R590.
Insurance, Administration. (Effective 6-8-07)
R590-240. Procedure to Obtain
Exemption of Student Health Programs From Insurance Code.
R590-240-1. Authority.
This rule is promulgated and adopted pursuant to Subsection
31A-1-103(3)(d) and Section 31A-2-201.
R590-240-2. Purpose and
Scope.
(1) The purpose of this rule is to exempt student health programs
established by institutions of higher education from regulation under the Utah
Insurance Code.
(2) Health insurance from an insurer made available by an institution
to its students is not exempt from provisions of the Utah Insurance Code under
this rule, even if:
(i) the insurer’s policy is integrated into the overall student health
program offered by the institution to its students; or
(ii) use of the institution’s student health center is an integral, or
mandatory, part of health care coverage under the insurer’s policy.
R590-240-3. Definitions.
(1) All definitions in Section 31A-1-301 are incorporated by reference.
(2) “Board” means the State Board of Regents established in Section
53B-1-103.
(3) “Eligible member” means:
(a) an eligible student;
(b) a spouse of an eligible student; or
(c) a child of, dependent of, or child placed for adoption with, an
eligible student.
(4) “Eligible recipient” means:
(a) an eligible member;
(b) the institution’s officers, faculty, and employees; or
(c) upon application by the institution or the institution’s student
health center, other persons approved by written order of the commissioner.
(5) “Eligible student” is as defined by each institution, but shall, at
a minimum, require that the student be enrolled with the institution.
(6) “Health care provider” means a person who provides health care
services.
(7) “Health care services” means “health care” as defined in Section
31A-1-301.
(8) "Institution” means an institution of higher education or
postsecondary educational institute that consists of the following:
(a) an institution described in Section 53B-1-102; or
(b) an institution of higher education that has been accredited by the
Northwest Commission on Colleges and Universities.
(9) “Student health center” means a facility that is operated to
provide health care services to eligible recipients:
(a) by that institution or pursuant to contract with that institution;
(b) that employs health care providers, or contracts with health care
providers, which may make referrals to other health care providers;
(c) is funded, at least in part, by payment from one of the following
sources, which payment grants access to the student health center during the
period of time for which the eligible student is registered:
(i) a fee assessed to and paid by each eligible student at
registration, which ; or
(ii) the tuition paid by the eligible student;
(d) may accept insurance payments, or assist users in completing claims
forms for insurance claims; and
(e) may require eligible recipients to pay;
(i) an additional fee for each time the student health center is
visited;
(ii) an additional fee for specialty services;
(iii) an additional fee for medical equipment; or
(iv) an additional fee for medication received at the student health
center.
(10)(a) “Student health program” means a plan organized, established,
or adopted, by an
institution to provide or arrange for health care services for eligible
members.
(b) A “student health program” may include providing:
(i) coverage for limited health care services;
(ii) coverage for health care services on an emergency basis; or
(iii) coverage for health care services by out-of-area health care
providers under the following situations:
(A) on an emergency basis, where a prudent layperson would expect the
absence of immediate medical attention to result in placing the eligible
member’s health in serious jeopardy, serious impairment to bodily functions or
serious dysfunction of any bodily organ or part;
(B) during periods when the individual is not enrolled in any classes
at the institution, but is still matriculated with the institution. Such
periods may include time between semesters or quarters, traditional breaks for
the summer, or time away from the institution while attending another higher
education institution under a plan approved by the institution; and
(C) during periods when the individual is enrolled in classes at the
institution, but is not living within commuting distance of the institution,
such as while participating in an internship program.
(11)(a) “Supplemental health care services” means health care services
provided by the student health program in addition to those available at a
student health center.
(b) “Supplemental health care services” includes health care services
provided by contract between:
(i) the institution, and
(ii) any of the following or any combination of the following:
(A) a healthcare provider;
(B) a clinic or other association of health care providers;
(C) a network plan; or
(D) an insurer authorized to provide health insurance.
(12) “Utah Insurance Code” means Title 31A, Utah Code Annotated.
Rule R590-240-4.
Supporting Facts.
(1) Student health programs are offered only to eligible members at
institutions. These institutions have an interest in providing affordable
health care coverage to their students in order to enable the students to
receive limited health care to ensure that progress toward a degree or
certificate is not impeded by unattended medical needs. In some instances,
student health programs may also be offered to the spouses of students and other
dependents of students, as ell.
(2) Student health programs are not established to enable the
institutions to make a profit from providing health care coverage. Providing or
arranging for health care services for students is not the primary purpose of
institutions; it is only incidental to the institutions’ primary purpose, which
is to educate those that matriculate with the institution. In addition, the
economic impact on health care providers directly, and the public indirectly,
from students receiving medical services and then not being able to pay for
those services, is mitigated by providing students at institutions with access
to affordable health care coverage through student health programs.
(3) An institution is either a state institution under the direct
control of, and supervised by, the Board, or it must be accredited by the
Northwest Commission on Colleges and Universities. In order to be accredited,
an institution must meet strict accounting standards, and be able to demonstrate
it is financially solid. An institution must therefore comply with the strict
accounting and financial requirements of the Board or the Northwest Commission
on Colleges and Universities, which would include the need to reflect on the
financial statements of the institution any liability for risks the institution
assumes, or costs the institutions may incur, for its student health program.
Any shortfall in providing health care services at the student health center
would become the obligation of the institution.
R590-240-5. Exemption
Requirements.
A student health program may be exempted from the
provisions of the Utah Insurance Code if it meets all of the requirements of
this Section 5, applies for exemption under Section 6, and the exemption is
granted.
(1) A student health program must be:
(a) established by an institution;
(b)(i) owned by an institution; or
(ii) owned by the trustees of a trust established by an institution;
and
(c) operated by:
(i) an institution; or
(ii) the institution’s authorized agent or affiliate.
(2) The primary purpose of the institution must be higher education,
and not the providing of a student health program.
(3) [The student health program or the institution or both must
provide adequate assets to secure payment of all risks of the student health
program by:
(a) placing, into a trust account dedicated for the payment of eligible
member health care service claims, assets in an amount and type that would be
required under Chapter 17 of the Utah Insurance Code;
(b) under such terms and conditions as the commissioner determines by
written order, pledging, or obtaining a pledge of, assets dedicated for the
payment of eligible member health care service claims in an amount and type that
would be required under Chapter 17 of the Utah Insurance Code;
(c) under such terms and conditions as the commissioner determines by
written order, obtaining performance guarantees or payment guarantees or both
from third parties, in an amount and type that would be required under Chapter
17 of the Utah Insurance Code; or
(d) using a combination of Subsections 5(3)(a), 5(3)(b) and 5(3)(c).
(a) that are:
(i) secured by being:
(A) pledged;
(B) guaranteed;
(C) contributed;
(D) placed in trust; or
(E) using a combination of Subsections 5(3)(a)(i)(A), 5(3)(a)(i)(B),
5(3)(a)(i)(C), and 5(3)(a)(i)(D); and
(ii) secured under Subsection 5(3)(a)(i) by:
(A) the student health program;
(B) the institution that organizes, adopts, or establishes the
student health program;
(C) the owner of the institution described in Subsection
5(3)(a)(ii)(B);
(D) an affiliate of the entity described in Subsection 5(3)(a)(ii)(C);
or
(E) a combination of the entities described in Subsections 5(3)(a)(ii)(A),
5(3)(a)(ii)(B), 5(3)(a)(ii)(C), and 5(3)(a)(ii)(D); and
(b) in an amount and type that would be required under Chapter 17
of the Utah Insurance Code; and
(c) under such terms and conditions as the commissioner
determines by written order.
(4) The student health program may not be offered to or enroll
anyone other than an eligible member.
(5) The student health program must have a comprehensive legal
structure that demonstrates that:
(a) the assets described in Subsection 5(3) will be administered in a
fiduciary manner to assure that assets are available to provide eligible health
care services and to provide payments to health care providers, as outlined in
any contracts between the student health program and health care providers;
(b) the student health program will be administered by an experienced
administrator; and
(c) the student health program shall be administered according to
contracts between:
(i)(A)(I) the student health program; or
(II) the institution; or
(III) both the student health program and the institution; and
(B) the enrollees; and
(ii)(A)(I) the student health program; or
(II) the institution; or
(III) both the student health program and the institution; and
(B) health care providers.
(6) Except for emergency health care services, or out-of-area or
out-of-country health care providers, health care services for those enrolled in
the student health program must be provided:
(a) at a student health center; or
(b) pursuant to a contract with health care service providers, by which
those health care providers will provide health care services upon a referral
from the student health center.
(7) Any supplemental health care services provided by the student
health program must:
(a) be obtained from an insurer authorized to provide health insurance;
(b) be backed by assets under the conditions set forth in Subsection
5(3); or
(c) use a combination of Subsections 5(7)(a) and 5(7)(b).
(8) The student health program must provide review procedures
substantially similar, and materially equal, to those presently in effect for
insurers, health maintenance organizations, and limited health programs.
(9) The student health program or the institution or both [must
submit all policies, contracts, booklets, advertising, and any presentations
relating to the solicitation of the student health program to the department
before they are placed into use]shall annually provide the department an
informational copy of all current policies, booklets, and advertising.
(10) The student health program or the institution or both must state
in a prominent and appropriate place in all policies, contracts, booklets,
explanatory material, advertising or other promotional material, and any
presentations relating to solicitations of the student health program, that the
student health program is not insurance, and the student health program has been
exempted from regulation under the Utah Insurance Code, and must cite the date,
docket number, and title of the docket by which the exemption was granted.
(11) The student health program must reduce any applicable preexisting
condition provisions for any individual covered by the student health program by
the amount of previous creditable coverage.
(12) The student health program must provide a certificate of
creditable coverage upon request by an individual who was covered by the student
health program.
R590-240-6. Procedure
for Obtaining Exemption.
(1) An institution desiring to have its student health program exempted
from the provisions of the Utah Insurance Code shall file with the Utah
Insurance Department an application in a form prescribed by the commissioner for
an order exempting the student health program, and shall provide verifiable
documentation in support of its application, including documentation to support
the exemption requirements in Section 5 have been met. The application must
provide assurance the institution has sufficient assets placed in trust, or
otherwise pledged or guaranteed under Section 3, under conditions acceptable to
the commissioner, to meet any liability the institution may have for its student
health program.
(2) The commissioner may require the following:
(a) additional evidence or information, to be provided by the
institution;
(b) an examination of the student health program by the department, the
costs of which shall be borne by the institution; or
(c) a hearing on the application.
(3) Upon finding that the student health program complies with the
provisions of this rule, the commissioner may issue an order exempting the
student health program from the provisions of the Utah Insurance Code. The
commissioner may place any restrictions or conditions upon the exemption the
commissioner believes to be necessary to protect the interests of the residents
of this state.
(4) A student health program is not exempt from the Utah Insurance Code
unless the commissioner has issued a written order explicitly stating the
student health program is exempt from the Utah Insurance Code.
(5) The department shall retain continuing jurisdiction over the
institution’s student health program to assure compliance with the terms and
conditions in Section 5, including any changes in the law or the facts upon
which the exemption is granted.
R590-240-7. Rule and
Findings.
(1) A student health program is an insurer as defined in Section
31A-1-301, and must comply with the requirements of the Utah Insurance Code
unless it is exempted from regulation by statute or by this rule.
(2) Pursuant to Subsection 31A-1-103(3)(d)(i), the commissioner finds
that a student health program which operates in accordance with the provisions
of Section 5, and obtains an order of exemption under Section 6, does not
require regulation for the protection of the interests of the residents of this
state, and that such student health program is exempt from regulation under the
Utah Insurance Code.
(3) If the institution assumes any risk of the student health program,
the institution must:
(i) apply for authority to conduct the business of an insurer, or
(ii) apply to the commissioner for an exemption under this rule.
(4) Health insurance from an insurer made available by an institution
to its eligible members is not exempt from the Utah Insurance Code under this
rule, even if the health insurance from a health insurer is integrated into the
overall student health program offered by the institution, or use of the
institution’s student health center is an integral or required part of the
health care coverage under the insurer’s policy.
(5) Any inconsistencies between the provisions of this rule and any
order previously issued exempting a student health program from regulation under
the Utah Insurance Code are resolved by incorporating the provisions of this
rule.
R590-240-8. Enforcement
Date.
The commissioner will begin enforcing this rule 45 days from the rule’s
effective date.
R590-240-9.
Severability.
If any provision of this rule or the application thereof to any person
or circumstance is for any reason held to be invalid, the remainder of the rule
and the application of such provision to other persons or circumstances shall
not be affected thereby.
KEY: health insurance
exemption
2007
31A-1-103, 31A-2-201
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