Utah Admin. Code R590-126-8 - Outline of Coverage Requirements

(1) The outline of coverage in Table 1 shall be issued with a basic hospital expense insurance contract.

TABLE 1 Basic Hospital Expense Insurance Outline of Coverage

(COMPANY NAME) BASIC HOSPITAL EXPENSE COVERAGE THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS AND SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR COMPREHENSIVE HEALTH INSURANCE COVERAGE OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Basic hospital expense coverage is designed to provide, to persons insured, coverage for hospital expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services and hospital outpatient services, subject to any limitations, deductibles and copayment requirements set forth in the policy. Coverage is not provided for physician or surgeon fees or unlimited hospital expenses. A brief specific description of the benefits, including dollar amounts and number of days duration where applicable, contained in this policy, in the following order: daily hospital room and board; miscellaneous hospital services; hospital outpatient services; and other benefits, if any. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.

(2) The outline of coverage in Table 2 shall be issued with a basic medical-surgical expense insurance contract.

TABLE 2 Basic Medical-Surgical Expense Insurance Outline of Coverage

(COMPANY NAME) BASIC MEDICAL-SURGICAL EXPENSE COVERAGE THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS AND SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR COMPREHENSIVE HEALTH INSURANCE COVERAGE OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Basic medical-surgical expense coverage is designed to provide, to persons insured, coverage for medical-surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for surgical services, anesthesia services, and in-hospital medical services, subject to any limitations, deductibles and copayments set forth in the policy. Coverage is not provided for hospital expenses or unlimited medical-surgical expenses. A brief specific description of the benefits, including dollar amounts and number of days duration where applicable, contained in this policy, in the following order: surgical services; anesthesia services; in-hospital medical services; and other benefits, if any. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.

(3) The outline of coverage in Table 3 shall be issued with a basic hospital and medical-surgical expense insurance contract.

TABLE 3 Basic Hospital and Medical-Surgical Expense Insurance Outline of Coverage

(COMPANY NAME) BASIC HOSPITAL/MEDICAL-SURGICAL EXPENSE COVERAGE THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS AND SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR COMPREHENSIVE HEALTH INSURANCE COVERAGE OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Basic hospital/medical-surgical expense coverage is designed to provide, to persons insured, coverage for hospital and medical-surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, hospital outpatient services, surgical services, anesthesia services, and in-hospital medical services, subject to any limitations, deductibles and copayment requirements set forth in the policy. Coverage is not provided for unlimited hospital or medical surgical expenses. A brief specific description of the benefits, including dollar amounts and number of days duration where applicable, contained in this policy, in the following order: daily hospital room and board; miscellaneous hospital services; hospital outpatient services; surgical services; anesthesia services; in-hospital medical services; and other benefits, if any. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.

(4) The outline of coverage in Table 4 shall be issued with a hospital fixed indemnity insurance contract.

TABLE 4 Hospital Fixed Indemnity Insurance Outline of Coverage

(COMPANY NAME) HOSPITAL CONFINEMENT INDEMNITY COVERAGE THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of coverage. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Hospital indemnity coverage is designed to provide, to persons insured, coverage in the form of a fixed daily benefit during periods of hospitalization resulting from a covered accident or sickness, subject to any limitations set forth in the policy. Coverage is not provided for any benefits other than the fixed daily indemnity for hospital confinement and any additional benefit described below. A brief specific description of the benefits in the following order: daily benefit payable during hospital confinement; and duration of benefit A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefit. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums. Any benefits provided in addition to the daily hospital benefit.

(5) The outline of coverage in Table 5 shall be issued with an income replacement insurance contact.

TABLE 5 Income Replacement Insurance Outline of Coverage

(COMPANY NAME) INCOME REPLACEMENT INSURANCE COVERAGE THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL EXPENSES OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Income replacement insurance coverage is designed to provide, to persons insured, coverage for disabilities resulting from a covered accident or sickness, subject to any limitations set forth in the policy. Coverage is not provided for basic hospital, basic medical-surgical, or major medical expenses. A brief specific description of the benefits contained in the policy. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.

(6) The outline of coverage in Table 6 shall be issued with an accident only insurance contract.

TABLE 6 Accident Only Insurance Outline of Coverage

(COMPANY NAME) ACCIDENT ONLY COVERAGE THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS BENEFITS PROVIDED ARE SUPPLEMENTAL AND NOT INTENDED TO COVER ALL MEDICAL EXPENSES OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of the coverage. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Accident only coverage is designed to provide, to persons insured, coverage for certain losses resulting from a covered accident ONLY, subject to any limitations contained in the policy. Coverage is not provided for basic hospital, basic medical-surgical, or major medical expenses. A brief specific description of the benefits. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.

(7) The outline of coverage in Table 7 shall be issued with a specified accident insurance contract.

TABLE 7 Specified Accident Insurance Outline of Coverage

(COMPANY NAME) SPECIFIED ACCIDENT COVERAGE THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of coverage. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Specified accident coverage is designed to provide, to persons insured, restricted coverage paying benefits ONLY when certain losses occur as a result of specified accidents. Coverage is not provided for basic hospital, basic medical-surgical, or major medical expenses. A brief specific description of the benefits, including dollar amounts. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.

(8) The outline of coverage in Table 8 shall be issued with a specified disease insurance contract.

TABLE 8 Specified Disease Insurance Outline of Coverage

(COMPANY NAME) SPECIFIED DISEASE COVERAGE THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES OUTLINE OF COVERAGE Specified disease coverage is designed only as a supplement to a comprehensive health insurance policy and should not be purchased unless you have this underlying coverage. Persons covered under Medicaid should not purchase it. Read the Buyer's Guide to Specified Disease Insurance to review the possible limits on benefits in this type of coverage. Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of coverage. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Specified disease coverage is designed to provide, to persons insured, restricted coverage paying benefits ONLY when certain losses occur as a result of specified diseases. Coverage is not provided for basic hospital, basic medical-surgical, or major medical expenses. A brief specific description of the benefits, including dollar amounts. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.

(9) The outline of coverage in Table 9 shall be issued with a limited benefit health insurance contract.

TABLE 9 Limited Benefit Health Insurance Outline of Coverage

(COMPANY NAME) LIMITED BENEFIT HEALTH COVERAGE BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL MEDICAL EXPENSES OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! Limited benefit health coverage is designed to provide, to persons insured, limited or supplemental coverage. A brief specific description of the benefits, including amounts. A description of any provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.

(10) The outline of coverage in Table 10 shall be issued with a dental insurance contract.

TABLE 10 Dental Insurance Outline of Coverage

(COMPANY NAME) DENTAL COVERAGE BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL DENTAL EXPENSES OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! A brief specific description of the benefits. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage including age restrictions or any reservations of right to change premiums.

(11) The outline of coverage in Table 11 shall be issued with a vision insurance contract.

TABLE 11 Vision Insurance Outline of Coverage

(COMPANY NAME) VISION COVERAGE BENEFITS PROVIDED ARE SUPPLEMENTAL AND ARE NOT INTENDED TO COVER ALL VISION EXPENSES OUTLINE OF COVERAGE Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY! A brief specific description of the benefits. A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits. A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservations of right to change premiums.

(12) An insurer shall deliver an outline of coverage to an applicant or insured before or upon the sale of an accident and health insurance contract.

(13) If an outline of coverage was delivered at the time of application or enrollment and the contract is issued on a basis that requires a revision of the outline of coverage, a substitute outline of coverage describing the contract shall accompany the contract when it is delivered and shall include the following statement in no less than 12-point font, immediately above the company name, "NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application, and the coverage originally applied for has not been issued."

(14) An outline of coverage for fixed indemnity insurance, specified disease insurance, or limited benefit health insurance delivered to a person eligible for Medicare by reason of age shall include the following language, that shall be printed on or attached to the first page of the outline of coverage, "THIS IS NOT A MEDICARE SUPPLEMENT POLICY. If you are eligible for Medicare, review the Guide to Health Insurance for People With Medicare available from the company."

(15) If the outline of coverage is inappropriate for the coverage provided by the contract, an alternate outline of coverage shall be submitted to the commissioner for prior approval.

(16) An advertisement may fulfill the requirement for an outline of coverage if the advertisement satisfies the specified standards.

Notes

Utah Admin. Code R590-126-8

Adopted by Utah State Bulletin Number 2025-07, effective 3/24/2025