Proposed Additional Benefits for Health Coverage Plans


The list below shows instances where Colorado legislation required the division to submit to the federal Department of Health and Human Services its determination as to whether the benefit(s) specified in a bill are 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 to request that the federal department confirm the division's determination. 


HB23-1136 - Coverage of Prosthetic Devices for Recreational Activities

HB23-1136 requires carriers to cover an alternative prosthetic limb if the patient's physician determines that it is necessary to engage in physical or recreational activity. .

SB23-189 Increasing access to reproductive health care

SB23-189 requires carriers to provide coverage for the total cost of abortion care without requiring any cost sharing from enrollees.

SB21-016 - Coverage of Sexually Transmitted Infections Screening and Contraceptives

SB21-016 concerns services related to preventive health care, specifically testing for sexually transmitted infections (STIs) regardless of gender and
contraception without cost sharing.

HB21-1276 - To provide Coloradans with alternatives to opioids with the goal of lessening reliance on opioids.

HB21-1276 requires issuers to align cost-sharing amounts for
non pharmacological treatments for pain - including a minimum of six physical therapy visits, six occupational medicine visits, six chiropractic visits, and six acupuncture visits.

State Benchmark Plan - Annual Wellness Exam

The new Colorado benchmark plan that the DOI proposed in 2021, to be effective 2023, included one 45-60 minute mental health visit per year.

HB20-1158 - Availability of infertility coverage under state-regulated health plans.

During the 2020 legislative session, the Colorado General Assembly passed HB 20-1158 (Insurance Cover Infertility Diagnosis Treatment Preserve). Under Section 10-16-104(23) C.R.S, individual and group health benefit plans are required to provide coverage for the diagnosis and treatment for infertility and for standard preservation services. However, as detailed in the bill, if the federal government informed the Division of Insurance that the coverage would lead to the State having to defray costs pursuant to the Affordable Care Act, 42 U.S.C ยง 18031(d)(3)(B), the requirements for coverage for infertility treatment would not go into effect for markets subject to the ACA requirement. 

The Division released a proposed regulation clarifying that the infertility requirements in HB20-1158 would apply to carriers offering health benefit plans in the large group market for plans issued on or after January 1, 2022, in order to meet the legislative intent of the law, but that the requirement would not apply to individual and small group plans in 2022 based on uncertainty regarding State defrayal costs. After consideration of public comments received during the regulatory process and concerns raised about the legal authority of the Division to implement the law in the large group market, the Division withdrew the proposed regulation in November 2021. 

Therefore, at this time, carriers are not required to provide infertility coverage other than what is currently required by the benchmark plan for individual and small group plans. Consumers should contact their carriers to confirm what they may cover related to infertility services.

Request for Information (RFI) - Mental Health Wellness Exam and Substance Use Disorder Coverage

On Sept. 1, 2020, the Division of Insurance issued Requests for Information (RFI) on the costs and benefits associated with requiring health insurance coverage of annual mental health wellness exam and coverage of substance use disorder (SUD). Responses to these RFIs were due to the Division on, September 30, 2020.

Proposed Mental Health Wellness Exam Benefit Proposed Substance Use Disorder (SUD) Benefit

An annual mental health wellness examination of up to sixty (60) minutes in length with a qualified mental health provider without consumer cost-sharing. The examination may include services such as the following.

  • Behavioral health screening
  • Education and consultation on healthy lifestyle changes
  • Referrals to ongoing treatment, mental health services and other supports
  • Discussion of potential options for medication

This coverage proposal derives from HB20-1086, concerning an annual mental health wellness examination. Please refer to the legislation for additional information.

  • A minimum of six physical therapy visits, six occupational therapy visits, six acupuncture visits, and six chiropractic visits (with cost sharing that is no greater than that charged for a non-preventive services primary care visit) as non pharmacological alternatives to opioid treatment; 
  • Not require prior authorization for nonpharmacological treatments as an alternative to opioids;   
  • Provide coverage for at least one atypical opioid (defined as a nonopioid analgesic with far lower fatality rates than pure opioid agonists) for the treatment of acute or chronic pain at the lower cost tier, without step therapy or prior authorization for that atypical opioid; and
  • Not require step therapy for the prescription and use of any additional atypical opioid medications for the treatment of acute or chronic pain.

These coverage proposals derive from HB20-1085, concerning prevention of SUDs. Please refer to the legislation for additional information.


The Division requested information on the financial impact, the health benefits of the services, and the medical efficacy of the services proposed. As part of this analysis, the Division requested information on the following.

  1. The anticipated impact on premiums in the fully insured individual, small group, and large group markets and the underlying assumptions on which the impact is based; 
  2. The anticipated impact on consumer out of pocket costs and the underlying assumptions on which the impact is based; 
  3. The anticipated impact on the total cost of health care services, including potential benefits or savings to insurers, consumers, and employers resulting from prevention or early detection of the health condition related to such coverage, and the underlying assumptions for that determination;
  4. The potential health benefits of the proposed coverage and the extent to which scientific evidence exists regarding the potential health benefits;
  5. The extent to which the proposed coverage would be a substitute for more expensive or less safe treatment;
  6. The estimated change in utilization as a result of providing the coverage;
  7. The extent to which insurance coverage for the proposed coverage already exists or, if no coverage exists, the extent to which the lack of coverage results in inadequate health care or financial hardship for Coloradans; 
  8. The extent to which the proposed benefit would result in changes to existing benefits and/or reduce access to other health benefits; and 
  9. Any other data responsive to Colorado Revised Statute Section 10-16-103 or other information that the respondent believes relevant to the analysis. 

Responses to this RFI were submitted to DORA_INS_RulesandRegulations@state.co.us.  

For questions regarding this RFI, please contact Debra Judy at debra.judy@state.co.us.

Public Meeting

On Oct. 21, 2020, the Division held a virtual public meeting to take additional comments from the public for consideration in evaluating the impacts of requiring carriers to provide these health services:

10-21-20 Public Meeting on Costs & Benefits of Requiring Health Insurance Coverage for Certain Services

Responses to Requests for Information
RFI Findings