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H.B. 113

             1     

HIGH RISK INSURANCE POOL AMENDMENTS

             2     
2012 GENERAL SESSION

             3     
STATE OF UTAH

             4     
Chief Sponsor: James A. Dunnigan

             5     
Senate Sponsor: Stephen H. Urquhart

             6     
             7      LONG TITLE
             8      General Description:
             9          This bill amends the Comprehensive Health Insurance Pool Act.
             10      Highlighted Provisions:
             11          This bill:
             12          .    amends the eligibility standards for the state's high risk health insurance pool for
             13      new residents of the state who were covered by an individual policy in another state.
             14      Money Appropriated in this Bill:
             15          None
             16      Other Special Clauses:
             17          None
             18      Utah Code Sections Affected:
             19      AMENDS:
             20          31A-29-111, as last amended by Laws of Utah 2008, Chapters 382 and 385
             21     
             22      Be it enacted by the Legislature of the state of Utah:
             23          Section 1. Section 31A-29-111 is amended to read:
             24           31A-29-111. Eligibility -- Limitations.
             25          (1) (a) Except as provided in Subsection (1)(b), an individual who is not HIPAA
             26      eligible is eligible for pool coverage if the individual:
             27          (i) pays the established premium;


             28          (ii) is a resident of this state; and
             29          (iii) meets the health underwriting criteria under Subsection (5)(a).
             30          (b) Notwithstanding Subsection (1)(a), an individual who is not HIPAA eligible is not
             31      eligible for pool coverage if one or more of the following conditions apply:
             32          (i) the individual is eligible for health care benefits under Medicaid or Medicare,
             33      except as provided in Section 31A-29-112 ;
             34          (ii) the individual has terminated coverage in the pool, unless:
             35          (A) 12 months have elapsed since the termination date; or
             36          (B) the individual demonstrates that creditable coverage has been involuntarily
             37      terminated for any reason other than nonpayment of premium;
             38          (iii) the pool has paid the maximum lifetime benefit to or on behalf of the individual;
             39          (iv) the individual is an inmate of a public institution;
             40          (v) the individual is eligible for a public health plan, as defined in federal regulations
             41      adopted pursuant to 42 U.S.C. 300gg;
             42          (vi) the individual's health condition does not meet the criteria established under
             43      Subsection (5);
             44          (vii) the individual is eligible for coverage under an employer group that offers a health
             45      benefit plan or a self-insurance arrangement to its eligible employees, dependents, or members
             46      as:
             47          (A) an eligible employee;
             48          (B) a dependent of an eligible employee; or
             49          (C) a member;
             50          (viii) the individual is covered under any other health benefit plan;
             51          (ix) except as provided in Subsections (3) and (6), at the time of application, the
             52      individual has not resided in Utah for at least 12 consecutive months preceding the date of
             53      application; or
             54          (x) the individual's employer pays any part of the individual's health benefit plan
             55      premium, either as an insured or a dependent, for pool coverage.
             56          (2) (a) Except as provided in Subsection (2)(b), an individual who is HIPAA eligible is
             57      eligible for pool coverage if the individual:
             58          (i) pays the established premium; and


             59          (ii) is a resident of this state.
             60          (b) Notwithstanding Subsection (2)(a), a HIPAA eligible individual is not eligible for
             61      pool coverage if one or more of the following conditions apply:
             62          (i) the individual is eligible for health care benefits under Medicaid or Medicare,
             63      except as provided in Section 31A-29-112 ;
             64          (ii) the individual is eligible for a public health plan, as defined in federal regulations
             65      adopted pursuant to 42 U.S.C. 300gg;
             66          (iii) the individual is covered under any other health benefit plan;
             67          (iv) the individual is eligible for coverage under an employer group that offers a health
             68      benefit plan or self-insurance arrangements to its eligible employees, dependents, or members
             69      as:
             70          (A) an eligible employee;
             71          (B) a dependent of an eligible employee; or
             72          (C) a member;
             73          (v) the pool has paid the maximum lifetime benefit to or on behalf of the individual;
             74          (vi) the individual is an inmate of a public institution; or
             75          (vii) the individual's employer pays any part of the individual's health benefit plan
             76      premium, either as an insured or a dependent, for pool coverage.
             77          (3) (a) Notwithstanding Subsection (1)(b)(ix), if otherwise eligible under Subsection
             78      (1)(a), an individual whose health care insurance coverage from a state high risk pool with
             79      similar coverage is terminated because of nonresidency in another state is eligible for coverage
             80      under the pool subject to the conditions of Subsections (1)(b)(i) through (viii).
             81          (b) Coverage [sought] under Subsection (3)(a) shall be applied for within 63 days after
             82      the termination date of the previous high risk pool coverage.
             83          (c) The effective date of this state's pool coverage shall be the date of termination of
             84      the previous high risk pool coverage.
             85          (d) The waiting period of an individual with a preexisting condition applying for
             86      coverage under this chapter shall be waived:
             87          (i) to the extent to which the waiting period was satisfied under a similar plan from
             88      another state; and
             89          (ii) if the other state's benefit limitation was not reached.


             90          (4) (a) If an eligible individual applies for pool coverage within 30 days of being
             91      denied coverage by an individual carrier, the effective date for pool coverage shall be no later
             92      than the first day of the month following the date of submission of the completed insurance
             93      application to the carrier.
             94          (b) Notwithstanding Subsection (4)(a), for individuals eligible for coverage under
             95      Subsection (3), the effective date shall be the date of termination of the previous high risk pool
             96      coverage.
             97          (5) (a) The board shall establish and adjust, as necessary, health underwriting criteria
             98      based on:
             99          (i) health condition; and
             100          (ii) expected claims so that the expected claims are anticipated to remain within
             101      available funding.
             102          (b) The board, with approval of the commissioner, may contract with one or more
             103      providers under Title 63G, Chapter 6, Utah Procurement Code, to develop underwriting criteria
             104      under Subsection (5)(a).
             105          (c) If an individual is denied coverage by the pool under the criteria established in
             106      Subsection (5)(a), the pool shall issue a certificate of insurability to the individual for coverage
             107      under Subsection 31A-30-108 (3).
             108          (6) (a) Notwithstanding Subsection (1)(b)(ix), if otherwise eligible under Subsection
             109      (1)(a), an individual whose individual health care insurance coverage was involuntarily
             110      terminated, is eligible for coverage under the pool subject to the conditions of Subsections
             111      (1)(b)(i) through (viii) and (x).
             112          (b) Coverage under Subsection (6)(a) shall be applied for within 63 days after the
             113      termination date of the previous individual health care insurance coverage.
             114          (c) The effective date of this state's pool coverage shall be the date of termination of
             115      the previous individual coverage.
             116          (d) The waiting period of an individual with a preexisting condition applying for
             117      coverage under this chapter shall be waived to the extent to which the waiting period was
             118      satisfied under the individual health insurance plan.





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