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State of Utah
 
Request to Run
Utah’s Version of a
State-Based HealthExchange
Detailed Design Review Summary DocumentSteve Gooch12/14/2012
 
 
Request to Run Utah’s Version of a State
-Based Health Exchange 1 |Page 
Table of Contents
1.0 Legal Authority and Governance ............................................................................................................................. 2
 
2.0 Consumer and Stakeholder Engagement and Support ............................................................................................. 4
 
3.0 Eligibility and Enrollment ..................................................................................................................................... 20
 
4.0 Plan Management .................................................................................................................................................. 34
 
5.0 Risk Adjustment and Reinsurance ......................................................................................................................... 47
 
6.0 Small Business Health Options Program (SHOP) ................................................................................................. 50
 
7.0 Organization and Human Resources ...................................................................................................................... 55
 
8.0 Finance and Accounting ........................................................................................................................................ 57
 
9.0 Technology ............................................................................................................................................................ 59
 
10.0 Privacy and Security ............................................................................................................................................ 62
 
11.0 Oversight and Monitoring .................................................................................................................................... 65
 
12.0 Contracting, Outsourcing and Agreements .......................................................................................................... 70
 
 
 
Request to Run Utah’s Version of a State
-Based Health Exchange 2 |Page 
Detailed Design Review Summary Document
1.0 Legal Authority and Governance
December 14, 2012
Item Approach
1.1
 
 — 
The State has enablingauthority to operate an Affordable Insurance Exchange, including aSmall Business Health OptionsProgram (SHOP), compliant with Affordable Care Act Section1321(b) and implementingregulations.
The State of Utah has the necessary legal authority to establish a state-basedinsurance exchange for individuals and small businesses. Utah Code: Title63M, Chapter 1 is attached.This code created the Office of Consumer Health Services (OCHS) within the
Governor’s Office of 
Economic Development (GOED), a state agency.
63m01_250400.pdf 
 
Utah InsuranceCode.pdf 
 
Item Approach
1.2
 
 — 
The Exchange has beenestablished in compliance with ACA 1311(d) and 45 CFR155.110.
Utah has established the Office of Consumer Health Services within the
Governor’s Office of Economic Development, a state agency.
 
Item Approach
1.2a
 
 — 
The Exchange board and governance structure has beenestablished in compliance with ACA 1311(d) and 45 CFR155.110.
N/A
Item Approach
1.2b
 
 — 
The Exchange has a formal, publicly-adopted charter or bylaws.
N/A
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