Utah Department of Administrative Services Division of Administrative Rules

Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since August 1, 2014, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.


R590. Insurance, Administration.

Rule R590-232. Authorization for a Health Maintenance Organization to Provide Services as Third Party Administrator of Health Care Benefits.

As in effect on August 1, 2014

Table of Contents

R590-232-1. Authority.

This rule is promulgated and adopted pursuant to Subsection 31A-8-103(2) allowing the commissioner to waive provisions of Title 31A that he considers inapplicable to health maintenance organizations, and Section 31A-2-201 giving the commissioner authority to implement the provisions of Title 31A.

R590-232-2. Purpose.

The purpose of this rule is to authorize a health maintenance organization to provide services as a third party administrator of health care benefits.

R590-232-3. Definitions.

All definitions in Sections 31A-1-301 and 31A-8-101 are hereby adopted by reference.

R590-232-4. Findings.

A. The term "organization" includes a health maintenance organization by definition.

B. Subsection 31A-8-106 provides, "No organization may engage, directly or indirectly, in any business other than that of an organization and business reasonably incidental to that business."

C. For some time, there has been a question as to whether providing services by a health maintenance organization as a "third party administrator" of health care benefits could be deemed to be the "business . . . of an organization" or at least be deemed to be "business reasonably incidental to that business."

D. The Commissioner finds that when a health maintenance organization provides services as a third party administrator of health care benefits, that business is, at the very least, "business reasonably incidental to that business" of a health maintenance organization.

E. In addition, Subsection 31A-8-103(2) provides, "The commissioner may by rule waive other specific provisions of this title that the commissioner considers inapplicable to health maintenance organizations or limited health plans, upon a finding that the waiver will not endanger the interests of: (a) enrollees; (b) investors; or (c) the public."

F. To the extent the definition of "third party administrator" in Section 31A-1-301 can be read as prohibiting a health maintenance organization from providing services as a third party administrator of health care benefits, and to the extent Chapter 25 of Title 31A can be read as requiring that a health maintenance organization apply for a separate license to provide services as a third party administrator of health care benefits, the commissioner finds that waiving those provisions with respect to health maintenance organizations will not endanger the interests of (a) enrollees, (b) investors, or (c) the public, and therefore the commissioner hereby waives those provisions with respect to a health maintenance organization providing third party administrator services of health care benefits.

R590-232-5. Rule.

A health maintenance organization may provide services as a third party administrator of health care benefits, and may do so without acquiring a third party administrator license under Chapter 25 of Title 31A.

R590-232-6. 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 maintenance organizations

Date of Enactment or Last Substantive Amendment

December 29, 2004

Notice of Continuation

December 24, 2009

Authorizing, Implemented, or Interpreted Law

31A-2-201; 31A-2-202; 31A-21-312; 31A-26-301; 31A-26-303


Additional Information

Contact

For questions regarding the content or application of rules under Title R590, please contact the promulgating agency (Insurance, Administration). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.