R590-262-7. Voluntary Opt-In for Self-Funded Employee Plans

(1)(a) Each insurer providing claim administration services for an employer who maintains a self-funded employee plan shall provide an employer a copy of the APCD Self-funded Employee Health Plan Opt-In form for purposes of determining whether an employer agrees to opt-in to submission of its self-funded employee plan's health care claims data as described in this rule.

(b) An insurer may use a form that they have developed for multi-state use instead of the form referenced in Subsection (1)(a) if the form is substantially similar and is approved by the Office in advance.

(c) Each insurer shall provide the APCD Self-funded Employee Health Plan Opt-In form:

(i) by December 15, 2016 for existing clients; or

(ii) within 15 days after claims administration services are retained and it is determined the employer meets the requirements of this section, for clients retained after December 1, 2016.

(2)(a) Except as provided in Subsections (b) and (c), an opt-in is effective for the reporting period in which it is signed and all future reporting periods. An employer may not opt-in for a partial reporting period.

(b) An opt-in signed by an employer and received by an insurer before March 1, 2017 shall be effective for the claims adjudicated in 2016 and not previously submitted to the Office, if otherwise required by this rule.

(c) An employer that has opted-in may opt-out for subsequent reporting periods by notifying the insurer in writing at least 30 days before the beginning of the next reporting period.

(3) For a self-funded employee plan whose employer has made an affirmative election for the submission of health care claims data, the insurer shall:

(a) include the self-funded employee plan data as part of the insurer's data submission otherwise required by this rule; and

(b) for plans that opt-in before March 1, 2017 as provided in Subsection (2)(b), include claims adjudicated in 2016 that were not previously submitted to the Office.

(4) Each insurer shall file with the Office, annually by January 31 of each year the following for the prior calendar year:

(a) a list of the self-funded employee plans whose employer made an affirmative election for the submission of their health care claim data;

(b) a list of employers who previously filed an opt-in request and have elected to opt-out for future reporting periods as provided under Subsection (2)(c); and

(c) a certification from an officer of the insurer that the insurer has taken reasonable efforts to provide the form to all known required employers; and

(d) a list identifying the employers to whom the form was provided and their contact information.

(5) The APCD Self-funded Employee Health Plan Opt-In form is for use only with self-funded employee plans and does not affect the mandatory reporting otherwise required by this rule.

(6) Nothing in this section requires an insurer to submit claims processed before the insurer was contracted to provide services.