Utah Admin. Code R590-233-7 - Accident and Health Benefit Standards
(1)
(a) An
accident and health insurance contract subject to this rule may not be
delivered or issued for delivery unless it meets the required standard for the
specified category in this section.
(b) This section does not preclude the
issuance of a contract combining two or more categories set forth in Subsection
31A-22-605(5).
(c) If applicable, coverage shall include:
(i) inborn metabolic errors, as required by
Section 31A-22-623 and Rule R590-194; and
(ii) diabetes, as required by
Section 31A-22-636 and Rule
R590-200.
(2)
(a) Major medical expense coverage provides
hospital, medical, and surgical coverage for an expense incurred for a sickness
or injury.
(b)
(i) A major medical expense contract may
include:
(A) a lifetime maximum not less than
$1,000,000 per enrollee;
(B) a
coinsurance percentage or copay not to exceed 50% of covered charges per
enrollee per year;
(C) an
out-of-pocket maximum, after a deductible, that does not exceed $20,000 per
enrollee per year; or
(D) a
deductible on a per enrollee, per family, per illness, per benefit period, or
per year basis.
(ii) A
combination of the bases in Subsection (2)(b)(i) may not exceed 5% of the
lifetime maximum per enrollee.
(c) The following services shall be covered:
(i) daily hospital room and board expenses,
which may be limited to the average daily cost of the semiprivate room rate in
the area where the enrollee resides;
(ii) miscellaneous hospital services and
supplies;
(iii) surgical
services;
(iv) anesthesia
services;
(v) medical services
while inpatient;
(vi) outpatient
care for physician services provided on an ambulatory basis for:
(A) diagnosis and treatment of a sickness or
an injury;
(B) diagnostic
x-ray;
(C) laboratory
services;
(D) radiation therapy;
and
(E) hemodialysis ordered by a
physician; and
(vii) at
least three of the following additional benefits shall also be provided:
(A) inpatient private duty nursing
services;
(B) convalescent nursing
home care;
(C) diagnosis and
treatment by a radiologist or physiotherapist;
(D) medical equipment rental, as defined in
the contract;
(E) artificial limbs
or eyes, casts, splints, trusses, or braces;
(F) treatment for mental health conditions;
or
(G) outpatient prescription
drugs and medications.
(d) Benefits may be subject to a deductible,
coinsurance, a copay, and the contract exclusion or limitation
provisions.
(e) A major medical
expense contract may limit a service covered under Subsection (c).
(f) Except under Subsection (2)(e), a major
medical expense contract shall cover the usual and customary or reasonable
charges, after the deductible, coinsurance, and copay, for a covered service up
to the lifetime maximum.
(3) Basic medical expense coverage provides
hospital, medical, and surgical coverage for an expense incurred for a sickness
or injury.
(a) A basic medical expense
contract may include:
(i) a lifetime maximum
not less than $500,000 per enrollee;
(ii) a coinsurance percentage or copay not to
exceed 50% of covered charges per enrollee per year;
(iii) an out-of-pocket maximum, after a
deductible, that does not exceed $25,000 per enrollee per year; or
(iv) a deductible on a per enrollee, per
family, per illness, per benefit period, or per year basis.
(b) A combination of the bases in
Subsections (1)(a)(ii), (1)(a)(iii), and (1)(a)(iv) may not exceed 10% of the
aggregate maximum limit under the contract.
(c) The following services shall be covered:
(i) daily hospital room and board expenses
that may be limited to the semiprivate room rate in the area where the enrollee
resides or another rate agreed to between the insurer and provider, for a
period of not less than 31 days during a continuous hospital confinement;
(ii) miscellaneous hospital
services and supplies;
(iii)
surgical services;
(iv) anesthesia
services;
(v) medical services while
inpatient;
(vi) outpatient care,
for physician services provided on an ambulatory basis for:
(A) diagnosis and treatment of a sickness or
an injury;
(B) diagnostic
x-ray;
(C) laboratory
services;
(D) radiation therapy;
and
(E) hemodialysis ordered by a
physician; and
(vii)
three of the following additional benefits shall also be provided:
(A) inpatient private duty nursing
services;
(B) convalescent nursing
home care;
(C) diagnosis and
treatment by a radiologist or physiotherapist;
(D) medical equipment rental, as defined in
the contract;
(E) artificial limbs
or eyes, casts, splints, trusses, or braces;
(F) treatment for mental health conditions;
or
(G) outpatient prescription
drugs and medications.
(d) If a basic medical expense contract is to
complement an underlying basic hospital expense contract and basic
medical-surgical expense contract, the deductible may be increased by the
amount of the benefits provided by the underlying contract.
(e) Benefits may be subject to a deductible,
coinsurance, a copay, and the contract exclusion or limitation
provisions.
(f) A basic medical
expense contract may have an internal limitation for:
(i) prescription drugs;
(ii) a nursing facility;
(iii) an intensive care facility;
(iv) a mental health condition or substance
abuse treatment;
(v) a
transplant;
(vi) experimental
treatment;
(vii) a mandated benefit
required by law;
(viii) services in
Subsection (3)(c); and
(ix) other
internal limitations as approved by the commissioner.
(g) Except under Subsection (3)(f), a basic
medical expense contract shall cover the usual and customary or reasonable
charges, after the deductible, coinsurance, and copay, for a covered service up
to the lifetime maximum.
(4) Catastrophic coverage is a contract that:
(a) provides a benefit for a medical expense
to a lifetime maximum of not less than $1,000,000 per enrollee;
(b) does not include a separate internal
dollar limit;
(c) may be subject to
a deductible that does not exceed 2% of the contract limit or the amount of
another in-force accident and health insurance contract for the same medical
expenses; and
(d) does not include
a percentage participation or coinsurance clause for an expense that exceeds
the deductible.
Notes
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.
The following standards for benefits are prescribed for the categories of coverage noted in the following subsections. An
Benefits for coverages listed in this section shall include coverage of inborn metabolic errors as required by Sections 31A-22-623 and Rule R590-194, and benefits for diabetes as required by Sections 31A-22-626 and Rule R590-200, if applicable.
(1) Major Medical Expense Coverage.
Major medical expense coverage is a policy of
(a) An aggregate maximum of not less than $1,000,000 may be applied and include any combination of the following:
(i) coinsurance percentage, paid by the covered person, not to exceed 50% of covered charges per covered person per year;
(ii) coinsurance out-of-pocket maximum after any deductibles not to exceed $20,000 per covered person per year; or
(iii) deductibles stated on per person, per family, per illness, per benefit period, or per year basis.
(b) A combination of the bases provided under Subsections(1)(a)(i), (ii), and (iii) may not exceed 5% of the aggregate maximum limit under the policy for each covered person.
(c) The following services must be provided:
(i) daily hospital room and board expenses subject only to limitations based on average daily cost of the semiprivate room rate in the area where the insured resides;
(ii) miscellaneous hospital services;
(iii) surgical services;
(iv) anesthesia services;
(v) in-hospital medical services;
(vi) out-of-hospital care, consisting of physician services rendered on an ambulatory basis where coverage is not provided elsewhere in the policy for diagnosis and treatment of sickness or injury , diagnostic x-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician; and
(vii) at least three of the following additional benefits must also be provided:
(A) in-hospital private duty registered nurse services;
(B) convalescent nursing home care;
(C) diagnosis and treatment by a radiologist or physiotherapist;
(D) rental of special medical equipment, as defined by the insurer in the policy;
(E) artificial limbs or eyes, casts, splints, trusses or braces;
(F) treatment for functional nervous disorders, and mental and emotional disorders; or
(G) out-of-hospital prescription drugs and medications.
(d) All required benefits may be subject to all applicable deductibles, coinsurance and general policy exceptions and limitations.
(e) A major medical expense policy may also have special or internal limitations for those services covered under Subsection (1)(c).
(f) Except as authorized by this subsection through the application of special or internal limitations, a major medical expense policy must be designed to cover, after any deductibles or coinsurance provisions are met, the usual, customary and reasonable charges, as determined consistently by the carrier and as subject to approval by the commissioner, or another rate agreed to between the insurer and provider, for covered services up to the lifetime policy maximum.
(2) Basic Medical Expense Coverage.
Basic medical expense coverage is a policy of
(a) An aggregate maximum of not less than $500,000 may be applied, and may include any combination of the following:
(i) coinsurance percentage, paid by the covered person, not to exceed 50% of covered charges per covered person per year;
(ii) coinsurance out-of-pocket maximum after any deductibles, not to exceed $25,000 per covered person per year; or
(iii) deductibles stated on per person, per family, per illness, per benefit period, or per year basis.
(b) A combination of the bases provided in Subsections (2)(a)(i), (ii) and (iii) may not exceed 10% of the aggregate maximum limit under the policy.
(c) The following services must be covered:
(i) daily hospital room and board expenses subject only to limitations based on average daily cost of the semiprivate room rate in the area where the insured resides or such other rate agreed to between the insurer and provider for a period of not less than 31 days during continuous hospital confinement;
(ii) miscellaneous hospital services;
(iii) surgical services;
(iv) anesthesia services;
(v) in-hospital medical services;
(vi) out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis where coverage is not provided elsewhere in the policy for diagnosis and treatment of sickness or injury , diagnostic x-ray, laboratory services, radiation therapy and hemodialysis ordered by a physician; and
(vii) three of the following additional benefits must also be provided:
(A) in-hospital private duty registered nurse services;
(B) convalescent nursing home care;
(C) diagnosis and treatment by a radiologist or physiotherapist;
(D) rental of special medical equipment, as defined by the insurer in the policy;
(E) artificial limbs or eyes, casts, splints, trusses or braces;
(F) treatment for functional nervous disorders, and mental and emotional disorders; or
(G) out-of-hospital prescription drugs and medications.
(d) If the policy is written to complement underlying basic hospital expense coverage and basic medical-surgical expense coverage, the deductible may be increased by the amount of the benefits provided by the underlying basic coverage.
(e) The benefits required by Subsection (2) may be subject to all applicable deductibles, coinsurance and general policy exceptions and limitations.
(f) Basic medical expense policies may also have special or internal limitations for prescription drugs, nursing facilities, intensive care facilities, mental health treatment, alcohol or substance abuse treatment, transplants, experimental treatments, mandated benefits required by law and those services covered under Subsection (2)(c) and other such special or internal limitations as are authorized or approved by the commissioner.
(g) Except as authorized by this subsection through the application of special or internal limitations, basic medical expense policies must be designed to cover, after any deductibles or coinsurance provisions are met, the usual customary and reasonable charges, as determined consistently by the carrier and as subject to approval by the commissioner, or another rate agreed to between the insurer and provider, for covered services up to the lifetime policy maximum.
(3) Catastrophic Coverage.
Catastrophic coverage is a policy of
(a) provides benefits for medical expenses incurred by the insured to an aggregate maximum of not less than $1,000,000;
(b) contains no separate internal dollar limits;
(c) may be subject to a policy deductible which does not exceed the greater of 2% of the policy limit or the amount of other in-force accident and health insurance coverage for the same medical expenses; and
(d) contains no percentage participation or coinsurance clause for expenses which exceed the deductible.