Utah Admin. Code R590-286-5 - General Requirements and Required Provisions
(1) A contract may not include a definition
regarding a matter defined in Section
R590-286-3 unless the definition
complies with that section.
(2)
(a) A contract shall include:
(i) an expiration provision that specifies
the condition for renewal or extension; and
(ii) the total number of months or days for
the full term of the contract under Subsection (1)(c).
(b) The provision shall be appropriately
captioned and appear on the first page of the contract.
(c) Considering any renewal, extension, or
continuation of premium payments, a contract is limited to 36 months.
(3) A contract that
provides coverage to a spouse of the contract holder:
(a) may not provide for termination of
coverage of the spouse solely because of the occurrence of an event specified
for termination of coverage of the contract holder, other than for nonpayment
of premium; and
(b) shall provide
that in the event of the contract holder's death, the spouse shall become the
contract holder.
(4)
(a) An application or enrollment form
question regarding a health condition may not be vague and shall reference a
reasonable time frame in relation to the health condition.
(b)
(i) A
completed enrollment form shall be made part of the policy.
(ii) A copy of the completed application or
enrollment form shall be provided to the applicant or enrollee before or upon
delivery of the contract.
(c) An application or enrollment form shall
include:
(i) on the first page of the
contract, or attached to it, in either contrasting color or boldface type at
least equal to the font size used for headings or captions of sections in the
contract, the following prominent disclosure statement, "Short-Term Limited
Duration Health Insurance provides limited benefits. The (policy)(certificate),
either by itself or bundled with other limited benefit products, is not meant
to replace comprehensive health care insurance. It does not include benefits
required by PPACA. Review your (policy)(certificate) carefully.";
(ii) a statement regarding any preexisting
waiting period as required by Subsection
31A-22-605.1(5)(b);
and
(iii) a question regarding
whether the contract to be issued is intended to replace any other accident and
health insurance presently in force.
(d) A supplementary application or other form
signed by the applicant containing the question in Subsection (4)(c)(iii) may
be used.
(5)
(a) Except for an endorsement by which the
insurer effectuates a written request by the policyholder, signed acceptance by
the policyholder is required for an endorsement that reduces or eliminates a
benefit or coverage and is added to a policy after the date of issue.
(b) After the date of policy issue, an
endorsement that increases a benefit or coverage with a concurrent increase in
premium during the policy term shall be agreed to in writing and signed by the
policyholder, except if the increased benefit or coverage is required by
law.
(6) When a separate
additional premium is charged for a benefit provided in connection with an
endorsement, the premium charge shall be set forth in the policy and
certificate.
(7) A contract that
provides for the payment of a benefit based on a standard described as usual
and customary, reasonable and customary, or similar words, shall include a
definition and explanation of the term in its accompanying outline of coverage
or certificate.
(8)
(a) If a policy or certificate includes a
limitation regarding preexisting conditions, the limitation shall appear as a
separate paragraph and be labeled as "Preexisting Condition
Limitation."
(b) The limitation
shall include a description of the existence and term of the preexisting
condition exclusion, including the maximum preexisting exclusion
period.
(9) A short-term
limited duration health insurance policy or certificate shall include, on the
first page of the policy or certificate, or attached to it, in either
contrasting color or boldface type at least equal to the font size used for
headings or captions of sections in the policy or certificate, the following
prominent disclosure statement, "Notice to Buyer: This coverage is not required
to comply with certain federal market requirements for comprehensive health
insurance, principally those contained in the Affordable Care Act. Be sure to
read your (policy)(certificate) carefully to make sure you are aware of any
exclusions or limitations regarding coverage of preexisting conditions or
health benefits, such as hospitalization, emergency services, maternity care,
preventive care, prescription drugs, and mental health and substance use
disorder services. Your (policy)(certificate) might also have lifetime and/or
annual dollar limits on health benefits. If this coverage expires or you lose
eligibility for this coverage, you might have to wait until an open enrollment
period to get other health insurance coverage."
(10) Termination of a policy shall be without
prejudice to any continuous loss or deterioration of health that commenced
while the policy or certificate was in force, limited to the duration of the
benefit period or payment of the maximum benefits.
(11) A contract may not be offered:
(a) to an employer group as directed by:
(i) Part A of Title XXVII of the Public
Health Services Act;
(ii) Part 7 of
ERISA; or
(iii) Chapter 100 of the
Internal Revenue Code; or
(b) as a blanket insurance policy.
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.
(1) Policy expiration.
(a) A policy and certificate shall include:
(i) an expiration provision that specifies the conditions for renewal or extension; and
(ii) the total number of months or days for the full term of contract, pursuant to Subsection R590-286-5(1)(c).
(b) The provision shall be appropriately captioned and appear on the first page of the policy and certificate.
(c) Considering any renewal or extension, a short-term limited duration health insurance policy or certificate is limited to 36 months.
(2) Rights of spouse. The following provisions apply to policies that provide coverage to a spouse of the insured:
(a) A policy or certificate may not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the insured, other than for nonpayment of premium.
(b) A policy or certificate shall provide that in the event of the insured's death the spouse of the insured shall become the insured.
(3) Applications.
(a) Questions used to elicit health condition information may not be vague and must reference a reasonable time frame in relation to the health condition.
(b) A completed application shall be made part of the policy. A copy of the completed application shall be provided to the applicant prior to or upon delivery of the policy.
(c) Each application shall contain a prominent statement by type, stamp or other appropriate means in either contrasting color or boldface type at least equal to the size type used for the headings or captions of sections of the application and in close conjunction with the applicant's signature block on the application as follows, "Short-Term Limited Duration Health Insurance provides limited benefits. The (policy)(certificate), either by itself or bundled with other limited benefit products, is not meant to replace comprehensive health care insurance. It does not include benefits required by the PPACA. Review your (policy)(certificate) carefully."
(d) A statement regarding any preexisting waiting period as required by Subsection 31A-22-605.1(5)(b).
(e) An application form shall include a question designed to elicit information as to whether the insurance to be issued is intended to replace any other accident and health insurance presently in force. A supplementary application or other form to be signed by the applicant containing the question may be used.
(4) Endorsement acceptance.
(a) Except for an endorsement by which the insurer effectuates a request made in writing by the policyholder, an endorsement added to a policy after date of issue that reduces or eliminates benefits or coverage in the policy shall require signed acceptance by the policyholder.
(b) After the date of policy issue, an endorsement that increases benefits or coverage with a concurrent increase in premium during the policy term, must be agreed to in writing signed by the policyholder, except if the increased benefits or coverage is required by law.
(5) Additional premium. Where a separate additional premium is charged for benefits provided in connection with an endorsement, the premium charge shall be set forth in the policy and certificate.
(6) Benefit payment standard. A policy that provides for the payment of benefits based on standards described as usual and customary, reasonable and customary, or words of similar import, shall include a definition of the terms and an explanation of the terms in its accompanying outline of coverage or certificate.
(7) Preexisting conditions. If a policy or certificate contains any limitations with respect to preexisting conditions, the limitations shall appear as a separate paragraph of the policy and certificate and be labeled as "Preexisting Condition Limitation."
(a) The limitation shall include a description of the existence and terms of any preexisting condition exclusion under the policy, including the maximum preexisting exclusion period; and
(b) state that the exclusion period ends no later than 12 months after the first issuance of the policy or certificate.
(8) Notice to Buyer.
Any short-term limited duration health insurance policy or certificate shall display prominently on the first page of the policy or certificate, in either contrasting color or in boldface type at least equal to the size type used for headings or captions of section in the policy or certificate, the following:
"Notice to Buyer: This coverage is not required to comply with certain federal market requirements for comprehensive health insurance, principally those contained in the Affordable Care Act. Be sure to read your (policy)(certificate) carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits, such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services. Your (policy)(certificate) might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage."
(9) Termination of the policy shall be without prejudice to a continuous loss or deterioration of health that commenced while the policy or certificate was in force, limited to the duration of the benefit period or payment of the maximum benefits.