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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