No. 32415: R590-175-3. General Requirements

DAR File No.: 32415
Filed: 06/02/2009, 01:51
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to correct the major medical deductible from $1,500 to $1,000. This change was made in H.B. 188 in the 2009 Legislative Session. The bill made the changed to Subsection 31A-22-613.5(4)(d)(i)(A). (DAR NOTE: H.B. 188 (2009) is found at Chapter 12, Laws of Utah 2009, and was effective 03/11/2009.)

Summary of the rule or change:

In Subsection R590-175-3(10)5(a)(i), the major medical deductible needs to be changed from $1,500 to $1,000 as per recent changes to Subsection 31A-22-613.5(4)(d)(i)(A). (DAR NOTE: This change in proposed rule has been filed to make additional changes to a proposed amendment that was published in the March 15, 2009, issue of the Utah State Bulletin, on page 65. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike out indicates text that has been deleted. You must view the change in proposed rule and the proposed amendment together to understand all of the changes that will be enforceable should the agency make this rule effective.)

State statutory or constitutional authorization for this rule:

Sections 31A-2-201 and 31A-22-613.5

Anticipated cost or savings to:

the state budget:

This change will have no fiscal impact on the department's budget since it will not require the department to do additional work that would require the hiring of additional employees, nor will it change the revenues stream into the department or the budget. No additional fees will be required or lost.

local governments:

Since this rule deals with the relationship between the department and its licensees, it will have no fiscal impact on local governments.

small businesses and persons other than businesses:

The reduction in the size of the major medical deductible may have some effect on large and small insurers. The wording states that the deductible should not be less than $1,000 per person. So, insurers may reduce their deductible amount or leave it at the current amount.

Compliance costs for affected persons:

The reduction in the size of the major medical deductible may have some effect on large and small insurers. The wording states that the deductible should not be less than $1,000 per person. So, insurers may reduce their deductible amount or leave it at the current amount. If the amount is reduced to $1,000 per person it will reduce the amount their insured will have to pay for major medical coverage.

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

The changes to this rule will have little effect on insurers in Utah since it is possible for them to leave their deductibles at current levels, as long as it does not go below $1,000 for major medical coverage. 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:

07/31/2009

This rule may become effective on:

08/07/2009

Authorized by:

Jilene Whitby, Information Specialist

RULE TEXT

R590. Insurance, Administration.

R590-175. Basic Health Care Plan Rule.

R590-175-3. General Requirements.

(1) Each insurer who is required to offer a health care plan under the open enrollment provisions of Chapter 30 shall file with the department at least one basic health care plan which is specified by the insurer as complying with the provisions of this rule and which must be offered for sale to anyone qualifying for open enrollment under Chapter 30.

(2) The basic health care plan shall not be designed or marketed in a manner that tends to discourage its purchase by anyone under the open enrollment provisions of Chapter 30.

(3) A plan having actuarial equivalence may be considered, at the sole discretion of the commissioner.

(4) Each insurer must use the language in this rule to present covered services, limitations and exclusions.

(5) A plan offered in compliance with the open enrollment provisions of Chapter 30 must contain at least the benefits set forth in the Basic Health Care Plan as adopted by the commissioner.

(6) The basic health care plan is to be offered as a package, in its entirety, and is mutually exclusive of and not comparable on a line by line basis to an insurer's other plans.

(7) If the basic health care plan is offered by a preferred provider organization, PPO, the benefit levels shown in the plan are for contracting providers; benefit levels for non-contracting providers' services may be reduced in accordance with Section 31A-22-617.

(8) Each insurer is to include its usual contracting provisions in its basic health care plan including submission of claims, coordination of benefits, eligibility and coverage termination, grievance procedures general terms and conditions, etc.

(9) Each insurer who is required to offer a group conversion plan under Subsection 31A-33-723 shall file with the department at least one basic health care plan that complies with the provisions of this rule and must be offered for sale to anyone qualifying for conversion.

(10) The form to follow for the Basic Health Care Plan is as follows:

 

TABLE
BASIC HEALTH CARE PLAN

  1.  MAXIMUM BENEFIT. The maximum benefit per person for the

entire period for which this policy coverage is in effect shall

be $1,000,000.

  2.  ANNUAL MAXIMUM BENEFIT. The maximum annual benefit per

person shall not be less than $250,000.

  3.  OUT OF POCKET MAXIMUM PER PERSON.  The annual out of

pocket maximum per person not to exceed $5,000, including

any deductibles, copayments or coinsurances in the plan,

for family coverage, not to exceed three times the per person

out-of-pocket maximum.

  4.  PREEXISTING CONDITION LIMITATION.

  (a)  Any preexisting condition limitation shall be in

compliance with Utah Code Subsection 31A-22-605.1(4); and

  (b)  Any waiting period shall not exceed 12 months, or 18

months in the case of a late enrollee[s], with credit for prior

coverage when applicable.

  5.  GENERAL COST-SHARING FOR MEDICAL BENEFITS.

  Cost-sharing shall be based on eligible expenses. The cost-

sharing features of the plan shall be the following:

  (a)  Annual Deductible.

  (i)  A major medical deductible of not less than [$1,500]$1,000

per person, for family coverage not to exceed three times the per

person deductible for major medical expenses; and

  (ii)  an annual deductible for prescription benefits not to

exceed $1000 per person, for family coverage not to exceed three

times the per person deductible.

  (b)  Copayment and Coinsurance.

  (i)(A)  A copayment of not less than $25 per visit for office

visits, including preventive care services; and

  (B)  A copayment of not less than $150 per visit to the emergency

room; or

  (ii)  [A coinsurance of not ]less than 20% coinsurance per

visit for office services and 20% per emergency room visits.

  6.  PREVENTIVE SERVICES. Preventive services covered under a

managed care plan shall not be subject to the annual deductible.

Covered preventive services shall consist of at least the following:

  (a)  childhood immunizations in accordance with guidelines as

recommended by the Centers for Disease Control, as directed and

modified from time to time;

  (b)  well-baby care through age five in accordance with

guidelines recommended by the American Academy of Pediatrics, as

directed and modified from time to time;

  (c)  for adults and adolescents, age, sex and risk appropriate

preventive and screening services in accordance with

Classification A guidelines recommended by the U.S. Preventive

Services Task Force, as directed and modified from time to time.

  7.  COST SHARING FOR PRESCRIPTION DRUGS. Benefits for

prescription drugs, other than self injectable drugs, except

insulin, shall be subject to either:

  (a)  a copayment of not more than:

  (i)  the lesser of the cost of the prescription drug or $15

for the lowest level of cost for prescription drugs;

  (ii)  the lesser of the cost of the prescription drug or $25

for the second level of cost for prescription drugs; and

  (iii)  the lesser of the cost of the prescription drug or $35

for the highest level of cost for prescription drugs; or

  (b)  a coinsurance of not less than:

  (i)  the lesser of the cost of the prescription drug or 25% for

the lowest level of cost for prescription;

  (ii)  the lesser of the cost of the prescription drug or 40% for

the second level of cost for prescription drugs; and

  (iii)  the lesser of the cost of the prescription drug or 60% for

the highest level of cost for prescription drugs.

  8.  COST SHARING FOR MENTAL HEALTH BENEFITS AND/OR SUBSTANCE

ABUSE SERVICES.

  Benefits for mental health and substance abuse services shall

provide:

  (i) for individual policies:

  (A) coinsurance of 50% of eligible expenses;

  (B) inpatient services limited to 10 days annually per person; and

  (C) benefits for outpatient services limited to 20 visits annually

per person;

  (ii) small employer group policies shall be subject to Sections

31A-22-625 and 31A-22-715; and

  (iii) large employer group policies shall be subject to the Paul

Wellstone and Pete Domenici Mental Health Parity and Addiction Equity

Act of 2008.

 

KEY: insurance

Date of Enactment or Last Substantive Amendment: 2009

Notice of Continuation: November 8, 2005

Authorizing, and Implemented or Interpreted Law: 31A-22-613.5