Utah Code 31A-22-648. Vision insurance — Contract provisions
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(1) As used in this section:
Terms Used In Utah Code 31A-22-648
- 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
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: includes an insured. See Utah Code 31A-1-301
- Equal: means , with respect to biological sex, of the same value. See Utah Code 68-3-12.5
- health insurance: means insurance providing:
(84)(a)(i) a health care benefit; or(84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301- Individual: means a natural person. See Utah Code 31A-1-301
- Insurance: includes :
(96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;(96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and(96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301- Person: includes :
(146)(a) an individual;(146)(b) a partnership;(146)(c) a corporation;(146)(d) an incorporated or unincorporated association;(146)(e) a joint stock company;(146)(f) a trust;(146)(g) a limited liability company;(146)(h) a reciprocal;(146)(i) a syndicate; or(146)(j) another similar entity or combination of entities acting in concert. 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 individual” means an individual who has insurance coverage under a vision plan.(1)(b) “Covered service” means a vision service that:(1)(b)(i) is reimbursable under or would be reimbursable under an enrollee‘s vision plan, but for the application of at least one of the following contractual provisions:(1)(b)(i)(A) a deductible;(1)(b)(i)(B) a copayment;(1)(b)(i)(C) coinsurance;(1)(b)(i)(D) a waiting period;(1)(b)(i)(E) an annual or lifetime maximum;(1)(b)(i)(F) a frequency limitation; or(1)(b)(i)(G) an alternative benefit payment; and(1)(b)(ii) is not merely nominal, for the purpose of avoiding the requirements of this section.(1)(c) “Optometrist” means an individual licensed under Title 58, Chapter 16a, Utah Optometry Practice Act.(1)(d) “Vendor” means a person who provides ophthalmic goods to a vision service provider.(1)(e) “Vision plan” means a health insurance policy or contract that provides vision coverage.(1)(f) “Vision service” means:(1)(f)(i) professional work performed by a vision service provider; or(1)(f)(ii) an opthalmic medical device, such as lenses, opthalmic frames, contact lenses, or a prosthetic device that treats a condition of the human eye or the areas surrounding the human eye.(1)(g) “Vision service provider” means:(1)(g)(i) an optometrist; or(1)(g)(ii) an individual who provides a vision service and is licensed under:(1)(g)(ii)(A) Title 58, Chapter 67, Utah Medical Practice Act; or(1)(g)(ii)(B) Title 58, Chapter 68, Utah Osteopathic Medical Practice Act.(2)(2)(a) This section applies to:(2)(a)(i) a vision plan that a person enters into or renews on or after January 1, 2019; and(2)(a)(ii) an administrator providing third-party administration services or a provider network for a vision plan.(2)(b) This section does not apply to a self-insured vision plan that is regulated by federal law.(3) A contract between a vision plan and a vision service provider to provide a covered service may not:(3)(a) except as provided in Subsection (4), require that a vision service provider provide a vision service to a covered individual at a fee set by, or a fee subject to the approval of, the vision plan unless the vision service is a covered service;(3)(b) prohibit a vision service provider from offering or providing a vision service that is not a covered service to a covered individual at a fee determined by:(3)(b)(i) the vision service provider; or(3)(b)(ii) the vision service provider and the covered individual; or(3)(c) require a vision service provider to use one or more specific vendors to replenish the vision service provider’s inventory of spectacle lenses after the vision service provider dispenses the vision service provider’s inventory to eligible members of the vision plan as a covered vision service.(4)(4)(a) In accordance with Subsections (4)(b) and (c), a vision service provider may, in a contract with a vision plan, agree to participate in a discount program sponsored by the vision plan.(4)(b) A contract between a vision service provider and a vision plan to provide a covered service may not be contingent on whether the vision service provider agrees to participate in a discount program sponsored by the vision plan.(4)(c) Regardless of whether a vision service provider participates in a discount program sponsored by the vision plan, a vision plan shall offer equal treatment to a vision service provider under contract with the vision plan to provide a covered service, regarding:(4)(c)(i) promotional treatment;(4)(c)(ii) marketing benefits;(4)(c)(iii) materials; and(4)(c)(iv) contract terms for providing a covered service.(5) Notwithstanding Subsection (4)(c), a vision plan may, when providing a typically-formatted list of vision service providers that accept the vision plan, identify whether a vision service provider participates in a discount program sponsored by the vision plan.