As used in this chapter:

(1) “Actuarial certification” means a written statement by a member of the American Academy of Actuaries or other individual approved by the commissioner that a covered carrier is in compliance with this chapter, based upon the examination of the covered carrier, including review of the appropriate records and of the actuarial assumptions and methods used by the covered carrier in establishing premium rates for applicable health benefit plans.
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Terms Used In Utah Code 31A-30-103

  • Base premium rate: means , for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under a rating system for that class of business by the covered carrier to covered insureds with similar case characteristics for health benefit plans with the same or similar coverage. See Utah Code 31A-30-103
  • Bona fide employer association: means an association of employers:
              (4)(a)(i) that meets the requirements of Section 31A-22-505;
              (4)(a)(ii) in which the employers of the association, either directly or indirectly, exercise control over the plan;
              (4)(a)(iii) that is organized:
                   (4)(a)(iii)(A) based on a commonality of interest between the employers and their employees that participate in the plan by some common economic or representation interest or genuine organizational relationship unrelated to the provision of benefits; and
                   (4)(a)(iii)(B) to act in the best interests of its employers to provide benefits for the employer's employees and their spouses and dependents, and other benefits relating to employment; and
              (4)(a)(iv) whose association sponsored health plan complies with Utah Code 31A-30-103
  • Carrier: means a person that provides health insurance in this state including:
         (5)(a) an insurance company;
         (5)(b) a prepaid hospital or medical care plan;
         (5)(c) a health maintenance organization;
         (5)(d) a multiple employer welfare arrangement; and
         (5)(e) another person providing a health insurance plan under this title. See Utah Code 31A-30-103
  • case characteristics: means demographic or other objective characteristics of a covered insured that are considered by the carrier in determining premium rates for the covered insured. See Utah Code 31A-30-103
  • Class of business: means all or a separate grouping of covered insureds that is permitted by the commissioner in accordance with Section 31A-30-105. See Utah Code 31A-30-103
  • Contract: A legal written agreement that becomes binding when signed.
  • Covered carrier: means an individual carrier or small employer carrier subject to this chapter. See Utah Code 31A-30-103
  • Covered individual: means an individual who is covered under a health benefit plan subject to this chapter. See Utah Code 31A-30-103
  • Covered insureds: means small employers and individuals who are issued a health benefit plan that is subject to this chapter. See Utah Code 31A-30-103
  • Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
  • health insurance: means insurance providing:
              (84)(a)(i) a health care benefit; or
              (84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301
  • Individual: means a natural person. See Utah Code 31A-1-301
  • Individual carrier: means a carrier that provides coverage on an individual basis through a health benefit plan regardless of whether:
         (14)(a) coverage is offered through:
              (14)(a)(i) an association;
              (14)(a)(ii) a trust;
              (14)(a)(iii) a discretionary group; or
              (14)(a)(iv) other similar groups; or
         (14)(b) the policy or contract is situated out-of-state. See Utah Code 31A-30-103
  • Insurance: includes :
              (96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
              (96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
              (96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
  • insurance company: means a person doing an insurance business as a principal including:
              (104)(a)(i) a fraternal benefit society;
              (104)(a)(ii) an issuer of a gift annuity other than an annuity specified in Subsections 31A-22-1305(2) and (3);
              (104)(a)(iii) a motor club;
              (104)(a)(iv) an employee welfare plan;
              (104)(a)(v) a person purporting or intending to do an insurance business as a principal on that person's own account; and
              (104)(a)(vi) a health maintenance organization. See Utah Code 31A-1-301
  • Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
              (103)(a)(i) a policyholder;
              (103)(a)(ii) a subscriber;
              (103)(a)(iii) a member; and
              (103)(a)(iv) a beneficiary. See Utah Code 31A-1-301
  • Member: means a person having membership rights in an insurance corporation. See Utah Code 31A-1-301
  • Month: means a calendar month, unless otherwise expressed. See Utah Code 68-3-12.5
  • Person: includes :
         (146)(a) an individual;
         (146)(b) a partnership;
         (146)(c) a corporation;
         (146)(d) an incorporated or unincorporated association;
         (146)(e) a joint stock company;
         (146)(f) a trust;
         (146)(g) a limited liability company;
         (146)(h) a reciprocal;
         (146)(i) a syndicate; or
         (146)(j) another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301
  • Policy: includes a service contract issued by:
              (150)(b)(i) a motor club under Chapter 11, Motor Clubs;
              (150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and
              (150)(b)(iii) a corporation licensed under:
                   (150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or
                   (150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301
  • Premium: means money paid by covered insureds and covered individuals as a condition of receiving coverage from a covered carrier, including fees or other contributions associated with the health benefit plan. See Utah Code 31A-30-103
  • Process: means a writ or summons issued in the course of a judicial proceeding. See Utah Code 68-3-12.5
  • Rate: means :
              (163)(a)(i) the cost of a given unit of insurance; or
              (163)(a)(ii) for property or casualty insurance, that cost of insurance per exposure unit either expressed as:
                   (163)(a)(ii)(A) a single number; or
                   (163)(a)(ii)(B) a pure premium rate, adjusted before the application of individual risk variations based on loss or expense considerations to account for the treatment of:
                        (163)(a)(ii)(B)(I) expenses;
                        (163)(a)(ii)(B)(II) profit; and
                        (163)(a)(ii)(B)(III) individual insurer variation in loss experience. See Utah Code 31A-1-301
  • Rating period: means the calendar period for which premium rates established by a covered carrier are assumed to be in effect, as determined by the carrier. See Utah Code 31A-30-103
  • Small employer: means , in connection with a health benefit plan and with respect to a calendar year and to a plan year, an employer who:
              (182)(a)(i)
                   (182)(a)(i)(A) employed at least one but not more than 50 eligible employees on business days during the preceding calendar year; or
                   (182)(a)(i)(B) if the employer did not exist for the entirety of the preceding calendar year, reasonably expects to employ an average of at least one but not more than 50 eligible employees on business days during the current calendar year;
              (182)(a)(ii) employs at least one employee on the first day of the plan year; and
              (182)(a)(iii) for an employer who has common ownership with one or more other employers, is treated as a single employer under Utah Code 31A-1-301
  • State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
  • under common control: means the direct or indirect possession of the power to direct or cause the direction of the management and policies of a person. See Utah Code 31A-1-301
(2) “Affiliate” or “affiliated” means a person who directly or indirectly through one or more intermediaries, controls or is controlled by, or is under common control with, a specified person.
(3) “Base premium rate” means, for each class of business as to a rating period, the lowest premium rate charged or that could have been charged under a rating system for that class of business by the covered carrier to covered insureds with similar case characteristics for health benefit plans with the same or similar coverage.
(4)

     (4)(a) “Bona fide employer association” means an association of employers:

          (4)(a)(i) that meets the requirements of Section 31A-22-505;
          (4)(a)(ii) in which the employers of the association, either directly or indirectly, exercise control over the plan;
          (4)(a)(iii) that is organized:

               (4)(a)(iii)(A) based on a commonality of interest between the employers and their employees that participate in the plan by some common economic or representation interest or genuine organizational relationship unrelated to the provision of benefits; and
               (4)(a)(iii)(B) to act in the best interests of its employers to provide benefits for the employer’s employees and their spouses and dependents, and other benefits relating to employment; and
          (4)(a)(iv) whose association sponsored health plan complies with 45 C.F.R. § 146.121.
     (4)(b) The commissioner shall consider the following with regard to determining whether an association of employers is a bona fide employer association under Subsection (4)(a):

          (4)(b)(i) how association members are solicited;
          (4)(b)(ii) who participates in the association;
          (4)(b)(iii) the process by which the association was formed;
          (4)(b)(iv) the purposes for which the association was formed, and what, if any, were the pre-existing relationships of its members;
          (4)(b)(v) the powers, rights and privileges of employer members; and
          (4)(b)(vi) who actually controls and directs the activities and operations of the benefit programs.
(5) “Carrier” means a person that provides health insurance in this state including:

     (5)(a) an insurance company;
     (5)(b) a prepaid hospital or medical care plan;
     (5)(c) a health maintenance organization;
     (5)(d) a multiple employer welfare arrangement; and
     (5)(e) another person providing a health insurance plan under this title.
(6)

     (6)(a) Except as provided in Subsection (6)(b), “case characteristics” means demographic or other objective characteristics of a covered insured that are considered by the carrier in determining premium rates for the covered insured.
     (6)(b) “Case characteristics” do not include:

          (6)(b)(i) duration of coverage since the policy was issued;
          (6)(b)(ii) claim experience; and
          (6)(b)(iii) health status.
(7) “Class of business” means all or a separate grouping of covered insureds that is permitted by the commissioner in accordance with Section 31A-30-105.
(8) “Covered carrier” means an individual carrier or small employer carrier subject to this chapter.
(9) “Covered individual” means an individual who is covered under a health benefit plan subject to this chapter.
(10) “Covered insureds” means small employers and individuals who are issued a health benefit plan that is subject to this chapter.
(11) “Dependent” means an individual to the extent that the individual is defined to be a dependent by:

     (11)(a) the health benefit plan covering the covered individual; and
(12) “Established geographic service area” means a geographical area approved by the commissioner within which the carrier is authorized to provide coverage.
(13) “Index rate” means, for each class of business as to a rating period for covered insureds with similar case characteristics, the arithmetic average of the applicable base premium rate and the corresponding highest premium rate.
(14) “Individual carrier” means a carrier that provides coverage on an individual basis through a health benefit plan regardless of whether:

     (14)(a) coverage is offered through:

          (14)(a)(i) an association;
          (14)(a)(ii) a trust;
          (14)(a)(iii) a discretionary group; or
          (14)(a)(iv) other similar groups; or
     (14)(b) the policy or contract is situated out-of-state.
(15) “Individual conversion policy” means a conversion policy issued to:

     (15)(a) an individual; or
     (15)(b) an individual with a family.
(16) “New business premium rate” means, for each class of business as to a rating period, the lowest premium rate charged or offered, or that could have been charged or offered, by the carrier to covered insureds with similar case characteristics for newly issued health benefit plans with the same or similar coverage.
(17) “Premium” means money paid by covered insureds and covered individuals as a condition of receiving coverage from a covered carrier, including fees or other contributions associated with the health benefit plan.
(18)

     (18)(a) “Rating period” means the calendar period for which premium rates established by a covered carrier are assumed to be in effect, as determined by the carrier.
     (18)(b) A covered carrier may not have:

          (18)(b)(i) more than one rating period in any calendar month; and
          (18)(b)(ii) no more than 12 rating periods in any calendar year.
(19) “Small employer carrier” means a carrier that provides health benefit plans covering eligible employees of one or more small employers in this state, regardless of whether:

     (19)(a) coverage is offered through:

          (19)(a)(i) an association;
          (19)(a)(ii) a trust;
          (19)(a)(iii) a discretionary group; or
          (19)(a)(iv) other similar grouping; or
     (19)(b) the policy or contract is situated out-of-state.
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