Colorado Health Insurance Enforcement and Consumer Protections Grant Award

Cycle I Grant Application Summary

Colorado Grantee: Colorado Division of Insurance

Award Date: October 31, 2016

Total Award: $1,328,508

Baseline Award: $476,998

Selected Market Reforms Amount: $30,000

Workload Award Amount: $251,510

• Section 2707 - The Colorado Division of Insurance will investigate and make recommendations on best practices. The Division will refine a checklist to include checks on items that may be associated with discriminatory benefits, i.e., limitations on benefits for gender identity issues and limitations on treatment for chronic conditions. The Division will develop a tool to compare Essential Health Benefit benefit designs between products offered by carriers to ascertain which carriers are offering richer or poorer benefit designs. The Division will compare benefit levels between Metal plans to determine if increased cost sharing contributes to discrimination in benefit design. The Division will review commission schedules and contracts to determine if there are any tiers that may be related to prohibited marketing practices and will review zip code distribution to determine if there are certain zip codes that are underrepresented. The Division will also review formularies and create a standard operating procedure so that form filing reviewers can successfully review formularies and related documents. Finally, the Division will select a subset of the United State Pharmacopeia category and class and do a more in depth investigation of drugs or common diseases and conditions that are a higher cost to treat and therefore may be more likely to be limited.
• Section 2713 - The Colorado Division of Insurance will review company to consumer advertising, i.e., brochures, media, and social media, and Summaries of Benefits and Coverage, to determine if presentation of preventive benefits are consistent and in accordance with federal law, and to assure that it is clearly indicated that there are no cost shares associated with preventive benefits, especially related to women’s health care, including contraceptives, and childhood immunizations. The Division will review policies to assure that preventive benefits are clearly communicated and that it is clear that cost sharing does not apply. The Division will also review denied claims data to determine if claims for certain diagnoses codes are being denied or are subject to increased review. Finally, the Division will develop educational material and expand consumer-friendly outreach campaigns to help consumers understand their rights to preventive care.
• Section 2718 - The Colorado Division of Insurance will use the 24 Agreed Upon Procedures to review the Medical Loss Ratio (MLR). The Division will compare health insurance issuers’ Federal MLR Reporting Form against the Supplemental Health Care Exhibit that the issuer submitted to the state, ensuring that reporting is consistent. The Division will release a detailed report that delineates each MLR element that was tested and the results of the review.
• Section 2719 - The Colorado Division of Insurance will analyze data regarding the number of first level, voluntary second level (group only) external review appeals completed in the previous three calendar years. Based on the number of first and second level appeals that are upheld, the Division will select the insurers with less than a reasonable number of external appeals reported. These insurers will be examined to confirm that their policies and procedures are in compliance, and that the covered person was provided with adequate information to request an external review.
• Section 2726 - The Colorado Division of Insurance will train staff on how to identify substance abuse and mental health parity compliance. The Division will map cost share and benefit limitations between medical and surgical benefits and mental health and substance use disorder benefits. This will address concerns of permitting specialist cost shares rather than physician office visit cost shares. The Division will develop a parity compliance worksheet and then require all carriers to complete the worksheet for its plans. The worksheet will require the insurance plan issuer to submit data related to parity compliance including the financial requirements, Quantitative Treatment Limitations, and Non-Quantitative Treatment Limitations applied for both medical/surgical benefits and behavioral health benefits. The Division will also develop educational materials and expand consumer-friendly outreach campaigns to help consumers understand their rights under the mental health parity laws, including how to file appeals, and provide information about issuer non-compliance.