No. 29999 (Amendment): R590-233-4. Prohibited Policy Provisions

DAR File No.: 29999
Filed: 05/31/2007, 12:05
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

Representatives of the health insurance industry have requested that the allowable Exclusions subsection of this rule be changed.

Summary of the rule or change:

The department has deleted the reference to gastric bypass in the cosmetic exclusion and have created a stand-alone exclusion clarifying that all gastric surgeries related to obesity are excluded.

State statutory or constitutional authorization for this rule:

Sections 31A-2-201, 31A-2-202, 31A-23a-412, 31A-22-605, 31A-22-623, 31A-22-626, 31A-23a-402, and 31A-26-301

Anticipated cost or savings to:

the state budget:

There will be no change to the state or the department's budgets. The changes will not require additional filings, fees, or changes in the department's workload. This is a change that reflects what is already being done in the marketplace.

local governments:

Since the changes to this rule deal solely with the relationship between the department and its licensees, it will have no effect on local government.

other persons:

The changes clarify that all gastric surgeries related to obesity are excluded. Since this is the interpretation the industry has given the rule already, it will have no effect on insurers and consumers.

Compliance costs for affected persons:

The changes clarify that all gastric surgeries related to obesity are excluded. Since this is the interpretation the industry has given the rule already, it will have no effect on insurers and consumers.

Comments by the department head on the fiscal impact the rule may have on businesses:

These changes are a clarification of how the rule is already being applied by the industry. As a result, the changes being made will have no fiscal impact on Utah businesses. D. Kent Michie, Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Insurance
Administration
Room 3110 STATE OFFICE BLDG
450 N MAIN ST
SALT LAKE CITY UT 84114-1201

Direct questions regarding this rule to:

Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/16/2007

This rule may become effective on:

07/23/2007

Authorized by:

Jilene Whitby, Information Specialist

RULE TEXT

R590. Insurance, Administration.

R590-233. Health Benefit Plan Insurance Standards.

R590-233-4. Prohibited Policy Provisions.

(1) Probationary periods.

(a) A policy shall not contain provisions establishing a probationary period during which no coverage is provided under the policy except as provided in R590-233-4(1)(b), (c), and (d).

(b) A policy may specify a probationary period not to exceed twelve months for losses resulting from:

(i) amenorrhea;

(ii) cataracts;

(iii) congenital deformities, unless coverage is required pursuant to Subsection 31A-22-610(2);

(iv) cystocele;

(v) dysmenorrhea;

(vi) enterocele;

(vii) infertility;

(viii) rectocele;

(ix) seasonal allergies, limited to testing and treatment;

(x) sleep disorders, including sleep studies;

(xi) surgical treatment for;

(A) adenoidectony,

(B) bunionectomy,

(C) carpal tunnel,

(D) hysterectomy, except in cases 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 injuries 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 must be provided for conditions and procedures prohibited in Subsection (1)(b) for emergency medical conditions in compliance with Section 31A-22-627.

(d) The probationary period must be reduced by the number of days of creditable coverage the enrollee has as of the enrollment date, in accordance with Subsection 31A-22-605.1(4)(b).

(2) Preexisting conditions provisions shall comply with Sections 31A-1-301, and 31A-22-605.1.

(3) Limitations or exclusions. A policy shall not limit or exclude coverage or benefits by type of illness, accident, treatment or medical condition, except as follows:

(a) abortion;

(b) acupuncture and acupressure services;

(c) administrative charges for completing insurance forms, duplication services, interest, finance charges, or other administrative charges, unless otherwise required by law;

(d) administrative exams and services;

(e) alcoholism and drug addictions;

(f) allergy tests and treatments;

(g) aviation;

(h) axillary hyperhidrosis;

(i) benefits provided under:

(i) Medicare or other governmental program, except Medicaid;

(ii) state or federal worker's compensation; or

(iii) employer's liability or occupational disease law.

(j) cardiopulmonary fitness training, exercise equipment, and membership fees to a spa or health club;

(k) charges for appointments scheduled and not kept;

(l) chiropractic;

(m) complementary and alternative medicine;

(n) corrective lenses, and examination for the prescription or fitting thereof, but policies may not exclude required lens implants following cataract surgery;

(o) cosmetic surgery[ including gastric procedures]; reversal, revision, repair, complications, or treatment related to a non-covered cosmetic surgery[,]. This exclusions does not apply to[except that cosmetic surgery shall not include] reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part; or[and] reconstructive surgery because of congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;

(p) custodial care;

(q) dental care or treatment;[,]

(r) dietary products, except as required by Rule R590-194;

(s) educational and nutritional training, except as required by Rule R590-200;

(t) experimental and/or investigational services;

(u) felony, riot or insurrection, when the insured is a voluntary participant;

(v) foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet, including orthotics. The exclusion of routine foot care does not apply to cutting or removal of corns, calluses, or nails when provided to a person who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency, of such severity that unskilled performance of the procedure would be hazardous;

(w) gastric or intestinal bypass services including lap banding, gastric stapling, and other similar procedures to facilitate weight loss; the reversal, or revision of such procedures; or services required for the treatment of complications from such procedures;

(x) gene therapy;

(y)[(x)] genetic testing;

(z)[(y)] hearing aids, and examination for the prescription or fitting thereof;

(aa)[(z)] illegal activities, limited to losses related directly to the insured's voluntary participation;

(bb)[(aa)] infertility services, except as required by Rule R590-76;

(cc)[(bb)] interscholastic sports, with respect to short-term nonrenewable policies;

(dd)[(cc)] mental or emotional disorders;

(ee)[(dd)] motor vehicle no-fault law, except when the covered person is required by law to have no-fault coverage, the exclusion applies to charges up to the minimum coverage required by law whether or not such coverage is in effect;

(ff)[(ee)] nuclear release;

(gg)[(ff)] preexisting conditions or diseases as allowed under Section 31A-22-605.1, except for coverage of congenital anomalies as required by Section 31A-22-610;

(hh)[(gg)] pregnancy, except for complications of pregnancy;

(ii)[(hh)] refractive eye surgery;

(jj)[(ii)] rehabilitation therapy services, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident or illness;

(kk)[(jj)] respite care;

(ll)[(kk)] rest cures;

(mm)[(ll)] routine physical examinations;

(nn)[(mm)] service in the armed forces or units' auxiliary to it;

(oo)[(nn)] services rendered by employees of hospitals, laboratories or other institutions;

(pp)[(oo)] services performed by a member of the covered person's immediate family;

(qq)[(pp)] services for which no charge is normally made in the absence of insurance;

(rr)[(qq)] sexual dysfunction;

(ss)[(rr)] shipping and handling, unless otherwise required by law;

(tt)[(ss)] suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury;

(uu)[(tt)] telephone/electronic consultations;

(vv)[(uu)] territorial limitations outside the United States;

(ww)[(vv)] terrorism, including acts of terrorism;

(xx)[(ww)] transplants;

(yy)[(xx)] transportation;

(zz)[(yy)] treatment provided in a government hospital, except for hospital indemnity policies;

(aaa)[(zz)] war or act of war, whether declared or undeclared; or

(bbb)[(aaa)] others as may be approved by the commissioner.

(4) Waivers. All waivers issued must comply with 31A-30-107.5. Where waivers are required as a condition of issuance, renewal or reinstatement, signed acceptance by the insured is required.

(5) Commissioner authority. Policy provisions precluded in this section shall not be construed as a limitation on the authority of the commissioner to prohibit other policy provisions that in the opinion of the commissioner are unjust, unfair or unfairly discriminatory to the policyholder, beneficiary or a person insured under the policy.

 

KEY: health insurance

Date of Enactment or Last Substantive Amendment: [December 28, 2005]2007

Authorizing, and Implemented or Interpreted Law: 31A-2-201; 31A-2-202; 31A-22-605; 31A-22-623; 31A-22-626; 31A-23a-402; 31A-23a-412; 31A-26-301