Insurance, Administration

Rule R590-266

Utah Essential Health Benefits Package

Notice of 120-Day (Emergency) Rule

DAR File No.: 36703
Filed: 08/30/2012 03:50:17 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to designate an essential health benefits package in Utah as provided by Section 1302 of the Patient Protection and Affordable Care Act of 2010, as amended by the Health Care Education Reconciliation Act of 2010 (ACA).

Summary of the rule or change:

As outlined in Section 31A-30-116, Utah has chosen to designate its own essential health benefits rather than accept a federal determination. On 08/16/2012, the Chairmen of the Legislature's Health System Reform Task Force notified the Insurance Commissioner that the Task Force had voted to recommend the Public Employees Health Program's (PEHP) Utah Basic Plus Plan as Utah's Essential Health Benefit Package for the purposes of the ACA. (DAR NOTE: A corresponding proposed new Rule R590-266 is under DAR No. 36708 in this issue, September 15, 2012, of the Bulletin.)

Emergency rule reason and justification:

Regular rulemaking procedures would place the agency in violation of federal or state law.

Justification: In the 2012 General Session, the Legislature passed H.B. 144, Health System Reform Amendments, which requires the department to adopt via emergency rule, Subsection 31A-30-116(3)(b). The insurers need this information immediately so they can start development of the products and systems to manage the new requirements.

State statutory or constitutional authorization for this rule:

• Subsection 31A-30-116(3)(b)

This rule or change incorporates by reference the following material:

• Adds PEHP Utah Basic Plus 2012 Plan, published by Public Employees Health Plan, 2012

Anticipated cost or savings to:

the state budget:

The requirements of this rule will increase rate and form filings to the department from 65 health insurers offering comprehensive health insurance products. The increase in filings will not increase the department or state's revenues, just increase the workload of the department and since the department does not have the fiscal appropriation to hire anyone for the additional workload it will have to be assimilated among current employees.

local governments:

This rule will have no impact on local governments since it deals solely with the relationship between the department and their licensees.

small businesses:

This rule will change the type of health insurance products agencies will offer to their clients. It may affect the cost of the health plan chosen by the small employers. If current plan does not meet the minimum requirements the premiums will more than likely increase to account for the increase in benefits.

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

This rule will impact 65 health insurers that sell insurance in Utah. Health insurers may need to develop new products, train their workforce and update their computer program. It may affect the cost of the health plan chosen by the large employer. If their current plan does not meet minimum requirements the premium of an approved plan will more than likely increase to account for the increase in benefits.

Compliance costs for affected persons:

This rule will impact 65 health insurers that sell insurance in Utah. Health insurers may need to develop new products, train their workforce, and update their computer program.

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

Utah has chosen to designate its own essential heath benefits rather than accept the federal determination. The benefits designated by the Health System Reform Task Force and myself were selected in order to maximize choice and minimize the premium impact on employers. Fiscal impacts for health insurers may be minimally dependent on their current plan designs.

Neal T. Gooch, 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 [email protected]

This rule is effective on:

08/30/2012

Authorized by:

Jilene Whitby, Information Specialist

R590. Insurance, Administration.

R590-266. Utah Essential Health Benefits Package.

R590-266-1. Authority.

This rule is promulgated pursuant to Subsection 31A-30-116(3)(b) wherein the commissioner is directed to adopt a rule for purposes of designating the essential health benefits for Utah.

 

R590-266-2. Purpose and Scope.

(1) The purpose of this rule is to designate an essential health benefits package in Utah as provided by Section 1302 of the Patient Protection and Affordable Care Act of 2010, as amended by the Health Care Education Reconciliation Act of 2010 (ACA).

(2) This rule applies to all non-grandfathered individual and small employer health benefit plans issued or renewed on or after January 1, 2014.

 

R590-266-3. Definitions.

In addition to the definitions in Sections 31A-1-301 and 31A-30-103, the following definitions shall apply for the purpose of this rule:

(1) "Essential health benefits" means the following health care service categories that must be included in non-grandfathered individual and small employer health benefit plans beginning January 1, 2014:

(a) ambulatory patient services;

(b) emergency services;

(c) hospitalization;

(d) maternity and newborn care;

(e) mental health and substance use disorder services, including behavioral health treatment;

(f) prescription drugs;

(g) rehabilitative and habilitative services and devices;

(h) laboratory services;

(i) preventive and wellness services and chronic disease management; and

(j) pediatric services, including oral and vision care.

(2) "Grandfathered health plan" means an individual or small employer health benefit plan that:

(a) was in existence when the ACA was enacted on March 23, 2010;

(b) has not had any significant changes that reduce benefits or increase costs to consumer including:

(i) a significant cut or reduction in benefits, such as excluding coverage for people with diabetes;

(ii) an increase in co-pays by more than $5, adjusted annually for medical inflation, or a percentage equal to medical inflation plus 15%;

(iii) the employer reduces contributions by more than five percentage points; or

(iv) reducing annual dollar limits, or adding a new limit; and

(c) the insured has received notification from the carrier that their health benefit plan is a grandfathered plan.

(3) "Non-Grandfathered health plan" means an individual or small employer health benefit plan:

(a) that is issued after the ACA was enacted on March 23, 2010; or

(b) a grandfathered health plan that has made significant changes that reduce benefits or increase costs to consumers that has caused the plan to lose the grandfathered status as provided in (2)(b).

(4) "Utah Essential Health Benefits Package" means the benefits designated in this rule by the commissioner as essential health benefits in non-grandfathered plans for the purposes of the ACA in Utah.

 

R590-266-4. Utah Essential Health Benefits.

As outlined in Section 31A-30-116, Utah has chosen to designate its own essential health benefits rather than accept a federal determination. On August 16, 2012, the Chairmen of the Legislature's Health System Reform Task Force (Task Force) notified the commissioner that the Task Force had voted to recommend the Public Employees Health Program's (PEHP) Utah Basic Plus Plan as Utah's Essential Health Benefit Package for the purposes of the ACA.

(1)(a) The commissioner hereby designates the PEHP Utah Basic Plus plan as the Utah Essential Health Benefits Package for purposes of the ACA in Utah.

(b) The PEHP Utah Basic Plus 2012 Plan as incorporated herein and available at http://insurance.utah.gov/health/healthreform.html.

(2)(a) Except as provided in Subsection (b), an individual or small employer carrier who issues or renews a non-grandfathered plan on or after January 1, 2014, must include at a minimum the benefits of the Utah Essential Health Benefits Package.

(b) A carrier may substitute coverage provided in the Utah Essential Health Benefits Package as long as substitutions are actuarially equivalent and complies with the standards set forth in 42 CFR 457.431.

(3) This rule does not prohibit an individual or small employer carrier from offering a non-grandfathered plan with benefits in addition to the Utah Essential Health Benefits Package.

 

R590-266-5. Penalties.

A person found to be in violation of this rule shall be subject to penalties as provided under Section 31A-2-308.

 

R590-266-6. Enforcement Date.

The commissioner will begin enforcing this rule January 1, 2014.

 

R590-266-7. Severability.

If any provision of this rule or its application to any person or circumstances is for any reason held to be invalid, the remainder of the rule and the application of the provision to other persons or circumstances shall not be affected thereby.

 

KEY: essential health benefit insurance

Date of Enactment or Last Substantive Amendment: August 30, 2012

Authorizing, and Implemented or Interpreted Law: 31A-30-116(3)(b)