§ 49-20-401 — Program -- Powers and duties.

(1) The program shall:

(1)(a) act as a self-insurer of employee benefit plans and administer those plans;
(1)(b) enter into contracts with private insurers or carriers to underwrite employee benefit plans as considered appropriate by the program;
(1)(c) indemnify employee benefit plans or purchase commercial reinsurance as considered appropriate by the program;
(1)(d) provide descriptions of all employee benefit plans under this chapter in cooperation with covered employers;
(1)(e) process claims for all employee benefit plans under this chapter or enter into contracts, after competitive bids are taken, with other benefit administrators to provide for the administration of the claims process;
(1)(f) obtain an annual actuarial review of all health and dental benefit plans and a periodic review of all other employee benefit plans;
(1)(g) consult with the covered employers to evaluate employee benefit plans and develop recommendations for benefit changes;
(1)(h) annually submit a budget and audited financial statements to the governor and Legislature that includes total projected benefit costs and administrative costs;
(1)(i) maintain reserves sufficient to liquidate the unrevealed claims liability and other liabilities of the employee benefit plans as certified by the program's consulting actuary;
(1)(j) submit, in advance, the program's recommended benefit and rate adjustments for state employees, which may include actuarially substantiated member premium differentials between networks to:
(1)(j)(i) the Legislature; and
(1)(j)(ii) the director of the state Division of Human Resource Management;
(1)(k) determine benefits and rates, upon approval of the board, for multi-employer risk pools, retiree coverage, and conversion coverage;
(1)(l) determine benefits and rates based on the total estimated costs and the employee premium share established by the Legislature, upon approval of the board, for state employees;
(1)(m) administer benefits and rates, upon ratification of the board, for single-employer risk pools;
(1)(n) request proposals for one or more out-of-state provider networks and a dental health plan administered by a third-party carrier at least once every three years for the purposes of:
(1)(n)(i) stimulating competition for the benefit of covered individuals;
(1)(n)(ii) establishing better geographical coverage of medical care services; and
(1)(n)(iii) providing coverage for both active and retired covered individuals;
(1)(o) for a proposal that meets the criteria specified in a request for proposals and is accepted by the program:
(1)(o)(i) offer the proposal to active and retired state-covered individuals; and
(1)(o)(ii) at the option of the covered employer, offer the proposal to active and retired covered individuals of other covered employers;
(1)(p) perform the same functions established in Subsections (1)(a), (b), (e), and (h) for the Department of Health and Human Services if the program provides program benefits to children enrolled in the Utah Children's Health Insurance Program created in Title 26B, Chapter 3, Part 9, Utah Children's Health Insurance Program;
(1)(q) establish rules and procedures governing the admission of political subdivisions or educational institutions and their employees to the program;
(1)(r) (1)(r)(i) contract directly with medical providers to provide services for covered individuals at commercially competitive rates; and
(1)(r)(ii) (1)(r)(ii)(A) discontinue the preferred network, which offers in-network access to all in-state hospitals, for the state risk pool created in Subsection 49-20-202(1)(a) for plan years starting on or after July 1, 2022; and
(1)(r)(ii)(B) for an employee in the state risk pool who fails to elect one of the remaining networks before July 1, 2022, enroll the employee and the employee's dependents into the network that best reflects the utilization pattern of that employee and the employee's dependents;
(1)(s) (1)(s)(i) require state employees and the state employees' dependents to participate in the electronic exchange of clinical health records in accordance with Section 26B-8-411 unless the enrollee opts out of participation; and
(1)(s)(ii) prior to enrolling the state employee, each time the state employee logs onto the program's website, and each time the enrollee receives written enrollment information from the program, provide notice to the enrollee of the enrollee's participation in the electronic exchange of clinical health records and the option to opt out of participation at any time;
(1)(t) at the request of a procurement unit, as that term is defined in Section 63G-6a-103, that administers benefits to program recipients who are not covered by Title 26B, Utah Health and Human Services Code, provide services for:
(1)(t)(i) drugs;
(1)(t)(ii) medical devices; or
(1)(t)(iii) other types of medical care; and
(1)(u) take additional actions necessary or appropriate to carry out the purposes of this chapter.
(2) (2)(a) Funds budgeted and expended shall accrue from rates paid by the covered employers and covered individuals.
(2)(b) The board shall approve administrative costs and report the administrative costs to the governor and the Legislature.
(3) The Division of Human Resource Management shall include the benefit and rate adjustments described in Subsection (1)(j) in the total compensation plan recommended to the governor required under Subsection 63A-17-307(5)(a).
(4) The program may establish a partnership with a public entity in a different state to purchase or share services related to the administration of medical benefits if:

(4)(a) the program receives approval for the partnership from the board; and
(4)(b) the partnership:
(4)(b)(i) creates cost savings for Utah;
(4)(b)(ii) does not commingle state funds with funds of the public entity in the other state; and
(4)(b)(iii) does not pose a greater actuarial risk to Utah than the program has already assumed.

Legislative History

Amended by Chapter 194, 2023 General Session; Amended by Chapter 328, 2023 General Session