31A-22-724 - Offer of alternative coverage -- Utah NetCare Plan. - Utah Statutes

31A-22-724. Offer of alternative coverage -- Utah NetCare Plan.
(1) For purposes of this section, "alternative coverage" means:
(a) the high deductible or low deductible Utah NetCare Plan described in Subsection (2)for conversion policies offered under Section 31A-22-723; and
(b) the high deductible and low deductible Utah NetCare Plans described in Subsection(2) as an alternative to COBRA and mini-COBRA policies offered under Section 31A-22-722.
(2) The Utah NetCare Plans shall include:
(a) healthy lifestyle and wellness incentives;
(b) the benefits described in this Subsection (2) or at least the actuarial equivalent of thebenefits described in this Subsection (2);
(c) a lifetime maximum benefit per person of not less than $1,000,000;
(d) an annual maximum benefit per person of not less than $250,000;
(e) the following deductibles:
(i) for the low deductible plans:
(A) $2,000 for an individual plan;
(B) $4,000 for a two party plan; and
(C) $6,000 for a family plan;
(ii) for the high deductible plans:
(A) $4,000 for an individual plan;
(B) $8,000 for a two party plan; and
(C) $12,000 for a family plan;
(f) the following out-of-pocket maximum costs, including deductibles, copayments, andcoinsurance:
(i) for the low deductible plans:
(A) $5,000 for an individual plan;
(B) $10,000 for a two party plan; and
(C) $15,000 for a family plan; and
(ii) for the high deductible plan:
(A) $10,000 for an individual plan;
(B) $20,000 for a two party plan; and
(C) $30,000 for a family plan;
(g) the following benefits before applying any deductible requirements and in accordancewith IRC Section 223:
(i) all well child exams and immunizations up to age five, with no annual maximum;
(ii) preventive care up to a $500 annual maximum;
(iii) primary care and specialist and urgent care not covered under Subsection (2)(g)(i) or(ii) up to a $300 annual maximum; and
(iv) supplemental accident coverage up to a $500 annual maximum;
(h) the following copayments for each exam:
(i) $15 for preventive care and well child exams;
(ii) $25 for primary care; and
(iii) $50 for urgent care and specialist care;
(i) a $200 copayment for emergency room visits after applying the deductible;
(j) no more than a 30% coinsurance after deductible for covered plan benefits for hospitalservices, maternity, laboratory work, x-rays, radiology, outpatient surgery services, injectable

medications not otherwise covered under a pharmacy benefit, durable medical equipment,ambulance services, in-patient mental health services, and out-patient mental health services; and
(k) the following cost-sharing features for prescription drugs:
(i) up to a $15 copayment for generic drugs;
(ii) up to a 50% coinsurance for name brand drugs; and
(iii) may include formularies and preferred drug lists.
(3) The Utah NetCare Plans may exclude:
(a) the benefit mandates described in Subsections 31A-22-618.5(2)(b) and (3)(b); and
(b) unless required by federal law, mandated coverage required by the following sectionsand related administrative rules:
(i) Section 31A-22-610.1, Adoption indemnity benefits;
(ii) Section 31A-22-623, Inborn metabolic errors;
(iii) Section 31A-22-624, Primary care physicians;
(iv) Section 31A-22-626, Coverage of diabetes;
(v) Section 31A-22-628, Standing referral to a specialist; and
(vi) coverage mandates enacted after January 1, 2009 that are not required by federal law.
(4) (a) Beginning January 1, 2010, and except as provided in Subsection (5), a personmay elect alternative coverage under this section if the person:
(i) is eligible for continuation of employer group coverage under federal COBRA laws;
(ii) is eligible for continuation of employer group coverage under state mini-COBRAunder Section 31A-22-722; or
(iii) is eligible for a conversion to an individual plan after the exhaustion of benefitsunder:
(A) alternative coverage elected in place of federal COBRA; or
(B) state mini-COBRA under Section 31A-22-722.
(b) The right to extend coverage under Subsection (4)(a) applies to any spouse ordependent coverages, including a surviving spouse or dependent whose coverage under thepolicy terminates by reason of the death of the employee or member.
(5) If a person elects federal COBRA coverage, or state mini-COBRA coverage underSection 31A-22-722, the person is not eligible to elect alternative coverage under this sectionuntil the person is eligible to convert coverage to an individual policy under the provisions ofSection 31A-22-723 and Subsection (1)(a).
(6) (a) If the alternative coverage is selected as an alternative to COBRA ormini-COBRA under Section 31A-22-722, the provisions of Section 31A-22-722 apply to thealternative coverage.
(b) If the alternative coverage is selected as a conversion policy under Section31A-22-723, the provisions of Section 31A-22-723 apply.
(7) (a) An insurer subject to Sections 31A-22-722 through 31A-22-724 shall, prior toSeptember 1, 2009, file an alternative coverage policy with the department in accordance withSections 31A-21-201 and 31A-21-201.1.
(b) The department shall, by November 1, 2009, adopt administrative rules in accordancewith Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to develop a model letter foremployers to use to notify an employee of the employee's options for alternative coverage.

Enacted by Chapter 12, 2009 General Session