3 Colo. Code Regs. § 702-4-2-64-4
Current through Register Vol. 48, No. 1, January 10, 2025
Section 3 CCR 702-4-2-64-4 - [Effective 1/30/2025] DefinitionsA. "Aggregate lifetime dollar limit" means, for the purposes of this regulation, a dollar limitation on the total amount of specified benefits that may be paid under a health benefit plan for any coverage unit.B. "American Society of Addiction Medicine (ASAM) Criteria" means, for the purposes of this regulation, ASAM Criteria for Addictive, Substance-related, and Co-Occurring Conditions as referenced in § 10-16-104 (5.5)(a)(I)(B), C.R.S.C. "Annual dollar limit" means, for the purposes of this regulation, a dollar limitation on the total amount of specified benefits that may be paid in a 12-month period under a health benefit plan for any coverage unit.D. "Autism spectrum disorder" shall have the same meaning as defined at § 10-16-104 (1.4)(a)(III), C.R.S.E. "Behavioral health benefits" means, for the purposes of this regulation, the benefits supplied for items or services for behavioral health conditions.F. "Behavioral, mental health, and substance use disorder" shall have the same meaning as defined at § 10-16-104 (5.5)(d), C.R.S.G. "Carrier" shall have the same meaning as found at § 10-16-102(8), C.R.S.H. "Colorado Option Standardized Plan" or "Standardized Plan" shall have the same meaning as defined at § 10-16-1303(14), C.R.S.I. "Diagnostic and Statistical Manual of Mental Disorders (DSM)" shall have the same meaning as the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defined in 45 C.F.R. § 146.136(a)(2).J. "Evidentiary standards" are any evidence, sources, or standards that a health benefit plan or carrier considered or relied upon in designing or applying a factor with respect to a non-quantitative treatment limitation, including specific benchmarks or thresholds. Evidentiary standards may be empirical, statistical, or clinical in nature, and include: sources acquired or originating from an objective third party, such as recognized medical literature, professional standards and protocols (which may include comparative effectiveness studies and clinical trials), published research studies, payment rates for items and services (such as publicly available databases of the "usual, customary and reasonable" rates paid for items and services), and clinical treatment guidelines; internal carrier data, such as claims or utilization data or criteria for assuring a sufficient mix and number of network providers; and benchmarks or thresholds, such as measures of excessive utilization, cost levels, time or distance standards, or network participation percentage thresholds.K. "Factors" are all information, including processes and strategies (but not evidentiary standards), that a health benefit plan or carrier considered or relied upon to design a non-quantitative treatment limitation, or to determine whether or how the non-quantitative treatment limitation applies to benefits under the plan or coverage. Examples of factors include, but are not limited to: provider discretion in determining a diagnosis or type or length of treatment; clinical efficacy of any proposed treatment or service; licensing and accreditation of providers; claim types with a high percentage of fraud; quality measures; treatment outcomes; severity or chronicity of condition; variability in the cost of an episode of treatment; high cost growth; variability in cost and quality; elasticity of demand; and geographic location.L. "FDA" means, for the purposes of this regulation, the Food and Drug Administration in the United States Department of Health and Human Services.M. "Financial requirements" means, for the purposes of this regulation, the deductibles, copayments, coinsurance, or out-of-pocket maximums imposed under a health benefit plan. Financial requirements do not include aggregate lifetime or annual dollar limits.N. "Health benefit plan" shall have the same meaning as defined at § 10-16-102(32), C.R.S.O. "International Statistical Classification of Diseases and Related Health Problems" or "(ICD)" shall have the same meaning as the World Health Organization's International Classification of Diseases defined in 45 C.F.R. § 146.136(a)(2).P. "Material difference" means, for the purposes of this regulation, data-driven differences in access between mental health and substance use disorder benefits compared to medical and surgical benefits based on all relevant facts and circumstances.Q. "Medical/surgical benefits" for health benefit plans shall have the same meaning as 45 C.F.R. § 146.136(a)(2).R. "Mental health benefits" for health benefit plans shall have the same meaning as 45 C.F.R. § 146.136(a)(2), except for generally recognized independent standards of current medical practice shall also include The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood as referenced in § 10-16-104 (5.5)(d)(I)(C), C.R.S.S. "Medication-Assisted Treatment (MAT)" shall have the same meaning as found at § 23-21-803(4), C.R.S.T. "MHPAEA" shall have the same meaning as found at § 10-16-102 (43.5) C.R.S.U. "Participating provider" shall have the same meaning as found at § 10-16-104(46), C.R.S.V. "Prior authorization" shall have the same meaning as found at § 10-16-112.5(7)(d), C.R.S.W. "Processes" are actions, steps, or procedures that a health benefit plan or carrier uses to apply a non-quantitative treatment limitation, including actions, steps, or procedures established by the health benefit plan or carrier as requirements in order for a participant or beneficiary to access benefits, including through actions by a participant's or beneficiary's authorized representative or a provider or facility. Examples of processes include, but are not limited to: procedures to submit information to authorize coverage for an item or service prior to receiving the benefit or while treatment is ongoing (including requirements for peer or expert clinical review of that information); provider referral requirements that are used to determine when and how a participant or beneficiary may access certain services; and the development and approval of a treatment plan used in a concurrent review process to determine whether a specific request should be granted or denied. Processes also include the specific procedures used by staff or other representatives of a health benefit plan or carrier (or the service provider of a health benefit plan or carrier) to administer the application of non-quantitative treatment limitations, such as how a panel of staff members applies the non-quantitative treatment limitation (including the qualifications of staff involved, number of staff members allocated, and time allocated), consultations with panels of experts in applying the non-quantitative treatment limitation, and the degree of reviewer discretion in adhering to criteria hierarchy when applying a non-quantitative treatment limitation.X. "Provider" shall have the same meaning as found at § 10-16-104(56), C.R.S.Y. "SERFF" means, for the purposes of this regulation, the NAIC System for Electronic Rate and Form Filing.Z. "Short-term limited duration health insurance policy" and "short-term policy" shall have the same meaning as found at § 10-16-102(60), C.R.S.AA. "Step therapy" shall have the same meaning as found at § 10-16-145(1)(g), C.R.S.AB. "Strategies" are practices, methods, or internal metrics that a health benefit plan or carrier considers, reviews, or uses to design a non-quantitative treatment limitation. Examples of strategies include, but are not limited to: the development of the clinical rationale used in approving or denying benefits; the method of determining whether and how to deviate from generally accepted standards of care in concurrent reviews; the selection of information deemed reasonably necessary to make medical necessity determinations; reliance on treatment guidelines or guidelines provided by third-party organizations in the design of a non-quantitative treatment limitation; and rationales used in selecting and adopting certain threshold amounts to apply a non-quantitative treatment limitation, professional standards and protocols to determine utilization management standards, and fee schedules used to determine provider reimbursement rates, used as part of a non-quantitative treatment limitation. Strategies also include the method of creating and determining the composition of the staff or other representatives of a health benefit plan or carrier (or the service provider of a health benefit plan or carrier) that deliberates, or otherwise makes decisions, on the design of non-quantitative treatment limitations, including the health benefit plan or carrier's methods for making decisions related to the qualifications of staff involved, number of staff members allocated, and time allocated; breadth of sources and evidence considered; consultations with panels of experts in designing the non-quantitative treatment limitation; and the composition of the panels used to design a non-quantitative treatment limitation.AC. "Student health insurance coverage" and "student health policy" shall have the same meaning as found at § 10-16-102(65), C.R.S.AD. "Substance use disorder benefits" means for health benefit plans shall have the same meaning as 45 C.F.R. § 146.136(a)(2), except for generally recognized independent standards of current medical practice shall also include The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood as referenced in § 10-16-104 (5.5)(d)(I)(C), C.R.S.AE. "Treatment limitations" include limits on benefits based on the frequency of treatment, number of visits, days of coverage, days in a waiting period, or other similar limits on the scope or duration of treatment. Treatment limitations include both quantitative treatment limitations, which are expressed numerically (such as 50 outpatient visits per year), and non-quantitative treatment limitations (such as standards related to network composition), which otherwise limit the scope or duration of benefits for treatment under a plan or coverage. (See Section 7 of this regulation for an illustrative, non-exhaustive list of non-quantitative treatment limitations.) A complete exclusion of all benefits for a particular condition or disorder, however, is not a treatment limitation for purposes of this definition.37 CR 11, June 10, 2014, effective 7/1/201437 CR 12, June 25, 2014, effective 7/15/2014Colorado Register, Vol 37, No. 14. July 25, 2014, effective 8/15/201437 CR 23, December 10, 2014, effective 1/1/201538 CR 03, February 10, 2015, effective 3/15/201538 CR 06, March 25, 2015, effective 4/30/201538 CR 09, May 10, 2015, effective 6/1/201538 CR 13, July 10, 2015, effective 7/30/201538 CR 19, October 10, 2015, effective 11/1/201538 CR 21, November 10, 2015, effective 1/1/201638 CR 23, December 10, 2015, effective 1/1/201639 CR 01, January 10, 2016, effective 2/1/201639 CR 05, March 10, 2016, effective 4/1/201639 CR 08, April 25, 2016, effective 5/15/201639 CR 19, October 10, 2016, effective 11/1/201639 CR 20, October 25, 2016, effective 1/1/201739 CR 22, November 25, 2016, effective 1/1/201739 CR 23, December 10, 2016, effective 1/1/201739 CR 23, December 25, 2016, effective 1/1/201740 CR 03, February 10, 2017, effective 3/15/201740 CR 09, May 10, 2017, effective 6/1/201740 CR 15, August 10, 2017, effective 9/1/201740 CR 17, September 10, 2017, effective 10/1/201740 CR 21, November 10, 2017, effective 12/1/201741 CR 04, February 25, 2018, effective 4/1/201841 CR 05, March 10, 2018, effective 6/1/201841 CR 08, April 25, 2018, effective 6/1/201841 CR 09, May 10, 2018, effective 6/1/201841 CR 11, June 10, 2018, effective 7/1/201841 CR 15, August 10, 2018, effective 9/1/201841 CR 17, September 10, 2018, effective 10/1/201841 CR 18, September 25, 2018, effective 10/15/201841 CR 21, November 10, 2018, effective 12/1/201841 CR 23, December 10, 2018, effective 1/1/201942 CR 01, January 10, 2019, effective 2/1/201941 CR 19, October 10, 2018, effective 3/1/201942 CR 03, February 10, 2019, effective 4/1/201942 CR 04, February 25, 2019, effective 4/1/201942 CR 06, March 25, 2019, effective 6/1/201942 CR 08, April 10, 2019, effective 6/1/201942 CR 15, August 10, 2019, effective 9/1/201942 CR 17, September 10, 2019, effective 10/1/201943 CR 02, January 25, 2020, effective 12/20/201943 CR 02, January 25, 2020, effective 12/23/201942 CR 23, December 10, 2019, effective 1/1/202043 CR 01, January 10, 2020, effective 2/1/202042 CR 24, December 25, 2019, effective 2/2/202043 CR 06, March 25, 2020, effective 4/15/202043 CR 10, May 25, 2020, effective 8/1/202043 CR 14, July 25, 2020, effective 8/15/202043 CR 17, September 10, 2020, effective 10/1/202043 CR 18, September 25, 2020, effective 11/1/202043 CR 22, November 25, 2020, effective 12/15/202043 CR 24, December 25, 2020, effective 1/15/202144 CR 03, February 10, 2021, effective 3/15/202144 CR 08, April 25, 2021, effective 5/15/202144 CR 09, May 10, 2021, effective 6/1/202144 CR 10, May 25, 2021, effective 6/14/202144 CR 10, May 25, 2021, effective 6/15/202144 CR 13, July 10, 2021, effective 8/1/202144 CR 15, August 10, 2021, effective 9/1/202144 CR 19, October 10, 2021, effective 11/1/202144 CR 21, November 10, 2021, effective 12/1/202144 CR 23, December 10, 2021, effective 12/30/202144 CR 21, November 10, 2021, effective 1/1/202244 CR 23, December 10, 2021, effective 1/15/202244 CR 24, December 25, 2021, effective 1/15/202245 CR 03, February 10, 2022, effective 3/2/202245 CR 08, April 25, 2022, effective 5/30/202245 CR 09, May 10, 2022, effective 5/30/202245 CR 10, May 25, 2022, effective 6/14/202245 CR 11, June 10, 2022, effective 6/30/202245 CR 11, June 10, 2022, effective 7/15/202245 CR 19, October 10, 2022, effective 11/1/202245 CR 20, October 25, 2022, effective 11/14/202245 CR 21, November 10, 2022, effective 11/30/202245 CR 24, December 25, 2022, effective 1/14/202346 CR 01, January 10, 2023, effective 2/14/202346 CR 06, March 25, 2023, effective 2/15/202346 CR 03, February 10, 2022, effective 3/2/202346 CR 04, February 25, 2023, effective 3/17/202346 CR 05, March 10, 2023, effective 4/15/202346 CR 09, May 10, 2023, effective 5/30/202346 CR 09, May 10, 2023, effective 6/1/202346 CR 10, May 25, 2023, effective 6/15/202346 CR 11, June 10, 2023, effective 6/30/202348 CR 01, January 10, 2025, effective 1/30/2025