! The Capitol Complex is closed to the public due to COVID-19. All meetings will be held virtually online. View procedures and guidelines (PDF) for remote public comment and virtual meeting instructions (PDF).

Download Zipped Enrolled WordPerfect HB0160.ZIP
[Introduced][Amended][Status][Bill Documents][Fiscal Note][Bills Directory]

H.B. 160 Enrolled

             1     

HEALTH SYSTEM REFORM AMENDMENTS

             2     
2013 GENERAL SESSION

             3     
STATE OF UTAH

             4     
Chief Sponsor: James A. Dunnigan

             5     
Senate Sponsor: Evan J. Vickers

             6     
             7      LONG TITLE
             8      General Description:
             9          This bill amends provisions in the Insurance Code and in Governor's Programs related
             10      to health system reform.
             11      Highlighted Provisions:
             12          This bill:
             13          .    authorizes the insurance commissioner to regulate the state insurance market as it
             14      transitions to new rating practices and health plan requirements of federal law;
             15          .    gives insurance producers and agents the authority to sell, solicit, and negotiate
             16      health insurance on a federal health insurance exchange;
             17          .    permits an insurer to pass through commission payments from an insured to a
             18      producer;
             19          .    establishes the requirements for a navigator license;
             20          .    amends definitions in the Individual, Small Employer and Group Health Insurance
             21      Act;
             22          .    establishes separate risk pools for the individual health insurance market and the
             23      small group health insurance market;
             24          .    amends discontinuation and nonrenewal limitations and conditions;
             25          .    amends small employer participation and contribution requirements;
             26          .    amends provisions regarding actuarial review of rates;
             27          .    gives the commissioner administrative rulemaking authority to facilitate state
             28      regulation of insurers, qualified health plans, and the health insurance market when
             29      federal insurance exchanges begin operating in the state, including:


             30              .    rate review and approval; and
             31              .    creating uniform open enrollment periods for the individual health                 
             32      insurance market;
             33          .    removes the requirement that a carrier in Utah's defined contribution arrangement
             34      market (Avenue H) must offer certain health benefit products on Avenue H;
             35          .    authorizes free-standing dental and vision plans on Utah's Avenue H;
             36          .    extends the sunset date for the Risk Adjuster Board for the defined contribution
             37      arrangement market;
             38          .    removes the rating parity requirement for plans offered on Avenue H;
             39          .    establishes regulations for stop-loss and re-insurance insurers for small employers;
             40          .    establishes the general insurance laws that apply to small employer stop-loss
             41      insurers;
             42          .    applies the regulations to stop-loss contracts issued or renewed on or after July 1,
             43      2013;
             44          .    gives the commissioner administrative rulemaking authority.
             45          .    makes technical amendments;
             46          .    amends executive branch reporting requirements related to the Patient Protection
             47      and Affordable Care Act (PPACA) implementation; and
             48          .    reauthorizes the Health System Reform Task Force until December 30, 2015.
             49      Money Appropriated in this Bill:
             50          This bill appropriates in fiscal year 2013-14:
             51          .    to the Legislature-Senate as a one-time appropriation:
             52              .    from the General Fund, One-time, $30,000
             53          .    to the Legislature-House as a one-time appropriation:
             54              .    from the General Fund, One-time, $52,000.
             55      Other Special Clauses:
             56          This bill provides an effective date.
             57          This bill provides a repeal date.


             58      Utah Code Sections Affected:
             59      AMENDS:
             60          31A-2-212, as last amended by Laws of Utah 2011, Chapters 284 and 400
             61          31A-23a-501, as last amended by Laws of Utah 2012, Chapter 279
             62          31A-30-104, as last amended by Laws of Utah 2011, Chapter 400
             63          31A-30-105, as last amended by Laws of Utah 2011, Chapter 284
             64          31A-30-107.3, as last amended by Laws of Utah 2011, Chapter 297
             65          31A-30-112, as last amended by Laws of Utah 2012, Chapter 253
             66          31A-30-115, as last amended by Laws of Utah 2011, Second Special Session, Chapter 5
             67          31A-30-208, as last amended by Laws of Utah 2011, Chapter 400
             68          63I-2-231 (Superseded 07/01/13), as last amended by Laws of Utah 2012, Chapter 279
             69          63I-2-231 (Effective 07/01/13), as last amended by Laws of Utah 2012, Chapters 243
             70      and 279
             71          63M-1-2505.5, as enacted by Laws of Utah 2010, Chapter 51
             72      ENACTS:
             73          31A-23a-208, Utah Code Annotated 1953
             74          31A-23b-101, Utah Code Annotated 1953
             75          31A-23b-102, Utah Code Annotated 1953
             76          31A-23b-201, Utah Code Annotated 1953
             77          31A-23b-202, Utah Code Annotated 1953
             78          31A-23b-203, Utah Code Annotated 1953
             79          31A-23b-204, Utah Code Annotated 1953
             80          31A-23b-205, Utah Code Annotated 1953
             81          31A-23b-206, Utah Code Annotated 1953
             82          31A-23b-207, Utah Code Annotated 1953
             83          31A-23b-208, Utah Code Annotated 1953
             84          31A-23b-209, Utah Code Annotated 1953
             85          31A-23b-210, Utah Code Annotated 1953


             86          31A-23b-211, Utah Code Annotated 1953
             87          31A-23b-301, Utah Code Annotated 1953
             88          31A-23b-401, Utah Code Annotated 1953
             89          31A-23b-402, Utah Code Annotated 1953
             90          31A-23b-403, Utah Code Annotated 1953
             91          31A-23b-404, Utah Code Annotated 1953
             92          31A-30-117, Utah Code Annotated 1953
             93          31A-30-202.6, Utah Code Annotated 1953
             94          31A-43-101, Utah Code Annotated 1953
             95          31A-43-102, Utah Code Annotated 1953
             96          31A-43-201, Utah Code Annotated 1953
             97          31A-43-202, Utah Code Annotated 1953
             98          31A-43-301, Utah Code Annotated 1953
             99          31A-43-302, Utah Code Annotated 1953
             100          31A-43-303, Utah Code Annotated 1953
             101          31A-43-304, Utah Code Annotated 1953
             102      Uncodified Material Affected:
             103      ENACTS UNCODIFIED MATERIAL
             104     
             105      Be it enacted by the Legislature of the state of Utah:
             106          Section 1. Section 31A-2-212 is amended to read:
             107           31A-2-212. Miscellaneous duties.
             108          (1) Upon issuance of an order limiting, suspending, or revoking a person's authority to
             109      do business in Utah, and when the commissioner begins a proceeding against an insurer under
             110      Chapter 27a, Insurer Receivership Act, the commissioner:
             111          (a) shall notify by mail the producers of the person or insurer of whom the
             112      commissioner has record; and
             113          (b) may publish notice of the order or proceeding in any manner the commissioner


             114      considers necessary to protect the rights of the public.
             115          (2) When required for evidence in a legal proceeding, the commissioner shall furnish a
             116      certificate of authority of a licensee to transact the business of insurance in Utah on any
             117      particular date. The court or other officer shall receive the certificate of authority in lieu of the
             118      commissioner's testimony.
             119          (3) (a) On the request of an insurer authorized to do a surety business, the
             120      commissioner shall furnish a copy of the insurer's certificate of authority to a designated public
             121      officer in this state who requires that certificate of authority before accepting a bond.
             122          (b) The public officer described in Subsection (3)(a) shall file the certificate of
             123      authority furnished under Subsection (3)(a).
             124          (c) After a certified copy of a certificate of authority is furnished to a public officer, it
             125      is not necessary, while the certificate of authority remains effective, to attach a copy of it to any
             126      instrument of suretyship filed with that public officer.
             127          (d) Whenever the commissioner revokes the certificate of authority or begins a
             128      proceeding under Chapter 27a, Insurer Receivership Act, against an insurer authorized to do a
             129      surety business, the commissioner shall immediately give notice of that action to each public
             130      officer who is sent a certified copy under this Subsection (3).
             131          (4) (a) The commissioner shall immediately notify every judge and clerk of the courts
             132      of record in the state when:
             133          (i) an authorized insurer doing a surety business:
             134          (A) files a petition for receivership; or
             135          (B) is in receivership; or
             136          (ii) the commissioner has reason to believe that the authorized insurer doing surety
             137      business:
             138          (A) is in financial difficulty; or
             139          (B) has unreasonably failed to carry out any of its contracts.
             140          (b) Upon the receipt of the notice required by this Subsection (4), it is the duty of the
             141      judges and clerks to notify and require a person that files with the court a bond on which the


             142      authorized insurer doing surety business is surety to immediately file a new bond with a new
             143      surety.
             144          (5) (a) The commissioner shall report to the Legislature in accordance with Section
             145      63M-1-2505.5 prior to adopting a rule authorized by Subsection (5)(b).
             146          (b) The commissioner shall require an insurer that issues, sells, renews, or offers health
             147      insurance coverage in this state to comply with[:(a) the Health Insurance Portability and
             148      Accountability Act, Pub. L. No. 104-191; and(b) subject to Section 63M-1-2505.5 , and to the
             149      extent required or applicable under the provisions of the Patient Protection and Affordable
             150      Care Act, Pub. L. No. 111-148 and the Health Care Education Reconciliation Act of 2010, Pub.
             151      L. No. 111-152,] the provisions of PPACA and administrative rules adopted by the
             152      commissioner related to regulation of health benefit plans, including:
             153          (i) lifetime and annual limits;
             154          (ii) prohibition of rescissions;
             155          (iii) coverage of preventive health services;
             156          (iv) coverage for a child or dependent;
             157          (v) pre-existing condition coverage for children;
             158          (vi) insurer transparency of consumer information including plan disclosures, uniform
             159      coverage documents, and standard definitions;
             160          (vii) premium rate reviews;
             161          (viii) essential health benefits;
             162          (ix) provider choice;
             163          (x) waiting periods; [and]
             164          (xi) appeals processes[.];
             165          (xii) rating restrictions;
             166          (xiii) uniform applications and notice provisions; and
             167          (xiv) certification and regulation of qualified health plans.
             168          (c) The commissioner shall preserve state control over:
             169          (i) the health insurance market in the state;


             170          (ii) qualified health plans offered in the state; and
             171          (iii) the conduct of navigators, producers, and in-person assisters operating in the state.
             172          (d) If the state enters into an agreement with the United States Department of Health
             173      and Human Services in which the state operates health insurance plan management, the
             174      commissioner may:
             175          (i) for fiscal year 2014, hire one temporary and two permanent full-time employees to
             176      be funded through the department's existing budget; and
             177          (ii) for fiscal year 2015, hire two permanent full-time employees funded through the
             178      Insurance Department Restricted Account, subject to appropriations from the Legislature and
             179      approval by the governor.
             180          Section 2. Section 31A-23a-208 is enacted to read:
             181          31A-23a-208. Producer and agency authority in health insurance exchange.
             182          A producer or agency licensed under this chapter, with a line of authority that permits
             183      the producer or agency to sell, negotiate, or solicit accident and health insurance, is authorized
             184      to sell, negotiate, or solicit qualified health plans offered on an exchange that is:
             185          (1) operated in the state; or
             186          (2) operated in the state and certified by the United States Department of Health and
             187      Human Services as a:
             188          (a) state-based exchange under PPACA;
             189          (b) a federally facilitated exchange under PPACA; or
             190          (c) a partnership exchange under PPACA.
             191          Section 3. Section 31A-23a-501 is amended to read:
             192           31A-23a-501. Licensee compensation.
             193          (1) As used in this section:
             194          (a) "Commission compensation" includes funds paid to or credited for the benefit of a
             195      licensee from:
             196          (i) commission amounts deducted from insurance premiums on insurance sold by or
             197      placed through the licensee; or


             198          (ii) commission amounts received from an insurer or another licensee as a result of the
             199      sale or placement of insurance.
             200          (b) (i) "Compensation from an insurer or third party administrator" means
             201      commissions, fees, awards, overrides, bonuses, contingent commissions, loans, stock options,
             202      gifts, prizes, or any other form of valuable consideration:
             203          (A) whether or not payable pursuant to a written agreement; and
             204          (B) received from:
             205          (I) an insurer; or
             206          (II) a third party to the transaction for the sale or placement of insurance.
             207          (ii) "Compensation from an insurer or third party administrator" does not mean
             208      compensation from a customer that is:
             209          (A) a fee or pass-through costs as provided in Subsection (1)(e); or
             210          (B) a fee or amount collected by or paid to the producer that does not exceed an
             211      amount established by the commissioner by administrative rule.
             212          (c) (i) "Customer" means:
             213          (A) the person signing the application or submission for insurance; or
             214          (B) the authorized representative of the insured actually negotiating the placement of
             215      insurance with the producer.
             216          (ii) "Customer" does not mean a person who is a participant or beneficiary of:
             217          (A) an employee benefit plan; or
             218          (B) a group or blanket insurance policy or group annuity contract sold, solicited, or
             219      negotiated by the producer or affiliate.
             220          (d) (i) "Noncommission compensation" includes all funds paid to or credited for the
             221      benefit of a licensee other than commission compensation.
             222          (ii) "Noncommission compensation" does not include charges for pass-through costs
             223      incurred by the licensee in connection with obtaining, placing, or servicing an insurance policy.
             224          (e) "Pass-through costs" include:
             225          (i) costs for copying documents to be submitted to the insurer; and


             226          (ii) bank costs for processing cash or credit card payments.
             227          (2) A licensee may receive from an insured or from a person purchasing an insurance
             228      policy, noncommission compensation if the noncommission compensation is stated on a
             229      separate, written disclosure.
             230          (a) The disclosure required by this Subsection (2) shall:
             231          (i) include the signature of the insured or prospective insured acknowledging the
             232      noncommission compensation;
             233          (ii) clearly specify the amount or extent of the noncommission compensation; and
             234          (iii) be provided to the insured or prospective insured before the performance of the
             235      service.
             236          (b) Noncommission compensation shall be:
             237          (i) limited to actual or reasonable expenses incurred for services; and
             238          (ii) uniformly applied to all insureds or prospective insureds in a class or classes of
             239      business or for a specific service or services.
             240          (c) A copy of the signed disclosure required by this Subsection (2) shall be maintained
             241      by any licensee who collects or receives the noncommission compensation or any portion of
             242      the noncommission compensation.
             243          (d) All accounting records relating to noncommission compensation shall be
             244      maintained by the person described in Subsection (2)(c) in a manner that facilitates an audit.
             245          (3) (a) A licensee may receive noncommission compensation when acting as a
             246      producer for the insured in connection with the actual sale or placement of insurance if:
             247          (i) the producer and the insured have agreed on the producer's noncommission
             248      compensation; and
             249          (ii) the producer has disclosed to the insured the existence and source of any other
             250      compensation that accrues to the producer as a result of the transaction.
             251          (b) The disclosure required by this Subsection (3) shall:
             252          (i) include the signature of the insured or prospective insured acknowledging the
             253      noncommission compensation;


             254          (ii) clearly specify the amount or extent of the noncommission compensation and the
             255      existence and source of any other compensation; and
             256          (iii) be provided to the insured or prospective insured before the performance of the
             257      service.
             258          (c) The following additional noncommission compensation is authorized:
             259          (i) compensation received by a producer of a compensated corporate surety who under
             260      procedures approved by a rule or order of the commissioner is paid by surety bond principal
             261      debtors for extra services;
             262          (ii) compensation received by an insurance producer who is also licensed as a public
             263      adjuster under Section 31A-26-203 , for services performed for an insured in connection with a
             264      claim adjustment, so long as the producer does not receive or is not promised compensation for
             265      aiding in the claim adjustment prior to the occurrence of the claim;
             266          (iii) compensation received by a consultant as a consulting fee, provided the consultant
             267      complies with the requirements of Section 31A-23a-401 ; or
             268          (iv) other compensation arrangements approved by the commissioner after a finding
             269      that they do not violate Section 31A-23a-401 and are not harmful to the public.
             270          (d) Subject to Section 31A-23a-402.5 , a producer for the insured may receive
             271      compensation from an insured through an insurer, for the negotiation and sale of a health
             272      benefit plan, if there is a separate written agreement between the insured and the licensee for
             273      the compensation. An insurer who passes through the compensation from the insured to the
             274      licensee under this Subsection (3)(d) is not providing direct or indirect compensation or
             275      commission compensation to the licensee.
             276          (4) (a) For purposes of this Subsection (4), "producer" includes:
             277          (i) a producer;
             278          (ii) an affiliate of a producer; or
             279          (iii) a consultant.
             280          (b) A producer may not accept or receive any compensation from an insurer or third
             281      party administrator for the initial placement of a health benefit plan, other than a hospital


             282      confinement indemnity policy, unless prior to the customer's initial purchase of the health
             283      benefit plan the producer discloses in writing to the customer that the producer will receive
             284      compensation from the insurer or third party administrator for the placement of insurance,
             285      including the amount or type of compensation known to the producer at the time of the
             286      disclosure.
             287          (c) A producer shall:
             288          (i) obtain the customer's signed acknowledgment that the disclosure under Subsection
             289      (4)(b) was made to the customer; or
             290          (ii) (A) sign a statement that the disclosure required by Subsection (4)(b) was made to
             291      the customer; and
             292          (B) keep the signed statement on file in the producer's office while the health benefit
             293      plan placed with the customer is in force.
             294          (d) (i) A licensee who collects or receives any part of the compensation from an insurer
             295      or third party administrator in a manner that facilitates an audit shall, while the health benefit
             296      plan placed with the customer is in force, maintain a copy of:
             297          (A) the signed acknowledgment described in Subsection (4)(c)(i); or
             298          (B) the signed statement described in Subsection (4)(c)(ii).
             299          (ii) The standard application developed in accordance with Section 31A-22-635 shall
             300      include a place for a producer to provide the disclosure required by this Subsection (4), and if
             301      completed, shall satisfy the requirement of Subsection (4)(d)(i).
             302          (e) Subsection (4)(c) does not apply to:
             303          (i) a person licensed as a producer who acts only as an intermediary between an insurer
             304      and the customer's producer, including a managing general agent; or
             305          (ii) the placement of insurance in a secondary or residual market.
             306          (5) This section does not alter the right of any licensee to recover from an insured the
             307      amount of any premium due for insurance effected by or through that licensee or to charge a
             308      reasonable rate of interest upon past-due accounts.
             309          (6) This section does not apply to bail bond producers or bail enforcement agents as


             310      defined in Section 31A-35-102 .
             311          (7) A licensee may not receive noncommission compensation from an insured or
             312      enrollee for providing a service or engaging in an act that is required to be provided or
             313      performed in order to receive commission compensation, except for the surplus lines
             314      transactions that do not receive commissions.
             315          Section 4. Section 31A-23b-101 is enacted to read:
             316     
CHAPTER 23b. NAVIGATOR LICENSE ACT

             317     
Part 1. General Provisions

             318          31A-23b-101. Title.
             319          This chapter is known as the "Navigator License Act."
             320          Section 5. Section 31A-23b-102 is enacted to read:
             321          31A-23b-102. Definitions.
             322          As used in this chapter:
             323          (1) "Compensation" is as defined in:
             324          (a) Subsections 31A-23a-501 (1)(a), (b), and (d); and
             325          (b) PPACA.
             326          (2) "Enroll" and "enrollment" mean to:
             327          (a) (i) obtain personally identifiable information about an individual; and
             328          (ii) inform an individual about accident and health insurance plans or public programs
             329      offered on an exchange;
             330          (b) solicit insurance; or
             331          (c) submit to the exchange:
             332          (i) personally identifiable information about an individual; and
             333          (ii) an individual's selection of a particular accident and health insurance plan or public
             334      program offered on the exchange.
             335          (3) (a) "Exchange" means an online marketplace:
             336          (i) for an individual to purchase a qualified health plan; and
             337          (ii) that is certified by the United States Department of Health and Human Services as


             338      either a state-based exchange or a federally facilitated exchange under PPACA.
             339          (b) (i) "Exchange" does not include:
             340          (A) an online marketplace for the purchase of health insurance if the online
             341      marketplace is not a certified exchange under PPACA; or
             342          (B) except as provided in Subsection (3)(b)(ii), an online marketplace for small
             343      employers that is certified as a PPACA compliant SHOP exchange.
             344          (ii) For purposes of this chapter, exchange does include a small employer SHOP
             345      exchange described under Subsection (3)(b)(i)(B) if:
             346          (A) federal regulations under PPACA require a small employer exchange to allow
             347      navigators to assist small employers and their employees with selection of qualified health
             348      plans on a small employer exchange; and
             349          (B) the state has not entered into an agreement with the United States Department of
             350      Health and Human Services that permits the state to limit the scope of practice of navigators to
             351      only the individual PPACA exchange.
             352          (4) "Navigator":
             353          (a) means a person who facilitates enrollment in an exchange by offering to assist, or
             354      who advertises any services to assist, with:
             355          (i) the selection of and enrollment in a qualified health plan or a public program
             356      offered on an exchange; or
             357          (ii) applying for premium subsidies through an exchange; and
             358          (b) includes a person who is an in-person assister or an application assister as described
             359      in:
             360          (i) federal regulations or guidance issued under PPACA; and
             361          (ii) the state exchange blueprint published by the Center for Consumer Information and
             362      Insurance Oversight within the Centers for Medicare and Medicaid Services in the United
             363      States Department of Health and Human Services.
             364          (5) "Personally identifiable information" is as defined in 45 C.F.R. Sec. 155.260.
             365          (6) "Public programs" means the state Medicaid program in Title 26, Chapter 18,


             366      Medical Assistance Act, and Chapter 40, Utah Children's Health Insurance Act.
             367          (7) "Solicit" is as defined in Section 31A-23a-102 .
             368          Section 6. Section 31A-23b-201 is enacted to read:
             369     
Part 2. Licensing

             370          31A-23b-201. Requirement of license.
             371          (1) (a) Except as provided in Section 31A-23b-211 , a person may not perform, offer to
             372      perform, or advertise any service as a navigator in the state, without:
             373          (i) a valid navigator license issued under this chapter; or
             374          (ii) a valid producer license under Subsection 31A-23a-106 (2)(a) with a line of
             375      authority that permits the person to sell, negotiate, or solicit accident and health insurance.
             376          (b) A person may not utilize the services of another as a navigator if that person knows
             377      or should know that the other person does not have a license as required by law.
             378          (2) An insurance contract is not invalid as a result of a violation of this section.
             379          Section 7. Section 31A-23b-202 is enacted to read:
             380          31A-23b-202. Qualifications for a license.
             381          (1) (a) The commissioner shall issue or renew a license to a person to act as a navigator
             382      if the person:
             383          (i) satisfies the:
             384          (A) application requirements under Section 31A-23b-203 ;
             385          (B) character requirements under Section 31A-23b-204 ;
             386          (C) examination and training requirements under Section 31A-23b-205 ; and
             387          (D) continuing education requirements under Section 31A-23b-206 ;
             388          (ii) certifies that, to the extent applicable, the applicant:
             389          (A) is in compliance with the surety bond requirements of Section 31A-23b-207 ; and
             390          (B) will maintain compliance with Section 31A-23b-207 during the period for which
             391      the license is issued or renewed; and
             392          (iii) has not committed an act that is a ground for denial, suspension, or revocation as
             393      provided in Section 31A-23b-401 .


             394          (b) A license issued under this chapter is valid for two years.
             395          (2) (a) A person shall report to the commissioner:
             396          (i) an administrative action taken against the person, including a denial of a new or
             397      renewal license application:
             398          (A) in another jurisdiction; or
             399          (B) by another regulatory agency in this state; and
             400          (ii) a criminal prosecution taken against the person in any jurisdiction.
             401          (b) The report required by Subsection (2)(a) shall be filed:
             402          (i) at the time the person files the application for an individual or agency license; and
             403          (ii) for an action or prosecution that occurs on or after the day on which the person files
             404      the application:
             405          (A) for an administrative action, within 30 days of the final disposition of the
             406      administrative action; or
             407          (B) for a criminal prosecution, within 30 days of the initial appearance before a court.
             408          (c) The report required by Subsection (2)(a) shall include a copy of the complaint or
             409      other relevant legal documents related to the action or prosecution described in Subsection
             410      (2)(a).
             411          (3) (a) The department may:
             412          (i) require a person applying for a license to submit to a criminal background check as
             413      a condition of receiving a license; or
             414          (ii) accept a background check conducted by another organization.
             415          (b) A person, if required to submit to a criminal background check under Subsection
             416      (3)(a), shall:
             417          (i) submit a fingerprint card in a form acceptable to the department; and
             418          (ii) consent to a fingerprint background check by:
             419          (A) the Utah Bureau of Criminal Identification; and
             420          (B) the Federal Bureau of Investigation.
             421          (c) For a person who submits a fingerprint card and consents to a fingerprint


             422      background check under Subsection (3)(b), the department may request:
             423          (i) criminal background information maintained pursuant to Title 53, Chapter 10, Part
             424      2, Bureau of Criminal Identification, from the Bureau of Criminal Identification; and
             425          (ii) complete Federal Bureau of Investigation criminal background checks through the
             426      national criminal history system.
             427          (d) Information obtained by the department from the review of criminal history records
             428      received under this Subsection (3) shall be used by the department for the purposes of:
             429          (i) determining if a person satisfies the character requirements under Section
             430      31A-23b-204 for issuance or renewal of a license;
             431          (ii) determining if a person failed to maintain the character requirements under Section
             432      31A-23b-204 ; and
             433          (iii) preventing a person who violates the federal Violent Crime Control and Law
             434      Enforcement Act of 1994, 18 U.S.C. Sec. 1033, from engaging in the business of a navigator or
             435      in-person assistor in the state.
             436          (e) If the department requests the criminal background information, the department
             437      shall:
             438          (i) pay to the Department of Public Safety the costs incurred by the Department of
             439      Public Safety in providing the department criminal background information under Subsection
             440      (3)(c)(i);
             441          (ii) pay to the Federal Bureau of Investigation the costs incurred by the Federal Bureau
             442      of Investigation in providing the department criminal background information under
             443      Subsection (3)(c)(ii); and
             444          (iii) charge the person applying for a license a fee equal to the aggregate of Subsections
             445      (3)(e)(i) and (ii).
             446          (4) The commissioner may deny an application for a license under this chapter if the
             447      person applying for the license:
             448          (a) fails to satisfy the requirements of this section; or
             449          (b) commits an act that is grounds for denial, suspension, or revocation as set forth in


             450      Section 31A-23b-401 .
             451          Section 8. Section 31A-23b-203 is enacted to read:
             452          31A-23b-203. Application for individual license -- Application for agency license.
             453          (1) This section applies to an initial or renewal license as a navigator.
             454          (2) (a) Subject to Subsection (2)(b), to obtain or renew an individual license, an
             455      individual shall:
             456          (i) file an application for an initial or renewal individual license with the commissioner
             457      on forms and in a manner the commissioner prescribes; and
             458          (ii) pay a license fee that is not refunded if the application:
             459          (A) is denied; or
             460          (B) is incomplete when filed and is never completed by the applicant.
             461          (b) An application described in this Subsection (2) shall provide:
             462          (i) information about the applicant's identity;
             463          (ii) the applicant's Social Security number;
             464          (iii) the applicant's personal history, experience, education, and business record;
             465          (iv) whether the applicant is 18 years of age or older;
             466          (v) whether the applicant has committed an act that is a ground for denial, suspension,
             467      or revocation as set forth in Section 31A-23b-401 or 31A-23b-402 ;
             468          (vi) that the applicant complies with the surety bond requirements of Section
             469      31A-23b-207 ;
             470          (vii) that the applicant completed the training requirements in Section 31A-23b-205 ;
             471      and
             472          (viii) any other information the commissioner reasonably requires.
             473          (3) The commissioner may require a document reasonably necessary to verify the
             474      information contained in an application filed under this section.
             475          (4) An applicant's Social Security number contained in an application filed under this
             476      section is a private record under Section 63G-2-302 .
             477          (5) (a) Subject to Subsection (5)(b), to obtain or renew a navigator agency license, a


             478      person shall:
             479          (i) file an application for an initial or renewal navigator agency license with the
             480      commissioner on forms and in a manner the commissioner prescribes; and
             481          (ii) pay a license fee that is not refunded if the application:
             482          (A) is denied; or
             483          (B) is incomplete when filed and is never completed by the applicant.
             484          (b) An application described in Subsection (5)(a) shall provide:
             485          (i) information about the applicant's identity;
             486          (ii) the applicant's federal employer identification number;
             487          (iii) the designated responsible licensed individual;
             488          (iv) the identity of the owners, partners, officers, and directors;
             489          (v) whether the applicant, or individual identified in Subsections (5)(b)(iii) and (iv),
             490      has committed an act that is a ground for denial, suspension, or revocation as set forth in
             491      Section 31A-23b-401 ; and
             492          (vi) any other information the commissioner reasonably requires.
             493          Section 9. Section 31A-23b-204 is enacted to read:
             494          31A-23b-204. Character requirements.
             495          An applicant for a license under this chapter shall demonstrate to the commissioner
             496      that:
             497          (1) the applicant has the intent, in good faith, to engage in the practice of a navigator as
             498      the license would permit;
             499          (2) (a) if a natural person, the applicant is competent and trustworthy; or
             500          (b) if the applicant is an agency:
             501          (i) the partners, directors, or principal officers or persons having comparable powers
             502      are trustworthy; and
             503          (ii) that it will transact business in a way that the acts that may only be performed by a
             504      licensed navigator are performed only by a natural person who is licensed under this chapter, or
             505      Chapter 23a, Insurance Marketing-Licensing Producers, Consultants, and Reinsurance


             506      Intermediaries;
             507          (3) the applicant intends to comply with the surety bond requirements of Section
             508      31A-23b-207 ;
             509          (4) if a natural person, the applicant is at least 18 years of age; and
             510          (5) the applicant does not have a conflict of interest as defined by regulations issued
             511      under PPACA.
             512          Section 10. Section 31A-23b-205 is enacted to read:
             513          31A-23b-205. Examination and training requirements.
             514          (1) The commissioner may require applicants for a license to pass an examination and
             515      complete a training program as a requirement for a license.
             516          (2) The examination described in Subsection (1) shall reasonably relate to:
             517          (a) the duties and functions of a navigator;
             518          (b) requirements for navigators as established by federal regulation under PPACA; and
             519          (c) other requirements that may be established by the commissioner by administrative
             520      rule.
             521          (3) The examination may be administered by the commissioner or as otherwise
             522      specified by administrative rule.
             523          (4) The training required by Subsection (1) shall be approved by the commissioner and
             524      shall include:
             525          (a) accident and health insurance plans;
             526          (b) qualifications for and enrollment in public programs;
             527          (c) qualifications for and enrollment in premium subsidies;
             528          (d) cultural and linguistic competence;
             529          (e) conflict of interest standards;
             530          (f) exchange functions; and
             531          (g) other requirements that may be adopted by the commissioner by administrative
             532      rule.
             533          (5) This section applies only to applicants who are natural persons.


             534          Section 11. Section 31A-23b-206 is enacted to read:
             535          31A-23b-206. Continuing education requirements.
             536          (1) The commissioner shall, by rule, prescribe continuing education requirements for a
             537      navigator.
             538          (2) (a) The commissioner may not require a degree from an institution of higher
             539      education as part of continuing education.
             540          (b) The commissioner may state a continuing education requirement in terms of hours
             541      of instruction received in:
             542          (i) accident and health insurance;
             543          (ii) qualification for and enrollment in public programs;
             544          (iii) qualification for and enrollment in premium subsidies;
             545          (iv) cultural competency;
             546          (v) conflict of interest standards; and
             547          (vi) other exchange functions.
             548          (3) (a) Continuing education requirements shall require:
             549          (i) that a licensee complete 24 credit hours of continuing education for every two-year
             550      licensing period;
             551          (ii) that 3 of the 24 credit hours described in Subsection (3)(a)(i) be ethics courses; and
             552          (iii) that the licensee complete at least half of the required hours through classroom
             553      hours of insurance and exchange related instruction.
             554          (b) An hour of continuing education in accordance with Subsection (3)(a)(i) may be
             555      obtained through:
             556          (i) classroom attendance;
             557          (ii) home study;
             558          (iii) watching a video recording;
             559          (iv) experience credit; or
             560          (v) another method approved by rule.
             561          (c) A licensee may obtain continuing education hours at any time during the two-year


             562      license period.
             563          (d) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the
             564      commissioner shall, by rule:
             565          (i) publish a list of insurance professional designations whose continuing education
             566      requirements can be used to meet the requirements for continuing education under Subsection
             567      (3)(b); and
             568          (ii) authorize one or more continuing education providers, including a state or national
             569      professional producer or consultant associations, to:
             570          (A) offer a qualified program on a geographically accessible basis; and
             571          (B) collect a reasonable fee for funding and administration of a continuing education
             572      program, subject to the review and approval of the commissioner.
             573          (4) The commissioner shall approve a continuing education provider or a continuing
             574      education course that satisfies the requirements of this section.
             575          (5) In accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, the
             576      commissioner shall by rule establish the procedures for continuing education provider
             577      registration and course approval.
             578          (6) This section applies only to a navigator who is a natural person.
             579          (7) A navigator shall keep documentation of completing the continuing education
             580      requirements of this section for two years after the end of the two-year licensing period to
             581      which the continuing education applies.
             582          Section 12. Section 31A-23b-207 is enacted to read:
             583          31A-23b-207. Requirement to obtain surety bond.
             584          (1) (a) Except as provided in Subsections (1)(b)(ii) and (2), a navigator shall obtain a
             585      surety bond in an amount designated by the commissioner by administrative rule to cover the
             586      legal liability of the navigator as the result of an erroneous act or failure to act in the navigator's
             587      capacity as a navigator.
             588          (b) The navigator shall:
             589          (i) maintain a surety bond at all times during the term of the navigator's license; or


             590          (ii) demonstrate to the commissioner that the navigator is capable of covering a legal
             591      liability for erroneous acts or failure to act in a manner approved by the commissioner.
             592          (2) A navigator is not required to obtain and maintain a surety bond during a period in
             593      which the navigator's scope of practice is limited to assisting individuals with:
             594          (a) enrollment in public programs; and
             595          (b) qualification for premium and cost sharing subsidies.
             596          Section 13. Section 31A-23b-208 is enacted to read:
             597          31A-23b-208. Form and contents of license.
             598          (1) A license issued under this chapter shall be in the form the commissioner prescribes
             599      and shall set forth:
             600          (a) the name and address of the licensee;
             601          (b) the date of license issuance; and
             602          (c) any other information the commissioner considers necessary.
             603          (2) A licensee under this chapter doing business under a name other than the licensee's
             604      legal name shall notify the commissioner before using the assumed name in this state.
             605          Section 14. Section 31A-23b-209 is enacted to read:
             606          31A-23b-209. Agency designations.
             607          (1) An organization shall be licensed as a navigator agency if the organization acts as a
             608      navigator.
             609          (2) A navigator agency that does business in the state shall designate an individual who
             610      is licensed under this chapter to act on the agency's behalf.
             611          (3) A navigator agency shall report to the commissioner, at intervals and in the form
             612      the commissioner establishes by rule:
             613          (a) a new designation under Subsection (2); and
             614          (b) a terminated designation under Subsection (2).
             615          (4) (a) A navigator agency licensed under this chapter shall report to the commissioner
             616      the cause of termination of a designation if:
             617          (i) the reason for termination is a reason described in Subsection 31A-23b-401 (4)(b);


             618      or
             619          (ii) the navigator agency has knowledge that the individual licensee engaged in an
             620      activity described in Subsection 31A-23b-401 (4)(b) by:
             621          (A) a court;
             622          (B) a government body; or
             623          (C) a self-regulatory organization, which the commissioner may define by rule made in
             624      accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act.
             625          (b) The information provided to the commissioner under Subsection (4)(a) is a private
             626      record under Title 63G, Chapter 2, Government Records Access and Management Act.
             627          (c) A navigator agency is immune from civil action, civil penalty, or damages if the
             628      agency complies in good faith with this Subsection (4) by reporting to the commissioner the
             629      cause of termination of a designation.
             630          (d) A navigator agency is not immune from an action or resulting penalty imposed on
             631      the reporting agency as a result of proceedings brought by or on behalf of the department if the
             632      action is based on evidence other than the report submitted in compliance with this Subsection
             633      (4).
             634          (5) A navigator agency licensed under this chapter may act in a capacity for which it is
             635      licensed only through an individual who is licensed under this chapter to act in the same
             636      capacity.
             637          (6) A navigator agency licensed under this chapter shall designate and report to the
             638      commissioner, in accordance with any rule made by the commissioner, the name of the
             639      designated responsible licensed individual who has authority to act on behalf of the navigator
             640      agency in the matters pertaining to compliance with this title and orders of the commissioner.
             641          (7) If a navigator agency designates a licensee in reports submitted under Subsection
             642      (3) or (6), there is a rebuttable presumption that the designated licensee acts on behalf of the
             643      navigator agency.
             644          (8) (a) When a license is held by a navigator agency, both the navigator agency itself
             645      and any individual designated under the navigator agency license are considered the holders of


             646      the navigator agency license for purposes of this section.
             647          (b) If an individual designated under the navigator agency license commits an act or
             648      fails to perform a duty that is a ground for suspending, revoking, or limiting the navigator
             649      agency license, the commissioner may suspend, revoke, or limit the license of:
             650          (i) the individual;
             651          (ii) the navigator agency, if the navigator agency:
             652          (A) is reckless or negligent in its supervision of the individual; or
             653          (B) knowingly participates in the act or failure to act that is the ground for suspending,
             654      revoking, or limiting the license; or
             655          (iii) (A) the individual; and
             656          (B) the navigator agency, if the agency meets the requirements of Subsection (8)(b)(ii).
             657          Section 15. Section 31A-23b-210 is enacted to read:
             658          31A-23b-210. Place of business and residence address -- Records.
             659          (1) (a) A licensee under this chapter shall register and maintain with the commissioner:
             660          (i) the address and telephone numbers of the licensee's principal place of business; and
             661          (ii) a valid business email address at which the commissioner may contact the licensee.
             662          (b) If a licensee is an individual, in addition to complying with Subsection (1)(a), the
             663      individual shall register and maintain with the commissioner the individual's residence address
             664      and telephone number.
             665          (c) A licensee shall notify the commissioner within 30 days of a change of any of the
             666      following required to be registered with the commissioner under this section:
             667          (i) an address;
             668          (ii) a telephone number; or
             669          (iii) a business email address.
             670          (2) Except as provided under Subsection (3), a licensee under this chapter shall keep at
             671      the principal place of business address registered under Subsection (1), separate and distinct
             672      books and records of the transactions consummated under the Utah license.
             673          (3) Subsection (2) is satisfied if the books and records specified in Subsection (2) can


             674      be obtained immediately from a central storage place or elsewhere by online computer
             675      terminals located at the registered address.
             676          (4) (a) The books and records maintained under Subsection (2) shall be available for
             677      the inspection by the commissioner during the business hours for a period of time after the date
             678      of the transaction as specified by the commissioner by rule, but in no case for less than the
             679      current calendar year plus three years.
             680          (b) Discarding books and records after the applicable record retention period has
             681      expired does not place the licensee in violation of a later-adopted longer record retention
             682      period.
             683          Section 16. Section 31A-23b-211 is enacted to read:
             684          31A-23b-211. Exceptions to navigator licensing.
             685          (1) For purposes of this section:
             686          (a) "Negotiate" is as defined in Section 31A-23a-102 .
             687          (b) "Sell" is as defined in Section 31A-23a-102 .
             688          (c) "Solicit" is as defined in Section 31A-23a-102 .
             689          (2) The commissioner may not require a license as a navigator of:
             690          (a) a person who is employed by or contracts with:
             691          (i) a health care facility that is licensed under Title 26, Chapter 21, Health Care Facility
             692      Licensing and Inspection Act, to assist an individual with enrollment in a public program or an
             693      application for premium subsidy; or
             694          (ii) the state, a political subdivision of the state, an entity of a political subdivision of
             695      the state, or a public school district to assist an individual with enrollment in a public program
             696      or an application for premium subsidy;
             697          (b) a federally qualified health center as defined by Section 1905(1)(2)(B) of the Social
             698      Security Act which assists an individual with enrollment in a public program or an application
             699      for premium subsidy;
             700          (c) a person licensed under Chapter 23a, Insurance Marketing-Licensing, Consultants,
             701      and Reinsurance Intermediaries, if the person is licensed in the appropriate line of authority to


             702      sell, solicit, or negotiate accident and health insurance plans;
             703          (d) an officer, director, or employee of a navigator:
             704          (i) who does not receive compensation or commission from an insurer issuing an
             705      insurance contract, an agency administering a public program, an individual who enrolled in a
             706      public program or insurance product, or an exchange; and
             707          (ii) whose activities:
             708          (A) are executive, administrative, managerial, clerical, or a combination thereof;
             709          (B) only indirectly relate to the sale, solicitation, or negotiation of insurance, or the
             710      enrollment in a public program offered through the exchange;
             711          (C) are in the capacity of a special agent or agency supervisor assisting an insurance
             712      producer or navigator;
             713          (D) are limited to providing technical advice and assistance to a licensed insurance
             714      producer or navigator; or
             715          (E) do not include the sale, solicitation, or negotiation of insurance, or the enrollment
             716      in a public program; and
             717          (e) a person who does not sell, solicit, or negotiate insurance and is not directly or
             718      indirectly compensated by an insurer issuing an insurance contract, an agency administering a
             719      public program, an individual who enrolled in a public program or insurance product, or an
             720      exchange, including:
             721          (i) an employer, association, officer, director, employee, or trustee of an employee trust
             722      plan who is engaged in the administration or operation of a program:
             723          (A) of employee benefits for the employer's or association's own employees or the
             724      employees of a subsidiary or affiliate of an employer or association; and
             725          (B) that involves the use of insurance issued by an insurer or enrollment in a public
             726      health plan on an exchange;
             727          (ii) an employee of an insurer or organization employed by an insurer who is engaging
             728      in the inspection, rating, or classification of risk, or the supervision of training of insurance
             729      producers; or


             730          (iii) an employee who counsels or advises the employee's employer with regard to the
             731      insurance interests of the employer, or a subsidiary or business affiliate of the employer.
             732          (3) The exemption from licensure under Subsections (2)(a) and (b) does not apply if a
             733      person described in Subsections (2)(a) and (b) enrolls a person in a private insurance plan.
             734          (4) The commissioner may by rule exempt a class of persons from the license
             735      requirement of Subsection 31A-23b-201 (1) if:
             736          (a) the functions performed by the class of persons do not require:
             737          (i) special competence;
             738          (ii) special trustworthiness; or
             739          (iii) regulatory surveillance made possible by licensing; or
             740          (b) other existing safeguards make regulation unnecessary.
             741          Section 17. Section 31A-23b-301 is enacted to read:
             742     
Part 3. Unlawful Conduct and Limitation of Scope of Practice

             743          31A-23b-301. Unfair practices -- Compensation -- Limit of scope of practice.
             744          (1) As used in this section, "false or misleading information" includes, with intent to
             745      deceive a person examining it:
             746          (a) filing a report;
             747          (b) making a false entry in a record; or
             748          (c) willfully refraining from making a proper entry in a record.
             749          (2) (a) Communication that contains false or misleading information relating to
             750      enrollment in an insurance plan or a public program, including information that is false or
             751      misleading because it is incomplete, may not be made by:
             752          (i) a person who is or should be licensed under this title;
             753          (ii) an employee of a person described in Subsection (2)(a)(i);
             754          (iii) a person whose primary interest is as a competitor of a person licensed under this
             755      title; and
             756          (iv) a person on behalf of any of the persons listed in this Subsection (2)(a).
             757          (b) A licensee under this chapter may not:


             758          (i) use any business name, slogan, emblem, or related device that is misleading or
             759      likely to cause the exchange, insurer, or other licensee to be mistaken for another governmental
             760      agency, a PPACA exchange, insurer, or other licensee already in business; or
             761          (ii) use any advertisement or other insurance promotional material that would cause a
             762      reasonable person to mistakenly believe that a state or federal government agency, public
             763      program, or insurer:
             764          (A) is responsible for the insurance or public program enrollment assistance activities
             765      of the person;
             766          (B) stands behind the credit of the person; or
             767          (C) is a source of payment of any insurance obligation of or sold by the person.
             768          (c) A person who is not an insurer may not assume or use any name that deceptively
             769      implies or suggests that person is an insurer.
             770          (3) A person may not engage in an unfair method of competition or any other unfair or
             771      deceptive act or practice in the business of insurance, as defined by the commissioner by rule,
             772      after a finding that the method of competition, the act, or the practice:
             773          (a) is misleading;
             774          (b) is deceptive;
             775          (c) is unfairly discriminatory;
             776          (d) provides an unfair inducement; or
             777          (e) unreasonably restrains competition.
             778          (4) A navigator licensed under this chapter is subject to the inducement provisions of
             779      Section 31A-23a-402.5 .
             780          (5) A navigator licensed under this chapter or who should be licensed under this
             781      chapter:
             782          (a) may not receive direct or indirect compensation from an accident or health insurer
             783      or from an individual who receives services from a navigator in accordance with:
             784          (i) federal conflict of interest regulations established pursuant to PPACA; and
             785          (ii) administrative rule adopted by the department;


             786          (b) may be compensated by the exchange for performing the duties of a navigator;
             787          (c) (i) may perform, offer to perform, or advertise a service as a navigator only for a
             788      person selecting a qualified health plan or public program offered on an exchange; and
             789          (ii) may not perform, offer to perform, or advertise any services as a navigator for
             790      individuals or small employer groups selecting accident and health insurance plans, qualified
             791      health plans, public programs, business, or services that are not offered on an exchange; and
             792          (d) may not recommend a particular accident and health insurance plan or qualified
             793      health plan.
             794          Section 18. Section 31A-23b-401 is enacted to read:
             795     
Part 4. License Denial and Discipline

             796          31A-23b-401. Revocation, suspension, surrender, lapsing, limiting, or otherwise
             797      terminating a license -- Rulemaking for renewal or reinstatement.
             798          (1) A license as a navigator under this chapter remains in force until:
             799          (a) revoked or suspended under Subsection (4);
             800          (b) surrendered to the commissioner and accepted by the commissioner in lieu of
             801      administrative action;
             802          (c) the licensee dies or is adjudicated incompetent as defined under:
             803          (i) Title 75, Chapter 5, Part 3, Guardians of Incapacitated Persons; or
             804          (ii) Title 75, Chapter 5, Part 4, Protection of Property of Persons Under Disability and
             805      Minors;
             806          (d) lapsed under this section; or
             807          (e) voluntarily surrendered.
             808          (2) The following may be reinstated within one year after the day on which the license
             809      is no longer in force:
             810          (a) a lapsed license; or
             811          (b) a voluntarily surrendered license, except that a voluntarily surrendered license may
             812      not be reinstated after the license period in which the license is voluntarily surrendered.
             813          (3) Unless otherwise stated in a written agreement for the voluntary surrender of a


             814      license, submission and acceptance of a voluntary surrender of a license does not prevent the
             815      department from pursuing additional disciplinary or other action authorized under:
             816          (a) this title; or
             817          (b) rules made under this title in accordance with Title 63G, Chapter 3, Utah
             818      Administrative Rulemaking Act.
             819          (4) (a) If the commissioner makes a finding under Subsection (4)(b), as part of an
             820      adjudicative proceeding under Title 63G, Chapter 4, Administrative Procedures Act, the
             821      commissioner may:
             822          (i) revoke a license;
             823          (ii) suspend a license for a specified period of 12 months or less;
             824          (iii) limit a license in whole or in part; or
             825          (iv) deny a license application.
             826          (b) The commissioner may take an action described in Subsection (4)(a) if the
             827      commissioner finds that the licensee:
             828          (i) is unqualified for a license under Section 31A-23b-204 , 31A-23b-205 , or
             829      31A-23b-206 ;
             830          (ii) violated:
             831          (A) an insurance statute;
             832          (B) a rule that is valid under Subsection 31A-2-201 (3); or
             833          (C) an order that is valid under Subsection 31A-2-201 (4);
             834          (iii) is insolvent or the subject of receivership, conservatorship, rehabilitation, or other
             835      delinquency proceedings in any state;
             836          (iv) failed to pay a final judgment rendered against the person in this state within 60
             837      days after the day on which the judgment became final;
             838          (v) refused:
             839          (A) to be examined; or
             840          (B) to produce its accounts, records, and files for examination;
             841          (vi) had an officer who refused to:


             842          (A) give information with respect to the navigator's affairs; or
             843          (B) perform any other legal obligation as to an examination;
             844          (vii) provided information in the license application that is:
             845          (A) incorrect;
             846          (B) misleading;
             847          (C) incomplete; or
             848          (D) materially untrue;
             849          (viii) violated an insurance law, valid rule, or valid order of another state's insurance
             850      department;
             851          (ix) obtained or attempted to obtain a license through misrepresentation or fraud;
             852          (x) improperly withheld, misappropriated, or converted money or properties received
             853      in the course of doing insurance business;
             854          (xi) intentionally misrepresented the terms of an actual or proposed:
             855          (A) insurance contract;
             856          (B) application for insurance; or
             857          (C) application for public program;
             858          (xii) is convicted of a felony;
             859          (xiii) admitted or is found to have committed an insurance unfair trade practice or
             860      fraud;
             861          (xiv) in the conduct of business in this state or elsewhere:
             862          (A) used fraudulent, coercive, or dishonest practices; or
             863          (B) demonstrated incompetence, untrustworthiness, or financial irresponsibility;
             864          (xv) had an insurance license, navigator license, or its equivalent, denied, suspended,
             865      or revoked in another state, province, district, or territory;
             866          (xvi) forged another's name to:
             867          (A) an application for insurance;
             868          (B) a document related to an insurance transaction;
             869          (C) a document related to an application for a public program; or


             870          (D) a document related to an application for premium subsidies;
             871          (xvii) improperly used notes or another reference material to complete an examination
             872      for a license;
             873          (xviii) knowingly accepted insurance business from an individual who is not licensed;
             874          (xix) failed to comply with an administrative or court order imposing a child support
             875      obligation;
             876          (xx) failed to:
             877          (A) pay state income tax; or
             878          (B) comply with an administrative or court order directing payment of state income
             879      tax;
             880          (xxi) violated or permitted others to violate the federal Violent Crime Control and Law
             881      Enforcement Act of 1994, 18 U.S.C. Sec. 1033 and therefore under 18 U.S.C. Sec. 1033 is
             882      prohibited from engaging in the business of insurance; or
             883          (xxii) engaged in a method or practice in the conduct of business that endangered the
             884      legitimate interests of customers and the public.
             885          (c) For purposes of this section, if a license is held by an agency, both the agency itself
             886      and any individual designated under the license are considered to be the holders of the license.
             887          (d) If an individual designated under the agency license commits an act or fails to
             888      perform a duty that is a ground for suspending, revoking, or limiting the individual's license,
             889      the commissioner may suspend, revoke, or limit the license of:
             890          (i) the individual;
             891          (ii) the agency, if the agency:
             892          (A) is reckless or negligent in its supervision of the individual; or
             893          (B) knowingly participates in the act or failure to act that is the ground for suspending,
             894      revoking, or limiting the license; or
             895          (iii) (A) the individual; and
             896          (B) the agency if the agency meets the requirements of Subsection (4)(d)(ii).
             897          (5) A licensee under this chapter is subject to the penalties for acting as a licensee


             898      without a license if:
             899          (a) the licensee's license is:
             900          (i) revoked;
             901          (ii) suspended;
             902          (iii) surrendered in lieu of administrative action;
             903          (iv) lapsed; or
             904          (v) voluntarily surrendered; and
             905          (b) the licensee:
             906          (i) continues to act as a licensee; or
             907          (ii) violates the terms of the license limitation.
             908          (6) A licensee under this chapter shall immediately report to the commissioner:
             909          (a) a revocation, suspension, or limitation of the person's license in another state, the
             910      District of Columbia, or a territory of the United States;
             911          (b) the imposition of a disciplinary sanction imposed on that person by another state,
             912      the District of Columbia, or a territory of the United States; or
             913          (c) a judgment or injunction entered against that person on the basis of conduct
             914      involving:
             915          (i) fraud;
             916          (ii) deceit;
             917          (iii) misrepresentation; or
             918          (iv) a violation of an insurance law or rule.
             919          (7) (a) An order revoking a license under Subsection (4) or an agreement to surrender a
             920      license in lieu of administrative action may specify a time, not to exceed five years, within
             921      which the former licensee may not apply for a new license.
             922          (b) If no time is specified in an order or agreement described in Subsection (7)(a), the
             923      former licensee may not apply for a new license for five years from the day on which the order
             924      or agreement is made without the express approval of the commissioner.
             925          (8) The commissioner shall promptly withhold, suspend, restrict, or reinstate the use of


             926      a license issued under this chapter if so ordered by a court.
             927          (9) The commissioner shall by rule prescribe the license renewal and reinstatement
             928      procedures in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act.
             929          Section 19. Section 31A-23b-402 is enacted to read:
             930          31A-23b-402. Probation -- Grounds for revocation.
             931          (1) The commissioner may place a licensee on probation for a period not to exceed 24
             932      months as follows:
             933          (a) after an adjudicative proceeding under Title 63G, Chapter 4, Administrative
             934      Procedures Act, for any circumstances that would justify a suspension under this section; or
             935          (b) at the issuance of a new license:
             936          (i) with an admitted violation under 18 U.S.C. Secs. 1033 and 1034; or
             937          (ii) with a response to background information questions on a new license application
             938      indicating that:
             939          (A) the person has been convicted of a crime that is listed by rule made in accordance
             940      with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, as a crime that is a ground for
             941      probation;
             942          (B) the person is currently charged with a crime that is listed by rule made in
             943      accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, as a crime that is
             944      a ground for probation regardless of whether adjudication is withheld;
             945          (C) the person has been involved in an administrative proceeding regarding any
             946      professional or occupational license; or
             947          (D) any business in which the person is or was an owner, partner, officer, or director
             948      has been involved in an administrative proceeding regarding any professional or occupational
             949      license.
             950          (2) The commissioner may place a licensee on probation for a specified period no
             951      longer than 24 months if the licensee has admitted to a violation under 18 U.S.C. Secs. 1033
             952      and 1034.
             953          (3) The probation order shall state the conditions for revocation or retention of the


             954      license, which shall be reasonable.
             955          (4) Any violation of the probation is a ground for revocation pursuant to any
             956      proceeding authorized under Title 63G, Chapter 4, Administrative Procedures Act.
             957          Section 20. Section 31A-23b-403 is enacted to read:
             958          31A-23b-403. License lapse and voluntary surrender.
             959          (1) (a) A license issued under this chapter shall lapse if the licensee fails to:
             960          (i) pay when due a fee under Section 31A-3-103 ;
             961          (ii) complete continuing education requirements under Section 31A-23b-206 before
             962      submitting the license renewal application;
             963          (iii) submit a completed renewal application as required by Section 31A-23b-203 ;
             964          (iv) submit additional documentation required to complete the licensing process; or
             965          (v) maintain an active license in a resident state if the licensee is a nonresident
             966      licensee.
             967          (b) (i) A licensee whose license lapses due to the following may request an action
             968      described in Subsection (1)(b)(ii):
             969          (A) military service;
             970          (B) voluntary service for a period of time designated by the person for whom the
             971      licensee provides voluntary service; or
             972          (C) other extenuating circumstances, including long-term medical disability.
             973          (ii) A licensee described in Subsection (1)(b)(i) may request:
             974          (A) reinstatement of the license no later than one year after the day on which the
             975      license lapses; and
             976          (B) waiver of any of the following imposed for failure to comply with renewal
             977      procedures:
             978          (I) an examination requirement;
             979          (II) reinstatement fees set under Section 31A-3-103 ;
             980          (III) continuing education requirements; or
             981          (IV) other sanctions imposed for failure to comply with renewal procedures.


             982          (2) If a license issued under this chapter is voluntarily surrendered, the license may be
             983      reinstated:
             984          (a) during the license period in which the license is voluntarily surrendered; and
             985          (b) no later than one year after the day on which the license is voluntarily surrendered.
             986          (3) A voluntarily surrendered license that is reinstated during the license period set
             987      forth in Subsection (2) may not be reinstated until the person who voluntarily surrendered the
             988      license complies with any applicable continuing education requirements for the period during
             989      which the license was voluntarily surrendered.
             990          Section 21. Section 31A-23b-404 is enacted to read:
             991          31A-23b-404. Penalties.
             992          (1) (a) If, after notice and opportunity to be heard, the commissioner finds that the
             993      navigator or any other person has not materially complied with this part, or any rule made or
             994      order issued under this chapter, the commissioner may order the navigator or other person to
             995      cease doing business in the state.
             996          (b) If the commissioner finds that because of the material noncompliance an insurer,
             997      any policyholder of an insurer, or a recipient of a public program who used the services of the
             998      navigator or other person has suffered any loss or damage due to the material noncompliance,
             999      the commissioner may:
             1000          (i) maintain a civil action or may intervene in an action brought by or on behalf of the
             1001      insurer, policyholder, or the recipient of the public program, for recovery of compensatory
             1002      damages for the benefit of the insurer, policyholder, or recipient of a public program; or
             1003          (ii) seek other appropriate relief.
             1004          (2) Nothing in this section affects the right of the commissioner to impose any other
             1005      penalties provided for in this title.
             1006          (3) Nothing contained in this section is intended to or shall in any manner alter or
             1007      affect the rights of policyholders, claimants, creditors, or other third parties.
             1008          Section 22. Section 31A-30-104 is amended to read:
             1009           31A-30-104. Applicability and scope.


             1010          (1) This chapter applies to any:
             1011          (a) health benefit plan that provides coverage to:
             1012          (i) individuals;
             1013          (ii) small employers; or
             1014          (iii) both Subsections (1)(a)(i) and (ii); or
             1015          (b) individual conversion policy for purposes of Sections 31A-30-106.5 and
             1016      31A-30-107.5 .
             1017          (2) This chapter applies to a health benefit plan that provides coverage to small
             1018      employers or individuals regardless of:
             1019          (a) whether the contract is issued to:
             1020          (i) an association;
             1021          (ii) a trust;
             1022          (iii) a discretionary group; or
             1023          (iv) other similar grouping; or
             1024          (b) the situs of delivery of the policy or contract.
             1025          (3) This chapter does not apply to:
             1026          (a) short-term limited duration health insurance; or
             1027          (b) federally funded or partially funded programs.
             1028          (4) (a) Except as provided in Subsection (4)(b), for the purposes of this chapter:
             1029          (i) carriers that are affiliated companies or that are eligible to file a consolidated tax
             1030      return shall be treated as one carrier; and
             1031          (ii) any restrictions or limitations imposed by this chapter shall apply as if all health
             1032      benefit plans delivered or issued for delivery to covered insureds in this state by the affiliated
             1033      carriers were issued by one carrier.
             1034          (b) Upon a finding of the commissioner, an affiliated carrier that is a health
             1035      maintenance organization having a certificate of authority under this title may be considered to
             1036      be a separate carrier for the purposes of this chapter.
             1037          (c) Unless otherwise authorized by the commissioner or by Chapter 42, Defined


             1038      Contribution Risk Adjuster Act, a covered carrier may not enter into one or more ceding
             1039      arrangements with respect to health benefit plans delivered or issued for delivery to covered
             1040      insureds in this state if the ceding arrangements would result in less than 50% of the insurance
             1041      obligation or risk for the health benefit plans being retained by the ceding carrier.
             1042          (d) Section 31A-22-1201 applies if a covered carrier cedes or assumes all of the
             1043      insurance obligation or risk with respect to one or more health benefit plans delivered or issued
             1044      for delivery to covered insureds in this state.
             1045          (5) (a) A Taft Hartley trust created in accordance with Section 302(c)(5) of the Federal
             1046      Labor Management Relations Act, or a carrier with the written authorization of such a trust,
             1047      may make a written request to the commissioner for a waiver from the application of any of the
             1048      provisions of Subsection 31A-30-106 (1) with respect to a health benefit plan provided to the
             1049      trust.
             1050          (b) The commissioner may grant a trust or carrier described in Subsection (5)(a) a
             1051      waiver if the commissioner finds that application with respect to the trust would:
             1052          (i) have a substantial adverse effect on the participants and beneficiaries of the trust;
             1053      and
             1054          (ii) require significant modifications to one or more collective bargaining arrangements
             1055      under which the trust is established or maintained.
             1056          (c) A waiver granted under this Subsection (5) may not apply to an individual if the
             1057      person participates in a Taft Hartley trust as an associate member of any employee
             1058      organization.
             1059          (6) Sections 31A-30-106 , 31A-30-106.5 , 31A-30-106.7 , 31A-30-107 , 31A-30-108 , and
             1060      31A-30-111 apply to:
             1061          (a) any insurer engaging in the business of insurance related to the risk of a small
             1062      employer for medical, surgical, hospital, or ancillary health care expenses of the small
             1063      employer's employees provided as an employee benefit; and
             1064          (b) any contract of an insurer, other than a workers' compensation policy, related to the
             1065      risk of a small employer for medical, surgical, hospital, or ancillary health care expenses of the


             1066      small employer's employees provided as an employee benefit.
             1067          (7) The commissioner may make rules requiring that the marketing practices be
             1068      consistent with this chapter for:
             1069          (a) a small employer carrier;
             1070          (b) a small employer carrier's agent;
             1071          (c) an insurance producer; [and]
             1072          (d) an insurance consultant; and
             1073          (e) a navigator.
             1074          Section 23. Section 31A-30-105 is amended to read:
             1075           31A-30-105. Establishment of classes of business.
             1076          [(1) For a policy that takes effect on or after January 1, 2011] Effective January 1,
             1077      2014, a covered carrier may [not] establish [a separate class] up to four separate classes of
             1078      business [unless]:
             1079          [(a) the covered carrier submits an application to the commissioner to establish a
             1080      separate class of business;]
             1081          [(b) the covered carrier demonstrates to the satisfaction of the commissioner that a
             1082      separate class of business is justified under the provisions of this section; and]
             1083          [(c) the commissioner approves the carrier's application for the use of a separate class
             1084      of business.]
             1085          [(2) (a) The commissioner shall have a presumption against the use of a separate class
             1086      of business by a covered insured, except when the covered carrier demonstrates that this
             1087      Subsection (2) applies.]
             1088          [(b) The commissioner may approve the use of a separate class of business only if the
             1089      covered carrier can demonstrate that the use of a separate class of business is necessary due to
             1090      substantial differences in either expected claims experience or administrative costs related to
             1091      the following reasons:]
             1092          [(i) the covered carrier uses more than one type of system for the marketing and sale of
             1093      health benefit plans to covered insureds;]


             1094          [(ii) the covered carrier has acquired a class of business from another covered carrier;
             1095      or]
             1096          [(iii) the covered carrier provides coverage to one or more association groups.]
             1097          [(3) The commissioner may establish regulations to provide for a period of transition in
             1098      order for a covered carrier to come into compliance with Subsection (2) in the instance of
             1099      acquisition of an additional class of business from another covered carrier.]
             1100          [(4) The commissioner may approve the establishment of up to five classes of business
             1101      per covered carrier upon application to the commissioner and a finding by the commissioner
             1102      that such action would substantially enhance the efficiency and fairness of the health insurance
             1103      marketplace subject to this chapter.]
             1104          [(5) A covered carrier may not establish a class of business based solely on the
             1105      marketing or sale of a health benefit plan as a defined contribution arrangement health benefit
             1106      plan, or through the Health Insurance Exchange.]
             1107          (1) one class of business for individual health benefit plans that are not grandfathered
             1108      under PPACA;
             1109          (2) one class of business for small employer health benefit plans that are not
             1110      grandfathered under PPACA;
             1111          (3) one class of business for individual health benefit plans that are grandfathered
             1112      under PPACA; and
             1113          (4) one class of business for small employer health benefit plans that are grandfathered
             1114      under PPACA.
             1115          Section 24. Section 31A-30-107.3 is amended to read:
             1116           31A-30-107.3. Discontinuance and nonrenewal limitations and conditions.
             1117          (1) [(a)] A carrier that elects to discontinue offering [a] all individual health benefit
             1118      [plan] plans under Subsection [ 31A-30-107 (3)(e) or] 31A-30-107.1 (3)(e) is prohibited from
             1119      writing new business[:(i) in the small employer and] in the individual market in this state[; and
             1120      (ii)] for a period of five years beginning on the date of discontinuation of the last individual
             1121      health benefit plan coverage that is discontinued.


             1122          [(b) The prohibition described in Subsection (1)(a) may be waived if the commissioner
             1123      finds that waiver is in the public interest:]
             1124          [(i) to promote competition; or]
             1125          [(ii) to resolve inequity in the marketplace.]
             1126          (2) A carrier that elects to discontinue offering all small employer health benefit plans
             1127      under Subsection 31A-30-107 (3)(e) is prohibited from writing new business in the small group
             1128      market in this state for a period of five years beginning on the date of discontinuation of the
             1129      last small employer coverage that is discontinued.
             1130          [(2)] (3) (a) If the Comprehensive Health Insurance Pool as set forth under Title 31A,
             1131      Chapter 29, Comprehensive Health Insurance Pool Act, is dissolved or discontinued, or if
             1132      enrollment is capped or suspended, an individual carrier:
             1133          (i) may, except as prohibited by Section 31A-30-117 , elect to discontinue offering new
             1134      individual health benefit plans, except to HIPAA eligibles, but shall keep existing individual
             1135      health benefit plans in effect, except those individual plans that are not renewed under the
             1136      provisions of Subsection 31A-30-107 (2) or 31A-30-107.1 (2);
             1137          (ii) may elect to continue to offer new individual and small employer health benefit
             1138      plans; or
             1139          (iii) may elect to discontinue all of the covered carrier's health benefit plans in the
             1140      individual or small group market under the provisions of Subsection 31A-30-107 (3)(e) or
             1141      31A-30-107.1 (3)(e).
             1142          (b) A carrier that makes an election under Subsection [(2)] (3)(a)(i):
             1143          (i) is prohibited from writing new business:
             1144          (A) in the individual market in this state; and
             1145          (B) for a period of five years beginning on the date of discontinuation;
             1146          (ii) may continue to write new business in the small employer market; and
             1147          (iii) shall provide written notice of the election under Subsection [(2)] (3)(a)(i) within
             1148      two calendar days of the election to the Utah Insurance Department.
             1149          (c) The prohibition described in Subsection [(2)] (3)(b)(i) may be waived if the


             1150      commissioner finds that waiver is in the public interest:
             1151          (i) to promote competition; or
             1152          (ii) to resolve inequity in the marketplace.
             1153          (d) A carrier that makes an election under Subsection [(2)] (3)(a)(iii) is subject to the
             1154      provisions of Subsection (1).
             1155          [(3)] (4) If a carrier is doing business in one established geographic service area of the
             1156      state, Sections 31A-30-107 and 31A-30-107.1 apply only to the carrier's operations in that
             1157      geographic service area.
             1158          [(4)] (5) If a small employer employs less than two eligible employees, a carrier may
             1159      not discontinue or not renew the health benefit plan until the first renewal date following the
             1160      beginning of a new plan year, even if the carrier knows as of the beginning of the plan year that
             1161      the employer no longer has at least two current employees.
             1162          Section 25. Section 31A-30-112 is amended to read:
             1163           31A-30-112. Employee participation levels.
             1164          (1) (a) For purposes of this section, "participation" is as defined in Section 31A-1-301 .
             1165          [(1) (a)] (b) Except as provided in Subsection (2) and Section 31A-30-206 , a
             1166      requirement used by a covered carrier in determining whether to provide coverage to a small
             1167      employer, including a participation requirement [for minimum participation of eligible
             1168      employees] and a minimum employer [contributions] contribution requirement, shall be
             1169      applied uniformly among all small employers with the same number of eligible employees
             1170      applying for coverage or receiving coverage from the covered carrier.
             1171          [(b) In addition to applying Subsection 31A-1-301 (124), a covered carrier may require
             1172      that a small employer have a minimum of two eligible employees to meet participation
             1173      requirements.]
             1174          (2) A covered carrier may not increase a [requirement for minimum employee]
             1175      participation requirement or a requirement for minimum employer contribution, applicable to a
             1176      small employer, at any time after the small employer is accepted for coverage.
             1177          Section 26. Section 31A-30-115 is amended to read:


             1178           31A-30-115. Actuarial review of health benefit plans.
             1179          (1) (a) The department shall conduct an actuarial review of rates submitted by [small
             1180      employer carriers] a carrier that offers a small employer plan and a carrier that offers an
             1181      individual plan under this chapter:
             1182          [(i) prior to the publication of the premium rates on the Health Insurance Exchange;]
             1183          [(ii) except as permitted by Subsection 31A-30-207 (2), to determine if the carrier is
             1184      using the same rating and underwriting practices in both the defined contribution arrangement
             1185      market in the Health Insurance Exchange and the defined benefit market offered outside the
             1186      Health Insurance Exchange, in compliance with Subsection 31A-30-202.5 (1)(b);]
             1187          [(iii) to verify the validity of the rates, underwriting and risk factors, and premiums of
             1188      plans both in and outside of the Health Insurance Exchange;]
             1189          [(iv) to verify that insurers are pricing similar health benefit plans and groups the same
             1190      in and out of the exchange, except as permitted by Subsection 31A-30-207 (2); and]
             1191          (i) to verify the valildity of the rates, risk factors, and premiums of the plans; and
             1192          [(v)] (ii) as the department determines is necessary to oversee market conduct.
             1193          (b) The actuarial review by the department shall be funded from a fee:
             1194          (i) established by the department in accordance with Section 63J-1-504 ; and
             1195          (ii) paid by [all small employer carriers participating in the defined contribution
             1196      arrangement market and small employer carriers offering health benefit plans under Part 1,
             1197      Individual and Small Employer Group] a carrier offering a health benefit plan subject to this
             1198      chapter.
             1199          (c) The department shall:
             1200          (i) report aggregate data from the actuarial review to the risk adjuster board created in
             1201      Section 31A-42-201 ; and
             1202          (ii) contact carriers, if the department determines it is appropriate, to:
             1203          (A) inform a carrier of the department's findings regarding the rates of a particular
             1204      carrier; and
             1205          (B) request a carrier to recalculate or verify base rates, rating factors, and premiums.


             1206          (d) A carrier shall comply with the department's request under Subsection (1)(c)(ii).
             1207          (2) (a) There is created in the General Fund a restricted account known as the "Health
             1208      Insurance Actuarial Review Restricted Account."
             1209          (b) The Health Insurance Actuarial Review Restricted Account shall consist of money
             1210      received by the commissioner under this section.
             1211          (c) The commissioner shall administer the Health Insurance Actuarial Review
             1212      Restricted Account. Subject to appropriations by the Legislature, the commissioner shall use
             1213      money deposited into the Health Insurance Actuarial Review Restricted Account to pay for the
             1214      actuarial review conducted by the department under this section.
             1215          Section 27. Section 31A-30-117 is enacted to read:
             1216          31A-30-117. Patient Protection and Affordable Care Act -- Market transition.
             1217          (1) (a) After complying with the reporting requirements of Section 63M-1-2505.5 , the
             1218      commissioner may adopt administrative rules that change the rating and underwriting
             1219      requirements of this chapter as necessary to transition the insurance market to meet federal
             1220      qualified health plan standards and rating practices under PPACA.
             1221          (b) Administrative rules adopted by the commissioner under this section may include:
             1222          (i) the regulation of health benefit plans as described in Subsections 31A-2-212 (5)(a)
             1223      and (b); and
             1224          (ii) disclosure of records and information required by PPACA and state law.
             1225          (c) (i) The commissioner shall establish by administrative rule one statewide open
             1226      enrollment period that applies to the individual insurance market that is not on the PPACA
             1227      certified individual exchange.
             1228          (ii) The statewide open enrollment period:
             1229          (A) may be shorter, but no longer than the open enrollment period established for the
             1230      individual insurance market offered in the PPACA certified exchange; and
             1231          (B) may not be extended beyond the dates of the open enrollment period established
             1232      for the individual insurance market offered in the PPACA certified exchange.
             1233          (2) A carrier that offers health benefit plans in the individual market that is not part of


             1234      the individual PPACA certified exchange:
             1235          (a) shall open enrollment:
             1236          (i) during the statewide open enrollment period established in Subsection (1)(c); and
             1237          (ii) at other times, for qualifying events, as determined by administrative rule adopted
             1238      by the commissioner; and
             1239          (b) may open enrollment at any time.
             1240          (3) (a) The commissioner shall identify a new mandated benefit that is in excess of the
             1241      essential health benefits required by PPACA.
             1242          (b) In accordance with 45 C.F.R. Sec. 155.170, the state shall make a payment to
             1243      defray the cost of a new mandated benefit in the amount calculated under Subsection (3)(c)
             1244      directly to the qualified health plan issuer on behalf of an individual who receives an advance
             1245      premium tax credit under PPACA.
             1246          (c) The state shall quantify the cost attributable to each additional mandated benefit
             1247      specified in Subsection (3)(a) based on a qualified health plan issuer's calculation of the cost
             1248      associated with the mandated benefit, which shall be:
             1249          (i) calculated in accordance with generally accepted actuarial principles and
             1250      methodologies;
             1251          (ii) conducted by a member of the American Academy of Actuaries; and
             1252          (iii) reported to the commissioner and to the individual exchange operating in the state.
             1253          (d) The commissioner may require a proponent of a new mandated benefit under
             1254      Subsection (3)(a) to provide the commissioner with a cost analysis conducted in accordance
             1255      with Subsection (3)(c). The commissioner may use the cost information provided under this
             1256      Subsection (3)(d) to establish estimates of the cost to the state for premium subsidies under
             1257      Subsection (3)(b).
             1258          Section 28. Section 31A-30-202.6 is enacted to read:
             1259          31A-30-202.6. Dental and vision plans on the defined contribution arrangement
             1260      market.
             1261          (1) Beginning January 1, 2014, a carrier may offer dental and vision plans in the


             1262      defined contribution arrangement market.
             1263          (2) (a) A carrier that offers a dental or vision plan in the defined contribution
             1264      arrangement market is not required to offer the same dental or vision plans outside the defined
             1265      contribution arrangement market and does not have to use the same rating and underwriting
             1266      practices in and out of the defined contribution arrangement market.
             1267          (b) If a carrier offers a dental or vision plan in the defined contribution arrangement
             1268      market, the carrier shall allow an employee of a small employer group to enroll in a dental and
             1269      vision plan in accordance with Subsection (3).
             1270          (3) (a) A small employer group shall participate in a defined contribution arrangement
             1271      and meet participation requirements for the defined contribution arrangement before the
             1272      employer may elect to offer its employees dental or vision plans under Subsection (3)(b).
             1273          (b) A small employer who meets the requirements of Subsection (3)(a) may elect to
             1274      offer its employees:
             1275          (i) a dental plan offered in the defined contribution arrangement market;
             1276          (ii) a vision plan offered in the defined contribution arrangement market; or
             1277          (iii) both a vision plan and a dental plan offered in the defined contribution
             1278      arrangement market.
             1279          (4) An employee whose employer has offered its employees a defined contribution
             1280      medical plan and met participation requirements under Subsection (3)(a) may elect to enroll, or
             1281      not enroll, in the dental and vision plan selected by the employer.
             1282          (5) An employer's small group must meet participation requirements established by the
             1283      commissioner by administrative rule for each dental or vision plan selected by an employer
             1284      under Subsection (3).
             1285          Section 29. Section 31A-30-208 is amended to read:
             1286           31A-30-208. Enrollment for defined contribution arrangements.
             1287          (1) An insurer offering a health benefit plan in the defined contribution arrangement
             1288      market:
             1289          (a) shall allow an employer to enroll in a small employer defined contribution


             1290      arrangement plan; and
             1291          [(b) may not impose a surcharge under Section 31A-30-106.7 for a small employer
             1292      group selecting a defined contribution arrangement health benefit plan on or before January 1,
             1293      2012; and]
             1294          [(c)] (b) shall otherwise comply with the requirements of this part, Chapter 42, Defined
             1295      Contribution Risk Adjuster Act, and Title 63M, Chapter 1, Part 25, Health System Reform Act.
             1296          (2) (a) [Except as provided in Subsection 31A-30-202.5 (2), in accordance with
             1297      Subsection (2)(b), on January 1 of each year, an] An insurer may enter or exit the defined
             1298      contribution arrangement market on January 1 of each year.
             1299          (b) An insurer may offer new or modify existing products in the defined contribution
             1300      arrangement market:
             1301          (i) on January 1 of each year;
             1302          (ii) when required by changes in other law; and
             1303          (iii) at other times as established by the risk adjuster board created in Section
             1304      31A-42-201 .
             1305          (c) [(i)] An insurer shall give the department, the Health Insurance Exchange, and the
             1306      risk adjuster board 90 days' advance written notice of any event described in Subsection (2)(a)
             1307      or (b).
             1308          [(ii) When an insurer elects to participate in the defined contribution arrangement
             1309      market, the insurer shall participate in the defined contribution arrangement market for no less
             1310      than two years.]
             1311          Section 30. Section 31A-43-101 is enacted to read:
             1312     
CHAPTER 43. SMALL EMPLOYER STOP-LOSS INSURANCE ACT

             1313     
Part 1. General Provisions

             1314          31A-43-101. Title.
             1315          This chapter is known as the "Small Employer Stop-Loss Insurance Act."
             1316          Section 31. Section 31A-43-102 is enacted to read:
             1317          31A-43-102. Definitions.


             1318          For purposes of this chapter:
             1319          (1) "Actuarial certification" means a written statement by a member of the American
             1320      Academy of Actuaries, or by another individual acceptable to the commissioner, that an insurer
             1321      is in compliance with the provisions of this chapter, based upon the individual's examination
             1322      and including a review of the appropriate records and the actuarial assumptions and methods
             1323      used by the stop-loss insurer in establishing attachment points and other applicable
             1324      determinations in conjunction with the provision of stop-loss insurance coverage.
             1325          (2) "Aggregate attachment point" means the dollar amount in losses for eligible
             1326      expenses incurred by a small employer plan beyond which the stop-loss insurer incurs liability
             1327      for all or part of the losses incurred by the small employer plan, subject to limitations included
             1328      in the contract.
             1329          (3) "Coverage" means the combination of the employer plan design and the stop-loss
             1330      contract design.
             1331          (4) "Expected claims" means the amount of claims that, in the absence of a stop-loss
             1332      contract, are projected to be incurred by a small employer health plan using reasonable and
             1333      accepted actuarial principles.
             1334          (5) "Lasering":
             1335          (a) means increasing or removing stop-loss coverage for a specific individual within an
             1336      employer group; and
             1337          (b) includes other practices that are prohibited by the commissioner by administrative
             1338      rule that result in lowering the stop-loss premium for the employer by transferring the risk for
             1339      an individual.
             1340          (6) "Small employer" means an employer who, with respect to a calendar year and to a
             1341      plan year:
             1342          (a) employed an average of at least two employees but not more than 50 eligible
             1343      employees on each business day during the preceding calendar year; and
             1344          (b) employs at least two employees on the first day of the plan year.
             1345          (7) "Specific attachment point" means the dollar amount in losses for eligible expenses


             1346      attributable to a single individual covered by a small employer plan in a contract year beyond
             1347      which the stop-loss insurer assumes all or part of the liability for losses incurred by the small
             1348      employer plan, subject to limitations included in the contract.
             1349          (8) "Stop-loss insurance" means insurance purchased by a small employer for which
             1350      the stop-loss insurer assumes, on a per-loss basis, all loss amounts of the small employer's plan
             1351      in excess of a stated amount, subject to the policy limit.
             1352          Section 32. Section 31A-43-201 is enacted to read:
             1353     
Part 2. Scope of Chapter

             1354          31A-43-201. Scope of chapter.
             1355          (1) This chapter establishes criteria for the issuance of stop-loss insurance contracts or
             1356      re-insurance contracts for small employers that establish self-funded or partially self-funded
             1357      health plans for the small employer's employees. This chapter does not:
             1358          (a) impose any requirement or duty on any person other than a stop-loss insurer or
             1359      re-insurer who issues a stop-loss insurance contract to a small employer;
             1360          (b) treat any stop-loss insurance contract as a direct policy of health insurance; or
             1361          (c) constitute an attempt to exercise authority over self-funded or partially self-funded
             1362      health benefit plans sponsored by a small employer.
             1363          (2) This chapter applies to a small employer stop-loss contract issued or renewed on or
             1364      after July 1, 2013.
             1365          Section 33. Section 31A-43-202 is enacted to read:
             1366          31A-43-202. Laws applicable to stop-loss insurance.
             1367          A stop-loss insurance contract or a re-insurance contract issued to a small employer that
             1368      establishes a self-funded or partially self-funded health plan:
             1369          (1) is not reinsurance under this title, and is not subject to the regulations for
             1370      reinsurance under this title;
             1371          (2) is subject to regulation as stop-loss insurance under this chapter; and
             1372          (3) is subject to the contract provisions of this title in the same manner as insurance
             1373      contracts issued by any other insurer.


             1374          Section 34. Section 31A-43-301 is enacted to read:
             1375     
Part 3. Stop-loss Insurance

             1376          31A-43-301. Stop-loss insurance coverage standards.
             1377          (1) A small employer stop-loss insurance contract shall:
             1378          (a) be issued to the small employer to provide insurance to the group health benefit
             1379      plan, not the employees of the small employer;
             1380          (b) use a standard application form developed by the commissioner by administrative
             1381      rule;
             1382          (c) have a contract term with guaranteed rates for at least 12 months, without
             1383      adjustment, unless there is a change in the benefits provided under the small employer's health
             1384      plan during the contract period;
             1385          (d) include both a specific attachment point and an aggregate attachment point in a
             1386      contract;
             1387          (e) align stop-loss plan benefit limitations and exclusions with a small employer's
             1388      health plan benefit limitations and exclusions, including any annual or lifetime limits in the
             1389      employer's health plan;
             1390          (f) have an annual specific attachment point that is at least $10,000;
             1391          (g) have an annual aggregate attachment point that may not be less than 90% of
             1392      expected claims;
             1393          (h) pay stop-loss claims:
             1394          (i) incurred during the contract period; and
             1395          (ii) submitted within 12 months after the expiration date of the contract; and
             1396          (i) include provisions to cover incurred and unpaid claims if a small employer plan
             1397      terminates.
             1398          (2) A small employer stop-loss contract shall not:
             1399          (a) include lasering; and
             1400          (b) pay claims directly to an individual employee, member, or participant.
             1401          Section 35. Section 31A-43-302 is enacted to read:


             1402          31A-43-302. Stop-loss restrictions -- Filing requirements.
             1403          (1) A stop-loss insurer shall demonstrate to the commissioner that the rates associated
             1404      with specific and aggregate attachment points retained by a small employer group under the
             1405      insurer's stop-loss plan are actuarially sound.
             1406          (2) A stop-loss insurer shall file the stop-loss insurance contract form and rates with
             1407      the commissioner pursuant to Sections 31A-2-201 and 31A-2-201.1 before the stop-loss
             1408      insurance contract may be issued or delivered in the state.
             1409          (3) A stop-loss insurer shall file with the commissioner, annually on or before April 1,
             1410      in a form and manner required by the commissioner by administrative rule adopted by the
             1411      commissioner:
             1412          (a) an actuarial memorandum and certification which demonstrates that the insurer is in
             1413      compliance with this chapter; and
             1414          (b) the stop-loss insurer's stop-loss experience.
             1415          (4) Each insurer shall maintain at its principal place of business:
             1416          (a) a complete and detailed description of its rating practices and renewal underwriting
             1417      practices, including information and documentation that demonstrate the rating methods and
             1418      practices are:
             1419          (i) based upon commonly accepted actuarial assumptions; and
             1420          (ii) in accordance with sound actuarial principles; and
             1421          (b) a copy of the actuarial certification required by Subsection (3).
             1422          Section 36. Section 31A-43-303 is enacted to read:
             1423          31A-43-303. Stop-loss insurance disclosure.
             1424          A stop-loss insurance contract delivered, issued for delivery, or entered into shall
             1425      include the disclosure exhibit required by the commissioner through administrative rule, which
             1426      shall include at least the following information:
             1427          (1) the complete costs for the stop-loss contract;
             1428          (2) the date on which the insurance takes effect and terminates, including renewability
             1429      provisions;


             1430          (3) the aggregate attachment point and the specific attachment point;
             1431          (4) any limitations on coverage;
             1432          (5) an explanation of monthly accommodation and disclosure about any monthly
             1433      accommodation features included in the stop-loss contract; and
             1434          (6) a description of terminal liability funding, including:
             1435          (a) cost of processing claims before and after the termination of the contract; and
             1436          (b) maximum claims liability to the employer.
             1437          Section 37. Section 31A-43-304 is enacted to read:
             1438          31A-43-304. Administrative rules.
             1439          The commissioner may adopt administrative rules in accordance with Title 63G,
             1440      Chapter 3, Utah Administrative Rulemaking Act, to:
             1441          (1) implement this chapter;
             1442          (2) assure that differences in rates charged are reasonable and reflect objective
             1443      differences in plan design;
             1444          (3) define lasering practices that are prohibited by this chapter;
             1445          (4) establish the form and manner of the actuarial certification and the annual report on
             1446      stop-loss experience required by Section 31A-43-302 ;
             1447          (5) establish the form and manner of the disclosure required by Section 31A-43-303 ;
             1448          (6) assure the rates associated with the specific attachment points and aggregate
             1449      attachment points are actuarially sound and are not against the public interest; and
             1450          (7) assure that stop-loss contracts include provisions to cover incurred and unpaid
             1451      claims if a small employer plan terminates.
             1452          Section 38. Section 63I-2-231 (Superseded 07/01/13) is amended to read:
             1453           63I-2-231 (Superseded 07/01/13). Repeal dates, Title 31A.
             1454          Title 31A, Chapter 42, Defined Contribution Risk Adjuster Act, is repealed July 1,
             1455      [2013] 2015.
             1456          Section 39. Section 63I-2-231 (Effective 07/01/13) is amended to read:
             1457           63I-2-231 (Effective 07/01/13). Repeal dates, Title 31A.


             1458          (1) Section 31A-22-315.5 is repealed July 1, 2016.
             1459          (2) Title 31A, Chapter 42, Defined Contribution Risk Adjuster Act, is repealed July 1,
             1460      [2013] 2015.
             1461          Section 40. Section 63M-1-2505.5 is amended to read:
             1462           63M-1-2505.5. Reporting on federal health reform -- Prohibition of individual
             1463      mandate.
             1464          (1) The Legislature finds that:
             1465          (a) the state has embarked on a rigorous process of implementing a strategic plan for
             1466      health system reform pursuant to Section 63M-1-2505 ;
             1467          (b) the health system reform efforts for the state were developed to address the unique
             1468      circumstances within Utah and to provide solutions that work for Utah;
             1469          (c) Utah is a leader in the nation for health system reform which includes:
             1470          (i) developing and using health data to control costs and quality; and
             1471          (ii) creating a defined contribution insurance market to increase options for employers
             1472      and employees; and
             1473          (d) the federal government proposals for health system reform:
             1474          (i) infringe on state powers;
             1475          (ii) impose a uniform solution to a problem that requires different responses in
             1476      different states;
             1477          (iii) threaten the progress Utah has made towards health system reform; and
             1478          (iv) infringe on the rights of citizens of this state to provide for their own health care
             1479      by:
             1480          (A) requiring a person to enroll in a third party payment system;
             1481          (B) imposing fines, penalties, and taxes on a person who chooses to pay directly for
             1482      health care rather than use a third party payer;
             1483          (C) imposing fines, penalties, and taxes on an employer that does not meet federal
             1484      standards for providing health care benefits for employees; and
             1485          (D) threatening private health care systems with competing government supported


             1486      health care systems.
             1487          (2) (a) For purposes of this section:
             1488          (i) "Implementation" includes adopting or changing an administrative rule, applying for
             1489      or spending federal grant money, issuing a request for proposal to carry out a requirement of
             1490      PPACA, entering into a memorandum of understanding with the federal government regarding
             1491      a provision of PPACA, or amending the state Medicaid plan.
             1492          (ii) "PPACA" is as defined in Section 31A-1-301 .
             1493          [(2) (a)] (b) A department or agency of the state may not implement any part of [federal
             1494      health care reform, as defined in Subsection (3), that is passed by the United States Congress
             1495      after March 1, 2010,] PPACA unless, prior to implementation, the department or agency
             1496      reports in writing, and, if practicable, in person if requested, to the Legislature's Business and
             1497      Labor Interim Committee [and if authorized], the Health Reform Task Force, [and] or the
             1498      legislative Executive Appropriations Committee in accordance with Subsection (2)[(c)](d).
             1499          [(b)] (c) The Legislature may pass legislation specifically authorizing or prohibiting the
             1500      state's compliance with, or participation in[, federal health care reform] provisions of PPACA.
             1501          [(c)] (d) The report required under Subsection (2)[(a)](b) shall include:
             1502          (i) the specific federal statute or regulation that requires the state to implement a
             1503      [federal reform] provision of PPACA;
             1504          (ii) whether [the reform provision] PPACA has any state waiver or options;
             1505          (iii) exactly what [the reform provision] PPACA requires the state to do, and how it
             1506      would be implemented;
             1507          (iv) who in the state will be impacted by adopting the federal reform provision, or not
             1508      adopting the federal reform provision;
             1509          (v) what is the cost to the state or citizens of the state to implement the federal reform
             1510      provision; [and]
             1511          (vi) the consequences to the state if the state does not comply with [the federal reform
             1512      provision.] PPACA;
             1513          [(3) For purposes of this section, "federal health care reform" means federal legislation


             1514      or federal regulation that:]
             1515          [(a) mandates an individual to purchase health insurance;]
             1516          [(b) mandates a small employer to provide health insurance coverage for employees;]
             1517          [(c) imposes penalties on small employers who do not provide health insurance for
             1518      their employees;]
             1519          [(d) expands the eligibility for the Medicaid program or the Children's Health
             1520      Insurance Program, and passes the cost of that expansion to the state;]
             1521          [(e) creates new insurance coverage mandates; or]
             1522          [(f) creates a new government run, public insurance program.]
             1523          (vii) the impact, if any, of the PPACA requirements regarding:
             1524          (A) the state's protection of a health care provider's refusal to perform an abortion on
             1525      religious or moral grounds as provided in Section 76-7-306 ; and
             1526          (B) abortion insurance coverage restrictions provided in Section 31A-22-726 .
             1527          [(4)] (3) (a) [An individual in this state may not be required] The state shall not require
             1528      an individual in the state to obtain or maintain health insurance as defined in [Section
             1529      31A-1-301 ] PPACA, regardless of whether the individual has or is eligible for health insurance
             1530      coverage under any policy or program provided by or through the individual's employer or a
             1531      plan sponsored by the state or federal government.
             1532          (b) The provisions of this title may not be used to facilitate the federal PPACA
             1533      individual mandate or to hold an individual in this state liable for any penalty, assessment, fee,
             1534      or fine as a result of the individual's failure to procure or obtain health insurance coverage.
             1535          (c) This section does not apply to an individual who voluntarily applies for coverage
             1536      under a state administered program pursuant to Title XIX or Title XXI of the Social Security
             1537      Act.
             1538          Section 41. Health Reform Task Force -- Creation -- Membership -- Interim rules
             1539      followed -- Compensation -- Staff.
             1540          (1) There is created the Health Reform Task Force consisting of the following 11
             1541      members:


             1542          (a) four members of the Senate appointed by the president of the Senate, no more than
             1543      three of whom may be from the same political party; and
             1544          (b) seven members of the House of Representatives appointed by the speaker of the
             1545      House of Representatives, no more than five of whom may be from the same political party.
             1546          (2) (a) The president of the Senate shall designate a member of the Senate appointed
             1547      under Subsection (1)(a) as a cochair of the task force.
             1548          (b) The speaker of the House of Representatives shall designate a member of the House
             1549      of Representatives appointed under Subsection (1)(b) as a cochair of the task force.
             1550          (3) In conducting its business, the task force shall comply with the rules of legislative
             1551      interim committees.
             1552          (4) Salaries and expenses of the members of the task force shall be paid in accordance
             1553      with Section 36-2-2 and Legislative Joint Rules, Title 5, Chapter 3, Expense and Mileage
             1554      Reimbursement for Authorized Legislative Meetings, Special Sessions, and Veto Override
             1555      Sessions.
             1556          (5) The Office of Legislative Research and General Counsel shall provide staff support
             1557      to the task force.
             1558          Section 42. Duties -- Interim report.
             1559          (1) The task force shall review and make recommendations on the following issues:
             1560          (a) the impact of implementation of the federal health reform law and federal
             1561      regulations on the state;
             1562          (b) options for the state regarding Medicaid expansion and reform;
             1563          (c) health care cost containment strategies;
             1564          (d) the role of the state defined contribution arrangement market and online health
             1565      insurance market places established under PPACA;
             1566          (e) governing structure for the state's defined contribution arrangement market;
             1567          (f) Medicaid behavioral health delivery and payment reform models within Medicaid
             1568      accountable care organizations and other county provided delivery settings, including:
             1569          (i) the development of a system to encourage, track, evaluate, share, and disseminate


             1570      results from existing pilot projects; and
             1571          (ii) payment reform models that promote performance based reimbursement;
             1572          (g) the delivery of charity care in the state, including:
             1573          (i) the identification of:
             1574          (A) medically underserved and needy populations and geographic areas of the state;
             1575          (B) barriers in the current health care delivery and payment models to the promotion of
             1576      a comprehensive charity care system; and
             1577          (C) current resources available for medical care for medically under-served populations
             1578      and medically underserved geographic areas in the state; and
             1579          (ii) proposals to establish:
             1580          (A) wellness education;
             1581          (B) personal responsibility for health care; and
             1582          (C) a coordinated, statewide, private sector approach to universal, basic health care for
             1583      Utah's medically underserved populations and geographic areas, using private partners to affect
             1584      cost savings and market efficiencies; and
             1585          (h) the use of self-insured health plans by small employers and the regulation of small
             1586      employer stop-loss insurance in the state.
             1587          (2) A final report, including any proposed legislation, shall be presented to the
             1588      Business and Labor Interim Committee before November 30, 2013, and before November 30,
             1589      2014.
             1590          Section 43. Appropriation.
             1591          Under the terms and conditions of Title 63J, Chapter 1, Budgetary Procedures Act, for
             1592      the fiscal year beginning July 1, 2013, and ending June 30, 2014, the following sums of money
             1593      are appropriated from resources not otherwise appropriated, or reduced from amounts
             1594      previously appropriated, out of the funds or accounts indicated. These sums of money are in
             1595      addition to any amounts previously appropriated for fiscal year 2014.
             1596          To Legislature - Senate
             1597              From General Fund, One-time                    $30,000


             1598              Schedule of Programs:
             1599                  Administration                $30,000
             1600          To Legislature - House of Representatives                    $52,000
             1601              From General Fund, One-time
             1602              Schedule of Programs:
             1603                  Administration                $52,000
             1604          Section 44. Effective date.
             1605          (1) Except as provided in Subsection (2), if approved by two-thirds of all the members
             1606      elected to each house, this bill takes effect upon approval by the governor, or the day following
             1607      the constitutional time limit of Utah Constitution Article VII, Section 8, without the governor's
             1608      signature, or in the case of a veto, the date of veto override.
             1609          (2) The actions affecting Section 63I-2-231 (Effective 07/01/13) take effect on July 1,
             1610      2013.
             1611          Section 45. Repeal date.
             1612          The Health Reform Task Force is repealed December 30, 2015.


[Bill Documents][Bills Directory]