31A-22-723 - Group and blanket conversion coverage.
31A-22-723. Group and blanket conversion coverage.
(1) Notwithstanding Subsection 31A-1-103(3)(f), and except as provided in Subsection(3), all policies of accident and health insurance offered on a group basis under this title, or Title49, Chapter 20, Public Employees' Benefit and Insurance Program Act, shall provide that aperson whose insurance under the group policy has been terminated is entitled to choose aconverted individual policy in accordance with this section and Section 31A-22-724.
(2) A person who has lost group coverage may elect conversion coverage with the insurerthat provided prior group coverage if the person:
(a) has been continuously covered for a period of three months by the group policy or thegroup's preceding policies immediately prior to termination;
(b) has exhausted either:
(i) Utah mini-COBRA coverage as required in Section 31A-22-722;
(ii) federal COBRA coverage; or
(iii) alternative coverage under Section 31A-22-724;
(c) has not acquired or is not covered under any other group coverage that covers allpreexisting conditions, including maternity, if the coverage exists; and
(d) resides in the insurer's service area.
(3) This section does not apply if the person's prior group coverage:
(a) is a stand alone policy that only provides one of the following:
(i) catastrophic benefits;
(ii) aggregate stop loss benefits;
(iii) specific stop loss benefits;
(iv) benefits for specific diseases;
(v) accidental injuries only;
(vi) dental; or
(vii) vision;
(b) is an income replacement policy;
(c) was terminated because the insured:
(i) failed to pay any required individual contribution;
(ii) performed an act or practice that constitutes fraud in connection with the coverage; or
(iii) made intentional misrepresentation of material fact under the terms of coverage; or
(d) was terminated pursuant to Subsection 31A-8-402.3(2)(a), 31A-22-721(2)(a), or31A-30-107(2)(a).
(4) (a) The employer shall provide written notification of the right to an individualconversion policy within 30 days of the insured's termination of coverage to:
(i) the terminated insured;
(ii) the ex-spouse; or
(iii) in the case of the death of the insured:
(A) the surviving spouse; and
(B) the guardian of any dependents, if different from a surviving spouse.
(b) The notification required by Subsection (4)(a) shall:
(i) be sent by first class mail;
(ii) contain the name, address, and telephone number of the insurer that will provide theconversion coverage; and
(iii) be sent to the insured's last-known address as shown on the records of the employer
of:
(A) the insured;
(B) the ex-spouse; and
(C) if the policy terminates by reason of the death of the insured to:
(I) the surviving spouse; and
(II) the guardian of any dependents, if different from a surviving spouse.
(5) (a) An insurer is not required to issue a converted policy which provides benefits inexcess of those provided under the group policy from which conversion is made.
(b) Except as provided in Subsection (5)(c), if the conversion is made from a healthbenefit plan, the employee or member shall be offered:
(i) at least the basic benefit plan as provided in Section 31A-22-613.5 through December31, 2009; and
(ii) beginning January 1, 2010, only the alternative coverage as provided in Subsection31A-22-724(1)(a).
(c) If the benefit levels required under Subsection (5)(b) exceed the benefit levelsprovided under the group policy, the conversion policy may offer benefits which are substantiallysimilar to those provided under the group policy.
(6) Written application for the converted policy shall be made and the first premium paidto the insurer no later than 60 days after termination of the group accident and health insurance.
(7) The converted policy shall be issued without evidence of insurability.
(8) (a) The initial premium for the converted policy for the first 12 months andsubsequent renewal premiums shall be determined in accordance with premium rates applicableto age, class of risk of the person, and the type and amount of insurance provided.
(b) The initial premium for the first 12 months may not be raised based on pregnancy ofa covered insured.
(c) The premium for converted policies shall be payable monthly or quarterly as requiredby the insurer for the policy form and plan selected, unless another mode or premium payment ismutually agreed upon.
(9) The converted policy becomes effective at the time the insurance under the grouppolicy terminates.
(10) (a) A newly issued converted policy covers the employee or the member and mustalso cover all dependents covered by the group policy at the date of termination of the groupcoverage.
(b) The only dependents that may be added after the policy has been issued are childrenand dependents as required by Section 31A-22-610 and Subsections 31A-22-610.5(6) and (7).
(c) At the option of the insurer, a separate converted policy may be issued to cover anydependent.
(11) (a) To the extent the group policy provided maternity benefits, the conversion policyshall provide maternity benefits equal to the lesser of the maternity benefits of the group policyor the conversion policy until termination of a pregnancy that exists on the date of conversion ifone of the following is pregnant on the date of the conversion:
(i) the insured;
(ii) a spouse of the insured; or
(iii) a dependent of the insured.
(b) The requirements of this Subsection (11) do not apply to a pregnancy that occurs after
the date of conversion.
(12) Except as provided in this Subsection (12), a converted policy is renewable withrespect to all individuals or dependents at the option of the insured. An insured may beterminated from a converted policy for the following reasons:
(a) a dependent is no longer eligible under the policy;
(b) for a network plan, if the individual no longer lives, resides, or works in:
(i) the insured's service area; or
(ii) the area for which the covered carrier is authorized to do business;
(c) the individual fails to pay premiums or contributions in accordance with the terms ofthe converted policy, including any timeliness requirements;
(d) the individual performs an act or practice that constitutes fraud in connection with thecoverage;
(e) the individual makes an intentional misrepresentation of material fact under the termsof the coverage; or
(f) coverage is terminated uniformly without regard to any health status-related factorrelating to any covered individual.
(13) Conditions pertaining to health may not be used as a basis for classification underthis section.
(14) An insurer is only required to offer a conversion policy that complies withSubsection 31A-22-724(1)(b) and, notwithstanding Sections 31A-8-402.5 and 31A-30-107.1,may discontinue any other conversion policy if:
(a) the discontinued conversion policy is discontinued uniformly without regard to anyhealth related factor;
(b) any affected individual is provided with 90 days' advanced written notice of thediscontinuation of the existing conversion policy;
(c) the policy holder is offered the insurer's conversion policy that complies withSubsection 31A-22-724(1)(b); and
(d) the policy holder is not re-rated for purposes of premium calculation.
Amended by Chapter 68, 2010 General Session