DAR File No. 38534

Insurance, Administration

Rule R590-270

Risk Adjustment Data Submission Requirements

Notice of Proposed Rule

(New Rule)

DAR File No.: 38534
Filed: 05/15/2014 03:58:47 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule is to outline the responsibilities of a carrier with regard to the required data submission to the All Payer Claims Database (APCD) that is necessary for the evaluation of a state-based risk adjustment program in the individual and small employer health benefit plan markets. The commissioner was given the authority to write this rule as a result of H.B. 141 passed during the 2014 General Legislative Session.

Summary of the rule or change:

This rule outlines the responsibilities of a carrier with regard to the required data submission to the APCD that is necessary for the evaluation of a state-based risk adjustment program in the individual and small employer health benefit plan markets. The commissioner was given the authority to write this rule through the addition of a new section of the code, 31A-30-302, in H.B. 141 passed during the 2014 General Legislative Session.

State statutory or constitutional authorization for this rule:

• Subsection 31A-30-302(3)(a)
• Subsection 31A-30-302(4)(a)

This rule or change incorporates by reference the following material:

• Adds DSG2.0 Additional Data Elements, published by Utah Insurance Department, 05/05/2014
• Adds One-time APCD Supplemental Eligibility File, published by Utah Insurance Department, 05/05/2014

Anticipated cost or savings to:

the state budget:

There is a cost to the Health Department and the Insurance Department to collect and analyze the data provided by health carriers. The expense to do this has been covered by a grant from the United States Department of Health and Human Services.

local governments:

This rule will have no impact on local government. It deals solely with health insurance carriers that issue risk adjustment covered plans to Utah residents and small employers.

small businesses:

This rule will have no fiscal impact on insurance agencies that are for the most part small businesses. There are a few health insurance companies that are considered small businesses. They will be affected as noted in "Persons other than small businesses, or local government entities" below.

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

Health insurance carriers are now submitting health insurance data regarding their individual and small group plans, with Health and Human Services and paying a fee to them to collect and analyze the data. The new law would divert this responsibility to state government, specifically the Utah Health Department and Insurance Department, to collect and analyze this data. Money the insurance carriers were paying to the federal government will then go the Utah Health and Insurance Departments. Insurers will now be required to forward their data to the All Payer Claims Database. The data to be given to the All Payer Claims Database, a state agency, will require more information and a formatting of the data. These changes will create a fiscal impact on some insurers who will have a difficult time adjusting to these changes due to how their systems and programs are set up and how they process change administratively. Other insurers will adjust with very little fiscal impact or adjustment to their processes. Health insurance carriers who are impacted financially could pass the costs on to their consumers.

Compliance costs for affected persons:

The amount of the fee insurers pay to the federal government for the collection and analysis of their data may not change. Who they pay the fee to will change. Instead of the federal government the fee will be given to Utah agencies now collecting and analyzing the data. Changes in the data required and changes to the formatting of the data will have a substantial impact on some insurance companies who will have a difficult time to adjust their systems and administrative processes to these changes. The fiscal impact will vary from company to company.

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

The impact of the requirements of this rule will be felt more by those health insurers that insure a large number of small groups and individual plans. The fee amount for the gathering and analyzing of the data will not change. Whether or not there will be a fiscal impact on an insurers as a result of a change in the information gathered and its formatting will depend on how their data is structured and what their administrative processes are. It will all vary from company to company.

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:

07/01/2014

Interested persons may attend a public hearing regarding this rule:

• 06/16/2014 09:00 AM, State Office Building, 450 N State St, Room 3112, Salt Lake City, UT

This rule may become effective on:

07/08/2014

Authorized by:

Todd Kiser, Commissioner

R590. Insurance, Administration.

R590-270. Risk Adjustment Data Submission Requirements.

R590-270-1. Authority.

This rule is promulgated pursuant to Subsections 31A-30-302(3)(a) and (4)(a) wherein the commissioner may adopt a rule to require a carrier to submit data to the All Payer Claims Database (APCD).

 

R590-270-2. Purpose.

The purpose of this rule is to outline the responsibilities of a carrier with regard to the required data submission to the APCD that is necessary for the evaluation of a state-based risk adjustment program in the individual and small employer health benefit plan markets.

 

R590-270-3. Applicability and Scope.

(1) This rule applies:

(a) to a carrier that issues a risk adjustment covered plan to a Utah:

(i) resident; or

(ii) domiciled small employer; and

(b) regardless of any limitations or exemptions offered in R428 rules or Section 26-33a-102, based on the number of covered individual Utah residents.

(2) This rule does not apply to a transitional health benefit plan.

 

R590-270-4. Definitions.

In addition to the definitions in Sections 31A-1-301 and 26-33a-102, and R428 rules, the following definitions apply for the purpose of this rule.

(1) "Non-grandfathered health plan" means a health benefit plan issued to an individual or small employer:

(a) after March 23, 2010; or

(b) on or before March 23, 2010 that lost grandfather status at a renewal that occurred after March 23, 2010.

(2) "Risk adjustment covered plan" means a plan as defined by 45 CFR 155.20.

(3) "Subscriber premium" means the monthly premium for the subscriber and associated dependents that correspond to the carrier's rate data template filed with the Utah Insurance Department.

(4) "Transitional plan" means a non-grandfathered health plan issued to an individual or small employer prior to January 1, 2014, that is renewed after January 1, 2014 pursuant to guidance issued by the United States Department of Health and Human Services Office for Consumer Information and Insurance Oversight dated November 14, 2013 and March 5, 2014.

(5) "APCD Carrier" means a carrier that is required to submit data to the APCD based on parameters outlined in R428 rules.

(6) "RA Carrier" means a carrier that is not required to submit data to the APCD based on parameters outlined in R428 rules, but issues risk adjustment covered plans where that plan is subject to risk adjustment in Utah.

 

R590-270-5. APCD Carrier Data Submission Requirements.

(1) An APCD Carrier shall submit complete and accurate data to the APCD as prescribed by R428 rules.

(2) For any submissions to the APCD on or after January 1, 2015, an APCD Carrier shall include in the medical eligibility file the DSG2.0 Additional Data Elements, which is hereby incorporated by reference and available on the Department's website at insurance.utah.gov.

(a) The DSG2.0 Additional Data Elements shall be inserted into the medical eligibility file after all existing fields, that is, after field ME899.

(b) The DSG2.0 Additional Data Elements may be submitted with null values for records that are not subject to risk adjustment as outlined in 45 CFR Section 156.80.

(3) For any submissions to the APCD on or after January 1, 2015, an APCD Carrier shall submit data to the APCD for non-Utah residents if the individual receives coverage through a risk adjustment covered plan issued to a Utah domiciled small employer group.

(4)(a) An APCD Carrier shall submit the required data to the APCD by the end of the month following the applicable data month.

(b) Notwithstanding any exemption or extension requested under R428 rules, an APCD Carrier must provide to the APCD, in production format by August 31,2014, at least all claims adjudicated on or after January 1, 2014 and ending on or before June 30, 2014.

(5)(a) An APCD Carrier shall submit a one-time supplemental eligibility file to the Office of Health Care Statistics. The supplemental eligibility file shall:

(i) be a supplement to the monthly medical eligibility file;

(ii) be submitted through a secure method agreed upon by OHCS;

(iii) be submitted by November 1, 2014; and

(iv) have a one to one match to records in the most recent available monthly medical eligibility file submitted to the APCD; and

(b) The one-time supplemental eligibility file shall follow:

(i) the record layout in the medical eligibility file in the One-time APCD Supplemental Eligibility File, which is hereby incorporated by reference and available on the Department's website at insurance.utah.gov; or

(ii) an alternative format as approved by the commissioner.

 

R590-270-6. RA Carrier Data Submission Requirements.

(1) Starting January 1, 2015, a RA Carrier shall submit complete and accurate data to the APCD as prescribed by R428 rules, regardless of any limitations or exemptions offered in R428 rules or Section 26-33a-102 based on the number of covered individual Utah residents.

(2) For any submissions to the APCD on or after January 1, 2015, a RA Carrier shall include the DSG2.0 Additional Data Elements in the medical eligibility file.

(a) The DSG2.0 Additional Data Elements shall be inserted into the medical eligibility file after all existing fields, that is, after field ME899.

(b) The DSG2.0 Additional Data Elements may be submitted with null values for records that are not subject to risk adjustment as outlined in 45 CFR Section 156.80.

(3) For any submissions to the APCD on or after January 1, 2015, a RA Carrier shall submit data to the APCD for non-Utah residents if the covered individual receives coverage through a risk adjustment covered plan issued to a Utah domiciled small employer group.

(4) A RA Carrier shall submit the required data to the APCD by the end of the month following the applicable data month.

(5) The commissioner may approve an alternate submission method if a RA Carrier demonstrates to the satisfaction of the commissioner that the requirements of this rule impose an unreasonable burden to the RA Carrier and would place the RA Carrier in a state of supervision, insolvency, or liquidation.

 

R590-270-7. Data Use Limitations.

The additional fields required by this rule will be used exclusively for purposes identified in Subsection 26-33a-106.1(1).

 

R590-270-8. Penalties.

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

 

R590-270-9. Enforcement Date.

The commissioner will begin enforcing the provisions of this rule 45 days from the rule's effective date.

 

R590-270-10. Severability.

If any provision of this rule or its application to any person or situation is held to be invalid, that invalidity shall not affect any other provision or application of this rule which can be given effect without the invalid provision or application, and to this end the provisions of this rule are declared to be severable.

 

KEY: insurance, risk adjustment program

Date of Enactment or Last Substantive Amendment: 2014

Authorizing, and Implemented or Interpreted Law: 31A-30-302(3)(a) and (4)(a)