31A-22-618.6. Discontinuance, nonrenewal, or changes to group health benefit plans.
(1)
Except as otherwise provided in this section, a group health benefit plan for a plan sponsor is renewable and continues in force:
Terms Used In Utah Code 31A-22-618.6
Affiliate: means a person who controls, is controlled by, or is under common control with, another person. See Utah Code 31A-1-301
Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
Contract: A legal written agreement that becomes binding when signed.
Dependent: A person dependent for support upon another.
Eligible employee: includes :
(i)
an owner, sole proprietor, or partner who:
(A)
works on a full-time basis;
(B)
has a normal work week of 30 or more hours; and
(C)
employs at least one common employee; and
(ii)
an independent contractor if the individual is included under a health benefit plan of a small employer. See Utah Code 31A-1-301
Employee: means :
(a)
an individual employed by an employer; or
(b)
an individual who meets the requirements of Subsection (53)(b). See Utah Code 31A-1-301
Fraud: Intentional deception resulting in injury to another.
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
a summary plan description of a group health plan;
(b)
if the plan document or summary plan description does not designate a plan year or there is no plan document or summary plan description:
(i)
the year used to determine deductibles or limits;
(ii)
the policy year, if the plan does not impose deductibles or limits on a yearly basis; or
(iii)
the employer's taxable year if:
(A)
the plan does not impose deductibles or limits on a yearly basis; and
(B)
(I)
the plan is not insured; or
(II)
the insurance policy is not renewed on an annual basis; or
(c)
in a case not described in Subsection (144)(a) or (b), the calendar year. See Utah Code 31A-1-301
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
State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
with respect to all eligible employees and dependents; and
(b)
at the option of the plan sponsor.
(2)
A group health benefit plan for a plan sponsor may be discontinued or nonrenewed:
(a)
for noncompliance with the insurer’s employer contribution requirements;
(b)
if there is no longer any enrollee under the group health benefit plan who lives, resides, or works in:
(i)
the service area of the insurer; or
(ii)
the area for which the insurer is authorized to do business;
(c)
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 discontinued or nonrenewed uniformly without regard to any health status-related factor relating to any covered individual; or
(d)
for noncompliance with the insurer’s minimum employee participation requirements, except as provided in Subsection (3).
(3)
If a small employer no longer employs at least one eligible employee, a carrier may not discontinue or not renew the group health benefit plan until the first renewal date following the beginning of a new plan year, even if the carrier knows at the beginning of the plan year that the employer no longer has at least one eligible employee.
(4)
(a)
A small employer that, after purchasing a group health benefit plan in the small group market, employs on average more than 50 eligible employees on each business day in a calendar year may continue to renew the group health benefit plan purchased in the small group market.
(b)
A large employer that, after purchasing a group health benefit plan in the large group market, employs on average fewer than 51 eligible employees on each business day in a calendar year may continue to renew the group health benefit plan purchased in the large group market.
(5)
A health benefit plan for a plan sponsor may be discontinued or nonrenewed 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 insurer:
(i)
elects to discontinue offering a particular group health benefit plan delivered or issued for delivery in this state;
(ii)
provides notice of the discontinuation in writing to each plan sponsor, employee, and dependent of an employee, at least 90 days before the day on which the coverage discontinues;
(iii)
provides notice of the discontinuation in writing to the commissioner, and at least three working days before the day on which the notice is sent to each affected plan sponsor, employee, and dependent of an employee;
(iv)
offers to each plan sponsor, on a guaranteed issue basis, the option to purchase all other group health benefit plans currently being offered by the insurer in the market or, in the case of a large employer, any other group health benefit plans currently being offered in that market; and
(v)
in exercising the option to discontinue the group health benefit plan and in offering the option of coverage in this section, acts uniformly without regard to the claims experience of a plan sponsor, any health status-related factor relating to any covered participant or beneficiary, or any health status-related factor relating to any new participant or beneficiary who may become eligible for the coverage; or
(e)
the insurer:
(i)
elects to discontinue offering all of the insurer’s group health benefit plans in:
(A)
the small employer market;
(B)
the large employer market; or
(C)
both the small employer and large employer markets;
(ii)
provides notice of the discontinuation in writing to each plan sponsor, employee, and dependent of an employee at least 180 days before the day on which the coverage discontinues;
(iii)
provides notice of the discontinuation in writing to the commissioner in each state in which an affected insured individual is known to reside and, at least 30 working days before the day on which the notice is sent to each affected plan sponsor, employee, and dependent of an employee;
(iv)
discontinues and nonrenews all plans issued or delivered for issuance in the market described in Subsection (5)(e)(i) ; and
(v)
(A)
provides a plan of orderly withdrawal as required by Section 31A-4-115; or
(B)
places the plan with an affiliate of the insurer with a plan of the same or similar coverage.
(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 in connection with the coverage that constitutes fraud; or
(ii)
makes an intentional misrepresentation of material fact in connection with the coverage.
(b)
An eligible employee whose coverage is discontinued under Subsection (6)(a) may reenroll:
(i)
12 months after the day on which the employee’s coverage discontinues; 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 discontinues under Subsection (6)(a), the insurer shall notify the eligible employee of the right to reenroll as described in Subsection (6)(b).
(d)
An eligible employee’s coverage 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 group health benefit plan is made available by an insurer in the employer market only through:
(i)
an association;
(ii)
a trust; or
(iii)
a discretionary group.
(8)
An insurer may modify a group health benefit plan for a plan sponsor only:
(a)
at the time of coverage renewal; and
(b)
if the modification is effective uniformly among all plans.
