Colorado health-insurance questions blend national medical-plan design with a layer of Colorado-specific marketplace, continuation, and consumer-protection rules. This guide reviews the building blocks every health agent needs—plan types and cost-sharing—then makes the Colorado overlay the spine: the state marketplace Connect for Health Colorado, Medicaid as Health First Colorado, continuation and conversion rights, the Colorado Life and Health Insurance Protection Association, and the policy provisions the Division of Insurance enforces.

The national base: types of medical plans

Most health questions begin with how a plan balances cost, choice, and network:

• Indemnity / fee-for-service — reimburses a share of covered charges with broad provider choice; now uncommon.
• HMO (Health Maintenance Organization) — lowest cost, network-only care through a primary care physician (PCP) who acts as a gatekeeper and gives referrals to specialists.
• PPO (Preferred Provider Organization) — a network with lower in-network cost but out-of-network access at higher cost, usually without referrals.
• EPO (Exclusive Provider Organization) — network-only like an HMO (no out-of-network benefit except emergencies) but typically no PCP/referral requirement.
• POS (Point of Service) — a hybrid letting the member choose in- or out-of-network at the time of service, often using a PCP gatekeeper.

Universal cost-sharing terms apply across all designs: the premium (what you pay to have coverage), the deductible (paid before the plan shares), the copay (a flat per-visit charge), coinsurance (a percentage split after the deductible—e.g., 80/20), and the out-of-pocket (OOP) maximum (the annual cap after which the plan pays 100% of covered, in-network care). Plans may pay providers by capitation (a fixed amount per member per period) and measure charges against a usual, customary, and reasonable (UCR) standard. Tax-advantaged accounts also appear: an HSA must be paired with a qualified high-deductible health plan, while an FSA lets employees set aside pre-tax dollars for qualified medical expenses. Coverage is sold group (employer-sponsored) versus individual (bought directly).

The ACA floor (federal minimums)

The Affordable Care Act sets a national floor every Colorado plan must meet:

• Guaranteed issue — insurers cannot decline an applicant for health reasons.
• No health rating — premiums vary only by age, geography, tobacco use, and family size, not health status.
• Pre-existing conditions covered — no exclusions or waiting periods for prior conditions.
• Essential health benefits — required categories such as hospitalization, maternity, prescription drugs, mental health, and preventive care (many in-network preventive services covered at no cost-sharing).
• Dependents to age 26 — adult children may stay on a parent's plan.

Colorado builds on top of this floor; it does not subtract from it.

Connect for Health Colorado and Health First Colorado

Two Colorado names are worth memorizing and not confusing:

• Connect for Health Colorado is the state's state-based health insurance marketplace (exchange), where individuals and small groups compare and buy plans and where eligible enrollees claim premium subsidies.
• Health First Colorado is the brand name of Colorado Medicaid, the income- and need-based public program. It is administered by the Department of Health Care Policy and Financing (HCPF)—not by the Division of Insurance.

The exam loves to test that the marketplace (Connect for Health Colorado) and Medicaid (Health First Colorado / HCPF) are different things, and that Medicaid is a joint federal-state program based largely on financial need, distinct from age-based Medicare.

Colorado mandated benefits

Like every state, Colorado requires insured (non-self-funded) health plans to include certain state-mandated benefits that often exceed the federal minimum. Treat these by category rather than memorizing dollar caps, which change, and verify specifics:

• Mental health and substance use coverage consistent with parity rules.
• Preventive screenings and immunizations.
• Maternity and newborn care.
• Diabetes management and supplies.
• Other condition-specific mandates the legislature adds over time.

Self-funded ERISA plans are generally exempt from state mandates—a common exam distinction.

Group continuation and conversion

• Federal COBRA applies to employers with 20 or more employees and lets qualified beneficiaries continue group coverage for a limited time (generally up to 18 months, or 36 months for certain events) by paying the full premium themselves.
• State continuation fills the gap for smaller employers below the federal COBRA threshold; treat the eligibility and duration figures as ones to verify with current Colorado law.
• Conversion privilege — separate from continuation, group coverage often carries a conversion privilege letting a departing member move to an individual policy without new evidence of insurability within a set window. On the exam, distinguish continuation (keeping the same group plan temporarily) from conversion (moving to an individual policy).

Group-plan mechanics also tested: the master contract goes to the employer/sponsor while members get certificates; premiums may be experience rated; a noncontributory plan (employer pays all) usually requires 100% participation; and coordination of benefits prevents collecting more than the total allowable expense from multiple plans.

Required policy provisions and timelines

The Colorado Division of Insurance enforces standard health-policy provisions, including:

• Free look — a window to return a newly delivered policy for a full refund; commonly at least 10 days for individual health policies (verify; some products allow longer).
• Grace period — extra time to pay a late premium before the policy lapses.
• Entire contract — the policy plus the attached application form the whole agreement.
• Incontestability / time limit on certain defenses — after the policy has been in force a stated period, the insurer generally cannot contest it for application misstatements.
• Notice of claim, proof of loss, and time of payment — commonly cited as notice within 20 days (or as soon as reasonable), proof of loss within 90 days (or as soon as reasonable), and prompt payment once acceptable proof is received.
• Guaranty backstop — if a health insurer becomes insolvent, the Colorado Life and Health Insurance Protection Association provides limited protection for covered obligations.

Key Colorado numbers to memorize

Common exam traps

• Confusing the marketplace with Medicaid. Connect for Health Colorado is the exchange; Health First Colorado (via HCPF) is Medicaid.
• Sending Medicaid questions to the Division of Insurance. Medicaid is run by HCPF, not the Division.
• Mixing up continuation and conversion. Continuation keeps the group plan temporarily; conversion moves to an individual policy with no new evidence of insurability.
• Missizing COBRA. Federal COBRA = 20+ employees; smaller employers fall under state continuation (verify the details).
• Pairing an HSA with the wrong plan. An HSA requires a qualified high-deductible health plan.
• Assuming the ACA floor can be undercut. Guaranteed issue, no health rating, and pre-existing coverage are federal minimums Colorado cannot reduce.
• Asserting exact mandate caps, durations, or free-look days. Treat them as statutory and verify.

Quick recap

Colorado medical-plan questions start with national design—HMO, PPO, EPO, POS, and indemnity—and the universal cost-sharing terms (premium, deductible, copay, coinsurance, OOP max, plus HSA/FSA), layered with the ACA floor: guaranteed issue, no health rating, pre-existing coverage, essential health benefits, and dependents to age 26. The Colorado overlay is the spine: the Connect for Health Colorado marketplace, Health First Colorado Medicaid through HCPF, state continuation for small employers (below federal COBRA's 20+ rule), and a conversion privilege to individual coverage. Add the provisions the Division of Insurance enforces—~10-day free look, grace period, incontestability, prompt claim handling—plus the Colorado Life and Health Insurance Protection Association backstop, and verify any specific number.