R590. Insurance, Administration.R590-283. Defrayal of State-Required Benefits.
R590-283-1. Authority.
This rule is promulgated by the commissioner pursuant to Sections 31A-2-201, 31A-22-642, and 31A-30-118.
R590-283-2. Purpose and Scope.
(1) The purpose of this rule is to establish the method and timing for the defrayal of the cost of a state-required benefit enacted on or after January 1, 2012, that is subject to 45 CFR 155.170 of PPACA.
(2) This rule applies to a health benefit plan that:
(a) is a qualified health plan;
(b) is offered on the exchange in the individual or small group market;
(c) has an effective date of coverage on or after January 1, 2020; and
(d) offers a state-required benefit in excess of the Utah Essential Health Benefits Package.
R590-283-3. Definitions.
Terms used in this rule are defined in Sections 31A-1-301 and 31A-30-103, and Rule R590-266. Additional terms are defined as follows:
(1) "Defrayal payment" means the amount payable to a carrier from the state for expenses incurred for a state-required benefit under:
(a) 45 C.F.R. 155.170(b);
(b) Section 31A-30-118; and
(c) this rule.
(2) "EHB" means essential health benefits.
(3) "Exchange" means exchange as defined in 45 CFR 155.20.
(4) "Member month" means a count of one for each month during a calendar year during which an individual has coverage under a plan subject to this rule where coverage is evaluated on the first of the month.
(5) "Qualified health plan" means a qualified health plan as defined in 45 CFR 155.20.
(6) "State-required benefit" means a benefit required by the state:
(a) on or after January 1, 2012;
(b) for a purpose other than compliance with a federal requirement;
(c) that is in excess of the Utah Essential Health Benefits Package; and
(d) that is eligible for a defrayal payment.
R590-283-4. Defrayal of a State-Required Benefit.
(1) A health benefit plan offering a state-required benefit that is offered exclusively off-exchange is not eligible for a defrayal payment.
(2) A carrier seeking a defrayal payment shall, on or before September 1 of each year, submit to the commissioner a request that includes the following information:
(a) the state-required benefit for which the carrier is seeking a defrayal payment;
(b) the Mandate Defrayal Data template with the final data submission tab completed;
(c) an explanation for any increase in the allowable amount in the per unit cost for each CPT code that increased more than 5%;
(d) a description of any treatment plan review under Subsection 31A-22-642(6); and
(e) a certification stating:
(i) any durational limit, amount limit, deductible, copayment, and coinsurance for the treatment of autism spectrum disorder are similar to, or identical to, coverage provided for other illnesses or diseases; and
(ii) the defrayal payment request complies with Subsection 31A-30-118(1)(b).
(3)(a) The total defrayal payments are based on an aggregate of the data received under Subsection (2) from all carriers.
(b) The defrayal payment is calculated based on the sum of the total state-required benefit defrayable costs incurred across all carriers divided by the sum of the total member months of individuals receiving state-required benefit services across all carriers, and the result is multiplied by the sum of the member months of individuals receiving state-required benefit services for each carrier.
(c) A carrier may not receive a defrayal payment in excess of the amount the carrier incurred for a state-required benefit during the preceding calendar year.
(4) A request for defrayal payment shall be submitted via the System for Electronic Rate and Form Filings, SERFF.
(5)(a) Each defrayal payment is paid in arrears.
(b) The defrayal payment will be paid in the first quarter of the state's fiscal year following the submission of a valid request for a defrayal payment submitted under Subsection (2).
(c) For example, a carrier submits a request for a defrayal payment in August 2023 for claims incurred during calendar year 2022. The defrayal payment will be paid during the first quarter of the state's fiscal year 2025, July 1, 2024, through September 30, 2024.
