Utah Code 31A-30-107.5. Preexisting condition exclusion — Condition-specific exclusion riders — Limitation periods
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(1) A health benefit plan may impose a preexisting condition exclusion only if the provision complies with Subsection 31A-22-605.1(4).
Terms Used In Utah Code 31A-30-107.5
- Carrier: means a person that provides health insurance in this state including:(5)(a) an insurance company;(5)(b) a prepaid hospital or medical care plan;(5)(c) a health maintenance organization;(5)(d) a multiple employer welfare arrangement; and(5)(e) another person providing a health insurance plan under this title. See Utah Code 31A-30-103
- 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
- Individual: means a natural person. See Utah Code 31A-1-301
- Individual carrier: means a carrier that provides coverage on an individual basis through a health benefit plan regardless of whether:
(14)(a) coverage is offered through:(14)(a)(i) an association;(14)(a)(ii) a trust;(14)(a)(iii) a discretionary group; or(14)(a)(iv) other similar groups; or(14)(b) the policy or contract is situated out-of-state. See Utah Code 31A-30-103- 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- 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- Rider: means an endorsement to:
(173)(a) an insurance policy; or(173)(b) an insurance certificate. See Utah Code 31A-1-301- Secondary medical condition: means a complication related to an exclusion from coverage in accident and health insurance. See Utah Code 31A-1-301
- 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(2)(2)(a) In accordance with Subsection (2)(b), an individual carrier:(2)(a)(i) may, when the individual carrier and the insured mutually agree in writing to a condition-specific exclusion rider, offer to issue an individual policy that excludes all treatment and prescription drugs related to:(2)(a)(i)(A) a specific physical condition;(2)(a)(i)(B) a specific disease or disorder; and(2)(a)(i)(C) any specific or class of prescription drugs; and(2)(a)(ii) may offer an individual policy that may establish separate cost sharing requirements including, deductibles and maximum limits that are specific to covered services and supplies, including drugs, when utilized for the treatment and care of the conditions, diseases, or disorders listed in Subsection (2)(b).(2)(b)(2)(b)(i) Except as provided in Section 31A-22-630 and Subsection (2)(b)(ii), the following may be the subject of a condition-specific exclusion rider:(2)(b)(i)(A) conditions, diseases, and disorders of the bones or joints of the ankle, arm, elbow, fingers, foot, hand, hip, knee, leg, mandible, mastoid, wrist, shoulder, spine, and toes, including bone spurs, bunions, carpal tunnel syndrome, club foot, cubital tunnel syndrome, hammertoe, syndactylism, and treatment and prosthetic devices related to amputation;(2)(b)(i)(B) anal fistula, anal fissure, anal stricture, breast implants, breast reduction, chronic cystitis, chronic prostatitis, cystocele, rectocele, enuresis, hemorrhoids, hydrocele, hypospadius, interstitial cystitis, kidney stones, uterine leiomyoma, varicocele, spermatocele, endometriosis;(2)(b)(i)(C) allergic rhinitis, nonallergic rhinitis, hay fever, dust allergies, pollen allergies, deviated nasal septum, and sinus related conditions, diseases, and disorders;(2)(b)(i)(D) hemangioma, keloids, scar revisions, and other skin related conditions, diseases, and disorders;(2)(b)(i)(E) goiter and other thyroid related conditions, diseases, or disorders;(2)(b)(i)(F) cataracts, cornea transplant, detached retina, glaucoma, keratoconus, macular degeneration, strabismus and other eye related conditions, diseases, and disorders;(2)(b)(i)(G) otitis media, cholesteatoma, otosclerosis, and other internal/external ear conditions, diseases, and disorders;(2)(b)(i)(H) Baker’s cyst, ganglion cyst;(2)(b)(i)(I) abdominoplasty, esophageal reflux, hernia, Meniere’s disease, migraines, TIC Doulourex, varicose veins, vestibular disorders;(2)(b)(i)(J) sleep disorders and speech disorders; and(2)(b)(i)(K) any specific or class of prescription drugs.(2)(b)(ii) Subsection (2)(b)(i) does not apply:(2)(b)(ii)(A) for the treatment of asthma; or(2)(b)(ii)(B) when the condition is due to cancer.(2)(b)(iii) A condition-specific exclusion rider:(2)(b)(iii)(A) shall be limited to the excluded condition, disease, or disorder and any complications from that condition, disease, or disorder;(2)(b)(iii)(B) may not extend to any secondary medical condition; and(2)(b)(iii)(C) shall include the following informed consent paragraph: “I agree by signing below, to the terms of this rider, which excludes coverage for all treatment, including medications, related to the specific condition(s), disease(s), and/or disorder(s) stated herein and that if treatment or medications are received that I have the responsibility for payment for those services and items. I further understand that this rider does not extend to any secondary medical condition, disease, or disorder.”(2)(c) If an individual carrier issues a condition-specific exclusion rider, the condition-specific exclusion rider shall remain in effect for the duration of the policy at the individual carrier’s option.(2)(d) An individual policy issued in accordance with this Subsection (2) is not subject to Subsection 31A-26-301.6(7).(3) Notwithstanding the other provisions of this section, a health benefit plan may impose a limitation period if:(3)(a) each policy that imposes a limitation period under the health benefit plan specifies the physical condition, disease, or disorder that is excluded from coverage during the limitation period;(3)(b) the limitation period does not exceed 12 months;(3)(c) the limitation period is applied uniformly; and(3)(d) the limitation period is reduced in compliance with Subsections 31A-22-605.1(4)(a) and (4)(b). - 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: