Utah Admin. Code R590-286-6 - Minimum Benefit Standards
(1)
(a) A short-term limited duration health
insurance contract shall specify that the initial term is less than 12
months.
(b) The maximum duration,
including any extensions, has an expiration date that is not more than 36
months after the first issuance of the policy or certificate.
(c) Subject to Subsection
R590-286-6(1)(b),
a policy may not be renewed.
(2) A contract shall provide medical coverage
that includes, at a minimum, the following benefits:
(a) hospital, surgical, and medical expense
coverage, to an aggregate maximum of not less than:
(i) $1,000,000; and
(ii) copayment or coinsurance not to exceed
50% of covered charges;
(b) hospital services, including:
(i) inpatient services; and
(ii) other miscellaneous services associated
with admission to a hospital for diagnosis and treatment of a covered
condition, including medically necessary services delivered in a hospital
setting, including:
(A) professional
services;
(B) anesthesia;
(C) facility fees;
(D) supplies;
(E) imaging;
(F) laboratory;
(G) pharmacy services and prescription
drugs;
(H) treatments;
(I) therapy; and
(J) other services delivered on an inpatient
basis;
(c)
outpatient services, including medically necessary services ordered by the
enrollee's attending health care practitioner and provided on an ambulatory
basis for the diagnosis and treatment of a covered condition, including:
(i) office and clinic visits;
(ii) diagnostic imaging;
(iii) laboratory services;
(iv) radiation therapy;
(v) physical therapy;
(vi) speech therapy;
(vii) occupational therapy; and
(viii) hemodialysis;
(d) surgical services for the diagnosis and
treatment of a covered condition, which must include:
(i) inpatient and outpatient surgical
services at a hospital, ambulatory surgical facility, surgical suite, or a
provider's office; and
(ii)
medically necessary services related to a surgical service delivered in a
hospital, ambulatory surgical facility, surgical suite, or a provider's office,
including:
(A) a professional
service;
(B)
anesthesiology;
(C) facility
fees;
(D) a supply;
(E) laboratory; and
(F) a pharmaceutical service or prescription
drug related to, or required as a result of, the surgical procedure;
and
(e) a
medical service for the diagnosis and treatment of a covered condition,
including:
(i) an office visit;
(ii) a benefit for inborn metabolic errors as
required under Section
31A-22-623 and Rule
R590-194;
(iii) a benefit for
diabetes as required under Section
31A-22-626 and Rule R590-220;
and
(iv) telehealth services and
telemedicine services as appropriate.
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) The duration of a short-term limited duration health insurance policy shall specify that the contract is less than 12 months after the first issuance of the policy or certificate.
(a) The maximum duration, considering any extensions, has an expiration date which is not more than 36 months after the first issuance of the policy or certificate.
(b) Subject to Subsection R590-286-6(1)(a), a short-term limited duration health insurance policy cannot be renewed.
(2) Short-term limited duration health insurance provides medical coverage that includes, at a minimum, the following benefits:
(a) hospital, surgical, and medical expense coverage, to an aggregate maximum of not less than:
(i) $1,000,000; and
(ii) copayment or coinsurance not to exceed 50% of covered charges;
(b) hospital services, including:
(i) inpatient services; and
(ii) other miscellaneous services associated with admission to a hospital for diagnosis and treatment of a covered condition, including medically necessary services delivered in a hospital setting, including:
(A) professional services;
(B) anesthesia;
(C) facility fees;
(D) supplies;
(E) imaging;
(F) laboratory;
(G) pharmacy services and prescription drugs;
(H) treatments;
(I) therapy; and
(J) other services delivered on an inpatient basis;
(c) outpatient services, including medically necessary services ordered by the insured's attending health care practitioner and rendered on an ambulatory basis for diagnosis and treatment of a covered condition, including:
(i) office and clinic visits;
(ii) diagnostic imaging;
(iii) laboratory services;
(iv) radiation therapy;
(v) physical therapy;
(vi) speech therapy;
(vii) occupational therapy; and
(viii) hemodialysis;
(d) surgical services for diagnosis and treatment of a covered condition must include:
(i) inpatient and outpatient surgical services at a hospital, ambulatory surgical facility, surgical suite, or provider's office; and
(ii) medically necessary services delivered in a hospital, ambulatory surgical facility, surgical suite, or provider's office related to provision of a surgical service, including:
(A) professional services;
(B) anesthesiology;
(C) facility fees;
(D) supplies;
(E) laboratory; and
(F) pharmacy services and prescription drugs related to, or required as a result of, the surgical procedure; and
(e) medical services for diagnosis and treatment of a covered condition including;
(i) office visits;
(ii) benefits for inborn metabolic errors as required by Section 31A-22-623 and Rule R590-194;
(iii) benefits for diabetes as required by Section 31A-22-626 and Rule R590-220; and
(iv) telehealth services and telemedicine services as appropriate.