R590-277-4. Prohibited Provisions

(1) A contract may not impose a preexisting condition limitation or exclusion provision. (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 services; (c) administrative charge for completing an insurance form, duplication service, interest, finance charge, or other administrative charge; (d) administrative exam or service; (e) applied behavioral analysis therapy, except as required under Section 31A-22-642; (f) aviation, to a non-fare-paying passenger; (g) axillary hyperhidrosis; (h) benefits paid for under: (i) employers' liability or occupational disease law; (ii) Medicare or another governmental program except Medicaid; or (iii) state or federal workers' compensation; (i) charge for a missed appointment; (j) chiropractic care; (k) complementary or alternative medicine; (l) corrective lenses, including examination for the prescription or fitting, except: (i) lens implant following cataract surgery; and (ii) as required under Rule R590-266; (m) 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; or (ii) due to a congenital disease or anomaly of a covered dependent child that has resulted in a functional defect; (n) custodial care; (o) dental care or treatment, except as required under Section R590-266-4; (p) dietary products, except as required under Rule R590-194; (q) educational or nutritional training, except as required under Rule R590-200; (r) experimental or investigational services; (s) expenses before coverage begins or after coverage ends; (t) felony, riot, or insurrection, when it is determined the enrollee was a voluntary participant; (u) fitness training, exercise equipment, or membership fee to a spa or health club; (v)(i) foot care for a corn, a callus, flat feet, 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; (w)(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 under Subsection (2)(w)(i); or (iii) a service required for the treatment of a complication from a procedure in Subsection (2)(w)(i); (x) gender reassignment, except as required under Section 1557 of PPACA; (y) gene therapy; (z) genetic testing; (aa) hearing aid, including examination for the prescription or fitting; (bb) infertility services, except as required under Subsection 31A-22-610.1(1); (cc) 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; (dd) mental health condition or substance use disorder services, except as required under Section 31A-22-625 and Rule R590-266; (ee) nuclear release; (ff) refractive eye surgery; (gg) rehabilitation or habilitative therapy services, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident, injury, or illness, or as required under Rule R590-266; (hh) respite care; (ii) rest cures; (jj) services performed by an enrollee's parent, spouse, sibling, or child, including a step or in-law relationship; (kk) services performed by an employee of a hospital, laboratory, or other institution; (ll) services that are not medically necessary; (mm) services for which no charge is normally made in the absence of insurance; (nn) services while in the armed forces or an auxiliary unit; (oo) services in connection with a prearranged surrogacy agreement, except for services for the baby, where the covered person relinquishes a baby and receives payment or other compensation arising out of such services; (pp) sexual dysfunction procedures, equipment, or drugs; (qq) shipping or handling; (rr) telephone or electronic consultation, except as required under Sections 31A-22-649 and 31A-22-649.5; (ss) territorial limitations outside the United States, except as required under Section 31A-22-627; (tt) terrorism, including acts of terrorism; (uu) transplants, except as required by Rule R590-266; (vv) transportation, except medically necessary ambulance services; (ww) war or act of war, whether declared or undeclared; (xx) except under Subsection (2)(yy), 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; (yy) a loss established under Subsection (3) 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 (zz) 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)(yy) 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 managed care organization; (B) renders an independent and impartial decision on a decision to deny coverage based on the exclusion; and (C) is paid for by the managed care organization. (ii) The independent review entity may not have a material professional, familial, or financial conflict of interest with: (A) the managed care organization; (B) an officer, director, or management employee of the managed care organization; (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)(yy) does not apply to an enrollee who is under 18 years of age. (4) A contract 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.