31A-30-118.  Patient Protection and Affordable Care Act — State insurance mandates — Cost of additional benefits.

(1) 

Terms Used In Utah Code 31A-30-118

  • Appropriation: The provision of funds, through an annual appropriations act or a permanent law, for federal agencies to make payments out of the Treasury for specified purposes. The formal federal spending process consists of two sequential steps: authorization
  • Individual: means a natural person. See Utah Code 31A-1-301
  • Insurance: includes :
(i) 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
  • Member: means a person having membership rights in an insurance corporation. See Utah Code 31A-1-301
  • PPACA: means the Patient Protection and Affordable Care Act, Pub. See Utah Code 31A-1-301
  • Premium: means money paid by covered insureds and covered individuals as a condition of receiving coverage from a covered carrier, including fees or other contributions associated with the health benefit plan. See Utah Code 31A-30-103
  • Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
  • Rebate: means a licensee paying, allowing, giving, or offering to pay, allow, or give, directly or indirectly:
    (i) a refund of premium or portion of premium;
    (ii) a refund of commission or portion of commission;
    (iii) a refund of all or a portion of a consultant fee; or
    (iv) providing services or other benefits not specified in an insurance or annuity contract. 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
    • (a)  The commissioner shall identify a new mandated benefit that is in excess of the essential health benefits required by PPACA.

    (b)  The state shall quantify the cost attributable to each additional mandated benefit specified in Subsection (1)(a) based on a qualified health plan issuer’s calculation of the cost associated with the mandated benefit, which shall be:

    (i)  calculated in accordance with generally accepted actuarial principles and methodologies;

    (ii)  conducted by a member of the American Academy of Actuaries; and

    (iii)  reported to the commissioner and to the individual exchange operating in the state.

    (c)  The commissioner may require a proponent of a new mandated benefit under Subsection (1)(a) to provide the commissioner with a cost analysis conducted in accordance with Subsection (1)(b). The commissioner may use the cost information provided under this Subsection (1)(c) to establish estimates of the cost to the state under Subsection (2).

    • (2)  If the state is required to defray the cost of additional required benefits under the provisions of 45 C.F.R. § 155.170:

    (a)  the state shall make the required payments:

    (i)  in accordance with Subsection (3); and

    (ii)  directly to the qualified health plan issuer in accordance with 45 C.F.R. § 155.170;

    (b)  an issuer of a qualified health plan that receives a payment under the provisions of Subsection (1) and 45 C.F.R. § 155.170 shall:

    (i)  reduce the premium charged to the individual on whose behalf the issuer will be paid under Subsection (1), in an amount equal to the amount of the payment under Subsection (1); or

    (ii)  notwithstanding Subsection 31A-23a-402.5(5), provide a premium rebate to an individual on whose behalf the issuer received a payment under Subsection (1), in an amount equal to the amount of the payment under Subsection (1); and

    (c)  a premium rebate made under this section is not a prohibited inducement under Section 31A-23a-402.5.

    (3)  A payment required under 45 C.F.R. § 155.170(c) shall:

    (a)  unless otherwise required by PPACA, be based on a statewide average of the cost of the additional benefit for all issuers who are entitled to payment under the provisions of 45 C.F.R. § 155.170; and

    (b)  be submitted to an issuer through a process established by the commissioner.

    (4) 

    (a)  As used in this Subsection (4), “account” means the State Mandated Insurer Payments Restricted Account created in Subsection (4)(b).

    (b)  There is created in the General Fund a restricted account known as the “State Mandated Insurer Payments Restricted Account.”

    (c)  The account shall consist of:

    (i)  money appropriated to the account by the Legislature; and

    (ii)  interest earned on money in the account.

    (d)  Subject to appropriations from the Legislature, the commissioner shall administer the account for the sole benefit of a qualified health plan issuer who is eligible to receive payments under this section.

    (e)  An appropriation from the account is nonlapsing.

    (5)  The commissioner may adopt rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to:

    (a)  administer the provisions of this section and 45 C.F.R. § 155.170; and

    (b)  establish or implement a process for submitting a payment to an issuer under Subsection (3)(b).

    Amended by Chapter 194, 2023 General Session

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