Utah Administrative Code
Topic - Insurance
Title R590 - Administration
Rule R590-283 - Defrayal of State-Required Benefits
Section R590-283-4 - Defrayal of a State-Required Benefit

Universal Citation: UT Admin Code R 590-283-4

Current through Bulletin 2024-06, March 15, 2024

(1) A health benefit plan offering a state-required benefit that is offered exclusively off-exchange is not eligible for a defrayal payment.

(2) A carrier seeking a defrayal payment shall, on or before September 1 of each year, submit to the commissioner a request that includes the following information:

(a) the state-required benefit for which the carrier is seeking a defrayal payment;

(b) the Mandate Defrayal Data template with the final data submission tab completed;

(c) an explanation for any increase in the allowable amount in the per unit cost for each CPT code that increased more than 5%;

(d) a description of any treatment plan review under Subsection 31A-22-642(6); and

(e) a certification stating:
(i) any durational limit, amount limit, deductible, copayment, and coinsurance for the treatment of autism spectrum disorder are similar to, or identical to, coverage provided for other illnesses or diseases; and

(ii) the defrayal payment request complies with Subsection 31A-30-118(1)(b).

(3)

(a) The total defrayal payments are based on an aggregate of the data received under Subsection (2) from all carriers.

(b) The defrayal payment is calculated based on the sum of the total state-required benefit defrayable costs incurred across all carriers divided by the sum of the total member months of individuals receiving state-required benefit services across all carriers, and the result is multiplied by the sum of the member months of individuals receiving state-required benefit services for each carrier.

(c) A carrier may not receive a defrayal payment in excess of the amount the carrier incurred for a state-required benefit during the preceding calendar year.

(4) A request for defrayal payment shall be submitted via the System for Electronic Rate and Form Filings, SERFF.

(5)

(a) Each defrayal payment is paid in arrears .

(b) The defrayal payment will be paid in the first quarter of the state's fiscal year following the submission of a valid request for a defrayal payment submitted under Subsection (2).

(c) For example, a carrier submits a request for a defrayal payment in August 2023 for claims incurred during calendar year 2022. The defrayal payment will be paid during the first quarter of the state's fiscal year 2025, July 1, 2024, through September 30, 2024.

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