Department of Regulatory Agencies
Division of Insurance
3 ccr 702-4
Life, Accident and Health
Proposed Amended Regulation 4-6-5
CONCERNING SMALL EMPLOYER GROUP HEALTH BENEFIT PLANS AND THE BASIC AND STANDARD HEALTH BENEFIT PLANS
Section 1	Authority
Section 2	Scope and Purpose
Section 3	Applicability
Section 4	Rules
Section 5	Enforcement
Section 6	Severability
Section 7	Effective Date
Section 8	History
Section 1	Authority
This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§ 10-1-109, 10-16-105(7.2), 10-16-108.5(8), and 10-16-109, C.R.S.
Section 2	Scope and Purpose
The purpose of the amendment to this regulation is to adopt recommendations from the Health Benefit Plan Advisory Committee for changes to the basic and standard health benefit plans required to be offered to small employer groups and which are used for the purpose of conversion from group coverage as well as to incorporate other changes necessary for compliance with Colorado law comply with the enactment of Senate Bill 08-057, which mandates coverage of hearing aids for children under the age of 18 and House Bill 08-1410, concerning the coverage of colorectal cancer prevention services.  This regulation specifies the requirements for the basic and standard health benefit plans as well as other requirements for small employer carriers.
Section 3	Applicability
This regulation shall apply to all small employer carriers as defined in §10-16-102(41), C.R.S., and to all carriers required to provide conversion products pursuant to §10-16-108, C.R.S.
Section 4	Rules
A.	Plans
1.	Basic Plan.  The form and content of the basic health benefit plan may be one or more of the three plan design options as appended to this regulation and shall constitute the basic health benefit plan design pursuant to §10-16-105(7.2), C.R.S.  At least one of these three plan design options, two of which are high deductible, HSA-qualified plan options, shall be required for use in Colorado’s small employer group market pursuant to §10-16-105(7.3), C.R.S., and as conversion coverage pursuant to §10-16-108, C.R.S.  However, if the carrier chooses to offer more than one basic health benefit plan design, it shall offer all of its basic plan options to every small employer that expresses an interest in the basic health benefit plan or to those individuals purchasing a basic conversion plan.   
2.	Standard Plan.  The form and content of the standard health benefit plan, as appended to this regulation, shall constitute the standard health benefit plan required for use in Colorado's small employer group market pursuant to §10-16-105(7.3), C.R.S., and for use as conversion coverage pursuant to §10-16-108, C.R.S. 
B.	The basic and standard health benefit plans shall be identified as specified below.
1.	Each small employer carrier shall title and market its basic health benefit plan as follows: “[Carrier name] [Type of plan (i.e., Indemnity, Preferred Provider or HMO) (Basic Limited Mandate Health Benefit Plan, Basic HSA Health Benefit Plan or Basic HSA Limited Mandate Health Benefit Plan)] for Colorado”.
2.	Each small employer carrier shall title and market the standard health benefit plan as follows: “[Carrier name] [Type of plan (i.e., Indemnity, Preferred Provider, or HMO)] Standard Health Benefit Plan for Colorado”.
C.	a small employer carrier shall actively market the basic and standard health benefit plans to small employers in this state.
D.	In marketing the basic and standard health benefit plans to small employers, a small employer carrier shall use at least the same sources and methods of distribution that it uses to market other health benefit plans to small employers.  Any producer authorized by a small employer carrier to market health benefit plans to small employers in the state shall also be authorized to market the basic and standard health benefit plans.
E.	Disclosure Statement
1.	The following disclosure statement, prominently displayed in bold face capital letters no smaller than 14 point font for printed materials or in a clear and conspicuous manner for printed materials, electronic or internet-based communications shall appear on all small employer marketing materials (except the Colorado Health Benefit Plan Description Form pursuant to Colorado Insurance Regulation 4-2-20), the Colorado Small Group Uniform Employee Application form, small employer renewal notices, and on all written refusals to insure that are related to health coverage for a business group of one.
“Colorado insurance law requires all carriers in the small group market to issue any health benefit plan it markets in Colorado to small employers of 2-50 employees, including a basic or standard health benefit plan, upon the request of a small employer to the entire small group, regardless of the health status of any of the individuals in the group.  Business groups of one cannot be rejected under a basic or standard health benefit plan during open enrollment periods as specified by law.”
2.	“Clear and conspicuous” means with respect to a disclosure that the disclosure is reasonably understandable and designed to call attention to the nature and significance of the information it contains.  A disclosure is considered designed to call attention to the nature and significance of the information in it if the carrier:
a.	Uses a typeface and type size that are easy to read;
b.	Provides wide margins and ample line spacing;
c.	Uses boldface, underscoring, capitals or italics for key words and phrases; and
d.	In a form that combines the disclosure with other information, uses a plain-language heading to call attention to the disclosure portion of the document and uses a type size that is greater than the type size predominantly used in the rest of the document or uses style and graphic devices, such as shading or sidebars.
3.	If a disclosure is provided on a web page, the carrier must design its disclosure to call attention to the nature and significance of the information in it.  For example, the carrier uses text or visual cues to encourage scrolling down the page, if necessary, to view the entire disclosure.  The carrier must ensure that other elements on the web site (such as text, graphics, hyperlinks or sound) do not distract attention from the disclosure, and the carrier either: 
a.	Places the disclosure on a screen that consumers frequently access, such as a page on which transactions are conducted; or
b.	Places a link on a screen that consumers frequently access, such as a page on which transactions are conducted, that connects directly to the disclosure and is labeled appropriately to convey the importance, nature and relevance of the disclosure.
F.	Except as specified in §10-16-105.2(3), C.R.S., a small employer carrier shall offer the basic and standard health benefit plans along with all of its other small group plans to any small employer that applies for or makes an inquiry regarding health coverage from the small employer carrier.  The offer may be provided directly to the small employer or delivered through a producer.  The offer shall be in writing and shall include information as required by §10-16-105(5), C.R.S.
G.	Quotes
1.	A small employer carrier shall provide a price quote to a small employer (directly or through an authorized producer) within five (5) business days of receiving all information necessary to provide a requested quote.  Each price quote must be calculated using the carrier’s filed rate, as defined in Colorado Insurance Regulation 4-6-7.
2.	A small employer carrier shall notify a small employer (directly or through an authorized producer) within five (5) business days of receiving a request for a price quote if any additional information is needed.  If a small employer carrier provides a price quote prior to receiving all information necessary to calculate any premium adjustments allowed under §10-16-105(8.5)(a), C.R.S., that quote must be the filed rate.  The quote shall include a statement indicating that the rate is not final, and once all information is received, the rate will be recalculated using rating factors allowable by law, and may vary from the initial price quote.	
3.	A price quote shall be provided without requiring verification of the eligibility of the small group, including business groups of one.  The fact that a price quote has been issued shall not prevent the small employer carrier from verifying the group’s eligibility before issuing the coverage.
4.	A small employer carrier shall not apply more stringent or detailed requirements related to the price quote or application process for the basic and standard health benefit plans than are applied for other small group health benefit plans offered by the small employer carrier, except as allowed for underwriting business groups of one.
5.	Quotes for the basic and standard health benefit plans shall include quotes for each type of basic and standard health benefit plan the carrier markets (e.g., PPO, indemnity, HMO, HSA-qualified).
H.	If a small employer carrier denies coverage to a business group of one for any of its health benefit plans on the basis of risk characteristics, the denial shall be in writing and shall state with specificity the reasons for the denial (subject to any restrictions related to the confidentiality of medical information).  The written denial shall be accompanied by a written explanation of the availability of the basic and standard health benefit plans from the small employer carrier.  The explanation shall include at least the following:
1.	A copy of the Colorado Health Benefit Plan Description Form for each basic and standard health benefit plan offered by the small employer carrier;
2.	A price quote, in the manner required by Section 4.G. of this regulation, for each such plan if the business group of one is in its open enrollment period or a sample price quote reflecting current rates if the business group of one is not in its open enrollment period.  In the case of a sample price quote, the small employer carrier shall disclose that the actual rates may be different than the sample rates if there are changes in the small employer carrier’s filed rates or application of rating factors; and
3.	Information describing how the business group of one can enroll in such plans.  The explanation shall be provided directly to the business group of one or through an authorized producer within the time frames provided in Paragraphs G.1 and G.2.
I.	A small employer carrier shall establish and maintain a toll-free telephone service to provide information to small employers regarding the availability of small employer health benefit plans in this state.  The service shall provide information to callers on how to apply for coverage from the carrier.  The information may include the names and phone numbers of producers located geographically proximate to the caller or other such information that is reasonably designed to assist the caller to locate an authorized producer or otherwise apply for coverage through the carrier.
J.	A small employer carrier may not require, as a condition for the offer or sale of a basic or standard health benefit plan, that the small employer purchase or qualify for any other product, service, or association.
K.	A small employer carrier shall conform to the renewability requirements specified in §10-16-201.5, C.R.S.
L.	Small employer carriers shall elicit, at the time of application, information from applicants necessary to determine whether or not small group laws apply pursuant to §10-16-105.2(1), C.R.S.  If a small employer carrier fails to elicit this information, it shall be deemed to be on notice of any information that could reasonably have been attained if the small employer carrier had done so.
M.	Annual Report
1.	A small employer carrier shall file annually, on a form or in the manner specified by the Commissioner, information related to health benefit plans issued by the small employer carrier to small employers in this state.  This information may include, but is not limited to:
a.	The number of small employers that were issued health benefit plans in the previous calendar year;
b.	The number of small employers that were issued the basic health benefit plan and the standard health benefit plan in the previous calendar year;
c.	The number of individuals issued coverage under small employer plans who were uninsured for at least three months prior to their effective date of coverage;
d.	The total number of individuals, separated as to employees and dependents, insured under basic and standard health benefit plans in the previous calendar year; and
e.	The total number of individuals, separated as to employees and dependents, insured under all small employer health benefit plans.
2.	The information described in Paragraph M.1. shall be filed no later than March 1 of each year on the form or in the manner specified by the Commissioner.
Section 5	Enforcement
Noncompliance with this regulation is a violation of §10-3-1104, C.R.S., and subject to the sanctions specified in §10-3-1108, C.R.S., including the imposition of fines and the suspension or revocation of the certificate of authority.
Section 6	Severability
If any provision of this regulation is for any reason held to be invalid, the remainder of the regulation shall not be affected thereby.
Section 7	Effective Date 
This amended regulation is effective on March 1, 2008February 1, 2009.
Section 8	History
1.	Original regulation effective January 1, 1995.
2.	Amended regulation adopted recommended changes from Health Benefit Plan Advisory Committee to be effective January 1, 1996.
3.	Emergency amendment for exclusion of work related illnesses and injuries effective January 1, 1996.
4.	Amended regulation adopting emergency amendment as permanent effective April 1, 1996.
5.	Amended regulation adopting recommended changes from the Health Benefit Plan Advisory Committee effective January 1, 1997.
6.	Amended regulation incorporating changes required by 1997 legislation and recommendations of the Health Benefit Plan Advisory Committee effective January 1, 1998.
7.	Amended regulation incorporating recommendations from the Health Benefit Plan Advisory Committee effective January 1, 1999.
8.	Amended regulation incorporating recommendations from the Health Benefit Plan Advisory Committee effective January 1, 2000.
9.	Amended regulation, correcting errors in the Basic Indemnity Out-of-Pocket Maximum, the Basic PPO In-network Family Coinsurance, and the Standard Indemnity and PPO Maternity benefit.  Corrections effective January 1, 2000.
10.	Amended regulation incorporating recommendations from the Health Benefit Plan Advisory Committee effective January 1, 2001.
11.	Amended regulation incorporating recommendations from the Health Benefit Plan Advisory Committee effective January 1, 2002.
12.	Emergency regulation, effective January 1, 2003.
13.	Amended regulation effective February 1, 2003.
14.	Amended regulation effective January 1, 2004.
15.	Emergency Regulation 04-E-4 effective July 1, 2004.
16.	Emergency Regulation 04-E-9 effective September 29, 2004.
17.	Amended regulation effective November 1, 2004.
18.	Amended regulation effective January 1, 2006.
19.	Amended regulation effective January 1, 2008.
20.	Attachment 1 amended effective March 1, 2008.
21.	Amended regulation effective February 1, 2009.

BASIC AND STANDARD HEALTH BENEFIT PLAN POLICY REQUIREMENTS FOR 
THE STATE OF COLORADO
Colorado Division of Insurance
Effective January 1, 2008February 1, 2009
1.	The basic health benefit plan as defined by the Commissioner pursuant to §10-16-105(7.2)(b), C.R.S., for an indemnity, preferred provider organization (PPO), and health maintenance organization (HMO) plan shall include the specific benefits and coverages outlined in one of the attached tables labeled “Basic Limited Mandate Health Benefit Plan”, “Basic HSA Health Benefit Plan”, or “Basic HSA Limited Mandate Health Benefit Plan”.
2.	The standard health benefit plan for an indemnity, PPO, and HMO plan shall include the specific benefits and coverages outlined in the attached table labeled “Standard Health Benefit Plan”.
3.	All provisions of Title 10, Article 16 of the Colorado Revised Statutes that apply to small employer group plans shall apply to the basic and standard health benefit plans.
All other provisions of Title 10 which apply to group sickness and accident insurers, nonprofit health and hospital service corporations, and health maintenance organizations, and all rules and regulations related to those provisions, as they relate to small employer group plans, shall also apply.
4.	Modifications to the basic and standard health benefit plans (unless specifically stated otherwise in statute) shall apply to any basic or standard health benefit plan, whether group or conversion, when issued or renewed on or after the effective date specified above.
5.	All basic and standard health benefit plans shall also comply with the following requirements:
A.	Balance Billing:  In-network providers are prohibited from balance billing individuals covered under the basic or standard health benefit plan.  “Balance billing” refers to the practice whereby a provider bills an individual covered under the basic or standard health benefit plan for the difference between the amount the provider normally charges for a service and the amount the plan, policy, or contract recognizes as the allowable charge or negotiated price for the services delivered.
In the case of indemnity plans and out-of-network PPO plan benefits, carriers must alert those covered under the basic and standard health benefit plans to the fact that their provider is not prohibited from balance billing except as proscribed in §10-16-704, C.R.S.  Consumers should be encouraged to discuss the issue with their provider.
B.	Benefit Modifications:  The form and level of coverages specified in the tables labeled “Basic Limited Mandate Health Benefit Plan”, “Basic HSA Health Benefit Plan”, “Basic HSA Limited Mandate Health Benefit Plan” and “Standard Health Benefit Plan” may be expanded to add additional coverage through a rider or endorsement at the option of the policyholder only.
C.	Cost Containment:  In their basic and standard health benefit plans, carriers shall disclose whether or not, and to what extent, they use or require the use of the following cost containment approaches:  utilization review; second surgical opinions; pre-admission and pre-certification; use of non-physician primary care providers; alternative dispute resolution; and managed care.  For PPO plans, accumulations for deductibles and out-of-pocket maximums are calculated separately for in-network and out-of-network.  Carriers must disclose deductible and out-of-pocket maximum calculations on the Colorado Health Benefit Plan Description Form as required in Colorado Insurance Regulation 4-2-20.
Use of gatekeepers is encouraged but not required.  Carriers must offer the most managed care version of each indemnity, PPO, and/or HMO plan they offer in Colorado. A small employer carrier must offer the same choice of networks for its basic and standard health benefit plans as it offers for all of its other small group health benefit plans (e.g., if a carrier markets to small employers both a PPO plan with a broad network and one with a limited network, it must provide basic and standard PPO options using each of the networks).
D.	Eligibility:  “Actively at work” and “non-confinement” provisions are prohibited.
E.	Employer Contribution and Participation Requirements:  The employer contribution and participation requirements applied to the basic and standard health benefit plans shall be in compliance with §10-16-105(7.4), C.R.S.
F.	Enrollment:  To enroll an employee and dependents, the carrier shall require that:
1.	Employers:
a.	Submit a written request for coverage;
b.	Provide information necessary to determine eligibility; and
c.	Agree to pay the required premium.
2.	Eligible employees, on the Colorado Small Group Uniform Employee Application, a form made available by the employer:
a.	Submit a written request for coverage for himself/herself and any dependents; and
b.	Provide information necessary to determine eligibility, if it is required.
G.	Family Planning Services:  Family planning services must be included as a covered benefit under both the basic and standard health benefit plans.  At a minimum, family planning services shall include maternity care, prenatal and postnatal care and counseling, treatment and screening as appropriate for sexually transmitted diseases, sterilization, contraceptives, and contraception counseling.*
H.	Out-of-pocket Maximum:   All cost sharing (deductibles, coinsurance, copays), unless specifically noted otherwise, apply toward the annual out-of-pocket maximum.  After the out-of-pocket maximum is satisfied, benefits are paid at 100%.  PPO out-of-network, out-of-pocket maximum amounts are separate from the in-network, out-of-pocket maximum amounts.
I.	Primary Care Providers:  Carriers may use non-physician providers, such as certified nurse practitioners and physician’s assistants, as primary care providers under the basic and standard health benefit plans.  However, carriers are not mandated to include non-physician providers.
J.	Copays:  All coverages that have any type of flat dollar copay are not subject to the deductible except for the Basic Limited Mandate Health Benefit Plan’s prescription drug deductible.
K.	Deductibles:  None of the basic and standard health benefit plans that include deductibles provide fourth quarter carryover credit.  PPO out-of-network deductibles are separate from in-network deductibles.
L.	Usual, Customary and Reasonable Determinations:  For all basic and standard health benefit plans, each carrier shall use the same method of determining usual, customary and reasonable charge allowances as it uses for its most frequently sold non-basic, non-standard group health benefit plan in Colorado.
*  Infertility treatment and counseling, and abortion services shall be covered by a carrier under the basic and standard health benefit plans if such services are covered by the carrier under its most frequently sold non-basic, non-standard group health benefit plan in Colorado.  Benefits, including deductibles and copayments, shall be provided in accordance with the appropriate level of benefits in the Basic and Standard plans based on the type and location of the services provided (e.g., office visit, lab, X-ray, etc.).

[NOTE:  This benefit grid has been formatted to more closely conform to the Colorado Health Benefit Plan Description Form.  However, it does not reflect full compliance with that form as the intent is to provide carriers with a description of the plan benefits.]

January 1, 2008FEBRUARY 1, 2009 Colorado BASIC LIMITED MANDATE HEALTH BENEFIT PLANS: 
INDEMNITY, PPO AND HMO

PART A: TYPE OF COVERAGE
	BASIC INDEMNITY PLAN	BASIC PPO PLAN	BASIC HMO PLAN	
1.  TYPE OF PLAN	Medical expense policy	Preferred provider organization plan (PPO)	Health maintenance organization (HMO)	
2.  OUT-OF-NETWORK CARE COVERED? 1	Yes, policy makes no distinction between in- and out-of-network care.	Yes, but patient pays more for out-of-network care.	Only for emergency and urgent care.	
3.  AREAS OF COLORADO WHERE PLAN IS AVAILABLE	Plan is available throughout Colorado.	Varies by carrier.	Varies by HMO.	

PART B: SUMMARY OF BENEFITS
(Please note:  all coinsurance percentages listed are what the carrier will pay for the service.  For the HMO plan, the flat dollar or percentage copay listed is what the member will pay.)

	BASIC INDEMNITY PLAN	BASIC PPO  PLAN	BASIC HMO PLAN	
Basic LIMITED MANDATE 
Health Benefit Plan		IN-NETWORK	OUT-OF-NETWORK 2	IN-NETWORK ONLY (Out-of-network care is not covered except as noted.)	
4.	ANNUAL DEDUCTIBLE
(Deductibles do not apply to benefits with flat dollar copays except as noted.)			(Deductibles are separate from in-network deductibles)		
	a)	Individual	$  4,000	$ 4,000	$ 8,000	No deductible.	
         b)	Family	$  12,000	$ 12,000	$ 24,000	No deductible.	
5.      OUT-OF-POCKET ANNUAL MAXIMUM 3
            (Includes deductibles and coinsurance. Copays apply for the HMO plan only.  The prescription drug deductible and all prescription drug copays are excluded.)		(Excludes flat dollar copays.)	(Out-of pocket amounts are separate from in-network out-of-pocket amounts.)		
        a)	Individual		$ 12,000	$ 8,000 	$ 16,000	$ 6,000	
        b)	Family	$ 24,000	$ 16,000 	$ 32,000	$ 12,000	
5A.	COINSURANCE (amount paid by carrier) or COPAY (amount paid by insured/member)			50% coinsurance	70% coinsurance	50% coinsurance	Depends on the service, see details below. 4	
6.	LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE	$ 2 million	$ 5 million	No lifetime maximum.	
7A.	COVERED PROVIDERS	All providers licensed or certified to provide benefits.	List of covered in-network providers varies by carrier.	All providers licensed or certified to provide benefits.	List of covered providers varies by HMO.	
7B.	With respect to network plans, are all the providers listed in 7A accessible to me through my primary care physician?	Not applicable.  This is not a network plan.	Answer varies by carrier.	Not applicable.	Answer varies by HMO.	

8.	MEDICAL OFFICE VISITS 5
                      PCP
               Specialist
	
50% coinsurance
50% coinsurance	
$40 copay/visit
$60 copay/visit	
50% coinsurance
50% coinsurance	
$40 copay/visit
$60 copay/visit	
9.	PREVENTIVE CARE 6	For all plans, only specified preventive services are covered.	
a)	Children’s services  
          (No deductible prior to application
           of coinsurance.)	50% coinsurance	$40 copay/visit.	50% coinsurance	$40 copay/visit.	
         b)	Adults’ services 6a	50% coinsurance	$40 copay/visit.	50% coinsurance	$40 copay/visit.	
10.    MATERNITY 7		50% coinsurance	70% coinsurance
(A one-time $40 copay for all routine prenatal visits combined, then deductible and coinsurance apply to 
  all other services)	50% coinsurance	A one-time $40 copay for all routine prenatal visits combined; then applicable copays for type of service 8	
11.	PRESCRIPTION DRUGS 9
                 Deductible 
                (Must be satisfied prior to 
        application of copays.)	
$100 annual deductible per person	$100 annual deductible per person	$100 annual deductible per person
(Not included in out-of-pocket maximum)	
	(Deductible and copays do not apply to out-of-pocket maximums.)
	$20 copay preferred generic;
$50 copay preferred brand name
$70 copay non-
       preferred 9a	$20 copay preferred generic;

$50 copay preferred brand name

$70 copay non-preferred 9a	$20 copay preferred generic;
$50 copay preferred brand name
$70 copay non-
       preferred 9a	
12.	INPATIENT HOSPITAL	50% coinsurance	70% coinsurance	50% coinsurance	$500/day to $2,000 max per admission 10	
13.	OUTPATIENT/AMBULATORY SURGERY	50% coinsurance	70% coinsurance	50% coinsurance	$300 copay/visit10a	
14.	DIAGNOSTICS 11
a)  Laboratory & X-ray	
50% coinsurance
	
70% coinsurance
If these services are delivered  in conjunction with an office visit where a copay was charged, no additional copay or coinsurance requirement for lab & x-ray services applies.	
50% coinsurance
	
No copay
	
b)  MRI, Nuclear Medicine, CT, 
     CTA, MRA, and PET scans	50% coinsurance	70% coinsurance	50% coinsurance	$ 300 copay	
15.	EMERGENCY CARE 12, 13	50% coinsurance	$250 copay then carrier pays
70% coinsurance
(No deductible)	$250 copay/visit 14 for in- and out-of-network emergency care.	
16.	AMBULANCE	50% coinsurance	70% coinsurance	$100 copay	
		After satisfaction of in-network deductible.		
17.	URGENT, NON-ROUTINE, AFTER HOURS CARE	50% coinsurance	$100 copay	50% coinsurance	$100 copay/visit.  
Out-of-network urgent care covered only if temporarily out of service area.	
18.	BIOLOGICALLY BASED MENTAL ILLNESS 15 CARE	For all plans, coverage is no less extensive than the coverage for any other physical illness under that plan.	
19.	OTHER MENTAL HEALTH CARE 
	a)	Inpatient care
b)	Outpatient care	Excluded	Excluded	Excluded	
20.	ALCOHOL AND SUBSTANCE ABUSE 	Excluded	Excluded	Excluded	
21.	OUTPATIENT PHYSICAL, OCCUPATIONAL & SPEECH THERAPY 16	50% coinsurance
(Limited to 25 visits per therapy per year)	70% coinsurance
(Limited to 25 visits per therapy per year combined in and out-network)	50% coinsurance
Limited to 25 visits per therapy per year combined in and out-network)	$40 copay
(Limited to 25 visits per therapy per year)	
22.	DURABLE MEDICAL EQUIPMENT 17	50% coinsurance

$1,000/year maximum

	70% coinsurance	50% coinsurance	2030% copay

$1,000/year maximum
	
		$1,000/year maximum  
 (In-network deductible applies to network providers and the out-of-network deductible applies to out-of-network providers.  However, the maximum benefit is combined for in-network and out-of-network benefits.) 		
23.	OXYGEN	(Included under durable medical equipment)	(Included under durable medical equipment)	(Included under durable medical equipment)	
24.	ORGAN TRANSPLANTS 18

    (Organ Transplants continued.)
(Organ transplants, continued)	Covered transplants include: liver, heart, heart/lung, lung, cornea, kidney, kidney/pancreas, other single and multi-organ transplants, and bone marrow for Hodgkin's, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer, and Wiskott-Aldrich syndrome only.  Peripheral stem cell support is a covered benefit for the same conditions as listed above for bone marrow transplants.	
	50% coinsurance	70% coinsurance	50% coinsurance	Coverage is no less extensive than the coverage for any other physical illness.	
25.	HOME HEALTH CARE 18a	50% coinsurance
Limited to 60 visits per year	70% coinsurance	50% coinsurance	$20 copay per visit	
		Limited to 60 visits per year combined maximum	Limited to 60 visits per year	
26.	HOSPICE CARE 18a, 18b	50% coinsurance	70% coinsurance	50% coinsurance	$50 inpatient per diem copay
$20 outpatient per diem copay	
27.	SKILLED NURSING FACILITY CARE 19	50% coinsurance
(Not to exceed 100 days/year)	70% coinsurance
(Not to exceed 100 days/year)	50% coinsurance 
(Not to exceed 100 days/year)	$50 copay/day
(Not to exceed 100 days/year)	
28.	DENTAL CARE	For all plans, not covered except for dental care needed as a result of an accident.	
29.	VISION CARE	Excluded	Excluded	Excluded	Excluded	
30.	CHIROPRACTIC CARE	Excluded	Excluded	Excluded	Excluded	
31.   SIGNIFICANT ADDITIONAL SERVICES   (List up to 5)

a)  Hearing Aids 19a	None

Benefit level determined by place of service	None

Benefit level determined by place of service	None

Benefit level determined by place of service	None

Benefit level determined by place of service	

PART C:  LIMITATIONS AND EXCLUSIONS

	BASIC INDEMNITY PLAN	BASIC PPO PLAN	BASIC HMO PLAN	
Basic LIMITED MANDATE 
Health Benefit Plan		IN-NETWORK	OUT-OF-NETWORK		
32.	PERIOD DURING WHICH PRE-EXISTING CONDITIONS ARE NOT COVERED 20, 21	Business Groups of One:  Up to 12 months for all pre-existing conditions
Business Groups of 2 – 50:  Up to 6 months for all pre-existing conditions	Not applicable; plan does not impose limitation periods for pre-existing conditions.	
33.	EXCLUSIONARY RIDERS
	Can an individual’s specific, pre-existing condition be entirely excluded from the policy?	No	No	No	No	
34.	HOW DOES THE POLICY DEFINE A “PRE-EXISTING CONDITION”?	A pre-existing condition is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 months immediately preceding the date of enrollment or, if earlier, the first day of the waiting period; except that pre-existing condition exclusions may not be imposed on a newly adopted child, a child placed for adoption, a newborn, other special enrollees, or for pregnancy.	Not applicable.  Plan does not exclude coverage for pre-existing conditions.	
35.	WHAT TREATMENTS AND CONDITIONS ARE EXCLUDED UNDER THIS POLICY?	Standard exclusions, including benefits covered by employer liability laws; care that is not medically necessary; cosmetic care; custodial care; dental care except for accidents21a; educational training problems; experimental and investigational procedures; eye glasses and contact lenses; hearing aids and fitting21b; learning disorders; marital or social counseling; nursing home care except as specifically otherwise covered under this plan; sexual dysfunction, infertility treatment and counseling except as specifically otherwise covered under the policy requirements of this plan; TMJ; treatment for work-related illnesses and injuries except for those individuals who are not required to maintain or be covered by workers’ compensation insurance as defined by workers’ compensation laws 22; transplants except for those listed above; charges related to the surgical treatment of obesity; and war.	
1	"Network” refers to a specified group of physicians, hospitals, medical clinics and other health care providers that the plan may require the insured/member to use in order to get any coverage at all under the plan, or that the plan may encourage the insured/member to use because it may pay more of the bill if their network providers are used (i.e., go in-network) than if they aren’t used (i.e., go out-of-network).

2	Out-of-network cost sharing (deductibles, coinsurance, and out-of-pocket maximums) levels apply ONLY IF plan has network providers for the covered benefit and insured/member goes out of the network.  Otherwise, in-network levels apply.
3	“Out-of-pocket maximum” refers to the maximum amount the insured/member will have to pay for allowable covered expenses under a health plan, which includes the deductible, coinsurance and copays, as specified.  The deductible and copays for prescription drugs, however, are not applied to the out-of-pocket maximum.  Under this basic plan, copays for other than prescription drugs are applied to the out-of-pocket maximum on HMO plans only. 
4	However, notwithstanding the copay amounts listed in the Basic HMO Plan, under no circumstances, with the exception of the prescription drug benefit, shall the copay amount paid by the insured exceed 50% of charges for any single service.
5	“Medical office visits” include physician, mid-level practitioner, and specialist visits, including the provision of injections of injectable drugs and outpatient psychotherapy visits for biologically based mental illnesses.
6	See Attachment 1 for list of covered preventive services.  Immunizations for children up to age 13 shall be provided in accordance with Colorado Division of Insurance Bulletin 4.24.
6a	Prostate cancer screening and routine mammograms are not covered.  Colorectal cancer screenings are covered, but the coverage requirements mandated by §10-16-104(18), C.R.S., do not apply to the Basic Limited Mandate Health Benefit Plan.
7	Well-baby care includes an in-hospital newborn pediatric visit and newborn hearing screening.  Well-baby charges incurred during the hospital stay are covered under the mother’s deductible.
8	The hospital copay applies to mother and well baby together; there are not separate copays.
9	Includes expendable medical supplies for the treatment of diabetes.  Carriers are allowed to provide a mail order benefit or discount in the manner they do for their most frequently sold non-basic, non-standard group health benefit plan in Colorado.  Additionally, as noted above in footnote 3, prescription drug benefits, are not applied to the out-of-pocket maximums.  Coverage levels for injectable drugs are based on place of service (e.g., office: included under office visit copay; pharmacy: covered at appropriate copay level based on drug type).
9a	Prescription drugs otherwise excluded are not covered, regardless of whether preferred generic, preferred brand name, or non-preferred.  
10	Inpatient care includes all physician, surgical, and other services delivered during a hospital stay.
10a	Copay includes all physician, facility services and supplies delivered during the visit.
11	Includes diagnostic low dose mammography. (Routine mammography screenings are not covered.)  Diagnostic services do not include therapeutic treatment.
12	“Emergency care” means services delivered by an emergency care facility that are necessary to screen and stabilize a covered person.  The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed than an emergency medical condition or life or limb threatening emergency existed.  

13	Non-emergency care delivered in an emergency room is covered only if the covered person receiving such care was referred to the emergency room by his/her carrier or primary care physician.  If emergency departments are used by the plan for non-emergency after hours care, then urgent care coinsurance and copays apply.
14	Emergency copay is waived if patient is admitted to hospital since hospital copay would apply.
15	“Biologically based mental illnesses” means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. Outpatient psychotherapy visits for biologically based mental illnesses are covered at the same level as medical office visits.
16	Coverage for medically necessary therapeutic treatment only; benefits will not be paid for maintenance therapy after maximum medical improvement achieved, except as required by law for children under 6 years of age.  The services covered and the benefits provided for children under 6 years of age must be in accordance with the requirements of §10-16-104, C.R.S., subsections (1.3) and (1.7).
17	Coverage for lesser of purchase or rental price for medically necessary durable medical equipment.  DME includes, but is not limited to, home-administered oxygen, and reusable equipment for the treatment of diabetes, and prostheses.   Although tThe cost of all prosthetics devices does not applyies to the annual DME maximum, benefits for prosthetic devices for arms or legs (or any part thereof) themselves are not subject to this maximum. The benefit level for prosthetic devices for arms or legs or parts thereof shall be as required by §10-16-104(14), C.R.S.  Repair or replacement of defective equipment is covered at no additional charge; repair and replacement needed because of normal usage is covered, up to the annual maximum; and but repair and replacement needed due to misuse/abuse by the insured is not covered. 
18	Transplants will be covered only if they are medically necessary and meet clinical standards for the procedure.
18a	Covered services are defined in Colorado Insurance Regulation 4-2-8.  
18b	Although the number of days for this benefit is not limited, ancillary services, such as bereavement, shall be provided consistent with Colorado Insurance Regulation 4-2-8.
19	Coverage for medically necessary skilled nursing facility care only.  Benefits will not be paid for custodial care or maintenance care or when maximum medical improvement is achieved and no further significant measurable improvement can be anticipated.
19a	As of January 1, 2009, hearing aids for dependent children under the age of 18 are covered in compliance with §10-16-104(19), C.R.S.  The coverage includes the initial assessment, fitting, adjustments, and the required auditory training.  Initial hearing aids and replacement hearing aids are not covered more frequently than every five (5) years; however, a new hearing aid is covered when alterations to the existing hearing aid cannot adequately meet the needs of the child.  Hearing aids are not considered to be durable medical equipment.  Benefits shall be provided in the same manner as the same types of services for other covered conditions and are determined by where the hearing aid is accessed (i.e. an office visit copay will apply if the hearing aid is provided as part of an office visit).  Hearing aids are subject to utilization review as provided in §§10-16-112, 10-16-113, and 10-16-113.5, C.R.S.
20	“Waiver of pre-existing condition exclusions”.  State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage the insured/member recently may have had.   
21	The plan shall waive any time period applicable to a pre-existing condition limitation period for the period of time an individual was covered by creditable coverage, if such creditable coverage was continuous to a date not more than ninety days prior to the effective date of the new coverage.  Any waiting period before the effective date of the new coverage applied by the employer or the carrier shall not be considered a lapse of coverage and shall count toward satisfying any applicable pre-existing condition limitation.
21a	Dental care related to accidental injury:  treatment, supplies and appliances that are needed to restore the mouth, sound natural teeth or jaws to the condition they were in immediately prior to the accident.  The first dental services must be performed within 60 days of the accident unless the patient’s medical condition prohibits the initial dental care from being provided within that timeframe.  Only services provided within 12 months of the accident are covered.
21b	As of January 1, 2009, only hearing aids for dependent children under the age of 18 are covered in compliance with §10-16-104(19), C.R.S.
22	Except that, if a workers’ compensation policy is in place (although not required by state labor law), the workers’ compensation policy, not this plan, is responsible for medical benefits for work-related illnesses and injuries.  Also, if this plan is a federally qualified HMO plan, proof of workers’ compensation coverage, if such coverage is required by law, may be required as a condition of coverage if such proof is required on the HMO’s other small employer plans.

[NOTE:  This benefit grid has been formatted to more closely conform to the Colorado Health Benefit Plan Description Form.  However, it does not reflect full compliance with that form as the intent is to provide carriers with a description of the plan benefits.]

January 1, 2008FEBRUARY 1, 2009 Colorado BASIC HSA HEALTH BENEFIT PLANS:
INDEMNITY, PPO, AND HMO

PART A: TYPE OF COVERAGE

	BASIC INDEMNITY PLAN	BASIC PPO PLAN	BASIC HMO PLAN	
1.  TYPE OF PLAN	Medical expense policy	Preferred provider organization plan (PPO)	Health maintenance organization (HMO)	
2.  OUT-OF-NETWORK CARE COVERED? 1	Yes, policy makes no distinction between in- and out-of-network care.	Yes, but patient pays more for out-of-network care.	Only for emergency and urgent care.	
3.  AREAS OF COLORADO WHERE PLAN IS AVAILABLE	Plan is available throughout Colorado.	Varies by carrier.	Varies by HMO.	

PART B: SUMMARY OF BENEFITS
(Please note:  all coinsurance percentages listed are what the carrier will pay for the service.  For the HMO plan, the flat dollar or percentage copay listed is what the member will pay.)

	BASIC INDEMNITY PLAN	BASIC PPO PLAN	BASIC HMO PLAN	
Basic HSA 
Health Benefit Plan		IN-NETWORK	OUT-OF-NETWORK1a	IN-NETWORK ONLY (Out-of-network care is not covered except as noted.)	
4.	ANNUAL DEDUCTIBLE 2		For all plans, deductible applies to all services unless specifically noted.		
        a)     Single Coverage	$ 4,000	$ 4,000	$ 8,000	$ 4,000	
b)     Non-Single Coverage 
(Employee + Spouse or Employee + Children or Employee, Spouse and Children)	$ 8,000
	$ 8,000	$ 16,000
(Deductibles are separate from in-network deductibles.)	$ 8,000
	
5.     OUT-OF-POCKET ANNUAL MAXIMUM 3
(Includes deductibles, coinsurance and copays.)
a)	Single Coverage
b)	Non-Single Coverage
(Employee + Spouse or Employee + Children or Employee, Spouse and Children)					
	$ 5,500
$ 11,000	$ 5,500
$ 11,000	$ 11,000
$ 22,000
(Out-of pocket amounts are separate from in-network out-of-pocket amounts.)	$ 5,500
$ 11,000	
5A.	COINSURANCE (amount paid by carrier) or COPAY (amount paid by the insured/member)		
50% coinsurance	
70% coinsurance	
50% coinsurance	
30% copay	
6.	LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE	$ 2 million	$ 5 million	No lifetime maximum.	
7A.	COVERED PROVIDERS	All providers licensed or certified to provide benefits.	List of covered in-network providers varies by carrier.	All providers licensed or certified to provide benefits.	List of covered providers varies by HMO.	
7B.	With respect to network plans, are all the providers listed in 7A accessible to me through my primary care physician?	Not applicable.  This is not a network plan.	Answer varies by carrier.	Not applicable.	Answer varies by HMO.	

8.	MEDICAL OFFICE VISITS4
             PCP or Specialist    	
50% coinsurance	
70% coinsurance	
50% coinsurance	
30% copay	
9.	PREVENTIVE CARE 5	For all plans, only specified preventive services are covered.	
a)      Children’s services  
           (No deductible)	50% coinsurance	$40 copay/visit.	50% coinsurance	$40 copay/visit.	
b)	Adults’ services
           (No deductible)

c)	Colorectal screening 
         services 5a, 5b	50% coinsurance

50%
(Deductible does not apply.)	$40 copay/visit.

$40 copay
(Deductible does not apply.)	50% coinsurance

50%
(Deductible does not apply.)	$40 copay/visit.

$40 copay except as required by Footnote 5c	
10.    MATERNITY 6
(Deductible, coinsurance, and copay percentage apply to all services.)
	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
11.	PRESCRIPTION DRUGS  7, 8
       (Deductible and out-of-pocket 
         maximums apply.) 	50% coinsurance	50% coinsurance	50% coinsurance	50% copay	
12.	INPATIENT HOSPITAL 9	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
13.	OUTPATIENT/AMBULATORY 
         SURGERY	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
14.	DIAGNOSTICS 10					
         a)  Laboratory & X-ray	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
         b)  MRI, Nuclear Medicine, CT, CTA,
              MRA, and PET scans	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
15.	EMERGENCY CARE 11, 12	50% coinsurance	70% coinsurance
(In-network deductible applies regardless of where service is provided.)	30% copay	
16.	AMBULANCE	50% coinsurance	70% coinsurance	30% copay	
		After satisfaction of in-network deductible.		
17.	URGENT, NON-ROUTINE, AFTER 
         HOURS CARE	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
18.	BIOLOGICALLY BASED MENTAL 
         ILLNESS 13 CARE	For all plans, coverage is no less extensive than the coverage for any other physical illness under that plan.	
19.	OTHER MENTAL HEALTH CARE 14
	a)	Inpatient care
	
50% coinsurance.  Maximum 45 inpatient or 90 partial days/year.	
50% coinsurance.  Maximum 45 inpatient or 90 partial days/year.	
50% copay.  Maximum 45 inpatient or 90 partial days/year.	
	b)	Outpatient care	50% coinsurance.  Plan/Insurer pays a maximum of  $1,000 per year.	50% coinsurance.  Plan/Insurer pays a maximum of  $1,000 per year.
(In-network deductible applies to network providers and out-of-network deductible applies to out-of-network providers.  However, the maximum benefit is combined for in-network and out-of-network benefits.)	50% copay.  Plan pays a maximum of  $1,000 per year.	
20.	ALCOHOL AND SUBSTANCE 
         ABUSE 	Acute detox:  maximum 5 days per episode and 2 episodes per lifetime.  
Covered at 50% coinsurance. 	Acute detox:  maximum 5 days per episode and 2 episodes per lifetime.  
Covered at 50% coinsurance.
(In-network deductible applies to network providers and the out-of-network deductible applies to out-of-network providers.  However, the maximum benefit is combined for in-network and out-of-network benefits.)	Acute detox:  maximum 5 days per episode and 2 episodes per lifetime.  
Covered at 50% copay. 	
21.	OUTPATIENT PHYSICAL, 
         OCCUPATIONAL & SPEECH 
         THERAPY 15	50% coinsurance
(Limited to 25 visits per therapy per year)	70% coinsurance	50% coinsurance	30% copay
(Limited to 25 visits per therapy per year)	
		(Limited to 25 visits per therapy per year combined in- and out-network)		
22.	DURABLE MEDICAL EQUIPMENT 16	50% coinsurance

$1,000/year maximum	70% coinsurance	50% coinsurance	30% copay

$1,000/year maximum

		$1,000/year maximum
(In-network deductible applies to network providers and the out-of-network deductible applies to out-of-network providers.  However, the maximum benefit is combined for in- and out-of-network benefits.)			
23.	OXYGEN	(Included under durable medical equipment)	(Included under durable medical equipment)	(Included under durable medical equipment)	
24.	ORGAN TRANSPLANTS 17	Covered transplants include: liver, heart, heart/lung, lung, cornea, kidney, kidney/pancreas, other single and multi-organ transplants, and bone marrow for Hodgkin's, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer, and Wiskott-Aldrich syndrome only.  Peripheral stem cell support is a covered benefit for the same conditions as listed above for bone marrow transplants.	
	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
25.	HOME HEALTH CARE 17a	50% coinsurance
Limited to 60 visits per year 	70% coinsurance	50% coinsurance	30% copay	
		Limited to 60 visits per year combined maximum	Limited to 60 visits per year	
26.	HOSPICE CARE  17a, 18	50% coinsurance 
per diem	70% coinsurance 
per diem	50% coinsurance 
per diem	30% copay per diem	
27.	SKILLED NURSING FACILITY 
         CARE 19	50% coinsurance 
(Not to exceed 100 days/year)	70% coinsurance 
(Not to exceed 100 days/year)	50% coinsurance  
(Not to exceed 100 days/year)	30% copay
(Not to exceed 100 days/year)	
28.	DENTAL CARE	For all plans, not covered except for dental care needed as a result of an accident.	
29.	VISION CARE	Excluded	Excluded	Excluded	Excluded	
30.	CHIROPRACTIC CARE	Excluded	Excluded	Excluded	Excluded	
31.   SIGNIFICANT ADDITIONAL SERVICES   (List up to 5)

a)  Hearing Aids 19a	None

Benefit level determined by place of service	None

Benefit level determined by place of service	None

Benefit level determined by place of service	None

Benefit level determined by place of service	

PART C:  LIMITATIONS AND EXCLUSIONS

	BASIC INDEMNITY PLAN	BASIC PPO PLAN	BASIC HMO PLAN	
Basic HSA 
Health Benefit Plan		IN-NETWORK	OUT-OF-NETWORK		
32.	PERIOD DURING WHICH PRE-EXISTING CONDITIONS ARE NOT COVERED 20, 21	Business Groups of One:  Up to 12 months for all pre-existing conditions
Business Groups of 2 – 50:  Up to 6 months for all pre-existing conditions	Not applicable; plan does not impose limitation periods for pre-existing conditions.	
33.	EXCLUSIONARY RIDERS
	Can an individual’s specific, pre-existing condition be entirely excluded from the policy?	No	No	No	No	
34.	HOW DOES THE POLICY DEFINE A “PRE-EXISTING CONDITION”?	A pre-existing condition is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 months immediately preceding the date of enrollment or, if earlier, the first day of the waiting period; except that pre-existing condition exclusions may not be imposed on a newly adopted child, a child placed for adoption, a newborn, other special enrollees, or for pregnancy.	Not applicable.  Plan does not exclude coverage for pre-existing conditions.	
35.	WHAT TREATMENTS AND 
         CONDITIONS ARE EXCLUDED 
         UNDER THIS POLICY?	Standard exclusions, including benefits covered by employers liability laws; care that is not medically necessary; cosmetic care; custodial care; dental care except for accidents21a; educational training problems; experimental and investigational procedures; eye glasses and contact lenses; hearing aids and fitting21b; learning disorders; marital or social counseling; nursing home care except as specifically otherwise covered under this plan; sexual dysfunction, infertility treatment and counseling except as specifically otherwise covered under the policy requirements of this plan; TMJ; treatment for work-related illnesses and injuries except for those individuals who are not required to maintain or be covered by workers’ compensation insurance as defined by workers’ compensation laws 22; transplants except for those listed above; charges related to the surgical treatment of obesity; and war.	
1	“Network” refers to a specified group of physicians, hospitals, medical clinics and other health care providers that the plan may require the insured/member to use in order to get any coverage at all under the plan, or that the plan may encourage the insured/member to use because it may pay more of the bill if their network providers are used (i.e., go in-network) than if they aren’t used (i.e., go out-of-network).

1a	Out-of-network cost sharing (deductibles, coinsurance, and out-of-pocket maximums) levels apply ONLY IF plan has network providers for the covered benefit and insured/member goes out of the network.  Otherwise, in-network-levels apply.
2	“Annual Deductible”.  The stated annual deductible must be met prior to any benefits being payable except as otherwise indicated.
3	“Out-of-pocket maximum” refers to the maximum amount the insured/member will have to pay for allowable covered expenses under a health plan, which includes the deductible, copays, and coinsurance.  
4	“Medical office visits” include physician, mid-level practitioner, and specialist visits including the provision of injections of injectable drugs and outpatient psychotherapy visits for biologically based mental illnesses.
5	See Attachment 1 for list of covered preventive services.  Immunizations for children up to age 13 shall be provided in accordance with Colorado Division of Insurance Bulletin 4.24. 
5a	This benefit is effective for policies delivered, issued, renewed or reinstated on or after July 1, 2009. Coverage shall be provided for asymptomatic, average risk adults who are 50 years of age or older and covered persons who are at high risk for colorectal cancer, including covered persons who have a family medical history of colorectal cancer; a prior occurrence of cancer or precursor neoplastic polyps; a prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, Crohn’s disease, or ulcerative colitis; or other predisposing factors as determined by the provider.  Colorectal cancer screenings are covered prior to July 1, 2009; however, the requirements mandated by §10-16-104(18), C.R.S., do not apply until July 1, 2009.
5b	Benefits are provided for the following tests as determined by the provider to detect adenomatous polyps or colorectal cancer: modalities that are currently included in an “A” recommendation or a “B” recommendation of the U.S. Preventive Services Task Force, or any successor organization, sponsored by the Agency for Healthcare Research and Quality, the health services research arm of the federal Department of Health and Human Services.
5c	For an HMO that provides health care services directly to its enrollees, a 10% copay shall be assessed.  Services are covered only if they are rendered by a provider who is designated by and affiliated with the HMO.
6	Well-baby care includes an in-hospital newborn pediatric visit and newborn hearing screening.  Well-baby charges incurred during the hospital stay are covered under the mother’s deductible.
7	Includes expendable medical supplies for the treatment of diabetes.  Carriers are allowed to provide a mail order benefit or discount in the manner they do for their most frequently sold non-basic, non-standard group health plan in Colorado.  
8	Prescription drugs otherwise excluded are not covered.
9	Inpatient care includes all physician, surgical, and other services delivered during a hospital stay.
10	Includes diagnostic low dose mammography.  Routine mammograms are covered.  Diagnostic services do not include therapeutic treatment.
11	“Emergency care” means services delivered by an emergency care facility that are necessary to screen and stabilize a covered person.  The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed than an emergency medical condition or life or limb threatening emergency existed.  

12	Non-emergency care delivered in an emergency room is covered only if the covered person receiving such care was referred to the emergency room by his/her carrier or primary care physician.  If emergency departments are used by the plan for non-emergency after hours care, then urgent care coinsurance applies.
13	“Biologically based mental illnesses” means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. Outpatient psychotherapy visits for biologically based mental illnesses are covered at the same level as medical office visits.
14	Pursuant to §10-16-105(1), C.R.S., the following small employers may exclude mental health coverage from their plans:  any small employer who has not provided group sickness and accident insurance to employees after July 1, 1989, and any small employer who has provided group sickness and accident from a person or entity licensed pursuant to §10-3-903.5, C.R.S., that did not include mental health coverage after July 1, 1989.  However, carriers allowing for such an exclusion must follow all the relevant provisions of §10-16-105(2), C.R.S., relating to such an exclusion.
15	Coverage for medically necessary therapeutic treatment only; benefits will not be paid for maintenance therapy after maximum medical improvement achieved, except as required by law for children under 6 years of age.  The services covered and the benefits provided for children under 6 years of age must be in accordance with the requirements of §10-16-104, C.R.S., subsections (1.3) and (1.7).
16	Coverage for lesser of purchase or rental price for medically necessary durable medical equipment.  DME includes, but is not limited to, home-administered oxygen, and reusable equipment for the treatment of diabetes, and prostheses.   Although tThe cost of all prosthetics devices does not applyies to the annual DME maximum, benefits for prosthetic devices for arms or legs (or any part thereof) themselves are not subject to this maximum. The benefit level for prosthetic devices for arms or legs or parts thereof shall be as required by §10-16-104(14), C.R.S.  Repair or replacement of defective equipment is covered at no additional charge; repair and replacement needed because of normal usage is covered, up to the annual maximum; and but repair and replacement needed due to misuse/abuse by the insured is not covered 
17	Transplants will be covered only if they are medically necessary and meet clinical standards for the procedure.
17a	Covered services are defined in Colorado Insurance Regulation 4-2-8.
18	Although the number of days for this benefit is not limited, ancillary services, such as bereavement, shall be provided consistent with Colorado Insurance Regulation 4-2-8.
19	Coverage for medically necessary skilled nursing facility care only.  Benefits will not be paid for custodial care or maintenance care or when maximum medical improvement is achieved and no further significant measurable improvement can be anticipated.
19a	As of January 1, 2009, hearing aids for dependent children under the age of 18 are covered in compliance with §10-16-104(19), C.R.S.  The coverage includes the initial assessment, fitting, adjustments, and the required auditory training.  Initial hearing aids and replacement hearing aids are not covered more frequently than every five (5) years; however, a new hearing aid is covered when alterations to the existing hearing aid cannot adequately meet the needs of the child.  Hearing aids are not considered to be durable medical equipment.  Benefits shall be provided in the same manner as the same types of services for other covered conditions and are determined by where the hearing aid is accessed (i.e. an office visit copay will apply if the hearing aid is provided as part of an office visit).  Hearing aids are subject to utilization review as provided in §§10-16-112, 10-16-113, and 10-16-113.5, C.R.S. 
20	“Waiver of pre-existing condition exclusions”.  State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage the insured/member recently may have had. 

21	The plan shall waive any time period applicable to a pre-existing condition limitation period for the period of time an individual was covered by creditable coverage, if such creditable coverage was continuous to a date not more than ninety days prior to the effective date of the new coverage.  Any waiting period before the effective date of the new coverage applied by the employer or the carrier shall not be considered a lapse of coverage and shall count toward satisfying any applicable pre-existing condition limitation.
21a	Dental care related to accidental injury:  treatment, supplies and appliances that are needed to restore the mouth, sound natural teeth or jaws to the condition they were in immediately prior to the accident.  The first dental services must be performed within 60 days of the accident unless the patient’s medical condition prohibits the initial dental care from being provided within that timeframe.  Only services provided within 12 months of the accident are covered.
21b	As of January 1, 2009, only hearing aids for dependent children under the age of 18 are covered in compliance with §10-16-104(19), C.R.S.
22	Except that, if a workers’ compensation policy is in place (although not required by state labor law), the workers’ compensation policy, not this plan, is responsible for medical benefits for work-related illnesses and injuries.  Also, if this plan is a federally qualified HMO plan, proof of workers’ compensation coverage, if such coverage is required by law, may be required as a condition of coverage if such proof is required on the HMO’s other small employer plans. 

[NOTE:  This benefit grid has been formatted to more closely conform to the Colorado Health Benefit Plan Description Form.  However, it does not reflect full compliance with that form as the intent is to provide carriers with a description of the plan benefits.]

January 1, 2008FEBRUARY 1, 2009 Colorado BASIC HSA LIMITED MANDATE HEALTH BENEFIT PLANS:
INDEMNITY, PPO, AND HMO

PART A: TYPE OF COVERAGE

	BASIC INDEMNITY PLAN	BASIC PPO PLAN	BASIC HMO PLAN	
1.  TYPE OF PLAN	Medical expense policy	Preferred provider organization plan (PPO)	Health maintenance organization (HMO)	
2.  OUT-OF-NETWORK CARE 
     COVERED? 1	Yes, policy makes no distinction between in- and out-of-network care.	Yes, but patient pays more for out-of-network care.	Only for emergency and urgent care.	
3.  AREAS OF COLORADO WHERE 
     PLAN IS AVAILABLE	Plan is available throughout Colorado.	Varies by carrier.	Varies by HMO.	

PART B: SUMMARY OF BENEFITS
(Please note:  all coinsurance percentages listed are what the carrier will pay for the service.  For the HMO plan, the flat dollar or percentage copay listed is what the member will pay.)

	BASIC INDEMNITY PLAN	BASIC PPO PLAN	BASIC HMO PLAN	
Basic HSA Limited Mandate 
Health Benefit Plan		IN-NETWORK	OUT-OF-NETWORK1a	IN-NETWORK ONLY (Out-of-network care is not covered except as noted.)	
4.	ANNUAL DEDUCTIBLE 2		For all plans, deductible applies to all services unless specifically noted.		
a)      Single Coverage
b)     Non-Single Coverage 
(Employee + Spouse or Employee + Children or Employee, Spouse and Children)	$ 4,000
$ 8,000

	$ 4,000
$ 8,000

	$ 8,000
$ 16,000
(Deductibles are separate from in-network deductibles)	$ 4,000
$ 8,000

5.     OUT-OF-POCKET ANNUAL MAXIMUM 3
(Includes deductibles, coinsurance 
and copays.)					
a)	Single Coverage
b)     Non-Single Coverage
         (Employee + Spouse or 
Employee + Children or 
Employee, Spouse and Children)	$ 5,500
$ 11,000
	$ 5,500
$ 11,000
	$ 11,000
$ 22,000

(Out-of pocket amounts are separate from in-network out-of-pocket amounts.)	$ 5,500
$ 11,000
	
5A.	COINSURANCE (amount paid by carrier) or COPAY (amount paid by the insured/member)		
50% coinsurance	
70% coinsurance	
50% coinsurance	
30% copay	
6.	LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE	$ 2 million	$ 5 million	No lifetime maximum.	
7A.	COVERED PROVIDERS	All providers licensed or certified to provide benefits.	List of covered in-network providers varies by carrier.	All providers licensed or certified to provide benefits.	List of covered providers varies by HMO.	
7B.	With respect to network plans, are all the providers listed in 7A accessible to me through my primary care physician?	Not applicable.  This is not a network plan.	Answer varies by carrier.	Not applicable.	Answer varies by HMO.	

8.	MEDICAL OFFICE 
         VISITS 4 					
         PCP or Specialist	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
9.	PREVENTIVE CARE 5	For all plans, only specified preventive services are covered.	
         a)      Children’s services  
            (No deductible)	50% coinsurance	$40 copay/visit.	50% coinsurance	$40 copay/visit.	
b)	Adults’ services 5a
           (No deductible)	50% coinsurance	$40 copay/visit.	50% coinsurance	$40 copay/visit.	
10.    MATERNITY 6
(Deductible, coinsurance, and copay percentage apply to all services.)	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
11.	PRESCRIPTION DRUGS  7, 8
(Deductible and out-of-pocket
 maximums apply.)	50% coinsurance	50% coinsurance	50% coinsurance	50% copay	
12.	INPATIENT HOSPITAL 9	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
13.	OUTPATIENT/AMBULATORY 
         SURGERY	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
14.	DIAGNOSTICS 10					
         a)  Laboratory & X-ray	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
         b)  MRI, Nuclear Medicine, CT, 
              CTA, MRA, and PET scans	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
15.	EMERGENCY CARE 11, 12
	50% coinsurance	70% coinsurance
(In-network deductible applies regardless of where service is provided.)	30% copay	
16.	AMBULANCE	50% coinsurance	70% coinsurance	30% copay	
		After satisfaction of in-network deductible.		
17.	URGENT, NON-ROUTINE, AFTER 
         HOURS CARE	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
18.	BIOLOGICALLY BASED MENTAL 
         ILLNESS 13 CARE	For all plans, coverage is no less extensive than the coverage for any other physical illness under that plan.	
19.	OTHER MENTAL HEALTH CARE 
	a)	Inpatient care
	b)	Outpatient care	Excluded	Excluded	Excluded	Excluded	
20.	ALCOHOL AND SUBSTANCE 
         ABUSE 	Excluded	Excluded	Excluded	Excluded	
21.	OUTPATIENT PHYSICAL, 
         OCCUPATIONAL & SPEECH 
         THERAPY 14	50% coinsurance
(Limited to 25 visits per therapy per year)	70% coinsurance	50% coinsurance	30% copay
(Limited to 25 visits per therapy per year)	
		(Limited to 25 visits per therapy per year combined in- and out-network)		
22.	DURABLE MEDICAL EQUIPMENT 15	50% coinsurance
$1,000/year maximum	70% coinsurance	50% coinsurance	30% copay
$1,000/year maximum

		$1,000/year maximum
(In-network deductible applies to network providers and the out-of-network deductible applies to out-of-network providers.  However, the maximum benefit is combined for in-network and out-of-network benefits.)		
23.	OXYGEN	(Included under durable medical equipment)	(Included under durable medical equipment)	(Included under durable medical equipment)	
24.	ORGAN TRANSPLANTS 16	Covered transplants include: liver, heart, heart/lung, lung, cornea, kidney, kidney/pancreas, other single and multi-organ transplants, and bone marrow for Hodgkin's, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer, and Wiskott-Aldrich syndrome only.  Peripheral stem cell support is a covered benefit for the same conditions as listed above for bone marrow transplants.	
	50% coinsurance	70% coinsurance	50% coinsurance	30% copay	
25.	HOME HEALTH CARE 16a	50% coinsurance
Limited to 60 visits per year	70% coinsurance	50% coinsurance	30% copay	
		Limited to 60 visits per year combined maximum	Limited to 60 visits per year	
26.	HOSPICE CARE  16a, 16b	50% coinsurance 
per diem	70% coinsurance 
per diem	50% coinsurance 
per diem	30% copay 
per diem	
27.	SKILLED NURSING FACILITY 
         CARE 17	50% coinsurance (Not to exceed 100 days/year)	70% coinsurance (Not to exceed 100 days/year)	50% coinsurance  (Not to exceed 100 days/year)	30% copay
(Not to exceed 100 days/year)	
28.	DENTAL CARE	For all plans, not covered except for dental care needed as a result of an accident.	
29.	VISION CARE	Excluded	Excluded	Excluded	Excluded	
30.	CHIROPRACTIC CARE	Excluded	Excluded	Excluded	Excluded	
31.    SIGNIFICANT ADDITIONAL 
         SERVICES (List up to 5)

          a)  Hearing Aids 17a	None

Benefit level determined by place of service	None

Benefit level determined by place of service	None

Benefit level determined by place of service	None

Benefit level determined by place of service	

PART C:  LIMITATIONS AND EXCLUSIONS

	BASIC INDEMNITY PLAN	BASIC PPO PLAN	BASIC HMO PLAN	
Basic HSA Limited Mandate
Health Benefit Plan		IN-NETWORK	OUT-OF-NETWORK1a	IN-NETWORK ONLY (Out-of-network care is not covered except as noted.)	
32.	PERIOD DURING WHICH PRE-EXISTING CONDITIONS ARE NOT COVERED 18, 19	Business Groups of One:  Up to 12 months for all pre-existing conditions
Business Groups of 2 – 50:  Up to 6 months for all pre-existing conditions	Not applicable; plan does not impose limitation periods for pre-existing conditions.	
33.	EXCLUSIONARY RIDERS
	Can an individual’s specific, pre-existing condition be entirely excluded from the policy?	No	No	No	No	
34.	HOW DOES THE POLICY DEFINE A “PRE-EXISTING CONDITION”?	A pre-existing condition is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 months immediately preceding the date of enrollment or, if earlier, the first day of the waiting period; except that pre-existing condition exclusions may not be imposed on a newly adopted child, a child placed for adoption, a newborn, other special enrollees, or for pregnancy.	Not applicable.  Plan does not exclude coverage for pre-existing conditions.	
35.	WHAT TREATMENTS AND 
         CONDITIONS ARE EXCLUDED 
         UNDER THIS POLICY?	Standard exclusions, including benefits covered by employers liability laws; care that is not medically necessary; cosmetic care; custodial care; dental care except for accidents19a; educational training problems; experimental and investigational procedures; eye glasses and contact lenses; hearing aids and fitting19b; learning disorders; marital or social counseling; nursing home care except as specifically otherwise covered under this plan; sexual dysfunction, infertility treatment and counseling except as specifically otherwise covered under the policy requirements of this plan; TMJ; treatment for work-related illnesses and injuries except for those individuals who are not required to maintain or be covered by workers’ compensation insurance as defined by workers’ compensation laws 20; transplants except for those listed above; charges for surgical treatment of obesity; and war.	
1	“Network” refers to a specified group of physicians, hospitals, medical clinics and other health care providers that the plan may require the insured/member to use in order to get any coverage at all under the plan, or that the plan may encourage the insured/member to use because it may pay more of the bill if their network providers are used (i.e., go in-network) than if they aren’t used (i.e., go out-of-network).

1a	Out-of-network cost sharing (deductibles, coinsurance, and out-of-pocket maximums) levels apply ONLY IF plan has network providers for the covered benefit and insured/member goes out of the network.  Otherwise, in-network-levels apply.
2	“Annual Deductible”.  The stated annual deductible must be met prior to any benefits being payable except as otherwise indicated.
3	“Out-of-pocket maximum” refers to the maximum amount the insured/member will have to pay for allowable covered expenses under a health plan, which includes the deductible, copays, and coinsurance.  
4	“Medical office visits” include physician, mid-level practitioner, and specialist visits including the provision of injections of injectable drugs and outpatient psychotherapy visits for biologically based mental illnesses.
5	See Attachment 1 for list of covered preventive services.  Immunizations for children up to age 13 shall be provided in accordance with Colorado Division of Insurance Bulletin 4.24.
5a	Prostate cancer screening and routine mammograms are not covered.  Colorectal cancer screenings are covered, but the coverage requirements mandated by §10-16-104(18), C.R.S., do not apply to the Basic HSA Limited Mandate Health Benefit Plan.
6	Well-baby care includes an in-hospital newborn pediatric visit and newborn hearing screening.  Well-baby charges incurred during the hospital stay are covered under the mother’s deductible.
7	Includes expendable medical supplies for the treatment of diabetes.  Carriers are allowed to provide a mail order benefit or discount in the manner they do for their most frequently sold non-basic, non-standard group health plan in Colorado.
8	Prescription drugs otherwise excluded are not covered.
9	Inpatient care includes all physician, surgical, and other services delivered during a hospital stay.
10	Includes diagnostic low dose mammography.  (Routine mammograms are not covered.)  Diagnostic services do not include therapeutic treatment.
11	“Emergency care” means services delivered by an emergency care facility that are necessary to screen and stabilize a covered person.  The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed than an emergency medical condition or life or limb threatening emergency existed.  
12	Non-emergency care delivered in an emergency room is covered only if the covered person receiving such care was referred to the emergency room by his/her carrier or primary care physician.  If emergency departments are used by the plan for non-emergency after hours care, then urgent care coinsurance applies.
13	“Biologically based mental illnesses” means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. Outpatient psychotherapy visits for biologically based mental illnesses are covered at the same level as medical office visits.
14	Coverage for medically necessary therapeutic treatment only; benefits will not be paid for maintenance therapy after maximum medical improvement achieved, except as required by law for children under 6 years of age.  The services covered and the benefits provided for children under 6 years of age must be in accordance with the requirements of §10-16-104, C.R.S., subsections (1.3) and (1.7).

15	Coverage for lesser of purchase or rental price for medically necessary durable medical equipment.  DME includes, but is not limited to, home-administered oxygen, and reusable equipment for the treatment of diabetes, and prostheses.   Although tThe cost of all prosthetics devices does not applyies to the annual DME maximum, benefits for prosthetic devices for arms or legs (or any part thereof) themselves are not subject to this maximum. The benefit level for prosthetic devices for arms or legs or parts thereof shall be as required by §10-16-104(14), C.R.S.  Repair or replacement of defective equipment is covered at no additional charge; repair and replacement needed because of normal usage is covered, up to the annual maximum; and but repair and replacement needed due to misuse/abuse by the insured is not covered 
16	Transplants will be covered only if they are medically necessary and meet clinical standards for the procedure.
16a	Covered services are defined in Colorado Insurance Regulation 4-2-8.
16b	Although the number of days for this benefit is not limited, ancillary services, such as bereavement, shall be provided consistent with Colorado Insurance Regulation 4-2-8.
17	Coverage for medically necessary skilled nursing facility care only.  Benefits will not be paid for custodial care or maintenance care or when maximum medical improvement is achieved and no further significant measurable improvement can be anticipated.
17a	As of January 1, 2009, hearing aids for dependent children under the age of 18 are covered in compliance with §10-16-104(19), C.R.S.  The coverage includes the initial assessment, fitting, adjustments, and the required auditory training.  Initial hearing aids and replacement hearing aids are not covered more frequently than every five (5) years; however, a new hearing aid is covered when alterations to the existing hearing aid cannot adequately meet the needs of the child.  Hearing aids are not considered to be durable medical equipment.  Benefits shall be provided in the same manner as the same types of services for other covered conditions and are determined by where the hearing aid is accessed (i.e. an office visit copay will apply if the hearing aid is provided as part of an office visit).  Hearing aids are subject to utilization review as provided in §§10-16-112, 10-16-113, and 10-16-113.5, C.R.S.
18	“Waiver of pre-existing condition exclusions”.  State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage insured/member recently may have had.  
19	The plan shall waive any time period applicable to a pre-existing condition limitation period for the period of time an individual was covered by creditable coverage, if such creditable coverage was continuous to a date not more than ninety days prior to the effective date of the new coverage.  Any waiting period before the effective date of the new coverage applied by the employer or the carrier shall not be considered a lapse of coverage and shall count toward satisfying any applicable pre-existing condition limitation.
19a	Dental care related to accidental injury:  treatment, supplies and appliances that are needed to restore the mouth, sound natural teeth or jaws to the condition they were in immediately prior to the accident.  The first dental services must be performed within 60 days of the accident unless the patient’s medical condition prohibits the initial dental care from being provided within that timeframe.  Only services provided within 12 months of the accident are covered.
19b	As of January 1, 2009, only hearing aids for dependent children under the age of 18 are covered in compliance with §10-16-104(19), C.R.S.
20	Except that, if a workers’ compensation policy is in place (although not required by state labor law), the workers’ compensation policy, not this plan, is responsible for medical benefits for work-related illnesses and injuries.  Also, if this plan is a federally qualified HMO plan, proof of workers’ compensation coverage, if such coverage is required by law, may be required as a condition of coverage if such proof is required on the HMO’s other small employer plans. 

[NOTE:  This benefit grid has been formatted to more closely conform to the Colorado Health Benefit Plan Description Form.  However, it does not reflect full compliance with that form as the intent is to provide carriers with a description of the plan benefits.]

January 1, 2008FEBRUARY 1, 2009 Colorado STANDARD HEALTH BENEFIT PLANS: INDEMNITY, PPO, AND HMO

Part A: TYPE OF COVERAGE

	STANDARD INDEMNITY PLAN	STANDARD PPO PLAN	STANDARD HMO PLAN	
1.	TYPE OF PLAN	Medical expense policy	Preferred provider organization plan (PPO)	Health maintenance organization (HMO)	
2.	OUT-OF-NETWORK CARE COVERED? 1	Yes, policy makes no distinction between in- and out-of-network care.	Yes, but patient pays more for out-of-network care.	Only for emergency and urgent care.	
3.	AREAS OF COLORADO WHERE PLAN IS AVAILABLE	Plan is available throughout Colorado.	Varies by carrier.	Varies by HMO.	

PART B:  SUMMARY OF BENEFITS
(Please note:  all coinsurance percentages listed are what the carrier will pay for the service.  For the HMO plan, the flat dollar or percentage copay listed is what the member will pay.)
		STANDARD PPO PLAN	STANDARD HMO PLAN	
	STANDARD INDEMNITY PLAN	IN-NETWORK	OUT-OF-NETWORK 2	IN-NETWORK ONLY
(Out-of-network care is not covered except as noted.)	
4.	ANNUAL DEDUCTIBLE
(Deductibles do not apply to benefits with flat dollar copays.)			(Deductibles are separate from in-network deductibles) 	.	
       a)	Individual	$ 2,000	$ 1,500	$ 3,000	No deductible	
       b)	Family	$ 6,000	$ 4,500	$ 9,000	No deductible	
5.	OUT-OF-POCKET ANNUAL MAXIMUM 3
	(Includes deductibles and coinsurance. Copays apply for the HMO plan only.  All copays for prescription drugs are excluded.)		(Excludes flat dollar copays.)	(Out-of-pocket amounts are separate from in-network out-of-pocket amounts.)		
a)	Individual
	$ 4,000	$ 3,500 	$ 7,000	$ 3,000	
         b)	Family	$ 12,000	$ 7,000	$ 14,000	$ 6,000	
5A.	COINSURANCE (amount paid by carrier) or COPAY (amount paid by insured/member)		80% coinsurance	80% coinsurance	50% coinsurance	Depends on the service, see details below. 4	
6.	LIFETIME OR BENEFIT MAXIMUM PAID BY THE PLAN FOR ALL CARE	$ 2 million	$ 5 million	No lifetime maximum.	
7A.	COVERED PROVIDERS	All providers licensed or certified to provide benefits.	List of covered in-network providers varies by carrier.	All providers licensed or certified to provide benefits.	List of covered providers varies by HMO.	
7B.	With respect to network plans, are all the providers listed in 7A accessible to me through my primary care physician?	Not applicable.  This is not a network plan.	Answer varies by carrier.	Not applicable.	Answer varies by HMO.	

8.	MEDICAL OFFICE VISITS 5
         PCP
         Specialist	
80% coinsurance
80% coinsurance	
$25 copay/visit
$40 copay/visit	
50% coinsurance
50% coinsurance	
$25 copay/visit
$40 copay/visit	
9.	PREVENTIVE CARE 6	For all plans, only specified preventive services are covered.	
a)	Children’s services
          (No deductible prior to application of 
            coinsurance.)	80% coinsurance	$25 copay/visit	50% coinsurance	$25 copay/visit
	
         b)	Adults’ services
         c) 	Colorectal screening 
         services 6a, 6b	80% coinsurance
80%
(Deductible does not apply.)	$25 copay/visit
$25 copay
(Deductible does not apply.)	50% coinsurance
50%
(Deductible does not apply.)	$25 copay/visit
$25 copay 
except as required by Footnote 6c	
10.	MATERNITY 7		80% coinsurance
Deductible and coinsurance apply	80% coinsurance
(A one-time $25 copay for all routine prenatal visits combined,  then deductible and coinsurance for all other charges)	50% coinsurance	A one-time $25 copay for all routine prenatal visits combined; then applicable copays for type of service. 8	
11.	PRESCRIPTION DRUGS 9
(Copays do not apply to out-of-pocket maximums.)	$ 10 copay preferred generic;
$ 40 copay preferred brand name
$ 60 copay non-preferred 9a	$ 10 copay preferred generic;
$ 40 copay preferred brand name
$ 60 copay non-preferred 9a	$ 10 copay preferred generic;
$ 40 copay preferred brand name
$ 60 copay non-preferred 9a	$ 10 copay preferred generic;
$ 40 copay preferred brand name
$ 60 copay non-preferred 9a	
12.	INPATIENT HOSPITAL	80% coinsurance	80% coinsurance	50% coinsurance	$250/day to a max. of $1,000 per admission 10	
13.	OUTPATIENT/AMBULATORY SURGERY	80% coinsurance	80% coinsurance	50% coinsurance	$150 copay/visit10a	
14.	DIAGNOSTICS 11
a)  Laboratory & X-ray

	
80% coinsurance

	
80% coinsurance
If these services are delivered  in conjunction with an office visit  where a copay was charged, no additional copay or coinsurance requirement for lab & x-ray services applies.	
50% coinsurance

	
No copay for physician-ordered services.

	
b)  MRI, Nuclear Medicine, CT, CTA, 
      MRA, and PET scans	80% coinsurance	80% coinsurance	50% coinsurance	$150 copay	
15.	EMERGENCY CARE 12, 13
	80% coinsurance	$150 copay then plan pays 80% coinsurance
(No deductible.)	$150 copay/visit 14 for in- and out-of-network emergency care.	
16.	AMBULANCE	80% coinsurance	80% coinsurance	$100 copay	
		After satisfaction of in-network deductible.		
17.	URGENT, NON-ROUTINE, AFTER HOURS CARE	80% coinsurance	$75 copay/visit	50% coinsurance	$75 copay/visit
Out-of-network urgent care covered only if temporarily traveling out of service area.	
18.	BIOLOGICALLY BASED MENTAL ILLNESS 15 CARE	For all plans, coverage is no less extensive than the coverage for any other physical illness under that plan.	
19.	OTHER MENTAL HEALTH CARE 1716				
	a)	Inpatient care 1617	50% coinsurance
Maximum 45 inpatient or 90 partial days/year	50% coinsurance 
Maximum 45 inpatient or 90 partial days/year	50% copay
Maximum 45 inpatient or 90 partial days/year	
         b)	Outpatient care	50% coinsurance
Plan/carrier 
pays maximum $1,500/year	50% coinsurance
Plan/carrier pays maximum $1,500/year	50% copay
Plans pay maximum 20 visits or $1,500/year	
20.	ALCOHOL AND SUBSTANCE ABUSE 	Acute detox:  maximum 5 days per episode and 2 episodes per lifetime, 50% coinsurance.18	Acute detox:  maximum 5 days per episode and 2 episodes per lifetime, 
 50% coinsurance.18	Diagnosis, medical treatment & referral services.  50% copay.19	
					
21.	OUTPATIENT PHYSICAL, OCCUPATIONAL & SPEECH THERAPY 20	80% coinsurance
(Limited to 25 visits per therapy per year)	80% coinsurance	50% coinsurance	$25 copay
(Limited to 25 visits per therapy per year)	
		(Limited to 25 visits per therapy per year combined in and out-network)		
22.	DURABLE MEDICAL EQUIPMENT 21  
	80% coinsurance
$2,000/year maximum	80% coinsurance	50% coinsurance	20% copay
$2,000/year maximum
	
		$2,000/year maximum 
(In-network deductible applies to network providers and the out-of-network deductible applies to out-of-network providers.  However, the maximum benefit is combined for in-network and out-of-network benefits.)		
23.	OXYGEN	(Included under durable medical equipment)	(Included under durable medical equipment)	(Included under durable medical equipment)	
24.	ORGAN TRANSPLANTS 22

	Covered transplants include: liver, heart, heart/lung, lung, cornea, kidney, kidney/pancreas, other single and multi-organ transplants, and bone marrow for Hodgkin's, aplastic anemia, leukemia, immunodeficiency disease, neuroblastoma, lymphoma, high risk stage II and III breast cancer, and Wiskott-Aldrich syndrome only.  Peripheral stem cell support is a covered benefit for the same conditions as listed above for bone marrow transplants.	
	80% coinsurance	80% coinsurance	50% coinsurance	Coverage is no less extensive than the coverage for any other physical illness.	
25.	HOME HEALTH CARE 22a	80% coinsurance	80% coinsurance	50% coinsurance	No copay
(100% covered)	
26.	HOSPICE CARE 22a, 22b 	80% coinsurance 
per diem	80% coinsurance 
per diem	50% coinsurance 
per diem	No copay
(100% covered)	
27.	SKILLED NURSING FACILITY 
CARE 23 	80% coinsurance 
(Not to exceed 100 days/year)	80% coinsurance
(Not to exceed 100 days/year)	50% coinsurance 
(Not to exceed 100 days/year)	$50 copay/day
(Not to exceed 100 days/year)	
28.	DENTAL CARE	For all plans, not covered except for dental care needed as a result of an accident.	
29.	VISION CARE	Excluded	Excluded	Excluded	Excluded	
30.	CHIROPRACTIC CARE	No  [See 31(1)]	No  [See 31(1)]	No [See 31(1)]	No  [See 31(1)]	
31.    SIGNIFICANT ADDITIONAL SERVICES (List up to 5)					
	a)	Spinal manipulation
	b)	Hearing Aids 23a	80% coinsurance
Benefit level determined by place of service	80% coinsurance
Benefit level determined by place of service	50% coinsurance
Benefit level determined by place of service	$25 copay
Benefit level determined by place of service	

PART C:  LIMITATIONS AND EXCLUSIONS

STANDARD INDEMNITY PLAN	STANDARD PPO PLAN	STANDARD HMO PLAN	
		IN-NETWORK	OUT-OF-NETWORK		
32.	PERIOD DURING WHICH PRE-EXISTING CONDITIONS ARE NOT COVERED 24, 25	Business Groups of One:  Up to 12 months for all pre-existing conditions
Business Groups of 2 – 50:  Up to 6 months for all pre-existing conditions	Not applicable; plan does not impose limitation periods for pre-existing conditions.	
33.	EXCLUSIONARY RIDERS
	Can an individual’s specific, pre-existing condition be entirely excluded from the policy?	No	No	No	No	
34.	HOW DOES THE POLICY DEFINE A “PRE-EXISTING CONDITION”?	A pre-existing condition is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 months immediately preceding the date of enrollment or, if earlier, the first day of the waiting period; except that pre-existing condition exclusions may not be imposed on a newly adopted child, a child placed for adoption, a newborn, other special enrollees, or for pregnancy.	Not applicable.  Plan does not exclude coverage for pre-existing conditions.	

35.	WHAT TREATMENTS AND CONDITIONS ARE EXCLUDED UNDER THIS POLICY?	Standard exclusions, including benefits covered by employers liability laws; care that is not medically necessary; cosmetic care; custodial care; dental care except for accidents25a and anesthesia for dependent children as required by law; educational training problems; experimental and investigational procedures; eye glasses and contact lenses; hearing aids and fitting25b; learning disorders; marital or social counseling; nursing home care except as specifically otherwise covered under this plan; sexual dysfunction, infertility treatment and counseling except as specifically otherwise covered under the policy requirements of this plan; TMJ; treatment for work-related illnesses and injuries except for those individuals who are not required to maintain or be covered by workers’ compensation insurance as defined by workers’ compensation laws 26; transplants except for those listed above; charges related to the surgical treatment of obesity; and war.	
1	"Network” refers to a specified group of physicians, hospitals, medical clinics and other health care providers that the plan may require the insured/member to use in order to get any coverage at all under the plan, or that the plan may encourage the insured/member to use because it may pay more of the bill if their network providers are used (i.e., go in-network) than if they aren’t used (i.e., go out-of-network).

2	Out-of-network cost sharing (deductibles, coinsurance, and out-of-pocket maximums) levels apply ONLY IF plan has network providers for the covered benefit and insured/member goes out of the network.  Otherwise, in-network-levels apply.
3	“Out-of-pocket maximum” refers to the maximum amount the insured/member will have to pay for allowable covered expenses under a health plan, which includes the deductible, coinsurance and copayments, as specified. Copays for prescription drugs, however, are not applied to the deductible or out-of-pocket maximum.  Under the standard plans, copays for other than prescription drugs are applied to the out-of-pocket maximum on HMO plans only. 
 4	However, notwithstanding the copay amounts listed in this Standard HMO Plan, under no circumstances, with the exception of the prescription drug benefit, shall the copay amount paid by the insured exceed 50% of charges for any single service.
5	“Medical office visits” include physician, mid-level practitioner, and specialist visits, including the provision of injections of injectable drugs and outpatient psychotherapy visits for biologically based mental illnesses.
6	See Attachment 1 for list of covered preventive services.  Immunizations for children up to age 13 shall be provided in accordance with Colorado Division of Insurance Bulletin 4.24.
6a	This benefit is effective for policies delivered, issued, renewed or reinstated on or after July 1, 2009.  Coverage shall be provided for asymptomatic, average risk adults who are 50 years of age or older and covered persons who are at high risk for colorectal cancer, including covered persons who have a family medical history of colorectal cancer; a prior occurrence of cancer or precursor neoplastic polyps; a prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, Crohn’s disease, or ulcerative colitis; or other predisposing factors as determined by the provider.  Colorectal cancer screenings are covered prior to July 1, 2009; however, the requirements mandated by §10-16-104(18), C.R.S., do not apply until July 1, 2009.
6b	Benefits provided for the following tests as determined by the provider to detect adenomatous polyps or colorectal cancer: modalities that are currently included in an “A” recommendation or a “B” recommendation of the U.S. Preventive Services Task Force, or any successor organization, sponsored by the Agency for Healthcare Research and Quality, the health services research arm of the federal Department of Health and Human Services.
6c	For an HMO that provides health care services directly to its enrollees, a 10% copay shall be assessed.  Services are covered only if they are rendered by a provider who is designated by and affiliated with the HMO.
7	Well-baby care includes an in-hospital newborn pediatric visit and newborn hearing screening.  Well-baby charges incurred during the hospital stay are covered under the mother’s deductible.
8	The hospital copay applies to mother and well baby together; there are not separate copays.
9	Includes expendable medical supplies for the treatment of diabetes.  Carriers are allowed to provide a mail order benefit or discount in the manner they do for their most frequently sold non-basic, non-standard group health plan in Colorado.  Additionally, as noted above in footnote 3, prescription drug benefits are not subject to the deductible and the copays are not applied to the out-of-pocket maximums.  Coverage levels for injectable drugs are based on place of service (office: included under office visit copay; pharmacy: covered at appropriate copay level based on drug type).
9a	Prescription drugs otherwise excluded are not covered, regardless of whether preferred generic, preferred brand name, or non-preferred.  

10	Inpatient care includes all physician, surgical, and other services delivered during a hospital stay.
10a	Copay includes all physician, facility services and supplies delivered during the visit.
11	Includes low dose mammography screening not otherwise covered under the list of preventive care services, as mandated by Colorado law, §10-16-104(4), C.R.S.  Diagnostic services do not include therapeutic treatment.
12	“Emergency care” means services delivered by an emergency care facility that are necessary to screen and stabilize a covered person.  The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed than an emergency medical condition or life or limb threatening emergency existed.
13	Non-emergency care delivered in an emergency room is covered only if the covered person receiving such care was referred to the emergency room by his/her carrier or primary care physician.  If emergency departments are used by the plan for non-emergency after hours care, then urgent care coinsurance and copays apply.
14	Emergency copay is waived if patient is admitted to hospital since hospital copay would apply.
15	“Biologically based mental illnesses” means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. Outpatient psychotherapy visits for biologically based mental illnesses are covered at the same level as medical office visits; however, the copay amount paid by the insured/member shall not exceed 50% of the charge for any single office visit.
16	The day cost of residential care must be less than or equal to the cost of a partial day of hospitalization.  Each two days of residential or partial hospital care counts as one day of inpatient care.
176	Pursuant to §10-16-105(1), C.R.S., the following small employers may exclude mental health coverage from their plans:  any small employer who has not provided group sickness and accident insurance to employees after July 1, 1989, and any small employer who has provided group sickness and accident from a person or entity licensed pursuant to §10-3-903.5, C.R.S., that did not include mental health coverage after July 1, 1989.  However, carriers allowing for such an exclusion must follow all the relevant provisions of §10-16-105(2), C.R.S., relating to such an exclusion.
17	The day cost of residential care must be less than or equal to the cost of a partial day of hospitalization.  Each two days of residential or partial hospital care counts as one day of inpatient care.
18	Carriers shall also offer alcoholism coverage pursuant to §10-16-104(9), C.R.S., as may be amended.
19	Federally-qualified HMOs shall comply with the alcohol and drug abuse benefit for federally qualified HMOs pursuant to 42 C.F.R., Section 417.101 (a)(5).
20	Coverage for medically necessary therapeutic treatment only; benefits will not be paid for maintenance therapy after maximum medical improvement achieved, except as required by law for children under 6 years of age.  The services covered and the benefits provided for children under 6 years of age must be in accordance with the requirements of §10-16-104, C.R.S., subsections (1.3) and (1.7).

21	Coverage for lesser of purchase or rental price for medically necessary durable medical equipment.  DME includes, but is not limited to, home-administered oxygen, and reusable equipment for the treatment of diabetes, and prostheses.   Although tThe cost of all prosthetics devices does not applyies to the annual DME maximum, benefits for prosthetic devices for arms or legs (or any part thereof) themselves are not subject to this maximum. The benefit level for prosthetic devices for arms or legs or parts thereof shall be as required by §10-16-104(14), C.R.S.  Repair or replacement of defective equipment is covered at no additional charge; repair and replacement needed because of normal usage is covered, up to the annual maximum; and but repair and replacement needed due to misuse/abuse by the insured is not covered
22	Transplants will be covered only if they are medically necessary and meet clinical standards for the procedure.
22a	Covered services are defined in Colorado Insurance Regulation 4-2-8.
22b	Although the number of days for this benefit is not limited, ancillary services, such as bereavement, shall be provided consistent with Colorado Insurance Regulation 4-2-8.
23	Coverage for medically necessary skilled nursing facility care only.  Benefits will not be paid for custodial care or maintenance care or when maximum medical improvement is achieved and no further significant measurable improvement can be anticipated.
23a	As of January 1, 2009, hearing aids for dependent children under the age of 18 are covered in compliance with §10-16-104(19), C.R.S.  The coverage includes the initial assessment, fitting, adjustments, and the required auditory training.  Initial hearing aids and replacement hearing aids are not covered more frequently than every five (5) years; however, a new hearing aid is covered when alterations to the existing hearing aid cannot adequately meet the needs of the child.  Hearing aids are not considered to be durable medical equipment.  Benefits shall be provided in the same manner as the same types of services for other covered conditions and are determined by where the hearing aid is accessed (i.e. an office visit copay will apply if the hearing aid is provided as part of an office visit).  Hearing aids are subject to utilization review as provided in §§10-16-112, 10-16-113, and 10-16-113.5, C.R.S.
24	“Waiver of pre-existing condition exclusions”.  State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage the insured/member recently may have had. 
25	The plan shall waive any time period applicable to a pre-existing condition limitation period for the period of time an individual was covered by creditable coverage, if such creditable coverage was continuous to a date not more than ninety days prior to the effective date of the new coverage.  Any waiting period before the effective date of the new coverage applied by the employer or the carrier shall not be considered a lapse of coverage and shall count toward satisfying any applicable pre-existing condition limitation.
25a	Dental care related to accidental injury:  treatment, supplies and appliances that are needed to restore the mouth, sound natural teeth or jaws to the condition they were in immediately prior to the accident.  The first dental services must be performed within 60 days of the accident unless the patient’s medical condition prohibits the initial dental care from being provided within that timeframe.  Only services provided within 12 months of the accident are covered.
25b	As of January 1, 2009, only hearing aids for dependent children under the age of 18 are covered in compliance with §10-16-104(19), C.R.S.
26	Except that, if a workers’ compensation policy is in place (although not required by state labor law), the workers’ compensation policy, not this plan, is responsible for medical benefits for work-related illnesses and injuries.  Also, if this plan is a federally qualified HMO plan, proof of workers’ compensation coverage, if such coverage is required by law, may be required as a condition of coverage if such proof is required on the HMO’s other small employer plans. 

Attachment 1

Covered Preventive Services 1	
All Persons	1 smoking cessation education program benefit under physician supervision or as authorized by plan per lifetime, not to exceed $150 payment by insurer.	
	Chicken pox vaccination for all persons who have not had chicken pox.	
Females	Full cost of cervical cancer vaccine 1a	
All Children	Immunizations. 
Immunization deficient children are not bound by “recommended ages”.	
Age 0-12 months	1 newborn home visit during first week of life if newborn released from hospital less than 48 hours after delivery.	
	6 well-child visits 2	
	1 PKU	
Age 13-35 months	3 well-child visits	
Age 3-6	4 well-child visits	
Age 7-12	4 well-child visits	

Age 13-18	1 age appropriate health maintenance visit 3 every year	
	1 Td	
	Females: screening pap smears not to exceed 1 per year 	
	1 hepatitis B vaccination if not given previously	
1	Not all preventive services and screenings are specifically listed, but the list is considered to include all services and screenings deemed to be preventive by the Federal Department of the Treasury for HSA (health savings account) compliant plans.
1a	Age limitations as recommended by the U.S. Department of Health and Human Services’ Advisory Committee on Immunization Practices.
2	"Well-child visit" means a visit to a primary care provider that includes the following elements:  age appropriate physical exam (but not a complete physical exam unless this is age appropriate), history, anticipatory guidance and education (e.g., examine family functioning and dynamics, injury prevention counseling, discuss dietary issues, review age appropriate behaviors, etc.), and growth and development assessment.  For older children, this also includes safety and health education counseling.  The schedule of these visits, through age 12, is based on the recommendations of the American Academy of Pediatrics.
3	“Age appropriate health maintenance visit” means an exam which includes the following components:  age appropriate physical exam (but not a complete physical exam unless this is age appropriate), history, anticipatory guidance and education (e.g., examine family functioning and dynamics, discuss dietary issues, review health promotion activities of the patient, etc.), and exercise and nutrition counseling (including folate counseling for women of child bearing age).

Age 19-39	1 Td every ten years	
	1 age appropriate health maintenance visit every three years	
	1 fasting lipid panel	
	Females ages 35-39: 1 baseline screening mammogram and clinical breast exam 
(Mammograms is are not covered under the Basic Limited Mandate Health Benefit Plans and the Basic HSA Limited Mandate Health Benefit Plans.)	
	Females: screening pap smears not to exceed 1 per year	
Age 40-64	1 Td every ten years	
	1 fasting lipid panel every five years	
	Either annual fecal occult blood testing or 2 colorectal visualizations between ages 50 and 75 4	
	1 age appropriate health maintenance visit every 24 months	
	Females ages 40-49: 1 screening mammogram and clinical breast exam every 2 years (annually, if high risk) 
(Mammograms is are not covered under the Basic Limited Mandate Health Benefit Plans and the Basic HSA Limited Mandate Health Benefit Plans.)	
	Females ages 50-64: 1 screening mammogram and clinical breast exam every 12 months 
(Mammograms is are not covered under the Basic Limited Mandate Health Benefit Plans and the Basic HSA Limited Mandate Health Benefit Plans.)	
	Females: screening pap smears not to exceed 1 per year 	
	Males: Prostate screening as specified in state law 
(Not covered under the Basic Limited Mandate Health Benefit Plans and the Basic HSA Limited Mandate Health Benefit Plans.)	
Age 65 and older	1 influenza immunization every year	
	1 pneumococcal vaccine at or after age 65	
	Females: screening pap smears not to exceed 1 per year 	
	1 Td every ten years	
	1 age appropriate health maintenance visit every year	
	Females age 65 to 74:  1 screening mammogram and clinical breast exam every 12 months
(Mammograms is are not covered under the Basic Limited Mandate Health Benefit Plans and the Basic HSA Limited Mandate Health Benefit Plans.)	
	Either annual fecal occult blood testing or 2 colorectal visualizations between ages 50 and 75 4	
	Males: Prostate screening as specified in state law 
(Not covered under the Basic Limited Mandate Health Benefit Plans and the Basic HSA Limited Mandate Health Benefit Plans.)	
4	For policies delivered, issued, renewed or reinstated on or after July 1, 2009, the following colorectal screening services shall be provided: In compliance with §10-16-104(18), C.R.S., coverage shall be provided for the preventive health care services for asymptomatic, average risk adults who are 50 years of age or older and covered persons who are at high risk for colorectal cancer, including covered persons who have a family medical history of colorectal cancer; a prior occurrence of cancer or precursor neoplastic polyps; a prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, Crohn’s disease, or ulcerative colitis; or other predisposing factors as determined by the provider.  Colorectal cancer screenings are covered prior to July 1, 2009; however, the requirements mandated by §10-16-104(18), C.R.S., do not apply until July 1, 2009.  
Benefits are provided for the following tests as determined by the provider that detect adenomatous polyps or colorectal cancer: modalities that are currently included in an “A” recommendation or a “B” recommendation of the U.S. Preventive Services Task Force, or any successor organization, sponsored by the Agency for Healthcare Research and Quality, the health services research arm of the federal Department of Health and Human Services.
Coverage shall not be subject to policy deductibles, but copayments and/or coinsurance will apply as specified.  For an HMO that provides health care services directly to its enrollees, a 10% copay shall be assessed.  Services are covered only if they are rendered by a provider who is designated by and affiliated with the HMO.