CO| Colorado Amended Regulation 4-2-64 sets comprehensive standards to ensure full parity between behavioral health (including mental health and substance use disorders) and medical/surgical benefits in Colorado health benefit plans, by defining required behavioral health coverage (including preventive services, court-ordered treatment, ASAM-based SUD care, eating disorder standards, and network access), aligning financial requirements and treatment limitations with federal MHPAEA rules, imposing strict comparability and data-driven oversight of nonquantitative treatment limitations (e.g., prior authorization, network design, utilization review), and establishing detailed annual filing, reporting, documentation, and confidentiality requirements for carriers, with enforcement provisions and an effective date of May 15, 2026.
Key Issues:
- Benefit design and coverage mandates carriers must cover specified behavioral health preventive services, court-ordered treatment, medication-assisted treatment without PA or step therapy, meaningful MH/SUD benefits in every classification where medical/surgical is covered, and may not use BMI/IBW-based criteria for eating disorder medical necessity.
- Parity in limitations and management financial requirements, quantitative and nonquantitative treatment limitations (including utilization review, medical necessity criteria, formulary design, and network composition) for MH/SUD cannot be more restrictive than those applied to substantially all comparable medical/surgical benefits, and must be designed and applied using comparable factors, evidentiary standards, and ongoing outcome data analysis to detect and correct material access differences.
- Extensive carrier reporting and accountability carriers must annually submit attestations, quantitative treatment limitation classifications, and a suite of NQTL and network-related templates (utilization review, out-of-network use, provider engagement, ASAM usage, eating disorder criteria, pharmacy management, and a six-step NQTL comparative analysis), with specified signatures, SERFF filing structure, confidentiality handling, and are subject to sanctions, including fines and license actions, for noncompliance.