Second 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: Allen M. Christensen

             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          .    instructs the Department of Health to:
             16              *    work with the Legislature's Health Reform Task Force to develop a     
             17      Section 1332 Medicaid waiver; and
             18              *    submit an amendment of the Utah Premium Partnership and Primary Care
             19      Network waiver to the Centers for Medicare and Medicaid Services to
             20      incorporate the Access Utah program.
             21          .    amends the Utah Health Data Authority Act to facilitate:
             22              .    the coordination of eligibility for health insurance benefits; and
             23              .    cost and quality reports for episodes of care;
             24          .    amends the health insurance navigator license chapter of the Insurance Code to:
             25              .    create two types of navigator licenses;


             26              .    establish different training for the types of licenses; and
             27              .    add an exception to the license requirement for Indian health centers;
             28          .    amends the state Comprehensive Health Insurance Pool to:
             29              .    close the pool to new enrollees;
             30              .    pay out claims incurred by enrollees; and
             31              .    close down the business of the pool;
             32          .    permits an enrollee to re-new an insurance plan as long as permitted by federal
             33      policy;
             34          .    establishes the state option for calculating the cost to the state if the state mandates
             35      additional benefits to the PPACA essential health benefits;
             36          .    creates the Individual and Small Employer Risk Adjustment Act, which:
             37              .    requires the insurance commissioner to work with stakeholders to develop a
             38      state based risk adjustment program for the individual and small group market;
             39              .    describes the risk adjustment models the commissioner may consider;
             40              .    requires the commissioner to report to the Legislature before implementing a
             41      risk adjustment model;
             42              .    authorizes the commissioner to set fees for the operation of the risk adjustment
             43      program; and
             44              .    establishes an Individual and Small Employer Risk Adjustment Enterprise Fund
             45      for the operation of the program;
             46          .    requires the Office of Consumer Health Services, which runs the small employer
             47      health insurance exchange, to provide the form required for the federal small
             48      employer premium tax credit to small employers who purchase qualified health
             49      plans; and
             50          .    makes technical and conforming amendments.
             51      Money Appropriated in this Bill:
             52          None
             53      Other Special Clauses:
             54          This bill provides an effective date.
             55          This bill coordinates with H.B. 24, Insurance Related Amendments, by providing
             56      superseding and substantive amendments.


             57          This bill coordinates with H.B. 35, Reauthorization of Utah Health Data Authority Act,
             58      by providing superseding and substantive amendments.
             59      Utah Code Sections Affected:
             60      AMENDS:
             61           17B-2a-818.5 , as last amended by Laws of Utah 2012, Chapter 347
             62           19-1-206 , as last amended by Laws of Utah 2012, Chapter 347
             63           26-33a-106.1 , as last amended by Laws of Utah 2012, Chapter 279
             64           26-33a-106.5 , as last amended by Laws of Utah 2012, Chapter 279
             65           26-33a-109 , as last amended by Laws of Utah 2010, Chapter 68
             66           31A-4-115 , as last amended by Laws of Utah 2002, Chapter 308
             67           31A-8-402.3 , as last amended by Laws of Utah 2004, Chapter 329
             68           31A-22-721 , as last amended by Laws of Utah 2011, Chapter 284
             69           31A-23b-205 , as enacted by Laws of Utah 2013, Chapter 341
             70           31A-23b-206 , as enacted by Laws of Utah 2013, Chapter 341
             71           31A-23b-211 , as enacted by Laws of Utah 2013, Chapter 341
             72           31A-29-106 , as last amended by Laws of Utah 2013, Chapter 319
             73           31A-29-110 , as last amended by Laws of Utah 2012, Chapter 347
             74           31A-29-111 , as last amended by Laws of Utah 2012, Chapters 158 and 347
             75           31A-29-113 , as last amended by Laws of Utah 2013, Chapter 319
             76           31A-29-114 , as last amended by Laws of Utah 2006, Chapter 95
             77           31A-29-115 , as last amended by Laws of Utah 2004, Chapter 2
             78           31A-30-103 , as last amended by Laws of Utah 2013, Chapter 168
             79           31A-30-107 , as last amended by Laws of Utah 2009, Chapter 12
             80           31A-30-108 , as last amended by Laws of Utah 2011, Chapter 284
             81           31A-30-117 , as enacted by Laws of Utah 2013, Chapter 341
             82           63A-5-205 , as last amended by Laws of Utah 2012, Chapter 347
             83           63C-9-403 , as last amended by Laws of Utah 2012, Chapter 347
             84           63I-1-231 (Effective 07/01/14), as last amended by Laws of Utah 2013, Chapters 261
             85      and 417
             86           63M-1-2504 , as last amended by Laws of Utah 2013, Chapter 255
             87           72-6-107.5 , as last amended by Laws of Utah 2012, Chapter 347


             88           79-2-404 , as last amended by Laws of Utah 2012, Chapter 347
             89      ENACTS:
             90           31A-23b-202.5 , Utah Code Annotated 1953
             91           31A-30-118 , Utah Code Annotated 1953
             92           31A-30-301 , Utah Code Annotated 1953
             93           31A-30-302 , Utah Code Annotated 1953
             94           31A-30-303 , Utah Code Annotated 1953
             95      Utah Code Sections Affected by Coordination Clause:
             96           26-33a-106.1 , as last amended by Laws of Utah 2012, Chapter 279
             97           31A-23b-205 , as enacted by Laws of Utah 2013, Chapter 341
             98           31A-23b-206 , as enacted by Laws of Utah 2013, Chapter 341
             99     
             100      Be it enacted by the Legislature of the state of Utah:
             101          Section 1. Section 17B-2a-818.5 is amended to read:
             102           17B-2a-818.5. Contracting powers of public transit districts -- Health insurance
             103      coverage.
             104          (1) For purposes of this section:
             105          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             106      34A-2-104 who:
             107          (i) works at least 30 hours per calendar week; and
             108          (ii) meets employer eligibility waiting requirements for health care insurance which
             109      may not exceed the first day of the calendar month following [90] 60 days from the date of
             110      hire.
             111          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             112          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             113          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             114          (2) (a) Except as provided in Subsection (3), this section applies to a design or
             115      construction contract entered into by the public transit district on or after July 1, 2009, and to a
             116      prime contractor or to a subcontractor in accordance with Subsection (2)(b).
             117          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             118      amount of $1,500,000 or greater.


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


             150          (i) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             151          (ii) the Department of Natural Resources in accordance with Section 79-2-404 ;
             152          (iii) the State Building Board in accordance with Section 63A-5-205 ;
             153          (iv) the State Capitol Preservation Board in accordance with Section 63C-9-403 ; and
             154          (v) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             155          (b) which establish:
             156          (i) the requirements and procedures a contractor shall follow to demonstrate to the
             157      public transit district compliance with this section which shall include:
             158          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             159      (b) more than twice in any 12-month period; and
             160          (B) that the actuarially equivalent determination required for the qualified health
             161      insurance coverage in Subsection (1) is met by the contractor if the contractor provides the
             162      department or division with a written statement of actuarial equivalency from either:
             163          (I) the Utah Insurance Department;
             164          (II) an actuary selected by the contractor or the contractor's insurer; or
             165          (III) an underwriter who is responsible for developing the employer group's premium
             166      rates;
             167          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             168      violates the provisions of this section, which may include:
             169          (A) a three-month suspension of the contractor or subcontractor from entering into
             170      future contracts with the public transit district upon the first violation;
             171          (B) a six-month suspension of the contractor or subcontractor from entering into future
             172      contracts with the public transit district upon the second violation;
             173          (C) an action for debarment of the contractor or subcontractor in accordance with
             174      Section 63G-6a-904 upon the third or subsequent violation; and
             175          (D) monetary penalties which may not exceed 50% of the amount necessary to
             176      purchase qualified health insurance coverage for employees and dependents of employees of
             177      the contractor or subcontractor who were not offered qualified health insurance coverage
             178      during the duration of the contract; and
             179          (iii) a website on which the district shall post the benchmark for the qualified health
             180      insurance coverage identified in Subsection (1)(c).


             181          (7) (a) (i) In addition to the penalties imposed under Subsection (6)(b)(ii), a contractor
             182      or subcontractor who intentionally violates the provisions of this section shall be liable to the
             183      employee for health care costs that would have been covered by qualified health insurance
             184      coverage.
             185          (ii) An employer has an affirmative defense to a cause of action under Subsection
             186      (7)(a)(i) if:
             187          (A) the employer relied in good faith on a written statement of actuarial equivalency
             188      provided by an:
             189          (I) actuary; or
             190          (II) underwriter who is responsible for developing the employer group's premium rates;
             191      or
             192          (B) a department or division determines that compliance with this section is not
             193      required under the provisions of Subsection (3) or (4).
             194          (b) An employee has a private right of action only against the employee's employer to
             195      enforce the provisions of this Subsection (7).
             196          (8) Any penalties imposed and collected under this section shall be deposited into the
             197      Medicaid Restricted Account created in Section 26-18-402 .
             198          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             199      coverage as required by this section:
             200          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             201      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             202      Procurement Code; and
             203          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             204      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             205      or construction.
             206          Section 2. Section 19-1-206 is amended to read:
             207           19-1-206. Contracting powers of department -- Health insurance coverage.
             208          (1) For purposes of this section:
             209          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             210      34A-2-104 who:
             211          (i) works at least 30 hours per calendar week; and


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


             243          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             244      or a modification to a contract, when the contract does not meet the initial threshold required
             245      by Subsection (2).
             246          (b) A person who intentionally uses change orders or contract modifications to
             247      circumvent the requirements of Subsection (2) is guilty of an infraction.
             248          (5) (a) A contractor subject to Subsection (2) shall demonstrate to the executive
             249      director that the contractor has and will maintain an offer of qualified health insurance
             250      coverage for the contractor's employees and the employees' dependents during the duration of
             251      the contract.
             252          (b) If a subcontractor of the contractor is subject to Subsection (2), the contractor shall
             253      demonstrate to the executive director that the subcontractor has and will maintain an offer of
             254      qualified health insurance coverage for the subcontractor's employees and the employees'
             255      dependents during the duration of the contract.
             256          (c) (i) (A) A contractor who fails to comply with Subsection (5)(a) during the duration
             257      of the contract is subject to penalties in accordance with administrative rules adopted by the
             258      department under Subsection (6).
             259          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             260      requirements of Subsection (5)(b).
             261          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during
             262      the duration of the contract is subject to penalties in accordance with administrative rules
             263      adopted by the department under Subsection (6).
             264          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             265      requirements of Subsection (5)(a).
             266          (6) The department shall adopt administrative rules:
             267          (a) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             268          (b) in coordination with:
             269          (i) a public transit district in accordance with Section 17B-2a-818.5 ;
             270          (ii) the Department of Natural Resources in accordance with Section 79-2-404 ;
             271          (iii) the State Building Board in accordance with Section 63A-5-205 ;
             272          (iv) the State Capitol Preservation Board in accordance with Section 63C-9-403 ;
             273          (v) the Department of Transportation in accordance with Section 72-6-107.5 ; and


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


             305          (ii) An employer has an affirmative defense to a cause of action under Subsection
             306      (7)(a)(i) if:
             307          (A) the employer relied in good faith on a written statement of actuarial equivalency
             308      provided by:
             309          (I) an actuary; or
             310          (II) an underwriter who is responsible for developing the employer group's premium
             311      rates; or
             312          (B) the department determines that compliance with this section is not required under
             313      the provisions of Subsection (3) or (4).
             314          (b) An employee has a private right of action only against the employee's employer to
             315      enforce the provisions of this Subsection (7).
             316          (8) Any penalties imposed and collected under this section shall be deposited into the
             317      Medicaid Restricted Account created in Section 26-18-402 .
             318          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             319      coverage as required by this section:
             320          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             321      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             322      Procurement Code; and
             323          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             324      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             325      or construction.
             326          Section 3. Section 26-33a-106.1 is amended to read:
             327           26-33a-106.1. Health care cost and reimbursement data.
             328          [(1) (a) The committee shall, as funding is available, establish an advisory panel to
             329      advise the committee on the development of a plan for the collection and use of health care
             330      data pursuant to Subsection 26-33a-104 (6) and this section.]
             331          [(b) The advisory panel shall include:]
             332          [(i) the chairman of the Utah Hospital Association;]
             333          [(ii) a representative of a rural hospital as designated by the Utah Hospital
             334      Association;]
             335          [(iii) a representative of the Utah Medical Association;]


             336          [(iv) a physician from a small group practice as designated by the Utah Medical
             337      Association;]
             338          [(v) two representatives who are health insurers, appointed by the committee;]
             339          [(vi) a representative from the Department of Health as designated by the executive
             340      director of the department;]
             341          [(vii) a representative from the committee;]
             342          [(viii) a consumer advocate appointed by the committee;]
             343          [(ix) a member of the House of Representatives appointed by the speaker of the House;
             344      and]
             345          [(x) a member of the Senate appointed by the president of the Senate.]
             346          [(c) The advisory panel shall elect a chair from among its members, and shall be
             347      staffed by the committee.]
             348          [(2) (a)] (1) The committee shall, as funding is available:
             349          [(i)] (a) establish a plan for collecting data from data suppliers, as defined in Section
             350      26-33a-102 , to determine measurements of cost and reimbursements for risk-adjusted episodes
             351      of health care;
             352          [(ii)] (b) share data regarding insurance claims and an individual's and small employer
             353      group's health risk factor and characteristics of insurance arrangements that affect claims and
             354      usage with [insurers participating in the defined contribution market created in Title 31A,
             355      Chapter 30, Part 2, Defined Contribution Arrangements] the Insurance Department, only to the
             356      extent necessary for:
             357          (i) risk adjusting; and
             358          (ii) the review and analysis of health insurers' premiums and rate filings; and
             359          [(A) establishing rates and prospective risk adjusting in the defined contribution
             360      arrangement market; and]
             361          [(B) risk adjusting in the defined contribution arrangement market; and]
             362          [(iii)] (c) assist the Legislature and the public with awareness of, and the promotion of,
             363      transparency in the health care market by reporting on:
             364          [(A)] (i) geographic variances in medical care and costs as demonstrated by data
             365      available to the committee; and
             366          [(B)] (ii) rate and price increases by health care providers:


             367          [(I)] (A) that exceed the Consumer Price Index - Medical as provided by the United
             368      States Bureau of Labor Statistics;
             369          [(II)] (B) as calculated yearly from June to June; and
             370          [(III)] (C) as demonstrated by data available to the committee[.]; and
             371          (d) provided on at least a monthly basis, enrollment data collected by the committee to
             372      a not-for-profit, broad-based coalition of state health care insurers and health care providers
             373      that are involved in the standardized electronic exchange of health data as described in Section
             374      31A-22-614.5 , to the extent necessary:
             375          (A) for the department or the Medicaid Office of the Inspector General to determine
             376      insurance enrollment of an individual for the purpose of determining Medicaid third part
             377      liability;
             378          (B) for an insurer that is a data supplier, to determine insurance enrollment of an
             379      individual for the purpose of coordination of health care benefits; and
             380          (C) for a health care provider, to determine insurance enrollment for a patient for the
             381      purpose of claims submission by the health care provider.
             382          (2) (a) The Medicaid Office of Inspector General shall annually report to the
             383      Legislature's Health and Human Services Interim Committee regarding how the office used the
             384      data obtained under Subsection (1)(c)(iii) and the results of obtaining the data.
             385          (b) A data supplier shall not be liable for a breach of or unlawful disclosure of the data
             386      obtained by an entity described in Subsection (1)(c)(iii).
             387          [(b)] (3) The plan adopted under [this] Subsection [(2)] (1) shall include:
             388          [(i)] (a) the type of data that will be collected;
             389          [(ii)] (b) how the data will be evaluated;
             390          [(iii)] (c) how the data will be used;
             391          [(iv)] (d) the extent to which, and how the data will be protected; and
             392          [(v)] (e) who will have access to the data.
             393          Section 4. Section 26-33a-106.5 is amended to read:
             394           26-33a-106.5. Comparative analyses.
             395          (1) The committee may publish compilations or reports that compare and identify
             396      health care providers or data suppliers from the data it collects under this chapter or from any
             397      other source.


             398          (2) (a) [The] Except as provided in Subsection (7)(c), the committee shall publish
             399      compilations or reports from the data it collects under this chapter or from any other source
             400      which:
             401          (i) contain the information described in Subsection (2)(b); and
             402          (ii) compare and identify by name at least a majority of the health care facilities, health
             403      care plans, and institutions in the state.
             404          (b) [The] Except as provided in Subsection (7)(c), the report required by this
             405      Subsection (2) shall:
             406          (i) be published at least annually; and
             407          (ii) contain comparisons based on at least the following factors:
             408          (A) nationally or other generally recognized quality standards;
             409          (B) charges; and
             410          (C) nationally recognized patient safety standards.
             411          (3) The committee may contract with a private, independent analyst to evaluate the
             412      standard comparative reports of the committee that identify, compare, or rank the performance
             413      of data suppliers by name. The evaluation shall include a validation of statistical
             414      methodologies, limitations, appropriateness of use, and comparisons using standard health
             415      services research practice. The analyst shall be experienced in analyzing large databases from
             416      multiple data suppliers and in evaluating health care issues of cost, quality, and access. The
             417      results of the analyst's evaluation shall be released to the public before the standard
             418      comparative analysis upon which it is based may be published by the committee.
             419          (4) The committee shall adopt by rule a timetable for the collection and analysis of data
             420      from multiple types of data suppliers.
             421          (5) The comparative analysis required under Subsection (2) shall be available:
             422          (a) free of charge and easily accessible to the public; and
             423          (b) on the Health Insurance Exchange either directly or through a link.
             424          (6) (a) The department shall include in the report required by Subsection (2)(b), or
             425      include in a separate report, comparative information on commonly recognized or generally
             426      agreed upon measures of cost and quality identified in accordance with Subsection (7), for:
             427          (i) routine and preventive care; and
             428          (ii) the treatment of diabetes, heart disease, and other illnesses or conditions as


             429      determined by the committee.
             430          (b) The comparative information required by Subsection (6)(a) shall be based on data
             431      collected under Subsection (2) and clinical data that may be available to the committee, and
             432      shall [beginning on or after July 1, 2012,] compare:
             433          (i) beginning December 31, 2014, results for health care facilities or institutions;
             434          (ii) beginning December 31, 2014, results for health care providers by geographic
             435      regions of the state;
             436          [(ii)] (iii) beginning July 1, 2016, a clinic's aggregate results for a physician who
             437      practices at a clinic with five or more physicians; and
             438          [(iii)] (iv) beginning July 1, 2016, a geographic region's aggregate results for a
             439      physician who practices at a clinic with less than five physicians, unless the physician requests
             440      physician-level data to be published on a clinic level.
             441          (c) The department:
             442          (i) may publish information required by this Subsection (6) directly or through one or
             443      more nonprofit, community-based health data organizations;
             444          (ii) may use a private, independent analyst under Subsection (3) in preparing the report
             445      required by this section; and
             446          (iii) shall identify and report to the Legislature's Health and Human Services Interim
             447      Committee by July 1, [2012] 2014, and every July 1[,] thereafter until July 1, [2015, at least
             448      five] 2019, at least three new measures of quality to be added to the report each year.
             449          (d) A report published by the department under this Subsection (6):
             450          (i) is subject to the requirements of Section 26-33a-107 ; and
             451          (ii) shall, prior to being published by the department, be submitted to a neutral,
             452      non-biased entity with a broad base of support from health care payers and health care
             453      providers in accordance with Subsection (7) for the purpose of validating the report.
             454          (7) (a) The Health Data Committee shall, through the department, for purposes of
             455      Subsection (6)(a), use the quality measures that are developed and agreed upon by a neutral,
             456      non-biased entity with a broad base of support from health care payers and health care
             457      providers.
             458          (b) If the entity described in Subsection (7)(a) does not submit the quality measures,
             459      the department may select the appropriate number of quality measures for purposes of the


             460      report required by Subsection (6).
             461          (c) (i) For purposes of the reports published on or after July 1, [2012] 2014, the
             462      department may not compare individual facilities or clinics as described in Subsections
             463      (6)(b)(i) through [(iii)] (iv) if the department determines that the data available to the
             464      department can not be appropriately validated, does not represent nationally recognized
             465      measures, does not reflect the mix of cases seen at a clinic or facility, or is not sufficient for the
             466      purposes of comparing providers.
             467          (ii) The department shall report to the Legislature's Executive Appropriations
             468      Committee prior to making a determination not to publish a report under Subsection (7)(c)(i).
             469          Section 5. Section 26-33a-109 is amended to read:
             470           26-33a-109. Exceptions to prohibition on disclosure of identifiable health data.
             471          (1) The committee may not disclose any identifiable health data unless:
             472          (a) the individual has authorized the disclosure; or
             473          (b) the disclosure complies with the provisions of:
             474          (i) this section[.];
             475          (ii) insurance enrollment and coordination of benefits under Subsection
             476      26-33a-104 (1)(b); or
             477          (iii) risk adjusting under Subsection 26-33a-106.1 (1)(c)(iii).
             478          (2) The committee shall consider the following when responding to a request for
             479      disclosure of information that may include identifiable health data:
             480          (a) whether the request comes from a person after that person has received approval to
             481      do the specific research and statistical work from an institutional review board; and
             482          (b) whether the requesting entity complies with the provisions of Subsection (3).
             483          (3) A request for disclosure of information that may include identifiable health data
             484      shall:
             485          (a) be for a specified period; or
             486          (b) be solely for bona fide research and statistical purposes as determined in
             487      accordance with administrative rules adopted by the department, which shall require:
             488          (i) the requesting entity to demonstrate to the department that the data is required for
             489      the research and statistical purposes proposed by the requesting entity; and
             490          (ii) the requesting entity to enter into a written agreement satisfactory to the department


             491      to protect the data in accordance with this chapter or other applicable law.
             492          (4) A person accessing identifiable health data pursuant to Subsection (3) may not
             493      further disclose the identifiable health data:
             494          (a) without prior approval of the department; and
             495          (b) unless the identifiable health data is disclosed or identified by control number only.
             496          Section 6. Section 31A-4-115 is amended to read:
             497           31A-4-115. Plan of orderly withdrawal.
             498          (1) (a) When an insurer intends to withdraw from writing a line of insurance in this
             499      state or to reduce its total annual premium volume by 75% or more, the insurer shall file with
             500      the commissioner a plan of orderly withdrawal.
             501          (b) For purposes of this section, a discontinuance of a health benefit plan pursuant to
             502      one of the following provisions is a withdrawal from a line of insurance:
             503          (i) Subsection 31A-30-107 (3)(e); or
             504          (ii) Subsection 31A-30-107.1 (3)(e).
             505          (2) An insurer's plan of orderly withdrawal shall:
             506          (a) indicate the date the insurer intends to begin and complete its withdrawal plan; and
             507          (b) include provisions for:
             508          (i) meeting the insurer's contractual obligations;
             509          (ii) providing services to its Utah policyholders and claimants;
             510          (iii) meeting any applicable statutory obligations; and
             511          (iv) (A) the payment of a withdrawal fee of $50,000 to the Utah Comprehensive Health
             512      Insurance Pool if:
             513          (I) the insurer is an accident and health insurer; and
             514          (II) the insurer's line of business is not assumed or placed with another insurer
             515      approved by the commissioner; or
             516          (B) the payment of a withdrawal fee of $50,000 to the department if:
             517          (I) the insurer is not an accident and health insurer; and
             518          (II) the insurer's line of business is not assumed or placed with another insurer
             519      approved by the commissioner.
             520          (3) The commissioner shall approve a plan of orderly withdrawal if the plan adequately
             521      demonstrates that the insurer will:


             522          (a) protect the interests of the people of the state;
             523          (b) meet the insurer's contractual obligations;
             524          (c) provide service to the insurer's Utah policyholders and claimants; and
             525          (d) meet any applicable statutory obligations.
             526          (4) Section 31A-2-302 governs the commissioner's approval or disapproval of a plan for
             527      orderly withdrawal.
             528          (5) The commissioner may require an insurer to increase the deposit maintained in
             529      accordance with Section 31A-4-105 or Section 31A-4-105.5 and place the deposit in trust in
             530      the name of the commissioner upon finding, after an adjudicative proceeding that:
             531          (a) there is reasonable cause to conclude that the interests of the people of the state are
             532      best served by such action; and
             533          (b) the insurer:
             534          (i) has filed a plan of orderly withdrawal; or
             535          (ii) intends to:
             536          (A) withdraw from writing a line of insurance in this state; or
             537          (B) reduce the insurer's total annual premium volume by 75% or more.
             538          (6) An insurer is subject to the civil penalties under Section 31A-2-308 , if the insurer:
             539          (a) withdraws from writing insurance in this state; or
             540          (b) reduces its total annual premium volume by 75% or more in any year without
             541      having submitted a plan or receiving the commissioner's approval.
             542          (7) An insurer that withdraws from writing all lines of insurance in this state may not
             543      resume writing insurance in this state for five years unless[: (a)] the commissioner finds that
             544      the prohibition should be waived because the waiver is:
             545          [(i)] (a) in the public interest to promote competition; or
             546          [(ii)] (b) to resolve inequity in the marketplace[; and].
             547          [(b) the insurer complies with Subsection 31A-30-108 (5), if applicable.]
             548          (8) The commissioner shall adopt rules necessary to implement this section.
             549          Section 7. Section 31A-8-402.3 is amended to read:
             550           31A-8-402.3. Discontinuance, nonrenewal, or changes to group health benefit
             551      plans.
             552          (1) Except as otherwise provided in this section, a group health benefit plan for a plan


             553      sponsor is renewable and continues in force:
             554          (a) with respect to all eligible employees and dependents; and
             555          (b) at the option of the plan sponsor.
             556          (2) A health benefit plan for a plan sponsor may be discontinued or nonrenewed[: (a)]
             557      for a network plan, if:
             558          [(i)] (a) there is no longer any enrollee under the group health plan who lives, resides,
             559      or works in:
             560          [(A)] (i) the service area of the insurer; or
             561          [(B)] (ii) the area for which the insurer is authorized to do business; [and] or
             562          [(ii) in the case of the small employer market, the insurer applies the same criteria the
             563      insurer would apply in denying enrollment in the plan under Subsection 31A-30-108 (7); or]
             564          (b) for coverage made available in the small or large employer market only through an
             565      association, if:
             566          (i) the employer's membership in the association ceases; and
             567          (ii) the coverage is terminated uniformly without regard to any health status-related
             568      factor relating to any covered individual.
             569          (3) A health benefit plan for a plan sponsor may be discontinued if:
             570          (a) a condition described in Subsection (2) exists;
             571          (b) the plan sponsor fails to pay premiums or contributions in accordance with the
             572      terms of the contract;
             573          (c) the plan sponsor:
             574          (i) performs an act or practice that constitutes fraud; or
             575          (ii) makes an intentional misrepresentation of material fact under the terms of the
             576      coverage;
             577          (d) the insurer:
             578          (i) elects to discontinue offering a particular health benefit product delivered or issued
             579      for delivery in this state; and
             580          (ii) (A) provides notice of the discontinuation in writing:
             581          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             582          (II) at least 90 days before the date the coverage will be discontinued;
             583          (B) provides notice of the discontinuation in writing:


             584          (I) to the commissioner; and
             585          (II) at least three working days prior to the date the notice is sent to the affected plan
             586      sponsors, employees, and dependents of the plan sponsors or employees;
             587          (C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase:
             588          (I) all other health benefit products currently being offered by the insurer in the market;
             589      or
             590          (II) in the case of a large employer, any other health benefit product currently being
             591      offered in that market; and
             592          (D) in exercising the option to discontinue that product and in offering the option of
             593      coverage in this section, acts uniformly without regard to:
             594          (I) the claims experience of a plan sponsor;
             595          (II) any health status-related factor relating to any covered participant or beneficiary; or
             596          (III) any health status-related factor relating to any new participant or beneficiary who
             597      may become eligible for the coverage; or
             598          (e) the insurer:
             599          (i) elects to discontinue all of the insurer's health benefit plans in:
             600          (A) the small employer market;
             601          (B) the large employer market; or
             602          (C) both the small employer and large employer markets; and
             603          (ii) (A) provides notice of the discontinuation in writing:
             604          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             605          (II) at least 180 days before the date the coverage will be discontinued;
             606          (B) provides notice of the discontinuation in writing:
             607          (I) to the commissioner in each state in which an affected insured individual is known
             608      to reside; and
             609          (II) at least 30 working days prior to the date the notice is sent to the affected plan
             610      sponsors, employees, and the dependents of the plan sponsors or employees;
             611          (C) discontinues and nonrenews all plans issued or delivered for issuance in the
             612      market; and
             613          (D) provides a plan of orderly withdrawal as required by Section 31A-4-115 .
             614          (4) A large employer health benefit plan may be discontinued or nonrenewed:


             615          (a) if a condition described in Subsection (2) exists; or
             616          (b) for noncompliance with the insurer's:
             617          (i) minimum participation requirements; or
             618          (ii) employer contribution requirements.
             619          (5) A small employer health benefit plan may be discontinued or nonrenewed:
             620          (a) if a condition described in Subsection (2) exists; or
             621          (b) for noncompliance with the insurer's employer contribution requirements.
             622          (6) A small employer health benefit plan may be nonrenewed:
             623          (a) if a condition described in Subsection (2) exists; or
             624          (b) for noncompliance with the insurer's minimum participation requirements.
             625          (7) (a) Except as provided in Subsection (7)(d), an eligible employee may be
             626      discontinued if after issuance of coverage the eligible employee:
             627          (i) engages in an act or practice in connection with the coverage that constitutes fraud;
             628      or
             629          (ii) makes an intentional misrepresentation of material fact in connection with the
             630      coverage.
             631          (b) An eligible employee that is discontinued under Subsection (7)(a) may reenroll:
             632          (i) 12 months after the date of discontinuance; and
             633          (ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies
             634      to reenroll.
             635          (c) At the time the eligible employee's coverage is discontinued under Subsection
             636      (7)(a), the insurer shall notify the eligible employee of the right to reenroll when coverage is
             637      discontinued.
             638          (d) An eligible employee may not be discontinued under this Subsection (7) because of
             639      a fraud or misrepresentation that relates to health status.
             640          (8) For purposes of this section, a reference to "plan sponsor" includes a reference to
             641      the employer:
             642          (a) with respect to coverage provided to an employer member of the association; and
             643          (b) if the health benefit plan is made available by an insurer in the employer market
             644      only through:
             645          (i) an association;


             646          (ii) a trust; or
             647          (iii) a discretionary group.
             648          (9) An insurer may modify a health benefit plan for a plan sponsor only:
             649          (a) at the time of coverage renewal; and
             650          (b) if the modification is effective uniformly among all plans with that product.
             651          Section 8. Section 31A-22-721 is amended to read:
             652           31A-22-721. A health benefit plan for a plan sponsor -- Discontinuance and
             653      nonrenewal.
             654          (1) Except as otherwise provided in this section, a health benefit plan for a plan
             655      sponsor is renewable and continues in force:
             656          (a) with respect to all eligible employees and dependents; and
             657          (b) at the option of the plan sponsor.
             658          (2) A health benefit plan for a plan sponsor may be discontinued or nonrenewed[: (a)]
             659      for a network plan, if:
             660          [(i)] (a) there is no longer any enrollee under the group health plan who lives, resides,
             661      or works in:
             662          [(A)] (i) the service area of the insurer; or
             663          [(B)] (ii) the area for which the insurer is authorized to do business; [and] or
             664          [(ii) in the case of the small employer market, the insurer applies the same criteria the
             665      insurer would apply in denying enrollment in the plan under Subsection 31A-30-108 (7); or]
             666          (b) for coverage made available in the small or large employer market only through an
             667      association, if:
             668          (i) the employer's membership in the association ceases; and
             669          (ii) the coverage is terminated uniformly without regard to any health status-related
             670      factor relating to any covered individual.
             671          (3) A health benefit plan for a plan sponsor may be discontinued if:
             672          (a) a condition described in Subsection (2) exists;
             673          (b) the plan sponsor fails to pay premiums or contributions in accordance with the
             674      terms of the contract;
             675          (c) the plan sponsor:
             676          (i) performs an act or practice that constitutes fraud; or


             677          (ii) makes an intentional misrepresentation of material fact under the terms of the
             678      coverage;
             679          (d) the insurer:
             680          (i) elects to discontinue offering a particular health benefit product delivered or issued
             681      for delivery in this state;
             682          (ii) (A) provides notice of the discontinuation in writing:
             683          (I) to each plan sponsor, employee, and dependent of a plan sponsor or employee; and
             684          (II) at least 90 days before the date the coverage will be discontinued;
             685          (B) provides notice of the discontinuation in writing:
             686          (I) to the commissioner; and
             687          (II) at least three working days prior to the date the notice is sent to the affected plan
             688      sponsors, employees, and dependents of plan sponsors or employees;
             689          (C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase any
             690      other health benefit products currently being offered:
             691          (I) by the insurer in the market; or
             692          (II) in the case of a large employer, any other health benefit plan currently being
             693      offered in that market; and
             694          (D) in exercising the option to discontinue that product and in offering the option of
             695      coverage in this section, the insurer acts uniformly without regard to:
             696          (I) the claims experience of a plan sponsor;
             697          (II) any health status-related factor relating to any covered participant or beneficiary; or
             698          (III) any health status-related factor relating to a new participant or beneficiary who
             699      may become eligible for coverage; or
             700          (e) the insurer:
             701          (i) elects to discontinue all of the insurer's health benefit plans:
             702          (A) in the small employer market; or
             703          (B) the large employer market; or
             704          (C) both the small and large employer markets; and
             705          (ii) (A) provides notice of the discontinuance in writing:
             706          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             707          (II) at least 180 days before the date the coverage will be discontinued;


             708          (B) provides notice of the discontinuation in writing:
             709          (I) to the commissioner in each state in which an affected insured individual is known
             710      to reside; and
             711          (II) at least 30 business days prior to the date the notice is sent to the affected plan
             712      sponsors, employees, and dependents of a plan sponsor or employee;
             713          (C) discontinues and nonrenews all plans issued or delivered for issuance in the
             714      market; and
             715          (D) provides a plan of orderly withdrawal as required by Section 31A-4-115 .
             716          (4) A large employer health benefit plan may be discontinued or nonrenewed:
             717          (a) if a condition described in Subsection (2) exists; or
             718          (b) for noncompliance with the insurer's:
             719          (i) minimum participation requirements; or
             720          (ii) employer contribution requirements.
             721          (5) A small employer health benefit plan may be discontinued or nonrenewed:
             722          (a) if a condition described in Subsection (2) exists; or
             723          (b) for noncompliance with the insurer's employer contribution requirements.
             724          (6) A small employer health benefit plan may be nonrenewed:
             725          (a) if a condition described in Subsection (2) exists; or
             726          (b) for noncompliance with the insurer's minimum participation requirements.
             727          (7) (a) Except as provided in Subsection (7)(d), an eligible employee may be
             728      discontinued if after issuance of coverage the eligible employee:
             729          (i) engages in an act or practice that constitutes fraud in connection with the coverage;
             730      or
             731          (ii) makes an intentional misrepresentation of material fact in connection with the
             732      coverage.
             733          (b) An eligible employee that is discontinued under Subsection (7)(a) may reenroll:
             734          (i) 12 months after the date of discontinuance; and
             735          (ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies
             736      to reenroll.
             737          (c) At the time the eligible employee's coverage is discontinued under Subsection
             738      (7)(a), the insurer shall notify the eligible employee of the right to reenroll when coverage is


             739      discontinued.
             740          (d) An eligible employee may not be discontinued under this Subsection (7) because of
             741      a fraud or misrepresentation that relates to health status.
             742          (8) (a) Except as provided in Subsection (8)(b), an insurer that elects to discontinue
             743      offering a health benefit plan under Subsection (3)(e) shall be prohibited from writing new
             744      business in such market in this state for a period of five years beginning on the date of
             745      discontinuation of the last coverage that is discontinued.
             746          (b) The commissioner may waive the prohibition under Subsection (8)(a) when the
             747      commissioner finds that waiver is in the public interest:
             748          (i) to promote competition; or
             749          (ii) to resolve inequity in the marketplace.
             750          (9) If an insurer is doing business in one established geographic service area of the
             751      state, this section applies only to the insurer's operations in that geographic service area.
             752          (10) An insurer may modify a health benefit plan for a plan sponsor only:
             753          (a) at the time of coverage renewal; and
             754          (b) if the modification is effective uniformly among all plans with a particular product
             755      or service.
             756          (11) For purposes of this section, a reference to "plan sponsor" includes a reference to
             757      the employer:
             758          (a) with respect to coverage provided to an employer member of the association; and
             759          (b) if the health benefit plan is made available by an insurer in the employer market
             760      only through:
             761          (i) an association;
             762          (ii) a trust; or
             763          (iii) a discretionary group.
             764          (12) (a) A small employer that, after purchasing a health benefit plan in the small group
             765      market, employs on average more than 50 eligible employees on each business day in a
             766      calendar year may continue to renew the health benefit plan purchased in the small group
             767      market.
             768          (b) A large employer that, after purchasing a health benefit plan in the large group
             769      market, employs on average less than 51 eligible employees on each business day in a calendar


             770      year may continue to renew the health benefit plan purchased in the large group market.
             771          (13) An insurer offering employer sponsored health benefit plans shall comply with the
             772      Health Insurance Portability and Accountability Act, 42 U.S.C. Sec. 300gg and 300gg-1.
             773          Section 9. Section 31A-23b-202.5 is enacted to read:
             774          31A-23b-202.5. License types.
             775          (1) A license issued under this chapter shall be issued under the license types described
             776      in Subsection (2).
             777          (2) A license type under this chapter shall be a navigator line of authority or a certified
             778      application counselor line of authority. A license type is intended to describe the matters to be
             779      considered under any education, examination, and training required of an applicant under this
             780      chapter.
             781          (3) (a) A navigator line of authority includes the enrollment process as described in
             782      Subsection 31A-23b-102 (4)(a).
             783          (b) (i) A certified application counselor line of authority is limited to providing
             784      information and assistance to individuals and employees about public programs and premium
             785      subsidies available through the exchange.
             786          (ii) A certified application counselor line of authority does not allow the certified
             787      application counselor to assist a person with the selection of or enrollment in a qualified health
             788      plan offered on an exchange.
             789          Section 10. Section 31A-23b-205 is amended to read:
             790           31A-23b-205. Examination and training requirements.
             791          (1) The commissioner may require [applicants] an applicant for a license to pass an
             792      examination and complete a training program as a requirement for a license.
             793          (2) The examination described in Subsection (1) shall reasonably relate to:
             794          (a) the duties and functions of a navigator;
             795          (b) requirements for navigators as established by federal regulation under PPACA; and
             796          (c) other requirements that may be established by the commissioner by administrative
             797      rule.
             798          (3) The examination may be administered by the commissioner or as otherwise
             799      specified by administrative rule.
             800          (4) The training required by Subsection (1) shall be approved by the commissioner and


             801      shall include:
             802          (a) accident and health insurance plans;
             803          (b) qualifications for and enrollment in public programs;
             804          (c) qualifications for and enrollment in premium subsidies;
             805          (d) cultural and linguistic competence;
             806          (e) conflict of interest standards;
             807          (f) exchange functions; and
             808          (g) other requirements that may be adopted by the commissioner by administrative
             809      rule.
             810          (5) (a) For the navigator line of authority, the training required by Subsection (1) shall
             811      consist of at least 21 credit hours of training before obtaining the license, which shall include:
             812          (i) at least two hours of training on defined contribution arrangements and the small
             813      employer health insurance exchange; and
             814          (ii) the navigator training and certification program developed by the Centers for
             815      Medicare and Medicaid Services.
             816          (b) For the certified application counselor line of authority, the training required by
             817      Subsection (1) shall consist of at least six hours of training before obtaining a license, which
             818      shall include:
             819          (i) at least one hour of training on defined contribution arrangements and the small
             820      employer health insurance exchange; and
             821          (ii) the certified application counselor training and certification program developed by
             822      the Centers for Medicare and Medicaid Services.
             823          [(5)] (6) This section applies only to [applicants who are natural persons] an applicant
             824      who is a natural person.
             825          Section 11. Section 31A-23b-206 is amended to read:
             826           31A-23b-206. Continuing education requirements.
             827          (1) The commissioner shall, by rule, prescribe continuing education requirements for a
             828      navigator.
             829          (2) (a) The commissioner may not require a degree from an institution of higher
             830      education as part of continuing education.
             831          (b) The commissioner may state a continuing education requirement in terms of hours


             832      of instruction received in:
             833          (i) accident and health insurance;
             834          (ii) qualification for and enrollment in public programs;
             835          (iii) qualification for and enrollment in premium subsidies;
             836          (iv) cultural competency;
             837          (v) conflict of interest standards; and
             838          (vi) other exchange functions.
             839          (3) (a) [Continuing] For a navigator line of authority, continuing education
             840      requirements shall require:
             841          (i) that a licensee complete [24] 12 credit hours of continuing education for every
             842      [two-year] one-year licensing period;
             843          (ii) that [3] at least two of the [24] 12 credit hours described in Subsection (3)(a)(i) be
             844      ethics courses; [and]
             845          [(iii) that the licensee complete at least half of the required hours through classroom
             846      hours of insurance and exchange related instruction.]
             847          (iii) that at least one of the 12 credit hours described in Subsection (3)(a)(i) be training
             848      on defined contribution arrangements and the use of the small employer health insurance
             849      exchange; and
             850          (iv) that a licensee complete the annual navigator training and certification program
             851      developed by the Centers for Medicare and Medicaid Services.
             852          (b) For a certified application counselor, the continuing education requirements shall
             853      require:
             854          (i) that a licensee complete six credit hours of continuing education for every one-year
             855      licensing period;
             856          (ii) that at least two of the six credit hours described in Subsection (3)(b)(i) be on
             857      ethics courses;
             858          (iii) that at least one of the six credit hours described in Subsection (3)(b)(i) be training
             859      on defined contribution arrangements and the use of the small employer health insurance
             860      exchange; and
             861          (iv) that a licensee complete the annual certified application counselor training and
             862      certification program developed by the Centers for Medicare and Medicaid Services.


             863          [(b)] (c) An hour of continuing education in accordance with [Subsection] Subsections
             864      (3)(a)(i) and(b)(i) may be obtained through:
             865          (i) classroom attendance;
             866          (ii) home study;
             867          (iii) watching a video recording; or
             868          [(iv) experience credit; or]
             869          [(v)] (iv) another method approved by rule.
             870          [(c)] (d) A licensee may obtain continuing education hours at any time during the
             871      [two-year] one-year license period.
             872          [(d)] (e) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking
             873      Act, the commissioner shall, by rule[: (i) publish a list of insurance professional designations
             874      whose continuing education requirements can be used to meet the requirements for continuing
             875      education under Subsection (3)(b); and (ii)], authorize one or more continuing education
             876      providers, including a state or national professional producer or consultant associations, to:
             877          [(A)] (i) offer a qualified program on a geographically accessible basis; and
             878          [(B)] (ii) collect a reasonable fee for funding and administration of a continuing
             879      education program, subject to the review and approval of the commissioner.
             880          (4) The commissioner shall approve a continuing education provider or a continuing
             881      education course that satisfies the requirements of this section.
             882          (5) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the
             883      commissioner shall by rule establish the procedures for continuing education provider
             884      registration and course approval.
             885          (6) This section applies only to a navigator who is a natural person.
             886          (7) A navigator shall keep documentation of completing the continuing education
             887      requirements of this section for two years after the end of the two-year licensing period to
             888      which the continuing education applies.
             889          Section 12. Section 31A-23b-211 is amended to read:
             890           31A-23b-211. Exceptions to navigator licensing.
             891          (1) For purposes of this section:
             892          (a) "Negotiate" is as defined in Section 31A-23a-102 .
             893          (b) "Sell" is as defined in Section 31A-23a-102 .


             894          (c) "Solicit" is as defined in Section 31A-23a-102 .
             895          (2) The commissioner may not require a license as a navigator of:
             896          (a) a person who is employed by or contracts with:
             897          (i) a health care facility that is licensed under Title 26, Chapter 21, Health Care Facility
             898      Licensing and Inspection Act, to assist an individual with enrollment in a public program or an
             899      application for premium subsidy; or
             900          (ii) the state, a political subdivision of the state, an entity of a political subdivision of
             901      the state, or a public school district to assist an individual with enrollment in a public program
             902      or an application for premium subsidy;
             903          (b) a federally qualified health center as defined by Section 1905(1)(2)(B) of the Social
             904      Security Act which assists an individual with enrollment in a public program or an application
             905      for premium subsidy;
             906          (c) a person licensed under Chapter 23a, Insurance Marketing-Licensing, Consultants,
             907      and Reinsurance Intermediaries, if the person is licensed in the appropriate line of authority to
             908      sell, solicit, or negotiate accident and health insurance plans;
             909          (d) an officer, director, or employee of a navigator:
             910          (i) who does not receive compensation or commission from an insurer issuing an
             911      insurance contract, an agency administering a public program, an individual who enrolled in a
             912      public program or insurance product, or an exchange; and
             913          (ii) whose activities:
             914          (A) are executive, administrative, managerial, clerical, or a combination thereof;
             915          (B) only indirectly relate to the sale, solicitation, or negotiation of insurance, or the
             916      enrollment in a public program offered through the exchange;
             917          (C) are in the capacity of a special agent or agency supervisor assisting an insurance
             918      producer or navigator;
             919          (D) are limited to providing technical advice and assistance to a licensed insurance
             920      producer or navigator; or
             921          (E) do not include the sale, solicitation, or negotiation of insurance, or the enrollment
             922      in a public program; [and]
             923          (e) a person who does not sell, solicit, or negotiate insurance and is not directly or
             924      indirectly compensated by an insurer issuing an insurance contract, an agency administering a


             925      public program, an individual who enrolled in a public program or insurance product, or an
             926      exchange, including:
             927          (i) an employer, association, officer, director, employee, or trustee of an employee trust
             928      plan who is engaged in the administration or operation of a program:
             929          (A) of employee benefits for the employer's or association's own employees or the
             930      employees of a subsidiary or affiliate of an employer or association; and
             931          (B) that involves the use of insurance issued by an insurer or enrollment in a public
             932      health plan on an exchange;
             933          (ii) an employee of an insurer or organization employed by an insurer who is engaging
             934      in the inspection, rating, or classification of risk, or the supervision of training of insurance
             935      producers; or
             936          (iii) an employee who counsels or advises the employee's employer with regard to the
             937      insurance interests of the employer, or a subsidiary or business affiliate of the employer[.]; and
             938          (f) an Indian health clinic or Urban Indian Health Center, as defined in Title V of the
             939      Indian Health Care Improvement Act, which assists a person with enrollment in a public
             940      program or an application for a premium subsidy.
             941          (3) The exemption from licensure under Subsections (2)(a) [and], (b), and (f) does not
             942      apply if a person described in Subsections (2)(a) [and], (b), and (f) enrolls a person in a private
             943      insurance plan.
             944          (4) The commissioner may by rule exempt a class of persons from the license
             945      requirement of Subsection 31A-23b-201 (1) if:
             946          (a) the functions performed by the class of persons do not require:
             947          (i) special competence;
             948          (ii) special trustworthiness; or
             949          (iii) regulatory surveillance made possible by licensing; or
             950          (b) other existing safeguards make regulation unnecessary.
             951          Section 13. Section 31A-29-106 is amended to read:
             952           31A-29-106. Powers of board.
             953          (1) The board shall have the general powers and authority granted under the laws of
             954      this state to insurance companies licensed to transact health care insurance business. In
             955      addition, the board shall [have the specific authority to]:


             956          (a) have the specific authority to enter into contracts to carry out the provisions and
             957      purposes of this chapter, including, with the approval of the commissioner, contracts with:
             958          (i) similar pools of other states for the joint performance of common administrative
             959      functions; or
             960          (ii) persons or other organizations for the performance of administrative functions;
             961          (b) sue or be sued, including taking such legal action necessary to avoid the payment of
             962      improper claims against the pool or the coverage provided through the pool;
             963          (c) establish appropriate rates, rate schedules, rate adjustments, expense allowances,
             964      agents' referral fees, claim reserve formulas, and any other actuarial function appropriate to the
             965      operation of the pool;
             966          [(d) issue policies of insurance in accordance with the requirements of this chapter;]
             967          (d) (i) close enrollment in the plans issued by the pool and cancel the plans issued by
             968      the pool in accordance with the plan of operation approved by the commissioner; and
             969          (ii) close out the business of the pool in accordance with the plan of operation,
             970      including processing and paying valid claims incurred by enrollees prior to the date enrollment
             971      is closed under Subsection (1)(d)(i);
             972          (e) retain an executive director and appropriate legal, actuarial, and other personnel as
             973      necessary to provide technical assistance in the operations of the pool and to close pool
             974      business in accordance with Subsection (1)(d);
             975          (f) establish rules, conditions, and procedures for reinsuring risks under this chapter;
             976          (g) cause the pool to have an annual and a final audit of its operations by the state
             977      auditor;
             978          [(h) coordinate with the Department of Health in seeking to obtain from the Centers for
             979      Medicare and Medicaid Services, or other appropriate office or agency of government, all
             980      appropriate waivers, authority, and permission needed to coordinate the coverage available
             981      from the pool with coverage available under Medicaid, either before or after Medicaid
             982      coverage, or as a conversion option upon completion of Medicaid eligibility, without the
             983      necessity for requalification by the enrollee;]
             984          [(i)] (h) provide for and employ cost containment measures and requirements including
             985      preadmission certification, concurrent inpatient review, and individual case management for
             986      the purpose of making the pool more cost-effective;


             987          [(j) offer pool coverage through contracts with health maintenance organizations,
             988      preferred provider organizations, and other managed care systems that will manage costs while
             989      maintaining quality care;]
             990          [(k)] (i) establish annual limits on benefits payable under the pool to or on behalf of
             991      any enrollee;
             992          [(l)] (j) exclude from coverage under the pool specific benefits, medical conditions,
             993      and procedures for the purpose of protecting the financial viability of the pool;
             994          [(m)] (k) administer the Pool Fund;
             995          [(n)] (l) make rules in accordance with Title 63G, Chapter 3, Utah Administrative
             996      Rulemaking Act, to implement this chapter;
             997          [(o)] (m) adopt, trademark, and copyright a trade name for the pool for use in
             998      marketing and publicizing the pool and its products; and
             999          [(p)] (n) transition health care coverage for all individuals covered under the pool as
             1000      part of the conversion to health insurance coverage, regardless of preexisting conditions, under
             1001      PPACA.
             1002          (2) (a) The board shall prepare and submit an annual and final report to the Legislature
             1003      which shall include:
             1004          (i) the net premiums anticipated;
             1005          (ii) actuarial projections of payments required of the pool;
             1006          (iii) the expenses of administration; and
             1007          (iv) the anticipated reserves or losses of the pool.
             1008          (b) The budget for operation of the pool is subject to the approval of the board.
             1009          (c) The administrative budget of the board and the commissioner under this chapter
             1010      shall comply with the requirements of Title 63J, Chapter 1, Budgetary Procedures Act, and is
             1011      subject to review and approval by the Legislature.
             1012          [(3) (a) The board shall on or before September 1, 2004, require the plan administrator
             1013      or an independent actuarial consultant retained by the plan administrator to redetermine the
             1014      reasonable equivalent of the criteria for uninsurability required under Subsection
             1015      31A-30-106 (1)(h) that is used by the board to determine eligibility for coverage in the pool.]
             1016          [(b) The board shall redetermine the criteria established in Subsection (3)(a) at least
             1017      every five years thereafter.]


             1018          Section 14. Section 31A-29-110 is amended to read:
             1019           31A-29-110. Pool administrator -- Selection -- Powers.
             1020          (1) The board shall select a pool administrator in accordance with Title 63G, Chapter
             1021      6a, Utah Procurement Code. The board shall evaluate bids based on criteria established by the
             1022      board, which shall include:
             1023          (a) ability to manage medical expenses;
             1024          (b) proven ability to handle accident and health insurance;
             1025          (c) efficiency of claim paying procedures;
             1026          (d) marketing and underwriting;
             1027          (e) proven ability for managed care and quality assurance;
             1028          (f) provider contracting and discounts;
             1029          (g) pharmacy benefit management;
             1030          (h) an estimate of total charges for administering the pool; and
             1031          (i) ability to administer the pool in a cost-efficient manner.
             1032          (2) A pool administrator may be:
             1033          (a) a health insurer;
             1034          (b) a health maintenance organization;
             1035          (c) a third-party administrator; or
             1036          (d) any person or entity which has demonstrated ability to meet the criteria in
             1037      Subsection (1).
             1038          (3) [(a)] The pool administrator shall serve for a period of three years, with [two
             1039      one-year] yearly extension options until the operations of the pool are closed pursuant to
             1040      Subsection 31A-29-106 (1)(d), subject to the terms, conditions, and limitations of the contract
             1041      between the board and the administrator.
             1042          [(b) At least one year prior to the expiration of the contract between the board and the
             1043      pool administrator, the board shall invite all interested parties, including the current pool
             1044      administrator, to submit bids to serve as the pool administrator].
             1045          [(c) Selection of the pool administrator for a succeeding period shall be made at least
             1046      six months prior to the expiration of the period of service under Subsection (3)(a).]
             1047          (4) The pool administrator is responsible for all operational functions of the pool and
             1048      shall:


             1049          (a) have access to all nonpatient specific experience data, statistics, treatment criteria,
             1050      and guidelines compiled or adopted by the Medicaid program, the Public Employees Health
             1051      Plan, the Department of Health, or the Insurance Department, and which are not otherwise
             1052      declared by statute to be confidential;
             1053          (b) perform all marketing, eligibility, enrollment, member agreements, and
             1054      administrative claim payment functions relating to the pool;
             1055          (c) establish, administer, and operate a monthly premium billing procedure for
             1056      collection of premiums from enrollees;
             1057          (d) perform all necessary functions to assure timely payment of benefits to enrollees,
             1058      including:
             1059          (i) making information available relating to the proper manner of submitting a claim
             1060      for benefits to the pool administrator and distributing forms upon which submission shall be
             1061      made; and
             1062          (ii) evaluating the eligibility of each claim for payment by the pool;
             1063          (e) submit regular reports to the board regarding the operation of the pool, the
             1064      frequency, content, and form of which reports shall be determined by the board;
             1065          (f) following the close of each calendar year, determine net written and earned
             1066      premiums, the expense of administration, and the paid and incurred losses for the year and
             1067      submit a report of this information to the board, the commissioner, and the Division of Finance
             1068      on a form prescribed by the commissioner; and
             1069          (g) be paid as provided in the plan of operation for expenses incurred in the
             1070      performance of the pool administrator's services.
             1071          Section 15. Section 31A-29-111 is amended to read:
             1072           31A-29-111. Eligibility -- Limitations.
             1073          (1) (a) Except as provided in Subsection (1)(b) and Subsection 31A-29-106 (1)(d), an
             1074      individual who is not HIPAA eligible is eligible for pool coverage if the individual:
             1075          (i) pays the established premium;
             1076          (ii) is a resident of this state; and
             1077          (iii) meets the health underwriting criteria under Subsection (5)(a).
             1078          (b) Notwithstanding Subsection (1)(a), an individual who is not HIPAA eligible is not
             1079      eligible for pool coverage if one or more of the following conditions apply:


             1080          (i) the individual is eligible for health care benefits under Medicaid or Medicare,
             1081      except as provided in Section 31A-29-112 ;
             1082          (ii) the individual has terminated coverage in the pool, unless:
             1083          (A) 12 months have elapsed since the termination date; or
             1084          (B) the individual demonstrates that creditable coverage has been involuntarily
             1085      terminated for any reason other than nonpayment of premium;
             1086          (iii) the pool has paid the maximum lifetime benefit to or on behalf of the individual;
             1087          (iv) the individual is an inmate of a public institution;
             1088          (v) the individual is eligible for a public health plan, as defined in federal regulations
             1089      adopted pursuant to 42 U.S.C. 300gg;
             1090          (vi) the individual's health condition does not meet the criteria established under
             1091      Subsection (5);
             1092          (vii) the individual is eligible for coverage under an employer group that offers a health
             1093      benefit plan or a self-insurance arrangement to its eligible employees, dependents, or members
             1094      as:
             1095          (A) an eligible employee;
             1096          (B) a dependent of an eligible employee; or
             1097          (C) a member;
             1098          (viii) the individual is covered under any other health benefit plan;
             1099          (ix) except as provided in Subsections (3) and (6), at the time of application, the
             1100      individual has not resided in Utah for at least 12 consecutive months preceding the date of
             1101      application; or
             1102          (x) the individual's employer pays any part of the individual's health benefit plan
             1103      premium, either as an insured or a dependent, for pool coverage.
             1104          (2) (a) Except as provided in Subsection (2)(b) and Subsection 31A-29-106 (1)(d), an
             1105      individual who is HIPAA eligible is eligible for pool coverage if the individual:
             1106          (i) pays the established premium; and
             1107          (ii) is a resident of this state.
             1108          (b) Notwithstanding Subsection (2)(a), a HIPAA eligible individual is not eligible for
             1109      pool coverage if one or more of the following conditions apply:
             1110          (i) the individual is eligible for health care benefits under Medicaid or Medicare,


             1111      except as provided in Section 31A-29-112 ;
             1112          (ii) the individual is eligible for a public health plan, as defined in federal regulations
             1113      adopted pursuant to 42 U.S.C. 300gg;
             1114          (iii) the individual is covered under any other health benefit plan;
             1115          (iv) the individual is eligible for coverage under an employer group that offers a health
             1116      benefit plan or self-insurance arrangements to its eligible employees, dependents, or members
             1117      as:
             1118          (A) an eligible employee;
             1119          (B) a dependent of an eligible employee; or
             1120          (C) a member;
             1121          (v) the pool has paid the maximum lifetime benefit to or on behalf of the individual;
             1122          (vi) the individual is an inmate of a public institution; or
             1123          (vii) the individual's employer pays any part of the individual's health benefit plan
             1124      premium, either as an insured or a dependent, for pool coverage.
             1125          (3) (a) Notwithstanding Subsection (1)(b)(ix), if otherwise eligible under Subsection
             1126      (1)(a), an individual whose health care insurance coverage from a state high risk pool with
             1127      similar coverage is terminated because of nonresidency in another state is eligible for coverage
             1128      under the pool subject to the conditions of Subsections (1)(b)(i) through (viii).
             1129          (b) Coverage under Subsection (3)(a) shall be applied for within 63 days after the
             1130      termination date of the previous high risk pool coverage.
             1131          (c) The effective date of this state's pool coverage shall be the date of termination of
             1132      the previous high risk pool coverage.
             1133          (d) The waiting period of an individual with a preexisting condition applying for
             1134      coverage under this chapter shall be waived:
             1135          (i) to the extent to which the waiting period was satisfied under a similar plan from
             1136      another state; and
             1137          (ii) if the other state's benefit limitation was not reached.
             1138          (4) (a) If an eligible individual applies for pool coverage within 30 days of being
             1139      denied coverage by an individual carrier, the effective date for pool coverage shall be no later
             1140      than the first day of the month following the date of submission of the completed insurance
             1141      application to the carrier.


             1142          (b) Notwithstanding Subsection (4)(a), for individuals eligible for coverage under
             1143      Subsection (3), the effective date shall be the date of termination of the previous high risk pool
             1144      coverage.
             1145          (5) (a) The board shall establish and adjust, as necessary, health underwriting criteria
             1146      based on:
             1147          (i) health condition; and
             1148          (ii) expected claims so that the expected claims are anticipated to remain within
             1149      available funding.
             1150          (b) The board, with approval of the commissioner, may contract with one or more
             1151      providers under Title 63G, Chapter 6a, Utah Procurement Code, to develop underwriting
             1152      criteria under Subsection (5)(a).
             1153          (c) If an individual is denied coverage by the pool under the criteria established in
             1154      Subsection (5)(a), the pool shall issue a certificate of insurability to the individual for coverage
             1155      under [Subsection] Section 31A-30-108 [(3)].
             1156          (6) (a) Notwithstanding Subsection (1)(b)(ix), if otherwise eligible under Subsection
             1157      (1)(a), an individual whose individual health care insurance coverage was involuntarily
             1158      terminated, is eligible for coverage under the pool subject to the conditions of Subsections
             1159      (1)(b)(i) through (viii) and (x).
             1160          (b) Coverage under Subsection (6)(a) shall be applied for within 63 days after the
             1161      termination date of the previous individual health care insurance coverage.
             1162          (c) The effective date of this state's pool coverage shall be the date of termination of
             1163      the previous individual coverage.
             1164          (d) The waiting period of an individual with a preexisting condition applying for
             1165      coverage under this chapter shall be waived to the extent to which the waiting period was
             1166      satisfied under the individual health insurance plan.
             1167          Section 16. Section 31A-29-113 is amended to read:
             1168           31A-29-113. Benefits -- Additional types of pool insurance -- Preexisting
             1169      conditions -- Waiver -- Maximum benefits.
             1170          (1) (a) The pool policy shall pay for eligible medical expenses rendered or furnished
             1171      for the diagnoses or treatment of illness or injury that:
             1172          (i) exceed the deductible and copayment amounts applicable under Section


             1173      31A-29-114 ; and
             1174          (ii) are not otherwise limited or excluded.
             1175          (b) Eligible medical expenses are the allowed charges established by the board for the
             1176      health care services and items rendered during times for which benefits are extended under the
             1177      pool policy.
             1178          (c) Section 31A-21-313 applies to coverage issued under this chapter.
             1179          (2) The coverage to be issued by the pool, its schedule of benefits, exclusions, and
             1180      other limitations shall be established by the board.
             1181          (3) The commissioner shall approve the benefit package developed by the board to
             1182      ensure its compliance with this chapter.
             1183          [(4) The pool shall offer at least one benefit plan through a managed care program as
             1184      authorized under Section 31A-29-106 .]
             1185          [(5)] (4) This chapter may not be construed to prohibit the pool from issuing additional
             1186      types of pool policies with different types of benefits which in the opinion of the board may be
             1187      of benefit to the citizens of Utah.
             1188          [(6)] (5) (a) The board shall design and require an administrator to employ cost
             1189      containment measures and requirements including preadmission certification and concurrent
             1190      inpatient review for the purpose of making the pool more cost effective.
             1191          (b) Sections 31A-22-617 and 31A-22-618 do not apply to coverage issued under this
             1192      chapter.
             1193          [(7)] (6) (a) A pool policy may contain provisions under which coverage for a
             1194      preexisting condition is excluded if:
             1195          (i) the exclusion relates to a condition, regardless of the cause of the condition, for
             1196      which medical advice, diagnosis, care, or treatment was recommended or received, from an
             1197      individual licensed or similarly authorized to provide such services under state law and
             1198      operating within the scope of practice authorized by state law, within the six-month period
             1199      ending on the effective date of plan coverage; and
             1200          (ii) except as provided in Subsection (8), the exclusion extends for a period no longer
             1201      than the six-month period following the effective date of plan coverage for a given individual.
             1202          (b) Subsection [(7)] (6)(a) does not apply to a HIPAA eligible individual.
             1203          [(8)] (7) (a) A pool policy may contain provisions under which coverage for a


             1204      preexisting pregnancy is excluded during a ten-month period following the effective date of
             1205      plan coverage for a given individual.
             1206          (b) Subsection [(8)] (7)(a) does not apply to a HIPAA eligible individual.
             1207          [(9)] (8) (a) The pool will waive the preexisting condition exclusion described in
             1208      Subsections [(7)] (6)(a) and [(8)] (7)(a) for an individual that is changing health coverage to the
             1209      pool, to the extent to which similar exclusions have been satisfied under any prior health
             1210      insurance coverage if the individual applies not later than 63 days following the date of
             1211      involuntary termination, other than for nonpayment of premiums, from health coverage.
             1212          (b) If this Subsection [(9)] (8) applies, coverage in the pool shall be effective from the
             1213      date on which the prior coverage was terminated.
             1214          [(10)] (9) Covered benefits available from the pool may not exceed a $1,800,000
             1215      lifetime maximum, which includes a per enrollee calendar year maximum established by the
             1216      board.
             1217          Section 17. Section 31A-29-114 is amended to read:
             1218           31A-29-114. Deductibles -- Copayments.
             1219          (1) (a) A pool policy shall impose a deductible on a per calendar year basis.
             1220          (b) At least two deductible plans shall be offered.
             1221          (c) The deductible is applied to all of the eligible medical expenses [as defined in
             1222      Section 31A-29-113 ,] incurred by the enrollee until the deductible has been satisfied. There
             1223      are no benefits payable before the deductible has been satisfied.
             1224          (d) The pool may offer separate deductibles for prescription benefits.
             1225          (2) (a) A mandatory coinsurance requirement shall be imposed at the rate of at least
             1226      20%, except for a qualified high deductible health plan, of eligible medical expenses in excess
             1227      of the mandatory deductible.
             1228          (b) Any coinsurance imposed under this Subsection (2) shall be designated in the pool
             1229      policy.
             1230          (3) The board shall establish maximum aggregate out-of-pocket payments for eligible
             1231      medical expenses incurred by the enrollee for each of the deductible plans offered under
             1232      Subsection (1)(b).
             1233          (4) (a) When the enrollee has incurred the maximum aggregate out-of-pocket payments
             1234      under Subsection (3), the board may establish a coinsurance requirement to be imposed on


             1235      eligible medical expenses in excess of the maximum aggregate out-of-pocket expense.
             1236          (b) The circumstances in which the coinsurance authorized by this Subsection (4) may
             1237      be imposed shall be designated in the pool policy.
             1238          (c) The coinsurance authorized by this Subsection (4) may be imposed at a rate not to
             1239      exceed 5% of eligible medical expenses.
             1240          (5) The limits on maximum aggregate out-of-pocket payments for eligible medical
             1241      expenses incurred by the enrollee under this section may not include out-of-pocket payments
             1242      for prescription benefits.
             1243          Section 18. Section 31A-29-115 is amended to read:
             1244           31A-29-115. Cancellation -- Notice.
             1245          (1) [(a)] On the date of renewal, the pool may cancel an enrollee's policy if:
             1246          [(i)] (a) the enrollee's health condition does not meet the criteria established in
             1247      Subsection 31A-29-111 (5); and
             1248          [(ii)] (b) the pool has provided written notice to the enrollee's last-known address no
             1249      less than 60 days before cancellation[; and].
             1250          [(iii) at least one individual carrier has not reached the individual enrollment cap
             1251      established in Section 31A-30-110 .]
             1252          [(b) The pool shall issue a certificate of insurability to an enrollee whose policy is
             1253      cancelled under Subsection (1)(a) for coverage under Subsection 31A-30-108 (3) if the
             1254      requirements of Subsection 31A-29-111 (5) are met.]
             1255          (2) The pool may cancel an enrollee's policy at any time if:
             1256          (a) the pool has provided written notice to the enrollee's last-known address no less
             1257      than 15 days before cancellation; and
             1258          (b) (i) the enrollee establishes a residency outside of Utah for three consecutive
             1259      months;
             1260          (ii) there is nonpayment of premiums; or
             1261          (iii) the pool determines that the enrollee does not meet the eligibility requirements set
             1262      forth in Section 31A-29-111 , in which case:
             1263          (A) the policy may be retroactively terminated for the period of time in which the
             1264      enrollee was not eligible;
             1265          (B) retroactive termination may not exceed three years; and


             1266          (C) the board's remedy under this Subsection (2)(b) shall be a cause of action against
             1267      the enrollee for benefits paid during the period of ineligibility in accordance with Subsection
             1268      31A-29-119 (3).
             1269          Section 19. Section 31A-30-103 is amended to read:
             1270           31A-30-103. Definitions.
             1271          As used in this chapter:
             1272          (1) "Actuarial certification" means a written statement by a member of the American
             1273      Academy of Actuaries or other individual approved by the commissioner that a covered carrier
             1274      is in compliance with Sections 31A-30-106 and 31A-30-106.1 , based upon the examination of
             1275      the covered carrier, including review of the appropriate records and of the actuarial
             1276      assumptions and methods used by the covered carrier in establishing premium rates for
             1277      applicable health benefit plans.
             1278          (2) "Affiliate" or "affiliated" means any entity or person who directly or indirectly
             1279      through one or more intermediaries, controls or is controlled by, or is under common control
             1280      with, a specified entity or person.
             1281          (3) "Base premium rate" means, for each class of business as to a rating period, the
             1282      lowest premium rate charged or that could have been charged under a rating system for that
             1283      class of business by the covered carrier to covered insureds with similar case characteristics for
             1284      health benefit plans with the same or similar coverage.
             1285          (4) (a) "Bona fide employer association" means an association of employers:
             1286          (i) that meets the requirements of Subsection 31A-22-701 (2)(b);
             1287          (ii) in which the employers of the association, either directly or indirectly, exercise
             1288      control over the plan;
             1289          (iii) that is organized:
             1290          (A) based on a commonality of interest between the employers and their employees
             1291      that participate in the plan by some common economic or representation interest or genuine
             1292      organizational relationship unrelated to the provision of benefits; and
             1293          (B) to act in the best interests of its employers to provide benefits for the employer's
             1294      employees and their spouses and dependents, and other benefits relating to employment; and
             1295          (iv) whose association sponsored health plan complies with 45 C.F.R. 146.121.
             1296          (b) The commissioner shall consider the following with regard to determining whether


             1297      an association of employers is a bona fide employer association under Subsection (4)(a):
             1298          (i) how association members are solicited;
             1299          (ii) who participates in the association;
             1300          (iii) the process by which the association was formed;
             1301          (iv) the purposes for which the association was formed, and what, if any, were the
             1302      pre-existing relationships of its members;
             1303          (v) the powers, rights and privileges of employer members; and
             1304          (vi) who actually controls and directs the activities and operations of the benefit
             1305      programs.
             1306          (5) "Carrier" means any person or entity that provides health insurance in this state
             1307      including:
             1308          (a) an insurance company;
             1309          (b) a prepaid hospital or medical care plan;
             1310          (c) a health maintenance organization;
             1311          (d) a multiple employer welfare arrangement; and
             1312          (e) any other person or entity providing a health insurance plan under this title.
             1313          (6) (a) Except as provided in Subsection (6)(b), "case characteristics" means
             1314      demographic or other objective characteristics of a covered insured that are considered by the
             1315      carrier in determining premium rates for the covered insured.
             1316          (b) "Case characteristics" do not include:
             1317          (i) duration of coverage since the policy was issued;
             1318          (ii) claim experience; and
             1319          (iii) health status.
             1320          (7) "Class of business" means all or a separate grouping of covered insureds that is
             1321      permitted by the commissioner in accordance with Section 31A-30-105 .
             1322          (8) "Conversion policy" means a policy providing coverage under the conversion
             1323      provisions required in Chapter 22, Part 7, Group Accident and Health Insurance.
             1324          (9) "Covered carrier" means any individual carrier or small employer carrier subject to
             1325      this chapter.
             1326          (10) "Covered individual" means any individual who is covered under a health benefit
             1327      plan subject to this chapter.


             1328          (11) "Covered insureds" means small employers and individuals who are issued a
             1329      health benefit plan that is subject to this chapter.
             1330          (12) "Dependent" means an individual to the extent that the individual is defined to be
             1331      a dependent by:
             1332          (a) the health benefit plan covering the covered individual; and
             1333          (b) Chapter 22, Part 6, Accident and Health Insurance.
             1334          (13) "Established geographic service area" means a geographical area approved by the
             1335      commissioner within which the carrier is authorized to provide coverage.
             1336          (14) "Index rate" means, for each class of business as to a rating period for covered
             1337      insureds with similar case characteristics, the arithmetic average of the applicable base
             1338      premium rate and the corresponding highest premium rate.
             1339          (15) "Individual carrier" means a carrier that provides coverage on an individual basis
             1340      through a health benefit plan regardless of whether:
             1341          (a) coverage is offered through:
             1342          (i) an association;
             1343          (ii) a trust;
             1344          (iii) a discretionary group; or
             1345          (iv) other similar groups; or
             1346          (b) the policy or contract is situated out-of-state.
             1347          (16) "Individual conversion policy" means a conversion policy issued to:
             1348          (a) an individual; or
             1349          (b) an individual with a family.
             1350          (17) "Individual coverage count" means the number of natural persons covered under a
             1351      carrier's health benefit products that are individual policies.
             1352          (18) "Individual enrollment cap" means the percentage set by the commissioner in
             1353      accordance with Section 31A-30-110 .
             1354          (19) "New business premium rate" means, for each class of business as to a rating
             1355      period, the lowest premium rate charged or offered, or that could have been charged or offered,
             1356      by the carrier to covered insureds with similar case characteristics for newly issued health
             1357      benefit plans with the same or similar coverage.
             1358          (20) "Premium" means money paid by covered insureds and covered individuals as a


             1359      condition of receiving coverage from a covered carrier, including any fees or other
             1360      contributions associated with the health benefit plan.
             1361          (21) (a) "Rating period" means the calendar period for which premium rates
             1362      established by a covered carrier are assumed to be in effect, as determined by the carrier.
             1363          (b) A covered carrier may not have:
             1364          (i) more than one rating period in any calendar month; and
             1365          (ii) no more than 12 rating periods in any calendar year.
             1366          (22) "Resident" means an individual who has resided in this state for at least 12
             1367      consecutive months immediately preceding the date of application.
             1368          (23) "Short-term limited duration insurance" means a health benefit product that:
             1369          (a) is not renewable; and
             1370          (b) has an expiration date specified in the contract that is less than 364 days after the
             1371      date the plan became effective.
             1372          (24) "Small employer carrier" means a carrier that provides health benefit plans
             1373      covering eligible employees of one or more small employers in this state, regardless of
             1374      whether:
             1375          (a) coverage is offered through:
             1376          (i) an association;
             1377          (ii) a trust;
             1378          (iii) a discretionary group; or
             1379          (iv) other similar grouping; or
             1380          (b) the policy or contract is situated out-of-state.
             1381          [(25) "Uninsurable" means an individual who:]
             1382          [(a) is eligible for the Comprehensive Health Insurance Pool coverage under the
             1383      underwriting criteria established in Subsection 31A-29-111 (5); or]
             1384          [(b) (i) is issued a certificate for coverage under Subsection 31A-30-108 (3); and]
             1385          [(ii) has a condition of health that does not meet consistently applied underwriting
             1386      criteria as established by the commissioner in accordance with Subsections 31A-30-106 (1)(g)
             1387      and (h) for which coverage the applicant is applying.]
             1388          [(26) "Uninsurable percentage" for a given calendar year equals UC/CI where, for
             1389      purposes of this formula:]


             1390          [(a) "CI" means the carrier's individual coverage count as of December 31 of the
             1391      preceding year; and]
             1392          [(b) "UC" means the number of uninsurable individuals who were issued an individual
             1393      policy on or after July 1, 1997.]
             1394          Section 20. Section 31A-30-107 is amended to read:
             1395           31A-30-107. Renewal -- Limitations -- Exclusions -- Discontinuance and
             1396      nonrenewal.
             1397          (1) Except as otherwise provided in this section, a small employer health benefit plan is
             1398      renewable and continues in force:
             1399          (a) with respect to all eligible employees and dependents; and
             1400          (b) at the option of the plan sponsor.
             1401          (2) A small employer health benefit plan may be discontinued or nonrenewed:
             1402          (a) for a network plan, if[: (i)] there is no longer any enrollee under the group health
             1403      plan who lives, resides, or works in:
             1404          [(A)] (i) the service area of the covered carrier; or
             1405          [(B)] (ii) the area for which the covered carrier is authorized to do business; [and] or
             1406          [(ii) in the case of the small employer market, the small employer carrier applies the
             1407      same criteria the small employer carrier would apply in denying enrollment in the plan under
             1408      Subsection 31A-30-108 (7); or]
             1409          (b) for coverage made available in the small or large employer market only through an
             1410      association, if:
             1411          (i) the employer's membership in the association ceases; and
             1412          (ii) the coverage is terminated uniformly without regard to any health status-related
             1413      factor relating to any covered individual.
             1414          (3) A small employer health benefit plan may be discontinued if:
             1415          (a) a condition described in Subsection (2) exists;
             1416          (b) except as prohibited by Section 31A-30-206 , the plan sponsor fails to pay
             1417      premiums or contributions in accordance with the terms of the contract;
             1418          (c) the plan sponsor:
             1419          (i) performs an act or practice that constitutes fraud; or
             1420          (ii) makes an intentional misrepresentation of material fact under the terms of the


             1421      coverage;
             1422          (d) the covered carrier:
             1423          (i) elects to discontinue offering a particular small employer health benefit product
             1424      delivered or issued for delivery in this state; and
             1425          (ii) (A) provides notice of the discontinuation in writing:
             1426          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             1427          (II) at least 90 days before the date the coverage will be discontinued;
             1428          (B) provides notice of the discontinuation in writing:
             1429          (I) to the commissioner; and
             1430          (II) at least three working days prior to the date the notice is sent to the affected plan
             1431      sponsors, employees, and dependents of the plan sponsors or employees;
             1432          (C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase all
             1433      other small employer health benefit products currently being offered by the small employer
             1434      carrier in the market; and
             1435          (D) in exercising the option to discontinue that product and in offering the option of
             1436      coverage in this section, acts uniformly without regard to:
             1437          (I) the claims experience of a plan sponsor;
             1438          (II) any health status-related factor relating to any covered participant or beneficiary; or
             1439          (III) any health status-related factor relating to any new participant or beneficiary who
             1440      may become eligible for the coverage; or
             1441          (e) the covered carrier:
             1442          (i) elects to discontinue all of the covered carrier's small employer health benefit plans
             1443      in:
             1444          (A) the small employer market;
             1445          (B) the large employer market; or
             1446          (C) both the small employer and large employer markets; and
             1447          (ii) (A) provides notice of the discontinuation in writing:
             1448          (I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
             1449          (II) at least 180 days before the date the coverage will be discontinued;
             1450          (B) provides notice of the discontinuation in writing:
             1451          (I) to the commissioner in each state in which an affected insured individual is known


             1452      to reside; and
             1453          (II) at least 30 working days prior to the date the notice is sent to the affected plan
             1454      sponsors, employees, and the dependents of the plan sponsors or employees;
             1455          (C) discontinues and nonrenews all plans issued or delivered for issuance in the
             1456      market; and
             1457          (D) provides a plan of orderly withdrawal as required by Section 31A-4-115 .
             1458          (4) A small employer health benefit plan may be discontinued or nonrenewed:
             1459          (a) if a condition described in Subsection (2) exists; or
             1460          (b) except as prohibited by Section 31A-30-206 , for noncompliance with the insurer's
             1461      employer contribution requirements.
             1462          (5) A small employer health benefit plan may be nonrenewed:
             1463          (a) if a condition described in Subsection (2) exists; or
             1464          (b) except as prohibited by Section 31A-30-206 , for noncompliance with the insurer's
             1465      minimum participation requirements.
             1466          (6) (a) Except as provided in Subsection (6)(d), an eligible employee may be
             1467      discontinued if after issuance of coverage the eligible employee:
             1468          (i) engages in an act or practice that constitutes fraud in connection with the coverage;
             1469      or
             1470          (ii) makes an intentional misrepresentation of material fact in connection with the
             1471      coverage.
             1472          (b) An eligible employee that is discontinued under Subsection (6)(a) may reenroll:
             1473          (i) 12 months after the date of discontinuance; and
             1474          (ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies
             1475      to reenroll.
             1476          (c) At the time the eligible employee's coverage is discontinued under Subsection
             1477      (6)(a), the covered carrier shall notify the eligible employee of the right to reenroll when
             1478      coverage is discontinued.
             1479          (d) An eligible employee may not be discontinued under this Subsection (6) because of
             1480      a fraud or misrepresentation that relates to health status.
             1481          (7) For purposes of this section, a reference to "plan sponsor" includes a reference to
             1482      the employer:


             1483          (a) with respect to coverage provided to an employer member of the association; and
             1484          (b) if the small employer health benefit plan is made available by a covered carrier in
             1485      the employer market only through:
             1486          (i) an association;
             1487          (ii) a trust; or
             1488          (iii) a discretionary group.
             1489          (8) A covered carrier may modify a small employer health benefit plan only:
             1490          (a) at the time of coverage renewal; and
             1491          (b) if the modification is effective uniformly among all plans with that product.
             1492          Section 21. Section 31A-30-108 is amended to read:
             1493           31A-30-108. Eligibility for small employer and individual market.
             1494          (1) (a) [Small employer carriers shall accept residents] A small employer carrier shall
             1495      accept a small employer that applies for small group coverage as set forth in the Health
             1496      Insurance Portability and Accountability Act, Sec. 2701(f) and 2711(a) and PPACA, Sec. 2702.
             1497          [(b) Individual carriers shall accept residents for individual coverage pursuant to:]
             1498          [(i) Health Insurance Portability and Accountability Act, Sec. 2741(a)-(b); and]
             1499          [(ii) Subsection (3).]
             1500          (b) An individual carrier shall accept an individual that applies for individual coverage
             1501      as set forth in PPACA, Sec. 2702.
             1502          (2) (a) [Small] A small employer [carriers] carrier shall offer to accept all eligible
             1503      employees and their dependents at the same level of benefits under any health benefit plan
             1504      provided to a small employer.
             1505          (b) [Small] A small employer [carriers] carrier may:
             1506          (i) request a small employer to submit a copy of the small employer's quarterly income
             1507      tax withholdings to determine whether the employees for whom coverage is provided or
             1508      requested are bona fide employees of the small employer; and
             1509          (ii) deny or terminate coverage if the small employer refuses to provide documentation
             1510      requested under Subsection (2)(b)(i).
             1511          [(3) Except as provided in Subsections (5) and (6) and Section 31A-30-110 , individual
             1512      carriers shall accept for coverage individuals to whom all of the following conditions apply:]
             1513          [(a) the individual is not covered or eligible for coverage:]


             1514          [(i) (A) as an employee of an employer;]
             1515          [(B) as a member of an association; or]
             1516          [(C) as a member of any other group; and]
             1517          [(ii) under:]
             1518          [(A) a health benefit plan; or]
             1519          [(B) a self-insured arrangement that provides coverage similar to that provided by a
             1520      health benefit plan as defined in Section 31A-1-301 ;]
             1521          [(b) the individual is not covered and is not eligible for coverage under any public
             1522      health benefits arrangement including:]
             1523          [(i) the Medicare program established under Title XVIII of the Social Security Act;]
             1524          [(ii) any act of Congress or law of this or any other state that provides benefits
             1525      comparable to the benefits provided under this chapter; or]
             1526          [(iii) coverage under the Comprehensive Health Insurance Pool Act created in Chapter
             1527      29, Comprehensive Health Insurance Pool Act;]
             1528          [(c) unless the maximum benefit has been reached the individual is not covered or
             1529      eligible for coverage under any:]
             1530          [(i) Medicare supplement policy;]
             1531          [(ii) conversion option;]
             1532          [(iii) continuation or extension under COBRA; or]
             1533          [(iv) state extension;]
             1534          [(d) the individual has not terminated or declined coverage described in Subsection
             1535      (3)(a), (b), or (c) within 93 days of application for coverage, unless the individual is eligible for
             1536      individual coverage under Health Insurance Portability and Accountability Act, Sec. 2741(b),
             1537      in which case, the requirement of this Subsection (3)(d) does not apply; and]
             1538          [(e) the individual is certified as ineligible for the Health Insurance Pool if:]
             1539          [(i) the individual applies for coverage with the Comprehensive Health Insurance Pool
             1540      within 30 days after being rejected or refused coverage by the covered carrier and reapplies for
             1541      coverage with that covered carrier within 30 days after the date of issuance of a certificate
             1542      under Subsection 31A-29-111 (5)(c); or]
             1543          [(ii) the individual applies for coverage with any individual carrier within 45 days
             1544      after:]


             1545          [(A) notice of cancellation of coverage under Subsection 31A-29-115 (1); or]
             1546          [(B) the date of issuance of a certificate under Subsection 31A-29-111 (5)(c) if the
             1547      individual applied first for coverage with the Comprehensive Health Insurance Pool.]
             1548          [(4) (a) If coverage is obtained under Subsection (3)(e)(i) and the required premium is
             1549      paid, the effective date of coverage shall be the first day of the month following the individual's
             1550      submission of a completed insurance application to that covered carrier.]
             1551          [(b) If coverage is obtained under Subsection (3)(e)(ii) and the required premium is
             1552      paid, the effective date of coverage shall be the day following the:]
             1553          [(i) cancellation of coverage under Subsection 31A-29-115 (1); or]
             1554          [(ii) submission of a completed insurance application to the Comprehensive Health
             1555      Insurance Pool].
             1556          [(5) (a) An individual carrier is not required to accept individuals for coverage under
             1557      Subsection (3) if the carrier issues no new individual policies in the state after July 1, 1997.]
             1558          [(b) A carrier described in Subsection (5)(a) may not issue new individual policies in
             1559      the state for five years from July 1, 1997.]
             1560          [(c) Notwithstanding Subsection (5)(b), a carrier may request permission to issue new
             1561      policies after July 1, 1999, which may only be granted if:]
             1562          [(i) the carrier accepts uninsurables as is required of a carrier entering the market under
             1563      Subsection 31A-30-110 ; and]
             1564          [(ii) the commissioner finds that the carrier's issuance of new individual policies:]
             1565          [(A) is in the best interests of the state; and]
             1566          [(B) does not provide an unfair advantage to the carrier.]
             1567          [(6) (a) If the Comprehensive Health Insurance Pool, as set forth under Chapter 29,
             1568      Comprehensive Health Insurance Pool Act, is dissolved or discontinued, or if enrollment is
             1569      capped or suspended, an individual carrier may decline to accept individuals applying for
             1570      individual enrollment, other than individuals applying for coverage as set forth in Health
             1571      Insurance Portability and Accountability Act, Sec. 2741 (a)-(b).]
             1572          [(b) Within two calendar days of taking action under Subsection (6)(a), an individual
             1573      carrier will provide written notice to the department.]
             1574          [(7) (a) If a small employer carrier offers health benefit plans to small employers
             1575      through a network plan, the small employer carrier may:]


             1576          [(i) limit the employers that may apply for the coverage to those employers with
             1577      eligible employees who live, reside, or work in the service area for the network plan; and]
             1578          [(ii) within the service area of the network plan, deny coverage to an employer if the
             1579      small employer carrier has demonstrated to the commissioner that the small employer carrier:]
             1580          [(A) will not have the capacity to deliver services adequately to enrollees of any
             1581      additional groups because of the small employer carrier's obligations to existing group contract
             1582      holders and enrollees; and]
             1583          [(B) applies this section uniformly to all employers without regard to:]
             1584          [(I) the claims experience of an employer, an employer's employee, or a dependent of
             1585      an employee; or]
             1586          [(II) any health status-related factor relating to an employee or dependent of an
             1587      employee].
             1588          [(b) (i) A small employer carrier that denies a health benefit product to an employer in
             1589      any service area in accordance with this section may not offer coverage in the small employer
             1590      market within the service area to any employer for a period of 180 days after the date the
             1591      coverage is denied.]
             1592          [(ii) This Subsection (7)(b) does not:]
             1593          [(A) limit the small employer carrier's ability to renew coverage that is in force; or]
             1594          [(B) relieve the small employer carrier of the responsibility to renew coverage that is in
             1595      force.]
             1596          [(c) Coverage offered within a service area after the 180-day period specified in
             1597      Subsection (7)(b) is subject to the requirements of this section.]
             1598          Section 22. Section 31A-30-117 is amended to read:
             1599           31A-30-117. Patient Protection and Affordable Care Act -- Market transition.
             1600          (1) (a) After complying with the reporting requirements of Section 63M-1-2505.5 , the
             1601      commissioner may adopt administrative rules that change the rating and underwriting
             1602      requirements of this chapter as necessary to transition the insurance market to meet federal
             1603      qualified health plan standards and rating practices under PPACA.
             1604          (b) Administrative rules adopted by the commissioner under this section may include:
             1605          (i) the regulation of health benefit plans as described in Subsections 31A-2-212 (5)(a)
             1606      and (b); and


             1607          (ii) disclosure of records and information required by PPACA and state law.
             1608          (c) (i) The commissioner shall establish by administrative rule one statewide open
             1609      enrollment period that applies to the individual insurance market that is not on the PPACA
             1610      certified individual exchange.
             1611          (ii) The statewide open enrollment period:
             1612          (A) may be shorter, but no longer than the open enrollment period established for the
             1613      individual insurance market offered in the PPACA certified exchange; and
             1614          (B) may not be extended beyond the dates of the open enrollment period established
             1615      for the individual insurance market offered in the PPACA certified exchange.
             1616          (2) A carrier that offers health benefit plans in the individual market that is not part of
             1617      the individual PPACA certified exchange:
             1618          (a) shall open enrollment:
             1619          (i) during the statewide open enrollment period established in Subsection (1)(c); and
             1620          (ii) at other times, for qualifying events, as determined by administrative rule adopted
             1621      by the commissioner; and
             1622          (b) may open enrollment at any time.
             1623          [(3) (a) The commissioner shall identify a new mandated benefit that is in excess of the
             1624      essential health benefits required by PPACA.]
             1625          [(b) In accordance with 45 C.F.R. Sec. 155.170, the state shall make a payment to
             1626      defray the cost of a new mandated benefit in the amount calculated under Subsection (3)(c)
             1627      directly to the qualified health plan issuer on behalf of an individual who receives an advance
             1628      premium tax credit under PPACA.]
             1629          [(c) The state shall quantify the cost attributable to each additional mandated benefit
             1630      specified in Subsection (3)(a) based on a qualified health plan issuer's calculation of the cost
             1631      associated with the mandated benefit, which shall be:]
             1632          [(i) calculated in accordance with generally accepted actuarial principles and
             1633      methodologies;]
             1634          [(ii) conducted by a member of the American Academy of Actuaries; and]
             1635          [(iii) reported to the commissioner and to the individual exchange operating in the
             1636      state.]
             1637          [(d) The commissioner may require a proponent of a new mandated benefit under


             1638      Subsection (3)(a) to provide the commissioner with a cost analysis conducted in accordance
             1639      with Subsection (3)(c). The commissioner may use the cost information provided under this
             1640      Subsection (3)(d) to establish estimates of the cost to the state for premium subsidies under
             1641      Subsection (3)(b).]
             1642          (3) To the extent permitted by the Centers for Medicare and Medicaid Services policy,
             1643      or federal regulation, the commissioner shall allow a health insurer to choose to continue
             1644      coverage and individuals and small employers to choose to re-enroll in coverage in
             1645      nongrandfathered health coverage that is not in compliance with market reforms required by
             1646      PPACA.
             1647          Section 23. Section 31A-30-118 is enacted to read:
             1648          31A-30-118. Patient Protection and Affordable Care Act -- State insurance
             1649      mandates -- Cost of additional benefits.
             1650          (1) (a) The commissioner shall identify a new mandated benefit that is in excess of the
             1651      essential health benefits required by PPACA.
             1652          (b) The state shall quantify the cost attributable to each additional mandated benefit
             1653      specified in Subsection (1)(a) based on a qualified health plan issuer's calculation of the cost
             1654      associated with the mandated benefit, which shall be:
             1655          (i) calculated in accordance with generally accepted actuarial principles and
             1656      methodologies;
             1657          (ii) conducted by a member of the American Academy of Actuaries; and
             1658          (iii) reported to the commissioner and to the individual exchange operating in the state.
             1659          (c) The commissioner may require a proponent of a new mandated benefit under
             1660      Subsection (1)(a) to provide the commissioner with a cost analysis conducted in accordance
             1661      with Subsection (1)(b). The commissioner may use the cost information provided under this
             1662      Subsection (1)(c) to establish estimates of the cost to the state under Subsection (2).
             1663          (2) If the state is required to defray the cost of additional required benefits under the
             1664      provisions of 45 C.F.R. 155.170:
             1665          (a) the state shall make the required payments:
             1666          (i) in accordance with Subsection (3); and
             1667          (ii) directly to the qualified health plan issuer in accordance with 45 C.F.R. 155.170;
             1668          (b) an issuer of a qualified health plan that receives a payment under the provisions of


             1669      Subsection (1) and 45 C.F.R. 155.170 shall:
             1670          (i) reduce the premium charged to the individual on whose behalf the issuer will be
             1671      paid under Subsection (1), in an amount equal to the amount of the payment under Subsection
             1672      (1); or
             1673          (ii) notwithstanding Subsection 31A-23a-402.5 (5), provide a premium rebate to an
             1674      individual on whose behalf the issuer received a payment under Subsection (1), in an amount
             1675      equal to the amount of the payment under Subsection (1); and
             1676          (c) a premium rebate made under this section is not a prohibited inducement under
             1677      Section 31A-23a-402.5 .
             1678          (3) A payment required under 45 C.F.R. 155.170(c) shall:
             1679          (a) unless otherwise required by PPACA, be based on a statewide average of the cost
             1680      of the additional benefit for all issuers who are entitled to payment under the provisions of 45
             1681      C.F.R. 155.70; and
             1682          (b) be submitted to an issuer through a process established and administered by:
             1683          (i) the federal marketplace exchange for the state under PPACA for individual health
             1684      plans; or
             1685          (ii) Avenue H small employer market exchange for qualified health plans offered on
             1686      the exchange.
             1687          (4) The commissioner:
             1688          (a) may adopt rules as necessary to administer the provisions of this section and 45
             1689      C.F.R. 155.170; and
             1690          (b) may not establish or implement the process for submitting the payments to an issuer
             1691      under Subsection (3)(b)(i) unless the cost of establishing and implementing the process for
             1692      submitting payments is paid for by the federal exchange marketplace.
             1693          Section 24. Section 31A-30-301 is enacted to read:
             1694     
Part 3. Individual and Small Employer Risk Adjustment Act

             1695          31A-30-301. Title.
             1696          This part is known as the "Individual and Small Employer Risk Adjustment Act."
             1697          Section 25. Section 31A-30-302 is enacted to read:
             1698          31A-30-302. Creation of state risk adjustment program.
             1699          (1) The commissioner shall convene a group of stakeholders and actuaries to assist the


             1700      commissioner with the evaluation or the risk adjustment options described in Subsection (2). If
             1701      the commissioner determines that a state-based risk adjustment program is in the best interest
             1702      of the state, the commissioner shall establish an individual and small employer market risk
             1703      adjustment program in accordance with 42 U.S.C. 18063 and this section.
             1704          (2) The risk adjustment program adopted by the commissioner may include one of the
             1705      following models:
             1706          (a) continue the United States Department of Health and Human Services
             1707      administration of the federal model for risk adjustment for the individual and small employer
             1708      market in the state;
             1709          (b) have the state administer the federal model for risk adjustment for the individual
             1710      and small employer market in the state;
             1711          (c) establish and operate a state based risk adjustment program for the individual and
             1712      small employer market in the state; or
             1713          (d) another risk adjustment model developed by the commissioner under Subsection
             1714      (1).
             1715          (3) Before adopting one of the models described in Subsection (2), the commissioner:
             1716          (a) may enter into contracts to carry out the services needed to evaluate and establish
             1717      one of the risk adjustment options described in Subsection (2); and
             1718          (b) shall, prior to October 30, 2014, comply with the reporting requirements of Section
             1719      63M-1-2505.5 regarding the commissioner's evaluation of the risk adjustment options
             1720      described in Subsection (2).
             1721          (4) The commissioner may:
             1722          (a) adopt administrative rules in accordance with Title 63G, Chapter 3, Utah
             1723      Administrative Rulemaking Act, that require an insurer that is subject to the state based risk
             1724      adjustment program to submit data to the all payers claims database created under Section
             1725      26-33a-106.1 ; and
             1726          (b) establish fees in accordance with Title 63J, Chapter 1, Budgetary Procedures Act,
             1727      to cover the ongoing administrative cost of running the state based risk adjustment program.
             1728          Section 26. Section 31A-30-303 is enacted to read:
             1729          31A-30-303. Enterprise fund.
             1730          (1) There is created an enterprise fund known as the Individual and Small Employer


             1731      Risk Adjustment Enterprise Fund.
             1732          (2) The following funds shall be credited to the fund:
             1733          (a) appropriations from the General Fund;
             1734          (b) fees established by the commissioner under Section 31A-30-302 ;
             1735          (c) risk adjustment payments received from insurers participating in the risk adjustment
             1736      program; and
             1737          (d) all interest and dividends earned on the fund's assets.
             1738          (3) All money received by the fund shall be deposited in compliance with Section
             1739      51-4-1 and shall be held by the state treasurer and invested in accordance with Title 51,
             1740      Chapter 7, State Money Management Act.
             1741          (4) The fund shall comply with the accounting policies, procedures, and reporting
             1742      requirements established by the Division of Finance.
             1743          (5) The fund shall comply with Title 63A, Utah Administrative Services Code.
             1744          (6) The fund shall be used to implement and operate the risk adjustment program
             1745      created by this part.
             1746          Section 27. Section 63A-5-205 is amended to read:
             1747           63A-5-205. Contracting powers of director -- Retainage -- Health insurance
             1748      coverage.
             1749          (1) As used in this section:
             1750          (a) "Capital developments" has the same meaning as provided in Section 63A-5-104 .
             1751          (b) "Capital improvements" has the same meaning as provided in Section 63A-5-104 .
             1752          (c) "Employee" means an "employee," "worker," or "operative" as defined in Section
             1753      34A-2-104 who:
             1754          (i) works at least 30 hours per calendar week; and
             1755          (ii) meets employer eligibility waiting requirements for health care insurance which
             1756      may not exceed the first day of the calendar month following [90] 60 days from the date of
             1757      hire.
             1758          (d) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             1759          (e) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             1760          (f) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             1761          (2) In accordance with Title 63G, Chapter 6a, Utah Procurement Code, the director


             1762      may:
             1763          (a) subject to Subsection (3), enter into contracts for any work or professional services
             1764      which the division or the State Building Board may do or have done; and
             1765          (b) as a condition of any contract for architectural or engineering services, prohibit the
             1766      architect or engineer from retaining a sales or agent engineer for the necessary design work.
             1767          (3) (a) Except as provided in Subsection (3)(b), this Subsection (3) applies to all design
             1768      or construction contracts entered into by the division or the State Building Board on or after
             1769      July 1, 2009, and:
             1770          (i) applies to a prime contractor if the prime contract is in the amount of $1,500,000 or
             1771      greater; and
             1772          (ii) applies to a subcontractor if the subcontract is in the amount of $750,000 or greater.
             1773          (b) This Subsection (3) does not apply:
             1774          (i) if the application of this Subsection (3) jeopardizes the receipt of federal funds;
             1775          (ii) if the contract is a sole source contract;
             1776          (iii) if the contract is an emergency procurement; or
             1777          (iv) to a change order as defined in Section 63G-6a-103 , or a modification to a
             1778      contract, when the contract does not meet the threshold required by Subsection (3)(a).
             1779          (c) A person who intentionally uses change orders or contract modifications to
             1780      circumvent the requirements of Subsection (3)(a) is guilty of an infraction.
             1781          (d) (i) A contractor subject to Subsection (3)(a) shall demonstrate to the director that
             1782      the contractor has and will maintain an offer of qualified health insurance coverage for the
             1783      contractor's employees and the employees' dependents.
             1784          (ii) If a subcontractor of the contractor is subject to Subsection (3)(a), the contractor
             1785      shall demonstrate to the director that the subcontractor has and will maintain an offer of
             1786      qualified health insurance coverage for the subcontractor's employees and the employees'
             1787      dependents.
             1788          (e) (i) (A) A contractor who fails to meet the requirements of Subsection (3)(d)(i)
             1789      during the duration of the contract is subject to penalties in accordance with administrative
             1790      rules adopted by the division under Subsection (3)(f).
             1791          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             1792      requirements of Subsection (3)(d)(ii).


             1793          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (3)(d)(ii)
             1794      during the duration of the contract is subject to penalties in accordance with administrative
             1795      rules adopted by the division under Subsection (3)(f).
             1796          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             1797      requirements of Subsection (3)(d)(i).
             1798          (f) The division shall adopt administrative rules:
             1799          (i) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             1800          (ii) in coordination with:
             1801          (A) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             1802          (B) the Department of Natural Resources in accordance with Section 79-2-404 ;
             1803          (C) a public transit district in accordance with Section 17B-2a-818.5 ;
             1804          (D) the State Capitol Preservation Board in accordance with Section 63C-9-403 ;
             1805          (E) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             1806          (F) the Legislature's Administrative Rules Review Committee; and
             1807          (iii) which establish:
             1808          (A) the requirements and procedures a contractor must follow to demonstrate to the
             1809      director compliance with this Subsection (3) which shall include:
             1810          (I) that a contractor will not have to demonstrate compliance with Subsection (3)(d)(i)
             1811      or (ii) more than twice in any 12-month period; and
             1812          (II) that the actuarially equivalent determination required for the qualified health
             1813      insurance coverage in Subsection (1) is met by the contractor if the contractor provides the
             1814      department or division with a written statement of actuarial equivalency from either:
             1815          (Aa) the Utah Insurance Department;
             1816          (Bb) an actuary selected by the contractor or the contractor's insurer; or
             1817          (Cc) an underwriter who is responsible for developing the employer group's premium
             1818      rates;
             1819          (B) the penalties that may be imposed if a contractor or subcontractor intentionally
             1820      violates the provisions of this Subsection (3), which may include:
             1821          (I) a three-month suspension of the contractor or subcontractor from entering into
             1822      future contracts with the state upon the first violation;
             1823          (II) a six-month suspension of the contractor or subcontractor from entering into future


             1824      contracts with the state upon the second violation;
             1825          (III) an action for debarment of the contractor or subcontractor in accordance with
             1826      Section 63G-6a-904 upon the third or subsequent violation; and
             1827          (IV) monetary penalties which may not exceed 50% of the amount necessary to
             1828      purchase qualified health insurance coverage for an employee and the dependents of an
             1829      employee of the contractor or subcontractor who was not offered qualified health insurance
             1830      coverage during the duration of the contract; and
             1831          (C) a website on which the department shall post the benchmark for the qualified
             1832      health insurance coverage identified in Subsection (1)(e).
             1833          (g) (i) In addition to the penalties imposed under Subsection (3)(f)(iii), a contractor or
             1834      subcontractor who intentionally violates the provisions of this section shall be liable to the
             1835      employee for health care costs that would have been covered by qualified health insurance
             1836      coverage.
             1837          (ii) An employer has an affirmative defense to a cause of action under Subsection
             1838      (3)(g)(i) if:
             1839          (A) the employer relied in good faith on a written statement of actuarial equivalency
             1840      provided by:
             1841          (I) an actuary; or
             1842          (II) an underwriter who is responsible for developing the employer group's premium
             1843      rates; or
             1844          (B) the department determines that compliance with this section is not required under
             1845      the provisions of Subsection (3)(b).
             1846          (iii) An employee has a private right of action only against the employee's employer to
             1847      enforce the provisions of this Subsection (3)(g).
             1848          (h) Any penalties imposed and collected under this section shall be deposited into the
             1849      Medicaid Restricted Account created by Section 26-18-402 .
             1850          (i) The failure of a contractor or subcontractor to provide qualified health insurance
             1851      coverage as required by this section:
             1852          (i) may not be the basis for a protest or other action from a prospective bidder, offeror,
             1853      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             1854      Procurement Code; and


             1855          (ii) may not be used by the procurement entity or a prospective bidder, offeror, or
             1856      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             1857      or construction.
             1858          (4) The judgment of the director as to the responsibility and qualifications of a bidder
             1859      is conclusive, except in case of fraud or bad faith.
             1860          (5) The division shall make all payments to the contractor for completed work in
             1861      accordance with the contract and pay the interest specified in the contract on any payments that
             1862      are late.
             1863          (6) If any payment on a contract with a private contractor to do work for the division or
             1864      the State Building Board is retained or withheld, it shall be retained or withheld and released as
             1865      provided in Section 13-8-5 .
             1866          Section 28. Section 63C-9-403 is amended to read:
             1867           63C-9-403. Contracting power of executive director -- Health insurance coverage.
             1868          (1) For purposes of this section:
             1869          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             1870      34A-2-104 who:
             1871          (i) works at least 30 hours per calendar week; and
             1872          (ii) meets employer eligibility waiting requirements for health care insurance which
             1873      may not exceed the first of the calendar month following [90] 60 days from the date of hire.
             1874          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             1875          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             1876          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             1877          (2) (a) Except as provided in Subsection (3), this section applies to a design or
             1878      construction contract entered into by the board or on behalf of the board on or after July 1,
             1879      2009, and to a prime contractor or a subcontractor in accordance with Subsection (2)(b).
             1880          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             1881      amount of $1,500,000 or greater.
             1882          (ii) A subcontractor is subject to this section if a subcontract is in the amount of
             1883      $750,000 or greater.
             1884          (3) This section does not apply if:
             1885          (a) the application of this section jeopardizes the receipt of federal funds;


             1886          (b) the contract is a sole source contract; or
             1887          (c) the contract is an emergency procurement.
             1888          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             1889      or a modification to a contract, when the contract does not meet the initial threshold required
             1890      by Subsection (2).
             1891          (b) A person who intentionally uses change orders or contract modifications to
             1892      circumvent the requirements of Subsection (2) is guilty of an infraction.
             1893          (5) (a) A contractor subject to Subsection (2) shall demonstrate to the executive
             1894      director that the contractor has and will maintain an offer of qualified health insurance
             1895      coverage for the contractor's employees and the employees' dependents during the duration of
             1896      the contract.
             1897          (b) If a subcontractor of the contractor is subject to Subsection (2)(b), the contractor
             1898      shall demonstrate to the executive director that the subcontractor has and will maintain an offer
             1899      of qualified health insurance coverage for the subcontractor's employees and the employees'
             1900      dependents during the duration of the contract.
             1901          (c) (i) (A) A contractor who fails to meet the requirements of Subsection (5)(a) during
             1902      the duration of the contract is subject to penalties in accordance with administrative rules
             1903      adopted by the division under Subsection (6).
             1904          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             1905      requirements of Subsection (5)(b).
             1906          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during
             1907      the duration of the contract is subject to penalties in accordance with administrative rules
             1908      adopted by the department under Subsection (6).
             1909          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             1910      requirements of Subsection (5)(a).
             1911          (6) The department shall adopt administrative rules:
             1912          (a) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             1913          (b) in coordination with:
             1914          (i) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             1915          (ii) the Department of Natural Resources in accordance with Section 79-2-404 ;
             1916          (iii) the State Building Board in accordance with Section 63A-5-205 ;


             1917          (iv) a public transit district in accordance with Section 17B-2a-818.5 ;
             1918          (v) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             1919          (vi) the Legislature's Administrative Rules Review Committee; and
             1920          (c) which establish:
             1921          (i) the requirements and procedures a contractor must follow to demonstrate to the
             1922      executive director compliance with this section which shall include:
             1923          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             1924      (b) more than twice in any 12-month period; and
             1925          (B) that the actuarially equivalent determination required for the qualified health
             1926      insurance coverage in Subsection (1) is met by the contractor if the contractor provides the
             1927      department or division with a written statement of actuarial equivalency from either:
             1928          (I) the Utah Insurance Department;
             1929          (II) an actuary selected by the contractor or the contractor's insurer; or
             1930          (III) an underwriter who is responsible for developing the employer group's premium
             1931      rates;
             1932          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             1933      violates the provisions of this section, which may include:
             1934          (A) a three-month suspension of the contractor or subcontractor from entering into
             1935      future contracts with the state upon the first violation;
             1936          (B) a six-month suspension of the contractor or subcontractor from entering into future
             1937      contracts with the state upon the second violation;
             1938          (C) an action for debarment of the contractor or subcontractor in accordance with
             1939      Section 63G-6a-904 upon the third or subsequent violation; and
             1940          (D) monetary penalties which may not exceed 50% of the amount necessary to
             1941      purchase qualified health insurance coverage for employees and dependents of employees of
             1942      the contractor or subcontractor who were not offered qualified health insurance coverage
             1943      during the duration of the contract; and
             1944          (iii) a website on which the department shall post the benchmark for the qualified
             1945      health insurance coverage identified in Subsection (1)(c).
             1946          (7) (a) (i) In addition to the penalties imposed under Subsection (6)(c), a contractor or
             1947      subcontractor who intentionally violates the provisions of this section shall be liable to the


             1948      employee for health care costs that would have been covered by qualified health insurance
             1949      coverage.
             1950          (ii) An employer has an affirmative defense to a cause of action under Subsection
             1951      (7)(a)(i) if:
             1952          (A) the employer relied in good faith on a written statement of actuarial equivalency
             1953      provided by:
             1954          (I) an actuary; or
             1955          (II) an underwriter who is responsible for developing the employer group's premium
             1956      rates; or
             1957          (B) the department determines that compliance with this section is not required under
             1958      the provisions of Subsection (3) or (4).
             1959          (b) An employee has a private right of action only against the employee's employer to
             1960      enforce the provisions of this Subsection (7).
             1961          (8) Any penalties imposed and collected under this section shall be deposited into the
             1962      Medicaid Restricted Account created in Section 26-18-402 .
             1963          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             1964      coverage as required by this section:
             1965          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             1966      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             1967      Procurement Code; and
             1968          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             1969      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             1970      or construction.
             1971          Section 29. Section 63I-1-231 (Effective 07/01/14) is amended to read:
             1972           63I-1-231 (Effective 07/01/14). Repeal dates, Title 31A.
             1973          (1) Section 31A-2-208.5 , Comparison tables, is repealed July 1, 2015.
             1974          (2) Section 31A-2-217 , Coordination with other states, is repealed July 1, 2023.
             1975          (3) Section 31A-22-619.6 , Coordination of benefits with workers' compensation
             1976      claim--Health insurer's duty to pay, is repealed on July 1, 2018.
             1977          (4) Title 31A, Chapter 29, Comprehensive Health Insurance Pool Act, is repealed July
             1978      1, 2015.


             1979          Section 30. Section 63M-1-2504 is amended to read:
             1980           63M-1-2504. Creation of Office of Consumer Health Services -- Duties.
             1981          (1) There is created within the Governor's Office of Economic Development the Office
             1982      of Consumer Health Services.
             1983          (2) The office shall:
             1984          (a) in cooperation with the Insurance Department, the Department of Health, and the
             1985      Department of Workforce Services, and in accordance with the electronic standards developed
             1986      under Sections 31A-22-635 and 63M-1-2506 , create a Health Insurance Exchange that:
             1987          (i) provides information to consumers about private and public health programs for
             1988      which the consumer may qualify;
             1989          (ii) provides a consumer comparison of and enrollment in a health benefit plan posted
             1990      on the Health Insurance Exchange; and
             1991          (iii) includes information and a link to enrollment in premium assistance programs and
             1992      other government assistance programs;
             1993          (b) contract with one or more private vendors for:
             1994          (i) administration of the enrollment process on the Health Insurance Exchange,
             1995      including establishing a mechanism for consumers to compare health benefit plan features on
             1996      the exchange and filter the plans based on consumer preferences;
             1997          (ii) the collection of health insurance premium payments made for a single policy by
             1998      multiple payers, including the policyholder, one or more employers of one or more individuals
             1999      covered by the policy, government programs, and others; and
             2000          (iii) establishing a call center in accordance with Subsection [(3)] (4);
             2001          (c) assist employers with a free or low cost method for establishing mechanisms for the
             2002      purchase of health insurance by employees using pre-tax dollars;
             2003          (d) establish a list on the Health Insurance Exchange of insurance producers who, in
             2004      accordance with Section 31A-30-209 , are appointed producers for the Health Insurance
             2005      Exchange; [and]
             2006          (e) submit, before November 1, an annual written report to the Business and Labor
             2007      Interim Committee and the Health System Reform Task Force regarding the operations of the
             2008      Health Insurance Exchange required by this chapter[.]; and
             2009          (f) in accordance with Subsection (3), provide a form to a small employer that certifies:


             2010          (i) that the small employer offered a qualified health plan to the small employer's
             2011      employees; and
             2012          (ii) the period of time within the taxable year in which the small employer maintained
             2013      the qualified health plan coverage.
             2014          (3) The form required by Subsection (2)(f) shall be provided to a small employer if:
             2015          (a) the small employer selected a qualified health plan on the small employer health
             2016      exchange created by this section; or
             2017          (b) (i) the small employer selected a health plan in the small employer market that is
             2018      not offered through the exchange created by this section; and
             2019          (ii) the issuer of the health plan selected by the small employer submits to the office, in
             2020      a form and manner required by the office:
             2021          (A) an affidavit from a member of the American Academy of Actuaries stating that
             2022      based on generally accepted actuarial principles and methodologies the issuer's health plan
             2023      meets the benefit and actuarial requirements for a qualified health plan under PPACA as
             2024      defined in Section 31A-1-301 ; and
             2025          (B) an affidavit from the issuer that includes the dates of coverage for the small
             2026      employer during the taxable year.
             2027          [(3)] (4) A call center established by the office:
             2028          (a) shall provide unbiased answers to questions concerning exchange operations, and
             2029      plan information, to the extent the plan information is posted on the exchange by the insurer;
             2030      and
             2031          (b) may not:
             2032          (i) sell, solicit, or negotiate a health benefit plan on the Health Insurance Exchange;
             2033          (ii) receive producer compensation through the Health Insurance Exchange; and
             2034          (iii) be designated as the default producer for an employer group that enters the Health
             2035      Insurance Exchange without a producer.
             2036          [(4)] (5) The office:
             2037          (a) may not:
             2038          (i) regulate health insurers, health insurance plans, health insurance producers, or
             2039      health insurance premiums charged in the exchange;
             2040          (ii) adopt administrative rules, except as provided in Section 63M-1-2506 ; or


             2041          (iii) act as an appeals entity for resolving disputes between a health insurer and an
             2042      insured;
             2043          (b) may establish and collect a fee for the cost of the exchange transaction in
             2044      accordance with Section 63J-1-504 for:
             2045          (i) processing an application for a health benefit plan;
             2046          (ii) accepting, processing, and submitting multiple premium payment sources;
             2047          (iii) providing a mechanism for consumers to filter and compare health benefit plans in
             2048      the exchange based on consumer preferences; and
             2049          (iv) funding the call center; and
             2050          (c) shall separately itemize the fee established under Subsection [(4)] (5)(b) as part of
             2051      the cost displayed for the employer selecting coverage on the exchange.
             2052          Section 31. Section 72-6-107.5 is amended to read:
             2053           72-6-107.5. Construction of improvements of highway -- Contracts -- Health
             2054      insurance coverage.
             2055          (1) For purposes of this section:
             2056          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             2057      34A-2-104 who:
             2058          (i) works at least 30 hours per calendar week; and
             2059          (ii) meets employer eligibility waiting requirements for health care insurance which
             2060      may not exceed the first day of the calendar month following [90] 60 days from the date of
             2061      hire.
             2062          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             2063          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             2064          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             2065          (2) (a) Except as provided in Subsection (3), this section applies to contracts entered
             2066      into by the department on or after July 1, 2009, for construction or design of highways and to a
             2067      prime contractor or to a subcontractor in accordance with Subsection (2)(b).
             2068          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             2069      amount of $1,500,000 or greater.
             2070          (ii) A subcontractor is subject to this section if a subcontract is in the amount of
             2071      $750,000 or greater.


             2072          (3) This section does not apply if:
             2073          (a) the application of this section jeopardizes the receipt of federal funds;
             2074          (b) the contract is a sole source contract; or
             2075          (c) the contract is an emergency procurement.
             2076          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             2077      or a modification to a contract, when the contract does not meet the initial threshold required
             2078      by Subsection (2).
             2079          (b) A person who intentionally uses change orders or contract modifications to
             2080      circumvent the requirements of Subsection (2) is guilty of an infraction.
             2081          (5) (a) A contractor subject to Subsection (2) shall demonstrate to the department that
             2082      the contractor has and will maintain an offer of qualified health insurance coverage for the
             2083      contractor's employees and the employees' dependents during the duration of the contract.
             2084          (b) If a subcontractor of the contractor is subject to Subsection (2), the contractor shall
             2085      demonstrate to the department that the subcontractor has and will maintain an offer of qualified
             2086      health insurance coverage for the subcontractor's employees and the employees' dependents
             2087      during the duration of the contract.
             2088          (c) (i) (A) A contractor who fails to meet the requirements of Subsection (5)(a) during
             2089      the duration of the contract is subject to penalties in accordance with administrative rules
             2090      adopted by the department under Subsection (6).
             2091          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             2092      requirements of Subsection (5)(b).
             2093          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during
             2094      the duration of the contract is subject to penalties in accordance with administrative rules
             2095      adopted by the department under Subsection (6).
             2096          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             2097      requirements of Subsection (5)(a).
             2098          (6) The department shall adopt administrative rules:
             2099          (a) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             2100          (b) in coordination with:
             2101          (i) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             2102          (ii) the Department of Natural Resources in accordance with Section 79-2-404 ;


             2103          (iii) the State Building Board in accordance with Section 63A-5-205 ;
             2104          (iv) the State Capitol Preservation Board in accordance with Section 63C-9-403 ;
             2105          (v) a public transit district in accordance with Section 17B-2a-818.5 ; and
             2106          (vi) the Legislature's Administrative Rules Review Committee; and
             2107          (c) which establish:
             2108          (i) the requirements and procedures a contractor must follow to demonstrate to the
             2109      department compliance with this section which shall include:
             2110          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             2111      (b) more than twice in any 12-month period; and
             2112          (B) that the actuarially equivalent determination required for qualified health insurance
             2113      coverage in Subsection (1) is met by the contractor if the contractor provides the department or
             2114      division with a written statement of actuarial equivalency from either:
             2115          (I) the Utah Insurance Department;
             2116          (II) an actuary selected by the contractor or the contractor's insurer; or
             2117          (III) an underwriter who is responsible for developing the employer group's premium
             2118      rates;
             2119          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             2120      violates the provisions of this section, which may include:
             2121          (A) a three-month suspension of the contractor or subcontractor from entering into
             2122      future contracts with the state upon the first violation;
             2123          (B) a six-month suspension of the contractor or subcontractor from entering into future
             2124      contracts with the state upon the second violation;
             2125          (C) an action for debarment of the contractor or subcontractor in accordance with
             2126      Section 63G-6a-904 upon the third or subsequent violation; and
             2127          (D) monetary penalties which may not exceed 50% of the amount necessary to
             2128      purchase qualified health insurance coverage for an employee and a dependent of the employee
             2129      of the contractor or subcontractor who was not offered qualified health insurance coverage
             2130      during the duration of the contract; and
             2131          (iii) a website on which the department shall post the benchmark for the qualified
             2132      health insurance coverage identified in Subsection (1)(c).
             2133          (7) (a) (i) In addition to the penalties imposed under Subsection (6), a contractor or


             2134      subcontractor who intentionally violates the provisions of this section shall be liable to the
             2135      employee for health care costs that would have been covered by qualified health insurance
             2136      coverage.
             2137          (ii) An employer has an affirmative defense to a cause of action under Subsection
             2138      (7)(a)(i) if:
             2139          (A) the employer relied in good faith on a written statement of actuarial equivalency
             2140      provided by:
             2141          (I) an actuary; or
             2142          (II) an underwriter who is responsible for developing the employer group's premium
             2143      rates; or
             2144          (B) the department determines that compliance with this section is not required under
             2145      the provisions of Subsection (3) or (4).
             2146          (b) An employee has a private right of action only against the employee's employer to
             2147      enforce the provisions of this Subsection (7).
             2148          (8) Any penalties imposed and collected under this section shall be deposited into the
             2149      Medicaid Restricted Account created in Section 26-18-402 .
             2150          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             2151      coverage as required by this section:
             2152          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             2153      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             2154      Procurement Code; and
             2155          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             2156      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             2157      or construction.
             2158          Section 32. Section 79-2-404 is amended to read:
             2159           79-2-404. Contracting powers of department -- Health insurance coverage.
             2160          (1) For purposes of this section:
             2161          (a) "Employee" means an "employee," "worker," or "operative" as defined in Section
             2162      34A-2-104 who:
             2163          (i) works at least 30 hours per calendar week; and
             2164          (ii) meets employer eligibility waiting requirements for health care insurance which


             2165      may not exceed the first day of the calendar month following [90] 60 days from the date of
             2166      hire.
             2167          (b) "Health benefit plan" has the same meaning as provided in Section 31A-1-301 .
             2168          (c) "Qualified health insurance coverage" is as defined in Section 26-40-115 .
             2169          (d) "Subcontractor" has the same meaning provided for in Section 63A-5-208 .
             2170          (2) (a) Except as provided in Subsection (3), this section applies a design or
             2171      construction contract entered into by, or delegated to, the department or a division, board, or
             2172      council of the department on or after July 1, 2009, and to a prime contractor or to a
             2173      subcontractor in accordance with Subsection (2)(b).
             2174          (b) (i) A prime contractor is subject to this section if the prime contract is in the
             2175      amount of $1,500,000 or greater.
             2176          (ii) A subcontractor is subject to this section if a subcontract is in the amount of
             2177      $750,000 or greater.
             2178          (3) This section does not apply to contracts entered into by the department or a
             2179      division, board, or council of the department if:
             2180          (a) the application of this section jeopardizes the receipt of federal funds;
             2181          (b) the contract or agreement is between:
             2182          (i) the department or a division, board, or council of the department; and
             2183          (ii) (A) another agency of the state;
             2184          (B) the federal government;
             2185          (C) another state;
             2186          (D) an interstate agency;
             2187          (E) a political subdivision of this state; or
             2188          (F) a political subdivision of another state; or
             2189          (c) the contract or agreement is:
             2190          (i) for the purpose of disbursing grants or loans authorized by statute;
             2191          (ii) a sole source contract; or
             2192          (iii) an emergency procurement.
             2193          (4) (a) This section does not apply to a change order as defined in Section 63G-6a-103 ,
             2194      or a modification to a contract, when the contract does not meet the initial threshold required
             2195      by Subsection (2).


             2196          (b) A person who intentionally uses change orders or contract modifications to
             2197      circumvent the requirements of Subsection (2) is guilty of an infraction.
             2198          (5) (a) A contractor subject to Subsection (2)(b)(i) shall demonstrate to the department
             2199      that the contractor has and will maintain an offer of qualified health insurance coverage for the
             2200      contractor's employees and the employees' dependents during the duration of the contract.
             2201          (b) If a subcontractor of the contractor is subject to Subsection (2)(b)(ii), the contractor
             2202      shall demonstrate to the department that the subcontractor has and will maintain an offer of
             2203      qualified health insurance coverage for the subcontractor's employees and the employees'
             2204      dependents during the duration of the contract.
             2205          (c) (i) (A) A contractor who fails to meet the requirements of Subsection (5)(a) during
             2206      the duration of the contract is subject to penalties in accordance with administrative rules
             2207      adopted by the department under Subsection (6).
             2208          (B) A contractor is not subject to penalties for the failure of a subcontractor to meet the
             2209      requirements of Subsection (5)(b).
             2210          (ii) (A) A subcontractor who fails to meet the requirements of Subsection (5)(b) during
             2211      the duration of the contract is subject to penalties in accordance with administrative rules
             2212      adopted by the department under Subsection (6).
             2213          (B) A subcontractor is not subject to penalties for the failure of a contractor to meet the
             2214      requirements of Subsection (5)(a).
             2215          (6) The department shall adopt administrative rules:
             2216          (a) in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act;
             2217          (b) in coordination with:
             2218          (i) the Department of Environmental Quality in accordance with Section 19-1-206 ;
             2219          (ii) a public transit district in accordance with Section 17B-2a-818.5 ;
             2220          (iii) the State Building Board in accordance with Section 63A-5-205 ;
             2221          (iv) the State Capitol Preservation Board in accordance with Section 63C-9-403 ;
             2222          (v) the Department of Transportation in accordance with Section 72-6-107.5 ; and
             2223          (vi) the Legislature's Administrative Rules Review Committee; and
             2224          (c) which establish:
             2225          (i) the requirements and procedures a contractor must follow to demonstrate
             2226      compliance with this section to the department which shall include:


             2227          (A) that a contractor will not have to demonstrate compliance with Subsection (5)(a) or
             2228      (b) more than twice in any 12-month period; and
             2229          (B) that the actuarially equivalent determination required for qualified health insurance
             2230      coverage in Subsection (1) is met by the contractor if the contractor provides the department or
             2231      division with a written statement of actuarial equivalency from either:
             2232          (I) the Utah Insurance Department;
             2233          (II) an actuary selected by the contractor or the contractor's insurer; or
             2234          (III) an underwriter who is responsible for developing the employer group's premium
             2235      rates;
             2236          (ii) the penalties that may be imposed if a contractor or subcontractor intentionally
             2237      violates the provisions of this section, which may include:
             2238          (A) a three-month suspension of the contractor or subcontractor from entering into
             2239      future contracts with the state upon the first violation;
             2240          (B) a six-month suspension of the contractor or subcontractor from entering into future
             2241      contracts with the state upon the second violation;
             2242          (C) an action for debarment of the contractor or subcontractor in accordance with
             2243      Section 63G-6a-904 upon the third or subsequent violation; and
             2244          (D) monetary penalties which may not exceed 50% of the amount necessary to
             2245      purchase qualified health insurance coverage for an employee and a dependent of an employee
             2246      of the contractor or subcontractor who was not offered qualified health insurance coverage
             2247      during the duration of the contract; and
             2248          (iii) a website on which the department shall post the benchmark for the qualified
             2249      health insurance coverage identified in Subsection (1)(c).
             2250          (7) (a) (i) In addition to the penalties imposed under Subsection (6), a contractor or
             2251      subcontractor who intentionally violates the provisions of this section shall be liable to the
             2252      employee for health care costs that would have been covered by qualified health insurance
             2253      coverage.
             2254          (ii) An employer has an affirmative defense to a cause of action under Subsection
             2255      (7)(a)(i) if:
             2256          (A) the employer relied in good faith on a written statement of actuarial equivalency
             2257      provided by:


             2258          (I) an actuary; or
             2259          (II) an underwriter who is responsible for developing the employer group's premium
             2260      rates; or
             2261          (B) the department determines that compliance with this section is not required under
             2262      the provisions of Subsection (3) or (4).
             2263          (b) An employee has a private right of action only against the employee's employer to
             2264      enforce the provisions of this Subsection (7).
             2265          (8) Any penalties imposed and collected under this section shall be deposited into the
             2266      Medicaid Restricted Account created in Section 26-18-402 .
             2267          (9) The failure of a contractor or subcontractor to provide qualified health insurance
             2268      coverage as required by this section:
             2269          (a) may not be the basis for a protest or other action from a prospective bidder, offeror,
             2270      or contractor under Section 63G-6a-1603 or any other provision in Title 63G, Chapter 6a, Utah
             2271      Procurement Code; and
             2272          (b) may not be used by the procurement entity or a prospective bidder, offeror, or
             2273      contractor as a basis for any action or suit that would suspend, disrupt, or terminate the design
             2274      or construction.
             2275          Section 33. Effective date.
             2276          (1) Except as provided in Subsection (2), this bill takes effect May 13, 2014.
             2277          (2) The amendments to Section 63I-1-231 (Effective 07/01/14) take effect on July 1,
             2278      2014.
             2279          Section 34. Coordinating H.B. 141 with H.B. 24 -- Superseding technical and
             2280      substantive amendments.
             2281          If this H.B. 141 and H.B. 24, Insurance Related Amendments, both pass and become
             2282      law, it is the intent of the Legislature that the amendments to Sections 31A-23b-205 and
             2283      31A-23b-206 in this bill, supersede the amendments to Sections 31A-23b-205 and
             2284      31A-23b-206 in H.B. 24, when the Office of Legislative Research and General Counsel
             2285      prepares the Utah Code database for publication.
             2286          Section 35. Coordinating H.B. 141 with H.B. 35 -- Superseding technical and
             2287      substantive amendments.
             2288          If this H.B. 141 and H.B. 35, Reauthorization of Health Data Authority Act, both pass


             2289      and become law, it is the intent of the Legislature that the amendments to Section 26-33a-106.1
             2290      in this bill, supersede the amendments to Section 26-33a-106.1 in H.B. 35, when the Office of
             2291      Legislative Research and General Counsel prepares the Utah Code database for publication.


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