Utah Admin. Code R590-286-4 - Prohibited Policy Provisions

(1) Preexisting conditions.

(a) A preexisting condition shall not be defined more restrictively than the existence of a symptom or a condition that would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment within 24 months preceding the effective date, or a condition for which medical advice or treatment was recommended by a health care provider within a 12-month period preceding the effective date of the policy or certificate of the insured person.

(b) A short-term limited duration health insurance policy for the entire term of the contract, including any renewals or re-issuance, may not exclude coverage for a loss due to a preexisting condition for a period greater than 12 months following the first issuance of the policy or certificate.

(2) Limitations or exclusions. Unless otherwise required by law, a short-term limited duration health insurance policy or certificate 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, unless otherwise required by law;

(d) administrative exams and services;

(e) applied behavioral analysis therapy;

(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) charges for appointments scheduled and not kept;

(j) chiropractic care;

(k) complementary and alternative medicine;

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

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

(n) custodial care;

(o) dental care or treatment;

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

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

(r) experimental or investigational services;

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

(t) felony, riot, or insurrection, when it has been determined the covered person was a voluntary participant;

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

(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 PPACA;

(y) gene therapy;

(z) genetic testing;

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

(bb) except as provided in Subsection R590-286-4(2)(cc), a loss directly related to the insured's voluntary participation in an activity where the insured:

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

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

(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 R590-286-4(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 request for an independent review where the findings support a decision to deny coverage based on the exclusions of Subsection R590-286-4(2)(cc)(i);

(iii) for purposes of Subsection R590-286-4(2)(cc):

(A) an independent review means a process that:

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

(II) renders an independent and impartial decision on a decision to deny coverage based on the exclusion in Subsection R590-286-4(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 insurer;

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

(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; and

(C) 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;

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

(gg) nuclear release;

(hh) preexisting conditions or diseases:

(i) to the extent allowed under Subsections 31A-22-605.1(5) and R590-286-4(1); and

(ii) except for coverage of congenital anomalies as required by Subsection 31A-22-610(2)(b);

(ii) pregnancy, except for complications of pregnancy;

(jj) refractive eye surgery;

(kk) 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;

(ll) respite care;

(mm) rest cures;

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

(oo) services that are not medically necessary;

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

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

(rr) sexual dysfunction procedures, equipment, and drugs;

(ss) shipping and handling;

(tt) telephone or electronic consultations;

(uu) territorial limitations outside the United States;

(vv) terrorism, including acts of terrorism;

(ww) transplants;

(xx) transportation, except medically necessary ambulance services;

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

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

Notes

Utah Admin. Code R590-286-4

Adopted by Utah State Bulletin Number 2021-07, effective 3/11/2021