Utah Admin. Code R590-146-7 - Minimum Benefit Standards for Pre-Standardized Plans

A policy or certificate may not be advertised, solicited, or issued for delivery in this state as a pre-standardized plan unless it meets or exceeds the minimum standards of this section. The minimum standards do not preclude the inclusion of other provisions or benefits that are consistent with these standards.

(1) General Standards. The general standards apply to a policy or certificate and are in addition to any other requirement of this rule.

(a) A policy or certificate may not exclude or limit benefits for losses incurred more than six months after the effective date of coverage for a preexisting condition.

(b) A policy or certificate may not indemnify against losses resulting from sickness on a different basis than losses resulting from accidents.

(c) A policy or certificate shall provide that benefits designed to cover cost sharing amounts under Medicare will be changed automatically to coincide with any changes in the applicable Medicare deductible, copayment, or coinsurance amounts. Premiums may be modified to correspond with such changes.

(d) A noncancelable, guaranteed renewable, or noncancelable and guaranteed renewable policy may not:

(i) provide for termination of coverage of a spouse solely because of an event specified for termination of coverage of the insured, other than the nonpayment of premium; or

(ii) be canceled or nonrenewed by the issuer solely on the grounds of deterioration of health.

(e)

(i) Except as authorized by the commissioner, an issuer may not cancel or nonrenew a policy or certificate for any reason other than nonpayment of premium or material misrepresentation.

(ii) If a group policy is terminated by the group policyholder and not replaced as provided in Subsection (1)(e)(iv), the issuer shall offer to each certificate holder a policy with one of the choices as follows:

(A) an individual policy currently offered by the issuer having comparable benefits to those contained in the terminated group policy; or

(B) an individual policy that only provides benefits required to meet the basic core benefits under Subsection R590-146-8a(2).

(iii) If membership in a group is terminated, the issuer shall:

(A) offer the certificate holder the conversion opportunity described in Subsection (1)(e)(ii); or

(B) at the option of the group policyholder, offer the certificate holder continuation of coverage under the group policy.

(iv) If a group policy is replaced by another group policy purchased by the same policyholder, the issuer of the replacement policy shall offer coverage to each insured under the old group policy on its date of termination. Coverage under the new group policy may not result in an exclusion for a preexisting condition that would have been covered under the group policy being replaced.

(f)

(i) Termination of a policy or certificate shall be without prejudice to any continuous loss that started while the policy or certificate was in force.

(ii) The extension of benefits beyond the period during which the policy was in force may be conditioned upon the continuous total disability of the insured, limited to:

(A) the duration of the policy benefit period, if any; or

(B) payment of the maximum benefits.

(iii) Receipt of Medicare Part D benefits may not be considered in determining a continuous loss.

(g) If a policy eliminates an outpatient prescription drug benefit due to requirements imposed by the Medicare Prescription Drug, Improvement and Modernization Act of 2003, the modified policy is considered to satisfy the guaranteed renewal requirements of this subsection.

(2) An issuer shall include the minimum benefits:

(a) coverage of Medicare Part A eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day through the 90th day in any Medicare benefit period;

(b) coverage for either all or none of the Medicare Part A inpatient hospital deductible amount;

(c) coverage of Medicare Part A eligible expenses incurred as daily hospital charges during use of Medicare's lifetime hospital inpatient reserve days;

(d) upon exhaustion of all Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 90% of all Medicare Part A eligible expenses for hospitalization not covered by Medicare subject to a lifetime maximum benefit of an additional 365 days;

(e) coverage under Medicare Part A for the reasonable cost of the first three pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations or already paid for under Medicare Part B;

(f) coverage for the coinsurance amount, or in the case of hospital outpatient department services paid under a prospective payment system, the copayment amount of Medicare eligible expenses under Medicare Part B regardless of hospital confinement, subject to a maximum calendar year out-of-pocket amount equal to the Medicare Part B deductible; and

(g) effective January 1, 1990, coverage under Medicare Part B for the reasonable cost of the first three pints of blood, or equivalent quantities of packed red blood cells, as defined under federal regulations, unless replaced in accordance with federal regulations or already paid for under Medicare Part A, subject to the Medicare deductible amount.

Notes

Utah Admin. Code R590-146-7

Amended by Utah State Bulletin Number 2019-13, effective 6/7/2019 Adopted by Utah State Bulletin Number 2024-16, effective 8/7/2024