31A-22-613.5 - Price and value comparisons of health insurance -- Basic Health Care Plan.
31A-22-613.5. Price and value comparisons of health insurance -- Basic HealthCare Plan.
(1) (a) This section applies to all health benefit plans.
(b) Subsection (2) applies to:
(i) all health benefit plans; and
(ii) coverage offered to state employees under Subsection 49-20-202(1)(a).
(2) (a) The commissioner shall promote informed consumer behavior and responsiblehealth benefit plans by requiring an insurer issuing a health benefit plan to:
(i) provide to all enrollees, prior to enrollment in the health benefit plan writtendisclosure of:
(A) restrictions or limitations on prescription drugs and biologics including:
(I) the use of a formulary;
(II) co-payments and deductibles for prescription drugs; and
(III) requirements for generic substitution;
(B) coverage limits under the plan; and
(C) any limitation or exclusion of coverage including:
(I) a limitation or exclusion for a secondary medical condition related to a limitation orexclusion from coverage; and
(II) easily understood examples of a limitation or exclusion of coverage for a secondarymedical condition; and
(ii) provide the commissioner with:
(A) the information described in Subsections 63M-1-2506(3) through (6) in thestandardized electronic format required by Subsection 63M-1-2506(1); and
(B) information regarding insurer transparency in accordance with Subsection (5).
(b) An insurer shall provide the disclosure required by Subsection (2)(a)(i) in writing tothe commissioner:
(i) upon commencement of operations in the state; and
(ii) anytime the insurer amends any of the following described in Subsection (2)(a)(i):
(A) treatment policies;
(B) practice standards;
(C) restrictions;
(D) coverage limits of the insurer's health benefit plan or health insurance policy; or
(E) limitations or exclusions of coverage including a limitation or exclusion for asecondary medical condition related to a limitation or exclusion of the insurer's health insuranceplan.
(c) An insurer shall provide the enrollee with notice of an increase in costs forprescription drug coverage due to a change in benefit design under Subsection (2)(a)(i)(A):
(i) either:
(A) in writing; or
(B) on the insurer's website; and
(ii) at least 30 days prior to the date of the implementation of the increase in cost, or assoon as reasonably possible.
(d) If under Subsection (2)(a)(i)(A) a formulary is used, the insurer shall make availableto prospective enrollees and maintain evidence of the fact of the disclosure of:
(i) the drugs included;
(ii) the patented drugs not included;
(iii) any conditions that exist as a precedent to coverage; and
(iv) any exclusion from coverage for secondary medical conditions that may result fromthe use of an excluded drug.
(e) (i) The department shall develop examples of limitations or exclusions of a secondarymedical condition that an insurer may use under Subsection (2)(a)(i)(C).
(ii) Examples of a limitation or exclusion of coverage provided under Subsection(2)(a)(i)(C) or otherwise are for illustrative purposes only, and the failure of a particular factsituation to fall within the description of an example does not, by itself, support a finding ofcoverage.
(3) An insurer who offers a health benefit plan under Chapter 30, Individual, SmallEmployer, and Group Health Insurance Act, shall offer a basic health care plan subject to theopen enrollment provisions of Chapter 30, Individual, Small Employer, and Group HealthInsurance Act, that:
(a) is a federally qualified high deductible health plan;
(b) has a deductible that is within $250 of the lowest deductible that qualifies under afederally qualified high deductible health plan, as adjusted by federal law; and
(c) does not exceed an annual out of pocket maximum equal to three times the amount ofthe annual deductible.
(4) The commissioner:
(a) shall forward the information submitted by an insurer under Subsection (2)(a)(ii) tothe Health Insurance Exchange created under Section 63M-1-2504; and
(b) may request information from an insurer to verify the information submitted by theinsurer under this section.
(5) The commissioner shall:
(a) convene a group of insurers, a member representing the Public Employees' Benefitand Insurance Program, consumers, and an organization described in Subsection31A-22-614.6(3)(b), to develop information for consumers to compare health insurers and healthbenefit plans on the Health Insurance Exchange, which shall include consideration of:
(i) the number and cost of an insurer's denied health claims;
(ii) the cost of denied claims that is transferred to providers;
(iii) the average out-of-pocket expenses incurred by participants in each health benefitplan that is offered by an insurer in the Health Insurance Exchange;
(iv) the relative efficiency and quality of claims administration and other administrativeprocesses for each insurer offering plans in the Health Insurance Exchange; and
(v) consumer assessment of each insurer or health benefit plan;
(b) adopt an administrative rule that establishes:
(i) definition of terms;
(ii) the methodology for determining and comparing the insurer transparencyinformation;
(iii) the data, and format of the data, that an insurer must submit to the department inorder to facilitate the consumer comparison on the Health Insurance Exchange in accordancewith Section 63M-1-2506; and
(iv) the dates on which the insurer must submit the data to the department in order for thedepartment to transmit the data to the Health Insurance Exchange in accordance with Section
63M-1-2506; and
(c) implement the rules adopted under Subsection (5)(b) in a manner that protects thebusiness confidentiality of the insurer.
Amended by Chapter 68, 2010 General Session
Amended by Chapter 149, 2010 General Session
Amended by Chapter 149, 2010 General Session, (Coordination Clause)