This document includes House Committee Amendments incorporated into the bill on Fri, Feb 17, 2017 at 2:57 PM by ryoung.
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7 LONG TITLE
8 General Description:
9 This bill amends and enacts code sections related to health care insurance and the health
10 care insurance market.
11 Highlighted Provisions:
12 This bill:
13 ▸ amends definitions for the Insurance Code;
14 ▸ effective January 1, 2018, merges the regulation of health insurance plans that are
15 offered by managed care organizations into a managed care organization chapter of
16 the Insurance Code;
17 ▸ amends the duties of the Office of Consumer Health Services within the Governor's
18 Office of Economic Development to require the office to wind down the small
19 employer health insurance exchange known as Avenue H Ĥ→ [
20 ▸ removes health plan transparency reporting requirements for plans offered on the
21 small employer health insurance exchange;
22 ▸ repeals the defined contribution arrangements and the individual and small
23 employer risk adjustment, which are part of the small employer health insurance
24 exchange, effective July 1, 2019;
25 ▸ reauthorizes the Health Reform Task Force for two years;
26 ▸ establishes the duties of the task force; and
27 ▸ makes technical amendments and conforming amendments.
28 Money Appropriated in this Bill:
29 This bill appropriates for fiscal year 2017:
30 ▸ to Legislature - Senate as a one-time appropriation:
31 • from the General Fund, One-time, $20,000;
32 ▸ to Legislature - House of Representatives as a one-time appropriation:
33 • from the General Fund, One-time, $34,000.
34 Other Special Clauses:
35 This bill provides a special effective date.
36 Utah Code Sections Affected:
37 AMENDS:
38 26-19-14, as last amended by Laws of Utah 1995, Chapter 102
39 31A-1-301, as last amended by Laws of Utah 2016, Chapter 138
40 31A-2-201.2, as last amended by Laws of Utah 2015, Chapter 283
41 31A-4-115, as last amended by Laws of Utah 2014, Chapters 290, 300, and 425
42 31A-8-101, as last amended by Laws of Utah 2002, Chapter 308
43 31A-8-103, as last amended by Laws of Utah 2010, Chapter 324
44 31A-21-106, as last amended by Laws of Utah 2003, Chapter 252
45 31A-22-610.1, as last amended by Laws of Utah 2014, Chapter 353
46 31A-22-610.5, as last amended by Laws of Utah 2011, Chapter 297
47 31A-22-613.5, as last amended by Laws of Utah 2015, Chapters 257 and 283
48 31A-22-618, as last amended by Laws of Utah 2015, Chapter 367
49 31A-22-618.5, as last amended by Laws of Utah 2014, Chapters 290 and 300
50 31A-22-627, as last amended by Laws of Utah 2016, Chapter 295
51 31A-22-628, as enacted by Laws of Utah 2000, Chapter 37
52 31A-22-635, as last amended by Laws of Utah 2015, Chapter 283
53 31A-22-642, as enacted by Laws of Utah 2014, Chapter 379
54 31A-23a-402, as last amended by Laws of Utah 2015, Chapters 244 and 283
55 31A-30-102, as last amended by Laws of Utah 2015, Chapter 283
56 31A-30-104, as last amended by Laws of Utah 2014, Chapters 290 and 300
57 31A-30-106.7, as last amended by Laws of Utah 2014, Chapters 290 and 300
58 31A-30-204, as last amended by Laws of Utah 2015, Chapter 283
59 31A-34-110, as last amended by Laws of Utah 2001, Chapter 108
60 49-20-407, as last amended by Laws of Utah 2012, Chapter 127
61 53-2a-1102, as last amended by Laws of Utah 2015, Chapter 408
62 58-16a-601, as last amended by Laws of Utah 2014, Chapter 305
63 63I-2-231, as last amended by Laws of Utah 2016, Chapter 138
64 63N-11-104, as renumbered and amended by Laws of Utah 2015, Chapter 283
65 ENACTS:
66 31A-45-101, Utah Code Annotated 1953
67 31A-45-102, Utah Code Annotated 1953
68 31A-45-103, Utah Code Annotated 1953
69 31A-45-201, Utah Code Annotated 1953
70 31A-45-301, Utah Code Annotated 1953
71 31A-45-302, Utah Code Annotated 1953
72 31A-45-402, Utah Code Annotated 1953
73 RENUMBERS AND AMENDS:
74 31A-22-618.6, (Renumbered from 31A-8-402.3, as last amended by Laws of Utah
75 2014, Chapters 290, 300, and 425)
76 31A-22-618.7, (Renumbered from 31A-8-402.5, as last amended by Laws of Utah
77 2003, Chapter 252)
78 31A-22-618.8, (Renumbered from 31A-8-402.7, as last amended by Laws of Utah
79 2005, Chapter 78)
80 31A-45-303, (Renumbered from 31A-22-617, as last amended by Laws of Utah 2014,
81 Chapters 290 and 300)
82 31A-45-304, (Renumbered from 31A-22-617.1, as enacted by Laws of Utah 2005, First
83 Special Session, Chapter 3)
84 31A-45-401, (Renumbered from 31A-8-502, as enacted by Laws of Utah 2004, Chapter
85 178)
86 31A-45-501, (Renumbered from 31A-8-501, as last amended by Laws of Utah 2012,
87 Chapter 369)
88 REPEALS:
89 31A-22-721, as last amended by Laws of Utah 2014, Chapters 290, 300, and 425
90 31A-30-107, as last amended by Laws of Utah 2014, Chapters 290, 300, and 425
91 31A-30-107.1, as last amended by Laws of Utah 2003, Chapter 252
92 31A-30-107.3, as last amended by Laws of Utah 2013, Chapter 341
93 31A-30-116, as last amended by Laws of Utah 2016, Chapter 138
94 63N-11-107, as renumbered and amended by Laws of Utah 2015, Chapter 283
95 Uncodified Material Affected:
96 ENACTS UNCODIFIED MATERIAL
97
98 Be it enacted by the Legislature of the state of Utah:
99 Section 1. Section 26-19-14 is amended to read:
100 26-19-14. Insurance policies not to deny or reduce benefits of persons eligible for
101 state medical assistance -- Exemptions.
102 (1) A policy of accident or sickness insurance [
103 may not contain any provision denying or reducing benefits because services are rendered to an
104 insured or dependent who is eligible for or receiving medical assistance from the state.
105 (2) [
106 deliver, issue for delivery, or renew any subscriber's contract which contains any provisions
107 denying or reducing benefits because services are rendered to a subscriber or dependent who is
108 eligible for or receiving medical assistance from the state.
109 (3) [
110 authorized to do business in this state and which provides or pays for any health care benefits
111 may not deny or reduce benefits because services are rendered to a beneficiary who is eligible
112 for or receiving medical assistance from the state.
113 (4) Notwithstanding Subsection (1), (2), or (3), the Utah State Public Employees
114 Health Program, administered by the Utah State Retirement Board, is not required to reimburse
115 any agency of state government for custodial care which the agency provides, through its staff
116 or facilities, to members of the Utah State Public Employees Health Program.
117 [
118 Section 2. Section 31A-1-301 is amended to read:
119 31A-1-301. Definitions.
120 As used in this title, unless otherwise specified:
121 (1) (a) "Accident and health insurance" means insurance to provide protection against
122 economic losses resulting from:
123 (i) a medical condition including:
124 (A) a medical care expense; or
125 (B) the risk of disability;
126 (ii) accident; or
127 (iii) sickness.
128 (b) "Accident and health insurance":
129 (i) includes a contract with disability contingencies including:
130 (A) an income replacement contract;
131 (B) a health care contract;
132 (C) an expense reimbursement contract;
133 (D) a credit accident and health contract;
134 (E) a continuing care contract; and
135 (F) a long-term care contract; and
136 (ii) may provide:
137 (A) hospital coverage;
138 (B) surgical coverage;
139 (C) medical coverage;
140 (D) loss of income coverage;
141 (E) prescription drug coverage;
142 (F) dental coverage; or
143 (G) vision coverage.
144 (c) "Accident and health insurance" does not include workers' compensation insurance.
145 (2) "Actuary" is as defined by the commissioner by rule, made in accordance with Title
146 63G, Chapter 3, Utah Administrative Rulemaking Act.
147 (3) "Administrator" means the same as that term is defined in Subsection [
148 (4) "Adult" means an individual who has attained the age of at least 18 years.
149 (5) "Affiliate" means a person who controls, is controlled by, or is under common
150 control with, another person. A corporation is an affiliate of another corporation, regardless of
151 ownership, if substantially the same group of individuals manage the corporations.
152 (6) "Agency" means:
153 (a) a person other than an individual, including a sole proprietorship by which an
154 individual does business under an assumed name; and
155 (b) an insurance organization licensed or required to be licensed under Section
156 31A-23a-301, 31A-25-207, or 31A-26-209.
157 (7) "Alien insurer" means an insurer domiciled outside the United States.
158 (8) "Amendment" means an endorsement to an insurance policy or certificate.
159 (9) "Annuity" means an agreement to make periodical payments for a period certain or
160 over the lifetime of one or more individuals if the making or continuance of all or some of the
161 series of the payments, or the amount of the payment, is dependent upon the continuance of
162 human life.
163 (10) "Application" means a document:
164 (a) (i) completed by an applicant to provide information about the risk to be insured;
165 and
166 (ii) that contains information that is used by the insurer to evaluate risk and decide
167 whether to:
168 (A) insure the risk under:
169 (I) the coverage as originally offered; or
170 (II) a modification of the coverage as originally offered; or
171 (B) decline to insure the risk; or
172 (b) used by the insurer to gather information from the applicant before issuance of an
173 annuity contract.
174 (11) "Articles" or "articles of incorporation" means:
175 (a) the original articles;
176 (b) a special law;
177 (c) a charter;
178 (d) an amendment;
179 (e) restated articles;
180 (f) articles of merger or consolidation;
181 (g) a trust instrument;
182 (h) another constitutive document for a trust or other entity that is not a corporation;
183 and
184 (i) an amendment to an item listed in Subsections (11)(a) through (h).
185 (12) "Bail bond insurance" means a guarantee that a person will attend court when
186 required, up to and including surrender of the person in execution of a sentence imposed under
187 Subsection 77-20-7(1), as a condition to the release of that person from confinement.
188 (13) "Binder" means the same as that term is defined in Section 31A-21-102.
189 (14) "Blanket insurance policy" means a group policy covering a defined class of
190 persons:
191 (a) without individual underwriting or application; and
192 (b) that is determined by definition without designating each person covered.
193 (15) "Board," "board of trustees," or "board of directors" means the group of persons
194 with responsibility over, or management of, a corporation, however designated.
195 (16) "Bona fide office" means a physical office in this state:
196 (a) that is open to the public;
197 (b) that is staffed during regular business hours on regular business days; and
198 (c) at which the public may appear in person to obtain services.
199 (17) "Business entity" means:
200 (a) a corporation;
201 (b) an association;
202 (c) a partnership;
203 (d) a limited liability company;
204 (e) a limited liability partnership; or
205 (f) another legal entity.
206 (18) "Business of insurance" means the same as that term is defined in Subsection
207 [
208 (19) "Business plan" means the information required to be supplied to the
209 commissioner under Subsections 31A-5-204(2)(i) and (j), including the information required
210 when these subsections apply by reference under:
211 (a) Section 31A-7-201;
212 (b) Section 31A-8-205; or
213 (c) Subsection 31A-9-205(2).
214 (20) (a) "Bylaws" means the rules adopted for the regulation or management of a
215 corporation's affairs, however designated.
216 (b) "Bylaws" includes comparable rules for a trust or other entity that is not a
217 corporation.
218 (21) "Captive insurance company" means:
219 (a) an insurer:
220 (i) owned by another organization; and
221 (ii) whose exclusive purpose is to insure risks of the parent organization and an
222 affiliated company; or
223 (b) in the case of a group or association, an insurer:
224 (i) owned by the insureds; and
225 (ii) whose exclusive purpose is to insure risks of:
226 (A) a member organization;
227 (B) a group member; or
228 (C) an affiliate of:
229 (I) a member organization; or
230 (II) a group member.
231 (22) "Casualty insurance" means liability insurance.
232 (23) "Certificate" means evidence of insurance given to:
233 (a) an insured under a group insurance policy; or
234 (b) a third party.
235 (24) "Certificate of authority" is included within the term "license."
236 (25) "Claim," unless the context otherwise requires, means a request or demand on an
237 insurer for payment of a benefit according to the terms of an insurance policy.
238 (26) "Claims-made coverage" means an insurance contract or provision limiting
239 coverage under a policy insuring against legal liability to claims that are first made against the
240 insured while the policy is in force.
241 (27) (a) "Commissioner" or "commissioner of insurance" means Utah's insurance
242 commissioner.
243 (b) When appropriate, the terms listed in Subsection (27)(a) apply to the equivalent
244 supervisory official of another jurisdiction.
245 (28) (a) "Continuing care insurance" means insurance that:
246 (i) provides board and lodging;
247 (ii) provides one or more of the following:
248 (A) a personal service;
249 (B) a nursing service;
250 (C) a medical service; or
251 (D) any other health-related service; and
252 (iii) provides the coverage described in this Subsection (28)(a) under an agreement
253 effective:
254 (A) for the life of the insured; or
255 (B) for a period in excess of one year.
256 (b) Insurance is continuing care insurance regardless of whether or not the board and
257 lodging are provided at the same location as a service described in Subsection (28)(a)(ii).
258 (29) (a) "Control," "controlling," "controlled," or "under common control" means the
259 direct or indirect possession of the power to direct or cause the direction of the management
260 and policies of a person. This control may be:
261 (i) by contract;
262 (ii) by common management;
263 (iii) through the ownership of voting securities; or
264 (iv) by a means other than those described in Subsections (29)(a)(i) through (iii).
265 (b) There is no presumption that an individual holding an official position with another
266 person controls that person solely by reason of the position.
267 (c) A person having a contract or arrangement giving control is considered to have
268 control despite the illegality or invalidity of the contract or arrangement.
269 (d) There is a rebuttable presumption of control in a person who directly or indirectly
270 owns, controls, holds with the power to vote, or holds proxies to vote 10% or more of the
271 voting securities of another person.
272 (30) "Controlled insurer" means a licensed insurer that is either directly or indirectly
273 controlled by a producer.
274 (31) "Controlling person" means a person that directly or indirectly has the power to
275 direct or cause to be directed, the management, control, or activities of a reinsurance
276 intermediary.
277 (32) "Controlling producer" means a producer who directly or indirectly controls an
278 insurer.
279 (33) (a) "Corporation" means an insurance corporation, except when referring to:
280 (i) a corporation doing business:
281 (A) as:
282 (I) an insurance producer;
283 (II) a surplus lines producer;
284 (III) a limited line producer;
285 (IV) a consultant;
286 (V) a managing general agent;
287 (VI) a reinsurance intermediary;
288 (VII) a third party administrator; or
289 (VIII) an adjuster; and
290 (B) under:
291 (I) Chapter 23a, Insurance Marketing - Licensing Producers, Consultants, and
292 Reinsurance Intermediaries;
293 (II) Chapter 25, Third Party Administrators; or
294 (III) Chapter 26, Insurance Adjusters; or
295 (ii) a noninsurer that is part of a holding company system under Chapter 16, Insurance
296 Holding Companies.
297 [
298 [
299 (34) (a) "Creditable coverage" has the same meaning as provided in federal regulations
300 adopted pursuant to the Health Insurance Portability and Accountability Act.
301 (b) "Creditable coverage" includes coverage that is offered through a public health plan
302 such as:
303 (i) the Primary Care Network Program under a Medicaid primary care network
304 demonstration waiver obtained subject to Section 26-18-3;
305 (ii) the Children's Health Insurance Program under Section 26-40-106; or
306 (iii) the Ryan White Program Comprehensive AIDS Resources Emergency Act, Pub. L.
307 No. 101-381, and Ryan White HIV/AIDS Treatment Modernization Act of 2006, Pub. L. No.
308 109-415.
309 (35) "Credit accident and health insurance" means insurance on a debtor to provide
310 indemnity for payments coming due on a specific loan or other credit transaction while the
311 debtor has a disability.
312 (36) (a) "Credit insurance" means insurance offered in connection with an extension of
313 credit that is limited to partially or wholly extinguishing that credit obligation.
314 (b) "Credit insurance" includes:
315 (i) credit accident and health insurance;
316 (ii) credit life insurance;
317 (iii) credit property insurance;
318 (iv) credit unemployment insurance;
319 (v) guaranteed automobile protection insurance;
320 (vi) involuntary unemployment insurance;
321 (vii) mortgage accident and health insurance;
322 (viii) mortgage guaranty insurance; and
323 (ix) mortgage life insurance.
324 (37) "Credit life insurance" means insurance on the life of a debtor in connection with
325 an extension of credit that pays a person if the debtor dies.
326 (38) "Creditor" means a person, including an insured, having a claim, whether:
327 (a) matured;
328 (b) unmatured;
329 (c) liquidated;
330 (d) unliquidated;
331 (e) secured;
332 (f) unsecured;
333 (g) absolute;
334 (h) fixed; or
335 (i) contingent.
336 (39) "Credit property insurance" means insurance:
337 (a) offered in connection with an extension of credit; and
338 (b) that protects the property until the debt is paid.
339 (40) "Credit unemployment insurance" means insurance:
340 (a) offered in connection with an extension of credit; and
341 (b) that provides indemnity if the debtor is unemployed for payments coming due on a:
342 (i) specific loan; or
343 (ii) credit transaction.
344 (41) (a) "Crop insurance" means insurance providing protection against damage to
345 crops from unfavorable weather conditions, fire or lightning, flood, hail, insect infestation,
346 disease, or other yield-reducing conditions or perils that is:
347 (i) provided by the private insurance market; or
348 (ii) subsidized by the Federal Crop Insurance Corporation.
349 (b) "Crop insurance" includes multiperil crop insurance.
350 (42) (a) "Customer service representative" means a person that provides an insurance
351 service and insurance product information:
352 (i) for the customer service representative's:
353 (A) producer;
354 (B) surplus lines producer; or
355 (C) consultant employer; and
356 (ii) to the customer service representative's employer's:
357 (A) customer;
358 (B) client; or
359 (C) organization.
360 (b) A customer service representative may only operate within the scope of authority of
361 the customer service representative's producer, surplus lines producer, or consultant employer.
362 (43) "Deadline" means a final date or time:
363 (a) imposed by:
364 (i) statute;
365 (ii) rule; or
366 (iii) order; and
367 (b) by which a required filing or payment must be received by the department.
368 (44) "Deemer clause" means a provision under this title under which upon the
369 occurrence of a condition precedent, the commissioner is considered to have taken a specific
370 action. If the statute so provides, a condition precedent may be the commissioner's failure to
371 take a specific action.
372 (45) "Degree of relationship" means the number of steps between two persons
373 determined by counting the generations separating one person from a common ancestor and
374 then counting the generations to the other person.
375 (46) "Department" means the Insurance Department.
376 (47) "Director" means a member of the board of directors of a corporation.
377 (48) "Disability" means a physiological or psychological condition that partially or
378 totally limits an individual's ability to:
379 (a) perform the duties of:
380 (i) that individual's occupation; or
381 (ii) an occupation for which the individual is reasonably suited by education, training,
382 or experience; or
383 (b) perform two or more of the following basic activities of daily living:
384 (i) eating;
385 (ii) toileting;
386 (iii) transferring;
387 (iv) bathing; or
388 (v) dressing.
389 (49) "Disability income insurance" means the same as that term is defined in
390 Subsection [
391 (50) "Domestic insurer" means an insurer organized under the laws of this state.
392 (51) "Domiciliary state" means the state in which an insurer:
393 (a) is incorporated;
394 (b) is organized; or
395 (c) in the case of an alien insurer, enters into the United States.
396 (52) (a) "Eligible employee" means:
397 (i) an employee who:
398 (A) works on a full-time basis; and
399 (B) has a normal work week of 30 or more hours; or
400 (ii) a person described in Subsection (52)(b).
401 (b) "Eligible employee" includes:
402 (i) an owner who:
403 (A) works on a full-time basis; and
404 (B) has a normal work week of 30 or more hours; and
405 (ii) if the individual is included under a health benefit plan of a small employer:
406 (A) a sole proprietor;
407 (B) a partner in a partnership; or
408 (C) an independent contractor.
409 (c) "Eligible employee" does not include, unless eligible under Subsection (52)(b):
410 (i) an individual who works on a temporary or substitute basis for a small employer;
411 (ii) an employer's spouse who does not meet the requirements of Subsection (52)(a)(i);
412 or
413 (iii) a dependent of an employer who does not meet the requirements of Subsection
414 (52)(a)(i).
415 (53) "Employee" means:
416 (a) an individual employed by an employer; and
417 (b) an owner who meets the requirements of Subsection (52)(b)(i).
418 (54) "Employee benefits" means one or more benefits or services provided to:
419 (a) an employee; or
420 (b) a dependent of an employee.
421 (55) (a) "Employee welfare fund" means a fund:
422 (i) established or maintained, whether directly or through a trustee, by:
423 (A) one or more employers;
424 (B) one or more labor organizations; or
425 (C) a combination of employers and labor organizations; and
426 (ii) that provides employee benefits paid or contracted to be paid, other than income
427 from investments of the fund:
428 (A) by or on behalf of an employer doing business in this state; or
429 (B) for the benefit of a person employed in this state.
430 (b) "Employee welfare fund" includes a plan funded or subsidized by a user fee or tax
431 revenues.
432 (56) "Endorsement" means a written agreement attached to a policy or certificate to
433 modify the policy or certificate coverage.
434 (57) (a) "Enrollee" means:
435 (i) a policyholder;
436 (ii) a certificate holder;
437 (iii) a subscriber; or
438 (iv) a covered individual:
439 (A) who has entered into a contract with an organization for health care; or
440 (B) on whose behalf an arrangement for health care has been made.
441 (b) "Enrollee" includes an insured.
442 [
443 (a) the first day of coverage; or
444 (b) if there is a waiting period, the first day of the waiting period.
445 [
446 involving one or more affiliates of an insurer that, if not remedied promptly, is likely to have a
447 material adverse effect upon the financial condition or liquidity of the insurer or its insurance
448 holding company system as a whole, including anything that would cause:
449 (a) the insurer's risk-based capital to fall into an action or control level as set forth in
450 Sections 31A-17-601 through 31A-17-613; or
451 (b) the insurer to be in hazardous financial condition set forth in Section 31A-27a-101.
452 [
453 (i) a transaction that effects the sale, transfer, encumbering, or leasing of real property,
454 when a person not a party to the transaction, and neither having nor acquiring an interest in the
455 title, performs, in accordance with the written instructions or terms of the written agreement
456 between the parties to the transaction, any of the following actions:
457 (A) the explanation, holding, or creation of a document; or
458 (B) the receipt, deposit, and disbursement of money;
459 (ii) a settlement or closing involving:
460 (A) a mobile home;
461 (B) a grazing right;
462 (C) a water right; or
463 (D) other personal property authorized by the commissioner.
464 (b) "Escrow" does not include:
465 (i) the following notarial acts performed by a notary within the state:
466 (A) an acknowledgment;
467 (B) a copy certification;
468 (C) jurat; and
469 (D) an oath or affirmation;
470 (ii) the receipt or delivery of a document; or
471 (iii) the receipt of money for delivery to the escrow agent.
472 [
473 requirements of Sections 31A-4-107, 31A-14-211, and 31A-23a-204, who is acting through an
474 individual title insurance producer licensed with an escrow subline of authority.
475 [
476 also excluded.
477 (b) The items listed in a list using the term "excludes" are representative examples for
478 use in interpretation of this title.
479 [
480 insurer does not provide insurance coverage, for whatever reason, for one of the following:
481 (a) a specific physical condition;
482 (b) a specific medical procedure;
483 (c) a specific disease or disorder; or
484 (d) a specific prescription drug or class of prescription drugs.
485 [
486 (a) written to provide a payment for an expense relating to hospital confinement
487 resulting from illness or injury; and
488 (b) written:
489 (i) as a daily limit for a specific number of days in a hospital; and
490 (ii) to have a one or two day waiting period following a hospitalization.
491 [
492 holding a position of public or private trust.
493 [
494 (i) submitted to the department as required by and in accordance with applicable
495 statute, rule, or filing order;
496 (ii) received by the department within the time period provided in applicable statute,
497 rule, or filing order; and
498 (iii) accompanied by the appropriate fee in accordance with:
499 (A) Section 31A-3-103; or
500 (B) rule.
501 (b) "Filed" does not include a filing that is rejected by the department because it is not
502 submitted in accordance with Subsection [
503 [
504 department including:
505 (a) a policy;
506 (b) a rate;
507 (c) a form;
508 (d) a document;
509 (e) a plan;
510 (f) a manual;
511 (g) an application;
512 (h) a report;
513 (i) a certificate;
514 (j) an endorsement;
515 (k) an actuarial certification;
516 (l) a licensee annual statement;
517 (m) a licensee renewal application;
518 (n) an advertisement;
519 (o) a binder; or
520 (p) an outline of coverage.
521 [
522 insurer agrees to pay a claim submitted to it by the insured for the insured's losses.
523 [
524 an alien insurer.
525 [
526 (i) a policy;
527 (ii) a certificate;
528 (iii) an application;
529 (iv) an outline of coverage; or
530 (v) an endorsement.
531 (b) "Form" does not include a document specially prepared for use in an individual
532 case.
533 [
534 through a mass marketing arrangement involving a defined class of persons related in some
535 way other than through the purchase of insurance.
536 [
537 (a) the general lines of insurance in Subsection [
538 (b) title insurance under one of the following sublines of authority:
539 (i) title examination, including authority to act as a title marketing representative;
540 (ii) escrow, including authority to act as a title marketing representative; and
541 (iii) title marketing representative only;
542 (c) surplus lines;
543 (d) workers' compensation; and
544 (e) another line of insurance that the commissioner considers necessary to recognize in
545 the public interest.
546 [
547 (a) accident and health;
548 (b) casualty;
549 (c) life;
550 (d) personal lines;
551 (e) property; and
552 (f) variable contracts, including variable life and annuity.
553 [
554 that the plan provides medical care:
555 (a) (i) to an employee; or
556 (ii) to a dependent of an employee; and
557 (b) (i) directly;
558 (ii) through insurance reimbursement; or
559 (iii) through another method.
560 [
561 that is issued:
562 (i) to a policyholder on behalf of the group; and
563 (ii) for the benefit of a member of the group who is selected under a procedure defined
564 in:
565 (A) the policy; or
566 (B) an agreement that is collateral to the policy.
567 (b) A group insurance policy may include a member of the policyholder's family or a
568 dependent.
569 [
570 connection with an extension of credit that pays the difference in amount between the
571 insurance settlement and the balance of the loan if the insured automobile is a total loss.
572 [
573
574 [
575 [
576 [
577 [
578 [
579 [
580 [
581 [
582 [
583 [
584 [
585 [
586 [
587 [
588 [
589 [
590 (77) (a) "Health benefit plan" means, except as provided in Subsection (77)(b), a
591 policy, contract, certificate, or agreement offered or issued by a health carrier to provide,
592 deliver, arrange for, pay for, or reimburse any of the costs of health care.
593 (b) "Health benefit plan" does not include:
594 (i) coverage only for accident or disability income insurance, or any combination
595 thereof;
596 (ii) coverage issued as a supplement to liability insurance;
597 (iii) liability insurance, including general liability insurance and automobile liability
598 insurance;
599 (iv) workers' compensation or similar insurance;
600 (v) automobile medical payment insurance;
601 (vi) credit-only insurance;
602 (vii) coverage for on-site medical clinics;
603 (viii) other similar insurance coverage, specified in federal regulations issued pursuant
604 to Pub. L. No. 104-191, under which benefits for health care services are secondary or
605 incidental to other insurance benefits;
606 (ix) the following benefits if they are provided under a separate policy, certificate, or
607 contract of insurance or are otherwise not an integral part of the plan:
608 (A) limited scope dental or vision benefits;
609 (B) benefits for long-term care, nursing home care, home health care,
610 community-based care, or any combination thereof; or
611 (C) other similar, limited benefits specified in federal regulations issued pursuant to
612 Pub. L. No. 104-191;
613 (x) the following benefits if the benefits are provided under a separate policy,
614 certificate, or contract of insurance, there is no coordination between the provision of benefits
615 and any exclusion of benefits under any health plan, and the benefits are paid with respect to an
616 event without regard to whether benefits are provided under any health plan:
617 (A) coverage only for specified disease or illness; or
618 (B) hospital indemnity or other fixed indemnity insurance; and
619 (xi) the following if offered as a separate policy, certificate, or contract of insurance:
620 (A) Medicare supplemental health insurance as defined under of the Social Security
621 Act, 42 U.S.C. Sec. 1395ss(g)(1);
622 (B) coverage supplemental to the coverage provided under Unites States Code, Title
623 10, Chapter 55, Civilian Health and Medical Program of the Uniformed Services
624 (CHAMPUS); or
625 (C) similar supplemental coverage provided to coverage under a group health insurance
626 plan.
627 [
628 treatment, mitigation, or prevention of a human ailment or impairment:
629 (a) a professional service;
630 (b) a personal service;
631 (c) a facility;
632 (d) equipment;
633 (e) a device;
634 (f) supplies; or
635 (g) medicine.
636 [
637 providing:
638 (i) a health care benefit; or
639 (ii) payment of an incurred health care expense.
640 (b) "Health care insurance" or "health insurance" does not include accident and health
641 insurance providing a benefit for:
642 (i) replacement of income;
643 (ii) short-term accident;
644 (iii) fixed indemnity;
645 (iv) credit accident and health;
646 (v) supplements to liability;
647 (vi) workers' compensation;
648 (vii) automobile medical payment;
649 (viii) no-fault automobile;
650 (ix) equivalent self-insurance; or
651 (x) a type of accident and health insurance coverage that is a part of or attached to
652 another type of policy.
653 (80) "Health care provider" means the same as that term is defined in Section
654 78B-3-403.
655 [
656 Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936, as
657 amended.
658 [
659 insurance written to provide payments to replace income lost from accident or sickness.
660 [
661 insured loss.
662 [
663 under Section 31A-26-201 who engages in insurance adjusting as a representative of an insurer.
664 [
665 Section 31A-15-104.
666 [
667 [
668 (a) property in transit on or over land;
669 (b) property in transit over water by means other than boat or ship;
670 (c) bailee liability;
671 (d) fixed transportation property such as bridges, electric transmission systems, radio
672 and television transmission towers and tunnels; and
673 (e) personal and commercial property floaters.
674 [
675 (a) an insurer is unable to pay its debts or meet its obligations as the debts and
676 obligations mature;
677 (b) an insurer's total adjusted capital is less than the insurer's mandatory control level
678 RBC under Subsection 31A-17-601(8)(c); or
679 (c) an insurer is determined to be hazardous under this title.
680 [
681 (i) an arrangement, contract, or plan for the transfer of a risk or risks from one or more
682 persons to one or more other persons; or
683 (ii) an arrangement, contract, or plan for the distribution of a risk or risks among a
684 group of persons that includes the person seeking to distribute that person's risk.
685 (b) "Insurance" includes:
686 (i) a risk distributing arrangement providing for compensation or replacement for
687 damages or loss through the provision of a service or a benefit in kind;
688 (ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a
689 business and not as merely incidental to a business transaction; and
690 (iii) a plan in which the risk does not rest upon the person who makes an arrangement,
691 but with a class of persons who have agreed to share the risk.
692 [
693 investigation, negotiation, or settlement of a claim under an insurance policy other than life
694 insurance or an annuity, on behalf of an insurer, policyholder, or a claimant under an insurance
695 policy.
696 [
697 (a) providing health care insurance by an organization that is or is required to be
698 licensed under this title;
699 (b) providing a benefit to an employee in the event of a contingency not within the
700 control of the employee, in which the employee is entitled to the benefit as a right, which
701 benefit may be provided either:
702 (i) by a single employer or by multiple employer groups; or
703 (ii) through one or more trusts, associations, or other entities;
704 (c) providing an annuity:
705 (i) including an annuity issued in return for a gift; and
706 (ii) except an annuity provided by a person specified in Subsections 31A-22-1305(2)
707 and (3);
708 (d) providing the characteristic services of a motor club as outlined in Subsection
709 [
710 (e) providing another person with insurance;
711 (f) making as insurer, guarantor, or surety, or proposing to make as insurer, guarantor,
712 or surety, a contract or policy of title insurance;
713 (g) transacting or proposing to transact any phase of title insurance, including:
714 (i) solicitation;
715 (ii) negotiation preliminary to execution;
716 (iii) execution of a contract of title insurance;
717 (iv) insuring; and
718 (v) transacting matters subsequent to the execution of the contract and arising out of
719 the contract, including reinsurance;
720 (h) transacting or proposing a life settlement; and
721 (i) doing, or proposing to do, any business in substance equivalent to Subsections
722 [
723 [
724 (a) advises another person about insurance needs and coverages;
725 (b) is compensated by the person advised on a basis not directly related to the insurance
726 placed; and
727 (c) except as provided in Section 31A-23a-501, is not compensated directly or
728 indirectly by an insurer or producer for advice given.
729 [
730 affiliated persons, at least one of whom is an insurer.
731 [
732 to be licensed under the laws of this state to sell, solicit, or negotiate insurance.
733 (b) (i) "Producer for the insurer" means a producer who is compensated directly or
734 indirectly by an insurer for selling, soliciting, or negotiating an insurance product of that
735 insurer.
736 (ii) "Producer for the insurer" may be referred to as an "agent."
737 (c) (i) "Producer for the insured" means a producer who:
738 (A) is compensated directly and only by an insurance customer or an insured; and
739 (B) receives no compensation directly or indirectly from an insurer for selling,
740 soliciting, or negotiating an insurance product of that insurer to an insurance customer or
741 insured.
742 (ii) "Producer for the insured" may be referred to as a "broker."
743 [
744 makes a promise in an insurance policy and includes:
745 (i) a policyholder;
746 (ii) a subscriber;
747 (iii) a member; and
748 (iv) a beneficiary.
749 (b) The definition in Subsection [
750 (i) applies only to this title; [
751 (ii) does not define the meaning of [
752 or certificate[
753 (iii) includes an enrollee.
754 [
755 including:
756 (i) a fraternal benefit society;
757 (ii) an issuer of a gift annuity other than an annuity specified in Subsections
758 31A-22-1305(2) and (3);
759 (iii) a motor club;
760 (iv) an employee welfare plan; [
761 (v) a person purporting or intending to do an insurance business as a principal on that
762 person's own account[
763 (vi) a health maintenance organization.
764 (b) "Insurer" does not include a governmental entity to the extent the governmental
765 entity is engaged in an activity described in Section 31A-12-107.
766 [
767 Subsection [
768 [
769 (a) offered in connection with an extension of credit; and
770 (b) that provides indemnity if the debtor is involuntarily unemployed for payments
771 coming due on a:
772 (i) specific loan; or
773 (ii) credit transaction.
774 [
775 employer who, with respect to a calendar year and to a plan year:
776 (i) employed an average of at least 51 employees on business days during the preceding
777 calendar year; and
778 (ii) employs at least one employee on the first day of the plan year.
779 (b) The number of employees shall be determined using the method set forth in 26
780 U.S.C. Sec. 4980H(c)(2).
781 [
782 individual whose enrollment is a late enrollment.
783 [
784 enrollment of an individual other than:
785 (a) on the earliest date on which coverage can become effective for the individual
786 under the terms of the plan; or
787 (b) through special enrollment.
788 [
789 31A-1-103, "legal expense insurance" means insurance written to indemnify or pay for a
790 specified legal expense.
791 (b) "Legal expense insurance" includes an arrangement that creates a reasonable
792 expectation of an enforceable right.
793 (c) "Legal expense insurance" does not include the provision of, or reimbursement for,
794 legal services incidental to other insurance coverage.
795 [
796 (i) for death, injury, or disability of a human being, or for damage to property,
797 exclusive of the coverages under:
798 (A) [
799 (B) [
800 (C) [
801 (ii) for a medical, hospital, surgical, and funeral benefit to a person other than the
802 insured who is injured, irrespective of legal liability of the insured, when issued with or
803 supplemental to insurance against legal liability for the death, injury, or disability of a human
804 being, exclusive of the coverages under:
805 (A) [
806 (B) [
807 (C) [
808 (iii) for loss or damage to property resulting from an accident to or explosion of a
809 boiler, pipe, pressure container, machinery, or apparatus;
810 (iv) for loss or damage to property caused by:
811 (A) the breakage or leakage of a sprinkler, water pipe, or water container; or
812 (B) water entering through a leak or opening in a building; or
813 (v) for other loss or damage properly the subject of insurance not within another kind
814 of insurance as defined in this chapter, if the insurance is not contrary to law or public policy.
815 (b) "Liability insurance" includes:
816 (i) vehicle liability insurance;
817 (ii) residential dwelling liability insurance; and
818 (iii) making inspection of, and issuing a certificate of inspection upon, an elevator,
819 boiler, machinery, or apparatus of any kind when done in connection with insurance on the
820 elevator, boiler, machinery, or apparatus.
821 [
822 in an activity that is part of or related to the insurance business.
823 (b) "License" includes a certificate of authority issued to an insurer.
824 [
825 (i) insurance on a human life; and
826 (ii) insurance pertaining to or connected with human life.
827 (b) The business of life insurance includes:
828 (i) granting a death benefit;
829 (ii) granting an annuity benefit;
830 (iii) granting an endowment benefit;
831 (iv) granting an additional benefit in the event of death by accident;
832 (v) granting an additional benefit to safeguard the policy against lapse; and
833 (vi) providing an optional method of settlement of proceeds.
834 [
835 (a) is issued for a specific product of insurance; and
836 (b) limits an individual or agency to transact only for that product or insurance.
837 [
838 insurance:
839 (a) credit life;
840 (b) credit accident and health;
841 (c) credit property;
842 (d) credit unemployment;
843 (e) involuntary unemployment;
844 (f) mortgage life;
845 (g) mortgage guaranty;
846 (h) mortgage accident and health;
847 (i) guaranteed automobile protection; and
848 (j) another form of insurance offered in connection with an extension of credit that:
849 (i) is limited to partially or wholly extinguishing the credit obligation; and
850 (ii) the commissioner determines by rule should be designated as a form of limited line
851 credit insurance.
852 [
853 solicits, or negotiates one or more forms of limited line credit insurance coverage to an
854 individual through a master, corporate, group, or individual policy.
855 [
856 (a) bail bond;
857 (b) limited line credit insurance;
858 (c) legal expense insurance;
859 (d) motor club insurance;
860 (e) car rental related insurance;
861 (f) travel insurance;
862 (g) crop insurance;
863 (h) self-service storage insurance;
864 (i) guaranteed asset protection waiver;
865 (j) portable electronics insurance; and
866 (k) another form of limited insurance that the commissioner determines by rule should
867 be designated a form of limited line insurance.
868 [
869 Subsection [
870 [
871 limited lines insurance.
872 [
873 advertised, marketed, offered, or designated to provide coverage:
874 (i) in a setting other than an acute care unit of a hospital;
875 (ii) for not less than 12 consecutive months for a covered person on the basis of:
876 (A) expenses incurred;
877 (B) indemnity;
878 (C) prepayment; or
879 (D) another method;
880 (iii) for one or more necessary or medically necessary services that are:
881 (A) diagnostic;
882 (B) preventative;
883 (C) therapeutic;
884 (D) rehabilitative;
885 (E) maintenance; or
886 (F) personal care; and
887 (iv) that may be issued by:
888 (A) an insurer;
889 (B) a fraternal benefit society;
890 (C) (I) a nonprofit health hospital; and
891 (II) a medical service corporation;
892 (D) a prepaid health plan;
893 (E) a health maintenance organization; or
894 (F) an entity similar to the entities described in Subsections [
895 through (E) to the extent that the entity is otherwise authorized to issue life or health care
896 insurance.
897 (b) "Long-term care insurance" includes:
898 (i) any of the following that provide directly or supplement long-term care insurance:
899 (A) a group or individual annuity or rider; or
900 (B) a life insurance policy or rider;
901 (ii) a policy or rider that provides for payment of benefits on the basis of:
902 (A) cognitive impairment; or
903 (B) functional capacity; or
904 (iii) a qualified long-term care insurance contract.
905 (c) "Long-term care insurance" does not include:
906 (i) a policy that is offered primarily to provide basic Medicare supplement coverage;
907 (ii) basic hospital expense coverage;
908 (iii) basic medical/surgical expense coverage;
909 (iv) hospital confinement indemnity coverage;
910 (v) major medical expense coverage;
911 (vi) income replacement or related asset-protection coverage;
912 (vii) accident only coverage;
913 (viii) coverage for a specified:
914 (A) disease; or
915 (B) accident;
916 (ix) limited benefit health coverage; or
917 (x) a life insurance policy that accelerates the death benefit to provide the option of a
918 lump sum payment:
919 (A) if the following are not conditioned on the receipt of long-term care:
920 (I) benefits; or
921 (II) eligibility; and
922 (B) the coverage is for one or more the following qualifying events:
923 (I) terminal illness;
924 (II) medical conditions requiring extraordinary medical intervention; or
925 (III) permanent institutional confinement.
926 (113) "Managed care organization" means a person:
927 (a) licensed as a health maintenance organization under Chapter 8, Health Maintenance
928 Organizations and Limited Health Plans; or
929 (b) (i) licensed under:
930 (A) Chapter 5, Domestic Stock and Mutual Insurance Corporations;
931 (B) Chapter 7, Nonprofit Health Service Insurance Corporations; or
932 (C) Chapter 14, Foreign Insurers; and
933 (ii) that requires an enrollee to use, or offers incentives, including financial incentives,
934 for an enrollee to use, network providers.
935 [
936 incident to the practice and provision of a medical service other than the practice and provision
937 of a dental service.
938 [
939 corporation.
940 [
941 must be constantly maintained by a stock insurance corporation as required by statute.
942 [
943 connection with an extension of credit that provides indemnity for payments coming due on a
944 mortgage while the debtor has a disability.
945 [
946 mortgagee or other creditor is indemnified against losses caused by the default of a debtor.
947 [
948 connection with an extension of credit that pays if the debtor dies.
949 [
950 (a) licensed under:
951 (i) Chapter 5, Domestic Stock and Mutual Insurance Corporations;
952 (ii) Chapter 11, Motor Clubs; or
953 (iii) Chapter 14, Foreign Insurers; and
954 (b) that promises for an advance consideration to provide for a stated period of time
955 one or more:
956 (i) legal services under Subsection 31A-11-102(1)(b);
957 (ii) bail services under Subsection 31A-11-102(1)(c); or
958 (iii) (A) trip reimbursement;
959 (B) towing services;
960 (C) emergency road services;
961 (D) stolen automobile services;
962 (E) a combination of the services listed in Subsections [
963 (D); or
964 (F) other services given in Subsections 31A-11-102(1)(b) through (f).
965 [
966 [
967 (a) that is issued by an insurer; and
968 (b) under which the financing and delivery of medical care is provided, in whole or in
969 part, through a defined set of providers under contract with the insurer, including the financing
970 and delivery of an item paid for as medical care.
971 (123) "Network provider" means a health care provider who has an agreement with a
972 managed care organization to provide health care services to an enrollee with an expectation of
973 receiving payment, other than coinsurance, copayments, or deductibles, directly from the
974 managed care organization.
975 [
976 not entitled to receive a dividend representing a share of the surplus of the insurer.
977 [
978 (a) ships or hulls of ships;
979 (b) goods, freight, cargoes, merchandise, effects, disbursements, profits, money,
980 securities, choses in action, evidences of debt, valuable papers, bottomry, respondentia
981 interests, or other cargoes in or awaiting transit over the oceans or inland waterways;
982 (c) earnings such as freight, passage money, commissions, or profits derived from
983 transporting goods or people upon or across the oceans or inland waterways; or
984 (d) a vessel owner or operator as a result of liability to employees, passengers, bailors,
985 owners of other vessels, owners of fixed objects, customs or other authorities, or other persons
986 in connection with maritime activity.
987 [
988 [
989 health insurance policy.
990 [
991 entitled to receive a dividend representing a share of the surplus of the insurer.
992 [
993 relating to the minimum percentage of eligible employees that must be enrolled in relation to
994 the total number of eligible employees of an employer reduced by each eligible employee who
995 voluntarily declines coverage under the plan because the employee:
996 (a) has other group health care insurance coverage; or
997 (b) receives:
998 (i) Medicare, under the Health Insurance for the Aged Act, Title XVIII of the Social
999 Security Amendments of 1965; or
1000 (ii) another government health benefit.
1001 [
1002 (a) an individual;
1003 (b) a partnership;
1004 (c) a corporation;
1005 (d) an incorporated or unincorporated association;
1006 (e) a joint stock company;
1007 (f) a trust;
1008 (g) a limited liability company;
1009 (h) a reciprocal;
1010 (i) a syndicate; or
1011 (j) another similar entity or combination of entities acting in concert.
1012 [
1013 coverage sold for primarily noncommercial purposes to:
1014 (a) an individual; or
1015 (b) a family.
1016 [
1017 U.S.C. Sec. 1002(16)(B).
1018 [
1019 (a) the year that is designated as the plan year in:
1020 (i) the plan document of a group health plan; or
1021 (ii) a summary plan description of a group health plan;
1022 (b) if the plan document or summary plan description does not designate a plan year or
1023 there is no plan document or summary plan description:
1024 (i) the year used to determine deductibles or limits;
1025 (ii) the policy year, if the plan does not impose deductibles or limits on a yearly basis;
1026 or
1027 (iii) the employer's taxable year if:
1028 (A) the plan does not impose deductibles or limits on a yearly basis; and
1029 (B) (I) the plan is not insured; or
1030 (II) the insurance policy is not renewed on an annual basis; or
1031 (c) in a case not described in Subsection [
1032 [
1033 application that:
1034 (i) purports to be an enforceable contract; and
1035 (ii) memorializes in writing some or all of the terms of an insurance contract.
1036 (b) "Policy" includes a service contract issued by:
1037 (i) a motor club under Chapter 11, Motor Clubs;
1038 (ii) a service contract provided under Chapter 6a, Service Contracts; and
1039 (iii) a corporation licensed under:
1040 (A) Chapter 7, Nonprofit Health Service Insurance Corporations; or
1041 (B) Chapter 8, Health Maintenance Organizations and Limited Health Plans.
1042 (c) "Policy" does not include:
1043 (i) a certificate under a group insurance contract; or
1044 (ii) a document that does not purport to have legal effect.
1045 [
1046 contract by ownership, premium payment, or otherwise.
1047 [
1048 nonguaranteed elements of a policy of life insurance over a period of years.
1049 [
1050 insurance policy.
1051 [
1052 No. 111-148 and the Health Care Education Reconciliation Act of 2010, Pub. L. No. 111-152,
1053 and related federal regulations and guidance.
1054 [
1055 (a) means a condition that was present before the effective date of coverage, whether or
1056 not medical advice, diagnosis, care, or treatment was recommended or received before that day;
1057 and
1058 (b) does not include a condition indicated by genetic information unless an actual
1059 diagnosis of the condition by a physician has been made.
1060 [
1061 (b) "Premium" includes, however designated:
1062 (i) an assessment;
1063 (ii) a membership fee;
1064 (iii) a required contribution; or
1065 (iv) monetary consideration.
1066 (c) (i) "Premium" does not include consideration paid to a third party administrator for
1067 the third party administrator's services.
1068 (ii) "Premium" includes an amount paid by a third party administrator to an insurer for
1069 insurance on the risks administered by the third party administrator.
1070 [
1071 Subsection 31A-5-203(3).
1072 [
1073 [
1074 incident to the practice of a profession and provision of a professional service.
1075 [
1076 insurance" means insurance against loss or damage to real or personal property of every kind
1077 and any interest in that property:
1078 (i) from all hazards or causes; and
1079 (ii) against loss consequential upon the loss or damage including vehicle
1080 comprehensive and vehicle physical damage coverages.
1081 (b) "Property insurance" does not include:
1082 (i) inland marine insurance; and
1083 (ii) ocean marine insurance.
1084 [
1085 long-term care insurance contract" means:
1086 (a) an individual or group insurance contract that meets the requirements of Section
1087 7702B(b), Internal Revenue Code; or
1088 (b) the portion of a life insurance contract that provides long-term care insurance:
1089 (i) (A) by rider; or
1090 (B) as a part of the contract; and
1091 (ii) that satisfies the requirements of Sections 7702B(b) and (e), Internal Revenue
1092 Code.
1093 [
1094 (a) is:
1095 (i) organized under the laws of the United States or any state; or
1096 (ii) in the case of a United States office of a foreign banking organization, licensed
1097 under the laws of the United States or any state;
1098 (b) is regulated, supervised, and examined by a United States federal or state authority
1099 having regulatory authority over a bank or trust company; and
1100 (c) meets the standards of financial condition and standing that are considered
1101 necessary and appropriate to regulate the quality of a financial institution whose letters of credit
1102 will be acceptable to the commissioner as determined by:
1103 (i) the commissioner by rule; or
1104 (ii) the Securities Valuation Office of the National Association of Insurance
1105 Commissioners.
1106 [
1107 (i) the cost of a given unit of insurance; or
1108 (ii) for property or casualty insurance, that cost of insurance per exposure unit either
1109 expressed as:
1110 (A) a single number; or
1111 (B) a pure premium rate, adjusted before the application of individual risk variations
1112 based on loss or expense considerations to account for the treatment of:
1113 (I) expenses;
1114 (II) profit; and
1115 (III) individual insurer variation in loss experience.
1116 (b) "Rate" does not include a minimum premium.
1117 [
1118 organization" means a person who assists an insurer in rate making or filing by:
1119 (i) collecting, compiling, and furnishing loss or expense statistics;
1120 (ii) recommending, making, or filing rates or supplementary rate information; or
1121 (iii) advising about rate questions, except as an attorney giving legal advice.
1122 (b) "Rate service organization" does not mean:
1123 (i) an employee of an insurer;
1124 (ii) a single insurer or group of insurers under common control;
1125 (iii) a joint underwriting group; or
1126 (iv) an individual serving as an actuarial or legal consultant.
1127 [
1128 renewal policy premiums:
1129 (a) a manual of rates;
1130 (b) a classification;
1131 (c) a rate-related underwriting rule; and
1132 (d) a rating formula that describes steps, policies, and procedures for determining
1133 initial and renewal policy premiums.
1134 [
1135 pay, allow, or give, directly or indirectly:
1136 (i) a refund of premium or portion of premium;
1137 (ii) a refund of commission or portion of commission;
1138 (iii) a refund of all or a portion of a consultant fee; or
1139 (iv) providing services or other benefits not specified in an insurance or annuity
1140 contract.
1141 (b) "Rebate" does not include:
1142 (i) a refund due to termination or changes in coverage;
1143 (ii) a refund due to overcharges made in error by the licensee; or
1144 (iii) savings or wellness benefits as provided in the contract by the licensee.
1145 [
1146 (a) the date delivered to and stamped received by the department, if delivered in
1147 person;
1148 (b) the post mark date, if delivered by mail;
1149 (c) the delivery service's post mark or pickup date, if delivered by a delivery service;
1150 (d) the received date recorded on an item delivered, if delivered by:
1151 (i) facsimile;
1152 (ii) email; or
1153 (iii) another electronic method; or
1154 (e) a date specified in:
1155 (i) a statute;
1156 (ii) a rule; or
1157 (iii) an order.
1158 [
1159 association of persons:
1160 (a) operating through an attorney-in-fact common to all of the persons; and
1161 (b) exchanging insurance contracts with one another that provide insurance coverage
1162 on each other.
1163 [
1164 consideration, transfers any portion of the risk it has assumed to another insurer. In referring to
1165 reinsurance transactions, this title sometimes refers to:
1166 (a) the insurer transferring the risk as the "ceding insurer"; and
1167 (b) the insurer assuming the risk as the:
1168 (i) "assuming insurer"; or
1169 (ii) "assuming reinsurer."
1170 [
1171 authority to assume reinsurance.
1172 [
1173 liability resulting from or incident to the ownership, maintenance, or use of a residential
1174 dwelling that is a detached single family residence or multifamily residence up to four units.
1175 [
1176 assumed under a reinsurance contract.
1177 (b) A reinsurer "retrocedes" when the reinsurer reinsures with another insurer part of a
1178 liability assumed under a reinsurance contract.
1179 [
1180 (a) an insurance policy; or
1181 (b) an insurance certificate.
1182 [
1183 exclusion from coverage in accident and health insurance.
1184 [
1185 (i) note;
1186 (ii) stock;
1187 (iii) bond;
1188 (iv) debenture;
1189 (v) evidence of indebtedness;
1190 (vi) certificate of interest or participation in a profit-sharing agreement;
1191 (vii) collateral-trust certificate;
1192 (viii) preorganization certificate or subscription;
1193 (ix) transferable share;
1194 (x) investment contract;
1195 (xi) voting trust certificate;
1196 (xii) certificate of deposit for a security;
1197 (xiii) certificate of interest of participation in an oil, gas, or mining title or lease or in
1198 payments out of production under such a title or lease;
1199 (xiv) commodity contract or commodity option;
1200 (xv) certificate of interest or participation in, temporary or interim certificate for,
1201 receipt for, guarantee of, or warrant or right to subscribe to or purchase any of the items listed
1202 in Subsections [
1203 (xvi) another interest or instrument commonly known as a security.
1204 (b) "Security" does not include:
1205 (i) any of the following under which an insurance company promises to pay money in a
1206 specific lump sum or periodically for life or some other specified period:
1207 (A) insurance;
1208 (B) an endowment policy; or
1209 (C) an annuity contract; or
1210 (ii) a burial certificate or burial contract.
1211 [
1212 person, including:
1213 (a) common stock;
1214 (b) preferred stock;
1215 (c) debt obligations; and
1216 (d) any other security convertible into or evidencing the right of any of the items listed
1217 in this Subsection [
1218 [
1219 provides for spreading its own risks by a systematic plan.
1220 (b) Except as provided in this Subsection [
1221 include an arrangement under which a number of persons spread their risks among themselves.
1222 (c) "Self-insurance" includes:
1223 (i) an arrangement by which a governmental entity undertakes to indemnify an
1224 employee for liability arising out of the employee's employment; and
1225 (ii) an arrangement by which a person with a managed program of self-insurance and
1226 risk management undertakes to indemnify its affiliates, subsidiaries, directors, officers, or
1227 employees for liability or risk that is related to the relationship or employment.
1228 (d) "Self-insurance" does not include an arrangement with an independent contractor.
1229 [
1230 (a) by any means;
1231 (b) for money or its equivalent; and
1232 (c) on behalf of an insurance company.
1233 [
1234 advertised, marketed, offered, or designed to provide coverage that is similar to long-term care
1235 insurance, but that provides coverage for less than 12 consecutive months for each covered
1236 person.
1237 [
1238 during each of which an individual does not have creditable coverage.
1239 [
1240 with respect to a calendar year and to a plan year, an employer who:
1241 (i) employed at least one employee but not more than 50 employees on business days
1242 during the preceding calendar year; and
1243 (ii) employs at least one employee on the first day of the plan year.
1244 (b) The number of employees shall:
1245 (i) be determined using the method set forth in 26 U.S.C. Sec. 4980H(c)(2); and
1246 (ii) include an owner described in Subsection (52)(b)(i).
1247 (c) "Small employer" does not include a sole proprietor that does not employ at least
1248 one employee.
1249 [
1250 the same meaning as provided in federal regulations adopted pursuant to the Health Insurance
1251 Portability and Accountability Act.
1252 [
1253 either directly or indirectly through one or more affiliates or intermediaries.
1254 (b) "Wholly owned subsidiary" of a person is a subsidiary of which all of the voting
1255 shares are owned by that person either alone or with its affiliates, except for the minimum
1256 number of shares the law of the subsidiary's domicile requires to be owned by directors or
1257 others.
1258 [
1259 (a) a guarantee against loss or damage resulting from the failure of a principal to pay or
1260 perform the principal's obligations to a creditor or other obligee;
1261 (b) bail bond insurance; and
1262 (c) fidelity insurance.
1263 [
1264 and liabilities.
1265 (b) (i) "Permanent surplus" means the surplus of an insurer or organization that is
1266 designated by the insurer or organization as permanent.
1267 (ii) Sections 31A-5-211, 31A-7-201, 31A-8-209, 31A-9-209, and 31A-14-205 require
1268 that insurers or organizations doing business in this state maintain specified minimum levels of
1269 permanent surplus.
1270 (iii) Except for assessable mutuals, the minimum permanent surplus requirement is the
1271 same as the minimum required capital requirement that applies to stock insurers.
1272 (c) "Excess surplus" means:
1273 (i) for a life insurer, accident and health insurer, health organization, or property and
1274 casualty insurer as defined in Section 31A-17-601, the lesser of:
1275 (A) that amount of an insurer's or health organization's total adjusted capital that
1276 exceeds the product of:
1277 (I) 2.5; and
1278 (II) the sum of the insurer's or health organization's minimum capital or permanent
1279 surplus required under Section 31A-5-211, 31A-9-209, or 31A-14-205; or
1280 (B) that amount of an insurer's or health organization's total adjusted capital that
1281 exceeds the product of:
1282 (I) 3.0; and
1283 (II) the authorized control level RBC as defined in Subsection 31A-17-601(8)(a); and
1284 (ii) for a monoline mortgage guaranty insurer, financial guaranty insurer, or title insurer
1285 that amount of an insurer's paid-in-capital and surplus that exceeds the product of:
1286 (A) 1.5; and
1287 (B) the insurer's total adjusted capital required by Subsection 31A-17-609(1).
1288 [
1289 collects charges or premiums from, or who, for consideration, adjusts or settles claims of
1290 residents of the state in connection with insurance coverage, annuities, or service insurance
1291 coverage, except:
1292 (a) a union on behalf of its members;
1293 (b) a person administering a:
1294 (i) pension plan subject to the federal Employee Retirement Income Security Act of
1295 1974;
1296 (ii) governmental plan as defined in Section 414(d), Internal Revenue Code; or
1297 (iii) nonelecting church plan as described in Section 410(d), Internal Revenue Code;
1298 (c) an employer on behalf of the employer's employees or the employees of one or
1299 more of the subsidiary or affiliated corporations of the employer;
1300 (d) an insurer licensed under the following, but only for a line of insurance for which
1301 the insurer holds a license in this state:
1302 (i) Chapter 5, Domestic Stock and Mutual Insurance Corporations;
1303 (ii) Chapter 7, Nonprofit Health Service Insurance Corporations;
1304 (iii) Chapter 8, Health Maintenance Organizations and Limited Health Plans;
1305 (iv) Chapter 9, Insurance Fraternals; or
1306 (v) Chapter 14, Foreign Insurers;
1307 (e) a person:
1308 (i) licensed or exempt from licensing under:
1309 (A) Chapter 23a, Insurance Marketing - Licensing Producers, Consultants, and
1310 Reinsurance Intermediaries; or
1311 (B) Chapter 26, Insurance Adjusters; and
1312 (ii) whose activities are limited to those authorized under the license the person holds
1313 or for which the person is exempt; or
1314 (f) an institution, bank, or financial institution:
1315 (i) that is:
1316 (A) an institution whose deposits and accounts are to any extent insured by a federal
1317 deposit insurance agency, including the Federal Deposit Insurance Corporation or National
1318 Credit Union Administration; or
1319 (B) a bank or other financial institution that is subject to supervision or examination by
1320 a federal or state banking authority; and
1321 (ii) that does not adjust claims without a third party administrator license.
1322 [
1323 owner of real or personal property or the holder of liens or encumbrances on that property, or
1324 others interested in the property against loss or damage suffered by reason of liens or
1325 encumbrances upon, defects in, or the unmarketability of the title to the property, or invalidity
1326 or unenforceability of any liens or encumbrances on the property.
1327 [
1328 organization's statutory capital and surplus as determined in accordance with:
1329 (a) the statutory accounting applicable to the annual financial statements required to be
1330 filed under Section 31A-4-113; and
1331 (b) another item provided by the RBC instructions, as RBC instructions is defined in
1332 Section 31A-17-601.
1333 [
1334 a corporation.
1335 (b) "Trustee," when used in reference to an employee welfare fund, means an
1336 individual, firm, association, organization, joint stock company, or corporation, whether acting
1337 individually or jointly and whether designated by that name or any other, that is charged with
1338 or has the overall management of an employee welfare fund.
1339 [
1340 insurer" means an insurer:
1341 (i) not holding a valid certificate of authority to do an insurance business in this state;
1342 or
1343 (ii) transacting business not authorized by a valid certificate.
1344 (b) "Admitted insurer" or "authorized insurer" means an insurer:
1345 (i) holding a valid certificate of authority to do an insurance business in this state; and
1346 (ii) transacting business as authorized by a valid certificate.
1347 [
1348 insurer.
1349 [
1350 from or incident to ownership, maintenance, or use of a land vehicle or aircraft, exclusive of a
1351 vehicle comprehensive or vehicle physical damage coverage under Subsection [
1352 [
1353 security convertible into a security with a voting right associated with the security.
1354 [
1355 pass before coverage for an individual, who is otherwise eligible to enroll under the terms of
1356 the health benefit plan, can become effective.
1357 [
1358 (a) insurance for indemnification of an employer against liability for compensation
1359 based on:
1360 (i) a compensable accidental injury; and
1361 (ii) occupational disease disability;
1362 (b) employer's liability insurance incidental to workers' compensation insurance and
1363 written in connection with workers' compensation insurance; and
1364 (c) insurance assuring to a person entitled to workers' compensation benefits the
1365 compensation provided by law.
1366 Section 3. Section 31A-2-201.2 is amended to read:
1367 31A-2-201.2. Evaluation of health insurance market.
1368 (1) Each year the commissioner shall:
1369 (a) conduct an evaluation of the state's health insurance market;
1370 (b) report the findings of the evaluation to the Health and Human Services Interim
1371 Committee before October 1 of each year; and
1372 (c) publish the findings of the evaluation on the department website.
1373 (2) The evaluation required by this section shall:
1374 (a) analyze the effectiveness of the insurance regulations and statutes in promoting a
1375 healthy, competitive health insurance market that meets the needs of the state, and includes an
1376 analysis of:
1377 (i) the availability and marketing of individual and group products;
1378 (ii) rate changes;
1379 (iii) coverage and demographic changes;
1380 (iv) benefit trends;
1381 (v) market share changes; and
1382 (vi) accessibility;
1383 (b) assess complaint ratios and trends within the health insurance market, which
1384 assessment shall include complaint data from the Office of Consumer Health Assistance within
1385 the department;
1386 (c) contain recommendations for action to improve the overall effectiveness of the
1387 health insurance market, administrative rules, and statutes; and
1388 (d) include claims loss ratio data for each health insurance company doing business in
1389 the state.
1390 [
1391
1392 [
1393
1394 [
1395
1396 [
1397
1398 [
1399 commissioner may seek the input of insurers, employers, insured persons, providers, and others
1400 with an interest in the health insurance market.
1401 [
1402 collecting the data required by this section, taking into account the business confidentiality of
1403 the insurers.
1404 [
1405 by the commissioner as protected records under Title 63G, Chapter 2, Government Records
1406 Access and Management Act.
1407 Section 4. Section 31A-4-115 is amended to read:
1408 31A-4-115. Plan of orderly withdrawal.
1409 (1) (a) When an insurer intends to withdraw from writing a line of insurance in this
1410 state or to reduce its total annual premium volume by 75% or more, the insurer shall file with
1411 the commissioner a plan of orderly withdrawal.
1412 (b) For purposes of this section, a discontinuance of a health benefit plan [
1413
1414 [
1415 31A-22-618.6(5) or 31A-22-618.7(3).
1416 (2) An insurer's plan of orderly withdrawal shall:
1417 (a) indicate the date the insurer intends to begin and complete its withdrawal plan; and
1418 (b) include provisions for:
1419 (i) meeting the insurer's contractual obligations;
1420 (ii) providing services to its Utah policyholders and claimants;
1421 (iii) meeting applicable statutory obligations; and
1422 (iv) the payment of a withdrawal fee of $50,000 to the department if the insurer's line
1423 of business is not assumed or placed with another insurer approved by the commissioner.
1424 (3) The commissioner shall approve a plan of orderly withdrawal if the plan of orderly
1425 withdrawal adequately demonstrates that the insurer will:
1426 (a) protect the interests of the people of the state;
1427 (b) meet the insurer's contractual obligations;
1428 (c) provide service to the insurer's Utah policyholders and claimants; and
1429 (d) meet applicable statutory obligations.
1430 (4) Section 31A-2-302 governs the commissioner's approval or disapproval of a plan for
1431 orderly withdrawal.
1432 (5) The commissioner may require an insurer to increase the deposit maintained in
1433 accordance with Section 31A-4-105 or Section 31A-4-105.5 and place the deposit in trust in
1434 the name of the commissioner upon finding, after an adjudicative proceeding that:
1435 (a) there is reasonable cause to conclude that the interests of the people of the state are
1436 best served by such action; and
1437 (b) the insurer:
1438 (i) has filed a plan of orderly withdrawal; or
1439 (ii) intends to:
1440 (A) withdraw from writing a line of insurance in this state; or
1441 (B) reduce the insurer's total annual premium volume by 75% or more.
1442 (6) An insurer is subject to the civil penalties under Section 31A-2-308, if the insurer:
1443 (a) withdraws from writing insurance in this state without receiving the commissioner's
1444 approval of a plan of orderly withdrawal; or
1445 (b) reduces its total annual premium volume by 75% or more in any year without
1446 receiving the commissioner's approval of a plan of orderly withdrawal.
1447 (7) An insurer that withdraws from writing all lines of insurance in this state may not
1448 resume writing insurance in this state for five years unless the commissioner finds that the
1449 prohibition should be waived because the waiver is:
1450 (a) in the public interest to promote competition; or
1451 (b) to resolve inequity in the marketplace.
1452 (8) The commissioner shall adopt rules necessary to implement this section.
1453 Section 5. Section 31A-8-101 is amended to read:
1454 31A-8-101. Definitions.
1455 For purposes of this chapter:
1456 (1) "Basic health care services" means:
1457 (a) emergency care;
1458 (b) inpatient hospital and physician care;
1459 (c) outpatient medical services; and
1460 (d) out-of-area coverage.
1461 [
1462 [
1463 [
1464
1465 [
1466 [
1467 [
1468 [
1469 [
1470 (a) other than:
1471 (i) an insurer licensed under Chapter 7, Nonprofit Health Service Insurance
1472 Corporations; or
1473 (ii) an individual who contracts to render professional or personal services that the
1474 individual directly performs; and
1475 (b) that:
1476 (i) furnishes at a minimum, either directly or through arrangements with others, basic
1477 health care services to an enrollee in return for prepaid periodic payments agreed to in amount
1478 prior to the time during which the health care may be furnished; and
1479 (ii) is obligated to the enrollee to arrange for or to directly provide available and
1480 accessible health care.
1481 [
1482 (3)(b), [
1483 arrangements with others[
1484 [
1485 [
1486 [
1487 [
1488 [
1489 [
1490 [
1491 [
1492 [
1493 [
1494 [
1495 [
1496 [
1497 [
1498 [
1499 [
1500 during which the services may be furnished; and
1501 [
1502 provide the available and accessible services described in this Subsection [
1503 (b) "Limited health plan" does not include:
1504 (i) a health maintenance organization;
1505 (ii) an insurer licensed under Chapter 7, Nonprofit Health Service Insurance
1506 Corporations; or
1507 (iii) an individual who contracts to render professional or personal services that the
1508 individual performs.
1509 [
1510 no part of the income of which is distributable to its members, trustees, or officers, or a
1511 nonprofit cooperative association, except in a manner allowed under Section 31A-8-406.
1512 (b) "Nonprofit health maintenance organization" and "nonprofit limited health plan"
1513 are used when referring specifically to one of the types of organizations with "nonprofit" status.
1514 [
1515 plan, unless used in the context of:
1516 [
1517 [
1518 31A-8-206; or
1519 [
1520
1521
1522
1523 [
1524 [
1525 [
1526 [
1527 covered by an organization for which an enrollee is liable in the event of the organization's
1528 insolvency.
1529 [
1530 that are projected to involve fewer than 10% of the organization's enrollees' encounters with
1531 providers, measured on an annual basis over the organization's entire enrollment.
1532 Section 6. Section 31A-8-103 is amended to read:
1533 31A-8-103. Applicability to other provisions of law.
1534 (1) (a) Except for exemptions specifically granted under this title, an organization is
1535 subject to regulation under all of the provisions of this title.
1536 (b) Notwithstanding any provision of this title, an organization licensed under this
1537 chapter:
1538 (i) is wholly exempt from:
1539 (A) Chapter 7, Nonprofit Health Service Insurance Corporations;
1540 (B) Chapter 9, Insurance Fraternals;
1541 (C) Chapter 10, Annuities;
1542 (D) Chapter 11, Motor Clubs;
1543 (E) Chapter 12, State Risk Management Fund;
1544 [
1545 [
1546 [
1547 Association Act; and
1548 (ii) is not subject to:
1549 (A) Chapter 3, Department Funding, Fees, and Taxes, except for Part 1, Funding the
1550 Insurance Department;
1551 (B) Section 31A-4-107;
1552 (C) Chapter 5, Domestic Stock and Mutual Insurance Corporations, except for
1553 provisions specifically made applicable by this chapter;
1554 (D) Chapter 14, Foreign Insurers, except for provisions specifically made applicable by
1555 this chapter;
1556 (E) Chapter 17, Determination of Financial Condition, except:
1557 (I) Part 2, Qualified Assets, and Part 6, Risk-Based Capital; or
1558 (II) as made applicable by the commissioner by rule consistent with this chapter;
1559 (F) Chapter 18, Investments, except as made applicable by the commissioner by rule
1560 consistent with this chapter; and
1561 (G) Chapter 22, Contracts in Specific Lines, except for Part 6, Accident and Health
1562 Insurance, Part 7, Group Accident and Health Insurance, and Part 12, Reinsurance.
1563 (2) The commissioner may by rule waive other specific provisions of this title that the
1564 commissioner considers inapplicable to [
1565 plans, upon a finding that the waiver will not endanger the interests of:
1566 (a) enrollees;
1567 (b) investors; or
1568 (c) the public.
1569 (3) Title 16, Chapter 6a, Utah Revised Nonprofit Corporation Act, and Title 16,
1570 Chapter 10a, Utah Revised Business Corporation Act, do not apply to an organization except as
1571 specifically made applicable by:
1572 (a) this chapter;
1573 (b) a provision referenced under this chapter; or
1574 (c) a rule adopted by the commissioner to deal with corporate law issues of health
1575 maintenance organizations that are not settled under this chapter.
1576 (4) (a) Whenever in this chapter, Chapter 5, Domestic Stock and Mutual Insurance
1577 Corporations, or Chapter 14, Foreign Insurers, is made applicable to an organization, the
1578 application is:
1579 (i) of those provisions that apply to a mutual corporation if the organization is
1580 nonprofit; and
1581 (ii) of those that apply to a stock corporation if the organization is for profit.
1582 (b) When Chapter 5, Domestic Stock and Mutual Insurance Corporations, or Chapter
1583 14, Foreign Insurers, is made applicable to an organization under this chapter, "mutual" means
1584 nonprofit organization.
1585 (5) Solicitation of enrollees by an organization is not a violation of any provision of
1586 law relating to solicitation or advertising by health professionals if that solicitation is made in
1587 accordance with:
1588 (a) this chapter; and
1589 (b) Chapter 23a, Insurance Marketing - Licensing Producers, Consultants, and
1590 Reinsurance Intermediaries.
1591 (6) This title does not prohibit any health maintenance organization from meeting the
1592 requirements of any federal law that enables the health maintenance organization to:
1593 (a) receive federal funds; or
1594 (b) obtain or maintain federal qualification status.
1595 (7) Except as provided in [
1596 Organizations, an organization is exempt from statutes in this title or department rules that
1597 restrict or limit the organization's freedom of choice in contracting with or selecting health care
1598 providers, including Section 31A-22-618.
1599 (8) An organization is exempt from the assessment or payment of premium taxes
1600 imposed by Sections 59-9-101 through 59-9-104.
1601 Section 7. Section 31A-21-106 is amended to read:
1602 31A-21-106. Incorporation by reference.
1603 (1) (a) Except as provided in Subsection (1)(b), an insurance policy may not contain
1604 any agreement or incorporate any provision not fully set forth in the policy or in an application
1605 or other document attached to and made a part of the policy at the time of its delivery, unless
1606 the policy, application, or agreement accurately reflects the terms of the incorporated
1607 agreement, provision, or attached document.
1608 (b) (i) A policy may by reference incorporate rate schedules and classifications of risks
1609 and short-rate tables filed with the commissioner.
1610 (ii) By rule or order, the commissioner may authorize incorporation by reference of
1611 provisions for:
1612 (A) administrative arrangements;
1613 (B) premium schedules; and
1614 (C) payment procedures for complex contracts.
1615 (c) (i) A policy of title insurance insuring the mortgage or deed of trust of an
1616 institutional lender may, if requested by an institutional lender, incorporate by reference
1617 generally applicable policy terms that are contained in a specifically identified policy that has
1618 been filed with the commissioner.
1619 (ii) As used in Subsection (1)(c)(i), "institutional lender" means a person that regularly
1620 engages in the business of making loans secured by real estate.
1621 (d) A policy may incorporate by reference the following by citing in the policy:
1622 (i) a federal law or regulation;
1623 (ii) a state law or rule; or
1624 (iii) a public directive of a federal or state agency.
1625 (2) A purported modification of a contract during the term of the policy may not affect
1626 the obligations of a party to the contract:
1627 (a) unless the modification is:
1628 (i) in writing; and
1629 (ii) agreed to by the party against whose interest the modification operates; and
1630 (b) except:
1631 (i) as provided in:
1632 (A) Subsection (3) or (4);
1633 (B) Subsection [
1634 [
1635 [
1636 (ii) as otherwise mandated by law.
1637 (3) Subsection (2) does not prevent a change in coverage under group contracts
1638 resulting from:
1639 (a) provisions of an employer eligibility rule;
1640 (b) the terms of a collective bargaining agreement; or
1641 (c) provisions in federal Employee Retirement Income Security Act plan documents.
1642 (4) Subsection (2) does not prevent a premium increase at any renewal date that is
1643 applicable uniformly to all comparable persons.
1644 Section 8. Section 31A-22-610.1 is amended to read:
1645 31A-22-610.1. Indemnity benefit for adoption or infertility treatments.
1646 (1) (a) (i) If an insured has coverage for maternity benefits on the date of an adoptive
1647 placement, the insured's policy shall provide an adoption indemnity benefit payable to the
1648 insured, if a child is placed for adoption with the insured within 90 days of the child's birth. If
1649 more than one child from the same birth is placed for adoption with the insured, only one
1650 adoption indemnity benefit is required.
1651 (ii) This section does not prevent an accident and health insurer from:
1652 (A) adjusting the benefit payable under this section for cost sharing measures imposed
1653 under the policy or contract for maternity benefit coverage; or
1654 (B) providing additional adoption indemnity benefits including:
1655 (I) extending the period of time after birth in which a child must be placed with an
1656 insured; or
1657 (II) providing a benefit in excess of the amount specified in Subsection (1)(c).
1658 (b) An insurer that has paid the adoption indemnity benefit under Subsection (1)(a)
1659 may seek reimbursement of the benefit if:
1660 (i) the postplacement evaluation disapproves the adoption placement; and
1661 (ii) a court rules the adoption may not be finalized because of an act or omission of an
1662 adoptive parent or parents that affects the child's health or safety.
1663 (c) (i) The amount of the adoption indemnity benefit provided under Subsection (1) is
1664 $4,000 subject to the adjustments permitted by Subsection (1)(a)(ii).
1665 (ii) An insurer may comply with the provisions of this section by providing the $4,000
1666 adoption indemnity benefit to an enrollee to be used for the purpose of the enrollee obtaining
1667 infertility treatments rather than seeking reimbursement for an adoption in accordance with
1668 terms designated by the insurer.
1669 (d) Each insurer shall pay its pro rata share of the adoption indemnity benefit if each
1670 adoptive parent:
1671 (i) has coverage for maternity benefits with a different insurer; and
1672 (ii) makes a claim for the adoption indemnity benefit provided in Subsection (1)(a).
1673 (2) If a policy offers optional maternity benefits, it shall also offer coverage for
1674 adoption indemnity benefits if:
1675 (a) a child is placed for adoption with the insured within 90 days of the child's birth;
1676 and
1677 (b) the adoption is finalized within one year of the child's birth.
1678 (3) If an insured qualifies for the adoption indemnity benefit under this section and
1679 receives services from a [
1680
1681 the amount that the contracting health care provider is entitled to receive for such services
1682 under the contract, including any applicable copayment.
1683 [
1684 [
1685 [
1686 Section 9. Section 31A-22-610.5 is amended to read:
1687 31A-22-610.5. Dependent coverage.
1688 (1) As used in this section, "child" has the same meaning as defined in Section
1689 78B-12-102.
1690 (2) (a) Any individual or group accident and health insurance policy or [
1691
1692 certificate holder's dependent may not terminate coverage of an unmarried dependent by reason
1693 of the dependent's age before the dependent's 26th birthday and shall, upon application, provide
1694 coverage for all unmarried dependents up to age 26.
1695 (b) The cost of coverage for unmarried dependents 19 to 26 years of age shall be
1696 included in the premium on the same basis as other dependent coverage.
1697 (c) This section does not prohibit the employer from requiring the employee to pay all
1698 or part of the cost of coverage for unmarried dependents.
1699 (d) An individual or group health insurance policy[
1700
1701 dependent through the last day of the month in which the dependent ceases to be a dependent:
1702 (i) if premiums are paid; and
1703 (ii) notwithstanding [
1704
1705 [
1706
1707
1708
1709 [
1710 [
1711 [
1712
1713 [
1714 [
1715 health insurance coverage for a child, an accident and health insurer may not deny enrollment
1716 of a child under the accident and health insurance plan of the child's parent on the grounds the
1717 child:
1718 (i) was born out of wedlock and is entitled to coverage under Subsection [
1719 (ii) was born out of wedlock and the custodial parent seeks enrollment for the child
1720 under the custodial parent's policy;
1721 (iii) is not claimed as a dependent on the parent's federal tax return; or
1722 (iv) does not reside with the parent or in the insurer's service area.
1723 (b) A child enrolled as required under Subsection [
1724 of the accident and health insurance plan contract pertaining to services received outside of an
1725 insurer's service area. [
1726
1727 [
1728 noncustodial parent, and when requested by the noncustodial or custodial parent, the insurer
1729 shall:
1730 (a) provide information to the custodial parent as necessary for the child to obtain
1731 benefits through that coverage, but the insurer or employer, or the agents or employees of either
1732 of them, are not civilly or criminally liable for providing information in compliance with this
1733 Subsection [
1734 request;
1735 (b) permit the custodial parent or the service provider, with the custodial parent's
1736 approval, to submit claims for covered services without the approval of the noncustodial
1737 parent; and
1738 (c) make payments on claims submitted in accordance with Subsection [
1739 directly to the custodial parent, the child who obtained benefits, the provider, or the state
1740 Medicaid agency.
1741 [
1742 coverage for a child, and the parent is eligible for family health coverage, the insurer shall:
1743 (a) permit the parent to enroll, under the family coverage, a child who is otherwise
1744 eligible for the coverage without regard to an enrollment season restrictions;
1745 (b) if the parent is enrolled but fails to make application to obtain coverage for the
1746 child, enroll the child under family coverage upon application of the child's other parent, the
1747 state agency administering the Medicaid program, or the state agency administering 42 U.S.C.
1748 Sec. 651 through 669, the child support enforcement program; and
1749 (c) (i) when the child is covered by an individual policy, not disenroll or eliminate
1750 coverage of the child unless the insurer is provided satisfactory written evidence that:
1751 (A) the court or administrative order is no longer in effect; or
1752 (B) the child is or will be enrolled in comparable accident and health coverage through
1753 another insurer which will take effect not later than the effective date of disenrollment; or
1754 (ii) when the child is covered by a group policy, not disenroll or eliminate coverage of
1755 the child unless the employer is provided with satisfactory written evidence, which evidence is
1756 also provided to the insurer, that Subsection [
1757 [
1758 assigned the rights of an individual eligible for medical assistance under Medicaid and covered
1759 for accident and health benefits from the insurer that are different from requirements applicable
1760 to an agent or assignee of any other individual so covered.
1761 [
1762 level in effect on May 1, 1993.
1763 [
1764 coverage, which is available through an employer doing business in this state, the employer
1765 shall:
1766 (a) permit the parent to enroll under family coverage any child who is otherwise
1767 eligible for coverage without regard to any enrollment season restrictions;
1768 (b) if the parent is enrolled but fails to make application to obtain coverage of the child,
1769 enroll the child under family coverage upon application by the child's other parent, by the state
1770 agency administering the Medicaid program, or the state agency administering 42 U.S.C. Sec.
1771 651 through 669, the child support enforcement program;
1772 (c) not disenroll or eliminate coverage of the child unless the employer is provided
1773 satisfactory written evidence that:
1774 (i) the court order is no longer in effect;
1775 (ii) the child is or will be enrolled in comparable coverage which will take effect no
1776 later than the effective date of disenrollment; or
1777 (iii) the employer has eliminated family health coverage for all of its employees; and
1778 (d) withhold from the employee's compensation the employee's share, if any, of
1779 premiums for health coverage and to pay this amount to the insurer.
1780 [
1781 medical support order" for the purpose of enrolling a dependent child in a group accident and
1782 health insurance plan as defined in Section 609(a), Federal Employee Retirement Income
1783 Security Act of 1974.
1784 [
1785 of any child being covered under any policy of insurance that:
1786 (a) the parent continues to be eligible for coverage;
1787 (b) the child shall be identified to the insurer with adequate information to comply with
1788 this section; and
1789 (c) the premium shall be paid when due.
1790 [
1791 defined in Section 26-19-2.
1792 [
1793 section with regard to out-of-area court ordered dependent coverage.
1794 Section 10. Section 31A-22-613.5 is amended to read:
1795 31A-22-613.5. Price and value comparisons of health insurance.
1796 (1) (a) This section applies to all health benefit plans.
1797 (b) Subsection (2) applies to:
1798 (i) all health benefit plans; and
1799 (ii) coverage offered to state employees under Subsection 49-20-202(1)(a).
1800 (2) [
1801 health benefit plans by requiring an insurer issuing a health benefit plan to[
1802 enrollees, [
1803 [
1804 [
1805 [
1806 [
1807 [
1808 [
1809 [
1810 limitation or exclusion from coverage; and
1811 [
1812 secondary medical condition; and
1813 [
1814 Section 31A-22-610.1 for infertility treatments, in accordance with Subsection
1815 31A-22-610.1(1)(c)(ii) and the terms associated with the exchange of benefits[
1816 [
1817 [
1818
1819 [
1820 [
1821 writing to the commissioner:
1822 [
1823 [
1824 (2)[
1825 [
1826 [
1827 [
1828 [
1829 or
1830 [
1831 secondary medical condition related to a limitation or exclusion of the insurer's health
1832 insurance plan.
1833 [
1834 prescription drug coverage due to a change in benefit design under Subsection (2)(a)[
1835 (i) either:
1836 (A) in writing; or
1837 (B) on the insurer's website; and
1838 (ii) at least 30 days prior to the date of the implementation of the increase in cost, or as
1839 soon as reasonably possible.
1840 [
1841 available to prospective enrollees and maintain evidence of the fact of the disclosure of:
1842 (i) the drugs included;
1843 (ii) the patented drugs not included;
1844 (iii) any conditions that exist as a precedent to coverage; and
1845 (iv) any exclusion from coverage for secondary medical conditions that may result
1846 from the use of an excluded drug.
1847 [
1848 secondary medical condition that an insurer may use under Subsection (2)[
1849 (ii) Examples of a limitation or exclusion of coverage provided under Subsection
1850 (2)[
1851 fact situation to fall within the description of an example does not, by itself, support a finding
1852 of coverage.
1853 [
1854 [
1855
1856 [
1857
1858 [
1859 [
1860
1861
1862
1863
1864 [
1865 [
1866 [
1867
1868 [
1869
1870 [
1871 [
1872 [
1873 [
1874
1875 [
1876
1877
1878 [
1879
1880
1881 [
1882
1883 Section 11. Section 31A-22-618 is amended to read:
1884 31A-22-618. Nondiscrimination among health care professionals.
1885 [
1886
1887 Organizations and Limited Health Plans, no insurer may unfairly discriminate against any
1888 licensed class of health care providers by structuring contract exclusions which exclude
1889 payment of benefits for the treatment of any illness, injury, or condition by any licensed class
1890 of health care providers when the treatment is within the scope of the licensee's practice and the
1891 illness, injury, or condition falls within the coverage of the contract. Upon the written request
1892 of an insured alleging an insurer has violated this section, the commissioner shall hold a
1893 hearing to determine if the violation exists. The commissioner may consolidate two or more
1894 related alleged violations into a single hearing.
1895 [
1896
1897 [
1898 insurer in accordance with Section 58-61-714. Nothing in this section prohibits an insurer
1899 from electing to provide coverage for other licensed professionals whose scope of practice
1900 includes behavior analysis.
1901 Section 12. Section 31A-22-618.5 is amended to read:
1902 31A-22-618.5. Coverage of insurance mandates imposed after January 1, 2009.
1903 (1) The purpose of this section is to increase the range of health benefit plans available
1904 in the small group, small employer group, large group, and individual insurance markets.
1905 (2) A health maintenance organization that is subject to Chapter 8, Health Maintenance
1906 Organizations and Limited Health Plans:
1907 (a) shall offer to potential purchasers at least one health benefit plan that is subject to
1908 the requirements of Chapter 8, Health Maintenance Organizations and Limited Health Plans;
1909 and
1910 (b) may offer to a potential purchaser one or more health benefit plans that:
1911 (i) are not subject to one or more of the following:
1912 (A) the limitations on insured indemnity benefits in Subsection 31A-8-105(4); or
1913 [
1914
1915 [
1916 defined in Section 31A-8-101; or
1917 [
1918 federal law, provided that the insurer offers one plan under Subsection (2)(a) that covers the
1919 mandate enacted after January 1, 2009; and
1920 (ii) when offering a health plan under this section, provide coverage for an emergency
1921 medical condition as required by Section 31A-22-627 [
1922 [
1923
1924
1925 [
1926
1927
1928
1929 (3) An insurer that offers a health benefit plan that is not subject to Chapter 8, Health
1930 Maintenance Organizations and Limited Health Plans:
1931 (a) may offer a health benefit plan that is not subject to Section 31A-22-618 and
1932 Subsection 31A-45-303(3)(b)(iii);
1933 (b) when offering a health plan under this Subsection (3), shall provide coverage of
1934 emergency care services as required by Section 31A-22-627; and
1935 (c) is not subject to coverage mandates enacted after January 1, 2009 that are not
1936 required by federal law, provided that an insurer offers one plan that covers a mandate enacted
1937 after January 1, 2009.
1938 (4) Section 31A-8-106 does not prohibit the offer of a health benefit plan under
1939 Subsection (2)(b).
1940 (5) (a) Any difference in price between a health benefit plan offered under Subsections
1941 (2)(a) and (b) shall be based on actuarially sound data.
1942 (b) Any difference in price between a health benefit plan offered under Subsection
1943 (3)(a) shall be based on actuarially sound data.
1944 (6) Nothing in this section limits the number of health benefit plans that an insurer may
1945 offer.
1946 Section 13. Section 31A-22-618.6, which is renumbered from Section 31A-8-402.3 is
1947 renumbered and amended to read:
1948 [
1949 group health benefit plans.
1950 (1) Except as otherwise provided in this section, a group health benefit plan for a plan
1951 sponsor is renewable and continues in force:
1952 (a) with respect to all eligible employees and dependents; and
1953 (b) at the option of the plan sponsor.
1954 (2) A health benefit plan for a plan sponsor may be discontinued or nonrenewed [
1955
1956 (a) for noncompliance with the insurer's employer contribution requirements;
1957 [
1958 resides, or works in:
1959 (i) the service area of the insurer; or
1960 (ii) the area for which the insurer is authorized to do business; [
1961 [
1962 through an association, if:
1963 (i) the employer's membership in the association ceases; and
1964 (ii) the coverage is terminated uniformly without regard to any health status-related
1965 factor relating to any covered individual[
1966 (d) for noncompliance with the insurer's minimum employee participation
1967 requirements, except as provided in Subsection (3).
1968 (3) If a small employer employs fewer than two eligible employees, a carrier may not
1969 discontinue or not renew the health benefit plan until the first renewal date following the
1970 beginning of a new plan year, even if the carrier knows at the beginning of the plan year that
1971 the employer no longer has at least two current employees.
1972 (4) (a) A small employer that, after purchasing a health benefit plan in the small group
1973 market, employs on average more than 50 eligible employees on each business day in a
1974 calendar year may continue to renew the health benefit plan purchased in the small group
1975 market.
1976 (b) A large employer that, after purchasing a health benefit plan in the large group
1977 market, employs on average fewer than 51 eligible employees on each business day in a
1978 calendar year may continue to renew the health benefit plan purchased in the large group
1979 market.
1980 [
1981 (a) a condition described in Subsection (2) exists;
1982 (b) the plan sponsor fails to pay premiums or contributions in accordance with the
1983 terms of the contract;
1984 (c) the plan sponsor:
1985 (i) performs an act or practice that constitutes fraud; or
1986 (ii) makes an intentional misrepresentation of material fact under the terms of the
1987 coverage;
1988 (d) the insurer:
1989 (i) elects to discontinue offering a particular health benefit plan product delivered or
1990 issued for delivery in this state; and
1991 (ii) (A) provides notice of the discontinuation in writing[
1992 employee, or dependent of a plan sponsor or an employee[
1993 date the coverage will be discontinued;
1994 (B) provides notice of the discontinuation in writing[
1995
1996 plan sponsors, employees, and dependents of the plan sponsors or employees;
1997 (C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase[
1998
1999
1999a plans ←Ĥ currently being
2000 offered in that market; and
2001 (D) in exercising the option to discontinue that product and in offering the option of
2002 coverage in this section, acts uniformly without regard to[
2003 sponsor[
2004 beneficiary[
2005 beneficiary who may become eligible for the coverage; or
2006 (e) the insurer:
2007 (i) elects to discontinue all of the insurer's health benefit plans in:
2008 (A) the small employer market;
2009 (B) the large employer market; or
2010 (C) both the small employer and large employer markets; and
2011 (ii) (A) provides notice of the discontinuation in writing[
2012 employee, or dependent of a plan sponsor or an employee[
2013 the date the coverage will be discontinued;
2014 (B) provides notice of the discontinuation in writing[
2015 state in which an affected insured individual is known to reside[
2016 working days [
2017 employees, and the dependents of the plan sponsors or employees;
2018 (C) discontinues and nonrenews all plans issued or delivered for issuance in the market
2019 described in Subsection (5)(e)(i) ; and
2020 (D) provides a plan of orderly withdrawal as required by Section 31A-4-115.
2021 [
2022 [
2023 [
2024 [
2025 [
2026 [
2027 [
2028 [
2029 [
2030 [
2031 [
2032 [
2033 discontinued if after issuance of coverage the eligible employee:
2034 (i) engages in an act or practice in connection with the coverage that constitutes fraud;
2035 or
2036 (ii) makes an intentional misrepresentation of material fact in connection with the
2037 coverage.
2038 (b) An eligible employee that is discontinued under Subsection [
2039 reenroll:
2040 (i) 12 months after the date of discontinuance; and
2041 (ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies
2042 to reenroll.
2043 (c) At the time the eligible employee's coverage is discontinued under Subsection [
2044 (6)(a), the insurer shall notify the eligible employee of the right to reenroll when coverage is
2045 discontinued.
2046 (d) An eligible employee may not be discontinued under this Subsection [
2047 because of a fraud or misrepresentation that relates to health status.
2048 [
2049 to the employer:
2050 (a) with respect to coverage provided to an employer member of the association; and
2051 (b) if the health benefit plan is made available by an insurer in the employer market
2052 only through:
2053 (i) an association;
2054 (ii) a trust; or
2055 (iii) a discretionary group.
2056 [
2057 (a) at the time of coverage renewal; and
2058 (b) if the modification is effective uniformly among all plans with that product.
2059 Section 14. Section 31A-22-618.7, which is renumbered from Section 31A-8-402.5 is
2060 renumbered and amended to read:
2061 [
2062 (1) (a) Except as otherwise provided in this section, a health benefit plan offered on an
2063 individual basis is renewable and continues in force:
2064 (i) with respect to all [
2065 (ii) at the option of the [
2066 (b) Subsection (1)(a) applies regardless of:
2067 (i) whether the contract is issued through:
2068 (A) a trust;
2069 (B) an association;
2070 (C) a discretionary group; or
2071 (D) other similar grouping; or
2072 (ii) the situs of delivery of the policy or contract.
2073 (2) [
2074 (a) [
2075 (i) [
2076 benefit plan who lives, resides, or works in:
2077 (A) the service area of the insurer; or
2078 (B) the area for which the insurer is authorized to do business; and
2079 (ii) coverage is terminated uniformly without regard to any health status-related factor
2080 relating to any covered [
2081 (b) for coverage made available through an association, if:
2082 (i) the [
2083 (ii) the coverage is terminated uniformly without regard to any health status-related
2084 factor relating to any covered [
2085 (3) [
2086 (a) a condition described in Subsection (2) exists;
2087 (b) the [
2088 the terms of the health benefit plan, including any timeliness requirements;
2089 (c) the [
2090 (i) performs an act or practice in connection with the coverage that constitutes fraud; or
2091 (ii) makes an intentional misrepresentation of material fact under the terms of the
2092 coverage;
2093 (d) the insurer:
2094 (i) elects to discontinue offering a particular health benefit [
2095 delivered or issued for delivery in this state; and
2096 (ii) (A) provides notice of the discontinuation in writing[
2097 enrollee provided coverage[
2098 discontinued;
2099 (B) provides notice of the discontinuation in writing[
2100
2101 [
2102 (C) offers to each covered [
2103 option to purchase all other individual health benefit Ĥ→ [
2103a being offered by
2104 the insurer for individuals in that market; and
2105 (D) acts uniformly without regard to any health status-related factor of covered
2106 [
2107 eligible for coverage; or
2108 (e) the insurer:
2109 (i) elects to discontinue all of the insurer's health benefit plans in the individual market;
2110 and
2111 (ii) (A) provides notice of the discontinuation in writing[
2112 enrollee provided coverage[
2113 discontinued;
2114 (B) provides notice of the discontinuation in writing[
2115 state in which an affected [
2116 least 30 working days [
2117 enrollees;
2118 (C) discontinues and nonrenews all health benefit plans the insurer issues or delivers
2119 for issuance in the individual market; and
2120 (D) acts uniformly without regard to any health status-related factor of covered
2121 [
2122 eligible for coverage.
2123 (4) An insurer may modify an individual health benefit plan only:
2124 (a) at the time of coverage renewal; and
2125 (b) if the modification is effective uniformly among all health benefit plans.
2126 Section 15. Section 31A-22-618.8, which is renumbered from Section 31A-8-402.7 is
2127 renumbered and amended to read:
2128 [
2129 (1) Subject to Section 31A-4-115, an insurer that elects to discontinue offering a health
2130 benefit plan under Subsections [
2131 31A-22-618.7(3)(e) is prohibited from writing new business:
2132 (a) in the market in this state for which the insurer discontinues or does not renew; and
2133 (b) for a period of five years beginning on the date of discontinuation of the last
2134 coverage that is discontinued.
2135 (2) If an insurer is doing business in one established geographic service area of the
2136 state, Sections [
2137 the insurer's operations in that service area.
2138 (3) The commissioner may, by rule or order, define the scope of service area.
2139 Section 16. Section 31A-22-627 is amended to read:
2140 31A-22-627. Coverage of emergency medical services.
2141 (1) A health insurance policy or [
2142 contract:
2143 (a) shall provide, at a minimum, coverage of emergency services as required in 29
2144 C.F.R. Sec. 2590.715-2719A; and
2145 (b) may not:
2146 (i) require any form of preauthorization for treatment of an emergency medical
2147 condition until after the insured's condition has been stabilized; or
2148 (ii) deny a claim for any covered evaluation, covered diagnostic test, or other covered
2149 treatment considered medically necessary to stabilize the emergency medical condition of an
2150 insured.
2151 (2) A health insurance policy or [
2152 contract may require authorization for the continued treatment of an emergency medical
2153 condition after the insured's condition has been stabilized. If such authorization is required, an
2154 insurer who does not accept or reject a request for authorization may not deny a claim for any
2155 evaluation, diagnostic testing, or other treatment considered medically necessary that occurred
2156 between the time the request was received and the time the insurer rejected the request for
2157 authorization.
2158 (3) For purposes of this section:
2159 (a) "Emergency medical condition" means a medical condition manifesting itself by
2160 acute symptoms of sufficient severity, including severe pain, such that a prudent layperson,
2161 who possesses an average knowledge of medicine and health, would reasonably expect the
2162 absence of immediate medical attention at a hospital emergency department to result in:
2163 (i) placing the insured's health, or with respect to a pregnant woman, the health of the
2164 woman or her unborn child, in serious jeopardy;
2165 (ii) serious impairment to bodily functions; or
2166 (iii) serious dysfunction of any bodily organ or part[
2167 (b) "Hospital emergency department" means that area of a hospital in which emergency
2168 services are provided on a 24-hour-a-day basis.
2169 (c) "Stabilize" means the same as that term is defined in 42 U.S.C. Sec. 1395dd(e)(3).
2170 (4) Nothing in this section may be construed as:
2171 (a) altering the level or type of benefits that are provided under the terms of a contract
2172 or policy; or
2173 (b) restricting a policy or contract from providing enhanced benefits for certain
2174 emergency medical conditions that are identified in the policy or contract.
2175 (5) Notwithstanding Section 31A-2-308, if the commissioner finds an insurer has
2176 violated this section, the commissioner may:
2177 (a) work with the insurer to improve the insurer's compliance with this section; or
2178 (b) impose the following fines:
2179 (i) not more than $5,000; or
2180 (ii) twice the amount of any profit gained from violations of this section.
2181 Section 17. Section 31A-22-628 is amended to read:
2182 31A-22-628. Standing referral to a specialist.
2183 (1) With respect to a health insurance policy or [
2184 organization contract that does not allow an insured to have direct access to a health care
2185 specialist, the insurer shall establish and implement a procedure by which an insured may
2186 obtain a standing referral to a health care specialist.
2187 (2) The procedure established under Subsection (1):
2188 (a) shall provide for a standing referral to a specialist if the insured's primary care
2189 provider determines, in consultation with the specialist, that the insured needs continuing care
2190 from the specialist; and
2191 (b) may require the insurer's approval of a treatment plan designed by the specialist, in
2192 consultation with the primary care provider and the insured, which may include:
2193 (i) a limit on the number of visits to the specialist;
2194 (ii) a time limit on the duration of the referral; and
2195 (iii) mandatory updates on the insured's condition.
2196 Section 18. Section 31A-22-635 is amended to read:
2197 31A-22-635. Uniform application -- Uniform waiver of coverage.
2198 (1) For purposes of this section, "insurer":
2199 (a) is defined in Subsection 31A-22-634(1); and
2200 (b) includes the state employee's risk pool under Section 49-20-202.
2201 (2) (a) Insurers offering a health benefit plan to an individual or small employer shall
2202 use a uniform application form.
2203 (b) The uniform application form:
2204 (i) may not include questions about an applicant's health history; and
2205 (ii) shall be shortened and simplified in accordance with rules adopted by the
2206 commissioner.
2207 (c) Insurers offering a health benefit plan to a small employer shall use a uniform
2208 waiver of coverage form, which may not include health status related questions, and is limited
2209 to:
2210 (i) information that identifies the employee;
2211 (ii) proof of the employee's insurance coverage; and
2212 (iii) a statement that the employee declines coverage with a particular employer group.
2213 (3) Notwithstanding the requirements of Subsection (2)(a), the uniform application and
2214 uniform waiver of coverage forms may, if the combination or modification is approved by the
2215 commissioner, be combined or modified to facilitate a more efficient and consumer friendly
2216 experience for[
2217 electronic applications.
2218 (4) (a) The uniform application form, and uniform waiver form, shall be adopted and
2219 approved by the commissioner in accordance with Title 63G, Chapter 3, Utah Administrative
2220 Rulemaking Act.
2221 [
2222
2223 [
2224
2225
2226 [
2227
2228 [
2229
2230 [
2231
2232 [
2233
2234
2235 [
2236 [
2237 [
2238 [
2239
2240 [
2241
2242
2243 [
2244
2245 [
2246 [
2247 [
2248 [
2249
2250 [
2251
2252 [
2253
2254
2255
2256 [
2257
2258
2259 (b) The commissioner shall regulate the fees charged by insurers to an enrollee for a
2260 uniform application form or electronic submission of the application forms.
2261 Section 19. Section 31A-22-642 is amended to read:
2262 31A-22-642. Insurance coverage for autism spectrum disorder.
2263 (1) As used in this section:
2264 (a) "Applied behavior analysis" means the design, implementation, and evaluation of
2265 environmental modifications, using behavioral stimuli and consequences, to produce socially
2266 significant improvement in human behavior, including the use of direct observation,
2267 measurement, and functional analysis of the relationship between environment and behavior.
2268 (b) "Autism spectrum disorder" means pervasive developmental disorders as defined
2269 by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders
2270 (DSM).
2271 (c) "Behavioral health treatment" means counseling and treatment programs, including
2272 applied behavior analysis, that are:
2273 (i) necessary to develop, maintain, or restore, to the maximum extent practicable, the
2274 functioning of an individual; and
2275 (ii) provided or supervised by a:
2276 (A) board certified behavior analyst; or
2277 (B) person licensed under Title 58, Chapter 1, Division of Occupational and
2278 Professional Licensing Act, whose scope of practice includes mental health services.
2279 (d) "Diagnosis of autism spectrum disorder" means medically necessary assessments,
2280 evaluations, or tests:
2281 (i) performed by a licensed physician who is board certified in neurology, psychiatry,
2282 or pediatrics and has experience diagnosing autism spectrum disorder, or a licensed
2283 psychologist with experience diagnosing autism spectrum disorder; and
2284 (ii) necessary to diagnose whether an individual has an autism spectrum disorder.
2285 (e) "Pharmacy care" means medications prescribed by a licensed physician and any
2286 health-related services considered medically necessary to determine the need or effectiveness
2287 of the medications.
2288 (f) "Psychiatric care" means direct or consultative services provided by a psychiatrist
2289 licensed in the state in which the psychiatrist practices.
2290 (g) "Psychological care" means direct or consultative services provided by a
2291 psychologist licensed in the state in which the psychologist practices.
2292 (h) "Therapeutic care" means services provided by licensed or certified speech
2293 therapists, occupational therapists, or physical therapists.
2294 (i) "Treatment for autism spectrum disorder":
2295 (i) means evidence-based care and related equipment prescribed or ordered for an
2296 individual diagnosed with an autism spectrum disorder by a physician or a licensed
2297 psychologist described in Subsection (1)(d) who determines the care to be medically necessary;
2298 and
2299 (ii) includes:
2300 (A) behavioral health treatment, provided or supervised by a person described in
2301 Subsection (1)(c)(ii);
2302 (B) pharmacy care;
2303 (C) psychiatric care;
2304 (D) psychological care; and
2305 (E) therapeutic care.
2306 (2) Notwithstanding the provisions of Section 31A-22-618.5, a health benefit plan
2307 offered in the individual market or the large group market and entered into or renewed on or
2308 after January 1, 2016, shall provide coverage for the diagnosis and treatment of autism
2309 spectrum disorder:
2310 (a) for a child who is at least two years old, but younger than 10 years old; and
2311 (b) in accordance with the requirements of this section and rules made by the
2312 commissioner.
2313 (3) The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah
2314 Administrative Rulemaking Act, to set the minimum standards of coverage for the treatment of
2315 autism spectrum disorder.
2316 (4) Subject to Subsection (5), the rules described in Subsection (3) shall establish
2317 durational limits, amount limits, deductibles, copayments, and coinsurance for the treatment of
2318 autism spectrum disorder that are similar to, or identical to, the coverage provided for other
2319 illnesses or diseases.
2320 (5) (a) Coverage for behavioral health treatment for a person with an autism spectrum
2321 disorder shall cover at least 600 hours a year. Other terms and conditions in the health benefit
2322 plan that apply to other benefits covered by the health benefit plan apply to coverage required
2323 by this section.
2324 (b) Notwithstanding [
2325 plan providing treatment under Subsection (5)(a) shall include in the plan's provider network
2326 both board certified behavior analysts and mental health providers qualified under Subsection
2327 (1)(c)(ii).
2328 (6) A health care provider shall submit a treatment plan for autism spectrum disorder to
2329 the insurer within 14 business days of starting treatment for an individual. If an individual is
2330 receiving treatment for an autism spectrum disorder, an insurer shall have the right to request a
2331 review of that treatment not more than once every six months. A review of treatment under
2332 this Subsection (6) may include a review of treatment goals and progress toward the treatment
2333 goals. If an insurer makes a determination to stop treatment as a result of the review of the
2334 treatment plan under this subsection, the determination of the insurer may be reviewed under
2335 Section 31A-22-629.
2336 (7) (a) In accordance with Subsection (7)(b), the commissioner shall waive the
2337 requirements of this section for all insurers in the individual market or the large group market,
2338 if an insurer demonstrates to the commissioner that the insurer's entire pool of business in the
2339 individual market or the large group market has incurred claims for the autism coverage
2340 required by this section in a 12 consecutive month period that will cause a premium increase
2341 for the insurer's entire pool of business in the individual market or the large group market in
2342 excess of 1% over the insurer's premiums in the previous 12 consecutive month period.
2343 (b) The commissioner shall waive the requirements of this section if:
2344 (i) after a public hearing in accordance with Title 63G, Chapter 4, Administrative
2345 Procedures Act, the commissioner finds that the insurer has demonstrated to the commissioner
2346 based on generally accepted actuarial principles and methodologies that the insurer's entire pool
2347 of business in the individual market or the large group market will experience a premium
2348 increase of 1% or greater as a result of the claims for autism services as described in this
2349 section; or
2350 (ii) the attorney general issues a legal opinion that the limits under Subsection (5)(a)
2351 cannot be implemented by an insurer in a manner that complies with federal law.
2352 (8) If a waiver is granted under Subsection (7), the insurer may:
2353 (a) continue to offer autism coverage under the existing plan until the next renewal
2354 period for the plan, at which time the insurer:
2355 (i) may delete the autism coverage from the plan without having to re-apply for the
2356 waiver under Subsection (7); and
2357 (ii) file the plan with the commissioner in accordance with guidelines issued by the
2358 commissioner;
2359 (b) discontinue offering plans subject to Subsection (2), no earlier than the next
2360 calendar quarter following the date the waiver is granted, subject to filing guidelines issued by
2361 the commissioner; or
2362 (c) nonrenew existing plans that are subject to Subsection (2), in compliance with
2363 Subsection [
2364 (9) This section sunsets in accordance with Section 63I-1-231.
2365 Section 20. Section 31A-23a-402 is amended to read:
2366 31A-23a-402. Unfair marketing practices -- Communication -- Unfair
2367 discrimination -- Coercion or intimidation -- Restriction on choice.
2368 (1) (a) (i) Any of the following may not make or cause to be made any communication
2369 that contains false or misleading information, relating to an insurance product or contract, any
2370 insurer, or any licensee under this title, including information that is false or misleading
2371 because it is incomplete:
2372 (A) a person who is or should be licensed under this title;
2373 (B) an employee or producer of a person described in Subsection (1)(a)(i)(A);
2374 (C) a person whose primary interest is as a competitor of a person licensed under this
2375 title; and
2376 (D) a person on behalf of any of the persons listed in this Subsection (1)(a)(i).
2377 (ii) As used in this Subsection (1), "false or misleading information" includes:
2378 (A) assuring the nonobligatory payment of future dividends or refunds of unused
2379 premiums in any specific or approximate amounts, but reporting fully and accurately past
2380 experience is not false or misleading information; and
2381 (B) with intent to deceive a person examining it:
2382 (I) filing a report;
2383 (II) making a false entry in a record; or
2384 (III) wilfully refraining from making a proper entry in a record.
2385 (iii) A licensee under this title may not:
2386 (A) use any business name, slogan, emblem, or related device that is misleading or
2387 likely to cause the insurer or other licensee to be mistaken for another insurer or other licensee
2388 already in business; or
2389 (B) use any name, advertisement, or other insurance promotional material that would
2390 cause a reasonable person to mistakenly believe that a state or federal government agency,
2391 including [
2392 small employer health insurance exchange known as "Avenue H," [
2393
2394
2395 Chapter 40, Utah Children's Health Insurance Act:
2396 (I) is responsible for the insurance sales activities of the person;
2397 (II) stands behind the credit of the person;
2398 (III) guarantees any returns on insurance products of or sold by the person; or
2399 (IV) is a source of payment of any insurance obligation of or sold by the person.
2400 (iv) A person who is not an insurer may not assume or use any name that deceptively
2401 implies or suggests that person is an insurer.
2402 (v) A person other than persons licensed as health maintenance organizations under
2403 Chapter 8, Health Maintenance Organizations and Limited Health Plans, may not use the term
2404 "Health Maintenance Organization" or "HMO" in referring to itself.
2405 (b) A licensee's violation creates a rebuttable presumption that the violation was also
2406 committed by the insurer if:
2407 (i) the licensee under this title distributes cards or documents, exhibits a sign, or
2408 publishes an advertisement that violates Subsection (1)(a), with reference to a particular
2409 insurer:
2410 (A) that the licensee represents; or
2411 (B) for whom the licensee processes claims; and
2412 (ii) the cards, documents, signs, or advertisements are supplied or approved by that
2413 insurer.
2414 (2) (a) A title insurer, individual title insurance producer, or agency title insurance
2415 producer or any officer or employee of the title insurer, individual title insurance producer, or
2416 agency title insurance producer may not pay, allow, give, or offer to pay, allow, or give,
2417 directly or indirectly, as an inducement to obtaining any title insurance business:
2418 (i) any rebate, reduction, or abatement of any rate or charge made incident to the
2419 issuance of the title insurance;
2420 (ii) any special favor or advantage not generally available to others;
2421 (iii) any money or other consideration, except if approved under Section 31A-2-405; or
2422 (iv) material inducement.
2423 (b) "Charge made incident to the issuance of the title insurance" includes escrow
2424 charges, and any other services that are prescribed in rule by the Title and Escrow Commission
2425 after consultation with the commissioner and subject to Section 31A-2-404.
2426 (c) An insured or any other person connected, directly or indirectly, with the
2427 transaction may not knowingly receive or accept, directly or indirectly, any benefit referred to
2428 in Subsection (2)(a), including:
2429 (i) a person licensed under Title 61, Chapter 2c, Utah Residential Mortgage Practices
2430 and Licensing Act;
2431 (ii) a person licensed under Title 61, Chapter 2f, Real Estate Licensing and Practices
2432 Act;
2433 (iii) a builder;
2434 (iv) an attorney; or
2435 (v) an officer, employee, or agent of a person listed in this Subsection (2)(c)(iii).
2436 (3) (a) An insurer may not unfairly discriminate among policyholders by charging
2437 different premiums or by offering different terms of coverage, except on the basis of
2438 classifications related to the nature and the degree of the risk covered or the expenses involved.
2439 (b) Rates are not unfairly discriminatory if they are averaged broadly among persons
2440 insured under a group, blanket, or franchise policy, and the terms of those policies are not
2441 unfairly discriminatory merely because they are more favorable than in similar individual
2442 policies.
2443 (4) (a) This Subsection (4) applies to:
2444 (i) a person who is or should be licensed under this title;
2445 (ii) an employee of that licensee or person who should be licensed;
2446 (iii) a person whose primary interest is as a competitor of a person licensed under this
2447 title; and
2448 (iv) one acting on behalf of any person described in Subsections (4)(a)(i) through (iii).
2449 (b) A person described in Subsection (4)(a) may not commit or enter into any
2450 agreement to participate in any act of boycott, coercion, or intimidation that:
2451 (i) tends to produce:
2452 (A) an unreasonable restraint of the business of insurance; or
2453 (B) a monopoly in that business; or
2454 (ii) results in an applicant purchasing or replacing an insurance contract.
2455 (5) (a) (i) Subject to Subsection (5)(a)(ii), a person may not restrict in the choice of an
2456 insurer or licensee under this chapter, another person who is required to pay for insurance as a
2457 condition for the conclusion of a contract or other transaction or for the exercise of any right
2458 under a contract.
2459 (ii) A person requiring coverage may reserve the right to disapprove the insurer or the
2460 coverage selected on reasonable grounds.
2461 (b) The form of corporate organization of an insurer authorized to do business in this
2462 state is not a reasonable ground for disapproval, and the commissioner may by rule specify
2463 additional grounds that are not reasonable. This Subsection (5) does not bar an insurer from
2464 declining an application for insurance.
2465 (6) A person may not make any charge other than insurance premiums and premium
2466 financing charges for the protection of property or of a security interest in property, as a
2467 condition for obtaining, renewing, or continuing the financing of a purchase of the property or
2468 the lending of money on the security of an interest in the property.
2469 (7) (a) A licensee under this title may not refuse or fail to return promptly all indicia of
2470 agency to the principal on demand.
2471 (b) A licensee whose license is suspended, limited, or revoked under Section
2472 31A-2-308, 31A-23a-111, or 31A-23a-112 may not refuse or fail to return the license to the
2473 commissioner on demand.
2474 (8) (a) A person may not engage in an unfair method of competition or any other unfair
2475 or deceptive act or practice in the business of insurance, as defined by the commissioner by
2476 rule, after a finding that the method of competition, the act, or the practice:
2477 (i) is misleading;
2478 (ii) is deceptive;
2479 (iii) is unfairly discriminatory;
2480 (iv) provides an unfair inducement; or
2481 (v) unreasonably restrains competition.
2482 (b) Notwithstanding Subsection (8)(a), for purpose of the title insurance industry, the
2483 Title and Escrow Commission shall make rules, subject to Section 31A-2-404, that define an
2484 unfair method of competition or unfair or deceptive act or practice after a finding that the
2485 method of competition, the act, or the practice:
2486 (i) is misleading;
2487 (ii) is deceptive;
2488 (iii) is unfairly discriminatory;
2489 (iv) provides an unfair inducement; or
2490 (v) unreasonably restrains competition.
2491 Section 21. Section 31A-30-102 is amended to read:
2492 31A-30-102. Purpose statement.
2493 The purpose of this chapter is to:
2494 (1) prevent abusive rating practices;
2495 (2) require disclosure of rating practices to purchasers;
2496 (3) establish rules regarding:
2497 (a) a universal individual and small group application; and
2498 (b) renewability of coverage;
2499 (4) improve the overall fairness and efficiency of the individual and small group
2500 insurance market; and
2501 (5) provide increased access for individuals and small employers to health insurance[
2502
2503 [
2504
2505
2506 Section 22. Section 31A-30-104 is amended to read:
2507 31A-30-104. Applicability and scope.
2508 (1) This chapter applies to any:
2509 (a) health benefit plan that provides coverage to:
2510 (i) individuals;
2511 (ii) small employers, except as provided in Subsection (3); or
2512 (iii) both Subsections (1)(a)(i) and (ii); or
2513 (b) individual conversion policy for purposes of Sections 31A-30-106.5 and
2514 31A-30-107.5.
2515 (2) This chapter applies to a health benefit plan that provides coverage to small
2516 employers or individuals regardless of:
2517 (a) whether the contract is issued to:
2518 (i) an association, except as provided in Subsection (3);
2519 (ii) a trust;
2520 (iii) a discretionary group; or
2521 (iv) other similar grouping; or
2522 (b) the situs of delivery of the policy or contract.
2523 (3) This chapter does not apply to:
2524 (a) short-term limited duration health insurance;
2525 (b) federally funded or partially funded programs; or
2526 (c) a bona fide employer association.
2527 (4) (a) Except as provided in Subsection (4)(b), for the purposes of this chapter:
2528 (i) carriers that are affiliated companies or that are eligible to file a consolidated tax
2529 return shall be treated as one carrier; and
2530 (ii) any restrictions or limitations imposed by this chapter shall apply as if all health
2531 benefit plans delivered or issued for delivery to covered insureds in this state by the affiliated
2532 carriers were issued by one carrier.
2533 (b) Upon a finding of the commissioner, an affiliated carrier that is a health
2534 maintenance organization having a certificate of authority under this title may be considered to
2535 be a separate carrier for the purposes of this chapter.
2536 (c) Unless otherwise authorized by the commissioner [
2537
2538 arrangements with respect to health benefit plans delivered or issued for delivery to covered
2539 insureds in this state if the ceding arrangements would result in less than 50% of the insurance
2540 obligation or risk for the health benefit plans being retained by the ceding carrier.
2541 (d) Section 31A-22-1201 applies if a covered carrier cedes or assumes all of the
2542 insurance obligation or risk with respect to one or more health benefit plans delivered or issued
2543 for delivery to covered insureds in this state.
2544 (5) (a) A Taft Hartley trust created in accordance with Section 302(c)(5) of the Federal
2545 Labor Management Relations Act, or a carrier with the written authorization of such a trust,
2546 may make a written request to the commissioner for a waiver from the application of any of the
2547 provisions of Subsections 31A-30-106(1) and 31A-30-106.1(1) with respect to a health benefit
2548 plan provided to the trust.
2549 (b) The commissioner may grant a trust or carrier described in Subsection (5)(a) a
2550 waiver if the commissioner finds that application with respect to the trust would:
2551 (i) have a substantial adverse effect on the participants and beneficiaries of the trust;
2552 and
2553 (ii) require significant modifications to one or more collective bargaining arrangements
2554 under which the trust is established or maintained.
2555 (c) A waiver granted under this Subsection (5) may not apply to an individual if the
2556 person participates in a Taft Hartley trust as an associate member of any employee
2557 organization.
2558 (6) Sections 31A-22-618.6, 31A-30-106, 31A-30-106.1, 31A-30-106.5, 31A-30-106.7,
2559 [
2560 (a) any insurer engaging in the business of insurance related to the risk of a small
2561 employer for medical, surgical, hospital, or ancillary health care expenses of the small
2562 employer's employees provided as an employee benefit; and
2563 (b) any contract of an insurer, other than a workers' compensation policy, related to the
2564 risk of a small employer for medical, surgical, hospital, or ancillary health care expenses of the
2565 small employer's employees provided as an employee benefit.
2566 (7) The commissioner may make rules requiring that the marketing practices be
2567 consistent with this chapter for:
2568 (a) a small employer carrier;
2569 (b) a small employer carrier's agent;
2570 (c) an insurance producer;
2571 (d) an insurance consultant; and
2572 (e) a navigator.
2573 Section 23. Section 31A-30-106.7 is amended to read:
2574 31A-30-106.7. Surcharge for groups changing carriers.
2575 (1) (a) Except as provided in Subsection (1)(b), if prior notice is given, a covered
2576 carrier may impose upon a small group that changes coverage to that carrier from another
2577 carrier a one-time surcharge of up to 25% of the annualized premium that the carrier could
2578 otherwise charge under Section 31A-30-106.1.
2579 (b) A covered carrier may not impose the surcharge described in Subsection (1)(a) if:
2580 (i) the change in carriers occurs on the anniversary of the plan year, as defined in
2581 Section 31A-1-301;
2582 (ii) the previous coverage was terminated under Subsection [
2583 31A-22-618.6(5);
2584 (iii) employees from an existing group form a new business; and
2585 (iv) the surcharge is not applied uniformly to all similarly situated small groups.
2586 (2) A covered carrier may not impose the surcharge described in Subsection (1) if the
2587 offer to cover the group occurs at a time other than the anniversary of the plan year because:
2588 (a) (i) the application for coverage is made prior to the anniversary date in accordance
2589 with the covered carrier's published policies; and
2590 (ii) the offer to cover the group is not issued until after the anniversary date; or
2591 (b) (i) the application for coverage is made prior to the anniversary date in accordance
2592 with the covered carrier's published policies; and
2593 (ii) additional underwriting or rating information requested by the covered carrier is not
2594 received until after the anniversary date.
2595 (3) If a covered carrier chooses to apply a surcharge under Subsection (1), the
2596 application of the surcharge and the criteria for incurring or avoiding the surcharge shall be
2597 clearly stated in the:
2598 (a) written application materials provided to the applicant at the time of application;
2599 and
2600 (b) written producer guidelines.
2601 (4) The commissioner shall adopt rules in accordance with Title 63G, Chapter 3, Utah
2602 Administrative Rulemaking Act, to ensure compliance with this section.
2603 Section 24. Section 31A-30-204 is amended to read:
2604 31A-30-204. Employer election -- Defined benefit -- Defined contribution
2605 arrangements -- Responsibilities.
2606 (1) (a) An employer participating in the defined contribution arrangement market on
2607 the Health Insurance Exchange shall make an initial election to offer its employees either a
2608 defined benefit plan or a defined contribution arrangement health benefit plan.
2609 (b) If an employer elects to offer a defined benefit plan:
2610 (i) the employer or the employer's producer shall enroll the employer in the Health
2611 Insurance Exchange;
2612 (ii) the employees shall submit the uniform application required for the Health
2613 Insurance Exchange; and
2614 (iii) the employer shall select the defined benefit plan in accordance with Section
2615 31A-30-208.
2616 (c) When an employer makes an election under Subsections (1)(a) and (b):
2617 (i) the employer may not offer its employees a defined contribution arrangement health
2618 benefit plan; and
2619 (ii) the employees may not select a defined contribution arrangement health benefit
2620 plan in the Health Insurance Exchange.
2621 (d) If an employer elects to offer its employees a defined contribution arrangement
2622 health benefit plan, the employer shall comply with the provisions of Subsections (2) through
2623 (5).
2624 (2) (a) (i) An employer that chooses to participate in a defined contribution
2625 arrangement health benefit plan may not offer to an employee a health benefit plan that is not a
2626 defined contribution arrangement health benefit plan in the Health Insurance Exchange.
2627 (ii) Subsection (2)(a)(i) does not prohibit the offer of supplemental or limited benefit
2628 policies such as dental or vision coverage, or other types of federally qualified savings accounts
2629 for health care expenses.
2630 (b) (i) To the extent permitted by Sections 31A-1-301, 31A-30-112, and 31A-30-206,
2631 and the risk adjustment plan adopted under Section 31A-42-204, the employer reserves the
2632 right to determine:
2633 (A) the criteria for employee eligibility, enrollment, and participation in the employer's
2634 health benefit plan; and
2635 (B) the amount of the employer's contribution to that plan.
2636 (ii) The determinations made under Subsection (2)(b) may only be changed during
2637 periods of open enrollment.
2638 (3) An employer that chooses to establish a defined contribution arrangement health
2639 benefit plan to provide a health benefit plan for its employees shall:
2640 (a) establish a mechanism for its employees to use pre-tax dollars to purchase a health
2641 benefit plan from the defined contribution arrangement market on the [
2642
2643 Avenue H, which may include:
2644 (i) a health reimbursement arrangement;
2645 (ii) a Section 125 Cafeteria plan; or
2646 (iii) another plan or arrangement similar to Subsection (3)(a)(i) or (ii) which is
2647 excluded or deducted from gross income under the Internal Revenue Code;
2648 (b) before the employee's health benefit plan selection period:
2649 (i) inform each employee of the health benefit plan the employer has selected as the
2650 default health benefit plan for the employer group;
2651 (ii) offer each employee a choice of any of the defined contribution arrangement health
2652 benefit plans available through the defined contribution arrangement market on the Health
2653 Insurance Exchange; and
2654 (iii) notify the employee that the employee will be enrolled in the default health benefit
2655 plan selected by the employer and payroll deductions initiated for premium payments, unless
2656 the employee, before the employee's selection period ends:
2657 (A) selects a different defined contribution arrangement health benefit plan available in
2658 the Health Insurance Exchange;
2659 (B) provides proof of coverage from another health benefit plan; or
2660 (C) specifically declines coverage in a health benefit plan.
2661 (4) An employer shall enroll an employee in the default defined contribution
2662 arrangement health benefit plan selected by the employer if the employee does not make one of
2663 the choices described in Subsection (3)(b)(iii) before the end of the employee selection period,
2664 which may not be less than 14 calendar days.
2665 (5) The employer's notice to the employee under Subsection (3)(b)(iii) shall inform the
2666 employee that the failure to act under Subsections (3)(b)(iii)(A) through (C) is considered an
2667 affirmative election under pre-tax payroll deductions for the employer to begin payroll
2668 deductions for health benefit plan premiums.
2669 Section 25. Section 31A-34-110 is amended to read:
2670 31A-34-110. Contracts with member employers and contracted insurers.
2671 (1) Contracts between an alliance and members shall provide that the alliance is the
2672 contract holder of the health benefit plan policy on behalf of members and enrollees.
2673 (2) Contracts between an alliance and a contracted insurer shall specify how premiums
2674 will be transferred, what penalties and grace periods will be, and how examination costs will be
2675 allocated to contracted insurers.
2676 [
2677
2678
2679
2680
2681 Section 26. Section 31A-45-101 is enacted to read:
2682
2683
2684 31A-45-101. Title.
2685 This chapter is known as "Managed Care Organizations."
2686 Section 27. Section 31A-45-102 is enacted to read:
2687 31A-45-102. Definitions.
2688 As used in this chapter:
2689 (1) "Covered benefit" or "benefit" means the health care services to which a covered
2690 person is entitled under the terms of a health benefit plan.
2691 (2) "Managed care organization" means:
2692 (a) a managed care organization as that term is defined in Section 31A-1-103; and
2693 (b) a third party administrator as that term is defined in Section 31A-1-103.
2694 Section 28. Section 31A-45-103 is enacted to read:
2695 31A-45-103. Managed care contract standards.
2696 The commissioner shall adopt rules relating to standards for the manner and content of
2697 policy provisions, and disclosures to be made in connection with the sale of policies covered by
2698 this chapter, dealing with at least the following matters:
2699 (1) terms of renewability;
2700 (2) initial and subsequent conditions of eligibility;
2701 (3) nonduplication of coverage provisions;
2702 (4) coverage of dependents;
2703 (5) termination of insurance;
2704 (6) limitations;
2705 (7) exceptions;
2706 (8) reductions;
2707 (9) definition of terms; and
2708 (10) rating practices.
2709 Section 29. Section 31A-45-201 is enacted to read:
2710
2711 31A-45-201. Applicability to other provisions of law -- Commissioner discretion.
2712 (1) Except for exemptions specifically granted under this title, a managed care
2713 organization is subject to regulation under all of the provisions of this title.
2714 (2) The commissioner may by rule waive other specific provisions of this title that the
2715 commissioner considers inapplicable to managed care organizations, upon a finding that the
2716 waiver will not endanger the interests of:
2717 (a) enrollees;
2718 (b) investors;
2719 (c) the public; or
2720 (d) health care providers.
2721 Section 30. Section 31A-45-301 is enacted to read:
2722
2723 31A-45-301. Written contracts -- Limited liability of enrollee -- Provider claim
2724 disputes -- Leased networks.
2725 (1) A managed care organization may not contract with a health care provider for
2726 treatment of illness or injury unless the health care provider is licensed to perform that
2727 treatment. Every contract between a managed care organization and a network provider shall be
2728 in writing and shall set forth that if the managed care organization:
2729 (a) fails to pay for health care services as set forth in the contract, the enrollee is not
2730 liable to the health care provider for any sums owed by the managed care organization; and
2731 (b) becomes insolvent, the rehabilitator or liquidator may require the network provider
2732 to:
2733 (i) continue to provide health care services under the contract between the network
2734 provider and the managed care organization until the earlier of:
2735 (A) 90 days after the date of the filing of a petition for rehabilitation or a petition for
2736 liquidation; or
2737 (B) the date the term of the contract ends; and
2738 (ii) subject to Subsection (3), reduce the fees the network provider is otherwise entitled
2739 to receive from the managed care organization under the contract between the network provider
2740 and the managed care organization during the time period described in Subsection (1)(b)(i).
2741 (2) If the conditions of Subsection (3) are met, the network provider:
2742 (a) shall accept the reduced payment as payment in full; and
2743 (b) as provided in Subsection (1)(a), may not collect additional amounts from the
2744 insolvent managed care organization's enrollee, except as may be owed under Subsection
2745 (3)(b).
2746 (3) Notwithstanding Subsection (1)(b)(ii):
2747 (a) the rehabilitator or liquidator may not reduce a fee to less than 75% of the regular
2748 fee set forth in the network provider contract; and
2749 (b) the enrollee shall continue to pay the same copayments, deductibles, and other
2750 payments for services received from the network provider that the enrollee was required to pay
2751 before the filing of:
2752 (i) the petition for rehabilitation; or
2753 (ii) the petition for liquidation.
2754 (4) A network provider may not collect or attempt to collect from the enrollee sums
2755 owed by the managed care organization or the amount of the regular fee reduction authorized
2756 under Subsection (1)(b)(ii) if the network provider contract:
2757 (a) is not in writing as required in Subsection (1); or
2758 (b) fails to contain the language required by Subsection (1).
2759 (5) (a) A person listed in Subsection (5)(b) may not bill or maintain any action at law
2760 against an enrollee to collect:
2761 (i) sums owed by the organization; or
2762 (ii) the amount of the regular fee reduction authorized under Subsection (1)(b)(ii).
2763 (b) Subsection (5)(a) applies to:
2764 (i) a network provider;
2765 (ii) an agent;
2766 (iii) a trustee; or
2767 (iv) an assignee of a person described in Subsections (5)(b)(i) through (iii).
2768 (c) In any dispute involving a network provider's claim for reimbursement, the network
2769 provider's claim shall be determined in accordance with applicable law, the network provider
2770 contract, the enrollee contract, and the managed care organization's written payment policies in
2771 effect at the time services were rendered.
2772 (d) If the parties are unable to resolve their dispute, the matter shall be subject to
2773 binding arbitration by a jointly selected arbitrator. Each party shall bear its own expense except
2774 that the cost of the jointly selected arbitrator shall be equally shared. This Subsection (5)(d)
2775 does not apply to the claim of a general acute hospital to the extent the claim is inconsistent
2776 with the hospital's provider agreement.
2777 (e) A managed care organization may not penalize a network provider solely for
2778 pursuing a claims dispute or otherwise demanding payment for a sum believed owing.
2779 (6) If a managed care organization permits another private entity with which the
2780 managed care organization does not share common ownership or control to use or otherwise
2781 lease one or more of the organization's networks that include network providers, the managed
2782 care organization shall ensure, at a minimum, that the entity pays the network providers
2783 included in the managed care organization's network in accordance with the same fee schedule
2784 and general payment policies as the managed care organization would pay for those network
2785 providers, unless payment for services is governed by a public program's fee schedule.
2786 Section 31. Section 31A-45-302 is enacted to read:
2787 31A-45-302. Provider payment information -- Notice of admissions.
2788 (1) (a) A managed care organization shall provide the managed care organization's
2789 network providers access to current information necessary for the network provider to
2790 determine:
2791 (i) the effect of procedure codes on payment or compensation before a claim is
2792 submitted for a procedure;
2793 (ii) the plans and carrier networks that the network provider is subject to as part of the
2794 contract with the managed care organization; and
2795 (iii) in accordance with Subsection 31A-26-301.6(10)(f), the specific rate and terms
2796 under which the network provider will be paid for health care services.
2797 (b) The information required by Subsection (1)(a) may be provided through a website,
2798 and if requested by the network provider, notice of the updated website shall be provided by
2799 the managed care organization.
2800 (2) (a) A managed care organization may not require a health care provider by contract,
2801 reimbursement procedure, or otherwise to notify the managed care organization of a hospital
2802 inpatient emergency admission within a period of time that is less than one business day of the
2803 hospital inpatient admission, if compliance with the notification requirement would result in
2804 notification by the health care provider on a weekend or federal holiday.
2805 (b) Subsection (2)(a) does not prohibit the applicability or administration of other
2806 contract provisions between a managed care organization and a network provider that require
2807 preauthorization for scheduled inpatient admissions.
2808 Section 32. Section 31A-45-303, which is renumbered from Section 31A-22-617 is
2809 renumbered and amended to read:
2810 [
2811 [
2812 (1) Managed care organizations may provide for [
2813 services or reimbursement under the [
2814 [
2815 [
2816
2817 [
2818 provider and supply services, at prices specified in the contracts, to [
2819
2820 [
2821
2822 in full, relinquishing the right to collect [
2823 coinsurance, and deductibles from the [
2824 [
2825
2826
2827 [
2828
2829
2830
2831
2832 [
2833
2834 [
2835
2836
2837
2838
2839 [
2840 [
2841 (i) reducing premium rates;
2842 (ii) reducing deductibles;
2843 (iii) coinsurance;
2844 (iv) other copayments; or
2845 (v) any other reasonable manner.
2846 [
2847
2848 [
2849
2850 [
2851
2852 [
2853
2854 [
2855 [
2856
2857
2858 [
2859 [
2860 [
2861
2862 [
2863
2864
2865
2866 [
2867 [
2868 [
2869
2870
2871 [
2872 [
2873 [
2874 [
2875 [
2876 [
2877
2878 [
2879
2880
2881 [
2882 [
2883 [
2884
2885
2886 [
2887
2888 (i) make direct payment to the [
2889 [
2890 (ii) impose a deductible on coverage of health care providers not under contract.
2891 (b) (i) Subsections (3)(b)(iii) and (c) apply to a managed care organization licensed
2892 under:
2893 (A) Chapter 5, Domestic Stock and Mutual Insurance Corporations;
2894 (B) Chapter 7, Nonprofit Health Service Insurance Corporations; or
2895 (C) Chapter 14, Foreign Insurers; and
2896 (ii) Subsections (3)(b)(iii) and (c) and Subsection (6)(b) do not apply to a managed care
2897 organization licensed under Chapter 8, Health Maintenance Organizations and Limited Health
2898 Plans.
2899 [
2900 Subsection [
2901 may not unfairly discriminate between classes of health care providers, but may discriminate
2902 within a class of health care providers, subject to Subsection [
2903 [
2904 care providers includes:
2905 (i) refusal to contract with class members in reasonable proportion to the number of
2906 insureds covered by the insurer and the expected demand for services from class members; and
2907 (ii) refusal to cover procedures for one class of providers that are:
2908 (A) commonly used by members of the class of health care providers for the treatment
2909 of illnesses, injuries, or conditions;
2910 (B) otherwise covered by the [
2911 (C) within the scope of practice of the class of health care providers.
2912 [
2913 managed care organization shall fully disclose to the [
2914 care organization has entered into [
2915 [
2916
2917 insurance contract. The [
2918 following information:
2919 (a) a list of the health care providers under contract, and if requested their business
2920 locations and specialties;
2921 (b) a description of the insured benefits, including deductibles, coinsurance, or other
2922 copayments;
2923 (c) a description of the quality assurance program required under Subsection [
2924 and
2925 (d) a description of the adverse benefit determination procedures required under
2926 [
2927 [
2928 (5) (a) A managed care organization using network provider contracts shall maintain a
2929 quality assurance program for assuring that the care provided by the [
2930
2931 (b) The commissioner in consultation with the executive director of the Department of
2932 Health may designate qualified persons to perform an audit of the quality assurance program.
2933 The auditors shall have full access to all records of the managed care organization and [
2934 managed care organization's health care providers, including medical records of individual
2935 patients.
2936 (c) The information contained in the medical records of individual patients shall
2937 remain confidential. All information, interviews, reports, statements, memoranda, or other data
2938 furnished for purposes of the audit and any findings or conclusions of the auditors are
2939 privileged. The information is not subject to discovery, use, or receipt in evidence in any legal
2940 proceeding except hearings before the commissioner concerning alleged violations of this
2941 section.
2942 [
2943
2944
2945 [
2946
2947 [
2948 discriminate against a [
2949 Subsection [
2950 (b) (i) Ĥ→ [
2950a managed care organization that is described
2951 in Subsection (3)(b)(i) and Ĥ→ [
2951a in
2952 Subsection (3)(b)(ii).
2953 (ii) A health care provider licensed to treat an illness or injury within the scope of the
2954 health care provider's practice, [
2955 established by the [
2956
2957
2958 limitations on the number of designated [
2959 substantial objective and economic grounds, or expected use of particular services based upon
2960 prior provider-patient profiles.
2961 [
2962 contract, the commissioner may hold a hearing to determine if the [
2963 organization's exclusion of the provider is based on the criteria set forth in Subsection [
2964 (6)(b).
2965 [
2966 care organization to offer a certain benefit or service as part of a health benefit plan.
2967 [
2968
2969 [
2970
2971 party administrator is not required to, but may, enter into a contract with a licensed athletic
2972 trainer, licensed under Title 58, Chapter 40a, Athletic Trainer Licensing Act.
2973 Section 33. Section 31A-45-304, which is renumbered from Section 31A-22-617.1 is
2974 renumbered and amended to read:
2975 [
2976 participating providers -- Termination of contracts -- Review process.
2977 (1) (a) [
2978
2979 organization shall establish criteria for adding health care providers to a new or existing
2980 network provider panel.
2981 (b) Criteria under Subsection (1)(a) may include[
2982 (i) training, certification, and hospital privileges;
2983 (ii) number of [
2984 [
2985 (iii) any other factor that is reasonably related to promote or protect good patient care,
2986 address costs, take into account on-call and cross-coverage relationships between providers, or
2987 serve the lawful interests of the [
2988 (c) [
2989 provider upon request and shall file the same with the department.
2990 (d) Upon receipt of a provider application and upon receiving all necessary
2991 information, [
2992 application for participation within 120 days.
2993 (e) If the provider applicant is rejected, the [
2994 inform the provider of the reason for the rejection relative to the criteria established in
2995 accordance with Subsection (1)(b).
2996 (f) [
2997 solely on:
2998 (i) the provider's staff privileges at a general acute care hospital not under contract with
2999 the [
3000 (ii) the provider's referral patterns for patients who are not covered by the [
3001 managed care organization.
3002 (g) Criteria set out in Subsection (1)(b) may be modified or changed from time to time
3003 to meet the business needs of the market in which the [
3004 operates and, if modified, will be filed with the department as provided in Subsection (1)(c).
3005 (h) With the exception of Subsection (1)(f), this section does not create any new or
3006 additional private right of action for redress.
3007 (2) (a) For the first two years, [
3008 its contract with a provider with or without cause upon giving the requisite amount of notice
3009 provided in the agreement, but in no case shall it be less than 60 days.
3010 (b) An agreement may be terminated for cause as provided in the contract established
3011 between the [
3012 sufficiently certain criteria so that the provider can be reasonably informed of the grounds for
3013 termination for cause.
3014 (c) [
3015 organization:
3016 (i) shall inform the provider of the intent to terminate and the grounds for doing so;
3017 (ii) shall at the request of the provider, meet with the provider to discuss the reasons for
3018 termination;
3019 (iii) if the [
3020 provider may correct the conduct giving rise to the notice of termination, [
3021 its discretion, place the provider on probation with corrective action requirements, restrictions,
3022 or both, as necessary to protect patient care; and
3023 (iv) if the [
3024 provider has engaged in fraudulent conduct or poses a significant risk to patient care or safety,
3025 [
3026 contract, provided that the remaining provisions of this Subsection (2) are followed in a timely
3027 manner before termination may become final.
3028 (d) Each [
3029 for actions that may result in terminated participation with cause and make known to the
3030 provider the procedure for appealing such termination.
3031 (i) Providers dissatisfied with the results of the appeal process may, if both parties
3032 agree, submit the matters in dispute to mediation.
3033 (ii) If the matters in dispute are not mediated, or should mediation be unsuccessful, the
3034 dispute shall be subject to binding arbitration by an arbitrator jointly selected by the parties, the
3035 cost of which shall be jointly shared. Each party shall bear its own additional expenses.
3036 (e) A termination under Subsection (2)(a) or (b) may not be based on:
3037 (i) the provider's staff privileges at a general acute care hospital not under contract with
3038 the [
3039 (ii) the provider's referral patterns for patients who are not covered by the [
3040 managed care organization.
3041 (3) Notwithstanding any other section of this title, [
3042 organization may not take adverse action against or reduce reimbursement to a [
3043 network provider who is not under a capitated reimbursement arrangement because of the
3044 decision of an [
3045 non-network provider in a manner permitted by the [
3046 regardless of how the plan is designated.
3047 Section 34. Section 31A-45-401, which is renumbered from Section 31A-8-502 is
3048 renumbered and amended to read:
3049
3050 [
3051 reside outside the service area.
3052 (1) (a) The requirements of Subsection (2) apply to a [
3053
3054 organization health benefit plan:
3055 (i) restricts coverage for nonemergency services to services provided by contracted
3056 providers within the organization's service area; and
3057 (ii) does not offer a benefit that permits members the option of obtaining covered
3058 services from a [
3059 (b) The requirements of Subsection (2) do not apply to a [
3060 managed care organization if:
3061 (i) the child that is the subject of a court or administrative support order is over the age
3062 of 18 and is no longer enrolled in high school; or
3063 (ii) a parent's employer offers the parent a choice to select health insurance coverage
3064 that is not a [
3065 or administrative support order, or at a subsequent open enrollment period. This exemption
3066 from Subsection (2) applies even if the parent ultimately chooses the [
3067 managed care organization plan.
3068 (2) If a parent is required by a court or administrative support order to provide health
3069 insurance coverage for a child who resides outside of a [
3070 organization's service area, the [
3071 (a) comply with the provisions of Section 31A-22-610.5;
3072 (b) allow the enrollee parent to enroll the child on the organization plan;
3073 (c) pay for otherwise covered health care services rendered to the child outside of the
3074 service area by a [
3075 (i) if the child, noncustodial parent, or custodial parent has complied with prior
3076 authorization or utilization review otherwise required by the organization; and
3077 (ii) in an amount equal to the dollar amount the organization pays under a noncapitated
3078 arrangement for comparable services to a [
3079 health care providers as the provider who rendered the services; and
3080 (d) make payments on claims submitted in accordance with Subsection (2)(c) directly
3081 to the provider, custodial parent, the child who obtained benefits, or state Medicaid agency.
3082 (3) (a) The parents of the child who is the subject of the court or administrative support
3083 order are responsible for any charges billed by the provider in excess of those paid by the
3084 organization.
3085 (b) This section does not affect any court or administrative order regarding the
3086 responsibilities between the parents to pay any medical expenses not covered by accident and
3087 health insurance or a [
3088 (4) The commissioner shall adopt rules as necessary to administer this section and
3089 Section 31A-22-610.5.
3090 Section 35. Section 31A-45-402 is enacted to read:
3091 31A-45-402. Alcohol and drug dependency treatment.
3092 (1) A managed care organization offering a health benefit plan providing coverage for
3093 alcohol or drug dependency treatment may require an inpatient facility to be licensed by:
3094 (a) (i) the Department of Human Services, under Title 62A, Chapter 2, Licensure of
3095 Programs and Facilities; or
3096 (ii) the Department of Health; or
3097 (b) for an inpatient facility located outside the state, a state agency similar to one
3098 described in Subsection (1)(a).
3099 (2) For inpatient coverage provided pursuant to Subsection (1), a managed care
3100 organization may require an inpatient facility to be accredited by the following:
3101 (a) the Joint Commission; and
3102 (b) one other nationally recognized accrediting agency.
3103 Section 36. Section 31A-45-501, which is renumbered from Section 31A-8-501 is
3104 renumbered and amended to read:
3105
3106 [
3107 (1) As used in this section:
3108 (a) "Class of health care provider" means a health care provider or a health care facility
3109 regulated by the state within the same professional, trade, occupational, or certification
3110 category established under Title 58, Occupations and Professions, or within the same facility
3111 licensure category established under Title 26, Chapter 21, Health Care Facility Licensing and
3112 Inspection Act.
3113 (b) "Covered health care services" or "covered services" means health care services for
3114 which an enrollee is entitled to receive under the terms of a health maintenance organization
3115 contract.
3116 (c) "Credentialed staff member" means a health care provider with active staff
3117 privileges at an independent hospital or federally qualified health center.
3118 (d) "Federally qualified health center" means as defined in the Social Security Act, 42
3119 U.S.C. Sec. 1395x.
3120 (e) "Independent hospital" means a general acute hospital or a critical access hospital
3121 that:
3122 (i) is either:
3123 (A) located 20 miles or more from any other general acute hospital or critical access
3124 hospital; or
3125 (B) licensed as of January 1, 2004;
3126 (ii) is licensed pursuant to Title 26, Chapter 21, Health Care Facility Licensing and
3127 Inspection Act; and
3128 (iii) is controlled by a board of directors of which 51% or more reside in the county
3129 where the hospital is located and:
3130 (A) the board of directors is ultimately responsible for the policy and financial
3131 decisions of the hospital; or
3132 (B) the hospital is licensed for 60 or fewer beds and is not owned, in whole or in part,
3133 by an entity that owns or controls a health maintenance organization if the hospital is a
3134 contracting facility of the organization.
3135 (f) "Noncontracting provider" means an independent hospital, federally qualified health
3136 center, or credentialed staff member [
3137 managed care organization to provide health care services to enrollees of the managed care
3138 organization.
3139 (2) Except for a [
3140 the common ownership or control of an entity with a hospital located within 10 paved road
3141 miles of an independent hospital, a [
3142 for covered health care services rendered to an enrollee by an independent hospital, a
3143 credentialed staff member at an independent hospital, or a credentialed staff member at his
3144 local practice location if:
3145 (a) the enrollee:
3146 (i) lives or resides within 30 paved road miles of the independent hospital; or
3147 (ii) if Subsection (2)(a)(i) does not apply, lives or resides in closer proximity to the
3148 independent hospital than a contracting hospital;
3149 (b) the independent hospital is located prior to December 31, 2000 in a county with a
3150 population density of less than 100 people per square mile, or the independent hospital is
3151 located in a county with a population density of less than 30 people per square mile; and
3152 (c) the enrollee has complied with the prior authorization and utilization review
3153 requirements otherwise required by the [
3154 contract.
3155 (3) A [
3156 services rendered to an enrollee at a federally qualified health center if:
3157 (a) the enrollee:
3158 (i) lives or resides within 30 paved road miles of the federally qualified health center;
3159 or
3160 (ii) if Subsection (3)(a)(i) does not apply, lives or resides in closer proximity to the
3161 federally qualified health center than a contracting provider;
3162 (b) the federally qualified health center is located in a county with a population density
3163 of less than 30 people per square mile; and
3164 (c) the enrollee has complied with the prior authorization and utilization review
3165 requirements otherwise required by the [
3166 contract.
3167 (4) (a) A [
3168 noncontracting provider or the enrollee for covered services rendered pursuant to Subsection
3169 (2) a like dollar amount as it pays to contracting providers under a noncapitated arrangement
3170 for comparable services.
3171 (b) A [
3172 qualified health center or the enrollee for covered services rendered pursuant to Subsection (3)
3173 a like amount as paid by the [
3174 noncapitated arrangement for comparable services to a contracting provider in the same class
3175 of health care providers as the provider who rendered the service.
3176 (5) (a) A noncontracting independent hospital may not balance bill a patient when the
3177 health maintenance organization reimburses a noncontracting independent hospital or an
3178 enrollee in accordance with Subsection (4)(a).
3179 (b) A noncontracting federally qualified health center may not balance bill a patient
3180 when the federally qualified health center or the enrollee receives reimbursement in accordance
3181 with Subsection (4)(b).
3182 (6) A noncontracting provider may only refer an enrollee to another noncontracting
3183 provider so as to obligate the enrollee's [
3184 for the resulting services if:
3185 (a) the noncontracting provider making the referral or the enrollee has received prior
3186 authorization from the organization for the referral; or
3187 (b) the practice location of the noncontracting provider to whom the referral is made:
3188 (i) is located in a county with a population density of less than 25 people per square
3189 mile; and
3190 (ii) is within 30 paved road miles of:
3191 (A) the place where the enrollee lives or resides; or
3192 (B) the independent hospital or federally qualified health center at which the enrollee
3193 may receive covered services pursuant to Subsection (2) or (3).
3194 (7) Notwithstanding this section, a [
3195 may contract directly with an independent hospital, federally qualified health center, or
3196 credentialed staff member.
3197 (8) (a) A [
3198 of this section is subject to sanctions as determined by the commissioner in accordance with
3199 Section 31A-2-308.
3200 (b) Violations of this section include:
3201 (i) failing to provide the notice required by Subsection (8)(d) by placing the notice in
3202 any [
3203 including any website maintained by the [
3204 (ii) failing to provide notice of an enrollee's rights under this section when:
3205 (A) an enrollee makes personal contact with the [
3206 organization by telephone, electronic transaction, or in person; and
3207 (B) the enrollee inquires about [
3208 hospital or federally qualified health center; and
3209 (iii) refusing to reprocess or reconsider a claim, initially denied by the [
3210
3211 claim.
3212 (c) The commissioner shall, pursuant to Chapter 2, Part 2, Duties and Powers of
3213 Commissioner:
3214 (i) adopt rules as necessary to implement this section;
3215 (ii) identify in rule:
3216 (A) the counties with a population density of less than 100 people per square mile;
3217 (B) independent hospitals as defined in Subsection (1)(e); and
3218 (C) federally qualified health centers as defined in Subsection (1)(d).
3219 (d) (i) A [
3220 (A) use the information developed by the commissioner under Subsection (8)(c) to
3221 identify the rural counties, independent hospitals, and federally qualified health centers that are
3222 located in the [
3223 (B) include the providers identified under Subsection (8)(d)(i)(A) in the notice required
3224 in Subsection (8)(d)(ii).
3225 (ii) The [
3226 notice, in bold type, to enrollees as specified under Subsection (8)(b)(i), and shall keep the
3227 notice current:
3228 "You may be entitled to coverage for health care services from the following
3229 [
3230 miles of the listed providers, or if you live or reside in closer proximity to the listed providers
3231 than to your [
3232 This list may change periodically, please check on our website or call for verification.
3233 Please be advised that if you choose a noncontracted provider you will be responsible for any
3234 charges not covered by your health insurance plan.
3235 If you have questions concerning your rights to see a provider on this list you may
3236 contact your [
3237 managed care organization does not resolve your problem, you may contact the Office of
3238 Consumer Health Assistance in the Insurance Department, toll free."
3239 (e) A person whose interests are affected by an alleged violation of this section may
3240 contact the Office of Consumer Health Assistance and request assistance, or file a complaint as
3241 provided in Section 31A-2-216.
3242 Section 37. Section 49-20-407 is amended to read:
3243 49-20-407. Insurance mandates.
3244 Notwithstanding the provisions of Subsection 31A-1-103(3)(f):
3245 (1) health coverage offered to the state employee risk pool under Subsection
3246 49-20-202(1)(a) shall comply with the provisions of Sections [
3247 and Ĥ→ [
3248 (2) a health plan offered to public school districts, charter schools, and institutions of
3249 higher education under Subsection 49-20-201(1)(b) shall comply with the provisions of Section
3250 31A-22-605.5.
3251 Section 38. Section 53-2a-1102 is amended to read:
3252 53-2a-1102. Search and Rescue Financial Assistance Program -- Uses --
3253 Rulemaking -- Distribution.
3254 (1) (a) "Assistance card program" means the Utah Search and Rescue Assistance Card
3255 Program created within this section.
3256 (b) "Card" means the Search and Rescue Assistance Card issued under this section to a
3257 participant.
3258 (c) "Participant" means an individual, family, or group who is registered pursuant to
3259 this section as having a valid card at the time search, rescue, or both are provided.
3260 (d) "Program" means the Search and Rescue Financial Assistance Program created
3261 within this section.
3262 (e) (i) "Reimbursable expenses," as used in this section, means those reasonable
3263 expenses incidental to search and rescue activities.
3264 (ii) "Reimbursable expenses" include:
3265 (A) rental for fixed wing aircraft, helicopters, snowmobiles, boats, and generators;
3266 (B) replacement and upgrade of search and rescue equipment;
3267 (C) training of search and rescue volunteers;
3268 (D) costs of providing workers' compensation benefits for volunteer search and rescue
3269 team members under Section 67-20-7.5; and
3270 (E) any other equipment or expenses necessary or appropriate for conducting search
3271 and rescue activities.
3272 (iii) "Reimbursable expenses" do not include any salary or overtime paid to any person
3273 on a regular or permanent payroll, including permanent part-time employees of any agency of
3274 the state.
3275 (f) "Rescue" means search services, rescue services, or both search and rescue services.
3276 (2) There is created the Search and Rescue Financial Assistance Program within the
3277 division.
3278 (3) (a) The program shall be funded from the following revenue sources:
3279 (i) any voluntary contributions to the state received for search and rescue operations;
3280 (ii) money received by the state under Subsection (11) and under Sections 23-19-42,
3281 41-22-34, and 73-18-24; and
3282 (iii) appropriations made to the program by the Legislature.
3283 (b) All money received from the revenue sources in Subsections (3)(a)(i) and (ii) shall
3284 be deposited into the General Fund as a dedicated credit to be used solely for the purposes
3285 under this section.
3286 (c) All funding for the program is nonlapsing.
3287 (4) The director shall use the money to reimburse counties for all or a portion of each
3288 county's reimbursable expenses for search and rescue operations, subject to:
3289 (a) the approval of the Search and Rescue Advisory Board as provided in Section
3290 53-2a-1104;
3291 (b) money available in the program; and
3292 (c) rules made under Subsection (7).
3293 (5) Program money may not be used to reimburse for any paid personnel costs or paid
3294 man hours spent in emergency response and search and rescue related activities.
3295 (6) The Legislature finds that these funds are for a general and statewide public
3296 purpose.
3297 (7) The division, with the approval of the Search and Rescue Advisory Board, shall
3298 make rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, and
3299 consistent with this section:
3300 (a) specifying the costs that qualify as reimbursable expenses;
3301 (b) defining the procedures of counties to submit expenses and be reimbursed;
3302 (c) defining a participant in the assistance card program, including:
3303 (i) individuals; and
3304 (ii) families and organized groups who qualify as participants;
3305 (d) defining the procedure for issuing a card to a participant;
3306 (e) defining excluded expenses that may not be reimbursed under the program,
3307 including medical expenses;
3308 (f) establishing the card renewal cycle for the Utah Search and Rescue Assistance Card
3309 Program;
3310 (g) establishing the frequency of review of the fee schedule;
3311 (h) providing for the administration of the program; and
3312 (i) providing a formula to govern the distribution of available money among the
3313 counties for uncompensated search and rescue expenses based on:
3314 (i) the total qualifying expenses submitted;
3315 (ii) the number of search and rescue incidents per county population;
3316 (iii) the number of victims that reside outside the county; and
3317 (iv) the number of volunteer hours spent in each county in emergency response and
3318 search and rescue related activities per county population.
3319 (8) (a) The division shall, in consultation with the Outdoor Recreation Office, establish
3320 the fee schedule of the Search and Rescue Assistance Card under Subsection 63J-1-504(6).
3321 (b) The division shall provide a discount of not less than 10% of the card fee under
3322 Subsection (8)(a) to a person who has paid a fee under Section 23-19-42, 41-22-34, or
3323 73-18-24 during the same calendar year in which the person applies to be a participant in the
3324 assistance card program.
3325 (9) (a) Counties may bill reimbursable expenses to an individual for costs incurred for
3326 the rescue of an individual, if the individual is not a participant in the Utah Search and Rescue
3327 Assistance Card Program.
3328 (b) Counties may bill a participant for reimbursable expenses for costs incurred for the
3329 rescue of the participant if the participant is found by the rescuing county to have acted
3330 recklessly or to have intentionally created a situation resulting in the need for a county to
3331 provide rescue service for the participant.
3332 (10) (a) There is created the Utah Search and Rescue Assistance Card Program. The
3333 program is located within the division.
3334 (b) The program may not be utilized to cover any expenses, such as medically related
3335 expenses, that are not reimbursable expenses related to the rescue.
3336 (11) (a) To participate in the program, a person shall purchase a Search and Rescue
3337 Assistance Card from the division by paying the fee as determined by the division in
3338 Subsection (8).
3339 (b) The money generated by the fees shall be deposited into the General Fund as a
3340 dedicated credit for the Search and Rescue Financial Assistance Program created in this
3341 section.
3342 (c) Participation and payment of fees by a person under Sections 23-19-42, 41-22-34,
3343 and 73-18-24 do not constitute purchase of a card under this section.
3344 (12) The division shall consult with the Outdoor Recreation Office regarding:
3345 (a) administration of the assistance card program; and
3346 (b) outreach and marketing strategies.
3347 (13) Pursuant to Subsection 31A-1-103(7), the Utah Search and Rescue Assistance
3348 Card Program under this section is exempt from being considered [
3349
3350 Section 39. Section 58-16a-601 is amended to read:
3351 58-16a-601. Scope of practice.
3352 (1) An optometrist may:
3353 (a) provide optometric services not specifically prohibited under this chapter or
3354 division rules if the services are within the optometrist's training, skills, and scope of
3355 competence; and
3356 (b) prescribe or administer pharmaceutical agents for the eye and its adnexa, including
3357 oral agents, subject to the following conditions:
3358 (i) an optometrist may prescribe oral antibiotics for only eyelid related ocular
3359 conditions or diseases, and other ocular conditions or diseases specified by division rule; and
3360 (ii) an optometrist may administer or prescribe a hydrocodone combination drug, or a
3361 Schedule III controlled substance, as defined in Section 58-37-4, only if:
3362 (A) the substance is administered or prescribed for pain of the eye or adnexa;
3363 (B) the substance is administered orally or topically or is prescribed for oral or topical
3364 use;
3365 (C) the amount of the substance administered or prescribed does not exceed a 72-hour
3366 quantity; and
3367 (D) if the substance is prescribed, the prescription does not include refills.
3368 (2) An optometrist may not:
3369 (a) perform surgery, including laser surgery; or
3370 (b) prescribe or administer a Schedule II controlled substance, as defined in Section
3371 58-37-4, except for a hydrocodone combination drug, if so scheduled and prescribed or
3372 administered in accordance with Subsection (1)(b).
3373 (3) For purposes of Sections [
3374 optometrist is a health care provider.
3375 Section 40. Section 63I-2-231 is amended to read:
3376 63I-2-231. Repeal dates, Title 31A.
3377 (1) Section 31A-22-315.5 is repealed July 1, 2019.
3378 (2) Title 31A, Chapter 30, Part 2, Defined Contribution Arrangements is repealed July
3379 1, 2019.
3380 (3) Title 31A, Chapter 30, Part 3, Individual and Small Employer Risk Adjustment Act
3381 is repealed July 1, 2019.
3382 [
3383 December 31, 2018.
3384 (5) Section 31A-45-503 is repealed July 1, 2022.
3385 Section 41. Section 63N-11-104 is amended to read:
3386 63N-11-104. Creation of Office of Consumer Health Services -- Duties.
3387 (1) There is created within the Governor's Office of Economic Development the Office
3388 of Consumer Health Services.
3389 (2) The [
3390 [
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3392
3393 [
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3457
3458 (a) carry out the duties described in Section 63N-11-103;
3459 (b) maintain the services provided by the office for the Avenue H small employer
3460 health insurance exchange until Ĥ→ [
3460a Subsection (2)(d);
3460b (c) beginning July 1, 2017, enroll or renew a small employer group with a single insurer
3460c selected by the small employer, while allowing for employee choice among health benefit plans
3460d offered by the single insurer selected by the small employer; and
3461 [
3461a employer
3462 health insurance exchange effective Ĥ→ [
3463 Section 42. Health Reform Task Force -- Creation -- Membership -- Interim rules
3464 followed -- Compensation -- Staff.
3465 (1) There is created the Health Reform Task Force consisting of the following 11
3466 members:
3467 (a) four members of the Senate appointed by the president of the Senate, no more than
3468 three of whom may be from the same political party; and
3469 (b) seven members of the House of Representatives appointed by the speaker of the
3470 House of Representatives, no more than five of whom may be from the same political party.
3471 (2) (a) The president of the Senate shall designate a member of the Senate appointed
3472 under Subsection (1)(a) as a cochair of the task force.
3473 (b) The speaker of the House of Representatives shall designate a member of the House
3474 of Representatives appointed under Subsection (1)(b) as a cochair of the task force.
3475 (3) In conducting the task force's business, the task force shall comply with the rules of
3476 legislative interim committees.
3477 (4) Salaries and expenses of the members of the task force shall be paid in accordance
3478 with Section 36-2-2 and Legislative Joint Rules, Title 5, Chapter 3, Legislator Compensation.
3479 (5) The Office of Legislative Research and General Counsel shall provide staff support
3480 to the task force.
3481 Section 43. Duties -- Interim report.
3482 (1) The task force shall review and make recommendations on the following issues:
3483 (a) the need for state statutory and regulatory changes in response to federal actions
3484 affecting health care;
3485 (b) Medicaid and reforms to the Medicaid program;
3486 (c) options for increasing state flexibility, including the use of federal waivers;
3487 (d) the state's health insurance marketplace;
3488 (e) combining managed care organizations and health insurers into a guaranty
3489 association that includes only health insurers;
3490 (f) health insurance code modifications;
3491 (g) insurance network adequacy standards and balance billing;
3492 (h) access to health care for medically underserved populations in the state; and
3493 (i) the state's strategic plan for health system reform in Section 63N-11-105.
3494 (2) A final report, including any proposed legislation, shall be presented to the
3495 Business and Labor Interim Committee and Health and the Human Services Interim Committee
3496 before November 30, 2017, and November 30, 2018.
3497 Section 44. Repealer.
3498 This bill repeals:
3499 Section 31A-22-721, A health benefit plan for a plan sponsor -- Discontinuance
3500 and nonrenewal.
3501 Section 31A-30-107, Renewal -- Limitations -- Exclusions -- Discontinuance and
3502 nonrenewal.
3503 Section 31A-30-107.1, Individual discontinuance and nonrenewal.
3504 Section 31A-30-107.3, Discontinuance and nonrenewal limitations and conditions.
3505 Section 31A-30-116, Essential health benefits.
3506 Section 63N-11-107, Health benefit plan information on Health Insurance
3507 Exchange -- Insurer transparency.
3508 Section 45. Appropriation.
3509 The following sums of money are appropriated for the fiscal year beginning July 1,
3510 2017, and ending June 30, 2018. These are additions to amounts previously appropriated for
3511 fiscal year 2018. Under the terms and conditions of Title 63J, Chapter 1, Budgetary Procedures
3512 Act, the Legislature appropriates the following sums of money from the funds or accounts
3513 indicated for the use and support of the government of the state of Utah.
3514 ITEM 1
3515 To Legislature - Senate
3516 From General Fund, One-time
$20,000
3517 Schedule of Programs:
3518 Administration $20,000
3519 ITEM 2
3520 To Legislature - House of Representatives
3521 From General Fund, One-time
$34,000
3522 Schedule of Programs:
3523 Administration $34,000
3524 Section 46. Repeal date.
3525 The Health Reform Task Force created in Sections 42 and 43 is repealed January 1,
3526 2019.
3527 Section 47. Effective date.
3528 (1) Except as provided in Subsections (2) and (3), this bill takes effect on May 9, 2017.
3529 (2) The actions affecting the following sections take effect on January 1, 2018:
3530 (a) Section 31A-22-610.1;
3531 (b) Section 31A-22-618;
3532 (c) Section 31A-22-618.5;
3533 (d) Section 31A-22-627;
3534 (e) Section 31A-22-635;
3535 (f) Section 31A-22-642;
3536 (g) Section 31A-45-101;
3537 (h) Section 31A-45-102;
3538 (i) Section 31A-45-103;
3539 (j) Section 31A-45-201;
3540 (k) Section 31A-45-301;
3541 (l) Section 31A-45-302;
3542 (m) Section 31A-45-303;
3543 (n) Section 31A-45-304;
3544 (o) Section 31A-45-401;
3545 (p) Section 31A-45-402;
3546 (q) Section 31A-45-501;
3547 (r) Section 49-20-407; and
3548 (s) Section 58-16a-601.
3549 (3) The repeal of Section 63N-11-107 takes effect on Ĥ→ [
Legislative Review Note
Office of Legislative Research and General Counsel