Colorado Insurance Law and Cleft Lip and Cleft

Colorado Insurance Law and Cleft Lip and Cleft Palate Coverage Dayle Axman, FLMI, ACS, AIE, AIS Colorado Division of Insurance October 10, 2015

Introduction to the Division of Insurance v Regulate insurance to ensure that insurance rates are not excessive, inadequate, or unfairly discriminatory v Give consumers the greatest choice of policies at the most reasonable cost possible v Permit and encourage open competition between insurers on a sound financial basis • CRS 10 -1 -101

Finance and Administration v Actuarial v Financial Examiners v Corporate Affairs v Rates and Forms § Life and Health § Property and Casualty v Financial Affairs v Market Regulation

Consumer Affairs v Consumer Affairs Life and Health n Property and Casualty n v Senior Health Insurance Program (SHIP/SMP) v Compliance v Licensing and Investigations

Consumer Protection v Consumer Affairs § Complaint process § Referral to Market Regulation for enforcement action § Referral to Licensing and Investigations v Market Regulation n n Market Analysis Targeted Market Conduct Examinations

Consumer Affairs v Education § 13, 000 calls, emails and written inquiries v Consumer Recoveries (Fiscal Year 2014 -2015) § $7, 436, 522 for all lines of insurance

How do I know if my plan is a Colorado-regulated plan? Check your member ID card: Does it have a “CO-DOI” designation on it? If so, Colorado insurance laws apply and the Division can help you.

What Can’t the Division Help With? v Individual policies issued in other states v Health plans that are “self-funded” by employers v Single employer plans where the master contract is issued in another state v Medicare and Medicaid v Federal employee benefit plans

Cleft coverage mandates in other states 15 other states have some type of mandated coverage*: ü California ü New York ü Connecticut ü North Carolina ü Florida ü South Carolina ü Indiana ü Texas ü Louisiana ü Vermont ü Maryland ü Virginia ü Massachusetts ü Wisconsin ü Minnesota * According to Cleft. Advocate. org and the internet

Section 10 -16 -104(1)(c)(II), C. R. S. Effective July 1, 1975 Generally covers 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 and there is no age limit. Provides medically necessary coverage for: ü Oral and facial surgery

Coverage (continued) ü Surgical management and follow-up care by plastic and oral surgeons ü Prosthetic treatment, such as: § Obturators § Speech appliances § Feeding appliances

Coverage (continued) ü Orthodontic treatment ü Prosthodontic treatment ü Habilitative speech therapy ü Otolaryngology treatment ü Audiological assessments and treatment

Other Requirements v If there is also a dental policy: § It must provide full coverage for all orthodontics or dental care needed. § May apply the same copayment provisions that apply to other conditions or procedures covered by the policy.

Where do I go to ask a question or to file a complaint? If you have a Colorado plan: v Call (303)894 -7490 or 1 -800 -930 -3745 v www. dora. colorado. gov/Insurance v Complaints – file electronically through our website or send us a letter

DOI Mission: Promote compliance and enforce laws to help protect consumers 15