reglab/statecodes huggingface dataset:
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 5 - Group Life Insurance › Section 519 - Death pending conversion.

31A-22-519.
Death pending conversion.
If a person insured under a group life insurance policy, or the insured dependent of that person, dies during the period of eligibility for conversion under Section 31A-22-517 or 31A-22-518 and before the individual policy becomes effective, the amount of life insurance to which the insured would have been entitled to have issued under the individual policy is payable as a claim under the group policy, whether or not application for the individual policy or the payment of the first premium has been made.
Amended by Chapter 319, 2013 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 5 - Group Life Insurance › Section 520 - Continuation of coverage during total disability.

31A-22-520.
Continuation of coverage during total disability.
(1) An insured person in a group life insurance policy may continue coverage during the total disability of the insured person or dependent by timely payment to the policyholder of that portion, if any, of the premium that would have been required on behalf of the insured person in the absence of total disability.
(2) The continuation shall be on a premium paying basis until the earlier of:
(a) six months from the date of total disability;
(b) approval by the insurer of continuation of the coverage under any disability provision the group insurance policy may contain; or
(c) the discontinuance of the group insurance policy.
(3) If the group policy has a waiting period for an accident and health benefit, the continuation extends to the end of the waiting period, even if the group policy is otherwise discontinued.
Amended by Chapter 116, 2001 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 5 - Group Life Insurance › Section 521 - Notice of right to convert under group policy.

31A-22-521.
Notice of right to convert under group policy.
Certificates of insurance evidencing coverage under a group life insurance policy shall prominently notify individuals of conversion rights and contain information concerning the time and manner in which conversion to an individual life insurance policy may be made.
Repealed and Re-enacted by Chapter 316, 1994 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 5 - Group Life Insurance › Section 522 - Required provision for notice of termination.

Effective 5/5/2021
31A-22-522.
Required provision for notice of termination.
(1) A group insurance policy offering life insurance coverage or a blanket insurance policy offering life insurance coverage shall include a provision that obligates the policyholder to notify each employee or group member:
(a) in writing;
(b) 30 days before the day on which the coverage terminates; and
(c)
(i) that the group insurance policy offering life insurance coverage or blanket insurance policy offering life insurance coverage is being terminated; and
(ii) the rights the employee or group member has to convert coverage upon termination.
(2) For a group insurance policy offering life insurance coverage or a blanket insurance policy offering life insurance coverage described in Subsection (1), an insurer shall:
(a) include a statement of a policyholder's obligations under Subsection (1) in the insurer's monthly notice to the policyholder of premium payments due; and
(b) provide a sample notice to the policyholder at least once a year.
Amended by Chapter 252, 2021 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 600 - Scope of Part 6.

Effective 5/5/2021
31A-22-600.
Scope of Part 6.
(1) Except where a provision's application is otherwise specifically limited, this part applies to all:
(a) accident and health insurance contracts, including credit accident and health;
(b) franchise;
(c) group contracts; and
(d) life insurance and annuity policies that directly or through a rider provide:
(i) accident and health insurance benefits; or
(ii) accelerated benefits where the receipt of benefits is contingent on morbidity requirements.
(2) Nothing in this part applies to or affects:
(a) workers' compensation insurance;
(b) reinsurance; or
(c) accident and health insurance when it is part of or supplemental to liability, steam boiler, elevator, automobile, or other insurance covering loss of or damage to property, provided the loss, damage, or expense arises out of a hazard directly related to the other insurance.
(3) Except as provided in Subsection (1), this part does not apply to or affect a life insurance or annuity policy including a life insurance policy:
(a) with a rider or supplemental benefit that accelerates the death benefit contingent upon a mortality risk specifically for one or more of the qualifying events of:
(i) terminal illness;
(ii) medical conditions requiring extraordinary medical intervention; or
(iii) permanent institutional confinement; and
(b) that provides the option of a lump-sum payment for those benefits.
Amended by Chapter 252, 2021 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 601 - Applicability of life insurance provisions.

31A-22-601.
Applicability of life insurance provisions.
Sections 31A-22-412 through 31A-22-417 apply to death benefits in accident and health insurance policies.
Amended by Chapter 116, 2001 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 602 - Premium rates.

Effective 5/4/2022
31A-22-602.
Premium rates.
(1) Except as provided in Subsection 31A-22-701(4), this section does not apply to group accident and health insurance.
(2) The benefits in an accident and health insurance policy shall be reasonable in relation to the premiums charged.
(3) The commissioner shall prohibit the use of an accident and health insurance form or rates if the form or rates do not satisfy Subsection (2).
Amended by Chapter 198, 2022 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 603 - Persons insured under an individual accident and health policy.

Effective 5/10/2016
31A-22-603.
Persons insured under an individual accident and health policy.
A policy of individual accident and health insurance may insure only one person, except that originally or by subsequent amendment, upon the application of an adult policyholder, a policy may insure any two or more eligible members of the policyholder's family, including spouse, dependent children, and any other person dependent upon the policyholder.
Amended by Chapter 138, 2016 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 604 - Reimbursement by insurers of Medicaid benefits.

Effective 5/3/2023
31A-22-604.
Reimbursement by insurers of Medicaid benefits.
(1) As used in this section, "Medicaid" means the program under Title XIX of the federal Social Security Act.
(2) Any accident and health insurer, including a group accident and health insurance plan, as defined in Section 607(1), Federal Employee Retirement Income Security Act of 1974, or health maintenance organization as defined in Section 31A-8-101, is prohibited from considering the availability or eligibility for medical assistance in this or any other state under Medicaid, when considering eligibility for coverage or making payments under its plan for eligible enrollees, subscribers, policyholders, or certificate holders.
(3) To the extent that payment for covered expenses has been made under the state Medicaid program for health care items or services furnished to an individual in any case when a third party has a legal liability to make payments, the state is considered to have acquired the rights of the individual to payment by any other party for those health care items or services.
(4)Title 26B, Chapter 3, Part 10, Medical Benefits Recovery, applies to reimbursement of insurers of Medicaid benefits.
Amended by Chapter 327, 2023 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 606 - Policy examination period.

31A-22-606.
Policy examination period.
(1)
(a) Except as provided in Subsection (2), all accident and health policies shall contain a notice prominently printed on or attached to the cover or front page stating that the policyholder has the right to return the policy for any reason within 10 days after its delivery.
(b) "Return" means delivery to the insurer or its agent or mailing of the policy to either, properly addressed and stamped for first class handling, with a written statement on the policy or an accompanying communication that it is being returned for termination of coverage. A policy returned under this Subsection (1) is void from the beginning and a policyholder returning his policy is entitled to a refund of any premium paid.
(2) This section does not apply to:
(a) group policies;
(b) policies issued to persons entitled to a 30-day examination period under Subsection 31A-22-605(9);
(c) single premium nonrenewable policies issued for terms not longer than 60 days;
(d) policies covering accidents only or accidental bodily injury only; and
(e) other classes of policies which the commissioner by rule specifies after a finding that a right to return those policies would be impracticable or unnecessary to protect the policyholder's interests.
Amended by Chapter 78, 2005 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 608 - Reinstatement of individual or franchise accident and health insurance policies.

Effective 5/5/2021
31A-22-608.
Reinstatement of individual or franchise accident and health insurance policies.
(1) Every individual or franchise accident and health insurance policy shall contain a provision which reads substantially as follows:
"REINSTATEMENT: If any renewal premium is not paid within the time granted the insured for payment, a subsequent acceptance of premium by the insurer or by any agent duly authorized by the insurer to accept the premium, without also requiring an application for reinstatement, shall reinstate the policy. However, if the insurer or agent requires an application for reinstatement and issues a conditional receipt for the premium tendered, the policy shall be reinstated upon approval of this application from the insurer or, lacking this approval, upon the 45th day following the date of the conditional receipt, unless the insurer has previously notified the insured in writing of its disapproval of the application. The reinstated policy shall cover only loss resulting from such accidental injury as may be sustained after the date of reinstatement and loss due to such sickness as may begin more than 10 days after that date. In all other respects the insured and insurer have the same rights under the reinstated policy as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed on or attached to this policy in connection with the reinstatement. Any premium accepted in connection with a reinstatement shall be applied to a period for which premium has not been previously paid, but not to any period more than 60 days prior to the date of reinstatement."
(2) The last sentence of the provision described in Subsection (1) may be omitted from any policy that the insured has the right to continue in force subject to the policy's terms by the timely payment of premiums until at least age 50, or in the case of a policy issued after age 44, for at least five years from the day on which the insurer issues the policy.
Amended by Chapter 252, 2021 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 609 - Incontestability for accident and health insurance.

31A-22-609.
Incontestability for accident and health insurance.
(1)
(a) A statement made by an applicant relating to the person's insurability, except fraudulent misrepresentation, may not be a basis for avoidance of a policy, coverage, or denial of a claim for loss incurred or disability commencing after the coverage has been in effect for two years.
(b) The insurer has the burden of proving fraud by clear and convincing evidence.
(2) Except as provided under Section 31A-22-605.1, a claim for loss incurred or disability commencing after two years from the date of issue of the policy may not be reduced or denied on the ground that a disease or physical condition existed prior to the effective date of coverage, unless the condition was excluded from coverage by name or specific description in a provision that was in effect on the date of loss.
(3) Except as provided in Subsection (1)(a), a specified disease policy may not include wording that provides a defense based upon a disease or physical condition that existed prior to the effective date of coverage except as allowed under Subsection 31A-22-605.1(2).
Amended by Chapter 78, 2005 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 610.1 - Indemnity benefit for adoption or infertility treatments.

Effective 1/1/2018
31A-22-610.1.
Indemnity benefit for adoption or infertility treatments.
(1)
(a)
(i) If an insured has coverage for maternity benefits on the date of an adoptive placement, the insured's policy shall 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. If more than one child from the same birth is placed for adoption with the insured, only one adoption indemnity benefit is required.
(ii) This section does not prevent an accident and health insurer from:
(A) adjusting the benefit payable under this section for cost sharing measures imposed under the policy or contract for maternity benefit coverage; or
(B) providing additional adoption indemnity benefits including:
(I) extending the period of time after birth in which a child must be placed with an insured; or
(II) providing a benefit in excess of the amount specified in Subsection (1)(c).
(b) An insurer that has paid the adoption indemnity benefit under Subsection (1)(a) may seek reimbursement of the benefit if:
(i) the postplacement evaluation disapproves the adoption placement; and
(ii) a court rules the adoption may not be finalized because of an act or omission of an adoptive parent or parents that affects the child's health or safety.
(c)
(i) The amount of the adoption indemnity benefit provided under Subsection (1) is $4,000 subject to the adjustments permitted by Subsection (1)(a)(ii).
(ii) An insurer may comply with the provisions of this section by providing the $4,000 adoption indemnity benefit to an enrollee to be used for the purpose of the enrollee obtaining infertility treatments rather than seeking reimbursement for an adoption in accordance with terms designated by the insurer.
(d) Each insurer shall pay its pro rata share of the adoption indemnity benefit if each adoptive parent:
(i) has coverage for maternity benefits with a different insurer; and
(ii) makes a claim for the adoption indemnity benefit provided in Subsection (1)(a).
(2) If a policy offers optional maternity benefits, it shall also offer coverage for adoption indemnity benefits if:
(a) a child is placed for adoption with the insured within 90 days of the child's birth; and
(b) the adoption is finalized within one year of the child's birth.
(3) If an insured qualifies for the adoption indemnity benefit under this section and receives services from a network provider, the network provider may only collect from the insured the amount that the contracting health care provider is entitled to receive for such services under the contract, including any applicable copayment.
Amended by Chapter 292, 2017 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 610.2 - Maternity stay minimum limits.

31A-22-610.2.
Maternity stay minimum limits.
(1)
(a) If an insured has coverage for maternity benefits, the policy may not be limited to a less than a 48-hour benefit for both mother and newborn with a normal vaginal delivery.
(b) If an insured has coverage for maternity benefits, the policy may not be limited to a less than 96-hour benefit for both mother and newborn with a caesarean section delivery.
(2) Subsection (1) applies to an accident and health insurer who offers maternity coverage.
Amended by Chapter 116, 2001 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 610.6 - Special enrollment for individuals receiving premium assistance.

Effective 5/3/2023
31A-22-610.6.
Special enrollment for individuals receiving premium assistance.
(1) As used in this section:
(a) "Premium assistance" means assistance under Title 26B, Chapter 3, Health Care - Administration and Assistance, in the payment of premium.
(b) "Qualified beneficiary" means an individual who is approved to receive premium assistance.
(2) Subject to the other provisions in this section, an individual may enroll under this section at a time outside of an employer health benefit plan open enrollment period, regardless of previously waiving coverage, if the individual is:
(a) a qualified beneficiary who is eligible for coverage as an employee under the employer health benefit plan; or
(b) a dependent of the qualified beneficiary who is eligible for coverage under the employer health benefit plan.
(3) To be eligible to enroll outside of an open enrollment period, an individual described in Subsection (2) shall enroll in the employer health benefit plan by no later than 30 days from the day on which the qualified beneficiary receives initial written notification, after July 1, 2008, that the qualified beneficiary is eligible to receive premium assistance.
(4) An individual described in Subsection (2) may enroll under this section only in an employer health benefit plan that is available at the time of enrollment to similarly situated eligible employees or dependents of eligible employees.
(5) Coverage under an employer health benefit plan for an individual described in Subsection (2) may begin as soon as the first day of the month immediately following enrollment of the individual in accordance with this section.
(6) This section does not modify any requirement related to premiums that applies under an employer health benefit plan to a similarly situated eligible employee or dependent of an eligible employee under the employer health benefit plan.
(7) An employer health benefit plan may require an individual described in Subsection (2) to satisfy a preexisting condition waiting period that:
(a) is allowed under the Health Insurance Portability and Accountability Act; and
(b) is not longer than 12 months.
Amended by Chapter 327, 2023 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 611 - Coverage for children with a disability.

Effective 5/14/2019
31A-22-611.
Coverage for children with a disability.
(1) For the purposes of this section:
(a) "Dependent with a disability" means a child who is and continues to be both:
(i) unable to engage in substantial gainful employment to the degree that the child can achieve economic independence due to a medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than 12 months; and
(ii) chiefly dependent upon an insured for support and maintenance since the child reached the age specified in Subsection 31A-22-610.5(2).
(b) "Mental impairment" means a mental or psychological disorder such as:
(i) an intellectual disability;
(ii) organic brain syndrome;
(iii) emotional or mental illness; or
(iv) specific learning disabilities as determined by the insurer.
(c) "Physical impairment" means a physiological disorder, condition, or disfigurement, or anatomical loss affecting one or more of the following body systems:
(i) neurological;
(ii) musculoskeletal;
(iii) special sense organs;
(iv) respiratory organs;
(v) speech organs;
(vi) cardiovascular;
(vii) reproductive;
(viii) digestive;
(ix) genito-urinary;
(x) hemic and lymphatic;
(xi) skin; or
(xii) endocrine.
(2) The insurer may require proof of the impairment and dependency be furnished by the person insured under the policy within 30 days of the effective date or the date the child attains the age specified in Subsection 31A-22-610.5(2), and at any time thereafter, except that the insurer may not require proof more often than annually after the two-year period immediately following attainment of the limiting age by the dependent with a disability.
(3) Any individual or group accident and health insurance policy or health maintenance organization contract that provides coverage for a policyholder's or certificate holder's dependent shall, upon application, provide coverage for all unmarried dependents with a disability who have been continuously covered, with no break of more than 63 days, under any accident and health insurance since the age specified in Subsection 31A-22-610.5(2).
(4) Every accident and health insurance policy or contract that provides coverage of a dependent with a disability may not terminate the policy due to an age limitation.
Amended by Chapter 193, 2019 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 612 - Conversion privileges for insured former spouse.

Effective 5/5/2021
31A-22-612.
Conversion privileges for insured former spouse.
(1) An accident and health insurance policy, that in addition to covering the insured also provides coverage to the spouse of the insured, may not contain a provision for termination of coverage of a spouse covered under the policy, except by entry of a valid decree of divorce, legal separation, or annulment between the parties.
(2) Every policy that contains the type of provision described in Subsection (1) shall provide that:
(a) upon the entry of the divorce decree the spouse is entitled to have issued an individual policy offering accident and health insurance without evidence of insurability, upon application to the company and payment of the appropriate premium; and
(b) the individual policy described in Subsection (2)(a) shall:
(i) provide the coverage that is most nearly similar to the terminated coverage; and
(ii) consider a probationary or waiting period satisfied to the extent the coverage was in force under the prior policy.
(3)
(a) When an insurer receives actual notice that the coverage of a spouse is to be terminated because of a divorce, legal separation, or annulment, the insurer shall promptly provide the spouse written notification of the right to obtain individual coverage as provided in Subsection (2), the premium amounts required, and the manner, place, and time in which premiums may be paid.
(b) The premium is determined in accordance with the insurer's table of premium rates applicable to the age and class of risk of the persons to be covered and to the type and amount of coverage provided.
(c) If a spouse applies and tenders the first monthly premium to the insurer within 30 days after the day on which the spouse receives the notice provided by this Subsection (3), the spouse shall receive individual coverage that commences immediately upon termination of coverage under the insured's policy.
(4) This section does not apply to:
(a) a blanket insurance policy offering accident and health insurance; or
(b) a health benefit plan.
Amended by Chapter 252, 2021 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 614 - Claims under accident and health policies.

31A-22-614.
Claims under accident and health policies.
(1) Section 31A-21-312 applies generally to claims under accident and health policies.
(2)
(a) Subject to Subsection (1), an accident and health insurance policy may not contain a claim notice requirement less favorable to the insured than one which requires written notice of the claim within 20 days after the occurrence or commencement of any loss covered by the policy. The policy shall specify to whom claim notices may be given.
(b) If a loss of time benefit under a policy may be paid for a period of at least two years, an insurer may require periodic notices that the insured continues to have a disability, unless the insured is legally incapacitated. The insured's delay in giving that notice does not impair the insured's or beneficiary's right to any indemnity which would otherwise have accrued during the six months preceding the date on which that notice is actually given.
(3) An accident and health insurance policy may not contain a time limit on proof of loss which is more restrictive to the insured than a provision requiring written proof of loss, delivered to the insurer, within the following time:
(a) for a claim where periodic payments are contingent upon continuing loss, within 90 days after the termination of the period for which the insurer is liable; or
(b) for any other claim, within 90 days after the date of the loss.
(4)
(a)
(i) Section 31A-26-301 applies generally to the payment of claims.
(ii) Indemnity for loss of life is paid in accordance with the beneficiary designation effective at the time of payment. If no valid beneficiary designation exists, the indemnity is paid to the insured's estate. Any other accrued indemnities unpaid at the insured's death are paid to the insured's estate.
(b) Reasonable facility of payment clauses, specified by the commissioner by rule or in approving the policy form, are permitted. Payment made in good faith and in accordance with those clauses discharges the insurer's obligation to pay those claims.
(c) All or a portion of any indemnities provided under an accident and health policy on account of hospital, nursing, medical, or surgical services may, at the insurer's option, be paid directly to the hospital or person rendering the services.
Amended by Chapter 366, 2011 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 614.7 - Uniform claims processing -- Electronic exchange of prescription drug pre-authorization.

Effective 5/9/2017
31A-22-614.7.
Uniform claims processing -- Electronic exchange of prescription drug pre-authorization.
The commissioner shall consult with national and state organizations involved with the standardized exchange of health data, and the electronic exchange of health data, to study and review:
(1) the process of prior authorization of prescription drugs; and
(2) the standards for the use and electronic exchange of a uniform prescription drug prior authorization form that meet federal mandatory minimum standards and follow the adoption of national requirements for transaction and data elements in the federal Health Insurance Portability and Accountability Act.
Amended by Chapter 18, 2017 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 618 - Nondiscrimination among health care professionals.

Effective 5/14/2019
31A-22-618.
Nondiscrimination among health care professionals.
(1) Except as provided under Section 31A-45-303 and Subsection (2), and except as to insurers licensed under Chapter 8, Health Maintenance Organizations and Limited Health Plans, no insurer may 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. Upon the written request of an insured alleging an insurer has violated this section, the commissioner shall hold a hearing to determine if the violation exists. The commissioner may consolidate two or more related alleged violations into a single hearing.
(2) Coverage for licensed providers for behavioral analysis may be limited by an insurer in accordance with Section 58-61-714. Nothing in this section prohibits an insurer from electing to provide coverage for other licensed professionals whose scope of practice includes behavior analysis.
Amended by Chapter 136, 2019 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 618.5 - Coverage of insurance mandates imposed after January 1, 2009.

Effective 1/1/2018
31A-22-618.5.
Coverage of insurance mandates imposed after January 1, 2009.
(1) The purpose of this section is to increase the range of health benefit plans available in the small group, small employer group, large group, and individual insurance markets.
(2) A health maintenance organization that is subject to Chapter 8, Health Maintenance Organizations and Limited Health Plans:
(a) shall offer to potential purchasers at least one health benefit plan that is subject to the requirements of Chapter 8, Health Maintenance Organizations and Limited Health Plans; and
(b) may offer to a potential purchaser one or more health benefit plans that:
(i) are not subject to one or more of the following:
(A) the limitations on insured indemnity benefits in Subsection 31A-8-105(4);
(B) except as provided in Subsection (2)(b)(ii), basic health care services as defined in Section 31A-8-101; or
(C) coverage mandates enacted after January 1, 2009 that are not required by federal law, provided that the insurer offers one plan under Subsection (2)(a) that covers the mandate enacted after January 1, 2009; and
(ii) when offering a health plan under this section, provide coverage for an emergency medical condition as required by Section 31A-22-627.
(3) An insurer that offers a health benefit plan that is not subject to Chapter 8, Health Maintenance Organizations and Limited Health Plans:
(a) may offer a health benefit plan that is not subject to Section 31A-22-618 and Subsection 31A-45-303(3)(b)(iii);
(b) when offering a health plan under this Subsection (3), shall provide coverage of emergency care services as required by Section 31A-22-627; and
(c) is not subject to coverage mandates enacted after January 1, 2009 that are not required by federal law, provided that an insurer offers one plan that covers a mandate enacted after January 1, 2009.
(4) Section 31A-8-106 does not prohibit the offer of a health benefit plan under Subsection (2)(b).
(5)
(a) Any difference in price between a health benefit plan offered under Subsections (2)(a) and (b) shall be based on actuarially sound data.
(b) Any difference in price between a health benefit plan offered under Subsection (3)(a) shall be based on actuarially sound data.
(6) Nothing in this section limits the number of health benefit plans that an insurer may offer.
Amended by Chapter 292, 2017 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 618.8 - Discontinuance and nonrenewal limitations for health benefit plans.

Effective 5/4/2022
31A-22-618.8.
Discontinuance and nonrenewal limitations for health benefit plans.
(1) Subject to Section 31A-4-115, an insurer that elects to discontinue offering a health benefit plan under Subsection 31A-22-618.6(5)(e) or 31A-22-618.7(3)(e) is prohibited from writing new business:
(a) in the market in this state for which the insurer discontinues or does not renew; and
(b) for a period of five years beginning on the day on which the last coverage that is discontinued.
(2) If an insurer is doing business in one established geographic service area of the state, Subsections 31A-22-618.6(5)(e) and 31A-22-618.7(3)(e) apply only to the insurer's operations in that service area.
(3) The commissioner may, by rule or order, define the scope of service area.
Amended by Chapter 198, 2022 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 619 - Coordination of benefits.

31A-22-619.
Coordination of benefits.
(1) The commissioner shall:
(a) adopt rules concerning the coordination of benefits between accident and health insurance policies;
(b) publish a coordination of benefits guide;
(c) post the coordination of benefits guide on the state insurance exchange; and
(d) work with the Health Data Authority, health care provider groups, and with state and national organizations that are developing uniform standards for the electronic exchange of health insurance claims to develop standardized language regarding coordination of benefits for the purpose of including the standardized language in an insurer's explanation of benefits.
(2) Rules adopted by the commissioner under Subsection (1):
(a) may not prohibit coordination of benefits with individual accident and health insurance policies;
(b) shall apply equally to all accident and health insurance policies without regard to whether the policies are group or individual policies; and
(c) shall include standardized language regarding the coordination of benefits process that shall be included in each insurer's accident and health insurance policy.
Amended by Chapter 285, 2010 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 623 - Coverage of inborn metabolic errors.

31A-22-623.
Coverage of inborn metabolic errors.
(1) As used in this section:
(a) "Dietary products" means medical food or a low protein modified food product that:
(i) is specifically formulated to treat inborn errors of amino acid or urea cycle metabolism;
(ii) is not a natural food that is naturally low in protein; and
(iii) is used under the direction of a physician.
(b) "Inborn errors of amino acid or urea cycle metabolism" means a disease caused by an inherited abnormality of body chemistry which is treatable by the dietary restriction of one or more amino acid.
(2) The commissioner shall establish, by rule, minimum standards of coverage for dietary products used for the treatment of inborn errors of amino acid or urea cycle metabolism at levels consistent with the major medical benefit provided under an accident and health insurance policy.
Amended by Chapter 116, 2001 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 624 - Primary care physician or physician assistant.

Effective 5/14/2019
31A-22-624.
Primary care physician or physician assistant.
An accident and health insurance policy that requires an insured to select a primary care physician to receive optimum coverage:
(1) shall permit an insured to select a participating provider who:
(a) is an:
(i) obstetrician;
(ii) gynecologist;
(iii) pediatrician; or
(iv) physician assistant who works with a physician:
(A) providing primary care; or
(B) described in Subsections (1)(a)(i), (ii), or (iii); and
(b) is qualified and willing to provide primary care services, as defined by the health care plan, as the insured's provider from whom primary care services are received;
(2) shall clearly state in literature explaining the policy the option available to insureds under Subsection (1); and
(3) may not impose a higher premium, higher copayment requirement, or any other additional expense on an insured because the insured selected a primary care physician in accordance with Subsection (1).
Amended by Chapter 349, 2019 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 627 - Coverage of emergency medical services.

Effective 5/4/2022
31A-22-627.
Coverage of emergency medical services.
(1) A health insurance policy or managed care organization contract:
(a) shall provide coverage of emergency services; and
(b) may not:
(i) require any form of preauthorization for treatment of an emergency medical condition until after the insured's condition has been stabilized;
(ii) deny a claim for any covered evaluation, covered diagnostic test, or other covered treatment considered medically necessary to stabilize the emergency medical condition of an insured; or
(iii) impose any cost-sharing requirement for out-of-network that exceeds the cost-sharing requirement imposed for in-network.
(2)
(a) A health insurance policy or managed care organization contract may require authorization for the continued treatment of an emergency medical condition after the insured's condition has been stabilized.
(b) If authorization described in Subsection (2)(a) is required, an insurer who does not accept or reject a request for authorization may not deny a claim for any evaluation, diagnostic testing, or other treatment considered medically necessary that occurred between the time the request was received and the time the insurer rejected the request for authorization.
(3) For purposes of this section:
(a) "Hospital emergency department" means that area of a hospital in which emergency services are provided on a 24-hour-a-day basis.
(b) "Stabilize" means the same as that term is defined in 42 U.S.C. Sec. 1395dd(e)(3).
(4) Nothing in this section may be construed as:
(a) altering the level or type of benefits that are provided under the terms of a contract or policy; or
(b) restricting a policy or contract from providing enhanced benefits for certain emergency medical conditions that are identified in the policy or contract.
(5) Notwithstanding Section 31A-2-308, if the commissioner finds an insurer has violated this section, the commissioner may:
(a) work with the insurer to improve the insurer's compliance with this section; or
(b) impose the following fines:
(i) not more than $5,000; or
(ii) twice the amount of any profit gained from violations of this section.
Amended by Chapter 198, 2022 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 628 - Standing referral to a specialist.

Effective 5/9/2017
31A-22-628.
Standing referral to a specialist.
(1) With respect to a health insurance policy or managed care organization contract that does not allow an insured to have direct access to a health care specialist, the insurer shall establish and implement a procedure by which an insured may obtain a standing referral to a health care specialist.
(2) The procedure established under Subsection (1):
(a) shall provide for a standing referral to a specialist if the insured's primary care provider determines, in consultation with the specialist, that the insured needs continuing care from the specialist; and
(b) may require the insurer's approval of a treatment plan designed by the specialist, in consultation with the primary care provider and the insured, which may include:
(i) a limit on the number of visits to the specialist;
(ii) a time limit on the duration of the referral; and
(iii) mandatory updates on the insured's condition.
Amended by Chapter 292, 2017 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 630 - Mastectomy coverage.

31A-22-630.
Mastectomy coverage.
(1) If an insured has coverage that provides medical and surgical benefits with respect to a mastectomy, it shall provide coverage, with consultation of the attending physician and the patient, for:
(a) reconstruction of the breast on which the mastectomy has been performed;
(b) surgery and reconstruction of the breast on which the mastectomy was not performed to produce symmetrical appearance; and
(c) prostheses and physical complications with regards to all stages of mastectomy, including lymphedemas.
(2)
(a) This section does not prevent an accident and health insurer from imposing cost-sharing measures for health benefits relating to this coverage, if cost-sharing measures are not greater than those imposed on any other medical condition.
(b) For purposes of this Subsection (2), cost-sharing measures include imposing a deductible or coinsurance requirement.
(3) Written notice of the availability of the coverage described in Subsection (1) shall be delivered to the participant:
(a) upon enrollment; and
(b) annually after the enrollment.
Amended by Chapter 116, 2001 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 631 - Policy summary or illustration.

31A-22-631.
Policy summary or illustration.
(1)
(a) Except as provided in Subsection (1)(b), at the time a life insurance policy is delivered, a policy summary or illustration shall be delivered for the life insurance policy if:
(i) the life insurance policy includes riders or supplemental benefits, including accelerated benefits; and
(ii) receipt of benefits under the life insurance policy is contingent upon morbidity requirements.
(b) In the case of a direct response solicitation, the insurer shall deliver the policy summary or illustration at the sooner of:
(i) the applicant's request; or
(ii) at the time of policy delivery regardless of whether the applicant requests a policy summary or illustration.
(2) In addition to complying with all applicable requirements, the policy summary or illustration shall include:
(a) a clear and prominent disclosure of how the rider or supplemental benefit interacts with other components of the policy, including deductions from death benefits and policy values;
(b) an illustration for each covered person of:
(i) the amount of benefits;
(ii) the length of benefits; and
(iii) the guaranteed lifetime benefits, if any;
(c) a disclosure of the maximum premiums for the rider or supplemental benefit;
(d) any exclusions, reductions, or limitations on the benefits of the rider or supplemental benefit; and
(e) if applicable to the policy type:
(i) a disclosure of the effects of exercising other rights under the policy; and
(ii) guaranteed maximum lifetime benefits.
Enacted by Chapter 116, 2001 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 632 - Report to policy holder.

31A-22-632.
Report to policy holder.
(1) An insurer shall provide the policyholder a monthly report if an accident and health rider or supplemental benefit is:
(a) funded through a life insurance vehicle by acceleration of the death benefit; and
(b) in benefit payment status.
(2) The report required by Subsection (1) shall include:
(a) any rider or supplemental benefits paid out during the month;
(b) an explanation of any changes in the policy due to rider or supplemental benefits being paid out such as:
(i) death benefits; or
(ii) cash values; and
(c) the amount of the rider or supplemental benefits existing or remaining.
Enacted by Chapter 116, 2001 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 633 - Exemptions from standards.

Effective 5/3/2023
31A-22-633.
Exemptions from standards.
Notwithstanding the provisions of this title, any accident and health insurer or health maintenance organization may offer a choice of coverage that is less or different than is otherwise required by applicable state law if:
(1) the Department of Health and Human Services offers a choice of coverage as part of a Medicaid waiver under Title 26B, Chapter 3, Health Care - Administration and Assistance, which includes:
(a) less or different coverage than the basic coverage;
(b) less or different coverage than is otherwise required in an insurance policy or health maintenance organization contract under applicable state law; or
(c) less or different coverage than required by Subsection 31A-22-605(4)(b); and
(2) the choice of coverage offered by the carrier:
(a) is the same or similar coverage as the coverage offered by the Department of Health and Human Services under Subsection (1);
(b) is offered to the same or similar population as the coverage offered by the Department of Health and Human Services under Subsection (1); and
(c) contains an explanation for each insured of coverage exclusions and limitations.
Amended by Chapter 328, 2023 General Session
2023 Utah Code › Title 31A - Insurance Code › Chapter 22 - Contracts in Specific Lines › Part 6 - Accident and Health Insurance › Section 634 - Prohibition against certain use of Social Security number -- Exceptions -- Applicability of section.

31A-22-634.
Prohibition against certain use of Social Security number -- Exceptions -- Applicability of section.
(1) As used in this section:
(a) "Insurer" means:
(i) insurers governed by this part as described in Section 31A-22-600, and includes:
(A) a health maintenance organization; and
(B) a third-party administrator that is subject to this title; and
(ii) notwithstanding Subsection 31A-1-103(3)(f) and Section 31A-22-600, a health, dental, medical, Medicare supplement, or conversion program offered under Title 49, Chapter 20, Public Employees' Benefit and Insurance Program Act.
(b) "Publicly display" or "publicly post" means to intentionally communicate or otherwise make available to the general public.
(2) An insurer or its subcontractors, including a pharmacy benefit manager, may not do any of the following:
(a) publicly display or publicly post in any manner an individual's Social Security number; or
(b) 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.
(3) This section does not prevent the collection, use, or release of a Social Security number as required by state or federal law, or the use of a Social Security number for internal verification or administrative purposes, or the release of a Social Security number to a health care provider for claims administration purposes, or as part of the verification, eligibility, or payment process.
(4) If a federal law takes effect requiring the United States Department of Health and Human Services to establish a national unique patient health identifier program, an insurer that complies with the federal law shall be considered in compliance with this section.
(5) An insurer shall comply with the provisions of this section by July 1, 2004.
(6)
(a) An insurer may obtain an extension for compliance with the requirements of this section in accordance with Subsections (6)(b) and (c).
(b) The request for extension:
(i) shall be submitted in writing to the department prior to July 1, 2004; and
(ii) shall provide an explanation as to why the insurer cannot comply with the requirements of this section by July 1, 2004.
(c) The commissioner shall grant a request for extension:
(i) for a period of time not to exceed March 1, 2005; and
(ii) if the commissioner finds that the explanation provided under Subsection (6)(b)(ii) is a reasonable explanation.
Amended by Chapter 297, 2011 General Session