Utah Code 31A-22-613.5. Price and value comparisons of health insurance
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Terms Used In Utah Code 31A-22-613.5
- Enrollee: includes an insured. See Utah Code 31A-1-301
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Exclusion: means for the purposes of accident and health insurance that an insurer does not provide insurance coverage, for whatever reason, for one of the following:(67)(a) a specific physical condition;(67)(b) a specific medical procedure;(67)(c) a specific disease or disorder; or(67)(d) a specific prescription drug or class of prescription drugs. 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
- 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- Indemnity: means the payment of an amount to offset all or part of an insured loss. 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- Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. 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- Precedent: A court decision in an earlier case with facts and law similar to a dispute currently before a court. Precedent will ordinarily govern the decision of a later similar case, unless a party can show that it was wrongly decided or that it differed in some significant way.
- Secondary medical condition: means a complication related to an exclusion from coverage in accident and health insurance. See Utah Code 31A-1-301
- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
- Writing: includes :
(48)(a) printing;(48)(b) handwriting; and(48)(c) information stored in an electronic or other medium if the information is retrievable in a perceivable format. See Utah Code 68-3-12.5(1)(a) This section applies to all health benefit plans.(1)(b) Subsection (2) applies to:(1)(b)(i) all health benefit plans; and(1)(b)(ii) coverage offered to state employees under Subsection 49-20-202(1)(a).(2) The commissioner shall promote informed consumer behavior and responsible health benefit plans by requiring an insurer issuing a health benefit plan to provide to all enrollees, before enrollment in the health benefit plan, written disclosure of:(2)(a) restrictions or limitations on prescription drugs and biologics, including:(2)(a)(i) the use of a formulary;(2)(a)(ii) co-payments and deductibles for prescription drugs; and(2)(a)(iii) requirements for generic substitution;(2)(b) coverage limits under the plan;(2)(c) any limitation or exclusion of coverage, including:(2)(c)(i) a limitation or exclusion for a secondary medical condition related to a limitation or exclusion from coverage; and(2)(c)(ii) easily understood examples of a limitation or exclusion of coverage for a secondary medical condition;(2)(d)(2)(d)(i)(2)(d)(i)(A) each drug, device, and covered service that is subject to a preauthorization requirement as defined in Section 31A-22-650; or(2)(d)(i)(B) if listing each device or covered service in accordance with Subsection (2)(d)(i)(A) is too numerous to list separately, all devices or covered services in a particular category where all devices or covered services have the same preauthorization requirement;(2)(d)(ii) each requirement for authorization as defined in Section 31A-22-650 for:(2)(d)(ii)(A) each drug, device, or covered service described in Subsection (2)(d)(i)(A); and(2)(d)(ii)(B) each category of devices or covered services described in Subsection (2)(d)(i)(B); and(2)(d)(iii) sufficient information to allow a network provider or enrollee to submit all of the information to the insurer necessary to meet each requirement for authorization described in Subsection (2)(d)(ii);(2)(e) whether the insurer permits an exchange of the adoption indemnity benefit in Section 31A-22-610.1 for infertility treatments, in accordance with Subsection 31A-22-610.1(1)(c)(ii) and the terms associated with the exchange of benefits; and(2)(f) whether the insurer provides coverage for telehealth services in accordance with Section 26B-3-123 and terms associated with that coverage.(3) An insurer shall provide the disclosure required by Subsection (2) in writing to the commissioner:(3)(a) upon commencement of operations in the state; and(3)(b) anytime the insurer amends any of the following described in Subsection (2):(3)(b)(i) treatment policies;(3)(b)(ii) practice standards;(3)(b)(iii) restrictions;(3)(b)(iv) coverage limits of the insurer’s health benefit plan or health insurance policy; or(3)(b)(v) limitations or exclusions of coverage including a limitation or exclusion for a secondary medical condition related to a limitation or exclusion of the insurer’s health insurance plan.(4)(4)(a) An insurer shall provide the enrollee with notice of an increase in costs for prescription drug coverage due to a change in benefit design under Subsection (2)(a):(4)(a)(i) either:(4)(a)(i)(A) in writing; or(4)(a)(i)(B) on the insurer’s website; and(4)(a)(ii) at least 30 days prior to the date of the implementation of the increase in cost, or as soon as reasonably possible.(4)(b) If under Subsection (2)(a) a formulary is used, the insurer shall make available to prospective enrollees and maintain evidence of the fact of the disclosure of:(4)(b)(i) the drugs included;(4)(b)(ii) the patented drugs not included;(4)(b)(iii) any conditions that exist as a precedent to coverage; and(4)(b)(iv) any exclusion from coverage for secondary medical conditions that may result from the use of an excluded drug.(4)(c) The commissioner shall develop examples of limitations or exclusions of a secondary medical condition that an insurer may use under Subsection (2)(c).(5) Examples of a limitation or exclusion of coverage provided under this section or otherwise are for illustrative purposes only, and the failure of a particular fact situation to fall within the description of an example does not, by itself, support a finding of coverage.(6) An insurer shall:(6)(a) post the information described in Subsection (2)(d) on the insurer’s website and provider portal;(6)(b) if requested by an enrollee, provide the enrollee with the information required by this section by mail or email; and(6)(c) if requested by a network provider for a specific drug, device, or covered service, provide the network provider with the information described in Subsection (2)(d) for the drug, device, or covered service by mail or email.