R590. Insurance, Administration.
(Effective 11-1-06)
R590-236. HIPAA Eligibility Following Receipt of a Certificate of Insurability
or Denial by an Individual Carrier.
R590-236-1. Authority.
This rule is promulgated and adopted pursuant to Subsections
31A-2-201(3), 31A-29-106(1)(f), and 31A-30-104(7).
R590-236-2. Purpose and Scope.
(1) The purpose of this rule is to provide interpretation of the
interplay between federal and state statutes that affect the protections
provided by the federal Health Insurance Portability and Accountability Act (HIPAA),
Pub.L. 104-191, 110 Stat. 1962, to applicants that apply for coverage with
HIPUtah and receive a certificate of insurability from HIPUtah, or denial of
coverage by an individual carrier.
(2) The rule addresses the effective dates of coverage for HIPAA eligible
applicants applying for coverage with an individual carrier or HIPUtah.
(3) The rule provides guidance for actual and potential interplay between
HIPAA, Sections 31A-22-605.1, 31A-30-108, and 31A-29-111 to:
(i) individual carriers,
(ii) the HIPUtah pool administrator; and
(iii) HIPUtah applicants.
R590-236-3. Definitions.
As used in this rule:
(1) "Certificate of insurability" means a certificate issued by HIPUtah
pursuant to Subsection 31A-29-111.
(2) "HIPAA" means the federal Health Insurance Portability and
Accountability Act, Pub.L. 104-191, 110 Stat. 1962.
(3) "HIPAA eligible" means an applicant who is eligible for coverage under
the provisions of the Health Insurance Portability and Accountability Act of
1996, Pub. L. 104-191, 110 Stat. 1962.
(4) "HIPAA eligibility" means the eligibility required by the federal
Health Insurance Portability and Accountability Act, Pub. L. 104-191, 110 Stat.
1962.
(5) "HIPUtah" means the Utah Comprehensive Health Insurance Pool
established by Section 31A-29-104.
(6) "Individual carrier" has the same meaning as defined in Subsection
31A-30-103.
(7) "Preexisting condition" means preexisting condition as defined in
Subsection 31A-1-301.
(8) "Waiting period" means the period of time beginning on the date the
HIPAA eligible submits a substantially complete application for coverage and
ends on the date:
(a) coverage is effective;
(b) the application is denied by the insurer; or
(c) which the offer of coverage lapses without being accepted by the HIPAA
eligible.
R590-236-4. HIPAA and Subsection 31A-22-605.1,
Eligibility and Creditable Coverage.
(1) A HIPAA eligible must submit a substantially complete application
no later than 63 consecutive days, excluding waiting periods, following
termination of any preceding HIPAA qualified coverage, to preserve HIPAA rights.
(2) A HIPAA eligible cannot have a break in qualifying coverage of 63 or
more consecutive days, except for applicable waiting periods to preserve HIPAA
rights.
(3) HIPAA eligibles applying within the time period in R590-236-4(1) will
receive creditable coverage toward a preexisting condition waiting period.
(4) A waiting period does not count in determining whether a break in
qualifying coverage occurred.
R590-236-5. HIPAA and
Subsection 31A-29-111(4)(a), 30-Day Provision.
(1) This section applies to a HIPAA eligible that has been denied by
an individual carrier and is approved by HIPUtah.
(2) When a HIPAA eligible submits a substantially completed application to
an individual carrier within the HIPAA 63-day time period and is denied
coverage, to preserve HIPAA rights, the HIPAA eligible must make application to
HIPUtah no later than:
(a) the remainder of the 63 consecutive day time period under HIPAA; or
(b) 30 consecutive days after denial by the individual carrier.
(3) Effective Dates.
(a) A HIPAA eligible applying within the time period in R590-236-5(2)(a),
shall have an effective date with HIPUtah on the first day of the month
following the submission of a substantially completed application, if the
required premium is paid.
(b) A HIPAA eligible applying within the time period in R590-236-5(2)(b),
shall have an effective date with HIPUtah on the first day of the month
following the date of submission of a substantially completed application to the
individual carrier who denied coverage immediately prior to the application to
HIPUtah, if the required premium is paid.
(c) When a HIPAA eligible applies within both time periods in
R590-236-5(2)(a) and (b), the HIPAA eligible shall choose the effective date
provided in R590-236-5(3)(a) or (b).
R590-236-6. HIPAA and
Subsection 31A-30-108(3)(e)(i), 30-Day Provision.
(1) This section applies to a HIPAA eligible who meets HIPUtah's
eligibility requirements but does not meet HIPUtah's
health underwriting criteria, having been previously denied by an
individual carrier, and is issued a certificate of insurability under Section
31A-29-111.
(2)(a) A HIPAA eligible may reapply with the individual carrier who
denied coverage immediately prior to HIPUtah's issuance of a certificate of
insurability to preserve HIPAA rights, no later than:
(i) the remainder of the 63 consecutive day time period under HIPAA; or
(ii) 30 consecutive days after the date of issuance of a certificate of
insurability.
(b) R590-236-6(2)(a) applies only to a HIPAA eligible that has:
(i) submitted a substantially completed application to an individual
carrier within the HIPAA 63-day time period;
(ii) is denied coverage by an individual carrier; and
(iii) makes application to HIPUtah no later than:
(I) the remainder of the 63 consecutive day time period under HIPAA; or
(II) 30 consecutive days after denial by the individual carrier.
(3) Effective Dates.
(a) A HIPAA eligible applying within the time period in R590-236-6(2)(a)(i),
shall have an effective date with the individual carrier on the first day of the
month following the submission of a substantially completed application, if the
required premium is paid.
(b) A HIPAA eligible applying within the time period in R590-236-6(2)(a)(ii),
shall have an effective date with the individual carrier on the first day of the
month following the original submission of a substantially completed application
to the individual carrier who denied coverage immediately prior to the
application to HIPUtah, if the required premium is paid.
(c) When a HIPAA eligible applies within both time periods in
R590-236-6(2)(a)(i) and (ii), the HIPAA eligible shall choose the effective date
provided in R590-236-6(3)(a) or (b).
R590-236-7. HIPAA and Subsection 31A-30-108(3)(e)(ii)(B),
45-Day Provision.
(1) This section applies to a HIPAA eligible who applies first with
HIPUtah, meets HIPUtah's eligibility requirements, but does
not meet HIPUtah's health underwriting criteria and is issued a certificate of
insurability under Section 31A-29-111.
(2) When a HIPAA eligible submits a substantially completed application to
HIPUtah within the HIPAA 63-day time period and is issued a certificate of
insurability, the HIPAA eligible may make application
to an individual carrier no later than:
(a) the remainder of the 63 consecutive day time period under HIPAA; or
(b) 45 consecutive days after the date of issuance of a certificate of
insurability by HIPUtah.
(3) Effective Dates.
(a) A HIPAA eligible qualifying under option R590-236-7(2)(a) shall have
an effective date of the first of the month following the submission of the
substantially completed application to an individual carrier, if the required
premium is paid.
(b) A HIPAA eligible qualifying under R590-236-7(2)(b) shall have an
effective date of the day following the submission of the substantially
completed application to HIPUtah, if the required premium is paid.
(c) When a HIPAA eligible applies within both time periods in
R590-236-7(2)(a) and (b), the HIPAA eligible shall choose the effective date
provided in R590-236-7(3)(a) or (b).
R590-236-8. Severability.
If any provision of this rule or the application of the rule to any
person or circumstance is for any reason held to be invalid, the remainder of
the rule and the application of the rule to other persons or circumstances shall
not be affected by such a determination.
R590-236-9. Enforcement
Date.
The commissioner will begin enforcing the provisions of this rule
immediately upon the effective date of the rule.
KEY: HIPAA eligibility
Date of Enactment or Last Substantive Amendment: April 9, 2007
Authorizing, and Implemented or Interpreted Law: 31A-29-106, 31A-30-104,
31A-2-201
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