31A-22-618.5. Coverage of insurance mandates imposed after January 1, 2009.
(1)
The purpose of this section is to increase the range of health benefit plans available in the small group, small employer group, large group, and individual insurance markets.
Terms Used In Utah Code 31A-22-618.5
Emergency medical condition: means a medical condition that:
(a)
manifests itself by acute symptoms, including severe pain; and
(b)
would cause a prudent layperson possessing an average knowledge of medicine and health to reasonably expect the absence of immediate medical attention through a hospital emergency department to result in:
(i)
placing the layperson's health or the layperson's unborn child's health in serious jeopardy;
Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment:
a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
(ii)
a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
(iii)
a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
Small employer: means , in connection with a health benefit plan and with respect to a calendar year and to a plan year, an employer who:
(i)
(A)
employed at least one but not more than 50 eligible employees on business days during the preceding calendar year; or
(B)
if the employer did not exist for the entirety of the preceding calendar year, reasonably expects to employ an average of at least one but not more than 50 eligible employees on business days during the current calendar year;
(ii)
employs at least one employee on the first day of the plan year; and
(iii)
for an employer who has common ownership with one or more other employers, is treated as a single employer under 26 U. See Utah Code 31A-1-301
may offer to a potential purchaser one or more health benefit plans that:
(i)
are not subject to one or more of the following:
(A)
the limitations on insuredindemnity benefits in Subsection 31A-8-105(4);
(B)
except as provided in Subsection (2)(b)(ii), basic health care services as defined in Section 31A-8-101; or
(C)
coverage mandates enacted after January 1, 2009 that are not required by federal law, provided that the insurer offers one plan under Subsection (2)(a) that covers the mandate enacted after January 1, 2009; and
(ii)
when offering a health plan under this section, provide coverage for an emergency medical condition as required by Section 31A-22-627.
when offering a health plan under this Subsection (3), shall provide coverage of emergency care services as required by Section 31A-22-627; and
(c)
is not subject to coverage mandates enacted after January 1, 2009 that are not required by federal law, provided that an insurer offers one plan that covers a mandate enacted after January 1, 2009.
(4)
Section 31A-8-106 does not prohibit the offer of a health benefit plan under Subsection (2)(b).
(5)
(a)
Any difference in price between a health benefit plan offered under Subsections (2)(a) and (b) shall be based on actuarially sound data.
(b)
Any difference in price between a health benefit plan offered under Subsection (3)(a) shall be based on actuarially sound data.
(6)
Nothing in this section limits the number of health benefit plans that an insurer may offer.
