DEPARTMENT OF REGULATORY AGENCIES



DEPARTMENT OF REGULATORY AGENCIES

DIVISION OF INSURANCE

3 CCR 702-4

LIFE, ACCIDENT AND HEALTH

NEW REGULATION 4-2-50

CONCERNING PEDIATRIC DENTAL COVERAGE REQUIREMENTS

Section 1 Authority

Section 2 Scope and Purpose

Section 3 Applicability

Section 4 Definitions

Section 5 Rules

Section 6 Notices

Section 7 Severability

Section 8 Enforcement

Section 9 Effective Date

Section 10 History

Section 1 Authority

This regulation is promulgated under the authority of §§ 10-1-109, C.R.S., and HB 14-1053.

Section 2 Scope and Purpose

The purpose of this regulation is to establish a requirement that carriers cannot sell a health benefit plan in the individual or small group market inside or outside the Exchange that does not contain pediatric dental essential health benefit (EHB) coverage without obtaining reasonable assurance that such coverage has been purchased.

Section 3 Applicability

This regulation shall apply to all insurance carriers who offer individual and small group health benefit plans, and/or stand alone dental plans, issued or renewed on or after January 1, 2015, in the state of Colorado.

Section 4 Definitions

A. “Carrier” shall have the same meaning as found at § 10-16-102(8), C.R.S.

B. “Clear and conspicuous” means, for the purposes of this regulation, and 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:

1. Uses a typeface and type size that are easy to read;

2. Provides wide margins and ample line spacing;

3. Uses boldface, italics, underscoring, or capitals for key words and phrases; and

4. 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.

C. “Essential health benefits” and “EHB” shall have the same meaning as found at § 10-16-102(22), C.R.S.

D. “Exchange” shall have the same meaning as found at § 10-16-102(26), C.R.S.

E. “Health benefit plan” shall have the same meaning as found at § 10-16-102(32), C.R.S.

F. “Patient Protection and Affordable Care Act” and “ACA” mean, for the purposes of this regulation, the Patient Protection and Affordable Care Act, Pub. L. 111-148 and the Health Care and Education Reconciliation Act of 2010, Pub. L. 111-152.

Section 5 Rules

A. Pediatric dental coverage is one of the ten (10) essential health benefits (EHB) that must be covered by health benefit plans subject to the requirements of the ACA.

B. Obtaining pediatric dental coverage.

1. Carriers selling individual and small group health benefit plans must ensure that consumers purchasing their health plans obtain pediatric dental EHB coverage.

2. Carriers shall give consumers notice, in accordance with Section 6 of this regulation, if the plan they have selected for purchase does not include the required pediatric dental EHB coverage.

3. Carriers shall provide a clear and conspicuous notice to consumers on their websites or with all pediatric dental plan marketing materials describing how out-of-pocket maximums for stand-alone pediatric dental plans are treated differently than out-of-pocket maximums for dental plans that are provided with, or contained within, a health benefit plan. This notice shall also be provided to consumers as a separate document that is included with the dental plan policy documents given to policyholders.

4. Carriers must be reasonably assured that the required pediatric dental EHB coverage has been purchased through one of the following methods:

a. The purchase of a health benefit plan which contains the required pediatric dental EHB coverage;

b. The purchase of a health benefit plan which provides the required pediatric dental EHB coverage through a contractual arrangement with a dental carrier; or

c. The purchase of a stand-alone dental plan that provides the required pediatric dental EHB coverage.

C. In order for a carrier to sell an individual or small group health benefit plan that does not include coverage of the pediatric dental EHB, the carrier must be reasonably assured that a consumer has or will purchase such coverage. Reasonable assurance may be obtained by one or more of the following:

1. Obtaining a certification from the consumer that they have purchased pediatric dental EHB coverage;

2. Obtaining proof of purchase from the consumer who is a childless adult that they possess low-cost/no-cost child-only pediatric dental EHB coverage; or

3. Obtaining an attestation as supplied on the individual application that the consumer has or will purchase pediatric dental EHB coverage.

D. Supplying only the notice as required in Section 6 of this regulation does not constitute reasonable assurance.

Section 6 Notices for No-Adult-Benefit Pediatric Dental Plans

A. Carriers must provide notice to consumers purchasing pediatric-only dental EHB coverage, whether in a standalone dental policy or as part of a health benefit plan, that such coverage does not provide any dental benefits to individuals age nineteen (19) or older.

B. The required notice shall be prominently displayed on the first page of the policy form and shall be contained in all marketing materials for that policy.

C. The required notice shall consist of the following language:

“This policy does not provide any dental benefits to individuals age nineteen (19) or older. This policy is being offered so the purchaser will have pediatric dental coverage as required by the Affordable Care Act. If you want adult dental benefits, you will need to buy a plan that has adult dental benefits. This plan will not pay for any adult dental care, so you will have to pay the full price of any care you receive.”

Section 7 Severability

If any provisions of this regulation or the application thereof to any person or circumstances are for any reason held to be invalid, the remainder of the regulation shall not be affected in any way.

Section 8 Enforcement

Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.

Section 9 Effective Date

This regulation is effective July 15, 2014.

Section 10 History

Regulation effective July 15, 2014.

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