DAR File No. 38785
This rule was published in the September 1, 2014, issue (Vol. 2014, No. 17) of the Utah State Bulletin.
Insurance, Administration
Rule R590-236
HIPAA Eligibility Following Receipt of a Certificate of Insurability or Denial by an Individual Carrier
Notice of Proposed Rule
(Repeal)
DAR File No.: 38785
Filed: 08/15/2014 03:43:06 PM
RULE ANALYSIS
Purpose of the rule or reason for the change:
Due to changes in the Affordable Care Act (ACA), Public Health Service Act (PHSA) 2702, this rule is no longer needed.
Summary of the rule or change:
Due to the ACA that requires health insurance companies to no longer deny coverage, and has resulted in the withdrawal of the Comprehensive Health Insurance Pool (Pool) from the market, this rule is no longer needed. Therefore, this rule is repealed in its entirety.
State statutory or constitutional authorization for this rule:
- Subsection 31A-30-104(7)
- Subsection 31A-2-201(3)
- Subsection 31A-29-106(1)(f)
Anticipated cost or savings to:
the state budget:
This rule will have no fiscal impact on the department and the state's budget. The rule has to do with effective dates of coverage for HIPAA eligible applicants applying for coverage with an individual carrier or the Pool.
local governments:
The rule will have no fiscal impact on local governments. It has to do with effective dates of coverage for HIPAA eligible applicants applying for coverage with an individual carrier or the Pool.
small businesses:
This rule does not apply to small businesses. The rule applied to individuals seeking coverage from the pool or who were certified by them to seek coverage from individual carriers and the effective dates of coverage for those individuals. The rule was procedural in nature.
persons other than small businesses, businesses, or local governmental entities:
The repeal of this rule will have no fiscal impact on individuals or large employers. The rule applied to individuals seeking coverage from the pool or who were certified by them to seek coverage from individual carriers and the effective dates of coverage for those individuals. The rule was procedural in nature.
Compliance costs for affected persons:
The repeal of this rule will have no fiscal impact on individuals or large employers. The rule applied to individuals seeking coverage from the pool or who were certified by them to seek coverage from individual carriers and the effective dates of coverage for those individuals. The rule was procedural in nature.
Comments by the department head on the fiscal impact the rule may have on businesses:
The repeal of this rule will have no fiscal impact.
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:
InsuranceAdministration
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]
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:
10/01/2014
This rule may become effective on:
10/08/2014
Authorized by:
Todd Kiser, Commissioner
RULE TEXT
R590. Insurance, Administration.
[R590-236. HIPAA Eligibility Following Receipt of a
Certificate of Insurability or Denial by an Individual
Carrier.
R590-236-1. Authority.
This rule is promulgated and adopted pursuant to
Subsections 31A-2-201(3), 31A-29-106(1)(f), and
31A-30-104(7).
R590-236-2. Purpose and Scope.
(1) The purpose of this rule is to provide interpretation
of the interplay between federal and state statutes that affect
the protections provided by the federal Health Insurance
Portability and Accountability Act (HIPAA), Pub.L. 104-191, 110
Stat. 1962, to applicants that apply for coverage with HIPUtah
and receive a certificate of insurability from HIPUtah, or denial
of coverage by an individual carrier.
(2) The rule addresses the effective dates of coverage
for HIPAA eligible applicants applying for coverage with an
individual carrier or HIPUtah.
(3) The rule provides guidance for actual and potential
interplay between HIPAA, Sections 31A-22-605.1, 31A-30-108, and
31A-29-111 to:
(i) individual carriers,
(ii) the HIPUtah pool administrator; and
(iii) HIPUtah applicants.
R590-236-3. Definitions.
As used in this rule:
(1) "Certificate of insurability" means a
certificate issued by HIPUtah pursuant to Subsection
31A-29-111.
(2) "HIPAA" means the federal Health Insurance
Portability and Accountability Act, Pub.L. 104-191, 110 Stat.
1962.
(3) "HIPAA eligible" means an applicant who is
eligible for coverage under the provisions of the Health
Insurance Portability and Accountability Act of 1996, Pub. L.
104-191, 110 Stat. 1962.
(4) "HIPAA eligibility" means the eligibility
required by the federal Health Insurance Portability and
Accountability Act, Pub. L. 104-191, 110 Stat. 1962.
(5) "HIPUtah" means the Utah Comprehensive
Health Insurance Pool established by Section 31A-29-104.
(6) "Individual carrier" has the same meaning
as defined in Subsection 31A-30-103.
(7) "Preexisting condition" means preexisting
condition as defined in Subsection 31A-1-301.
(8) "Waiting period" means the period of time
beginning on the date the HIPAA eligible submits a substantially
complete application for coverage and ends on the date:
(a) coverage is effective;
(b) the application is denied by the insurer; or
(c) which the offer of coverage lapses without being
accepted by the HIPAA eligible.
R590-236-4. HIPAA and Subsection 31A-22-605.1, Eligibility
and Creditable Coverage.
(1) A HIPAA eligible must submit a substantially complete
application no later than 63 consecutive days, excluding waiting
periods, following termination of any preceding HIPAA qualified
coverage, to preserve HIPAA rights.
(2) A HIPAA eligible cannot have a break in qualifying
coverage of 63 or more consecutive days, except for applicable
waiting periods to preserve HIPAA rights.
(3) HIPAA eligibles applying within the time period in
R590-236-4(1) will receive creditable coverage toward a
preexisting condition waiting period.
(4) A waiting period does not count in determining
whether a break in qualifying coverage occurred.
R590-236-5. HIPAA and Subsection 31A-29-111(4)(a), 30-Day
Provision.
(1) This section applies to a HIPAA eligible that has
been denied by an individual carrier and is approved by
HIPUtah.
(2) When a HIPAA eligible submits a substantially
completed application to an individual carrier within the HIPAA
63-day time period and is denied coverage, to preserve HIPAA
rights, the HIPAA eligible must make application to HIPUtah no
later than:
(a) the remainder of the 63 consecutive day time period
under HIPAA; or
(b) 30 consecutive days after denial by the individual
carrier.
(3) Effective Dates.
(a) A HIPAA eligible applying within the time period in
R590-236-5(2)(a), shall have an effective date with HIPUtah on
the first day of the month following the submission of a
substantially completed application, if the required premium is
paid.
(b) A HIPAA eligible applying within the time period in
R590-236-5(2)(b), shall have an effective date with HIPUtah on
the first day of the month following the date of submission of a
substantially completed application to the individual carrier who
denied coverage immediately prior to the application to HIPUtah,
if the required premium is paid.
(c) When a HIPAA eligible applies within both time
periods in R590-236-5(2)(a) and (b), the HIPAA eligible shall
choose the effective date provided in R590-236-5(3)(a) or
(b).
R590-236-6. HIPAA and Subsection 31A-30-108(3)(e)(i), 30-Day
Provision.
(1) This section applies to a HIPAA eligible who meets
HIPUtah's eligibility requirements but does not meet
HIPUtah's health underwriting criteria, having been
previously denied by an individual carrier, and is issued a
certificate of insurability under Section 31A-29-111.
(2)(a) A HIPAA eligible may reapply with the individual
carrier who denied coverage immediately prior to HIPUtah's
issuance of a certificate of insurability to preserve HIPAA
rights, no later than:
(i) the remainder of the 63 consecutive day time period
under HIPAA; or
(ii) 30 consecutive days after the date of issuance of a
certificate of insurability.
(b) R590-236-6(2)(a) applies only to a HIPAA eligible
that has:
(i) submitted a substantially completed application to an
individual carrier within the HIPAA 63-day time period;
(ii) is denied coverage by an individual carrier;
and
(iii) makes application to HIPUtah no later
than:
(I) the remainder of the 63 consecutive day time period
under HIPAA; or
(II) 30 consecutive days after denial by the individual
carrier.
(3) Effective Dates.
(a) A HIPAA eligible applying within the time period in
R590-236-6(2)(a)(i), shall have an effective date with the
individual carrier on the first day of the month following the
submission of a substantially completed application, if the
required premium is paid.
(b) A HIPAA eligible applying within the time period in
R590-236-6(2)(a)(ii), shall have an effective date with the
individual carrier on the first day of the month following the
original submission of a substantially completed application to
the individual carrier who denied coverage immediately prior to
the application to HIPUtah, if the required premium is
paid.
(c) When a HIPAA eligible applies within both time
periods in R590-236-6(2)(a)(i) and (ii), the HIPAA eligible shall
choose the effective date provided in R590-236-6(3)(a) or
(b).
R590-236-7. HIPAA and Subsection 31A-30-108(3)(e)(ii)(B),
45-Day Provision.
(1) This section applies to a HIPAA eligible who applies
first with HIPUtah, meets HIPUtah's eligibility requirements,
but does not meet HIPUtah's health underwriting criteria and
is issued a certificate of insurability under Section
31A-29-111.
(2) When a HIPAA eligible submits a substantially
completed application to HIPUtah within the HIPAA 63-day time
period and is issued a certificate of insurability, the HIPAA
eligible may make application to an individual carrier no later
than:
(a) the remainder of the 63 consecutive day time period
under HIPAA; or
(b) 45 consecutive days after the date of issuance of a
certificate of insurability by HIPUtah.
(3) Effective Dates.
(a) A HIPAA eligible qualifying under option
R590-236-7(2)(a) shall have an effective date of the first of the
month following the submission of the substantially completed
application to an individual carrier, if the required premium is
paid.
(b) A HIPAA eligible qualifying under R590-236-7(2)(b)
shall have an effective date of the day following the submission
of the substantially completed application to HIPUtah, if the
required premium is paid.
(c) When a HIPAA eligible applies within both time
periods in R590-236-7(2)(a) and (b), the HIPAA eligible shall
choose the effective date provided in R590-236-7(3)(a) or
(b).
R590-236-8. Severability.
If any provision of this rule or the application of the
rule to any person or circumstance is for any reason held to be
invalid, the remainder of the rule and the application of the
rule to other persons or circumstances shall not be affected by
such a determination.
R590-236-9. Enforcement Date.
The commissioner will begin enforcing the provisions of
this rule immediately upon the effective date of the
rule.
KEY: HIPAA eligibility
Date of Enactment or Last Substantive Amendment: April 9, 2007
Notice of Continuation: October 25, 2011
Authorizing, and Implemented or Interpreted Law: 31A-29-106; 31A-30-104; 31A-2-201]
Additional Information
More information about a Notice of Proposed Rule is available online.
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2014/b20140901.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact 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]. For questions about the rulemaking process, please contact the Division of Administrative Rules.