Colorado law requires Accident & Health (A&H) policies to include specific mandated benefits, standards of coverage, and consumer protections. These statutory requirements ensure equitable access to essential health services and impose fair business practices on insurers.

Maternity and Newborn Coverage

Ref: 10-16-104(1); 10-16-104(3)

All individual and group health insurance policies must provide maternity coverage. Newborn children must be covered as a dependent from the moment of birth by their parents’ policy. Adopted children (even unborn) are covered by the adoptive parent’s policy from the moment the adoption becomes legal. The newborn or newly adopted child may be enrolled within 30 days without any pre-existing condition limitations.

• Coverage for newborn children begins at birth and includes:
  • Injury or sickness, including congenital defects
  • Illness
  • Preventive care
• To continue newborn coverage beyond the initial period, the policyholder must add the child within 30 days.
• A dependent child may remain on a parent’s policy until age 26, regardless of student status.
• However, a mentally or physically handicapped child (any age) can be covered as a dependent on their parents’ policy until they become self-supporting.

Complications of Pregnancy

• Complications of pregnancy must be treated as any other illness.
• Examples include ectopic pregnancy, hemorrhage, preeclampsia, and other medically diagnosed conditions.
• Insurers cannot apply separate or more restrictive limits.

Essential Health Benefits (EHBs)

Reference: C.R.S. §10-16-102(22); §10-16-103.4; Colorado Regulation 4-2-42

Overview

Essential Health Benefits (EHBs) are a standardized set of health care services that certain health insurance plans are required to cover. Under the Affordable Care Act (ACA) and Colorado law, all individual and small group health insurance policies must include coverage for all 10 categories of Essential Health Benefits.

Colorado adopts a benchmark plan, which serves as the reference model that defines the scope and level of benefits that must be included in EHB-compliant plans sold in the state.

Plans Required to Cover EHBs

In Colorado, EHB requirements apply to:

• Individual health insurance plans
• Small group health insurance plans (generally employers with 1–50 employees)

These plans must cover every EHB category, although insurers may vary:

• The specific services within each category
• Cost-sharing structures (deductibles, copays, coinsurance), within ACA limits

Plans may not exclude an entire EHB category.

The 10 Essential Health Benefit Categories

Colorado-compliant individual and small group plans must include coverage for the following 10 EHB categories:

1. Ambulatory Patient Services
   • Outpatient care received without hospital admission, such as doctor visits, clinics, and same-day procedures.
2. Emergency Services
   • Emergency care without prior authorization, including emergency room visits, regardless of network status.
3. Hospitalization
   • Inpatient hospital care, including surgery, overnight stays, and related services.
4. Maternity and Newborn Care
   • Prenatal care, labor and delivery, and postnatal care for both the mother and newborn.
5. Mental Health and Substance Use Disorder Services
   • Includes behavioral health treatment, counseling, psychotherapy, and substance use disorder treatment, subject to mental health parity laws.
6. Prescription Drugs
   • Coverage for medications listed on the plan’s formulary, including certain brand-name and generic drugs.
7. Rehabilitative and Habilitative Services and Devices
   • Services that help individuals recover skills lost due to injury or illness (rehabilitative), or develop skills never acquired (habilitative).
8. Laboratory Services
   • Diagnostic tests such as blood work, imaging, and screenings used to diagnose or monitor health conditions.
9. Preventive and Wellness Services and Chronic Disease Management
   • Preventive care such as immunizations, screenings, and annual wellness visits—often covered without cost-sharing when provided in-network.
10. Pediatric Services, Including Oral and Vision Care
    • Health care services for children, including dental and vision coverage, which are considered essential benefits for pediatric populations.

Colorado’s Benchmark Plan

Colorado uses a state-selected benchmark plan to define the minimum standards for EHB coverage. Insurers must ensure their plans are substantially equal to the benchmark in both scope and value.

The benchmark plan:

• Establishes the minimum level of benefits
• Prevents insurers from offering stripped-down coverage
• Promotes consistency across plans offered in the individual and small group markets

The Colorado Division of Insurance oversees compliance and ensures that EHB requirements are met.

What EHBs Do Not Guarantee

It is important for exam purposes to understand what EHBs do not require:

• They do not guarantee unlimited coverage
• They do not eliminate deductibles or copayments
• They do not apply to all plan types (e.g., many large group or grandfathered plans are exempt)

EHBs define what must be covered, not how much the consumer pays.

Exam Focus Tips

• If a question involves an individual or small group plan, assume EHB coverage is mandatory
• If an answer choice removes or excludes an entire EHB category, it is incorrect
• Pediatric dental and vision are EHBs—even though adult dental and vision are not
• Mental health and substance use disorder services must be included and treated comparably to other medical benefits

Medicare supplement (Medigap) policies To reduce confusion about the many types of Medicare supplement policies, federal law requires national standardization of Medigap policies. Insurers must offer a limited number of standardized Medigap plans developed by the NAIC.

Currently, the available plans are A, B, C, D, F, G, K, L, M, and N. Plans E, H, I, and J have been eliminated.

In addition, Plans C and F are not available to individuals who became newly eligible for Medicare on or after January 1, 2020.

Plan A includes the “core” benefits (Parts A and B co-payments, 365 additional days of hospitalization, and the first 3 pints of blood). If an insurer sells any Medigap policies in the state, it must offer Plan A.

A Buyer’s Guide and an Outline of Coverage are delivered at the time of application, prior to accepting any premium payment.

Health First Colorado
Health First Colorado (Colorado’s Medicaid program) is free or low-cost health care for Colorado children and adults who qualify. Since 2016, Colorado Medicaid has been called Health First Colorado.

For the purpose of the exam, Medicaid and Health First Colorado are interchangeable terms.

This final chapter focused on Colorado laws and regulations specific to Accident & Health (A&H) insurance, with an emphasis on mandated benefits, consumer protections, and standardized coverage requirements. These rules ensure equitable access to essential health services while imposing fair business practices on insurers and producers operating in Colorado.

Oversight and enforcement of these requirements are handled by the Colorado Division of Insurance, which ensures compliance with state statutes, ACA-related mandates, and Colorado-specific regulations.