Health plans - Utah

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. State laws include the following provisions:

• If the plan covers family members, it must cover newly born children from the moment of birth; and adopted children. (§31A-22-610)
• If the plan provides maternity benefits on the date of an adoptive placement, it must provide an adoption indemnity benefit payable to the insured, if a child is placed for adoption with the insured within 90 days of the child's birth. (§31A-22-610.1)
• It the plan covers dependents, it must not terminate coverage of an unmarried dependent by reason of the dependent's age before the dependent's 26th birthday and must, upon application, provide coverage for all unmarried dependents up to age 26. (§31A-610.5)
• If the plan covers dependents, it must not allow the age limitation to terminate the coverage of a dependent child while the child is and continues to be both incapable of self-sustaining employment because of mental retardation or physical disability; and chiefly dependent upon the person insured under the policy for support and maintenance. Effective May 1, 2006, the plan must cover all unmarried disabled dependents who have been continuously covered, with no break of more than 63 days. (§31A-22-611)
• If an insured is otherwise eligible for maternity benefits, the plan may not require an insured to obtain any additional preauthorization or preapproval for customary and reasonable maternity care expenses or for the delivery of the child after an initial preauthorization or preapproval has been obtained from the insurer for prenatal care. (§31A-22-613)
• The plan may provide for insureds to receive services or reimbursement in accordance with preferred health care provider contracts. (§31A-22-617)
• The plan may not unfairly discriminate against any licensed class of health care providers by structuring contract exclusions which exclude payment of benefits for the treatment of any illness, injury, or condition by any licensed class of health care providers when the treatment is within the scope of the licensee's practice and the illness, injury, or condition falls within the coverage of the contract. (§31A-22-618)
• The plan must cover the dietary products used for treatment of inborn errors of amino acid or urea cycle metabolism. (§31A-22-623)
• The insurer must offer optional catastrophic mental health coverage. (§31A-22-625)
• Insurers must offer large employers mental health and substance use disorder benefit per the federal Public Health Service Act (42 USC, §300GG-5 and related federal regulations adopted. (§31A-22-625)
• The plan must cover diabetes self-management training and patient management, including medical nutrition therapy. (§31A-22-626)
• The plan may not require any form of preauthorization for treatment of an emergency medical condition until after the insured's condition has been stabilized; or deny a claim for any evaluation, diagnostic test, or other covered treatment considered medically necessary to stabilize the emergency medical condition. (§31A-22-627)
• If the plan doe not allow an insured to have direct access to a health care specialist, the insurer must establish and implement a procedure by which an insured may obtain a standing referral to a health care specialist. (§31A-22-628)
• An insurer or its subcontractors, including a pharmacy benefit manager, must not print an individual's Social Security number on any card required for the individual to access products or services provided or covered by the insurer. (§31A-22-634)
• The plan must offer optional coverage for alcohol or drug dependency treatment. (§31A-22-715)
• If the plan covers dependents, it may not deny eligibility for coverage to a child solely because the child does not reside with the group member or solely because the child is solely dependent on a former spouse of the group member rather than on the group member. A child who does not reside with the group member may be excluded on the same basis as children who do reside with the group member. (§31A-22-718)
• The plan must provide that a person whose insurance under the group policy has been terminated is entitled to choose a converted individual policy of similar accident and health insurance. (§31A-22-723)
• Effective January 1, 2011, insurers that provide a health benefit plan must offer at least one plan covering benefits for prosthetics (§31A-22-638).
• Effective for plans after October 31, 2013, if a health insurer covers both oral chemotherapy and intravenous chemotherapy, the insurer must apply the same cost sharing requirements to both oral chemotherapy and intravenous chemotherapy; or must not impose a cost sharing for oral chemotherapy that exceeds $300, if the insurer imposes different cost sharing for oral chemotherapy and intravenous chemotherapy. Insurers are also prohibited from increasing the cost sharing for oral or intravenous chemotherapy for the purpose of achieving compliance with this provision. (§31A-22-641)

Under the Utah Department of Health, if your health insurance plan meets the following guidelines, it may be an eligible plan under the Utah Premium Partnership for Health Insurance (UPP):

• Cover physicians visits, well child exams, hospital inpatient services, child immunizations, and pharmacy
• Employer must pay at least 50 percent of the cost for the employee’s coverage
• Have a deductible of $1,000 per person or less
• A lifetime maximum of $1,000,000 or more
• Plan pays 70 percent of inpatient costs after the deductible

UPP helps encourage employees to take advantage of their employer's health plan by reimbursing the employees up to $15 per adult each month and $100 per child.

• Utah has set up exchanges in regard to the health care reform.
• Effective 9/30/10, insurance issuers must provide coverage to children up to age 26 and not apply preexisting condition exclusions for children under age 19. As of September 23, 2010, insurers had declined coverage to dependent children until the state defined the terms of an "Open Enrollment Period." The PPACA requires the state to define the terms of an open enrollment period. If a health insurer offers an individual health benefit plan beginning on or after September 23, 2010, a health insurer must offer open enrollment periods each year that:
• Begin November 1 and extends through December 15 for coverage effective January 1; and
• Begin May 1 and extends through June 15 for coverage effective July 1. (R590-259)

HB 128, effective May 10, 2011, requires group health benefit plans to have reasonable plan premium rates and to comply with standards established by the Insurance Department. It applies to small employer plans.

State

Contacts

Utah Insurance Department

Utah Department of Health

Regulations

Utah Code

Title 31A – Insurance

§31A-22-610 Dependent coverage from moment of birth or adoption

§31A-22-610.1 Adoption indemnity benefit

§31A-22-610.5 Dependent coverage

§31A-22-611 Policy extension for children with a disability

§31A-22-613 Permitted provisions for accident and health insurance policies

§31A-22-617Preferred provider contract provisions

§31A-22-618 Nondiscrimination among health care professionals

§31A-22-623 Coverage of inborn metabolic errors

§31A-22-625Catastrophic coverage of mental health conditions

§31A-22-626 Coverage of diabetes

§31A-22-627 Coverage of emergency medical services.

§31A-22-628 Standing referral to a specialist

§31A-22-634 Prohibition against certain use of Social Security number

§31A-22-715 Optional rider for alcohol and drug dependency treatment

§31A-22-718 Dependent coverage

§31A-22-701 Group and blanket conversion coverage

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)