31A-43-102. Definitions. For purposes of this chapter:
(1)
“Actuarial certification” means a written statement by a member of the American Academy of Actuaries, or by another individual acceptable to the commissioner, that an insurer is in compliance with this chapter, based upon the individual’s examination and including a review of the appropriate records and the actuarial assumptions and methods used by the stop-loss insurer in establishing attachment points and other applicable determinations in conjunction with the provision of stop-loss insurance coverage.
Terms Used In Utah Code 31A-43-102
Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
Contract: A legal written agreement that becomes binding when signed.
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
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
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
(2)
“Aggregate attachment point” means the dollar amount of covered claims incurred by a small employer plan beyond which the stop-loss insurer incurs liability for losses incurred by the small employer plan, subject to limitations included in the contract.
(3)
“Coverage” means the combination of the employer plan design and the stop-loss contract design.
(4)
“Expected claims” means the amount of claims that, in the absence of aggregate stop-loss insurance, are projected to be incurred by a small employer health plan using reasonable and accepted actuarial principles.
(5)
“Lasering”:
(a)
means increasing or removing stop-loss coverage for a specific individual within an employer group; and
(b)
includes other practices that are prohibited by the commissioner by administrative rule that result in lowering the stop-loss premium for the employer by transferring the risk for an individual’s claims back to the employer.
(6)
“Small employer” means an employer who, with respect to a calendar year and to a plan year:
(a)
employed an average of at least two employees but not more than 50 eligible employees on each business day during the preceding calendar year; and
(b)
employs at least two employees on the first day of the plan year.
(7)
“Specific attachment point” means the dollar amount of covered claims attributable to a single individual covered by a small employer plan in a contract year beyond which the stop-loss insurer assumes the liability for losses incurred by the small employer plan, subject to limitations included in the contract.
(8)
“Stop-loss insurance” means insurance purchased by a small employer for which the stop-loss insurer assumes all loss amounts of the small employer’s plan in excess of a stated amount, subject to the policy limit.
Amended by Chapter 290, 2014 General Session Amended by Chapter 300, 2014 General Session
