Utah Admin. Code R590-146-8a - Benefit Standards for 2010 Standardized Plans Issued for Delivery with an Effective Date for Coverage on or After June 1, 2010

A policy or certificate may not be advertised, solicited, delivered, or issued for delivery in this state as a 2010 plan unless it complies with the standards in this section.

(1) General Standards. The general standards in this subsection apply to a 2010 plan, 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 a 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 policy or certificate may not 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.

(e) A policy shall be guaranteed renewable.

(i) An issuer may not cancel or nonrenew a policy solely on the grounds of the health status of an insured.

(ii) An issuer may not cancel or nonrenew a policy for any reason other than nonpayment of premium or material misrepresentation.

(iii) If a group policyholder terminates a policy and the policy is not replaced as provided under Subsection (1)(e)(v), the issuer shall offer each certificate holder a policy that, at the option of the certificate holder, provides for:

(A) continuation of the benefits contained in the group policy; or

(B) an individual policy with benefits that otherwise meet the requirements of this subsection.

(iv) If a certificate holder in a group terminates membership in the group, the issuer shall:

(A) offer the certificate holder a conversion opportunity; or

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

(v) 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 covered under the prior 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 prior group policy.

(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)

(i) A policy or certificate shall provide that benefits and premiums be suspended at the request of the policyholder or certificate holder for a period, not to exceed 24 months, in which the policyholder or certificate holder has applied for and is determined to be entitled to medical assistance under Title XIX of the Social Security Act, if the policyholder or certificate holder notifies the issuer of the policy or certificate within 90 days after the date the insured becomes entitled to assistance.

(ii) If the policy or certificate is suspended and the policyholder or certificate holder loses entitlement to medical assistance, the policy or certificate shall be automatically reinstated, effective on the date medical assistance terminated if the policyholder or certificate holder provides notice of loss of entitlement within 90 days after the date of loss and pays the required premium.

(iii)

(A) A policy shall provide that benefits and premiums under the policy be suspended, for any period that may be provided by federal regulation, at the request of the policyholder if the policyholder is entitled to benefits under Section 226(b) of the Social Security Act and is covered under a group health plan, as defined in Section 1862(b)(1)(A)(v) of the Social Security Act.

(B) If suspension occurs and if the policyholder or certificate holder loses coverage under the group health plan, the policy or certificate shall be automatically reinstated, effective on the date of loss of coverage if the policyholder or certificate holder provides notice of loss of coverage within 90 days of the loss.

(C) Reinstated coverage:

(I) may not include a preexisting condition waiting period;

(II) shall provide for resumption of coverage substantially equivalent to the coverage in effect before the date of suspension; and

(III) shall classify premiums on terms at least as favorable to the policyholder or certificate holder as the premium classification terms that applied had the coverage not been suspended.

(2) Standards for 2010 Plans A, B, C, D, F, High Deductible F, G, M, and N.

(a) An issuer shall offer to an applicant a policy or certificate that only includes the basic core benefits, Plan A. An issuer may offer any other 2010 plan, but not in lieu of Plan A.

(b) In addition to the basic core benefits, the benefits in this subsection shall be included in Plans B, C, D, F, High Deductible F, G, M, and N, only as provided in Subsection R590-146-9a:

(i) 100% of the Medicare Part A deductible;

(ii) 50% of the Medicare Part A deductible;

(iii) skilled nursing facility care;

(iv) 100% of the Medicare Part B deductible;

(v) 100% of the Medicare Part B excess charges; and

(vi) medically necessary emergency care in a foreign country.

Notes

Utah Admin. Code R590-146-8a

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