2023 Utah Health Insurance Market Report
State of Utah
SPENCER J. COX
Governor
DEIDRE M. HENDERSON
Lieutenant Governor
Insurance Department
JONATHAN T. PIKE
Insurance Commissioner
The 2023 Utah Health Insurance Market Report was prepared by Jeffrey E. Hawley, Ph.D. of
the Health & Life Insurance Division for the Utah Insurance Commissioner pursuant to Utah
Code § 31A-2-201.2. Publication date: March 1, 2024.
For questions about this report contact:
Jeffrey E. Hawley, Ph.D.
Research Consultant
Health & Life Insurance Division
Utah Insurance Department
4315 S. 2700 West, Suite 2300
Taylorsville, Utah 84129
801-957-9284
Shelley Wiseman, MPA
Director
Health & Life Insurance Division
Utah Insurance Department
4315 S. 2700 West, Suite 2300
Taylorsville, Utah 84129
801-957-9296
swiseman@utah.gov
Table of Contents
List of Tables ................................................................................................................................. iii
List of Figures ................................................................................................................................ vi
Executive Summary ...................................................................................................................... vii
Introduction ..................................................................................................................................... 1
What is Health Insurance? ....................................................................................................... 1
Estimate of Health Insurance Coverage in Utah ...................................................................... 2
Utah’s Commercial Health Insurance Market ................................................................................ 4
Commercial Health Insurance Market Overview .................................................................... 4
Commercial Health Insurance Market by Policy Type ........................................................... 6
Consumer Complaints Against Commercial Health Insurance Companies ............................ 7
Independent Reviews by an Independent Review Organization ........................................... 12
Health Care Preauthorization Reporting ....................................................................................... 15
Utah’s Comprehensive Health Insurance Market ......................................................................... 16
Comprehensive Market by Domicile ..................................................................................... 16
Comprehensive Market by Group Size .................................................................................. 16
Comprehensive Market by Plan Types .................................................................................. 18
Comprehensive Market by Regulatory Type ......................................................................... 20
Comprehensive Market Trends .............................................................................................. 24
Utah’s Stop-Loss Insurance Market.............................................................................................. 43
Stop-Loss Insurance Market Trends ...................................................................................... 43
Stop-Loss Insurance Market by Domicile ............................................................................. 43
Stop-Loss Insurance Market by Group Size .......................................................................... 44
ii
Stop-Loss Insurance Market by Attachment Points .............................................................. 45
Utah’s Long-Term Care Insurance Market ................................................................................... 47
Long-Term Care Market by Domicile ................................................................................... 47
Long-Term Care Market by Group Size ................................................................................ 47
Long-Term Care Market by Age ........................................................................................... 48
Utah’s Medicare Product Market .................................................................................................. 49
Medicare Products by Domicile ............................................................................................ 49
Medicare Products by Age ..................................................................................................... 51
Medicare Products by Plan Type ........................................................................................... 52
Pharmacy Benefit Manager Rebates ............................................................................................. 54
Summary ....................................................................................................................................... 55
References ..................................................................................................................................... 61
Appendix ....................................................................................................................................... 64
Recommendations ......................................................................................................................... 65
List of Comprehensive Health Insurers ........................................................................................ 66
List of Health Insurance Mandates in Utah .................................................................................. 67
Coverage Mandates ............................................................................................................... 67
Benefit Mandates ................................................................................................................... 68
Provider Mandates ................................................................................................................. 69
Statutory Requirements and Methods Overview .......................................................................... 70
Statutory Requirements ......................................................................................................... 70
Methods Overview ................................................................................................................. 71
Glossary ........................................................................................................................................ 73
iii
List of Tables
Table 1. Estimate of Health Insurance Coverage for 2022 ............................................................. 3
Table 2. Total Commercial Health Insurance Market by Insurer Type for 2022 ........................... 5
Table 3. Total Commercial Health Insurance Market by Policy Type for 2022 ............................ 6
Table 4. Number of Consumer Telephone Contacts Handled by OCHA Staff: 2013 - 2022 ......... 7
Table 5. Complaints Filed with OCHA by Type: 2013 - 2022 ....................................................... 8
Table 6. Complaints Filed with OCHA by Reason: 2013 - 2022 ................................................... 9
Table 7. Complaint Ratios for the Commercial Health Insurance Market: 2013 - 2022 .............. 10
Table 8. Commercial Health Insurance Companies with Consumer Complaints during 2022 .... 11
Table 9. Requests for Independent Reviews by Eligibility: 2013 - 2022 ..................................... 13
Table 10. Requests for Independent Reviews by Reason: 2013 - 2022........................................ 13
Table 11. IRO Decisions by Outcome: 2013 – 2022 .................................................................... 14
Table 12. Health Care Preauthorizations processed after one week during 2022 ........................ 15
Table 13. Total Comprehensive Market by Domicile for 2022 .................................................... 16
Table 14. Total Comprehensive Market by Group Size for 2022................................................. 17
Table 15. Total Comprehensive Market by Plan Type for 2022 .................................................. 19
Table 16. Total Comprehensive Market by ACA Market Segment for 2022 ............................... 21
Table 17. Metal Tier Plans on Federally Facilitated Marketplace for 2022 ................................. 22
Table 18. HSA-Qualified High Deductible Health Plans for 2022 .............................................. 23
Table 19. Changes in the Number of Comprehensive Health Insurers: 2013 - 2022 ................... 24
Table 20. Changes in Comprehensive Membership by Group Size: 2013 - 2022 ........................ 28
Table 21. Changes in Comprehensive Membership by Plan Type: 2013 - 2022 ......................... 29
Table 22. Changes in Government Sponsored Health Benefit Plans: 2013 - 2022 ...................... 31
iv
Table 23. Comprehensive Premium Compared to National Economic Trends: 2013 – 2022 ...... 32
Table 24. Comprehensive Losses Compared to National Health Care Spending: 2013 - 2022 ... 33
Table 25. Changes in Comprehensive Premium and Per Capita Income: 2013 - 2022 ................ 35
Table 26. Comparison of Utah Premium to National Premium: 2013 - 2022 .............................. 39
Table 27. State Benefit Mandate Defrayal Payments for Autism Behavioral Health Treatment:
2020 - 2022 ................................................................................................................................... 39
Table 28. Total Stop-Loss Market: 2013 - 2022 ........................................................................... 43
Table 29. Total Stop-Loss Market by Domicile for 2022 ............................................................. 44
Table 30. Total Stop-Loss Market by Group Size for 2022 ......................................................... 44
Table 31. Stop-Loss Membership by Specific Attachment Points for 2022................................. 45
Table 32. Stop-Loss Membership by Aggregate Attachment Points for 2022 ............................. 46
Table 33. Total Long-Term Care Market by Domicile for 2022 .................................................. 47
Table 34. Total Long-Term Care Market by Group Size for 2022 ............................................... 48
Table 35. Long-Term Care Membership by Age for 2022 ........................................................... 48
Table 36. Total Medicare Supplement Market by Domicile for 2022 .......................................... 50
Table 37. Total Medicare Advantage Market by Domicile for 2022 ........................................... 50
Table 38. Total Medicare Part D Market by Domicile for 2022 .................................................. 50
Table 39. Medicare Supplement Membership by Age for 2022 ................................................... 51
Table 40. Medicare Advantage Membership by Age for 2022 .................................................... 51
Table 41. Medicare Part D Membership by Age for 2022 ........................................................... 52
Table 42. Medicare Supplement Membership by Plan Type for 2022 ......................................... 52
Table 43. Medicare Advantage Membership by Plan Type for 2022 ........................................... 53
Table 44. Pharmacy Benefit Manager Rebates and Administrative Fees for 2022 ...................... 54
vi
List of Figures
Figure 1. Estimate of Health Insurance Coverage for 2022............................................................ 2
Figure 2. Comprehensive Premium PMPM by Group Size: 2013 - 2022 .................................... 36
Figure 3. Income After Expenses For Comprehensive Health Insurers: 2013 - 2022 .................. 40
vii
Executive Summary
Health insurance is an important issue for the people of Utah. Utah’s residents receive
their health insurance coverage through health plans sponsored by the government, employers,
and commercial health insurers. The commercial health insurance market is the only source of
health insurance directly regulated by the Utah Insurance Department, hereafter referred to as the
Insurance Department for the purposes of this report.
Approximately 38 percent of Utah’s commercial health insurance market is
comprehensive health insurance (also known as major medical). Comprehensive health insurance
membership as a percentage of Utah residents increased slightly during 2022 and the
comprehensive health insurance industry serves nearly 23 percent of Utah residents. The typical
policy in this industry is an employer group policy with a managed care plan administered by a
domestic commercial health insurer.
A key function of the Insurance Department is to assist consumers with questions and
concerns they have about insurance coverage. The Office of Consumer Health Assistance
(OCHA) is the agency within the Insurance Department that handles consumer concerns about
their health insurance.
The total number of consumer complaints received by the Insurance Department
increased from 2013 to 2016, declined from 2017 to 2020, and then increased during 2021 and
2022. Consumers continue to contact the Insurance Department in significant numbers. The
number of consumer complaints increased during the early implementation of the ACA, but has
started to decline towards pre-ACA levels. From 2021 to 2022, the number of complaints
increased by about 20 percent. Another important trend over the last eight years has been an
increase in the number of complaints related to the issue of balance billing, where a health care
provider bills the patient for the difference between the provider’s charge and the amount paid by
health insurance. Balance billing complaints accounted for about 10 percent of all consumer
complaints from 2015 to 2017, about 16 percent during 2018, about 8 percent during 2019, about
10 percent during 2020, about 6 percent during 2021, and about 3 percent during 2022. In
response to this pattern in Utah and other states, the federal government passed the No Surprises
Act. This new law addresses the issue of balance billing and provides consumer protections for
surprise medical billing. This federal law applies to individual and group health benefit plans and
took effect on January 1, 2022.
In addition to consumer complaints, the Insurance Department receives and processes
requests from consumers for an independent review of their denied claims by an Independent
Review Organization (IRO). The number of independent reviews remained stable from 2013 to
2014, increased during 2015 and 2016, remained stable during 2017, increased during 2018,
declined during 2019 to 2021, and increased during 2022. From 2021 to 2022, the number of
requests for independent reviews increased by about 18 percent.
viii
Over the last ten years, there have been four significant trends in the comprehensive
health insurance market that the Insurance Department continues to monitor: changes in the
number of insurers, the number of Utah residents with comprehensive health insurance, the cost
of comprehensive health insurance, and the financial status of the health insurance market.
The number of comprehensive health insurers declined from 2013 to 2020, increased
during 2021, and declined during 2022. The decline from 2013 to 2020 has primarily been due to
a decrease in the number of small and very small foreign comprehensive health insurers. In
contrast, while there has been some shifting within the market as part of the full implementation
of the ACA including health insurers leaving the market, the total number of large insurers has
generally remained stable. Large domestic comprehensive health insurers continue to account for
more than 85 percent of the market. The number of medium insurers has fluctuated during this
period. Financial stress and regulatory uncertainty in the market have made it difficult for some
insurers to participate in the comprehensive market and to sustain participation in the Federally
Facilitated Marketplace (FFM). From 2014 to 2022, there has been some market shifting
including several new insurers that entered the market to participate in the Federally Facilitated
Marketplace (FFM). Recent improvements in premium income and market stability have made it
easier for health insurers to participate. Six comprehensive health insurers participated in the
FFM during 2022.
From 2013 to 2022, the number of Utah residents covered by comprehensive health
insurance as a relative percentage of Utah’s population has declined by about 4.6 percent.
Comprehensive health insurance membership has averaged about 763,000 members over the last
10 years. During 2022, comprehensive membership increased by about 3.2 percent. This increase
appears to be due to changes in the individual and small group markets.
From 2014 to 2016, membership in the individual market grew significantly. Most of this
growth was driven by the federal individual mandate which required most persons to maintain
health insurance, the availability of coverage through the FFM, where persons whose income is
between 100 percent and 400 percent of the federal poverty level receive subsidies to make
coverage more affordable, and changes to health insurance regulations, including guaranteed
issue and community rating, which have made it easier for Utah residents to get and keep
coverage in the individual market.
During 2017, the individual market declined by over 32,000 members. This decline
occurred among individuals with Off-Exchange plans who pay the full cost of any premium
increases in the individual market and do not receive any subsidies under the ACA to make
coverage more affordable. Membership in FFM plans, where most members have premium
subsidies, did not experience the same change. Consumers and health insurers were experiencing
significant market uncertainty during 2017, such as the question of how rising health care costs
and changes to government regulations and the ACA would affect consumers, as well as the
ending of Cost-Sharing Reduction (CSR) payments and the possibility of the repeal of the ACA.
During 2018, membership in the individual market remained stable, followed by an increase of
over 11,000 members during 2019 and 2020. This change appears to be due to steady growth in
FFM membership and the availability of enhanced Advance Premium Tax Credit (APTC)
payments during this period.
ix
During 2021 and 2022, membership in the individual market increased significantly. The
number of members in the individual market, driven by growth in FFM membership, increased
by more than 35,000 during 2021 and more than 24,000 during 2022. This growth appears to be
related to the American Rescue Plan Act of 2021 (ARPA). The APRA was designed to assist
persons effected by the COVID-19 pandemic, which includes expanded premium tax credits for
individuals who are eligible for the FFM and also offers subsidies to persons with incomes
greater than 400 percent of the federal poverty level. The ARPA provisions are temporary and
were scheduled to last until the end of 2022 but have been extended through 2025 under the
Inflation Reduction Act of 2022.
Membership in the small group market declined from 2016 to 2019. This decline in small
group membership followed premium increases in the small group market during this period. It
is also possible that some small group membership may have shifted to the individual market,
and healthy small groups have moved to self-funded health benefit plan arrangements to
circumvent several of the ACA provisions. Small group market membership remained stable
during 2020 and then increased during 2021 and 2022.
Large group membership declined from 2014 to 2016, remained stable during 2017, and
then declined from 2018 to 2022. This change appears to be due to some employer groups
moving to self-funding arrangements, although one cannot rule out the possibility of some
shifting to the individual market.
Comprehensive health insurance premium per member per month increased from 2021 to
2022. The average premium per member per month increased from $388 during 2021 to $404
during 2022, an increase of 4.1 percent. Over the last ten years, increases in comprehensive
premium per member per month have averaged 5.1 percent per year, while increases in losses
per member per month have averaged 5.5 percent per year.
From 2014 to 2016, comprehensive health insurers reported high loss ratios, as
premiums, even after payments from the various reinsurance and risk adjustment programs under
the ACA, were not sufficient to cover the healthcare costs of their insured members. The shift to
ACA compliant plans, changes in rating methods, and expanded coverage for higher risk
individuals, combined with lower than expected payments from the federal risk corridor
program, all contributed to these higher loss ratios. Comprehensive health insurers in both 2014
and 2015 had limited claim history to work with to produce reasonable projections, were unable
to underwrite for insurance risk on an individual basis, and 2014 rates were set prior to the
creation of “transitional plans” which prevented insurers from making rate adjustments prior to
2014. During 2016, comprehensive health insurers had more claim experience to work with, but
there was still considerable market uncertainty which made pricing their products more difficult.
During 2017, health insurers had more accurate pricing information and implemented
higher rates that more precisely represented their actual risk experience and this resulted in
improved loss ratios in the individual market. During 2018, the combination of more accurate
pricing information and the elimination of the CSR payment program by the federal government
in October 2017 required health insurers to significantly raise premium rates. The higher
premiums collected during 2018 improved loss ratios in the individual market, allowing health
x
insurers to cover the cost of health care services that they were paying out for their members.
During 2019, comprehensive premiums remained stable as comprehensive health insurers
maintained the rate increases set during 2018.
During 2020, comprehensive health insurers were impacted by the COVID-19 pandemic.
In the spring of 2020, health care spending declined as consumers reduced elective health care to
preserve hospital capacity and implement social distancing measures. Although other forms of
health care spending increased, the net impact of the COVID-19 pandemic appears to have kept
health care spending and comprehensive premiums stable during 2020.
During 2021, comprehensive health insurers experienced uncertainty as to how the
COVID-19 pandemic would affect the insurance market. Comprehensive health insurers
responded to this uncertainty by setting rates in the individual and small group markets at levels
similar to or slightly lower than 2020. Comprehensive health insurers in the individual market
reported lower premium per member per month, but experienced higher loss ratios.
Comprehensive health insurers in the large group market reported higher premium per member
per month, but did not report higher loss ratios.
During 2022, comprehensive health insurers experienced uncertainty around how the
COVID-19 pandemic, the ARPA enhanced premium tax credits, and higher inflation would
affect the insurance market. Comprehensive health insurers increased premiums to cover the
recent increases in comprehensive claim costs and the cost of health care services.
Comprehensive health insurers, whether for-profit or non-profit, need enough income
after expenses to fund state-mandated reserve requirements, reinvest in new equipment and new
markets, and acquire and maintain needed capital. The top insurers in the comprehensive health
insurance industry have experienced an average financial gain of 2.2 percent in net income after
expenses over the last ten years, with top comprehensive health insurers reporting an average
gain of 2.4 percent in net income after expenses during 2022.
The first three years of the full implementation of the ACA were financially difficult for
Utah’s core comprehensive health insurers. Comprehensive health insurers had a limited claim
history to work with and were unable to generate enough premium income to cover their losses.
Changes to the federal risk corridor program meant comprehensive health insurers did not
receive the additional payments that were expected under the program that would have helped
them cover their costs.
From 2014 through 2016, the combination of not having enough information to
adequately price their products and not receiving the additional payments from the federal risk
corridor program as expected produced higher losses for health insurers participating in the
individual market and the FFM. Several comprehensive health insurers withdrew from the FFM
due to concerns that these losses were not sustainable.
xi
During 2017, the fourth year of the full implementation of the ACA was a mixture of
financial and regulatory challenges combined with an increase in financial stability. Regulatory
uncertainty such as the possible repeal of the ACA, elimination of the cost-sharing reduction
(CSR) payments, and reductions in advertising for the FFM created higher market uncertainty for
both consumers and health insurers than would normally have existed under the ACA as written.
During October 2017, the federal government ended the CSR payment program, which
required comprehensive health insurers to raise rates higher than they would have been had the
CSR payments continued. The combination of higher premium revenue and more accurate
pricing information for health insurers led to the beginning of a financial recovery.
Comprehensive health insurers reported better financial results during 2017 than they did during
the first three years of the full implementation of the ACA, suggesting that health insurers were
returning to profitability.
During 2018, the fifth year of the full implementation of the ACA, comprehensive health
insurers reported significantly improved financial results. The high losses that were common
from 2014 to 2016 were no longer occurring as the large rate increases that were implemented
during 2017 and 2018 allowed health insurers to cover the cost of the health care services being
provided for their members. The combination of higher premium revenue and more accurate
pricing information, particularly in the individual market, has led to a financial recovery.
Comprehensive health insurers reported a level of profitability not seen since prior to the full
implementation of the ACA.
During 2019, the sixth year of the full implementation of the ACA, premium income
stabilized and the financial pattern started in 2018 continued through 2019. The higher premium
income helped health insurers cover the cost of health care services that they were paying out for
their members. Comprehensive health insurers reported positive financial results for the third
year in a row.
During 2020, the seventh year of the full implementation of the ACA, net income
increased significantly. This was due to a slight decline in health care spending caused by
members delaying or forgoing healthcare treatment due to the COVID-19 pandemic, stable
premium income, and a one-time risk corridor payment from the federal government.
During 2021, the eighth year of the full implementation of the ACA, net income declined
compared to 2020. Although losses were higher during 2021, premium income remained stable
and health insurers were able to cover the costs of their members’ health care services.
Comprehensive health insurers reported a level of profitability comparable to 2017.
During 2022, the ninth year of the full implementation of the ACA, net income declined
compared to 2021. Comprehensive health insurers increased premiums to cover the increasing
costs of health care services. Comprehensive health insurers reported a level of profitability
comparable to 2013.
xii
As required by Utah Code § 31A-22-650, the Insurance Department collected data from
insurers with a health care preauthorization requirement. This data includes information on the
percentage of authorizations for the previous calendar year, not including a claim involving
urgent care, for which the insurer notified a provider regarding an authorization or adverse
preauthorization determination more than one week after the day on which the insurer received
the authorization request. An insurer may not have a preauthorization requirement for emergency
health care as described in Utah Code § 31A-22-627. On average, the percentage of health care
authorizations processed more than one week after the day on which the insurer received the
authorization request was 6.0 percent (see page 15).
As required by Utah Code § 31A-46-301, the Insurance Department collected data from
licensed pharmacy benefit managers operating in the State of Utah. This data included the total
value of all rebates and administrative fees and the percentage of aggregate rebates that were
retained under the pharmacy benefit manager’s agreement to provide pharmacy benefits
management services to a contracting insurer. Based on these reports, the overall percentage of
rebates retained was 3.01 percent (see page 54).
As requested by the Utah Legislature, the Insurance Department has developed a list of
recommendations for legislative action that have the potential to improve Utah’s health insurance
market. These recommendations are reported in the Appendix (see page 65).
1
Introduction
For most people, health insurance is the financing mechanism to manage personal health
care costs. Health insurance protects against the risk of financial loss that can occur from
unexpected accidents and illnesses. It also provides a way for chronic health problems to be
treated and managed in ways that many people could not otherwise afford. Because health
insurance is so important to the citizens of Utah, it is in the interest of the State to monitor and
maintain a stable health insurance industry.
An important purpose of the Insurance Department is to ensure that Utah has an adequate
and healthy insurance market. The purpose of this report is to provide an annual evaluation of
Utah’s commercial health insurance market as required by Utah Code § 31A-2-201.2.
What is Health Insurance?
In general, health insurance transfers the risk of paying for personal health care from an
individual to an entity that pools the risk. The individual shares in the management of his or her
personal health care risk through the use of deductibles, coinsurance, and the health benefits
provided by insurance. Individuals obtain their health benefits from one or more of several
sources, such as government sponsored health benefit plans, employer sponsored self-funded
health benefit plans, and commercial insurance health benefit plans. The health benefits provided
by these plans will range from comprehensive major medical benefits to single disease or
accident only benefits.
Government sponsored health benefit plans are government programs that provide health
benefits. These programs may be funded entirely by government funds or by a combination of
government funds and premiums paid by the covered individuals enrolled in the program. The
risk of financial loss is borne by the government. These programs may provide comprehensive
major medical health benefits (such as Medicaid and Medicare), limited primary health benefits
(such as county health clinics), or limited specialized health benefits.
Employer sponsored self-funded health benefit plans are plans sponsored by an employer
to provide health benefits to the employer’s employees. These plans may be funded entirely by
the employer or by a combination of employer funds and amounts withheld from covered
employees’ wages. The risk of financial loss is borne by the employer. However, most self-
funded plans purchase commercial stop-loss insurance coverage for added protection. These
plans usually provide comprehensive major medical health insurance benefits and may provide
benefits only to the employee or to the employee and the employee’s dependents.
Commercial health insurance plans are plans marketed by an insurance company to
provide health insurance benefits to insured persons. These plans are funded by the premiums
collected from insured employers and individuals. The risk of financial loss is borne by the
insurance company. Commercial insurance benefit plans can be issued as fee-for-service plans,
nonprofit health service plans, health maintenance organizations, and limited health plans. The
health insurance benefits provided will vary from comprehensive major medical health insurance
to specified limited health insurance benefits such as dental, vision, or specified disease.
2
Each of these three sources of health benefits is regulated by a different set of laws and
government programs. Government sponsored health benefit plans are regulated by Federal
regulatory agencies like the Centers for Medicare and Medicaid Services (CMS). Employer
sponsored self-funded health benefit plans are regulated for the most part under the Federal
ERISA statute through the U.S. Department of Labor (DOL), the Centers for Medicare and
Medicaid Services (CMS), and the Internal Revenue Service (IRS). Commercial health insurance
is governed by state and federal law and is regulated by state insurance departments. This report
focuses on the commercial health insurance market regulated by the Insurance Department.
Estimate of Health Insurance Coverage in Utah
As mentioned previously, health insurance comes from three sources: government,
employers, and commercial insurers. The Insurance Department has attempted to estimate how
much of the state is insured by each source of health insurance. The estimate is for
comprehensive health insurance coverage only (also known as major medical). A general
overview of the department’s estimate is shown below in Figure 1 (see Table 1 for details).
Figure 1. Estimate of Health Insurance Coverage for 2022
Data Sources: Centers for Medicare and Medicaid Services, Deseret Mutual Benefit Administrators, Public
Employee Health Program, Utah Department of Health and Human Services, Utah Insurance Department, and the
U.S. Census Bureau.
Note: The estimate of the 2022 employer sponsored self-funded membership is based on limited data from
commercial insurers and employers. It is not a complete count of the self-funded membership in Utah and should be
used with caution. Estimates may not total exactly due to rounding and differences in methodology.
Commercial
22.7%
Uninsured
8.1%
Government
27.8%
Self Funded
36.7%
Self-Funded
(PEHP)
4.7%
3
Caution should be used interpreting these results, however, as multiple data sources with
different methods were required to create this estimate. For example, membership data for
government sponsored health benefit plans was obtained from the Utah Department of Health
and Human Services and the Centers for Medicare and Medicaid Services (CMS). Membership
data for commercial health insurance was obtained from the Utah Accident & Health Survey, a
survey conducted annually by the Insurance Department. The estimate for the uninsured was
obtained from the U.S. Census Bureau.
Membership for employer sponsored self-funded health benefit plans was estimated using
the best information available to the Insurance Department. Currently, there is no single source
of self-funded membership data for Utah. As a result, a “best guess” estimate was created using a
combination of membership data obtained from government sponsored plans, large self-funded
employers, and commercial health insurers who administer self-funded health benefit plans. The
result is imperfect, but it does provide an estimate of the self-funded population.
Given these limitations, the Insurance Department estimates that nearly 28 percent of
Utah residents were covered by government plans, about 41 percent were covered by self-funded
plans, nearly 23 percent were covered by commercial health insurance, and about 8 percent were
uninsured (see Table 1).
Table 1. Estimate of Health Insurance Coverage for 2022
Coverage Type
Population
Estimate
Percent of
Population
Government Sponsored Plans
938,497
27.8%
Medicare
439,708
13.0%
Medicaid
492,316
14.6%
Children’s Health Insurance Program (CHIP)
6,473
0.2%
Employer Sponsored Self-Funded Plans
1,401,166
41.4%
Plans Administered by Commercial Insurers
808,540
23.9%
Public Employee Health Program (PEHP)
159,165
4.7%
Federal Employee Health Benefit Plan (FEHBP)
119,553
3.5%
Other Known Self-Funded Plans
61,915
1.8%
Other Self-Funded Plans (Estimated)
251,993
7.5%
Commercial Health Insurance Plans
768,137
22.7%
Group
490,182
14.5%
Individual
277,955
8.2%
Uninsured Estimate
273,000
8.1%
Total
3,380,800
100.0%
Data Sources: Centers for Medicare and Medicaid Services, Deseret Mutual Benefit Administrators, Public Employee Health
Program, Utah Department of Health
and Human Services, Utah Insurance Department, and the U.S. Census Bureau.
Note: The estimate of the 2022 employer sponsored self-funded membership is based on limited data from commercial
insurers and employers. It is not a complete count of the self
-funded membership in Utah and should be used with caution.
Estimates may not total exactly due to rounding and differences in methodology
.
4
Utah’s Commercial Health Insurance Market
Commercial insurers are companies in the business of managing risk. They accept the
risk of loss to individuals or organizations in exchange for a premium. In doing so, the risk of
loss is shared (or pooled) so that any one individual does not bear all the risk of loss.
Insurance companies report financial data to the Insurance Department and the National
Association of Insurance Commissioners (NAIC) on the health insurance business written in
Utah. Health insurance premium data includes premiums from individual and group
policyholders and government sponsored programs such as Medicare and Medicaid. The
premium reported does not include fees paid to insurers for the administration of self-funded
health benefit plans.
One measure of a commercial insurer’s financial health is the ratio of incurred losses to
premiums earned. This ratio is called a loss ratio. A ratio of less than 100 indicates that an
insurance company received more premium income than it paid out in claims. A ratio of more
than 100 indicates that a company paid more in claims than it received in premium income.
While the benchmarks vary depending on the type of insurance, commercial health insurers
generally try to maintain a loss ratio of less than 85 (85 cents of losses for every dollar of
premium). If the loss ratio increases much beyond 85, an insurer may have more expenses than
income and suffer a financial loss. Loss ratios calculated in this report use the traditional loss
ratio methodology rather than the NAIC medical loss ratio methodology that adjusts for taxes
and fees, as these ratios do not apply to all types of commercial health insurance.
Commercial Health Insurance Market Overview
Among commercial health insurers, there is a broad universe of “health insurance”
products. Commercial health insurance may include comprehensive health insurance, as well as
insurance products that cover a specialized category such as long-term care, dental, vision,
disability, accident, specified disease, or as a supplement to other kinds of health benefit plans.
There were 1,474 commercial fraternal, life, health, and property and casualty insurers
licensed with the Insurance Department at the end of 2022. Of these, 348 commercial insurers
reported commercial health insurance business in Utah on their 2022 annual financial statements.
These insurers represent all of the commercial health insurance sold in Utah. Each commercial
insurer reported direct premiums and losses in Utah, as well as total revenue and net income for
their company.
Table 2 summarizes some of the characteristics of Utah’s commercial health insurance
market that can be obtained from annual financial statements. As a group, Utah’s commercial
health insurers had a loss ratio of 84 and a net income of 3.8 percent (see Table 2). Although
company loss ratios for accident & health business in Utah do provide an accurate view of
commercial health insurers’ Utah operations, net income (at the company level) does not. In this
case, net income is not a good measure of the financial health of Utah’s market as less than one
percent of the total revenues reported were in Utah. A more accurate view is obtained by looking
at an insurer’s state of domicile.
5
Domestic insurers have a home office in Utah. Foreign insurers have a home office in
another state. About 75 percent of Utah’s commercial health insurance market is domestic. These
26 domestic insurers are much more representative of the Utah market as about 71 percent of
their total revenue comes from Utah business. Thus, their loss ratios and net income are a much
more accurate measure of the Utah market. As a group, domestic insurers had a loss ratio of 86
and a net income of 0.8 percent. Utah’s commercial health insurance market is highly
concentrated among twelve domestic commercial health insurers, which account for about 73
percent of the commercial health insurance market. These twelve commercial health insurers
represent about 98 percent of the domestic market. They had a loss ratio of 86 and a net income
of 2.7 percent. The remaining two percent of the domestic market consists of life insurers and
limited health plans.
There are 322 foreign insurers in Utah’s commercial health insurance market, most of
which are life insurers. These foreign insurers account for about 25 percent of Utah’s market.
Foreign insurers had a loss ratio of 77 for Utah business. Net income was 3.9 percent, but a
negligible amount of total revenue (less than 1 percent) was from Utah business and is, therefore,
not representative of Utah (see Table 2). Overall, foreign insurers have a small presence in
Utah’s health insurance market.
Table 2. Total Commercial Health Insurance Market by Insurer Type for 2022
Utah Operations
National Operations
Insurer Type
Company
Count
Direct Earned
Premium
Market
Share
Loss
Ratio
Total
Revenue
Net
Income
(% Rev)
Domestic Insurers
Health
12
$7,101,112,424
73.49%
86.46
$8,177,051,457
2.7%
Life
11
$125,466,420
1.30%
80.28
$2,049,060,731
-7.1%
Limited Health Plan
3
$5,972,677
0.06%
53.45
$6,177,664
-2.8%
Total Domestic
26
$7,232,551,521
74.85%
86.33
$10,232,289,852
0.8%
Foreign Insurers
Fraternal
11
$1,262,554
0.01%
83.46
$14,421,218,575
9.9%
Life
262
$2,367,094,913
24.50%
77.54
$969,573,094,179
4.2%
Property & Casualty
49
$61,213,017
0.63%
77.69
$168,484,823,086
1.4%
Total Foreign
322
$2,429,570,484
25.15%
77.55
$1,152,479,135,840
3.9%
Utah Insurers
Fraternal
11
$1,262,554
0.01%
83.46
$14,421,218,575
9.9%
Health
12
$7,101,112,424
73.49%
86.46
$8,177,051,457
2.7%
Life
273
$2,492,561,333
25.80%
77.68
$971,622,154,910
4.2%
Limited Health Plan
3
$5,972,677
0.06%
53.45
$6,177,664
-2.8%
Property & Casualty
49
$61,213,017
0.63%
77.69
$168,484,823,086
1.4%
Total Utah
348
$9,662,122,005
100.00%
84.12
$1,162,711,425,692
3.8%
Data Source: NAIC Financial Database
Note: The total direct earned premium and total revenue reported here is based
on the annual financial statement
data submitted by commercial insurers to the National Association of Insurance Commissioners (NAIC).
Estimates
may not total exactly due to rounding
.
6
Commercial Health Insurance Market by Policy Type
Financial statement data is designed to measure the financial solvency of commercial
insurers. As such, it is not designed to provide detailed information on a particular type of
insurance. To compensate for this, Utah’s commercial health insurers are required to participate
in the Utah Accident & Health Survey. This survey collects data about the various types of
health insurance in greater detail than the annual statement. Data was collected from 348
commercial health insurers who reported accident & health premium in Utah for 2022.
The top four policy types by market share were comprehensive health insurance
(38 percent), Medicare Advantage products (26 percent), Medicaid/CHIP (13 percent), and
Federal Employee Health Benefit Plan (FEHBP) (7 percent) (see Table 3). The results of the
survey differ slightly from the total accident & health reported on the 2022 annual statement,
however, the difference is small. The net difference in the total reported direct earned premium is
less than 0.1 percent.
Table 3. Total Commercial Health Insurance Market by Policy Type for 2022
Policy Type
Company
Count
a
Member
Count
b
Direct
Earned
Premium
Market
Share
Loss
Ratio
Comprehensive
27
768,137
$3,690,309,784
38.19%
86.37
Hospital-Medical-Surgical
33
37,676
$6,159,978
0.06%
24.53
Short-Term Limited Duration
7
7,947
$10,168,289
0.11%
65.99
Medicare Supplement
114
85,607
$202,240,491
2.09%
80.96
Medicare Advantage
17
201,102
$2,502,327,900
25.89%
85.86
Medicare Drug Plan
12
106,998
$56,581,377
0.59%
75.43
Dental Only
73
1,014,698
$338,111,190
3.50%
77.86
Vision Only
46
1,079,161
$54,725,620
0.57%
60.40
FEHBP
7
119,553
$684,440,458
7.08%
91.68
Medicaid/CHIP
3
322,792
$1,241,747,032
12.85%
81.61
Stop-Loss
46
720,377
$380,021,434
3.93%
88.97
Disability Income
124
866,122
$255,770,897
2.65%
71.01
Long-Term Care
68
31,095
$43,627,801
0.45%
91.91
Credit A&H
19
107,257
$6,710,600
0.07%
22.52
All Other A&H
203
-
$190,944,309
1.98%
45.67
Total Accident & Health
348
-
$9,663,887,160
100.00%
84.19
Data Source: Utah Accident & Health Survey
Note: The Federal Employee Health Benefit Plans (FEHBP), Medicare, and Medicaid business
reported here
may include some health benefit plans that are not fully insured as NAIC accounting
rules allow certain types of administrative business to be reported on the state page of the annual
statement. These categories are included here to ensure that the accident & health b
usiness being
reported in the Utah Accident & Health Survey is consistent with the accident & health business being
reported on the Utah stat
e page of the NAIC annual statement.
Estimates may not total exactly due to
rounding
.
a
Company count column does not add up to the total because an insurer may have more than one
policy type.
b
A total is not reported for the column “Member Count” and for “Other.” A sum total of the
membership counts of all types of health insurance would overestimate the actual number of
persons covered by commercial health insurance due to uncontrolled double counting of members.
7
Consumer Complaints Against Commercial Health Insurance Companies
A key function of the Insurance Department is to assist consumers with questions and
concerns that they have about commercial health insurance coverage. The primary agency within
the Insurance Department that assists consumers with health insurance issues is the Office of
Consumer Health Assistance (OCHA) within the Health and Life Division.
OCHA seeks to provide a variety of needed services to health care consumers and
policymakers, including (but not limited to):
• Assisting consumers in understanding their contractual rights and responsibilities,
statutory protections, and available remedies under their health plan
• Providing health care consumer education (producing, collecting, disseminating
educational materials; conducting outreach programs and other educational activities)
• Investigating and resolving complaints
• Assistance to those having difficulty accessing their health care plan because of language,
disability, age, or ethnicity
• Providing information and referral to these persons as well as help with initiating the
grievance process
• Analyzing and monitoring federal and state regulations that apply to health care
consumers
Consumers contact OCHA for a variety of reasons. These contacts range from simple
questions about how to obtain health insurance coverage to complaints against a particular health
insurance company. OCHA engages in more than 6,000 telephone contacts with consumers on
average each year. In addition to telephone contacts, OCHA staff also respond to a wide variety
of health and life cases based on the needs of a consumer. Total cases include general inquiries,
complaints for health and life, independent reviews, investigations, and complaints against self-
funded plans and policies issued in other states where the Insurance Department does not have
jurisdiction. The COVID-19 pandemic had an effect on the number of telephone contacts and
total cases during 2020 (see Table 4). Consumers delayed or reduced elective healthcare
treatment in order to comply with social distancing guidelines and to preserve hospital capacity.
Table 4. Number of Consumer Telephone Contacts Handled by OCHA Staff: 2013 - 2022
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Telephone (in/out)
5,563 4,202 4,369 6,892 5,685 8,349 9,691 7,274 7,357 6,385
Total Cases
a
- - - - - 1,115 1,043 846 1,013 999
Data Source: Utah Insurance Department
Note: Due to a software limitation in the Utah Insurance
Department’s phone system during 2020, 2021 and 2022
, this data
may not include all of the phone calls received by an employee’s direct line.
a
Total cases are reported for 2018-2022. All data is current as of Dec. 31 of the report year.
8
When a consumer contact involves a possible violation by a commercial health insurance
company of Utah insurance regulations or federal regulations the Insurance Department is
mandated to regulate, OCHA encourages consumers to file a written complaint. Once a written
complaint is received, OCHA conducts an investigation and seeks to resolve the consumer
complaint. OCHA tracks all written complaints made against commercial health insurers. These
complaints are classified into two types: confirmed and unconfirmed.
Confirmed Complaints. Confirmed complaints are those where the Insurance
Department rules in favor of the consumer making the complaint. The Insurance Department
determines that the complaint is warranted under the law and resolves the complaint by requiring
the commercial health insurer to act to correct the problem.
Unconfirmed Complaints. Unconfirmed complaints are those where the Insurance
Department rules in favor of the commercial insurer as the insurer was found to be acting within
the bounds of the law or that the Insurance Department was unable to make a ruling, either
because there are unresolved questions about the facts of the case or because the department does
not have the legal authority to do so. In these situations, the Insurance Department educates
consumers as to their rights under the law and how health insurance contracts work.
As shown in Table 5, the total number of complaints increased from 2013 to 2016,
declined from 2017 to 2020, and then increased during 2021 and 2022. The number of confirmed
complaints increased significantly from 2013 to 2016, declined from 2017 to 2020, and then
increased during 2021 and 2022. The number of unconfirmed complaints remained stable from
2013 to 2014, followed by a significant increase from 2015 to 2017, declined from 2018 to 2020,
and then increased during 2021 and 2022 (see Table 5).
Table 5. Complaints Filed with OCHA by Type: 2013 - 2022
Total
Confirmed
Unconfirmed
Year
Count
Percent
of Total
Count
Percent
of Total
Count
Percent
of Total
2013
180
100.0%
80
44.4%
100
55.6%
2014
201
100.0%
101
50.2%
100
49.8%
2015
280
100.0%
136
48.6%
144
51.4%
2016
344
100.0%
140
40.7%
204
59.3%
2017
324
100.0%
85
26.2%
239
73.8%
2018
265
100.0%
46
17.4%
219
82.6%
2019
215
100.0%
28
13.0%
187
87.0%
2020
146
100.0%
12
8.2%
134
91.8%
2021
177
100.0%
22
12.4%
155
87.6%
2022
213
100.0%
23
10.8%
190
89.2%
Average
234
100.0%
67
28.6%
167
71.4%
Data Source: Utah Insurance Department
Note: Estimates may not total exactly due to rounding.
9
The OCHA staff and the Utah health insurance industry work diligently to resolve
consumer concerns before they rise to the level of a formal written complaint. Consumers
continue to contact the Insurance Department in significant numbers (see Table 4). The number
of consumer complaints increased during the implementation of the ACA, but has started to
decline towards pre-ACA levels. In addition, the COVID-19 pandemic has had an effect on the
number of complaints and independent reviews processed by OCHA staff. Consumers delayed or
reduced elective healthcare treatment during the COVID-19 pandemic in order to comply with
social distancing guidelines and to preserve hospital capacity. During 2022, the number of
complaints increased by about 20 percent from the previous year.
Another important trend over the last eight years has been an increase in the number of
complaints related to the issue of balance billing, where a health care provider bills the patient
for the difference between the provider’s charge and the amount paid by health insurance.
Balance billing complaints accounted for about 10 percent of all consumer complaints from 2015
to 2017, about 16 percent during 2018, about 8 percent during 2019, about 10 percent during
2020, about 6 percent during 2021, and about 3 percent during 2022. In response to this pattern
in Utah and other states, the federal government passed the No Surprises Act (No Surprises Act,
2021). This new law addresses the issue of balance billing and provides consumer protections for
surprise medical billing. This federal law applies to individual and group health benefit plans and
took effect on January 1, 2022.
In addition to tracking the number of written complaints and how they are resolved, the
Insurance Department also tracks the reason for the complaint. As shown in Table 6, on average,
about 68 percent of all consumer complaints are due to claim handling issues, while policyholder
services and marketing & sales issues account for the remainder (see Table 6).
Table 6. Complaints Filed with OCHA by Reason: 2013 - 2022
Total
Claim
Handling
Policyholder
Services
Marketing
& Sales
Year
Count
a
Percent
of Total
Count
Percent
of Total
Count
Percent
of Total
Count
Percent
of Total
2013
180
100.0%
132
73.3%
39
21.7%
9
5.0%
2014
201
100.0%
118
58.7%
77
38.3%
6
3.0%
2015
280
100.0%
174
62.1%
89
31.8%
17
6.1%
2016
344
100.0%
200
58.1%
130
37.8%
14
4.1%
2017
334
100.0%
239
71.6%
90
26.9%
5
1.5%
2018
279
100.0%
196
70.3%
75
26.9%
8
2.9%
2019
229
100.0%
165
72.1%
50
21.8%
14
6.1%
2020
148
100.0%
121
81.8%
27
18.2%
0
0.0%
2021
189
100.0%
122
64.6%
53
28.0%
14
7.4%
2022
227
100.0%
171
75.3%
19
8.4%
37
16.3%
Average
241
100.0%
164
68.0%
65
27.0%
12
5.0%
Data Source: Utah Insurance Department
Note:
Policyholder Services includes complaints regarding policyholder services and underwriting practices. Estimates may not
total exactly due to rounding.
a
A complaint may have more than one reason code, so totals may be higher than the actual number of complaints.
10
Complaint Ratios. Another measure of complaint activity is the complaint ratio. A
complaint ratio is a measure of how many consumer complaints were received compared to the
amount of business a commercial health insurer did in the state. Table 7 reports the average
complaint ratios for the commercial health insurance market from 2013 to 2022 (see Table 7).
Each complaint ratio reports the number of complaints per $1,000,000 in total direct earned
premium. For example, a ratio of 1 means the insurer had 1 complaint for every $1,000,000 in
premium.
Table 7. Complaint Ratios for the Commercial Health Insurance Market: 2013 - 2022
Total
Confirmed
Unconfirmed
Year
Direct Earned
Premium
Count
Ratio
Count
Ratio
Count
Ratio
2013
$5,052,971,179
180
0.04
80
0.02
100
0.02
2014
$5,467,438,932
201
0.04
101
0.02
100
0.02
2015
$5,705,636,933
280
0.05
136
0.02
144
0.03
2016
$6,215,575,220
344
0.06
140
0.02
204
0.03
2017
$6,577,788,210
324
0.05
85
0.01
239
0.04
2018
$7,134,644,985
265
0.04
46
0.01
219
0.03
2019
$7,421,241,744
215
0.03
28
< 0.01
187
0.03
2020
$8,307,738,287
146
0.02
12
< 0.01
134
0.02
2021
$8,822,179,189
177
0.02
22
< 0.01
155
0.02
2022
$9,662,122,005
213
0.02
23
< 0.01
190
0.02
Average
$7,036,733,668
234
0.03
67
0.01
167
0.02
Data Sources: NAIC Financial Database and the Utah Insurance Department
Note: Estimates may not total exactly due to rounding.
As Table 7 shows, the average complaint ratio for the commercial market is about 0.03
for all complaints, about 0.01 for confirmed complaints, and about 0.02 for unconfirmed
complaints. Using this average as a benchmark, the complaint ratios for 2022 are equal to or
lower than the ten-year average.
Table 8 reports individual complaint ratios for commercial health insurance companies
during 2022. The averages in Table 7 can be used to give perspective to these individual ratios.
For example, a commercial health insurer with a total complaint ratio of greater than 0.03 has a
higher than average number of complaints, while a ratio of less than 0.03 means a lower than
average number of complaints. It is also important to remember that a complaint ratio is only one
aspect of evaluating a commercial health insurance company (see Table 8).
11
Table 8. Commercial Health Insurance Companies with Consumer Complaints during 2022
Total
a
Confirmed
Unconfirmed
Company Name
Direct Earned
Premium
Market
Share
Count
Ratio
Count
Ratio
Count
Ratio
Aetna Health of Utah Inc
$144,591,793
1.50%
1
0.01
1
0.01
-
-
Aetna Life Ins Co
$237,414,828
2.46%
5
0.02
-
-
5
0.02
American Continental Ins Co
$3,543,978
0.04%
1
0.28
-
-
1
0.28
American National Life Ins Co Of TX
$3,372,781
0.03%
3
0.89
-
-
3
0.89
Ameritas Life Ins Corp
$49,204,852
0.51%
4
0.08
-
-
4
0.08
Bankers Life & Cas Co
$2,341,570
0.02%
1
0.43
-
-
1
0.43
Chesapeake Life Ins Co
$5,276,970
0.05%
1
0.19
-
-
1
0.19
Cigna Health & Life Ins Co
$285,181,646
2.95%
9
0.03
-
-
9
0.03
Citizens Security Life Ins Co
$1,250,942
0.01%
1
0.80
-
-
1
0.80
Colonial Life & Accident Ins Co
$8,423,460
0.09%
2
0.24
-
-
2
0.24
Delta Dental Ins Co
$15,482,252
0.16%
4
0.26
2
0.13
2
0.13
Educators Health Plans Life Acc & Health
$59,427,429
0.62%
3
0.05
-
-
3
0.05
Educators Mutual Ins Assoc
$31,939,449
0.33%
2
0.06
-
-
2
0.06
Golden Rule Ins Co
$4,136,367
0.04%
2
0.48
-
-
2
0.48
Guardian Life Ins Co Of Amer
$21,136,855
0.22%
2
0.09
-
-
2
0.09
Hartford Life & Accident Ins Co
$60,314,198
0.62%
1
0.02
-
-
1
0.02
Humana Ins Co
$174,598,927
1.81%
3
0.02
2
0.01
1
0.01
Humanadental Ins Co
$6,489,731
0.07%
3
0.46
1
0.15
2
0.31
Life Ins Co Of N Amer
$25,960,480
0.27%
1
0.04
-
-
1
0.04
LifeMap Assur Co
$13,605,159
0.14%
1
0.07
-
-
1
0.07
Lincoln National Life Ins Co
$38,584,058
0.40%
2
0.05
-
-
2
0.05
Metropolitan Life Ins Co
$67,701,740
0.70%
8
0.12
-
-
8
0.12
Molina Hlthcare of UT Inc
$581,796,238
6.02%
31
0.05
4
0.01
27
0.05
Motivhealth Ins Co
$29,947,422
0.31%
1
0.03
-
-
1
0.03
National Guardian Life Ins Co
$4,694,064
0.05%
1
0.21
-
-
1
0.21
National Health Ins Co
$12,705,118
0.13%
4
0.31
-
-
4
0.31
National Foundation Life Ins Co
$26,093,380
0.27%
4
0.15
-
-
4
0.15
Physicians Mutual Ins Co
$1,807,492
0.02%
1
0.55
-
-
1
0.55
Principal Life Ins Co
$19,377,081
0.20%
1
0.05
-
-
1
0.05
Regence BCBS of UT
$1,199,893,515
12.42%
17
0.01
1
< 0.01
16
0.01
SelectHealth Inc
$3,603,713,309
37.30%
43
0.01
6
< 0.01
37
0.01
Standard Ins Co
$19,225,353
0.20%
1
0.05
-
-
1
0.05
Standard Life & Accident Ins Co
$3,650,854
0.04%
1
0.27
-
-
1
0.27
Transamerica Life Ins Co
$6,624,239
0.07%
2
0.30
-
-
2
0.30
UnitedHealthcare Ins Co
$375,928,289
3.89%
28
0.07
3
0.01
25
0.07
University of UT Health Ins Plans
$115,233,617
1.19%
7
0.06
-
-
7
0.06
Unum Ins Co
$2,088,583
0.02%
1
0.48
-
-
1
0.48
Unum Life Ins Co Of Amer
$30,921,512
0.32%
1
0.03
-
-
1
0.03
Top 38 companies with complaints
b
$7,293,679,531
75.49%
204
0.03
20
< 0.01
184
0.03
Remaining 4 companies with complaints
c
$1,407,739
0.01%
9
6.39
3
2.13
6
4.26
Companies without complaints
d
$2,367,034,735
24.50%
-
-
-
-
-
-
Total Commercial Market
$9,662,122,005
100.00%
213
0.02
23
< 0.01
190
0.02
Data Sources: NAIC Financial Database and the Utah Insurance Department
Note: Estimates may not total exactly due to
rounding.
a
Total complaints includes Confirmed and Unconfirmed.
b
Describes all companies with complaints that had at least $1,000,000 in total direct earned premium.
c
Separate complaint ratios were not calculated for companies with less than $1,000,000 in total direct earned premium because it
produces distorted ratios that cannot be directly compared to other companies.
d
There were 306 companies without complaints.
12
Independent Reviews by an Independent Review Organization
In addition to consumer complaints, the Insurance Department receives and processes
requests from consumers for an independent review of their denied claims by an Independent
Review Organization (IRO). An independent review may be filed after the consumer has
exhausted the standard claim appeals process with their commercial health insurer.
When the Insurance Department receives a request for an independent review of a denied
claim, it is assigned to an IRO for review. IROs conduct an independent review of certain classes
of claims denied by commercial health insurers. Not all denied claims are eligible for an
independent review. The independent review primarily focuses on claims where health care
services were denied, but were medically necessary or experimental. For example, a claim that
was denied because it was not a covered benefit under the consumer’s health benefit plan would
not be eligible for an independent review, however, a claim that was denied because the insurer
determined it was experimental or not medically necessary might be eligible for a review.
The independent review process produces one of three outcomes: not eligible,
overturned, or upheld.
Not eligible. The denied claim did not meet the minimum eligibility criteria to be
reviewed. Not all denied claims are eligible for independent review. In most cases, a denied
claim must involve a question of medical necessity or health care services that are experimental
or investigational.
Overturned. The IRO reviewer reverses the decision made by the commercial health
insurer and rules in favor of the consumer. The health insurer is asked to cover the health care
services in the claim under the terms of the health insurance policy.
Upheld. The IRO reviewer agrees with the original decision made by the commercial
health insurer and determines that the insurer acted appropriately. No other appeals are possible.
As shown in Table 9, the Insurance Department receives, on average, about 144 requests
for an independent review each year. About 74 percent of these requests are eligible for a review.
During 2022, the Insurance Department received 176 requests for an independent review. This is
an increase of about 18 percent compared to the number of requests received during 2021. Of the
176 requests for an independent review received during 2022, nearly 78 percent were eligible for
an independent review (see Table 9).
13
Table 9. Requests for Independent Reviews by Eligibility: 2013 - 2022
Total
Not Eligible
Eligible
Year
Count
Percent
of Total
Count
Percent
of Total
Count
Percent
of Total
2013
66
100.0%
16
24.2%
50
75.8%
2014
69
100.0%
16
23.2%
53
76.8%
2015
111
100.0%
30
27.0%
81
73.0%
2016
157
100.0%
55
35.0%
102
65.0%
2017
159
100.0%
35
22.0%
124
78.0%
2018
216
100.0%
55
25.5%
161
74.5%
2019
180
100.0%
51
28.3%
129
71.7%
2020
161
100.0%
42
26.1%
119
73.9%
2021
149
100.0%
35
23.5%
114
76.5%
2022
176
100.0%
39
22.2%
137
77.8%
Average
144
100.0%
37
25.7%
107
74.3%
Data Source: Utah Insurance Department
Note: Estimates may not total exactly due to rounding.
The Insurance Department also tracks the reason for the request for an independent
review. As shown in Table 10, about 58 percent of all requests for independent reviews are for
medical necessity; with experimental and investigational accounting for about 19 percent and
contract denial accounting for nearly 23 percent (see Table 10).
Table 10. Requests for Independent Reviews by Reason: 2013 - 2022
Total
Contract
Denial
Experimental /
Investigational
Medical
Necessity
Year
Count
a
Percent
of Total
Count
Percent
of Total
Count
Percent
of Total
Count
Percent
of Total
2013
68
100.0%
18
26.5%
14
20.6%
36
52.9%
2014
69
100.0%
1
1.4%
6
8.7%
62
89.9%
2015
111
100.0%
33
29.7%
32
28.8%
46
41.4%
2016
157
100.0%
27
17.2%
42
26.8%
88
56.1%
2017
159
100.0%
13
8.2%
41
25.8%
105
66.0%
2018
216
100.0%
9
4.2%
37
17.1%
170
78.7%
2019
191
100.0%
28
14.7%
40
20.9%
123
64.4%
2020
228
100.0%
80
35.1%
25
11.0%
123
53.9%
2021
222
100.0%
73
32.9%
35
15.8%
114
51.3%
2022
219
100.0%
85
38.8%
48
21.9%
86
39.3%
Average
164
100.0%
37
22.6%
32
19.5%
95
57.9%
Data Source: Utah Insurance Department
Note: Estimates may not total exactly due to rounding.
Contract denials may include rescissions. Rescissions are rare and not
broken out as a separate
category.
a
An independent review may have more than one reason code, so totals may be higher than the actual number of independent
reviews.
14
As mentioned previously, not all requests for an independent review are eligible for an
independent review, regardless of the reason for the request. On average, about 74 percent of
independent reviews are eligible. During 2022, nearly 78 percent of requests for an independent
review were eligible. Out of the requests eligible for an independent review, over 47 percent
were upheld, while nearly 53 percent were overturned. On average, over 49 percent of
independent reviews are upheld and nearly 51 percent are overturned (see Table 11).
Table 11. IRO Decisions by Outcome: 2013 – 2022
Total Eligible
Upheld
Overturned
Year
Count
Percent
of Total
Count
Percent
of Total
Count
Percent
of Total
2013
50
100.0%
38
76.0%
12
24.0%
2014
53
100.0%
30
56.6%
23
43.4%
2015
81
100.0%
50
61.7%
31
38.3%
2016
102
100.0%
52
51.0%
50
49.0%
2017
124
100.0%
55
44.4%
69
55.6%
2018
161
100.0%
72
44.7%
89
55.3%
2019
129
100.0%
61
47.3%
68
52.7%
2020
119
100.0%
55
46.2%
64
53.8%
2021
114
100.0%
51
44.7%
63
55.3%
2022
137
100.0%
65
47.4%
72
52.6%
Average
107
100.0%
53
49.5%
54
50.5%
Data Source: Utah Insurance Department
Note: Estimates may not total exactly due to rounding.
15
Health Care Preauthorization Reporting
Utah Code § 31A-22-650 requires an insurer with a health care preauthorization
requirement to submit a report to the Insurance Department on or before April 1, 2021, and each
year thereafter. Each insurer is required to report the percentage of authorizations for the
previous calendar year, not including a claim involving urgent care as defined in 29 C.F.R. Sec.
2560.503-1, for which the insurer notified a provider regarding an authorization or adverse
preauthorization determination more than one week after the day on which the insurer received
the authorization request. An insurer may not have a preauthorization requirement for emergency
health care as described in Utah Code § 31A-22-627.
There were 27 comprehensive health insurers doing business in Utah during 2022. Below
is a summary of the information reported to the Insurance Department for the calendar year 2022
(see Table 12). Based on these reports, sixteen companies reported authorizations processed
more than one week after the day on which the insurer received the authorization request. The
insurer average was 6.0 percent.
Table 12. Health Care Preauthorizations processed after one week during 2022
Company Name
State of
Domicile
Percentage Processed
After One Week
4 Ever Life Insurance Company
IL
0.0%
Aetna Health of Utah, Inc.
UT
4.7%
Aetna Life Insurance Company
CT
5.6%
All Savers Insurance Company
IN
12.6%
American National Insurance Company
TX
0.0%
American National Life Insurance Company of Texas
TX
0.0%
Angle Insurance Company of Utah dba Angle Health
UT
56.4%
Bridgespan Health Company
UT
8.6%
Cigna Health & Life Insurance Company
CT
3.2%
Educators Health Plans Life, Accident and Health
UT
0.0%
Equitable Financial Life Insurance Company
NY
0.0%
Freedom Life Insurance Company of America
TX
0.0%
Health Care Service Corporation, a Mutual Legal Re
IL
5.0%
Humana Insurance Company
WI
5.7%
Metropolitan Life Insurance Company
NY
0.0%
Molina Healthcare of Utah, Inc.
UT
7.2%
MotivHealth Insurance Company
UT
39.7%
Prudential Insurance Company of America
NJ
0.0%
Regence BlueCross BlueShield of Utah
UT
3.7%
SelectHealth, Inc.
UT
4.5%
Standard Life and Accident Insurance Company
TX
0.0%
State Farm Mutual Automobile Insurance Company
IL
0.0%
Transamerica Life Insurance Company
IA
0.0%
UnitedHealthcare Insurance Company
CT
5.4%
UnitedHealthcare of Utah, Inc.
UT
7.0%
University of Utah Health Insurance Plans
UT
38.9%
WMI Mutual Insurance Company
UT
8.3%
All Comprehensive Health Insurers
27
6.0%
Data Source: Utah Adverse Preauthorization Determination Survey
16
Utah’s Comprehensive Health Insurance Market
Comprehensive health insurance makes up approximately 38 percent of the commercial
health insurance market in the state of Utah (see Table 3) and affects nearly 23 percent of Utah
residents (see Table 1). It is the only type of major medical health benefit plan directly regulated
by the Insurance Department. The following analysis of the comprehensive market examines
various aspects of the market including state of domicile, group size, health benefit plan types,
and market trends.
Comprehensive Market by Domicile
State of domicile refers to the state in which an insurer’s home office is located. An
insurer can only be domiciled in one state. Domestic insurers generally have a larger presence in
their state of domicile than foreign insurers. Their local status may assist them in negotiating
more favorable provider contracts and creating larger provider networks than foreign insurers.
Approximately 85 percent of the comprehensive health insurance market is served by
domestic insurers and is highly concentrated among eleven insurers. Sixteen foreign insurers
represent the remaining market share. Premiums in Utah were higher for foreign insurers than
domestic with $421 per member per month for foreign and $401 per member per month for
domestic. Loss ratios were higher for domestic insurers (see Table 13).
Table 13. Total Comprehensive Market by Domicile for 2022
Domicile
Company
Count
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Premium
PMPM
a
Domestic
11
655,984
$3,137,511,172
85.02%
86.91
$401
Foreign
16
112,153
$552,798,612
14.98%
83.26
$421
Total
27
768,137
$3,690,309,784
100.00%
86.37
$404
Data Source: Utah Accident & Health Survey
a
Direct earned premium per member per month
Comprehensive Market by Group Size
Comprehensive health insurance plans are sold either as an individual policy or a group
policy. Individual policies are sold directly to individual consumers. In contrast, group policies
are sold as a single contract to a group of individuals, such as a group of employees. Groups with
1 to 50 eligible employees are classified as small employer groups. Groups with 51 or more
eligible employees are classified as large employer groups.
Prior to the passage of the Patient Protection and Affordable Care Act (ACA), individual
and small group policy rates were primarily set on the health status of the individual or the small
employer group as required by state law. There were no federal regulations limiting how health
insurers set their rates. With the enactment of the ACA, individual, small group, and large group
policies are now all underwritten without taking individual health status into account, a practice
also called community rating. Under community rating, rates are set so that the insurance risk is
17
spread over the entire community of insured members and individuals pay similar rates
regardless of health status.
Under the ACA, rates are set by community rating, without regard to health status or
gender. The only factors that may be used in setting rates are the number of individuals or family
members enrolled in the health benefit plan, geographic area (some geographic areas have higher
medical costs than others), age (older adults have higher health care costs than younger adults,
but the top rating tier cannot be more than the 3 times the bottom tier), and tobacco use (rates for
tobacco users cannot be more than 1.5 times the rate of non-tobacco users). These changes mean
that traditional rating factors such as health status and gender are no longer used. These changes
have the most impact on the individual market, where rates were primarily based on the health
status of an individual.
In 2022, large group policies reported a higher premium per member per month ($432)
than individual policies ($397) or small group policies ($359). Loss ratios were higher for
individual and small group policies than for large group policies (see Table 14). Individual
policies purchased through the FFM may also receive premium subsidies through the Advance
Premium Tax Credit (APTC). About 94 percent of the individual policies sold through the FFM
received an APTC. On average, the APTC accounted for about 90 percent of the total monthly
premium (Centers for Medicare and Medicaid Services, 2023).
Table 14. Total Comprehensive Market by Group Size for 2022
Group Size
Company
Count
a
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Premium
PMPM
b
Total Individual
15
277,955
$1,314,035,036
35.61%
88.13
$397
Small Group (1-50)
7
164,251
$705,660,369
19.12%
88.70
$359
Large Group (51+)
19
325,931
$1,670,614,379
45.27%
84.00
$432
Total Group
19
490,182
$2,376,274,748
64.39%
85.39
$408
Total Comprehensive
27
768,137
$3,690,309,784
100.00%
86.37
$404
Data Source: Utah Accident & Health Survey
a
Company count column does not add up to the total because an insurer may have more than one plan type.
b
Direct earned premium per member per month
Prior to 2016, comprehensive health insurers did not have enough information to
adequately price their products and did not receive the additional payments from the federal risk
corridor program as expected. Rating for 2016 was the first year that companies had a full year’s
claim experience to work with, but there was still significant market uncertainty that made it
difficult to price their products and premiums remained insufficient to cover their losses. During
2017, comprehensive health insurers had more accurate pricing information to work with, and
this, combined with higher rates that more precisely represented their actual risk experience,
resulted in improved loss ratios in the individual market. In October 2017, the federal
government eliminated the cost-sharing reduction (CSR) payment program, which required
health insurers to raise rates higher than they would have been. During 2018, comprehensive
health insurers raised rates in the individual market by approximately 39.9 percent (Utah
Insurance Department, 2017), which increased individual premium per member per month by
about 45 percent. The impact of the rate increase for an FFM individual plan was significantly
18
offset due to the APTC funded by the federal government (Centers for Medicare and Medicaid
Services, 2018). In contrast, group premium per member per month only increased by 4 percent.
During 2019, comprehensive health insurers maintained the premium increases set in 2018 and
comprehensive premium per member per month stabilized, increasing by 1.1 percent. During
2020, comprehensive health insurance premium per member per month remained stable, only
increasing by 0.8 percent. During 2021, comprehensive health insurance premium continued to
remain stable, increasing slightly by 0.5 percent. During 2022, comprehensive health insurance
premium increased by 4.1 percent.
Comprehensive Market by Plan Types
In this report, comprehensive health insurance plans are classified into five major plan
types: Fee for Service (FFS), Preferred Provider Organization (PPO), Exclusive Provider
Organization (EPO), Health Maintenance Organization (HMO), and Health Maintenance
Organization with Point of Service features (HMO with POS). These plan types differ in the
amount of managed care used to maintain quality and manage the cost of health care services.
The term “managed care” refers to the methods many third-party payers use to ensure quality
care (such as disease management programs) and to reduce utilization and cost of health care
services (such as pharmacy benefit managers and medical review boards). HMO plans generally
have the most management of care, whereas FFS plans generally have the least.
A Fee for Service (FFS) plan refers to a traditional indemnity plan. Under a FFS plan,
members can use any health care provider they choose (as long as the services are a covered
benefit on the insurance contract). There are no preferred provider networks and all services are
reimbursed at the same cost sharing level (usually a fixed percentage of billed charges).
A Preferred Provider Organization (PPO) plan refers to a health plan that offers a
network of “preferred” providers that have contracted to provide health care services for a
reduced fee. Members have financial incentives to use this network of preferred providers, as
costs for health care services are typically lower. Members are also free to use providers outside
of the network, but services may be denied, or be reimbursed at a lower rate. Regardless,
members must pay a larger portion of the cost for health care services when obtaining services
from health care providers outside of the network. PPO plans usually include deductibles, co-
pays, or coinsurance.
An Exclusive Provider Organization (EPO) plan refers to a health plan that is similar to a
PPO in that it offers a network of “preferred” providers that have contracted to provide health
care services for a reduced fee. However, unlike a PPO, members may not use providers outside
of the network providers and must only use network providers exclusively. EPO plans are similar
to HMO plans in that services are usually limited to an exclusive set of network providers,
except in the case of an emergency.
A Health Maintenance Organization (HMO) plan refers to a health insurance plan that
provides services through a network of health care providers that have negotiated a fee schedule
with the HMO. Members enrolled in the plan generally pay a deductible and fixed co-pay for
19
health care visits and drugs. Services are usually not available outside the provider network,
except for emergencies.
A Health Maintenance Organization with Point of Service features (HMO with POS) plan
is a plan type offered by a licensed HMO. An HMO with POS refers to an HMO plan that gives
members the option to use providers who are outside of the HMO network, but at a lower
reimbursement rate resulting in members bearing a much larger portion of the cost for health
care services in addition to the fixed co-pay and deductibles.
HMO, HMO with POS, PPO, and EPO plans are considered managed care plans. FFS
plans typically do not involve any form of managed care. Over 97 percent of Utah’s
comprehensive health insurance market involves some type of managed care; with
approximately 70 percent of the comprehensive health market in an HMO or HMO with POS.
Nearly 3 percent of the market had a FFS plan (see Table 15).
Table 15. Total Comprehensive Market by Plan Type for 2022
Plan Type
Company
Count
a
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Premium
PMPM
b
Fee for Service
13
19,396
$93,597,688
2.54%
100.63
$386
Preferred Provider Organization
15
169,020
$855,133,090
23.17%
79.57
$437
Exclusive Provider Organization
4
26,552
$165,801,110
4.49%
100.20
$525
Health Maintenance Organization
5
369,732
$1,698,017,195
46.01%
85.44
$383
HMO with Point of Service features
c
2
183,437
$877,760,701
23.79%
90.66
$400
Total
27
768,137
$3,690,309,784
100.00%
86.37
$404
Data Source: Utah Accident & Health Survey
a
Company count column does not add up to total because an insurer may have more than one plan type.
b
Direct earned premium per member per month
c
SelectHealth, Inc., an HMO, provides Point of Service benefits in conjunction with its affiliated indemnity company
SelectHealth Benefit Assurance, Inc.
Premium per member per month was higher for EPO plans compared to the other plan
types, while HMO plans were the lowest among traditional insurance products. Caution should
be used in drawing conclusions from this data, however. This comparison does not control for
differences in plan structure, covered benefits, health status, or demographics. For example, one
reason some plans have lower premiums than other plans may be a higher deductible and fewer
benefits. When a member accepts a higher deductible, the insurer pays for fewer health care
services and the member is responsible for a larger portion of their health care expenses. Thus,
the insurer bears less financial risk, which is reflected in a lower premium. Another cost control
measure used by insurers is the breadth of the provider network. Some plans have very narrow
networks, limiting the number of providers a member may use to obtain covered services. The
insurer utilizes narrow networks to negotiate with providers to drive more members to a small
provider community. These narrow network plans result in lower negotiated provider
reimbursements and lower member premiums.
20
Comprehensive Market by Regulatory Type
As part of the ongoing health care reform efforts, the federal government has created
specialized plans that must conform to certain regulations. Requiring compliance to specific
statutes is a tool legislatures use to encourage commercial health insurers to provide new
insurance products that may meet the needs of specific segments of the market or may provide
coverage for people who would not purchase coverage under normal market conditions. Tables
16-18 describe some of the regulatory types that have been created as a result of either state or
federal legislation and for which comprehensive health insurers have reported enrollment in
Utah.
ACA Compliant Plans vs Non-ACA Compliant Plans. ACA compliant plans are
comprehensive health insurance plans that are in full compliance with the federal regulations that
have been established for health benefit plans under the Patient Protection and Affordable Care
Act (ACA). Non-ACA compliant plans are comprehensive health insurance plans that have
qualified for some type of exemption from part of the ACA regulations, termed either
grandfathered plans or transitional plans. The majority (nearly 95 percent) of the comprehensive
market were enrolled in ACA compliant plans (see Table 16), with about 94 percent of the large
and small group markets and about 95 percent of the individual market enrolled in ACA
compliant plans.
Off-Exchange Plans. In addition to ACA compliance, plans can be further divided into
“Off-Exchange” or “On-Exchange” plans. An Off-Exchange plan refers to health benefit plans
that are sold outside of the state or federal exchanges. In other words, they are sold directly to
individuals and employer groups by the commercial health insurer independent of a health
exchange. On-Exchange plans refer to health benefit plans that are sold on the Federally
Facilitated Marketplace (FFM). All small and large group health benefit plans are Off-Exchange
plans. Most (68 percent) of the comprehensive market were enrolled in Off-Exchange plans. The
higher percentage of Off-Exchange plans is due to employer groups not having an exchange
option. Most (89 percent) of the individual market were enrolled in the FFM. Off-Exchange
membership was enrolled in both ACA compliant plans (92 percent) and Non-ACA complaint
plans (8 percent).
21
Federally Facilitated Marketplace (FFM). The Federally Facilitated Marketplace
(FFM) is Utah’s health exchange for individuals. Policies sold through the FFM are rated using
community rating and may be eligible for federal subsidies and income support for purchasing
insurance. As of December 2022, there were 247,037 members (about 32 percent of the market)
and 6 comprehensive health insurers participating in the FFM (see Table 16). All of the policies
sold through the FFM are ACA compliant plans.
Table 16. Total Comprehensive Market by ACA Market Segment for 2022
Market Segment by Group Size
Company
Count
a
Member
Count
Percent of Members
Individual
15
277,955
36.2%
Non-ACA Compliant
Off-Exchange
11
12,848
1.7%
ACA Compliant
Off-Exchange
4
18,070
2.4%
Federally Facilitated Marketplace
6
247,037
32.2%
Small Group
7
164,251
21.4%
Non-ACA Compliant
Off-Exchange
4
18,222
2.4%
ACA Compliant
Off-Exchange
6
146,029
19.0%
Large Group
19
325,931
42.4%
Non-ACA Compliant
Off-Exchange
7
9,673
1.3%
ACA Compliant
Off-Exchange
16
316,258
41.2%
Total
27
768,137
100.0%
Non-ACA Compliant
Off-Exchange
15
40,743
5.3%
ACA Compliant
Off-Exchange
16
480,357
62.5%
Federally Facilitated Marketplace
b
6
247,037
32.2%
Data Source: Utah Accident & Health Survey
Note:
Estimates may not total exactly due to rounding. Data is current as of Dec. 31, 2022.
a
Company count column does not add up to total because an insurer may have more than one market segment.
b
Bright Health Insurance Company was active on the Federally Facilitated Marketplace during 2022. They withdrew from Utah in
the fall of 2022
. As of Dec. 31, 2022, Bright Health Insurance Company was inactive and no longer doing
business in Utah. They are
not included in the analysis for 2022.
22
Metal Tier Plans (Actuarial Value). ACA compliant plans also can be classified by
actuarial value. Below is a summary of membership by the actuarial value of plans on the FFM.
Actuarial value is a method to measure the relative cost-sharing value of health benefit plans. For
example, a Gold plan covers approximately 80 percent of the eligible health care costs under the
health benefit plan. The member is responsible for the rest. By comparison, a Bronze plan only
covers about 60 percent of the eligible health care costs under the health benefit plan, and the
member is responsible for a higher portion of the cost. Starting in 2018, Bronze plans included a
subcategory called the extended Bronze plan. An extended Bronze plan may include benefit
options that approach the average actuarial value of 60 percent, but the actuarial value may range
from 56 percent to 65 percent. Health benefit plans with a higher actuarial value are usually more
expensive and those with a lower actuarial value are usually less expensive. However, the cost
that individual consumers pay may differ significantly depending on their individual
circumstances.
A majority of members on the FFM were enrolled in Silver plans (52.4 percent), followed
by Bronze plans (45.7 percent), Gold plans (1.7 percent), and Catastrophic plans (less than 1
percent). Under the ACA, Catastrophic plans are only available in the individual market to
individuals under the age of 30 or those with a hardship exemption (see Table 17).
Table 17. Metal Tier Plans on Federally Facilitated Marketplace for 2022
Market Segment by Metal Tier
Member
Count
Percent of
Members
Federally Facilitated Marketplace
247,037
100.0%
Platinum (90% AV)
0
0.0%
Gold (80% AV)
4,314
1.7%
Silver (70% AV)
129,412
52.4%
Bronze (60% AV)
113,013
45.7%
Catastrophic
298
0.1%
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding. Data is current as of Dec. 31, 20
22.
There
were
6 commercial health insurers participating in the Federally Facilitated Marketplace as of Dec.
31, 2022.
Bright Health Insurance Company was active on the Federally Facilitated Marketplace
during 2022. They withdrew from Utah in the fall of 2022. As of Dec. 31, 2022, Bright Health
Insurance Company was inactive and
no longer doing
business in Utah. They are not included in the
analysis for 2022
.
23
HSA-Qualified High Deductible Health Plans. HSA-Qualified High Deductible Health
Plans are high deductible health plans that can be combined with a savings account called a
Health Savings Account (HSA). The deductible levels of these plans are set by federal statute
and plans must comply with federal guidelines to qualify for use with an HSA. Payments made
into an HSA are tax deductible and can be used to pay for current health care expenses or saved
for the future. When the health care expenses reach the level of the deductible, the high
deductible health plan pays for covered health care expenses beyond the deductible. High
deductible health plans can also be used in conjunction with Health Reimbursement
Arrangements (HRA). HRAs are similar to HSAs, except the employer owns the savings account
(rather than the individual) and only the employer can deposit funds into the account. There were
287,439 members (over 37 percent of the market) enrolled in HSA-Qualified High Deductible
Health Plans (see Table 18).
Standard Plans. Standard plans are simply the typical health benefit plan that operates
under the current statutory requirements of the Utah insurance code and does not qualify for or
make use of any of the features available under HSA-Qualified High Deductible Health Plans.
Most health benefit plans in Utah’s health insurance market are Standard Plans. There were
480,698 members (nearly 63 percent of the market) enrolled in Standard Plans (see Table 18).
Table 18. HSA-Qualified High Deductible Health Plans for 2022
Market Segment by Group Size
Member
Count
Percent of
Members
Individual
277,955
36.2%
HSA-Qualified High Deductible Health Plan
50,716
6.6%
Standard Plan
227,239
29.6%
Small Group
164,251
21.4%
HSA-Qualified High Deductible Health Plan
79,970
10.4%
Standard Plan
84,281
11.0%
Large Group
325,931
42.4%
HSA-Qualified High Deductible Health Plan
156,753
20.4%
Standard Plan
169,178
22.0%
Total
768,137
100.0%
HSA-Qualified High Deductible Health Plan
287,439
37.4%
Standard Plan
480,698
62.6%
Data Source: Utah
Accident & Health Survey
Note: Estimates may not total exactly due to rounding. Data is current as of Dec. 31, 20
22.
Membership in HSA-Qualified High Deductible Health Plans has grown steadily in Utah.
In 2013, about 22 percent of the comprehensive health insurance market was enrolled in an
HSA-Qualified High Deductible Health Plan. From 2013 to 2021, the percentage of the
comprehensive membership covered by an HSA-Qualified High Deductible Health Plan
increased by 1.8 percent per year on average. As of 2022, HSA-Qualified High Deductible
Health Plan membership accounts for about 37 percent of the market, a decline of about 3
percent compared to 2021.
24
Comprehensive Market Trends
This section reports on four significant trends in Utah’s comprehensive health insurance
market: the number of insurers, the number of insured members, the cost of insurance, and the
financial status of the market. Each measure represents a different aspect of the market’s
“health.”
Trends in the number of insurers. The Insurance Department continues to monitor the
number of commercial health insurance companies that are providing comprehensive health
insurance. As shown in Table 19, the number of comprehensive health insurers declined from
2013 to 2020. In 2013, fifty-one commercial health insurance companies reported
comprehensive health insurance. By 2020, this number had dropped to 27. During 2021, the
number of comprehensive health insurers increased to 29. During 2022, the number of
comprehensive health insurers declined to 27.
Table 19. Changes in the Number of Comprehensive Health Insurers: 2013 - 2022
Insurer Category
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Net
Change
Domestic Insurers
Greater than 100 Million
3
3
4
4
3
3
3
3
3
3
0
Between 10 and 100 Million
0
2
4
4
5
3
1
3
3
4
+4
Between 1 and 10 Million
4
5
3
5
3
4
6
4
4
2
-2
Less than 1 Million
1
1
1
0
1
1
1
1
2
2
+1
Total Domestic
8
11
12
13
12
11
11
11
12
11
+3
Foreign Insurers
Greater than 100 Million
1
1
1
1
1
1
1
2
2
3
+2
Between 10 and 100 Million
6
5
5
5
5
4
4
3
3
2
-4
Between 1 and 10 Million
7
5
3
2
2
2
2
2
3
2
-5
Less than 1 Million
29
27
18
17
17
13
10
9
9
9
-20
Total Foreign
43
38
27
25
25
20
17
16
17
16
-27
All Insurers
Greater than 100 Million
4
4
5
5
4
4
4
5
5
6
+2
Between 10 and 100 Million
6
7
9
9
10
7
5
6
6
6
0
Between 1 and 10 Million
11
10
6
7
5
6
8
6
7
4
-7
Less than 1 Million
30
28
19
17
18
14
11
10
11
11
-19
Total Utah
51
49
39
38
37
31
28
27
29
27
-24
Data Source: Utah Accident & Health Survey
Note: Comprehensive health insurers are counted by relative size, broken into four categories of direct earned
premium measured in
millions of US dollars.
Bright Health Insurance Company was active on the Federally Facilitated Marketplace during 2022. They
withdrew from Utah in the fall of 2022. As of Dec. 31, 2022, Bright Health Insurance Company was inactive and no longer doing
business in Utah. They are not included in the analysis for 2022
The decline from 2013 to 2020 has primarily been among very small foreign insurers
with less than $1 million in premium, although small insurers have also contributed to this
decline in recent years. In contrast, the number of large insurers has remained stable, while
medium insurers have fluctuated. These carriers account for more than 95 percent of the market.
From 2014 to 2022, there has been some market shifting including several new insurers that
entered the market to participate in the Federally Facilitated Marketplace (FFM). Recent
25
improvements in premium income and market stability have made it easier for health insurers to
participate. There were six comprehensive health insurers participating in the FFM as of
December 2022.
The typical comprehensive health insurer needs to be large enough to be able to drive
membership volume to providers in order to remain competitive. While there is no absolute rule
for how large an insurer needs to be, an insurer with a large number of members has more
leverage in contract negotiations with providers. This arrangement can benefit both consumers
and providers. Consumers may benefit from lower prices and providers may benefit from a
higher volume of clients. Many small comprehensive health insurers cannot “drive volume” as
effectively as a large insurer.
Most of the decline in the number of comprehensive health insurers has occurred
primarily among very small comprehensive health insurers; particularly foreign insurers with
less than $1 million in comprehensive health insurance premium (see Table 19). In many cases,
these very small foreign comprehensive health insurers are providing coverage for “non-
situated” policies, which are commercial health insurance policies that are issued in another state
to an employer with less than 25 percent of their employees living in the state of Utah. The
premium is reported as covering a Utah resident, but the policy itself was not sold in Utah. Many
of these companies are not actively selling health insurance in the Utah health insurance market
and are only here because they sold a health insurance policy to a company that has an employee
who is currently a resident in the state. As a result, many of these insurers leave the market when
the employees leave the company. Thus, many of these very small foreign comprehensive health
insurers are covering a special class of Utah residents and may not be competing directly in the
mainstream health insurance market in Utah.
During 2013 to 2017, there was some turnover in the total number of medium insurers
(between $10 to $100 million in premiums) and several new medium sized insurers entered the
market, including several new domestic insurers that entered the market to participate in the
FFM. During 2018 and 2019, the number of medium sized insurers declined as the market
shifted with several insurers decreasing in size. The number of medium sized insurers increased
during 2020. The number of medium sized insurers remained stable during 2021 and 2022.
Large comprehensive health insurers represent the core of the comprehensive health
insurance market. These large insurers account for more than 85 percent of the market. These
insurers provide an important level of strength, stability, and choice for Utah’s comprehensive
health insurance market. During 2019, Molina Healthcare of Utah, SelectHealth, Inc., and
University of Utah Insurance Plans participated in the FFM. During 2020, Cigna Health & Life
Insurance Company and Bridgespan Health Company also entered the FFM, bringing the
number of health insurers on the FFM to five. During 2021, Regence BlueCross BlueShield of
Utah entered the FFM, bringing the numbers of insurers on the FFM to six. During 2022, Bright
Health Insurance Company entered the FFM, temporarily increasing the number of insurers on
the FFM to seven. However, Bright Health Insurance Company withdrew from Utah in the fall
of 2022. As of Dec. 31, 2022, Bright Health Insurance Company was inactive and no longer
doing business in Utah. They were not included in the analysis for 2022. There were six health
insurers active on the FFM in Utah at the end of 2022.
26
With the changes in the number of medium sized insurers and the continuing decline in
the number of small and very small insurers, the market has become more concentrated at the
top, with more large and medium insurers and fewer small and very small insurers. Increased
federal regulation and higher costs of doing business due to these regulations may make it harder
for small and very small insurers to participate.
Trends in the number of members by group size. Since 2013, the number of residents
insured by comprehensive health insurance as a relative percentage of Utah’s total population
has declined by about 4.6 percent. During this same time period, Utah’s population has increased
by about 16.5 percent. In absolute numbers, comprehensive membership has averaged about
763,000 members over the last ten years (about 24 percent of Utah’s population in any given
year). Year to year changes has been less than 38,100 members (see Table 20). During 2022,
comprehensive membership increased by about 3.2 percent. This increase appears to be due to
changes in the individual and small group markets.
Starting in 2014, the number of members in the individual market began to grow
significantly. Membership increased by more than 80,000 during 2014 through 2016. Most of
this growth was driven by the federal individual mandate which required most persons to
maintain health insurance, the availability of coverage through the FFM, where persons whose
income is between 100 percent and 400 percent of the federal poverty level receive subsidies to
make coverage more affordable, and changes to health insurance regulations, including
guaranteed issue and community rating, which have made it easier for Utah residents to get and
keep coverage in the individual market.
During 2017, the individual market declined by over 32,000 members. This appears to be
due to several factors. This decline occurred among individuals with Off-Exchange plans who
pay the full cost of any premium increases in the individual market and do not receive any
subsidies under the ACA to make coverage more affordable. Membership in FFM plans, where
most members have premium subsidies, did not experience the same change. Other factors may
include significant market uncertainty during 2017 regarding rising health care costs and how
changes to federal government regulations and the ACA would affect consumers, such as the
ending of CSR payments and the possibility of the repeal of the ACA. This decline is also
consistent with the increase in the uninsured rate during 2017. During 2018, membership in the
individual market remained stable, followed by an increase of over 11,000 members during 2019
and 2020. This change appears to be due to steady growth in FFM membership and the
availability of enhanced APTC payments during this period.
During 2021 and 2022, membership in the individual market increased significantly. The
number of members in the individual market, driven by growth in FFM membership, increased
by more than 35,000 during 2021 and more than 24,000 during 2022. This growth appears to be
related to the American Rescue Plan Act of 2021 (ARPA) (American Rescue Plan Act, 2021).
The APRA was designed to assist persons effected by the COVID-19 pandemic, which includes
expanded premium tax credits for individuals who are eligible for the FFM and also offers
subsidies to persons with incomes greater than 400 percent of the federal poverty level. The
ARPA provisions are temporary and were scheduled to last until the end of 2022 but have been
extended through 2025 under the Inflation Reduction Act of 2022.
27
Membership in the small group market declined from 2016 to 2019. This decline in small
group membership followed premium increases in the small group markets during this period. It
is also possible that some small group membership may have shifted to the individual market,
and healthy small groups may have moved to self-funded health benefit plan arrangements to
circumvent several of the ACA provisions. Small group market membership remained stable
during 2020 and then increased during 2021 and 2022.
Large group membership increased during 2013, followed by a period of decline from
2014 to 2016. Large group membership was stable during 2017 and then declined from 2018 to
2022. These changes are probably due to some employers moving to self-funding arrangements,
although one cannot rule out the possibility of some shifting to the individual market or short-
term limited duration plans. ACA regulations are most likely increasing self-funded
arrangements as well.
Trends in the number of members by plan type. During 2016, the number of members in
FFS and HMO plans increased, while PPO and HMO with POS plans decreased. The increase in
HMO plans appears to be due to a shift from HMO to POS plans to HMO plans within the
market. HMO plans increased from 8.9 percent during 2015 to 9.7 percent in 2016. A number of
new EPO plans also entered the market during 2016, but their market share was very small (see
Table 21).
During 2017, the total number of members in the comprehensive market decreased by
nearly 5 percent. Most of this change was due to reductions in the number of members in HMO
and HMO with POS plans. The decline in the number of members in HMO plans accounted for
the majority of the change, while the decline in the number of members in HMO with POS plans
accounted for most of the remaining change. The number of members in PPO and EPO plans
increased, while HMO, HMO with POS, and FFS plans decreased. HMO plan membership
declined by 8.9 percent. HMO with POS plan membership declined by 6.1 percent. EPO plan
membership increased, but the EPO plan market share remained very small.
28
Table 20. Changes in Comprehensive Membership by Group Size: 2013 - 2022
Group Size
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Net
Change
a
Individual
158,047
204,601
226,927
238,637
205,992
206,222
210,215
217,524
253,344
277,955
+119,908
Percent of population
b
5.4%
7.0%
7.6%
7.8%
6.6%
6.5%
6.6%
6.6%
7.6%
8.2%
+2.8%
Small Group
195,398
187,580
192,306
177,948
173,004
161,316
155,776
155,963
161,722
164,251
-31,147
Percent of population
6.7%
6.4%
6.4%
5.8%
5.6%
5.1%
4.9%
4.8%
4.8%
4.9%
-1.8%
Large Group
439,873
418,070
406,876
375,818
375,322
354,309
346,556
332,988
329,380
325,931
-113,942
Percent of population
15.2%
14.2%
13.6%
12.3%
12.1%
11.2%
10.8%
10.2%
9.9%
9.6%
-5.6%
Total Group
635,271
605,650
599,182
553,766
548,326
515,625
502,332
488,951
491,102
490,182
-145,089
Percent of population
21.9%
20.6%
20.0%
18.1%
17.7%
16.3%
15.7%
14.9%
14.7%
14.5%
-7.4%
Total Comprehensive
793,318
810,251
826,109
792,403
754,318
721,847
712,547
706,475
744,446
768,137
-25,181
Percent of population
27.3%
27.5%
27.6%
26.0%
24.3%
22.8%
22.2%
21.6%
22.3%
22.7%
-4.6%
Utah Population
2,900,872
2,942,902
2,995,919
3,051,217
3,101,833
3,161,105
3,205,958
3,271,616
3,337,975
3,380,800
+479,928
Percent of population
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
0.0%
Data Sources: Utah Accident & Health Survey, Utah Population Estimates Committee, and the U.S. Census Bureau.
Note: Estimates may not add up exactly to totals due to rounding.
a
“Net Change” measures the difference in the absolute number of members from 2013 to 2022 as well as the change in membership as a relative percentage of Utah’s
total population. Please note that Utah’s population increased by approximately 16.5 percent during this period.
b
“Percent of population” estimates the membership as a relative percentage of Utah’s total population in each particular year.
29
Table 21. Changes in Comprehensive Membership by Plan Type: 2013 - 2022
Plan Type
a
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Net
Change
b
FFS
14,135
19,971
15,018
21,621
20,051
19,863
21,049
21,890
19,912
19,396
+5,261
Percent of population
c
0.5%
0.7%
0.5%
0.7%
0.6%
0.6%
0.7%
0.7%
0.6%
0.6%
0.1%
PPO
288,683
251,606
248,071
234,642
237,760
197,909
195,821
180,830
170,891
169,020
-119,663
Percent of population
10.0%
8.5%
8.3%
7.7%
7.7%
6.3%
6.1%
5.5%
5.1%
5.0%
-5.0%
EPO
-
-
-
4,052
5,138
24,590
22,977
25,355
25,226
26,552
+26,552
Percent of population
-
-
-
0.1%
0.2%
0.8%
0.7%
0.8%
0.8%
0.8%
+0.8%
HMO
181,002
243,636
267,842
294,663
268,340
265,380
d
270,379
278,237
347,315
369,732
+188,730
Percent of population
6.2%
8.3%
8.9%
9.7%
8.7%
8.4%
8.4%
8.5%
10.4%
10.9%
+4.7%
HMO with POS
309,498
295,038
295,178
237,425
223,029
214,105
202,321
200,163
181,102
183,437
-126,061
Percent of population
10.7%
10.0%
9.9%
7.8%
7.2%
6.8%
6.3%
6.1%
5.4%
5.4%
-5.3%
Total Comprehensive
793,318
810,251
826,109
792,403
754,318
721,847
712,547
706,475
744,446
768,137
-25,181
Percent of population
27.3%
27.5%
27.6%
26.0%
24.3%
22.8%
22.2%
21.6%
22.3%
22.7%
-4.6%
Utah Population
2,900,872
2,942,902
2,995,919
3,051,217
3,101,833
3,161,105
3,205,958
3,271,616
3,337,975
3,380,800
+479,928
Percent of population
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
0.0%
Data Sources: Utah Accident & Survey, Utah Population Estimates Committee, and the U.S. Census Bureau.
Note: Estimates may not add up exactly to totals due to rounding. Estimate totals may differ from
previous reports due to category changes.
a
Plan Types Key: FFS = Fee For Service / Indemnity, PPO = Preferred Provider Organization, EPO = Exclusive Provider Organization, HMO = Health Maintenance
Organization, HMO with POS = Health Maintenance Organization with Point of Service features
b
“Net Change” measures the difference in the absolute number of members from 2013 to 2022 as well as the change in membership as a relative percentage of Utah’s
total population. Please note that Utah’s population increased by approximately 16.5 percent during this period.
c
“Percent of population” measures the plan membership as a relative percentage of Utah’s total population in each particular year.
d
Previous versions of Table 21 reported HMO membership for 2019 as 270,375. The correct number is 270,379, a difference of 4. The difference is statistically insignificant.
The updated version of Table 21 was published in the 2023
version of the Health Insurance Market Report.
30
During 2018, the total number of members in the comprehensive market decreased by
over 4 percent. Most of this change was due to a reduction in the number of members in PPO
plans and HMO with POS plans. PPO plan membership declined by nearly 17 percent and HMO
with POS plan membership declined by 4 percent. In contrast, EPO plan membership increased
substantially, growing from about 5,000 during 2017 to over 24,000 during 2018. EPO plan
membership is now greater than the FFS plan membership.
During 2019, the total number of members in the comprehensive market decreased by
about 1 percent. Most of this change was due to a reduction in the number of members in PPO
plans, EPO plans, and HMO with POS plans. PPO plan membership declined by 1 percent, EPO
plan membership declined by 6.6 percent, and HMO with POS plan membership declined by 5.5
percent. In contrast, FFS plans and HMO plans increased. FFS plan membership increased by 6
percent and HMO plan membership increased by nearly 2 percent.
During 2020, the total number of members in the comprehensive market decreased by
about 0.9 percent. Most of this change was due to a reduction in the number of members in PPO
and HMO with POS plans. Membership in EPO and HMO plans increased while membership in
FFS plans remained stable. Increases in the number of members with EPO and HMO plans were
associated with increases in individual policies issued through the FFM.
During 2021, the total number of members in the comprehensive market increased by 5.4
percent. Most of this change was due to a significant increase in the number of members in HMO
plans. There was a decline in the number of members for FFS, PPO, EPO, and HMO with POS.
FFS plan membership declined by 9 percent, PPO plan membership declined by 5.5 percent,
EPO plan membership declined by 0.5 percent, and HMO with POS plan membership declined
by 9.5 percent. These declines were offset, however, by a significant increase in HMO plan
members, which increased by nearly 25 percent. The growth in the number of members with
HMO plans was primarily driven by an increase in individual policies issued through the FFM.
During 2022, the total number of members in the comprehensive market increased by 3.2
percent. Most of this change was due to an increase in the number of members in HMO plans.
There was a decline in the number of members in FFS and PPO plans. FFS plan membership
declined by nearly 3 percent and PPO plan membership declined by 1 percent. Membership in
EPO, HMO and POS plans increased. EPO plan membership increased by 5 percent, HMO plan
membership increased by 6.5 percent, and POS plan membership increased by 1 percent. The
growth in the number of members was primarily driven by an increase in individual policies
issued through the FFM (see Table 21).
31
Government sponsored health benefit plans. Data on government sponsored health
benefit plans in Utah continues to show a steady increase in membership (see Table 22). Most of
the increases are in Medicare and Medicaid. During 2014, there was a large shift from the
Children’s Health Insurance Program (CHIP) to Medicaid. This was due to changes required by
the ACA, which required states to shift children in families with incomes between 100 percent
and 138 percent of the federal poverty level out of CHIP and into Medicaid. Medicaid
membership also increased significantly during 2020, 2021, and 2022. On January 1, 2020,
adults age 19-64 with household incomes up to 138 percent of the federal poverty level became
eligible for Medicaid in Utah. On March 18, 2020, the federal government passed the Families
First Coronavirus Response Act (Families First Coronavirus Response Act, 2020). This law
increased Medicaid enrollment by providing enhanced federal funding for continuous enrollment
and allowing individuals to remain enrolled during the COVID-19 public health emergency.
Table 22. Changes in Government Sponsored Health Benefit Plans: 2013 - 2022
Plan Type
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Net
Change
a
Medicare
317,413
329,943
340,968
355,492
371,770
398,399
424,323
410,689
428,379
439,708
+122,295
Medicaid
268,393
287,736
295,123
297,552
298,251
303,913
317,353
366,428
455,927
492,316
+223,923
CHIP
35,343
15,760
16,588
18,577
19,651
18,959
17,512
16,354
9,521
6,473
-28,870
PCN
16,134
14,021
13,203
17,304
13,605
13,222
-
-
-
-
-16,134
HIPUtah
2,900
-
-
-
-
-
-
-
-
-
-2,900
Government Plans
640,183
647,460
665,882
688,925
703,277
734,493
759,188
793,471
893,827
938,497
+298,314
As percent of
population
b
22.1%
22.0%
22.2%
22.6%
22.7%
23.2%
23.7%
24.3%
26.8%
27.8%
+5.7%
Data Sources: Centers for Medicare and Medicaid Services, Utah Department of Health and Human Services and HIPUtah.
Note
: Estimates may not total exactly due to rounding.
This table reports the following Government Sponsored Health Benefit Plans
in Utah: Medicare, Medicaid,
Children’s Health Insurance Program (CHIP), Primary Care Network (PCN), and the Utah
Comprehensive Health Insurance Pool (HIPUtah). The HIPUtah program ended in 2014.
a
“Net Change” measures the difference in the absolute number of members from 2013 to 2022 as well as the change in
membership as a relative percentage of Utah’s total population. Please note that Utah’s population increased by approximately
16.5 percent over this period.
b
“As percent of population” measures the relative percentage of Utah’s total population in each particular year.
Estimates of the uninsured. Data from the Census Bureau’s American Community
Survey estimates Utah’s uninsured rate to be 8.1 percent for 2022 and 9.0 percent for 2021
(Conway and Branch, 2023; Conway and Branch, 2022). Due to the impact of the COVID-19
pandemic on data collection, the Census Bureau has not published state and local uninsured
estimates for 2020 (Keisler-Starkey and Bunch, 2021). Previous data from the Census Bureau’s
American Community Survey estimates Utah’s uninsured rate to be 9.7 percent for 2019
(Keisler-Starkey and Bunch, 2020), 9.4 percent for 2018 (Berchick, Barnett, and Upton, 2019),
9.2 percent for 2017 (Berchick, Hood, and Barnett, 2018), and 8.8 percent for 2016 (Barnett and
Berchick, 2017).
32
Health care sharing ministries. Health care sharing ministries (HCSMs) are non-profit
501(c)(3) organizations created to assist their members with health care costs. Members share a
common set of religious beliefs and make monthly payments that are used to pay for the health
care expenses of other members.
HCSMs are not health insurance. HCSMs are exempt from state regulation and are not
regulated by the Insurance Department. HCSMs do not have to comply with the consumer
protections under the ACA (Patient Protection Affordable Care Act, 2010).
The Insurance Department has attempted to estimate how many individuals are enrolled
in HCSMs in Utah. Based on the available information provided by HCSMs operating in Utah,
the Insurance Department estimates that approximately 25,000 Utah residents were enrolled in a
HCSM during 2022. This estimate should be used with caution. The Insurance Department does
not have a complete list of HCSMs operating in Utah and this estimate may not include all Utah
residents enrolled in an HCSM.
Trends in the cost of insurance. Utah’s comprehensive health insurance premiums have
increased over the last 10 years. For example, from 2013 to 2022, the average premium per
member per month for comprehensive health insurance has increased on average by about 5.1
percent per year. In 2022, premium growth increased and the average premium per member per
month for comprehensive health insurance was 4.1 percent higher than in 2021 (see Table 23).
Table 23. Comprehensive Premium Compared to National Economic Trends: 2013 – 2022
Comprehensive Premium in Utah
National Economic Trends
Year
Total
Premium
a
Premium
PMPM
b
Premium
PMPY
c
Annual Percent
Change
Health Insurance Premium
Annual Percent Change
d
2013
$2,423,407,576
$259
$3,108
4.9%
3.8%
2014
$2,670,928,970
$277
$3,324
6.9%
3.0%
2015
$2,767,877,369
$280
$3,360
1.1%
4.2%
2016
$2,929,832,909
$300
$3,600
7.1%
3.4%
2017
$3,020,205,133
$330
$3,960
10.0%
3.4%
2018
$3,325,579,764
$379
$4,548
14.8%
e
4.5%
2019
$3,287,778,900
$383
$4,596
1.1%
4.9%
2020
$3,295,470,583
$386
$4,632
0.8%
3.7%
2021
$3,392,957,126
$388
$4,656
0.5%
4.1%
2022
$3,690,309,784
$404
$4,848
4.1%
1.1%
Data Sources: Utah premium data are from the Utah Accident & Health Survey from 2013 to 2022. The national trend data
used as
a comparison comes from the 2022 Kaiser Family Foundation Employer Health Benefits Survey.
a
Total direct earned premium
b
Direct earned premium per member per month
c
Direct earned premium per member per year
d
“Health Insurance Premium” trends are based on premium changes for family coverage under an employer based plan.
e
The federal government ended the CSR payment program which required comprehensive health insurers to raise rates
higher than they would have been had the CSR payments continued.
33
One of the main causes of the general trend towards higher premiums is a steady increase
in the underlying cost of health care. For example, from 2013 to 2022, the average losses per
member per month for comprehensive health insurance increased by about 5.5 percent per year.
In 2022, the average losses per member per month for comprehensive health insurance were 3.6
percent higher than in 2021 (see Table 24).
Historically, health care costs have been driven by multiple factors, including changes in
medical technology, pharmaceutical costs, government regulations, payment models,
demographics, lifestyle choices, and general inflation (PriceWaterhouseCoopers, 2018).
Utilization of health care services and unit prices of health care continue to be important factors
(PriceWaterhouseCoopers, 2017). Other studies have also found evidence of excess spending in
the areas of unnecessary medical services, administrative costs and complexity, fraud and abuse,
and the pricing of services (Institute of Medicine, 2012; Shrank, Rogstad, and Parekh, 2019).
Coverage expansions under the ACA and increases in retail prescription drug costs have also
affected the cost of health care (Hartman, Martin, Espinosa, Catlin, and the National Health
Expenditure Accounts Team, 2018). Prescription drug spending is growing faster than other
types of health care spending (American Academy of Actuaries, 2018). Recent increases in the
price of health care, particularly the price of prescription drugs has become a key area of focus as
a way to manage rising healthcare costs (PriceWaterhouseCoopers, 2017;
PriceWaterhouseCoopers, 2018).
Table 24. Comprehensive Losses Compared to National Health Care Spending: 2013 - 2022
Comprehensive Losses in Utah
National Health Care Expenditures
(in Millions of Dollars)
Year
Loss
Ratio
a
Losses
PMPM
b
Losses
PMPY
c
Annual
Percent
Change
Total
NHE
(All Sources)
Annual
Percent
Change
NHE for
Private Health
Insurance Only
Annual
Percent
Change
2013
83.54
$216
$2,592
4.7%
$2,856,626
2.6%
$879,501
0.2%
2014
87.96
$244
$2,928
13.0%
$3,002,623
5.1%
$922,987
4.9%
2015
95.34
$267
$3,204
9.4%
$3,165,394
5.4%
$976,911
5.8%
2016
92.92
$279
$3,348
4.5%
$3,307,404
4.5%
$1,030,833
5.5%
2017
89.07
$294
$3,528
5.4%
$3,446,454
4.2%
$1,080,044
4.8%
2018
83.09
$315
$3,780
7.1%
$3,604,428
4.6%
$1,129,836
4.6%
2019
84.39
$323
$3,876
2.5%
$3,757,382
4.2%
$1,157,796
2.5%
2020
83.13
$321
$3,852
-0.6%
$4,144,077
10.3%
$1,145,190
-1.1%
2021
86.66
$337
$4,044
5.0%
$4,255,127
2.7%
$1,211,431
5.8%
2022
86.37
$349
$4,188
3.6%
$4,439,792
4.3%
$1,247,975
3.0%
Data Sources: Utah loss data are from the Utah Accident & Health Survey from 2013 to 2022. The National Health Care Expenditure
data are
from the Centers for Medicare and Medicaid Services (CMS), Office of the Actuary (2022). NHE historical data were used for
201
3 to 2021. NHE projected data were used for 2022.
a
Ratio of direct incurred losses to direct earned premium
b
Direct incurred losses per member per months
c
Direct incurred losses per member per year
34
National health care spending grew faster during 2014 compared to the previous five
years. This growth was driven primarily by the major coverage expansions under the ACA,
particularly for Medicaid and private health insurance (Martin, Hartman, Benson, Catlin, and the
National Health Expenditure Accounts Team, 2016). Growth in national health costs for
employer groups was modest during 2014 (Claxton, Rae, Panchal, Whitmore, Damico, and
Kenward, 2014; Kaiser/HRET, 2015), while costs in the individual market increased
significantly as people shifted to ACA compliant plans, and as previously uninsured or higher
risk individuals obtained insurance in the individual market.
National health costs for employer groups were stable during 2015 continuing a pattern
of more modest growth (Claxton, Rae, Panchal, Whitmore, Damico, Kenward, and Long, 2015;
Kaiser/HRET, 2016). Growth in health spending was slower during 2016. This change was
broad-based, as spending by payer and by service decelerated. Slower enrollment trends under
the ACA also contributed to this slowdown (Hartman, Martin, Espinosa, Catlin, and the National
Health Expenditure Accounts Team, 2018). Health care spending slowed during 2017. This
slower growth was primarily due to reductions in the use and intensity of healthcare services for
hospital care, physician services, and retail drugs (Martin, Hartman, Washington, Catlin, and the
National Health Expenditure Accounts Team, 2019). Health care spending increased during
2018. This increase was driven by growth in Medicare and private insurance spending (Hartman,
Martin, Benson, Catlin, and the National Health Expenditure Accounts Team, 2020).
National health care spending during 2019 grew at a similar rate as 2018 (Martin,
Hartman, Lassman, Catlin, and the National Health Expenditure Accounts Team, 2021). Recent
estimates of national health care spending for 2020 reported a significant increase in health care
spending compared to 2019. Total health care spending increased by 9.7 percent. This was
primarily due to a significant increase in federal spending in response to the COVID-19
pandemic (Hartman, Martin, Washington, Catlin, and the National Health Expenditure Accounts
Team, 2022). However, health care spending for private health insurance declined by 1.2 percent
during 2020 due to reduced or delayed health care services in response to the COVID-19
pandemic (Centers for Medicare and Medicaid Services, 2022). National health care spending
slowed during 2021. This was primary due to the decline in federal health care spending that
followed the increase in federal spending during the COVID-19 pandemic (Martin, Hartman,
Benson, Catlin, and the National Health Expenditure Accounts Team, 2023).
Estimates based on national health expenditure data suggest that national health care
spending is expected to grow by about 5.4 percent per year during 2022 to 2031. Enrollment in
health insurance coverage and health care spending are projected to grow over the next decade
(Keehan, Fiore, Poisal, Cuckler, Sisko, Smith, Madison, and Rennie, 2023).
The cost of health care continues to create significant economic pressure on
comprehensive health insurers. For example, if Utah’s comprehensive health insurers had kept
premiums at 2013 levels and costs had continued to increase, by 2022, the industry’s loss ratio
would be approximately 135. In other words, the industry would be paying out nearly $1.35 in
claims for every $1.00 in premium. No business can afford to lose money at such rates for long,
so comprehensive insurers responded by raising premiums to levels that would cover their costs.
In addition to claim costs, comprehensive insurers also have to pay general administrative costs
35
such as general business expenses and the cost of processing claims. Furthermore, commercial
health insurers are also required by state law to maintain adequate financial reserves and to
remain financially solvent. This is because commercial health insurers are selling “a promise to
pay in the future.” When a consumer purchases a health insurance contract, they are buying a
promise to pay for future health care costs under certain conditions. Insurers cannot pay claims
on behalf of consumers without adequate funds to do so.
For Utah employers and consumers, this trend towards higher premiums means that
health care continues to be expensive. For a single individual, the average premium per member
per year increased from $3,108 in 2013 to $4,848 in 2022 (without taking into account any
advance premium tax credits an individual may have received). This is an increase of about 56
percent over the last ten years. Both consumers and employers are being impacted by these
increases. In most cases, employers pay a significant portion of this premium. Nationally,
employers pay more than two-thirds of the premium cost (Kaiser Family Foundation, 2023a;
Kaiser Family Foundation, 2023b). However, many employers are responding to the rising cost
of health care by increasing the employee’s portion of the premium, reducing benefits, increasing
deductibles and cost sharing, or looking at new plan designs to reduce costs (Kaiser Family
Foundation, 2023a). These changes continue to be difficult for many consumers to absorb
because the rate of increase in consumer income has not kept pace with the rate of increase in
health care costs and, as a result, many consumers continue to struggle with the cost of using
their health insurance to obtain necessary health care (see Table 25).
Table 25. Changes in Comprehensive Premium and Per Capita Income: 2013 - 2022
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Premium PMPY
a
$3,108
$3,324
$3,360
$3,600
$3,960
$4,548
$4,596
$4,632
$4,656
$4,848
Percent change in Premium
4.9%
6.9%
1.1%
7.1%
10.0%
14.8%
1.1%
0.8%
0.5%
4.1%
Per Capita Income in Utah
$36,511
$38,168
$40,459
$41,750
$43,241
$45,665
$48,580
$52,220
$56,019
$57,578
e
Percent change in Income
1.4%
4.5%
6.0%
3.2%
3.6%
5.6%
6.4%
7.5%
7.3%
2.8%
Data Sources: Utah premium data are from the Utah Accident & Health Survey. Per capita income data are from the 2023 Economic
Report to the Governor, David Eccles School of Business and the Utah Governor’s Office of Management and Budget.
a
Direct earned premium per member per year
e
Estimate
Prior to 2014, premium increases were relatively uniform among different group types.
Premium increases were larger among small and large group plans, while individual plans
reported lower increases over time. In 2014, that pattern changed. Under the ACA, policies are
underwritten using community rating, which means that the insurance risk is spread over the
entire community of insured members regardless of health status. This means that the cost of
covering higher risk and lower risk individuals tends to average out, which can be beneficial to
individuals with higher health care costs. Starting in 2014, the individual market began using a
form of community rating to set rates, which included covering individuals with higher costs
which has increased rates significantly. During 2022, individual premium per member per month
increased by 2.3 percent, small group premium per member per month increased by 3.5 percent,
and large group premium per member per month increased by 5.6 percent. Individual premium
per member per month was close to the market average and large group premium per member
per month was higher than the market average (see Figure 2).
36
Figure 2. Comprehensive Premium PMPM by Group Size: 2013 - 2022
Data Source: Utah Accident & Health Survey
One of the primary reasons for the increase in individual premium per member per month
was the shift in the individual market to the community rating required by ACA compliant plans
and expanded coverage for higher risk individuals starting in 2014. The mixture of market
demographics of products and insured members within the individual market changed
significantly and there was a rapid growth in the FFM as more people moved from non-ACA to
ACA compliant plans.
Also, comprehensive health insurers did not have a full year’s claim experience to use
when pricing their products during 2014 and 2015. Comprehensive health insurers usually base
their rates on previous experience in the market and current market trends. Due to the nature of
the ACA marketplace, comprehensive health insurers did not have all of the information they
needed to price their products. This made it difficult to set rates that would cover their actual
costs.
$145
$170
$195
$220
$245
$270
$295
$320
$345
$370
$395
$420
$445
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Total Individual Small Group Large Group All Plans
37
During 2016, comprehensive health insurers had more claim experience to work with, but
there was still considerable market uncertainty which made pricing their products difficult.
Comprehensive health insurers were also basing their rates on the assumption that they would be
receiving additional funding from the federal risk corridor program to help manage the costs of
covering high risk individuals. However, due to changes to the federal funding of the risk
corridor program made by the United States Congress, comprehensive health insurers did not
receive the additional payments that were expected under the program that would have helped
them cover their costs.
During 2017, comprehensive health insurers continued to experience significant market
uncertainty, but using the more accurate pricing information now available, health insurers were
able to demonstrate that higher premium rates were required to cover the actual risk that health
insurers were experiencing and the termination of the risk corridor program. As a result of these
recent rate increases, many comprehensive health insurers in the individual market experienced
significantly lower loss ratios during 2017, and the general financial stability of health insurers in
Utah began to improve. During October 2017, the federal government unexpectedly ended
federal funding for the CSR payment program, which required health insurers to raise 2018 rates
higher than they would have been had the CSR payments continued.
During 2018, due to the significant rate increases implemented in the individual market,
premium income increased significantly which brought loss ratios down to more manageable
levels and significantly improved comprehensive health insurers’ financial stability. Premiums in
the individual market were much more likely to cover comprehensive health insurers’ claim
costs and, in some cases, consumers and employers received premium rebates as required under
the ACA.
During 2019, comprehensive premiums stabilized. Comprehensive health insurers
generally maintained the rates that were set during 2018. Comprehensive claim costs stabilized
and premiums were sufficient to cover comprehensive health insurers’ claim costs.
During 2020, comprehensive health insurers were impacted by the COVID-19 pandemic.
In the spring of 2020, health care spending declined as consumers reduced elective health care to
preserve hospital capacity and implement social distancing measures. Although other forms of
health care spending increased, the net impact of the COVID-19 pandemic appears to have kept
health care spending, health insurer loss ratios, and comprehensive premiums stable during 2020.
During 2021, comprehensive health insurers experienced uncertainty as to how the
COVID-19 pandemic would affect the insurance market. Comprehensive health insurers
responded to this uncertainty by setting rates in the individual and small group markets at levels
similar to or slightly lower than 2020. Comprehensive health insurers in the individual market
reported lower premium per member per month, but also reported higher loss ratios.
Comprehensive health insurers in the large group market reported higher premium per member
per month, but did not report higher loss ratios.
38
During 2022, comprehensive health insurers experienced uncertainty around how the
COVID-19 pandemic, the ARPA enhanced premium tax credits, and higher inflation would
affect the insurance market. Comprehensive health insurers increased premiums to cover the
recent increases in comprehensive claim costs and the cost of health care services.
In the past, increases in large group plan premiums have had the most impact on the
premium trends in the market. This is primarily due to the fact that more Utah residents in the
comprehensive health insurance market are covered by large group plans than by any other type.
As a result, changes in this category have had a larger impact on market averages than changes in
the individual or small group markets. This has changed, and the individual market is having a
much larger impact on the market average than in previous years.
Although Utah continues to experience significant increases in the cost of comprehensive
health insurance coverage, when one compares Utah premiums on a per member per month basis
to national data from the National Association of Insurance Commissioners (NAIC), Utah’s
premium appears to be lower than the national average (see Table 26). For example, during
2022, the average premium for Utah’s comprehensive health insurers was approximately $404
per member per month. In contrast, the average premium for commercial health insurers
reporting comprehensive health insurance to the NAIC financial database was approximately
$518 per member per month. Although this comparison does not control for differences in
benefits, health status, or demographics, this data suggests that Utah’s average premium is lower
than the average premium reported to the NAIC. Utah also has fewer health insurance mandates
than many other states.
However, the premiums that consumers actually pay may differ significantly from the
market average depending on their individual circumstances and plan choice. Furthermore,
although Utah’s premiums may be lower by this measure, Utah’s premiums are increasing at
rates that are comparable to comprehensive health insurers nationally (5.1 percent for Utah, 5.4
percent for comprehensive health insurers reporting to NAIC), and continue to be financially
challenging for many consumers.
39
Table 26. Comparison of Utah Premium to National Premium: 2013 - 2022
Utah Estimate
National Estimate
Year
Premium PMPM for
Comprehensive
Health Insurance
a
Annual
Percent
Change
Premium PMPM for
Comprehensive
Health Insurance
Annual
Percent
Change
2013
$259
4.9%
$324
1.3%
2014
$277
6.9%
$348
7.4%
2015
$280
1.1%
$364
4.6%
2016
$300
7.1%
$389
6.9%
2017
$330
10.0%
$423
8.7%
2018
$379
14.8%
$461
9.0%
2019
$383
1.1%
$467
1.3%
2020
$386
0.8%
$486
4.1%
2021
$388
0.5%
$498
2.5%
2022
$404
4.1%
$518
4.0%
Data Sources: Utah Accident & Health Survey and the NAIC Financial Database
Note: The Utah estimate is based on data obtained from the Utah Accident & Health Survey for comprehensive
health insurance. The national estimate is based on data obtained from the NAIC Financial Database. The data
represents the average premium per membe
r per month for comprehensive health insurance business as
reported by commercial health insurers who filed
on the annual financial statement for health related insurance
business. Both data sources include only information on commercial health insurers.
a
Premium per member per month is the average premium per person per month for comprehensive health
insurance. This is the estimated cost of health insurance for all types of hospital and medical coverage on a
per person basis. A division into single and family rates is not possible using data from the Utah Accident &
Health Survey or the NAIC Financial Database. This comparison does not control for differences in plan
structure, covered benefits, health status, or demographics.
Health insurance mandates. The ACA requires a comprehensive health insurance plan
qualified to be sold on the Federally Facilitated Marketplace (FFM) to meet a minimum
standard, or essential health benefits requirement. If a state requires an insurer to offer a benefit
that exceeds the essential health benefits, the state must reimburse those costs through a defrayal
payment, 45 C.F.R. 155.170. In 2019, the Utah Legislature passed SB95, Autism Amendments,
requiring a comprehensive health insurer in the individual or large group market to provide
coverage for behavioral health treatment for a person with an autism spectrum disorder, Utah
Code § 31A-22-642(5)(b). The mandated coverage requirement as it applies to a comprehensive
health insurance plan in the individual market and eligible to be sold on the FFM is subject to the
federal defrayal payment requirement (see Table 27).
Table 27. State Benefit Mandate Defrayal Payments for
Autism Behavioral Health Treatment: 2020 - 2022
Year
Member
Months
a
Defrayal Cost
PMPM
State Defrayal
Payments
2020
1,685
$1,253
$1,828,871
2021
2,362
$2,159
$4,630,581
2022
2,649
$3,206
$8,082,107
Data Source: Utah Insurance Department
a
T
he total months of coverage for members that received autism benefits
during the year.
40
Financial trends. To measure the current financial condition of the market, the financial
results of the major comprehensive health insurers in Utah were used as an index of Utah’s
comprehensive health insurance market. These companies were selected because: 1) they
represent more than 80 percent of the comprehensive health insurance market, 2) a majority of
their revenues come from Utah business, and 3) their business model is that of a comprehensive
health insurer. These companies are Utah’s best examples of comprehensive health insurers and
they can provide an index of how well comprehensive health insurers are doing in the Utah
market over time (see Figure 3).
Comprehensive health insurers, whether for-profit or non-profit, need enough income
after expenses to fund state-mandated reserve requirements, to reinvest in new equipment and
new markets, and to acquire and maintain needed capital. The results of this index indicate that
Utah’s comprehensive health insurance market has experienced an average financial gain of 2.2
percent in net income per year over the last 10 years. During 2022, these companies reported an
average gain in net income of 2.4 percent. According to the NAIC, the industry average for net
income after expenses for health insurers during 2022 was 2.0 percent, which indicates that
Utah’s comprehensive health insurers performed higher than the industry average during 2022.
Figure 3. Income After Expenses For Comprehensive Health Insurers: 2013 - 2022
Data Source: NAIC Financial Database
Note: This figure represents the ratio of net income to total revenue as reported on the NAIC annual statement for the
major managed care health insurers that have been operating in Utah from 2013 to 2022. Results are rounded to the
nearest 0.1 percent.
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Income
2.1% -0.4% -8.8% -3.2% 3.4% 4.9% 4.7% 7.0% 4.0% 2.4%
-10%
-9%
-8%
-7%
-6%
-5%
-4%
-3%
-2%
-1%
0%
1%
2%
3%
4%
5%
6%
7%
8%
Percent of Income
Financial Year
41
The first three years of the full implementation of the ACA were financially difficult for
Utah’s core comprehensive health insurers. Comprehensive health insurers had limited claim
history to work with and were unable to generate enough premium income to cover their losses.
Changes to the federal risk corridor program meant comprehensive health insurers did not
receive the additional payments that were expected under the program that would have helped
them cover their costs.
From 2014 through 2016, the combination of not having enough information to
adequately price their products and not receiving the additional payments from the federal risk
corridor program as expected produced higher losses for health insurers participating in the
individual market and the FFM. Several comprehensive health insurers withdrew from the FFM
due to concerns that these losses were not sustainable.
During 2017, the fourth year of the full implementation of the ACA was a mixture of
financial and regulatory challenges combined with an increase in financial stability. Regulatory
uncertainty such as the possible repeal of the ACA, elimination of the federal funding for cost-
sharing reduction (CSR) payments, and reductions in advertising for the FFM created higher
market uncertainty for both consumers and health insurers than would normally have existed
under the ACA as written.
During October 2017, the federal government ended the federal funding for the CSR
payment program, which required comprehensive health insurers to raise rates higher than they
would have been had the CSR payments continued. The combination of higher premium revenue
and more accurate pricing information for health insurers led to the beginning of a financial
recovery. Comprehensive health insurers reported better financial results during 2017 than they
did during the first three years of the full implementation of the ACA, suggesting that health
insurers were returning to profitability.
During 2018, the fifth year of the full implementation of the ACA, comprehensive health
insurers reported significantly improved financial results. The high losses that were common
from 2014 to 2016 were no longer occurring as the large rate increases that were implemented
during 2017 and 2018 allowed health insurers to cover the cost of the health care services being
provided for their members. The combination of higher premium revenue and more accurate
pricing information, particularly in the individual market, has led to a financial recovery.
Comprehensive health insurers reported a level of profitability not seen since prior to the full
implementation of the ACA.
During 2019, the sixth year of the full implementation of the ACA, premium income
stabilized and the financial pattern started in 2018 continued through 2019. Premiums remained
stable with little increase. Higher premium income helped health insurers cover the cost of health
care services that they were paying out for their members. Comprehensive health insurers
reported positive financial results for the third year in a row.
42
During 2020, the seventh year of the full implementation of the ACA, net income
increased significantly. This was due to a slight decline in health care spending caused by
members delaying or forgoing healthcare treatment due to the COVID-19 pandemic, stable
premium income and a one-time risk corridor payment from the federal government as a result of
the final ruling in the Maine Community Health Options v. United States case.
During 2021, the eighth year of the full implementation of the ACA, net income declined
compared to 2020. Although losses were higher during 2021, premium income remained stable
and health insurers were able to cover the costs of their members’ health care services.
Comprehensive health insurers reported a level of profitability comparable to 2017.
During 2022, the ninth year of the full implementation of the ACA, net income declined
compared to 2021. Comprehensive health insurers increased premiums to cover the increasing
costs of health care services. Comprehensive health insurers reported a level of profitability
comparable to 2013 (see Figure 3).
43
Utah’s Stop-Loss Insurance Market
Stop-loss insurance protects against unexpected or catastrophic claims. Stop-loss
insurance makes up nearly 4 percent of the commercial health insurance market in the state of
Utah (see Table 3). This section focuses on medical stop-loss insurance that provides insurance
coverage for self-funded employer health benefit plans and is sold as an accident & health
insurance product in Utah’s commercial health insurance market. The following analysis of the
medical stop-loss market examines various aspects of the market including market trends, state
of domicile, group size, and coverage attachment points.
Stop-Loss Insurance Market Trends
Under the ACA, commercial and self-funded health benefit plans may not have annual or
lifetime limits on essential health care benefits, which can increase the risk exposure for
commercial and self-funded health benefit plans. Since the full implementation of the ACA,
there appears to be an increased demand by self-funded employers who are looking for ways to
manage risk and health care costs. From 2021 to 2022, the number of members covered by stop-
loss insurance increased by about 4 percent (see Table 28).
Table 28. Total Stop-Loss Market: 2013 - 2022
Year
Company
Count
Member
Count
Direct Earned
Premium
Loss
Ratio
2013
37
393,157
$110,554,917
68.17
2014
38
483,290
$116,769,903
65.35
2015
41
468,760
$140,070,917
71.88
2016
44
607,058
$171,862,070
82.86
2017
46
625,174
$205,785,395
79.76
2018
48
591,099
$241,941,465
80.03
2019
46
649,783
$288,558,315
82.99
2020
42
663,501
$311,042,258
72.45
2021
43
691,963
$350,273,879
82.96
2022
46
720,377
$380,021,434
88.97
Average
43
598,416
$231,688,055
77.54
Data Source: Utah Accident & Health Survey
Stop-Loss Insurance Market by Domicile
State of domicile refers to the state in which an insurer’s home office is located. An
insurer can only be domiciled in one state. Domestic insurers generally have a larger presence in
their state of domicile than foreign insurers.
Approximately 77 percent of the stop-loss insurance market was served by 41 foreign
insurers, with 5 domestic insurers covering the remaining 23 percent of the market. Premiums
were higher for domestic insurers than foreign insurers with $62 per member per month for
domestic insurers and $41 per member per month for foreign insurers. Loss ratios were higher
for domestic insurers (see Table 29). Loss ratios were higher during 2022, which is consistent
with the higher healthcare spending reported by third-party payers during this period.
44
Table 29. Total Stop-Loss Market by Domicile for 2022
Domicile
Company
Count
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Premium
PMPM
a
Domestic
5
116,017
$85,741,069
22.56%
92.00
$62
Foreign
41
604,360
$294,280,365
77.44%
88.09
$41
Total
46
720,377
$380,021,434
100.00%
88.97
$44
Data Source: Utah Accident & Health Survey
Note
: Estimates may not total exactly due to rounding.
a
Direct earned premium per member per month
Stop-Loss Insurance Market by Group Size
Stop-loss insurance plans are sold to self-funded employer plans. Some self-funded
employer plans, especially small employers, purchase stop-loss insurance plans with lower
attachment points to reduce their financial risk. Data was collected for three group sizes: Small
Group (1 to 50 eligible employees), Large Group (51 to 100 eligible employees), and Large
Group (101 or more eligible employees).
Table 30. Total Stop-Loss Market by Group Size for 2022
Group Size
Company
Count
a
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Premium
PMPM
b
Small Group (1-50)
11
13,190
$21,363,549
5.62%
74.30
$133
Large Group (51-100)
15
16,370
$18,486,891
4.86%
83.45
$97
Large Group (101 +)
39
690,817
$340,170,994
89.51%
90.20
$41
Total Stop-Loss
46
720,377
$380,021,434
100.00%
88.97
$44
Data Source: Utah Accident & Health Survey
Note
: Estimates may not total exactly due to rounding.
a
Company count column does not add up to total because an insurer may have more than one group type.
b
Direct earned premium per member per month
Small Group (1 to 50) reported the highest premium per member per month. Large Group
(51 to 100) reported a higher premium per member per month than Large Group (101 or more).
These higher premiums are probably due to differences in stop-loss coverage attachment points,
with Small Group (1 to 50) and Large Group (51 to 100) reporting lower specific attachment
points (see Table 30). Specific stop-loss is often more expensive than aggregate stop-loss and
accounts for more of the premium. Large Group (101 or more) typically includes stop-loss
coverage with higher specific and aggregate attachment points, which is consistent with their
lower premium per member per month.
45
Stop-Loss Insurance Market by Attachment Points
Stop-loss insurance includes two types of coverage, specific and aggregate. These two
types of coverage work together to protect a self-funded employer plan: specific stop-loss
provides protection against the severity of unexpected claims, and aggregate stop-loss provides
protection against the frequency of unexpected claims.
Specific stop-loss. Specific stop-loss (also known as individual stop-loss) provides
protection for the employer plan against larger claims costs for a single covered individual.
Specific stop-loss coverage includes a specified limit, or attachment point, when a stop-loss
insurance policy will pay for an individual or a claim. The attachment point (also known as
individual stop-loss deductible) is the dollar amount at which specific stop-loss protection
reimburses the self-funded employer plan.
Table 31. Stop-Loss Membership by Specific Attachment Points for 2022
Small Group
(1 – 50)
Large Group
(51 – 100)
Large Group
(101 or more)
Total
Attachment Point
Member
Count
a
Percent
of Total
Member
Count
Percent
of Total
Member
Count
Percent
of Total
Member
Count
Percent
of Total
NONE
36
< 0.1%
364
0.1%
3,290
0.5%
3,690
0.5%
$10,000
3,233
0.4%
1,342
0.2%
255
< 0.1%
4,830
0.7%
$20,000
341
< 0.1%
280
< 0.1%
8,356
1.2%
8,977
1.2%
$30,000
3,119
0.4%
1,243
0.2%
16,145
2.2%
20,507
2.8%
$40,000
384
0.1%
1,767
0.2%
10,283
1.4%
12,434
1.7%
$50,000
309
< 0.1%
577
0.1%
37,636
5.2%
38,522
5.3%
$60,000
32
< 0.1%
137
< 0.1%
5,294
0.7%
5,463
0.8%
$70,000
-
-
92
< 0.1%
11,496
1.6%
11,588
1.6%
$80,000
-
-
-
-
3,201
0.4%
3,201
0.4%
$90,000
-
-
-
-
5,194
0.7%
5,194
0.7%
$100,000
5,736
0.8%
10,568
1.5%
147,774
20.5%
164,078
22.8%
$200,000
-
-
-
-
103,645
14.4%
103,645
14.4%
$300,000
-
-
-
-
86,020
11.9%
86,020
11.9%
$400,000
-
-
-
-
48,937
6.8%
48,937
6.8%
$500,000
-
-
-
-
64,442
8.9%
64,442
8.9%
$600,000
-
-
-
-
14,558
2.0%
14,558
2.0%
$700,000
-
-
-
-
30,193
4.2%
30,193
4.2%
$800,000
-
-
-
-
1,445
0.2%
1,445
0.2%
$900,000
-
-
-
-
5,801
0.8%
5,801
0.8%
$1,000,000
-
-
-
-
73,487
10.2%
73,487
10.2%
$2,000,000 or more
-
-
-
-
13,365
1.9%
13,365
1.9%
Total
13,190
1.8%
16,370
2.3%
690,817
95.9%
720,377
100.0%
Data Source: Utah Accident & Health Survey
Note: Estimates may not add up exactly to totals due to rounding.
a
Under Utah Code § 31A-43-301, a small group stop-loss policy is required to have a specific attachment point that is at least
$10,000. During 20
22, there was one stop-loss insurer that incorrectly issued a policy without specific attachment point coverage to
small group
s. This was eventually corrected by the stop-loss insurer.
46
Over 99 percent of the total stop-loss membership included some kind of specific
attachment point coverage. Nearly 84 percent reported a specific attachment point of $100,000 or
more, with about 16 percent reporting a specific attachment point of less than $100,000. About
57 percent of the Small Group (1 to 50) membership had a specific attachment point of $60,000
or less, while nearly 43 percent had a specific attachment point of $100,000. Small Group
policies are required to have a specific attachment point of at least $10,000. All (100 percent) of
Large Group (51 to 100) membership had a specific attachment point of $100,000 or less. About
85 percent of Large Group (101 or more) membership had a specific attachment point of
$100,000 or more. The most common specific attachment point in Large Group (101 or more)
membership was $100,000, which accounted for about 20.5 percent of the stop-loss membership
(see Table 31).
Aggregate stop-loss. Aggregate stop-loss protects a self-funded employer group against
an unusually high level of excess claim costs that affect the entire employer group. Under a
typical stop-loss policy, the aggregate attachment point (also known as an aggregate deductible
or aggregate attachment factor) is the threshold at which the stop-loss carrier begins to pay for
eligible medical expenses during a given contract period. This threshold, commonly referred to
as an aggregate margin, is usually expressed as a percentage of expected claims. For example, an
attachment point of 125 percent means the stop-loss coverage starts to pay when the percentage
of excess claims reaches 25 percent above the 100 percent of expected claim costs.
Table 32. Stop-Loss Membership by Aggregate Attachment Points for 2022
Small Group
(1 – 50)
Large Group
(51 – 100)
Large Group
(101 or more)
Total
Attachment Point
Member
Count
a
Percent
of Total
Member
Count
Percent
of Total
Member
Count
Percent
of Total
Member
Count
Percent
of Total
NONE
-
-
71
< 0.1%
250,359
34.8%
250,430
34.8%
85% to 89%
1,079
0.1%
-
-
49,126
6.8%
50,205
7.0%
90% to 94%
-
-
-
-
-
-
-
-
95% to 99%
-
-
-
-
-
-
-
-
100% to 104%
5,492
0.8%
9,117
1.3%
25,741
3.6%
40,350
5.6%
105% to 109%
-
-
-
-
33
< 0.1%
33
< 0.1%
110% to 114%
2,853
0.4%
849
0.1%
23,055
3.2%
26,757
3.7%
115% to 119%
44
< 0.1%
-
-
36,505
5.1%
36,549
5.1%
120% to 124%
226
< 0.1%
250
< 0.1%
21,588
3.0%
22,064
3.1%
125% to 129%
3,496
0.5%
6,083
0.8%
282,506
39.2%
292,085
40.5%
130% or more
-
-
-
-
1,904
0.3%
1,904
0.3%
Total
13,190
1.8%
16,370
2.3%
690,817
95.9%
720,377
100.0%
Data Source: Utah
Accident & Health Survey
Note:
Estimates may not add up exactly to totals due to rounding.
Most (65 percent) of the stop-loss membership included some kind of aggregate stop-loss
coverage, with the rest (35 percent) reporting “none”. The most commonly reported aggregate
attachment point was between 125% and 129% and accounted for approximately 40 percent of
the stop-loss membership, with about 24 percent spread out between 85% to 124%, and less than
1 percent at 130% or more (see Table 32). Small Group policies may not have an aggregate
attachment point of less than 85 percent.
47
Utah’s Long-Term Care Insurance Market
Long-term care insurance is designed to provide specialized insurance coverage for
skilled nursing care and custodial care in a nursing home, assisted living facility, or at home.
Long-term care insurance typically covers specialized services that are not usually covered by
comprehensive or major medical health insurance.
Long-term care insurance accounts for approximately 0.5 percent of the commercial
health insurance market in Utah (see Table 3). Long-term care insurers provide coverage for
about 31,095 members or approximately 1 percent of Utah residents. These estimates only refer
to commercial long-term care insurance regulated by the Insurance Department. They do not
include other types of long-term care coverage offered by self-funded employers or government
programs. This section summarizes various aspects of the market including state of domicile,
group size, and age and gender demographics. Enrollment in long-term care insurance is
continually declining due to a shift in marketing and product availability. Many insurers are
focusing on incorporating long-term care benefits as an option for life insurance policies rather
than offering stand-alone products.
Long-Term Care Market by Domicile
State of domicile refers to the state in which an insurer’s home office is located. An
insurer can only be domiciled in one state. Foreign insurers provide nearly all of Utah’s long-
term care insurance. Sixty-six foreign insurers account for over 97 percent of the market, with
only two domestic insurers providing long-term care coverage (see Table 33). Loss ratios were
higher for foreign insurers than for domestic insurers.
Table 33. Total Long-Term Care Market by Domicile for 2022
Domicile
Company
Count
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Domestic
2
623
$1,224,365
2.81%
76.60
Foreign
66
30,472
$42,403,436
97.19%
92.35
Total
68
31,095
$43,627,801
100.00%
91.91
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
Long-Term Care Market by Group Size
Long-term care insurance plans are sold either as an individual or a group policy.
Individual policies are sold directly to individual consumers. In contrast, group policies are sold
as a single contract to a group of individuals, such as a group of employees, or an association
plan.
Most long-term care insurers reported individual business, while only 26 companies
reported group business. Loss ratios were lower for group policies than for individual policies
(see Table 34).
48
Table 34. Total Long-Term Care Market by Group Size for 2022
Group Size
Company
Count
a
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Individual
61
17,220
$32,587,952
74.70%
95.76
Group
26
13,875
$11,039,849
25.30%
80.55
Total
68
31,095
$43,627,801
100.00%
91.91
Data Source: Utah Accident & Health Survey
Note
: Estimates may not total exactly due to rounding.
a
Company count column does not add up to total because an insurer may have more than one group size.
Long-Term Care Market by Age
As Utah’s population has grown, the number of individuals over the age of 65 has
increased. As we age, the cost of health care, particularly end of life care, increases. As a result,
the role of long-term care insurance coverage has grown in importance for older Utah residents.
Long-Term Care membership by age. Commercial health insurers reported 31,095
members with long-term care insurance in Utah during 2022. Over thirty-five percent of the
members were under age 65 and nearly sixty-five percent were sixty-five or older (see Table 35).
Table 35. Long-Term Care Membership by Age for 2022
Age
Member
Count
Percent
Age 0-59
7,887
25.4%
Age 60-64
3,040
9.8%
Age 65-69
4,307
13.9%
Age 70-74
5,082
16.3%
Age 75-79
4,497
14.5%
Age 80-84
3,185
10.2%
Age 85+
3,097
10.0%
Total Members
31,095
100.0%
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
49
Utah’s Medicare Product Market
Medicare Supplement and Medicare Advantage policies are specialized health insurance
products designed to complement the federal Medicare program. Medicare Supplement policies
are sold as a “supplement” to the basic Medicare Part A (Hospital) and Part B (Medical)
programs and provide additional coverage beyond the basic Medicare benefits. Medicare
Advantage (also known as Medicare Part C) policies, however, are sold as full replacement
products. In other words, instead of providing specialized coverage for the “gaps” in Medicare
like a supplementary product (with Medicare still bearing most of the insurance risk), Medicare
Advantage products replace Medicare completely and the health insurance company bears the
full risk of financial loss.
Another important Medicare product is Medicare Part D. Medicare Part D became
available during 2006 as a result of changes to the federal Medicare program. Medicare allows
commercial health insurers to offer stand-alone pharmacy coverage via specialized insurance
products called Medicare Part D drug plans. These plans provide coverage for prescription drugs,
a medical benefit that Medicare Part A and B do not normally pay for. Medicare Part D is also
included in many Medicare Advantage policies.
Medicare Supplement and Medicare Advantage products account for 28 percent of
Utah’s accident & health insurance market, with approximately 2.1 percent of the market share
in Medicare Supplement coverage and about 25.9 percent of the market share in Medicare
Advantage coverage. Approximately 8.5 percent of Utah residents had coverage under a
Medicare Supplement or Medicare Advantage product, with about 2.5 percent in Medicare
Supplement product and about 5.9 percent in a Medicare Advantage product. Medicare Part D
products account for about 0.6 percent of Utah’s accident & health insurance market and provide
coverage for approximately 3.2 percent of Utah residents.
These estimates only refer to commercial Medicare products offered in Utah’s
commercial health insurance market. They do not include other types of Medicare products
offered by self-funded employers or government programs. This section summarizes various
aspects of the market including state of domicile, age and gender demographics, and plan type.
Medicare Products by Domicile
State of domicile refers to the state in which an insurer’s home office is located. An
insurer can only be domiciled in one state.
Medicare Supplement by domicile. The majority of Utah’s Medicare Supplement
coverage is provided by foreign insurers. One hundred and six foreign insurers account for
nearly 69 percent of the market, with eight domestic insurers providing the remaining 31 percent
(see Table 36). Loss ratios were higher for the foreign insurers than for the domestic insurers.
50
Table 36. Total Medicare Supplement Market by Domicile for 2022
Domicile
Company
Count
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Domestic
8
25,317
$63,412,056
31.35%
79.31
Foreign
106
60,290
$138,828,435
68.65%
81.72
Total
114
85,607
$202,240,491
100.00%
80.96
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
Medicare Advantage by domicile. Utah’s Medicare Advantage market has more
domestic than foreign insurers, with most (79 percent) of the coverage provided by domestic
insurers, and the remaining 21 percent provided by foreign insurers (see Table 37). Loss ratios
were higher for domestic insurers than foreign insurers.
Table 37. Total Medicare Advantage Market by Domicile for 2022
Domicile
Company
Count
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Domestic
10
160,686
$1,967,854,982
78.64%
86.81
Foreign
7
40,416
$534,472,918
21.36%
82.39
Total
17
201,102
$2,502,327,900
100.00%
85.86
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
Medicare Part D by domicile. Foreign insurers provide for nearly 94 percent of Utah’s
Medicare Part D coverage. Domestic insurers provide the remaining 6 percent (see Table 38).
Loss ratios were higher for domestic insurers than foreign insurers.
Table 38. Total Medicare Part D Market by Domicile for 2022
Domicile
Company
Count
Member
Count
Direct
Earned
Premium
Market
Share
Loss
Ratio
Domestic
2
4,052
$3,471,639
6.14%
80.28
Foreign
10
102,946
$53,109,738
93.86%
75.11
Total
12
106,998
$56,581,377
100.00%
75.43
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
51
Medicare Products by Age
The number of individuals in Utah over the age of 65 continues to grow. Medicare
products, such as Medicare Supplement policies, Medicare Advantage products, and Medicare
Part D drug plans are specifically designed for this population and provide an important type of
health care coverage for older Utah residents.
Medicare Supplement membership by age. One hundred and fourteen commercial health
insurers reported 85,607 members with Medicare Supplement coverage. Nearly all (99 percent)
of the residents with coverage were over age 65. This is probably due to Medicare’s eligibility
requirements, which requires most people to be age 65 or older in order to receive coverage (see
Table 39). Additionally, Utah does not mandate that insurers offer Medicare Supplement
coverage to those individuals who are eligible for Medicare for reasons other than age, such as
end-stage renal disease.
Table 39. Medicare Supplement Membership by Age for 2022
Age
Member
Count
Percent
Age 0-64
1,163
1.4%
Age 65 and Older
84,444
98.6%
Total Members
85,607
100.0%
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
Medicare Advantage membership by age. Seventeen commercial health insurers reported
201,102 members with Medicare Advantage coverage. Most (92 percent) of the residents with
coverage were over age 65. This is probably due to Medicare’s eligibility requirements, which
requires most people to be age 65 or older in order to receive coverage (see Table 40).
Additionally, Utah does not mandate that insurers offer Medicare Advantage coverage to those
individuals who are eligible for Medicare for reasons other than age, such as end-stage renal
disease.
Table 40. Medicare Advantage Membership by Age for 2022
Age
Member
Count
Percent
Age 0-64
16,643
8.3%
Age 65 and Older
184,459
91.7%
Total Members
201,102
100.0%
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
52
Medicare Part D membership by age. Twelve commercial health insurers reported
106,998 members with Medicare Part D Drug Plan coverage. Most (91 percent) of the residents
with coverage were over age 65. This is probably due to Medicare’s eligibility requirements,
which requires most people to be age 65 or older in order to receive coverage (see Table 41).
Table 41. Medicare Part D Membership by Age for 2022
Age
Member
Count
Percent
Age 0-64
10,098
9.4%
Age 65 and Older
96,900
90.6%
Total Members
106,998
100.0%
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
Medicare Products by Plan Type
Medicare Supplement membership by plan type. Commercial health insurers reported
85,607 members with Medicare Supplement in Utah during 2022 (see Table 42). Commercial
health insurers reported members in one of 17 Standardized Medicare Supplement plans, or in
Pre-Standardized plans (plans in force prior to the federal government standardizing the plans
that can be offered).
Table 42. Medicare Supplement Membership by Plan Type for 2022
Plan Type
Member
Count
Percent
Plan A
608
0.7%
Plan B
157
0.2%
Plan C
1,115
1.3%
Plan D
471
0.6%
Plan E
123
0.1%
Plan F
17,892
20.9%
Plan F (High Deductible Plan)
17,822
20.8%
Plan G
28,529
33.3%
Plan G (High Deductible Plan)
7,950
9.3%
Plan H
176
0.2%
Plan I
165
0.2%
Plan J
721
0.8%
Plan J (High Deductible Plan)
685
0.8%
Plan K
450
0.5%
Plan L
228
0.3%
Plan M
81
0.1%
Plan N
8,178
9.6%
Pre-Standardized Plans
256
0.3%
Total Members
85,607
100.0%
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
53
The most commonly reported Medicare Supplement plan was Plan G with 33.3 percent of
the membership. The next closest plans were Medicare Supplement Plan F, with 20.9 percent;
Medicare Supplement Plan F (High Deductible Plan), with 20.8 percent; Medicare Supplement
Plan N, with 9.6 percent; and Medicare Supplement Plan G (High Deductible Plan), with 9.3
percent. All other plans had less than 2.0 percent of the membership (see Table 42). Plans E, H,
I, J, and J (High Deductible Plan) were discontinued in 2010. Plans C, F, and F (High Deductible
Plan) were discontinued in 2020. These plans are no longer available to new beneficiaries.
Medicare Advantage membership by plan type. Commercial health insurers reported
201,102 members with Medicare Advantage (full Medicare replacement policies) in Utah during
2022. Medicare Advantage plans (which completely replace Medicare and bear the full risk of
loss) are available in one of five major plan types.
During 2022, most of the membership was covered under a Health Maintenance
Organization plan, with nearly 73 percent of the membership. The second most common was a
Preferred Provider Organization plan, with about 20 percent of the membership. The third most
common was a Private Fee-for-Service plan, with nearly 7 percent of the membership. Medical
Savings Accounts and Special Need Plans were the least common, with each accounting for less
than 0.4 percent respectively (see Table 43).
Table 43. Medicare Advantage Membership by Plan Type for 2022
Plan Type
Member
Count
Percent
Private Fee-for-Service
13,471
6.7%
Preferred Provider Organization
40,100
19.9%
Health Maintenance Organization
146,265
72.7%
Medical Savings Account
408
0.2%
Special Needs Plan
858
0.4%
Total Members
201,102
100.0%
Data Source: Utah Accident & Health Survey
Note: Estimates may not total exactly due to rounding.
54
Pharmacy Benefit Manager Rebates
Utah Code § 31A-46-301 and Utah Admin. Code R590-282 requires every licensed
pharmacy benefit manager operating in the State of Utah to submit a report to the Insurance
Department on or before April 1, 2020, and each year thereafter.
Each licensed pharmacy benefit manager is required to report the total value, in
aggregate, of all rebates and administrative fees that are attributable to enrollees of a contracting
insurer; and if applicable, the percentage of aggregate rebates that the pharmacy benefit manager
retained under the pharmacy benefit manager’s agreement to provide pharmacy benefits
management services to a contracting insurer.
The Insurance Department is required to publish this information in a manner that does
not make a specific submission from a contracting insurer or pharmacy benefit manager
identifiable, or disclose information that is a trade secret as defined in Utah Code § 13-24-2 (see
Utah Code § 31A-46-301).
There were 47 licensed pharmacy benefit managers operating in Utah during 2022.
Below is a summary of the information reported to the Insurance Department for the calendar
year 2022 (see Table 44). Among these 47 companies, seventeen companies reported data and
were actively doing business in Utah during 2022. Based on these reports, the overall percentage
of rebates retained was 3.01 percent.
Table 44. Pharmacy Benefit Manager Rebates and Administrative Fees for 2022
Plan Type
Count
Total
Rebates
Total
Retained
Rebates
Percent
Rebates
Retained
Total
Administrative
Fees
PBMs actively doing business
17
$330,913,293
$9,945,201
3.01%
$22,557,507
PBMs that did not report any business
30
$0
$0
0.00%
$0
Total
47
$330,913,293
$9,945,201
3.01%
$22,557,507
Data Source: Utah Pharmacy Benefit Manager Report
Note: Estimates may not total exactly due to rounding.
55
Summary
Health insurance is an important issue for the people of Utah. Utah’s residents receive
their health insurance coverage through health plans sponsored by the government, employers,
and commercial health insurers. The commercial health insurance market is the only source of
health insurance directly regulated by the Utah Insurance Department, hereafter referred to as the
Insurance Department for the purposes of this report.
Approximately 38 percent of Utah’s commercial health insurance market is
comprehensive health insurance (also known as major medical). Comprehensive health insurance
membership as a percentage of Utah residents increased slightly during 2022 and the
comprehensive health insurance industry serves nearly 23 percent of Utah residents. The typical
policy in this industry is an employer group policy with a managed care plan administered by a
domestic commercial health insurer.
A key function of the Insurance Department is to assist consumers with questions and
concerns they have about insurance coverage. The Office of Consumer Health Assistance
(OCHA) is the agency within the Insurance Department that handles consumer concerns about
their health insurance.
The total number of consumer complaints received by the Insurance Department
increased from 2013 to 2016, declined from 2017 to 2020, and then increased during 2021 and
2022. Consumers continue to contact the Insurance Department in significant numbers. The
number of consumer complaints increased during the early implementation of the ACA, but has
started to decline towards pre-ACA levels. From 2021 to 2022, the number of complaints
increased by about 20 percent. Another important trend over the last eight years has been an
increase in the number of complaints related to the issue of balance billing, where a health care
provider bills the patient for the difference between the provider’s charge and the amount paid by
health insurance. Balance billing complaints accounted for about 10 percent of all consumer
complaints from 2015 to 2017, about 16 percent during 2018, about 8 percent during 2019, about
10 percent during 2020, about 6 percent during 2021, and about 3 percent during 2022. In
response to this pattern in Utah and other states, the federal government passed the No Surprises
Act. This new law addresses the issue of balance billing and provides consumer protections for
surprise medical billing. This federal law applies to individual and group health benefit plans and
took effect on January 1, 2022.
In addition to consumer complaints, the Insurance Department receives and processes
requests from consumers for an independent review of their denied claims by an Independent
Review Organization (IRO). The number of independent reviews remained stable from 2013 to
2014, increased during 2015 and 2016, remained stable during 2017, increased during 2018,
declined during 2019 to 2021, and increased during 2022. From 2021 to 2022, the number of
requests for independent reviews increased by about 18 percent.
56
Over the last ten years, there have been four significant trends in the comprehensive
health insurance market that the Insurance Department continues to monitor: changes in the
number of insurers, the number of Utah residents with comprehensive health insurance, the cost
of comprehensive health insurance, and the financial status of the health insurance market.
The number of comprehensive health insurers declined from 2013 to 2020, increased
during 2021, and declined during 2022. The decline from 2013 to 2020 has primarily been due to
a decrease in the number of small and very small foreign comprehensive health insurers. In
contrast, while there has been some shifting within the market as part of the full implementation
of the ACA including health insurers leaving the market, the total number of large insurers has
generally remained stable. Large domestic comprehensive health insurers continue to account for
more than 85 percent of the market. The number of medium insurers has fluctuated during this
period. Financial stress and regulatory uncertainty in the market have made it difficult for some
insurers to participate in the comprehensive market and to sustain participation in the Federally
Facilitated Marketplace (FFM). From 2014 to 2022, there has been some market shifting
including several new insurers that entered the market to participate in the Federally Facilitated
Marketplace (FFM). Recent improvements in premium income and market stability have made it
easier for health insurers to participate. Six comprehensive health insurers participated in the
FFM during 2022.
From 2013 to 2022, the number of Utah residents covered by comprehensive health
insurance as a relative percentage of Utah’s population has declined by about 4.6 percent.
Comprehensive health insurance membership has averaged about 763,000 members over the last
10 years. During 2022, comprehensive membership increased by about 3.2 percent. This increase
appears to be due to changes in the individual and small group markets.
From 2014 to 2016, membership in the individual market grew significantly. Most of this
growth was driven by the federal individual mandate which required most persons to maintain
health insurance, the availability of coverage through the FFM, where persons whose income is
between 100 percent and 400 percent of the federal poverty level receive subsidies to make
coverage more affordable, and changes to health insurance regulations, including guaranteed
issue and community rating, which have made it easier for Utah residents to get and keep
coverage in the individual market.
During 2017, the individual market declined by over 32,000 members. This decline
occurred among individuals with Off-Exchange plans who pay the full cost of any premium
increases in the individual market and do not receive any subsidies under the ACA to make
coverage more affordable. Membership in FFM plans, where most members have premium
subsidies, did not experience the same change. Consumers and health insurers were experiencing
significant market uncertainty during 2017, such as the question of how rising health care costs
and changes to government regulations and the ACA would affect consumers, as well as the
ending of Cost-Sharing Reduction (CSR) payments and the possibility of the repeal of the ACA.
During 2018, membership in the individual market remained stable, followed by an increase of
over 11,000 members during 2019 and 2020. This change appears to be due to steady growth in
FFM membership and the availability of enhanced Advance Premium Tax Credit (APTC)
payments during this period.
57
During 2021 and 2022, membership in the individual market increased significantly. The
number of members in the individual market, driven by growth in FFM membership, increased
by more than 35,000 during 2021 and more than 24,000 during 2022. This growth appears to be
related to the American Rescue Plan Act of 2021 (ARPA). The APRA was designed to assist
persons effected by the COVID-19 pandemic, which includes expanded premium tax credits for
individuals who are eligible for the FFM and also offers subsidies to persons with incomes
greater than 400 percent of the federal poverty level. The ARPA provisions are temporary and
were scheduled to last until the end of 2022 but have been extended through 2025 under the
Inflation Reduction Act of 2022.
Membership in the small group market declined from 2016 to 2019. This decline in small
group membership followed premium increases in the small group market during this period. It
is also possible that some small group membership may have shifted to the individual market,
and healthy small groups have moved to self-funded health benefit plan arrangements to
circumvent several of the ACA provisions. Small group market membership remained stable
during 2020 and then increased during 2021 and 2022.
Large group membership declined from 2014 to 2016, remained stable during 2017, and
then declined from 2018 to 2022. This change appears to be due to some employer groups
moving to self-funding arrangements, although one cannot rule out the possibility of some
shifting to the individual market.
Comprehensive health insurance premium per member per month increased from 2021 to
2022. The average premium per member per month increased from $388 during 2021 to $404
during 2022, an increase of 4.1 percent. Over the last ten years, increases in comprehensive
premium per member per month have averaged 5.1 percent per year, while increases in losses
per member per month have averaged 5.5 percent per year.
From 2014 to 2016, comprehensive health insurers reported high loss ratios, as
premiums, even after payments from the various reinsurance and risk adjustment programs under
the ACA, were not sufficient to cover the healthcare costs of their insured members. The shift to
ACA compliant plans, changes in rating methods, and expanded coverage for higher risk
individuals, combined with lower than expected payments from the federal risk corridor
program, all contributed to these higher loss ratios. Comprehensive health insurers in both 2014
and 2015 had limited claim history to work with to produce reasonable projections, were unable
to underwrite for insurance risk on an individual basis, and 2014 rates were set prior to the
creation of “transitional plans” which prevented insurers from making rate adjustments prior to
2014. During 2016, comprehensive health insurers had more claim experience to work with, but
there was still considerable market uncertainty which made pricing their products more difficult.
During 2017, health insurers had more accurate pricing information and implemented
higher rates that more precisely represented their actual risk experience and this resulted in
improved loss ratios in the individual market. During 2018, the combination of more accurate
pricing information and the elimination of the CSR payment program by the federal government
in October 2017 required health insurers to significantly raise premium rates. The higher
premiums collected during 2018 improved loss ratios in the individual market, allowing health
58
insurers to cover the cost of health care services that they were paying out for their members.
During 2019, comprehensive premiums remained stable as comprehensive health insurers
maintained the rate increases set during 2018.
During 2020, comprehensive health insurers were impacted by the COVID-19 pandemic.
In the spring of 2020, health care spending declined as consumers reduced elective health care to
preserve hospital capacity and implement social distancing measures. Although other forms of
health care spending increased, the net impact of the COVID-19 pandemic appears to have kept
health care spending and comprehensive premiums stable during 2020.
During 2021, comprehensive health insurers experienced uncertainty as to how the
COVID-19 pandemic would affect the insurance market. Comprehensive health insurers
responded to this uncertainty by setting rates in the individual and small group markets at levels
similar to or slightly lower than 2020. Comprehensive health insurers in the individual market
reported lower premium per member per month, but experienced higher loss ratios.
Comprehensive health insurers in the large group market reported higher premium per member
per month, but did not report higher loss ratios.
During 2022, comprehensive health insurers experienced uncertainty around how the
COVID-19 pandemic, the ARPA enhanced premium tax credits, and higher inflation would
affect the insurance market. Comprehensive health insurers increased premiums to cover the
recent increases in comprehensive claim costs and the cost of health care services.
Comprehensive health insurers, whether for-profit or non-profit, need enough income
after expenses to fund state-mandated reserve requirements, reinvest in new equipment and new
markets, and acquire and maintain needed capital. The top insurers in the comprehensive health
insurance industry have experienced an average financial gain of 2.2 percent in net income after
expenses over the last ten years, with top comprehensive health insurers reporting an average
gain of 2.4 percent in net income after expenses during 2022.
The first three years of the full implementation of the ACA were financially difficult for
Utah’s core comprehensive health insurers. Comprehensive health insurers had a limited claim
history to work with and were unable to generate enough premium income to cover their losses.
Changes to the federal risk corridor program meant comprehensive health insurers did not
receive the additional payments that were expected under the program that would have helped
them cover their costs.
From 2014 through 2016, the combination of not having enough information to
adequately price their products and not receiving the additional payments from the federal risk
corridor program as expected produced higher losses for health insurers participating in the
individual market and the FFM. Several comprehensive health insurers withdrew from the FFM
due to concerns that these losses were not sustainable.
59
During 2017, the fourth year of the full implementation of the ACA was a mixture of
financial and regulatory challenges combined with an increase in financial stability. Regulatory
uncertainty such as the possible repeal of the ACA, elimination of the cost-sharing reduction
(CSR) payments, and reductions in advertising for the FFM created higher market uncertainty for
both consumers and health insurers than would normally have existed under the ACA as written.
During October 2017, the federal government ended the CSR payment program, which
required comprehensive health insurers to raise rates higher than they would have been had the
CSR payments continued. The combination of higher premium revenue and more accurate
pricing information for health insurers led to the beginning of a financial recovery.
Comprehensive health insurers reported better financial results during 2017 than they did during
the first three years of the full implementation of the ACA, suggesting that health insurers were
returning to profitability.
During 2018, the fifth year of the full implementation of the ACA, comprehensive health
insurers reported significantly improved financial results. The high losses that were common
from 2014 to 2016 were no longer occurring as the large rate increases that were implemented
during 2017 and 2018 allowed health insurers to cover the cost of the health care services being
provided for their members. The combination of higher premium revenue and more accurate
pricing information, particularly in the individual market, has led to a financial recovery.
Comprehensive health insurers reported a level of profitability not seen since prior to the full
implementation of the ACA.
During 2019, the sixth year of the full implementation of the ACA, premium income
stabilized and the financial pattern started in 2018 continued through 2019. The higher premium
income helped health insurers cover the cost of health care services that they were paying out for
their members. Comprehensive health insurers reported positive financial results for the third
year in a row.
During 2020, the seventh year of the full implementation of the ACA, net income
increased significantly. This was due to a slight decline in health care spending caused by
members delaying or forgoing healthcare treatment due to the COVID-19 pandemic, stable
premium income, and a one-time risk corridor payment from the federal government.
During 2021, the eighth year of the full implementation of the ACA, net income declined
compared to 2020. Although losses were higher during 2021, premium income remained stable
and health insurers were able to cover the costs of their members’ health care services.
Comprehensive health insurers reported a level of profitability comparable to 2017.
During 2022, the ninth year of the full implementation of the ACA, net income declined
compared to 2021. Comprehensive health insurers increased premiums to cover the increasing
costs of health care services. Comprehensive health insurers reported a level of profitability
comparable to 2013.
60
As required by Utah Code § 31A-22-650, the Insurance Department collected data from
insurers with a health care preauthorization requirement. This data includes information on the
percentage of authorizations for the previous calendar year, not including a claim involving
urgent care, for which the insurer notified a provider regarding an authorization or adverse
preauthorization determination more than one week after the day on which the insurer received
the authorization request. An insurer may not have a preauthorization requirement for emergency
health care as described in Utah Code § 31A-22-627. On average, the percentage of health care
authorizations processed more than one week after the day on which the insurer received the
authorization request was 6.0 percent (see page 15).
As required by Utah Code § 31A-46-301, the Insurance Department collected data from
licensed pharmacy benefit managers operating in the State of Utah. This data included the total
value of all rebates and administrative fees and the percentage of aggregate rebates that were
retained under the pharmacy benefit manager’s agreement to provide pharmacy benefits
management services to a contracting insurer. Based on these reports, the overall percentage of
rebates retained was 3.01 percent (see page 54).
61
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Accounts Team. (2016). National health spending in 2014: Faster growth driven by
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spending outweighs greater use of health care. Health Affairs, 42 (1), 6-17.
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64
Appendix
65
Recommendations
As requested by the Utah Legislature, the Insurance Department has developed a list of
recommendations for legislative action that have the potential to improve Utah’s health insurance
market.
1) Consider whether the state should conduct a study to determine the feasibility of a state-
based program designed to lower health benefit plan insurance premiums and increase the
stabilization in the market through a Section 1332 waiver for state innovation.
2) Require all insurers offering Medigap insurance to extend product offerings to Medicare
recipients who are eligible by disability.
3) Develop and implement effective protocols to prevent disease and improve the health of
children through school wellness programs that encourage increased physical activity,
nutritional education, and school meals with healthy food choices.
4) Improve education and training on the nature of health care and health insurance costs in
State consumer and financial education curriculum standards, with an emphasis on
teaching consumers how to spend less and get more value out of their health care
purchases.
66
List of Comprehensive Health Insurers
Table 45. List of Comprehensive Health Insurers during 2022
Company Name
State of
Domicile
Direct
Earned
Premium
Market
Share
Loss
Ratio
SelectHealth, Inc.
UT
$2,466,422,342
66.84%
86.69
Regence BlueCross BlueShield of Utah
UT
$441,715,511
11.97%
80.76
UnitedHealthcare Insurance Company
CT
$256,301,216
6.95%
77.56
Cigna Health and Life Insurance Company
CT
$132,567,453
3.59%
102.23
Aetna Life Insurance Company
CT
$110,307,789
2.99%
74.09
University of Utah Health Insurance Plans
UT
$100,346,923
2.72%
107.16
Molina Healthcare of Utah, Inc.
UT
$75,824,621
2.05%
101.33
Health Care Service Corporation, a Mutual Legal Re
IL
$36,598,990
0.99%
75.78
Aetna Health of Utah Inc
UT
$19,108,770
0.52%
94.85
UnitedHealthcare of Utah, Inc.
UT
$14,020,781
0.38%
93.69
Angle Insurance Company of Utah
UT
$12,126,290
0.33%
98.02
All Savers Insurance Company
IN
$11,443,326
0.31%
112.30
WMI Mutual Insurance Company
UT
$4,858,684
0.13%
50.62
State Farm Mutual Automobile Insurance Company
IL
$2,836,023
0.08%
74.21
Humana Insurance Company
WI
$2,127,364
0.06%
48.09
MotivHealth Insurance Company
UT
$1,731,549
0.05%
83.02
Educators Health Plans Life, Accident and Health,
UT
$954,319
0.03%
45.06
Bridgespan Health Company
UT
$401,382
0.01%
80.26
4 Ever Life Insurance Company
IL
$266,462
0.01%
55.82
American National Life Insurance Company of Texas
TX
$247,885
0.01%
103.90
Freedom Life Insurance Company of America
TX
$46,474
0.00%
160.05
Prudential Insurance Company of America
NJ
$15,457
0.00%
216.36
Metropolitan Life Insurance Company
NY
$12,974
0.00%
0.00
Equitable Financial Life Insurance Company
NY
$12,596
0.00%
150.40
American National Insurance Company
TX
$8,376
0.00%
137.25
Standard Life and Accident Insurance Company
TX
$5,900
0.00%
-5.34
Transamerica Life Insurance Company
IA
$327
0.00%
0.00
All Comprehensive Health Insurers
27
$3,690,309,784
100.00%
86.37
Data Source: Utah Accident & Health Survey
67
List of Health Insurance Mandates in Utah
Coverage Mandates
Required by Federal statute:
1. Dependent coverage from the moment of birth or adoption (31A-22-610)
2. Coverage through a noncustodial parent (31A-22-610.5; Social Security Act)
3. Open enrollment for child coverage ordered by a court (31A-22-610.5; Social
Security Act)
4. Medicare supplemental insurance, including preexisting conditions provision
(31A-22-620; NAIC Standard; Title XVIII of the Social Security Amendment,
1965)
5. Individual and small group guaranteed renewability (31A-22-618.6; 31A-22-
618.7; Health Insurance Portability and Accountability Act, 1997; Patient
Protection and Affordable Care Act, 2010)
6. Individual and small group limit on exclusions and preexisting conditions
(31A-1-301; 31A-22-605.1; Health Insurance Portability and Accountability
Act, 1997; Patient Protection and Affordable Care Act, 2010)
7. Small group portability and individual guaranteed issue (31A-30-108; Health
Insurance Portability and Accountability Act, 1997; Patient Protection and
Affordable Care Act, 2010)
8. Maternity coverage on groups of 15 or more employees (Pregnancy
Discrimination Act, Public Law 95-555, 1978)
9. COBRA benefits for employees of an employer with 20 or more employees
(Consolidated Omnibus Budget Reconciliation Act, Public Law 99-272, 1985)
10. Preexisting conditions (31A-22-605.1; Health Insurance Portability and
Accountability Act, 1997; Patient Protection and Affordable Care Act, 2010)
11. Limitation of annual and lifetime limits for essential benefits (Patient
Protection and Affordable Care Act, 2010)
12. Coverage for preventative health services (Patient Protection and Affordable
Care Act, 2010)
13. Coverage for children up to age 26, including married children (31A-22-
610.5; Patient Protection and Affordable Care Act, 2010)
14. Coverage for individuals participating in approved clinical trials (Patient
Protection and Affordable Care Act, 2010)
15. Comprehensive health insurance coverage, coverage of essential health
benefits and actuarial value (Patient Protection and Affordable Care Act,
2010)
68
Required by State statute:
1. Policy provision standards (31A-22-605)
2. Extension of policy for a dependent child with a disability (31A-22-611)
3. Mini-COBRA benefits for employees of an employer with less than 20
employees (31A-22-722)
4. Provisions pertaining to armed forces (31A-22-717)
5. Court order coverage for minor children outside the service area (31A-45-401)
6. Rural health care (31A-45-501)
7. Insurance coverage for autism spectrum disorder (31A-22-642)
Benefit Mandates
Required by Federal statute:
1. Maternity stay minimum limits (31A-22-610.2; Newborn & Mothers Health
Protection Act, 1997)
2. Pediatric vaccines – the level of benefit (31A-22-610.5, Omnibus Budget
Reconciliation Act, 1993)
3. Catastrophic coverage of mental health conditions and substance abuse (31A-
22-625; Mental Health Parity and Addiction Equity Act, 2008)
4. Coverage of emergency medical services (31A-22-627; Federal Patient Bill of
Rights Plus Act, Patient Protection and Affordable Care Act, 2010)
5. Mastectomy provisions (31A-22-630; 31A-22-719; Women’s Health &
Cancer Rights Act, 1996)
6. Alcohol and drug dependency treatment (31A-22-645; Patient Protection and
Affordable Care Act, 2010)
Required by State statute:
1. $4,000 minimum adoption indemnity benefit (31A-22-610.1)
2. Coordination of benefits (31A-22-619)
3. Dietary products for inborn metabolic errors (31A-22-623)
4. Access to OB/GYNs, pediatricians as primary care physician (31A-22-624)
5. Diabetes coverage (31A-22-626)
6. Standing referral to a specialist (31A-22-628)
7. Coverage for prosthetic devices (31A-22-638)
8. Cancer treatment parity (31A-22-641)
9. Diagnosis and treatment for autism spectrum disorder (31A-22-642)
69
Provider Mandates
Required by Federal statute:
None
Required by State statute:
1. Network provider contract provisions (31A-45-303)
2. Managed care organization payments to noncontracting providers in rural
areas (31A-45-501)
70
Statutory Requirements and Methods Overview
Statutory Requirements
Utah Code § 31A-2-201.2 requires that the Utah Insurance Department produce an
annual evaluation of the health insurance market. The statutory requirements for this evaluation
are shown below:
(1) Each year the commissioner shall:
(a) conduct an evaluation of the state's health insurance market;
(b) report the findings of the evaluation to the Health and Human Services Interim
Committee before December 1 of each year; and
(c) publish the findings of the evaluation on the department website.
(2) The evaluation required by this section shall:
(a) analyze the effectiveness of the insurance regulations and statutes in promoting a
healthy, competitive health insurance market that meets the needs of the state, and
includes an analysis of:
(i) the availability and marketing of individual and group products;
(ii) rate changes;
(iii) coverage and demographic changes;
(iv) benefit trends;
(v) market share changes; and
(vi) accessibility;
(b) assess complaint ratios and trends within the health insurance market, which
assessment shall include complaint data from the Office of Consumer Health
Assistance within the department;
(c) contain recommendations for action to improve the overall effectiveness of the health
insurance market, administrative rules, and statues;
(d) include claims loss ratio data for each health insurance company doing business in the
state;
(e) include information about pharmacy benefit managers collected under Section 31A-
46-301; and
(f) include information, for each health insurance company doing business in the state,
regarding:
(i) preauthorization determinations; and
(ii) adverse benefit determinations.
(3) When preparing the evaluation and report required by this section, the commissioner may
seek the input of insurers, employers, insured persons, providers, and others with an interest
in the health insurance market.
(4) The commissioner may adopt administrative rules for the purpose of collecting the data
required by this section, taking into account the business confidentiality of the insurers.
(5) Records submitted to the commissioner under this section shall be maintained by the
commissioner as protected records under Title 63G, Chapter 2, Government Records Access
and Management Act.
71
Methods Overview
This report primarily uses data from two sources: the NAIC Financial Database and the
Utah Accident & Health Survey. It also uses information from national data sources and
government agencies. The report will continue to evolve as required to meet the needs of the
Utah Legislature.
Qualifications. The accuracy of the information in this publication depends on the
quality of the data supplied by commercial health insurers. While the information presented here
is believed to be correct and every effort has been made to obtain accurate information, the
Insurance Department cannot control for variations in the quality of the data supplied by
commercial health insurers or differences in how insurers interpret NAIC and Insurance
Department data submission guidelines.
NAIC Financial Database. The NAIC Financial Database is a nationwide database
maintained by the National Association of Insurance Commissioners. It contains data obtained
from insurance companies’ annual financial statements. The data summarizes the total accident
& health premium and losses in Utah reported by commercial health insurers to the NAIC.
Utah Accident & Health Survey. The Utah Accident & Health Survey is submitted
annually to the Insurance Department. All commercial health insurers are required to file this
report. This survey provides detailed information on commercial insurance activity in Utah. It
includes information that allows the Insurance Department to estimate trends in Utah’s
commercial health insurance market, including market share, number of covered lives, loss
ratios, and cost of insurance. Data was collected for the years 2013 to 2022.
The survey includes several major components: accident & health insurance, stop-loss
insurance, Medicare supplemental insurance, long term care insurance, administration of self-
funded plans, as well as comprehensive health insurance. The accident & health insurance
portion of the survey must balance to the total accident & health insurance business reported on
the Utah business section of the annual statement. The comprehensive insurance section includes
detailed information on plan types, group size, and year-end member months. This additional
detail allows the Insurance Department to evaluate changes in the comprehensive health
insurance market with much greater accuracy.
During 2010, the Utah Accident & Health Survey was reorganized and expanded to
include more detailed measures of the comprehensive health insurance market including the
Small Employer Defined Contribution Market, analysis of certain types of benefit plans, and
measures of certain types of insurance code mandates.
During 2014, the Utah Accident & Health Survey was expanded to include more detailed
measures of the comprehensive health insurance market including measures of ACA compliant
and Non-ACA compliant plans, and the Federally Facilitated Marketplace (FFM).
The Utah Accident & Health Survey does not specifically measure differences in benefit
structure, demographics, or the health status of the commercially insured population. Despite this
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limitation, this survey (along with the NAIC Financial Database) is a valuable source of data on
Utah’s commercial health insurance market and as such provides useful information on
commercial health insurance.
Loss Ratios vs MLR. The loss ratios used in this report differ from the NAIC medical
loss ratio (MLR) methodology that adjusts for taxes and fees. This report uses the traditional loss
ratio methodology, incurred claims divided by earned premium. The MLR methodology is
designed for use with comprehensive health insurance business and cannot be applied to all other
types of accident & health insurance. Using the traditional loss ratio allows us to compare all
types of accident & health insurance.
Health Care Preauthorization Reporting. As required by Utah Code § 31A-22-650, the
Insurance Department collects data on health care preauthorizations. Starting in 2020,
comprehensive health insurers doing business in Utah are required to annually submit the Utah
Adverse Preauthorization Survey to the Insurance Department. This survey provides detailed
information on health care authorizations. Data was collected for the years 2020 to 2022.
Utah Pharmacy Benefit Manager Report. As required by Utah Code § 31A-46-301, the
Insurance Department collects data on pharmacy drug rebates. Starting in 2019, Pharmacy
Benefit Managers licensed in the State of Utah are required to annually submit the Utah
Pharmacy Benefit Manager Report to the Insurance Department. This report provides detailed
information on pharmacy drug rebates and administrative fees. Data was collected for the years
2019 to 2022.
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Glossary
This section includes a brief glossary of some specialized terms used in this report, which may
be unclear to readers who are unfamiliar with Utah’s health insurance industry.
Commercial health insurance: Any type of accident or health insurance product sold by a
commercial health insurer. It refers to any type of accident or health insurance product permitted
under the Utah Insurance Code.
Commercial health insurer: An insurance company that is registered with the Utah Insurance
Department and is licensed to sell any type of accident or health insurance product in the State of
Utah.
Commercial insurance health benefit plan: Another name for comprehensive health insurance.
See also Comprehensive health insurance and Comprehensive health insurer.
Comprehensive health insurance: A subset of commercial health insurance. A comprehensive
health plan is a general-purpose health insurance product that provides a broad range of
insurance coverage for basic medical services typically provided by a physician, including
hospital and medical services, and in most cases, durable medical equipment and drugs. Because
of the wide variety of basic medical services it covers, these plans are frequently called “major
medical”, “comprehensive health”, or “comprehensive hospital and medical” to distinguish them
from other types of accident or health insurance products with more limited benefits. It is the
insurance product most people think of when they hear the term “health insurance”.
Comprehensive health insurer: A commercial health insurer that offers a comprehensive health
insurance product.
Domestic insurer: An insurance company licensed to sell insurance in Utah and which also has
its home office in Utah. Insurance companies that have a home office in Utah are said to be
“domiciled in Utah”. The state of domicile is important because most of the direct regulation of
individual insurance companies is done by the state where the company is domiciled (e.g.,
solvency requirements, etc). See also Foreign insurer.
Employer sponsored self-funded health benefit plan: The key feature of these plans is that the
risk of loss is born by the sponsoring organization (e.g., a health benefit plan offered by a large
employer or non-profit association group), rather than a commercial health insurer. These plans
are exempt from state regulation under the Federal ERISA statute, as they are not considered the
“business of insurance”, but an employee benefit plan. Self-funded plans are regulated by the
Federal Department of Labor and states have no regulatory authority over these plans.
Foreign insurer: An insurance company licensed to sell insurance in Utah, but it does not have
a home office in Utah. It is domiciled in another state. See also Domestic insurer.
Government sponsored health benefit plan: Any health benefit plan offered by a federal or
state government agency, where the government bears the risk of loss. These plans include
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Medicare, Medicaid, Children’s Health Insurance Program (CHIP), Primary Care Network
(PCN), and the Utah Comprehensive Health Insurance Pool (HIPUtah). The PCN program ended
in 2019 and the HIPUtah program ended in 2014. These plans do not include any health benefit
plans for government employees, which are considered employer sponsored self-funded health
benefit plans. See also Employer sponsored self-funded health benefit plans.
