Health Insurance Benefit Coverage Law Summaries

Health Insurance Benefit Coverage Law Summaries

Utah, Health Insurance Benefit Coverage Law Summaries

Utah's mandated health care law is located in the Utah Code Annotated at Title 31A. Some of the coordination of benefits provisions are located in the Utah Administrative Code at Section R590-131-4.

DEFINITIONS

“Catastrophic mental health coverage” means coverage in a health insurance policy or HMO contract that does not impose any lifetime limit, annual payment limit, episodic limit, inpatient or outpatient service limit, or maximum out-of-pocket limit that places a greater financial burden on an insured for the evaluation and treatment of a mental health condition (see definition below) than for the evaluation and treatment of a physical condition (Sec. 31A-22-625(1)(a)(i), as added by H. 35, L. 2000, effective May 1, 2000).

“Catastrophic mental health coverage” may include a restriction on cost sharing factors, such as deductibles, copayments, or coinsurance, prior to reaching any maximum out-of-pocket limit (Sec. 31A-22-625(1)(a)(ii), as added by H. 35, L. 2000, effective May 1, 2000).

“Catastrophic mental health coverage” may include one maximum out-of-pocket limit for physical health conditions and another maximum out-of-pocket limit for mental health conditions, provided that, if separate out-of-pocket limits are established, the out-of-pocket limit for mental health conditions may not exceed the out-of-pocket limit for physical health conditions (Sec. 31A-22-625(1)(a)(iii), as added by H. 35, L. 2000, effective May 1, 2000).

“Genetic analysis” or “genetic test” means the testing or analysis of an identifiable individual's DNA that results in information that is derived from the presence, absence, alteration, or mutation of an inherited gene or genes, or the presence or absence of a specific DNA marker or markers. These terms do not mean (Sec. 26-45-102, as added by H. 56, L. 2002, effective January 1, 2003):

1. a routine physical exam;

2. a routine chemical, blood, or urine analysis;

3. a test to identify the presence of drugs or HIV infection; or

4. a test performed due to the presence of signs, symptoms, or other manifestations of a disease, illness, impairment, or other disorder.

“Private genetic information” means any information about an identifiable individual that is derived from the presence, absence, alteration, or mutation of an inherited gene or genes, or the presence or absence of a specific DNA marker or markers, and that has been obtained from a genetic test or analysis of the individual's DNA or from a genetic test or analysis of a person's DNA to whom the individual is a blood relative. This term does not include information that is derived from (Sec. 26-45-102, as added by H. 56, L. 2002, effective January 1, 2003):

1. a routine physical exam;

2. a routine chemical, blood, or urine analysis;

3. a test to identify the presence of drugs or HIV infection; or

4. a test performed due to the presence of signs, symptoms, or other manifestations of a disease, illness, impairment, or other disorder.

“Mental health condition” means any condition or disorder involving mental illness that falls under any of the diagnostic categories listed in the Diagnostic and Statistical Manual, as periodically revised. The term does not include the following when diagnosed as the primary or substantial reason or need for treatment (Sec. 31A-22-625(1), as added by H. 35, L. 2000, effective May 1, 2000):

1. marital or family problem;

2. social, occupational, religious or other social maladjustment;

3. conduct disorder;

4. chronic adjustment disorder;

5. psychosexual disorder;

6. chronic organic brain syndrome;

7. personality disorder;

8. specific developmental disorder or learning disability; or

9. mental retardation.

A “small employer” is any person, firm, corporation, partnership, or association that is actively engaged in business that on at least half (50 percent) of its working days during the preceding calendar quarter employed at least one but no more than 25 eligible employees, the majority of whom are employed in Utah. Companies that are affiliated companies or eligible to file a combined tax return for the state are considered one employer (Sec. 31A-30-103).

WHAT THE EMPLOYER MUST DO

Utah does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.

Mental health coverage.- A group disability plan offered by an insurer must comply with Sec. 31A-22-720(1)(b) (below) if the group disability plan (Sec. 31A-22-720(1)(a), as added by S. 190, L. 2000, effective May 1, 2000):

1. applies an aggregate lifetime limit to plan payments for medical or surgical services covered by the group disability plan; and

2. provides a mental health benefit.

A group disability plan described in Sec. 31A-22-720(1)(a) (above) must (Sec. 31A-22-720(1)(b), as added by S. 190, L. 2000, effective May 1, 2000):

1. include in the aggregate lifetime limit for medical or surgical services covered by the group disability plan the payments made under the plan for mental health services; or

2. establish a separate aggregate lifetime limit to plan payments for mental health services covered by the group disability plan, but only if the dollar amount of the aggregate lifetime limit for mental health services covered by that plan is equal to or greater than the dollar amount of the aggregate lifetime limit for medical or surgical services covered by that plan.

A group disability plan offered by an insurer must comply with Sec. 31A-22-720(2)(b) (below) if the group disability plan (Sec. 31A-22-720(2)(a), as added by S. 190, L. 2000, effective May 1, 2000):

1. applies an annual limit to plan payments for medical or surgical services covered by the group disability plan; and

2. provides a mental health benefit.

A group disability plan described in Sec. 31A-22-720(2)(a) (above) must (Sec. 31A-22-720(2)(b), as added by S. 190, L. 2000, effective May 1, 2000):

1. include in the annual limit for medical or surgical services covered by the group disability plan the payments made under the plan for mental health services; or

2. establish a separate annual limit to plan payments for mental health services covered by the group disability plan, but only if the dollar amount of the annual limit for mental health services covered by that plan is equal to or greater than the dollar amount of the annual limit for medical or surgical services covered by that plan.

The mental health parity provisions described above do not apply to benefits for substance abuse or chemical dependency, nor to disability benefits or plans paid under Title XVII or XIX of the Social Security Act, nor to plans maintained by employers that employ less than 50 employees (Sec. 31A-22-720(4) and (5), as added by S. 190, L. 2000, effective May 1, 2000).

Catastrophic mental health coverage.- At the time of purchase and renewal, an insurer must offer to each small employer that it insures or seeks to insure a choice between catastrophic mental health coverage (see DEFINITIONS above) and 50/50 mental health coverage (Sec. 31A-22-625(2)(a), as added by H. 35, L. 2000, effective May 1, 2000). 50/50 mental health coverage means coverage in a health insurance policy or HMO contract that pays for at least 50% of covered services for the diagnosis and treatment of mental health conditions (see DEFINITIONS above). 50/50 mental health coverage may include a restriction on episodic limits, inpatient or outpatient service limits, or maximum out-of-pocket limits (Sec. 31A-22-625(1), as added by H. 35, L. 2000, effective May 1, 2000).

In addition to Sec. 31A-22-625(2)(a) just above, an insurer may offer to provide (Sec. 31A-22-625(2)(b), as added by H. 35, L. 2000, effective May 1, 2000):

1. catastrophic mental health coverage, 50/50 mental health coverage, or both at levels that exceed the minimum requirements of this section; or

2. coverage that excludes benefits for mental health conditions.

A small employer may, at its option, choose either catastrophic mental health coverage, 50/50 mental health coverage, or coverage offered under Sec. 31A-22-625(2)(b) just above, regardless of the employer's previous coverage for mental health conditions (Sec. 31A-22-625(2)(c), as added by H. 35, L. 2000, effective May 1, 2000).

At the time of purchase and renewal, an insurer must offer catastrophic mental health coverage to each large employer that it insures or seeks to insure. In addition to this coverage, an insurer may offer to provide catastrophic mental health coverage at levels that exceed the minimum requirements of this section. A large employer may, at its option, choose either catastrophic mental health coverage, coverage that excludes benefits for mental health conditions, or coverage that exceeds the minimum requirements of this section (Sec. 31A-22-625(3), as added by H. 35, L. 2000, effective May 1, 2000).

An insurer may provide catastrophic mental health coverage through a managed care organization or system in a manner consistent with Utah's HMO law, regardless of whether the policy or contract uses a managed care organization or system for the treatment of physical health conditions (Sec. 31A-22-625(4), as added by H. 35, L. 2000, effective May 1, 2000).

An insurer may (Sec. 31A-22-625(4), as added by H. 35, L. 2000, effective May 1, 2000):

1. establish a closed panel of providers for catastrophic mental health coverage; and

2. refuse to provide any benefit to be paid for services rendered by a nonpanel provider unless the insured is referred to a nonpanel provider with the prior authorization of the insurer and the nonpanel provider agrees to follow the insurer's protocols and treatment guidelines.

If an insured receives services from a nonpanel provider in the manner permitted by item (2) just above, the insurer must reimburse the insured for not less than 75% of the average amount paid by the insurer for comparable services of panel providers under a noncapitated arrangement who are members of the same class of health care providers (Sec. 31A-22-625(4), as added by H. 35, L. 2000, effective May 1, 2000).

To be eligible for catastrophic mental health coverage, a diagnosis or treatment of a mental health condition must be rendered (Sec. 31A-22-625(4), as added by H. 35, L. 2000, effective May 1, 2000):

1. by a mental health therapist; or

2. in a health care facility licensed or otherwise authorized to provide mental health services pursuant to Utah's Health Care Facility Licensing and Inspection Act or the state's law dealing with licensure of programs and facilities, that provides a program for the treatment of a mental health condition pursuant to a written plan.

An insurer must offer catastrophic mental health coverage as part of an HMO contract that is governed by Utah's HMO law, that is in effect on or after January 1, 2001. An insurer must offer catastrophic mental health coverage as a part of a health insurance policy that is not governed by Utah's HMO law, that is in effect on or after July 1, 2001 (Sec. 31A-22-625(8), as added by H. 35, L. 2000, effective May 1, 2000).

Dependent care coverage.- If any disability insurance policy provides coverage for any members of the policyholder's or certificate holder's family, the policy must also provide that any health insurance benefits applicable to dependents of the insured are applicable on the same basis to a newly born child from the moment of birth, and to an adopted child (a) beginning from the moment of birth if placement for adoption occurs within 30 days of the child's birth; or (b) beginning from the date of placement if placement for adoption occurs 30 days or more after the child's birth (Sec. 31A-22-610, as amended by S.B. 194, L. 1996).

This coverage includes any injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities or prematurity (Sec. 31A-22-610, as amended by S.B. 194, L. 1996).

Any group accident and health insurance policy or HMO contract that provides coverage for a policyholder's or certificate holder's dependent may not terminate coverage of an unmarried dependent by reason of the dependent's age before the dependent's 26th birthday and must, upon application, provide coverage for all unmarried dependents up to age 26 (Sec. 31A-22-610.5, as amended by Ch. 108 (H. 207), L. 2004).

Adoption.- The coverage required as to children placed for the purpose of adoption with a policyholder or certificate holder continues in the same manner as it would with respect to a child of the policyholder or certificate holder unless the placement is disrupted prior to legal adoption and the child is removed from placement. The coverage requirement ends if the child is removed from placement prior to being legally adopted (Sec. 31A-22-610, as amended by S. 194, L. 1996).

If an insured has coverage for maternity benefits on the date of an adoptive placement, the insured's policy shall provide an adoption indemnity benefit payable to the insured, if a child is placed for adoption with the insured within 90 days of the child's birth. If more than one child from the same birth is placed for adoption with the insured, only one adoption indemnity benefit is required. If a policy offers optional maternity benefits, it shall also offer coverage for adoption indemnity benefits if (1) a child is placed for adoption with the insured within 90 days of the child's birth; and (2) the adoption is finalized within one year of the child's birth (Sec. 31A-22-610.1, as amended by H. 85, L. 2004).

Disabilities.- Every disability insurance policy or contract that provides that coverage of a dependent child of a person insured under the policy terminates upon reaching a limiting age as specified in the policy, must also provide that the age limitation does not terminate the coverage of an unmarried disabled dependent. “Disabled dependent” means a child who is and continues to be both unable to engage in substantial gainful employment such that the child can achieve economic independence due to a medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than 12 months; and chiefly dependent upon an insured for support and maintenance (Sec. 31A-22-611, as amended by Ch. 188, L. 2006).

Substance abuse coverage.- Each group disability insurance policy must contain an optional rider allowing certificate holders to obtain coverage for alcohol or drug dependency treatment in programs licensed by the Department of Human Services, inpatient hospitals accredited by the Joint Commission on the Accreditation of Hospitals, or facilities licensed by the Department of Health (Sec. 31A-22-715).

Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, HMOs, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.

Health plans must specify how benefits will be coordinated (Secs. 31A-2-201 and 31A-21-307, and Utah Administrative Code Sec. R590-131-4).

Order of benefits.- The following priority applies when coordinating health benefit payments (Utah Administrative Code Sec. R590-131-4):

1. Employee/Dependent: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;

2. Dependent Child/Birthday Rule: For a dependent child whose parents are not separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time. If only one of the two plans specifies this rule, benefits will be paid first according to the order of benefits specified in the plan without the birthday rule;

3. Dependent Child/Divorced or Separated Parents: For a dependent child whose parents are separated or divorced and who is covered by two health benefit plans, HMOs, or health insurance policies, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent. If the specific terms of the court decree state that the parents must share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child will follow the order of benefit determination rules specified in the birthday rule;

4. Active/Inactive Employee: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored; and

5. Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, HMO, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time.

Providers.- Insurers may not unfairly discriminate against any licensed class of health care providers by structuring contract exclusions that exclude payment of benefits for the treatment of any illness, injury, or condition by any licensed class of health care providers when the treatment is within the scope of the licensee's practice and the illness, injury, or condition falls within the coverage of the contract (Sec. 31A-22-618, as amended by H. 35, L. 2000, effective May 1, 2000).

Primary care physician.- Any disability insurance policies that require insureds to select a primary care physician must permit an insured to select a participating provider who is an obstetrician/gynecologist as long as the provider is qualified and willing to provide primary care services (Sec. 31A-22-623, enacted by HB 86, effective January 1, 1999).

Preexisting conditions.- Group health insurance plans may deny health benefit coverage because of preexisting conditions if the condition first manifested itself within six months immediately before the effective date of coverage. Coverage will not be excluded due to preexisting conditions for longer than 12 months after the effective date (Sec. 31A-22-605).

Small employers.- Group health insurance plans for small employers may deny health benefit coverage if the condition that would cause a prudent person to seek diagnosis, care, treatment, or medical advice first manifested itself within six months immediately before the effective date of coverage; medical advice or treatment was recommended or received within six months immediately before the effective date of coverage; or the insured was pregnant on the effective date of coverage. Coverage will not be excluded due to preexisting conditions for longer than 12 months after the effective date (Sec. 31A-30-107).

Metabolic disorders.- The Insurance Commissioner will establish minimum standards of coverage for dietary products used for the treatment of inborn errors of amino acid or urea cycle metabolism at levels consistent with the major medical benefit provided under a disability insurance policy (Sec. 31A-22-623, as added by H. 205, L. 1998).

Mastectomies.- If an insured has coverage that provides medical and surgical benefits with respect to a mastectomy, it must provide coverage, with consultation of the attending physician and the patient, for (Sec. 31A-22-625, as added by S. 190, L. 2000, effective May 1, 2000):

1. reconstruction of the breast on which the mastectomy has been performed;

2. surgery and reconstruction of the breast on which the mastectomy was not performed to produce symmetrical appearance; and

3. prostheses and physical complications with regards to all stages of mastectomy, including lymphedemas.

Maternity benefits.- If an insured has coverage for maternity benefits, the policy may not be limited to less than a 48-hour benefit for both mother and newborn with a normal vaginal delivery. If an insured has coverage for maternity benefits, the policy may not be limited to a less than 96-hour benefit for both mother and newborn with a caesarean section delivery (Sec. 31A-22-610.2, as added by S. 190, L. 2000, effective May 1, 2000).

Referrals to specialists.- With respect to a health insurance policy or HMO contract that does not allow an insured to have direct access to a health care specialist, the insurer must establish and implement a procedure by which an insured may obtain a standing referral to a health care specialist (Sec. 31A-22-625, as added by H. 186, L. 2000, effective July 1, 2000).

Genetic information/testing.- With respect to matters related to genetic testing and private genetic information, an insurer must comply with Sec. 26-45-104 below and the other applicable provisions of Title 26, Ch. 45, Genetic Testing Privacy Act (Sec. 31A-22-1602, as added by H. 56, L. 2002, effective January 1, 2003).

Except as provided in Sec. 26-45-104(2) below, an insurer offering health care insurance as defined in Sec. 31A-1-301 may not in connection with the offer or renewal of an insurance product or in the determination of premiums, coverage, renewal, cancellation, or any other underwriting decision that pertains directly to the individual or any group of which the individual is a member that purchases insurance jointly (Sec. 26-45-104(1), as added by H. 56, L. 2002, effective January 1, 2003):

1. access or otherwise take into consideration private genetic information about an individual;

2. request or require an individual to consent to a release for the purpose of accessing private genetic information about the individual;

3. request or require an individual or his or her blood relative to submit to a genetic test; and

4. inquire into or otherwise take into consideration the fact that an asymptomatic individual or his or her blood relative has taken or refused to take a genetic test.

An insurer offering health care insurance (Sec. 26-45-104(2), as added by H. 56, L. 2002, effective January 1, 2003):

1. may request information regarding the necessity of a genetic test, but not the results of the test, if a claim for payment for the test has been made against an individual's health insurance policy;

2. may request that portion of private genetic information that is necessary to determine the insurer's obligation to pay for health care services where (a) the primary basis for rendering such services to an individual is the result of a genetic test; and (b) a claim for payment for such services has been made against the individual's health insurance policy;

3. may only store information obtained under this subsection in accordance with HIPAA; and

4. may only use or otherwise disclose the information obtained under this subsection in connection with a proceeding to determine the obligation of an insurer to pay for a genetic test or health care services, provided that, in accordance with HIPAA, the insurer makes a reasonable effort to limit disclosure to the minimum necessary to carry out the purposes of the disclosure.

An insurer may, to the extent permitted by Sec. 26-45-104(2) above, seek an order compelling the disclosure of private genetic information held by an individual or third party. An order authorizing the disclosure of private genetic information pursuant to Sec. 26-45-104(2) above must (Sec. 26-45-104(3), as added by H. 56, L. 2002, effective January 1, 2003):

1. limit disclosure to those parts of the record containing information essential to fulfill the objective of the order;

2. limit disclosure to those persons whose need for the information is the basis of the order; and

3. include such other measures as may be necessary to limit disclosure for the protection of the individual.

Private right of action.- An individual whose legal rights arising under this law have been violated after June 30, 2003, may recover damages and be granted equitable relief in a civil action. Any insurance company that violates the legal rights of an individual arising from this law will be liable to the individual for each separate violation in an amount equal to (Sec. 26-45-105, as added by H. 56, L. 2002, effective January 1, 2003):

1. actual damages sustained as a result of the violation;

2. $100,000 if the violation is the result of an intentional and wilful act, or punitive damages if the violation is the result of a malicious act; and

3. reasonable attorneys' fees.

Enforcement.- Whenever the attorney general has reason to believe that any person is using or is about to use any method, act, or practice in violation of the provisions of this law, and that proceedings would be in the public interest, the attorney general may bring an action against the person to restrain or enjoin the use of such method, act or practice. In addition to restraining or enjoining the use of a method, act or practice, the court may, after June 30, 2003, require the payment of (Sec. 26-45-106, as added by H. 56, L. 2002, effective January 1, 2003):

1. a civil fine of not more than $25,000 for each separate intentional violation; and

2. reasonable costs of investigation and litigation.

State contractors.- Businesses with construction or design contracts of at least $1.5 million (or subcontracts of at least $750,000) with certain state entities must offer qualified health insurance coverage to eligible employees and their dependents for the duration of the contracts. State entities affected include: the Department of Environmental Quality, the Capitol Preservation Board, the Department of National Resources, the Division of Facilities Construction and Management, the Utah Department of Transportation, and public transit districts (Secs. 17B-2a-818.5, 19-1-206, 63-34-22, 63C-9-403, and 72-6-107.5 as added by, and Sec. 63A-5-205 as amended by, H. 331, L. 2009, effective for contracts entered into on or after July 1, 2009).

WHO TO CONTACT

Contact the Insurance Commissioner at 3110 State Office Building, Salt Lake City, UT 84114. Telephone: (801) 538-3804. Fax: (801) 538-3829.

<p>Contact the Insurance Commissioner at 3110 State Office Building, Salt Lake City, UT 84114. Telephone: (801) 538-3804. Fax: (801) 538-3829.</p>

Utah, Health Insurance Benefit Coverage Law Summaries

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