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

(1) A contract may not impose a preexisting condition limitation or exclusion provision.

(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 services;

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

(d) administrative exam or service;

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

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

(g) axillary hyperhidrosis;

(h) benefits paid for under:

(i) employers' liability or occupational disease law;

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

(iii) state or federal workers' compensation;

(i) charge for a missed appointment;

(j) chiropractic care;

(k) complementary or alternative medicine;

(l) corrective lenses, including examination for the prescription or fitting, except:

(i) lens implant following cataract surgery; and

(ii) as required under Rule R590-266;

(m) 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; or

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

(n) custodial care;

(o) dental care or treatment, except as required under Section R590-266-4;

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

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

(r) experimental or investigational services;

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

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

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

(v)

(i) foot care for a corn, a callus, flat feet, 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;

(w)

(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 under Subsection (2)(w)(i); or

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

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

(y) gene therapy;

(z) genetic testing;

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

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

(cc) 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;

(dd) mental health condition or substance use disorder services, except as required under Section 31A-22-625 and Rule R590-266;

(ee) nuclear release;

(ff) refractive eye surgery;

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

(hh) respite care;

(ii) rest cures;

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

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

(ll) services that are not medically necessary;

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

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

(oo) 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;

(pp) sexual dysfunction procedures, equipment, or drugs;

(qq) shipping or handling;

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

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

(tt) terrorism, including acts of terrorism;

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

(vv) transportation, except medically necessary ambulance services;

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

(xx) except under Subsection (2)(yy), 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;

(yy) a loss established under Subsection (3) 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

(zz) 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)(yy) 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 managed care organization;

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

(C) is paid for by the managed care organization.

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

(A) the managed care organization;

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

(C) the enrollee;

(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.

(c) The exclusion in Subsection (2)(yy) does not apply to an enrollee who is under 18 years of age.

(4) A contract 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 R590-277-4

Adopted by Utah State Bulletin Number 2019-18, effective 8/20/2019 Amended by Utah State Bulletin Number 2020-09, effective 4/22/2020 Adopted by Utah State Bulletin Number 2025-12, effective 6/10/2025