The Division of Insurance (DOI) also reviews plans to ensure that they meet the requirements of the Affordable Care Act (ACA), such as not having pre-existing condition exclusions, offering guaranteed renewability, and compliance with open enrollment and special enrollment period requirements.
In addition, DOI reviews the plans to make sure they cover Essential Health Benefits (EHBs). Essential Health Benefits are specific benefits that new individual and small group plans are required to cover. They fall into 10 basic categories.
- emergency services
- maternity and newborn care
- mental health and substance use disorder services
- prescription drugs
- laboratory services
- pediatric services
- preventive/wellness/disease management services
- ambulatory services
- rehabilitative and habilitative services and devices
While these categories are strictly defined in federal law, carriers have flexibility in how they structure the benefits within each category. However, DOI also ensures the plans meet the standards of Colorado law, and cover all state-mandated benefits. For example, Colorado law requires insurance carriers to provide coverage of congenital anomalies, including cleft lip/palate.
In addition to proposed rates and benefits, carriers had to submit information regarding their marketing materials for these plans, along with information about their networks of doctors, hospitals and other providers.