DAR File No. 38088

Insurance, Administration

Rule R590-269

Individual Open Enrollment Period

Notice of Proposed Rule

(New Rule)

DAR File No.: 38088
Filed: 11/01/2013 09:39:09 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

As a result of passage of H.B. 160 during the 2013 General Legislative Session, Subsection 31A-30-117(1)(c) was added to the Insurance code requiring a rule to establish a statewide open enrollment period that applies to the individual insurance market that is not on the Patient Protection and Affordable Care Act (PPACA) certified individual exchange.

Summary of the rule or change:

The rule sets the time period and conditions for the open enrollment period.

State statutory or constitutional authorization for this rule:

• Subsection 31A-30-117(1)(c)

Anticipated cost or savings to:

the state budget:

No company filings are required that department personnel would need to review. There are no provisions that would create a cost or saving for the department.

local governments:

The new law requiring that the department establish a statewide open enrollment period that applies to those individuals that do not purchase coverage on the PPACA certified individual exchange will provide a way for more individuals within the state to be covered for health insurance. This could alleviate impact on local services provided for the uninsured.

small businesses:

This rule provides an open enrollment period for individuals. It does not deal with small businesses.

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

The rule allows individuals to apply for a health benefit plan with guaranteed issue of health coverage. This will be available once every year. The cost impact will be felt by insurers providing coverage to individuals that previously they would have denied. These costs cannot be calculated at this time.

Compliance costs for affected persons:

The rule allows individuals to apply for a health benefit plan with guaranteed issue of health coverage. This will be available once every year. The cost impact will be felt by insurers providing coverage to individuals that previously they would have denied. These costs cannot be calculated at this time.

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

Health insurers who provide coverage to individuals during the open enrollment period will be required to accept all applicants without the requirement that they first pass a physical examination. This will likely result in an increase in claims for these insurers.

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:

• Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at jwhitby@utah.gov

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:

12/16/2013

Interested persons may attend a public hearing regarding this rule:

• 12/10/2013 09:00 AM, State Office Bldg, 450 N State St, Room 3112, Salt Lake City, UT

This rule may become effective on:

12/23/2013

Authorized by:

Todd Kiser, Commissioner

R590. Insurance, Administration.

R590-269. Individual Open Enrollment Period.

R590-269-1. Authority.

This rule is promulgated pursuant to Subsection 31A-30-117(1)(c) wherein the commissioner is directed to adopt a rule to establish one statewide open enrollment period for the individual insurance market that is not part of the Federally Facilitated Marketplace.

 

R590-269-2. Purpose and Scope.

(1) The purpose of this rule is to establish an open enrollment period for a carrier that offers an individual health benefit plan outside the Federally Facilitated Marketplace.

(2) This rule applies to a carrier that offers an individual health benefit plan outside the Federally Facilitated Marketplace with an effective date on or after January 1, 2014.

 

R590-269-3. Definitions.

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

(1) "Federally Facilitated Marketplace" means an exchange set up by the federal government to facilitate the purchase of individual health insurance in accordance with the Patient Protection and Affordability Care Act (PPACA).

(2) "Qualifying life event" means an event that triggers a special enrollment period because an individual or dependent:

(a) loses minimum essential coverage;

(b) gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption;

(c) enrollment or non-enrollment is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee or agent of an exchange or the United States Department of Health and Human Services, or its instrumentalities as evaluated and determined by an exchange;

(d) adequately demonstrates to the individual carrier that the health benefit plan in which he or she is previously enrolled substantially violated a material provision of its contract in relation to the enrollee;

(e) is newly ineligible for advance payment of premium tax credits; or

(f) permanently moves into a new service area.

(2)(a) "Loss of minimum essential coverage" means those circumstances described in 26 CFR 54.9801-6(a)(3)(i) through (iii).

(b) Loss of minimum essential coverage does not include termination or loss due to:

(i) failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage; or

(ii) situations allowing for a rescission as specified in 45 CFR 147.128.

 

R590-269-4. Open and Special Enrollment Periods.

(1)(a)(i) Except as otherwise provided herein, the initial open enrollment period for an individual health benefit plan outside the Federally Facilitated Marketplace is October 1, 2013 through March 31, 2014.

(ii) The open enrollment period in Subsection (a)(i) shall be extended to be consistent with the open enrollment period for the Federally Facilitated Marketplace if the United States Department of Health and Human Services extends the open enrollment period for the Federally Facilitated Marketplace beyond March 31, 2014.

(iii)(A) Coverage begins on January 1, 2014 for individuals who enroll on or before December 15, 2013.

(B) After December 15, 2013, if an individual enrollment occurs between the first and the fifteenth of the month, coverage is effective the first day of the following month. If enrollment occurs between the sixteen and the last day of the month, then coverage is effective the first day of the second following month.

(b) After the initial enrollment period in Subsection (a), the open enrollment period is annually from October 15 through December 7 for a coverage effective date of January 1 the immediately following year.

(2)(a) An individual carrier shall offer to an individual experiencing a qualifying life event, a special enrollment period for at least 60 days.

(b) In the case of birth, adoption or placement for adoption, the coverage is effective on the date of:

(i) birth;

(ii) adoption; or

(iii) placement for adoption

(c) Coverage is effective the first day of the month following the date the insurer receives the request for special enrollment in the case of:

(i) marriage;

(ii) an individual or dependent loses minimum essential coverage;

(iii) an individual or dependent's enrollment or non-enrollment is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee or agent of an exchange or the United States Department of Health and Human Services, or its instrumentalities as evaluated and determined by an exchange ;

(iv) an individual adequately demonstrates to the individual carrier that the health benefit plan in which he or she is previously enrolled substantially violated a material provision of its contract in relation to the enrollee; or

(v) an individual permanently moves into a new service area.

(3) Nothing in this rule prohibits an insurer from offering open or special enrollment periods in addition to the open and special enrollment periods required by this rule.

 

R590-269-5. Penalties.

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

 

R590-269-6. Enforcement Date.

The commissioner will begin enforcing this rule 30 days from the rule's effective date.

 

R590-269-7. 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: individual open enrollment period

Date of Enactment or Last Substantive Amendment: 2013

Authorizing, and Implemented or Interpreted Law: 31A-30-117