Utah Admin. Code R590-277-4 - Prohibited Policy Provisions

(1) A health benefit plan may not impose any preexisting condition limitation or exclusion provisions.

(2) Limitations or exclusions. Unless otherwise required by law, a policy may 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;

(d) administrative exams and services;

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

(f) aviation;

(g) axillary hyperhidrosis;

(h) 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;

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

(j) charges for appointments scheduled and not kept;

(k) chiropractic care;

(l) complementary and alternative medicine;

(m) corrective lenses, and examination for the prescription or fitting thereof, except lens implant following cataract surgery and as required by Rule R590-266;

(n) cosmetic surgery; reversal, revision, repair, complications, or treatment related to a non-covered cosmetic surgery. This exclusion 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 party; or reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;

(o) custodial care;

(p) dental care or treatment;

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

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

(s) experimental or investigational services;

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

(u) felony, riot or insurrection, when it has been determined the covered person was 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) gender reassignment, except as required by Section 1557 of the Patient Protection and Affordable Care Act;

(y) gene therapy;

(z) genetic testing;

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

(bb)

(i) except as provided in Subsection R590-277-4(2)(cc), a loss directly related to the insured's voluntary participation in an activity where the insured:

(A) is found guilty of an illegal activity in a criminal proceeding; or

(B) is found liable for the activity in a civil proceeding.

(ii) A guilty finding includes a plea of guilty, a no contest plea, and a plea in abeyance;

(cc)

(i) a loss directly related to the insured or dependent violating:

(A) Section 41-6a-502; or

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

(ii) Violations of Subsection R590-277-4(2)(cc)(i) shall be established:

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

(B) a managed care organization's request for an independent review where the findings support a decision to deny coverage based on the exclusions of Subsection R590-277-4(2)(cc)(i);

(iii) For purposes of Subsection R590-277-4(2)(cc):

(A) An independent review means a process that:

(I) is conducted by an independent entity designated by the managed care organization;

(II) renders an independent and impartial decision on a decision to deny coverage based on the exclusion in Subsection R590-277-4(2)(cc)(i); and

(III) is paid for by the insurer.

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

(I) the managed care organization;

(II) an officer, director, or management employee of the managed care organization;

(III) the enrollee;

(IV) the enrollee's health care provider;

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

(VI) a health care facility where services were provided;

(iv) this exclusion does not apply to an insured or dependent who is under 18 years of age;

(dd) infertility services;

(ee) mental health and substance use disorder services, except as required by Section 31A-22-625 and Rule R590-266;

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

(gg) nuclear release;

(hh) refractive eye surgery;

(ii) rehabilitation or habilitative therapy services, such as physical, speech, and occupational, except as required to correct an impairment caused by a covered accident or illness, or as required by Rule R590-266;

(jj) respite care;

(kk) rest cures;

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

(mm) services that are not medically necessary;

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

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

(pp) services in connection with a prearranged surrogacy agreement, except for services for the baby, where the covered person relinquishes a baby and receives payment or other compensation arising out of such services;

(qq) sexual dysfunction procedures, equipment and drugs;

(rr) shipping and handling;

(ss) telephone/electronic consultations;

(tt) territorial limitations outside the United States;

(uu) terrorism, including acts of terrorism;

(vv) transplants, except as required by Rule R590-266;

(ww) transportation, except medically necessary ambulance services;

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

(yy) others that in the opinion of the commissioner are not inequitable, misleading, deceptive, obscure, unjust, unfair or unfairly discriminatory to the policyholder, beneficiary , or covered person under the policy.

Notes

Utah Admin. Code R590-277-4

Adopted by Utah State Bulletin Number 2019-18, effective 8/20/2019 Amended by Utah State Bulletin Number 2020-09, effective 4/22/2020