No. 27445: R590-76. Health Maintenance Organizations and Limited Health Plans

DAR File No.: 27445
Filed: 09/23/2004, 12:39
Received by: NL

 

NOTICE OF REVIEW AND STATEMENT OF CONTINUATION

Concise explanation of the particular statutory provisions under which the rule is enacted and how these provisions authorize or require the rule:

The purpose of this rule is to implement Title 31a, Chapter 8, entitled the same as the rule. There are many places in Title 31A, Chapter 8, where authority is given to the commissioner to write rules to implement the code. The areas of the code that provide specific authority to write this rule are: Subsection 31A-8-104(1)(b) authorizing the commissioner and the director of the Health Department to write rules regarding a quality assurance plan. Section R590-76-9 provides requirements for a quality assurance plan provided by HMOs and the information they are to give to the directors of the Health Department. Subsection 31A-8-402.7(4) gives the commissioner the authority to define the scope of the HMO's service area. This is done in Section R590-76-7. Subsection 31A-2-201(3) gives the commissioner general rulemaking authority to make rules to implement the provisions of Title 31A.

 

Summary of written comments received during and since the last five-year review of the rule from interested persons supporting or opposing the rule:

Within the past five years the department made changes to this rule several times beginning 08/01/02 to 04/01/03. The process began as a result of legislation passed by the federal and state government. During that period we had two hearings and five comment periods and received 11 written comments from the insurance industry. No one suggested the rule be repealed but they did suggest revisions to proposed language. The following is a summary of suggestions received: 1) in Subsection R590-76-4(1), allow providers to balance bill and reference Section R590-165-3; 2) in Subsection R590-76-4(7), eliminate "extension of benefits;" 3) in Subsection R590-76-5(1)(a), replace "evidence of coverage" with "outline of coverage," to be consistent with Rule R590-126; 4) in Subsection R590-76-5(1)(c), eliminate time frames; 5) in Subsection R590-76-5(6), add out-of-area service language; 6) in Subsection R590-76-5(7), include the term "coinsurance;" 8) in Subsection R590-76-5(10), change the reference Section R590-76-9 to Subsection R590-76-8(4); 9) in Subsection R590-76-5(11), replace "the contract..." with "the group contract...," and remove "continuation of coverage"; 10) in Section R590-76-6, some were for and some against including language regarding deductibles, out-of-pocket maximums, and lifetime maximum benefit limits; 11) in Subsection R590-76-7(1)(b), delete "continuity of care"; 12) in Subsection R590-76-7(1)(c)(ii), delete mandate of "emergency telephone consultation on a 24 hours per day, 7 days per week basis"; 13) in Subsection R590-76-7(2)(d)(iii), specify that special diets applies only to phenylketonuria (PKU) or inborn errors of amino acid or urea cycle metabolism; 14) in Subsection R590-76-7(2)(d)(vii), delete "a broad range of...;" 15) in Subsection R590-76-7(3)(a), add "coinsurance" and "deductible," and specify that this section does not apply to out of area emergency care service;" 16) in Subsection R590-76-7(3)(b), eliminate reference to "transportation" services since there is no statutory authority; 17) in Subsection R590-76-8(1)(a), require notification when a provider is terminated by an HMO for cause, and notify of changes in providers via the internet rather than any other method; 19) in Subsection R590-76-8(2), eliminate notification requirement to subscribers who are not affected by a change in the service area; 20) define "enrollee"; 21) in Subsection R590-76-8(3), clarify authority of HMOs and PPOs to balance bill; 22) in Subsection R590-76-9(1)(b), one insurer warned their HMO would be put out of business because of the certification costs, and asked that acronyms be spelled out; and 23) in Subsection R590-76-9(2), exempt certified HMOs from audits of their quality control system.

 

Reasoned justification for continuation of the rule, including reasons why the agency disagrees with comments in opposition to the rule, if any:

This rule provides protection to a great number of Utah citizens. The rule gives HMOs guidance regarding coverage and evidence of coverage requirements. It also gives guidance on what services must be in the policy, the quality controls an insurer must provide and notification requirement they must follow when the provider list changes. All of these requirements and guidelines help the department ensure that consumers receive the notifications and coverages required under the law, therefore, this rule should be continued.

 

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]

 

Authorized by:

Jilene Whitby, Information Specialist