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H.B. 41






Sponsor: Judy Ann Buffmire

             7      LONG TITLE
             8      General Description:
             9          This bill amends the Insurance Code and clarifies the duties of a Health Maintenance
             10      Organization when a court orders a noncustodial parent to provide health insurance.
             11      Highlighted Provisions:
             12          This bill:
             13          .    requires a health maintenance organization to allow a child who lives outside the
             14      organization's service area to enroll in a health plan if the enrollee parent is ordered
             15      by a court to provide health insurance;
             16          .    requires a health maintenance organization to pay claims submitted by the
             17      out-of-area child in the same manner as the organization pays under a noncapitated
             18      arrangement; and
             19          .    provides certain circumstances in which a health maintenance organization does not
             20      have to allow the out-of-area child to enroll in the plan.
             21      Monies Appropriated in this Bill:
             22          None
             23      Other Special Clauses:
             24          This bill takes effect on July 1, 2004.
             25      Utah Code Sections Affected:
             26      ENACTS:
             27          31A-8-502, Utah Code Annotated 1953

             29      Be it enacted by the Legislature of the state of Utah:
             30          Section 1. Section 31A-8-502 is enacted to read:
             31          31A-8-502. Court ordered coverage for minor children who reside outside the
             32      service area.
             33          (1) (a) The requirements of Subsection (2) apply to a health maintenance organization
             34      if the health maintenance organization plan:
             35          (i) restricts coverage for nonemergency services to services provided by contracted
             36      providers within the organization's service area; and
             37          (ii) does not include a point of service benefit subject to Section 31A-8-408 .
             38          (b) The requirements of Subsection (2) do not apply to a health maintenance
             39      organization if:
             40          (i) the child that is the subject of a court or administrative support order is over the age
             41      of 18 and is no longer enrolled in high school; or
             42          (ii) a parent's employer offers the parent a choice to select health insurance coverage
             43      that is not a health maintenance organization plan either at the time of the court or
             44      administrative support order, or at a subsequent open enrollment period. This exemption from
             45      Subsection (2) applies even if the parent ultimately chooses the health maintenance
             46      organization plan.
             47          (2) If a parent is required by a court or administrative support order to provide health
             48      insurance coverage for a child who resides outside of a health maintenance organization's
             49      service area, the health maintenance organization shall:
             50          (a) comply with the provisions of Section 31A-22-610.5 ;
             51          (b) allow the enrollee parent to enroll the child on the organization plan;
             52          (c) pay for otherwise covered health care services rendered to the child outside of the
             53      service area by a noncontracted provider:
             54          (i) if the child, noncustodial parent, or custodial parent has complied with prior
             55      authorization or utilization review otherwise required by the organization; and
             56          (ii) in an amount equal to the dollar amount the organization pays under a noncapitated
             57      arrangement for comparable services to a contracting provider in the same class of health care
             58      providers as the provider who rendered the services; and

             59          (d) make payments on claims submitted in accordance with Subsection (2)(c) directly
             60      to the provider, custodial parent, or state Medicaid agency.
             61          (3) (a) The parents of the child who is the subject of the court or administrative support
             62      order are responsible for any charges billed by the provider in excess of those paid by the
             63      organization.
             64          (b) This section does not affect any court or administrative order regarding the
             65      responsibilities between the parents to pay any medical expenses not covered by accident and
             66      health insurance or a health maintenance organization plan.
             67          (4) The commissioner shall adopt rules as necessary to administer this section and
             68      Section 31A-22-610.5 .
             69          Section 2. Effective date.
             70          This bill takes effect on July 1, 2004.

Legislative Review Note
    as of 11-14-03 10:33 AM

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

Office of Legislative Research and General Counsel

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