R590. Insurance, Administration.R590-275. Qualified Health Plan Alternate Enrollment.
R590-275-1. Authority.
This rule is promulgated by the commissioner pursuant to Sections 31A-2-201 and 31A-2-212.
R590-275-2. Purpose and Scope.
(1) The purpose of this rule is to identify an alternate enrollment system for a PPACA qualified health plan as provided in 45 CFR 155.335(j)(3).
(2) This rule applies:
(a) when an insurer will have no qualified health plan available to an individual on the health insurance exchange for the upcoming plan year;
(b) to an insurer who offers a qualified health plan to an individual on the health insurance exchange; and
(c) to the health insurance exchange.
R590-275-3. Definitions.
Terms used in this rule are defined in Sections 31A-1-301 and 31A-30-103. Additional terms are defined as follows:
(1)(a) "Metal level" means the health plan category based on how an insured individual and the plan split the cost of health care.
(b) A plan in the marketplace is presented in one of four health plan categories:
(i) bronze;
(ii) silver;
(iii) gold; or
(iv) platinum.
(2) "Qualified health plan" or "QHP" means a health benefit plan that is certified to meet the standards recognized by the health insurance exchange.
R590-275-4. Alternate Enrollment Process.
(1) If an insurer will have no health insurance exchange option available for the upcoming plan year due to the insurer no longer offering an individual QHP in a particular service area in which it previously offered coverage on the health insurance exchange, the health insurance exchange shall direct enrollment for an enrollee to a QHP issued by a different insurer subject to Subsection (3) and the insurer's ability to absorb new enrollment.
(2) At renewal, if an enrollee does not have an individual QHP available from the same insurer through the health insurance exchange in which to enroll, the health insurance exchange shall direct enrollment for an enrollee to a QHP issued by a different insurer subject to Subsection (3) and the insurer's ability to absorb new enrollment.
(3)(a) The enrollee's coverage will be matched to a QHP in the same service area:
(i) at the same metal level; or
(ii) if more than one QHP is available, the coverage will be matched to a QHP at the same metal level with the lowest premium.
(b) If no QHP is available at the same metal level in the same service area, the enrollee will be matched to a QHP in the same service area:
(i) that is one metal level lower than the enrollee's current QHP; or
(ii) if more than one QHP is available, coverage will be matched to a QHP at one metal level lower with the lowest premium.
(c) If no QHP is available at the same metal level or one metal level lower and in the same service area, the enrollee will be matched to a QHP that is:
(i) one metal level higher than the enrollee's current QHP; or
(ii) if more than one QHP is available at one metal level higher, coverage will be matched to a QHP at one metal level higher with the lowest premium.
(d) If no QHP is available at the same metal level, one metal level lower, or one metal level higher in the same service area, the enrollee will be matched to any QHP at any metal at the lowest premium in the same service area.
(4) The alternate enrollment provisions in Subsection (3) do not apply to an enrollee who terminates coverage, including termination of coverage in connection with voluntarily selecting a different QHP in accordance with 45 CFR 155.430.
R590-275-5. Severability.
If any provision of this rule, Rule R590-275, or its application to any person or situation is held invalid, such invalidity does not affect any other provision or application of this rule that can be given effect without the invalid provision or application. The remainder of this rule shall be given effect without the invalid provision or application.
KEY: insurance, enrollment
Date of Last Change: May 9, 2023
Notice of Continuation: October 14, 2022
Authorizing, and Implemented or Interpreted Law: 31A-2-201; 31A-22-212(5)
