COHBE Qualified Plan Certification
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SB-200 Requirements
• CRS 10-22-104 The exchange shall not duplicate or replace the
duties of the commissioner established in section 10-1-108,
including rate approval, except as directed by the federal act. The
exchange shall foster a competitive marketplace for insurance and
shall not solicit bids or engage in the active purchasing of insurance.
• CRS 10-22-106(1)
– (i) Consider the unique needs of rural Coloradans as they pertain to
access, affordability, and choice in purchasing health insurance;
– (j) Consider the affordability and cost in the context of quality care and
increased access to purchasing health insurance; and
– (k) Investigate requirements, develop options, and determine waivers,
if appropriate, to ensure that the best interests of Coloradans are
protected.
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Marketplace Rules
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Plan Management
• Certification, recertification, decertification
– Regulatory requirements
– Accreditation standards
• Business Relationship
– Data exchange standards
– Customer service standards
• Exchange will develop objective plan
management standards and communicate those
standards to carriers before certification.
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Exchange Partners
• Exchange will work with Division of Insurance,
Department of Public Health and
Environment, and Department of Health Care
Policy and Financing to minimize QHP burdens
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Certification Requirement Activities
Accreditation
Marketing
Requirements
Licensure Requirements
Complaint Data
MLR
requirements
Marketing
Requirements
Claim Payment Disclosures
Network
Adequacy
MLR requirements
Discriminatory Benefit Design Review
Out-of-Network
Disclosure Requirements
Network Adequacy
Essential Benefit Validation
Plan
Differentiation
Out-of-Network
Disclosure Requirements
Essential Community Health Providers
Provider
Directory
QHP Quality
Measures
Financial Disclosures
QHP
Quality
Measures
Provider
Directory
Formulary Requirements
Rate
Review
Solvency
Requirement
Licensure Requirements
Solvency Requirement
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State, Federal, or UX Guidance
Accreditation (Fed)
MLR Requirements (Fed)
Complaint Data (State)
Network Adequacy (State)
Claim Payment Disclosures (State)
Out-of-Network Disclosure Requirements
(State)
Financial Disclosures (State)
Provider Directory (UX)
Formulary Requirements (UX)
Rate Review (State)
Licensure Requirements (State)
Solvency Requirement (State)
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New Processes
Some Existing Processes
Essential Community Providers
QHP Quality Measures
Marketing Requirements
Completely New Processes
Discriminatory Benefit Design
Essential Benefit Validation
Plan Differentiation
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Decertification
• The Exchange will only decertify an issuer during
the year if the issuer is not able to meet
responsibilities (loses licensure, insolvency, or
inadequate network, etc.)
– The Exchange will work to move members to a new
QHP in an efficient manner
• An issuer who fails to meet necessary business
partnership levels will not be recertified but
members will continue to be enrolled in the QHP
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Recertification
• The Exchange will develop an annual
recertification process
• The recertification will allow the Exchange
board to change the baseline certification
processes in future years
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