denial of enrollment, and that coverage will not be issued until the required documentation confirming eligibility for the special enrollment period has been received.

(3) Individuals shall have no less than thirty (30) days from the date of the insufficient documentation notice to provide a carrier with sufficient documentation to establish eligibility for the requested special enrollment period.

(4) Carriers must make a verification determination within fourteen (14) days of receiving sufficient documentation in order to make an eligibility determination. If the verification determination is not made within the fourteen (14) day period, the individual shall be deemed verified and coverage shall be issued.

(5) A carrier must provide written notice to the individual of the outcome of the verification determination.

(6) The carrier may retroactively terminate or cancel an individual's enrollment if the carrier determines that the individual committed fraud or intentionally misrepresented their eligibility for a special enrollment period.

(7) A carrier is not required to provide thirty (30) days notice prior to denying, terminating, or cancelling an individual determined not to be eligible for a special enrollment period.

(8) A carrier shall notify an individual determined ineligible for a special enrollment period for an on-Exchange plan that they may appeal that decision with the Exchange, and the carrier shall respond to documentation requests from the Exchange concerning an appeal within seven (7) days of receiving that request.

(9) A carrier shall notify an individual determined ineligible for a special enrollment period for an off-Exchange plan that they may appeal that decision with the carrier and that they may appeal a carrier's final determination to the Division once the carrier's internal appeal process has been completed.

b. A carrier shall provide written confirmation of an individual's loss of creditable coverage to that individual within ten (10) business days of receiving such a request. The written confirmation must include the date of the loss of coverage and the reason for the loss of coverage.

c. The following documents shall constitute proof of a triggering event and sufficient documentation of eligibility for a special enrollment period:

(1) Evidence of gaining or becoming a dependent shall be considered sufficient if the individual produces one of the following documents:

(a) A marriage license, civil union certificate or common law documentation, if the gaining or becoming a dependent occurs due to marriage or civil union;

(b) A birth certificate, adoption documents, or foster care documents, if the gaining or becoming a dependent occurs due to birth, adoption, placement for adoption, or placement in foster care; or

(c) A court order or designated beneficiary documents, if the gaining or becoming a dependent occurs due to a court order.

(2) Evidence of losing a dependent or no longer being considered a dependent shall be considered sufficient if the individual produces:

(a) A copy of the death certificate or the obituary.

(b) Copies of the final divorce or separation documents.

(c) Proof of age and evidence of loss of creditable coverage when an individual turns 26 and loses coverage under a parent's health benefit plan at the end of the plan year.

(3) Evidence of a change in citizenship or immigration status shall be considered sufficient if the individual produces official documentation of the change.

(4) The following triggering events shall be confirmed by self-attestation:

(a) Evidence of an involuntary loss of credible coverage;

(b) Evidence of a permanent change in residence;

(c) Evidence of a material violation of a carrier's contract confirming eligibility for a special enrollment from the Division;

(d) Evidence of a status as American Indian/Native American; or

(e) Evidence of the termination of a short-term policy with an expiration date on or after April 1, 2019, that indicates that the carrier has exited the market, which includes, but is not limited to, written communication from the carrier or from a broker; or

(f) Evidence of the cessation of subsidies for COBRA or state continuation coverage.

(5) Evidence of pregnancy shall be considered sufficient if the individual provides written certification from a provider acting within the provider's scope of practice that the individual is pregnant.

(6) Any other documentation reasonably sufficient to verify eligibility for the special enrollment period requested.

d. Individuals eligible for a special enrollment period under Section 5.D.4.h.9. shall attest that they are currently not enrolled in a health benefit plan. Verbal attestation is sufficient for purposes of determining eligibility for this special enrollment period. Carriers shall not require additional verification or attestation beyond the eligibility and enrollment information provided by the Exchange. Carriers shall not require written documentation for verification of this special enrollment period and may waive the verbal attestation requirement.

e. Prior coverage requirements.

(1) For special enrollment period requests due to marriage or civil union, carriers may require that at least one individual demonstrate that they possessed minimum essential coverage for at least one (1) or more days during the sixty (60) days immediately preceding the date of the special enrollment period triggering event.

(2) For special enrollment period requests due to a permanent move, the requesting individual must demonstrate that they possessed minimum essential coverage for at least one (1) or more days during the sixty (60) days immediately preceding the date of the permanent move.

(3) If the requesting individual is unable to demonstrate that they possessed minimum essential coverage, carriers may require the requesting individual to demonstrate:

(a) They lived outside of the United States or in a United States territory for one (1) or more days during the sixty (60) days immediately preceding the date of the special enrollment period triggering event;

(b) They are an Indian, as defined by Section 4 of the Indian Health Care Improvement Act; or

(c) They lived for one (1) or more days during the sixty (60) days preceding the qualifying event or during his or her most recent preceding enrollment period in a service area where no qualified health plan was available through the Exchange.

f. The special enrollment period eligibility verification requirements do not apply to the special enrollment period found in Section 5.D.4.h.6.

6. Coverage effective dates will be:

a. In the case of birth, adoption, placement for adoption, or placement in foster care, coverage must be effective on either:

(1) The date of the event; or

(2) The first day of the month following the birth, adoption, placement for adoption, or placement in foster care, if requested by the primary individual policyholder.

b. In the case of an involuntary loss of existing creditable coverage in accordance with Section 5.D.4.a. of this regulation, coverage shall become effective either:

(1) On the first day of the month following the triggering event if plan selection is made on or before the effective date of the triggering event;

(2) In accordance with the effective dates specified in Section 5.D.6.g of this regulation if a plan selection is made after the effective date of the triggering event; or

(3) At the option of the Exchange, on the first day of the month following plan selection when plan selection is made after a triggering event.

c. In the case of gaining a dependent or becoming a dependent through a court order, coverage shall become effective either:

(1) On the date the court order is effective; or

(2) In accordance with the effective dates specified in Section 5.D.6.g of this regulation at the election of the primary individual policyholder.

d. The effective date of coverage for triggering events found in Section 5.D.4.f. and g. of this regulation must be an appropriate date based upon the circumstances of the special enrollment period.

e. Beginning January 1, 2024, the effective date of coverage for individuals who are pregnant is the first day of the month in which the individual receives written 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.

f. Beginning April 1, 2023 through November 30, 2024, the effective date of coverage for individuals who qualify under Section 5.D.4.h.9. is no later than the first day of the month following plan selection.

g. In the case of all other triggering events where individual coverage is selected, coverage shall become effective no later than the first day of the following month.

3 CCR 702-4-2-43-5

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

46 CR 23, December 10, 2023, effective 1/1/2024

47 CR 13, July 10, 2024, effective 7/30/2024