Utah Admin. Code R590-266-3 - Definitions

In addition to the definitions in Sections 31A-1-301 and 31A-30-103, the following definitions shall apply for the purpose of this rule:

(1) "Essential health benefits" means the following health care service categories that must be included in non-grandfathered individual and small employer health benefit plans beginning January 1, 2014:
(a) ambulatory patient services;
(b) emergency services;
(c) hospitalization;
(d) maternity and newborn care;
(e) mental health and substance use disorder services, including behavioral health treatment;
(f) prescription drugs;
(g) rehabilitative and habilitative services and devices;
(h) laboratory services;
(i) preventive and wellness services and chronic disease management; and
(j) pediatric services, including oral and vision care.
(2) "Grandfathered health plan" means an individual or small employer health benefit plan that:
(a) was in existence when the PPACA was enacted on March 23, 2010;
(b) has not had any significant changes that reduce benefits or increase costs to consumer including:
(i) a significant cut or reduction in benefits, such as excluding coverage for people with diabetes;
(ii) an increase in co-pays by more than $5, adjusted annually for medical inflation, or a percentage equal to medical inflation plus 15%;
(iii) the employer reduces contributions by more than five percentage points; or
(iv) reducing annual dollar limits, or adding a new limit; and
(c) the insured has received notification from the carrier that their health benefit plan is a grandfathered plan.
(3) "Habilitative" means health care services that help a person keep, learn, or improve skills and functioning for daily living. Habilitative services may include physical therapy, occupational therapy, speech-language pathology, and other services.
(4) "Non-Grandfathered health plan" means an individual or small employer health benefit plan:
(a) that is issued after the PPACA was enacted on March 23, 2010; or
(b) a grandfathered health plan that has made significant changes that reduce benefits or increase costs to consumers that has caused the plan to lose the grandfathered status as provided in (2)(b).
(5) "Rehabilitative" means the treatment of disease, injury, developmental delay, or other cause, by physical agents and methods to assist in the rehabilitation of normal physical bodily function, that is goal-oriented and where the person has potential for functional improvement and ability to progress.
(6) "Utah Essential Health Benefits Package" means the benefits designated in this rule by the commissioner as essential health benefits in non-grandfathered plans for the purposes of the PPACA in Utah.


Utah Admin. Code R590-266-3
Amended by Utah State Bulletin Number 2016-12, effective 5/23/2016

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