Colorado Sickness and Accident Insurance Requirements Introduction

Colorado’s accident and health (also known as Sickness and Accident) insurance laws establish critical consumer protections, mandate minimum benefit standards, and regulate how insurers market, issue, and administer health coverage in the state. These laws apply across individual, group, small-group, and specialized health insurance products—including Medicare Supplement policies, long-term care coverage, disability income policies, and major medical plans.

Understanding these regulations is essential for two primary reasons:

Exam Success

The Colorado-specific portion of the licensing exam places heavy emphasis on accident and health regulations. Pearson VUE’s content outline requires mastery of key areas such as:

• Mandatory health benefits
• Individual and group policy standards
• Guaranteed renewability rules
• Prompt pay requirements
• Utilization review procedures
• Replacement rules
• Small group eligibility, rating, and participation guidelines
• Sales and marketing restrictions
• Special product regulations (LTC, Med Supp, benefit plan summaries)

This chapter is structured to follow the exam outline exactly, ensuring you’re learning the material in the same format you’ll be tested on.

Real-World Application

As a licensed Accident & Health producer in Colorado, these statutes will guide your everyday actions, including:

• Explaining minimum mandated benefits to clients (e.g., diabetes supplies, maternity/newborn coverage, mental health parity).
• Ensuring accurate and ethical marketing of health insurance.
• Advising clients about enrollment periods, continuation rules, and termination rights.
• Complying with guaranteed-issue requirements in the individual and small-group markets.
• Understanding what carriers can and cannot consider when underwriting or setting rates.
• Navigating prompt-payment expectations to prevent delays in claims.
• Assisting consumers with appeals, grievances, and utilization review procedures. :::

Producers who lack knowledge of these regulations are at higher risk of compliance violations, complaints, and loss of licensure. This chapter gives you the practical understanding needed to avoid these pitfalls and provide competent, ethical service.

How This Chapter is Organized

Each topic corresponds directly to a section of the Colorado Revised Statutes (C.R.S.) Title 10 and applicable Colorado Division of Insurance Regulations. You will find clear explanations of:

• What the rule requires
• Why it exists
• When and how it applies in real insurance transactions

Examples and plain-language explanations are used throughout to convert legal requirements into scenarios you’ll actually encounter.

How to Interpret Statutory References

Throughout the chapter, you will see citations like:

• C.R.S. 10-16-104 (refers to Title 10, Article 16, Section 104 of the Colorado Revised Statutes)

• Reg. 4-2-8 (refers to a Colorado Division of Insurance regulation within Series 4, Part 2, Section 8)

You are not required to memorize statute numbers for the exam, but knowing what they represent will help you understand:

• Where the rules come from
• How Colorado organizes its insurance laws
• How to find the exact language if needed in your professional practice

What You Will Gain From This Chapter

By the end of this chapter, you will be able to:

• Identify Colorado’s mandatory health insurance benefits and explain them to consumers
• Understand the differences between individual, group, and small-group regulatory requirements
• Comply with renewal, termination, and continuation rules
• Recognize rules around replacements, disclosures, and suitability
• Navigate Utilization Review, Appeals, and Prompt Pay regulations
• Understand the strict marketing and ethical standards for Accident & Health coverage
• Apply state-specific rules for Medicare Supplement, Long Term Care, and other regulated health products