First Substitute H.B. 141

Representative James A. Dunnigan proposes the following substitute bill:


             1     
HEALTH REFORM AMENDMENTS

             2     
2014 GENERAL SESSION

             3     
STATE OF UTAH

             4     
Chief Sponsor: James A. Dunnigan

             5     
Senate Sponsor: ____________

             6     
             7      LONG TITLE
             8      General Description:
             9          This bill amends provisions related to health insurance and state and federal health care
             10      reform.
             11      Highlighted Provisions:
             12          This bill:
             13          .    amends the period of time in which an employee of a state contractor must be
             14      enrolled in health insurance to conform to federal law;
             15          .    updates language regarding the prohibition against Medicaid expansion to reflect
             16      current federal regulations;
             17          .    creates a two year pilot program known as Access Utah to provide a defined
             18      contribution health benefit to individuals who are below the federal poverty level
             19      and meet other need based requirements;
             20          .    establishes a coordinated care model for providing care in Access Utah;
             21          .    instructs the Department of Health to:
             22              *    work with the Legislature's Health Reform Task Force to develop a     
             23      Section 1332 Medicaid waiver; and
             24              *    submit an amendment of the Utah Premium Partnership and Primary Care
             25      Network waiver to the Centers for Medicare and Medicaid Services to


             26      incorporate the Access Utah program.
             27          .    amends the Utah Health Data Authority Act to facilitate:
             28              .    the coordination of eligibility for health insurance benefits; and
             29              .    cost and quality reports for episodes of care;
             30          .    amends the health insurance navigator license chapter of the Insurance Code to:
             31              .    create two types of navigator licenses;
             32              .    establish different training for the types of licenses; and
             33              .    add an exception to the license requirement for Indian health centers;
             34          .    amends the state Comprehensive Health Insurance Pool to:
             35              .    close the pool to new enrollees;
             36              .    pay out claims incurred by enrollees; and
             37              .    close down the business of the pool;
             38          .    establishes the state option for calculating the cost to the state if the state mandates
             39      additional benefits to the PPACA essential health benefits;
             40          .    creates the Individual and Small Employer Risk Adjustment Act, which:
             41              .    requires the insurance commissioner to work with stakeholders to develop a
             42      state based risk adjustment program for the individual and small group market;
             43              .    describes the risk adjustment models the commissioner may consider;
             44              .    requires the commissioner to report to the Legislature before implementing a
             45      risk adjustment model;
             46              .    authorizes the commissioner to set fees for the operation of the risk adjustment
             47      program; and
             48              .    establishes an Individual and Small Employer Risk Adjustment Enterprise Fund
             49      for the operation of the program;
             50          .    requires the Office of Consumer Health Services, which runs the small employer
             51      health insurance exchange, to provide the form required for the federal small
             52      employer premium tax credit to small employers who purchase qualified health
             53      plans; and
             54          .    makes technical and conforming amendments.
             55      Money Appropriated in this Bill:
             56          None


             57      Other Special Clauses:
             58          This bill provides an effective date.
             59          This bill coordinates with H.B. 24, Insurance Related Amendments, by providing
             60      superseding and substantive amendments.
             61          This bill coordinates with H.B. 35, Reauthorization of Utah Health Data Authority Act,
             62      by providing superseding and substantive amendments.
             63      Utah Code Sections Affected:
             64      AMENDS:
             65           17B-2a-818.5 , as last amended by Laws of Utah 2012, Chapter 347
             66           19-1-206 , as last amended by Laws of Utah 2012, Chapter 347
             67           26-18-18 , as enacted by Laws of Utah 2013, Chapter 477
             68           26-33a-106.1 , as last amended by Laws of Utah 2012, Chapter 279
             69           26-33a-106.5 , as last amended by Laws of Utah 2012, Chapter 279
             70           26-33a-109 , as last amended by Laws of Utah 2010, Chapter 68
             71           31A-4-115 , as last amended by Laws of Utah 2002, Chapter 308
             72           31A-8-402.3 , as last amended by Laws of Utah 2004, Chapter 329
             73           31A-22-721 , as last amended by Laws of Utah 2011, Chapter 284
             74           31A-23b-205 , as enacted by Laws of Utah 2013, Chapter 341
             75           31A-23b-206 , as enacted by Laws of Utah 2013, Chapter 341
             76           31A-23b-211 , as enacted by Laws of Utah 2013, Chapter 341
             77           31A-29-106 , as last amended by Laws of Utah 2013, Chapter 319
             78           31A-29-110 , as last amended by Laws of Utah 2012, Chapter 347
             79           31A-29-111 , as last amended by Laws of Utah 2012, Chapters 158 and 347
             80           31A-29-113 , as last amended by Laws of Utah 2013, Chapter 319
             81           31A-29-114 , as last amended by Laws of Utah 2006, Chapter 95
             82           31A-29-115 , as last amended by Laws of Utah 2004, Chapter 2
             83           31A-30-103 , as last amended by Laws of Utah 2013, Chapter 168
             84           31A-30-107 , as last amended by Laws of Utah 2009, Chapter 12
             85           31A-30-108 , as last amended by Laws of Utah 2011, Chapter 284
             86           31A-30-117 , as enacted by Laws of Utah 2013, Chapter 341
             87           63A-5-205 , as last amended by Laws of Utah 2012, Chapter 347


             88           63C-9-403 , as last amended by Laws of Utah 2012, Chapter 347
             89           63I-1-231 (Effective 07/01/14), as last amended by Laws of Utah 2013, Chapters 261
             90      and 417
             91           63M-1-2504 , as last amended by Laws of Utah 2013, Chapter 255
             92           72-6-107.5 , as last amended by Laws of Utah 2012, Chapter 347
             93           79-2-404 , as last amended by Laws of Utah 2012, Chapter 347
             94      ENACTS:
             95           26-18-20 , Utah Code Annotated 1953
             96           31A-23b-202.5 , Utah Code Annotated 1953
             97           31A-30-118 , Utah Code Annotated 1953
             98           31A-30-301 , Utah Code Annotated 1953
             99           31A-30-302 , Utah Code Annotated 1953
             100           31A-30-303 , Utah Code Annotated 1953
             101      Utah Code Sections Affected by Coordination Clause:
             102           26-33a-106.1 , as last amended by Laws of Utah 2012, Chapter 279
             103           31A-23b-205 , as enacted by Laws of Utah 2013, Chapter 341
             104           31A-23b-206 , as enacted by Laws of Utah 2013, Chapter 341
             105     
             106      Be it enacted by the Legislature of the state of Utah:
             107          Section 1. Section 17B-2a-818.5 is amended to read:
             108           17B-2a-818.5. Contracting powers of public transit districts -- Health insurance
             109      coverage.
             110          (1) For purposes of this section:
             111          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             112      34A-2-104 who:
             113          (i) works at least 30 hours per calendar week; and
             114          (ii) meets employer eligibility waiting requirements for health care insurance which
             115      may not exceed the first day of the calendar month following [90] 60 days from the date of
             116      hire.
             117          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             118          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .


             119          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             120          (2) (a) Except as provided in Subsection (3), this section applies to a design or
             121      construction contract entered into by the public transit district on or after July 1, 2009, and to a
             122      prime contractor or to a subcontractor in accordance with Subsection (2)(b).
             123          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             124      amount of $1,500,000 or greater.
             125          (ii) A subcontractor is subject to this section if a subcontract is in the amount of
             126      $750,000 or greater.
             127          (3) This section does not apply if:
             128          (a) the application of this section jeopardizes the receipt of federal funds;
             129          (b) the contract is a sole source contract; or
             130          (c) the contract is an emergency procurement.
             131          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             132      or a modification to a contract, when the contract does not meet the initial threshold required
             133      by Subsection (2).
             134          (b) A person who intentionally uses change orders or contract modifications to
             135      circumvent the requirements of Subsection (2) is guilty of an infraction.
             136          (5) (a) A contractor subject to Subsection (2) shall demonstrate to the public transit
             137      district that the contractor has and will maintain an offer of qualified health insurance coverage
             138      for the contractor's employees and the employee's dependents during the duration of the
             139      contract.
             140          (b) If a subcontractor of the contractor is subject to Subsection (2)(b), the contractor
             141      shall demonstrate to the public transit district that the subcontractor has and will maintain an
             142      offer of qualified health insurance coverage for the subcontractor's employees and the
             143      employee's dependents during the duration of the contract.
             144          (c) (i) (A) A contractor who fails to meet the requirements of Subsection (5)(a) during
             145      the duration of the contract is subject to penalties in accordance with an ordinance adopted by
             146      the public transit district under Subsection (6).
             147          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             148      requirements of Subsection (5)(b).
             149          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during


             150      the duration of the contract is subject to penalties in accordance with an ordinance adopted by
             151      the public transit district under Subsection (6).
             152          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             153      requirements of Subsection (5)(a).
             154          (6) The public transit district shall adopt ordinances:
             155          (a) in coordination with:
             156          (i) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             157          (ii) the Department of Natural Resources in accordance with Section 79-2-404 ;
             158          (iii) the State Building Board in accordance with Section 63A-5-205 ;
             159          (iv) the State Capitol Preservation Board in accordance with Section 63C-9-403 ; and
             160          (v) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             161          (b) which establish:
             162          (i) the requirements and procedures a contractor shall follow to demonstrate to the
             163      public transit district compliance with this section which shall include:
             164          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             165      (b) more than twice in any 12-month period; and
             166          (B) that the actuarially equivalent determination required for the qualified health
             167      insurance coverage in Subsection (1) is met by the contractor if the contractor provides the
             168      department or division with a written statement of actuarial equivalency from either:
             169          (I) the Utah Insurance Department;
             170          (II) an actuary selected by the contractor or the contractor's insurer; or
             171          (III) an underwriter who is responsible for developing the employer group's premium
             172      rates;
             173          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             174      violates the provisions of this section, which may include:
             175          (A) a three-month suspension of the contractor or subcontractor from entering into
             176      future contracts with the public transit district upon the first violation;
             177          (B) a six-month suspension of the contractor or subcontractor from entering into future
             178      contracts with the public transit district upon the second violation;
             179          (C) an action for debarment of the contractor or subcontractor in accordance with
             180      Section 63G-6a-904 upon the third or subsequent violation; and


             181          (D) monetary penalties which may not exceed 50% of the amount necessary to
             182      purchase qualified health insurance coverage for employees and dependents of employees of
             183      the contractor or subcontractor who were not offered qualified health insurance coverage
             184      during the duration of the contract; and
             185          (iii) a website on which the district shall post the benchmark for the qualified health
             186      insurance coverage identified in Subsection (1)(c).
             187          (7) (a) (i) In addition to the penalties imposed under Subsection (6)(b)(ii), a contractor
             188      or subcontractor who intentionally violates the provisions of this section shall be liable to the
             189      employee for health care costs that would have been covered by qualified health insurance
             190      coverage.
             191          (ii) An employer has an affirmative defense to a cause of action under Subsection
             192      (7)(a)(i) if:
             193          (A) the employer relied in good faith on a written statement of actuarial equivalency
             194      provided by an:
             195          (I) actuary; or
             196          (II) underwriter who is responsible for developing the employer group's premium rates;
             197      or
             198          (B) a department or division determines that compliance with this section is not
             199      required under the provisions of Subsection (3) or (4).
             200          (b) An employee has a private right of action only against the employee's employer to
             201      enforce the provisions of this Subsection (7).
             202          (8) Any penalties imposed and collected under this section shall be deposited into the
             203      Medicaid Restricted Account created in Section 26-18-402 .
             204          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             205      coverage as required by this section:
             206          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             207      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             208      Procurement Code; and
             209          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             210      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             211      or construction.


             212          Section 2. Section 19-1-206 is amended to read:
             213           19-1-206. Contracting powers of department -- Health insurance coverage.
             214          (1) For purposes of this section:
             215          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             216      34A-2-104 who:
             217          (i) works at least 30 hours per calendar week; and
             218          (ii) meets employer eligibility waiting requirements for health care insurance which
             219      may not exceed the first day of the calendar month following [90] 60 days from the date of
             220      hire.
             221          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             222          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             223          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             224          (2) (a) Except as provided in Subsection (3), this section applies to a design or
             225      construction contract entered into by or delegated to the department or a division or board of
             226      the department on or after July 1, 2009, and to a prime contractor or subcontractor in
             227      accordance with Subsection (2)(b).
             228          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             229      amount of $1,500,000 or greater.
             230          (ii) A subcontractor is subject to this section if a subcontract is in the amount of
             231      $750,000 or greater.
             232          (3) This section does not apply to contracts entered into by the department or a division
             233      or board of the department if:
             234          (a) the application of this section jeopardizes the receipt of federal funds;
             235          (b) the contract or agreement is between:
             236          (i) the department or a division or board of the department; and
             237          (ii) (A) another agency of the state;
             238          (B) the federal government;
             239          (C) another state;
             240          (D) an interstate agency;
             241          (E) a political subdivision of this state; or
             242          (F) a political subdivision of another state;


             243          (c) the executive director determines that applying the requirements of this section to a
             244      particular contract interferes with the effective response to an immediate health and safety
             245      threat from the environment; or
             246          (d) the contract is:
             247          (i) a sole source contract; or
             248          (ii) an emergency procurement.
             249          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             250      or a modification to a contract, when the contract does not meet the initial threshold required
             251      by Subsection (2).
             252          (b) A person who intentionally uses change orders or contract modifications to
             253      circumvent the requirements of Subsection (2) is guilty of an infraction.
             254          (5) (a) A contractor subject to Subsection (2) shall demonstrate to the executive
             255      director that the contractor has and will maintain an offer of qualified health insurance
             256      coverage for the contractor's employees and the employees' dependents during the duration of
             257      the contract.
             258          (b) If a subcontractor of the contractor is subject to Subsection (2), the contractor shall
             259      demonstrate to the executive director that the subcontractor has and will maintain an offer of
             260      qualified health insurance coverage for the subcontractor's employees and the employees'
             261      dependents during the duration of the contract.
             262          (c) (i) (A) A contractor who fails to comply with Subsection (5)(a) during the duration
             263      of the contract is subject to penalties in accordance with administrative rules adopted by the
             264      department under Subsection (6).
             265          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             266      requirements of Subsection (5)(b).
             267          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during
             268      the duration of the contract is subject to penalties in accordance with administrative rules
             269      adopted by the department under Subsection (6).
             270          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             271      requirements of Subsection (5)(a).
             272          (6) The department shall adopt administrative rules:
             273          (a) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;


             274          (b) in coordination with:
             275          (i) a public transit district in accordance with Section 17B-2a-818.5 ;
             276          (ii) the Department of Natural Resources in accordance with Section 79-2-404 ;
             277          (iii) the State Building Board in accordance with Section 63A-5-205 ;
             278          (iv) the State Capitol Preservation Board in accordance with Section 63C-9-403 ;
             279          (v) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             280          (vi) the Legislature's Administrative Rules Review Committee; and
             281          (c) which establish:
             282          (i) the requirements and procedures a contractor shall follow to demonstrate to the
             283      public transit district compliance with this section that shall include:
             284          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             285      (b) more than twice in any 12-month period; and
             286          (B) that the actuarially equivalent determination required for the qualified health
             287      insurance coverage in Subsection (1) is met by the contractor if the contractor provides the
             288      department or division with a written statement of actuarial equivalency from either:
             289          (I) the Utah Insurance Department;
             290          (II) an actuary selected by the contractor or the contractor's insurer; or
             291          (III) an underwriter who is responsible for developing the employer group's premium
             292      rates;
             293          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             294      violates the provisions of this section, which may include:
             295          (A) a three-month suspension of the contractor or subcontractor from entering into
             296      future contracts with the state upon the first violation;
             297          (B) a six-month suspension of the contractor or subcontractor from entering into future
             298      contracts with the state upon the second violation;
             299          (C) an action for debarment of the contractor or subcontractor in accordance with
             300      Section 63G-6a-904 upon the third or subsequent violation; and
             301          (D) notwithstanding Section 19-1-303 , monetary penalties which may not exceed 50%
             302      of the amount necessary to purchase qualified health insurance coverage for an employee and
             303      the dependents of an employee of the contractor or subcontractor who was not offered qualified
             304      health insurance coverage during the duration of the contract; and


             305          (iii) a website on which the department shall post the benchmark for the qualified
             306      health insurance coverage identified in Subsection (1)(c).
             307          (7) (a) (i) In addition to the penalties imposed under Subsection (6)(c), a contractor or
             308      subcontractor who intentionally violates the provisions of this section shall be liable to the
             309      employee for health care costs that would have been covered by qualified health insurance
             310      coverage.
             311          (ii) An employer has an affirmative defense to a cause of action under Subsection
             312      (7)(a)(i) if:
             313          (A) the employer relied in good faith on a written statement of actuarial equivalency
             314      provided by:
             315          (I) an actuary; or
             316          (II) an underwriter who is responsible for developing the employer group's premium
             317      rates; or
             318          (B) the department determines that compliance with this section is not required under
             319      the provisions of Subsection (3) or (4).
             320          (b) An employee has a private right of action only against the employee's employer to
             321      enforce the provisions of this Subsection (7).
             322          (8) Any penalties imposed and collected under this section shall be deposited into the
             323      Medicaid Restricted Account created in Section 26-18-402 .
             324          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             325      coverage as required by this section:
             326          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             327      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             328      Procurement Code; and
             329          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             330      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             331      or construction.
             332          Section 3. Section 26-18-18 is amended to read:
             333           26-18-18. Optional Medicaid expansion.
             334          (1) For purposes of this section:
             335          (a) "Optional expansion population" means individuals who:


             336          (i) do not qualify for the state's Medicaid program; and
             337          (ii) the Centers for Medicare and Medicaid Services within the United States
             338      Department of Health and Human Services would otherwise determine are eligible for funding
             339      at the enhanced federal medical assistance percentage available under PPACA beginning
             340      January 1, 2014.
             341          (c) PPACA is as defined in Section 31A-1-301 .
             342          (2) The department and the governor shall not expand the state's Medicaid program to
             343      the optional expansion population under PPACA unless:
             344          [(a) the Health Reform Task Force has completed a thorough analysis of a statewide
             345      charity care system;]
             346          [(b) the department and its contractors have:]
             347          [(i) completed a thorough analysis of the impact to the state of expanding the state's
             348      Medicaid program to optional populations under PPACA; and]
             349          [(ii) made the analysis conducted under Subsection (2)(b)(i) available to the public;]
             350          [(c)] (a) the governor or the governor's designee has reported the intention to expand
             351      the state Medicaid program under PPACA to the Legislature in compliance with the legislative
             352      review process in Sections 63M-1-2505.5 and 26-18-3 ; and
             353          [(d)] (b) notwithstanding Subsection 63J-5-103 (2), the governor submits the request
             354      for expansion of the Medicaid program for optional populations to the Legislature under the
             355      high impact federal funds request process required by Section 63J-5-204 , Legislative review
             356      and approval of certain federal funds request.
             357          Section 4. Section 26-18-20 is enacted to read:
             358          26-18-20. Access Utah -- Eligibility -- Defined contribution.
             359          (1) For purposes of this section:
             360          (a) "Access Utah" means the defined contribution program created in this section.
             361          (b) "Medically frail" means an individual who meets the criteria of 42 C.F.R. 440.315
             362      as determined by the department based on methodology administered by the department or
             363      another entity selected by the department.
             364          (c) "Optional expansion population" is as defined in Section 26-18-18 .
             365          (2) (a) The department shall establish a two-year pilot program known as "Access
             366      Utah" which shall:


             367          (i) begin on January 1, 2015, and end on January 1, 2017; and
             368          (ii) provide a defined contribution to eligible individuals in accordance with this
             369      section.
             370          (b) The department shall work with the Legislature's Health Reform Task Force to
             371      develop a Medicaid waiver proposal under Section 1332 of the Social Security Act to submit to
             372      the Centers for Medicare and Medicaid Services within the United States Department of Health
             373      and Human Services.
             374          (3) An individual is eligible for Access Utah if the individual:
             375          (a) (i) is in the optional expansion population and below 100% of the federal poverty
             376      level; and
             377          (ii) (A) is medically frail; or
             378          (B) is an adult with a child; and
             379          (b) if funding permits, is an individual described in Subsection (3)(a)(i), but not
             380      Subsection (3)(a)(ii).
             381          (4) (a) Within appropriations from the Legislature, the department shall offer to an
             382      eligible individual a defined contribution in an amount determined by the department.
             383          (b) An eligible individual shall use the defined contribution to purchase employer
             384      sponsored health insurance coverage if the individual is offered employer sponsored coverage.
             385          (c) If an eligible individual is not offered employer sponsored health insurance
             386      coverage, the individual may use the defined contribution to purchase:
             387          (i) a commercial health insurance policy; or
             388          (ii) access to a coordinated care model described in Subsection (5).
             389          (5) (a) The department may contract with public and private entities to provide or
             390      manage the delivery of a coordinated care model to an individual described in Subsection
             391      (4)(c)(ii).
             392          (b) The coordinated care model shall combine state and federal funding with charity
             393      care resources to:
             394          (i) provide, as funding permits, preventive care, outpatient care, pharmacy benefits,
             395      urgent and emergency care, and limited hospital benefits; and
             396          (ii) integrate physical health and behavioral health services.
             397          (6) The department shall evaluate and report to the Legislature's Health Reform Task


             398      Force on or before November 1, 2016, regarding:
             399          (a) the methods used to determine a medically frail individual, and the number of
             400      medically frail individuals who enrolled in Access Utah;
             401          (b) access to and quality of care in Access Utah; and
             402          (c) whether Access Utah helped to facilitate enrollee self-sufficiency.
             403          (7) (a) Notwithstanding Section 26-18-18 , the department shall seek an extension of
             404      Utah's Primary Care Network and the Utah Premium Partnership 1115 Waiver from the
             405      Centers for Medicare and Medicaid Services within the United States Department of Health
             406      and Human Services in accordance with Subsection (7)(b).
             407          (b) The department may modify the Primary Care Network and the Utah Premium
             408      Partnership scope of benefits and eligibility criteria as part of the waiver request under
             409      Subsection (7)(a) if:
             410          (i) the department develops the waiver request in coordination with the Legislature's
             411      Health Reform Task Force and reports to the Legislature's Executive Appropriations
             412      Committee regarding the waiver request; and
             413          (ii) the modification of benefits will:
             414          (A) not increase the state's expenditure for the Access Utah program beyond the
             415      Legislature's appropriation for the program; and
             416          (B) further the state's goal to reduce health costs, improve access to care, and improve
             417      health outcomes of Utah citizens.
             418          Section 5. Section 26-33a-106.1 is amended to read:
             419           26-33a-106.1. Health care cost and reimbursement data.
             420          [(1) (a) The committee shall, as funding is available, establish an advisory panel to
             421      advise the committee on the development of a plan for the collection and use of health care
             422      data pursuant to Subsection 26-33a-104 (6) and this section.]
             423          [(b) The advisory panel shall include:]
             424          [(i) the chairman of the Utah Hospital Association;]
             425          [(ii) a representative of a rural hospital as designated by the Utah Hospital
             426      Association;]
             427          [(iii) a representative of the Utah Medical Association;]
             428          [(iv) a physician from a small group practice as designated by the Utah Medical


             429      Association;]
             430          [(v) two representatives who are health insurers, appointed by the committee;]
             431          [(vi) a representative from the Department of Health as designated by the executive
             432      director of the department;]
             433          [(vii) a representative from the committee;]
             434          [(viii) a consumer advocate appointed by the committee;]
             435          [(ix) a member of the House of Representatives appointed by the speaker of the House;
             436      and]
             437          [(x) a member of the Senate appointed by the president of the Senate.]
             438          [(c) The advisory panel shall elect a chair from among its members, and shall be
             439      staffed by the committee.]
             440          [(2) (a)] (1) The committee shall, as funding is available:
             441          [(i)] (a) establish a plan for collecting data from data suppliers, as defined in Section
             442      26-33a-102 , to determine measurements of cost and reimbursements for risk-adjusted episodes
             443      of health care;
             444          [(ii)] (b) share data regarding insurance claims and an individual's and small employer
             445      group's health risk factor and characteristics of insurance arrangements that affect claims and
             446      usage with [insurers participating in the defined contribution market created in Title 31A,
             447      Chapter 30, Part 2, Defined Contribution Arrangements] the Insurance Department, only to the
             448      extent necessary for:
             449          (i) risk adjusting; and
             450          (ii) the review and analysis of health insurers' premiums and rate filings; and
             451          [(A) establishing rates and prospective risk adjusting in the defined contribution
             452      arrangement market; and]
             453          [(B) risk adjusting in the defined contribution arrangement market; and]
             454          [(iii)] (c) assist the Legislature and the public with awareness of, and the promotion of,
             455      transparency in the health care market by reporting on:
             456          [(A)] (i) geographic variances in medical care and costs as demonstrated by data
             457      available to the committee; [and]
             458          [(B)] (ii) rate and price increases by health care providers:
             459          [(I)] (A) that exceed the Consumer Price Index - Medical as provided by the United


             460      States Bureau of Labor Statistics;
             461          [(II)] (B) as calculated yearly from June to June; and
             462          [(III)] (C) as demonstrated by data available to the committee[.]; and
             463          (iii) at least a monthly basis, enrollment data collected by the committee to a
             464      not-for-profit, broad-based coalition of state health care insurers and health care providers that
             465      are involved in the standardized electronic exchange of health data as described in Section
             466      31A-22-614.5 , to the extent necessary:
             467          (A) for the department or the Medicaid Office of the Inspector General to determine
             468      insurance enrollment of an individual for the purpose of determining Medicaid third part
             469      liability;
             470          (B) for an insurer that is a data supplier, to determine insurance enrollment of an
             471      individual for the purpose of coordination of health care benefits; and
             472          (C) for a health care provider, to determine insurance enrollment for a patient for the
             473      purpose of claims submission by the health care provider.
             474          (2) (a) The Medicaid Office of Inspector General shall annually report to the
             475      Legislature's Health and Human Services Interim Committee regarding how the office used the
             476      data obtained under Subsection (1)(c)(iii) and the results of obtaining the data.
             477          (b) A data supplier shall not be liable for a breach of or unlawful disclosure of the data
             478      obtained by an entity described in Subsection (1)(c)(iii).
             479          [(b)] (3) The plan adopted under [this] Subsection [(2)] (1) shall include:
             480          [(i)] (a) the type of data that will be collected;
             481          [(ii)] (b) how the data will be evaluated;
             482          [(iii)] (c) how the data will be used;
             483          [(iv)] (d) the extent to which, and how the data will be protected; and
             484          [(v)] (e) who will have access to the data.
             485          Section 6. Section 26-33a-106.5 is amended to read:
             486           26-33a-106.5. Comparative analyses.
             487          (1) The committee may publish compilations or reports that compare and identify
             488      health care providers or data suppliers from the data it collects under this chapter or from any
             489      other source.
             490          (2) (a) [The] Except as provided in Subsection (7)(c), the committee shall publish


             491      compilations or reports from the data it collects under this chapter or from any other source
             492      which:
             493          (i) contain the information described in Subsection (2)(b); and
             494          (ii) compare and identify by name at least a majority of the health care facilities, health
             495      care plans, and institutions in the state.
             496          (b) [The] Except as provided in Subsection (7)(c), the report required by this
             497      Subsection (2) shall:
             498          (i) be published at least annually; and
             499          (ii) contain comparisons based on at least the following factors:
             500          (A) nationally or other generally recognized quality standards;
             501          (B) charges; and
             502          (C) nationally recognized patient safety standards.
             503          (3) The committee may contract with a private, independent analyst to evaluate the
             504      standard comparative reports of the committee that identify, compare, or rank the performance
             505      of data suppliers by name. The evaluation shall include a validation of statistical
             506      methodologies, limitations, appropriateness of use, and comparisons using standard health
             507      services research practice. The analyst shall be experienced in analyzing large databases from
             508      multiple data suppliers and in evaluating health care issues of cost, quality, and access. The
             509      results of the analyst's evaluation shall be released to the public before the standard
             510      comparative analysis upon which it is based may be published by the committee.
             511          (4) The committee shall adopt by rule a timetable for the collection and analysis of data
             512      from multiple types of data suppliers.
             513          (5) The comparative analysis required under Subsection (2) shall be available:
             514          (a) free of charge and easily accessible to the public; and
             515          (b) on the Health Insurance Exchange either directly or through a link.
             516          (6) (a) The department shall include in the report required by Subsection (2)(b), or
             517      include in a separate report, comparative information on commonly recognized or generally
             518      agreed upon measures of cost and quality identified in accordance with Subsection (7), for:
             519          (i) routine and preventive care; and
             520          (ii) the treatment of diabetes, heart disease, and other illnesses or conditions as
             521      determined by the committee.


             522          (b) The comparative information required by Subsection (6)(a) shall be based on data
             523      collected under Subsection (2) and clinical data that may be available to the committee, and
             524      shall [beginning on or after July 1, 2012,] compare:
             525          (i) beginning December 31, 2014, results for health care facilities or institutions;
             526          (ii) beginning December 31, 2014, results for health care providers by geographic
             527      regions of the state;
             528          [(ii)] (iii) beginning July 1, 2016, a clinic's aggregate results for a physician who
             529      practices at a clinic with five or more physicians; and
             530          [(iii)] (iv) beginning July 1, 2016, a geographic region's aggregate results for a
             531      physician who practices at a clinic with less than five physicians, unless the physician requests
             532      physician-level data to be published on a clinic level.
             533          (c) The department:
             534          (i) may publish information required by this Subsection (6) directly or through one or
             535      more nonprofit, community-based health data organizations;
             536          (ii) may use a private, independent analyst under Subsection (3) in preparing the report
             537      required by this section; and
             538          (iii) shall identify and report to the Legislature's Health and Human Services Interim
             539      Committee by July 1, [2012] 2014, and every July 1[,] thereafter until July 1, [2015, at least
             540      five] 2019, at least three new measures of quality to be added to the report each year.
             541          (d) A report published by the department under this Subsection (6):
             542          (i) is subject to the requirements of Section 26-33a-107 ; and
             543          (ii) shall, prior to being published by the department, be submitted to a neutral,
             544      non-biased entity with a broad base of support from health care payers and health care
             545      providers in accordance with Subsection (7) for the purpose of validating the report.
             546          (7) (a) The Health Data Committee shall, through the department, for purposes of
             547      Subsection (6)(a), use the quality measures that are developed and agreed upon by a neutral,
             548      non-biased entity with a broad base of support from health care payers and health care
             549      providers.
             550          (b) If the entity described in Subsection (7)(a) does not submit the quality measures,
             551      the department may select the appropriate number of quality measures for purposes of the
             552      report required by Subsection (6).


             553          (c) (i) For purposes of the reports published on or after July 1, [2012] 2014, the
             554      department may not compare individual facilities or clinics as described in Subsections
             555      (6)(b)(i) through [(iii)] (iv) if the department determines that the data available to the
             556      department can not be appropriately validated, does not represent nationally recognized
             557      measures, does not reflect the mix of cases seen at a clinic or facility, or is not sufficient for the
             558      purposes of comparing providers.
             559          (ii) The department shall report to the Legislature's Executive Appropriations
             560      Committee prior to making a determination not to publish a report under Subsection (7)(c)(i).
             561          Section 7. Section 26-33a-109 is amended to read:
             562           26-33a-109. Exceptions to prohibition on disclosure of identifiable health data.
             563          (1) The committee may not disclose any identifiable health data unless:
             564          (a) the individual has authorized the disclosure; or
             565          (b) the disclosure complies with the provisions of:
             566          (i) this section[.];
             567          (ii) insurance enrollment and coordination of benefits under Subsection
             568      26-33a-104 (1)(b); or
             569          (iii) risk adjusting under Subsection 26-33a-106.1 (1)(c)(iii).
             570          (2) The committee shall consider the following when responding to a request for
             571      disclosure of information that may include identifiable health data:
             572          (a) whether the request comes from a person after that person has received approval to
             573      do the specific research and statistical work from an institutional review board; and
             574          (b) whether the requesting entity complies with the provisions of Subsection (3).
             575          (3) A request for disclosure of information that may include identifiable health data
             576      shall:
             577          (a) be for a specified period; or
             578          (b) be solely for bona fide research and statistical purposes as determined in
             579      accordance with administrative rules adopted by the department, which shall require:
             580          (i) the requesting entity to demonstrate to the department that the data is required for
             581      the research and statistical purposes proposed by the requesting entity; and
             582          (ii) the requesting entity to enter into a written agreement satisfactory to the department
             583      to protect the data in accordance with this chapter or other applicable law.


             584          (4) A person accessing identifiable health data pursuant to Subsection (3) may not
             585      further disclose the identifiable health data:
             586          (a) without prior approval of the department; and
             587          (b) unless the identifiable health data is disclosed or identified by control number only.
             588          Section 8. Section 31A-4-115 is amended to read:
             589           31A-4-115. Plan of orderly withdrawal.
             590          (1) (a) When an insurer intends to withdraw from writing a line of insurance in this
             591      state or to reduce its total annual premium volume by 75% or more, the insurer shall file with
             592      the commissioner a plan of orderly withdrawal.
             593          (b) For purposes of this section, a discontinuance of a health benefit plan pursuant to
             594      one of the following provisions is a withdrawal from a line of insurance:
             595          (i) Subsection 31A-30-107 (3)(e); or
             596          (ii) Subsection 31A-30-107.1 (3)(e).
             597          (2) An insurer's plan of orderly withdrawal shall:
             598          (a) indicate the date the insurer intends to begin and complete its withdrawal plan; and
             599          (b) include provisions for:
             600          (i) meeting the insurer's contractual obligations;
             601          (ii) providing services to its Utah policyholders and claimants;
             602          (iii) meeting any applicable statutory obligations; and
             603          (iv) (A) the payment of a withdrawal fee of $50,000 to the Utah Comprehensive Health
             604      Insurance Pool if:
             605          (I) the insurer is an accident and health insurer; and
             606          (II) the insurer's line of business is not assumed or placed with another insurer
             607      approved by the commissioner; or
             608          (B) the payment of a withdrawal fee of $50,000 to the department if:
             609          (I) the insurer is not an accident and health insurer; and
             610          (II) the insurer's line of business is not assumed or placed with another insurer
             611      approved by the commissioner.
             612          (3) The commissioner shall approve a plan of orderly withdrawal if the plan adequately
             613      demonstrates that the insurer will:
             614          (a) protect the interests of the people of the state;


             615          (b) meet the insurer's contractual obligations;
             616          (c) provide service to the insurer's Utah policyholders and claimants; and
             617          (d) meet any applicable statutory obligations.
             618          (4) Section 31A-2-302 governs the commissioner's approval or disapproval of a plan for
             619      orderly withdrawal.
             620          (5) The commissioner may require an insurer to increase the deposit maintained in
             621      accordance with Section 31A-4-105 or Section 31A-4-105.5 and place the deposit in trust in
             622      the name of the commissioner upon finding, after an adjudicative proceeding that:
             623          (a) there is reasonable cause to conclude that the interests of the people of the state are
             624      best served by such action; and
             625          (b) the insurer:
             626          (i) has filed a plan of orderly withdrawal; or
             627          (ii) intends to:
             628          (A) withdraw from writing a line of insurance in this state; or
             629          (B) reduce the insurer's total annual premium volume by 75% or more.
             630          (6) An insurer is subject to the civil penalties under Section 31A-2-308 , if the insurer:
             631          (a) withdraws from writing insurance in this state; or
             632          (b) reduces its total annual premium volume by 75% or more in any year without
             633      having submitted a plan or receiving the commissioner's approval.
             634          (7) An insurer that withdraws from writing all lines of insurance in this state may not
             635      resume writing insurance in this state for five years unless[: (a)] the commissioner finds that
             636      the prohibition should be waived because the waiver is:
             637          [(i)] (a) in the public interest to promote competition; or
             638          [(ii)] (b) to resolve inequity in the marketplace[; and].
             639          [(b) the insurer complies with Subsection 31A-30-108 (5), if applicable.]
             640          (8) The commissioner shall adopt rules necessary to implement this section.
             641          Section 9. Section 31A-8-402.3 is amended to read:
             642           31A-8-402.3. Discontinuance, nonrenewal, or changes to group health benefit
             643      plans.
             644          (1) Except as otherwise provided in this section, a group health benefit plan for a plan
             645      sponsor is renewable and continues in force:


             646          (a) with respect to all eligible employees and dependents; and
             647          (b) at the option of the plan sponsor.
             648          (2) A health benefit plan for a plan sponsor may be discontinued or nonrenewed[: (a)]
             649      for a network plan, if:
             650          [(i)] (a) there is no longer any enrollee under the group health plan who lives, resides,
             651      or works in:
             652          [(A)] (i) the service area of the insurer; or
             653          [(B)] (ii) the area for which the insurer is authorized to do business; [and] or
             654          [(ii) in the case of the small employer market, the insurer applies the same criteria the
             655      insurer would apply in denying enrollment in the plan under Subsection 31A-30-108 (7); or]
             656          (b) for coverage made available in the small or large employer market only through an
             657      association, if:
             658          (i) the employer's membership in the association ceases; and
             659          (ii) the coverage is terminated uniformly without regard to any health status-related
             660      factor relating to any covered individual.
             661          (3) A health benefit plan for a plan sponsor may be discontinued if:
             662          (a) a condition described in Subsection (2) exists;
             663          (b) the plan sponsor fails to pay premiums or contributions in accordance with the
             664      terms of the contract;
             665          (c) the plan sponsor:
             666          (i) performs an act or practice that constitutes fraud; or
             667          (ii) makes an intentional misrepresentation of material fact under the terms of the
             668      coverage;
             669          (d) the insurer:
             670          (i) elects to discontinue offering a particular health benefit product delivered or issued
             671      for delivery in this state; and
             672          (ii) (A) provides notice of the discontinuation in writing:
             673          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             674          (II) at least 90 days before the date the coverage will be discontinued;
             675          (B) provides notice of the discontinuation in writing:
             676          (I) to the commissioner; and


             677          (II) at least three working days prior to the date the notice is sent to the affected plan
             678      sponsors, employees, and dependents of the plan sponsors or employees;
             679          (C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase:
             680          (I) all other health benefit products currently being offered by the insurer in the market;
             681      or
             682          (II) in the case of a large employer, any other health benefit product currently being
             683      offered in that market; and
             684          (D) in exercising the option to discontinue that product and in offering the option of
             685      coverage in this section, acts uniformly without regard to:
             686          (I) the claims experience of a plan sponsor;
             687          (II) any health status-related factor relating to any covered participant or beneficiary; or
             688          (III) any health status-related factor relating to any new participant or beneficiary who
             689      may become eligible for the coverage; or
             690          (e) the insurer:
             691          (i) elects to discontinue all of the insurer's health benefit plans in:
             692          (A) the small employer market;
             693          (B) the large employer market; or
             694          (C) both the small employer and large employer markets; and
             695          (ii) (A) provides notice of the discontinuation in writing:
             696          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             697          (II) at least 180 days before the date the coverage will be discontinued;
             698          (B) provides notice of the discontinuation in writing:
             699          (I) to the commissioner in each state in which an affected insured individual is known
             700      to reside; and
             701          (II) at least 30 working days prior to the date the notice is sent to the affected plan
             702      sponsors, employees, and the dependents of the plan sponsors or employees;
             703          (C) discontinues and nonrenews all plans issued or delivered for issuance in the
             704      market; and
             705          (D) provides a plan of orderly withdrawal as required by Section 31A-4-115 .
             706          (4) A large employer health benefit plan may be discontinued or nonrenewed:
             707          (a) if a condition described in Subsection (2) exists; or


             708          (b) for noncompliance with the insurer's:
             709          (i) minimum participation requirements; or
             710          (ii) employer contribution requirements.
             711          (5) A small employer health benefit plan may be discontinued or nonrenewed:
             712          (a) if a condition described in Subsection (2) exists; or
             713          (b) for noncompliance with the insurer's employer contribution requirements.
             714          (6) A small employer health benefit plan may be nonrenewed:
             715          (a) if a condition described in Subsection (2) exists; or
             716          (b) for noncompliance with the insurer's minimum participation requirements.
             717          (7) (a) Except as provided in Subsection (7)(d), an eligible employee may be
             718      discontinued if after issuance of coverage the eligible employee:
             719          (i) engages in an act or practice in connection with the coverage that constitutes fraud;
             720      or
             721          (ii) makes an intentional misrepresentation of material fact in connection with the
             722      coverage.
             723          (b) An eligible employee that is discontinued under Subsection (7)(a) may reenroll:
             724          (i) 12 months after the date of discontinuance; and
             725          (ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies
             726      to reenroll.
             727          (c) At the time the eligible employee's coverage is discontinued under Subsection
             728      (7)(a), the insurer shall notify the eligible employee of the right to reenroll when coverage is
             729      discontinued.
             730          (d) An eligible employee may not be discontinued under this Subsection (7) because of
             731      a fraud or misrepresentation that relates to health status.
             732          (8) For purposes of this section, a reference to "plan sponsor" includes a reference to
             733      the employer:
             734          (a) with respect to coverage provided to an employer member of the association; and
             735          (b) if the health benefit plan is made available by an insurer in the employer market
             736      only through:
             737          (i) an association;
             738          (ii) a trust; or


             739          (iii) a discretionary group.
             740          (9) An insurer may modify a health benefit plan for a plan sponsor only:
             741          (a) at the time of coverage renewal; and
             742          (b) if the modification is effective uniformly among all plans with that product.
             743          Section 10. Section 31A-22-721 is amended to read:
             744           31A-22-721. A health benefit plan for a plan sponsor -- Discontinuance and
             745      nonrenewal.
             746          (1) Except as otherwise provided in this section, a health benefit plan for a plan
             747      sponsor is renewable and continues in force:
             748          (a) with respect to all eligible employees and dependents; and
             749          (b) at the option of the plan sponsor.
             750          (2) A health benefit plan for a plan sponsor may be discontinued or nonrenewed[: (a)]
             751      for a network plan, if:
             752          [(i)] (a) there is no longer any enrollee under the group health plan who lives, resides,
             753      or works in:
             754          [(A)] (i) the service area of the insurer; or
             755          [(B)] (ii) the area for which the insurer is authorized to do business; [and] or
             756          [(ii) in the case of the small employer market, the insurer applies the same criteria the
             757      insurer would apply in denying enrollment in the plan under Subsection 31A-30-108 (7); or]
             758          (b) for coverage made available in the small or large employer market only through an
             759      association, if:
             760          (i) the employer's membership in the association ceases; and
             761          (ii) the coverage is terminated uniformly without regard to any health status-related
             762      factor relating to any covered individual.
             763          (3) A health benefit plan for a plan sponsor may be discontinued if:
             764          (a) a condition described in Subsection (2) exists;
             765          (b) the plan sponsor fails to pay premiums or contributions in accordance with the
             766      terms of the contract;
             767          (c) the plan sponsor:
             768          (i) performs an act or practice that constitutes fraud; or
             769          (ii) makes an intentional misrepresentation of material fact under the terms of the


             770      coverage;
             771          (d) the insurer:
             772          (i) elects to discontinue offering a particular health benefit product delivered or issued
             773      for delivery in this state;
             774          (ii) (A) provides notice of the discontinuation in writing:
             775          (I) to each plan sponsor, employee, and dependent of a plan sponsor or employee; and
             776          (II) at least 90 days before the date the coverage will be discontinued;
             777          (B) provides notice of the discontinuation in writing:
             778          (I) to the commissioner; and
             779          (II) at least three working days prior to the date the notice is sent to the affected plan
             780      sponsors, employees, and dependents of plan sponsors or employees;
             781          (C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase any
             782      other health benefit products currently being offered:
             783          (I) by the insurer in the market; or
             784          (II) in the case of a large employer, any other health benefit plan currently being
             785      offered in that market; and
             786          (D) in exercising the option to discontinue that product and in offering the option of
             787      coverage in this section, the insurer acts uniformly without regard to:
             788          (I) the claims experience of a plan sponsor;
             789          (II) any health status-related factor relating to any covered participant or beneficiary; or
             790          (III) any health status-related factor relating to a new participant or beneficiary who
             791      may become eligible for coverage; or
             792          (e) the insurer:
             793          (i) elects to discontinue all of the insurer's health benefit plans:
             794          (A) in the small employer market; or
             795          (B) the large employer market; or
             796          (C) both the small and large employer markets; and
             797          (ii) (A) provides notice of the discontinuance in writing:
             798          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             799          (II) at least 180 days before the date the coverage will be discontinued;
             800          (B) provides notice of the discontinuation in writing:


             801          (I) to the commissioner in each state in which an affected insured individual is known
             802      to reside; and
             803          (II) at least 30 business days prior to the date the notice is sent to the affected plan
             804      sponsors, employees, and dependents of a plan sponsor or employee;
             805          (C) discontinues and nonrenews all plans issued or delivered for issuance in the
             806      market; and
             807          (D) provides a plan of orderly withdrawal as required by Section 31A-4-115 .
             808          (4) A large employer health benefit plan may be discontinued or nonrenewed:
             809          (a) if a condition described in Subsection (2) exists; or
             810          (b) for noncompliance with the insurer's:
             811          (i) minimum participation requirements; or
             812          (ii) employer contribution requirements.
             813          (5) A small employer health benefit plan may be discontinued or nonrenewed:
             814          (a) if a condition described in Subsection (2) exists; or
             815          (b) for noncompliance with the insurer's employer contribution requirements.
             816          (6) A small employer health benefit plan may be nonrenewed:
             817          (a) if a condition described in Subsection (2) exists; or
             818          (b) for noncompliance with the insurer's minimum participation requirements.
             819          (7) (a) Except as provided in Subsection (7)(d), an eligible employee may be
             820      discontinued if after issuance of coverage the eligible employee:
             821          (i) engages in an act or practice that constitutes fraud in connection with the coverage;
             822      or
             823          (ii) makes an intentional misrepresentation of material fact in connection with the
             824      coverage.
             825          (b) An eligible employee that is discontinued under Subsection (7)(a) may reenroll:
             826          (i) 12 months after the date of discontinuance; and
             827          (ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies
             828      to reenroll.
             829          (c) At the time the eligible employee's coverage is discontinued under Subsection
             830      (7)(a), the insurer shall notify the eligible employee of the right to reenroll when coverage is
             831      discontinued.


             832          (d) An eligible employee may not be discontinued under this Subsection (7) because of
             833      a fraud or misrepresentation that relates to health status.
             834          (8) (a) Except as provided in Subsection (8)(b), an insurer that elects to discontinue
             835      offering a health benefit plan under Subsection (3)(e) shall be prohibited from writing new
             836      business in such market in this state for a period of five years beginning on the date of
             837      discontinuation of the last coverage that is discontinued.
             838          (b) The commissioner may waive the prohibition under Subsection (8)(a) when the
             839      commissioner finds that waiver is in the public interest:
             840          (i) to promote competition; or
             841          (ii) to resolve inequity in the marketplace.
             842          (9) If an insurer is doing business in one established geographic service area of the
             843      state, this section applies only to the insurer's operations in that geographic service area.
             844          (10) An insurer may modify a health benefit plan for a plan sponsor only:
             845          (a) at the time of coverage renewal; and
             846          (b) if the modification is effective uniformly among all plans with a particular product
             847      or service.
             848          (11) For purposes of this section, a reference to "plan sponsor" includes a reference to
             849      the employer:
             850          (a) with respect to coverage provided to an employer member of the association; and
             851          (b) if the health benefit plan is made available by an insurer in the employer market
             852      only through:
             853          (i) an association;
             854          (ii) a trust; or
             855          (iii) a discretionary group.
             856          (12) (a) A small employer that, after purchasing a health benefit plan in the small group
             857      market, employs on average more than 50 eligible employees on each business day in a
             858      calendar year may continue to renew the health benefit plan purchased in the small group
             859      market.
             860          (b) A large employer that, after purchasing a health benefit plan in the large group
             861      market, employs on average less than 51 eligible employees on each business day in a calendar
             862      year may continue to renew the health benefit plan purchased in the large group market.


             863          (13) An insurer offering employer sponsored health benefit plans shall comply with the
             864      Health Insurance Portability and Accountability Act, 42 U.S.C. Sec. 300gg and 300gg-1.
             865          Section 11. Section 31A-23b-202.5 is enacted to read:
             866          31A-23b-202.5. License types.
             867          (1) A license issued under this chapter shall be issued under the license types described
             868      in Subsection (2).
             869          (2) A license type under this chapter shall be a navigator line of authority or a certified
             870      application counselor line of authority. A license type is intended to describe the matters to be
             871      considered under any education, examination, and training required of an applicant under this
             872      chapter.
             873          (3) (a) A navigator line of authority includes the enrollment process as described in
             874      Subsection 31A-23b-102 (4)(a).
             875          (b) (i) A certified application counselor line of authority is limited to providing
             876      information and assistance to individuals and employees about public programs and premium
             877      subsidies available through the exchange.
             878          (ii) A certified application counselor line of authority does not allow the certified
             879      application counselor to assist a person with the selection of or enrollment in a qualified health
             880      plan offered on an exchange.
             881          Section 12. Section 31A-23b-205 is amended to read:
             882           31A-23b-205. Examination and training requirements.
             883          (1) The commissioner may require [applicants] an applicant for a license to pass an
             884      examination and complete a training program as a requirement for a license.
             885          (2) The examination described in Subsection (1) shall reasonably relate to:
             886          (a) the duties and functions of a navigator;
             887          (b) requirements for navigators as established by federal regulation under PPACA; and
             888          (c) other requirements that may be established by the commissioner by administrative
             889      rule.
             890          (3) The examination may be administered by the commissioner or as otherwise
             891      specified by administrative rule.
             892          (4) The training required by Subsection (1) shall be approved by the commissioner and
             893      shall include:


             894          (a) accident and health insurance plans;
             895          (b) qualifications for and enrollment in public programs;
             896          (c) qualifications for and enrollment in premium subsidies;
             897          (d) cultural and linguistic competence;
             898          (e) conflict of interest standards;
             899          (f) exchange functions; and
             900          (g) other requirements that may be adopted by the commissioner by administrative
             901      rule.
             902          (5) (a) For the navigator line of authority, the training required by Subsection (1) shall
             903      consist of at least 21 credit hours of training before obtaining the license, which shall include at
             904      least two hours of training on:
             905          (i) defined contribution arrangements and the small employer health insurance
             906      exchange; and
             907          (ii) the navigator training and certification program developed by the Centers for
             908      Medicare and Medicaid Services.
             909          (b) For the certified application counselor line of authority, the training required by
             910      Subsection (1) shall consist of at least six hours of training before obtaining a license, which
             911      shall include at least one hour of training on:
             912          (i) defined contribution arrangements and the small employer health insurance
             913      exchange; and
             914          (ii) the certified application counselor training and certification program developed by
             915      the Centers for Medicare and Medicaid Services.
             916          [(5)] (6) This section applies only to [applicants who are natural persons] an applicant
             917      who is a natural person.
             918          Section 13. Section 31A-23b-206 is amended to read:
             919           31A-23b-206. Continuing education requirements.
             920          (1) The commissioner shall, by rule, prescribe continuing education requirements for a
             921      navigator.
             922          (2) (a) The commissioner may not require a degree from an institution of higher
             923      education as part of continuing education.
             924          (b) The commissioner may state a continuing education requirement in terms of hours


             925      of instruction received in:
             926          (i) accident and health insurance;
             927          (ii) qualification for and enrollment in public programs;
             928          (iii) qualification for and enrollment in premium subsidies;
             929          (iv) cultural competency;
             930          (v) conflict of interest standards; and
             931          (vi) other exchange functions.
             932          (3) (a) [Continuing] For a navigator line of authority, continuing education
             933      requirements shall require:
             934          (i) that a licensee complete [24] 12 credit hours of continuing education for every
             935      [two-year] one-year licensing period;
             936          (ii) that [3] at least two of the [24] 12 credit hours described in Subsection (3)(a)(i) be
             937      ethics courses; [and]
             938          [(iii) that the licensee complete at least half of the required hours through classroom
             939      hours of insurance and exchange related instruction.]
             940          (iii) that at least one of the 12 credit hours described in Subsection (3)(a)(i) be training
             941      on defined contribution arrangements and the use of the small employer health insurance
             942      exchange; and
             943          (iv) that a licensee complete the annual navigator training and certification program
             944      developed by the Centers for Medicare and Medicaid Services.
             945          (b) For a certified application counselor, the continuing education requirements shall
             946      require:
             947          (i) that a licensee complete six credit hours of continuing education for every one-year
             948      licensing period;
             949          (ii) that at least two of the six credit hours described in Subsection (3)(b)(i) be on
             950      ethics courses;
             951          (iii) that at least one of the six credit hours described in Subsection (3)(b)(i) be training
             952      on defined contribution arrangements and the use of the small employer health insurance
             953      exchange; and
             954          (iv) that a licensee complete the annual certified application counselor training and
             955      certification program developed by the Centers for Medicare and Medicaid Services.


             956          [(b)] (c) An hour of continuing education in accordance with [Subsection] Subsections
             957      (3)(a)(i) and (b)(i) may be obtained through:
             958          (i) classroom attendance;
             959          (ii) home study;
             960          (iii) watching a video recording; or
             961          [(iv) experience credit; or]
             962          [(v)] (iv) another method approved by rule.
             963          [(c)] (d) A licensee may obtain continuing education hours at any time during the
             964      [two-year] one-year license period.
             965          [(d)] (e) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking
             966      Act, the commissioner shall, by rule[: (i) publish a list of insurance professional designations
             967      whose continuing education requirements can be used to meet the requirements for continuing
             968      education under Subsection (3)(b); and (ii)], authorize one or more continuing education
             969      providers, including a state or national professional producer or consultant associations, to:
             970          [(A)] (i) offer a qualified program on a geographically accessible basis; and
             971          [(B)] (ii) collect a reasonable fee for funding and administration of a continuing
             972      education program, subject to the review and approval of the commissioner.
             973          (4) The commissioner shall approve a continuing education provider or a continuing
             974      education course that satisfies the requirements of this section.
             975          (5) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the
             976      commissioner shall by rule establish the procedures for continuing education provider
             977      registration and course approval.
             978          (6) This section applies only to a navigator who is a natural person.
             979          (7) A navigator shall keep documentation of completing the continuing education
             980      requirements of this section for two years after the end of the two-year licensing period to
             981      which the continuing education applies.
             982          Section 14. Section 31A-23b-211 is amended to read:
             983           31A-23b-211. Exceptions to navigator licensing.
             984          (1) For purposes of this section:
             985          (a) "Negotiate" is as defined in Section 31A-23a-102 .
             986          (b) "Sell" is as defined in Section 31A-23a-102 .


             987          (c) "Solicit" is as defined in Section 31A-23a-102 .
             988          (2) The commissioner may not require a license as a navigator of:
             989          (a) a person who is employed by or contracts with:
             990          (i) a health care facility that is licensed under Title 26, Chapter 21, Health Care Facility
             991      Licensing and Inspection Act, to assist an individual with enrollment in a public program or an
             992      application for premium subsidy; or
             993          (ii) the state, a political subdivision of the state, an entity of a political subdivision of
             994      the state, or a public school district to assist an individual with enrollment in a public program
             995      or an application for premium subsidy;
             996          (b) a federally qualified health center as defined by Section 1905(1)(2)(B) of the Social
             997      Security Act which assists an individual with enrollment in a public program or an application
             998      for premium subsidy;
             999          (c) a person licensed under Chapter 23a, Insurance Marketing-Licensing, Consultants,
             1000      and Reinsurance Intermediaries, if the person is licensed in the appropriate line of authority to
             1001      sell, solicit, or negotiate accident and health insurance plans;
             1002          (d) an officer, director, or employee of a navigator:
             1003          (i) who does not receive compensation or commission from an insurer issuing an
             1004      insurance contract, an agency administering a public program, an individual who enrolled in a
             1005      public program or insurance product, or an exchange; and
             1006          (ii) whose activities:
             1007          (A) are executive, administrative, managerial, clerical, or a combination thereof;
             1008          (B) only indirectly relate to the sale, solicitation, or negotiation of insurance, or the
             1009      enrollment in a public program offered through the exchange;
             1010          (C) are in the capacity of a special agent or agency supervisor assisting an insurance
             1011      producer or navigator;
             1012          (D) are limited to providing technical advice and assistance to a licensed insurance
             1013      producer or navigator; or
             1014          (E) do not include the sale, solicitation, or negotiation of insurance, or the enrollment
             1015      in a public program; [and]
             1016          (e) a person who does not sell, solicit, or negotiate insurance and is not directly or
             1017      indirectly compensated by an insurer issuing an insurance contract, an agency administering a


             1018      public program, an individual who enrolled in a public program or insurance product, or an
             1019      exchange, including:
             1020          (i) an employer, association, officer, director, employee, or trustee of an employee trust
             1021      plan who is engaged in the administration or operation of a program:
             1022          (A) of employee benefits for the employer's or association's own employees or the
             1023      employees of a subsidiary or affiliate of an employer or association; and
             1024          (B) that involves the use of insurance issued by an insurer or enrollment in a public
             1025      health plan on an exchange;
             1026          (ii) an employee of an insurer or organization employed by an insurer who is engaging
             1027      in the inspection, rating, or classification of risk, or the supervision of training of insurance
             1028      producers; or
             1029          (iii) an employee who counsels or advises the employee's employer with regard to the
             1030      insurance interests of the employer, or a subsidiary or business affiliate of the employer[.]; and
             1031          (f) an Indian health clinic or Urban Indian Health Center, as defined in Title V of the
             1032      Indian Health Care Improvement Act, which assists a person with enrollment in a public
             1033      program or an application for a premium subsidy.
             1034          (3) The exemption from licensure under Subsections (2)(a) [and], (b), and (f) does not
             1035      apply if a person described in Subsections (2)(a) [and], (b), and (f) enrolls a person in a private
             1036      insurance plan.
             1037          (4) The commissioner may by rule exempt a class of persons from the license
             1038      requirement of Subsection 31A-23b-201 (1) if:
             1039          (a) the functions performed by the class of persons do not require:
             1040          (i) special competence;
             1041          (ii) special trustworthiness; or
             1042          (iii) regulatory surveillance made possible by licensing; or
             1043          (b) other existing safeguards make regulation unnecessary.
             1044          Section 15. Section 31A-29-106 is amended to read:
             1045           31A-29-106. Powers of board.
             1046          (1) The board shall have the general powers and authority granted under the laws of
             1047      this state to insurance companies licensed to transact health care insurance business. In
             1048      addition, the board shall [have the specific authority to]:


             1049          (a) have the specific authority to enter into contracts to carry out the provisions and
             1050      purposes of this chapter, including, with the approval of the commissioner, contracts with:
             1051          (i) similar pools of other states for the joint performance of common administrative
             1052      functions; or
             1053          (ii) persons or other organizations for the performance of administrative functions;
             1054          (b) sue or be sued, including taking such legal action necessary to avoid the payment of
             1055      improper claims against the pool or the coverage provided through the pool;
             1056          (c) establish appropriate rates, rate schedules, rate adjustments, expense allowances,
             1057      agents' referral fees, claim reserve formulas, and any other actuarial function appropriate to the
             1058      operation of the pool;
             1059          [(d) issue policies of insurance in accordance with the requirements of this chapter;]
             1060          (d) (i) close enrollment in the plans issued by the pool and cancel the plans issued by
             1061      the pool in accordance with the plan of operation approved by the commissioner; and
             1062          (ii) close out the business of the pool in accordance with the plan of operation,
             1063      including processing and paying valid claims incurred by enrollees prior to the date enrollment
             1064      is closed under Subsection (1)(d)(i);
             1065          (e) retain an executive director and appropriate legal, actuarial, and other personnel as
             1066      necessary to provide technical assistance in the operations of the pool and to close pool
             1067      business in accordance with Subsection (1)(d);
             1068          (f) establish rules, conditions, and procedures for reinsuring risks under this chapter;
             1069          (g) cause the pool to have an annual and a final audit of its operations by the state
             1070      auditor;
             1071          [(h) coordinate with the Department of Health in seeking to obtain from the Centers for
             1072      Medicare and Medicaid Services, or other appropriate office or agency of government, all
             1073      appropriate waivers, authority, and permission needed to coordinate the coverage available
             1074      from the pool with coverage available under Medicaid, either before or after Medicaid
             1075      coverage, or as a conversion option upon completion of Medicaid eligibility, without the
             1076      necessity for requalification by the enrollee;]
             1077          [(i)] (h) provide for and employ cost containment measures and requirements including
             1078      preadmission certification, concurrent inpatient review, and individual case management for
             1079      the purpose of making the pool more cost-effective;


             1080          [(j) offer pool coverage through contracts with health maintenance organizations,
             1081      preferred provider organizations, and other managed care systems that will manage costs while
             1082      maintaining quality care;]
             1083          [(k)] (i) establish annual limits on benefits payable under the pool to or on behalf of
             1084      any enrollee;
             1085          [(l)] (j) exclude from coverage under the pool specific benefits, medical conditions,
             1086      and procedures for the purpose of protecting the financial viability of the pool;
             1087          [(m)] (k) administer the Pool Fund;
             1088          [(n)] (l) make rules in accordance with Title 63G, Chapter 3, Utah Administrative
             1089      Rulemaking Act, to implement this chapter;
             1090          [(o)] (m) adopt, trademark, and copyright a trade name for the pool for use in
             1091      marketing and publicizing the pool and its products; and
             1092          [(p)] (n) transition health care coverage for all individuals covered under the pool as
             1093      part of the conversion to health insurance coverage, regardless of preexisting conditions, under
             1094      PPACA.
             1095          (2) (a) The board shall prepare and submit an annual and final report to the Legislature
             1096      which shall include:
             1097          (i) the net premiums anticipated;
             1098          (ii) actuarial projections of payments required of the pool;
             1099          (iii) the expenses of administration; and
             1100          (iv) the anticipated reserves or losses of the pool.
             1101          (b) The budget for operation of the pool is subject to the approval of the board.
             1102          (c) The administrative budget of the board and the commissioner under this chapter
             1103      shall comply with the requirements of Title 63J, Chapter 1, Budgetary Procedures Act, and is
             1104      subject to review and approval by the Legislature.
             1105          [(3) (a) The board shall on or before September 1, 2004, require the plan administrator
             1106      or an independent actuarial consultant retained by the plan administrator to redetermine the
             1107      reasonable equivalent of the criteria for uninsurability required under Subsection
             1108      31A-30-106 (1)(h) that is used by the board to determine eligibility for coverage in the pool.]
             1109          [(b) The board shall redetermine the criteria established in Subsection (3)(a) at least
             1110      every five years thereafter.]


             1111          Section 16. Section 31A-29-110 is amended to read:
             1112           31A-29-110. Pool administrator -- Selection -- Powers.
             1113          (1) The board shall select a pool administrator in accordance with Title 63G, Chapter
             1114      6a, Utah Procurement Code. The board shall evaluate bids based on criteria established by the
             1115      board, which shall include:
             1116          (a) ability to manage medical expenses;
             1117          (b) proven ability to handle accident and health insurance;
             1118          (c) efficiency of claim paying procedures;
             1119          (d) marketing and underwriting;
             1120          (e) proven ability for managed care and quality assurance;
             1121          (f) provider contracting and discounts;
             1122          (g) pharmacy benefit management;
             1123          (h) an estimate of total charges for administering the pool; and
             1124          (i) ability to administer the pool in a cost-efficient manner.
             1125          (2) A pool administrator may be:
             1126          (a) a health insurer;
             1127          (b) a health maintenance organization;
             1128          (c) a third-party administrator; or
             1129          (d) any person or entity which has demonstrated ability to meet the criteria in
             1130      Subsection (1).
             1131          (3) [(a)] The pool administrator shall serve for a period of three years, with [two
             1132      one-year] yearly extension options until the operations of the pool are closed pursuant to
             1133      Subsection 31A-29-106 (1)(d), subject to the terms, conditions, and limitations of the contract
             1134      between the board and the administrator.
             1135          [(b) At least one year prior to the expiration of the contract between the board and the
             1136      pool administrator, the board shall invite all interested parties, including the current pool
             1137      administrator, to submit bids to serve as the pool administrator].
             1138          [(c) Selection of the pool administrator for a succeeding period shall be made at least
             1139      six months prior to the expiration of the period of service under Subsection (3)(a).]
             1140          (4) The pool administrator is responsible for all operational functions of the pool and
             1141      shall:


             1142          (a) have access to all nonpatient specific experience data, statistics, treatment criteria,
             1143      and guidelines compiled or adopted by the Medicaid program, the Public Employees Health
             1144      Plan, the Department of Health, or the Insurance Department, and which are not otherwise
             1145      declared by statute to be confidential;
             1146          (b) perform all marketing, eligibility, enrollment, member agreements, and
             1147      administrative claim payment functions relating to the pool;
             1148          (c) establish, administer, and operate a monthly premium billing procedure for
             1149      collection of premiums from enrollees;
             1150          (d) perform all necessary functions to assure timely payment of benefits to enrollees,
             1151      including:
             1152          (i) making information available relating to the proper manner of submitting a claim
             1153      for benefits to the pool administrator and distributing forms upon which submission shall be
             1154      made; and
             1155          (ii) evaluating the eligibility of each claim for payment by the pool;
             1156          (e) submit regular reports to the board regarding the operation of the pool, the
             1157      frequency, content, and form of which reports shall be determined by the board;
             1158          (f) following the close of each calendar year, determine net written and earned
             1159      premiums, the expense of administration, and the paid and incurred losses for the year and
             1160      submit a report of this information to the board, the commissioner, and the Division of Finance
             1161      on a form prescribed by the commissioner; and
             1162          (g) be paid as provided in the plan of operation for expenses incurred in the
             1163      performance of the pool administrator's services.
             1164          Section 17. Section 31A-29-111 is amended to read:
             1165           31A-29-111. Eligibility -- Limitations.
             1166          (1) (a) Except as provided in Subsection (1)(b) and Subsection 31A-29-106 (1)(d), an
             1167      individual who is not HIPAA eligible is eligible for pool coverage if the individual:
             1168          (i) pays the established premium;
             1169          (ii) is a resident of this state; and
             1170          (iii) meets the health underwriting criteria under Subsection (5)(a).
             1171          (b) Notwithstanding Subsection (1)(a), an individual who is not HIPAA eligible is not
             1172      eligible for pool coverage if one or more of the following conditions apply:


             1173          (i) the individual is eligible for health care benefits under Medicaid or Medicare,
             1174      except as provided in Section 31A-29-112 ;
             1175          (ii) the individual has terminated coverage in the pool, unless:
             1176          (A) 12 months have elapsed since the termination date; or
             1177          (B) the individual demonstrates that creditable coverage has been involuntarily
             1178      terminated for any reason other than nonpayment of premium;
             1179          (iii) the pool has paid the maximum lifetime benefit to or on behalf of the individual;
             1180          (iv) the individual is an inmate of a public institution;
             1181          (v) the individual is eligible for a public health plan, as defined in federal regulations
             1182      adopted pursuant to 42 U.S.C. 300gg;
             1183          (vi) the individual's health condition does not meet the criteria established under
             1184      Subsection (5);
             1185          (vii) the individual is eligible for coverage under an employer group that offers a health
             1186      benefit plan or a self-insurance arrangement to its eligible employees, dependents, or members
             1187      as:
             1188          (A) an eligible employee;
             1189          (B) a dependent of an eligible employee; or
             1190          (C) a member;
             1191          (viii) the individual is covered under any other health benefit plan;
             1192          (ix) except as provided in Subsections (3) and (6), at the time of application, the
             1193      individual has not resided in Utah for at least 12 consecutive months preceding the date of
             1194      application; or
             1195          (x) the individual's employer pays any part of the individual's health benefit plan
             1196      premium, either as an insured or a dependent, for pool coverage.
             1197          (2) (a) Except as provided in Subsection (2)(b) and Subsection 31A-29-106 (1)(d), an
             1198      individual who is HIPAA eligible is eligible for pool coverage if the individual:
             1199          (i) pays the established premium; and
             1200          (ii) is a resident of this state.
             1201          (b) Notwithstanding Subsection (2)(a), a HIPAA eligible individual is not eligible for
             1202      pool coverage if one or more of the following conditions apply:
             1203          (i) the individual is eligible for health care benefits under Medicaid or Medicare,


             1204      except as provided in Section 31A-29-112 ;
             1205          (ii) the individual is eligible for a public health plan, as defined in federal regulations
             1206      adopted pursuant to 42 U.S.C. 300gg;
             1207          (iii) the individual is covered under any other health benefit plan;
             1208          (iv) the individual is eligible for coverage under an employer group that offers a health
             1209      benefit plan or self-insurance arrangements to its eligible employees, dependents, or members
             1210      as:
             1211          (A) an eligible employee;
             1212          (B) a dependent of an eligible employee; or
             1213          (C) a member;
             1214          (v) the pool has paid the maximum lifetime benefit to or on behalf of the individual;
             1215          (vi) the individual is an inmate of a public institution; or
             1216          (vii) the individual's employer pays any part of the individual's health benefit plan
             1217      premium, either as an insured or a dependent, for pool coverage.
             1218          (3) (a) Notwithstanding Subsection (1)(b)(ix), if otherwise eligible under Subsection
             1219      (1)(a), an individual whose health care insurance coverage from a state high risk pool with
             1220      similar coverage is terminated because of nonresidency in another state is eligible for coverage
             1221      under the pool subject to the conditions of Subsections (1)(b)(i) through (viii).
             1222          (b) Coverage under Subsection (3)(a) shall be applied for within 63 days after the
             1223      termination date of the previous high risk pool coverage.
             1224          (c) The effective date of this state's pool coverage shall be the date of termination of
             1225      the previous high risk pool coverage.
             1226          (d) The waiting period of an individual with a preexisting condition applying for
             1227      coverage under this chapter shall be waived:
             1228          (i) to the extent to which the waiting period was satisfied under a similar plan from
             1229      another state; and
             1230          (ii) if the other state's benefit limitation was not reached.
             1231          (4) (a) If an eligible individual applies for pool coverage within 30 days of being
             1232      denied coverage by an individual carrier, the effective date for pool coverage shall be no later
             1233      than the first day of the month following the date of submission of the completed insurance
             1234      application to the carrier.


             1235          (b) Notwithstanding Subsection (4)(a), for individuals eligible for coverage under
             1236      Subsection (3), the effective date shall be the date of termination of the previous high risk pool
             1237      coverage.
             1238          (5) (a) The board shall establish and adjust, as necessary, health underwriting criteria
             1239      based on:
             1240          (i) health condition; and
             1241          (ii) expected claims so that the expected claims are anticipated to remain within
             1242      available funding.
             1243          (b) The board, with approval of the commissioner, may contract with one or more
             1244      providers under Title 63G, Chapter 6a, Utah Procurement Code, to develop underwriting
             1245      criteria under Subsection (5)(a).
             1246          (c) If an individual is denied coverage by the pool under the criteria established in
             1247      Subsection (5)(a), the pool shall issue a certificate of insurability to the individual for coverage
             1248      under [Subsection] Section 31A-30-108 [(3)].
             1249          (6) (a) Notwithstanding Subsection (1)(b)(ix), if otherwise eligible under Subsection
             1250      (1)(a), an individual whose individual health care insurance coverage was involuntarily
             1251      terminated, is eligible for coverage under the pool subject to the conditions of Subsections
             1252      (1)(b)(i) through (viii) and (x).
             1253          (b) Coverage under Subsection (6)(a) shall be applied for within 63 days after the
             1254      termination date of the previous individual health care insurance coverage.
             1255          (c) The effective date of this state's pool coverage shall be the date of termination of
             1256      the previous individual coverage.
             1257          (d) The waiting period of an individual with a preexisting condition applying for
             1258      coverage under this chapter shall be waived to the extent to which the waiting period was
             1259      satisfied under the individual health insurance plan.
             1260          Section 18. Section 31A-29-113 is amended to read:
             1261           31A-29-113. Benefits -- Additional types of pool insurance -- Preexisting
             1262      conditions -- Waiver -- Maximum benefits.
             1263          (1) (a) The pool policy shall pay for eligible medical expenses rendered or furnished
             1264      for the diagnoses or treatment of illness or injury that:
             1265          (i) exceed the deductible and copayment amounts applicable under Section


             1266      31A-29-114 ; and
             1267          (ii) are not otherwise limited or excluded.
             1268          (b) Eligible medical expenses are the allowed charges established by the board for the
             1269      health care services and items rendered during times for which benefits are extended under the
             1270      pool policy.
             1271          (c) Section 31A-21-313 applies to coverage issued under this chapter.
             1272          (2) The coverage to be issued by the pool, its schedule of benefits, exclusions, and
             1273      other limitations shall be established by the board.
             1274          (3) The commissioner shall approve the benefit package developed by the board to
             1275      ensure its compliance with this chapter.
             1276          [(4) The pool shall offer at least one benefit plan through a managed care program as
             1277      authorized under Section 31A-29-106 .]
             1278          [(5)] (4) This chapter may not be construed to prohibit the pool from issuing additional
             1279      types of pool policies with different types of benefits which in the opinion of the board may be
             1280      of benefit to the citizens of Utah.
             1281          [(6)] (5) (a) The board shall design and require an administrator to employ cost
             1282      containment measures and requirements including preadmission certification and concurrent
             1283      inpatient review for the purpose of making the pool more cost effective.
             1284          (b) Sections 31A-22-617 and 31A-22-618 do not apply to coverage issued under this
             1285      chapter.
             1286          [(7)] (6) (a) A pool policy may contain provisions under which coverage for a
             1287      preexisting condition is excluded if:
             1288          (i) the exclusion relates to a condition, regardless of the cause of the condition, for
             1289      which medical advice, diagnosis, care, or treatment was recommended or received, from an
             1290      individual licensed or similarly authorized to provide such services under state law and
             1291      operating within the scope of practice authorized by state law, within the six-month period
             1292      ending on the effective date of plan coverage; and
             1293          (ii) except as provided in Subsection (8), the exclusion extends for a period no longer
             1294      than the six-month period following the effective date of plan coverage for a given individual.
             1295          (b) Subsection [(7)] (6)(a) does not apply to a HIPAA eligible individual.
             1296          [(8)] (7) (a) A pool policy may contain provisions under which coverage for a


             1297      preexisting pregnancy is excluded during a ten-month period following the effective date of
             1298      plan coverage for a given individual.
             1299          (b) Subsection [(8)] (7)(a) does not apply to a HIPAA eligible individual.
             1300          [(9)] (8) (a) The pool will waive the preexisting condition exclusion described in
             1301      Subsections [(7)] (6)(a) and [(8)] (7)(a) for an individual that is changing health coverage to the
             1302      pool, to the extent to which similar exclusions have been satisfied under any prior health
             1303      insurance coverage if the individual applies not later than 63 days following the date of
             1304      involuntary termination, other than for nonpayment of premiums, from health coverage.
             1305          (b) If this Subsection [(9)] (8) applies, coverage in the pool shall be effective from the
             1306      date on which the prior coverage was terminated.
             1307          [(10)] (9) Covered benefits available from the pool may not exceed a $1,800,000
             1308      lifetime maximum, which includes a per enrollee calendar year maximum established by the
             1309      board.
             1310          Section 19. Section 31A-29-114 is amended to read:
             1311           31A-29-114. Deductibles -- Copayments.
             1312          (1) (a) A pool policy shall impose a deductible on a per calendar year basis.
             1313          (b) At least two deductible plans shall be offered.
             1314          (c) The deductible is applied to all of the eligible medical expenses [as defined in
             1315      Section 31A-29-113 ,] incurred by the enrollee until the deductible has been satisfied. There
             1316      are no benefits payable before the deductible has been satisfied.
             1317          (d) The pool may offer separate deductibles for prescription benefits.
             1318          (2) (a) A mandatory coinsurance requirement shall be imposed at the rate of at least
             1319      20%, except for a qualified high deductible health plan, of eligible medical expenses in excess
             1320      of the mandatory deductible.
             1321          (b) Any coinsurance imposed under this Subsection (2) shall be designated in the pool
             1322      policy.
             1323          (3) The board shall establish maximum aggregate out-of-pocket payments for eligible
             1324      medical expenses incurred by the enrollee for each of the deductible plans offered under
             1325      Subsection (1)(b).
             1326          (4) (a) When the enrollee has incurred the maximum aggregate out-of-pocket payments
             1327      under Subsection (3), the board may establish a coinsurance requirement to be imposed on


             1328      eligible medical expenses in excess of the maximum aggregate out-of-pocket expense.
             1329          (b) The circumstances in which the coinsurance authorized by this Subsection (4) may
             1330      be imposed shall be designated in the pool policy.
             1331          (c) The coinsurance authorized by this Subsection (4) may be imposed at a rate not to
             1332      exceed 5% of eligible medical expenses.
             1333          (5) The limits on maximum aggregate out-of-pocket payments for eligible medical
             1334      expenses incurred by the enrollee under this section may not include out-of-pocket payments
             1335      for prescription benefits.
             1336          Section 20. Section 31A-29-115 is amended to read:
             1337           31A-29-115. Cancellation -- Notice.
             1338          (1) [(a)] On the date of renewal, the pool may cancel an enrollee's policy if:
             1339          [(i)] (a) the enrollee's health condition does not meet the criteria established in
             1340      Subsection 31A-29-111 (5); and
             1341          [(ii)] (b) the pool has provided written notice to the enrollee's last-known address no
             1342      less than 60 days before cancellation[; and].
             1343          [(iii) at least one individual carrier has not reached the individual enrollment cap
             1344      established in Section 31A-30-110 .]
             1345          [(b) The pool shall issue a certificate of insurability to an enrollee whose policy is
             1346      cancelled under Subsection (1)(a) for coverage under Subsection 31A-30-108 (3) if the
             1347      requirements of Subsection 31A-29-111 (5) are met.]
             1348          (2) The pool may cancel an enrollee's policy at any time if:
             1349          (a) the pool has provided written notice to the enrollee's last-known address no less
             1350      than 15 days before cancellation; and
             1351          (b) (i) the enrollee establishes a residency outside of Utah for three consecutive
             1352      months;
             1353          (ii) there is nonpayment of premiums; or
             1354          (iii) the pool determines that the enrollee does not meet the eligibility requirements set
             1355      forth in Section 31A-29-111 , in which case:
             1356          (A) the policy may be retroactively terminated for the period of time in which the
             1357      enrollee was not eligible;
             1358          (B) retroactive termination may not exceed three years; and


             1359          (C) the board's remedy under this Subsection (2)(b) shall be a cause of action against
             1360      the enrollee for benefits paid during the period of ineligibility in accordance with Subsection
             1361      31A-29-119 (3).
             1362          Section 21. Section 31A-30-103 is amended to read:
             1363           31A-30-103. Definitions.
             1364          As used in this chapter:
             1365          (1) "Actuarial certification" means a written statement by a member of the American
             1366      Academy of Actuaries or other individual approved by the commissioner that a covered carrier
             1367      is in compliance with Sections 31A-30-106 and 31A-30-106.1 , based upon the examination of
             1368      the covered carrier, including review of the appropriate records and of the actuarial
             1369      assumptions and methods used by the covered carrier in establishing premium rates for
             1370      applicable health benefit plans.
             1371          (2) "Affiliate" or "affiliated" means any entity or person who directly or indirectly
             1372      through one or more intermediaries, controls or is controlled by, or is under common control
             1373      with, a specified entity or person.
             1374          (3) "Base premium rate" means, for each class of business as to a rating period, the
             1375      lowest premium rate charged or that could have been charged under a rating system for that
             1376      class of business by the covered carrier to covered insureds with similar case characteristics for
             1377      health benefit plans with the same or similar coverage.
             1378          (4) (a) "Bona fide employer association" means an association of employers:
             1379          (i) that meets the requirements of Subsection 31A-22-701 (2)(b);
             1380          (ii) in which the employers of the association, either directly or indirectly, exercise
             1381      control over the plan;
             1382          (iii) that is organized:
             1383          (A) based on a commonality of interest between the employers and their employees
             1384      that participate in the plan by some common economic or representation interest or genuine
             1385      organizational relationship unrelated to the provision of benefits; and
             1386          (B) to act in the best interests of its employers to provide benefits for the employer's
             1387      employees and their spouses and dependents, and other benefits relating to employment; and
             1388          (iv) whose association sponsored health plan complies with 45 C.F.R. 146.121.
             1389          (b) The commissioner shall consider the following with regard to determining whether


             1390      an association of employers is a bona fide employer association under Subsection (4)(a):
             1391          (i) how association members are solicited;
             1392          (ii) who participates in the association;
             1393          (iii) the process by which the association was formed;
             1394          (iv) the purposes for which the association was formed, and what, if any, were the
             1395      pre-existing relationships of its members;
             1396          (v) the powers, rights and privileges of employer members; and
             1397          (vi) who actually controls and directs the activities and operations of the benefit
             1398      programs.
             1399          (5) "Carrier" means any person or entity that provides health insurance in this state
             1400      including:
             1401          (a) an insurance company;
             1402          (b) a prepaid hospital or medical care plan;
             1403          (c) a health maintenance organization;
             1404          (d) a multiple employer welfare arrangement; and
             1405          (e) any other person or entity providing a health insurance plan under this title.
             1406          (6) (a) Except as provided in Subsection (6)(b), "case characteristics" means
             1407      demographic or other objective characteristics of a covered insured that are considered by the
             1408      carrier in determining premium rates for the covered insured.
             1409          (b) "Case characteristics" do not include:
             1410          (i) duration of coverage since the policy was issued;
             1411          (ii) claim experience; and
             1412          (iii) health status.
             1413          (7) "Class of business" means all or a separate grouping of covered insureds that is
             1414      permitted by the commissioner in accordance with Section 31A-30-105 .
             1415          (8) "Conversion policy" means a policy providing coverage under the conversion
             1416      provisions required in Chapter 22, Part 7, Group Accident and Health Insurance.
             1417          (9) "Covered carrier" means any individual carrier or small employer carrier subject to
             1418      this chapter.
             1419          (10) "Covered individual" means any individual who is covered under a health benefit
             1420      plan subject to this chapter.


             1421          (11) "Covered insureds" means small employers and individuals who are issued a
             1422      health benefit plan that is subject to this chapter.
             1423          (12) "Dependent" means an individual to the extent that the individual is defined to be
             1424      a dependent by:
             1425          (a) the health benefit plan covering the covered individual; and
             1426          (b) Chapter 22, Part 6, Accident and Health Insurance.
             1427          (13) "Established geographic service area" means a geographical area approved by the
             1428      commissioner within which the carrier is authorized to provide coverage.
             1429          (14) "Index rate" means, for each class of business as to a rating period for covered
             1430      insureds with similar case characteristics, the arithmetic average of the applicable base
             1431      premium rate and the corresponding highest premium rate.
             1432          (15) "Individual carrier" means a carrier that provides coverage on an individual basis
             1433      through a health benefit plan regardless of whether:
             1434          (a) coverage is offered through:
             1435          (i) an association;
             1436          (ii) a trust;
             1437          (iii) a discretionary group; or
             1438          (iv) other similar groups; or
             1439          (b) the policy or contract is situated out-of-state.
             1440          (16) "Individual conversion policy" means a conversion policy issued to:
             1441          (a) an individual; or
             1442          (b) an individual with a family.
             1443          (17) "Individual coverage count" means the number of natural persons covered under a
             1444      carrier's health benefit products that are individual policies.
             1445          (18) "Individual enrollment cap" means the percentage set by the commissioner in
             1446      accordance with Section 31A-30-110 .
             1447          (19) "New business premium rate" means, for each class of business as to a rating
             1448      period, the lowest premium rate charged or offered, or that could have been charged or offered,
             1449      by the carrier to covered insureds with similar case characteristics for newly issued health
             1450      benefit plans with the same or similar coverage.
             1451          (20) "Premium" means money paid by covered insureds and covered individuals as a


             1452      condition of receiving coverage from a covered carrier, including any fees or other
             1453      contributions associated with the health benefit plan.
             1454          (21) (a) "Rating period" means the calendar period for which premium rates
             1455      established by a covered carrier are assumed to be in effect, as determined by the carrier.
             1456          (b) A covered carrier may not have:
             1457          (i) more than one rating period in any calendar month; and
             1458          (ii) no more than 12 rating periods in any calendar year.
             1459          (22) "Resident" means an individual who has resided in this state for at least 12
             1460      consecutive months immediately preceding the date of application.
             1461          (23) "Short-term limited duration insurance" means a health benefit product that:
             1462          (a) is not renewable; and
             1463          (b) has an expiration date specified in the contract that is less than 364 days after the
             1464      date the plan became effective.
             1465          (24) "Small employer carrier" means a carrier that provides health benefit plans
             1466      covering eligible employees of one or more small employers in this state, regardless of
             1467      whether:
             1468          (a) coverage is offered through:
             1469          (i) an association;
             1470          (ii) a trust;
             1471          (iii) a discretionary group; or
             1472          (iv) other similar grouping; or
             1473          (b) the policy or contract is situated out-of-state.
             1474          [(25) "Uninsurable" means an individual who:]
             1475          [(a) is eligible for the Comprehensive Health Insurance Pool coverage under the
             1476      underwriting criteria established in Subsection 31A-29-111 (5); or]
             1477          [(b) (i) is issued a certificate for coverage under Subsection 31A-30-108 (3); and]
             1478          [(ii) has a condition of health that does not meet consistently applied underwriting
             1479      criteria as established by the commissioner in accordance with Subsections 31A-30-106 (1)(g)
             1480      and (h) for which coverage the applicant is applying.]
             1481          [(26) "Uninsurable percentage" for a given calendar year equals UC/CI where, for
             1482      purposes of this formula:]


             1483          [(a) "CI" means the carrier's individual coverage count as of December 31 of the
             1484      preceding year; and]
             1485          [(b) "UC" means the number of uninsurable individuals who were issued an individual
             1486      policy on or after July 1, 1997.]
             1487          Section 22. Section 31A-30-107 is amended to read:
             1488           31A-30-107. Renewal -- Limitations -- Exclusions -- Discontinuance and
             1489      nonrenewal.
             1490          (1) Except as otherwise provided in this section, a small employer health benefit plan is
             1491      renewable and continues in force:
             1492          (a) with respect to all eligible employees and dependents; and
             1493          (b) at the option of the plan sponsor.
             1494          (2) A small employer health benefit plan may be discontinued or nonrenewed:
             1495          (a) for a network plan, if[: (i)] there is no longer any enrollee under the group health
             1496      plan who lives, resides, or works in:
             1497          [(A)] (i) the service area of the covered carrier; or
             1498          [(B)] (ii) the area for which the covered carrier is authorized to do business; [and] or
             1499          [(ii) in the case of the small employer market, the small employer carrier applies the
             1500      same criteria the small employer carrier would apply in denying enrollment in the plan under
             1501      Subsection 31A-30-108 (7); or]
             1502          (b) for coverage made available in the small or large employer market only through an
             1503      association, if:
             1504          (i) the employer's membership in the association ceases; and
             1505          (ii) the coverage is terminated uniformly without regard to any health status-related
             1506      factor relating to any covered individual.
             1507          (3) A small employer health benefit plan may be discontinued if:
             1508          (a) a condition described in Subsection (2) exists;
             1509          (b) except as prohibited by Section 31A-30-206 , the plan sponsor fails to pay
             1510      premiums or contributions in accordance with the terms of the contract;
             1511          (c) the plan sponsor:
             1512          (i) performs an act or practice that constitutes fraud; or
             1513          (ii) makes an intentional misrepresentation of material fact under the terms of the


             1514      coverage;
             1515          (d) the covered carrier:
             1516          (i) elects to discontinue offering a particular small employer health benefit product
             1517      delivered or issued for delivery in this state; and
             1518          (ii) (A) provides notice of the discontinuation in writing:
             1519          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             1520          (II) at least 90 days before the date the coverage will be discontinued;
             1521          (B) provides notice of the discontinuation in writing:
             1522          (I) to the commissioner; and
             1523          (II) at least three working days prior to the date the notice is sent to the affected plan
             1524      sponsors, employees, and dependents of the plan sponsors or employees;
             1525          (C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase all
             1526      other small employer health benefit products currently being offered by the small employer
             1527      carrier in the market; and
             1528          (D) in exercising the option to discontinue that product and in offering the option of
             1529      coverage in this section, acts uniformly without regard to:
             1530          (I) the claims experience of a plan sponsor;
             1531          (II) any health status-related factor relating to any covered participant or beneficiary; or
             1532          (III) any health status-related factor relating to any new participant or beneficiary who
             1533      may become eligible for the coverage; or
             1534          (e) the covered carrier:
             1535          (i) elects to discontinue all of the covered carrier's small employer health benefit plans
             1536      in:
             1537          (A) the small employer market;
             1538          (B) the large employer market; or
             1539          (C) both the small employer and large employer markets; and
             1540          (ii) (A) provides notice of the discontinuation in writing:
             1541          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             1542          (II) at least 180 days before the date the coverage will be discontinued;
             1543          (B) provides notice of the discontinuation in writing:
             1544          (I) to the commissioner in each state in which an affected insured individual is known


             1545      to reside; and
             1546          (II) at least 30 working days prior to the date the notice is sent to the affected plan
             1547      sponsors, employees, and the dependents of the plan sponsors or employees;
             1548          (C) discontinues and nonrenews all plans issued or delivered for issuance in the
             1549      market; and
             1550          (D) provides a plan of orderly withdrawal as required by Section 31A-4-115 .
             1551          (4) A small employer health benefit plan may be discontinued or nonrenewed:
             1552          (a) if a condition described in Subsection (2) exists; or
             1553          (b) except as prohibited by Section 31A-30-206 , for noncompliance with the insurer's
             1554      employer contribution requirements.
             1555          (5) A small employer health benefit plan may be nonrenewed:
             1556          (a) if a condition described in Subsection (2) exists; or
             1557          (b) except as prohibited by Section 31A-30-206 , for noncompliance with the insurer's
             1558      minimum participation requirements.
             1559          (6) (a) Except as provided in Subsection (6)(d), an eligible employee may be
             1560      discontinued if after issuance of coverage the eligible employee:
             1561          (i) engages in an act or practice that constitutes fraud in connection with the coverage;
             1562      or
             1563          (ii) makes an intentional misrepresentation of material fact in connection with the
             1564      coverage.
             1565          (b) An eligible employee that is discontinued under Subsection (6)(a) may reenroll:
             1566          (i) 12 months after the date of discontinuance; and
             1567          (ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies
             1568      to reenroll.
             1569          (c) At the time the eligible employee's coverage is discontinued under Subsection
             1570      (6)(a), the covered carrier shall notify the eligible employee of the right to reenroll when
             1571      coverage is discontinued.
             1572          (d) An eligible employee may not be discontinued under this Subsection (6) because of
             1573      a fraud or misrepresentation that relates to health status.
             1574          (7) For purposes of this section, a reference to "plan sponsor" includes a reference to
             1575      the employer:


             1576          (a) with respect to coverage provided to an employer member of the association; and
             1577          (b) if the small employer health benefit plan is made available by a covered carrier in
             1578      the employer market only through:
             1579          (i) an association;
             1580          (ii) a trust; or
             1581          (iii) a discretionary group.
             1582          (8) A covered carrier may modify a small employer health benefit plan only:
             1583          (a) at the time of coverage renewal; and
             1584          (b) if the modification is effective uniformly among all plans with that product.
             1585          Section 23. Section 31A-30-108 is amended to read:
             1586           31A-30-108. Eligibility for small employer and individual market.
             1587          (1) (a) [Small employer carriers shall accept residents] A small employer carrier shall
             1588      accept a small employer that applies for small group coverage as set forth in the Health
             1589      Insurance Portability and Accountability Act, Sec. 2701(f) and 2711(a) and PPACA, Sec. 2702.
             1590          [(b) Individual carriers shall accept residents for individual coverage pursuant to:]
             1591          [(i) Health Insurance Portability and Accountability Act, Sec. 2741(a)-(b); and]
             1592          [(ii) Subsection (3).]
             1593          (b) An individual carrier shall accept an individual that applies for individual coverage
             1594      as set forth in PPACA, Sec. 2702.
             1595          (2) (a) [Small] A small employer [carriers] carrier shall offer to accept all eligible
             1596      employees and their dependents at the same level of benefits under any health benefit plan
             1597      provided to a small employer.
             1598          (b) [Small] A small employer [carriers] carrier may:
             1599          (i) request a small employer to submit a copy of the small employer's quarterly income
             1600      tax withholdings to determine whether the employees for whom coverage is provided or
             1601      requested are bona fide employees of the small employer; and
             1602          (ii) deny or terminate coverage if the small employer refuses to provide documentation
             1603      requested under Subsection (2)(b)(i).
             1604          [(3) Except as provided in Subsections (5) and (6) and Section 31A-30-110 , individual
             1605      carriers shall accept for coverage individuals to whom all of the following conditions apply:]
             1606          [(a) the individual is not covered or eligible for coverage:]


             1607          [(i) (A) as an employee of an employer;]
             1608          [(B) as a member of an association; or]
             1609          [(C) as a member of any other group; and]
             1610          [(ii) under:]
             1611          [(A) a health benefit plan; or]
             1612          [(B) a self-insured arrangement that provides coverage similar to that provided by a
             1613      health benefit plan as defined in Section 31A-1-301 ;]
             1614          [(b) the individual is not covered and is not eligible for coverage under any public
             1615      health benefits arrangement including:]
             1616          [(i) the Medicare program established under Title XVIII of the Social Security Act;]
             1617          [(ii) any act of Congress or law of this or any other state that provides benefits
             1618      comparable to the benefits provided under this chapter; or]
             1619          [(iii) coverage under the Comprehensive Health Insurance Pool Act created in Chapter
             1620      29, Comprehensive Health Insurance Pool Act;]
             1621          [(c) unless the maximum benefit has been reached the individual is not covered or
             1622      eligible for coverage under any:]
             1623          [(i) Medicare supplement policy;]
             1624          [(ii) conversion option;]
             1625          [(iii) continuation or extension under COBRA; or]
             1626          [(iv) state extension;]
             1627          [(d) the individual has not terminated or declined coverage described in Subsection
             1628      (3)(a), (b), or (c) within 93 days of application for coverage, unless the individual is eligible for
             1629      individual coverage under Health Insurance Portability and Accountability Act, Sec. 2741(b),
             1630      in which case, the requirement of this Subsection (3)(d) does not apply; and]
             1631          [(e) the individual is certified as ineligible for the Health Insurance Pool if:]
             1632          [(i) the individual applies for coverage with the Comprehensive Health Insurance Pool
             1633      within 30 days after being rejected or refused coverage by the covered carrier and reapplies for
             1634      coverage with that covered carrier within 30 days after the date of issuance of a certificate
             1635      under Subsection 31A-29-111 (5)(c); or]
             1636          [(ii) the individual applies for coverage with any individual carrier within 45 days
             1637      after:]


             1638          [(A) notice of cancellation of coverage under Subsection 31A-29-115 (1); or]
             1639          [(B) the date of issuance of a certificate under Subsection 31A-29-111 (5)(c) if the
             1640      individual applied first for coverage with the Comprehensive Health Insurance Pool.]
             1641          [(4) (a) If coverage is obtained under Subsection (3)(e)(i) and the required premium is
             1642      paid, the effective date of coverage shall be the first day of the month following the individual's
             1643      submission of a completed insurance application to that covered carrier.]
             1644          [(b) If coverage is obtained under Subsection (3)(e)(ii) and the required premium is
             1645      paid, the effective date of coverage shall be the day following the:]
             1646          [(i) cancellation of coverage under Subsection 31A-29-115 (1); or]
             1647          [(ii) submission of a completed insurance application to the Comprehensive Health
             1648      Insurance Pool].
             1649          [(5) (a) An individual carrier is not required to accept individuals for coverage under
             1650      Subsection (3) if the carrier issues no new individual policies in the state after July 1, 1997.]
             1651          [(b) A carrier described in Subsection (5)(a) may not issue new individual policies in
             1652      the state for five years from July 1, 1997.]
             1653          [(c) Notwithstanding Subsection (5)(b), a carrier may request permission to issue new
             1654      policies after July 1, 1999, which may only be granted if:]
             1655          [(i) the carrier accepts uninsurables as is required of a carrier entering the market under
             1656      Subsection 31A-30-110 ; and]
             1657          [(ii) the commissioner finds that the carrier's issuance of new individual policies:]
             1658          [(A) is in the best interests of the state; and]
             1659          [(B) does not provide an unfair advantage to the carrier.]
             1660          [(6) (a) If the Comprehensive Health Insurance Pool, as set forth under Chapter 29,
             1661      Comprehensive Health Insurance Pool Act, is dissolved or discontinued, or if enrollment is
             1662      capped or suspended, an individual carrier may decline to accept individuals applying for
             1663      individual enrollment, other than individuals applying for coverage as set forth in Health
             1664      Insurance Portability and Accountability Act, Sec. 2741 (a)-(b).]
             1665          [(b) Within two calendar days of taking action under Subsection (6)(a), an individual
             1666      carrier will provide written notice to the department.]
             1667          [(7) (a) If a small employer carrier offers health benefit plans to small employers
             1668      through a network plan, the small employer carrier may:]


             1669          [(i) limit the employers that may apply for the coverage to those employers with
             1670      eligible employees who live, reside, or work in the service area for the network plan; and]
             1671          [(ii) within the service area of the network plan, deny coverage to an employer if the
             1672      small employer carrier has demonstrated to the commissioner that the small employer carrier:]
             1673          [(A) will not have the capacity to deliver services adequately to enrollees of any
             1674      additional groups because of the small employer carrier's obligations to existing group contract
             1675      holders and enrollees; and]
             1676          [(B) applies this section uniformly to all employers without regard to:]
             1677          [(I) the claims experience of an employer, an employer's employee, or a dependent of
             1678      an employee; or]
             1679          [(II) any health status-related factor relating to an employee or dependent of an
             1680      employee].
             1681          [(b) (i) A small employer carrier that denies a health benefit product to an employer in
             1682      any service area in accordance with this section may not offer coverage in the small employer
             1683      market within the service area to any employer for a period of 180 days after the date the
             1684      coverage is denied.]
             1685          [(ii) This Subsection (7)(b) does not:]
             1686          [(A) limit the small employer carrier's ability to renew coverage that is in force; or]
             1687          [(B) relieve the small employer carrier of the responsibility to renew coverage that is in
             1688      force.]
             1689          [(c) Coverage offered within a service area after the 180-day period specified in
             1690      Subsection (7)(b) is subject to the requirements of this section.]
             1691          Section 24. Section 31A-30-117 is amended to read:
             1692           31A-30-117. Patient Protection and Affordable Care Act -- Market transition.
             1693          (1) (a) After complying with the reporting requirements of Section 63M-1-2505.5 , the
             1694      commissioner may adopt administrative rules that change the rating and underwriting
             1695      requirements of this chapter as necessary to transition the insurance market to meet federal
             1696      qualified health plan standards and rating practices under PPACA.
             1697          (b) Administrative rules adopted by the commissioner under this section may include:
             1698          (i) the regulation of health benefit plans as described in Subsections 31A-2-212 (5)(a)
             1699      and (b); and


             1700          (ii) disclosure of records and information required by PPACA and state law.
             1701          (c) (i) The commissioner shall establish by administrative rule one statewide open
             1702      enrollment period that applies to the individual insurance market that is not on the PPACA
             1703      certified individual exchange.
             1704          (ii) The statewide open enrollment period:
             1705          (A) may be shorter, but no longer than the open enrollment period established for the
             1706      individual insurance market offered in the PPACA certified exchange; and
             1707          (B) may not be extended beyond the dates of the open enrollment period established
             1708      for the individual insurance market offered in the PPACA certified exchange.
             1709          (2) A carrier that offers health benefit plans in the individual market that is not part of
             1710      the individual PPACA certified exchange:
             1711          (a) shall open enrollment:
             1712          (i) during the statewide open enrollment period established in Subsection (1)(c); and
             1713          (ii) at other times, for qualifying events, as determined by administrative rule adopted
             1714      by the commissioner; and
             1715          (b) may open enrollment at any time.
             1716          [(3) (a) The commissioner shall identify a new mandated benefit that is in excess of the
             1717      essential health benefits required by PPACA.]
             1718          [(b) In accordance with 45 C.F.R. Sec. 155.170, the state shall make a payment to
             1719      defray the cost of a new mandated benefit in the amount calculated under Subsection (3)(c)
             1720      directly to the qualified health plan issuer on behalf of an individual who receives an advance
             1721      premium tax credit under PPACA.]
             1722          [(c) The state shall quantify the cost attributable to each additional mandated benefit
             1723      specified in Subsection (3)(a) based on a qualified health plan issuer's calculation of the cost
             1724      associated with the mandated benefit, which shall be:]
             1725          [(i) calculated in accordance with generally accepted actuarial principles and
             1726      methodologies;]
             1727          [(ii) conducted by a member of the American Academy of Actuaries; and]
             1728          [(iii) reported to the commissioner and to the individual exchange operating in the
             1729      state.]
             1730          [(d) The commissioner may require a proponent of a new mandated benefit under


             1731      Subsection (3)(a) to provide the commissioner with a cost analysis conducted in accordance
             1732      with Subsection (3)(c). The commissioner may use the cost information provided under this
             1733      Subsection (3)(d) to establish estimates of the cost to the state for premium subsidies under
             1734      Subsection (3)(b).]
             1735          (3) To the extent permitted by the Centers for Medicare and Medicaid Services policy,
             1736      or federal regulation, the commissioner shall allow a health insurer to choose to continue
             1737      coverage and individuals and small employers to choose to re-enroll in coverage in
             1738      nongrandfathered health coverage that is not in compliance with market reforms required by
             1739      PPACA.
             1740          Section 25. Section 31A-30-118 is enacted to read:
             1741          31A-30-118. Patient Protection and Affordable Care Act -- State insurance
             1742      mandates -- Cost of additional benefits.
             1743          (1) (a) The commissioner shall identify a new mandated benefit that is in excess of the
             1744      essential health benefits required by PPACA.
             1745          (b) The state shall quantify the cost attributable to each additional mandated benefit
             1746      specified in Subsection (1)(a) based on a qualified health plan issuer's calculation of the cost
             1747      associated with the mandated benefit, which shall be:
             1748          (i) calculated in accordance with generally accepted actuarial principles and
             1749      methodologies;
             1750          (ii) conducted by a member of the American Academy of Actuaries; and
             1751          (iii) reported to the commissioner and to the individual exchange operating in the state.
             1752          (c) The commissioner may require a proponent of a new mandated benefit under
             1753      Subsection (1)(a) to provide the commissioner with a cost analysis conducted in accordance
             1754      with Subsection (1)(b). The commissioner may use the cost information provided under this
             1755      Subsection (1)(c) to establish estimates of the cost to the state under Subsection (2).
             1756          (2) If the state is required to defray the cost of additional required benefits under the
             1757      provisions of 45 C.F.R. 155.170:
             1758          (a) the state shall make the required payments:
             1759          (i) in accordance with Subsection (3); and
             1760          (ii) directly to the qualified health plan issuer in accordance with 45 C.F.R. 155.170;
             1761          (b) an issuer of a qualified health plan that receives a payment under the provisions of


             1762      Subsection (1) and 45 C.F.R. 155.170 shall:
             1763          (i) reduce the premium charged to the individual on whose behalf the issuer will be
             1764      paid under Subsection (1), in an amount equal to the amount of the payment under Subsection
             1765      (1); or
             1766          (ii) notwithstanding Subsection 31A-23a-402.5 (5), provide a premium rebate to an
             1767      individual on whose behalf the issuer received a payment under Subsection (1), in an amount
             1768      equal to the amount of the payment under Subsection (1); and
             1769          (c) a premium rebate made under this section is not a prohibited inducement under
             1770      Section 31A-23a-402.5 .
             1771          (3) A payment required under 45 C.F.R. 155.170(c) shall:
             1772          (a) unless otherwise required by PPACA, be based on a statewide average of the cost
             1773      of the additional benefit for all issuers who are entitled to payment under the provisions of 45
             1774      C.F.R. 155.70; and
             1775          (b) be submitted to an issuer through a process established and administered by:
             1776          (i) the federal marketplace exchange for the state under PPACA for individual health
             1777      plans; or
             1778          (ii) Avenue H small employer market exchange for qualified health plans offered on
             1779      the exchange.
             1780          (4) The commissioner:
             1781          (a) may adopt rules as necessary to administer the provisions of this section and 45
             1782      C.F.R. 155.170; and
             1783          (b) may not establish or implement the process for submitting the payments to an issuer
             1784      under Subsection (3)(b)(i) unless the cost of establishing and implementing the process for
             1785      submitting payments is paid for by the federal exchange marketplace.
             1786          Section 26. Section 31A-30-301 is enacted to read:
             1787     
Part 3. Individual and Small Employer Risk Adjustment Act

             1788          31A-30-301. Title.
             1789          This part is known as the "Individual and Small Employer Risk Adjustment Act."
             1790          Section 27. Section 31A-30-302 is enacted to read:
             1791          31A-30-302. Creation of state risk adjustment program.
             1792          (1) The commissioner shall convene a group of stakeholders and actuaries to assist the


             1793      commissioner with the evaluation or the risk adjustment options described in Subsection (2). If
             1794      the commissioner determines that a state-based risk adjustment program is in the best interest
             1795      of the state, the commissioner shall establish an individual and small employer market risk
             1796      adjustment program in accordance with 42 U.S.C. 18063 and this section.
             1797          (2) The risk adjustment program adopted by the commissioner may include one of the
             1798      following models:
             1799          (a) continue the United States Department of Health and Human Services
             1800      administration of the federal model for risk adjustment for the individual and small employer
             1801      market in the state;
             1802          (b) have the state administer the federal model for risk adjustment for the individual
             1803      and small employer market in the state;
             1804          (c) establish and operate a state based risk adjustment program for the individual and
             1805      small employer market in the state; or
             1806          (d) another risk adjustment model developed by the commissioner under Subsection
             1807      (1).
             1808          (3) Before adopting one of the models described in Subsection (2), the commissioner:
             1809          (a) may enter into contracts to carry out the services needed to evaluate and establish
             1810      one of the risk adjustment options described in Subsection (2); and
             1811          (b) shall, prior to October 30, 2014, comply with the reporting requirements of Section
             1812      63M-1-2505.5 regarding the commissioner's evaluation of the risk adjustment options
             1813      described in Subsection (2).
             1814          (4) The commissioner may:
             1815          (a) adopt administrative rules in accordance with Title 63G, Chapter 3, Utah
             1816      Administrative Rulemaking Act, that require an insurer that is subject to the state based risk
             1817      adjustment program to submit data to the all payers claims database created under Section
             1818      26-33a-106.1 ; and
             1819          (b) establish fees in accordance with Title 63J, Chapter 1, Budgetary Procedures Act,
             1820      to cover the ongoing administrative cost of running the state based risk adjustment program.
             1821          Section 28. Section 31A-30-303 is enacted to read:
             1822          31A-30-303. Enterprise fund.
             1823          (1) There is created an enterprise fund known as the Individual and Small Employer


             1824      Risk Adjustment Enterprise Fund.
             1825          (2) The following funds shall be credited to the fund:
             1826          (a) appropriations from the General Fund;
             1827          (b) fees established by the commissioner under Section 31A-30-302 ;
             1828          (c) risk adjustment payments received from insurers participating in the risk adjustment
             1829      program; and
             1830          (d) all interest and dividends earned on the fund's assets.
             1831          (3) All money received by the fund shall be deposited in compliance with Section
             1832      51-4-1 and shall be held by the state treasurer and invested in accordance with Title 51,
             1833      Chapter 7, State Money Management Act.
             1834          (4) The fund shall comply with the accounting policies, procedures, and reporting
             1835      requirements established by the Division of Finance.
             1836          (5) The fund shall comply with Title 63A, Utah Administrative Services Code.
             1837          (6) The fund shall be used to implement and operate the risk adjustment program
             1838      created by this part.
             1839          Section 29. Section 63A-5-205 is amended to read:
             1840           63A-5-205. Contracting powers of director -- Retainage -- Health insurance
             1841      coverage.
             1842          (1) As used in this section:
             1843          (a) "Capital developments" has the same meaning as provided in Section 63A-5-104 .
             1844          (b) "Capital improvements" has the same meaning as provided in Section 63A-5-104 .
             1845          (c) "Employee" means an "employee," "worker," or "operative" as defined in Section
             1846      34A-2-104 who:
             1847          (i) works at least 30 hours per calendar week; and
             1848          (ii) meets employer eligibility waiting requirements for health care insurance which
             1849      may not exceed the first day of the calendar month following [90] 60 days from the date of
             1850      hire.
             1851          (d) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             1852          (e) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             1853          (f) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             1854          (2) In accordance with Title 63G, Chapter 6a, Utah Procurement Code, the director


             1855      may:
             1856          (a) subject to Subsection (3), enter into contracts for any work or professional services
             1857      which the division or the State Building Board may do or have done; and
             1858          (b) as a condition of any contract for architectural or engineering services, prohibit the
             1859      architect or engineer from retaining a sales or agent engineer for the necessary design work.
             1860          (3) (a) Except as provided in Subsection (3)(b), this Subsection (3) applies to all design
             1861      or construction contracts entered into by the division or the State Building Board on or after
             1862      July 1, 2009, and:
             1863          (i) applies to a prime contractor if the prime contract is in the amount of $1,500,000 or
             1864      greater; and
             1865          (ii) applies to a subcontractor if the subcontract is in the amount of $750,000 or greater.
             1866          (b) This Subsection (3) does not apply:
             1867          (i) if the application of this Subsection (3) jeopardizes the receipt of federal funds;
             1868          (ii) if the contract is a sole source contract;
             1869          (iii) if the contract is an emergency procurement; or
             1870          (iv) to a change order as defined in Section 63G-6a-103 , or a modification to a
             1871      contract, when the contract does not meet the threshold required by Subsection (3)(a).
             1872          (c) A person who intentionally uses change orders or contract modifications to
             1873      circumvent the requirements of Subsection (3)(a) is guilty of an infraction.
             1874          (d) (i) A contractor subject to Subsection (3)(a) shall demonstrate to the director that
             1875      the contractor has and will maintain an offer of qualified health insurance coverage for the
             1876      contractor's employees and the employees' dependents.
             1877          (ii) If a subcontractor of the contractor is subject to Subsection (3)(a), the contractor
             1878      shall demonstrate to the director that the subcontractor has and will maintain an offer of
             1879      qualified health insurance coverage for the subcontractor's employees and the employees'
             1880      dependents.
             1881          (e) (i) (A) A contractor who fails to meet the requirements of Subsection (3)(d)(i)
             1882      during the duration of the contract is subject to penalties in accordance with administrative
             1883      rules adopted by the division under Subsection (3)(f).
             1884          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             1885      requirements of Subsection (3)(d)(ii).


             1886          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (3)(d)(ii)
             1887      during the duration of the contract is subject to penalties in accordance with administrative
             1888      rules adopted by the division under Subsection (3)(f).
             1889          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             1890      requirements of Subsection (3)(d)(i).
             1891          (f) The division shall adopt administrative rules:
             1892          (i) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             1893          (ii) in coordination with:
             1894          (A) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             1895          (B) the Department of Natural Resources in accordance with Section 79-2-404 ;
             1896          (C) a public transit district in accordance with Section 17B-2a-818.5 ;
             1897          (D) the State Capitol Preservation Board in accordance with Section 63C-9-403 ;
             1898          (E) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             1899          (F) the Legislature's Administrative Rules Review Committee; and
             1900          (iii) which establish:
             1901          (A) the requirements and procedures a contractor must follow to demonstrate to the
             1902      director compliance with this Subsection (3) which shall include:
             1903          (I) that a contractor will not have to demonstrate compliance with Subsection (3)(d)(i)
             1904      or (ii) more than twice in any 12-month period; and
             1905          (II) that the actuarially equivalent determination required for the qualified health
             1906      insurance coverage in Subsection (1) is met by the contractor if the contractor provides the
             1907      department or division with a written statement of actuarial equivalency from either:
             1908          (Aa) the Utah Insurance Department;
             1909          (Bb) an actuary selected by the contractor or the contractor's insurer; or
             1910          (Cc) an underwriter who is responsible for developing the employer group's premium
             1911      rates;
             1912          (B) the penalties that may be imposed if a contractor or subcontractor intentionally
             1913      violates the provisions of this Subsection (3), which may include:
             1914          (I) a three-month suspension of the contractor or subcontractor from entering into
             1915      future contracts with the state upon the first violation;
             1916          (II) a six-month suspension of the contractor or subcontractor from entering into future


             1917      contracts with the state upon the second violation;
             1918          (III) an action for debarment of the contractor or subcontractor in accordance with
             1919      Section 63G-6a-904 upon the third or subsequent violation; and
             1920          (IV) monetary penalties which may not exceed 50% of the amount necessary to
             1921      purchase qualified health insurance coverage for an employee and the dependents of an
             1922      employee of the contractor or subcontractor who was not offered qualified health insurance
             1923      coverage during the duration of the contract; and
             1924          (C) a website on which the department shall post the benchmark for the qualified
             1925      health insurance coverage identified in Subsection (1)(e).
             1926          (g) (i) In addition to the penalties imposed under Subsection (3)(f)(iii), a contractor or
             1927      subcontractor who intentionally violates the provisions of this section shall be liable to the
             1928      employee for health care costs that would have been covered by qualified health insurance
             1929      coverage.
             1930          (ii) An employer has an affirmative defense to a cause of action under Subsection
             1931      (3)(g)(i) if:
             1932          (A) the employer relied in good faith on a written statement of actuarial equivalency
             1933      provided by:
             1934          (I) an actuary; or
             1935          (II) an underwriter who is responsible for developing the employer group's premium
             1936      rates; or
             1937          (B) the department determines that compliance with this section is not required under
             1938      the provisions of Subsection (3)(b).
             1939          (iii) An employee has a private right of action only against the employee's employer to
             1940      enforce the provisions of this Subsection (3)(g).
             1941          (h) Any penalties imposed and collected under this section shall be deposited into the
             1942      Medicaid Restricted Account created by Section 26-18-402 .
             1943          (i) The failure of a contractor or subcontractor to provide qualified health insurance
             1944      coverage as required by this section:
             1945          (i) may not be the basis for a protest or other action from a prospective bidder, offeror,
             1946      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             1947      Procurement Code; and


             1948          (ii) may not be used by the procurement entity or a prospective bidder, offeror, or
             1949      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             1950      or construction.
             1951          (4) The judgment of the director as to the responsibility and qualifications of a bidder
             1952      is conclusive, except in case of fraud or bad faith.
             1953          (5) The division shall make all payments to the contractor for completed work in
             1954      accordance with the contract and pay the interest specified in the contract on any payments that
             1955      are late.
             1956          (6) If any payment on a contract with a private contractor to do work for the division or
             1957      the State Building Board is retained or withheld, it shall be retained or withheld and released as
             1958      provided in Section 13-8-5 .
             1959          Section 30. Section 63C-9-403 is amended to read:
             1960           63C-9-403. Contracting power of executive director -- Health insurance coverage.
             1961          (1) For purposes of this section:
             1962          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             1963      34A-2-104 who:
             1964          (i) works at least 30 hours per calendar week; and
             1965          (ii) meets employer eligibility waiting requirements for health care insurance which
             1966      may not exceed the first of the calendar month following [90] 60 days from the date of hire.
             1967          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             1968          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             1969          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             1970          (2) (a) Except as provided in Subsection (3), this section applies to a design or
             1971      construction contract entered into by the board or on behalf of the board on or after July 1,
             1972      2009, and to a prime contractor or a subcontractor in accordance with Subsection (2)(b).
             1973          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             1974      amount of $1,500,000 or greater.
             1975          (ii) A subcontractor is subject to this section if a subcontract is in the amount of
             1976      $750,000 or greater.
             1977          (3) This section does not apply if:
             1978          (a) the application of this section jeopardizes the receipt of federal funds;


             1979          (b) the contract is a sole source contract; or
             1980          (c) the contract is an emergency procurement.
             1981          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             1982      or a modification to a contract, when the contract does not meet the initial threshold required
             1983      by Subsection (2).
             1984          (b) A person who intentionally uses change orders or contract modifications to
             1985      circumvent the requirements of Subsection (2) is guilty of an infraction.
             1986          (5) (a) A contractor subject to Subsection (2) shall demonstrate to the executive
             1987      director that the contractor has and will maintain an offer of qualified health insurance
             1988      coverage for the contractor's employees and the employees' dependents during the duration of
             1989      the contract.
             1990          (b) If a subcontractor of the contractor is subject to Subsection (2)(b), the contractor
             1991      shall demonstrate to the executive director that the subcontractor has and will maintain an offer
             1992      of qualified health insurance coverage for the subcontractor's employees and the employees'
             1993      dependents during the duration of the contract.
             1994          (c) (i) (A) A contractor who fails to meet the requirements of Subsection (5)(a) during
             1995      the duration of the contract is subject to penalties in accordance with administrative rules
             1996      adopted by the division under Subsection (6).
             1997          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             1998      requirements of Subsection (5)(b).
             1999          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during
             2000      the duration of the contract is subject to penalties in accordance with administrative rules
             2001      adopted by the department under Subsection (6).
             2002          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             2003      requirements of Subsection (5)(a).
             2004          (6) The department shall adopt administrative rules:
             2005          (a) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             2006          (b) in coordination with:
             2007          (i) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             2008          (ii) the Department of Natural Resources in accordance with Section 79-2-404 ;
             2009          (iii) the State Building Board in accordance with Section 63A-5-205 ;


             2010          (iv) a public transit district in accordance with Section 17B-2a-818.5 ;
             2011          (v) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             2012          (vi) the Legislature's Administrative Rules Review Committee; and
             2013          (c) which establish:
             2014          (i) the requirements and procedures a contractor must follow to demonstrate to the
             2015      executive director compliance with this section which shall include:
             2016          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             2017      (b) more than twice in any 12-month period; and
             2018          (B) that the actuarially equivalent determination required for the qualified health
             2019      insurance coverage in Subsection (1) is met by the contractor if the contractor provides the
             2020      department or division with a written statement of actuarial equivalency from either:
             2021          (I) the Utah Insurance Department;
             2022          (II) an actuary selected by the contractor or the contractor's insurer; or
             2023          (III) an underwriter who is responsible for developing the employer group's premium
             2024      rates;
             2025          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             2026      violates the provisions of this section, which may include:
             2027          (A) a three-month suspension of the contractor or subcontractor from entering into
             2028      future contracts with the state upon the first violation;
             2029          (B) a six-month suspension of the contractor or subcontractor from entering into future
             2030      contracts with the state upon the second violation;
             2031          (C) an action for debarment of the contractor or subcontractor in accordance with
             2032      Section 63G-6a-904 upon the third or subsequent violation; and
             2033          (D) monetary penalties which may not exceed 50% of the amount necessary to
             2034      purchase qualified health insurance coverage for employees and dependents of employees of
             2035      the contractor or subcontractor who were not offered qualified health insurance coverage
             2036      during the duration of the contract; and
             2037          (iii) a website on which the department shall post the benchmark for the qualified
             2038      health insurance coverage identified in Subsection (1)(c).
             2039          (7) (a) (i) In addition to the penalties imposed under Subsection (6)(c), a contractor or
             2040      subcontractor who intentionally violates the provisions of this section shall be liable to the


             2041      employee for health care costs that would have been covered by qualified health insurance
             2042      coverage.
             2043          (ii) An employer has an affirmative defense to a cause of action under Subsection
             2044      (7)(a)(i) if:
             2045          (A) the employer relied in good faith on a written statement of actuarial equivalency
             2046      provided by:
             2047          (I) an actuary; or
             2048          (II) an underwriter who is responsible for developing the employer group's premium
             2049      rates; or
             2050          (B) the department determines that compliance with this section is not required under
             2051      the provisions of Subsection (3) or (4).
             2052          (b) An employee has a private right of action only against the employee's employer to
             2053      enforce the provisions of this Subsection (7).
             2054          (8) Any penalties imposed and collected under this section shall be deposited into the
             2055      Medicaid Restricted Account created in Section 26-18-402 .
             2056          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             2057      coverage as required by this section:
             2058          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             2059      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             2060      Procurement Code; and
             2061          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             2062      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             2063      or construction.
             2064          Section 31. Section 63I-1-231 (Effective 07/01/14) is amended to read:
             2065           63I-1-231 (Effective 07/01/14). Repeal dates, Title 31A.
             2066          (1) Section 31A-2-208.5 , Comparison tables, is repealed July 1, 2015.
             2067          (2) Section 31A-2-217 , Coordination with other states, is repealed July 1, 2023.
             2068          (3) Section 31A-22-619.6 , Coordination of benefits with workers' compensation
             2069      claim--Health insurer's duty to pay, is repealed on July 1, 2018.
             2070          (4) Title 31A, Chapter 29, Comprehensive Health Insurance Pool Act, is repealed July
             2071      1, 2015.


             2072          Section 32. Section 63M-1-2504 is amended to read:
             2073           63M-1-2504. Creation of Office of Consumer Health Services -- Duties.
             2074          (1) There is created within the Governor's Office of Economic Development the Office
             2075      of Consumer Health Services.
             2076          (2) The office shall:
             2077          (a) in cooperation with the Insurance Department, the Department of Health, and the
             2078      Department of Workforce Services, and in accordance with the electronic standards developed
             2079      under Sections 31A-22-635 and 63M-1-2506 , create a Health Insurance Exchange that:
             2080          (i) provides information to consumers about private and public health programs for
             2081      which the consumer may qualify;
             2082          (ii) provides a consumer comparison of and enrollment in a health benefit plan posted
             2083      on the Health Insurance Exchange; and
             2084          (iii) includes information and a link to enrollment in premium assistance programs and
             2085      other government assistance programs;
             2086          (b) contract with one or more private vendors for:
             2087          (i) administration of the enrollment process on the Health Insurance Exchange,
             2088      including establishing a mechanism for consumers to compare health benefit plan features on
             2089      the exchange and filter the plans based on consumer preferences;
             2090          (ii) the collection of health insurance premium payments made for a single policy by
             2091      multiple payers, including the policyholder, one or more employers of one or more individuals
             2092      covered by the policy, government programs, and others; and
             2093          (iii) establishing a call center in accordance with Subsection [(3)] (4);
             2094          (c) assist employers with a free or low cost method for establishing mechanisms for the
             2095      purchase of health insurance by employees using pre-tax dollars;
             2096          (d) establish a list on the Health Insurance Exchange of insurance producers who, in
             2097      accordance with Section 31A-30-209 , are appointed producers for the Health Insurance
             2098      Exchange; [and]
             2099          (e) submit, before November 1, an annual written report to the Business and Labor
             2100      Interim Committee and the Health System Reform Task Force regarding the operations of the
             2101      Health Insurance Exchange required by this chapter[.]; and
             2102          (f) in accordance with Subsection (3), provide a form to a small employer that certifies:


             2103          (i) that the small employer offered a qualified health plan to the small employer's
             2104      employees; and
             2105          (ii) the period of time within the taxable year in which the small employer maintained
             2106      the qualified health plan coverage.
             2107          (3) The form required by Subsection (2)(f) shall be provided to a small employer if:
             2108          (a) the small employer selected a qualified health plan on the small employer health
             2109      exchange created by this section; or
             2110          (b) (i) the small employer selected a health plan in the small employer market that is
             2111      not offered through the exchange created by this section; and
             2112          (ii) the issuer of the health plan selected by the small employer submits to the office, in
             2113      a form and manner required by the office:
             2114          (A) an affidavit from a member of the American Academy of Actuaries stating that
             2115      based on generally accepted actuarial principles and methodologies the issuer's health plan
             2116      meets the benefit and actuarial requirements for a qualified health plan under PPACA as
             2117      defined in Section 31A-1-301 ; and
             2118          (B) an affidavit from the issuer that includes the dates of coverage for the small
             2119      employer during the taxable year.
             2120          [(3)] (4) A call center established by the office:
             2121          (a) shall provide unbiased answers to questions concerning exchange operations, and
             2122      plan information, to the extent the plan information is posted on the exchange by the insurer;
             2123      and
             2124          (b) may not:
             2125          (i) sell, solicit, or negotiate a health benefit plan on the Health Insurance Exchange;
             2126          (ii) receive producer compensation through the Health Insurance Exchange; and
             2127          (iii) be designated as the default producer for an employer group that enters the Health
             2128      Insurance Exchange without a producer.
             2129          [(4)] (5) The office:
             2130          (a) may not:
             2131          (i) regulate health insurers, health insurance plans, health insurance producers, or
             2132      health insurance premiums charged in the exchange;
             2133          (ii) adopt administrative rules, except as provided in Section 63M-1-2506 ; or


             2134          (iii) act as an appeals entity for resolving disputes between a health insurer and an
             2135      insured;
             2136          (b) may establish and collect a fee for the cost of the exchange transaction in
             2137      accordance with Section 63J-1-504 for:
             2138          (i) processing an application for a health benefit plan;
             2139          (ii) accepting, processing, and submitting multiple premium payment sources;
             2140          (iii) providing a mechanism for consumers to filter and compare health benefit plans in
             2141      the exchange based on consumer preferences; and
             2142          (iv) funding the call center; and
             2143          (c) shall separately itemize the fee established under Subsection [(4)] (5)(b) as part of
             2144      the cost displayed for the employer selecting coverage on the exchange.
             2145          Section 33. Section 72-6-107.5 is amended to read:
             2146           72-6-107.5. Construction of improvements of highway -- Contracts -- Health
             2147      insurance coverage.
             2148          (1) For purposes of this section:
             2149          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             2150      34A-2-104 who:
             2151          (i) works at least 30 hours per calendar week; and
             2152          (ii) meets employer eligibility waiting requirements for health care insurance which
             2153      may not exceed the first day of the calendar month following [90] 60 days from the date of
             2154      hire.
             2155          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             2156          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             2157          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             2158          (2) (a) Except as provided in Subsection (3), this section applies to contracts entered
             2159      into by the department on or after July 1, 2009, for construction or design of highways and to a
             2160      prime contractor or to a subcontractor in accordance with Subsection (2)(b).
             2161          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             2162      amount of $1,500,000 or greater.
             2163          (ii) A subcontractor is subject to this section if a subcontract is in the amount of
             2164      $750,000 or greater.


             2165          (3) This section does not apply if:
             2166          (a) the application of this section jeopardizes the receipt of federal funds;
             2167          (b) the contract is a sole source contract; or
             2168          (c) the contract is an emergency procurement.
             2169          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             2170      or a modification to a contract, when the contract does not meet the initial threshold required
             2171      by Subsection (2).
             2172          (b) A person who intentionally uses change orders or contract modifications to
             2173      circumvent the requirements of Subsection (2) is guilty of an infraction.
             2174          (5) (a) A contractor subject to Subsection (2) shall demonstrate to the department that
             2175      the contractor has and will maintain an offer of qualified health insurance coverage for the
             2176      contractor's employees and the employees' dependents during the duration of the contract.
             2177          (b) If a subcontractor of the contractor is subject to Subsection (2), the contractor shall
             2178      demonstrate to the department that the subcontractor has and will maintain an offer of qualified
             2179      health insurance coverage for the subcontractor's employees and the employees' dependents
             2180      during the duration of the contract.
             2181          (c) (i) (A) A contractor who fails to meet the requirements of Subsection (5)(a) during
             2182      the duration of the contract is subject to penalties in accordance with administrative rules
             2183      adopted by the department under Subsection (6).
             2184          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             2185      requirements of Subsection (5)(b).
             2186          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during
             2187      the duration of the contract is subject to penalties in accordance with administrative rules
             2188      adopted by the department under Subsection (6).
             2189          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             2190      requirements of Subsection (5)(a).
             2191          (6) The department shall adopt administrative rules:
             2192          (a) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             2193          (b) in coordination with:
             2194          (i) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             2195          (ii) the Department of Natural Resources in accordance with Section 79-2-404 ;


             2196          (iii) the State Building Board in accordance with Section 63A-5-205 ;
             2197          (iv) the State Capitol Preservation Board in accordance with Section 63C-9-403 ;
             2198          (v) a public transit district in accordance with Section 17B-2a-818.5 ; and
             2199          (vi) the Legislature's Administrative Rules Review Committee; and
             2200          (c) which establish:
             2201          (i) the requirements and procedures a contractor must follow to demonstrate to the
             2202      department compliance with this section which shall include:
             2203          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             2204      (b) more than twice in any 12-month period; and
             2205          (B) that the actuarially equivalent determination required for qualified health insurance
             2206      coverage in Subsection (1) is met by the contractor if the contractor provides the department or
             2207      division with a written statement of actuarial equivalency from either:
             2208          (I) the Utah Insurance Department;
             2209          (II) an actuary selected by the contractor or the contractor's insurer; or
             2210          (III) an underwriter who is responsible for developing the employer group's premium
             2211      rates;
             2212          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             2213      violates the provisions of this section, which may include:
             2214          (A) a three-month suspension of the contractor or subcontractor from entering into
             2215      future contracts with the state upon the first violation;
             2216          (B) a six-month suspension of the contractor or subcontractor from entering into future
             2217      contracts with the state upon the second violation;
             2218          (C) an action for debarment of the contractor or subcontractor in accordance with
             2219      Section 63G-6a-904 upon the third or subsequent violation; and
             2220          (D) monetary penalties which may not exceed 50% of the amount necessary to
             2221      purchase qualified health insurance coverage for an employee and a dependent of the employee
             2222      of the contractor or subcontractor who was not offered qualified health insurance coverage
             2223      during the duration of the contract; and
             2224          (iii) a website on which the department shall post the benchmark for the qualified
             2225      health insurance coverage identified in Subsection (1)(c).
             2226          (7) (a) (i) In addition to the penalties imposed under Subsection (6), a contractor or


             2227      subcontractor who intentionally violates the provisions of this section shall be liable to the
             2228      employee for health care costs that would have been covered by qualified health insurance
             2229      coverage.
             2230          (ii) An employer has an affirmative defense to a cause of action under Subsection
             2231      (7)(a)(i) if:
             2232          (A) the employer relied in good faith on a written statement of actuarial equivalency
             2233      provided by:
             2234          (I) an actuary; or
             2235          (II) an underwriter who is responsible for developing the employer group's premium
             2236      rates; or
             2237          (B) the department determines that compliance with this section is not required under
             2238      the provisions of Subsection (3) or (4).
             2239          (b) An employee has a private right of action only against the employee's employer to
             2240      enforce the provisions of this Subsection (7).
             2241          (8) Any penalties imposed and collected under this section shall be deposited into the
             2242      Medicaid Restricted Account created in Section 26-18-402 .
             2243          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             2244      coverage as required by this section:
             2245          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             2246      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             2247      Procurement Code; and
             2248          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             2249      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             2250      or construction.
             2251          Section 34. Section 79-2-404 is amended to read:
             2252           79-2-404. Contracting powers of department -- Health insurance coverage.
             2253          (1) For purposes of this section:
             2254          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             2255      34A-2-104 who:
             2256          (i) works at least 30 hours per calendar week; and
             2257          (ii) meets employer eligibility waiting requirements for health care insurance which


             2258      may not exceed the first day of the calendar month following [90] 60 days from the date of
             2259      hire.
             2260          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             2261          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             2262          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             2263          (2) (a) Except as provided in Subsection (3), this section applies a design or
             2264      construction contract entered into by, or delegated to, the department or a division, board, or
             2265      council of the department on or after July 1, 2009, and to a prime contractor or to a
             2266      subcontractor in accordance with Subsection (2)(b).
             2267          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             2268      amount of $1,500,000 or greater.
             2269          (ii) A subcontractor is subject to this section if a subcontract is in the amount of
             2270      $750,000 or greater.
             2271          (3) This section does not apply to contracts entered into by the department or a
             2272      division, board, or council of the department if:
             2273          (a) the application of this section jeopardizes the receipt of federal funds;
             2274          (b) the contract or agreement is between:
             2275          (i) the department or a division, board, or council of the department; and
             2276          (ii) (A) another agency of the state;
             2277          (B) the federal government;
             2278          (C) another state;
             2279          (D) an interstate agency;
             2280          (E) a political subdivision of this state; or
             2281          (F) a political subdivision of another state; or
             2282          (c) the contract or agreement is:
             2283          (i) for the purpose of disbursing grants or loans authorized by statute;
             2284          (ii) a sole source contract; or
             2285          (iii) an emergency procurement.
             2286          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             2287      or a modification to a contract, when the contract does not meet the initial threshold required
             2288      by Subsection (2).


             2289          (b) A person who intentionally uses change orders or contract modifications to
             2290      circumvent the requirements of Subsection (2) is guilty of an infraction.
             2291          (5) (a) A contractor subject to Subsection (2)(b)(i) shall demonstrate to the department
             2292      that the contractor has and will maintain an offer of qualified health insurance coverage for the
             2293      contractor's employees and the employees' dependents during the duration of the contract.
             2294          (b) If a subcontractor of the contractor is subject to Subsection (2)(b)(ii), the contractor
             2295      shall demonstrate to the department that the subcontractor has and will maintain an offer of
             2296      qualified health insurance coverage for the subcontractor's employees and the employees'
             2297      dependents during the duration of the contract.
             2298          (c) (i) (A) A contractor who fails to meet the requirements of Subsection (5)(a) during
             2299      the duration of the contract is subject to penalties in accordance with administrative rules
             2300      adopted by the department under Subsection (6).
             2301          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             2302      requirements of Subsection (5)(b).
             2303          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during
             2304      the duration of the contract is subject to penalties in accordance with administrative rules
             2305      adopted by the department under Subsection (6).
             2306          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             2307      requirements of Subsection (5)(a).
             2308          (6) The department shall adopt administrative rules:
             2309          (a) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             2310          (b) in coordination with:
             2311          (i) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             2312          (ii) a public transit district in accordance with Section 17B-2a-818.5 ;
             2313          (iii) the State Building Board in accordance with Section 63A-5-205 ;
             2314          (iv) the State Capitol Preservation Board in accordance with Section 63C-9-403 ;
             2315          (v) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             2316          (vi) the Legislature's Administrative Rules Review Committee; and
             2317          (c) which establish:
             2318          (i) the requirements and procedures a contractor must follow to demonstrate
             2319      compliance with this section to the department which shall include:


             2320          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             2321      (b) more than twice in any 12-month period; and
             2322          (B) that the actuarially equivalent determination required for qualified health insurance
             2323      coverage in Subsection (1) is met by the contractor if the contractor provides the department or
             2324      division with a written statement of actuarial equivalency from either:
             2325          (I) the Utah Insurance Department;
             2326          (II) an actuary selected by the contractor or the contractor's insurer; or
             2327          (III) an underwriter who is responsible for developing the employer group's premium
             2328      rates;
             2329          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             2330      violates the provisions of this section, which may include:
             2331          (A) a three-month suspension of the contractor or subcontractor from entering into
             2332      future contracts with the state upon the first violation;
             2333          (B) a six-month suspension of the contractor or subcontractor from entering into future
             2334      contracts with the state upon the second violation;
             2335          (C) an action for debarment of the contractor or subcontractor in accordance with
             2336      Section 63G-6a-904 upon the third or subsequent violation; and
             2337          (D) monetary penalties which may not exceed 50% of the amount necessary to
             2338      purchase qualified health insurance coverage for an employee and a dependent of an employee
             2339      of the contractor or subcontractor who was not offered qualified health insurance coverage
             2340      during the duration of the contract; and
             2341          (iii) a website on which the department shall post the benchmark for the qualified
             2342      health insurance coverage identified in Subsection (1)(c).
             2343          (7) (a) (i) In addition to the penalties imposed under Subsection (6), a contractor or
             2344      subcontractor who intentionally violates the provisions of this section shall be liable to the
             2345      employee for health care costs that would have been covered by qualified health insurance
             2346      coverage.
             2347          (ii) An employer has an affirmative defense to a cause of action under Subsection
             2348      (7)(a)(i) if:
             2349          (A) the employer relied in good faith on a written statement of actuarial equivalency
             2350      provided by:


             2351          (I) an actuary; or
             2352          (II) an underwriter who is responsible for developing the employer group's premium
             2353      rates; or
             2354          (B) the department determines that compliance with this section is not required under
             2355      the provisions of Subsection (3) or (4).
             2356          (b) An employee has a private right of action only against the employee's employer to
             2357      enforce the provisions of this Subsection (7).
             2358          (8) Any penalties imposed and collected under this section shall be deposited into the
             2359      Medicaid Restricted Account created in Section 26-18-402 .
             2360          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             2361      coverage as required by this section:
             2362          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             2363      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             2364      Procurement Code; and
             2365          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             2366      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             2367      or construction.
             2368          Section 35. Effective date.
             2369          (1) Except as provided in Subsection (2), this bill takes effect May 13, 2014.
             2370          (2) The amendments to Section 63I-1-231 (Effective 07/01/14) take effect on July 1,
             2371      2014.
             2372          Section 36. Coordinating H.B. 141 with H.B. 24 -- Superseding technical and
             2373      substantive amendments.
             2374          If this H.B. 141 and H.B. 24, Insurance Related Amendments, both pass and become
             2375      law, it is the intent of the Legislature that the amendments to Sections 31A-23b-205 and
             2376      31A-23b-206 in this bill, supersede the amendments to Sections 31A-23b-205 and
             2377      31A-23b-206 in H.B. 24, when the Office of Legislative Research and General Counsel
             2378      prepares the Utah Code database for publication.
             2379          Section 37. Coordinating H.B. 141 with H.B. 35 -- Superseding technical and
             2380      substantive amendments.
             2381          If this H.B. 141 and H.B. 35, Reauthorization of Health Data Authority Act, both pass


             2382      and become law, it is the intent of the Legislature that the amendments to Section 26-33a-106.1
             2383      in this bill, supersede the amendments to Section 26-33a-106.1 in H.B. 35, when the Office of
             2384      Legislative Research and General Counsel prepares the Utah Code database for publication.


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