S.B. 9

1

COMPREHENSIVE HEALTH INSURANCE POOL
2 AMENDMENTS
3 2003 GENERAL SESSION
4 STATE OF UTAH
5 Sponsor: Gene Davis
6 This act modifies the Comprehensive Health Insurance Pool Act. The act amends
7 definitions. The act amends the number of board members required for a quorum, the
8 powers of the board, and the duties of the pool administrator. The act amends eligibility
9 for the pool and the application of preexisting conditions in order to be in compliance
10 with federal law and to incorporate provisions of the Primary Care Network waiver for
11 the state Medicaid program. The act amends provisions related to copays, deductibles,
12 and cancellations of coverage. The act amends the frequency with which premiums may
13 be adjusted. The act amends benefit reduction and immunity provisions. The act makes
14 technical changes.
15 This act affects sections of Utah Code Annotated 1953 as follows:
16 AMENDS:
17 31A-29-103, as last amended by Chapters 9 and 116, Laws of Utah 2001
18 31A-29-104, as last amended by Chapter 176, Laws of Utah 2002
19 31A-29-106, as enacted by Chapter 232, Laws of Utah 1990
20 31A-29-107, as enacted by Chapter 232, Laws of Utah 1990
21 31A-29-109, as enacted by Chapter 232, Laws of Utah 1990
22 31A-29-110, as enacted by Chapter 232, Laws of Utah 1990
23 31A-29-111, as last amended by Chapter 114, Laws of Utah 2000
24 31A-29-112, as last amended by Chapter 265, Laws of Utah 1997
25 31A-29-113, as last amended by Chapter 308, Laws of Utah 2002
26 31A-29-114, as enacted by Chapter 232, Laws of Utah 1990
27 31A-29-115, as repealed and reenacted by Chapter 265, Laws of Utah 1997

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- 2 - 28 31A-29-117, as last amended by Chapter 116, Laws of Utah 2001
29 31A-29-119, as enacted by Chapter 232, Laws of Utah 1990
30 31A-29-120, as last amended by Chapter 265, Laws of Utah 1997
31 31A-29-122, as enacted by Chapter 232, Laws of Utah 1990
32 Be it enacted by the Legislature of the state of Utah:
33 Section 1. Section 31A-29-103 is amended to read:
34 31A-29-103. Definitions.
35 As used in this chapter:
36 (1) "Board" means the board of directors of the pool created in Section 31A-29-104 .
37 (2) (a) "Creditable coverage" has the same meaning as provided in the Health Insurance
38 Portability and Accountability Act, Pub. L. No. 104-191, 110 Stat.1956, Sec. 2701(c)(1) and 45
39 C.F.R. Sec. 146.11(a)(1);
40 (b) "Creditable coverage" does not include a period of time in which there is a
41 significant break in coverage as described in the Health Insurance Portability and
42 Accountability Act, Pub. L. No. 104-191, 110 Stat. 1956, Sec. 2701(c)(2).
43 (3) "Enrollee" means an individual who has met the eligibility requirements of the pool
44 and is covered by a pool policy under this chapter.
45 [(2)] (4) "Health care facility" means any entity providing health care services which is
46 licensed under Title 26, Chapter 21.
47 [(3)] (5) "Health care provider" has the same meaning as provided in Section 78-14-3 .
48 [(4)] (6) "Health care services" means any service or product used in furnishing to any
49 individual medical care or hospitalization, or incidental to furnishing medical care or
50 hospitalization, and any other service or product furnished for the purpose of preventing,
51 alleviating, curing, or healing human illness or injury.
52 [(5)] (7) (a) "Health insurance" means any:
53 (i) hospital and medical expense-incurred policy;
54 (ii) nonprofit health care service plan contract; [and] or
55 (iii) health maintenance organization subscriber contract.
56 (b) "Health insurance" does not [include] mean:
57 (i) any insurance arising out of the Workers' Compensation Act or similar law[,];
58 (ii) automobile medical payment insurance[,]; or

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- 3 - 59 (iii) insurance under which benefits are payable with or without regard to fault and
60 which is required by law to be contained in any liability insurance policy.
61 [(6)] (8) "Health maintenance organization" has the same meaning as provided in
62 Section 31A-8-101 .
63 [(7)] (9) "Health plan" means any arrangement by which [a person] an individual,
64 including a dependent or spouse, covered or making application to be covered under the pool
65 has access to hospital and medical benefits or reimbursement including group or individual
66 insurance or subscriber contract; coverage through a health maintenance organization, preferred
67 provider prepayment, group practice, or individual practice plan; coverage under an uninsured
68 arrangement of group or group-type contracts including employer self-insured, cost-plus, or
69 other benefits methodologies not involving insurance; coverage under a group type contract
70 which is not available to the general public and can be obtained only because of connection
71 with a particular organization or group; and coverage by Medicare or other governmental
72 benefit. The term includes coverage through health insurance.
73 [(8) "Insured" means an individual resident of this state who is eligible to receive
74 benefits from any insurer, health maintenance organization, or other health plan.]
75 (10) "HIPAA" means the Health Insurance Portability and Accountability Act, Pub. L.
76 No. 104-191, 110 Stat.1962.
77 (11) "HIPAA eligible" means an individual who is eligible under the provisions of the
78 Health Insurance Portability and Accountability Act, Pub. L. No. 104-191, 110 Stat. 1979, Sec.
79 2741(b).
80 [(9)] (12) "Insurer" means an insurance company authorized to transact accident and
81 health insurance business in this state, health maintenance organization, and a self-insurer not
82 subject to federal preemption.
83 [(10)] (13) "Medicaid" means coverage under Title XIX of the Social Security Act, 42
84 U.S.C. Sec. 1396 et seq., as amended.
85 [(11)] (14) "Medicare" means coverage under both Part A and B of Title XVIII of the
86 Social Security Act, 42 U.S.C. 1395 et seq., as amended.
87 [(12)] (15) "Plan of operation" means the plan developed by the board in accordance
88 with Section 31A-29-105 and includes the articles, bylaws, and operating rules adopted by the
89 board under Section 31A-29-106 .

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- 4 - 90 [(13)] (16) "Pool" means the Utah Comprehensive Health Insurance Pool created in
91 Section 31A-29-104 .
92 [(14)] (17) "Pool fund" means the Comprehensive Health Insurance Pool Enterprise
93 Fund created in Section 31A-29-120 .
94 [(15)] (18) "Pool policy" means [an] a health insurance policy issued under this
95 chapter.
96 (19) "Preexisting condition" means a condition, regardless of the cause of the
97 condition, for which medical advice, diagnosis, care, or treatment was recommended or
98 received within the six-month period immediately prior to the enrollment date.
99 (20) "Resident" or "residency" means an individual who is domiciled in this state as
100 defined in Section 23-13-2 .
101 [(16)] (21) "Third-party administrator" has the same meaning as provided in Section
102 31A-1-301 .
103 Section 2. Section 31A-29-104 is amended to read:
104 31A-29-104. Creation of pool -- Board of directors -- Appointment -- Terms --
105 Quorum -- Plan preparation.
106 (1) There is created the "Utah Comprehensive Health Insurance Pool," a nonprofit
107 entity within the Insurance Department.
108 (2) The pool shall be under the direction of a board of directors composed of 11
109 members.
110 (a) The governor shall appoint the directors with the consent of the Senate as follows:
111 (i) two representatives of health insurance companies or health service organizations;
112 (ii) one representative of a health maintenance organization;
113 (iii) one physician;
114 (iv) one representative of hospitals;
115 (v) one representative of the general public who is reasonably expected to qualify for
116 coverage under the pool;
117 (vi) one parent or spouse of such an individual;
118 (vii) one representative of the general public; and
119 (viii) one representative of employers.
120 (b) The board shall also include:

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- 5 - 121 (i) the commissioner or his designee; and
122 (ii) the executive director of the Department of Health or his designee.
123 (3) (a) Except as required by Subsection (3)(b), as terms of current board members
124 expire, the governor shall appoint each new member or reappointed member to a four-year
125 term.
126 (b) Notwithstanding the requirements of Subsection (3)(a), the governor shall, at the
127 time of appointment or reappointment, adjust the length of terms to ensure that the terms of
128 board members are staggered so that approximately half of the board is appointed every two
129 years.
130 (4) When a vacancy occurs in the membership for any reason, the replacement shall be
131 appointed for the unexpired term in the same manner as the original appointment was made.
132 (5) (a) (i) Members who are not government employees shall receive no compensation
133 or benefits for their services, but may receive per diem and expenses incurred in the
134 performance of the member's official duties at the rates established by the Division of Finance
135 under Sections 63A-3-106 and 63A-3-107 from the Pool Fund.
136 (ii) Members may decline to receive per diem and expenses for their service.
137 (b) (i) State government officer and employee members who do not receive salary, per
138 diem, or expenses from their agency for their service may receive per diem and expenses
139 incurred in the performance of their official duties from the pool at the rates established by the
140 Division of Finance under Sections 63A-3-106 and 63A-3-107 .
141 (ii) A state government member who is a member because of their state government
142 position may not receive per diem or expenses for their service.
143 (iii) State government officer and employee members may decline to receive per diem
144 and expenses for their service.
145 (6) The board shall elect annually a chair and vice chair from its membership.
146 (7) [Seven] Six board members are a quorum for the transaction of business.
147 (8) The action of a majority of the members of the quorum is the action of the board.
148 (9) The board shall submit a plan of operation to the commissioner no later than
149 January 1, 1991.
150 (10) The sale of policies under this chapter shall commence on July 1, 1991, or as soon
151 thereafter as adequate funding for the coverage is available as determined by the commissioner.

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- 6 - 152 Section 3. Section 31A-29-106 is amended to read:
153 31A-29-106. Powers of board.
154 (1) The board shall have the general powers and authority granted under the laws of
155 this state to insurance companies licensed to transact health care insurance business. In
156 addition, the board shall have the specific authority to:
157 [(1)] (a) enter into contracts to carry out the provisions and purposes of this chapter,
158 including, with the approval of the commissioner, contracts with:
159 [(a)] (i) similar pools of other states for the joint performance of common
160 administrative functions; or
161 [(b)] (ii) persons or other organizations for the performance of administrative
162 functions;
163 [(2)] (b) sue or be sued, including taking such legal action necessary to avoid the
164 payment of improper claims against the pool or the coverage provided through the pool;
165 [(3)] (c) establish appropriate rates, rate schedules, rate adjustments, expense
166 allowances, agents' referral fees, claim reserve formulas, and any other actuarial function
167 appropriate to the operation of the pool;
168 [(4)] (d) issue policies of insurance in accordance with the requirements of this chapter;
169 [(5)] (e) retain an executive director and appropriate legal, actuarial, and other
170 personnel as necessary to provide technical assistance in the operations of the pool;
171 [(6)] (f) establish rules, conditions, and procedures for reinsuring risks under this
172 chapter;
173 [(7)] (g) cause the pool to have an annual audit of its operations by the state auditor;
174 [(8)] (h) coordinate with the Department of Health in seeking to obtain from the
175 [United States Health Care Financing Administration] Centers for Medicare and Medicaid
176 Services, or other appropriate office or agency of government, all appropriate waivers,
177 authority, and permission needed to coordinate the coverage available from the pool with
178 coverage available under Medicaid, either before or after Medicaid coverage, or as a
179 conversion option upon completion of Medicaid eligibility, without the necessity for
180 requalification by the [insured] enrollee;
181 [(9)] (i) provide for and employ cost containment measures and requirements including
182 preadmission certification, concurrent inpatient review, and individual case management for

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- 7 - 183 the purpose of making the pool more cost-effective;
184 [(10)] (j) offer pool coverage through contracts with health maintenance organizations,
185 preferred provider organizations, and other managed care systems that will manage costs while
186 maintaining quality care;
187 [(11)] (k) establish annual limits on benefits payable under the pool to or on behalf of
188 any [person] enrollee;
189 [(12)] (l) exclude from coverage under the pool specific benefits, medical conditions,
190 and procedures for the purpose of protecting the financial viability of the pool;
191 [(13)] (m) administer the Pool Fund; [and]
192 [(14)] (n) make rules in accordance with Title 63, Chapter 46a, Utah Administrative
193 Rulemaking Act, to implement this chapter[.]; and
194 (o) adopt, trademark, and copyright a trade name for the pool for use in marketing and
195 publicizing the pool and its products.
196 (2) (a) The board shall prepare and submit an annual report to the Legislature which
197 shall include:
198 (i) the net premiums anticipated;
199 (ii) actuarial projections of payments required of the pool;
200 (iii) the expenses of administration; and
201 (iv) the anticipated reserves or losses of the pool.
202 (b) The budget for operation of the pool is subject to the approval of the board.
203 (c) The administrative budget of the board and the commissioner under this chapter
204 shall comply with the requirements of Title 63, Chapter 38, Budgetary Procedures Act, and is
205 subject to review and approval by the Legislature.
206 Section 4. Section 31A-29-107 is amended to read:
207 31A-29-107. Powers of commissioner.
208 (1) The commissioner shall, after notice and hearing, approve the plan of operation if
209 [he] the commissioner determines that the plan will assure the fair, reasonable, and equitable
210 administration of the pool.
211 (2) The plan shall be effective upon the commissioner's written approval.
212 (3) If the board fails to submit a proposed plan of operation by January 1, 1991, or any
213 time thereafter fails to submit proposed amendments to the plan of operation within a

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- 8 - 214 reasonable time after requested by the commissioner, the commissioner shall, after notice and
215 hearing, adopt such rules as necessary to effectuate the provisions of this chapter.
216 (4) Rules promulgated by the commissioner shall continue in force until modified by
217 him or until superseded by a subsequent plan of operation submitted by the board and approved
218 by the commissioner.
219 (5) The commissioner may designate an executive secretary from the department to
220 provide administrative assistance to the board in carrying out its responsibilities.
221 [(6) (a) The board shall prepare and submit annually to the Legislature a budget
222 forecast for operation of the pool which shall include:]
223 [(i) the net premiums anticipated;]
224 [(ii) actuarial projections of payments required of the pool;]
225 [(iii) the expenses of administration; and]
226 [(iv) the anticipated reserves or losses of the pool.]
227 [(b) The budget for operation of the pool is subject to the approval of the board.]
228 [(c) The administrative budget of the board and the commission under this chapter
229 shall comply with the requirements of Title 63, Chapter 38, Budgetary Procedures Act, and is
230 subject to review and approval by the Legislature.]
231 Section 5. Section 31A-29-109 is amended to read:
232 31A-29-109. Policy forms.
233 [(1)] All policy forms issued by the pool shall conform in substance to forms
234 developed by the board and shall be filed with the commissioner before they are issued.
235 [(2) The pool may not issue a pool policy to any person, who on the effective date of
236 the coverage applied for, has coverage substantially equivalent to a pool policy either as an
237 insured or a covered dependent, or who would be eligible for that coverage if he elected to
238 obtain it.]
239 Section 6. Section 31A-29-110 is amended to read:
240 31A-29-110. Pool administrator -- Selection -- Powers.
241 (1) The board shall select a pool administrator in accordance with Title 63, Chapter 56,
242 Utah Procurement Code. The board shall evaluate bids based on criteria established by the
243 board, which shall include:
244 (a) ability to manage medical expenses;

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- 9 - 245 (b) proven ability to handle accident and health insurance;
246 (c) efficiency of claim paying procedures;
247 (d) marketing and underwriting;
248 (e) proven ability for managed care and quality assurance;
249 (f) provider contracting and discounts;
250 (g) pharmacy benefit management;
251 [(d)] (h) an estimate of total charges for administering the pool; and
252 [(e)] (i) ability to administer the pool in a cost-efficient manner.
253 (2) A pool administrator may be:
254 (a) a health insurer;
255 (b) a health maintenance organization;
256 (c) a third-party administrator; or
257 (d) any person or entity which has demonstrated ability to meet the criteria in
258 Subsection (1).
259 (3) (a) The pool administrator shall serve for a period of three years subject to removal
260 for cause and subject to the terms, conditions, and limitations of the contract between the board
261 and the administrator.
262 (b) At least one year prior to the expiration of each three-year period of service by the
263 pool administrator, the board shall invite all interested parties, including the current pool
264 administrator, to submit bids to serve as the pool administrator for the succeeding three-year
265 period.
266 (c) Selection of the pool administrator for a succeeding period shall be made at least
267 six months prior to the expiration of a three-year period of service by the pool administrator.
268 (4) The pool administrator is responsible for all operational functions of the pool and
269 shall:
270 (a) have access to all nonpatient specific experience data, statistics, treatment criteria,
271 and guidelines compiled or adopted by the Medicaid program, the Public Employees Health
272 Plan, the Department of Health, or the Insurance Department, and which are not otherwise
273 declared by statute to be confidential;
274 (b) perform all marketing, eligibility, enrollment, member agreements, and
275 administrative claim payment functions relating to the pool;

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- 10 - 276 (c) establish, administer, and operate a monthly premium billing procedure for
277 collection of premiums from [insured persons] enrollees;
278 (d) perform all necessary functions to assure timely payment of benefits to [persons
279 covered under the pool] enrollees, including:
280 (i) making information available relating to the proper manner of submitting a claim
281 for benefits to the pool administrator and distributing forms upon which submission shall be
282 made; and
283 (ii) evaluating the eligibility of each claim for payment by the pool;
284 (e) submit regular reports to the board regarding the operation of the pool, the
285 frequency, content, and form of which reports shall be determined by the board;
286 (f) following the close of each calendar year, determine net written and earned
287 premiums, the expense of administration, and the paid and incurred losses for the year and
288 submit a report of this information to the board, the commissioner, and the Division of Finance
289 on a form prescribed by the commissioner; and
290 (g) be paid as provided in the plan of operation for expenses incurred in the
291 performance of the pool administrator's services.
292 Section 7. Section 31A-29-111 is amended to read:
293 31A-29-111. Eligibility -- Limitations.
294 (1) (a) Except as provided in Subsection (1)(b), [a person] an individual is eligible for
295 pool coverage if the individual:
296 (i) [(A) the person] pays the established premium; [and]
297 [(B)] (ii) is a resident of this state; [or] and
298 (iii) meets the health underwriting criteria under Subsection (4)(a).
299 [(ii) is a dependent child 25 years of age or less of a person described in Subsection
300 (1)(a)(i).]
301 (b) Notwithstanding Subsection (1)(a), [a person] an individual is not eligible for pool
302 coverage if one of the following conditions apply:
303 (i) at the time of application, the [person] individual is eligible for health care benefits
304 under Medicaid or Medicare, except as provided in Section 31A-29-112 ;
305 (ii) the [person] individual has terminated coverage in the pool, unless:
306 (A) 12 months have elapsed since the termination date; or

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- 11 - 307 (B) the [person] individual demonstrates that [continuous other] creditable coverage
308 has been involuntarily terminated for any reason other than nonpayment of premium;
309 (iii) the pool has paid the maximum lifetime benefit to or on behalf of the [person]
310 individual;
311 (iv) the [person] individual is an inmate of a public institution;
312 (v) the [person] individual is eligible for other public programs for which medical care
313 is provided;
314 (vi) the [person's] individual's health condition does not meet the criteria established
315 under Subsection (4);
316 (vii) the [person] individual is an eligible employee, a dependant of an eligible
317 employee, or a member of an employer group that offers health insurance or a self-insurance
318 arrangement to all its eligible employees, dependants, or members; [or]
319 (viii) at the time the pool coverage is applied for, the individual has coverage
320 substantially equivalent to a pool policy, as established by the board in administrative rule,
321 either as an insured or a covered dependant, or the individual would be eligible for the
322 substantially equivalent coverage if the individual elected to obtain the coverage; or
323 [(viii)] (ix) at the time of application, the [person] individual:
324 (A) is not [eligible for coverage that is subject to the Health Insurance Portability and
325 Accountability Act, P.L. 104-91, 110 Stat. 1962] HIPAA eligible; and
326 (B) has not resided in Utah for at least 12 consecutive months preceding the date of
327 application.
328 (2) (a) Notwithstanding Subsection (1)(b)[(viii)](ix), if otherwise eligible under
329 Subsection (1), [a person] an individual whose health insurance coverage from a state health
330 risk pool with similar coverage is terminated because of nonresidency in another state may
331 apply for coverage under the pool subject to the conditions of Subsections (1)(b)(i) through
332 (vii).
333 (b) (i) Coverage sought under Subsection (2)(a) shall be applied for within 63 days after
334 the termination date of the previous risk pool coverage.
335 (ii) If premiums are paid for the entire coverage period under the previous risk pool
336 with similar coverage, the effective date of [the pool's] this state's pool coverage shall be the
337 date of termination of the previous risk pool coverage.

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House Committee Amendments 2-5-2003 bh/cjd 338

(iii) If premiums are not paid back to the previous risk pool termination date, then the
339 effective date will be determined by the pool administrator in accordance with the date of
340 application.
341 (c) The waiting period of [a person] an individual with a preexisting condition applying
342 for coverage under this chapter shall be waived [if]:
343 (i) to the extent to which the waiting period was satisfied under a similar plan from
344 another state; and
345 (ii) if the other state's benefit limitation was not reached.
346 (3) If an eligible [person] individual applies for pool coverage within 30 days of being
347 denied coverage by an individual carrier, the effective date for pool coverage shall be [set at]
348 no later than the first day of the month following the date of submission of the completed
349 insurance application to the carrier.
350 (4) (a) The board shall establish and adjust, as necessary, health underwriting criteria
351 based on:
352 (i) health condition; and
353 (ii) expected claims so that the expected claims are anticipated to remain within
354 available funding.
355 (b) The [commissioner] board h , WITH APPROVAL OF THE COMMISSIONER, h may
355a contract with one or more providers under Title 63,
356 Chapter 56, Utah Procurement Code, to develop underwriting criteria under Subsection (4)(a).
357 (c) If [a person] an individual is denied coverage by the pool under the criteria
358 established in Subsection (4)(a), the pool shall issue a certificate of insurability to the
359 [applicant] individual for coverage under Subsection 31A-30-108 (3).
360 Section 8. Section 31A-29-112 is amended to read:
361 31A-29-112. Medicaid recipients.
362 (1) If authorized by federal statutes or rules, [a person] an individual receiving
363 Medicaid benefits may continue to receive those benefits while satisfying the preexisting
364 condition requirements established by Section 31A-29-113 and the terms of the pool policy
365 issued under this chapter.
366 (2) If allowed by federal statute, federal regulation, state statute, or rule, the
367 Department of Health shall allocate premiums paid to the pool by [a person] an individual
368 receiving Medicaid benefits to that [person's] individual's spenddown for purposes of the

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- 13 - 369 Medicaid [no-grant] program.
370 (3) (a) If [a person] an individual continues to receive Medicaid benefits after the
371 requirements for a preexisting condition are satisfied, the pool administrator may not issue [an
372 insurance] a pool policy or allow that [person] individual to receive any benefit from the pool.
373 (b) If [a person] an individual continues to receive Medicaid benefits when the
374 requirements for a preexisting condition are satisfied, the pool administrator shall give any
375 premiums collected by it during the preexisting conditions period to the Medicaid program.
376 (4) (a) If [any person is covered by a pool policy and] an enrollee becomes eligible to
377 receive Medicaid benefits, [that person's] the enrollee's coverage by the pool terminates as of
378 the effective date of [the receipt of] Medicaid [benefits] coverage.
379 (b) The pool administrator shall:
380 (i) include a provision in the [insurance] pool policy requiring [a person covered by a
381 pool policy] an enrollee to provide written notice to the pool administration if [he] the enrollee
382 becomes covered by Medicaid; and
383 (ii) terminate [a person's] an enrollee's coverage by the pool as of the effective date of
384 the [person's receipt of] enrollee's Medicaid [benefits] coverage when the pool administrator
385 becomes aware that the [person] enrollee is covered by Medicaid.
386 (5) If [a person] an individual terminates coverage under Medicaid and applies for
387 coverage under a pool policy within 45 days after terminating the coverage, the [person]
388 individual may begin coverage under a pool policy as of the date that Medicaid coverage
389 terminated, if [a person] an individual meets the other eligibility requirements of the chapter
390 and pays the required premium.
391 (6) [If a person's eligibility for Medicaid requires a spenddown, as defined in rule, that
392 exceeds the premium for a pool policy, that person shall be] Notwithstanding the provision of
393 Subsection 31A-29-111 (1)(b)(i), an individual is eligible for coverage by the pool if the
394 [remaining] requirements of Section 31A-29-111 are met[.] and if:
395 (a) the individual's eligibility for Medicaid requires a spenddown, as defined by rule,
396 that exceeds the premium for a pool policy; or
397 (b) the individual is eligible for the Primary Care Network program administered by
398 the Department of Health.
399 Section 9. Section 31A-29-113 is amended to read:

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- 14 - 400 31A-29-113. Benefits -- Additional types of pool insurance -- Preexisting
401 conditions -- Waiver -- Maximum benefits.
402 (1) (a) The pool policy shall pay for eligible medical expenses rendered or furnished
403 for the diagnoses or treatment of illness or injury that:
404 (i) exceed the deductible and copayment amounts applicable under Section
405 31A-29-114 ; and
406 (ii) are not otherwise limited or excluded.
407 (b) Eligible medical expenses are the allowed charges established by the board for the
408 health care services and items rendered during times for which benefits are extended under the
409 pool policy.
410 (2) The coverage to be issued by the pool, its schedule of benefits, exclusions, and
411 other limitations shall be established by the board.
412 (3) The commissioner shall approve the benefit package developed by the board to
413 ensure its compliance with this chapter.
414 (4) The pool shall offer at least one benefit plan through a managed care program as
415 authorized under Section 31A-29-106 .
416 (5) This chapter may not be construed to prohibit the pool from issuing additional types
417 of [health insurance] pool policies with different types of benefits which in the opinion of the
418 board may be of benefit to the citizens of Utah.
419 (6) The board shall design and require an administrator to employ cost containment
420 measures and requirements including preadmission certification and concurrent inpatient
421 review for the purpose of making the pool more cost effective. The provisions of Sections
422 31A-22-617 and 31A-22-618 [of this title] do not apply to coverage issued under this chapter.
423 (7) (a) A pool policy may contain provisions under which coverage for a preexisting
424 condition is excluded during a six-month period following the effective date of plan coverage
425 [as to] for a given individual [for a preexisting condition, as long as either of the following
426 exists:].
427 [(a) the condition has manifested itself within a period of six months before the
428 effective date of coverage in such a manner as would cause an ordinary, prudent person to seek
429 diagnosis or treatment; or]
430 [(b) medical advice or treatment was recommended or received for the condition

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- 15 - 431 within a period of six months before the effective date of coverage.]
432 (b) Subsection (7)(a) does not apply to a HIPAA eligible individual.
433 (8) A pool policy may exclude coverage for pregnancies for ten months following the
434 effective date of coverage, unless the individual is HIPAA eligible [to receive credit for
435 previous coverage under the Health Insurance Portability and Accountability Act, P. L. 104-91,
436 110 Stat. 1962].
437 [(9) (a) For individuals changing from individual health insurance, as defined in
438 Subsection 31A-29-103 (5), to the health insurance pool, the preexisting condition exclusion
439 described in Subsection (7) shall be waived to the extent to which similar exclusions have been
440 satisfied under any prior health insurance coverage:]
441 [(i) which was involuntarily terminated, other than for nonpayment of premium, if the
442 application for pool coverage is made not later than 63 days following the involuntary
443 termination; or]
444 [(ii) whose premium rate exceeds the rate of the pool for equal or lesser benefits.]
445 [(b) If Subsection (9)(a) applies, coverage in the pool shall be effective from the date
446 on which the prior coverage was terminated.]
447 [(10)] (9) (a) The pool [may not apply any] will waive the preexisting condition
448 exclusion [to] described in Subsection (7)(a) for an individual that is changing [group] health
449 coverage to the [health insurance] pool, to the extent to which similar exclusions have been
450 satisfied under any prior health insurance coverage if:
451 (i) the individual applies not later than 63 days following the date of involuntary
452 termination, other than for nonpayment of premiums, from [group] health coverage; or
453 [(ii) the individual has at least 18 months of creditable coverage as of the date the
454 individual seeks coverage from:]
455 [(A) the health insurance pool; or]
456 [(B) an individual health plan;]
457 [(iii) the individual's most recent prior creditable coverage was under:]
458 [(A) a group health plan;]
459 [(B) a government plan; or]
460 [(C) a church plan;]
461 [(iv) the individual is not eligible for coverage under:]

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Senate 3^rd Reading Amendments 1-31-2003 rd/cjd 462

[(A) a group health plan;]
463 [(B) Part A or Part B of Title XVIII of the Social Security Act; or]
464 [(C) a state plan under Title XIX of the Social Security Act;]
465 [(v) the individual does not have other health insurance coverage;]
466 [(vi) the individual's most recent coverage was not terminated because of:]
467 [(A) nonpayment of premiums; or]
468 [(B) fraud;]
469 [(vii) the individual has been offered the option of continuing coverage under:]
470 [(A) a continuation provision; or]
471 [(B) a similar state extension program; and]
472 [(viii)] (ii) the individual's premium rate exceeds the rate of the pool for equal or lesser
473 coverage provided that the application for pool coverage is made no later than 63 days
474 following the termination from the prior health insurance coverage.
475 (b) In accordance with Subsections (7)(b) and (8), the pool may not apply a preexisting
476 condition exclusion if the individual is HIPAA eligible.
477 [(b)] (c) If Subsection [(10)(a)] (9) applies, coverage in the pool shall be effective from
478 the date on which the prior coverage was terminated.
479 [(11) The board shall establish a policy allowing for the waiver of the preexisting
480 condition exclusion set forth in Subsection (7) for coverage of medically necessary outpatient
481 medical care.]
482 [(12) Benefits available under the pool may not exceed $1,000,000 paid to or on behalf
483 of any person.]
484 (10) Covered benefits available from the pool may not exceed a $1,000,000 lifetime
485 maximum, which includes a per enrollee calendar year maximum established by the board.
486 Section 10. Section 31A-29-114 is amended to read:
487 31A-29-114. Deductibles -- Copayments.
488 (1) (a) Subject to the [limitation] limits provided in Subsection (3), a pool policy shall
489 impose a deductible on a per calendar year basis.
490 (b) Deductible plans of $500 and $1,000 shall initially be offered. Other S HIGHER s deductible
491 plans may be offered by the pool.
492 (c) The deductible [must be] is applied to [the first $500 or $1,000] all of the eligible

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- 17 - 493 medical expenses as defined in Section 31A-29-113 , incurred by the [insured] enrollee until the
494 deductible has been satisfied. There are no benefits payable before the deductible has been
495 satisfied.
496 [(d) No more than three deductibles under the pool policy per family may be applied.]
497 (d) The pool may offer separate deductibles for prescription benefits.
498 (2) (a) Subject to the [limitations] limits provided in Subsection (3), a mandatory
499 [copayment] coinsurance requirement shall be imposed at the rate of at least 20% of eligible
500 medical expenses in excess of the mandatory deductible.
501 (b) Any coinsurance imposed under this Subsection (2) shall be designated in the pool
502 policy.
503 (3) Except as provided in Subsection (4), the maximum aggregate out-of-pocket
504 payments for eligible medical expenses incurred by the [insured] enrollee in the form of
505 deductibles and coinsurance may not exceed:
506 (a) $1,500 per individual [or $2,500 per family] per [policy] calendar year for the $500
507 deductible plan[. For the $1,000 deductible plan, the maximum aggregate out-of-pocket
508 payments for eligible expenses by the insured in the form of deductibles and coinsurance may
509 not exceed $2,000 per individual or $3,000 per family per policy year.];
510 (b) $2,000 per individual per calendar year for the $1,000 deductible plan; or
511 (c) if other deductible plans are offered by the pool, an amount per individual will be
512 established by the board.
513 (4) (a) [Notwithstanding] When the enrollee has incurred the maximum aggregate
514 out-of-pocket payments under Subsection (3), the board may establish a [copayment]
515 coinsurance requirement to be imposed on eligible medical expenses in excess of the maximum
516 aggregate out-of-pocket expense limits set forth in Subsection (3). [Such copayment
517 requirement]
518 (b) The circumstances in which the coinsurance authorized by this Subsection (4) may
519 be imposed shall be designated in the pool policy.
520 (c) The coinsurance authorized by this Subsection (4) may be imposed at a rate not to
521 exceed 5% of eligible medical expenses.
522 (5) The limits on maximum aggregate out-of-pocket payments for eligible medical
523 expenses incurred by the enrollee in the form of deductibles and coinsurance under this section

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- 18 - 524 shall not include out-of-pocket payments for prescription benefits.
525 Section 11. Section 31A-29-115 is amended to read:
526 31A-29-115. Cancellation -- Notice.
527 (1) (a) On the date of renewal, the pool may cancel [a person's] an enrollee's policy if:
528 (i) the [person's] enrollee's health condition does not meet the criteria established in
529 Subsection 31A-29-111 (4);
530 (ii) the pool has provided written notice to the [person's] enrollee's last-known address
531 no less than 60 days before cancellation; and
532 (iii) at least one individual carrier has not reached the individual enrollment cap
533 established in Section 31A-30-110 .
534 (b) The pool shall issue a certificate of insurability to [a person] an enrollee whose
535 policy is cancelled under Subsection (1)(a) for coverage under Subsection 31A-30-108 (3) if the
536 requirements of Subsection 31A-29-111 (4) are met.
537 (2) The pool may cancel [a person's] an enrollee's policy at any time if:
538 [(a) the person establishes a residency outside of Utah for three consecutive months;
539 and]
540 [(b)] (a) the pool has provided written notice to the [person's] enrollee's last-known
541 address no less than 15 days before cancellation[.]; and
542 (b) (i) the enrollee establishes a residency outside of Utah for three consecutive
543 months;
544 (ii) there is nonpayment of premiums; or
545 (iii) the pool determines that the enrollee does not meet the eligibility requirements set
546 forth in Section 31A-29-111 , in which case:
547 (A) the policy may be retroactively terminated for the period of time in which the
548 enrollee was not eligible;
549 (B) retroactive termination may not exceed three years; and
550 (C) the board's remedy under this Subsection (2)(b) shall be a cause of action against
551 the enrollee for benefits paid during the period of ineligibility in accordance with Subsection
552 31A-29-119 (3).
553 Section 12. Section 31A-29-117 is amended to read:
554 31A-29-117. Premium rates.

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- 19 - 555 (1) (a) Premium charges for coverage under the pool may not be unreasonable in
556 relation to:
557 (i) the benefits provided;
558 (ii) the risk experience; and
559 (iii) the reasonable expenses provided in the coverage.
560 (b) Separate schedules of premium rates based on age and other appropriate
561 demographic characteristics may apply for individual risks.
562 (2) A small employer carrier, as defined in Section 31A-1-301 , shall annually inform
563 the commissioner by April 1 of the carrier's:
564 (a) small employer index premium rates as of March 1 of the current and preceding
565 year; and
566 (b) average percentage change in the index premium rate as of March 1, of the current
567 and preceding year.
568 (3) (a) Premium rates [in effect as of January 1, 1997, shall be adjusted on July 1,
569 1997, and each following July 1 may be adjusted by the board] may be adjusted by the board on
570 a biannual basis, for an effective date of January 1 and July 1.
571 (b) In adjusting premium rates, the board shall:
572 (i) consider the average increase in small employer index rates for the five largest small
573 employer carriers submitted under Subsection (2); and
574 (ii) be subject to Subsection (1).
575 (4) The board may establish a premium scale based on income. The highest rate may
576 not exceed the expected claims and expenses for the individual.
577 (5) If [a person] an individual is [an] HIPAA eligible [individual as defined in the
578 Health Insurance Portability and Accountability Act, P.L. 104-191, 110 Stat. 1979, Sec.
579 2741(b)], the maximum premium rate for that [person] individual may not exceed the amount
580 permitted under [P.L. 104-191, 110 Stat. 1986, Sec. 2744(c)(2)(B)] HIPAA.
581 (6) All rates and rate schedules shall be submitted by the board to the commissioner for
582 approval.
583 Section 13. Section 31A-29-119 is amended to read:
584 31A-29-119. Benefit reduction.
585 (1) The pool shall be the last payer of benefits whenever any other benefit is available.

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- 20 - 586 (2) Benefits otherwise payable under pool coverage shall be reduced by:
587 (a) all amounts paid or payable through any other health insurance or any limited health
588 benefit plan, including a self-insured plan;
589 (b) all hospital and medical expense benefits paid or payable under any workers'
590 compensation coverage, automobile medical payment, or liability insurance, whether provided
591 on the basis of fault or no-fault; and
592 (c) any hospital or medical benefits paid or payable under or provided pursuant to any
593 state or federal law program.
594 (3) The pool administrator shall have a cause of action against an [insured] enrollee for
595 the recovery of the amount of benefits paid which are not for covered expenses. Benefits due
596 from the pool may be reduced or refused as a set-off against any amount recoverable under this
597 Subsection (3).
598 Section 14. Section 31A-29-120 is amended to read:
599 31A-29-120. Enterprise fund.
600 (1) There is created an enterprise fund known as the Comprehensive Health Insurance
601 Pool Enterprise Fund.
602 (2) The following funds shall be credited to the pool fund:
603 (a) [$5,000,000 appropriated] appropriations from the General Fund [for Fiscal Year
604 1997-98];
605 (b) pool policy premium payments; and
606 (c) all interest and dividends earned on the pool fund's assets.
607 (3) All money received by the pool fund shall be deposited in compliance with Section
608 51-4-1 and shall be held by the state treasurer and invested in accordance with Title 51,
609 Chapter 7, State Money Management Act.
610 (4) The pool fund shall comply with the accounting policies, procedures, and reporting
611 requirements established by the Division of Finance.
612 (5) The pool fund shall comply with Title 63A, Utah Administrative Services Code.
613 Section 15. Section 31A-29-122 is amended to read:
614 31A-29-122. Immunity.
615 There is no liability on the part of and no cause of action of any nature may arise against
616 any member of the board, the board's agents or employees, the executive director, the

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618 them in effecting the provisions of this chapter.

Legislative Review Note
as of 10-24-02 12:53 PM

A limited legal review of this legislation raises no obvious constitutional or statutory concerns.

Office of Legislative Research and General Counsel

Interim Committee Note
as of 12-12-02 1:38 PM

The Health and Human Services Interim Committee recommended this bill.