STATE OF COLORADO HEALTH INSURANCE LAWS

What Rights Do I Have Regarding Health Insurance?

Adapted from a publication of the Colorado Department of Regulatory Agencies-Colorado Division of Insurance.

Introduction:

Colorado law provides you certain protections regarding health insurance.

All companies selling health insurance in Colorado are to make sure their members receive:

Important health insurance information
Fair treatment, and
Coverage for benefits allowed under an insurance contract

To know more about how the Colorado Division of Insurance can help you, call (303) 894-7490, or (800) 930-3745, or use the website at www.dora.state.co.us/insurance .

SELF INSURED PLANS

Single employer self-funded (self-insured) plans are not regulated by the Colorado Division of Insurance.

Some employers chose to self-insure, which means the employer acts as the health insurer for their employees. The employer actually pays the bills for their employees' health care, using an insurance company or third party administrator only to process the claims . These self-insured plans are exempt from Colorado Law (and thus the requirements outlined in this writing) but must meet rules set forth by federal law called ERISA . Check with your employer to find out if your plan is self-insured.

Consumer Rights

People covered by health insurance plans regulated by the State of Colorado have certain rights through state law. Some of these rights apply to all types of plans; others apply only to managed-care plans.

All Health Plans

Regardless of the type of health insurance plans you are insured under, you have a right to:

Coverage for certain mandated benefits.
Know exactly what your plan does and does not cover.
Contact your insurer to complain and appeal all plan decisions with which you disagree.
Receive a standardized form that outlines benefits for comparison between companies and between health plans. Your health insurer should provide you with this form.
Get a written explanation of the reason, if a health insurer denies your application for enrollment, or excluded a health condition you may have from coverage.
Prompt payment of claims.

Managed Care Plans

Managed care plans, including health maintenance organization (HMO) and preferred provider organization (PPO) plans, encourage or require the use of specific doctors and hospitals, and closely review appropriateness of services.

In addition to the rights listed in the previous section, if you are enrolled in a managed care plan you also have the right to:

Be informed by your doctor of all treatment options, even if they are not covered by your plan. Your doctor cannot be prevented from protesting a coverage denial issued by your insurer, or discussing his or her financial arrangements with a managed care company.
An adequate provider network. If your managed care network does not have a provider for a covered benefit, the health plan must arrange for an appropriate referral, at no additional cost to you, other than your normal coinsurance and deductible amounts.
Prompt notification if your regular doctor's contract is terminating.
A complete list of providers covered by the plan at the time of enrollment and reenrollment, or upon request.
Review a managed care company's Access Plan. The Access Plan must describe the company's provider network, referral procedures, system for ensuring coordination and continuity of care, and efforts to accommodate people with diverse background and capacities.

Special Protections For Small Employer Groups

Colorado has established special health insurance rules for small employer groups (those with 50 or fewer employees), including qualified self-employed persons and household employees.

Neither the group as a whole, nor particular employees or dependents in the group, can be denied health coverage because of a medical condition.
An insurance company cannot cancel a health policy except for failure to pay premiums or for fraud.
An insurance company cannot raise a particular small group's premiums because that group has high medical expenses.
Small employers have the right to buy coverage through one of Colorado 's health care coverage cooperatives. Cooperatives offer the employer a choice of health care plan from different insurers.

Your Complaint And Appeal Rights

All health plans must have written procedures for receiving and resolving complaints.

Information on complaint procedures can be found in your policy or membership booklet, or by calling your plan's customer service representative.

The most common complaint occurs when a health plan denies coverage for a service or procedure on the grounds that it is not medically necessary, appropriate, efficient or effective. In such cases, Colorado requires companies to have a two-level appeals process, followed by the right to an independent external review.

Refer to the Section titled: "What Happens When Your Health Insurance Company Says No" for detailed information on the appeals process.

If You Cannot Afford Private Insurance Coverage

Colorado has a number of special programs for those who cannot afford private health insurance for themselves and/or their children due to limited income. Examples are:

Medicaid

Medicaid is a state-federal health insurance program for persons with very low incomes who meet certain categorical eligibility requirements. For more information call 303-866-3513 or 1-800-221-3943.

If Medicaid covers you, you have additional rights. Medicaid clients enrolled in managed care plans have different complaint procedures than privately managed care plans

Child Health Plan Plus

This is a subsidized health insurance program for uninsured children with family incomes below 185% of the federal poverty level who are not eligible for Medicaid. For more information, call 1-800-359-1991.

Colorado Indigent Care Program

Colorado Indigent Care is a state program that provides partial reimbursement to providers for some of the care they provide eligible low-income uninsured and underinsured Coloradoans. For more information, call (303) 866-2580.

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