Authority for rules promulgated in this chapter is found in:
State of Colorado Constitution Article XII, Section 13; The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA), and 26 United States Code (U.S.C.) 63; The Family Medical Leave Act (FMLA); Americans with Disabilities Act (ADA); Family Care Act (FCA); Uniformed Services Employment and Reemployment Rights Act (USERRA).
State of Colorado Revised Statutes (C.R.S.) § 24-50-104, 24-50-109.5, and Part 6, 1-6-115, 1-6-122, 1-7-102, 8-40-101, 14-2-101, 14-15-103, 24-11-101, 24-11-112, 24-18-102, 24-33.5-825, 24-50-401, 28-1-104, 28-3-601, 28-6-602, 28-3-607, 28-3-609, and 28-3-610.
General Principles
11-1. The state reserves the sole right to add, modify, or discontinue any State of Colorado Employees Group Benefits Plan (the "state benefits") as deemed necessary.11-2. The Director complies with applicable federal and state law and regulations that govern state benefits plans, as well as the terms and conditions of the state benefits plans contracts and plan documents. Governing laws and regulations, and these rules shall prevail in the event of a conflict with contracts or plan documents. (7/1/10)11-3. Chapter 11, State Benefits Plans rules apply to all departments administering and all employees eligible for state benefits plans. (02/2017) Director Responsibilities
11-4. The Director will provide all benefits information, written directives and training to departments necessary for department benefits administrators to fulfill their responsibilities as delegated agents to the plans. (7/1/10)11-5. The Director has sole authority to determine eligibility, negotiate contracts, determine plan designs, set rates and coverage tiers, define the plan year, and establish open enrollment periods, in accordance with law, regulations, and approved funding. (7/1/10)11-6. The Director's online benefits administration system is the official system of record for all eligibility and enrollment transactions. (7/1/10) Department Responsibilities
11-7. All departments shall exercise due diligence when administering benefits in the best interests of the plans and all members. Benefits administrators are delegated agents of the Director in their respective departments. As a delegated agent of the Director, the responsibilities of the department benefits administrator(s) include, but are not limited to, the following: A. Know and comply with plan documents and basic plan features, law and regulations, rules, benefits administration system, deadlines, the Director's website, and written directives;B. Communicate, disseminate, explain, and answer questions on all benefits-related information including, but not limited to, options and changes, process, requirements and eligibility;C. Provide prompt notice of enrollment opportunities and information so employees can elect benefits during open enrollment or enroll within thirty-one (31) days of hire or an employee's notice of a qualified event. The first day (day 1 of the 31 days) is the day after hire or a qualified event; 1. Qualifying Life Events due to Medicare or Medicaid, allow for sixty (60) day notification period.2. Effective dates for all Qualifying Life Events, except for births and adoptions, are the first of the month following the date the event is entered into the benefits administration system. Effective dates for births and adoptions are the date of the event.D. Monitor deadlines and assist employees with meeting those deadlines;E. Provide employees with access to and training in the use of the benefits administration system, and assist employees with transactions;F. Refrain from advising an employee of which individual elections to make and assisting an employee in the commission of fraud or attempted fraud of a state benefits plan; andG. Process timely and accurate transactions and payments. This includes regular review of pending actions, supporting documentation, and system reports in order to promptly approve elections, terminate coverage, investigate suspicious or questionable actions or data, correct errors, and verify continuing dependent eligibility.11-8. These responsibilities apply to all departments, including those that offer their own separate group benefits plans to other employees not covered by the 24-50-Section 6 "State Employees Group Benefits Act". (7/1/10) Employee Responsibilities
11-9. Employees are responsible for knowing, understanding, and adhering to these rules, plan documents for the terms and conditions of coverage, and eligibility and enrollment requirements in order to make timely and informed choices, including, but not limited to, the following: A. Employees shall enter all required information in the benefits administration system in a timely and accurate manner in order to comply with eligibility and enrollment requirements for themselves and eligible dependents;B. Enrollment of employees and eligible dependents is restricted to initial hire, annual open enrollment, and Qualifying Life Events defined by law and plan documents. Elections are irrevocable for the plan year, except in limited circumstances specified by law or regulations.1. Any permitted enrollment, modification, or termination of enrollment shall be entered into the official benefits administration system within thirty-one (31) days before or after a Qualifying Life Event (sixty (60) days for Medicare and Medicaid Qualifying Life Events).a. Coverage changes are effective the first of the month following the date the Qualifying Life Event is entered into the benefits administration system except for births/adoptions where coverage is retroactive to the date of birth/adoption.b. Any supporting documentation required for the enrollment, modification, or termination of enrollment shall be submitted within forty-five () days of the qualifying event.c. For open enrollment only, the transactions shall be entered into the official benefits administration system with accompanying documentation within the allotted time established. (07/01/2022)2. Due dates are strictly enforced. Employees shall proactively communicate with their department benefits administrator before missing a deadline to determine if an extension can be provided due to unforeseen circumstances.3. Employees are responsible for verifying their benefit elections annually during open enrollment; and4. Employees who transfer from one (1) department to another shall notify both department benefits administrators to avoid a potential lapse in coverage.C. Employees shall remove any dependent by the end of the month in which the dependent ceases to meet eligibility requirements.1. Failure to do so may result in the employee's continuing financial liability for total premium (employee and employer contributions) and/or cost of paid claims for the ineligible dependent, as specified in law and regulations, plan documents, and these rules.D. Any enrollment or qualified change to enrollment constitutes authorization to begin or end payroll deductions. 1. Employees shall verify the accuracy of their payroll deductions and notify their department benefits administrator of any error. The notice shall be in writing and within fifteen (15) days from the pay date in which the first payroll deduction occurred.2. If an employee fails to notify the department of the payroll error within the fifteen (15) day period, the employee may continue to be liable for the election for the remainder of the plan year unless the election is not consistent with plan documents, rules, laws, regulations, and written directives.11-10. It is unlawful for any employee or dependent to intentionally provide false, incomplete, or misleading facts, information, or documents in written or electronic form, including within the benefits administration system for the purpose of defrauding or attempting to defraud the State of Colorado. The Director shall investigate when there is reason to believe an employee or dependent is committing or attempting to commit fraud against any state benefits plan. If the Director finds evidence of fraud or attempted fraud, the employee, dependent, or both may be subject to any or all of the following sanctions: (7/1/10)A. Immediate termination of coverage;B. Denial of future enrollment;C. Requirement to reimburse the state contributions and claims costs during the time of ineligible coverage;D. Filing of criminal charges; and/orE. Notice to the employee's department, which may take employment action, such as corrective or disciplinary action. Eligibility
11-11. Employees and their dependents shall meet the eligibility requirements as defined in state law, plan documents, and rules to qualify for enrollment in the state benefits plans. (7/1/10) A. Dependents may not enroll in the state benefits plans unless the employee is enrolled.B. If the employee and spouse/partner are both employees of the state;1. Each employee may be enrolled separately, or may be covered as a dependent of one of the spouse/partners, but not both.2. If both the employee and spouse/partner make a separate election under the state benefits plans, only one (1) parent may enroll children as dependents.11-12. Additional criteria and documentation requirements are contained in the State of Colorado Employees Group Benefits Plan, law and regulations, rule, and other written directives, which are available in the Division of Human Resources (DHR) Employee Benefits Unit. Dependents may be federal tax dependents (qualified) or non-tax dependents (non-qualified). Coverage for non- qualified dependents is subject to taxable income regulations. Eligible dependents are specified in statutes, primarily § 24-50-603(5), C.R.S., as modified or further defined by other state statutes.11-13. Legal documentation is required to add any dependent to a state benefits plans. (1/1/14) Coverage of Benefits
11-14. Initial coverage in state benefits plans is effective on the first (1st) day of the month following the date of hire or initial eligibility unless otherwise specified by the contracts, law, or regulations. (1/1/14)11-15. All coverage for a qualifying event is prospective from the beginning of the next month or the date of entry into the official benefits administration system, whichever is later, except for initial coverage for new employees and newborn children. (1/1/14)11-16. Elections made during open enrollment are effective the first (1st) day of the new plan year.11-17. Termination of coverage is subject to law and regulation, plan documents, and contracts, as well as the following rules. (7/1/10)A. If at any time during the plan year any dependent ceases to meet the eligibility criteria, coverage ends on the last day of the month in which that dependent becomes ineligible.B. Coverage in state benefits plans is terminated on the last day of the month that employment ends. Payment of Contributions
11-18. Departments shall make prompt monthly payments based on enrollment in the official benefits administration system. (7/1/10)A. The employee's current department as of the last day of the month is responsible for payment.B. A department is liable for both state and employee contributions when failing to promptly enter an employee termination.11-19. Employees shall make an irrevocable election for the plan year to have contributions deducted on a pre-tax or after-tax basis as defined by the State of Colorado Salary Reduction Plan, law and regulations, rule, and written directives. The employee's contribution is deducted from the employee's pay or, under certain circumstances, paid by personal payment for the selected state benefits plans, in arrears by the end of the month in which an employee is covered. (02/2017)11-20. An enrolled employee who works or is on paid leave one (1) or more regularly scheduled, full workdays in a month, is eligible for the full state benefits contribution. (7/1/10)11-21. When an employee is on leave, departments shall continue to pay the state contribution for noncontributory, fully paid benefits (e.g., basic life and short-term disability) as long as the employee remains on the payroll, regardless of status. The department shall contact the employee to arrange a payment plan for benefit contributions that will be owed for the duration of the employee's leave. A. During paid leave or mandatory furlough, the employee contribution continues to be paid through payroll deduction and the department continues to pay the state contribution.B. During unpaid leave, the employee shall pay the total premium (employee and employer contributions) to the department within the month of coverage, except as follows. 1. During unpaid leave pursuant to the Family Medical Leave Act of 1993, the department shall continue to pay the state contribution as long as the employee continues to pay the employee contribution by the due date specified in the family/medical leave notice. If the employee fails to pay the employee contribution when due, coverage will be terminated but shall be reinstated upon return to work with the exception of any benefit that will require late entrant underwriting for reinstatement. In the event any contributions are owed upon the employee's return to work, such contributions shall be collected from the employee. If the employee fails to return after the leave, any contributions due will be recovered as specified by federal regulations. (02/2017)2. While an employee is on voluntary furlough or short-term disability leave, the department shall continue to pay the state contribution as long as the employee continues to pay the employee contribution in a timely manner. If the employee fails to pay the employee contribution by the due date, coverage shall be terminated and the employee may reapply subject to late entrant underwriting. 3. While an employee is on FAMLI leave, the state continues to pay its portion of insurance premiums. The employee shall continue to pay their share of the cost of benefits as required prior to the commencement of leave. (12/1/2023)11-22. Refunds for employee and state contributions are subject to plan limitations and as defined in law and regulations, rule, and written directives. (7/1/10)11-23. When there is a difference between the contribution paid by the employee and the actual contribution due, the difference is paid by the employee. (e.g., change in coverage tier). (7/1/10) Director's Review of Benefits Appeals
11-24. The Director's Benefits Appeal Filing. All Director's Benefits Appeals are administratively processed through the Division of Human Resources (DHR) Employee Benefits Unit using the Colorado State Employees Group Benefits Eligibility Determination Appeal Form. A.The Director's Benefits Appeal. The Director's Benefits Appeal shall use the Colorado State Employees Group Benefits Eligibility Determination Appeal Form found on the DHR website.B.Contents of the Director's Benefits Appeal. The Director's Benefits Appeal contains the information for denial of eligibility for the state benefits plan.C. The filing of a timely Director's Benefits Appeal must meet the following criteria: 1. The Director's Benefits Appeal shall be filed with the DHR Employee Benefits Unit within thirty-one (31) days of the denial of eligibility for state benefits plans. The first day of the count is the day after the date on the notification and each calendar day thereafter.2. If a deadline falls on a weekend, official state holiday, or by governor order the deadline is extended to the next regular business day.3. Any filing via facsimile or email that is received by the DHR Employee Benefits Unit by 5:00 p.m. Colorado time shall be deemed to have been filed on that date.4. If the filing is through mail by the United States Postal Services, the date of filing is the postmark.5. Failure to timely file an appeal may result in the Director's Benefits Appeal being dismissed without a review.D.Where to File. Appeals and other documents may be filed by United States Postal Service, facsimile, or via email. 1. The mailing address for filing is Department of Personnel and Administration, Division of Human Resources Employee Benefits Unit, 1525 Sherman Street, Denver, Colorado 80203. a. Normal business hours for the DHR Employee Benefits Unit are from 8:00 a.m. to 5:00 p.m., Monday through Friday, except for official state holidays or days that state offices in Denver are closed due to weather or safety by governor order.2. The facsimile number is 303-866-3879. Facsimile filings may not exceed ten (10) pages.3. The DHR Employee Benefits Unit's email address is state_benefits@state.co.us.E. The Director will issue a final written decision within forty-five (45) days of receipt of the benefits appeal. 1. The ineligibility decision may be overturned only if found to be arbitrary, capricious or contrary to rule or law. Denial of Claims Appeals
11-25. Provider Denied Claim: Appeals of denied claims under any of the state benefits plans shall follow the specific appeal process defined in the specific contract, plan document, summary plan description, or regulated entity. The provider will issue a final written decision in accordance with its process. (7/1/10) A. Appeals of denied claims under fully insured plans are regulated by the State of Colorado Division of Insurance, and follow the plan's appeal process as defined in the contract and plan document.B. Appeals of denied claims under self-funded plans are not regulated by the State of Colorado Division of Insurance, and follow the third-party administrator's appeal process as defined in the contract and plan document. Colorado State Employee Assistance Program (CSEAP)
11-26. Services provided include but are not limited to counseling services, crisis intervention, consultations with supervisors and managers, facilitated groups, trainings, and workshops. (7/1/10)11-27. Any state employee and any participating departments or entities may use CSEAP services. State employees from non-participating departments or entities may have limited access to CSEAP services.A. Participating departments and entities and individual state employees from participating departments and entities may access or participate in all CSEAP services. Some services provided by CSEAP may include cost(s) incurred by the participating department or employees.B. Any individual state employee from a non-participating department or entity may access counseling and available open-access webinar services from CSEAP.C. Non-participating departments or entities may access limited CSEAP crisis counseling or critical incident response services regardless of whether the department or entity financially contributes to CSEAP. Availability of these services to non-participating departments is based upon available CSEAP resources.D. The program may include other persons if necessary to provide effective assistance to the employee.E. The Director will determine the number of sessions available to employees within a twelve (12) month period. Additional sessions may be authorized at the discretion of the counselor.11-28. Participating departments or entities are defined as those that make payments to any state fund or account that funds CSEAP. In the event that departments or entities do not contribute to the state risk management fund and/or other funding source for CSEAP, departments or entities may arrange payment (when a structure for payment exists) to the Department of Personnel and Administration for CSEAP services. Supplement State Contribution Program
11-29. State employees who are eligible to enroll in medical and dental benefits and have at least one (1) dependent child who will be or could be covered under state benefits may apply to the Supplement State Contribution Program. A child cannot be covered under Child Health Plan Plus (CHP+).11-30. Approval of application is subject to the established Supplement State Contribution Program's policy.11-31. Determination of the Supplement State Contribution Program is final and cannot be appealed, as it does not relate to eligibility.37 CR 22, November 25, 2014, effective 1/1/201537 CR 24, December 25, 2014, effective 1/14/201540 CR 02, January 25, 2017, effective 2/14/201740 CR 23, December 10, 2017, effective 1/1/201840 CR 24, December 25, 2017, effective 1/14/201842 CR 19, October 10, 2019, effective 11/1/201943 CR 05, March 10, 2020, effective 4/1/202043 CR 13, July 10, 2020, effective 8/1/202043 CR 24, December 25, 2020, effective 2/1/202144 CR 05, March 10, 2021, effective 4/1/202144 CR 07, April 10, 2021, effective 5/1/202144 CR 10, May 25, 2021, effective 7/1/202144 CR 12, June 25, 2021, effective 9/1/202145 CR 11, June 10, 2022, effective 7/1/202245 CR 14, July 25, 2022, effective 9/1/202246 CR 08, April 25, 2023, effective 7/1/202346 CR 21, November 10, 2023, effective 12/1/2023