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[Utah Code Table of Contents]
[TITLE 31a. Table of Contents]
31A-30-101 Title.
This chapter is known as the "Individual, Small, and Group
Employer Health Insurance Act."
2002
31A-30-102 Purpose statement.
The purpose of this chapter is to:
(1) prevent abusive rating practices;
(2) require disclosure of rating practices to purchasers;
(3) establish rules regarding renewability of coverage;
(4) improve the overall fairness and efficiency of the individual and small group insurance market; and
(5) provide increased access for individuals and small
employers to health insurance.
1997
31A-30-103 Definitions.
As used in this chapter:
(1) "Actuarial certification" means a written statement by a member of the American Academy of Actuaries or other individual approved by the commissioner that a covered carrier is in compliance with Section 31A-30-106 , based upon the examination of the covered carrier, including review of the appropriate records and of the actuarial assumptions and methods used by the covered carrier in establishing premium rates for applicable health benefit plans.
(2) "Affiliate" or "affiliated" means any entity or person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, a specified entity or person.
(3) "Base premium rate" means, for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under a rating system for that class of business by the covered carrier to covered insureds with similar case characteristics for health benefit plans with the same or similar coverage.
(4) "Basic coverage" means the coverage provided in the Basic Health Care Plan under Subsection 31A-22-613.5 (2).
(5) "Carrier" means any person or entity that provides health insurance in this state including:
(a) an insurance company;
(b) a prepaid hospital or medical care plan;
(c) a health maintenance organization;
(d) a multiple employer welfare arrangement; and
(e) any other person or entity providing a health insurance plan under this title.
(6) (a) Except as provided in Subsection (6)(b), "case characteristics" means demographic or other objective characteristics of a covered insured that are considered by the carrier in determining premium rates for the covered insured.
(b) "Case characteristics" does not include:
(i) duration of coverage since the policy was issued;
(ii) claim experience; and
(iii) health status.
(7) "Class of business" means all or a separate grouping of covered insureds established under Section 31A-30-105 .
(8) "Conversion policy" means a policy providing coverage under the conversion provisions required in Chapter 22, Part VII, Group Accident and Health Insurance.
(9) "Covered carrier" means any individual carrier or small employer carrier subject to this chapter.
(10) "Covered individual" means any individual who is covered under a health benefit plan subject to this chapter.
(11) "Covered insureds" means small employers and individuals who are issued a health benefit plan that is subject to this chapter.
(12) "Dependent" means an individual to the extent that the individual is defined to be a dependent by:
(a) the health benefit plan covering the covered individual; and
(b) Chapter 22, Part VI, Accident and Health Insurance.
(13) "Established geographic service area" means a geographical area approved by the commissioner within which the carrier is authorized to provide coverage.
(14) "Index rate" means, for each class of business as to a rating period for covered insureds with similar case characteristics, the arithmetic average of the applicable base premium rate and the corresponding highest premium rate.
(15) "Individual carrier" means a carrier that provides coverage on an individual basis through a health benefit plan regardless of whether:
(a) coverage is offered through:
(i) an association;
(ii) a trust;
(iii) a discretionary group; or
(iv) other similar groups; or
(b) the policy or contract is situated out-of-state.
(16) "Individual conversion policy" means a conversion policy issued to:
(a) an individual; or
(b) an individual with a family.
(17) "Individual coverage count" means the number of natural persons covered under a carrier's health benefit products that are individual policies.
(18) "Individual enrollment cap" means the percentage set by the commissioner in accordance with Section 31A-30-110 .
(19) "New business premium rate" means, for each class of business as to a rating period, the lowest premium rate charged or offered, or that could have been charged or offered, by the carrier to covered insureds with similar case characteristics for newly issued health benefit plans with the same or similar coverage.
(20) "Preexisting condition" is as defined in Section 31A-1-301 .
(21) "Premium" means all monies paid by covered insureds and covered individuals as a condition of receiving coverage from a covered carrier, including any fees or other contributions associated with the health benefit plan.
(22) (a) "Rating period" means the calendar period for which premium rates established by a covered carrier are assumed to be in effect, as determined by the carrier.
(b) A covered carrier may not have:
(i) more than one rating period in any calendar month; and
(ii) no more than 12 rating periods in any calendar year.
(23) "Resident" means an individual who has resided in this state for at least 12 consecutive months immediately preceding the date of application.
(24) "Short-term limited duration insurance" means a health benefit product that:
(a) is not renewable; and
(b) has an expiration date specified in the contract that is less than 364 days after the date the plan became effective.
(25) "Small employer carrier" means a carrier that provides health benefit plans covering eligible employees of one or more small employers in this state, regardless of whether:
(a) coverage is offered through:
(i) an association;
(ii) a trust;
(iii) a discretionary group; or
(iv) other similar grouping; or
(b) the policy or contract is situated out-of-state.
(26) "Uninsurable" means an individual who:
(a) is eligible for the Comprehensive Health Insurance Pool coverage under the underwriting criteria established in Subsection 31A-29-111 (4); or
(b) (i) is issued a certificate for coverage under Subsection 31A-30-108 (3); and
(ii) has a condition of health that does not meet consistently applied underwriting criteria as established by the commissioner in accordance with Subsections 31A-30-106 (1)(i) and (j) for which coverage the applicant is applying.
(27) "Uninsurable percentage" for a given calendar year equals UC/CI where, for purposes of this formula:
(a) "UC" means the number of uninsurable individuals who were issued an individual policy on or after July 1, 1997; and
(b) "CI" means the carrier's individual coverage count
as of December 31 of the preceding year.
2002
31A-30-104 Applicability and scope.
(1) This chapter applies to any:
(a) health benefit plan that provides coverage to:
(i) individuals;
(ii) small employers; or
(iii) both Subsections (1)(a)(i) and (ii); or
(b) individual conversion policy for purposes of Sections 31A-30-106.5 and 31A-30-107.5 .
(2) This chapter applies to a health benefit plan that provides coverage to small employers or individuals regardless of:
(a) whether the contract is issued to:
(i) an association;
(ii) a trust;
(iii) a discretionary group; or
(iv) other similar grouping; or
(b) the situs of delivery of the policy or contract.
(3) This chapter does not apply to:
(a) a large employer health benefit plan; or
(b) short-term limited duration health insurance.
(4) (a) Except as provided in Subsection (4)(b), for the purposes of this chapter:
(i) carriers that are affiliated companies or that are eligible to file a consolidated tax return shall be treated as one carrier; and
(ii) any restrictions or limitations imposed by this chapter shall apply as if all health benefit plans delivered or issued for delivery to covered insureds in this state by the affiliated carriers were issued by one carrier.
(b) Upon a finding of the commissioner, an affiliated carrier that is a health maintenance organization having a certificate of authority under this title may be considered to be a separate carrier for the purposes of this chapter.
(c) Unless otherwise authorized by the commissioner, a covered carrier may not enter into one or more ceding arrangements with respect to health benefit plans delivered or issued for delivery to covered insureds in this state if the ceding arrangements would result in less than 50% of the insurance obligation or risk for the health benefit plans being retained by the ceding carrier.
(d) Section 31A-22-1201 applies if a covered carrier cedes or assumes all of the insurance obligation or risk with respect to one or more health benefit plans delivered or issued for delivery to covered insureds in this state.
(5) (a) A Taft Hartley trust created in accordance with Section 302(c)(5) of the Federal Labor Management Relations Act, or a carrier with the written authorization of such a trust, may make a written request to the commissioner for a waiver from the application of any of the provisions of Subsection 31A-30-106 (1) with respect to a health benefit plan provided to the trust.
(b) The commissioner may grant a trust or carrier described in Subsection (5)(a) a waiver if the commissioner finds that application with respect to the trust would:
(i) have a substantial adverse effect on the participants and beneficiaries of the trust; and
(ii) require significant modifications to one or more collective bargaining arrangements under which the trust is established or maintained.
(c) A waiver granted under this Subsection (5) may not apply to an individual if the person participates in a Taft Hartley trust as an associate member of any employee organization.
(6) Sections 31A-30-106 , 31A-30-106.5 , 31A-30-106.7 , 31A-30-107 , 31A-30-108 , and 31A-30-111 apply to:
(a) any insurer engaging in the business of insurance related to the risk of a small employer for medical, surgical, hospital, or ancillary health care expenses of the small employer's employees provided as an employee benefit; and
(b) any contract of an insurer, other than a workers' compensation policy, related to the risk of a small employer for medical, surgical, hospital, or ancillary health care expenses of the small employer's employees provided as an employee benefit.
(7) The commissioner may make rules requiring that the marketing practices be consistent with this chapter for:
(a) a small employer carrier;
(b) a small employer carrier's agent;
(c) an insurance producer; and
(d) an insurance consultant.
2003
31A-30-105 Establishment of classes of business.
(1) A covered carrier may establish a separate class of business only to reflect substantial differences in either expected claims experience or administrative costs related to the following reasons:
(a) the covered carrier uses more than one type of system for the marketing and sale of health benefit plans to covered insureds;
(b) the covered carrier has acquired a class of business from another covered carrier; or
(c) the covered carrier provides coverage to one or more association groups.
(2) A covered carrier may establish up to nine separate classes of business under Subsection (1).
(3) The commissioner may establish regulations to provide for a period of transition in order for a covered carrier to come into compliance with Subsection (2) in the instance of acquisition of an additional class of business from another covered carrier.
(4) The commissioner may approve the establishment of
additional classes of business upon application to the commissioner
and a finding by the commissioner that such action would
substantially enhance the efficiency and fairness of the
health insurance marketplace subject to this chapter.
1995
31A-30-106 Premiums - Rating restrictions - Disclosure.
(1) Premium rates for health benefit plans under this chapter are subject to the provisions of this Subsection (1).
(a) The index rate for a rating period for any class of business may not exceed the index rate for any other class of business by more than 20%.
(b) (i) For a class of business, the premium rates charged during a rating period to covered insureds with similar case characteristics for the same or similar coverage, or the rates that could be charged to such employers under the rating system for that class of business, may not vary from the index rate by more than 30% of the index rate, except as provided in Section 31A-22-625 .
(ii) A covered carrier that offers individual and small employer health benefit plans may use the small employer index rates to establish the rate limitations for individual policies, even if some individual policies are rated below the small employer base rate.
(c) The percentage increase in the premium rate charged to a covered insured for a new rating period, adjusted pro rata for rating periods less than a year, may not exceed the sum of the following:
(i) the percentage change in the new business premium rate measured from the first day of the prior rating period to the first day of the new rating period;
(ii) any adjustment, not to exceed 15% annually and adjusted pro rata for rating periods of less than one year, due to the claim experience, health status, or duration of coverage of the covered individuals as determined from the covered carrier's rate manual for the class of business, except as provided in Section 31A-22-625 ; and
(iii) any adjustment due to change in coverage or change in the case characteristics of the covered insured as determined from the covered carrier's rate manual for the class of business.
(d) (i) Adjustments in rates for claims experience, health status, and duration from issue may not be charged to individual employees or dependents.
(ii) Any adjustment described in Subsection (1)(d)(i) shall be applied uniformly to the rates charged for all employees and dependents of the small employer.
(e) A covered carrier may use industry as a case characteristic in establishing premium rates, provided that the highest rate factor associated with any industry classification does not exceed the lowest rate factor associated with any industry classification by more than 15%.
(f) (i) Covered carriers shall apply rating factors, including case characteristics, consistently with respect to all covered insureds in a class of business.
(ii) Rating factors shall produce premiums for identical groups that:
(A) differ only by the amounts attributable to plan design; and
(B) do not reflect differences due to the nature of the groups assumed to select particular health benefit products.
(iii) A covered carrier shall treat all health benefit plans issued or renewed in the same calendar month as having the same rating period.
(g) For the purposes of this Subsection (1), a health benefit plan that uses a restricted network provision may not be considered similar coverage to a health benefit plan that does not use such a network, provided that use of the restricted network provision results in substantial difference in claims costs.
(h) The covered carrier may not, without prior approval of the commissioner, use case characteristics other than:
(i) age;
(ii) gender;
(iii) industry;
(iv) geographic area;
(v) family composition; and
(vi) group size.
(i) (i) The commissioner may establish rules in accordance with Title 63, Chapter 46a, Utah Administrative Rulemaking Act, to:
(A) implement this chapter; and
(B) assure that rating practices used by covered carriers are consistent with the purposes of this chapter.
(ii) The rules described in Subsection (1)(i)(i) may include rules that:
(A) assure that differences in rates charged for health benefit products by covered carriers are reasonable and reflect objective differences in plan design, not including differences due to the nature of the groups assumed to select particular health benefit products;
(B) prescribe the manner in which case characteristics may be used by covered carriers;
(C) implement the individual enrollment cap under Section 31A-30-110 , including specifying:
(I) the contents for certification;
(II) auditing standards;
(III) underwriting criteria for uninsurable classification; and
(IV) limitations on high risk enrollees under Section 31A-30-111 ; and
(D) establish the individual enrollment cap under Subsection 31A-30-110 (1).
(j) Before implementing regulations for underwriting criteria for uninsurable classification, the commissioner shall contract with an independent consulting organization to develop industry-wide underwriting criteria for uninsurability based on an individual's expected claims under open enrollment coverage exceeding 200% of that expected for a standard insurable individual with the same case characteristics.
(k) The commissioner shall revise rules issued for Sections 31A-22-602 and 31A-22-605 regarding individual accident and health policy rates to allow rating in accordance with this section.
(2) For purposes of Subsection (1)(c)(i), if a health benefit product is a health benefit product into which the covered carrier is no longer enrolling new covered insureds, the covered carrier shall use the percentage change in the base premium rate, provided that the change does not exceed, on a percentage basis, the change in the new business premium rate for the most similar health benefit product into which the covered carrier is actively enrolling new covered insureds.
(3) (a) A covered carrier may not transfer a covered insured involuntarily into or out of a class of business.
(b) A covered carrier may not offer to transfer a covered insured into or out of a class of business unless the offer is made to transfer all covered insureds in the class of business without regard:
(i) to case characteristics;
(ii) claim experience;
(iii) health status; or
(iv) duration of coverage since issue.
(4) (a) Each covered carrier shall maintain at the covered carrier's principal place of business a complete and detailed description of its rating practices and renewal underwriting practices, including information and documentation that demonstrate that the covered carrier's rating methods and practices are:
(i) based upon commonly accepted actuarial assumptions; and
(ii) in accordance with sound actuarial principles.
(b) (i) Each covered carrier shall file with the commissioner, on or before March 15 of each year, in a form, manner, and containing such information as prescribed by the commissioner, an actuarial certification certifying that:
(A) the covered carrier is in compliance with this chapter; and
(B) the rating methods of the covered carrier are actuarially sound.
(ii) A copy of the certification required by Subsection (4)(b)(i) shall be retained by the covered carrier at the covered carrier's principal place of business.
(c) A covered carrier shall make the information and documentation described in this Subsection (4) available to the commissioner upon request.
(d) Records submitted to the commissioner under this section
shall be maintained by the commissioner as protected records
under Title 63, Chapter 2, Government Records Access and
Management Act.
2003
31A-30-106.5 Conversion policy - Premiums - Rating restrictions.
(1) All provisions of Section 31A-30-106 , except Subsection 31A-30-106 (1)(b), apply to conversion policies.
(2) Conversion policy premium rates may not exceed by more than 35% the index rate for individuals with similar case characteristics for any class of business in which the policy form has been approved.
(3) An insurer may not consider pregnancy of a covered
insured in determining its conversion policy premium rates.
2001
31A-30-106.6 Individual rates.
Notwithstanding any other provision of this chapter, an individual carrier may, for individuals provided coverage under Subsection 31A-30-108 (3):
(1) use, but not exceed, the rates established by the Comprehensive Health Insurance Pool under Section 31A-29-117 for basic coverage; and
(2) charge benefit adjusted actuarially equivalent rates
for coverage that is in addition to the basic benefit plan.
1997
31A-30-106.7 Surcharge for groups changing carriers.
(1) (a) Except as provided in Subsection (1)(b), if prior notice is given, a covered carrier may impose upon a small group that changes coverage to that carrier from another carrier a one-time surcharge of up to 25% of the annualized premium that the carrier could otherwise charge under Section 31A-30-106 .
(b) A covered carrier may not impose the surcharge described in Subsection (1)(a) if:
(i) the change in carriers occurs on the anniversary of the plan year, as defined in Section 31A-1-301 ;
(ii) the previous coverage was terminated under Subsection 31A-30-107 (3)(e); or
(iii) employees from an existing group form a new business.
(2) A covered carrier may not impose the surcharge described in Subsection (1) if the offer to cover the group occurs at a time other than the anniversary of the plan year because:
(a) (i) the application for coverage is made prior to the anniversary date in accordance with the covered carrier's published policies; and
(ii) the offer to cover the group is not issued until after the anniversary date; or
(b) (i) the application for coverage is made prior to the anniversary date in accordance with the covered carrier's published policies; and
(ii) additional underwriting or rating information requested by the covered carrier is not received until after the anniversary date.
(3) If a covered carrier chooses to apply a surcharge under Subsection (1), the application of the surcharge and the criteria for incurring or avoiding the surcharge shall be clearly stated in the:
(a) written application materials provided to the applicant at the time of application; and
(b) written producer guidelines.
(4) The commissioner shall adopt rules in accordance with
Title 63, Chapter 46a, Utah Administrative Rulemaking Act,
to ensure compliance with this section.
2002
31A-30-107 Renewal - Limitations - Exclusions - Discontinuance and nonrenewal.
(1) Except as otherwise provided in this section, a small employer health benefit plan is renewable and continues in force:
(a) with respect to all eligible employees and dependents; and
(b) at the option of the plan sponsor.
(2) A small employer health benefit plan may be discontinued or nonrenewed:
(a) for a network plan, if:
(i) there is no longer any enrollee under the group health plan who lives, resides, or works in:
(A) the service area of the covered carrier; or
(B) the area for which the covered carrier is authorized to do business; and
(ii) in the case of the small employer market, the small employer carrier applies the same criteria the small employer carrier would apply in denying enrollment in the plan under Subsection 31A-30-108 (6); or
(b) for coverage made available in the small or large employer market only through an association, if:
(i) the employer's membership in the association ceases; and
(ii) the coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual.
(3) A small employer health benefit plan may be discontinued if:
(a) a condition described in Subsection (2) exists;
(b) the plan sponsor fails to pay premiums or contributions in accordance with the terms of the contract;
(c) the plan sponsor:
(i) performs an act or practice that constitutes fraud; or
(ii) makes an intentional misrepresentation of material fact under the terms of the coverage;
(d) the covered carrier:
(i) elects to discontinue offering a particular small employer health benefit product delivered or issued for delivery in this state; and
(ii) (A) provides notice of the discontinuation in writing:
(I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
(II) at least 90 days before the date the coverage will be discontinued;
(B) provides notice of the discontinuation in writing:
(I) to the commissioner; and
(II) at least three working days prior to the date the notice is sent to the affected plan sponsors, employees, and dependents of the plan sponsors or employees;
(C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase all other small employer health benefit products currently being offered by the small employer carrier in the market; and
(D) in exercising the option to discontinue that product and in offering the option of coverage in this section, acts uniformly without regard to:
(I) the claims experience of a plan sponsor;
(II) any health status-related factor relating to any covered participant or beneficiary; or
(III) any health status-related factor relating to any new participant or beneficiary who may become eligible for the coverage; or
(e) the covered carrier:
(i) elects to discontinue all of the covered carrier's small employer health benefit plans in:
(A) the small employer market;
(B) the large employer market; or
(C) both the small employer and large employer markets; and
(ii) (A) provides notice of the discontinuation in writing:
(I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
(II) at least 180 days before the date the coverage will be discontinued;
(B) provides notice of the discontinuation in writing:
(I) to the commissioner in each state in which an affected insured individual is known to reside; and
(II) at least 30 working days prior to the date the notice is sent to the affected plan sponsors, employees, and the dependents of the plan sponsors or employees;
(C) discontinues and nonrenews all plans issued or delivered for issuance in the market; and
(D) provides a plan of orderly withdrawal as required by Section 31A-4-115 .
(4) A small employer health benefit plan may be discontinued or nonrenewed:
(a) if a condition described in Subsection (2) exists; or
(b) for noncompliance with the insurer's employer contribution requirements.
(5) A small employer health benefit plan may be nonrenewed:
(a) if a condition described in Subsection (2) exists; or
(b) for noncompliance with the insurer's minimum participation requirements.
(6) (a) Except as provided in Subsection (6)(d), an eligible employee may be discontinued if after issuance of coverage the eligible employee:
(i) engages in an act or practice that constitutes fraud in connection with the coverage; or
(ii) makes an intentional misrepresentation of material fact in connection with the coverage.
(b) An eligible employee that is discontinued under Subsection (6)(a) may reenroll:
(i) 12 months after the date of discontinuance; and
(ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies to reenroll.
(c) At the time the eligible employee's coverage is discontinued under Subsection (6)(a), the covered carrier shall notify the eligible employee of the right to reenroll when coverage is discontinued.
(d) An eligible employee may not be discontinued under this Subsection (6) because of a fraud or misrepresentation that relates to health status.
(7) For purposes of this section, a reference to "plan sponsor" includes a reference to the employer:
(a) with respect to coverage provided to an employer member of the association; and
(b) if the small employer health benefit plan is made available by a covered carrier in the employer market only through:
(i) an association;
(ii) a trust; or
(iii) a discretionary group.
(8) A covered carrier may modify a small employer health benefit plan only:
(a) at the time of coverage renewal; and
(b) if the modification is effective uniformly among all
plans with that product.
2003
31A-30-107.1 Individual discontinuance and nonrenewal.
(1) (a) Except as otherwise provided in this section, a health benefit plan offered on an individual basis is renewable and continues in force:
(i) with respect to all individuals or dependents; and
(ii) at the option of the individual.
(b) Subsection (1)(a) applies regardless of:
(i) whether the contract is issued through:
(A) a trust;
(B) an association;
(C) a discretionary group; or
(D) other similar grouping; or
(ii) the situs of delivery of the policy or contract.
(2) A health benefit plan may be discontinued or nonrenewed:
(a) for a network plan, if:
(i) the individual no longer lives, resides, or works in:
(A) the service area of the covered carrier; or
(B) the area for which the covered carrier is authorized to do business; and
(ii) coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual; or
(b) for coverage made available through an association, if:
(i) the individual's membership in the association ceases; and
(ii) the coverage is terminated uniformly without regard to any health status-related factor of covered individuals.
(3) A health benefit plan may be discontinued if:
(a) a condition described in Subsection (2) exists;
(b) the individual fails to pay premiums or contributions in accordance with the terms of the health benefit plan, including any timeliness requirements;
(c) the individual:
(i) performs an act or practice that constitutes fraud in connection with the coverage; or
(ii) makes an intentional misrepresentation of material fact under the terms of the coverage;
(d) the covered carrier:
(i) elects to discontinue offering a particular health benefit product delivered or issued for delivery in this state; and
(ii) (A) provides notice of the discontinuance in writing:
(I) to each individual provided coverage; and
(II) at least 90 days before the date the coverage will be discontinued;
(B) provides notice of the discontinuation in writing:
(I) to the commissioner; and
(II) at least three working days prior to the date the notice is sent to the affected individuals;
(C) offers to each covered individual on a guaranteed issue basis the option to purchase all other individual health benefit products currently being offered by the covered carrier for individuals in that market; and
(D) acts uniformly without regard to any health status-related factor of a covered individual or dependent of a covered individual who may become eligible for coverage; or
(e) the covered carrier:
(i) elects to discontinue all of the covered carrier's health benefit plans in the individual market; and
(ii) (A) provides notice of the discontinuation in writing:
(I) to each covered individual; and
(II) at least 180 days before the date the coverage will be discontinued;
(B) provides notice of the discontinuation in writing:
(I) to the commissioner in each state in which an affected insured individual is known to reside; and
(II) at least 30 working days prior to the date the notice is sent to the affected individuals;
(C) discontinues and nonrenews all health benefit plans the covered carrier issues or delivers for issuance in the individual market; and
(D) acts uniformly without regard to any health status-related
factor of a covered individual or a dependent of a covered
individual who may become eligible for coverage.
2003
31A-30-107.3 Discontinuance and nonrenewal limitations.
(1) (a) A carrier that elects to discontinue offering a health benefit plan under Subsection 31A-30-107 (3)(e) or 31A-30-107.1 (3)(e) is prohibited from writing new business:
(i) in the small employer and individual market in this state; and
(ii) for a period of five years beginning on the date of discontinuation of the last coverage that is discontinued.
(b) The prohibition described in Subsection (1)(a) may be waived if the commissioner finds that waiver is in the public interest:
(i) to promote competition; or
(ii) to resolve inequity in the marketplace.
(2) If a carrier is doing business in one established geographic service area of the state, Sections 31A-30-107 and 31A-30-107.1 apply only to the carrier's operations in that geographic service area.
(3) If a small employer employs less than two employees,
a carrier may not discontinue or not renew the health benefit
plan until the first renewal date following the beginning
of a new plan year, even if the carrier knows as of the beginning
of the plan year that the employer no longer has at least
two current employees.
2002
31A-30-107.5 Limitations and exclusions.
(1) A health benefit plan may impose a preexisting condition exclusion only if:
(a) the exclusion relates to a condition, regardless of the cause of the condition, for which medical advise, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date;
(b) the exclusion extends for a period of:
(i) not more than 12 months after the enrollment date; or
(ii) in the case of a late enrollee, 18 months after the enrollment date; and
(c) the period described in Subsection (1)(b) is reduced by the aggregate of the periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.
(2) Creditable coverage shall be provided for the period of time the individual was previously covered by:
(a) public or private health insurance; or
(b) any other group health plan as defined in 42 U.S.C. Section 300gg-91.
(3) (a) The period of continuous coverage under Subsection (1)(c) may not include any waiting period for the effective date of the new coverage applied by the employer or the carrier.
(b) This Subsection (3) does not preclude application of any waiting period applicable to all new enrollees under the plan.
(4) (a) Credit for previous coverage as provided under Subsection (1)(c) need not be given for any condition that was previously excluded under a condition-specific exclusion rider issued pursuant to Subsection (6).
(b) A new preexisting waiting period may be applied to any condition that was excluded by a rider under the terms of previous individual coverage.
(5) (a) For purposes of Subsection (1)(c), a period of creditable coverage may not be counted with respect to enrollment of an individual under a health benefit plan, if:
(i) after the period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage; or
(ii) the insured fails to provide notification of previous coverage to the covered carrier within 36 months of the coverage effective date if the covered carrier has previously requested the notification.
(b) (i) Credit for previous coverage as provided under Subsection (1)(c) need not be given for any condition that was previously excluded in compliance with Subsection (6).
(ii) A new preexisting waiting period may be applied to any condition that was excluded under the terms of previous individual coverage.
(6) (a) An individual carrier:
(i) shall offer a health benefit plan in compliance with Subsection (1); and
(ii) may, when the individual carrier and the insured mutually agree in writing to a condition-specific exclusion rider, offer to issue an individual policy that excludes a specific physical condition consistent with Subsection (6)(b).
(b) (i) The commissioner shall establish by rule a list of life threatening physical conditions that may not be the subject of a condition-specific exclusion rider.
(ii) A condition-specific exclusion rider:
(A) shall be limited to the excluded condition; and
(B) may not extend to any secondary medical condition that may or may not be directly related to the excluded condition.
(7) Notwithstanding the other provisions of this section, a health benefit plan may impose a limitation period if:
(a) each policy that imposes a limitation period under the health benefit plan specifies the physical condition that is excluded from coverage during the limitation period;
(b) the limitation period does not exceed 12 months;
(c) the limitation period is applied uniformly; and
(d) the limitation period is reduced in compliance with
Subsection (1)(c).
2003
31A-30-108 Eligibility for small employer and individual market.
(1) (a) Small employer carriers shall accept residents for small group coverage as set forth in the Health Insurance Portability and Accountability Act, P.L. 104-191, 110 Stat. 1962, Sec. 2701(f) and 2711(a).
(b) Individual carriers shall accept residents for individual coverage pursuant:
(i) to P.L. 104-191, 110 Stat. 1979, Sec. 2741(a)-(b); and
(ii) Subsection (3).
(2) (a) Small employer carriers shall offer to accept all eligible employees and their dependents at the same level of benefits under any health benefit plan provided to a small employer.
(b) Small employer carriers may:
(i) request a small employer to submit a copy of the small employer's quarterly income tax withholdings to determine whether the employees for whom coverage is provided or requested are bona fide employees of the small employer; and
(ii) deny or terminate coverage if the small employer refuses to provide documentation requested under Subsection (2)(b)(i).
(3) Except as provided in Subsection (5) and Section 31A-30-110 , individual carriers shall accept for coverage individuals to whom all of the following conditions apply:
(a) the individual is not covered or eligible for coverage:
(i) (A) as an employee of an employer;
(B) as a member of an association; or
(C) as a member of any other group; and
(ii) under:
(A) a health benefit plan; or
(B) a self-insured arrangement that provides coverage similar to that provided by a health benefit plan as defined in Section 31A-1-301 ;
(b) the individual is not covered and is not eligible for coverage under any public health benefits arrangement including:
(i) the Medicare program established under Title XVIII of the Social Security Act;
(ii) the Medicaid program established under Title XIX of the Social Security Act;
(iii) any act of Congress or law of this or any other state that provides benefits comparable to the benefits provided under this chapter; or
(iv) coverage under the Comprehensive Health Insurance Pool Act created in Chapter 29, Comprehensive Health Insurance Pool Act;
(c) unless the maximum benefit has been reached the individual is not covered or eligible for coverage under any:
(i) Medicare supplement policy;
(ii) conversion option;
(iii) continuation or extension under COBRA; or
(iv) state extension;
(d) the individual has not terminated or declined coverage described in Subsection (3)(a), (b), or (c) within 93 days of application for coverage, unless the individual is eligible for individual coverage under P.L. 104-191, 110 Stat. 1979, Sec. 2741(b), in which case, the requirement of this Subsection (3)(d) does not apply; and
(e) the individual is certified as ineligible for the Health Insurance Pool if:
(i) the individual applies for coverage with the Comprehensive Health Insurance Pool within 30 days after being rejected or refused coverage by the covered carrier and reapplies for coverage with that covered carrier within 30 days after the date of issuance of a certificate under Subsection 31A-29-111 (4)(c); or
(ii) the individual applies for coverage with any individual carrier within 45 days after:
(A) notice of cancellation of coverage under Subsection 31A-29-115 (1); or
(B) the date of issuance of a certificate under Subsection 31A-29-111 (4)(c) if the individual applied first for coverage with the Comprehensive Health Insurance Pool.
(4) (a) If coverage is obtained under Subsection (3)(e)(i) and the required premium is paid, the effective date of coverage shall be the first day of the month following the individual's submission of a completed insurance application to that covered carrier.
(b) If coverage is obtained under Subsection (3)(e)(ii) and the required premium is paid, the effective date of coverage shall be the day following the:
(i) cancellation of coverage under Subsection 31A-29-115 (1); or
(ii) submission of a completed insurance application to the Comprehensive Health Insurance Pool.
(5) (a) An individual carrier is not required to accept individuals for coverage under Subsection (3) if the carrier issues no new individual policies in the state after July 1, 1997.
(b) A carrier described in Subsection (5)(a) may not issue new individual policies in the state for five years from July 1, 1997.
(c) Notwithstanding Subsection (5)(b), a carrier may request permission to issue new policies after July 1, 1999, which may only be granted if:
(i) the carrier accepts uninsurables as is required of a carrier entering the market under Subsection 31A-30-110 ; and
(ii) the commissioner finds that the carrier's issuance of new individual policies:
(A) is in the best interests of the state; and
(B) does not provide an unfair advantage to the carrier.
(6) (a) If a small employer carrier offers health benefit plans to small employers through a network plan, the small employer carrier may:
(i) limit the employers that may apply for the coverage to those employers with eligible employees who live, reside, or work in the service area for the network plan; and
(ii) within the service area of the network plan, deny coverage to an employer if the small employer carrier has demonstrated to the commissioner that the small employer carrier:
(A) will not have the capacity to deliver services adequately to enrollees of any additional groups because of the small employer carrier's obligations to existing group contract holders and enrollees; and
(B) applies this section uniformly to all employers without regard to:
(I) the claims experience of an employer, an employer's employee, or a dependent of an employee; or
(II) any health status-related factor relating to an employee or dependent of an employee.
(b) (i) A small employer carrier that denies a health benefit product to an employer in any service area in accordance with this section may not offer coverage in the small employer market within the service area to any employer for a period of 180 days after the date the coverage is denied.
(ii) This Subsection (6)(b) does not:
(A) limit the small employer carrier's ability to renew coverage that is in force; or
(B) relieve the small employer carrier of the responsibility to renew coverage that is in force.
(c) Coverage offered within a service area after the 180-day
period specified in Subsection (6)(b) is subject to the requirements
of this section.
2002
31A-30-109 Basic benefit plan.
An individual carrier who offers individual coverage pursuant
to Section
31A-30-108
shall offer a choice of coverage that is at
least equal to or greater than basic coverage.
1997
31A-30-110 Individual enrollment cap.
(1) The commissioner shall set the individual enrollment cap at .5% on July 1, 1997.
(2) The commissioner shall raise the individual enrollment cap by .5% at the later of the following dates:
(a) six months from the last increase in the individual enrollment cap; or
(b) the date when CCI/TI is greater than .90, where:
(i) "CCI" is the total individual coverage count for all carriers certifying that their uninsurable percentage has reached the individual enrollment cap; and
(ii) "TI" is the total individual coverage count for all carriers.
(3) The commissioner may establish a minimum number of uninsurable individuals that a carrier entering the market who is subject to this chapter must accept under the individual enrollment provisions of this chapter.
(4) Beginning July 1, 1997, an individual carrier may decline to accept individuals applying for individual enrollment under Subsection 31A-30-108 (3), other than individuals applying for coverage as set forth in P.L. 104-191, 110 Stat. 1979, Sec. 2741 (a)-(b), if:
(a) the uninsurable percentage for that carrier equals or exceeds the cap established in Subsection (1); and
(b) the covered carrier has certified on forms provided by the commissioner that its uninsurable percentage equals or exceeds the individual enrollment cap.
(5) The department may audit a carrier's records to verify whether the carrier's uninsurable classification meets industry standards for underwriting criteria as established by the commissioner in accordance with Subsection 31A-30-106 (1)(i).
(6) (a) If the commissioner determines that individual enrollment is causing a substantial adverse effect on premiums, enrollment, or experience, the commissioner may suspend, limit, or delay further individual enrollment for up to 12 months.
(b) The commissioner shall adopt rules to establish a
uniform methodology for calculating and reporting loss ratios
for individual policies for determining whether the individual
enrollment provisions of Section
31A-30-108
should be waived for an individual carrier
experiencing significant and adverse financial impact as
a result of complying with those provisions.
2002
31A-30-111 Limitations on high risk enrollees.
(1) (a) The requirements of this chapter do not apply to any carrier that is currently in a state of supervision, insolvency, or liquidation.
(b) If a carrier demonstrates to the satisfaction of the commissioner that the requirements of this chapter would place the carrier in a state of supervision, insolvency, or liquidation the commissioner may waive or modify the requirements of Sections 31A-30-108 and 31A-30-110 .
(2) (a) A modification or waiver by the commissioner under Subsection (1)(b) shall be effective for a period of not more than one year.
(b) At the end of the period described in Subsection (2)(a), a carrier is subject to Sections 31A-30-108 and 31A-30-110 unless the carrier demonstrates to the satisfaction of the commissioner the need for a modification or waiver in accordance with Subsection (1)(b).
(3) Notwithstanding the requirements of this chapter, a carrier may deny health benefit plan coverage in the small employer and individual market if the carrier demonstrates to the satisfaction of the commissioner that the carrier:
(a) does not have the financial reserves necessary to underwrite additional coverage;
(b) is applying this section uniformly to all small employers and individuals without regard to:
(i) any health status-related factor of the individuals; or
(ii) whether the individuals are eligible individuals.
2002
31A-30-112 Employee participation levels.
(1) Except as provided in Subsection (2), requirements used by a covered carrier in determining whether to provide coverage to a small employer, including requirements for minimum participation of eligible employees and minimum employer contributions shall be applied uniformly among all small employers with the same number of eligible employees applying for coverage or receiving coverage from the covered carrier.
(2) A covered carrier may not increase any requirement
for minimum employee participation or any requirement for
minimum employer contribution applicable to a small employer
at any time after the small employer has been accepted for
coverage.
1995
31A-30-114 Disclosure.
(1) A covered carrier shall make the information described in Subsection (2) available:
(a) to:
(i) a small employer; or
(ii) an individual; and
(b) (i) at the time of solicitation; or
(ii) upon the request of:
(A) a small employer; or
(B) an individual;
(c) as part of the covered carrier's solicitation and sales materials.
(2) The following information is required to be disclosed or made available under Subsection (1):
(a) the provisions of the coverage concerning the covered carrier's right to change premium rates; and
(b) the factors that may effect changes in premium rates;
(c) the provisions of the coverage relating to renewability of coverage; and
(d) the provisions of the coverage relating to any preexisting
condition exclusion.
2002
