Utah Admin. Code R590-148-10 - Continuation and Conversion

(1) A group policy issued in this state on or after July 1, 2002, shall include a provision for continuation of coverage or conversion of coverage.

(2)

(a) A group policy that restricts benefits and services or contains incentives to use certain providers or facilities may provide continuation of coverage or conversion of coverage benefits that are substantially equivalent to the benefits of the existing group policy.

(b) The commissioner shall make a determination as to the substantial equivalency of benefits, taking into consideration the differences between managed care and non-managed care plans, including provider system arrangements, service availability, benefit levels, and administrative complexity.

(3)

(a) The insured shall make a written application for the converted policy and pay the first premium, if any, as directed by the insurer within 60 days after the termination of coverage under the group policy.

(b) The converted policy shall be issued effective on the day following the termination of coverage under the group policy and shall be renewable annually.

(4)

(a) Unless the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated based on the insured's age at inception of coverage under the group policy replaced.

(b) If the group policy from which conversion is made replaced previous group coverage, the premium for the converted policy shall be calculated based on the insured's age at inception of coverage under the group policy replaced.

(5) The premium for the individual converted policy may not exceed the insurer's premium rate at the time of the termination applicable to:

(a) the policy form;

(b) the benefit amount of the individual policy; and

(c) the class of risk to which the individual belonged when terminated from the group policy.

(6) Continuation of coverage or issuance of a converted policy is mandatory, except when:

(a) termination of group coverage resulted from an individual's failure to make any required payment of premium or contribution when due; or

(b) the terminating coverage is replaced within 31 days after termination by group coverage effective on the day following the termination of coverage:

(i) providing benefits identical to, or benefits determined by the commissioner to be substantially equivalent to or in excess of, those provided by the terminating coverage; and

(ii) having premiums calculated in a manner consistent with the requirements of Subsection (4).

(7)

(a) Notwithstanding any other provision of this section, a converted policy issued to an individual who, at the time of conversion, is covered by another long-term care insurance policy that provides benefits on the basis of an incurred expense, may contain a provision that results in a reduction of benefits payable if the benefits provided under the additional coverage, together with the full benefits provided by the converted policy, result in payment of more than 100% of incurred expenses.

(b) Subsection (7)(a) applies only if the converted policy provides for a premium decrease or refund that reflects the reduction in benefits payable.

(8) The converted policy may provide that the converted policy benefits, together with the benefits payable under the group policy from which conversion is made, not exceed what would have been payable had the individual's coverage under the group policy remained in force and in effect.

(9) Notwithstanding any other provision of this section, if an insured's eligibility for a group policy is based upon the insured's relationship to another insured, the insured is entitled to continuation of coverage under the group policy upon termination of the qualifying relationship by death or dissolution of marriage.

Notes

Utah Admin. Code R590-148-10

Adopted by Utah State Bulletin Number 2024-21, effective 10/22/2024