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H.B. 294

             1     

HEALTH SYSTEM REFORM AMENDMENTS

             2     
2010 GENERAL SESSION

             3     
STATE OF UTAH

             4     
Chief Sponsor: David Clark

             5     
Senate Sponsor: Wayne L. Niederhauser

             6     
             7      LONG TITLE
             8      General Description:
             9          This bill amends provisions related to health system reform for the insurance market,
             10      health care providers, the Health Code, and the Office of Consumer Health Services.
             11      Highlighted Provisions:
             12          This bill:
             13          .    provides access to the Department of Health's all payer database, for limited
             14      purposes, to the Insurance Department's health care delivery and health care
             15      payment reform demonstration project, and for the risk adjusting mechanism of the
             16      defined contribution insurance market;
             17          .    authorizes the all payer database to analyze the data it collects to provide consumer
             18      awareness of costs and transparency in the health care market including:
             19              .    reports on geographic variances in medical costs; and
             20              .    cost increases for health care;
             21          .    clarifies the restrictions and protections for identifiable health information;
             22          .    consolidates statutory language requiring insurance department reports concerning
             23      the health insurance market;
             24          .    makes technical and clarifying amendments to the price and value comparison of
             25      health benefit plans;
             26          .    requires the insurance commissioner to convene a group to develop a method of
             27      comparing health insurers' claims denial, and other information that would help a


             28      consumer compare the value of health plans, and requires an administrative rule to implement
             29      the transparency reports;
             30          .    instructs the Insurance Department to continue its work with the Office of
             31      Consumer Health Services and the Department of Health to develop additional
             32      demonstration projects for health care delivery and payment reform and to apply for
             33      available grants to implement and expand the demonstration projects;
             34          .    makes a technical amendment to the health plans an insurer may offer after July 1,
             35      2012;
             36          .    requires the Insurance Department to:
             37              .    convene a group to simplify the uniform health insurance application and
             38      decrease the number of questions; and
             39              .    develop a uniform waiver of coverage form;
             40          .    amends group and blanket conversion coverage related to NetCare;
             41          .    creates ongoing monthly enrollment for employers in the defined contribution
             42      market and makes conforming amendments;
             43          .    allows a pilot program for a limited number of large employer groups to enter the
             44      defined contribution market by January 1, 2011;
             45          .    requires an insurer in the defined contribution market to offer a choice of health
             46      benefit plans that vary in actuarial value as follows:
             47              .    the basic benefit plan;
             48              .    one plan that has an actuarial value that is at least 15% higher than the actuarial
             49      value of the basic benefit plan; and
             50              .    one plan that is a federally qualified high deductible plan with a $5,000
             51      deductible;
             52          .    allows an insurer in the defined contribution market to offer:
             53              .    any other health benefit plan that has a greater actuarial value than the actuarial
             54      value of the basic benefit plan; and
             55              .    any other health benefit plan that has an actuarial value that is no less than the
             56      actuarial value of the $5,000 high deductible plan;
             57          .    gives carriers the option to participate in the defined contribution market on the
             58      Health Insurance Exchange by offering defined contribution products or defined


             59      benefit products on the exchange;
             60          .    provides that a carrier that does not choose to participate in the Health Insurance
             61      Exchange by January 1, 2011 may not participate in the exchange until January 1,
             62      2013;
             63          .    allows small employers the choice of selecting insurance products in the Health
             64      Insurance Exchange or in the traditional market outside of the exchange;
             65          .    permits a carrier to offer defined benefit products in the traditional market outside
             66      of the Health Insurance Exchange if the carrier uses the same rating and
             67      underwriting practices in the defined benefit market and the Health Insurance
             68      Exchange so that rating practices do not favor one market over the other market;
             69          .    prohibits insurers in the defined contribution market from treating renewing groups
             70      as new business, subject to premium rate increases, based on the employer's move
             71      from the traditional market into a defined benefit or defined contribution plan in the
             72      Health Insurance Exchange;
             73          .    creates a procedure for a producer to be appointed as a producer for the defined
             74      contribution market;
             75          .    requires an insurer to obtain the Insurance Department's approval to use a class of
             76      businesses for underwriting purposes;
             77          .    effective January 1, 2011, modifies underwriting and rating practices in the small
             78      group market, in and out of the exchange;
             79          .    amends provisions related to small employer group rating practices and individual
             80      rating practices;
             81          .    makes amendments to the defined contribution risk adjuster to incorporate large
             82      groups into the risk adjuster;
             83          .    effective January 1, 2013, imposes a risk adjuster mechanism on the small group
             84      market inside and outside of the Health Insurance Exchange;
             85          .    requires health care providers to give consumers information about prices;
             86          .    requires the Health Insurance Exchange to:
             87              .    create an advisory board of appointed producers and consumers; and
             88              .    establish the electronic standards for delivering the uniform health insurance
             89      application;


             90          .    clarifies the type of information that an insurer must submit to the Health Insurance
             91      Exchange and to the Insurance Department; and
             92          .    re-authorizes the Health System Reform Task Force for one year.
             93      Monies Appropriated in this Bill:
             94          None
             95      Other Special Clauses:
             96          This bill provides an effective date.
             97      Utah Code Sections Affected:
             98      AMENDS:
             99          26-1-37, as enacted by Laws of Utah 2008, Chapter 379
             100          26-33a-106.1, as enacted by Laws of Utah 2007, Chapter 29
             101          26-33a-109, as enacted by Laws of Utah 1990, Chapter 305
             102          31A-2-201, as last amended by Laws of Utah 2008, Chapter 382
             103          31A-22-613.5, as last amended by Laws of Utah 2009, Chapter 12
             104          31A-22-614.6, as enacted by Laws of Utah 2009, Chapter 11
             105          31A-22-618.5, as enacted by Laws of Utah 2009, Chapter 12
             106          31A-22-625, as last amended by Laws of Utah 2008, Chapters 345 and 382
             107          31A-22-635, as enacted by Laws of Utah 2008, Chapter 383
             108          31A-22-723, as last amended by Laws of Utah 2009, Chapter 12
             109          31A-30-103, as last amended by Laws of Utah 2009, Chapter 12
             110          31A-30-105, as last amended by Laws of Utah 1995, Chapter 321
             111          31A-30-106, as last amended by Laws of Utah 2008, Chapters 382, 383, and 385
             112          31A-30-106.5, as last amended by Laws of Utah 2001, Chapter 116
             113          31A-30-202, as enacted by Laws of Utah 2009, Chapter 12
             114          31A-30-203, as enacted by Laws of Utah 2009, Chapter 12
             115          31A-30-204, as enacted by Laws of Utah 2009, Chapter 12
             116          31A-30-205, as enacted by Laws of Utah 2009, Chapter 12
             117          31A-30-207, as enacted by Laws of Utah 2009, Chapter 12
             118          31A-42-102, as enacted by Laws of Utah 2009, Chapter 12
             119          31A-42-103, as enacted by Laws of Utah 2009, Chapter 12
             120          31A-42-201, as enacted by Laws of Utah 2009, Chapter 12


             121          31A-42-202, as enacted by Laws of Utah 2009, Chapter 12
             122          63I-2-231, as last amended by Laws of Utah 2009, Chapter 11
             123          63M-1-2504, as last amended by Laws of Utah 2009, Chapter 12
             124          63M-1-2506, as enacted by Laws of Utah 2009, Chapter 12
             125      ENACTS:
             126          26-21-26, Utah Code Annotated 1953
             127          31A-2-201.2, Utah Code Annotated 1953
             128          31A-30-106.1, Utah Code Annotated 1953
             129          31A-30-202.5, Utah Code Annotated 1953
             130          31A-30-209, Utah Code Annotated 1953
             131          31A-42a-101, Utah Code Annotated 1953
             132          31A-42a-102, Utah Code Annotated 1953
             133          31A-42a-103, Utah Code Annotated 1953
             134          31A-42a-201, Utah Code Annotated 1953
             135          31A-42a-202, Utah Code Annotated 1953
             136          31A-42a-203, Utah Code Annotated 1953
             137          31A-42a-204, Utah Code Annotated 1953
             138          58-31b-802, Utah Code Annotated 1953
             139          58-67-804, Utah Code Annotated 1953
             140          58-68-804, Utah Code Annotated 1953
             141          58-69-806, Utah Code Annotated 1953
             142      REPEALS AND REENACTS:
             143          31A-30-208, as enacted by Laws of Utah 2009, Chapter 12
             144      Uncodified Material Affected:
             145      ENACTS UNCODIFIED MATERIAL
             146     
             147      Be it enacted by the Legislature of the state of Utah:
             148          Section 1. Section 26-1-37 is amended to read:
             149           26-1-37. Duty to establish standards for the electronic exchange of clinical health
             150      information.
             151          (1) For purposes of this section:


             152          (a) "Affiliate" means an organization that directly or indirectly through one or more
             153      intermediaries controls, is controlled by, or is under common control with another
             154      organization.
             155          (b) "Clinical health information" shall be defined by the department by administrative
             156      rule adopted in accordance with Subsection (2).
             157          (c) "Electronic exchange":
             158          (i) includes:
             159          (A) the electronic transmission of clinical health data via Internet or extranet; and
             160          (B) physically moving clinical health information from one location to another using
             161      magnetic tape, disk, or compact disc media; and
             162          (ii) does not include exchange of information by telephone or fax.
             163          (d) "Health care provider" means a licensing classification that is either:
             164          (i) licensed under Title 58, Occupations and Professions, to provide health care; or
             165          (ii) licensed under Chapter 21, Health Care Facility Licensing and Inspection Act.
             166          (e) "Health care system" shall include:
             167          (i) affiliated health care providers;
             168          (ii) affiliated third party payers; and
             169          (iii) other arrangement between organizations or providers as described by the
             170      department by administrative rule.
             171          (f) "Qualified network" means an entity that:
             172          (i) is a non-profit organization;
             173          (ii) is accredited by the Electronic Healthcare Network Accreditation Commission, or
             174      another national accrediting organization recognized by the department; and
             175          (iii) performs the electronic exchange of clinical health information among multiple
             176      health care providers not under common control, multiple third party payers not under common
             177      control, the department, and local health departments.
             178          [(f)] (g) "Third party payer" means:
             179          (i) all insurers offering health insurance who are subject to Section 31A-22-614.5 ; and
             180          (ii) the state Medicaid program.
             181          (2) (a) In addition to the duties listed in Section 26-1-30 , the department shall, in
             182      accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act:


             183          (i) define:
             184          (A) "clinical health information" subject to this section; and
             185          (B) "health system arrangements between providers or organizations" as described in
             186      Subsection (1)(e)(iii); and
             187          (ii) adopt standards for the electronic exchange of clinical health information between
             188      health care providers and third party payers that are [in compliance with] for treatment,
             189      payment, health care operations, or public health reporting, as provided for in 45 C.F.R. Parts
             190      160, 162, and 164, Health Insurance Reform: Security Standards.
             191          (b) The department shall coordinate its rule making authority under the provisions of
             192      this section with the rule making authority of the Insurance Department under Section
             193      31A-22-614.5 . The department shall establish procedures for developing the rules adopted
             194      under this section, which ensure that the Insurance Department is given the opportunity to
             195      comment on proposed rules.
             196          (3) (a) Except as provided in Subsection (3)[(b)](e), a health care provider or third
             197      party payer in Utah is required to use the standards adopted by the department under the
             198      provisions of Subsection (2) if the health care provider or third party payer elects to engage in
             199      an electronic exchange of clinical health information with another health care provider or third
             200      party payer.
             201          (b) A health care provider or third party payer may disclose information to the
             202      department or a local health department, by electronic exchange of clinical health information,
             203      as permitted by Subsection 45 C.F.R. 164.512(b).
             204          (c) When functioning in its capacity as a health care provider or payer, the department
             205      or a local health department may disclose clinical health information by electronic exchange to
             206      another health care provider or third party payer.
             207          (d) An electronic exchange of clinical health information by a health care provider, a
             208      third party payer, the department, or a local health department is a disclosure for treatment,
             209      payment, or health care operations if it complies with Subsection (3)(a) or (c) and is for
             210      treatment, payment, or health care operations, as those terms are defined in 45 C.F.R. Parts
             211      160, 162, and 164.
             212          [(b)] (e) A health care provider or third party payer is not required to use the standards
             213      adopted by the department under the provisions of Subsection (2) if the health care provider or


             214      third party payer engage in the electronic exchange of clinical health information within a
             215      particular health care system.
             216          (4) Nothing in this section shall limit the number of networks eligible to engage in the
             217      electronic data interchange of clinical health information using the standards adopted by the
             218      department under Subsection (2)(a)(ii).
             219          (5) The department, a local health department, a health care provider, a third party
             220      payer, or a qualified network is not subject to civil liability for a disclosure of clinical health
             221      information if the disclosure is in accordance both with Subsection (3)(a) and with Subsection
             222      (3)(b), 3(c), or 3(d).
             223          (6) Within a qualified network, information generated or disclosed in the electronic
             224      exchange of clinical health information is not subject to discovery, use, or receipt in evidence
             225      in any legal proceeding of any kind or character.
             226          [(5)] (7) The department shall report on the use of the standards for the electronic
             227      exchange of clinical health information to the legislative Health and Human Services Interim
             228      Committee no later than October 15[, 2008 and no later than every October 15th thereafter] of
             229      each year. The report shall include publicly available information concerning the costs and
             230      savings for the department, third party payers, and health care providers associated with the
             231      standards for the electronic exchange of clinical health records.
             232          Section 2. Section 26-21-26 is enacted to read:
             233          26-21-26. Consumer access to facility charges.
             234          Beginning January 1, 2011, a health care facility licensed under this chapter shall, when
             235      requested by a consumer:
             236          (1) make a list of prices charged by the facility available for the consumer that includes
             237      the facility's:
             238          (a) in-patient procedures;
             239          (b) out-patient procedures;
             240          (c) the 50 most commonly prescribed drugs in the facility;
             241          (d) imaging services; and
             242          (e) implants; and
             243          (2) provide the consumer with information regarding any discounts the facility
             244      provides for:


             245          (a) charges for services not covered by insurance; or
             246          (b) prompt payment of billed charges.
             247          Section 3. Section 26-33a-106.1 is amended to read:
             248           26-33a-106.1. Health care cost and reimbursement data.
             249          (1) (a) The committee shall, as funding is available, establish an advisory panel to
             250      advise the committee on the development of a plan for the collection and use of health care
             251      data pursuant to Subsection 26-33a-104 (6) and this section.
             252          (b) The advisory panel shall include:
             253          (i) the chairman of the Utah Hospital Association;
             254          (ii) a representative of a rural hospital as designated by the Utah Hospital Association;
             255          (iii) a representative of the Utah Medical Association;
             256          (iv) a physician from a small group practice as designated by the Utah Medical
             257      Association;
             258          (v) two representatives [from the Utah Health Insurance Association] who are health
             259      insurers, appointed by the committee;
             260          (vi) a representative from the Department of Health as designated by the executive
             261      director of the department;
             262          (vii) a representative from the committee;
             263          (viii) a consumer advocate appointed by the committee;
             264          (ix) a member of the House of Representatives appointed by the speaker of the House;
             265      and
             266          (x) a member of the Senate appointed by the president of the Senate.
             267          (c) The advisory panel shall elect a chair from among its members, and shall be staffed
             268      by the committee.
             269          (2) (a) The committee shall, as funding is available[,]:
             270          (i) establish a plan for collecting data from data suppliers, as defined in Section
             271      26-33a-102 , to determine measurements of cost and reimbursements for risk adjusted episodes
             272      of health care[.];
             273          (ii) assist the demonstration projects implemented by the Insurance Department
             274      pursuant to Section 31A-22-614.6 , with access to cost data, reimbursement data, care process
             275      data, and provider service data necessary for the demonstration projects' research, statistical


             276      analysis, and quality improvement activities:
             277          (A) notwithstanding Subsection 26-33a-108 (1) and Section 26-33a-109 ;
             278          (B) contingent upon approval by the committee; and
             279          (C) subject to a contract between the department and the entity providing analysis for
             280      the demonstration project;
             281          (iii) share data regarding insurance claims with insurers participating in the defined
             282      contribution market created in Title 31A, Chapter 30, Part 2, Defined Contribution
             283      Arrangements, only to the extent necessary for:
             284          (A) renewals of policies in the defined contribution arrangement market; and
             285          (B) risk adjusting in the defined contribution arrangement market; and
             286          (iv) assist the Legislature and the public with awareness of, and the promotion of,
             287      transparency in the health care market by reporting on:
             288          (A) geographic variances in medical care and costs as demonstrated by data available
             289      to the committee; and
             290          (B) rate and price increases by health care providers:
             291          (I) that exceed the consumer price index - medical as provided by the United States
             292      Bureau of Labor statistics;
             293          (II) as calculated yearly from June to June; and
             294          (III) as demonstrated by data available to the committee.
             295          (b) The plan adopted under this Subsection (2) shall include:
             296          (i) the type of data that will be collected;
             297          (ii) how the data will be evaluated;
             298          (iii) how the data will be used;
             299          (iv) the extent to which, and how the data will be protected; and
             300          (v) who will have access to the data.
             301          Section 4. Section 26-33a-109 is amended to read:
             302           26-33a-109. Exceptions to prohibition on disclosure of identifiable health data.
             303          (1) The committee may not disclose any identifiable health data unless:
             304          [(1)] (a) the individual has [consented to] authorized the disclosure; or
             305          [(2)] (b) the disclosure [is to any organization that has an institutional review board,]
             306      complies with the provisions of this section.


             307          (2) The committee shall consider the following when responding to a request for
             308      disclosure of information that may include identifiable health data:
             309          (a) whether the request comes from a person after that person has received approval to
             310      do the specific research and statistical work from an institutional review board; and
             311          (b) whether the requesting entity complies with the provisions of Subsection (3).
             312          (3) A request for disclosure of information that may include identifiable health data
             313      shall:
             314          (a) be for a specified period[,]; or
             315          (b) be solely for bona fide research and statistical purposes[,] as determined in
             316      accordance with administrative rules adopted by the department [rules, and], which shall
             317      require:
             318          (i) the requesting entity to demonstrate to the department [determines] that the data is
             319      required for the research and statistical purposes proposed by the requesting entity; and
             320          (ii) the requesting [individual or organization enters] entity to enter into a written
             321      agreement satisfactory to the department to protect the data in accordance with this chapter or
             322      other applicable law [and not permit further disclosure].
             323          (4) A person accessing identifiable health data pursuant to Subsection (3) may not
             324      further disclose the identifiable health data:
             325          (a) without prior approval of the department[. Any]; and
             326          (b) unless the identifiable health data is disclosed [shall be] or identified by control
             327      number only.
             328          Section 5. Section 31A-2-201 is amended to read:
             329           31A-2-201. General duties and powers.
             330          (1) The commissioner shall administer and enforce this title.
             331          (2) The commissioner has all powers specifically granted, and all further powers that
             332      are reasonable and necessary to enable the commissioner to perform the duties imposed by this
             333      title.
             334          (3) (a) The commissioner may make rules to implement the provisions of this title
             335      according to the procedures and requirements of Title 63G, Chapter 3, Utah Administrative
             336      Rulemaking Act.
             337          (b) In addition to the notice requirements of Section 63G-3-301 , the commissioner


             338      shall provide notice under Section 31A-2-303 of hearings concerning insurance department
             339      rules.
             340          (4) (a) The commissioner shall issue prohibitory, mandatory, and other orders as
             341      necessary to secure compliance with this title. An order by the commissioner is not effective
             342      unless the order:
             343          (i) is in writing; and
             344          (ii) is signed by the commissioner or under the commissioner's authority.
             345          (b) On request of any person who would be affected by an order under Subsection
             346      (4)(a), the commissioner may issue a declaratory order to clarify the person's rights or duties.
             347          (5) (a) The commissioner may hold informal adjudicative proceedings and public
             348      meetings, for the purpose of:
             349          (i) investigation;
             350          (ii) ascertainment of public sentiment; or
             351          (iii) informing the public.
             352          (b) An effective rule or order may not result from informal hearings and meetings
             353      unless the requirement of a hearing under this section is satisfied.
             354          (6) The commissioner shall inquire into violations of this title and may conduct any
             355      examinations and investigations of insurance matters, in addition to examinations and
             356      investigations expressly authorized, that the commissioner considers proper to determine:
             357          (a) whether or not any person has violated any provision of this title; or
             358          (b) to secure information useful in the lawful administration of this title.
             359          [(7) (a) Each year, the commissioner shall:]
             360          [(i) conduct an evaluation of the state's health insurance market;]
             361          [(ii) report the findings of the evaluation to the Health and Human Services Interim
             362      Committee before October 1; and]
             363          [(iii) publish the findings of the evaluation on the department website.]
             364          [(b) The evaluation required by Subsection (7)(a) shall:]
             365          [(i) analyze the effectiveness of the insurance regulations and statutes in promoting a
             366      healthy, competitive health insurance market that meets the needs of Utahns by assessing such
             367      things as:]
             368          [(A) the availability and marketing of individual and group products;]


             369          [(B) rate charges;]
             370          [(C) coverage and demographic changes;]
             371          [(D) benefit trends;]
             372          [(E) market share changes; and]
             373          [(F) accessibility;]
             374          [(ii) assess complaint ratios and trends within the health insurance market, which
             375      assessment shall integrate complaint data from the Office of Consumer Health Assistance
             376      within the department;]
             377          [(iii) contain recommendations for action to improve the overall effectiveness of the
             378      health insurance market, administrative rules, and statutes; and]
             379          [(iv) include claims loss ratio data for each insurance company doing business in the
             380      state.]
             381          [(c) When preparing the evaluation required by this Subsection (7), the commissioner
             382      may seek the input of insurers, employers, insured persons, providers, and others with an
             383      interest in the health insurance market.]
             384          Section 6. Section 31A-2-201.2 is enacted to read:
             385          31A-2-201.2. Evaluation of Health Insurance Market.
             386          (1) Each year the commissioner shall:
             387          (a) conduct an evaluation of the state's health insurance market;
             388          (b) report the findings of the evaluation to the Health and Human Services Interim
             389      Committee before October 1 of each year; and
             390          (c) publish the findings of the evaluation on the department website.
             391          (2) The evaluation required by this section shall:
             392          (a) analyze the effectiveness of the insurance regulations and statutes in promoting a
             393      healthy, competitive health insurance market that meets the needs of the state, and includes an
             394      analysis of:
             395          (i) the availability and marketing of individual and group products;
             396          (ii) rate changes;
             397          (iii) coverage and demographic changes;
             398          (iv) benefit trends;
             399          (v) market share changes; and


             400          (vi) accessibility;
             401          (b) assess complaint ratios and trends within the health insurance market, which
             402      assessment shall include complaint data from the Office of Consumer Health Assistance within
             403      the department;
             404          (c) contain recommendations for action to improve the overall effectiveness of the
             405      health insurance market, administrative rules, and statutes; and
             406          (d) include claims loss ratio data for each health insurance company doing business in
             407      the state.
             408          (3) When preparing the evaluation required by this section, the commissioner shall
             409      include a report of:
             410          (a) the types of health benefit plans sold in the Health Insurance Exchange created in
             411      Section 63M-1-2504 ;
             412          (b) the number of insurers participating in the defined contribution arrangement health
             413      benefit plans in the Health Insurance Exchange;
             414          (c) the number of employers and covered lives in the defined contribution arrangement
             415      market in the Health Insurance Exchange; and
             416          (d) the number of lives covered by health benefit plans that do not include state
             417      mandates as permitted by Subsection 31A-30-109 (2).
             418          (4) When preparing the evaluation and report required by this section, the
             419      commissioner may seek the input of insurers, employers, insured persons, providers, and others
             420      with an interest in the health insurance market.
             421          (5) The commissioner may adopt administrative rules for the purpose of collecting the
             422      data required by this section, taking into account the business confidentiality of the insurers.
             423          (6) Records submitted to the commissioner under this section shall be maintained by
             424      the commissioner as protected records under Title 63G, Chapter 2, Government Records
             425      Access and Management Act.
             426          Section 7. Section 31A-22-613.5 is amended to read:
             427           31A-22-613.5. Price and value comparisons of health insurance -- Basic Health
             428      Care Plan.
             429          (1) (a) [Except as provided in Subsection (1)(b), this] This section applies to all health
             430      [insurance policies and health maintenance organization contracts] benefit plans.


             431          (b) Subsection (2) applies to:
             432          (i) all [health insurance policies and health maintenance organization contracts] health
             433      benefit plans; and
             434          (ii) coverage offered to state employees under Subsection 49-20-202 (1)(a).
             435          (2) (a) The commissioner shall promote informed consumer behavior and responsible
             436      [health insurance and] health benefit plans by requiring an insurer issuing [health insurance
             437      policies or health maintenance organization contracts] a health benefit plan to:
             438          (i) provide to all enrollees, prior to enrollment in the health benefit plan [or health
             439      insurance policy,] written disclosure of:
             440          [(i)] (A) restrictions or limitations on prescription drugs and biologics including the use
             441      of a formulary and generic substitution;
             442          [(ii)] (B) coverage limits under the plan; and
             443          [(iii)] (C) any limitation or exclusion of coverage including:
             444          [(A)] (I) a limitation or exclusion for a secondary medical condition related to a
             445      limitation or exclusion from coverage; and
             446          [(B)] (II) [beginning July 1, 2009,] easily understood examples of a limitation or
             447      exclusion of coverage for a secondary medical condition[.]; and
             448          (ii) provide the commissioner with:
             449          (A) the information described in Subsections 63M-1-2506 (3) through (6) in the
             450      standardized electronic format required by Subsection 63M-1-2506 (1); and
             451          (B) information regarding insurer transparency in accordance with Subsection (5) of
             452      this section.
             453          (b) [In addition to the requirements of Subsections (2)(a), (d), and (e) an insurer
             454      described in Subsection (2)(a)] An insurer shall file the written disclosure required by [this]
             455      Subsection (2)(a)(i) [to] with the commissioner:
             456          (i) upon commencement of operations in the state; and
             457          (ii) anytime the insurer amends any of the following described in Subsection (2)(a)(i):
             458          (A) treatment policies;
             459          (B) practice standards;
             460          (C) restrictions;
             461          (D) coverage limits of the insurer's health benefit plan or health insurance policy; or


             462          (E) limitations or exclusions of coverage including a limitation or exclusion for a
             463      secondary medical condition related to a limitation or exclusion of the insurer's health
             464      insurance plan.
             465          [(c) The commissioner may adopt rules to implement the disclosure requirements of
             466      this Subsection (2), taking into account:]
             467          [(i) business confidentiality of the insurer;]
             468          [(ii) definitions of terms;]
             469          [(iii) the method of disclosure to enrollees; and]
             470          [(iv) limitations and exclusions.]
             471          [(d)] (c) If under Subsection (2)(a)(i)(A) a formulary is used, the insurer shall make
             472      available to prospective enrollees and maintain evidence of the fact of the disclosure of:
             473          (i) the drugs included;
             474          (ii) the patented drugs not included;
             475          (iii) any conditions that exist as a precedent to coverage; and
             476          (iv) any exclusion from coverage for secondary medical conditions that may result
             477      from the use of an excluded drug.
             478          [(e)] (d) (i) The department shall develop examples of limitations or exclusions of a
             479      secondary medical condition that an insurer may use under Subsection (2)(a)[(iii)](i)(C).
             480          (ii) Examples of a limitation or exclusion of coverage provided under Subsection
             481      (2)(a)[(iii)](i)(C) or otherwise are for illustrative purposes only, and the failure of a particular
             482      fact situation to fall within the description of an example does not, by itself, support a finding
             483      of coverage.
             484          (3) An insurer who offers a health [care] benefit plan under Chapter 30, Individual,
             485      Small Employer, and Group Health Insurance Act, shall[: (a) until January 1, 2010, offer the
             486      basic health care plan described in Subsection (4) subject to the open enrollment provisions of
             487      Chapter 30, Individual, Small Employer, and Group Health Insurance Act; and (b) beginning
             488      January 1, 2010,] offer a basic health care plan subject to the open enrollment provisions of
             489      Chapter 30, Individual, Small Employer, and Group Health Insurance Act, that:
             490          [(i)] (a) is a federally qualified high deductible health plan;
             491          [(ii)] (b) has the lowest deductible that qualifies under a federally qualified high
             492      deductible health plan, as adjusted by federal law; and


             493          [(iii)] (c) does not exceed an annual out of pocket maximum equal to three times the
             494      amount of the annual deductible.
             495          [(4) Until January 1, 2010, the Basic Health Care Plan under this section shall provide
             496      for:]
             497          [(a) a lifetime maximum benefit per person not less than $1,000,000;]
             498          [(b) an annual maximum benefit per person not less than $250,000;]
             499          [(c) an out-of-pocket maximum of cost-sharing features:]
             500          [(i) including:]
             501          [(A) a deductible;]
             502          [(B) a copayment; and]
             503          [(C) coinsurance;]
             504          [(ii) not to exceed $5,000 per person; and]
             505          [(iii) for family coverage, not to exceed three times the per person out-of-pocket
             506      maximum provided in Subsection (4)(c)(ii);]
             507          [(d) in relation to its cost-sharing features:]
             508          [(i) a deductible of:]
             509          [(A) not less than $1,000 per person for major medical expenses; and]
             510          [(B) for family coverage, not to exceed three times the per person deductible for major
             511      medical expenses under Subsection (4)(d)(i)(A); and]
             512          [(ii) (A) a copayment of not less than:]
             513          [(I) $25 per visit for office services; and]
             514          [(II) $150 per visit to an emergency room; or]
             515          [(B) coinsurance of not less than:]
             516          [(I) 20% per visit for office services; and]
             517          [(II) 20% per visit for an emergency room; and]
             518          [(e) in relation to cost-sharing features for prescription drugs:]
             519          [(i) (A) a deductible not to exceed $1,000 per person; and]
             520          [(B) for family coverage, not to exceed three times the per person deductible provided
             521      in Subsection (4)(e)(i)(A); and]
             522          [(ii) (A) a copayment of not less than:]
             523          [(I) the lesser of the cost of the prescription drug or $15 for the lowest level of cost for


             524      prescription drugs;]
             525          [(II) the lesser of the cost of the prescription drug or $25 for the second level of cost for
             526      prescription drugs; and]
             527          [(III) the lesser of the cost of the prescription drug or $35 for the highest level of cost
             528      for prescription drugs; or]
             529          [(B) coinsurance of not less than:]
             530          [(I) the lesser of the cost of the prescription drug or 25% for the lowest level of cost for
             531      prescription drugs;]
             532          [(II) the lesser of the cost of the prescription drug or 40% for the second level of cost
             533      for prescription drugs; and]
             534          [(III) the lesser of the cost of the prescription drug or 60% for the highest level of cost
             535      for prescription drugs.]
             536          [(5) The department shall include in its yearly insurance market report information
             537      about:]
             538          [(a) the types of health benefit plans sold on the Internet portal created in Section
             539      63M-1-2504 ;]
             540          [(b) the number of insurers participating in the defined contribution market on the
             541      Internet portal;]
             542          [(c) the number of employers and covered lives in the defined contribution market;
             543      and]
             544          [(d) the number of lives covered by health benefit plans that do not include state
             545      mandates as permitted by Subsection 31A-30-109 (2).]
             546          [(6)] (4) The commissioner:
             547          (a) shall forward the information submitted by an insurer under Subsection (2)(a)(ii) to
             548      the Health Insurance Exchange created under Subsection 63M-1-2504 ; and
             549          (b) may request information from an insurer to verify the information submitted by the
             550      insurer [to the Internet portal under Subsection 63M-1-2506 (4)] under this section.
             551          (5) The commissioner shall:
             552          (a) convene a group of insurers, a member representing the Public Employees' Benefit
             553      and Insurance Program, consumers, and an organization described in Subsection
             554      31A-22-614.6 (3)(b), to develop information for consumers to compare health insurers and


             555      health benefit plans on the Health Insurance Exchange, which shall include consideration of:
             556          (i) the number and cost of an insurer's denied health claims;
             557          (ii) the cost of denied claims that is transferred to providers;
             558          (iii) the average out-of-pocket expenses incurred by participants in each health benefit
             559      plan that is offered by an insurer in the Health Insurance Exchange;
             560          (iv) the relative efficiency and quality of claims administration and other administrative
             561      processes for each insurer offering plans in the Health Insurance Exchange; and
             562          (v) consumer assessment of each insurer or health benefit plan;
             563          (b) adopt an administrative rule that establishes:
             564          (i) definition of terms;
             565          (ii) the methodology for determining and comparing the insurer transparency
             566      information;
             567          (iii) the data, and format of the data that an insurer must submit to the department in
             568      order to facilitate the consumer comparison on the Health Insurance Exchange in accordance
             569      with Section 63M-1-2506 ; and
             570          (iv) the dates on which the insurer must submit the data to the department in order for
             571      the department to transmit the data to the Health Insurance Exchange in accordance with
             572      Section 63M-1-2506 ; and
             573          (c) implement the rules adopted under Subsection (5)(b) in a manner that protects the
             574      business confidentiality of the insurer.
             575          Section 8. Section 31A-22-614.6 is amended to read:
             576           31A-22-614.6. Health care delivery and payment reform demonstration projects.
             577          (1) The Legislature finds that:
             578          (a) current health care delivery and payment systems do not provide systemwide
             579      aligned incentives for the appropriate delivery of health care;
             580          (b) some health care providers and health care payers have developed ideas for health
             581      care delivery and payment system reform, but lack the critical number of patient lives and
             582      payer involvement to accomplish systemwide reform; and
             583          (c) there is a compelling state interest to encourage as many health care providers and
             584      health care payers to join together and coordinate efforts at systemwide health care delivery and
             585      payment reform.


             586          (2) (a) The Office of Consumer Health Services within the Governor's Office of
             587      Economic Development shall convene meetings of health care providers and health care payers
             588      through a neutral, non-biased entity that can demonstrate it has the support of a broad base of
             589      the participants in this process for the purpose of coordinating broad based demonstration
             590      projects for health care delivery and payment reform.
             591          (b) (i) The speaker of the House of Representatives may appoint a person who is a
             592      member of the House of Representatives, or from the Office of Legislative Research and
             593      General Counsel, to attend the meetings convened under Subsection (2)(a).
             594          (ii) The president of the Senate may appoint a person who is a senator, or from the
             595      Office of Legislative Research and General Counsel, to attend the meetings convened under
             596      Subsection (2)(a).
             597          (c) Participation in the coordination efforts by health care providers and health care
             598      payers is voluntary, but is encouraged.
             599          (3) The commissioner and the Office of Consumer Health Services shall facilitate
             600      several coordinated broad based demonstration projects for health care delivery reform and
             601      health care payment reform between [various] one or more health care providers and one or
             602      more health care payers who elect to participate in the demonstration projects by:
             603          (a) consulting with health care providers and health care payers who elect to join
             604      together in a broad based reform demonstration project; [and]
             605          (b) consulting with a neutral, non-biased third party with an established record for
             606      broad based, multi-payer and multi-provider quality assurance efforts and data collection;
             607          (c) applying for grants and assistance that may be available for creating and
             608      implementing the demonstration projects; and
             609          [(b)] (d) adopting administrative rules in accordance with Title 63G, Chapter 3, Utah
             610      Administrative Rulemaking Act, as necessary to develop, oversee, and implement the
             611      demonstration [project] projects.
             612          (4) The Office of Consumer Health Services and the commissioner shall report to the
             613      Health System Reform Task Force by October [2009] 2010, and to the Legislature's Business
             614      and Labor Interim Committee every October thereafter regarding the progress towards
             615      coordination of broad based health care system payment and delivery reform.
             616          Section 9. Section 31A-22-618.5 is amended to read:


             617           31A-22-618.5. Health plan offerings.
             618          (1) The purpose of this section is to increase the range of health benefit plans available
             619      in the small group, small employer group, large group, and individual insurance markets.
             620          (2) A health maintenance organization that is subject to Chapter 8, Health Maintenance
             621      Organizations and Limited Health Plans:
             622          (a) shall offer to potential purchasers at least one health benefit plan that is subject to
             623      the requirements of Chapter 8, Health Maintenance Organizations and Limited Health Plans;
             624      and
             625          (b) may offer to a potential purchaser one or more health benefit plans that:
             626          (i) are not subject to one or more of the following:
             627          (A) the limitations on insured indemnity benefits in Subsection 31A-8-105 (4);
             628          (B) the limitation on point of service products in Subsections 31A-8-408 (3) through
             629      (6);
             630          (C) except as provided in Subsection (2)(b)(ii), basic health care services as defined in
             631      Section 31A-8-101 ; or
             632          (D) coverage mandates enacted after January 1, 2009 that are not required by federal
             633      law, provided that the insurer offers one plan under Subsection (2)(a) that covers the mandate
             634      enacted after January 1, 2009; and
             635          (ii) when offering a health plan under this section, provide coverage for an emergency
             636      medical condition as required by Section 31A-22-627 as follows:
             637          (A) within the organization's service area, covered services shall include health care
             638      services from non-affiliated providers when medically necessary to stabilize an emergency
             639      medical condition; and
             640          (B) outside the organization's service area, covered services shall include medically
             641      necessary health care services for the treatment of an emergency medical condition that are
             642      immediately required while the enrollee is outside the geographic limits of the organization's
             643      service area.
             644          (3) An insurer that offers a health benefit plan that is not subject to Chapter 8, Health
             645      Maintenance Organizations and Limited Health Plans:
             646          (a) notwithstanding Subsection 31A-22-617 (2), may offer a health benefit plan that
             647      groups providers into the following reimbursement levels:


             648          (i) tier one contracted providers;
             649          (ii) tier two contracted providers who the insurer must reimburse at least 75% of tier
             650      one providers; and
             651          (iii) one or more tiers of non-contracted providers; and
             652          (b) notwithstanding Subsection 31A-22-617 (9) may offer a health benefit plan that is
             653      not subject to [Subsection 31A-22-617 (9) and] Section 31A-22-618 ;
             654          (c) beginning July 1, 2012, may offer products under Subsection (3)(a) that:
             655          (i) are not subject to Subsection 31A-22-617 (2); and
             656          (ii) are subject to the reimbursement requirements in Section 31A-8-501 ;
             657          (d) when offering a health plan under this Subsection (3), shall provide coverage of
             658      emergency care services as required by Section 31A-22-627 by providing coverage at a
             659      reimbursement level of at least 75% of tier one providers; and
             660          (e) are not subject to coverage mandates enacted after January 1, 2009 that are not
             661      required by federal law, provided that an insurer offers one plan that covers a mandate enacted
             662      after January 1, 2009.
             663          (4) Section 31A-8-106 does not prohibit the offer of a health benefit plan under
             664      Subsection (2)(b).
             665          (5) (a) Any difference in price between a health benefit plan offered under Subsections
             666      (2)(a) and (b) shall be based on actuarially sound data.
             667          (b) Any difference in price between a health benefit plan offered under Subsections
             668      (3)(a) and (b) shall be based on actuarially sound data.
             669          (6) Nothing in this section limits the number of health benefit plans that an insurer may
             670      offer.
             671          Section 10. Section 31A-22-625 is amended to read:
             672           31A-22-625. Catastrophic coverage of mental health conditions.
             673          (1) As used in this section:
             674          (a) (i) "Catastrophic mental health coverage" means coverage in a health benefit plan
             675      or health maintenance organization contract that does not impose a lifetime limit, annual
             676      payment limit, episodic limit, inpatient or outpatient service limit, or maximum out-of-pocket
             677      limit that places a greater financial burden on an insured for the evaluation and treatment of a
             678      mental health condition than for the evaluation and treatment of a physical health condition.


             679          (ii) "Catastrophic mental health coverage" may include a restriction on cost sharing
             680      factors, such as deductibles, copayments, or coinsurance, prior to reaching any maximum
             681      out-of-pocket limit.
             682          (iii) "Catastrophic mental health coverage" may include one maximum out-of-pocket
             683      limit for physical health conditions and another maximum out-of-pocket limit for mental health
             684      conditions, provided that, if separate out-of-pocket limits are established, the out-of-pocket
             685      limit for mental health conditions may not exceed the out-of-pocket limit for physical health
             686      conditions.
             687          (b) (i) "50/50 mental health coverage" means coverage in a health benefit plan or health
             688      maintenance organization contract that pays for at least 50% of covered services for the
             689      diagnosis and treatment of mental health conditions.
             690          (ii) "50/50 mental health coverage" may include a restriction on episodic limits,
             691      inpatient or outpatient service limits, or maximum out-of-pocket limits.
             692          (c) "Large employer" is as defined in Section 31A-1-301 .
             693          (d) (i) "Mental health condition" means any condition or disorder involving mental
             694      illness that falls under any of the diagnostic categories listed in the Diagnostic and Statistical
             695      Manual, as periodically revised.
             696          (ii) "Mental health condition" does not include the following when diagnosed as the
             697      primary or substantial reason or need for treatment:
             698          (A) marital or family problem;
             699          (B) social, occupational, religious, or other social maladjustment;
             700          (C) conduct disorder;
             701          (D) chronic adjustment disorder;
             702          (E) psychosexual disorder;
             703          (F) chronic organic brain syndrome;
             704          (G) personality disorder;
             705          (H) specific developmental disorder or learning disability; or
             706          (I) mental retardation.
             707          (e) "Small employer" is as defined in Section 31A-1-301 .
             708          (2) (a) At the time of purchase and renewal, an insurer shall offer to each small
             709      employer that it insures or seeks to insure a choice between catastrophic mental health


             710      coverage and 50/50 mental health coverage.
             711          (b) In addition to Subsection (2)(a), an insurer may offer to provide:
             712          (i) catastrophic mental health coverage, 50/50 mental health coverage, or both at levels
             713      that exceed the minimum requirements of this section; or
             714          (ii) coverage that excludes benefits for mental health conditions.
             715          (c) A small employer may, at its option, choose either catastrophic mental health
             716      coverage, 50/50 mental health coverage, or coverage offered under Subsection (2)(b),
             717      regardless of the employer's previous coverage for mental health conditions.
             718          (d) An insurer is exempt from the 30% index rating restriction in [Subsection
             719      31A-30-106 (1)(b)] Section 31A-30-106.1 and, for the first year only that catastrophic mental
             720      health coverage is chosen, the 15% annual adjustment restriction in [Subsection
             721      31A-30-106 (1)(c)(ii)] Section 31A-30-106.1, for any small employer with 20 or less enrolled
             722      employees who chooses coverage that meets or exceeds catastrophic mental health coverage.
             723          (3) (a) At the time of purchase and renewal of a health benefit plan, an insurer shall
             724      offer catastrophic mental health coverage to each large employer that it insures or seeks to
             725      insure.
             726          (b) In addition to Subsection (3)(a), an insurer may offer to provide catastrophic mental
             727      health coverage at levels that exceed the minimum requirements of this section.
             728          (c) A large employer may, at its option, choose either catastrophic mental health
             729      coverage, coverage that excludes benefits for mental health conditions, or coverage offered
             730      under Subsection (3)(b).
             731          (4) (a) An insurer may provide catastrophic mental health coverage through a managed
             732      care organization or system in a manner consistent with the provisions in Chapter 8, Health
             733      Maintenance Organizations and Limited Health Plans, regardless of whether the policy or
             734      contract uses a managed care organization or system for the treatment of physical health
             735      conditions.
             736          (b) (i) Notwithstanding any other provision of this title, an insurer may:
             737          (A) establish a closed panel of providers for catastrophic mental health coverage; and
             738          (B) refuse to provide any benefit to be paid for services rendered by a nonpanel
             739      provider unless:
             740          (I) the insured is referred to a nonpanel provider with the prior authorization of the


             741      insurer; and
             742          (II) the nonpanel provider agrees to follow the insurer's protocols and treatment
             743      guidelines.
             744          (ii) If an insured receives services from a nonpanel provider in the manner permitted by
             745      Subsection (4)(b)(i)(B), the insurer shall reimburse the insured for not less than 75% of the
             746      average amount paid by the insurer for comparable services of panel providers under a
             747      noncapitated arrangement who are members of the same class of health care providers.
             748          (iii) Nothing in this Subsection (4)(b) may be construed as requiring an insurer to
             749      authorize a referral to a nonpanel provider.
             750          (c) To be eligible for catastrophic mental health coverage, a diagnosis or treatment of a
             751      mental health condition must be rendered:
             752          (i) by a mental health therapist as defined in Section 58-60-102 ; or
             753          (ii) in a health care facility licensed or otherwise authorized to provide mental health
             754      services pursuant to Title 26, Chapter 21, Health Care Facility Licensing and Inspection Act, or
             755      Title 62A, Chapter 2, Licensure of Programs and Facilities, that provides a program for the
             756      treatment of a mental health condition pursuant to a written plan.
             757          (5) The commissioner may prohibit a policy or contract that provides mental health
             758      coverage in a manner that is inconsistent with this section.
             759          (6) The commissioner shall:
             760          (a) adopt rules as necessary to ensure compliance with this section; and
             761          (b) provide general figures on the percentage of contracts and policies that include no
             762      mental health coverage, 50/50 mental health coverage, catastrophic mental health coverage,
             763      and coverage that exceeds the minimum requirements of this section.
             764          (7) The Health and Human Services Interim Committee shall review:
             765          (a) the impact of this section on insurers, employers, providers, and consumers of
             766      mental health services before January 1, 2004; and
             767          (b) make a recommendation as to whether the provisions of this section should be
             768      modified and whether the cost-sharing requirements for mental health conditions should be the
             769      same as for physical health conditions.
             770          (8) (a) An insurer shall offer catastrophic mental health coverage as part of a health
             771      maintenance organization contract that is governed by Chapter 8, Health Maintenance


             772      Organizations and Limited Health Plans, that is in effect on or after January 1, 2001.
             773          (b) An insurer shall offer catastrophic mental health coverage as a part of a health
             774      benefit plan that is not governed by Chapter 8, Health Maintenance Organizations and Limited
             775      Health Plans, that is in effect on or after July 1, 2001.
             776          (c) This section does not apply to the purchase or renewal of an individual insurance
             777      policy or contract.
             778          (d) Notwithstanding Subsection (8)(c), nothing in this section may be construed as
             779      discouraging or otherwise preventing insurers from continuing to provide mental health
             780      coverage in connection with an individual policy or contract.
             781          (9) This section shall be repealed in accordance with Section 63I-1-231 .
             782          Section 11. Section 31A-22-635 is amended to read:
             783           31A-22-635. Development of uniform health insurance application.
             784          (1) For purposes of this section, "insurer":
             785          (a) is defined in Subsection 31A-22-634 (1); and
             786          (b) includes the state employee's risk pool under Section 49-20-202 .
             787          (2) (a) [Beginning July 1, 2009, all insurers] Insurers offering [health insurance] a
             788      health benefit plan to an individual or small employer shall:
             789          (i) except as provided in Subsection (6), use a uniform application form[.], which,
             790      beginning October 1, 2010:
             791          (A) except for cancer and transplants, may not include questions about an applicant's
             792      health history prior to the previous 10 years; and
             793          (B) shall be shortened and simplified in accordance with rules adopted by the
             794      department; and
             795          (ii) use a uniform waiver of coverage form, which:
             796          (A) may not include health status related questions other than pregnancy; and
             797          (B) is limited to:
             798          (I) information that identifies the employee;
             799          (II) proof of the employee's insurance coverage; and
             800          (III) a statement that the employee declines coverage with a particular employer group.
             801          (b) Notwithstanding the requirements of Subsection (2)(a), the uniform application and
             802      uniform waiver of coverage forms may be combined or modified to facilitate:


             803          (i) the electronic submission and processing of an application through the Health
             804      Insurance Exchange created pursuant to Section 63M-1-2504 or directly to all carriers; and
             805          (ii) a more efficient and understandable experience for a consumer submitting an
             806      application in the Health Insurance Exchange or directly to all carriers.
             807          (3) An insurer offering a defined contribution arrangement health benefit plan in the
             808      Health Insurance Exchange to a large group shall use a large group uniform application, and
             809      uniform waiver of coverage form that is adopted by the department by administrative rule.
             810          [(3)] (4) (a) (i) The uniform application form, and uniform waiver form, shall be
             811      adopted and approved by the commissioner in accordance with Title 63G, Chapter 3, Utah
             812      Administrative Rulemaking Act.
             813          (ii) Modifications to the uniform application necessary to facilitate the electronic
             814      submission and processing of an application through the Health Insurance Exchange shall be
             815      adopted by administrative rule adopted by the Office of Consumer Health Services in
             816      accordance with Section 63M-1-2506 .
             817          (b) The commissioner shall [consult with] convene the health insurance industry [when
             818      adopting the uniform application form], the Office of Consumer Health Services, and
             819      consumers to review the uniform application for the individual and small group market, and the
             820      large group market, and make recommendations regarding the uniform applications. The
             821      department shall report the findings of the group convened pursuant to this Subsection (4)(b) to
             822      the Legislature no later than July 1, 2010.
             823          [(4)] (5) (a) Beginning [July 1, 2010, all insurers] October 1, 2010, an insurer who
             824      offers a health benefit plan on the Health Insurance Exchange created in Section 63M-1-2504 ,
             825      shall [offer compatible systems of electronic submission of application forms, approved by the
             826      commissioner in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act.
             827      The systems approved by the commissioner may include monitoring and disseminating
             828      information concerning eligibility and coverage of individuals.]:
             829          (i) accept and process an electronic submission of the uniform application or uniform
             830      waiver from the Health Insurance Exchange using the electronic standards adopted pursuant to
             831      Section 63M-1-2506 ; and
             832          (ii) if requested, provide the applicant with a copy of the completed application either
             833      by mail or electronically.


             834          (b) The commissioner shall regulate any fees charged by insurers to an enrollee for a
             835      uniform application form or electronic submission of the application forms.
             836          (6) An insurer offering a health benefit plan outside the Health Insurance Exchange
             837      may use the uniform application in effect prior to May 15, 2010, until January 1, 2011.
             838          Section 12. Section 31A-22-723 is amended to read:
             839           31A-22-723. Group and blanket conversion coverage.
             840          (1) Notwithstanding Subsection 31A-1-103 (3)(f), and except as provided in Subsection
             841      (3), all policies of accident and health insurance offered on a group basis under this title, or
             842      Title 49, Chapter 20, Public Employees' Benefit and Insurance Program Act, shall provide that
             843      a person whose insurance under the group policy has been terminated is entitled to choose a
             844      converted individual policy in accordance with this section and Section 31A-22-724 .
             845          (2) A person who has lost group coverage may elect conversion coverage with the
             846      insurer that provided prior group coverage if the person:
             847          (a) has been continuously covered for a period of three months by the group policy or
             848      the group's preceding policies immediately prior to termination;
             849          (b) has exhausted either:
             850          (i) Utah mini-COBRA coverage as required in Section 31A-22-722 ;
             851          (ii) federal COBRA coverage; or
             852          (iii) alternative coverage under Section 31A-22-724 ;
             853          (c) has not acquired or is not covered under any other group coverage that covers all
             854      preexisting conditions, including maternity, if the coverage exists; and
             855          (d) resides in the insurer's service area.
             856          (3) This section does not apply if the person's prior group coverage:
             857          (a) is a stand alone policy that only provides one of the following:
             858          (i) catastrophic benefits;
             859          (ii) aggregate stop loss benefits;
             860          (iii) specific stop loss benefits;
             861          (iv) benefits for specific diseases;
             862          (v) accidental injuries only;
             863          (vi) dental; or
             864          (vii) vision;


             865          (b) is an income replacement policy;
             866          (c) was terminated because the insured:
             867          (i) failed to pay any required individual contribution;
             868          (ii) performed an act or practice that constitutes fraud in connection with the coverage;
             869      or
             870          (iii) made intentional misrepresentation of material fact under the terms of coverage; or
             871          (d) was terminated pursuant to Subsection 31A-8-402.3 (2)(a), 31A-22-721 (2)(a), or
             872      31A-30-107 (2)(a).
             873          (4) (a) The employer shall provide written notification of the right to an individual
             874      conversion policy within 30 days of the insured's termination of coverage to:
             875          (i) the terminated insured;
             876          (ii) the ex-spouse; or
             877          (iii) in the case of the death of the insured:
             878          (A) the surviving spouse; and
             879          (B) the guardian of any dependents, if different from a surviving spouse.
             880          (b) The notification required by Subsection (4)(a) shall:
             881          (i) be sent by first class mail;
             882          (ii) contain the name, address, and telephone number of the insurer that will provide
             883      the conversion coverage; and
             884          (iii) be sent to the insured's last-known address as shown on the records of the
             885      employer of:
             886          (A) the insured;
             887          (B) the ex-spouse; and
             888          (C) if the policy terminates by reason of the death of the insured to:
             889          (I) the surviving spouse; and
             890          (II) the guardian of any dependents, if different from a surviving spouse.
             891          (5) (a) An insurer is not required to issue a converted policy which provides benefits in
             892      excess of those provided under the group policy from which conversion is made.
             893          (b) Except as provided in Subsection (5)(c), if the conversion is made from a health
             894      benefit plan, the employee or member shall be offered:
             895          (i) at least the basic benefit plan as provided in Section 31A-22-613.5 through


             896      December 31, 2009; and
             897          (ii) beginning January 1, 2010, only the alternative coverage as provided in Subsection
             898      31A-22-724 (1)(a).
             899          (c) If the benefit levels required under Subsection (5)(b) exceed the benefit levels
             900      provided under the group policy, the conversion policy may offer benefits which are
             901      substantially similar to those provided under the group policy.
             902          (6) Written application for the converted policy shall be made and the first premium
             903      paid to the insurer no later than 60 days after termination of the group accident and health
             904      insurance.
             905          (7) The converted policy shall be issued without evidence of insurability.
             906          (8) (a) The initial premium for the converted policy for the first 12 months and
             907      subsequent renewal premiums shall be determined in accordance with premium rates
             908      applicable to age, class of risk of the person, and the type and amount of insurance provided.
             909          (b) The initial premium for the first 12 months may not be raised based on pregnancy
             910      of a covered insured.
             911          (c) The premium for converted policies shall be payable monthly or quarterly as
             912      required by the insurer for the policy form and plan selected, unless another mode or premium
             913      payment is mutually agreed upon.
             914          (9) The converted policy becomes effective at the time the insurance under the group
             915      policy terminates.
             916          (10) (a) A newly issued converted policy covers the employee or the member and must
             917      also cover all dependents covered by the group policy at the date of termination of the group
             918      coverage.
             919          (b) The only dependents that may be added after the policy has been issued are children
             920      and dependents as required by Section 31A-22-610 and Subsections 31A-22-610.5 (6) and (7).
             921          (c) At the option of the insurer, a separate converted policy may be issued to cover any
             922      dependent.
             923          (11) (a) To the extent the group policy provided maternity benefits, the conversion
             924      policy shall provide maternity benefits equal to the lesser of the maternity benefits of the group
             925      policy or the conversion policy until termination of a pregnancy that exists on the date of
             926      conversion if one of the following is pregnant on the date of the conversion:


             927          (i) the insured;
             928          (ii) a spouse of the insured; or
             929          (iii) a dependent of the insured.
             930          (b) The requirements of this Subsection (11) do not apply to a pregnancy that occurs
             931      after the date of conversion.
             932          (12) Except as provided in this Subsection (12), a converted policy is renewable with
             933      respect to all individuals or dependents at the option of the insured. An insured may be
             934      terminated from a converted policy for the following reasons:
             935          (a) a dependent is no longer eligible under the policy;
             936          (b) for a network plan, if the individual no longer lives, resides, or works in:
             937          (i) the insured's service area; or
             938          (ii) the area for which the covered carrier is authorized to do business;
             939          (c) the individual fails to pay premiums or contributions in accordance with the terms
             940      of the converted policy, including any timeliness requirements;
             941          (d) the individual performs an act or practice that constitutes fraud in connection with
             942      the coverage;
             943          (e) the individual makes an intentional misrepresentation of material fact under the
             944      terms of the coverage; or
             945          (f) coverage is terminated uniformly without regard to any health status-related factor
             946      relating to any covered individual.
             947          (13) Conditions pertaining to health may not be used as a basis for classification under
             948      this section.
             949          (14) An insurer is only required to offer a conversion policy that complies with
             950      Subsection 31A-22-724 (1)(b) and, notwithstanding Sections 31A-8-402.5 and 31A-30-107.1 ,
             951      may discontinue any other conversion policy if:
             952          (a) the discontinued conversion policy is discontinued uniformly without regard to any
             953      health related factor;
             954          (b) any affected individual is provided with 90 days advanced written notice of the
             955      discontinuation of the existing conversion policy;
             956          (c) the policy holder is offered the insurer's conversion policy that complies with
             957      Subsection 31A-22-724 (1)(b); and


             958          (d) the policy holder is not re-rated for purposes of premium calculation.
             959          Section 13. Section 31A-30-103 is amended to read:
             960           31A-30-103. Definitions.
             961          As used in this chapter:
             962          (1) "Actuarial certification" means a written statement by a member of the American
             963      Academy of Actuaries or other individual approved by the commissioner that a covered carrier
             964      is in compliance with Section 31A-30-106 , based upon the examination of the covered carrier,
             965      including review of the appropriate records and of the actuarial assumptions and methods used
             966      by the covered carrier in establishing premium rates for applicable health benefit plans.
             967          (2) "Affiliate" or "affiliated" means any entity or person who directly or indirectly
             968      through one or more intermediaries, controls or is controlled by, or is under common control
             969      with, a specified entity or person.
             970          (3) "Base premium rate" means, for each class of business as to a rating period, the
             971      lowest premium rate charged or that could have been charged under a rating system [for that
             972      class of business] by the covered carrier to covered insureds with similar case characteristics
             973      for health benefit plans with the same or similar coverage.
             974          (4) "Basic benefit plan" or "basic coverage" means the coverage provided in the Basic
             975      Health Care Plan under Section 31A-22-613.5 .
             976          (5) "Carrier" means any person or entity that provides health insurance in this state
             977      including:
             978          (a) an insurance company;
             979          (b) a prepaid hospital or medical care plan;
             980          (c) a health maintenance organization;
             981          (d) a multiple employer welfare arrangement; and
             982          (e) any other person or entity providing a health insurance plan under this title.
             983          (6) (a) Except as provided in Subsection (6)(b), "case characteristics" means
             984      demographic or other objective characteristics of a covered insured that are considered by the
             985      carrier in determining premium rates for the covered insured.
             986          (b) "Case characteristics" do not include:
             987          (i) duration of coverage since the policy was issued;
             988          (ii) claim experience; and


             989          (iii) health status.
             990          (7) "Class of business" means all or a separate grouping of covered insureds
             991      [established under] that is permitted by the department in accordance with Section
             992      31A-30-105 .
             993          (8) "Conversion policy" means a policy providing coverage under the conversion
             994      provisions required in Chapter 22, Part 7, Group Accident and Health Insurance.
             995          (9) "Covered carrier" means any individual carrier or small employer carrier subject to
             996      this chapter.
             997          (10) "Covered individual" means any individual who is covered under a health benefit
             998      plan subject to this chapter.
             999          (11) "Covered insureds" means small employers and individuals who are issued a
             1000      health benefit plan that is subject to this chapter.
             1001          (12) "Dependent" means an individual to the extent that the individual is defined to be
             1002      a dependent by:
             1003          (a) the health benefit plan covering the covered individual; and
             1004          (b) Chapter 22, Part 6, Accident and Health Insurance.
             1005          (13) "Established geographic service area" means a geographical area approved by the
             1006      commissioner within which the carrier is authorized to provide coverage.
             1007          (14) "Index rate" means, for each class of business as to a rating period for covered
             1008      insureds with similar case characteristics, the arithmetic average of the applicable base
             1009      premium rate and the corresponding highest premium rate.
             1010          (15) "Individual carrier" means a carrier that provides coverage on an individual basis
             1011      through a health benefit plan regardless of whether:
             1012          (a) coverage is offered through:
             1013          (i) an association;
             1014          (ii) a trust;
             1015          (iii) a discretionary group; or
             1016          (iv) other similar groups; or
             1017          (b) the policy or contract is situated out-of-state.
             1018          (16) "Individual conversion policy" means a conversion policy issued to:
             1019          (a) an individual; or


             1020          (b) an individual with a family.
             1021          (17) "Individual coverage count" means the number of natural persons covered under a
             1022      carrier's health benefit products that are individual policies.
             1023          (18) "Individual enrollment cap" means the percentage set by the commissioner in
             1024      accordance with Section 31A-30-110 .
             1025          (19) "New business premium rate" means, for each class of business as to a rating
             1026      period, the lowest premium rate charged or offered, or that could have been charged or offered,
             1027      by the carrier to covered insureds with similar case characteristics for newly issued health
             1028      benefit plans with the same or similar coverage.
             1029          [(20) "Plan year" means the year that is designated as the plan year in the plan
             1030      document of a group health plan, except that if the plan document does not designate a plan
             1031      year or if there is not a plan document, the plan year is:]
             1032          [(a) the deductible or limit year used under the plan;]
             1033          [(b) if the plan does not impose a deductible or limit on a yearly basis, the policy year;]
             1034          [(c) if the plan does not impose a deductible or limit on a yearly basis and either the
             1035      plan is not insured or the insurance policy is not renewed on an annual basis, the employer's
             1036      taxable year; or]
             1037          [(d) in any case not described in Subsections (20)(a) through (c), the calendar year.]
             1038          [(21) "Preexisting condition" is as defined in Section 31A-1-301 .]
             1039          [(22)] (20) "Premium" means all monies paid by covered insureds and covered
             1040      individuals as a condition of receiving coverage from a covered carrier, including any fees or
             1041      other contributions associated with the health benefit plan.
             1042          [(23)] (21) (a) "Rating period" means the calendar period for which premium rates
             1043      established by a covered carrier are assumed to be in effect, as determined by the carrier.
             1044          (b) A covered carrier may not have:
             1045          (i) more than one rating period in any calendar month; and
             1046          (ii) no more than 12 rating periods in any calendar year.
             1047          [(24)] (22) "Resident" means an individual who has resided in this state for at least 12
             1048      consecutive months immediately preceding the date of application.
             1049          [(25)] (23) "Short-term limited duration insurance" means a health benefit product that:
             1050          (a) is not renewable; and


             1051          (b) has an expiration date specified in the contract that is less than 364 days after the
             1052      date the plan became effective.
             1053          [(26)] (24) "Small employer carrier" means a carrier that provides health benefit plans
             1054      covering eligible employees of one or more small employers in this state, regardless of
             1055      whether:
             1056          (a) coverage is offered through:
             1057          (i) an association;
             1058          (ii) a trust;
             1059          (iii) a discretionary group; or
             1060          (iv) other similar grouping; or
             1061          (b) the policy or contract is situated out-of-state.
             1062          [(27)] (25) "Uninsurable" means an individual who:
             1063          (a) is eligible for the Comprehensive Health Insurance Pool coverage under the
             1064      underwriting criteria established in Subsection 31A-29-111 (5); or
             1065          (b) (i) is issued a certificate for coverage under Subsection 31A-30-108 (3); and
             1066          (ii) has a condition of health that does not meet consistently applied underwriting
             1067      criteria as established by the commissioner in accordance with Subsections 31A-30-106 (1)(i)
             1068      and (j) for which coverage the applicant is applying.
             1069          [(28)] (26) "Uninsurable percentage" for a given calendar year equals UC/CI where, for
             1070      purposes of this formula:
             1071          (a) "CI" means the carrier's individual coverage count as of December 31 of the
             1072      preceding year; and
             1073          (b) "UC" means the number of uninsurable individuals who were issued an individual
             1074      policy on or after July 1, 1997.
             1075          Section 14. Section 31A-30-105 is amended to read:
             1076           31A-30-105. Establishment of classes of business.
             1077          (1) [A] For policies that go into effect on or after January 1, 2011, a covered carrier
             1078      may not establish a separate class of business [only to reflect] unless:
             1079          (a) the covered carrier submits an application to the department to establish a separate
             1080      class of business;
             1081          (b) the covered carrier demonstrates to the satisfaction of the department that a separate


             1082      class of business is justified under the provisions of this section; and
             1083          (c) the department approves the carrier's application for the use of a separate class of
             1084      business.
             1085          (2) (a) The presumption of the department shall be against the use of a separate class of
             1086      business by a covered insured, except when the covered carrier demonstrates that the
             1087      provisions of this Subsection (2) apply.
             1088          (b) The department may approve the use of a separate class of business only if the
             1089      covered carrier can demonstrate that the use of a separate class of business is necessary due to
             1090      substantial differences in either expected claims experience or administrative costs related to
             1091      the following reasons:
             1092          [(a)] (i) the covered carrier uses more than one type of system for the marketing and
             1093      sale of health benefit plans to covered insureds;
             1094          [(b)] (ii) the covered carrier has acquired a class of business from another covered
             1095      carrier; or
             1096          [(c)] (iii) the covered carrier provides coverage to one or more association groups.
             1097          [(2) A covered carrier may establish up to nine separate classes of business under
             1098      Subsection (1).]
             1099          (3) The commissioner may establish regulations to provide for a period of transition in
             1100      order for a covered carrier to come into compliance with Subsection (2) in the instance of
             1101      acquisition of an additional class of business from another covered carrier.
             1102          (4) The commissioner may approve the establishment of [additional] up to five classes
             1103      of business per covered carrier upon application to the commissioner and a finding by the
             1104      commissioner that such action would substantially enhance the efficiency and fairness of the
             1105      health insurance marketplace subject to this chapter.
             1106          (5) A covered carrier may not establish a class of business based solely on the
             1107      marketing or sale of a health benefit plan as a defined contribution arrangement health benefit
             1108      plan, or through the Health Insurance Exchange.
             1109          Section 15. Section 31A-30-106 is amended to read:
             1110           31A-30-106. Individual premiums -- Rating restrictions -- Disclosure.
             1111          (1) Premium rates for health benefit plans for individuals under this chapter are subject
             1112      to the provisions of this [Subsection (1)] section.


             1113          (a) The index rate for a rating period for any class of business may not exceed the
             1114      index rate for any other class of business by more than 20%.
             1115          (b) (i) For a class of business, the premium rates charged during a rating period to
             1116      covered insureds with similar case characteristics for the same or similar coverage, or the rates
             1117      that could be charged to [such employers] the individual under the rating system for that class
             1118      of business, may not vary from the index rate by more than 30% of the index rate[, except as
             1119      provided in Section 31A-22-625 ] provided in Section 31A-30-106.1 .
             1120          (ii) A [covered] carrier that offers individual and small employer health benefit plans
             1121      may use the small employer index rates to establish the rate limitations for individual policies,
             1122      even if some individual policies are rated below the small employer base rate.
             1123          (c) The percentage increase in the premium rate charged to a covered insured for a new
             1124      rating period, adjusted pro rata for rating periods less than a year, may not exceed the sum of
             1125      the following:
             1126          (i) the percentage change in the new business premium rate measured from the first day
             1127      of the prior rating period to the first day of the new rating period;
             1128          (ii) any adjustment, not to exceed 15% annually [and adjusted pro rata] for rating
             1129      periods of less than one year, due to the claim experience, health status, or duration of coverage
             1130      of the covered individuals as determined from the [covered carrier's] rate manual for the class
             1131      of business[, except as provided in Section 31A-22-625 ] of the carrier offering an individual
             1132      health benefit plan; and
             1133          (iii) any adjustment due to change in coverage or change in the case characteristics of
             1134      the covered insured as determined from the [covered carrier's] rate manual for the class of
             1135      business of the carrier offering an individual health benefit plan.
             1136          [(d) (i) Adjustments in rates for claims experience, health status, and duration from
             1137      issue may not be charged to individual employees or dependents.]
             1138          [(ii) Any adjustment described in Subsection (1)(d)(i) shall be applied uniformly to the
             1139      rates charged for all employees and dependents of the small employer.]
             1140          [(e) A covered carrier may use industry as a case characteristic in establishing premium
             1141      rates, provided that the highest rate factor associated with any industry classification does not
             1142      exceed the lowest rate factor associated with any industry classification by more than 15%.]
             1143          [(f) (i) Covered carriers]


             1144          (d) (i) A carrier offering an individual health benefit plan shall apply rating factors,
             1145      including case characteristics, consistently with respect to all covered insureds in a class of
             1146      business.
             1147          (ii) Rating factors shall produce premiums for identical [groups] individuals that:
             1148          (A) differ only by the amounts attributable to plan design; and
             1149          (B) do not reflect differences due to the nature of the [groups] individuals assumed to
             1150      select particular health benefit products.
             1151          (iii) A [covered] carrier offering an individual health benefit plan shall treat all health
             1152      benefit plans issued or renewed in the same calendar month as having the same rating period.
             1153          [(g)] (e) For the purposes of this Subsection (1), a health benefit plan that uses a
             1154      restricted network provision may not be considered similar coverage to a health benefit plan
             1155      that does not use a restricted network provision, provided that use of the restricted network
             1156      provision results in substantial difference in claims costs.
             1157          [(h) The covered carrier] (f) A carrier offering a health benefit plan to an individual
             1158      may not, without prior approval of the commissioner, use case characteristics other than:
             1159          (i) age;
             1160          [(ii) gender;]
             1161          [(iii) industry;]
             1162          [(iv)] (ii) geographic area; and
             1163          [(v)] (iii) family composition[; and].
             1164          [(vi) group size.]
             1165          [(i)] (g) (i) The commissioner shall establish rules in accordance with Title 63G,
             1166      Chapter 3, Utah Administrative Rulemaking Act, to:
             1167          (A) implement this chapter; and
             1168          (B) assure that rating practices used by [covered] carriers who offer health benefit
             1169      plans to individuals are consistent with the purposes of this chapter.
             1170          (ii) The rules described in Subsection (1)[(i)](g)(i) may include rules that:
             1171          (A) assure that differences in rates charged for health benefit products by [covered]
             1172      carriers who offer health benefit plans to individuals are reasonable and reflect objective
             1173      differences in plan design, not including differences due to the nature of the [groups]
             1174      individuals assumed to select particular health benefit products;


             1175          (B) prescribe the manner in which case characteristics may be used by [covered]
             1176      carriers who offer health benefit plans to individuals;
             1177          (C) implement the individual enrollment cap under Section 31A-30-110 , including
             1178      specifying:
             1179          (I) the contents for certification;
             1180          (II) auditing standards;
             1181          (III) underwriting criteria for uninsurable classification; and
             1182          (IV) limitations on high risk enrollees under Section 31A-30-111 ; and
             1183          (D) establish the individual enrollment cap under Subsection 31A-30-110 (1).
             1184          [(j)] (h) Before implementing regulations for underwriting criteria for uninsurable
             1185      classification, the commissioner shall contract with an independent consulting organization to
             1186      develop industry-wide underwriting criteria for uninsurability based on an individual's expected
             1187      claims under open enrollment coverage exceeding 325% of that expected for a standard
             1188      insurable individual with the same case characteristics.
             1189          [(k)] (i) The commissioner shall revise rules issued for Sections 31A-22-602 and
             1190      31A-22-605 regarding individual accident and health policy rates to allow rating in accordance
             1191      with this section.
             1192          (2) For purposes of Subsection (1)(c)(i), if a health benefit product is a health benefit
             1193      product into which the covered carrier is no longer enrolling new covered insureds, the covered
             1194      carrier shall use the percentage change in the base premium rate, provided that the change does
             1195      not exceed, on a percentage basis, the change in the new business premium rate for the most
             1196      similar health benefit product into which the covered carrier is actively enrolling new covered
             1197      insureds.
             1198          (3) (a) A covered carrier may not transfer a covered insured involuntarily into or out of
             1199      a class of business.
             1200          (b) A covered carrier may not offer to transfer a covered insured into or out of a class
             1201      of business unless the offer is made to transfer all covered insureds in the class of business
             1202      without regard to:
             1203          (i) [to] case characteristics;
             1204          (ii) claim experience;
             1205          (iii) health status; or


             1206          (iv) duration of coverage since issue.
             1207          [(4) (a) Each covered carrier]
             1208          (4) (a) A carrier who offers a health benefit plan to an individual shall maintain at the
             1209      [covered] carrier's principal place of business a complete and detailed description of its rating
             1210      practices and renewal underwriting practices, including information and documentation that
             1211      demonstrate that the [covered] carrier's rating methods and practices are:
             1212          (i) based upon commonly accepted actuarial assumptions; and
             1213          (ii) in accordance with sound actuarial principles.
             1214          (b) (i) Each [covered] carrier subject to this section shall file with the commissioner,
             1215      on or before April 1 of each year, in a form, manner, and containing such information as
             1216      prescribed by the commissioner, an actuarial certification certifying that:
             1217          (A) the [covered] carrier is in compliance with this chapter; and
             1218          (B) the rating methods of the [covered] carrier are actuarially sound.
             1219          (ii) A copy of the certification required by Subsection (4)(b)(i) shall be retained by the
             1220      [covered] carrier at the [covered] carrier's principal place of business.
             1221          (c) A [covered] carrier shall make the information and documentation described in this
             1222      Subsection (4) available to the commissioner upon request.
             1223          (d) Records submitted to the commissioner under this section shall be maintained by
             1224      the commissioner as protected records under Title 63G, Chapter 2, Government Records
             1225      Access and Management Act.
             1226          Section 16. Section 31A-30-106.1 is enacted to read:
             1227          31A-30-106.1. Small employer premiums -- Rating restrictions -- Disclosure.
             1228          (1) Premium rates for small employer health benefit plans under this chapter are
             1229      subject to the provisions of this section for a health benefit plan that is issued or renewed, on or
             1230      after January 1, 2011.
             1231          (2) (a) The index rate for a rating period for any class of business may not exceed the
             1232      index rate for any other class of business by more than 20%.
             1233          (b) For a class of business, the premium rates charged during a rating period to covered
             1234      insureds with similar case characteristics for the same or similar coverage, or the rates that
             1235      could be charged to an employer group under the rating system for that class of business, may
             1236      not vary from the index rate by more than 30% of the index rate, except when catastrophic


             1237      mental health coverage is selected as provided in Subsection 31A-22-625 (2)(d).
             1238          (3) The percentage increase in the premium rate charged to a covered insured for a new
             1239      rating period, adjusted pro rata for rating periods less than a year, may not exceed the sum of
             1240      the following:
             1241          (a) the percentage change in the new business premium rate measured from the first
             1242      day of the prior rating period to the first day of the new rating period;
             1243          (b) any adjustment, not to exceed 15% annually for rating periods of less than one year,
             1244      due to the claim experience, health status, or duration of coverage of the covered individuals as
             1245      determined from the small employer carrier's rate manual for the class of business, except when
             1246      catastrophic mental health coverage is selected as provided in Subsection 31A-22-625 (2)(d);
             1247      and
             1248          (c) any adjustment due to change in coverage or change in the case characteristics of
             1249      the covered insured as determined for the class of business from the small employer carrier's
             1250      rate manual.
             1251          (4) (a) Adjustments in rates for claims experience, health status, and duration from
             1252      issue may not be charged to individual employees or dependents.
             1253          (b) Rating adjustments and factors, including case characteristics, shall be applied
             1254      uniformly and consistently to the rates charged for all employees and dependents of the small
             1255      employer.
             1256          (c) Rating factors shall produce premiums for identical groups that:
             1257          (i) differ only by the amounts attributable to plan design; and
             1258          (ii) do not reflect differences due to the nature of the groups assumed to select
             1259      particular health benefit products.
             1260          (d) A small employer carrier shall treat all health benefit plans issued or renewed in the
             1261      same calendar month as having the same rating period.
             1262          (5) A health benefit plan that uses a restricted network provision may not be considered
             1263      similar coverage to a health benefit plan that does not use a restricted network provision,
             1264      provided that use of the restricted network provision results in substantial difference in claims
             1265      costs.
             1266          (6) The small employer carrier may not use case characteristics other than the
             1267      following:


             1268          (a) age, as determined at the beginning of the plan year, limited to:
             1269          (i) the following age bands:
             1270          (A) less than 20;
             1271          (B) 20-24;
             1272          (C) 25-29;
             1273          (D) 30-34;
             1274          (E) 35-39;
             1275          (F) 40-44;
             1276          (G) 45-49;
             1277          (H) 50-54;
             1278          (I) 55-59;
             1279          (J) 60-64; and
             1280          (K) 65 and above; and
             1281          (ii) a standard slope ratio range for each age band, applied to each family composition
             1282      tier rating structure under Subsection (6)(c):
             1283          (A) as developed by the department by administrative rule;
             1284          (B) not to exceed an overall ratio of 4:1; and
             1285          (C) the age slope ratios for each age band may not overlap;
             1286          (b) geographic area; and
             1287          (c) family composition, limited to:
             1288          (i) an overall ratio of 4:1 or less; and
             1289          (ii) a four tier rating structure that includes:
             1290          (A) employee only;
             1291          (B) employee plus spouse;
             1292          (C) employee plus a dependent or dependents; and
             1293          (D) a family, consisting of an employee plus spouse, and a dependent or dependents.
             1294          (7) If a health benefit plan is a health benefit plan into which the small employer carrier
             1295      is no longer enrolling new covered insureds, the small employer carrier shall use the percentage
             1296      change in the base premium rate, provided that the change does not exceed, on a percentage
             1297      basis, the change in the new business premium rate for the most similar health benefit product
             1298      into which the small employer carrier is actively enrolling new covered insureds.


             1299          (8) (a) A covered carrier may not transfer a covered insured involuntarily into or out of
             1300      a class of business.
             1301          (b) A covered carrier may not offer to transfer a covered insured into or out of a class
             1302      of business unless the offer is made to transfer all covered insureds in the class of business
             1303      without regard to:
             1304          (i) case characteristics;
             1305          (ii) claim experience;
             1306          (iii) health status; or
             1307          (iv) duration of coverage since issue.
             1308          (9) (a) Each small employer carrier shall maintain at the small employer carrier's
             1309      principal place of business a complete and detailed description of its rating practices and
             1310      renewal underwriting practices, including information and documentation that demonstrate that
             1311      the small employer carrier's rating methods and practices are:
             1312          (i) based upon commonly accepted actuarial assumptions; and
             1313          (ii) in accordance with sound actuarial principles.
             1314          (b) (i) Each small employer carrier shall file with the commissioner on or before April
             1315      1 of each year, in a form and manner and containing information as prescribed by the
             1316      commissioner, an actuarial certification certifying that:
             1317          (A) the small employer carrier is in compliance with this chapter; and
             1318          (B) the rating methods of the small employer carrier are actuarially sound.
             1319          (ii) A copy of the certification required by Subsection (9)(b)(i) shall be retained by the
             1320      small employer carrier at the small employer carrier's principal place of business.
             1321          (c) A small employer carrier shall make the information and documentation described
             1322      in this Subsection (9) available to the commissioner upon request.
             1323          (10) (a) The commissioner shall, by July 1, 2010, establish rules in accordance with
             1324      Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to:
             1325          (i) implement this chapter; and
             1326          (ii) assure that rating practices used by small employer carriers under this section and
             1327      carriers for individual plans under Section 31A-30-106 , as effective on January 1, 2011, are
             1328      consistent with the purposes of this chapter.
             1329          (b) The rules may:


             1330          (i) assure that differences in rates charged for health benefit plans by carriers are
             1331      reasonable and reflect objective differences in plan design, not including differences due to the
             1332      nature of the groups or individuals assumed to select particular health benefit plans; and
             1333          (ii) prescribe the manner in which case characteristics may be used by small employer
             1334      and individual carriers.
             1335          (11) Records submitted to the commissioner under this section shall be maintained by
             1336      the commissioner as protected records under Title 63G, Chapter 2, Government Records
             1337      Access and Management Act.
             1338          Section 17. Section 31A-30-106.5 is amended to read:
             1339           31A-30-106.5. Conversion policy -- Premiums -- Rating restrictions.
             1340          (1) All provisions of Section [ 31A-30-106 , except Subsection 31A-30-106 (1)(b),]
             1341      31A-30-106.1 apply to conversion policies.
             1342          (2) Conversion policy premium rates may not exceed by more than 35% the index rate
             1343      for [individuals] small employers with similar case characteristics for any class of business in
             1344      which the policy form has been approved.
             1345          (3) An insurer may not consider pregnancy of a covered insured in determining its
             1346      conversion policy premium rates.
             1347          Section 18. Section 31A-30-202 is amended to read:
             1348           31A-30-202. Definitions.
             1349          For purposes of this part:
             1350          (1) "Defined benefit plan" means an employer group health benefit plan in which:
             1351          (a) the employer selects the health benefit plan or plans from a single insurer;
             1352          (b) employees are not provided a choice of health benefit plans on the Health Insurance
             1353      Exchange; and
             1354          (c) the employer is subject to contribution requirements in Section 31A-30-112 .
             1355          [(1)] (2) "Defined contribution arrangement":
             1356          (a) means a defined contribution arrangement employer group health benefit plan that:
             1357          [(a)] (i) complies with this part; and
             1358          [(b)] (ii) is sold through the [Internet portal] Health Insurance Exchange in accordance
             1359      with Title 63M, Chapter 1, Part 25, Health System Reform Act[.]; and
             1360          (b) beginning January 1, 2011, includes an employer choice of either a defined


             1361      contribution arrangement health benefit plan or a defined benefit plan offered through the
             1362      Health Insurance Exchange.
             1363          [(2)] (3) "Health reimbursement arrangement" means an employer provided health
             1364      reimbursement arrangement in which reimbursements for medical care expenses are excluded
             1365      from an employee's gross income under the Internal Revenue Code.
             1366          [(3)] (4) "Producer" is as defined in Subsection 31A-23a-501 (4)(a).
             1367          [(4)] (5) "Section 125 Cafeteria plan" means a flexible spending arrangement that
             1368      qualifies under Section 125, Internal Revenue Code, which permits an employee to contribute
             1369      pre-tax dollars to a health benefit plan.
             1370          [(5)] (6) "Small employer" is defined in Section 31A-1-301 .
             1371          Section 19. Section 31A-30-202.5 is enacted to read:
             1372          31A-30-202.5. Insurer participation in defined contribution arrangement market.
             1373          (1) A small employer carrier who chooses to participate in the defined contribution
             1374      arrangement market:
             1375          (a) shall offer the defined contribution arrangement health benefit plans required by
             1376      Section 31A-30-205 ;
             1377          (b) may:
             1378          (i) offer additional defined contribution arrangement health benefit plans in the Health
             1379      Insurance Exchange as permitted by Section 31A-30-205 ;
             1380          (ii) offer a defined benefit plan in the Health Insurance Exchange if the small employer
             1381      carrier offers a defined contribution arrangement health benefit plan that is actuarially
             1382      equivalent to the defined benefit plan that is offered in the Health Insurance Exchange; and
             1383          (iii) continue to offer defined benefit plans outside of the Health Insurance Exchange,
             1384      and the defined contribution arrangement market, if the carrier uses the same rating and
             1385      underwriting practices in both the defined contribution arrangement market in the Health
             1386      Insurance Exchange and the defined benefit market outside the Health Insurance Exchange.
             1387          (2) A carrier that does not elect to participate in the defined contribution arrangement
             1388      market by January 1, 2011, may not participate in the defined contribution arrangement market
             1389      in the Health Insurance Exchange until January 1, 2013.
             1390          Section 20. Section 31A-30-203 is amended to read:
             1391           31A-30-203. Eligibility for defined contribution arrangement market --


             1392      Enrollment.
             1393          (1) (a) [Beginning January 1, 2010, and during the open enrollment period described in
             1394      Section 31A-30-208 , an] An eligible small employer may choose to [participate in] participate
             1395      in:
             1396          (i) the defined contribution arrangement market in the Health Insurance Exchange
             1397      under this part; or
             1398          (ii) the traditional defined benefit market under Part 1, Individual and Small Employer
             1399      Group.
             1400          (b) A small employer may choose to offer its employees one of the following through
             1401      the defined contribution arrangement market in the Health Insurance Exchange:
             1402          (i) a defined contribution arrangement health benefit plan; or
             1403          (ii) a defined benefit plan.
             1404          (c) (i) Beginning January 1, 2011, and during the enrollment period, an eligible large
             1405      employer participating in the demonstration project under Subsection 31A-30-208 (1)(c) may
             1406      choose to offer its employees a defined contribution arrangement health benefit plan.
             1407          [(b)] (ii) Beginning January 1, 2012, [and during the open enrollment period described
             1408      in Section 31A-30-208 ,] an eligible large employer may choose to [participate in] offer its
             1409      employees a defined contribution arrangement health benefit plan.
             1410          [(c)] (d) Defined contribution arrangement health benefit plans are employer group
             1411      health plans individually selected by an employee of an employer.
             1412          (2) (a) Participating insurers[: (i)] shall offer to accept all eligible employees of an
             1413      employer described in Subsection (1), and their dependents, at the same level of benefits as
             1414      anyone else who has the same health benefit plan in the defined contribution arrangement
             1415      market[; and] on the Health Insurance Exchange.
             1416          [(ii) may not impose a premium surcharge under Section 31A-30-106.7 in the defined
             1417      contribution market.]
             1418          (b) A participating insurer may:
             1419          (i) request an employer to submit a copy of the employer's quarterly wage list to
             1420      determine whether the employees for whom coverage is provided or requested are bona fide
             1421      employees of the employer; and
             1422          (ii) deny or terminate coverage if the employer refuses to provide documentation


             1423      requested under Subsection (2)(b)(i).
             1424          Section 21. Section 31A-30-204 is amended to read:
             1425           31A-30-204. Employer election -- Defined benefit -- Defined contribution
             1426      arrangements -- Responsibilities.
             1427          (1) (a) An employer participating in the defined contribution arrangement market on
             1428      the Health Insurance Exchange shall make an initial election to offer its employees either a
             1429      defined benefit plan or a defined contribution arrangement health benefit plan.
             1430          (b) If an employer elects to offer a defined benefit plan:
             1431          (i) the employer or the employer's producer shall enroll the employer in the Health
             1432      Insurance Exchange;
             1433          (ii) the employees shall submit the uniform application required for the Health
             1434      Insurance Exchange; and
             1435          (iii) the employer shall select the defined benefit plan in accordance with Section
             1436      31A-30-208 .
             1437          (c) When an employer makes an election under Subsections (1)(a) and (b):
             1438          (i) the employer may not offer its employees a defined contribution arrangement health
             1439      benefit plan; and
             1440          (ii) the employees may not select a defined contribution arrangement health benefit
             1441      plan in the Health Insurance Exchange.
             1442          (d) If an employer elects to offer its employees a defined contribution arrangement
             1443      health benefit plan, the employer shall comply with the provisions of Subsections (2) through
             1444      (5).
             1445          [(1)] (2) (a) (i) An employer [described in Subsection 31A-30-203 (1)] that chooses to
             1446      participate in a defined contribution arrangement health benefit plan may not offer to an
             1447      employee a [major medical] health benefit plan that is not a [part of the] defined contribution
             1448      arrangement [to an employee] health benefit plan in the Health Insurance Exchange.
             1449          (ii) Subsection [(1)] (2)(a)(i) does not prohibit the offer of supplemental or limited
             1450      benefit policies such as dental or vision coverage, or other types of federally qualified savings
             1451      accounts for health care expenses.
             1452          (b) (i) To the extent permitted by Sections 31A-1-301 , 31A-30-112 , and 31A-30-206 ,
             1453      and the risk adjustment plan adopted under Section [ 31A-42-202 ] 31A-42-204 , the employer


             1454      reserves the right to determine:
             1455          (A) the criteria for employee eligibility, enrollment, and participation in the employer's
             1456      health benefit plan; and
             1457          (B) the amount of the employer's contribution to that plan.
             1458          (ii) The determinations made under Subsection [(1)] (2)(b) may only be changed
             1459      during periods of open enrollment.
             1460          [(2)] (3) An employer that chooses to establish a defined contribution arrangement
             1461      health benefit plan to provide a health benefit plan for its employees shall:
             1462          (a) establish a mechanism for its employees to use pre-tax dollars to purchase a health
             1463      benefit plan from the defined contribution arrangement market on the [Internet portal] Health
             1464      Insurance Exchange created in Section 63M-1-2504 , which may include:
             1465          (i) a health reimbursement arrangement;
             1466          (ii) a Section 125 Cafeteria plan; or
             1467          (iii) another plan or arrangement similar to Subsection [(2)] (3)(a)(i) or (ii) which is
             1468      excluded or deducted from gross income under the Internal Revenue Code;
             1469          (b) [by November 10 of the open enrollment period] before the employee's health
             1470      benefit plan selection period:
             1471          (i) inform each employee of the health benefit plan the employer has selected as the
             1472      default health benefit plan for the employer group;
             1473          (ii) offer each employee a choice of any of the defined contribution arrangement health
             1474      benefit plans available through the defined contribution arrangement market on the [Internet
             1475      portal] Health Insurance Exchange; and
             1476          (iii) notify the employee that the employee will be enrolled in the default health benefit
             1477      plan selected by the employer and payroll deductions initiated for premium payments, unless
             1478      the employee, [prior to November 25 of the open enrollment period] before the employee's
             1479      selection period ends:
             1480          (A) [notifies the employer that the employee has selected] selects a different defined
             1481      contribution arrangement health benefit plan available [through the defined contribution
             1482      arrangement] in the [Internet portal] Health Insurance Exchange;
             1483          (B) provides proof of coverage from another health benefit plan; or
             1484          (C) specifically declines coverage in a health benefit plan.


             1485          [(3)] (4) An employer shall enroll an employee in the default defined contribution
             1486      arrangement health benefit plan selected by the employer if the employee does not make one of
             1487      the choices described in Subsection [(2)(b)(ii) prior to November 25 of the open enrollment
             1488      period] (3)(b)(iii) before the end of the employee selection period, which may not be less than
             1489      14 calendar days.
             1490          [(4)] (5) The employer's notice to the employee under Subsection [(2)] (3)(b)(iii) shall
             1491      inform the employee that the failure to act under Subsections [(2)] (3)(b)(iii)(A) through (C) is
             1492      considered an affirmative election under pre-tax payroll deductions for the employer to begin
             1493      payroll deductions for health benefit plan premiums.
             1494          Section 22. Section 31A-30-205 is amended to read:
             1495           31A-30-205. Health benefit plans offered in the defined contribution market.
             1496          (1) An insurer who [chooses to offer a health benefit plan in the] offers a defined
             1497      contribution [market must] arrangement health benefit plan shall offer the following health
             1498      benefit plans as defined contribution arrangements:
             1499          [(a) one health benefit plan that:]
             1500          [(i) is a federally qualified high deductible health plan;]
             1501          [(ii) has the lowest deductible permitted for a federally qualified high deductible health
             1502      plan as adjusted by federal law; and]
             1503          [(iii) does not exceed annual out-of-pocket maximum equal to three times the amount
             1504      of the annual deductible; and]
             1505          (a) the basic benefit plan;
             1506          (b) one health benefit plan with [benefits that have] an aggregate actuarial value at least
             1507      15% greater [that] than the [plan described in Subsection (1)(a).] actuarial value of the basic
             1508      benefit plan; and
             1509          (c) one health benefit plan that is a federally qualified high deductible health plan that
             1510      has a deductible of $5,000 and does not exceed an annual out-of-pocket maximum of $15,000.
             1511          (2) (a) The provisions of Subsection (1) do not limit the number of defined
             1512      contribution arrangement health benefit plans an insurer may offer in the defined contribution
             1513      arrangement market.
             1514          (b) An insurer who offers the health benefit plans required by Subsection (1) may also
             1515      offer any other health benefit plan [in the] as a defined contribution [market] arrangement if:


             1516          (i) the health benefit plan provides benefits that are [actuarially richer] of greater
             1517      actuarial value than the benefits required in [Subsection (1)(a).] the basic benefit plan; or
             1518          (ii) the health benefit plan provides benefits with an aggregate actuarial value that is no
             1519      lower than the actuarial value of the plan required in Subsection (1)(c).
             1520          Section 23. Section 31A-30-207 is amended to read:
             1521           31A-30-207. Rating and underwriting restrictions for health plans in the defined
             1522      contribution market.
             1523          (1) The rating and underwriting restrictions for defined benefit plans and for the
             1524      defined contribution [market] arrangement health benefit plans offered in the Health Insurance
             1525      Exchange defined contribution arrangement market shall be:
             1526          (a) for small employer groups, in accordance with Section 31A-30-106.1 ;
             1527          (b) for large employer groups, as determined by the risk adjuster board for participation
             1528      in the risk adjustment mechanism under Chapter 42, Defined Contribution Risk Adjuster Act;
             1529      and
             1530          (c) established in accordance with the plan adopted under Chapter 42, Defined
             1531      Contribution Risk Adjuster Act[, and shall apply to employers who participate in the defined
             1532      contribution arrangement market].
             1533          (2) All insurers who participate in the defined contribution market [must] shall:
             1534          (a) participate in the risk adjuster mechanism developed under Chapter 42, Defined
             1535      Contribution Risk Adjuster Act[.] for all defined contribution arrangement health benefit plans;
             1536      and
             1537          (b) provide the risk adjuster board with:
             1538          (i) an employer group's risk factor; and
             1539          (ii) carrier enrollment data.
             1540          (3) When an employer group of any size enters the defined contribution arrangement
             1541      market for either a defined contribution arrangement health benefit plan, or a defined benefit
             1542      plan, and the employer group has a health plan with an insurer who is participating in the
             1543      defined contribution arrangement market, the risk factor applied to the employer group when it
             1544      enters the defined contribution market may not be greater than the employer group's renewal
             1545      risk factor for the same group of covered employees and the same effective date, as determined
             1546      by the employer group's insurer.


             1547          Section 24. Section 31A-30-208 is repealed and reenacted to read:
             1548          31A-30-208. Enrollment for defined contribution arrangements.
             1549          (1) An insurer offering a health benefit plan in the defined contribution arrangement
             1550      market:
             1551          (a) beginning on or after January 1, 2011, shall allow an employer to enroll in a small
             1552      employer defined contribution arrangement plan;
             1553          (b) may not impose a surcharge under Section 31A-30-106.7 for a small employer
             1554      group selecting a defined contribution arrangement health benefit plan on or before January 1,
             1555      2012;
             1556          (c) shall offer a limited pilot program in which a large employer group may enroll in a
             1557      defined contribution arrangement market plan that takes effect January 1, 2011;
             1558          (d) beginning January 1, 2012, shall allow a large employer group to enroll in the
             1559      defined contribution arrangement market; and
             1560          (e) shall otherwise comply with the requirements of this part, Chapter 42, Defined
             1561      Contribution Risk Adjuster Act, and Title 63M, Chapter 1, Part 25, Health System Reform Act.
             1562          (2) (a) Except as provided in Subsection 31A-30-202.5 (2), in accordance with
             1563      Subsection (2)(b) of this section, on January 1 of each year, an insurer may enter or exit the
             1564      defined contribution arrangement market.
             1565          (b) An insurer may offer new or modify existing products in the defined contribution
             1566      arrangement market on January 1 of each year, and at other times as established by the risk
             1567      adjuster board created in Section 31A-42-201 .
             1568          (c) (i) An insurer shall give the department, the Health Insurance Exchange, and the
             1569      risk adjuster board 90 days' advance written notice of any event described in Subsection (2)(a)
             1570      or (b).
             1571          (ii) When an insurer elects to participate in the defined contribution arrangement
             1572      market, the insurer shall participate in the defined contribution arrangement market for no less
             1573      than two years.
             1574          Section 25. Section 31A-30-209 is enacted to read:
             1575          31A-30-209. Appointment of insurance producers to Health Insurance Exchange.
             1576          (1) A producer may be listed on the Health Insurance Exchange as a producer for the
             1577      defined contribution arrangement market in accordance with Section 63M-1-2504 , if the


             1578      producer is designated as an appointed agent for the defined contribution arrangement market
             1579      in accordance with Subsection (2).
             1580          (2) A producer whose license under this title authorizes the producer to sell defined
             1581      contribution arrangement health benefit plans may be appointed to the defined contribution
             1582      arrangement market on the Health Insurance Exchange by the Insurance Department, if the
             1583      producer:
             1584          (a) submits an application to the Insurance Department to be appointed as a producer
             1585      for the defined contribution arrangement market on the Health Insurance Exchange;
             1586          (b) is an appointed agent with the majority of the carriers that offer a defined
             1587      contribution arrangement health benefit plan on the Health Insurance Exchange; and
             1588          (c) has completed a defined contribution arrangement training session that is an
             1589      approved training session as designated by the commissioner.
             1590          Section 26. Section 31A-42-102 is amended to read:
             1591           31A-42-102. Definitions.
             1592          As used in this chapter:
             1593          (1) "Board" means the board of directors of the Utah Defined Contribution Risk
             1594      Adjuster created in Section 31A-42-201 .
             1595          (2) "Defined benefit plan" is as defined in Section 31A-30-202 .
             1596          [(2)] (3) "Risk adjuster" means the defined contribution risk adjustment mechanism
             1597      created in Section 31A-42-201 .
             1598          Section 27. Section 31A-42-103 is amended to read:
             1599           31A-42-103. Applicability and scope.
             1600          This chapter applies to a carrier as defined in Section 31A-30-103 who offers a defined
             1601      contribution arrangement health benefit plan [in a defined contribution arrangement] under
             1602      Chapter 30, Part 2, Defined Contribution Arrangements.    
             1603          Section 28. Section 31A-42-201 is amended to read:
             1604           31A-42-201. Creation of risk adjuster mechanism -- Board of directors --
             1605      Appointment -- Terms -- Quorum -- Plan preparation.
             1606          (1) There is created the "Utah Defined Contribution Risk Adjuster," a nonprofit entity
             1607      within the [Insurance Department] department.
             1608          (2) (a) The risk adjuster [shall be] is under the direction of a board of directors


             1609      composed of up to nine members described in Subsection (2)(b).
             1610          (b) [The following directors shall be] The board of directors shall consist of:
             1611          (i) the following directors appointed by the governor with the consent of the Senate:
             1612          [(i)] (A) at least three, but up to five, directors with actuarial experience who represent
             1613      [insurance carriers] insurers:
             1614          [(A)] (I) that are participating or have committed to participate in the defined
             1615      contribution arrangement market in the state; and
             1616          [(B)] (II) including at least one and up to two directors who represent [a carrier] an
             1617      insurer that has a small percentage of lives in the defined contribution market;
             1618          [(ii)] (B) one director who represents either an individual employee or employer
             1619      [participant in the defined contribution market]; and
             1620          [(iii)] (C) one director [appointed by the governor to represent] who represents the
             1621      Office of Consumer Health Services within the Governor's Office of Economic Development;
             1622          [(iv)] (ii) one director representing the [Public Employee's Health Benefit Program]
             1623      Public Employees' Benefit and Insurance Program with actuarial experience, chosen by the
             1624      director of the [Public Employee's Health Benefit Program who shall serve as an ex officio
             1625      member] Public Employees' Benefit and Insurance Program; and
             1626          [(v)] (iii) the commissioner, or a representative [from the department with actuarial
             1627      experience] of the commissioner who:
             1628          (A) is appointed by the commissioner; and
             1629          (B) has actuarial experience.
             1630          (c) The commissioner or a representative appointed by the commissioner, [who will
             1631      only have voting privileges] may vote only in the event of a tie vote.
             1632          (3) (a) Except as required by Subsection (3)(b), as terms of current board members
             1633      appointed by the governor expire, the governor shall appoint each new member or reappointed
             1634      member to a four-year term.
             1635          (b) Notwithstanding the requirements of Subsection (3)(a), the governor shall, at the
             1636      time of appointment or reappointment, adjust the length of terms to ensure that the terms of
             1637      board members are staggered so that approximately half of the board is appointed every two
             1638      years.
             1639          (4) When a vacancy occurs in the membership for any reason, the replacement shall be


             1640      appointed for the unexpired term in the same manner as the original appointment was made.
             1641          (5) (a) [Members who are not government employees shall receive no] A board
             1642      member who is not a government employee may not receive compensation or benefits for the
             1643      members' services.
             1644          (b) A state government member who is a member because of the member's state
             1645      government position may not receive per diem or expenses for the member's service.
             1646          (6) The board shall elect annually a chair and vice chair from its membership.
             1647          (7) [Six] One-half of the board members are a quorum for the transaction of business.
             1648          (8) The action of a majority of the members of the quorum is the action of the board.
             1649          Section 29. Section 31A-42-202 is amended to read:
             1650           31A-42-202. Contents of plan.
             1651          (1) The board shall submit a plan of operation for the risk adjuster to the
             1652      commissioner. The plan shall:
             1653          (a) establish the methodology for implementing:
             1654          (i) Subsection (2) for the defined contribution arrangement market established under
             1655      Chapter 30, Part 2, Defined Contribution Arrangements; and
             1656          (ii) the participation of:
             1657          (A) small employer group defined contribution arrangement health benefit plans; and
             1658          (B) large employer group defined contribution arrangement health benefit plans;
             1659          (b) establish regular times and places for meetings of the board;
             1660          (c) establish procedures for keeping records of all financial transactions and for
             1661      sending annual fiscal reports to the commissioner;
             1662          (d) contain additional provisions necessary and proper for the execution of the powers
             1663      and duties of the risk adjuster; and
             1664          (e) establish procedures in compliance with Title 63A, Utah Administrative Services
             1665      Code, to pay for administrative expenses incurred.
             1666          (2) (a) The plan adopted by the board for the defined contribution arrangement market
             1667      shall include:
             1668          (i) parameters an employer may use to designate eligible employees for the defined
             1669      contribution arrangement market; and
             1670          (ii) underwriting mechanisms and employer eligibility guidelines:


             1671          (A) consistent with the federal Health Insurance Portability and Accountability Act;
             1672      and
             1673          (B) necessary to protect insurance carriers from adverse selection in the defined
             1674      contribution market.
             1675          (b) The plan required by Subsection (2)(a) shall outline how premium rates for a
             1676      qualified individual are determined, including:
             1677          (i) the identification of an initial rate for a qualified individual based on:
             1678          (A) standardized age bands submitted by participating insurers; and
             1679          (B) wellness incentives for the individual as permitted by federal law; and
             1680          (ii) the identification of a group risk factor to be applied to the initial age rate of a
             1681      qualified individual based on the health conditions of all qualified individuals in the same
             1682      employer group and, for small employers, in accordance with Sections 31A-30-105 and
             1683      [ 31A-30-106 ] 31A-30-106.1 .
             1684          (c) The plan adopted under Subsection (2)(a) shall outline how:
             1685          (i) premium contributions for qualified individuals shall be submitted to the [Internet
             1686      portal] Health Insurance Exchange in the amount determined under Subsection (2)(b); and
             1687          (ii) the [Internet portal] Health Insurance Exchange shall distribute premiums to the
             1688      insurers selected by qualified individuals within an employer group based on each individual's
             1689      [health risk] rating factor determined in accordance with the plan.
             1690          (d) The plan adopted under Subsection (2)(a) shall outline a mechanism for adjusting
             1691      risk between insurers that:
             1692          (i) identifies health care conditions subject to risk adjustment;
             1693          (ii) establishes an adjustment amount for each identified health care condition;
             1694          (iii) determines the extent to which an insurer has more or less individuals with an
             1695      identified health condition than would be expected; and
             1696          (iv) computes all risk adjustments.
             1697          (e) The board may amend the plan if necessary to:
             1698          (i) incorporate large group defined contribution arrangement health benefit plans into
             1699      the defined contribution arrangement market risk adjuster mechanism created by this chapter;
             1700          [(i)] (ii) maintain the proper functioning and solvency of the defined contribution
             1701      arrangement market and the risk adjuster mechanism;


             1702          [(ii)] (iii) mitigate significant issues of risk selection; or
             1703          [(iii)] (iv) improve the administration of the risk adjuster mechanism including opening
             1704      enrollment periodically until January 1, 2011, for the purpose of testing the enrollment and risk
             1705      adjusting process.
             1706          (3) (a) The board shall establish a mechanism in which the participating carriers shall
             1707      submit their plan base rates, rating factors, and premiums to an independent actuary, appointed
             1708      by the board, for review prior to the publication of the premium rates on the Health Insurance
             1709      Exchange.
             1710          (b) The actuary appointed by the board shall:
             1711          (i) be compensated for the analysis under this section from fees established in
             1712      accordance with Section 63J-1-504 :
             1713          (A) assessed by the board; and
             1714          (B) paid by all small employer carriers participating in the defined contribution
             1715      arrangement market and small employer carriers offering health benefit plans under Part 1,
             1716      Defined Contribution Risk Adjuster Act; and
             1717          (ii) review the information submitted:
             1718          (A) under Subsection (3)(a) for the purpose of verifying the validity of the rates, rating
             1719      factors, and premiums; and
             1720          (B) from carriers offering health benefit plans under Part 1, Defined Contribution Risk
             1721      Adjuster Act:
             1722          (I) for the purpose of verifying underwriting and rating practices; and
             1723          (II) as the actuary determines is necessary.
             1724          (c) Fees collected under Subsection (3)(b) shall be used to pay the actuary for the
             1725      purpose of overseeing market conduct.
             1726          (d) The actuary shall:
             1727          (i) report aggregate data to the risk adjuster board;
             1728          (ii) contact carriers:
             1729          (A) to inform a carrier of the actuary's findings regarding the particular carrier; and
             1730          (B) to request a carrier to re-calculate or verify base rates, rating factors, and
             1731      premiums; and
             1732          (iii) share the actuary's analysis and data with the department for the purposes


             1733      described in Section 31A-30-106.1 .
             1734          (e) A carrier shall re-submit premium rates if the actuary or the department contacts the
             1735      carrier under Subsection (3)(c).
             1736          Section 30. Section 31A-42a-101 is enacted to read:
             1737     
CHAPTER 42a. UTAH STATEWIDE RISK ADJUSTER ACT

             1738           31A-42a-101. Title.
             1739          This chapter is known as the "Utah Statewide Risk Adjuster Act."
             1740          Section 31. Section 31A-42a-102 is enacted to read:
             1741           31A-42a-102. Definitions.
             1742          As used in this chapter:
             1743          (1) "Board" means the Utah Statewide Risk Adjuster Board created in Section
             1744      31A-42a-201 .
             1745          (2) "Carrier" has the same meaning as defined in Section 31A-30-103 .
             1746          Section 32. Section 31A-42a-103 is enacted to read:
             1747           31A-42a-103. Applicability and scope.
             1748          This chapter applies:
             1749          (1) to a carrier that offers a health benefit plan in a defined contribution arrangement
             1750      under Chapter 30, Part 2, Defined Contribution Arrangements; and
             1751          (2) any health benefit plan offered to a small employer group on or after January
             1752      1,2011, including a plan offered to a small employer group not participating in a defined
             1753      contribution arrangement.
             1754          Section 33. Section 31A-42a-201 is enacted to read:
             1755           31A-42a-201. Creation of defined contribution market risk adjuster mechanism
             1756      -- Board of directors -- Appointment -- Terms -- Quorum -- Plan preparation.
             1757          (1) There is created the "Utah Statewide Risk Adjuster," a nonprofit entity within the
             1758      Insurance Department.
             1759          (2) (a) There is created the Utah Statewide Risk Adjuster Board composed of up to nine
             1760      members described in Subsection (2)(b).
             1761          (b) The board of directors shall consist of:
             1762          (i) the following directors appointed by the governor with the consent of the Senate:
             1763          (A) at least three, but up to five, directors with actuarial experience who represent


             1764      insurance carriers:
             1765          (I) that are participating or have committed to participate in the defined contribution
             1766      arrangement market in the state; and
             1767          (II) including at least one and up to two directors who represent a carrier that has a
             1768      small percentage of lives in the defined contribution market;
             1769          (B) one director who represents either an individual employee or employer; and
             1770          (C) one director who represents the Office of Consumer Health Services within the
             1771      Governor's Office of Economic Development;
             1772          (ii) one director representing the Public Employee's Health Program with actuarial
             1773      experience, chosen by the director of the Public Employee's Health Program; and
             1774          (iii) the commissioner, or a representative of the commissioner who:
             1775          (A) is appointed by the commissioner; and
             1776          (B) has actuarial experience.
             1777          (c) The commissioner or a representative appointed by the commissioner, may vote
             1778      only in the event of a tie vote.
             1779          (3) (a) Except as required by Subsection (3)(b), as terms of current board members
             1780      appointed by the governor expire, the governor shall appoint each new member or reappointed
             1781      member to a four-year term.
             1782          (b) Notwithstanding the requirements of Subsection (3)(a), the governor shall, at the
             1783      time of appointment or reappointment, adjust the length of terms to ensure that the terms of
             1784      board members are staggered so that approximately half of the board is appointed every two
             1785      years.
             1786          (4) When a vacancy occurs in the membership for any reason, the replacement shall be
             1787      appointed for the unexpired term in the same manner as the original appointment was made.
             1788          (5) (a) Members who are not government employees shall receive no compensation or
             1789      benefits for the members' services.
             1790          (b) A state government member who is a member because of the member's state
             1791      government position may not receive per diem or expenses for the member's service.
             1792          (6) The board shall elect annually a chair and vice chair from its membership.
             1793          (7) Six board members are a quorum for the transaction of business.
             1794          (8) The action of a majority of the members of the quorum is the action of the board.


             1795          (9) The commissioner may designate an executive secretary from the department to
             1796      provide administrative assistance to the board in carrying out its responsibilities.
             1797          (10) (a) The Utah Statewide Risk Adjuster operates under the direction of the board in
             1798      accordance with rules adopted by the commissioner under Section 31A-42a-204 .
             1799          (b) The budget for operation of the Utah Statewide Risk Adjuster is subject to the
             1800      approval of the board.
             1801          Section 34. Section 31A-42a-202 is enacted to read:
             1802           31A-42a-202. Contents of plan.
             1803          (1) The Utah Statewide Risk Adjuster Board shall submit to the commissioner a
             1804      proposed plan of operation for the Utah Statewide Risk Adjuster. The proposed plan of
             1805      operation shall:
             1806          (a) specify how the Utah Statewide Risk Adjuster shall adjust risk for:
             1807          (i) the defined contribution arrangement market established under Chapter 30, Part 2,
             1808      Defined Contribution Arrangements; and
             1809          (ii) any health benefit plan offered to a small employer group on or after January 1,
             1810      2011, including a plan offered to a small employer group not participating in a defined
             1811      contribution arrangement;
             1812          (b) establish regular times and places for meetings of the board;
             1813          (c) establish procedures for keeping records of all financial transactions and for
             1814      sending annual fiscal reports to the commissioner;
             1815          (d) contain additional provisions necessary and proper for the execution of the powers
             1816      and duties of the Utah Statewide Risk Adjuster; and
             1817          (e) establish procedures in compliance with Title 63A, Utah Administrative Services
             1818      Code, to pay for administrative expenses incurred.
             1819          (2) The proposed plan of operation under Subsection (1) shall include:
             1820          (a) for the defined contribution arrangement market:
             1821          (i) parameters an employer may use to designate eligible employees for the defined
             1822      contribution arrangement market;
             1823          (ii) employer eligibility guidelines that protect carriers from adverse selection in the
             1824      defined contribution market; and
             1825          (iii) (A) how premium contributions for qualified individuals shall be submitted to the


             1826      Internet portal in the amount determined under Subsection (2)(b); and
             1827          (B) how the Internet portal shall distribute premiums to the carriers selected by
             1828      qualified individuals within an employer group based on each individual's health risk factor
             1829      determined in accordance with the plan;
             1830          (b) for the defined contribution arrangement market and for any health benefit plan
             1831      offered to a small employer group on or after January 1, 2011, including a plan offered to a
             1832      small employer group not participating in a defined contribution arrangement:
             1833          (i) underwriting mechanisms:
             1834          (A) consistent with the federal Health Insurance Portability and Accountability Act;
             1835      and
             1836          (B) necessary to protect carriers from adverse selection;
             1837          (ii) how premium rates for an enrollee are calculated, including:
             1838          (A) calculation of an initial rate for an enrollee based on:
             1839          (I) standardized age bands submitted by carriers; and
             1840          (II) wellness incentives for the individual as permitted by federal law; and
             1841          (B) calculation of a group risk factor to be applied to the initial age rate based on the
             1842      health conditions of all qualified individuals in the same employer group and, for small
             1843      employer groups, in accordance with Sections 31A-30-105 and 31A-30-106 ; and
             1844          (iii) a mechanism for adjusting risk among carriers that:
             1845          (A) identifies health conditions subject to risk adjustment;
             1846          (B) establishes an adjustment amount for each identified health condition;
             1847          (C) determines the extent to which a carrier has more or fewer individuals with an
             1848      identified health condition than would be expected; and
             1849          (D) calculates all risk adjustments.
             1850          Section 35. Section 31A-42a-203 is enacted to read:
             1851           31A-42a-203. Powers and duties of board.
             1852          (1) The Utah Statewide Risk Adjuster Board may:
             1853          (a) enter into contracts to carry out the provisions and purposes of this chapter,
             1854      including, with the approval of the commissioner, contracts with persons or other organizations
             1855      for the performance of administrative functions; and
             1856          (b) sue or be sued, including taking legal action necessary to implement and enforce


             1857      rules adopted under Section 31A-42a-204 .
             1858          (2) In addition to the requirements of Section 31A-42a-202 , the Utah Statewide Risk
             1859      Adjuster Board shall:
             1860          (a) as necessary, submit to the commissioner proposed amendments to the proposed
             1861      plan of operation under Subsection 31A-42a-202 (1), and to rules adopted by the commissioner
             1862      under Section 31A-42a-204 , that:
             1863          (i) maintain the proper functioning and solvency of the defined contribution
             1864      arrangement market and promote the viability of health benefit plans offered to small employer
             1865      groups on or after January 1, 2011, including amendments affecting the calculation of rates,
             1866      underwriting, and other actuarial functions;
             1867          (ii) mitigate significant issues of risk selection; or
             1868          (iii) improve how the Utah Statewide Risk Adjuster adjusts risk;
             1869          (b) prepare and submit an annual report to the department for inclusion in the
             1870      department's annual market report, which shall include:
             1871          (i) the expenses incurred by the board and by the Utah Statewide Risk Adjuster;
             1872          (ii) a description of the types of policies sold in the defined contribution arrangement
             1873      market;
             1874          (iii) the number of insured lives in the defined contribution arrangement market;
             1875          (iv) the number of insured lives in health benefit plans that do not include state
             1876      mandates; and
             1877          (v) the effect of risk adjustment rules adopted under Section 31A-42a-204 on:
             1878          (A) plans offered in the defined contribution arrangement market; and
             1879          (B) plans offered to a small employer group on or after January 1, 2001; and
             1880          (c) beginning in 2010 and ending in 2012, report to the Health Reform Task Force and
             1881      to the Legislative Management Committee prior to October 1 of each year regarding the board's
             1882      progress in:
             1883          (i) developing the plan required under Section 31A-42a-202 ;
             1884          (ii) expanding choice of plans in the defined contribution arrangement market; and
             1885          (iii) expanding access to the defined contribution arrangement market in the Internet
             1886      portal for large employer groups.
             1887          (3) The administrative budget of the board and the commissioner under this chapter


             1888      shall comply with the requirements of Title 63J, Chapter 1, Budgetary Procedures Act, and is
             1889      subject to review and approval by the Legislature.
             1890          Section 36. Section 31A-42a-204 is enacted to read:
             1891           31A-42a-204. Powers of commissioner.
             1892          (1) The commissioner shall, after notice and hearing, adopt the Utah Statewide Risk
             1893      Adjuster Board's proposed plan of operation, and any amendment thereto, through
             1894      administrative rulemaking if the commissioner determines that the plan or amendment:
             1895          (a) meets the requirements of Sections 31A-42a-202 and 31A-42a-203 ; and
             1896          (b) ensures a fair and reasonable administration of risk by the Utah Statewide Risk
             1897      Adjuster.
             1898          (2) The plan, and any amendment thereto, shall be effective only after adoption by the
             1899      commissioner as an administrative rule in accordance with Title 63G, Chapter 3, Utah
             1900      Administrative Rulemaking Act.
             1901          (3) The commissioner shall, after notice and hearing, adopt such rules as necessary to
             1902      effectuate the provisions of this chapter, if:
             1903          (a) the board fails to submit to the commissioner a proposed plan of operation by
             1904      January 1, 2010, addressing each of the elements specified in Section 31A-42a-202 ;
             1905          (b) the board fails to submit to the commissioner by September 1, 2010, proposed
             1906      amendments to rules adopted under this section to implement changes made to this chapter
             1907      during the 2010 Annual General Session of the Legislature; or
             1908          (c) the board fails to submit a proposed amendment to rules adopted under this section
             1909      within a reasonable period, when requested to do so by the commissioner.
             1910          (4) Rules promulgated by the commissioner shall continue in force until modified by
             1911      the commissioner, by rule, or until superseded by a subsequent plan of operation, or an
             1912      amendment to the plan of operation, submitted by the board, approved by the commissioner,
             1913      and implemented by rule.
             1914          Section 37. Section 58-31b-802 is enacted to read:
             1915          58-31b-802. Consumer access to provider charges.
             1916          Beginning January 1, 2011, a nurse whose license under this chapter authorizes
             1917      independent practice shall, when requested by a consumer:
             1918          (1) make a list of prices charged by the nurse available for the consumer which


             1919      includes the nurse's 25 most frequently performed:
             1920          (a) clinic procedures or clinic services;
             1921          (b) out-patient procedures; and
             1922          (c) in-patient procedures; and
             1923          (2) provide the consumer with information regarding any discount available for:
             1924          (a) services not covered by insurance; or
             1925          (b) prompt payment of billed charges.
             1926          Section 38. Section 58-67-804 is enacted to read:
             1927          58-67-804. Consumer access to provider charges.
             1928          Beginning January 1, 2011, a physician licensed under this chapter shall, when
             1929      requested by a consumer:
             1930          (1) make a list of prices charged by the physician available for the consumer which
             1931      includes the physician's 25 most frequently performed:
             1932          (a) clinic procedures or clinic services;
             1933          (b) out-patient procedures; and
             1934          (c) in-patient procedures; and
             1935          (2) provide the consumer with information regarding any discount available for:
             1936          (a) services not covered by insurance; or
             1937          (b) prompt payment of billed charges.
             1938          Section 39. Section 58-68-804 is enacted to read:
             1939          58-68-804. Consumer access to provider charges.
             1940          Beginning January 1, 2011, an osteopathic physician licensed under this chapter shall,
             1941      when requested by a consumer:
             1942          (1) make a list of prices charged by the osteopathic physician available for the
             1943      consumer which includes the osteopathic physician's 25 most frequently performed:
             1944          (a) clinic procedures or clinic services;
             1945          (b) out-patient procedures; and
             1946          (c) in-patient procedures; and
             1947          (2) provide the consumer with information regarding any discount available for:
             1948          (a) services not covered by insurance; or
             1949          (b) prompt payment of billed charges.


             1950          Section 40. Section 58-69-806 is enacted to read:
             1951          58-69-806. Consumer access to provider charges.
             1952          Beginning January 1, 2011, a dentist licensed under this chapter shall, when requested
             1953      by a consumer:
             1954          (1) make a list of prices charged by the dentist available for the consumer which
             1955      includes the dentist's 25 most frequently performed:
             1956          (a) clinic procedures or clinic services;
             1957          (b) out-patient procedures; and
             1958          (c) in-patient procedures; and
             1959          (2) provide the consumer with information regarding any discount available for:
             1960          (a) services not covered by insurance; or
             1961          (b) prompt payment of billed charges.
             1962          Section 41. Section 63I-2-231 is amended to read:
             1963           63I-2-231. Repeal dates, Title 31A.
             1964          (1) Section 31A-23a-415 is repealed July 1, 2011.
             1965          (2) Section 31A-22-619 is repealed July 1, 2010.
             1966          (3) Title 31A, Chapter 42, Defined Contribution Risk Adjuster Act, is repealed January
             1967      1, 2013.
             1968          Section 42. Section 63M-1-2504 is amended to read:
             1969           63M-1-2504. Creation of Office of Consumer Health Services -- Duties.
             1970          (1) There is created within the Governor's Office of Economic Development the Office
             1971      of Consumer Health Services.
             1972          (2) The office shall:
             1973          (a) in cooperation with the Insurance Department, the Department of Health, and the
             1974      Department of Workforce Services, and in accordance with the electronic standards developed
             1975      under Sections 31A-22-635 and 63M-1-2506 , create [an Internet portal] a Health Insurance
             1976      Exchange that:
             1977          (i) is capable of providing access to private and government health insurance websites
             1978      and their electronic application forms and submission procedures;
             1979          (ii) provides a consumer comparison of and enrollment in a health benefit plan posted
             1980      on the [Internet portal] Health Insurance Exchange by an insurer for the:


             1981          (A) small employer group market;
             1982          (B) the individual market; and
             1983          (C) the defined contribution arrangement market; and
             1984          (iii) includes information and a link to enrollment in premium assistance programs and
             1985      other government assistance programs;
             1986          (b) facilitate a private sector method for the collection of health insurance premium
             1987      payments made for a single policy by multiple payers, including the policyholder, one or more
             1988      employers of one or more individuals covered by the policy, government programs, and others
             1989      by educating employers and insurers about collection services available through private
             1990      vendors, including financial institutions;
             1991          (c) assist employers with a free or low cost method for establishing mechanisms for the
             1992      purchase of health insurance by employees using pre-tax dollars;
             1993          (d) periodically convene health care providers, payers, and consumers to monitor the
             1994      progress being made regarding demonstration projects for health care delivery and payment
             1995      reform; [and]
             1996          (e) establish a list on the Health Insurance Exchange of insurance producers who, in
             1997      accordance with Section 31A-30-209 , are appointed producers for the defined contribution
             1998      arrangement market on the Health Insurance Exchange; and
             1999          [(e)] (f) report to the Business and Labor Interim Committee and the Health System
             2000      Reform Task Force prior to [November 1, 2009 and] November 1, 2010, and prior to the
             2001      Legislative interim day in November of each year thereafter regarding:
             2002          (i) the operations of the [Internet portal] Health Insurance Exchange required by this
             2003      chapter; and
             2004          (ii) the progress of the demonstration projects for health care payment and delivery
             2005      reform.
             2006          (3) The office:
             2007          (a) may not:
             2008          (i) regulate health insurers, health insurance plans, or health insurance producers;
             2009          (ii) adopt administrative rules, except as provided in Section 63M-1-2506 ; or
             2010          (iii) act as an appeals entity for resolving disputes between a health insurer and an
             2011      insured; and


             2012          (b) may establish and collect a fee in accordance with Section 63J-1-504 for the
             2013      transaction cost of:
             2014          (i) processing an application for a health benefit plan from the Internet portal to an
             2015      insurer; and
             2016          (ii) accepting, processing, and submitting multiple premium payment sources.
             2017          Section 43. Section 63M-1-2506 is amended to read:
             2018           63M-1-2506. Health benefit plan information on Health Insurance Exchange --
             2019      Insurer transparency.
             2020          (1) (a) The office shall adopt administrative rules in accordance with Title 63G,
             2021      Chapter 3, Utah Administrative Rulemaking Act, that:
             2022          (i) establish uniform electronic standards for:
             2023          (A) a health insurer to use when:
             2024          (I) transmitting information to [the Internet portal; or]:
             2025          (Aa) the Insurance Department under Subsection 31A-22-613.5 (2)(a)(ii); and
             2026          (Bb) the Health Insurance Exchange as required by this section;
             2027          (II) receiving information from the [Internet portal; and] Health Insurance Exchange;
             2028          (III) receiving or transmitting the universal health application to or from the Health
             2029      Insurance Exchange;
             2030          (B) facilitating the transmission and receipt of premium payments from multiple
             2031      sources in the defined contribution arrangement market; and
             2032          (C) the use of the uniform health insurance application required by Section
             2033      31A-22-635 on the Health Insurance Exchange;
             2034          (ii) designate the level of detail that would be helpful for a concise consumer
             2035      comparison of the items described in Subsections (4)[(a) through (d)] and (5) on the [Internet
             2036      portal] Health Insurance Exchange; [and]
             2037          (iii) assist the risk adjuster board created under Title 31A, Chapter 42, Defined
             2038      Contribution Risk Adjuster Act, and carriers participating in the defined contribution market on
             2039      the [Internet portal] Health Insurance Exchange with the determination of when an employer is
             2040      eligible to participate in the [Internet portal defined contribution market] Health Insurance
             2041      Exchange under Title 31A, Chapter 30, Part 2, Defined Contribution Arrangements[.]; and
             2042          (iv) create an advisory board to advise the exchange concerning the operation of the


             2043      exchange and transparency issues with the following members:
             2044          (A) two health producers who are registered with the Health Insurance Exchange;
             2045          (B) two consumers;
             2046          (C) one representative from a large insurer who participates on the exchange;
             2047          (D) one representative from a small insurer who participates on the exchange; and
             2048          (E) one representative from the Insurance Department.
             2049          (b) The office shall post or facilitate the posting of:
             2050          (i) the information required by this section on the [Internet portal] Health Insurance
             2051      Exchange created by this part; and
             2052          (ii) links to websites that provide cost and quality information from the Department of
             2053      Health Data Committee or neutral entities with a broad base of support from the provider and
             2054      payer communities.
             2055          (2) A health insurer shall use the uniform electronic standards when transmitting
             2056      information to the [Internet portal] Health Insurance Exchange or receiving information from
             2057      the [Internet portal] Health Insurance Exchange.
             2058          (3) (a) (i) An insurer who participates in the defined contribution arrangement market
             2059      under Title 31A, Chapter 30, Part 2, Defined Contribution Arrangements, shall post all plans
             2060      offered in [that] the defined contribution arrangement market on the [Internet portal] Health
             2061      Insurance Exchange and shall comply with the provisions of this section.
             2062          (ii) Beginning January 1, 2011, an insurer who offers a health benefit plan to a small
             2063      employer group in the state shall:
             2064          (A) post the health benefit plans in which the insurer is enrolling new groups, on the
             2065      Health Insurance Exchange; and
             2066          (B) comply with the provisions of this section.
             2067          (b) An insurer who offers [products] individual health benefit plans under Title 31A,
             2068      Chapter 30, Part 1, Individual and Small Employer Group:
             2069          (i) shall post on the Health Insurance Exchange the basic benefit plan required by
             2070      Section 31A-22-613.5 [for individual and small employer group plans on the Internet portal if
             2071      the insurer's plans are offered to the general public]; and
             2072          (ii) may publish on the Health Insurance Exchange any other health benefit plans that it
             2073      offers [on the Internet portal; and] in the individual market.


             2074          (c) An insurer who posts a health benefit plan on the Health Insurance Exchange:
             2075          [(iii)] (i) shall comply with the provisions of this section for every health benefit plan it
             2076      posts on the [Internet portal.] Health Insurance Exchange; and
             2077          (ii) may not offer products on the Health Insurance Exchange that are not health benefit
             2078      plans.
             2079          (4) A health insurer shall provide the [Internet portal] Health Insurance Exchange with
             2080      the following information for each health benefit plan submitted to the [Internet portal] Health
             2081      Insurance Exchange:
             2082          (a) plan design, benefits, and options offered by the health benefit plan including state
             2083      mandates the plan does not cover;
             2084          (b) provider networks;
             2085          (c) wellness programs and incentives; and
             2086          (d) descriptions of prescription drug benefits, exclusions, or limitations[; and].
             2087          [(e) at the same time as information is submitted under Subsection 31A-30-208 (2), the
             2088      following operational measures for each health insurer that submits information to the Internet
             2089      portal:]
             2090          (5) (a) An insurer offering any health benefit plan in the state shall submit the
             2091      information described in Subsection (5)(b) to the Insurance Department in the electronic format
             2092      required by Subsection (1).
             2093          (b) An insurer who offers a health benefit plan in the state shall submit to the Health
             2094      Insurance Exchange the following operational measures:
             2095          (i) the percentage of claims paid by the insurer within 30 days of the date a claim is
             2096      submitted to the insurer for the prior year; and
             2097          [(ii) the number of adverse benefit determinations by the insurer which were
             2098      subsequently overturned on independent review under Section 31A-22-629 as a percentage of
             2099      total claims paid by the insurer for the prior year.]
             2100          (ii) for all health benefit plans offered by the insurer in the state, the claims denial and
             2101      insurer transparency information developed in accordance with Subsection 31A-22-613.5 (5).
             2102          (c) The Insurance Department shall forward to the Health Insurance Exchange the
             2103      information submitted by an insurer in accordance with this section and Section 31A-22-613.5 .
             2104          [(5)] (6) The Insurance Department shall post on the [Internet portal] Health Insurance


             2105      Exchange the Insurance Department's solvency rating for each insurer who posts a health
             2106      benefit plan on the [Internet portal] Health Insurance Exchange. The solvency rating for each
             2107      carrier shall be based on methodology established by the Insurance Department by
             2108      administrative rule and shall be updated each calendar year.
             2109          [(6)] (7) The commissioner may request information from an insurer under Section
             2110      31A-22-613.5 to verify the data submitted to the [Internet portal] Insurance Department and to
             2111      the Health Insurance Exchange under this section.
             2112          [(7)] (8) A health insurer shall accept and process an application for a health benefit
             2113      plan from the [Internet portal] Health Insurance Exchange in accordance with this section and
             2114      Section 31A-22-635 .
             2115          Section 44. Health System Reform Task Force -- Creation -- Membership --
             2116      Interim rules followed -- Compensation -- Staff.
             2117          (1) There is created the Health System Reform Task Force consisting of the following
             2118      11 members:
             2119          (a) four members of the Senate appointed by the president of the Senate, no more than
             2120      three of whom may be from the same political party; and
             2121          (b) seven members of the House of Representatives appointed by the speaker of the
             2122      House of Representatives, no more than five of whom may be from the same political party.
             2123          (2) (a) The president of the Senate shall designate a member of the Senate appointed
             2124      under Subsection (1)(a) as a co-chair of the committee.
             2125          (b) The speaker of the House of Representatives shall designate a member of the House
             2126      of Representatives appointed under Subsection (1)(b) as a co-chair of the committee.
             2127          (3) In conducting its business, the committee shall comply with the rules of legislative
             2128      interim committees.
             2129          (4) Salaries and expenses of the members of the committee shall be paid in accordance
             2130      with Section 36-2-2 and Legislative Joint Rules, Title 5, Chapter 3, Expense and Mileage
             2131      Reimbursement for Authorized Legislative Meetings, Special Sessions, and Veto Override
             2132      Sessions.
             2133          (5) The Office of Legislative Research and General Counsel shall provide staff support
             2134      to the committee.
             2135          Section 45. Duties -- Interim report.


             2136          (1) The committee shall review and make recommendations on the following issues:
             2137          (a) the state's progress in implementing the strategic plan for health system reform as
             2138      described in Section 63M-1-2505 ;
             2139          (b) the implementation of statewide demonstration projects to provide systemwide
             2140      aligned incentives for the appropriate delivery of and payment for health care;
             2141          (c) the development of the defined contribution arrangement market and the plan
             2142      developed by the risk adjuster board for implementation by January 1, 2012, including:
             2143          (i) consumer experience and plan selection in the defined contribution market;
             2144          (ii) participation by large employer groups in the defined contribution market; and
             2145          (iii) risk allocation in the defined contribution market including the study of
             2146      implementing an individual health risk score;
             2147          (d) the operations and progress of the Health Insurance Exchange;
             2148          (e) mechanisms to increase transparency in the insurance market;
             2149          (f) the implementation and effectiveness of insurer wellness programs and incentives,
             2150      including outcome measures for the programs;
             2151          (g) developing with providers and insurers a more efficient process for
             2152      pre-authorization from an insurer for a medical procedure;
             2153          (h) the role that the Public Employees' Benefit and Insurance Program and other
             2154      associations that provide insurance may play in the defined contribution market;
             2155          (i) the development of strategies to keep community leaders, business leaders, and the
             2156      public involved in the process of health care reform; and
             2157          (j) the state's response to, and duties under federal health care reform.
             2158          (2) A final report shall be presented to the Business and Labor Interim Committee
             2159      before November 30, 2010.
             2160          Section 46. Effective date.
             2161          (1) Except as provided in Subsection (2), if approved by two-thirds of all the members
             2162      elected to each house, this bill takes effect upon approval by the governor, or the day following
             2163      the constitutional time limit of Utah Constitution Article VII, Section 8, without the governor's
             2164      signature, or in the case of a veto, the date of veto override, except that the amendments to
             2165      Sections 31A-30-103 and 31A-30-106 take effect on January 1, 201l.
             2166          (2) The following sections take effect on January 1, 2013:


             2167          (a) Section 31A-42a-101 ;
             2168          (b) Section 31A-42a-102 ;
             2169          (c) Section 31A-42a-103 ;
             2170          (d) Section 31A-42a-201 ;
             2171          (e) Section 31A-42a-202 ;
             2172          (f) Section 31A-42a-203 ; and
             2173          (g) Section 31A-42a-204 .




Legislative Review Note
    as of 2-3-10 3:46 PM


Office of Legislative Research and General Counsel


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