Colorado Insurance Laws and Cleft Coverage Mandates
Colorado Insurance
Law
and
Cleft Lip and
Cleft Palate Coverage
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Health Coverage in
Colorado – Pre-2014
Health Coverage
Subject to State Law –
Pre-2014
2014 Changes to the
Individual Health
Insurance Marketplace
Affordable Care Act (ACA)
Plans are “guaranteed-issue”
No more pre-existing exclusions
No more premium rate-ups due to
health conditions
2014 Changes to the
Individual Health
Insurance Marketplace
(continued)
No more exclusionary riders
Ability to qualify for help paying
premiums or with cost-sharing
requirements for plans purchased
via Connect for Health Colorado,
Colorado’s health insurance
exchange
When do Colorado
insurance laws apply?
Colorado insurance laws and
regulations only apply to health
plans sold in Colorado – does not
include:
Medicare or Medicaid
Employer plans that are self-
funded (aka ERISA self-funded
plans)
Or to…
Single employer plans where
the master contract is issued in
another state
Individual plans issued in
another state
How do I know if my
plan is a Colorado-
regulated plan?
Check your member ID card:
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If so, Colorado insurance laws
apply and the Division can help
you.
Cleft coverage mandates
in other states
•
California
•
Connecticut
•
Florida
•
Indiana
•
Louisiana
•
Maryland
•
Minnesota
•
Massachusetts
•
New York
•
North Carolina
•
South Carolina
•
Texas
•
Vermont
•
Virginia
•
Wisconsin
15 other states have some type of
mandated coverage*:
*
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Section 10-16-104(1)(c)(II),
Colorado Revised Statutes
Generally covers cleft lip, cleft palate, or
any condition or illness which is related
to or developed as a result of the cleft lip
or cleft palate and there is no age limit.
Provides medically necessary
coverage for:
Oral and facial surgery
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Coverage
(continued)
Surgical management and follow-
up care by plastic and oral
surgeons
Prosthetic treatment, such as:
Obturators
Speech appliances
Feeding appliances
Coverage
(continued)
Orthodontic treatment
Prosthodontic treatment
Habilitative speech therapy
Otolaryngology treatment
Audiological assessments and
treatment
Other Requirements
If there is also a dental policy:
•
It must provide full coverage for
all orthodontics or dental care
needed.
•
May apply the same copayment
provisions that apply to other
conditions or procedures covered
by the policy.
Where do I go to ask a
question or file a
complaint?
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Thank you!
DORA is dedicated to preserving the integrity of the
marketplace and is committed to promoting a fair and
competitive business environment in Colorado.
Consumer protection is our mission.
Explore the application of Colorado insurance laws to health plans, learn about cleft lip and cleft palate coverage mandates, and discover the changes in the individual health insurance marketplace in 2014. Additionally, find out how to identify if your plan is regulated by Colorado laws and discover other states with cleft coverage mandates.
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Presentation Transcript
Colorado Insurance Law and Cleft Lip and Cleft Palate Coverage Colorado Cleft Conference May 3, 2014 Dayle Axman, FLMI, ACS, AIE, AIS Colorado Division of Insurance
Health Coverage in Colorado Pre-2014
Health Coverage Subject to State Law Pre-2014
2014 Changes to the Individual Health Insurance Marketplace Affordable Care Act (ACA) Plans are guaranteed-issue No more pre-existing exclusions No more premium rate-ups due to health conditions
2014 Changes to the Individual Health Insurance Marketplace (continued) No more exclusionary riders Ability to qualify for help paying premiums or with cost-sharing requirements for plans purchased via Connect for Health Colorado, Colorado s health insurance exchange
When do Colorado insurance laws apply? Colorado insurance laws and regulations only apply to health plans sold in Colorado does not include: Medicare or Medicaid Employer plans that are self- funded (aka ERISA self-funded plans)
Or to Single employer plans where the master contract is issued in another state Individual plans issued in another state
How do I know if my plan is a Colorado- regulated plan? Check your member ID card: Does it have a CO-DOI designation on it? If so, Colorado insurance laws apply and the Division can help you.
Cleft coverage mandates in other states 15 other states have some type of mandated coverage*: California Connecticut Florida Indiana Louisiana Maryland Minnesota Massachusetts New York North Carolina South Carolina Texas Vermont Virginia Wisconsin * According to CleftAdvocate.org and the internet
Section 10-16-104(1)(c)(II), Colorado Revised Statutes Effective July 1, 1975 Generally covers cleft lip, cleft palate, or any condition or illness which is related to or developed as a result of the cleft lip or cleft palate and there is no age limit. Provides medically necessary coverage for: Oral and facial surgery
Coverage (continued) Surgical management and follow- up care by plastic and oral surgeons Prosthetic treatment, such as: Obturators Speech appliances Feeding appliances
Coverage (continued) Orthodontic treatment Prosthodontic treatment Habilitative speech therapy Otolaryngology treatment Audiological assessments and treatment
Other Requirements If there is also a dental policy: It must provide full coverage for all orthodontics or dental care needed. May apply the same copayment provisions that apply to other conditions or procedures covered by the policy.
Where do I go to ask a question or file a complaint? If you have a Colorado plan: Colorado Division of Insurance 303-894-7490 or 800-930-3745 File a complaint at: www.dora.colorado.gov/insurance
Other Resources If coverage is from Medicaid: Colorado Department of Health Care Policy and Financing 800-221-3943 If coverage is through an employer self-funded plan: U.S. Department of Labor, Employee Benefit Security Administration 816-285-1800 (Kansas City)
For more information about premium or other federal assistance, contact: Connect for Health Colorado 855-752-6749 connectforhealthco.com
Thank you! DORA is dedicated to preserving the integrity of the marketplace and is committed to promoting a fair and competitive business environment in Colorado. Consumer protection is our mission.
