SENATE BILL 23-179
BY SENATOR(S) Moreno and Will, Buckner, Coleman, Cutter, Exum,
Gonzales, Hansen, Hinrichsen, Jaquez Lewis, Marchman, Mullica, Priola;
also REPRESENTATIVE(S) Hartsook and Daugherty, Amabile, Bird,
Boesenecker, Brown, deGruy Kennedy, Dickson, Gonzales-Gutierrez,
Hamrick, Jodeh, Lindsay, Marshall, Michaelson Jenet, Ricks, Weissman,
Willford, Young, McCluskie.
C
ONCERNING INSURANCE CARRIER REQUIREMENTS FOR HEALTH COVERAGE
PLANS
, AND, IN CONNECTION THEREWITH , MAKING AN
APPROPRIATION
.
Be it enacted by the General Assembly of the State of Colorado:
SECTION 1. Legislative declaration. (1) The general assembly
finds and declares that:
(a) Access to quality dental care is an essential component of every
Coloradan's health and well-being, as untreated dental issues contribute to
a number of serious medical conditions, including chronic obstructive
pulmonary disease, heart disease, stroke, and preterm labor or premature
birth, all of which drastically increase costs to individuals and to the state;
NOTE: This bill has been prepared for the signatures of the appropriate legislative
officers and the Governor. To determine whether the Governor has signed the bill
or taken other action on it, please consult the legislative status sheet, the legislative
history, or the Session Laws.
________
Capital letters or bold & italic numbers indicate new material added to existing law; dashes
through words or numbers indicate deletions from existing law and such material is not part of
the act. (b) Meaningful insurance coverage is one of the most important
factors behind patients utilizing dental care services;
(c) Greater transparency on how premium dollars are spent by health
insurance carriers provides accountability for insurance plans and ensures
that patients get the most value for premiums paid;
(d) Patients should have visibility regarding how many of their
insurance premium dollars pay for health-care and dental services as
opposed to administrative, marketing, and operational costs;
(e) Medical loss ratio standards have been in place for health
insurance for more than 10 years;
(f) Dental plans in this state are not required to have equivalent
transparency and disclosure standards, known as dental loss ratios, in place;
(g) When patients and employers are comparing dental plans for
purchase, they should have access to information that shows how much
coverage is actually provided relative to what they pay in premiums for the
coverage;
(h) Bringing transparency to how much care the premiums are
actually paying for is an important step to drive efficiencies in care and
ensure value in patients' dental benefits; and
(i) As Colorado has long been a leader in policies that increase
transparency, value, accountability, and access to health care for consumers,
Colorado should continue to lead and provide protections for consumers in
accessing dental care coverage.
(2) In order to ensure dental care is accessible for all Coloradans, it
is critical that Colorado establish transparency and accountability for dental
plans.
SECTION 2. In Colorado Revised Statutes, 10-16-107, amend
(1)(a), (1)(f), (2)(a)(I) introductory portion, and (2)(b) as follows:
10-16-107. Rate filing regulation - benefits ratio - rules. (1) (a) A
carrier subject to part 2, 3, or
4, OR 5 of this article ARTICLE 16 shall not
PAGE 2-SENATE BILL 23-179 establish rates for any sickness, accident, or health insurance policy,
contract, certificate, or other evidence of coverage
OR DENTAL COVERAGE
PLAN
, AS DEFINED IN SECTION 10-16-165 (1)(a), issued or delivered to any
policyholder, enrollee, subscriber, or member in Colorado that are
excessive, inadequate, or unfairly discriminatory. To assure compliance
with the requirements of this section that rates are not excessive in relation
to benefits, the commissioner shall promulgate rules to require rate filings
and, as part of the rules, may require the submission of adequate
documentation and supporting information, including actuarial opinions or
certifications and set expected benefits ratios. The carrier shall submit
expected rate increases to the commissioner at least sixty days prior to the
proposed implementation of the rates. If the commissioner does not approve
or disapprove the rate filings within a sixty-day period, the carrier may
implement and reasonably rely upon the rates on the condition that the
commissioner may require correction of any deficiencies in the rate filing
upon later review if the rate the carrier charged is excessive, inadequate, or
unfairly discriminatory. A prospective rate adjustment is the sole remedy for
rate deficiencies pursuant to this subsection (1). If the commissioner finds
deficiencies in the rate filing after a sixty-day period, the commissioner
shall provide notice to the carrier, and the carrier shall correct the rate on a
prospective basis.
(f) Carriers shall file rate filings for insurance regulated under parts
1 to 4
5 of this article ARTICLE 16 electronically in a format made available
by the division, unless exempted by rule for an emergency situation as
determined by the commissioner. The division shall post on its website a
rate filing summary for insurance regulated under parts 1 to 4
5 of this
article ARTICLE 16 in order to provide notice to the public.
(2) (a) (I) Rates for an individual health coverage plan issued or
delivered to any policyholder, enrollee, subscriber, or member in Colorado
by an insurer subject to part 2 of this article 16 or an entity subject to part
3, or
4, OR 5 of this article 16 shall not be excessive, inadequate, or unfairly
discriminatory to assure compliance with the requirements of this section
that rates are not excessive in relation to benefits. Rates are excessive if
they are likely to produce a long run profit that is unreasonably high for the
insurance provided or if expenses are unreasonably high in relation to
services rendered. In determining if rates are excessive, the commissioner
may consider:
PAGE 3-SENATE BILL 23-179 (b) Notwithstanding any other provision of this article ARTICLE 16,
a carrier subject to part 2, 3, or 4, OR 5 of this article ARTICLE 16 shall not
vary the premium rate for an individual health coverage plan due to the
gender of the individual policyholder, enrollee, subscriber, or member. Any
premium rate based on the gender of the individual policyholder, enrollee,
subscriber, or member is unfairly discriminatory and is not allowed.
SECTION 3. In Colorado Revised Statutes, add 10-16-165 as
follows:
10-16-165. Dental coverage plans - dental loss ratio - rules -
definitions. (1) A
S USED IN THIS SECTION, UNLESS THE CONTEXT
OTHERWISE REQUIRES
:
(a) "C
OMMUNITY BENEFIT EXPENDITURE " MEANS AN EXPENDITURE
FOR AN ACTIVITY OR PROGRAM
, OR TO AN ORGANIZATION, WHICH SEEKS TO
ACHIEVE THE OBJECTIVES OF IMPROVING ACCESS TO DENTAL SERVICES AND
ENHANCING DENTAL PUBLIC HEALTH
. THIS INCLUDES AN ACTIVITY THAT:
(I) I
S AVAILABLE BROADLY TO THE PUBLIC AND SERVES LOW -INCOME
CONSUMERS
;
(II) R
EDUCES GEOGRAPHIC, FINANCIAL, OR CULTURAL BARRIERS TO
ACCESSING DENTAL SERVICES
, AND IF THE ACTIVITY CEASED TO EXIST
WOULD RESULT IN ACCESS PROBLEMS
;
(III) A
DDRESSES ORAL HEALTH WORKFORCE SHORTAGES , SUCH AS
ADVANCING EDUCATION AND TRAINING OF ORAL HEALTH PROFESSIONALS
;
OR
(IV) LEVERAGES OR ENHANCES DENTAL PUBLIC HEALTH ACTIVITIES .
(b) "D
ENTAL COVERAGE PLAN" MEANS A HEALTH COVERAGE PLAN
THAT INCLUDES COVERAGE FOR THE COSTS OF DENTAL CARE SERVICES
.
"D
ENTAL COVERAGE PLAN" INCLUDES A PLAN ISSUED BY A PREPAID DENTAL
PLAN ORGANIZATION THAT HAS A CERTIFICATE OF AUTHORITY TO OPERATE
PURSUANT TO PART
5 OF THIS ARTICLE 16.
(c) (I) "D
ENTAL LOSS RATIO" MEANS THE PERCENTAGE OF PREMIUM
DOLLARS COLLECTED EACH YEAR FOR A DENTAL COVERAGE PLAN THAT THE
PAGE 4-SENATE BILL 23-179 DENTAL COVERAGE PLAN INCURS ON DENTAL SERVICES PROVIDED TO AN
ENROLLEE
, SEPARATE FROM OVERHEAD AND ADMINISTRATIVE COSTS .
(II) T
HE DENTAL LOSS RATIO IS CALCULATED BY DIVIDING THE
NUMERATOR BY THE DENOMINATOR
, WHERE:
(A) T
HE NUMERATOR IS THE SUM OF THE AMOUNT INCURRED FOR
CLINICAL DENTAL SERVICES PROVIDED TO ENROLLEES
, THE AMOUNT
INCURRED ON ACTIVITIES THAT IMPROVE DENTAL CARE QUALITY
, AND THE
AMOUNT OF CLAIMS PAYMENTS IDENTIFIED THROUGH FRAUD REDUCTION
EFFORTS
; AND
(B) THE DENOMINATOR IS THE TOTAL AMOUNT OF PREMIUM
REVENUE
, EXCLUDING FEDERAL AND STATE TAXES , LICENSING AND
REGULATORY FEES PAID
, NONPROFIT COMMUNITY BENEFIT EXPENDITURES ,
AND ANY OTHER PAYMENTS REQUIRED BY FEDERAL LAW .
(2) (a) T
HE COMMISSIONER SHALL DEFINE BY RULE :
(I) E
XPENDITURES FOR CLINICAL DENTAL SERVICES ;
(II) A
CTIVITIES THAT IMPROVE DENTAL CARE QUALITY ;
(III) O
VERHEAD AND ADMINISTRATIVE COST EXPENDITURES ; AND
(IV) NONPROFIT COMMUNITY BENEFIT EXPENDITURES THAT ARE
ALIGNED WITH EXCLUSION PARAMETERS AND LIMITS OUTLINED IN
45 CFR
158.162;
EXCEPT THAT THE COMMISSIONER SHALL ENSURE THAT ONLY
EXPENDITURES THAT IMPROVE ACCESS TO DENTAL SERVICES OR ENHANCE
DENTAL HEALTH
, AND NO OVERHEAD OR ADMINISTRATIVE COSTS , ARE
REPORTED UNDER THIS SECTION
.
(b) T
HE DEFINITIONS PROMULGATED BY RULE PURSUANT TO THIS
SECTION MUST BE CONSISTENT WITH SIMILAR DEFINITIONS THAT ARE USED
FOR THE REPORTING OF MEDICAL LOSS RATIOS BY CARRIERS OFFERING
HEALTH BENEFIT PLANS IN THE STATE
. OVERHEAD AND ADMINISTRATIVE
COSTS MUST NOT BE INCLUDED IN THE NUMERATOR AS DESCRIBED IN
SUBSECTION
(1)(b)(II)(A) OF THIS SECTION.
(3) (a) O
N OR BEFORE JULY 31, 2024, AND ON OR BEFORE JULY 31
PAGE 5-SENATE BILL 23-179 EACH YEAR THEREAFTER , A CARRIER THAT ISSUES, SELLS, RENEWS, OR
OFFERS A DENTAL COVERAGE PLAN SHALL FILE A DENTAL LOSS RATIO FORM
ELECTRONICALLY WITH THE DIVISION FOR THE PRECEDING CALENDAR YEAR
IN WHICH DENTAL COVERAGE WAS PROVIDED BY THE DENTAL COVERAGE
PLAN
. THE COMMISSIONER MAY CREATE A NEW REPORTING FORM OR USE AN
EXISTING REPORTING FORM TO FACILITATE DATA COLLECTION
. THE
COMMISSIONER SHALL ENSURE THAT FIELDS ARE REPORTED CONSISTENTLY
BY CARRIERS
. THE FILING MUST:
(I) R
EPORT THE CALCULATED DENTAL LOSS RATIO ACCORDING TO
THE FORMULA IN SUBSECTION
(1)(b)(II) OF THIS SECTION;
(II) S
EPARATELY REPORT EACH DATA ELEMENT DESCRIBED IN
SUBSECTION
(1)(b) OF THIS SECTION;
(III) R
EPORT ADDITIONAL DATA THAT INCLUDES THE NUMBER OF
ENROLLEES
, THE PLAN COST-SHARING AND DEDUCTIBLE AM OUNTS , THE
ANNUAL MAXIMUM COVERAGE LIMIT
, AND THE NUMBER OF ENROLLEES WHO
MEET OR EXCEED THE ANNUAL COVERAGE LIMIT
;
(IV) R
EPORT DATA BY MARKET SEGMENT AND PRODUCT TYPE , AS
DEFINED BY RULE OF THE COMMISSIONER
; AND
(V) BE IN A FORM AND MANNER AS PRESCRIBED BY RULE OF THE
COMMISSIONER
.
(b) F
OR THE REPORT TO BE SUBMITTED ON OR BEFORE JULY 31, 2024,
A CARRIER SHALL ALSO SUBMIT THE INFORMATION REQUIRED IN SUBSECTION
(3)(a) OF THIS SECTION FOR THE PLAN YEARS 2021 THROUGH 2024.
(c) I
F THE COMMISSIONER DEEMS THAT DATA VERIFICATION OF A
CARRIER
'S DENTAL LOSS RATIO FOR A DENTAL COVERAGE PLAN IS
NECESSARY
, THE COMMISSIONER SHALL GIVE THE CARRIER AT LEAST THIRTY
DAYS NOTIFICATION PRIOR TO BEGINNING THE VERIFICATION PROCESS WITH
THE CARRIER
.
(d) (I) B
Y JANUARY 1 OF THE YEAR AFTER THE DIVISION RECEIVES
THE DENTAL LOSS RATIO INFORMATION COLLECTED PURSUANT TO
SUBSECTION
(3)(a) OF THIS SECTION, THE DIVISION SHALL MAKE THE
INFORMATION
, INCLUDING THE AGGREGATE DENTAL LOSS RATIO AND THE
PAGE 6-SENATE BILL 23-179 DATA REPORTED PURSUANT TO SUBSECTIONS (3)(a)(II) AND (3)(a)(III) OF
THIS SECTION
, AVAILABLE TO THE PUBLIC IN A SEARCHABLE FORMAT ON A
PUBLIC WEBSITE THAT ALLOWS MEMBERS OF THE PUBLIC TO COMPARE
DENTAL LOSS RATIOS AMONG CARRIERS BY PLAN TYPE BY
:
(A) P
OSTING THE INFORMATION ON THE DIVISION 'S WEBSITE; OR
(B) PROVIDING THE INFORMATION TO THE ADMINISTRATOR OF THE
ALL
-PAYER HEALTH CLAIMS DATABASE ESTABLISHED PURSUANT TO SECTION
25.5-1-204. IF THE DIVISION PROVIDES THE INFORMATION TO THE
ADMINISTRATOR
, THE ADMINISTRATOR SHALL MAKE THE INFORMATION
AVAILABLE TO THE PUBLIC IN A FORMAT DETERMINED BY THE DIVISION
.
(II) T
HE DIVISION SHALL REPORT THE DATA IN SUBSECTION (3)(a) OF
THIS SECTION
, AND, IF AVAILABLE, SUBSECTION (4)(a) OF THIS SECTION, TO
THE GENERAL ASSEMBLY DURING THE
"STATE MEASUREMENT FOR
ACCOUNTABLE, RESPONSIVE, AND TRANSPARENT (SMART) GOVERNMENT
ACT" HEARINGS HELD PURSUANT TO PART 2 OF ARTICLE 7 OF TITLE 2.
(4) (a) O
NCE THE DIVISION HAS COLLECTED THE DATA PURSUANT TO
SUBSECTION
(3) OF THIS SECTION FOR TWO CALENDAR YEARS , THE
COMMISSIONER SHALL PROMULGATE RULES THAT CREATE A PROCESS TO
IDENTIFY ANY CARRIERS THAT SIGNIFICANTLY DEVIATE FROM AVERAGE
DENTAL LOSS RATIOS AND TO INVESTIGATE THE CAUSES OF THE DEVIATION
.
S
UCH PROCESS SHALL INCLUDE:
(I) C
ALCULATING AN AVERAGE DENTAL LOSS RATIO FOR EACH
MARKET SEGMENT USING AGGREGATE DATA FOR A THREE
-YEAR PERIOD,
CONSISTING OF DATA FOR THE DENTAL LOSS RATIO REPORTING YEAR THAT
IS BEING REPORTED AND THE DATA FOR THE TWO PRIOR DENTAL LOSS RATIO
REPORTING YEARS
;
(II) I
DENTIFYING AS OUTLIERS THE DENTAL COVERAGE PLANS THAT
FALL OUTSIDE OF A SET NUMBER OF STANDARD DEVIATIONS FROM THE
AVERAGE DENTAL LOSS RATIO
, AS DETERMINED BY RULE OF THE
COMMISSIONER BASED ON REVIEW OF THE DATA AND CONSIDERATION OF THE
IMPACT OF NONPROFIT COMMUNITY BENEFIT EXPENDITURES ON ANY OUTLIER
CALCULATION
.
(b) T
HE COMMISSIONER MAY APPLY MORE RESTRICTIVE STANDARD
PAGE 7-SENATE BILL 23-179 DEVIATION METRICS OVER TIME TO PREVENT DECLINES IN THE AVERAGE
DENTAL LOSS RATIO IN A MARKET SEGMENT AND MAY ESTABLISH BY RULE
ADDITIONAL CRITERIA FOR USE IN IDENTIFYING OUTLIERS
.
(5) (a) T
HE COMMISSIONER MAY ENFORCE COMPLIANCE WITH THE
REPORTING REQUIREMENTS IN THIS SECTION AND IMPOSE A PENALTY OR
REMEDY AGAINST A PERSON WHO VIOLATES THIS SECTION
.
(b) T
HE COMMISSIONER MAY INVESTIGATE OR TAKE ENFORCEMENT
ACTIONS AGAINST CARRIERS THAT ARE DETERMINED TO BE OUTLIERS
PURSUANT TO SUBSECTION
(4) OF THIS SECTION AND RULES ADOPTED
PURSUANT TO SAID SUBSECTION
(4) AND IMPOSE A PENALTY OR REMEDY
AGAINST A PERSON WHO VIOLATES THIS SECTION
.
(6) T
HE COMMISSIONER MAY PROMULGATE RULES TO IMPLEMENT
THIS SECTION
.
SECTION 4. In Colorado Revised Statutes, 10-16-135, add (7) as
follows:
10-16-135. Health coverage plan information cards - rules -
standardization - contents. (7) T
HE COMMISSIONER SHALL ADOPT RULES
THAT REQUIRE EACH CARRIER THAT PROVIDES A DENTAL COVERAGE PLAN
,
AS DEFINED IN SECTION 10-16-165 (1)(a), TO ISSUE TO COVERED PERSONS TO
WHOM A DENTAL COVERAGE PLAN IDENTIFICATION CARD IS ISSUED A
STANDARDIZED WRITTEN OR VIRTUAL CARD CONTAINING PLAN
INFORMATION
. TO THE EXTENT POSSIBLE, THE RULES MUST INCORPORATE
AND NOT CONFLICT WITH THE REQUIREMENTS OF SECTION
10-16-124
REGARDING PRESCRIPTION INFORMATION CARDS . THE COMMISSIONER SHALL
ADOPT RULES BY
MARCH 31, 2024, THAT DESCRIBE THE FORMAT OF THE
STANDARDIZED CARD TO BE ISSUED BY CARRIERS
. THE RULES ESTABLISHING
THE FORMAT FOR THE CARD MUST INCLUDE A STANDARD SIZE
, MUST REQUIRE
THE CARD TO BE LEGIBLE AND PHOTOCOPIED
, AND MUST DELINEATE THE
INFORMATION TO BE CONTAINED ON THE CARD
, INCLUDING THE FOLLOWING,
AS APPLICABLE:
(a) T
HE COVERED PERSON 'S NAME AND THE APPLICABLE PLAN
NUMBER
;
(b) C
ONTACT INFORMATION FOR THE CARRIER OR DENTAL COVERAGE
PAGE 8-SENATE BILL 23-179 PLAN ADMINISTRATOR; AND
(c) AN INDICATION OF WHETHER THE DENTAL COVERAGE PLAN IS
REGULATED BY THE STATE OF
COLORADO.
SECTION 5. In Colorado Revised Statutes, 25.5-1-204, add (5)(j)
as follows:
25.5-1-204. Advisory committee to oversee the all-payer health
claims database - creation - members - duties - legislative declaration
- rules - report. (5) If sufficient funding is received, the executive director
shall direct the administrator to create the database and the administrator
shall:
(j) S
UBJECT TO AVAILABLE APPROPRIATIONS AND AT THE REQUEST
OF THE COMMISSIONER OF INSURANCE
, PUBLISH INFORMATION TO THE PUBLIC
CONCERNING DENTAL LOSS RATIO INFORMATION COLLECTED BY THE
DIVISION OF INSURANCE PURSUANT TO SECTION
10-16-165.
SECTION 6. Appropriation. For the 2023-24 state fiscal year,
$64,252 is appropriated to the department of regulatory agencies for use by
the division of insurance. This appropriation is from the division of
insurance cash fund created in section 10-1-103 (3), C.R.S. To implement
this act, the division may use this appropriation as follows:
(a) $56,637 for personal services, which amount is based on an
assumption that the division will require an additional 0.7 FTE; and
(b) $7,615 for operating expenses.
SECTION 7. Act subject to petition - effective date. This act
takes effect at 12:01 a.m. on the day following the expiration of the
ninety-day period after final adjournment of the general assembly; except
that, if a referendum petition is filed pursuant to section 1 (3) of article V
of the state constitution against this act or an item, section, or part of this act
within such period, then the act, item, section, or part will not take effect
unless approved by the people at the general election to be held in
PAGE 9-SENATE BILL 23-179 November 2024 and, in such case, will take effect on the date of the official
declaration of the vote thereon by the governor.
____________________________ ____________________________
Steve Fenberg Julie McCluskie
PRESIDENT OF SPEAKER OF THE HOUSE
THE SENATE OF REPRESENTATIVES
____________________________ ____________________________
Cindi L. Markwell Robin Jones
SECRETARY OF CHIEF CLERK OF THE HOUSE
THE SENATE OF REPRESENTATIVES
APPROVED________________________________________
(Date and Time)
_________________________________________
Jared S. Polis
GOVERNOR OF THE STATE OF COLORADO
PAGE 10-SENATE BILL 23-179