This document includes House Committee Amendments incorporated into the bill on Fri, Feb 17, 2017 at 2:57 PM by ryoung.
1     
HEALTH REFORM AMENDMENTS

2     
2017 GENERAL SESSION

3     
STATE OF UTAH

4     
Chief Sponsor: James A. Dunnigan

5     
Senate Sponsor: Curtis S. Bramble

6     

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→ [
, by January 1, 2018] ←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 [issued or renewed after May 12, 1981,]
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) [After May 12, 1981, no] An association, corporation, or organization may not
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) [After May 12, 1981, no] An association, corporation, business, or organization
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          [(5) This section is subject to the provisions of Subsection 31A-22-610.5(3).]
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 [(166)] (170).
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     [(89)] (91).
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          [(c)] (b) "Mutual" or "mutual corporation" means a mutual insurance corporation.
298          [(b)] (c) "Stock corporation" means a stock insurance corporation.
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 [(80)] (82).
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          [(57)] (58) "Enrollment date," with respect to a health benefit plan, means:
443          (a) the first day of coverage; or
444          (b) if there is a waiting period, the first day of the waiting period.
445          [(58)] (59) "Enterprise risk" means an activity, circumstance, event, or series of events
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          [(59)] (60) (a) "Escrow" means:
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          [(60)] (61) "Escrow agent" means an agency title insurance producer meeting the
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          [(61)] (62) (a) "Excludes" is not exhaustive and does not mean that another thing is not
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          [(62)] (63) "Exclusion" means for the purposes of accident and health insurance that an
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          [(63)] (64) "Expense reimbursement insurance" means insurance:
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          [(64)] (65) "Fidelity insurance" means insurance guaranteeing the fidelity of a person
492     holding a position of public or private trust.

493          [(65)] (66) (a) "Filed" means that a filing is:
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 [(65)] (66)(a).
503          [(66)] (67) "Filing," when used as a noun, means an item required to be filed with the
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          [(67)] (68) "First party insurance" means an insurance policy or contract in which the
522     insurer agrees to pay a claim submitted to it by the insured for the insured's losses.
523          [(68)] (69) "Foreign insurer" means an insurer domiciled outside of this state, including

524     an alien insurer.
525          [(69)] (70) (a) "Form" means one of the following prepared for general use:
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          [(70)] (71) "Franchise insurance" means an individual insurance policy provided
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          [(71)] (72) "General lines of authority" include:
537          (a) the general lines of insurance in Subsection [(72)] (73);
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          [(72)] (73) "General lines of insurance" include:
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          [(73)] (74) "Group health plan" means an employee welfare benefit plan to the extent
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          [(74)] (75) (a) "Group insurance policy" means a policy covering a group of persons
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          [(75)] (76) "Guaranteed automobile protection insurance" means insurance offered in
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          [(76) (a) Except as provided in Subsection (76)(b), "health benefit plan" means a policy
573     or certificate that:]
574          [(i) provides health care insurance;]
575          [(ii) provides major medical expense insurance; or]
576          [(iii) is offered as a substitute for hospital or medical expense insurance, such as:]
577          [(A) a hospital confinement indemnity; or]
578          [(B) a limited benefit plan.]
579          [(b) "Health benefit plan" does not include a policy or certificate that:]
580          [(i) provides benefits solely for:]
581          [(A) accident;]
582          [(B) dental;]
583          [(C) income replacement;]
584          [(D) long-term care;]
585          [(E) a Medicare supplement;]

586          [(F) a specified disease;]
587          [(G) vision; or]
588          [(H) a short-term limited duration; or]
589          [(ii) is offered and marketed as supplemental health insurance.]
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          [(77)] (78) "Health care" means any of the following intended for use in the diagnosis,
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          [(78)] (79) (a) "Health care insurance" or "health insurance" means insurance
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          [(79)] (81) "Health Insurance Portability and Accountability Act" means the Health
656     Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936, as
657     amended.
658          [(80)] (82) "Income replacement insurance" or "disability income insurance" means
659     insurance written to provide payments to replace income lost from accident or sickness.
660          [(81)] (83) "Indemnity" means the payment of an amount to offset all or part of an
661     insured loss.
662          [(82)] (84) "Independent adjuster" means an insurance adjuster required to be licensed
663     under Section 31A-26-201 who engages in insurance adjusting as a representative of an insurer.
664          [(83)] (85) "Independently procured insurance" means insurance procured under
665     Section 31A-15-104.
666          [(84)] (86) "Individual" means a natural person.
667          [(85)] (87) "Inland marine insurance" includes insurance covering:
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          [(86)] (88) "Insolvency" means that:
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          [(87)] (89) (a) "Insurance" means:
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          [(88)] (90) "Insurance adjuster" means a person who directs or conducts the
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          [(89)] (91) "Insurance business" or "business of insurance" includes:
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     [(117)] (120);

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     [(89)] (91)(a) through (h) in a manner designed to evade this title.
723          [(90)] (92) "Insurance consultant" or "consultant" means a person who:
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          [(91)] (93) "Insurance holding company system" means a group of two or more
730     affiliated persons, at least one of whom is an insurer.
731          [(92)] (94) (a) "Insurance producer" or "producer" means a person licensed or required
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          [(93)] (95) (a) "Insured" means a person to whom or for whose benefit an insurer
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 [(93)] (95)(a):
750          (i) applies only to this title; [and]
751          (ii) does not define the meaning of [this word] "insured" as used in an insurance policy
752     or certificate[.]; and
753          (iii) includes an enrollee.
754          [(94)] (96) (a) "Insurer" means a person doing an insurance business as a principal
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; [and]
761          (v) a person purporting or intending to do an insurance business as a principal on that
762     person's own account[.]; and
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          [(95)] (97) "Interinsurance exchange" means the same as that term is defined in
767     Subsection [(148)] (152).
768          [(96)] (98) "Involuntary unemployment insurance" means insurance:
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          [(97)] (99) (a) "Large employer," in connection with a health benefit plan, means an
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          [(98)] (100) "Late enrollee," with respect to an employer health benefit plan, means an
782     individual whose enrollment is a late enrollment.
783          [(99)] (101) "Late enrollment," with respect to an employer health benefit plan, means
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          [(100)] (102) (a) Except for a retainer contract or legal assistance described in Section
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          [(101)] (103) (a) "Liability insurance" means insurance against liability:
796          (i) for death, injury, or disability of a human being, or for damage to property,
797     exclusive of the coverages under:
798          (A) [Subsection (111) for] medical malpractice insurance;
799          (B) [Subsection (139) for] professional liability insurance; and
800          (C) [Subsection (175) for] workers' compensation insurance;
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) [Subsection (111) for] medical malpractice insurance;
806          (B) [Subsection (139) for] professional liability insurance; and
807          (C) [Subsection (175) for] workers' compensation insurance;
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          [(102)] (104) (a) "License" means authorization issued by the commissioner to engage
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          [(103)] (105) (a) "Life insurance" means:
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          [(104)] (106) "Limited license" means a license that:
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          [(105)] (107) "Limited line credit insurance" includes the following forms of
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          [(106)] (108) "Limited line credit insurance producer" means a person who sells,
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          [(107)] (109) "Limited line insurance" includes:
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          [(108)] (110) "Limited lines authority" includes the lines of insurance listed in
869     Subsection [(107)] (109).
870          [(109)] (111) "Limited lines producer" means a person who sells, solicits, or negotiates
871     limited lines insurance.
872          [(110)] (112) (a) "Long-term care insurance" means an insurance policy or rider
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 [(110)] (112)(a)(iv)(A)
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          [(111)] (114) "Medical malpractice insurance" means insurance against legal liability
936     incident to the practice and provision of a medical service other than the practice and provision
937     of a dental service.
938          [(112)] (115) "Member" means a person having membership rights in an insurance
939     corporation.
940          [(113)] (116) "Minimum capital" or "minimum required capital" means the capital that
941     must be constantly maintained by a stock insurance corporation as required by statute.
942          [(114)] (117) "Mortgage accident and health insurance" means insurance offered in
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          [(115)] (118) "Mortgage guaranty insurance" means surety insurance under which a
946     mortgagee or other creditor is indemnified against losses caused by the default of a debtor.
947          [(116)] (119) "Mortgage life insurance" means insurance on the life of a debtor in
948     connection with an extension of credit that pays if the debtor dies.
949          [(117)] (120) "Motor club" means a person:
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 [(117)] (120)(b)(iii)(A) through
963     (D); or
964          (F) other services given in Subsections 31A-11-102(1)(b) through (f).
965          [(118)] (121) "Mutual" means a mutual insurance corporation.
966          [(119)] (122) "Network plan" means health care insurance:
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          [(120)] (124) "Nonparticipating" means a plan of insurance under which the insured is
976     not entitled to receive a dividend representing a share of the surplus of the insurer.
977          [(121)] (125) "Ocean marine insurance" means insurance against loss of or damage to:
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          [(122)] (126) "Order" means an order of the commissioner.
988          [(123)] (127) "Outline of coverage" means a summary that explains an accident and

989     health insurance policy.
990          [(124)] (128) "Participating" means a plan of insurance under which the insured is
991     entitled to receive a dividend representing a share of the surplus of the insurer.
992          [(125)] (129) "Participation," as used in a health benefit plan, means a requirement
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          [(126)] (130) "Person" includes:
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          [(127)] (131) "Personal lines insurance" means property and casualty insurance
1013     coverage sold for primarily noncommercial purposes to:
1014          (a) an individual; or
1015          (b) a family.
1016          [(128)] (132) "Plan sponsor" [is as] means the same as that term is defined in 29
1017     U.S.C. Sec. 1002(16)(B).
1018          [(129)] (133) "Plan year" means:
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 [(129)] (133)(a) or (b), the calendar year.
1032          [(130)] (134) (a) "Policy" means a document, including an attached endorsement or
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          [(131)] (135) "Policyholder" means a person who controls a policy, binder, or oral
1046     contract by ownership, premium payment, or otherwise.
1047          [(132)] (136) "Policy illustration" means a presentation or depiction that includes
1048     nonguaranteed elements of a policy of life insurance over a period of years.
1049          [(133)] (137) "Policy summary" means a synopsis describing the elements of a life
1050     insurance policy.

1051          [(134)] (138) "PPACA" means the Patient Protection and Affordable Care Act, Pub. L.
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          [(135)] (139) "Preexisting condition," with respect to a health benefit plan:
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          [(136)] (140) (a) "Premium" means the monetary consideration for an insurance policy.
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          [(137)] (141) "Principal officers" for a corporation means the officers designated under
1071     Subsection 31A-5-203(3).
1072          [(138)] (142) "Proceeding" includes an action or special statutory proceeding.
1073          [(139)] (143) "Professional liability insurance" means insurance against legal liability
1074     incident to the practice of a profession and provision of a professional service.
1075          [(140)] (144) (a) Except as provided in Subsection [(140)] (144)(b), "property
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          [(141)] (145) "Qualified long-term care insurance contract" or "federally tax qualified
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          [(142)] (146) "Qualified United States financial institution" means an institution that:
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          [(143)] (147) (a) "Rate" means:
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          [(144)] (148) (a) Except as provided in Subsection [(144)] (148)(b), "rate service
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          [(145)] (149) "Rating manual" means any of the following used to determine initial and
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          [(146)] (150) (a) "Rebate" means a licensee paying, allowing, giving, or offering to
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          [(147)] (151) "Received by the department" means:
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          [(148)] (152) "Reciprocal" or "interinsurance exchange" means an unincorporated
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          [(149)] (153) "Reinsurance" means an insurance transaction where an insurer, for
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          [(150)] (154) "Reinsurer" means a person licensed in this state as an insurer with the
1171     authority to assume reinsurance.
1172          [(151)] (155) "Residential dwelling liability insurance" means insurance against
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          [(152)] (156) (a) "Retrocession" means reinsurance with another insurer of a liability
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          [(153)] (157) "Rider" means an endorsement to:
1180          (a) an insurance policy; or
1181          (b) an insurance certificate.
1182          [(154)] (158) "Secondary medical condition" means a complication related to an
1183     exclusion from coverage in accident and health insurance.
1184          [(155)] (159) (a) "Security" means a:
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 [(155)] (159)(a)(i) through (xiv); or
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          [(156)] (160) "Securityholder" means a specified person who owns a security of a
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 [(156)] (160).
1218          [(157)] (161) (a) "Self-insurance" means an arrangement under which a person
1219     provides for spreading its own risks by a systematic plan.
1220          (b) Except as provided in this Subsection [(157)] (161), "self-insurance" does not
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          [(158)] (162) "Sell" means to exchange a contract of insurance:
1230          (a) by any means;
1231          (b) for money or its equivalent; and
1232          (c) on behalf of an insurance company.
1233          [(159)] (163) "Short-term care insurance" means an insurance policy or rider
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          [(160)] (164) "Significant break in coverage" means a period of 63 consecutive days
1238     during each of which an individual does not have creditable coverage.
1239          [(161)] (165) (a) "Small employer" means, in connection with a health benefit plan and
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          [(162)] (166) "Special enrollment period," in connection with a health benefit plan, has
1250     the same meaning as provided in federal regulations adopted pursuant to the Health Insurance
1251     Portability and Accountability Act.
1252          [(163)] (167) (a) "Subsidiary" of a person means an affiliate controlled by that person
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          [(164)] (168) Subject to Subsection [(87)] (89)(b), "surety insurance" includes:
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          [(165)] (169) (a) "Surplus" means the excess of assets over the sum of paid-in capital
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          [(166)] (170) "Third party administrator" or "administrator" means a person who
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          [(167)] (171) "Title insurance" means the insuring, guaranteeing, or indemnifying of an
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          [(168)] (172) "Total adjusted capital" means the sum of an insurer's or health
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          [(169)] (173) (a) "Trustee" means "director" when referring to the board of directors of
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          [(170)] (174) (a) "Unauthorized insurer," "unadmitted insurer," or "nonadmitted
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          [(171)] (175) "Underwrite" means the authority to accept or reject risk on behalf of the
1348     insurer.
1349          [(172)] (176) "Vehicle liability insurance" means insurance against liability resulting
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 [(140)] (144).
1352          [(173)] (177) "Voting security" means a security with voting rights, and includes a
1353     security convertible into a security with a voting right associated with the security.
1354          [(174)] (178) "Waiting period" for a health benefit plan means the period that must
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          [(175)] (179) "Workers' compensation insurance" means:
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          [(3) When preparing the evaluation required by this section, the commissioner shall
1391     include a report of:]

1392          [(a) the types of health benefit plans sold in the Health Insurance Exchange created in
1393     Section 63N-11-104;]
1394          [(b) the number of insurers participating in the defined contribution arrangement health
1395     benefit plans in the Health Insurance Exchange; and]
1396          [(c) the number of employers and covered lives in the defined contribution
1397     arrangement market in the Health Insurance Exchange.]
1398          [(4)] (3) When preparing the evaluation and report required by this section, the
1399     commissioner may seek the input of insurers, employers, insured persons, providers, and others
1400     with an interest in the health insurance market.
1401          [(5)] (4) The commissioner may adopt administrative rules for the purpose of
1402     collecting the data required by this section, taking into account the business confidentiality of
1403     the insurers.
1404          [(6)] (5) Records submitted to the commissioner under this section shall be maintained
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 [pursuant to
1413     one of the following provisions] is a withdrawal from a line of insurance[: (i)] under
1414     [Subsection 31A-30-107(3)(e); or (ii) Subsection 31A-30-107.1(3)(e)] Subsections
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          [(2) "Director of health" means:]
1462          [(a) the executive director of the Department of Health; or]
1463          [(b) the authorized representative of the executive director of the Department of
1464     Health.]
1465          [(3) "Enrollee" means an individual:]
1466          [(a) who has entered into a contract with an organization for health care; or]
1467          [(b) in whose behalf an arrangement for health care has been made.]
1468          [(4) "Health care" is as defined in Section 31A-1-301.]
1469          [(5)] (2) "Health maintenance organization" means any person:
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          [(6)] (3) (a) "Limited health plan" means, except as limited under Subsection [(6)]
1482     (3)(b), [any] a person who furnishes dental or vision services, either directly or through
1483     arrangements with others[, services]:
1484          [(i) of:]

1485          [(A) dentists;]
1486          [(B) optometrists;]
1487          [(C) physical therapists;]
1488          [(D) podiatrists;]
1489          [(E) psychologists;]
1490          [(F) physicians;]
1491          [(G) chiropractic physicians;]
1492          [(H) naturopathic physicians;]
1493          [(I) osteopathic physicians;]
1494          [(J) social workers;]
1495          [(K) family counselors;]
1496          [(L) other health care providers; or]
1497          [(M) reasonable combinations of the services described in this Subsection (6)(a)(i);]
1498          [(ii)] (i) to an enrollee;
1499          [(iii)] (ii) in return for prepaid periodic payments agreed to in amount prior to the time
1500     during which the services may be furnished; and
1501          [(iv)] (iii) for which the person is obligated to the enrollee to arrange for or directly
1502     provide the available and accessible services described in this Subsection [(6)] (3)(a).
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          [(7)] (4) (a) "Nonprofit organization" or "nonprofit corporation" means an organization
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          [(8)] (5) "Organization" means a health maintenance organization and limited health
1515     plan, unless used in the context of:

1516          [(b)] (a) "organization expenses," which is described in Section 31A-8-208.
1517          [(a)] (b) "organization permit," which is described in Sections 31A-8-204 and
1518     31A-8-206; or
1519          [(9) "Participating provider" means a provider as defined in Subsection (10) who,
1520     under a contract with the health maintenance organization, agrees to provide health care
1521     services to enrollees with an expectation of receiving payment, directly or indirectly, from the
1522     health maintenance organization, other than copayment.]
1523          [(10) "Provider" means any person who:]
1524          [(a) furnishes health care directly to the enrollee; and]
1525          [(b) is licensed or otherwise authorized to furnish the health care in this state.]
1526          [(11)] (6) "Uncovered expenditures" means the costs of health care services that are
1527     covered by an organization for which an enrollee is liable in the event of the organization's
1528     insolvency.
1529          [(12)] (7) "Unusual or infrequently used health services" means those health services
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          [(F) Chapter 13, Employee Welfare Funds and Plans;]
1545          [(G)] (F) Chapter 19a, Utah Rate Regulation Act; and
1546          [(H)] (G) Chapter 28, Part 1, Utah Life and Health Insurance Guaranty [Associations]

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 [health maintenance organizations or] limited health
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 [Section 31A-8-501] Chapter 45, Managed Care
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 [31A-8-402.3] 31A-22-618.6(9); or
1634          [(C) Subsection 31A-22-721(10); or]
1635          [(D)] (C) Subsection [31A-30-107(8)] 31A-22-618.7(4); or
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 [health care provider under contract with his insurer, the contracting
1680     health care provider] network provider, the network provider may only collect from the insured
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          [(4) For purposes of this section, "contracting health care provider" means:]
1684          [(a) a "participating provider" as defined in Section 31A-8-101; or]
1685          [(b) a "preferred health care provider" as described in Section 31A-22-617.]
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 [health
1691     maintenance] managed care organization contract that provides coverage for a policyholder's or
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[, group health insurance policy, or
1700     health maintenance] or managed care organization shall continue in force coverage for a
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 [Section 31A-8-402.3, 31A-8-402.5, 31A-22-721, 31A-30-107.1,
1704     or 31A-30-107.3] Sections 31A-22-618.6 and 31A-22-618.7.
1705          [(3) An individual or group accident and health insurance policy or health maintenance
1706     organization contract shall reinstate dependent coverage, and for purposes of all exclusions and
1707     limitations, shall treat the dependent as if the coverage had been in force since it was
1708     terminated; if:]
1709          [(a) the dependent has not reached the age of 26 by July 1, 1995;]
1710          [(b) the dependent had coverage prior to July 1, 1994;]
1711          [(c) prior to July 1, 1994, the dependent's coverage was terminated solely due to the
1712     age of the dependent; and]
1713          [(d) the policy has not been terminated since the dependent's coverage was terminated.]
1714          [(4)] (3) (a) When a parent is required by a court or administrative order to provide
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 [(5)] (4);
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 [(4)] (3)(a)(iv) is subject to the terms
1724     of the accident and health insurance plan contract pertaining to services received outside of an
1725     insurer's service area. [A health maintenance organization shall comply with Section
1726     31A-8-502.]
1727          [(5)] (4) When a child has accident and health coverage through an insurer of a
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 [(5)] (4)(a), whether the information is provided pursuant to a verbal or written
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 [(5)] (4)(b)
1739     directly to the custodial parent, the child who obtained benefits, the provider, or the state
1740     Medicaid agency.
1741          [(6)] (5) When a parent is required by a court or administrative order to provide health
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 [(9)] (8)(c)(i), (ii), or (iii) has happened.
1757          [(7)] (6) An insurer may not impose requirements on a state agency that has been
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          [(8)] (7) Insurers may not reduce their coverage of pediatric vaccines below the benefit
1762     level in effect on May 1, 1993.
1763          [(9)] (8) When a parent is required by a court or administrative order to provide health

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          [(10)] (9) An order issued under Section 62A-11-326.1 may be considered a "qualified
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          [(11)] (10) This section does not affect any insurer's ability to require as a precondition
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          [(12)] (11) The provisions of this section apply to employee welfare benefit plans as
1791     defined in Section 26-19-2.
1792          [(13)] (12) The commissioner shall adopt rules interpreting and implementing this
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) [(a)] The commissioner shall promote informed consumer behavior and responsible
1801     health benefit plans by requiring an insurer issuing a health benefit plan to[: (i)] provide to all
1802     enrollees, [prior to] before enrollment in the health benefit plan, written disclosure of:
1803          [(A)] (a) restrictions or limitations on prescription drugs and biologics, including:
1804          [(I)] (i) the use of a formulary;
1805          [(II)] (ii) co-payments and deductibles for prescription drugs; and
1806          [(III)] (iii) requirements for generic substitution;
1807          [(B)] (b) coverage limits under the plan;
1808          [(C)] (c) any limitation or exclusion of coverage, including:
1809          [(I)] (i) a limitation or exclusion for a secondary medical condition related to a
1810     limitation or exclusion from coverage; and
1811          [(II)] (ii) easily understood examples of a limitation or exclusion of coverage for a
1812     secondary medical condition; and
1813          [(D)] (d) whether the insurer permits an exchange of the adoption indemnity benefit in
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[; and].
1816          [(ii) provide the commissioner with:]
1817          [(A) the information described in Subsections 31A-22-635(5) through (7) in the
1818     standardized electronic format required by Subsection 63N-11-107(1); and]
1819          [(B) information regarding insurer transparency in accordance with Subsection (4).]
1820          [(b)] (3) An insurer shall provide the disclosure required by Subsection (2)(a)(i) in
1821     writing to the commissioner:
1822          [(i)] (a) upon commencement of operations in the state; and
1823          [(ii)] (b) anytime the insurer amends any of the following described in Subsection
1824     (2)[(a)(i)]:
1825          [(A)] (i) treatment policies;

1826          [(B)] (ii) practice standards;
1827          [(C)] (iii) restrictions;
1828          [(D)] (iv) coverage limits of the insurer's health benefit plan or health insurance policy;
1829     or
1830          [(E)] (v) limitations or exclusions of coverage including a limitation or exclusion for a
1831     secondary medical condition related to a limitation or exclusion of the insurer's health
1832     insurance plan.
1833          [(c)] (4) (a) An insurer shall provide the enrollee with notice of an increase in costs for
1834     prescription drug coverage due to a change in benefit design under Subsection (2)(a)[(i)(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          [(d)] (b) If under Subsection (2)(a)[(i)(A)] a formulary is used, the insurer shall make
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          [(e)] (c) (i) The commissioner shall develop examples of limitations or exclusions of a
1848     secondary medical condition that an insurer may use under Subsection (2)[(a)(i)(C)](c).
1849          (ii) Examples of a limitation or exclusion of coverage provided under Subsection
1850     (2)[(a)(i)(C)](c) or otherwise are for illustrative purposes only, and the failure of a particular
1851     fact situation to fall within the description of an example does not, by itself, support a finding
1852     of coverage.
1853          [(3) The commissioner:]
1854          [(a) shall forward the information submitted by an insurer under Subsection (2)(a)(ii) to
1855     the Health Insurance Exchange created under Section 63N-11-104; and]
1856          [(b) may request information from an insurer to verify the information submitted by the

1857     insurer under this section.]
1858          [(4) The commissioner shall:]
1859          [(a) convene a group of insurers, a member representing the Public Employees' Benefit
1860     and Insurance Program, consumers, and an organization that provides multipayer and
1861     multiprovider quality assurance and data collection, to develop information for consumers to
1862     compare health insurers and health benefit plans on the Health Insurance Exchange, which
1863     shall include consideration of:]
1864          [(i) the number and cost of an insurer's denied health claims;]
1865          [(ii) the cost of denied claims that is transferred to providers;]
1866          [(iii) the average out-of-pocket expenses incurred by participants in each health benefit
1867     plan that is offered by an insurer in the Health Insurance Exchange;]
1868          [(iv) the relative efficiency and quality of claims administration and other
1869     administrative processes for each insurer offering plans in the Health Insurance Exchange; and]
1870          [(v) consumer assessment of each insurer or health benefit plan;]
1871          [(b) adopt an administrative rule that establishes:]
1872          [(i) definition of terms;]
1873          [(ii) the methodology for determining and comparing the insurer transparency
1874     information;]
1875          [(iii) the data, and format of the data, that an insurer shall submit to the commissioner
1876     in order to facilitate the consumer comparison on the Health Insurance Exchange in accordance
1877     with Section 63N-11-107; and]
1878          [(iv) the dates on which the insurer shall submit the data to the commissioner in order
1879     for the commissioner to transmit the data to the Health Insurance Exchange in accordance with
1880     Section 63N-11-107; and]
1881          [(c) implement the rules adopted under Subsection (4)(b) in a manner that protects the
1882     business confidentiality of the insurer.]
1883          Section 11. Section 31A-22-618 is amended to read:
1884          31A-22-618. Nondiscrimination among health care professionals.
1885          [(1)] Except as provided under Section [31A-22-617] 31A-45-303 and Subsection [(3)
1886     of this section] (2), and except as to insurers licensed under Chapter 8, Health Maintenance
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          [(2) This section does not apply to catastrophic mental health coverage provided in
1896     accordance with Section 31A-22-625.]
1897          [(3)] (2) Coverage for licensed providers for behavioral analysis may be limited by a
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          [(B) the limitation on point of service products in Subsections 31A-8-408(3) through
1914     (6);]
1915          [(C)] (B) except as provided in Subsection (2)(b)(ii), basic health care services as
1916     defined in Section 31A-8-101; or
1917          [(D)] (C) coverage mandates enacted after January 1, 2009 that are not required by
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 [as follows:].
1922          [(A) within the organization's service area, covered services shall include health care
1923     services from nonaffiliated providers when medically necessary to stabilize an emergency
1924     medical condition; and]
1925          [(B) outside the organization's service area, covered services shall include medically
1926     necessary health care services for the treatment of an emergency medical condition that are
1927     immediately required while the enrollee is outside the geographic limits of the organization's
1928     service area.]
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          [31A-8-402.3].      31A-22-618.6. Discontinuance, nonrenewal, or changes to
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 [for a
1955     network plan, if]:
1956          (a) for noncompliance with the insurer's employer contribution requirements;
1957          [(a)] (b) if there is no longer any enrollee under the group health plan who lives,
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; [or]
1961          [(b)] (c) for coverage made available in the small or large employer market only
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[.]; or
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          [(3)] (5) A health benefit plan for a plan sponsor may be discontinued if:

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[: (I)] to each plan sponsor,
1992     employee, or dependent of a plan sponsor or an employee[; and (II)], at least 90 days before the
1993     date the coverage will be discontinued;
1994          (B) provides notice of the discontinuation in writing[: (I)] to the commissioner[; and
1995     (II)], and at least three working days [prior to] before the date the notice is sent to the affected
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     (I)] all other health benefit plan products currently being offered by the insurer in the market[;
1999     or (II)] or, in the case of a large employer, any other health benefit Ĥ→ [
plan product]
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[: (I)] the claims experience of a plan
2003     sponsor[; (II)], any health status-related factor relating to any covered participant or
2004     beneficiary[; or (III)], or any health status-related factor relating to any new participant or
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[: (I)] to each plan sponsor,

2012     employee, or dependent of a plan sponsor or an employee[; and (II)] at least 180 days before
2013     the date the coverage will be discontinued;
2014          (B) provides notice of the discontinuation in writing[: (I)] to the commissioner in each
2015     state in which an affected insured individual is known to reside[; and (II)] and, at least 30
2016     working days [prior to] before the date the notice is sent to the affected plan sponsors,
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          [(4) A large employer health benefit plan may be discontinued or nonrenewed:]
2022          [(a) if a condition described in Subsection (2) exists; or]
2023          [(b) for noncompliance with the insurer's:]
2024          [(i) minimum participation requirements; or]
2025          [(ii) employer contribution requirements.]
2026          [(5) A small employer health benefit plan may be discontinued or nonrenewed:]
2027          [(a) if a condition described in Subsection (2) exists; or]
2028          [(b) for noncompliance with the insurer's employer contribution requirements.]
2029          [(6) A small employer health benefit plan may be nonrenewed:]
2030          [(a) if a condition described in Subsection (2) exists; or]
2031          [(b) for noncompliance with the insurer's minimum participation requirements.]
2032          [(7)] (6) (a) Except as provided in Subsection [(7)] (6)(d), an eligible employee may be
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 [(7)] (6)(a) may
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 [(7)]
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 [(7)] (6)
2047     because of a fraud or misrepresentation that relates to health status.
2048          [(8)] (7) For purposes of this section, a reference to "plan sponsor" includes a reference
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          [(9)] (8) An insurer may modify a health benefit plan for a plan sponsor only:
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          [31A-8-402.5].      31A-22-618.7. Individual discontinuance and nonrenewal.
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 [individuals] enrollees or dependents; and
2065          (ii) at the option of the [individual] enrollee.
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) [A] An individual health benefit plan may be discontinued or nonrenewed:

2074          (a) [for a network plan,] if:
2075          (i) [the individual no longer] there is no longer an enrollee under the individual health
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 [individual] enrollee; or
2081          (b) for coverage made available through an association, if:
2082          (i) the [individual's] enrollee's membership in the association ceases; and
2083          (ii) the coverage is terminated uniformly without regard to any health status-related
2084     factor relating to any covered [individual] enrollee.
2085          (3) [A] An individual health benefit plan may be discontinued if:
2086          (a) a condition described in Subsection (2) exists;
2087          (b) the [individual] enrollee fails to pay premiums or contributions in accordance with
2088     the terms of the health benefit plan, including any timeliness requirements;
2089          (c) the [individual] enrollee:
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 [product] plan product
2095     delivered or issued for delivery in this state; and
2096          (ii) (A) provides notice of the discontinuation in writing[: (I)] to each [individual]
2097     enrollee provided coverage[; and (II)] at least 90 days before the date the coverage will be
2098     discontinued;
2099          (B) provides notice of the discontinuation in writing[: (I)] to the commissioner[; and
2100     (II)] and, at least three working days [prior to] before the date the notice is sent, to the affected
2101     [individuals] enrollees;
2102          (C) offers to each covered [individual] enrollee on a guaranteed issue basis[,] the
2103     option to purchase all other individual health benefit Ĥ→ [
plan products] plans ←Ĥ currently
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     [individuals] enrollees or dependents of covered [individuals] enrollees who may become
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[: (I)] to each [individual]
2112     enrollee provided coverage[; and (II)] at least 180 days before the date the coverage will be
2113     discontinued;
2114          (B) provides notice of the discontinuation in writing[: (I)] to the commissioner in each
2115     state in which an affected [insured individual] enrollee is known to reside[; and (II)] and, at
2116     least 30 working days [prior to] before the date the notice is sent, to the affected [individuals]
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     [individuals] enrollees or dependents of covered [individuals] enrollees who may become
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          [31A-8-402.7].      31A-22-618.8. Discontinuance and nonrenewal limitations.
2129          (1) Subject to Section 31A-4-115, an insurer that elects to discontinue offering a health
2130     benefit plan under Subsections [31A-8-402.3] 31A-22-618.6(3)(e) and [31A-8-402.5]
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 [31A-8-402.3 and 31A-8-402.5] 31A-22-618.6 and 31A-22-618.7 apply only to
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 [health maintenance] managed care organization
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 [health maintenance] managed care organization
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[; and].

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 [health maintenance] managed care
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[: (a) enrollees using the Health Insurance Exchange; or (b)] insurers using
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          [(5) (a) An insurer who offers a health benefit plan on the Health Insurance Exchange
2222     created in Section 63N-11-104, shall:]
2223          [(i) accept and process an electronic submission of the uniform application or uniform
2224     waiver from the Health Insurance Exchange using the electronic standards adopted pursuant to
2225     Section 63N-11-107;]
2226          [(ii) if requested, provide the applicant with a copy of the completed application either
2227     by mail or electronically;]
2228          [(iii) post all health benefit plans offered by the insurer in the defined contribution

2229     arrangement market on the Health Insurance Exchange; and]
2230          [(iv) post the information required by Subsection (6) on the Health Insurance Exchange
2231     for every health benefit plan the insurer offers on the Health Insurance Exchange.]
2232          [(b) Except as provided in Subsection (5)(c), an insurer who posts health benefit plans
2233     on the Health Insurance Exchange may not directly or indirectly offer products on the Health
2234     Insurance Exchange that are not health benefit plans.]
2235          [(c) Notwithstanding Subsection (5)(b):]
2236          [(i) an insurer may offer a health savings account on the Health Insurance Exchange;]
2237          [(ii) an insurer may offer dental plans on the Health Insurance Exchange; and]
2238          [(iii) the department may make administrative rules to regulate the offer of dental plans
2239     on the Health Insurance Exchange.]
2240          [(6) An insurer shall provide the commissioner and the Health Insurance Exchange
2241     with the following information for each health benefit plan submitted to the Health Insurance
2242     Exchange, in the electronic format required by Subsection 63N-11-107(1):]
2243          [(a) plan design, benefits, and options offered by the health benefit plan including state
2244     mandates the plan does not cover;]
2245          [(b) information and Internet address to online provider networks;]
2246          [(c) wellness programs and incentives;]
2247          [(d) descriptions of prescription drug benefits, exclusions, or limitations;]
2248          [(e) the percentage of claims paid by the insurer within 30 days of the date a claim is
2249     submitted to the insurer for the prior year; and]
2250          [(f) the claims denial and insurer transparency information developed in accordance
2251     with Subsection 31A-22-613.5(4).]
2252          [(7) The department shall post on the Health Insurance Exchange the department's
2253     solvency rating for each insurer who posts a health benefit plan on the Health Insurance
2254     Exchange. The solvency rating for each insurer shall be based on methodology established by
2255     the department by administrative rule and shall be updated each calendar year.]
2256          [(8) (a) The commissioner may request information from an insurer under Section
2257     31A-22-613.5 to verify the data submitted to the department and to the Health Insurance
2258     Exchange.]
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 [Subsection 31A-22-617(6)] Section 31A-45-303, a health benefit
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 [31A-30-107(3)(d)] 31A-22-618.6(5) or Subsection 31A-22-618.7(3).
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 [the Health Insurance Exchange, also called the "Utah Health Exchange" or] Utah's
2392     small employer health insurance exchange known as "Avenue H," [created in Section
2393     63N-11-104, the Comprehensive Health Insurance Pool created in Chapter 29, Comprehensive
2394     Health Insurance Pool Act,] and the Children's Health Insurance Program created in Title 26,
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     and].
2503          [(6) provide an employer with the opportunity to establish a defined contribution
2504     arrangement for an employee to purchase a health benefit plan through the Health Insurance
2505     Exchange created by Section 63N-11-104.]
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 [or by Chapter 42, Defined
2537     Contribution Risk Adjuster Act], a covered carrier may not enter into one or more ceding
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     [31A-30-107,] and 31A-30-108, apply to:
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 [31A-30-107(3)(e)]
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 [Health Insurance
2642     Exchange created in Section 63N-11-104] small employer health insurance exchange known as
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          [(3) Subject only to Sections 31A-8-105.5 and 31A-8-501, and until July 1, 2004,
2677     health benefit plans offered exclusively in an alliance under this chapter may limit
2678     reimbursement to providers on the panel of a contracted insurer if the commissioner finds that
2679     the aggregate of alliance contracts available to its members provide a broad and substantial
2680     choice of providers, encompassing the vast majority of doctors and hospitals in the state.]
2681          Section 26. Section 31A-45-101 is enacted to read:
2682     
CHAPTER 45. MANAGED CARE ORGANIZATIONS

2683     
Part 1. General Provisions

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     
Part 2. Applicability to Other Provisions of Law

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     
Part 3. Relationships with Providers

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          [31A-22-617].      31A-45-303. Network provider contract provisions.
2811          [Health insurance policies]
2812          (1) Managed care organizations may provide for [insureds] enrollees to receive
2813     services or reimbursement under the [policies] health benefit plans in accordance with
2814     [preferred health care provider contracts as follows:] this section.
2815          [(1)] (2) (a) Subject to restrictions under this section, [an insurer or third party
2816     administrator] a managed care organization may enter into contracts with health care providers
2817     [as defined in Section 78B-3-403] under which the health care providers agree to be a network

2818     provider and supply services, at prices specified in the contracts, to [persons insured by an
2819     insurer] enrollees.
2820          [(a) (i) A health care] (b) A network provider contract [may] shall require the [health
2821     care] network provider to accept the specified payment in this Subsection [(1)] (2) as payment
2822     in full, relinquishing the right to collect [additional] amounts other than copayments,
2823     coinsurance, and deductibles from the [insured person] enrollee.
2824          [(ii) In a dispute involving a provider's claim for reimbursement, the same shall be
2825     determined in accordance with applicable law, the provider contract, the subscriber contract,
2826     and the insurer's written payment policies in effect at the time services were rendered.]
2827          [(iii) If the parties are unable to resolve their dispute, the matter shall be subject to
2828     binding arbitration by a jointly selected arbitrator. Each party is to bear its own expense except
2829     the cost of the jointly selected arbitrator shall be equally shared. This Subsection (1)(a)(iii)
2830     does not apply to the claim of a general acute hospital to the extent it is inconsistent with the
2831     hospital's provider agreement.]
2832          [(iv) An organization may not penalize a provider solely for pursuing a claims dispute
2833     or otherwise demanding payment for a sum believed owing.]
2834          [(v) If an insurer permits another entity with which it does not share common
2835     ownership or control to use or otherwise lease one or more of the organization's networks of
2836     participating providers, the organization shall ensure, at a minimum, that the entity pays
2837     participating providers in accordance with the same fee schedule and general payment policies
2838     as the organization would for that network.]
2839          [(b)] (c) The insurance contract may reward the [insured] enrollee for selection of
2840     [preferred health care] network providers by:
2841          (i) reducing premium rates;
2842          (ii) reducing deductibles;
2843          (iii) coinsurance;
2844          (iv) other copayments; or
2845          (v) any other reasonable manner.
2846          [(c) If the insurer is a managed care organization, as defined in Subsection
2847     31A-27a-403(1)(f):]
2848          [(i) the insurance contract and the health care provider contract shall provide that in the

2849     event the managed care organization becomes insolvent, the rehabilitator or liquidator may:]
2850          [(A) require the health care provider to continue to provide health care services under
2851     the contract until the earlier of:]
2852          [(I) 90 days after the date of the filing of a petition for rehabilitation or the petition for
2853     liquidation; or]
2854          [(II) the date the term of the contract ends; and]
2855          [(B) subject to Subsection (1)(c)(v), reduce the fees the provider is otherwise entitled
2856     to receive from the managed care organization during the time period described in Subsection
2857     (1)(c)(i)(A);]
2858          [(ii) the provider is required to:]
2859          [(A) accept the reduced payment under Subsection (1)(c)(i)(B) as payment in full; and]
2860          [(B) relinquish the right to collect additional amounts from the insolvent managed care
2861     organization's enrollee, as defined in Subsection 31A-27a-403(1)(b);]
2862          [(iii) if the contract between the health care provider and the managed care
2863     organization has not been reduced to writing, or the contract fails to contain the requirements
2864     described in Subsection (1)(c)(i), the provider may not collect or attempt to collect from the
2865     enrollee:]
2866          [(A) sums owed by the insolvent managed care organization; or]
2867          [(B) the amount of the regular fee reduction authorized under Subsection (1)(c)(i)(B);]
2868          [(iv) the following may not bill or maintain an action at law against an enrollee to
2869     collect sums owed by the insolvent managed care organization or the amount of the regular fee
2870     reduction authorized under Subsection (1)(c)(i)(B):]
2871          [(A) a provider;]
2872          [(B) an agent;]
2873          [(C) a trustee; or]
2874          [(D) an assignee of a person described in Subsections (1)(c)(iv)(A) through (C); and]
2875          [(v) notwithstanding Subsection (1)(c)(i):]
2876          [(A) a rehabilitator or liquidator may not reduce a fee by less than 75% of the
2877     provider's regular fee set forth in the contract; and]
2878          [(B) the enrollee shall continue to pay the copayments, deductibles, and other payments
2879     for services received from the provider that the enrollee was required to pay before the filing

2880     of:]
2881          [(I) a petition for rehabilitation; or]
2882          [(II) a petition for liquidation.]
2883          [(2) (a) Subject to Subsections (2)(b) through (2)(e), an insurer using preferred health
2884     care provider contracts is subject to the reimbursement requirements in Section 31A-8-501 on
2885     or after January 1, 2014.]
2886          [(b)] (3) (a) When reimbursing for services of health care providers [not under contract,
2887     the insurer may] that are not network providers, the managed care organization may:
2888          (i) make direct payment to the [insured.] enrollee; and
2889          [(c) An insurer using preferred health care provider contracts may]
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          [(d)] (iii) When selecting health care providers with whom to contract under
2900     Subsection [(1), an insurer] (2), a managed care organization described in Subsection (3)(b)(i)
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 [(7)] (6).
2903          [(e)] (c) For purposes of this section, unfair discrimination between classes of health
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 [insurer] managed care organization; and

2911          (C) within the scope of practice of the class of health care providers.
2912          [(3)] (4) Before the [insured] enrollee consents to the insurance contract, the [insurer]
2913     managed care organization shall fully disclose to the [insured that it] enrollee that the managed
2914     care organization has entered into [preferred health care] network provider contracts. The
2915     [insurer] managed care organization shall provide sufficient detail on the [preferred health
2916     care] network provider contracts to permit the [insured] enrollee to agree to the terms of the
2917     insurance contract. The [insurer] managed care organization shall provide at least 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 [(4)] (5);
2924     and
2925          (d) a description of the adverse benefit determination procedures required under
2926     [Subsection (5)] Section 31A-22-629.
2927          [(4) (a) An insurer using preferred health care]
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 [health care providers
2930     under contract] network providers meets prevailing standards in the state.
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 [its] the
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          [(5) An insurer using preferred health care provider contracts shall provide a
2943     reasonable procedure for resolving complaints and adverse benefit determinations initiated by
2944     the insureds and health care providers.]
2945          [(6) An insurer may not contract with a health care provider for treatment of illness or
2946     injury unless the health care provider is licensed to perform that treatment.]
2947          [(7)] (6) (a) A health care provider or [insurer] managed care organization may not
2948     discriminate against a [preferred health care] network provider for agreeing to a contract under
2949     Subsection [(1)] (2).
2950          (b) (i) Ĥ→ [
This Subsection (6)(b) applies] Subsections (6)(b) and (c) apply ←Ĥ to a
2950a     managed care organization that is described
2951     in Subsection (3)(b)(i) and Ĥ→ [
does] do ←Ĥ not apply to a managed care organization described
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, [who] that is willing and able to meet the terms and conditions
2955     established by the [insurer] managed care organization for designation as a [preferred health
2956     care] network provider, shall be able to apply for and receive the designation as a [preferred
2957     health care] network provider. Contract terms and conditions may include reasonable
2958     limitations on the number of designated [preferred health care] network providers based upon
2959     substantial objective and economic grounds, or expected use of particular services based upon
2960     prior provider-patient profiles.
2961          [(8)] (c) Upon the written request of a provider excluded from a network provider
2962     contract, the commissioner may hold a hearing to determine if the [insurer's] managed care
2963     organization's exclusion of the provider is based on the criteria set forth in Subsection [(7)]
2964     (6)(b).
2965          [(9)] (7) Nothing in this section is to be construed as to require [an insurer] a managed
2966     care organization to offer a certain benefit or service as part of a health benefit plan.
2967          [(10) This section does not apply to catastrophic mental health coverage provided in
2968     accordance with Section 31A-22-625.]
2969          [(11)] (8) Notwithstanding Subsection [(1),] (2) or Subsection [(7)] (6)(b), [and Section
2970     31A-22-618, an insurer] a managed care organization described in Subsection (3)(b)(i) or third
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          [31A-22-617.1].      31A-45-304. Objective criteria for adding or terminating
2976     participating providers -- Termination of contracts -- Review process.
2977          (1) (a) [Every insurer, including a health maintenance organization governed by
2978     Chapter 8, Health Maintenance Organizations and Limited Health Plans,] A managed care
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[, but are not limited to]:
2982          (i) training, certification, and hospital privileges;
2983          (ii) number of [physicians] health care providers needed to adequately serve the
2984     [insurer's] managed care organization's population; and
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 [insurer] managed care organization.
2988          (c) [An insurer] A managed care organization shall make such criteria available to any
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, [an insurer] a managed care organization shall make a decision on a provider's
2992     application for participation within 120 days.
2993          (e) If the provider applicant is rejected, the [insurer] managed care organization shall
2994     inform the provider of the reason for the rejection relative to the criteria established in
2995     accordance with Subsection (1)(b).
2996          (f) [An insurer] A managed care organization may not reject a provider applicant based
2997     solely on:
2998          (i) the provider's staff privileges at a general acute care hospital not under contract with
2999     the [insurer] managed care organization; or
3000          (ii) the provider's referral patterns for patients who are not covered by the [insurer]
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 [insurer] managed care organization

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, [an insurer] a managed care organization may terminate
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 [insurer] managed care organization and the provider. Such contract shall contain
3012     sufficiently certain criteria so that the provider can be reasonably informed of the grounds for
3013     termination for cause.
3014          (c) [Prior to] Before termination for cause, the [insurer shall] managed care
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 [insurer] managed care organization has a reasonable basis to believe that the
3020     provider may correct the conduct giving rise to the notice of termination, [the insurer] may, at
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 [insurer] managed care organization has a reasonable basis to believe that the
3024     provider has engaged in fraudulent conduct or poses a significant risk to patient care or safety,
3025     [the insurer] may immediately suspend the provider from further performance under the
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 [insurer] managed care organization shall establish an internal appeal process
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 [insurer] managed care organization; or
3039          (ii) the provider's referral patterns for patients who are not covered by the [insurer]
3040     managed care organization.
3041          (3) Notwithstanding any other section of this title, [an insurer] a managed care
3042     organization may not take adverse action against or reduce reimbursement to a [contracted]
3043     network provider who is not under a capitated reimbursement arrangement because of the
3044     decision of an [insured] enrollee to access health care services from a [noncontracted]
3045     non-network provider in a manner permitted by the [insured's] enrollee's health insurance plan,
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     
Part 4. Access To Services For Managed Care Enrollees

3050          [31A-8-502].      31A-45-401. Court ordered coverage for minor children who
3051     reside outside the service area.
3052          (1) (a) The requirements of Subsection (2) apply to a [health maintenance organization
3053     if the health maintenance organization plan] managed care organization if the managed care
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 [non-contracted] non-network provider.
3059          (b) The requirements of Subsection (2) do not apply to a [health maintenance]
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 [health maintenance] managed care organization plan either at the time of the court
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 [health maintenance]
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 [health maintenance] managed care
3070     organization's service area, the [health maintenance] managed care organization shall:
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 [noncontracted] non-network provider:
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 [contracting] network provider in the same class of
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 [health maintenance] managed care organization plan.
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     
Part 5. Network Adequacy

3106          [31A-8-501].      31A-45-501. Access to health care providers.
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 [who] that has not contracted with a [health maintenance]
3137     managed care organization to provide health care services to enrollees of the managed care
3138     organization.
3139          (2) Except for a [health maintenance] managed care organization [which] that is under
3140     the common ownership or control of an entity with a hospital located within 10 paved road
3141     miles of an independent hospital, a [health maintenance] managed care organization shall pay
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 [health maintenance] managed care organization
3154     contract.
3155          (3) A [health maintenance] managed care organization shall pay for covered health care
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 [health maintenance] managed care organization
3166     contract.
3167          (4) (a) A [health maintenance] managed care organization shall reimburse 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 [health maintenance] managed care organization shall reimburse a federally
3172     qualified health center or the enrollee for covered services rendered pursuant to Subsection (3)
3173     a like amount as paid by the [health maintenance] managed care organization under a
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 [health maintenance] managed care organization to pay
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 [health maintenance] managed care organization
3195     may contract directly with an independent hospital, federally qualified health center, or
3196     credentialed staff member.
3197          (8) (a) A [health maintenance] managed care organization that violates any provision
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 [health maintenance] managed care organization's provider list that is supplied to enrollees,
3203     including any website maintained by the [health maintenance] managed care organization;
3204          (ii) failing to provide notice of an enrollee's rights under this section when:
3205          (A) an enrollee makes personal contact with the [health maintenance] managed care
3206     organization by telephone, electronic transaction, or in person; and
3207          (B) the enrollee inquires about [his] the enrollee's rights to access an independent
3208     hospital or federally qualified health center; and
3209          (iii) refusing to reprocess or reconsider a claim, initially denied by the [health
3210     maintenance] managed care organization, when the provisions of this section apply to the
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 [health maintenance] managed care organization shall:
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 [health maintenance] managed care organization's service area; and
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 [health maintenance] managed care organization shall provide the following
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     [non-HMO contracted] noncontracted providers if you live or reside within 30 paved road
3230     miles of the listed providers, or if you live or reside in closer proximity to the listed providers
3231     than to your [HMO] contracted providers:
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 [health maintenance] managed care organization at ________. If the [HMO]
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 [31A-8-501 and] 31A-22-605.5
3247     and Ĥ→ [
31A-45-303;] 31A-45-501 ←Ĥ and
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 [an] insurance [program
3349     under Subsection 31A-1-301(86)] as that term is defined in Section 31A-1-301.
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 [31A-22-617 and] 31A-22-618 and 31A-45-303, an
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          [(2)] (4) Title 31A, Chapter 42, Defined Contribution Risk Adjuster Act, is repealed
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 [consumer health office] Office of Consumer Health Services shall:
3390          [(a) in cooperation with the Insurance Department, the Department of Health, and the
3391     Department of Workforce Services, and in accordance with the electronic standards developed
3392     under Sections 31A-22-635 and 63N-11-107, create a Health Insurance Exchange that:]
3393          [(i) provides information to consumers about private and public health programs for
3394     which the consumer may qualify;]
3395          [(ii) provides a consumer comparison of and enrollment in a health benefit plan posted
3396     on the Health Insurance Exchange; and]
3397          [(iii) includes information and a link to enrollment in premium assistance programs
3398     and other government assistance programs;]
3399          [(b) contract with one or more private vendors for:]
3400          [(i) administration of the enrollment process on the Health Insurance Exchange,
3401     including establishing a mechanism for consumers to compare health benefit plan features on
3402     the exchange and filter the plans based on consumer preferences;]
3403          [(ii) the collection of health insurance premium payments made for a single policy by
3404     multiple payers, including the policyholder, one or more employers of one or more individuals
3405     covered by the policy, government programs, and others; and]
3406          [(iii) establishing a call center in accordance with Subsection (4);]

3407          [(c) assist employers with a free or low cost method for establishing mechanisms for
3408     the purchase of health insurance by employees using pre-tax dollars;]
3409          [(d) establish a list on the Health Insurance Exchange of insurance producers who, in
3410     accordance with Section 31A-30-209, are appointed producers for the Health Insurance
3411     Exchange;]
3412          [(e) include in the annual written report described in Section 63N-1-301, a report on
3413     the operations of the Health Insurance Exchange required by this chapter; and]
3414          [(f) in accordance with Subsection (3), provide a form to a small employer that
3415     certifies:]
3416          [(i) that the small employer offered a qualified health plan to the small employer's
3417     employees; and]
3418          [(ii) the period of time within the taxable year in which the small employer maintained
3419     the qualified health plan coverage.]
3420          [(3) The form required by Subsection (2)(f) shall be provided to a small employer if:]
3421          [(a) the small employer selected a qualified health plan on the small employer health
3422     exchange created by this section; or]
3423          [(b) (i) the small employer selected a health plan in the small employer market that is
3424     not offered through the exchange created by this section; and]
3425          [(ii) the issuer of the health plan selected by the small employer submits to the office,
3426     in a form and manner required by the office:]
3427          [(A) an affidavit from a member of the American Academy of Actuaries stating that
3428     based on generally accepted actuarial principles and methodologies the issuer's health plan
3429     meets the benefit and actuarial requirements for a qualified health plan under PPACA as
3430     defined in Section 31A-1-301; and]
3431          [(B) an affidavit from the issuer that includes the dates of coverage for the small
3432     employer during the taxable year.]
3433          [(4) A call center established by the consumer health office:]
3434          [(a) shall provide unbiased answers to questions concerning exchange operations, and
3435     plan information, to the extent the plan information is posted on the exchange by the insurer;
3436     and]
3437          [(b) may not:]

3438          [(i) sell, solicit, or negotiate a health benefit plan on the Health Insurance Exchange;]
3439          [(ii) receive producer compensation through the Health Insurance Exchange; and]
3440          [(iii) be designated as the default producer for an employer group that enters the Health
3441     Insurance Exchange without a producer.]
3442          [(5) The consumer health office:]
3443          [(a) may not:]
3444          [(i) regulate health insurers, health insurance plans, health insurance producers, or
3445     health insurance premiums charged in the exchange;]
3446          [(ii) adopt administrative rules, except as provided in Section 63N-11-107; or]
3447          [(iii) act as an appeals entity for resolving disputes between a health insurer and an
3448     insured;]
3449          [(b) may establish and collect a fee for the cost of the exchange transaction in
3450     accordance with Section 63J-1-504 for:]
3451          [(i) processing an application for a health benefit plan;]
3452          [(ii) accepting, processing, and submitting multiple premium payment sources;]
3453          [(iii) providing a mechanism for consumers to filter and compare health benefit plans
3454     in the exchange based on consumer preferences; and]
3455          [(iv) funding the call center; and]
3456          [(c) shall separately itemize the fee established under Subsection (5)(b) as part of the
3457     cost displayed for the employer selecting coverage on the exchange.]
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→ [
January 1, 2018; and] operations of Avenue H end under
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          [
(c)] (d) ←Ĥ take steps necessary to wind down the operations of the Avenue H small
3461a     employer
3462     health insurance exchange effective Ĥ→ [
January] July ←Ĥ 1, 2018.
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→ [
January] July ←Ĥ 1, 2018.






Legislative Review Note
Office of Legislative Research and General Counsel