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 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
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
(a)
The department shall conduct an actuarial review of rates submitted by a carrier that offers a small employer plan and a carrier that offers an individual plan under this chapter:
(i)
to verify the validity of the rates, risk factors, and premiums of the plans; and
(ii)
as the department determines is necessary to oversee market conduct.
(b)
The actuarial review by the department shall be funded from a fee:
(i)
established by the department in accordance with Section 63J-1-504; and
(ii)
paid by a carrier offering a health benefit plan subject to this chapter.
(c)
The department shall contact carriers, if the department determines it is appropriate, to:
(i)
inform a carrier of the department’s findings regarding the rates of a particular carrier; and
(ii)
request a carrier to recalculate or verify base rates, rating factors, and premiums.
(d)
A carrier shall comply with the department’s request under Subsection (1)(c)(ii).
(2)
(a)
There is created in the General Fund a restricted account known as the “Health Insurance Actuarial Review Restricted Account.”
(b)
The Health Insurance Actuarial Review Restricted Account shall consist of money received by the commissioner under this section.
(c)
The commissioner shall administer the Health Insurance Actuarial Review Restricted Account. Subject to appropriations by the Legislature, the commissioner shall use money deposited into the Health Insurance Actuarial Review Restricted Account to pay for the actuarial review conducted by the department under this section.
