Utah Admin. Code R590-233-4 - Prohibited Contract Provisions

State Regulations
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(1)

(a) A contract may not establish a probationary period when coverage is not provided, except under Subsections (1)(b) and (1)(c).

(b) A contract may specify a probationary period not to exceed 12 months for a loss resulting from:

(i) amenorrhea;

(ii) cataracts;

(iii) a congenital deformity, except as required under Subsection 31A-22-610(2);

(iv) cystocele;

(v) dysmenorrhea;

(vi) enterocele;

(vii) infertility;

(viii) rectocele;

(ix) seasonal allergy, limited to testing and treatment;

(x) sleep disorder, including sleep studies;

(xi) surgical treatment for:

(A) adenoidectomy;

(B) bunionectomy;

(D) hysterectomy, except in a case of malignancy;

(E) joint replacement;

(F) reduction mammoplasty;

(G) Morton's neuroma;

(H) myringotomy and tympanotomy, with or without tubes inserted;

(I) nasal septal repair, except for an injury after the effective date of coverage;

(J) retained hardware removal;

(K) sterilization; and

(L) tonsillectomy;

(xii) urethrocele;

(xiii) uterine prolapse; and

(xiv) varicose veins.

(c) Coverage shall be provided for a disease, condition, or procedure in Subsection (1)(b) if the disease, condition, or procedure is treated on an emergency basis.

(2) Unless otherwise required by law, a contract may not limit or exclude coverage or benefits by type of illness, accident, injury, treatment, or medical condition, except:

(a) abortion;

(b) acupuncture or acupressure;

(c) administrative charge for completing an insurance form, duplication service, interest, finance charge, or other administrative charge;

(d) administrative exam or service;

(e) allergy test or treatment;

(f) applied behavioral analysis therapy, except as required under Section 31A-22-642;

(g) aviation, to a non-fare-paying passenger;

(h) axillary hyperhidrosis;

(i) benefits paid for under:

(i) employer's liability or occupational disease law;

(ii) Medicare or another governmental program, except Medicaid; or

(iii) state or federal workers' compensation;

(j) charge for a missed appointment;

(k) chiropractic care;

(l) complementary or alternative medicine;

(m) corrective lens, including an examination for prescription or fitting, except lens implant following cataract surgery;

(n) cosmetic surgery, including reversal, revision, repair, complication, or treatment related to a non-covered cosmetic surgery, except reconstructive surgery:

(i) when the service is incidental to or follows surgery resulting from trauma, infection, or other disease of the involved part; or

(ii) due to a congenital disease or anomaly of a covered dependent child that resulted in a functional defect;

(o) custodial care;

(p) dental care or treatment;

(q) dietary products, except as required under Rule R590-194;

(r) educational or nutritional training, except as required under Rule R590-200;

(s) expenses before coverage begins or after coverage ends;

(t) experimental or investigational service;

(u) felony, riot, or insurrection, when it is determined the enrollee was a voluntary participant;

(v) fitness training, exercise equipment, or a membership fee to a spa or health club;

(w)

(i) foot care for a corn, a callus, a flat foot, a fallen arch, a weak foot, chronic foot strain, or symptomatic complaints of a foot, including an orthotic; and

(ii) the cutting or removal of a corn, a callus, or a nail may not be excluded when provided to an enrollee who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency, if unskilled performance of the procedure would be hazardous;

(x)

(i) gastric or intestinal bypass service, including lap banding, gastric stapling, or a similar procedure to facilitate weight loss;

(ii) the reversal or revision of a procedure in Subsection (2)(x)(i); or

(iii) a service required for the treatment of a complication from a procedure in Subsection (2)(x)(i);

(y) gender reassignment, except as required under Section 1557 of PPACA;

(z) gene therapy;

(aa) genetic testing;

(bb) hearing aid, including examination for the prescription or fitting;

(cc) infertility service, except as required under Subsection 31A-22-610.1(1);

(dd) injury as a result of a motor vehicle, to the extent the enrollee is required to have no-fault coverage, up to the minimum coverage required by law whether or not coverage is in effect;

(ee) mental health condition or substance use disorder, except as required under 45 CFR 147.160 and Section 31A-22-625;

(ff) nuclear release;

(gg) preexisting condition, except as required under Section 31A-22-605.1 and Subsection 31A-22-610(2);

(hh) pregnancy, except for a complication of pregnancy;

(ii) refractive eye surgery;

(jj) rehabilitation therapy service, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident, injury, or illness;

(kk) respite care;

(ll) rest cure;

(mm) routine physical examination;

(nn) services performed by an enrollee's parent, spouse, sibling, or child, including a step or in-law relationship;

(oo) services performed by an employee of a hospital, laboratory, or other institution;

(pp) services that are not medically necessary;

(qq) services for which no charge is normally made in the absence of insurance;

(rr) services while in the armed forces or an auxiliary unit;

(ss) sexual dysfunction procedure, equipment, or drug;

(tt) shipping or handling;

(uu) suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury;

(vv) telephone or electronic consultation, except as required under Sections 31A-22-649 and 31A-22-649.5;

(ww) territorial limitation outside the United States, except as required under Section 31A-22-627;

(xx) terrorism, including an act of terrorism;

(yy) transplant;

(zz) transportation, except medically necessary ambulance services;

(aaa) war or act of war, whether declared or undeclared;

(bbb) except under Subsection (2)(ccc), a loss directly related to the enrollee's voluntary participation in an activity when the enrollee:

(i) is found guilty of an illegal activity in a criminal proceeding, including a plea of guilty, a no contest plea, and a plea in abeyance; or

(ii) is found liable for the activity in a civil proceeding;

(ccc) a loss established under Subsection (3)(a) that is directly related to the enrollee violating:

(i) Section 41-6a-502, if the loss occurred in Utah; or

(ii) a law in a state other than Utah that prohibits operating a motor vehicle while exceeding the legal limit of concentration of alcohol, drugs, or a combination of both in the blood, if the loss occurred in the other state; or

(ddd) any other exclusion that, in the opinion of the commissioner, is not inequitable, misleading, deceptive, obscure, unjust, unfair, or unfairly discriminatory to an enrollee.

(3)

(a) A violation under Subsection (2)(ccc) shall be established:

(i) in a criminal proceeding in which the enrollee is found guilty, enters a no contest plea or a plea in abeyance, or enters into a diversion agreement; or

(ii) by a request for an independent review when the findings support a decision to deny coverage based on the exclusion.

(b)

(i) For purposes of Subsection (3)(a)(ii), an independent review means a process that:

(A) is conducted by an independent entity designated by the insurer;

(B) renders an independent and impartial decision on a decision to deny coverage based on the exclusion; and

(ii) The independent review entity may not have a material professional, familial, or financial conflict of interest with:

(A) the insurer;

(B) an officer, director, or management employee of the insurer;

(D) the enrollee's health care provider;

(E) the health care provider's medical group or independent practice association; or

(F) a health care facility where services were provided.

(4)

(a) A waiver shall comply with Section 31A-30-107.5.

(b) A signed acceptance by the enrollee is required if a waiver is required as a condition of issuance, renewal, or reinstatement.

(5) A contractual provision precluded in this section may not be construed as a limitation on the commissioner's authority to prohibit a contract provision that, in the opinion of the commissioner, is unjust, unfair, or unfairly discriminatory to an enrollee.

Notes

Utah Admin. Code R590-233-4

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

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.

(1) Probationary periods.

(a) A policy shall not contain provisions establishing a probationary period during which no coverage is provided under the policy except as provided in R590-233-4(1)(b), (c), and (d).

(b) A policy may specify a probationary period not to exceed twelve months for losses resulting from:

(i) amenorrhea;

(ii) cataracts;

(iii) congenital deformities, unless coverage is required pursuant to Subsection 31A-22-610(2);

(iv) cystocele;

(v) dysmenorrhea;

(vi) enterocele;

(vii) infertility;

(viii) rectocele;

(ix) seasonal allergies, limited to testing and treatment;

(x) sleep disorders, including sleep studies;

(xi) surgical treatment for;

(A) adenoidectony,

(B) bunionectomy,

(D) hysterectomy, except in cases of malignancy,

(E) joint replacement,

(F) reduction mammoplasty,

(G) Morton's neuroma,

(H) myringotomy and tympanotomy, with or without tubes inserted,

(I) nasal septal repair, except for injuries after the effective date of coverage,

(J) retained hardware removal,

(K) sterilization, and

(L) tonsillectomy;

(xii) urethrocele;

(xiii) uterine prolapse; and

(xiv) varicose veins.

(c) Coverage must be provided for conditions and procedures prohibited in Subsection (1)(b) for emergency medical conditions in compliance with Section 31A-22-627.

(d) The probationary period must be reduced by the number of days of creditable coverage the enrollee has as of the enrollment date, in accordance with Subsection 31A-22-605.1(4)(b).

(2) Preexisting conditions provisions shall comply with Sections 31A-1-301, and 31A-22-605.1.

(3) Limitations or exclusions. A policy shall not limit or exclude coverage or benefits by type of illness, accident, treatment or medical condition, except as follows:

(a) abortion;

(b) acupuncture and acupressure services;

(c) administrative charges for completing insurance forms, duplication services, interest, finance charges, or other administrative charges, unless otherwise required by law;

(d) administrative exams and services;

(e) alcoholism and drug addictions;

(f) allergy tests and treatments;

(g) aviation;

(h) axillary hyperhidrosis;

(i) benefits provided under:

(i) Medicare or other governmental program, except Medicaid;

(ii) state or federal worker's compensation; or

(iii) employer's liability or occupational disease law.

(j) cardiopulmonary fitness training, exercise equipment, and membership fees to a spa or health club;

(k) charges for appointments scheduled and not kept;

(l) chiropractic;

(m) complementary and alternative medicine;

(n) corrective lenses, and examination for the prescription or fitting thereof, but policies may not exclude required lens implants following cataract surgery;

(o) cosmetic surgery; reversal, revision, repair, complications, or treatment related to a non- covered cosmetic surgery. This exclusions does not apply to reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part; or reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;

(p) custodial care;

(q) dental care or treatment;

(r) dietary products, except as required by Rule R590-194;

(s) educational and nutritional training, except as required by Rule R590-200;

(t) experimental and/or investigational services;

(u) felony, riot or insurrection, when the insured is a voluntary participant;

(v) foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet, including orthotics. The exclusion of routine foot care does not apply to cutting or removal of corns, calluses, or nails when provided to a person who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency, of such severity that unskilled performance of the procedure would be hazardous;

(w) gastric or intestinal bypass services including lap banding, gastric stapling, and other similar procedures to facilitate weight loss; the reversal, or revision of such procedures; or services required for the treatment of complications from such procedures;

(x) gene therapy;

(y) genetic testing;

(z) hearing aids, and examination for the prescription or fitting thereof;

(aa) illegal activities, limited to losses related directly to the insured's voluntary participation;

(bb) infertility services, except as required by Rule R590-76;

(cc) interscholastic sports, with respect to short-term nonrenewable policies;

(dd) mental or emotional disorders;

(ee) motor vehicle no-fault law, except when the covered person is required by law to have no-fault coverage, the exclusion applies to charges up to the minimum coverage required by law whether or not such coverage is in effect;

(ff) nuclear release;

(gg) preexisting conditions or diseases as allowed under Section 31A-22-605.1, except for coverage of congenital anomalies as required by Section 31A-22-610;

(hh) pregnancy, except for complications of pregnancy;

(ii) refractive eye surgery;

(jj) rehabilitation therapy services, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident or illness;

(kk) respite care;

(ll) rest cures;

(mm) routine physical examinations;

(nn) service in the armed forces or units' auxiliary to it;

(oo) services rendered by employees of hospitals, laboratories or other institutions;

(pp) services performed by a member of the covered person's immediate family;

(qq) services for which no charge is normally made in the absence of insurance;

(rr) sexual dysfunction;

(ss) shipping and handling, unless otherwise required by law;

(tt) suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury;

(uu) telephone/electronic consultations;

(vv) territorial limitations outside the United States;

(ww) terrorism, including acts of terrorism;

(xx) transplants;

(yy) transportation;

(zz) treatment provided in a government hospital, except for hospital indemnity policies;

(aaa) war or act of war, whether declared or undeclared; or

(bbb) others as may be approved by the commissioner.

(4) Waivers. All waivers issued must comply with 31A-30-107.5. Where waivers are required as a condition of issuance, renewal or reinstatement, signed acceptance by the insured is required.

(5) Commissioner authority. Policy provisions precluded in this section shall not be construed as a limitation on the authority of the commissioner to prohibit other policy provisions that in the opinion of the commissioner are unjust, unfair or unfairly discriminatory to the policyholder, beneficiary or a person insured under the policy.

Notes

Utah Admin. Code R590-233-4