R590-233-4. Prohibited Contract Provisions

(1)(a) A contract may not establish a probationary period when coverage is not provided, except under Subsections (1)(b) and (1)(c). (b) A contract may specify a probationary period not to exceed 12 months for a loss resulting from: (i) amenorrhea; (ii) cataracts; (iii) a congenital deformity, except as required under Subsection 31A-22-610(2); (iv) cystocele; (v) dysmenorrhea; (vi) enterocele; (vii) infertility; (viii) rectocele; (ix) seasonal allergy, limited to testing and treatment; (x) sleep disorder, including sleep studies; (xi) surgical treatment for: (A) adenoidectomy; (B) bunionectomy; (C) carpal tunnel; (D) hysterectomy, except in a case of malignancy; (E) joint replacement; (F) reduction mammoplasty; (G) Morton's neuroma; (H) myringotomy and tympanotomy, with or without tubes inserted; (I) nasal septal repair, except for an injury after the effective date of coverage; (J) retained hardware removal; (K) sterilization; and (L) tonsillectomy; (xii) urethrocele; (xiii) uterine prolapse; and (xiv) varicose veins. (c) Coverage shall be provided for a disease, condition, or procedure in Subsection (1)(b) if the disease, condition, or procedure is treated on an emergency basis. (2) Unless otherwise required by law, a contract may not limit or exclude coverage or benefits by type of illness, accident, injury, treatment, or medical condition, except: (a) abortion; (b) acupuncture or acupressure; (c) administrative charge for completing an insurance form, duplication service, interest, finance charge, or other administrative charge; (d) administrative exam or service; (e) allergy test or treatment; (f) applied behavioral analysis therapy, except as required under Section 31A-22-642; (g) aviation, to a non-fare-paying passenger; (h) axillary hyperhidrosis; (i) benefits paid for under: (i) employer's liability or occupational disease law; (ii) Medicare or another governmental program, except Medicaid; or (iii) state or federal workers' compensation; (j) charge for a missed appointment; (k) chiropractic care; (l) complementary or alternative medicine; (m) corrective lens, including an examination for prescription or fitting, except lens implant following cataract surgery; (n) cosmetic surgery, including reversal, revision, repair, complication, or treatment related to a non-covered cosmetic surgery, except reconstructive surgery: (i) when the service is incidental to or follows surgery resulting from trauma, infection, or other disease of the involved part; or (ii) due to a congenital disease or anomaly of a covered dependent child that resulted in a functional defect; (o) custodial care; (p) dental care or treatment; (q) dietary products, except as required under Rule R590-194; (r) educational or nutritional training, except as required under Rule R590-200; (s) expenses before coverage begins or after coverage ends; (t) experimental or investigational service; (u) felony, riot, or insurrection, when it is determined the enrollee was a voluntary participant; (v) fitness training, exercise equipment, or a membership fee to a spa or health club; (w)(i) foot care for a corn, a callus, a flat foot, a fallen arch, a weak foot, chronic foot strain, or symptomatic complaints of a foot, including an orthotic; and (ii) the cutting or removal of a corn, a callus, or a nail may not be excluded when provided to an enrollee who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency, if unskilled performance of the procedure would be hazardous; (x)(i) gastric or intestinal bypass service, including lap banding, gastric stapling, or a similar procedure to facilitate weight loss; (ii) the reversal or revision of a procedure in Subsection (2)(x)(i); or (iii) a service required for the treatment of a complication from a procedure in Subsection (2)(x)(i); (y) gender reassignment, except as required under Section 1557 of PPACA; (z) gene therapy; (aa) genetic testing; (bb) hearing aid, including examination for the prescription or fitting; (cc) infertility service, except as required under Subsection 31A-22-610.1(1); (dd) injury as a result of a motor vehicle, to the extent the enrollee is required to have no-fault coverage, up to the minimum coverage required by law whether or not coverage is in effect; (ee) mental health condition or substance use disorder, except as required under 45 CFR 147.160 and Section 31A-22-625; (ff) nuclear release; (gg) preexisting condition, except as required under Section 31A-22-605.1 and Subsection 31A-22-610(2); (hh) pregnancy, except for a complication of pregnancy; (ii) refractive eye surgery; (jj) rehabilitation therapy service, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident, injury, or illness; (kk) respite care; (ll) rest cure; (mm) routine physical examination; (nn) services performed by an enrollee's parent, spouse, sibling, or child, including a step or in-law relationship; (oo) services performed by an employee of a hospital, laboratory, or other institution; (pp) services that are not medically necessary; (qq) services for which no charge is normally made in the absence of insurance; (rr) services while in the armed forces or an auxiliary unit; (ss) sexual dysfunction procedure, equipment, or drug; (tt) shipping or handling; (uu) suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury; (vv) telephone or electronic consultation, except as required under Sections 31A-22-649 and 31A-22-649.5; (ww) territorial limitation outside the United States, except as required under Section 31A-22-627; (xx) terrorism, including an act of terrorism; (yy) transplant; (zz) transportation, except medically necessary ambulance services; (aaa) war or act of war, whether declared or undeclared; (bbb) except under Subsection (2)(ccc), a loss directly related to the enrollee's voluntary participation in an activity when the enrollee: (i) is found guilty of an illegal activity in a criminal proceeding, including a plea of guilty, a no contest plea, and a plea in abeyance; or (ii) is found liable for the activity in a civil proceeding; (ccc) a loss established under Subsection (3)(a) that is directly related to the enrollee violating: (i) Section 41-6a-502, if the loss occurred in Utah; or (ii) a law in a state other than Utah that prohibits operating a motor vehicle while exceeding the legal limit of concentration of alcohol, drugs, or a combination of both in the blood, if the loss occurred in the other state; or (ddd) any other exclusion that, in the opinion of the commissioner, is not inequitable, misleading, deceptive, obscure, unjust, unfair, or unfairly discriminatory to an enrollee. (3)(a) A violation under Subsection (2)(ccc) shall be established: (i) in a criminal proceeding in which the enrollee is found guilty, enters a no contest plea or a plea in abeyance, or enters into a diversion agreement; or (ii) by a request for an independent review when the findings support a decision to deny coverage based on the exclusion. (b)(i) For purposes of Subsection (3)(a)(ii), an independent review means a process that: (A) is conducted by an independent entity designated by the insurer; (B) renders an independent and impartial decision on a decision to deny coverage based on the exclusion; and (C) is paid for by the insurer. (ii) The independent review entity may not have a material professional, familial, or financial conflict of interest with: (A) the insurer; (B) an officer, director, or management employee of the insurer; (C) the enrollee; (D) the enrollee's health care provider; (E) the health care provider's medical group or independent practice association; or (F) a health care facility where services were provided. (c) The exclusion in Subsection (2)(ccc) does not apply to an enrollee who is under age 18. (4)(a) A waiver shall comply with Section 31A-30-107.5. (b) A signed acceptance by the enrollee is required if a waiver is required as a condition of issuance, renewal, or reinstatement. (5) A contractual provision precluded in this section may not be construed as a limitation on the commissioner's authority to prohibit a contract provision that, in the opinion of the commissioner, is unjust, unfair, or unfairly discriminatory to an enrollee.