Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since October 1, 2019, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.


R590. Insurance, Administration.

Rule R590-270. Risk Adjustment Data Submission Requirements.

As in effect on October 1, 2019

Table of Contents

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

September 22, 2014

Notice of Continuation

September 20, 2019

Authorizing, Implemented, or Interpreted Law

31A-30-302(3)(a) and (4)(a)


Additional Information

Contact

For questions regarding the content or application of rules under Title R590, please contact the promulgating agency (Insurance, Administration). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.