R590-175-2. Statement of Purpose and Scope.
     The purpose of the rule is to set standards for the Basic Health Care Plan which will be offered under the open enrollment provisions of Chapter 30. The commissioner has adopted the Basic Health Care Plan pursuant to Subsection 31A-22-613.5(2)(a) to be offered under those provisions. This rule applies to all insurers marketing health insurance policies subject to the open enrollment provisions of Chapter 30.

R590-175-3. General Requirements.
A. Each insurer who is required to offer a health care plan under the open enrollment provisions of Chapter 30 shall file with the department at least one health plan which is specified by the insurer as complying with the provisions of this rule and which must be offered for sale to anyone qualifying for open enrollment under Chapter 30.

B. The specified plan may offer additional services or provide a greater level of benefits than the Basic Health Care Plan. However, the specified plan must contain at least those benefits set forth in the Basic Health Care Plan.

C. The specified plan shall not be designed or marketed in a manner which may tend to discourage its purchase by anyone purchasing under the open enrollment provisions of Chapter 30.

D. A plan having actuarial equivalence may be considered, at the sole discretion of the commissioner.

E. Each insurer must use the language in this rule to present covered services, limitations and exclusions; however, any plan offered in compliance with the open enrollment provisions of Chapter 30 must contain at least the benefits set forth in the Basic Health Care Plan as adopted by the commissioner. The specified plan is to be offered as a package, in its entirety, and is mutually exclusive of and not comparable on a line by line basis to a carrier's other plans.

F. When the specified plan is offered by a preferred provider organization, PPO, the benefit levels shown in the Basic Health Care Plan are for contracting providers; benefit levels for non-contracting providers' services may be reduced in accordance with Section 31A-22-617.

G. Each insurer is to include its usual contracting provisions in its specified plan including submission of claims, coordination of benefits, eligibility and coverage termination, grievance procedures general terms and conditions, etc.

H. The form to follow for the Basic Health Care Plan is as follows:

TABLE

BASIC HEALTH CARE PLAN

1. MAXIMUM BENEFIT. The maximum benefit per person for the entire period for which coverage is in effect shall not be less than $1,000,000.

2. ANNUAL MAXIMUM BENEFIT. The maximum annual benefit per person shall not be less than $250,000.

3. PREEXISTING CONDITION LIMITATION. Any preexisting condition limitation shall be in compliance with Utah Code 31A-30-107(5); the waiting period shall not exceed 12 months with credit for prior coverage when applicable.

4. COST-SHARING. Cost-sharing shall be based on eligible expenses. The cost-sharing features of the plan shall be one of the following, at the option of the carrier:
(a)(i) Deductible. An annual deductible may not be greater than $1,000 per person and only two 
     deductibles per family unit. However, when the person has a medical savings account, the 
     deductible amount may be greater than $1,000.
(ii) Copayment. See paragraph 6 for benefits applicable to prescription drugs.
(iii) Coinsurance. For all covered services other than mental illness/substance abuse services and 
     prescriptions, the person shall pay not more than 20% coinsurance to an annual maximum of 
     $3,000 per person, $6,000 per family unit.
(b)(i) Deductible. An annual deductible may not be greater than $1,000 per person and only two 
     deductibles per family unit. However, when the person has a medical savings account, the 
     deductible amount may be greater than $1,000. Preventive services under a managed care 
     plan; e.g., HMO, PPO, are not subject to the deductible.
     (ii) Copayment. A copayment is not to exceed $15 per visit for office, including preventive 
          care, services. When a copayment is required, no coinsurance may be charged for the 
          same service. See paragraph 6 for benefits applicable to prescription drugs.
     (iii) Coinsurance. For all covered services other than mental illness/substance abuse services 
          and prescriptions, the person shall pay not more than 20% coinsurance to an annual 
          maximum of $3,000 per person, $6,000 per family unit.
(c)(i) Deductible. None.
     (ii) Copayment. A copayment is not to exceed $20 per visit for office, including preventive 
          care, services. When a copayment is required, no coinsurance may be charged for the 
          same service. See paragraph 6 for benefits applicable to prescription drugs.
     (iii) Coinsurance. For all covered services other than mental illness/substance abuse services 
          and prescriptions, the person shall pay not more than 30% coinsurance to an annual 
          maximum of $3,000 per person, $6,000 per family unit.

5. PREVENTIVE SERVICES. Preventive services covered under a managed care plan shall not be subject to the annual deductible. Preventive services under an indemnity or fee-for-service plan may be subject to the annual deductible. Covered preventive services shall consist of at least the following:
(a) childhood immunizations in accordance with guidelines as recommended by the Centers for 
     Disease Control, as modified from time to time;
(b) well-baby care through age five in accordance with guidelines recommended by the 
     American Academy of Pediatrics, as modified from time to time;
(c) for adults and adolescents, age, sex and risk appropriate preventive and screening services in 
     accordance with guidelines recommended by the U.S. Preventive Services Task Force, as 
     modified from time to time.

6. PRESCRIPTION DRUGS. Benefits for prescription drugs, other than self injectable drugs, except insulin, shall be subject to either:
(a) a copayment of not more than $15 for generic, $25 for brand-name formulary prescription 
     drugs, and $35 for non-formulary prescription drugs; or
(b) at the option of the carrier, benefits may be subject to a 30% maximum coinsurance.
     Carriers may use formularies and may choose to not apply out-of-pocket costs of 
     prescription drugs to out-of-pocket maximums.

7. OUTPATIENT REHABILITATION SERVICES. Benefits for outpatient rehabilitation services (e.g., physical therapy, occupational therapy, and speech therapy) shall be limited to not less than 10 visits for each illness or injury.

8. MENTAL ILLNESS AND/OR SUBSTANCE ABUSE SERVICES. Benefits for mental illness and/or substance abuse services may be subject to a deductible. Coinsurance may not exceed 50% of eligible expenses and may not apply toward the maximum. Benefits shall be one of the following, at the option of the carrier:
(a) benefits for inpatient services shall be limited to not less than ten days annually per person; 
     benefits for outpatient services shall be limited to not less than 20 visits annually per person;
(b) mental health and/or substance abuse services for group policies will be subject to 
     31A-22-625 and 31A-22-720.

9. HOME HEALTH CARE. Benefits for home health care shall be limited to not less than 30 days in any 12 month period and shall consist of services provided, in accordance with a plan of care, in the home by a licensed community home health agency or an approved hospital program for home health care when the person is physically unable to obtain necessary medical care on an outpatient basis, would otherwise be confined as an inpatient, and is under the care of a physician. A "plan of care" means a written plan that:
(a) is approved by the physician prior to commencement of treatment;
(b) is based on the assessment data or physician orders; and
(c) identifies the patient's needs, who will provide needed services, how often, treatment goals, 
     and anticipated outcomes.
     Covered services shall not include health aide services furnished when the person is not receiving professional services of a registered nurse (RN), licensed practical nurse (LPN), or licensed vocational nurse (LVN), nor shall it include housekeeping services.

10. DURABLE MEDICAL EQUIPMENT. Benefits for durable medical equipment, rental or purchase, at the option of the carrier. Prosthetics and orthotics shall be limited to not less than $5,000 per person for the entire period for which coverage is in effect.

11. COVERED SERVICES. Subject to medical necessity, provider network, and prior approval criteria established by the carrier, and subject to the limitations and exclusions and other terms and conditions of the policy, the following shall be covered services under the basic health care plan:
(a) inpatient hospital services:
     (i) semi-private room accommodations;
     (ii) ICU;
     (iii) hospital services and supplies;
(b) ambulatory service facility services:
     (i) birthing center services, when maternity care is covered;
     (ii) surgical facility services;
(c) office preventive services;
(d) office medical services:
     (i) diagnostic services; e.g., x-ray, lab tests;
     (ii) therapeutic services; e.g., injection of medication;
(e) outpatient hospital services:
     (i) emergency room services;
     (ii) diagnostic services;
     (iii) therapeutic services; e.g., chemotherapy, radiation therapy;
     (iv) surgical facility services;
(f) inpatient medical services; e.g., physician visits;
(g) surgery;
(h) assistant-at-surgery;
(i) anesthesia, including children's general anesthesia for dental, if necessary;
(j) consultation;
(k) dental care for accidental injury to sound natural teeth;
(l) limited home health care;
(m) emergency ambulance transportation;
(n) prescription drugs;
(o) durable medical equipment, prosthetics and orthotics, as limited; and medical supplies;
(p) maternity services:
     (i) for employer groups maternity benefits are provided on the same basis as benefits for 
         sickness;
     (ii) for individuals there are no maternity benefits;
     (iii) benefits for complications of pregnancy are provided on the same basis as benefits for 
          sickness. Complications of pregnancy will not be excluded solely because the pregnancy is
          a preexisting condition. "Complications of pregnancy" means an illness, distinct from 
          pregnancy, affecting the mother and occurring during pregnancy and requiring separate 
          and specific medical or surgical services for which separate and additional charges are 
          incurred. In no event will the presence of complications of pregnancy result in benefits 
          being provided for services normal to care and treatment of pregnancy and childbirth. 
          Such normal services include but are not limited to hospitalization for childbirth or 
          termination of pregnancy by any means, anesthesia services, ultrasound examinations, 
          prenatal diagnostic laboratory services, antepartum and postpartum care, vaginal or 
          cesarean delivery, threatened premature termination, premature termination, and routine 
          nursery care of the newborn;
     (iv) newborn and maternity inpatient time limits will conform to 31A-22-610.2. For  
          conversion plans, maternity will be covered with the lesser of benefits originally on plan 
          prior to conversion or the basic benefit plan. This coverage benefit is only for existing 
          pregnancies, known or unknown at the time of conversion. Additional premium for 
          pregnancy is not allowed;
(q) limited outpatient rehabilitation services;
(r) limited mental illness/substance abuse services;
(s) diabetes as required by 31A-22-626.
(t) inborn metabolic errors, PKU, nutritional benefits as required by 31A-22-623; and
(u) mastectomy as required by 31A-22-630 and 31A-22-719.

12. EXCLUSIONS. Benefits will not be provided for any of the following:
(a) services, supplies, or treatment provided prior to the effective date or after the termination 
     date of coverage;
(b) charges in connection with a work-related injury or sickness for which coverage is provided 
     under any state or federal worker's compensation, employer's liability, or occupational 
     disease law;
(c) services, supplies, or treatment for which coverage is provided under any motor vehicle 
     no-fault plan. When the person is required by law to have no-fault insurance in effect, this 
     exclusion applies to charges up to the minimum coverage required by law whether or not such 
     coverage is in effect.;
(d) services, supplies, or treatment for injury or sickness resulting from war or any act of war 
     whether declared or undeclared;
(e) services, supplies, or treatment for injury or sickness resulting from service in the military of 
     any country;
(f) services, supplies, or treatment for which benefits are provided under Medicare or any other 
     government program except Medicaid;
(g) services, supplies, or treatment for which no charge is made or for which the person is not 
     required to pay;
(h) services or supplies not incident to or necessary for the treatment of injury or sickness or 
     which are not medically necessary, as determined by the carrier;
(i) treatment or prevention of an injury or sickness, including mental illness, by means of 
     treatments, procedures, techniques, or therapy outside generally accepted health care 
     practice;
(j) services, supplies, or treatment required as a result of an injury or sickness sustained while 
     committing a felony or engaging in an illegal occupation;
(k) services to the extent benefits are provided by any governmental unit except as required by 
     federal law for treatment of veterans in Veterans Administration or armed forces facilities for 
     non-service related medical conditions;
(l) examinations, reports, or appearances in connection with legal proceedings; and services, 
     supplies, or accommodations pursuant to a court order, whether or not injury or sickness is
     involved;
(m) investigative/experimental technology, treatment, procedure, facility, equipment, drug, device 
     or supply, "technology," which does not, as determined by the carrier on a case by case 
     basis, meet all of the following criteria:
     (i) the technology must have final approval from appropriate governmental regulatory bodies, 
          if applicable;
     (ii) the technology must be available in significant number outside the clinical trial or research 
          setting;
     (iii) the available research regarding the technology must be substantial. For purposes of this 
          definition, "substantial" means sufficient to allow the carrier to conclude that:
          (A) the technology is both medically necessary and appropriate for the person's treatment;
          (B) the technology is safe and efficacious; and
          (C) more likely than not, the technology will be beneficial to the person's health;

     (iv) the regional medical community as a whole must generally recognize the technology as 
          appropriate;
(n) services in connection with any transplant of any whole organ or part thereof, live or cadaver, 
     bone marrow, either as donor or recipient, or any artificial organ, except for the following:
     (i) cornea transplants;
     (ii) kidney transplants;
     (iii) liver transplants for children under age 18 years;
     (iv) bone marrow transplants for children under age 18 years; and
     (v) evaluation, treatment and therapy involving the use of myeloablative chemotherapy with   
          autologous hematopoietic stem cell and/or colony stimulating factor support for children 
          under age 18 years;
(o) custodial care. "Custodial care" means:
     (i) institutional care, consisting mainly of room and board, which is for the primary purpose of 
          controlling the person's environment; and
     (ii) professional or personal care, consisting mainly of non-skilled nursing services with or 
          without medical supervision, which is for the primary purpose of managing the person's 
          disability or maintaining the person's degree of recovery already attained without 
          reasonable expectation of significant further recovery.

     "Custodial care" does not mean outpatient palliative and supportive care provided by a hospice program to a person who is terminally ill with a life expectancy of not more than six months and is in lieu of institutional or inpatient hospital care;
(p) services, supplies, or treatment in connection with cosmetic or reconstructive procedures 
     which alter appearance but do not restore or improve impaired physical function or which are 
     performed for psychological or emotional purposes, except when performed while a person is 
     covered under this policy for the following:
     (i) repair of defects resulting from an accident occurring within 90 days of the effective date of 
          this policy under creditable coverage or occurring during this policy;
     (ii) replacement of diseased tissue surgically removed for illness occurring within 90 days of 
         this policy under creditable coverage or occurring during this policy;
     (iii) treatment of a birth defect in a child who has met the pre-existing conditions requirement 
          since birth or date of placement for adoption; and
     (iv) mastectomy reconstruction as required by 31A-22-630 and 31A-22-719;
(q) dental services. This exclusion will not apply if dental services are required as a result of an 
     accidental injury which occurs while coverage is in force, dental services are received within 
     two years following the accidental injury, and the person has been continuously covered from 
     the date of the accidental injury through the date the dental services are provided;
(r) eyeglasses, contact lenses and/or servicing of eyeglasses and/or contact lenses. This exclusion 
     does not apply to contact lenses in the case of keratoconus or post-cataract surgery when the 
     contact lenses are medically necessary in the treatment of the condition;
(s) medical, non-surgical, care of weak, strained, flat, unstable or unbalanced feet routine foot 
     care. 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;
(t) orthopedic or corrective shoes, foot orthotics, or any other supportive devices for the feet;
(u) drugs and medicines which do not bear the legend "Caution - federal law prohibits dispensing 
     without a prescription" and/or which are not dispensed by a licensed pharmacist;
(v) charges in connection with jaw realignment procedures including, but not limited to, 
     osteotomy, upper or lower jaw augmentation or reduction procedures, and orthognathic 
     surgery; charges in connection with treatment of temporomandibular joint (TMJ) dysfunction, 
     including surgical procedures and injections of the TMJ, physical therapy, splints, and 
     orthodontic appliances. This exclusion will not apply to:
     (i) the initial diagnostic evaluation of TMJ dysfunction;
     (ii) surgical correction of the TMJ required as a result of an accidental injury which occurs
          while this coverage is in force; and
     (iii) physical therapy services related to and subsequent to covered TMJ surgery;
(w) treatment of obesity by means of surgical, medical or medication services and regardless of 
      associated medical, emotional, or psychological conditions;
(x) services or supplies in connection with genetic studies;
(y) implantable contraceptives (hormonal or other);
(z) reversal of a sterilization procedure;
(aa) any treatment for or diagnosis of infertility, artificial insemination, in vitro fertilization, and any 
     other male or female dysfunction;
(bb) vision testing, vision training;
(cc) radial keratotomy, laser and any surgical correction of errors of refraction;
(dd) educational service or counseling, including weight control clinics, stop smoking clinics, 
     cholesterol counseling, exercise programs or other types of physical fitness training, except for 
     those benefits required by 31A-22-626;
(ee) marriage counseling; family counseling; counseling for educational, social, occupational, 
     religious, or other similar maladjustment; behavior modification, biofeedback, or rest cures as 
     treatment for mental disorders; sensitivity or stress-management training; self-help training; 
     and residential treatment;
(ff) treatment for mental disorders which are irreversible or for which there is little or no 
     reasonable expectation for improvement, including mental retardation, personality disorders, 
     and chronic organic brain disease. This exclusion does not apply to the initial assessment for 
     diagnosis of the condition;
(gg) psychotherapy, counseling, or other services in connection with learning disabilities, 
     disruptive behavior disorders, conduct disorders, psychosexual disorders, or transexualism. 
     This exclusion does not apply to the initial assessment for diagnosis of the condition;
(hh) vitamins, special formulas, special diets, and food supplements except as provided by a 
     hospital or skilled nursing facility during a confinement for which benefits are available, except 
     as outlined in 31A-22-623;
(ii) any devices used to aid hearing, including cochlear implants, the fitting of such devices and 
      any routine hearing tests;
(jj) acupuncture or acupressure;
(kk) speech therapy for psychosocial speech delays;
(ll) all shipping, handling, or postage charges except as incidentally provided, without a separate  
      charge, in connection with covered services or supplies;
(mm) interest or finance charges except as specifically required by law;
(nn) charges for missed appointments, telephone consultations, and clerical services for     
       completion of special reports or claim forms;
(oo) travel expenses, whether or not prescribed;
(pp) care, except urgent or emergency care, rendered outside the United States;
(qq) services provided by a member of the person's immediate family or household; and
(rr) autopsy procedures.

I. The specified plan is to be filed with the department before use.
J. Conversion coverage provided pursuant to Section 31A-22-708, may provide additional benefits in addition to the Basic Health Care Plan.

R590-175-4. Severability.
     If a provision of this rule or its application to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of these provisions shall not be affected.

KEY: insurance
2001                                                                                                                 
31A-22-613.5