Utah Code 31A-43-301. Stop-loss insurance coverage standards
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(1) A small employer stop-loss insurance contract shall:
Terms Used In Utah Code 31A-43-301
- Attachment: A procedure by which a person's property is seized to pay judgments levied by the court.
- Contract: A legal written agreement that becomes binding when signed.
- Employee: means :(57)(a) an individual employed by an employer; or(57)(b) an individual who meets the requirements of Subsection (55)(b). See Utah Code 31A-1-301
- 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
- Individual: means a natural person. See Utah Code 31A-1-301
- 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- Member: means a person having membership rights in an insurance corporation. See Utah Code 31A-1-301
- 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(1)(a) be issued to the small employer to provide insurance to the group health benefit plan, not the employees of the small employer;(1)(b) have a contract term with guaranteed rates for at least 12 months, without adjustment, unless there is a change in the benefits provided under the small employer’s health plan during the contract period;(1)(c) include both a specific attachment point and an aggregate attachment point in a contract;(1)(d) align stop-loss plan benefit limitations and exclusions with a small employer’s health plan benefit limitations and exclusions, including any annual or lifetime limits in the employer’s health plan;(1)(e) have an annual specific attachment point that is at least $10,000;(1)(f) have an annual aggregate attachment point that may not be less than 85% of expected claims;(1)(g) pay stop-loss claims:(1)(g)(i) incurred during the contract period; and(1)(g)(ii) paid within 12 months after the expiration date of the contract; and(1)(h) include provisions to cover incurred and unpaid stop-loss claims when the small employer’s stop-loss plan terminates.(2) A small employer stop-loss contract shall not:(2)(a) include lasering; and(2)(b) pay claims directly to an individual employee, member, or participant.