(1) As used in this section:

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Terms Used In Utah Code 31A-22-658

  • 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
  • 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
  • Health care provider: means the same as that term is defined in Section 78B-3-403. 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
  • Member: means a person having membership rights in an insurance corporation. 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
  • Rate: means :
              (163)(a)(i) the cost of a given unit of insurance; or
              (163)(a)(ii) for property or casualty insurance, that cost of insurance per exposure unit either expressed as:
                   (163)(a)(ii)(A) a single number; or
                   (163)(a)(ii)(B) a pure premium rate, adjusted before the application of individual risk variations based on loss or expense considerations to account for the treatment of:
                        (163)(a)(ii)(B)(I) expenses;
                        (163)(a)(ii)(B)(II) profit; and
                        (163)(a)(ii)(B)(III) individual insurer variation in loss experience. See Utah Code 31A-1-301
     (1)(a) “Mental health condition” means the same as that term is defined in Section 31A-22-649.5.
     (1)(b) “Mental health provider” means:

          (1)(b)(i) a mental health therapist, as defined in Section 58-60-102; or
          (1)(b)(ii) an individual practicing within the scope of practice described in Title 58, Chapter 60, Part 5, Substance Use Disorder Counselor Act.
     (1)(c) “Mental health treatment” means treatment for a mental health condition.
(2)

     (2)(a) Except as provided in Subsection (3), and subject to Subsections (4) and (5), beginning January 1, 2024, a health benefit plan that offers coverage for mental health treatment shall, upon request of a health benefit plan enrollee who is employed as a health care provider, offer a single case agreement that allows the enrollee to receive covered mental health treatment from an out-of-network mental health provider selected by the enrollee.
     (2)(b) A single case agreement described in Subsection (2)(a) shall:

          (2)(b)(i) reimburse the out-of-network mental health provider for the covered mental health treatment at the equivalent out-of-network rate set by the health benefit plan, subject to the member cost-sharing requirements imposed by the health benefit plan;
          (2)(b)(ii) include the same coinsurance, copayments, and deductibles that would be applied for the mental health treatment if the mental health treatment was provided by a mental health provider who is a network provider;
          (2)(b)(iii) include the terms that a network provider is subject to under the health benefit plan; and
          (2)(b)(iv) define the length and scope of the single case agreement.
(3)

     (3)(a) Subsection (2) does not apply if:

          (3)(a)(i)

               (3)(a)(i)(A) the health benefit plan has network providers for the covered mental health treatment; and
               (3)(a)(i)(B) the network providers described in Subsection (3)(a)(i) do not provide the covered mental health treatment in the location where the enrollee works as a health care provider; or
          (3)(a)(ii) the enrollee selects a mental health provider for the covered mental health treatment who the health benefit plan knows or reasonably suspects has committed a fraudulent insurance act as described in Section 31A-31-103.
     (3)(b) For purposes of this Subsection (3), the location where an enrollee works as a health care provider includes all locations or facilities of the enrollee’s employer.
(4) Mental health treatment provided pursuant to a single case agreement under this section:

     (4)(a) shall be:

          (4)(a)(i) within the out-of-network mental health provider’s scope of practice; and
          (4)(a)(ii) a service that is otherwise covered under the enrollee’s health benefit plan; and
     (4)(b) may not be experimental.
(5)

     (5)(a) An enrollee shall request a single case agreement under Subsection (2) prior to receiving mental health treatment from an out-of-network mental health provider.
     (5)(b) With a request for a single case agreement under Subsection (2), an enrollee shall provide information about where the enrollee works as a health care provider sufficient for the health benefit plan to determine whether the circumstances described in Subsection (3)(a)(i) exist.
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