2011 Utah Code
Title 31A Insurance Code
Chapter 22 Contracts in Specific Lines
Section 724 Offer of alternative coverage -- Utah NetCare Plan.
(1) For purposes of this section, "alternative coverage" means:
(a) a high deductible or low deductible Utah NetCare Plan described in Subsection (2) for a conversion health benefit plan policy offered under Section 31A-22-723; and
(b) a high deductible and low deductible Utah NetCare Plans described in Subsection (2) as an alternative to COBRA and mini-COBRA health benefit plan coverage offered under Section 31A-22-722.
(2) A Utah NetCare Plan under this section is subject to Section 31A-2-212 and shall, except when prohibited by federal law, include:
(a) healthy lifestyle and wellness incentives;
(b) the benefits described in this Subsection (2) or at least the actuarial equivalent of the benefits described in this Subsection (2);
(c) a lifetime maximum benefit per person of not less than $1,000,000;
(d) an annual maximum benefit per person of not less than $250,000;
(e) the following deductibles:
(i) for a low deductible plan:
(A) $2,000 for an individual plan;
(B) $4,000 for a two party plan; and
(C) $6,000 for a family plan;
(ii) for a high deductible plan:
(A) $4,000 for an individual plan;
(B) $8,000 for a two party plan; and
(C) $12,000 for a family plan;
(f) the following out-of-pocket maximum costs, including deductibles, copayments, and coinsurance:
(i) for a low deductible plan:
(A) $5,000 for an individual plan;
(B) $10,000 for a two party plan; and
(C) $15,000 for a family plan; and
(ii) for a high deductible plan:
(A) $10,000 for an individual plan;
(B) $20,000 for a two party plan; and
(C) $30,000 for a family plan;
(g) the following benefits before applying a deductible requirement and in accordance with Section 223, Internal Revenue Code, and 42 U.S.C. Sec. 300gg-13:
(i) all well child exams and immunizations up to age five, with no annual maximum;
(ii) preventive care up to a $500 annual maximum;
(iii) primary care and specialist and urgent care not covered under Subsection (2)(g)(i) or (ii) up to a $300 annual maximum; and
(iv) supplemental accident coverage up to a $500 annual maximum;
(h) the following copayments for each exam:
(i) $15 for preventive care and well child exams;
(ii) $25 for primary care; and
(iii) $50 for urgent care and specialist care;
(i) a $200 copayment for an emergency room visit after applying the deductible;
(j) no more than a 30% coinsurance after deductible for covered plan benefits for:
(i) hospital services;
(ii) maternity;
(iii) laboratory work;
(iv) x-rays;
(v) radiology;
(vi) outpatient surgery services;
(vii) injectable medications not otherwise covered under a pharmacy benefit;
(viii) durable medical equipment;
(ix) ambulance services;
(x) in-patient mental health services; and
(xi) out-patient mental health services; and
(k) the following cost-sharing features for a prescription drug:
(i) up to a $15 copayment for a generic drug; and
(ii) up to a 50% coinsurance for a name brand drug.
(3) A Utah NetCare Plan may exclude:
(a) the benefit mandates described in Subsections 31A-22-618.5(2)(b) and (3)(b); and
(b) unless required by federal law, mandated coverage required by the following sections and related administrative rules:
(i) Section 31A-22-610.1, Adoption indemnity benefit;
(ii) Section 31A-22-623, Coverage of inborn metabolic errors;
(iii) Section 31A-22-624, Primary care physician;
(iv) Section 31A-22-626, Coverage of diabetes;
(v) Section 31A-22-628, Standing referral to a specialist; and
(vi) a mandated coverage enacted after January 1, 2009, that is not required by federal law.
(4) A Utah NetCare Plan may include a formulary or preferred drug list.
(5) (a) Except as provided in Subsection (6), a person may elect alternative coverage under this section if the person is eligible for:
(i) continuation of employer group health benefit plan coverage under federal COBRA laws;
(ii) continuation of employer group health benefit plan coverage under state mini-COBRA under Section 31A-22-722; or
(iii) a conversion to an individual health benefit plan after the exhaustion of benefits under:
(A) alternative coverage elected in place of federal COBRA; or
(B) state mini-COBRA under Section 31A-22-722.
(b) The right to extend coverage under Subsection (5)(a) applies to spouse or dependent coverages, including a surviving spouse or dependent whose coverage under the policy terminates by reason of the death of the employee or member.
(6) If a person elects federal COBRA or state mini-COBRA health benefit plan coverage under Section 31A-22-722, the person is not eligible to elect alternative coverage under this section until the person is eligible to convert coverage to an individual policy under Section 31A-22-723 and Subsection (1)(a).
(7) (a) (i) If alternative coverage is selected as an alternative to COBRA or mini-COBRA
health benefit plan coverage under Section 31A-22-722, Section 31A-22-722 applies to the alternative coverage.
(ii) If an employee of a small employer selects alternative coverage as an alternative to COBRA or mini-COBRA health benefit plan coverage, the insurer may not use a risk factor greater than the employer's most current risk factor for purposes of Subsection 31A-22-722(5).
(b) If alternative coverage is selected as a conversion policy under Section 31A-22-723, Section 31A-22-723 applies.
(8) The commissioner shall adopt administrative rules in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, to develop a model letter for employers to use to notify an employee of the employee's options for alternative coverage.
