3 Colo. Code Regs. § 702-4-6-8-5
Current through Register Vol. 47, No. 16, August 25, 2024
Section 3 CCR 702-4-6-8-5 - Issuance of CoverageA. Providing Coverage. 1. A small employer carrier shall actively offer to all small employers in the carrier's service area a choice of all small group plans the carrier markets in Colorado, as set forth in § 10-16-105, C.R.S. A small employer carrier shall issue coverage under any of its small group plans for which a small employer makes application. a. A small employer carrier shall be considered to have met the requirement to offer its small group product at the time a policy has been issued. In the event that a small employer's coverage is terminated due to non-payment of premiums, the carrier that issued the policy can deny a new application for the same small employer on the basis of this termination. Any new application can be denied for six (6) months after termination for non-payment or at the end of the original policy period, whichever is greater. This provision shall not relieve the employer of its responsibility for payment of any outstanding premiums or late charges owed for the prior period of coverage.
b. A small employer carrier shall be considered to have met the requirement to offer its small group product at the time a policy has been issued; therefore, a carrier does not have to honor requests to change policy provisions during the policy term.2. A small employer carrier shall offer to provide coverage to each eligible employee and to each dependent of an eligible employee. For managed care plans, an employee must either work or reside in the carrier's service area to be considered an eligible employee, except as provided in § 10-16-704(2)(g), C.R.S.3. A small employer carrier may offer the employees of a small employer the option of choosing among one or more health benefit plans, provided that each employee may choose any of the offered plans, except as provided in paragraph 4.A.5. of this section. The choice among benefit plans may not be limited, restricted or conditioned based upon health status-related factors of the employees or their dependents. Nothing in this section limits the ability of a small employer carrier to set participation rules based upon group size that may limit the availability of multi-option plans to a single employer as long as any of the component plans offered could be accessed individually by any small employer.4. A small employer carrier that only offers managed care plans may offer an indemnity plan to a small employer's out-of-area employees only (instead of to all employees). However, the following conditions may apply:a. A health maintenance organization (HMO) may offer coverage through an arrangement with an insurance carrier as long as the coverage is only made available to the out-of-area employees of a small employer. The use of insurance coverage for this purpose only will not result in the other carrier being considered a small employer carrier.b. An HMO may offer coverage to the out-of-area employees of a small employer or a small employer located outside of the HMO's approved service area pursuant to the notice, disclosure, and reimbursement provisions as described in § 10-16-704(2) and (2.5), C.R.S. If an HMO offers coverage to one or more out-of-area employees of a small employer or small employers, it must offer it to all small employers.c. A carrier offering a managed care plan may offer indemnity coverage as long as the coverage is only made available to the out-of-area employees of the small employer. For these plans, out-of-area employees are those working and residing outside of the state of Colorado.d. If a carrier offers indemnity out-of-area coverage to one or more small employers, it must offer it to all small employers.5. Pursuant to § 10-16-107(5), C.R.S., a small employer carrier shall not vary the premium rate for a small employer health benefit plan by any factor other than the allowable case characteristics. Notwithstanding § 10-16-105.6(3) and (4), C.R.S., and subject to the provisions of the Affordable Care Act Section 2701, a small employer carrier is not permitted to impose a premium surcharge on a small employer when that small employer: a. Has at any time in the previous twelve (12) months purchased health coverage that is self-funded or insured through a non-small group health benefit plan; orb. Has had its small group coverage discontinued because of non-payment of premium or fraud and is reapplying for coverage in the small group market.6. A small employer carrier is not required to issue a small group policy to a small group partnership which does not meet its minimum participation requirements established pursuant to § 10-16-105(3), C.R.S.B. Determining Who is an Eligible Employee and/or Dependent. 1. The Division finds that, when defining "eligible employee" in § 10-16-102(18), C.R.S., the sole intent of the General Assembly was to create a maximum weekly work requirement which small employer carriers may impose as a requirement for an employee's participation in a health benefit plan. Nothing in the definition of "eligible employee" was intended to limit an employer's traditional ability to set valid and acceptable standards for employee eligibility based upon the terms and conditions of employment, including a minimum weekly work requirement in excess of thirty (30) hours and eligibility based upon salaried versus hourly workers and management versus non-management employees.2. The Division finds that, subject to other statutory restrictions and the provisions of this regulation, a small employer carrier may offer a health benefit plan to the eligible employees of a small employer as that employer defines its eligible employees (herein after referred to as "employer-determined eligible employees"). However, a carrier must offer coverage to all small employers for all employees with a regular work week of at least thirty (30) hours on a regular basis. The decision of a small employer to limit eligibility for coverage as provided for in paragraph 1. of this subsection B. shall be solely at the small employer's discretion, without direct or indirect pressure or suggestion by the carrier, producer, or their representatives. The small employer carrier may offer coverage only to such employer-determined eligible employees and their dependents and may apply its minimum participation and contribution criteria solely to such employer-determined eligible employees.3. Listing of eligible employees and dependents.a. A small employer carrier shall require each small employer that applies for coverage, as part of the application process, to provide a complete list of eligible employees and dependents of eligible employees, and a list of employer-determined eligible employees and dependents, if this is a different list.b. The small employer carrier may require the small employer to provide appropriate supporting documentation, such as the Unemployment Insurance Quarterly Wage and Tax Report (UITR), often referred to as a W-2 Summary Wage and Tax Form, to verify the information required under this paragraph.c. In the event that a UITR form is not available because the employer was not in business during the preceding quarter or the employer has outsourced payroll functions or this form is not required due to federal tax exemptions related to the type of small business or not available due to the business form, the carrier shall accept reasonable alternate documentation for this information. Alternate documentation includes, but is not limited to, payroll documentation from the employer or the employer's payroll administrator or employee leasing company; organizational documents; or other reasonable proof.4. Waivers. a. A small employer carrier must secure a waiver with respect to each eligible employee and each dependent of such an eligible employee (or each employer-determined eligible employee and their dependents if this is different than the list of eligible employees) who declines an offer of coverage under a health benefit plan provided to a small employer.b. The waiver shall be signed by the eligible employee (on behalf of such employee or the dependent of such employee) and shall certify that the individual who declined coverage was informed of the availability of coverage under the health benefit plan.c. The waiver form shall require that the reason for declining coverage (such as being covered under another plan or cannot afford coverage) be stated on the form.d. Waiver forms shall be maintained by the small employer carrier. C. Waiting periods are permissible as long as they do not exceed ninety (90) days.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 6/30/2023