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Consumer Insurance Council Recommendations
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As of 7.6.2022
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REVIEW DATETOPICCOUNCIL ACTIONDATE OF ACTIONCOMMISSIONER RESPONSE
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R-1Consumer group submitted 6-1-20Council ActionDate of ActionCommissioner Response
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7/10/2020Facial Feminization Surgery
ISSUE:
Facial Feminization Surgery (FFS) is a life saving medically necessary procedure for many transgender and nonbinary individuals. Facial Feminization Surgery for the treatment of gender dysphoria is excluded from coverage in every insurance plan.
RECOMMENDATION:
The Division of Insurance should implement a state rule that requires insurance carriers cover FFS under treatment for gender dysphoria in all plans based in Colorado.
RATIONALE:
If every single carrier denies coverage for FFS to treat gender dysphoria, which is life saving for some patients, it suggests that there is a systemic problem that isn’t actually related to patient-by-patient medical necessity determinations. It is commonly known by the community that FFS is never covered for gender dysphoria but could be covered in the case of disfigurement from a car accident, for example. That suggests discriminatory practices based on diagnosis to treat, not medical necessity determination. Requiring coverage removes the systemic discriminatory practice of denying coverage based on diagnosis type. The reality of discrimination in coverage removes the argument of medical necessity, when medical necessity of the procedure is proven by coverage for other non-life threatening situations under other diagnosis types. To maintain alignment with state anti-discrimination law, carriers should be required in state rule to ensure access to FFS for transgender individuals at the same rate that it would be covered under other circumstances and diagnoses.		Passed7/10/2020The Division appreciates this thoughtful recommendation from the Council and agrees that carrier compliance with both federal and state
anti-discrimination provisions are incredibly important. With regard to FFS specifically, the Division has collected detailed information on
coverage for gender dysphoria treatment for the first time in 2020. We are in the process of reviewing these data and determining what, if
any, further action needs to be taken to ensure carriers are in compliance with non-discrimination provisions and mental health parity laws.
We would be happy to provide an update at a future CIC meeting on what our findings are, including for FFS.
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R-2Individual Consumer, submitted 5-20-20Council ActionDate of ActionCommissioner Response
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10/7/2020Health Insurance Rate-Setting
Recommendation: REAL transparency is needed in the consumer-facing information on health insurance annual premium rate setting.
The consumer-facing page should list the parameters that define the set of conditions within which carriers must function when setting premium rates. The consumer-facing page should list the assumptions each carrier makes when developing premium rates. The consumer-facing pages should list the experience history (at least two or three years) of the carriers. These three things might already be public information just difficult for the average person to access.		Passed10/7/2020The Division’s policy is to make our rate setting process as transparent as current law allows. For example, we currently make available on our website the universal rate review template which includes information about carrier experience. However, these tools may be difficult for educated consumers to navigate. Over the next year, the Division will consider ways to make this information more accessible and available to consumers through publicly available and readily accessible reports and tools.
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R-3Individual Consumer, submitted 5-20-20Council ActionDate of ActionCommissioner Response
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10/7/2020
Revised:
01/06/2021		DOI Website/Consumer Information

Issue:
The DOI website should be user-friendly,
not the cumbersome site that it is. As it is now, it discourages consumer use.

Recommendation:
Assess Division website with consumer assistance to ensure effectiveness in public communication.

Rationale:

Solicit ongoing feedback and Continuous Quality Improvement. Seek public input with onsite surveys, follow-up, focus groups. Ask open-ended and closed-ended survey questions. Secure outside assistance for Best Practices, e.g. for insurance rate comparison tools.

Review Website navigation.

Searchability issues. How well can the public search the website? (does a search bar exist that would bring up all the places the consumer can be helped) Can one figure out where to go? Are there multiple ways to get there, links? Is terminology consistent? Is there Mobile access?

Mechanics – does the website use up bandwidth on photos/images and other optional content? What devices can be used to load the website? Is the site speed being reviewed? Is the website Mobile-enabled and effective in that environment?

Evaluate Content. Is Content complete, accurate and transparent? Is Content up-to-date? Are all documents dated and identified as to author/contact for questions? Are there out of date materials that pull up more readily than current documents? Is content reviewed for errors, is there a way to notify of errors (e.g. article posted by assistant commissioner yields no text, just characters/wingdings/code— a download or posting error, but no way to provide that feedback as site has not been reviewed/tested internally before posting).

Assess content for readability, understandability, transparency. What is the readability score? (Best Practices recommended 6th- 8th grade readability score, especially to assist non-English as a first language, viewers with cognitive or physical challenges, and just for reader interest and comprehension. Typical pages show 11th grade and higher readability score. Is industry jargon and acronym usage a deterrent to understanding content?		Passed4/7/2021As of Fall 2020, the Division updated its website with a new content management system (CMS) that was part of a change for the entire Department of Regulatory Agencies (DORA). A key change is that the website is now solely the Division’s website - not a branch under DORA’s site. This means that the navigation and information on the site pertain only to the Division (except for one link to the main DORA site). It also means that the search bar function on the top of every page searches only the Division site and not all of DORA’s divisions sites.

As part of this change, the website underwent significant improvements. Using the sky blue navigation bar at the top of every page, users should be able to get to almost every page on the site. However, because not everyone uses navigation bars in that way, the main landing page for the site (doi.colorado.gov), has a variety of links to many of the more common pages that consumers and industry use, such as “File a Complaint” and the most common lines of insurance, near the top, while further down there are broad categories of links like “For Consumers,” “For Industry,” “Statues, Regulations and Bulletins,” and “News & Announcements.”

The site is mobile-enabled, as are all of the sites powered by Colorado Interactive, the State’s website contractor. This new CMS offers us the capability to add more features, like video and audio files. We will check to see how using such features impacts bandwidth for users.

In addition, DORA and its divisions have partnered with a company called SiteImprove (as have many other State agencies) to continuously evaluate the content in many respects, including readability, broken or missing links, and accessibility. We will continue to use their evaluations to improve the site.

The Division will continue to welcome any specific questions or feedback about the site, especially as it has undergone a major change in the last year.
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R-4Individual Consumer, submitted 5-20-20Council ActionDate of ActionCommissioner Response
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10-07-2020

Updated 6/7/2021

Updated 9/15/21		Credit Score Ratings and Other Soft Measures for Insurance

ISSUE:
Insurance carriers should not be allowed to rate individual policies on personal, indirect,
and soft measures of claims risk, such as credit scores, social media habits, locations, purchasing habits, home ownership, educational attainment, occupation, licensures, civil judgements, and court records in accordance with SB21-169.

RECOMMENDATION:
The council recommends that rules be promulgated to disallow use of credit scores, social media habits, locations, purchasing habits, home ownership, educational attainment, occupation, licensures, civil judgements, and court records to determine insurability, premium costs and increases in alignment with the language and intent of SB21-169.

RATIONALE:
SB21-169 clearly outlines that rules must be promulgated by the Division of Insurance to ensure that external consumer data and information sources are not used in carrier’s algorithms or predictive modeling to determine insurance rating, underwriting, claims, and other business practices if there is a significant negative impact on protected classes. Due to the inherent nature and systemically inequitable impact of these categories of soft measures having a negative impact on protected classes, rules be promulgated to disallow use of credit scores, social media habits, locations, purchasing habits, home ownership, educational attainment, occupation, licensures, civil judgements, and court records to determine insurability, premium costs and increases for the rules to comply with SB21-169.		Passed2/15/2022SB 21-169 authorizes the Division to hold stakeholder meetings and promulgate regulations to analzye and review the use of big data systems and the use of "external consumer data" for potential unfair discrimination against protected classes of people. SB 21-169 does not, however, give the Division blanket authority to prohibit certian rating factors from being used without first taking those steps to determine if those particular rating factors do result in unfair discrimination. We are the first state to successfuly pass legislation to broadly address potential algorithmic bias in the insurance industry. As a result, we are forging new ground and the industry as well as our fellow regulators are closely watching what we are doing. We are very excited about the work we have in front of us and we fully understand the importance of making sure we are successful.
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R-5Individual Consumer, submitted 5-20-20Council ActionDate of ActionCommissioner Response
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10/7/2020Escrow – Real Estate
The conversation needs to be reignited on how escrow is handled in this state. I know one person and talked to another whose escrow money ($10,000 and $20,000 respectively) was stolen electronically during a transaction (going from bank to escrow holder). Even though the money was not in the hands of the buyer, the onus fell back on the buyer because neither the bank nor the escrow holder would accept responsibility.		Council decision to not move forward at this time pending new information if it comes.7/7/2021
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R-6Individual Consumer, submitted 5-20-20Council ActionDate of ActionCommissioner Response
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10/7/2020Mortgages
Transparency is needed in home mortgages.		Removed from list.
Not under
DOI purview.		1/11/2021
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R-7Consumer group, submitted 5-21-20Council ActionDate of ActionCommissioner Response
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10/7/2020Business Interruption Insurance
Issue: Need to convene an investigation of the insurance industry related to business interruption insurance denials. Law suits, escalating to class action suits are being seen. Request is that DOI take a balanced approach to business owners concerns.


Recommendation: The Division should continue to maintain a balanced approach to this issue (of business
interruption insurance coverage), encouraging business insurance
consumers to submit claims and to continue to refrain from taking a position as to coverage under individual policies or as a general matter.		Passed10/7/2020The Colorado DOI continues to monitor at both the national and state levels the issues of business interruption insurance and denials due to COVID. The Division has received complaints and inquiries related to business interruption coverage and deals with each within the context of the specific policy language. In addition, the Division participated in the NAIC data collection on business interruption provisions which determined that in excess of 90% of policies in CO with business interruption coverage had both a virus exclusion and a physical damage requirement. The physical damage requirements (which do vary somewhat depending on specific policy language) have been the subject of litigation across the country, and while some businesses have prevailed, in the vast majority the businesses are not successful in obtaining coverage. On the virus exclusion. A very few reported cases have been found for the business when a fairly specific virus exclusion is contained in the policy. We will continue to monitor this issue as it continues to evolve.
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R-8Individual consumer, submitted 5-21-20Council ActionDate of ActionCommissioner Response
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10/7/2020Health Insurance Affordability
Issue: Lack of adequate affordable health insurance options for self-employed individuals

Recommendation: The Division of Insurance should support the proposal that was before the 2019 General Assembly for the Colorado option or a similar program or law to provide group coverage for self-employed individuals.		Passed10/7/2020The Division is actively working to make affordable, quality health insurance options available to all Coloradans, including the self-employed. The Colorado Reinsurance program has lowered rates on the individual market by 20 percent. The Division is also actively and quickly implementing the American Rescue plan which significantly increase tax credits for purchasing health care and will ensure that any person who purchases their own health insurance doesn’t have to pay more than 8.5% of their income for a Silver plan. We also continue to support Health Care Coverage Cooperatives, groups of employers and individuals that are working together to negotiate lower health care prices. These cooperatives have been able to significantly lower premiums in several Western slope counties.
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R-9Consumer group, submitted 5-21-20Council ActionDate of ActionCommissioner Response
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10/7/2020Health Insurance Rate-Setting
Add requirement that a public meeting be held within annual public comment period, each year and that any insurers requesting rates be present to answer questions related to rates.		Passed7/10/2020The Division appreciates this recommendation. The 60-day window that we have to review all individual and small group rates and forms
requires an all-hands-on-deck approach that is extremely time and resource intensive. We work hard to give consumers access to
necessary information to review preliminary rate filings and accept public comments for several weeks during the process. We do review
and consider every public comment submitted to us. However, we are happy to continue this discussion and find ways to meaningfully
engage consumers further in the rate review process.
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R-10Member suggestion, submitted 5-29-20Council ActionDate of Action
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10/7/2020DORA publication titled "Medicare Insurance Policies in Colorado".Laid over - Need more clarification from Councilmember4/7/2021
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R-11Member suggestion, submitted 9-20-20Council ActionDate of ActionCommissioner Response
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10/7/2020Medigap Options
Link to Medicare Supplement Insurance: Medigap Options for Colorado Consumers .

Recommendation: Augment the information in the published document on the DORA website Medicare Supplement Insurance.

Medigap Options for Colorado Consumers to show 1. The percentages of policy cost increases over a given time period (e.g Assured Life Association selling a “C” policy has increased its premium, on the average, by X percent over the past 5 years) and 2. indicate how long any given insurance company has been selling its current alpha policies in Colorado. It would also be very desirable if DORA could survey the insurance companies to see if they are offering benefits beyond what Medicare requires (e.g. gym membership, reduced dental coverage, foreign travel coverage) and publish that information. 3. Augment the DORA publication to provide guidance on “how to shop” for those consumers who would want to “shop for a Medicare supplement
insurance broker” And if there is any other type of information that would help the consumer distinguish between one insurance company and the next selling the same alpha policy, educate SHIP counselors about that information.		Passed10/7/20201. The Division’s website under Senior Health Care and Medicare, Medicare Supplement Insurance contains the most recent 3 years of our Medigap survey results/brochure to permit consumers to review recent policy cost increases. 2. SHIP counselors have access to a new Medigap comparison tool that shows the most current rates, how long the company has been in the market, and some additional information that is not contained in our annual survey. Please refer folks to their local/regional SHIP office to contact a SHIP counselor. We are collecting some information about additional benefits beyond those that are Medicare-required, and will see if they can be effectively and efficiently added to our publication. 3. The DORA website and publications contain links to Medicare.gov which has several resources available explaining Medigap eligibility, plan coverages and differences, and questions to ask when considering/comparing plans. Consumers can visit Medicare.gov/medigap-supplemental-insurance-plans to find policies in Colorado. We will take the suggestion to augment the Medigap information, “shopping for a Medicare supplement insurance broker” under advisement for possible inclusion in the future.
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R-12Individual consumer, submitted 12-18-20Council ActionDate of ActionCommissioner Response
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1/6/2021Health Ins Plans -Transparency, Communication, Public Input
ISSUE:
In 2020, less than a 30 day public review timeframe (July 29 to August 26) was provided by the Division of Insurance to review the public exchange proposed 2021 insurance plans/requested premiums. Additionally, per the same less than 30-day timeframe, the public was expected to "be prepared to spend time on this process" when reviewing filings, that are referred to as "very technical documents.”

RECOMMENDATION:
The Division of Insurance, in its capacity as the regulatory for Colorado's health benefit exchange (Connect For Health Colorado) plan's and health insurance offerings, must provide a minimum of 60 days between insurer's filing date, as well as providing increased transparency and communication (above and beyond expecting the public to consult the DOI website from time to time for announcements) of the process by pre-announcing the actual insurers filing dates and public comment end date (i.e. via email announcement to al public exchange enrolled members). The DOI assumes the general public is familiar with its geographical split of Colorado into 9 distinct rating areas, as the insurance filings are entitled District 1 thru 9 with no indication of the geographic area each District represents, some of which have greater shares of high-risk populations. There should be a prominent statement to the public that there are 9 distinct rating districts AND that not every district is offered the same set of plans in order to provide the public greater awareness and transparency.

RATIONALE:
As the Division of Insurance reviews proposed health insurer's plans for public exchange offerings by geographical area (Districts 1 thru 9), the general public is currently given extremely limited time to review very technical preliminary files and are not made aware of announcements or timelines unless they regularly check the DOI website which, among other areas of possible concerns, could reveal possible geographical discrimination by a carrier via excluding/including districts with high-risk populations (i.e. what might be termed "discrimination by zip code"). The DOI completed reviews to insure the proposed plans are "ACA-compliant"; however, the Colorado state legislative body, via passage of SB17-088, requires that any participating health insurer's provider's selection and tiering cannot "allow the insurer to discriminate against high-risk populations by excluding or tiering providers based on their location in a geographical area that contains high-risk populations''.		Passed1/6/2021The Division will strive to provide the public with the maximum amount of time possible to review public exchange rates. Under statute, the Division has only 60 days to review and approve rates. Because of technical limitations and the need to ensure filings are complete, DOI may not be able to make filings available immediately after they are filed. Further, the Division needs time to compile and consider public comments on these rates before they are finalized. Division staff would be happy to discuss in more detail how to make the public review of rate filings as transparent and accessible as possible.
(The Commissioner’s response has not changed) 7/2/2021
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TOPIC
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R-13Submitted by Council Member, Charles GrayCouncil ActionAction DateCommissioner Response REBUTTAL/ADDITIONAL DISCUSSION
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2/15/2022Health Insurance Claims Appeal Process:Passed4/6/20227/1/202211/28/2022
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ISSUE: As demonstrated by recent experiences of confusing PO Box addresses, certified mail received by insurance carrier, but carrier denies receiving, inconsistent customer service information and risks to the time window for appeals, this process is an undue burden. RECOMMENDATION: We recommend that all carriers provide:
- Clear and easily accessible information and instructions on how to appeal a claim
- Ability to submit an appeal over the phone or online through the member account portal
- Provide to member an immediate appeal case number and date generation confirming receipt of appeal submission, date of submission via either method (and confirmation of required uploaded documentation, if done online when SUBMIT button is pressed)
- Easy access to current appeal status by phone or after logging into member portal claims page		Additional discussion of Commissioner response. Matt Mortier will look into it and bring additional information to the Council at next meeting. 7/6/2022 UPDATED 11/28/2022Currently carriers are required to provide appeals information with every notice of an adverse determination per Colorado Insurance Regulation 4-2-17, including how to request an appeal, and request independent exteral review, if applicable. Further, consumers can request appeals verbally from carriers, though the Division will look into carrier processes to determine if appeals can be submitted through the consumer portal, but the Division has seen many appeals requested via email to a carrier. Matt Mortier confirmed that the three of the largest carriers (CIGNA, Kaiser, Anthem) do accept electronic appeals process. Matt offered to check with all of the carriers. Additional discussion about the original recommendation. That carriers have an electronic appeal process and the information is easily accessible. Can this be added on the Division's website?
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R-14Submitted by Council Member, Charles GrayCouncil ActionAction DateCommissioner ResponseREBUTTAL/ADDITIONAL DISCUSSION
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4/6/2022Out of Network Health Care Services Provided In NetworkPassed4/6/20227/1/202211/28/2022
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ISSUE: Often times services are referred to out-of-network providers even though the service is are sought in network. Consumers do not know their rights under Colorado law and may pay out-of-network claims inadvertently. RECOMMENDATION: We recommend that all carriers provide:
- Along with other existing disclosures to members, health insurance carriers should be required to provide bold notification of the consumer's rights under Section 10-16-704 (3) (b), C.R.S.
- Carriers should be required to establish software algorithm links during auto adjudication which can approve all claims for services provided or at the direction of an in-network provider or facility, without a member having to go through the efforts to appeal a claim which was erroneously denied.		There will be ongoing discussions and data gathering.The recently passed federal no surprises act, and the recently passed HB 22-1284 that aligned Colorado Law with that act, provides additional consumer disclosure and notification requiements. The Division is currently working with it's sister Divisions and other agencies to update consumer disclosures and notifications to comply with the changes in the bill. All claims, per statute, are permitted to go through the utilization management process. Claims may be denied for many reasons, including errors made by the provider in how the claims has been file. The current appeals processes established in statute and regulation are intended to ensure the appeals process is followed and claims are approved if they meet the requirements for coverage. It would be helpful if additional information could be provided around what sorts of erroneous denials are being experienced, and by which carriers, so the Division can look into the issue further. Chuck - let's wait and see what comes out with the new plan booklets in Jan 2023.
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R-15Submitted by Council Member, Charles GrayCouncil ActionAction DateCommissioner ResponseREBUTTAL/ADDITIONAL DISCUSSION
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2/8/2023Geographic Network Adequacy Standards
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ISSUE:
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R-16Submitted by Council Member, Robert GrieveCouncil ActionAction DateCommissioner ResponseREBUTTAL/ADDITIONAL DISCUSSION
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2/8/2023Concerns about HMO's and out of network care Passed7/12/2023
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ISSUE: In HMO policy’s, covered individuates do not have coverage provided by the policy if they go outside the network except for emergencies covered by the policy. There is a lack of PPO plans in the individual market - lack of coverage for OON care.

RECOMMENDATION: 1. Bold verbiage required upfront when researching these plans prior to purchasing to explain that there is no coverage outside the network and there are geographic limitations - except for emergency services. 2. Policy riders be made available for coverage during travel or school 3. Mandate a PPO plan be offered in the individual market by each carrier 4. Required disclosures at moment of purchase AND prior to signature

1. Response: HMO plans by their design do not provide non-emergency benefits for services provided by non-network providers without prior authorization from the carrier, and there are currently requirements that language describing that be included in plan policy documents, specifically in the policy documents themselves, as well as in the Evidence of Coverage (EOC) document, which is made available to consumers prior to purchase.
Those EOCs are available for download when shopping on the Connect for Health Colorado (the Exchange) website. There are also requirements that the EOCs state how benefits are covered for both in-network and out-of-network providers. Upon review of the HMO plans currently listed for the 2024 plan year on the Exchange website, all six carriers offering plans for 2024 stated on their EOCs that non-plan provider non-emergency services are not covered by the plan.
Federal language requirements for EOCs mandate that language be included in the EOC that states that a policyholder will pay more if they use an out-of-network provider.
A review of current EOCs available, and the language contained in the policy documents for HMO plans appears to already provide the language requested by the recommendation.
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2. Response: It is important to note that the federal Affordable Care Act does not allow riders to be placed on ACA health benefit plans, as any benefits of the plan must be placed within the plan. Coverage for non-emergency care during travel or while a covered person is at school is not a required Essential Health Benefit included in either state or federal law and is not in the state benchmark plan. While HMO Plans do not offer policy riders, there are other insurance products currently available, such as travel insurance, both domestic and international, as well as student health plans offered by educational institutions. Emergency coverage is always available when out of state for both state and federally regulated health benefit plans.
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3. Response: When the ACA was first implemented in Colorado, many carriers did offer PPO plans, but stopped offering them due to lack of enrollment and interest by consumers in Colorado due to their higher price. Most consumers purchase health plans based on price, and many carriers found there was insufficient enrollment and interest to continue offering such products in the individual market. Mandating that carriers offer PPO would also be difficult in the current market as the products each carrier can offer is based upon the type of license they hold, and not all carriers are licensed appropriately to offer PPO products in the state. There are currently only two carriers licensed to do so in Colorado, and one of those carriers is not currently active in the individual market, so such a mandate would only apply to a single carrier in the individual market at this time. After discussing this internally, and based on multiple factors, establishing such a PPO plan mandate is not something the Division will pursue at this time.
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4. Response: After internal discussion, this could potentially be implemented for online applications via a pop-up box, or as a separate disclosure form provided by brokers selling HMO plans, that would require a response before completing the sale. The Division will discuss internally the possibility of adding this requirement, though it is unclear what additional utility they would provide to consumers based on the language that is already included in the HMO EOCs policies that states that non-emergency care provided by out-of-network providers are not covered by an HMO plan. The Division will continue to discuss this recommendation internally.
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R-17Submitted by Council Member, Jacki Paone
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2/8/2023Underinsurance in Homeowners Insurance (including replacement cost coverage)
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