Terms Used In Utah Code > Title 31A > Chapter 30 > Part 1 - Individual and Small Employer Group

• Actuarial certification: means a written statement by a member of the American Academy of Actuaries or other individual approved by the commissioner that a covered carrier is in compliance with this chapter, based upon the examination of the covered carrier, including review of the appropriate records and of the actuarial assumptions and methods used by the covered carrier in establishing premium rates for applicable health benefit plans. See Utah Code 31A-30-103
• affiliated: means a person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, a specified person. See Utah Code 31A-30-103
• Application: means a document:

  (a)

  (i)  completed by an applicant to provide information about the risk to be insured; and (ii)  that contains information that is used by the insurer to evaluate risk and decide whether to: (A)  insure the risk under: (I)  the coverage as originally offered; or (II)  a modification of the coverage as originally offered; or (B)  decline to insure the risk; or

  (b)

  used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301 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 Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account. Base premium rate: means , for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under a rating system for that class of business by the covered carrier to covered insureds with similar case characteristics for health benefit plans with the same or similar coverage. See Utah Code 31A-30-103 Bona fide employer association: means an association of employers: (i)  that meets the requirements of Section 31A-22-505; (ii)  in which the employers of the association, either directly or indirectly, exercise control over the plan; (iii)  that is organized: (A)  based on a commonality of interest between the employers and their employees that participate in the plan by some common economic or representation interest or genuine organizational relationship unrelated to the provision of benefits; and (B)  to act in the best interests of its employers to provide benefits for the employer's employees and their spouses and dependents, and other benefits relating to employment; and (iv)  whose association sponsored health plan complies with 45 C. See Utah Code 31A-30-103 business of insurance: includes : (a)  providing health care insurance by an organization that is or is required to be licensed under this title; (b)  providing a benefit to an employee in the event of a contingency not within the control of the employee, in which the employee is entitled to the benefit as a right, which benefit may be provided either: (i)  by a single employer or by multiple employer groups; or (ii)  through one or more trusts, associations, or other entities; (c)  providing an annuity: (i)  including an annuity issued in return for a gift; and (ii)  except an annuity provided by a person specified in Subsections 31A-22-1305(2) and (3); (d)  providing the characteristic services of a motor club; (e)  providing another person with insurance; (f)  making as insurer, guarantor, or surety, or proposing to make as insurer, guarantor, or surety, a contract or policy offering title insurance; (g)  transacting or proposing to transact any phase of title insurance, including: (i)  solicitation; (ii)  negotiation preliminary to execution; (iii)  execution of a contract of title insurance; (iv)  insuring; and (v)  transacting matters subsequent to the execution of the contract and arising out of the contract, including reinsurance; (h)  transacting or proposing a life settlement; and (i)  doing, or proposing to do, any business in substance equivalent to Subsections (95)(a) through (h) in a manner designed to evade this title. See Utah Code 31A-1-301 Carrier: means a person that provides health insurance in this state including: (a)  an insurance company; (b)  a prepaid hospital or medical care plan; (c)  a health maintenance organization; (d)  a multiple employer welfare arrangement; and (e)  another person providing a health insurance plan under this title. See Utah Code 31A-30-103 Case action plan: means a document developed by the Department of Corrections that identifies: (a)  the program priorities for the treatment of the offender, including the criminal risk factors as determined by risk, needs, and responsivity assessments conducted by the department; and (b)  clearly defined completion requirements. See Utah Code 64-13-1 case characteristics: means demographic or other objective characteristics of a covered insured that are considered by the carrier in determining premium rates for the covered insured. See Utah Code 31A-30-103 Certificate: means evidence of insurance given to: (a)  an insured under a group insurance policy; or (b)  a third party. See Utah Code 31A-1-301 Class of business: means all or a separate grouping of covered insureds that is permitted by the commissioner in accordance with Section 31A-30-105. See Utah Code 31A-30-103 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 Contract: A legal written agreement that becomes binding when signed. Conviction: A judgement of guilt against a criminal defendant. Correctional facility: means any facility operated to house offenders in a secure or nonsecure setting: (a)  by the department; or (b)  under a contract with the department. See Utah Code 64-13-1 Covered carrier: means an individual carrier or small employer carrier subject to this chapter. See Utah Code 31A-30-103 Covered individual: means an individual who is covered under a health benefit plan subject to this chapter. See Utah Code 31A-30-103 Covered insureds: means small employers and individuals who are issued a health benefit plan that is subject to this chapter. See Utah Code 31A-30-103 Criminal risk factors: means an individual's characteristics and behaviors that: (a)  affect the individual's risk of engaging in criminal behavior; and (b)  are diminished when addressed by effective treatment, supervision, and other support resources, resulting in a reduced risk of criminal behavior. See Utah Code 64-13-1 Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries. Department: means the Department of Corrections. See Utah Code 64-13-1 Department: means the Insurance Department. See Utah Code 31A-1-301 Direct supervision: means a housing and supervision system that is designed to meet the goals described in Subsection 64-13-14(5) and has the elements described in Subsection 64-13-14(6). See Utah Code 64-13-1 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 Evidence-based: means a program or practice that has had multiple randomized control studies or a meta-analysis demonstrating that the program or practice is effective for a specific population or has been rated as effective by a standardized program evaluation tool. See Utah Code 64-13-1 Exclusion: means for the purposes of accident and health insurance that an insurer does not provide insurance coverage, for whatever reason, for one of the following: (a)  a specific physical condition; (b)  a specific medical procedure; (c)  a specific disease or disorder; or (d)  a specific prescription drug or class of prescription drugs. See Utah Code 31A-1-301 Executive director: means the executive director of the Department of Corrections. See Utah Code 64-13-1 Filed: means that a filing is: (i)  submitted to the department as required by and in accordance with applicable statute, rule, or filing order; (ii)  received by the department within the time period provided in applicable statute, rule, or filing order; and (iii)  accompanied by the appropriate fee in accordance with: (A)  Section 31A-3-103; or (B)  rule. See Utah Code 31A-1-301 Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006. Form: means one of the following prepared for general use: (i)  a policy; (ii)  a certificate; (iii)  an application; (iv)  an outline of coverage; or (v)  an endorsement. See Utah Code 31A-1-301 Habeas corpus: A writ that is usually used to bring a prisoner before the court to determine the legality of his imprisonment. It may also be used to bring a person in custody before the court to give testimony, or to be prosecuted. 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 Health care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment: (a)  a professional service; (b)  a personal service; (c)  a facility; (d)  equipment; (e)  a device; (f)  supplies; or (g)  medicine. See Utah Code 31A-1-301 health insurance: means insurance providing: (i)  a health care benefit; or (ii)  payment of an incurred health care expense. See Utah Code 31A-1-301 Index rate: means , for each class of business as to a rating period for covered insureds with similar case characteristics, the arithmetic average of the applicable base premium rate and the corresponding highest premium rate. See Utah Code 31A-30-103 Individual: means a natural person. See Utah Code 31A-1-301 Individual carrier: means a carrier that provides coverage on an individual basis through a health benefit plan regardless of whether: (a)  coverage is offered through: (i)  an association; (ii)  a trust; (iii)  a discretionary group; or (iv)  other similar groups; or (b)  the policy or contract is situated out-of-state. See Utah Code 31A-30-103 Inmate: means an individual who is: (a)  committed to the custody of the department; and (b)  housed at a correctional facility or at a county jail at the request of the department. See Utah Code 64-13-1 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 insurance company: means a person doing an insurance business as a principal including: (i)  a fraternal benefit society; (ii)  an issuer of a gift annuity other than an annuity specified in Subsections 31A-22-1305(2) and (3); (iii)  a motor club; (iv)  an employee welfare plan; (v)  a person purporting or intending to do an insurance business as a principal on that person's own account; and (vi)  a health maintenance organization. See Utah Code 31A-1-301 Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes: (i)  a policyholder; (ii)  a subscriber; (iii)  a member; and (iv)  a beneficiary. See Utah Code 31A-1-301 Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases. Member: means a person having membership rights in an insurance corporation. See Utah Code 31A-1-301 Month: means a calendar month, unless otherwise expressed. See Utah Code 68-3-12.5 New business premium rate: means , for each class of business as to a rating period, the lowest premium rate charged or offered, or that could have been charged or offered, by the carrier to covered insureds with similar case characteristics for newly issued health benefit plans with the same or similar coverage. See Utah Code 31A-30-103 Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period. Offender: means an individual who has been convicted of a crime for which the individual may be committed to the custody of the department and is at least one of the following: (a)  committed to the custody of the department; (b)  on probation; or (c)  on parole. See Utah Code 64-13-1 Person: means :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 Policy: includes a service contract issued by: (i)  a motor club under Chapter 11, Motor Clubs; (ii)  a service contract provided under Chapter 6a, Service Contracts; and (iii)  a corporation licensed under: (A)  Chapter 7, Nonprofit Health Service Insurance Corporations; or (B)  Chapter 8, Health Maintenance Organizations and Limited Health Plans. 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 Probable cause: A reasonable ground for belief that the offender violated a specific law. Probation: A sentencing alternative to imprisonment in which the court releases convicted defendants under supervision as long as certain conditions are observed. Probation officers: Screen applicants for pretrial release and monitor convicted offenders released under court supervision. Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5 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 Property: includes both real and personal property. See Utah Code 68-3-12.5 Rate: means : (i)  the cost of a given unit of insurance; or (ii)  for property or casualty insurance, that cost of insurance per exposure unit either expressed as: (A)  a single number; or (B)  a pure premium rate, adjusted before the application of individual risk variations based on loss or expense considerations to account for the treatment of: (I)  expenses; (II)  profit; and (III)  individual insurer variation in loss experience. See Utah Code 31A-1-301 Rating period: means the calendar period for which premium rates established by a covered carrier are assumed to be in effect, as determined by the carrier. See Utah Code 31A-30-103 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 Recidivism: means a return to criminal activity after a previous criminal conviction. See Utah Code 64-13-1 Rider: means an endorsement to: (a)  an insurance policy; or (b)  an insurance certificate. See Utah Code 31A-1-301 Risk and needs assessment: means an actuarial tool validated on criminal offenders that determines: (a)  an individual's risk of reoffending; and (b)  the criminal risk factors that, when addressed, reduce the individual's risk of reoffending. See Utah Code 64-13-1 Secondary medical condition: means a complication related to an exclusion from coverage in accident and health insurance. See Utah Code 31A-1-301 Secure correctional facility: means any prison, penitentiary, or other institution operated by the department or under contract for the confinement of offenders, where force may be used to restrain an offender if the offender attempts to leave the institution without authorization. See Utah Code 64-13-1 Sentencing guidelines: A set of rules and principles established by the United States Sentencing Commission that trial judges use to determine the sentence for a convicted defendant. Source: U.S. Courts Service of process: The service of writs or summonses to the appropriate party. 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 Small employer carrier: means a carrier that provides health benefit plans covering eligible employees of one or more small employers in this state, regardless of whether: (a)  coverage is offered through: (i)  an association; (ii)  a trust; (iii)  a discretionary group; or (iv)  other similar grouping; or (b)  the policy or contract is situated out-of-state. See Utah Code 31A-30-103 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 under common control: means the direct or indirect possession of the power to direct or cause the direction of the management and policies of a person. See Utah Code 31A-1-301 United States: includes each state, district, and territory of the United States of America. See Utah Code 68-3-12.5 Writing: includes :Utah Code 68-3-12.5