No. 31937 (Amendment): R590-176. Health Benefit Plan Enrollment

DAR File No.: 31937
Filed: 09/11/2008, 08:27
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule is being updated as a result of comments received during the most recent comment period.

Summary of the rule or change:

The Governor's Office of Planning and Budget has suggested that the full name and date of the uninsurable underwriting standard specified be included in the rule along with how the standard is to be used by the health insurance industry.

State statutory or constitutional authorization for this rule:

Sections 31A-2-201 and 31A-2-202

Anticipated cost or savings to:

the state budget:

The changes to this rule will not affect the revenues or expenditures of the state or the department. Fees or fines will not be increased nor will the changes create additional work for the department. The changes merely clarify the name and date of the uninsurable underwriting standard and how it will be used.

local governments:

The changes to this rule will have no effect on local governments since the rule deals solely with the relationship between the department and its licensees.

small businesses and persons other than businesses:

The changes to this rule simply clarify the name and date of the underwriting standard to be used in determining uninsurability of individuals seeking health insurance. This is a process that is already being used. The 2008 Legislature in H.B. 301 has required that the standard be updated. (DAR NOTE: H.B. 301 (2008) is found at Chapter 385, Laws of Utah 2008, and was effective 05/05/2008.)

Compliance costs for affected persons:

The changes to this rule simply clarify the name and date of the underwriting standard to be used in determining uninsurability of individuals seeking health insurance. This is a process that is already being used. The 2008 Legislature in H.B. 301 has required that the standard be updated.

Comments by the department head on the fiscal impact the rule may have on businesses:

The changes to this rule will have no fiscal impact on businesses. D. Kent Michie, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Insurance
Administration
Room 3110 STATE OFFICE BLDG
450 N MAIN ST
SALT LAKE CITY UT 84114-1201

Direct questions regarding this rule to:

Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

10/31/2008

This rule may become effective on:

11/07/2008

Authorized by:

Jilene Whitby, Information Specialist

RULE TEXT

R590. Insurance, Administration.

R590-176. Health Benefit Plan Enrollment.

R590-176-7. Individual Underwriting Criteria.

(1) Each carrier shall determine the number of individuals classified as uninsurable at initial enrollment. This determination shall be made in accordance with [underwriting standards established by ]this rule.

(2) An individual insured by the Utah Comprehensive Health Insurance Pool is classified as uninsurable.

(3) (a) An individual may be classified as uninsurable if the individual has:

(i) one or more medical [conditions (]conditions; or

(ii) one or more prescriptions; and

(iii) the conditions, prescriptions, or both, are [assigned]determined to have a total number of debit points equal to or greater than 99 debit points in the aggregate [according to the latest version of]consistent with the Milliman Health Cost Guidelines - Small Group Medical Underwriting[ Guidelines], June 2008, taking into account;

(A) elapsed time;

(B) additional criteria; and

(C) exception criteria.

(b) A carrier may not take into account conditions for which coverage is not provided. This includes conditions excluded as a pre-existing condition for which treatment is expected during the exclusion period if the applicant would not be considered uninsurable after the treatment.

(4) Determinations made by an insurer under Subsection (3)(iii) will be audited by an experienced independent underwriter retained by the board of the Utah Comprehensive Health Insurance Pool who will rely on the[The] Milliman Health Cost Guidelines - Small Group Medical Underwriting[ Guidelines], June 2008,[ are available at the HIPUtah administrator's place of business]to evaluate whether the debit points of the medical conditions, prescriptions, or both are equal to or greater than 99 debit points in the aggregate.

(5) A carrier may appeal [to the commissioner]a determination by the auditor under Section 3 that an individual has a combination [to have an individual classified as uninsurable if the individual has a combination ]of conditions, prescriptions, or both, that [would ]cause that individual to have debit points [assigned that equal or exceed]less than the number of debit points determined under Section (3) [pursuant to the latest version of the Small Group Medical Underwriting Guidelines]to the commissioner. The commissioner may appoint a designee to review these appeals.

(6) Only individuals enrolling under Subsection 31A-30-108(3) may be counted as uninsurable.

 

R590-176-8. Individual Carrier Enrollment Cap Calculation and Certification.

(1) Pursuant to Section 31A-30-110, an individual carrier may not decline enrollment until the carrier has:

(a) met its enrollment cap; and

(b) submitted a certification to the department in compliance with this section.

(2) An individual carrier may limit enrollment after submitting its certification.

(3) The commissioner may require additional enrollment after reviewing the certification.

(4) An officer of the individual carrier shall submit a certification that:

(a) lists the UC and CI as defined in Section 31A-30-103(28);

(b) lists the number of individual natural covered lives at the time of the certification;

(c) categorizes the UC into new applicants added to existing policies and newly issued policies;

(d) identifies the number of Comprehensive Health Insurance Pool participants; and

(e) identifies the qualifying condition[(]s[)], prescription[(]s[)], or both that cause the persons making up the carrier's UC to be considered uninsurable under Section 31A-30-106(1)(j)and Rule R590-176.

(5) Carriers, whose coverage count exceeds 200% of the coverage count as of the end of the prior year, shall determine the uninsurable percentage using counts as of the end of the most recent calendar quarter.

 

R590-176-11. Severability.

If a provision of this rule or [its]the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of the[se] provisions to other persons or circumstances shall[may] not be affected thereby.

 

KEY: health insurance

Date of Enactment or Last Substantive Amendment: 2008

Notice of Continuation: January 11, 2007

Authorizing, and Implemented or Interpreted Law: 31A-2-201; 31A-2-202