3 Colo. Code Regs. § 702-4-2-64-6
Current through Register Vol. 47, No. 24, December 25, 2024
Section 3 CCR 702-4-2-64-6 - Financial Requirements and Quantitative Treatment LimitationsA. Calculation of Substantially All and Predominant Level Benefits 1. Carriers shall not impose any financial requirement or quantitative treatment limitation to behavioral, mental health, or substance use disorders benefits in any classification that is more restrictive than the predominant financial requirement or treatment limitation applied to substantially all medical/surgical benefits in the same classification.2. Carriers shall not use any financial requirement or quantitative treatment limitation unless the carrier can provide verification that the following conditions have been met: a. Substantially All Test Carriers shall not apply any type of financial requirement or quantitative treatment limitation to behavioral, mental health, or substance use disorder benefits unless the financial requirement or treatment limitation applies to substantially all medical/surgical benefits in a permitted classification, which consists of no less than two-thirds (2/3) of the expected medical/surgical claims payments in that classification of benefits.
b. Predominant Level Test (1) If the financial requirement or quantitative treatment limitation applies to at least two-thirds (2/3) of the benefits in that classification, carriers shall not apply any specific level of financial requirement or treatment limitation to any behavioral, mental health, or substance use disorder benefit unless the financial requirement or quantitative treatment limitation applies to more than one-half (1/2) of the expected medical/surgical claims payments in that classification of benefits.(2) If a carrier determines that no one specific level of financial requirement or quantitative treatment level applies to more than one-half (1/2) of the expected claims for the classification, the carrier must use the least restrictive (lowest) amount that makes up one-half (1/2) of the expected claims. For example, if a carrier applies five (5) copayments in a particular classification of benefits, the carrier may use any combination of copayments to comprise this requirement. If the carrier utilizes the top three (3) copayments, the carrier shall use the lowest copayment of the three (3) as the behavioral, mental health, and substance use disorder copayment for that benefit classification.
3. Substantially All and Predominant Level Test Requirements a. The expected claim payments shall be based on the dollar amount of all plan payments for medical/surgical benefits in the classification expected to be paid under the plan for the plan year. If a carrier has sufficient plan-level claims data for a reasonable projection of expected claim payments, such claims data shall be used for the analysis. Other reasonable claims data may be used to project expected claim payments only if there is insufficient plan-level claims data. The assumptions used in choosing a data set and making projections shall be submitted to the Division if plan-level claims data are not used.
A reasonable and credible method shall be used to project the expected claim payments for medical/surgical benefits when performing the financial requirement or quantitative treatment limitation analysis. The method shall use appropriate and sufficient data to perform the analysis in compliance with applicable Actuarial Standards of Practice.
b. Carriers shall not consider estimated claims payments associated with behavioral, mental health, or substance use disorder benefits in the calculation.c. Carriers shall consider all estimated claims payments applying to the deductible and out-of-pocket maximum when calculating the deductible and out-of-pocket maximum applicability in determining if the deductible and out-of-pocket maximum apply to substantially all of the claims.B. Allowed Benefit Classifications The substantially all/predominant level test must be applied separately to these six (6) classifications of benefits:
2. Inpatient Out-of-Network;3. Outpatient In-Network, except that carriers may use the following sub-classifications: a. Office visits (such as physician visits); and b. All other outpatient services (such as outpatient surgery, facility charges for day treatment centers, laboratory charges, or other medical items);4. Outpatient Out-of-Network, except that carriers may use the following sub-classifications: a. Office visits (such as physician visits); and b. All other outpatient services (such as outpatient surgery, facility charges for day treatment centers, laboratory charges, or other medical items);C. Multiple In-Network Tiers 1. If a carrier provides benefits through multiple tiers of in-network providers (such as an in-network tier of preferred providers with more generous cost-sharing to members than a separate in-network tier of participating providers), the carrier may use those tiers to determine the appropriate behavioral, mental health, and substance use disorder benefits, if the tiering is based on reasonable factors determined in accordance with the rules in Section 7 of this regulation and without regard to whether a provider provides services with respect to medical/surgical benefits or behavioral, mental health, and substance use disorder benefits. Exceptions are as follows: a. Carriers shall not use any other type of tiers, including, but not limited, to intermediate services, intensive care, or any other tiers.b. Carriers shall not use different tiers for primary care providers and specialists in the outpatient classifications.2. After the tiers are established, the plan or issuers may not impose any financial requirement or treatment limitation on behavioral, mental health, and substance use disorder benefits in any tier that is more restrictive than the predominant financial requirement or treatment limitation that applies to substantially all medical/surgical benefits in the same tier.D. Other requirements1. Carriers shall not impose any type of financial requirement or quantitative treatment limitation on behavioral, mental health, or substance use disorder benefits that it does not impose on medical/surgical benefits.2. Carriers shall not impose annual maximums on the number of visits or dollar amounts for behavioral, mental health, or substance use disorder benefits.3. Carriers shall use a combined deductible for behavioral, mental health, and substance use disorder and medical/surgical benefits.4. Carriers shall use a combined out-of-pocket maximum for behavioral, mental health, and substance use disorder and medical/surgical benefits.5. Nothing in this section shall prohibit a carrier from: a. Providing some benefits that are subject to the deductible and other benefits that are not subject to the deductible within the same classification; orb. Applying, separately, a deductible or out-of-pocket maximum that differs between the in-network and out-of-network benefit levels, as long as the same deductible or out-of-pocket that applies to behavioral, mental health, or substance use disorder benefits applies to medical/surgical benefits.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