Utah Code 31A-22-646. Dental insurance — Contract provision for noncovered services
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(1) For purposes of this section:
Terms Used In Utah Code 31A-22-646
- Administrator: means the same as that term is defined in Subsection (187). See Utah Code 31A-1-301
- Application: means a document:(10)(a)(10)(a)(i) completed by an applicant to provide information about the risk to be insured; and(10)(a)(ii) that contains information that is used by the insurer to evaluate risk and decide whether to:(10)(a)(ii)(A) insure the risk under:(10)(a)(ii)(A)(I) the coverage as originally offered; or(10)(a)(ii)(A)(II) a modification of the coverage as originally offered; or(10)(a)(ii)(B) decline to insure the risk; or(10)(b) used by the insurer to gather information from the applicant before issuance of an annuity contract. See Utah Code 31A-1-301
- Certificate: means evidence of insurance given to:
(23)(a) an insured under a group insurance policy; or(23)(b) a third party. See Utah Code 31A-1-301- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: includes an insured. See Utah Code 31A-1-301
- Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
- Individual: means a natural person. See Utah Code 31A-1-301
- Policy: includes a service contract issued by:
(150)(b)(i) a motor club under Chapter 11, Motor Clubs;(150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and(150)(b)(iii) a corporation licensed under:(150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or(150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301(1)(a) “Covered services” means dental services for which reimbursement:(1)(a)(i) is available or would be reimbursable under an enrollee‘s dental plan but for the application of one or more of the following contractual provisions:(1)(a)(i)(A) deductibles;(1)(a)(i)(B) copayments;(1)(a)(i)(C) coinsurance;(1)(a)(i)(D) waiting periods;(1)(a)(i)(E) annual or lifetime maximums;(1)(a)(i)(F) frequency limitations; or(1)(a)(i)(G) alternative benefit payments; and(1)(a)(ii) is not merely nominal, for the purpose of avoiding the requirements of this section.(1)(b) “Dental plan”means:(1)(b)(i) a health benefit plan that includes coverage for dental services; and(1)(b)(ii) a policy or certificate that provides coverage solely for dental services.(1)(c) “Dentist” means an individual licensed under Title 58, Chapter 69, Dentist and Dental Hygienist Practice Act.(2)(2)(a) This section applies to:(2)(a)(i) a dental plan that is entered into or renewed on or after January 1, 2018; and(2)(a)(ii) an administrator providing third-party administration services or a provider network for a dental plan.(2)(b) This section does not apply to a self-insured dental plan that is regulated by federal law.(3) A contract between a dental plan and a dentist to provide covered services may not:(3)(a) require, directly or indirectly, that a dentist provide dental services to a covered individual at a fee set by, or a fee subject to the approval of, the dental plan unless:(3)(a)(i) the dental services are covered services under the dental plan; or(3)(a)(ii)(3)(a)(ii)(A) the dental services are not reimbursed by the dental plan;(3)(a)(ii)(B) the dental services are discounted for individuals who are part of a discount dental rates plan; and(3)(a)(ii)(C) the dentist who provided the dental services has elected to participate in the discount dental rates plan; and(3)(b) prohibit a dentist from offering or providing noncovered dental services to a covered individual at a fee determined by the dentist and the individual who will receive the noncovered services. - Certificate: means evidence of insurance given to: