Utah Admin. Code R590-240-5 - Exemption Requirements for a Student Health Program

(1) The commissioner may exempt an institution's student health program from Title 31A, Insurance Code, if:

(a) the student health program meets the requirements of this section;

(b) the institution applies for an exemption under Section R590-240-6; and

(c) the commissioner notifies the institution that the exemption is granted.

(2) A student health program shall:

(a) be established by an institution;

(b) have assets that are owned by:

(i) an institution;

(ii) a trust; or

(iii) the trustees, in their fiduciary capacities, of a trust established by an institution; and

(c) be operated by:

(i) an institution; or

(ii) the institution's authorized agent or affiliate.

(3) The primary purpose of the institution shall be higher education, not providing a student health program.

(4) Payment of covered claims of the student health program shall be secured by adequate assets:

(a) that are:

(i) secured by being:

(A) pledged;

(B) guaranteed;

(C) contributed;

(D) placed in trust; or

(E) a combination of Subsections (4)(a)(i)(A) through (4)(a)(i)(D); and

(ii) secured under Subsection (4)(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 (4)(a)(ii)(B);

(D) an affiliate of the entity described in Subsection (4)(a)(ii)(C); or

(E) a combination of the entities described in Subsections (4)(a)(ii)(A) through (4)(a)(ii)(D); and

(b)

(i) in an amount and type required under Title 31A, Chapter 17, Determination of Financial Condition; or

(ii) as approved by the commissioner by written order; and

(c) under such terms and conditions as the commissioner determines by written order.

(5) An institution may not offer a student health program to or enroll anyone other than an eligible member.

(6) A student health program shall have a comprehensive legal structure that demonstrates that:

(a) the assets described in Subsection (4) are administered in a fiduciary manner to guarantee 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 is administered by an experienced administrator; and

(c) the student health program is administered according to contracts between:

(i)

(A)

(I) the student health program;

(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;

(II) the institution; or

(III) both the student health program and the institution; and

(B) health care providers.

(7) Except for an emergency health care service or an out-of-area or an out-of-country health care provider, a health care service for an enrollee shall be provided:

(a) at a student health center; or

(b) pursuant to a contract with a health care service provider, by which the health care provider provides a health care service upon a referral from the student health center.

(8) A supplemental health care service provided by the student health program shall:

(a) be obtained from an insurer authorized to provide health insurance;

(b) be backed by assets described in Subsection (4); or

(c) use a combination of Subsections (8)(a) and (8)(b).

(9) A student health program shall provide review procedures substantially similar, and materially equal, to those presently in effect for insurers, health maintenance organizations, and limited health programs.

(10) A student health program or an institution, or both, shall annually provide the department an informational copy of all current policies, booklets, and advertising.

(11) A student health program or an institution, or both, shall 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 is exempt from Title 31A, Insurance Code, and shall cite the date, docket number, and title of the docket by which the exemption was granted.

(12) A student health program shall reduce any applicable preexisting condition provisions for any individual covered by the student health program by the amount of previous creditable coverage.

(13) A student health program shall provide a certificate of creditable coverage upon request by an individual who was covered by the student health program.

Notes

Utah Admin. Code R590-240-5

Amended by Utah State Bulletin Number 2023-23, effective 11/21/2023