Utah Code 31A-22-625. Catastrophic coverage of mental health conditions
Current as of: 2024 | Check for updates
|
Other versions
(1) As used in this section:
Terms Used In Utah Code 31A-22-625
- Disability: means a physiological or psychological condition that partially or totally limits an individual's ability to:(51)(a) perform the duties of:(51)(a)(i) that individual's occupation; or(51)(a)(ii) an occupation for which the individual is reasonably suited by education, training, or experience; or(51)(b) perform two or more of the following basic activities of daily living:(51)(b)(i) eating;(51)(b)(ii) toileting;(51)(b)(iii) transferring;(51)(b)(iv) bathing; or(51)(b)(v) dressing. 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 care: means any of the following intended for use in the diagnosis, treatment, mitigation, or prevention of a human ailment or impairment:
(83)(a) a professional service;(83)(b) a personal service;(83)(c) a facility;(83)(d) equipment;(83)(e) a device;(83)(f) supplies; or(83)(g) medicine. 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- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
(103)(a)(i) a policyholder;(103)(a)(ii) a subscriber;(103)(a)(iii) a member; and(103)(a)(iv) a beneficiary. See Utah Code 31A-1-301- Intellectual disability: means a significant, subaverage general intellectual functioning that:
(16)(a) exists concurrently with deficits in adaptive behavior; and(16)(b) is manifested during the developmental period as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. See Utah Code 68-3-12.5- Managed care organization: means a person:
(122)(a) licensed as a health maintenance organization under Chapter 8, Health Maintenance Organizations and Limited Health Plans; or(122)(b)(122)(b)(i) licensed under:(122)(b)(i)(A) Chapter 5, Domestic Stock and Mutual Insurance Corporations;(122)(b)(i)(B) Chapter 7, Nonprofit Health Service Insurance Corporations; or(122)(b)(i)(C) Chapter 14, Foreign Insurers; and(122)(b)(ii) that requires an enrollee to use, or offers incentives, including financial incentives, for an enrollee to use, network providers. 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- Small employer: means , in connection with a health benefit plan and with respect to a calendar year and to a plan year, an employer who:
(182)(a)(i)(182)(a)(i)(A) employed at least one but not more than 50 eligible employees on business days during the preceding calendar year; or(182)(a)(i)(B) if the employer did not exist for the entirety of the preceding calendar year, reasonably expects to employ an average of at least one but not more than 50 eligible employees on business days during the current calendar year;(182)(a)(ii) employs at least one employee on the first day of the plan year; and(182)(a)(iii) for an employer who has common ownership with one or more other employers, is treated as a single employer under Utah Code 31A-1-301(1)(a)(1)(a)(i) “Catastrophic mental health coverage” means coverage in a health benefit plan that does not impose a 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 than for the evaluation and treatment of a physical health condition.(1)(a)(ii) “Catastrophic mental health coverage” may include a restriction on cost sharing factors, such as deductibles, copayments, or coinsurance, before reaching a maximum out-of-pocket limit.(1)(a)(iii) “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, except 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.(1)(b)(1)(b)(i) “50/50 mental health coverage” means coverage in a health benefit plan that pays for at least 50% of covered services for the diagnosis and treatment of mental health conditions.(1)(b)(ii) “50/50 mental health coverage” may include a restriction on:(1)(b)(ii)(A) episodic limits;(1)(b)(ii)(B) inpatient or outpatient service limits; or(1)(b)(ii)(C) maximum out-of-pocket limits.(1)(c) “Large employer” is as defined in 42 U.S.C. § 300gg-91.(1)(d)(1)(d)(i) “Mental health condition” means a condition or disorder involving mental illness that falls under a diagnostic category listed in the Diagnostic and Statistical Manual, as periodically revised.(1)(d)(ii) “Mental health condition” does not include the following when diagnosed as the primary or substantial reason or need for treatment:(1)(d)(ii)(A) a marital or family problem;(1)(d)(ii)(B) a social, occupational, religious, or other social maladjustment;(1)(d)(ii)(C) a conduct disorder;(1)(d)(ii)(D) a chronic adjustment disorder;(1)(d)(ii)(E) a psychosexual disorder;(1)(d)(ii)(F) a chronic organic brain syndrome;(1)(d)(ii)(G) a personality disorder;(1)(d)(ii)(H) a specific developmental disorder or learning disability; or(1)(d)(ii)(I) an intellectual disability.(1)(e) “Small employer” is as defined in 42 U.S.C. § 300gg-91.(2)(2)(a) At the time of purchase and renewal, an insurer shall offer to a small employer that it insures or seeks to insure a choice between:(2)(a)(i)(2)(a)(i)(A) catastrophic mental health coverage; or(2)(a)(i)(B) federally qualified mental health coverage as described in Subsection (3); and(2)(a)(ii) 50/50 mental health coverage.(2)(b) In addition to complying with Subsection (2)(a), an insurer may offer to provide:(2)(b)(i) catastrophic mental health coverage, 50/50 mental health coverage, or both at levels that exceed the minimum requirements of this section; or(2)(b)(ii) coverage that excludes benefits for mental health conditions.(2)(c) A small employer may, at its option, regardless of the employer’s previous coverage for mental health conditions, choose either:(2)(c)(i) coverage offered under Subsection (2)(a)(i);(2)(c)(ii) 50/50 mental health coverage; or(2)(c)(iii) coverage offered under Subsection (2)(b).(2)(d) An insurer is exempt from the 30% index rating restriction in Section 31A-30-106.1 and, for the first year only that the employer chooses coverage that meets or exceeds catastrophic mental health coverage, the 15% annual adjustment restriction in Section 31A-30-106.1, for a small employer with 20 or less enrolled employees who chooses coverage that meets or exceeds catastrophic mental health coverage.(3)(3)(a) An insurer shall offer a large employer mental health and substance use disorder benefit in compliance with Section 2705 of the Public Health Service Act, 42 U.S.C. § 300gg-26, and federal regulations adopted pursuant to that act.(3)(b) An insurer shall provide in an individual or small employer health benefit plan, mental health and substance use disorder benefits in compliance with Sections 2705 and 2711 of the Public Health Service Act, 42 U.S.C. § 300gg-26, and federal regulations adopted pursuant to that act.(4)(4)(a) An insurer may provide catastrophic mental health coverage to a small employer through a managed care organization or system in a manner consistent with Chapter 8, Health Maintenance Organizations and Limited Health Plans, regardless of whether the insurance policy uses a managed care organization or system for the treatment of physical health conditions.(4)(b)(4)(b)(i) Notwithstanding any other provision of this title, an insurer may:(4)(b)(i)(A) establish a closed panel of providers for catastrophic mental health coverage; and(4)(b)(i)(B) refuse to provide a benefit to be paid for services rendered by a nonpanel provider unless:(4)(b)(i)(B)(I) the insured is referred to a nonpanel provider with the prior authorization of the insurer; and(4)(b)(i)(B)(II) the nonpanel provider agrees to follow the insurer’s protocols and treatment guidelines.(4)(b)(ii) If an insured receives services from a nonpanel provider in the manner permitted by Subsection (4)(b)(i)(B), the insurer shall 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.(4)(b)(iii) This Subsection (4)(b) may not be construed as requiring an insurer to authorize a referral to a nonpanel provider.(4)(c) To be eligible for catastrophic mental health coverage, a diagnosis or treatment of a mental health condition shall be rendered:(4)(c)(i) by a mental health therapist as defined in Section 58-60-102; or(4)(c)(ii) in a health care facility:(4)(c)(ii)(A) licensed or otherwise authorized to provide mental health services pursuant to:(4)(c)(ii)(A)(I) Title 26B, Chapter 2, Part 2, Health Care Facility Licensing and Inspection; or(4)(c)(ii)(A)(II) Title 26B, Chapter 2, Part 1, Human Services Programs and Facilities; and(4)(c)(ii)(B) that provides a program for the treatment of a mental health condition pursuant to a written plan.(5) The commissioner may prohibit an insurance policy that provides mental health coverage in a manner that is inconsistent with this section.(6) The commissioner may adopt rules, in accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, as necessary to ensure compliance with this section.