Utah Health Insurance Enforcement and Consumer Protections Grant Award

Cycle I Grant Application Summary

Utah Grantee: Utah Department of Insurance

Award Date: October 31, 2016

Total Award: $1,262,406.16

Baseline Award: $476,998

Selected Market Reforms Amount: $600,000

Workload Award Amount: $185,408.16

• Section 2707- The Utah Department of Insurance will perform market conduct examinations and provide education for staff insurance analysts. Utah will also incorporate the Center for Consumer Information and Insurance Oversight (CCIIO) drug tool into the review process to ensure ACA policies comply in benefit plan design, including Essential Health Benefit (EHB) benchmarks and non-discrimination requirements.

• Section 2713 - Utah will closely review health insurance issuers’ policy forms to ensure coverage without cost sharing for all required preventive services. The Utah Department of Insurance will ensure that no-cost coverage is provided for at least one form of contraception in each of the methods identified for women by the Food and Drug Administration (FDA), and that there is a meaningful exceptions process for a contraceptive item or service to be covered without cost sharing, as appropriate.

• Section 2718 - The Utah Department of Insurance will review and revise State administrative rules for compliance with Federal regulations. Utah will develop a process for substantive testing for each element of the Federal Medical Loss Ratio (MLR). The Department of Insurance will train staff examiners and conduct MLR examinations on health insurance issuers who offer coverage subject to the MLR law. Utah will also develop consumer friendly outreach information.

• Section 2719 - The Utah Department of Insurance will review appeals to assure health insurance issuers refer consumers for external reviews, conduct in-depth review of appeals, audit responses, and track trends. Any findings of noncompliance with market reforms will be sent to the Utah Market Conduct Assistant Director for further action.

• Section 2726 - In Utah there has been a significant uptake in the licensing of substance abuse treatment facilities. The Utah Department of Insurance will investigate fraud and work to ensure all patients who receive substance abuse treatment, receive treatment that is in parity with health care conditions, as well as parity with treatments provided.