31A-30-108 - Eligibility for small employer and individual market. - Utah Statutes

31A-30-108. Eligibility for small employer and individual market.
(1) (a) Small employer carriers shall accept residents for small group coverage as setforth in the Health Insurance Portability and Accountability Act, P.L. 104-191, 110 Stat. 1962,Sec. 2701(f) and 2711(a).
(b) Individual carriers shall accept residents for individual coverage pursuant:
(i) to P.L. 104-191, 110 Stat. 1979, Sec. 2741(a)-(b); and
(ii) Subsection (3).
(2) (a) Small employer carriers shall offer to accept all eligible employees and theirdependents at the same level of benefits under any health benefit plan provided to a smallemployer.
(b) Small employer carriers may:
(i) request a small employer to submit a copy of the small employer's quarterly incometax withholdings to determine whether the employees for whom coverage is provided orrequested are bona fide employees of the small employer; and
(ii) deny or terminate coverage if the small employer refuses to provide documentationrequested under Subsection (2)(b)(i).
(3) Except as provided in Subsections (5) and (6) and Section 31A-30-110, individualcarriers shall accept for coverage individuals to whom all of the following conditions apply:
(a) the individual is not covered or eligible for coverage:
(i) (A) as an employee of an employer;
(B) as a member of an association; or
(C) as a member of any other group; and
(ii) under:
(A) a health benefit plan; or
(B) a self-insured arrangement that provides coverage similar to that provided by a healthbenefit plan as defined in Section 31A-1-301;
(b) the individual is not covered and is not eligible for coverage under any public healthbenefits arrangement including:
(i) the Medicare program established under Title XVIII of the Social Security Act;
(ii) any act of Congress or law of this or any other state that provides benefits comparableto the benefits provided under this chapter; or
(iii) coverage under the Comprehensive Health Insurance Pool Act created in Chapter 29,Comprehensive Health Insurance Pool Act;
(c) unless the maximum benefit has been reached the individual is not covered or eligiblefor coverage under any:
(i) Medicare supplement policy;
(ii) conversion option;
(iii) continuation or extension under COBRA; or
(iv) state extension;
(d) the individual has not terminated or declined coverage described in Subsection (3)(a),(b), or (c) within 93 days of application for coverage, unless the individual is eligible forindividual coverage under P.L. 104-191, 110 Stat. 1979, Sec. 2741(b), in which case, therequirement of this Subsection (3)(d) does not apply; and
(e) the individual is certified as ineligible for the Health Insurance Pool if:
(i) the individual applies for coverage with the Comprehensive Health Insurance Pool

within 30 days after being rejected or refused coverage by the covered carrier and reapplies forcoverage with that covered carrier within 30 days after the date of issuance of a certificate underSubsection 31A-29-111(5)(c); or
(ii) the individual applies for coverage with any individual carrier within 45 days after:
(A) notice of cancellation of coverage under Subsection 31A-29-115(1); or
(B) the date of issuance of a certificate under Subsection 31A-29-111(5)(c) if theindividual applied first for coverage with the Comprehensive Health Insurance Pool.
(4) (a) If coverage is obtained under Subsection (3)(e)(i) and the required premium ispaid, the effective date of coverage shall be the first day of the month following the individual'ssubmission of a completed insurance application to that covered carrier.
(b) If coverage is obtained under Subsection (3)(e)(ii) and the required premium is paid,the effective date of coverage shall be the day following the:
(i) cancellation of coverage under Subsection 31A-29-115(1); or
(ii) submission of a completed insurance application to the Comprehensive HealthInsurance Pool.
(5) (a) An individual carrier is not required to accept individuals for coverage underSubsection (3) if the carrier issues no new individual policies in the state after July 1, 1997.
(b) A carrier described in Subsection (5)(a) may not issue new individual policies in thestate for five years from July 1, 1997.
(c) Notwithstanding Subsection (5)(b), a carrier may request permission to issue newpolicies after July 1, 1999, which may only be granted if:
(i) the carrier accepts uninsurables as is required of a carrier entering the market underSubsection 31A-30-110; and
(ii) the commissioner finds that the carrier's issuance of new individual policies:
(A) is in the best interests of the state; and
(B) does not provide an unfair advantage to the carrier.
(6) (a) If the Comprehensive Health Insurance Pool as set forth under Title 31A, Chapter29, is dissolved or discontinued, or if enrollment is capped or suspended, an individual carriermay decline to accept individuals applying for individual enrollment, other than individualsapplying for coverage as set forth in P.L. 104-191, 110 Stat. 1979, Sec. 2741 (a)-(b).
(b) Within two calendar days of taking action under Subsection (6)(a), an individualcarrier will provide written notice to the Utah Insurance Department.
(7) (a) If a small employer carrier offers health benefit plans to small employers througha network plan, the small employer carrier may:
(i) limit the employers that may apply for the coverage to those employers with eligibleemployees who live, reside, or work in the service area for the network plan; and
(ii) within the service area of the network plan, deny coverage to an employer if the smallemployer carrier has demonstrated to the commissioner that the small employer carrier:
(A) will not have the capacity to deliver services adequately to enrollees of anyadditional groups because of the small employer carrier's obligations to existing group contractholders and enrollees; and
(B) applies this section uniformly to all employers without regard to:
(I) the claims experience of an employer, an employer's employee, or a dependent of anemployee; or
(II) any health status-related factor relating to an employee or dependent of an employee.

---

(b) (i) A small employer carrier that denies a health benefit product to an employer in anyservice area in accordance with this section may not offer coverage in the small employer marketwithin the service area to any employer for a period of 180 days after the date the coverage isdenied.
(ii) This Subsection (7)(b) does not:
(A) limit the small employer carrier's ability to renew coverage that is in force; or
(B) relieve the small employer carrier of the responsibility to renew coverage that is inforce.
(c) Coverage offered within a service area after the 180-day period specified inSubsection (7)(b) is subject to the requirements of this section.

Amended by Chapter 383, 2008 General Session