Chief Sponsor: LaVar Christensen

Senate Sponsor: Brian E. Shiozawa


8     General Description:
9          This bill amends the Insurance Code related to accident and health insurance.
10     Highlighted Provisions:
11          This bill:
12          ▸     amends the price and value comparison disclosure requirements for an insurer to
13     require an insurer to disclose to an enrollee information about infertility coverage.
14     Money Appropriated in this Bill:
15          None
16     Other Special Clauses:
17          This bill provides a special effective date.
18     Utah Code Sections Affected:
19     AMENDS:
20          31A-22-613.5, as last amended by Laws of Utah 2012, Chapter 279

22     Be it enacted by the Legislature of the state of Utah:
23          Section 1. Section 31A-22-613.5 is amended to read:
24          31A-22-613.5. Price and value comparisons of health insurance.
25          (1) (a) This section applies to all health benefit plans.
26          (b) Subsection (2) applies to:
27          (i) all health benefit plans; and
28          (ii) coverage offered to state employees under Subsection 49-20-202(1)(a).
29          (2) (a) The commissioner shall promote informed consumer behavior and responsible

30     health benefit plans by requiring an insurer issuing a health benefit plan to:
31          (i) provide to all enrollees, prior to enrollment in the health benefit plan written
32     disclosure of:
33          (A) restrictions or limitations on prescription drugs and biologics including:
34          (I) the use of a formulary;
35          (II) co-payments and deductibles for prescription drugs; and
36          (III) requirements for generic substitution;
37          (B) coverage limits under the plan; [and]
38          (C) any limitation or exclusion of coverage including:
39          (I) a limitation or exclusion for a secondary medical condition related to a limitation or
40     exclusion from coverage; and
41          (II) easily understood examples of a limitation or exclusion of coverage for a secondary
42     medical condition; and
43          (D) whether the insurer permits an exchange of the adoption indemnity benefit in
44     Section 31A-22-610.1 for infertility treatments, in accordance with Subsection
45     31A-22-610.1(1)(c)(ii) and the terms associated with the exchange of benefits; and
46          (ii) provide the commissioner with:
47          (A) the information described in Subsections 31A-22-635(5) through (7) in the
48     standardized electronic format required by Subsection 63M-1-2506(1); and
49          (B) information regarding insurer transparency in accordance with Subsection (4).
50          (b) An insurer shall provide the disclosure required by Subsection (2)(a)(i) in writing to
51     the commissioner:
52          (i) upon commencement of operations in the state; and
53          (ii) anytime the insurer amends any of the following described in Subsection (2)(a)(i):
54          (A) treatment policies;
55          (B) practice standards;
56          (C) restrictions;
57          (D) coverage limits of the insurer's health benefit plan or health insurance policy; or

58          (E) limitations or exclusions of coverage including a limitation or exclusion for a
59     secondary medical condition related to a limitation or exclusion of the insurer's health
60     insurance plan.
61          (c) An insurer shall provide the enrollee with notice of an increase in costs for
62     prescription drug coverage due to a change in benefit design under Subsection (2)(a)(i)(A):
63          (i) either:
64          (A) in writing; or
65          (B) on the insurer's website; and
66          (ii) at least 30 days prior to the date of the implementation of the increase in cost, or as
67     soon as reasonably possible.
68          (d) If under Subsection (2)(a)(i)(A) a formulary is used, the insurer shall make
69     available to prospective enrollees and maintain evidence of the fact of the disclosure of:
70          (i) the drugs included;
71          (ii) the patented drugs not included;
72          (iii) any conditions that exist as a precedent to coverage; and
73          (iv) any exclusion from coverage for secondary medical conditions that may result
74     from the use of an excluded drug.
75          (e) (i) The commissioner shall develop examples of limitations or exclusions of a
76     secondary medical condition that an insurer may use under Subsection (2)(a)(i)(C).
77          (ii) Examples of a limitation or exclusion of coverage provided under Subsection
78     (2)(a)(i)(C) or otherwise are for illustrative purposes only, and the failure of a particular fact
79     situation to fall within the description of an example does not, by itself, support a finding of
80     coverage.
81          (3) The commissioner:
82          (a) shall forward the information submitted by an insurer under Subsection (2)(a)(ii) to
83     the Health Insurance Exchange created under Section 63M-1-2504; and
84          (b) may request information from an insurer to verify the information submitted by the
85     insurer under this section.

86          (4) The commissioner shall:
87          (a) convene a group of insurers, a member representing the Public Employees' Benefit
88     and Insurance Program, consumers, and an organization that provides multipayer and
89     multiprovider quality assurance and data collection, to develop information for consumers to
90     compare health insurers and health benefit plans on the Health Insurance Exchange, which
91     shall include consideration of:
92          (i) the number and cost of an insurer's denied health claims;
93          (ii) the cost of denied claims that is transferred to providers;
94          (iii) the average out-of-pocket expenses incurred by participants in each health benefit
95     plan that is offered by an insurer in the Health Insurance Exchange;
96          (iv) the relative efficiency and quality of claims administration and other administrative
97     processes for each insurer offering plans in the Health Insurance Exchange; and
98          (v) consumer assessment of each insurer or health benefit plan;
99          (b) adopt an administrative rule that establishes:
100          (i) definition of terms;
101          (ii) the methodology for determining and comparing the insurer transparency
102     information;
103          (iii) the data, and format of the data, that an insurer shall submit to the commissioner in
104     order to facilitate the consumer comparison on the Health Insurance Exchange in accordance
105     with Section 63M-1-2506; and
106          (iv) the dates on which the insurer shall submit the data to the commissioner in order
107     for the commissioner to transmit the data to the Health Insurance Exchange in accordance with
108     Section 63M-1-2506; and
109          (c) implement the rules adopted under Subsection (4)(b) in a manner that protects the
110     business confidentiality of the insurer.
111          Section 2. Effective date.
112          This bill takes effect on January 1, 2016.