31A-22-728. Large employer health benefit plan required report.
(1)
As used in this section:
Terms Used In Utah Code 31A-22-728
consultant: means a person who:
(a)
advises another person about insurance needs and coverages;
(b)
is compensated by the person advised on a basis not directly related to the insurance placed; and
(c)
except as provided in Section 31A-23a-501, is not compensated directly or indirectly by an insurer or producer for advice given. 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
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
Month: means a calendar month, unless otherwise expressed. See Utah Code 68-3-12.5
Person: includes :
(a)
an individual;
(b)
a partnership;
(c)
a corporation;
(d)
an incorporated or unincorporated association;
(e)
a joint stock company;
(f)
a trust;
(g)
a limited liability company;
(h)
a reciprocal;
(i)
a syndicate; or
(j)
another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301
Plan year: means :
(a)
the year that is designated as the plan year in:
(i)
the plan document of a group health plan; or
(ii)
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
producer: means a person licensed or required to be licensed under the laws of this state to sell, solicit, or negotiate insurance. See Utah Code 31A-1-301
(a)
“Claims run-out period” means the period beginning on the first day following the last day of a plan year and ending on the 90th day following the last day of a plan year.
(b)
“Large employer” means an employer who:
(i)
with respect to a calendar year and to a plan year:
(A)
employed an average of at least 51 employees on a business day during the preceding calendar year; and
(B)
employs at least one employee on the first day of the plan year; and
(ii)
has at least 51 but fewer than 100 enrolled eligible employees enrolled in a group health benefit plan during each consecutive month during the plan year.
(c)
“Medical loss ratio” means a group health benefit plan’s paid claims incurred during a plan year, including the claims run-out period, divided by the total premium revenue collected for the plan year.
(2)
Except as provided in Subsection (6), beginning on January 1, 2024, an insurer that offers a large employer health benefit plan to a large employer shall annually provide a report, upon request of:
(a)
the large employer;
(b)
the large employer’s appointed producer; or
(c)
the large employer’s consultant.
(3)
The report described in Subsection (2) shall include:
(a)
after the first renewal, the health benefit plan’s aggregate performance from the immediately preceding plan year that describes whether the health benefit plan had a medical loss ratio of:
(i)
less than 85%;
(ii)
between 85% and 125%; or
(iii)
greater than 125%; and
(b)
after the second renewal and each subsequent renewal thereafter, a summary of the health benefit plan’s aggregate 24-month medical loss ratio from the immediately preceding two plan years combined.
(4)
An insurer that offers a large employer health benefit plan shall provide the requested report described in Subsection (2) not less than 30 days after the claims run-out period.
(5)
(a)
The report described in Subsection (2) is proprietary to the large employer, the large employer’s appointed producer, or the large employer’s consultant.
(b)
A person may not share the report described in Subsection (2) with a party other than a party described in Subsection (5)(a).
(6)
An insurer is not required to provide a report as described in this section if:
(a)
the health benefit plan is a qualified health plan as defined in 45 C.F.R. § 155.20;
(b)
the health benefit plan is issued to a group other than an employee group described in Section 31A-22-502;
(c)
the large employer has not had continuous large employer health benefit plan coverage with the insurer for at least 18 months before the date on which the large employer requests the report;
(d)
the large employer does not renew coverage with the insurer; or
(e)
the insurer reasonably believes that providing the report would disclose information described in Subsection 13-61-102(2)(g).
(7)
An insurer that provides a report in compliance with this section is immune from civil liability for the insurer’s acts or omissions in providing information required under Subsection (3).
