DAR File No. 40273

Insurance, Administration

Rule R590-262

Health Data Authority Health Insurance Claims Reporting

Notice of Proposed Rule

(Amendment)

DAR File No.: 40273
Filed: 03/18/2016 11:26:27 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to update reporting standards as a result of the Supreme Court's ruling on Gobeille v. Liberty Mutual Insurance Company.

Summary of the rule or change:

The rule clarifies that self-funded employer welfare benefit plans no longer have to submit reports under this rule.

State statutory or constitutional authorization for this rule:

• Subsection 31A-22-614.5(3)(a)

Anticipated cost or savings to:

the state budget:

The Insurance Department will have very slight savings being that the Department is no longer able to collect data on employer self-funded plans.

local governments:

There is no impact on local government because it only affects ERISA plans.

small businesses:

Small third-party administrators may experience a slight savings being that they no longer will be required to submit data to the insurance department regarding employer self-funded plans.

persons other than small businesses, businesses, or local governmental entities:

There is no impact on any other persons because the rule change governs the reporting requirement between third-party administrators and state government.

Compliance costs for affected persons:

There will be a very slight reduction in compliance costs for affected persons because of minimal reporting requirements that will no longer be required.

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

The data previously collected by third-party administrators was helpful assessing the market as a whole. However, the Gobeille v. Liberty Mutual Insurance Company decision rules that a state may not in any way regulate a self-funded ERISA plan.

Todd E. Kiser, 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:

• Steve Gooch at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at [email protected]

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:

05/16/2016

This rule may become effective on:

05/23/2016

Authorized by:

Steve Gooch, Information Specialist

R590. Insurance, Administration.

R590-262. Health Data Authority Health Insurance Claims Reporting.

R590-262-2. Purpose and Scope.

(1) This rule establishes requirements for certain entities that pay for health care to submit data to the Utah Department of Health.

(2) This rule allows the data to be shared with the state's designated secure health information master index person index, Clinical Health Information Exchange (cHIE), to be used:

(a) in compliance with data security standards established by:

(i) the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, 110 Stat. 1936: and

(ii) the electronic commerce agreements established in a business associate agreement;

(b) for the purpose of coordination of health benefit plans; and

(c) for the enrollment data elements identified in Utah Administrative Rule R428-15, Health Data Authority Health Insurance Claims Reporting.

(3)(a) This rule applies to an insurer offering a health benefit plan.

(b) This rule does not apply to:

(i) an insurer that covers fewer than 2500 individual Utah residents:

(ii) a long-term care insurance policy; or

(iii) an income replacement policy.

(c) This rule does not require a person to provide information concerning a self-funded employee welfare benefit plan as defined in 29 U.S.C. Section 1002(1).

 

R590-262-3. Definitions.

In addition to the definitions in Section 31A-1-301, the following definitions shall apply for the purpose of this rule:

(1) "Claim" means a request or demand on an insurer for payment of a benefit.

(2) "Health care claims data" means information consisting of, or derived directly from, member enrollment, medical claims, and pharmacy claims that this rule requires an insurer to report.

(3) "Insurer" means:

(a) a person engaged in the business of offering a health benefit plan, including a business under an administrative services organization or administrative services contract arrangement;

(b) a third party administrator that collects premiums or settles claims for health care insurance policies;

(c) a governmental plan as defined in Section 414(d), Internal Revenue Code;

(d) a non-electing church plan as described in Section 410 (d), Internal Revenue Code; or

(e) a licensed professional employer organization that is acting as an administrator of a health care insurance policy[or a health benefit plan funded by a self-insurance arrangement].

(5) "Office" means the Office of Health Care Statistics within the Utah Department of Health, which serves as staff to the Utah Health Data Committee.

(6) "Technical specifications" means the technical specifications document published by the Health Data Committee describing the variables and formats of the data that are to be submitted as well as submission directions and guidelines.

 

KEY: health insurance claims reporting

Date of Enactment or Last Substantive Amendment: [October 3, 2012]2016

Authorizing, and Implemented or Interpreted Law: 31A-22-614.5(3)(a)