Mandatory coverage provisions - applicability - rules - definitions

10-16-104. Mandatory coverage provisions - applicability - rules - definitions. (1) Newborn children. (a) All group and individual sickness and accident insurance policies and all service or indemnity contracts issued by any entity subject to part 3 or 4 of this article shall provide coverage for a dependent newborn child of the insured or subscriber from the moment of birth. (b) (I) Coverage for a hospital stay for a newborn following a normal vaginal delivery shall not be limited to less than forty-eight hours. If forty-eight hours following delivery falls after 8 p.m., coverage shall continue until 8 a.m. the following morning. (II) Coverage for a hospital stay for a newborn following a cesarean section shall not be limited to less than ninety-six hours. If ninety-six hours following the cesarean section falls after 8 p.m., coverage shall continue until 8 a.m. the following morning. (III) The provisions of subparagraphs (I) and (II) of this paragraph (b) shall not apply in any case in which the decision to discharge the newborn prior to the minimum length of stay otherwise required under subparagraphs (I) and (II) of this paragraph (b) is made by an attending provider with the agreement of the mother. (IV) Nothing in this paragraph (b) shall be construed to require a mother who is a participant or beneficiary to give birth in a hospital or to stay in the hospital for a fixed period of time after the birth of her child. (V) Nothing in this paragraph (b) shall be construed as preventing a carrier from imposing deductibles, coinsurance, or other cost sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or newborn child under the plan; except that such coinsurance or other cost sharing for any portion of a period within a hospital length of stay required under subparagraphs (I) and (II) of this paragraph (b) may not be greater than such coinsurance or cost sharing for any other sickness, injury, disease, or condition that is otherwise covered under the policy or contract. (c) (I) Except as provided for cleft lip and cleft palate coverage in sub-subparagraph (A) of subparagraph (II) of this paragraph (c) and for inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic, and fatty acids and for which medically standard methods of diagnosis, treatment, and monitoring exist pursuant to sub-subparagraph (A) of subparagraph (III) of this paragraph (c), the benefits available to newborn children shall consist of coverage of injury or sickness, including all medically necessary care and treatment of medically diagnosed congenital defects and birth abnormalities for the first thirty-one days of the newborn's life, notwithstanding policy limitations and exclusions applicable to other conditions or procedures covered by the policy. Except as provided in sub-subparagraph (C) of subparagraph (II) of this paragraph (c), such coverage shall be subject to copayment, deductible, and aggregate dollar policy maximums that are no higher than are generally applicable under the policy to all other sicknesses, diseases, and conditions otherwise covered under the policy. (II) (A) With regard to newborn children born with cleft lip or cleft palate or both, there shall be no age limit on benefits for such conditions, and care and treatment shall include to the extent medically necessary: Oral and facial surgery, surgical management, and follow-up care by plastic surgeons and oral surgeons; prosthetic treatment such as obturators, speech appliances, and feeding appliances; medically necessary orthodontic treatment; medically necessary prosthodontic treatment; habilitative speech therapy; otolaryngology treatment; and audiological assessments and treatment. (B) Cleft lip, cleft palate, or any condition or illness which is related to or developed as a result of the cleft lip or cleft palate shall be considered to be compensable for coverage under the provisions of sub-subparagraph (A) of this subparagraph (II). (C) If a dental insurance policy, a contract for dental insurance, or an enrollee coverage contract issued pursuant to this article is in effect at the time of the birth, or is purchased after the birth, of a child with cleft lip or cleft palate or both, it shall provide fully for any orthodontics or dental care needed as a result of the cleft lip or cleft palate or both. Such policy or contract may contain the same copayment provisions for the coverage of cleft lip or cleft palate or both as apply to other conditions or procedures covered by the policy or contract. (III) (A) Coverage for inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic, and fatty acids as well as severe protein allergic conditions includes, without limitation, the following diagnosed conditions: Phenylketonuria; maternal phenylketonuria; maple syrup urine disease; tyrosinemia; homocystinuria; histidinemia; urea cycle disorders; hyperlysinemia; glutaric acidemias; methylmalonic acidemia; propionic acidemia; immunoglobulin E and nonimmunoglobulin E-mediated allergies to multiple food proteins; severe food protein induced enterocolitis syndrome; eosinophilic disorders as evidenced by the results of a biopsy; and impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, and motility of the gastrointestinal tract. Covered care and treatment of such conditions shall include, to the extent medically necessary, medical foods for home use for which a physician who is a participating provider has issued a written, oral, or electronic prescription. (B) There is no age limit on benefits for inherited enzymatic disorders specified in sub-subparagraph (A) of this paragraph (III) except for phenylketonuria. The maximum age to receive benefits for phenylketonuria is twenty-one years of age; except that the maximum age to receive benefits for phenylketonuria for women who are of child-bearing age is thirty-five years of age. (C) As used in this subparagraph (III), medical foods means prescription metabolic formulas and their modular counterparts and amino acid-based elemental formulas, obtained through a pharmacy, that are specifically designated and manufactured for the treatment of inherited enzymatic disorders caused by single gene defects involved in the metabolism of amino, organic, and fatty acids and for severe allergic conditions, if diagnosed by a board-certified allergist or board-certified gastroenterologist, for which medically standard methods of diagnosis, treatment, and monitoring exist. Such formulas are specifically processed or formulated to be deficient in one or more nutrients. The formulas for severe food allergies contain only singular form elemental amino acids. The formulas are to be consumed or administered enterally either via tube or oral route under the direction of a physician who is a participating provider. This sub-subparagraph (C) shall not be construed to apply to cystic fibrosis patients or lactose- or soy-intolerant patients. (D) Coverage of medical foods, as provided under this subparagraph (III), shall only apply to insurance plans that include an approved pharmacy benefit and shall not apply to alternative medicines. Such coverage shall only be available through participating pharmacy providers. Nothing in this subparagraph (III) shall be construed as preventing a carrier from imposing deductibles, coinsurance, or other cost-sharing methods. (d) If payment of a specific premium is required to provide coverage for a child, the policy may require that notification of birth of the newborn child and payment of the required premium must be furnished to the insurer or other entity within thirty-one days after the date of birth in order to have the coverage continue beyond such thirty-one-day period. (e) The requirements of this section shall apply to all individual sickness and accident policies issued on and after July 1, 1975, and to all blanket and group sickness and accident policies issued, renewed, or reinstated on and after July 1, 1975, and to all subscriber or enrollee coverage contracts delivered or issued for delivery in this state on and after July 1, 1975. (f) (I) Any contract of a prepaid dental plan of an entity subject to the provisions of part 5 of this article applied for that provides family coverage shall, as to such coverage of individuals in the family, also provide that the benefits applicable for children shall be payable with respect to a newly born child of the insured from the instant of such child's birth to the same extent that such coverage applies to other individuals in the family. If payment of a specific premium or capitation amount is required to provide coverage for a child, the contract may require that notification of birth of a newly born child and payment of the required premium or capitation amount shall be furnished to the organization within thirty-one days after the date of birth in order to have the coverage continue beyond the thirty-one-day period. (II) The coverage for newborn children shall include any orthodontics or dental care needed as the result of the child being born with a cleft lip or cleft palate or both. The contract providing such coverage may contain the same copayment provisions as apply to other conditions or procedures covered by the contract. (g) The health-care service plan issued by an entity subject to the provisions of part 4 of this article may provide that the benefits required pursuant to this subsection (1) shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization. (1.3) Early intervention services. (a) As used in this subsection (1.3), unless the context otherwise requires: (I) Division means the unit within the department of human services that is responsible for developmental disabilities services. (II) Early intervention services means services as defined by the division in accordance with part C that are authorized through an eligible child's IFSP but that exclude nonemergency medical transportation; respite care; service coordination, as defined in 34 CFR 303.12 (d)(11); and assistive technology, unless assistive technology is covered under the applicable insurance policy or service or indemnity contract as durable medical equipment. (III) Eligible child means an infant or toddler, from birth through two years of age, who is an eligible dependent and who, as defined by the department pursuant to section 26.5-3-402 (11), has significant delays in development or has a diagnosed physical or mental condition that has a high probability of resulting in significant delays in development or who is eligible for services pursuant to section 27-10.5-102 (11)(c). (IV) Individualized family service plan or IFSP means a written plan developed pursuant to 20 U.S.C. sec. 1436 and 34 CFR 303.340 that authorizes early intervention services to an eligible child and the child's family. An IFSP shall serve as the individualized plan, pursuant to section 27-10.5-102 (20)(c), C.R.S., for an eligible child from birth through two years of age. (V) Part C means the early intervention program for infants and toddlers who are eligible for services under part C of the federal Individuals with Disabilities Education Act, 20 U.S.C. sec. 1400 et seq. (VI) Qualified early intervention service provider or qualified provider means a person or agency, as defined by the division in accordance with part C, who provides early intervention services and is listed on the registry of early intervention service providers pursuant to section 26.5-3-408 (1). (b) (I) All individual and group sickness and accident insurance policies or contracts issued or renewed by an entity subject to part 2 of this article on or after January 1, 2008, and all service or indemnity contracts issued or renewed by an entity subject to part 3 or 4 of this article on or after January 1, 2008, that include dependent coverage shall provide coverage for early intervention services delivered by a qualified early intervention service provider to an eligible child. Early intervention services specified in an eligible child's IFSP shall qualify as meeting the standard for medically necessary health-care services as used by private health insurance plans. (II) (A) The coverage required by this subsection (1.3) must be available annually to an eligible child from birth up to the child's third birthday for early intervention services for each dependent child per calendar or policy year. The commissioner shall specify, by rule, the extent of the coverage for early intervention services required by this subsection (1.3), which, except for grandfathered health benefit plans, must require coverage of a number of early intervention services or visits that is actuarially equivalent to the dollar limit of the benefit as it existed prior to May 13, 2013. (B) For grandfathered health benefit plans, the coverage required by this subsection (1.3) per calendar or policy year for early intervention services for each eligible dependent child from birth up to the child's third birthday is limited to six thousand three hundred sixty-one dollars, including case management costs. Effective January 1, 2014, and each January 1 thereafter, the commissioner shall annually adjust the dollar limit for early intervention services coverage based on the Denver-Aurora-Lakewood consumer price index or, if applicable, its predecessor or successor index for the state fiscal year that ends in the immediately preceding calendar year, or by an additional amount equal to the increase by the general assembly in the annual appropriated rate to serve one child for one fiscal year in the state-funded early intervention program if that increase is more than the consumer price index increase. (III) Except as provided in paragraph (d) of this subsection (1.3), the coverage shall not be subject to deductibles or copayments, and any benefits paid under the coverage required by this subsection (1.3) shall not be applied to an annual or lifetime maximum benefit contained in the policy or contract. Unless the carrier agrees prior to the provision of early intervention services, a carrier shall not be required to pay a reimbursement rate for early intervention services provided by a nonparticipating provider that exceeds the reimbursement rate allowed for comparable early intervention services provided by a participating provider. (IV) Any limit on the amount of coverage for early intervention services specified by the commissioner by rule pursuant to sub-subparagraph (A) of subparagraph (II) of this paragraph (b) or, for grandfathered health benefit plans, specified in sub-subparagraph (B) of subparagraph (II) of this paragraph (b) shall not apply to: (A) Rehabilitation or therapeutic services that are necessary as the result of an acute medical condition or post-surgical rehabilitation; (B) Services provided to a child who is not participating in part C and services that are not provided pursuant to an IFSP. However, such services shall be covered at the level specified in paragraph (b) of subsection (1.7) of this section. (c) This subsection (1.3) shall not apply to the following: (I) Short-term, accident, fixed indemnity, or specified disease policies, disability income contracts, limited benefit health insurance, as defined by the commissioner by rule, credit disability insurance, or a medicare supplement policy as defined in section 10-18-101 (4); (II) Workers' compensation or similar insurance; (III) Automobile medical payment insurance or insurance under which benefits are payable with or without regard to fault and required by law to be contained in any liability insurance policy or equivalent self-insurance. (d) (I) The coverage required by this subsection (1.3) may be offered through a high deductible plan that would qualify for a health savings account pursuant to 26 U.S.C. sec. 223; except that a carrier may apply deductible amounts for the required coverage if it is not considered by the United States department of treasury to be preventive or to have an acceptable deductible amount. (II) If a high deductible plan that would qualify for a health savings account pursuant to 26 U.S.C. sec. 223 requires a deductible or copayment amount for the coverage required by this subsection (1.3), the deductible or copayment amount may be paid by the state as determined by rules adopted by the commissioner in accordance with article 4 of title 24, C.R.S., in consultation with the division of insurance. (d.5) (I) Upon notice from the department of early childhood pursuant to section 26.5-3-409 (1) that a child is eligible for early intervention services, the carrier shall submit payment of benefits for the eligible child in accordance with this subsection (1.3)(d.5)(I) and section 26.5-3-409 (1). If the eligible child is covered by a grandfathered health benefit plan, the carrier shall submit payment in the amount specified in subsection (1.3)(b)(II)(B) of this section, as adjusted annually pursuant to said subsection. If the eligible child is covered by any other policy or contract subject to this subsection (1.3), the carrier shall submit payment in an amount that equals the approximate value of the number of early intervention services or visits specified by the commissioner pursuant to subsection (1.3)(b)(II)(A) of this section. (II) Qualified early intervention service providers that receive reimbursement in accordance with this paragraph (d.5) shall accept the reimbursement as payment in full for services provided under this subsection (1.3) and shall not seek additional reimbursement from either the covered person or the carrier. (e) Within ninety days after the division determines that a child is no longer an eligible child for purposes of this subsection (1.3), the division shall notify the carrier that the child is no longer eligible and that the carrier is no longer required to provide the coverage required by this subsection (1.3) for that child. (f) Use of available coverage under this subsection (1.3) for the cost of early intervention services is mandatory, consistent with the requirements of part C. An eligible child must fully utilize available coverage under this subsection (1.3) prior to accessing state general funds or federal part C funds. A carrier shall not terminate or fail to renew health coverage on the basis that an eligible child has accessed or will be accessing early intervention services under this subsection (1.3). (g) Early intervention services shall be provided as specified in the eligible child's IFSP, and such services shall not duplicate or replace treatment for autism spectrum disorders provided in accordance with subsection (1.4) of this section. Services for the treatment of autism spectrum disorders provided in accordance with subsection (1.4) of this section shall be considered the primary service to an eligible child, and early intervention services provided under this subsection (1.3) shall supplement, but not replace, services provided under subsection (1.4) of this section. (1.4) Autism spectrum disorders. (a) As used in this subsection (1.4), unless the context otherwise requires: (I) Applied behavior analysis means the use of behavior analytic methods and research findings to change socially important behaviors in meaningful ways. (II) Autism services provider means any person who provides direct services to a person with autism spectrum disorder, is licensed, certified, or registered by the applicable state licensing board or by a nationally recognized organization, and meets one of the following: (A) Has a doctoral degree with a specialty in psychiatry, medicine, or clinical psychology, is actively licensed by the Colorado medical board, and has at least one year of direct experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism spectrum disorders; (B) Has a doctoral degree in one of the behavioral or health sciences and has completed one year of experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism spectrum disorders; (C) Has a master's degree or higher in behavioral sciences and is nationally certified as a board certified behavior analyst or certified by a similar nationally recognized organization; (D) Has a master's degree or higher in one of the behavior or health sciences, is credentialed as a related services provider, and has completed one year of direct supervised experience in behavioral therapies that are consistent with best practice and research on effectiveness for people with autism spectrum disorders. For the purposes of this sub-subparagraph (D), related services provider means a physical therapist, occupational therapist, or speech therapist. (E) Has a baccalaureate degree or higher in behavioral sciences and is nationally certified as a board certified associate behavior analyst by the behavior analyst certification board or by a similar nationally recognized organization; or (F) Is nationally registered as a registered behavior technician by the behavior analyst certification board or by a similar nationally recognized organization and provides direct services to a person with an autism spectrum disorder under the supervision of an autism services provider described in sub-subparagraph (A), (B), (C), (D), or (E) of this subparagraph (II). (III) Autism spectrum disorders or ASD: (A) Has the same meaning as set forth in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders in effect at the time of the diagnosis; and (B) Includes the following disorders, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders in effect at the time of the diagnosis: Autistic disorder, Asperger's disorder, and atypical autism as a diagnosis within pervasive developmental disorder not otherwise specified. (IV) Health benefit plan, does not include: (A) Short-term limited duration health insurance policies; or (B) Individual grandfathered health benefit plans. (V) Individualized education program shall have the same meaning as provided in section 22-20-103, C.R.S. (VI) Individualized family service plan shall have the same meaning as provided in section 27-10.5-102, C.R.S. (VII) Individualized plan has the same meaning as provided in section 25.5-10-202, C.R.S. (VIII) Pharmacy care means medications prescribed by a physician licensed by the Colorado medical board under the Colorado Medical Practice Act, article 240 of title 12. (IX) Psychiatric care means direct or consultative services provided by a psychiatrist licensed by the Colorado medical board under the Colorado Medical Practice Act, article 240 of title 12. (X) Psychological care means direct or consultative services provided by a psychologist licensed by the state board of psychologist examiners pursuant to part 3 of article 245 of title 12 or a social worker licensed by the state board of social work examiners pursuant to part 4 of article 245 of title 12. (XI) Therapeutic care means services provided by a speech therapist; an occupational therapist or occupational therapy assistant licensed to practice occupational therapy pursuant to article 270 of title 12; a physical therapist licensed to practice physical therapy pursuant to article 285 of title 12; or an autism services provider. Therapeutic care includes, but is not limited to, speech, occupational, and applied behavior analytic and physical therapies. (XII) Treatment for autism spectrum disorders shall be for treatments that are medically necessary. The treatments listed in this subparagraph (XII) are not considered experimental or investigational and are considered appropriate, effective, or efficient for the treatment of autism. Treatment for autism spectrum disorders shall include the following, as medically necessary: (A) Evaluation and assessment services; (B) Behavior training and behavior management and applied behavior analysis, including but not limited to consultations, direct care, supervision, or treatment, or any combination thereof, for autism spectrum disorders provided by autism services providers; (C) Habilitative or rehabilitative care, including, but not limited to, occupational therapy, physical therapy, or speech therapy, or any combination of those therapies. For a person who is also covered under subsection (1.7) of this section, the level of benefits for occupational therapy, physical therapy, or speech therapy shall exceed the limit of twenty visits for each therapy if such therapy is medically necessary to treat autism spectrum disorders under this subsection (1.4). (D) Pharmacy care and medication, if covered by the health benefit plan; (E) Psychiatric care; (F) Psychological care, including family counseling; and (G) Therapeutic care. (XIII) Treatment plan means a plan developed for an individual by an autism services provider and prescribed by a licensed physician or a licensed psychologist pursuant to a comprehensive evaluation or reevaluation for an individual consisting of the individual's diagnosis; proposed treatment by type, frequency, and anticipated treatment; the anticipated outcomes stated as goals; and the frequency by which the treatment plan will be updated. The treatment plan shall be developed in accordance with the patient-centered medical home as defined in section 25.5-1-103 (5.5), C.R.S. (b) (I) All health benefit plans issued or renewed in this state must provide coverage for the assessment, diagnosis, and treatment of autism spectrum disorders for a child pursuant to this subsection (1.4). (II) Nothing in this subsection (1.4): (A) Requires or permits a carrier to reduce benefits provided for autism spectrum disorders if a health benefit plan already provides coverage that exceeds the requirements of this subsection (1.4) and rules adopted by the commissioner; (B) Prevents a carrier from increasing benefits provided for autism spectrum disorders; or (C) Limits coverage for physical or mental health benefits covered under a health benefit plan. (c) Treatment for autism spectrum disorders shall be prescribed or ordered by a licensed physician or licensed psychologist. (d) A health benefit plan offered to residents of this state providing basic health-care services that is delivered, issued for delivery, or renewed in this state shall not exclude autism spectrum disorders or impose additional requirements for authorization of services that operate to exclude coverage for the assessment, diagnosis, and treatment of autism spectrum disorders. (e) Except as otherwise provided in paragraph (b) of this subsection (1.4), the coverage required under this subsection (1.4) shall not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to an insured than the dollar limits, deductibles, or coinsurance provisions that apply to physical illness generally under the health benefit plan. The benefits of this subsection (1.4) shall be in addition to any benefits provided for in subsections (1.3) and (1.7) of this section. (f) Benefits provided by a carrier on behalf of a covered individual for any care, treatment, intervention, service, or item, the provision of which was for the treatment of a health condition not diagnosed as an autism spectrum disorder, shall not be applied toward any maximum benefit amount established under this subsection (1.4). (g) A carrier may not deny or refuse to provide otherwise covered services, refuse to issue, renew, or reissue, or otherwise restrict or terminate coverage under a health benefit plan because the individual or his or her covered dependent is diagnosed with an autism spectrum disorder or due to the individual's or dependent's utilization of services for which benefits are mandated by this subsection (1.4). (h) Any review of a treatment plan or any appeal of a decision regarding treatment shall be subject to the rules of the commissioner on prompt investigation of health plan claims involving utilization review and denial of benefits. (i) Nothing in this subsection (1.4) shall be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized plan. The services required to be covered by this subsection (1.4) shall be in addition to any services provided to an individual under an individualized family service plan, an individualized education program, or an individualized plan. (j) Coverage under this subsection (1.4) is subject to all terms, conditions, definitions, restrictions, exclusions, limitations, and utilization review of health-care services that apply to any other coverage under the health benefit plan, including the treatment under the health benefit plan of services performed by participating and nonparticipating providers. (1.5) (Deleted by amendment, L. 2009, (HB 09-1204), ch. 344, p. 1802, � 2, effective January 1, 2010.) (1.7) Therapies for congenital defects and birth abnormalities. (a) After the first thirty-one days of life, policy limitations and exclusions that are generally applicable under the policy may apply; except that all individual and group health benefit plans shall provide medically necessary physical, occupational, and speech therapy for the care and treatment of congenital defects and birth abnormalities for a covered child from the child's third birthday to the child's sixth birthday. (b) The level of benefits required in paragraph (a) of this subsection (1.7) shall be the greater of the number of such visits provided under the policy or plan or twenty therapy visits per year each for physical therapy, occupational therapy, and speech therapy. Said therapy visits shall be distributed as medically appropriate throughout the yearly term of the policy or yearly term of the enrollee coverage contract, without regard to whether the condition is acute or chronic and without regard to whether the purpose of the therapy is to maintain or to improve functional capacity. (c) Repealed. (d) The health-care service plan issued by an entity subject to the provisions of part 4 of this article may provide that the benefits required pursuant to this subsection (1.7) shall be covered benefits only if the services are rendered by a provider who is designated by and affiliated with the health maintenance organization. (2) Complications of pregnancy and childbirth. (a) Any sickness and accident insurance policy providing indemnity for disability due to sickness issued by an entity subject to the provisions of part 2 of this article and any individual or group service or indemnity contract issued by an entity subject to part 3 of this article shall provide coverage for a sickness or disease which is a complication of pregnancy or childbirth in the same manner as any other similar sickness or disease is otherwise covered under the policy or contract. Any sickness and accident insurance policy providing indemnity for disability due to accident shall provide coverage for an accident which occurs during the course of pregnancy or childbirth in the same manner as any other similar accident is covered under the policy. (b) Any sickness and accident insurance policy providing coverage for sickness on an expense-incurred basis shall provide coverage for a sickness or disease which is a complication of pregnancy or childbirth in the same manner as any other similar sickness or disease is otherwise covered under the policy. (3) Maternity coverage. (a) (I) (A) All group sickness and accident insurance policies providing coverage within the state and issued to an employer by an entity subject to part 2 of this article 16, all group health service contracts issued by an entity subject to part 3 or 4 of this article 16 and issued to an employer, all individual sickness and accident insurance policies issued by an entity subject to part 2 of this article 16, and all individual health-care or indemnity contracts issued by an entity subject to part 3 or 4 of this article 16, except supplemental policies covering a specified disease or other limited benefit, must insure against the expense of normal pregnancy and childbirth or provide coverage for maternity care and provide coverage for contraception in the same manner as any other sickness, injury, disease, or condition is otherwise covered under the policy or contract; except that coverage for contraception must be consistent with the requirements in section 10-16-104.2. (B) Individual sickness and accident insurance policies or contracts may exclude coverage for pregnancy and delivery expenses on the grounds that pregnancy was a preexisting condition; except that the exclusion for a pregnancy as a preexisting condition under the policy or contract does not apply for any subsequent pregnancies. Group sickness and accident insurance policies or contracts must not exclude coverage for pregnancy and delivery expenses on the grounds that pregnancy was a preexisting condition. (II) Coverage for a hospital stay following a normal vaginal delivery shall not be limited to less than forty-eight hours. If forty-eight hours following delivery falls after 8 p.m., coverage shall continue until 8 a.m. the following morning. (III) Coverage for a hospital stay following a cesarean section shall not be limited to less than ninety-six hours. If ninety-six hours following the cesarean section falls after 8 p.m., coverage shall continue until 8 a.m. the following morning. (IV) The provisions of subparagraphs (II) and (III) of this paragraph (a) shall not apply in any case in which the decision to discharge prior to the minimum length of stay otherwise required under subparagraphs (II) and (III) of this paragraph (a) is made by an attending provider with the agreement of the mother. (V) Nothing in this paragraph (a) shall be construed to require a mother who is a participant or beneficiary to give birth in a hospital or to stay in the hospital for a fixed period of time after the birth of her child. (VI) Nothing in this paragraph (a) shall be construed as preventing a carrier from imposing deductibles, coinsurance, or other cost sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or newborn child under the plan; except that such coinsurance or other cost sharing for any portion of a period within a hospital length of stay required under subparagraphs (II) and (III) of this paragraph (a) may not be greater than such coinsurance or cost sharing for any other sickness, injury, disease, or condition that is otherwise covered under the policy or contract. (VII) [Editor's note: Subsection (3)(a)(VII) is effective January 1, 2027.] Except for a standardized health benefit plan offered pursuant to section 10-16-1305, for a health benefit plan providing maternity coverage pursuant to this subsection (3) that is issued or renewed on or after January 1, 2027, the health benefit plan must provide coverage without cost sharing for up to three prenatal care office visits. (b) The requirement in paragraph (a) of this subsection (3) shall not apply to policies or contracts purchased by employers who employ any number of full-time or part-time employees in fewer than fifteen full-time employee positions or to employers who employ any number of full-time or part-time employees for not more than six consecutive months each year on a seasonal basis if such coverage as required in paragraph (a) of this subsection (3) is provided by the employer in one of the following methods: (I) Self-insurance. All employers who elect under this subparagraph (I) to utilize self-insurance for providing this benefit shall provide written notice to affected employees and to the health insurance carrier of its choice to self-insure. (II) A policy purchased from an insurance company authorized to do business in this state which meets all of the requirements of the division of insurance for that purpose; (III) A contract issued by an entity subject to the provisions of part 3 or 4 of this article; (IV) A combination of the methods of obtaining insurance authorized in subparagraphs (I) to (III) of this paragraph (b). (c) An entity authorized under the provisions of part 3 or 4 of this article to issue service or indemnity-type contracts shall offer coverage for maternity care to both married and unmarried women in individual, nonfamily contracts and shall offer the same coverage and the same payment of costs for maternity benefits to unmarried women that it offers to married women. (d) A carrier offering a health benefit plan in the state shall reimburse participating providers who provide covered health-care services related to labor and delivery within the scope of the provider's practice in a manner that: (I) Promotes high-quality, cost-effective, and evidence-based care; (II) Promotes high-value, evidence-based payment models; and (III) Prevents risk in subsequent pregnancies. (e) Doula services - rules - definitions. (I) As used in this subsection (3)(e), unless the context otherwise requires: (A) Billing guidance means guidance from the department of health care policy and financing concerning coverage and billing for doula services after consideration of the findings and recommendations for doula services resulting from the stakeholder process required pursuant to section 25.5-4-506. (B) Doula means a trained birth companion who provides personal, nonmedical support to pregnant and postpartum people and their families prior to childbirth, during labor and delivery, and during the postpartum period and who has the qualifications and training required by the state. (C) Doula services means services provided by a doula. (D) Medical assistance program means the Colorado Medical Assistance Act, articles 4, 5, and 6 of title 25.5. (II) In the large group market, maternity coverage pursuant to this subsection (3) must include coverage for doula services, to the extent practicable, for the same scope and duration of coverage that is included in the department of health care policy and financing's request submitted pursuant to section 25.5-4-506 for federal authorization for doula services under the medical assistance program. The benefit may include the same qualifications for individuals providing doula services as recommended in the billing guidance for individuals providing doula services under the medical assistance program. (III) Except as provided in subsection (3)(e)(VI) of this section, in the individual and small group markets, maternity coverage pursuant to this subsection (3) must include coverage for doula services if the services are within the doula's area of professional competence and the doula services are: (A) Currently reimbursed when rendered by any other health-care providers; or (B) Covered as part of the maternity essential health benefit. (IV) This subsection (3)(e) applies to, and the division shall implement the requirements of this subsection (3)(e) for, large employer health benefit plans issued or renewed in this state on or after July 1, 2025, or twelve months after the date on which the department of health care policy and financing submits its request pursuant to section 25.5-4-506 for federal authorization for doula services under the medical assistance program, whichever is later. (V) With respect to individual and small group health benefit plans, the division shall: (A) Review the actuarial review conducted pursuant to section 10-16-155.5 and submit to the federal department of health and human services the division's determination as to whether the benefit specified in this subsection (3)(e) is in addition to essential health benefits and would be subject to defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); and (B) Request that the federal department of health and human services confirm the division's determination within sixty days after receipt of the division's request and submission of its determination. (VI) This subsection (3)(e) applies to, and the division shall implement the requirements of this subsection (3)(e) for, individual and small group health benefit plans issued or renewed in this state upon the earlier of: (A) Twelve months after the federal department of health and human services confirms the division's determination or otherwise informs the division that the coverage specified in this subsection (3)(e) does not constitute an additional benefit that requires defrayal by the state pursuant to 42 U.S.C. sec. 18031 (d)(3)(B); or (B) The passage of more than three hundred sixty-five days since the division submitted its determination and request for confirmation pursuant to subsection (3)(e)(V) of this section, and the federal department of health and human services has failed to respond to the request within that period, in which case the division shall consider the federal department's unreasonable delay a preclusion from requiring defrayal by the state. (VII) The commissioner may promulgate rules as necessary to implement this subsection (3). (4) (Deleted by amendment, L. 2009, (HB 09-1204), ch. 344, p. 1802, � 2, effective January 1, 2010.) (5) Repealed. (5.5) Behavioral, mental health, and substance use disorders. (a) (I) [Editor's note: This version of subsection (5.5)(a)(I) is effective until January 1, 2026.] Every health benefit plan subject to part 2, 3, or 4 of this article 16, except those described in section 10-16-102 (32)(b), must provide coverage: (A) For the prevention of, screening for, and treatment of behavioral, mental health, and substance use disorders that is no less extensive than the coverage provided for any physical illness and that complies with the requirements of the MHPAEA; and (B) At a minimum, for the treatment of substance use disorders in accordance with the American Society of Addiction Medicine criteria for placement, medical necessity, and utilization management determinations as set forth in the most recent edition of The ASAM Criteria for Addictive, Substance-related, and Co-occurring Conditions; except that the commissioner may identify by rule, in consultation with the department of health care policy and financing and the behavioral health administration in the department of human services, an alternate nationally recognized and evidence-based substance-use-disorder-specific criteria for placement, medical necessity, or utilization management, if the American Society of Addiction Medicine criteria are no longer available or relevant or do not follow best practices for substance use disorder treatment. (5.5) Behavioral, mental health, and substance use disorders - utilization review criteria - federal treatment limitation requirements - meaningful benefits - rules - definitions. (a) (I) [Editor's note: This version of subsection (5.5)(a)(I) is effective January 1, 2026.] Every health benefit plan subject to part 2, 3, or 4 of this article 16, except those described in section 10-16-102 (32)(b), must provide coverage: (A) For the prevention of, screening for, and treatment of behavioral, mental health, and substance use disorders that is no less extensive than the coverage provided for any physical illness, that complies with the requirements of the MHPAEA, and that does not discriminate in its benefit design against individuals because of their present or predicted behavioral, mental health, or substance use disorder; (B) At a minimum, for the treatment of substance use disorders in accordance with the American Society of Addiction Medicine criteria for placement, medical necessity, and utilization management determinations as set forth in the most recent edition of The ASAM Criteria: Treatment Criteria for Addictive, Substance-related, and Co-occurring Conditions; except that the commissioner may identify by rule, in consultation with the department of health care policy and financing and the behavioral health administration in the department of human services, alternate nationally recognized and evidence-based substance-use-disorder-specific not-for-profit utilization review criteria that is consistent with generally accepted standards of substance use disorder care for placement, medical necessity, or utilization review, if the American Society of Addiction Medicine criteria are no longer available or relevant or do not follow best practices for substance use disorder treatment; and (C) For medically necessary treatment of covered behavioral, mental health, and substance use disorder benefits, including services that are consistent with criteria, guidelines, or consensus recommendations from nationally recognized not-for-profit clinical specialty associations of the relevant behavioral, mental health, or substance use disorder specialty. (I.5) [Editor's note: Subsection (5.5)(a)(I.5) is effective January 1, 2026.] (A) All utilization review and utilization review criteria must be consistent with current generally accepted standards of behavioral, mental health, and substance use disorder care. (B) In conducting utilization review of covered services for the diagnosis, prevention, and treatment of behavioral or mental health disorders, a health benefit plan shall apply the criteria and guidelines set forth in the most recent version of the treatment criteria developed by unaffiliated nationally recognized not-for-profit clinical specialty associations of the relevant behavioral or mental health disorders. In conducting utilization review of covered services for the diagnosis, prevention, and treatment of substance use disorders, a health benefit plan shall apply the criteria specified in subsection (5.5)(a)(I)(B) of this section. (C) In conducting utilization review relating to service intensity, level of care placement, or any other patient care decisions that are within the scope of the sources specified in subsections (5.5)(a)(I)(B) and (5.5)(a)(I.5)(B) of this section, a health benefit plan shall not apply different, additional, conflicting, or more restrictive utilization review criteria than the criteria set forth in those sources. If the requested service intensity or level of care placement is inconsistent with the health benefit plan's assessment using the relevant criteria, as part of any adverse benefit determination, the health benefit plan shall provide full detail of its assessment and the relevant criteria used in the assessment to the provider and the covered person. (D) In conducting utilization review that is outside the scope of the criteria specified in subsections (5.5)(a)(I)(B) and (5.5)(a)(I.5)(B) of this section or related to advancements in technology or types of levels of care that are not addressed in the most recent versions of the sources specified in those subsections, a health benefit plan shall conduct utilization review in accordance with subsection (5.5)(a)(I.5)(A) of this section. If a health benefit plan purchases or licenses utilization review criteria pursuant to this subsection (5.5)(a)(I.5)(D), the health benefit plan shall verify and document before use that the criteria comply with the requirements of subsection (5.5)(a)(I.5)(A) of this section. (E) A health benefit plan must not limit benefits or coverage for chronic behavioral, mental health, or substance use disorders to short-term symptom reduction at any level-of-care placement. (II) (Deleted by amendment, L. 2013.) (III) (A) Except as provided in subsections (5.5)(a)(III)(B) and (5.5)(a)(III)(C) of this section, any preauthorization or utilization review mechanism used in the determination to provide the coverage required by this subsection (5.5)(a) must be the same as, or no more restrictive than, that used in the determination to provide coverage for a physical illness. The commissioner shall adopt rules as necessary to implement and administer this subsection (5.5). (B) A health benefit plan subject to this subsection (5.5) must provide coverage without prior authorization for a five-day supply of at least one of the FDA-approved drugs for the treatment of opioid dependence; except that this requirement is limited to a first request within a twelve-month period. (C) A health benefit