Federal & State Regulations | HIPAA - Utah | J. J. Keller® Compliance Network

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Summary of differences between federal and state regulations

Federal HIPAA portability provisions limit exclusions for preexisting conditions; prohibit discrimination against employees and dependents based on their health status; and allow a special opportunity to enroll in a new plan to individuals in certain circumstances.

States are allowed to go beyond the federal requirements. In Utah, plans must comply with federal requirements. (see 31A-2-212)

However, the Utah Code includes statues on preexisting condition exclusions. Health plans may impose preexisting condition exclusions only if:

The exclusion relates to a preexisting condition for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date from an individual licensed or similarly authorized to provide those services under state law and operating within the scope of practice authorized by state law;
The exclusion period ends no later than 12 months after the enrollment date, or in the case of a late enrollee, 18 months after the enrollment date; and
The exclusion period is reduced by the number of days of creditable coverage the enrollee has as of the enrollment date.

(see 31A-22-605.1)

The Utah Code also includes information on preexisting condition exclusions in regard limitation periods for condition-specific exclusion riders. A plan may impose a limitation period if the policy specifies the physical condition, disease, or disorder that is excluded form coverage during the limitation period, the limitation period does not exceed 12 months, the period is applied uniformly, and the period is reduced appropriately per creditable coverage. (see 31A-30-107.5)