Insurance

Administration

Rule R590-233: Health Benefit Plan Insurance Standards

Effective Date: 03/24/2025

Admin. Code Reference: R590-233

Rule Type: Current Rule

R590. Insurance, Administration.

R590-233. Health Benefit Plan Insurance Standards.

R590-233-1. Authority.

This rule is promulgated by the commissioner pursuant to Sections 31A-2-201, 31A-2-201.1, 31A-22-605, 31A-22-605.1, 31A-22-623, 31A-22-626, and 31A-23a-402.

R590-233-2. Purpose and Scope.

(1) The purpose of this rule is to:

(a) standardize and simplify the terms and coverage of a health benefit plan contract;

(b) facilitate public understanding and comparison of coverage;

(c) prohibit use of a provision that is misleading or confusing in connection with the purchase of coverage or the settlement of a claim;

(d) set minimum coverage requirements; and

(e) provide for full disclosure in the sale of insurance.

(2)(a) Except as excluded in Subsection (2)(b), this rule applies to a health benefit plan contract.

(b) This rule does not apply to a:

(i) health benefit plan issued to an employee group under Section 31A-22-502;

(ii) health benefit plan subject to Rule R590-277; or

(iii) short-term limited duration health insurance contract subject to Rule R590-286.

R590-233-3. Definitions.

Terms used in this rule are defined in Sections 31A-1-301 and 31A-22-625. Additional terms are defined as follows:

(1) "Certificate of completion" means a document issued by the Utah State Board of Education, or a similar organization in another state, to an individual:

(a) who completes an approved course of study not leading to a diploma;

(b) who passes a challenge for the course of study in Subsection (1)(a); or

(2) "Complication of pregnancy" means a disease or condition that is distinct from pregnancy but is adversely affected or caused by pregnancy and is not associated with a normal pregnancy.

(a) "Complication of pregnancy" includes:

(i) acute nephritis;

(ii) nephrosis;

(iii) cardiac decompensation;

(iv) terminated ectopic pregnancy;

(v) spontaneous termination of pregnancy when a viable birth is not possible;

(vi) puerperal infection;

(vii) eclampsia;

(viii) pre-eclampsia; or

(ix) toxemia.

(b) "Complication of pregnancy" does not include:

(i) false labor;

(ii) occasional spotting;

(iii) doctor prescribed rest during pregnancy;

(iv) morning sickness; or

(v) a condition of comparable severity associated with management of a difficult pregnancy.

(3) "Contract" means a policy or certificate.

(4) "Convalescent nursing home," "extended care facility," "hospital," or "skilled nursing facility" means such facility is licensed and operating within the scope of that license.

(5)(a) "Cosmetic surgery" or "reconstructive surgery" means a surgical procedure performed primarily to improve physical appearance.

(b) "Cosmetic surgery" or "reconstructive surgery" does not include surgery that is necessary:

(i) to correct damage caused by injury or sickness;

(ii) for reconstructive treatment following medically necessary surgery;

(iii) to provide or restore normal bodily function; or

(iv) to correct a congenital disorder that has resulted in a functional defect.

(6) "Custodial care" means a plan of care that does not provide treatment for sickness or injury, is for meeting personal needs and maintaining physical condition when there is no prospect of remission or restoration of the patient to a condition when care would not be required, and that may be provided by a person without nursing skills or qualifications.

(7) "Enrollment form" means an application as defined in Section 31A-1-301.

(8) "Experimental treatment" means a medical treatment, service, supply, medication, drug, or other method of therapy or medical practice that is not accepted as a valid course of treatment by the U.S. Food and Drug Administration, the American Medical Association, or the Surgeon General.

(9) "Home health agency" means a public agency, a private organization, or a subdivision of a health care facility that is licensed and operating within the scope of that license.

(10) "Home health aide" means an individual who obtains a certificate of completion, as required by law, that allows performance of:

(a) health care and other related services under the supervision of a registered nurse from the home health agency; or

(b) a simple procedure as an extension of physical, speech, or occupational therapy under the supervision of a licensed therapist.

(11) "Home health care" means a service provided by a home health agency.

(12) "Homemaker" means an individual who cares for the home through duties such as housekeeping, meal planning and preparation, laundry, shopping, and errands.

(13) "Hospice" means a program of care for the terminally ill and their families that occurs in a home or health care facility and provides medical, palliative, psychological, spiritual, or supportive care and treatment and is licensed and operating within the scope of that license.

(14)(a) "Injury" means a bodily injury resulting from an accident, independent of disease, that occurs while the coverage is in force.

(b) "Injury" is not limited to an injury with external, violent, visible wound, or similar description.

(15) "Intermediate nursing care" means a nursing service provided by, or under the supervision of, a nurse to treat a condition when confinement is required.

(16) "Licensed practical nurse" means a licensed practical nurse who provides services within the scope of their license.

(17)(a) "Medical necessity" means a health care service or product that a prudent health care provider would provide to a patient to prevent, diagnose, or treat an illness, injury, disease, or its symptoms in a manner that is:

(i) in accordance with generally accepted standards of medical practice in the United States;

(ii) clinically appropriate in terms of type, frequency, extent, site, and duration;

(iii) not primarily for the convenience of the patient, physician, or other health care provider; and

(iv) covered under the contract.

(b) If a medical question-of-fact exists, "medical necessity" shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective.

(c)(i) For an intervention not yet in widespread use, the effectiveness shall be based on scientific evidence.

(ii) For an established intervention, the effectiveness shall be based on:

(A) scientific evidence;

(B) professional standards; and

(18)(a) "Nurse" means a type of licensed nurse, such as a registered nurse or a licensed practical nurse.

(b) If the word "nurse" is used without specific instruction, then the use of this term requires the insurer to recognize the services of any individual who qualifies under this terminology under applicable laws.

(19) "Nursing care" means assistance provided for the health care needs of a sick or disabled individual, by or under the direction of a nurse.

(20) "Physician," "qualified physician," or "licensed physician" means a physician who provides services within the scope of their license.

(21) "Probationary period" or "waiting period" means the length of time following the date of issuance or effective date of the contract before a benefit is paid under the contract.

(22) "Registered nurse" means a registered nurse who provides services within the scope of their license.

(23)(a) "Scientific evidence" means:

(i) a scientific study published or accepted by a medical journal that meets nationally recognized standards for scientific manuscripts and that submits its published articles for review by experts who are not part of the editorial staff; or

(ii) a finding, study, or research conducted by or under the auspices of a federal government agency or nationally recognized federal research institute.

(b) "Scientific evidence" does not include:

(i) published peer-reviewed literature sponsored by:

(A) a pharmaceutical manufacturing company; or

(B) a medical device manufacturer; or

(ii) a single study without other supportable studies.

(24) "Sickness" means illness, disease, or disorder of an enrollee.

(25) "Skilled nursing care" means nursing services provided by, or under the supervision of, a registered nurse to treat the condition for which confinement is required and not for providing intermediate nursing care or custodial care.

(26) "Summary of benefits and coverage" means a written summary of the contract as described under 45 CFR 147.200.

(27) "Therapist" means a professionally trained or licensed individual, such as a physical therapist, occupational therapist, or speech therapist, who is skilled in applying treatment techniques and procedures under the general direction of a physician.

(28)(a) "Total disability" means an individual who:

(i) is not engaged in employment or occupation for which the individual is or becomes qualified by reason of education, training, or experience; and

(ii) is unable to perform each substantial and material duty of the individual's regular occupation.

(29) "Usual and customary" means the most common charge for a similar service, medicine, or supply within the geographical area in which a charge is incurred, considering one or more of the following factors:

(a) the level of skill, extent of training, and experience required to perform the procedure or service;

(b) the length of time required to perform the procedure or service as compared to the length of time required to perform a similar service;

(d) the amount charged for the same or comparable service, medicine, or supply in the geographical area or in other parts of the country;

(e) the cost to the provider of providing the service, medicine, or supply; or

(f) another factor determined by the insurer to be appropriate.

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;

(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

(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;

(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.

(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.

R590-233-5. General Requirements.

(1) A contract may not include a definition regarding a matter defined in Section R590-233-3 unless the definition complies with that section.

(2) A contract that provides coverage to a spouse of the contract holder:

(a) may not provide for termination of coverage of the spouse solely because of the occurrence of an event specified for termination of coverage of the contract holder, other than for nonpayment of premium; and

(b) shall provide that in the event of the contract holder's death, the spouse shall become the contract holder.

(3)(a) Termination of a contract shall be without prejudice to any continuous loss that commenced while the contract was in force.

(b) The continuous total disability of the enrollee may be a condition for an extension of benefits beyond the period the contract was in force, limited to the duration of the benefit period, if any, or payment of the maximum benefits.

(4) If a contract includes a status-type military service exclusion or a provision that suspends coverage during military service, the contract shall, upon receipt of a written request, provide for a refund of premiums, as applicable, to the enrollee on a pro-rata basis.

(5)(a) If an insurer cancels or refuses to renew a contract providing pregnancy benefits, the contract shall provide an extension of benefits for the pregnancy benefit, if:

(i) the pregnancy commenced while the contract was in force; and

(ii) a benefit would have been payable had the contract remained in force.

(b) Subsection (5)(a) does not apply to a contract that is canceled due to the enrollee:

(i) failing to pay the required premium in accordance with the contract terms;

(ii) performing an act or practice that constitutes fraud in connection with the coverage; or

(iii) making an intentional misrepresentation of material fact under the terms of the contract.

(6) A contract providing coverage for the recipient in a transplant operation shall also provide reimbursement of all medically necessary transplant expenses of a live donor, to the extent benefits remain and are available under the recipient's contract and after benefits for the recipient's expenses have been paid.

(7) A premium change notice shall be given no less than 45 days before the renewal date.

R590-233-6. Required Provisions.

(1)(a) An enrollment form question regarding a health condition may not be vague and shall reference a reasonable time frame in relation to the health condition.

(b)(i) A completed application shall be made part of the policy.

(ii) A copy of the completed enrollment form shall be provided to the applicant or enrollee before or at delivery of the contract.

(i) provide a statement regarding a preexisting waiting period and the requirement to receive any applicable credit for previous coverage; and

(ii) include a question regarding whether the insurance to be issued is intended to replace any other accident and health insurance presently in force.

(d) A supplementary enrollment form or other form signed by the applicant or enrollee containing the question in Subsection (1)(c)(ii) may be used.

(2)(a) A contract shall include a provision for renewal, continuation, and nonrenewal.

(b) Each provision shall:

(i) appear on the first page of the contract;

(ii) be appropriately captioned; and

(iii) clearly state the renewability of coverage.

(3)(a) Except for an endorsement by which the insurer effectuates a written request by the contract holder or exercises a specifically reserved right under the contract, signed acceptance by the policyholder is required for an endorsement that reduces or eliminates a benefit or coverage and is added to a contract after the date of issue, at reinstatement, or at renewal.

(b) After the contract issue date, an endorsement that increases a benefit or coverage with a concurrent increase in premium during the contract term shall be agreed to in writing and signed by the contract holder, except if the increased benefit or coverage is required by law.

(4) If a separate additional premium is charged for a benefit provided in connection with an endorsement, the premium charge shall be set forth in the contract.

(5) A contract that provides for the payment of a benefit based on a standard described as usual and customary, reasonable and customary, or similar words, shall include a definition and explanation of the term in its accompanying outline of coverage or benefit summary.

(6)(a) If a contract includes a limitation regarding a preexisting condition, the limitation shall appear as a separate paragraph in the contract and be labeled as "Preexisting Condition Limitation."

(b) The limitation shall include a description of the existence and term of the preexisting condition exclusion, including the maximum preexisting exclusion period.

R590-233-7. Accident and Health Benefit Standards.

(1)(a) An accident and health insurance contract subject to this rule may not be delivered or issued for delivery unless it meets the required standard for the specified category in this section.

(b) This section does not preclude the issuance of a contract combining two or more categories set forth in Subsection 31A-22-605(5).

(i) inborn metabolic errors, as required by Section 31A-22-623 and Rule R590-194; and

(ii) diabetes, as required by Section 31A-22-636 and Rule R590-200.

(2)(a) Major medical expense coverage provides hospital, medical, and surgical coverage for an expense incurred for a sickness or injury.

(b)(i) A major medical expense contract may include:

(A) a lifetime maximum not less than $1,000,000 per enrollee;

(B) a coinsurance percentage or copay not to exceed 50% of covered charges per enrollee per year;

(D) a deductible on a per enrollee, per family, per illness, per benefit period, or per year basis.

(ii) A combination of the bases in Subsection (2)(b)(i) may not exceed 5% of the lifetime maximum per enrollee.

(i) daily hospital room and board expenses, which may be limited to the average daily cost of the semiprivate room rate in the area where the enrollee resides;

(ii) miscellaneous hospital services and supplies;

(iii) surgical services;

(iv) anesthesia services;

(v) medical services while inpatient;

(vi) outpatient care for physician services provided on an ambulatory basis for:

(A) diagnosis and treatment of a sickness or an injury;

(B) diagnostic x-ray;

(D) radiation therapy; and

(E) hemodialysis ordered by a physician; and

(vii) at least three of the following additional benefits shall also be provided:

(A) inpatient private duty nursing services;

(B) convalescent nursing home care;

(D) medical equipment rental, as defined in the contract;

(E) artificial limbs or eyes, casts, splints, trusses, or braces;

(F) treatment for mental health conditions; or

(G) outpatient prescription drugs and medications.

(d) Benefits may be subject to a deductible, coinsurance, a copay, and the contract exclusion or limitation provisions.

(e) A major medical expense contract may limit a service covered under Subsection (c).

(f) Except under Subsection (2)(e), a major medical expense contract shall cover the usual and customary or reasonable charges, after the deductible, coinsurance, and copay, for a covered service up to the lifetime maximum.

(3) Basic medical expense coverage provides hospital, medical, and surgical coverage for an expense incurred for a sickness or injury.

(a) A basic medical expense contract may include:

(i) a lifetime maximum not less than $500,000 per enrollee;

(ii) a coinsurance percentage or copay not to exceed 50% of covered charges per enrollee per year;

(iii) an out-of-pocket maximum, after a deductible, that does not exceed $25,000 per enrollee per year; or

(iv) a deductible on a per enrollee, per family, per illness, per benefit period, or per year basis.

(b) A combination of the bases in Subsections (1)(a)(ii), (1)(a)(iii), and (1)(a)(iv) may not exceed 10% of the aggregate maximum limit under the contract.

(i) daily hospital room and board expenses that may be limited to the semiprivate room rate in the area where the enrollee resides or another rate agreed to between the insurer and provider, for a period of not less than 31 days during a continuous hospital confinement;

(ii) miscellaneous hospital services and supplies;

(iii) surgical services;

(iv) anesthesia services;

(v) medical services while inpatient;

(vi) outpatient care, for physician services provided on an ambulatory basis for:

(A) diagnosis and treatment of a sickness or an injury;

(B) diagnostic x-ray;

(D) radiation therapy; and

(E) hemodialysis ordered by a physician; and

(vii) three of the following additional benefits shall also be provided:

(A) inpatient private duty nursing services;

(B) convalescent nursing home care;

(D) medical equipment rental, as defined in the contract;

(E) artificial limbs or eyes, casts, splints, trusses, or braces;

(F) treatment for mental health conditions; or

(G) outpatient prescription drugs and medications.

(d) If a basic medical expense contract is to complement an underlying basic hospital expense contract and basic medical-surgical expense contract, the deductible may be increased by the amount of the benefits provided by the underlying contract.

(e) Benefits may be subject to a deductible, coinsurance, a copay, and the contract exclusion or limitation provisions.

(f) A basic medical expense contract may have an internal limitation for:

(i) prescription drugs;

(ii) a nursing facility;

(iii) an intensive care facility;

(iv) a mental health condition or substance abuse treatment;

(v) a transplant;

(vi) experimental treatment;

(vii) a mandated benefit required by law;

(viii) services in Subsection (3)(c); and

(ix) other internal limitations as approved by the commissioner.

(g) Except under Subsection (3)(f), a basic medical expense contract shall cover the usual and customary or reasonable charges, after the deductible, coinsurance, and copay, for a covered service up to the lifetime maximum.

(4) Catastrophic coverage is a contract that:

(a) provides a benefit for a medical expense to a lifetime maximum of not less than $1,000,000 per enrollee;

(b) does not include a separate internal dollar limit;

(c) may be subject to a deductible that does not exceed 2% of the contract limit or the amount of another in-force accident and health insurance contract for the same medical expenses; and

(d) does not include a percentage participation or coinsurance clause for an expense that exceeds the deductible.

R590-233-8. Outline of Coverage Requirements.

(1) The outline of coverage in Table 1 shall be issued with a major medical expense insurance contract.

TABLE 1

Major Medical Expense Insurance Outline of Coverage

(COMPANY NAME)

MAJOR MEDICAL EXPENSE COVERAGE

OUTLINE OF COVERAGE

Read Your (Policy)(Certificate) Carefully - This outline of coverage provides a very brief description of the important features of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY!

Major medical expense coverage is designed to provide, to persons insured, comprehensive coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, inpatient medical services, and out-of-hospital care, subject to any deductible, copayment provisions, or other limitations that may be set forth in the policy.

A brief specific description of the benefits, including dollar amounts, contained in this policy, in the following order: daily hospital room and board; miscellaneous hospital services; surgical services; anesthesia services; inpatient medical services; outpatient care; maximum dollar amount for covered charges; and other benefits, if any.

A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits.

A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.

(2) The outline of coverage in Table 2 shall be issued with a basic medical expense insurance contract.

TABLE 2

Basic Medical Expense Insurance Outline of Coverage

(COMPANY NAME)

BASIC MEDICAL EXPENSE COVERAGE

THIS (POLICY)(CERTIFICATE) PROVIDES LIMITED BENEFITS

OUTLINE OF COVERAGE

sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR (POLICY)(CERTIFICATE) CAREFULLY!

Basic medical expense coverage is designed to provide, to persons insured, limited coverage for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, inpatient medical services, and outpatient care, subject to any limitations, deductibles and copayment requirements set forth in the policy.

A brief specific description of the benefits, including dollar amounts, contained in this policy, in the following order: daily hospital room and board; miscellaneous hospital services; hospital outpatient services; surgical services; anesthesia services; in hospital medical services; and other benefits, if any.

A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits.

A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.

(3) The outline of coverage in Table 3 shall be issued with a catastrophic expense insurance contract.

TABLE 3

Catastrophic Expense Insurance Outline of Coverage

(COMPANY NAME)

CATASTROPHIC EXPENSE COVERAGE

OUTLINE OF COVERAGE

Catastrophic coverage is designed to provide benefits for medical expenses incurred by the insured. Coverage is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services, inpatient medical services, and outpatient care, subject to any deductibles with no separate internal dollar limits.

A brief specific description of the benefits, including dollar amounts, contained in this policy, in the following order: daily hospital room and board; miscellaneous hospital services; surgical services; anesthesia services; in hospital medical services; outpatient care; and other benefits, if any.

A description of any policy provisions that exclude, eliminate, restrict, reduce, limit, delay, or in any other manner operate to qualify payment of the benefits.

A description of policy provisions respecting renewability or continuation of coverage, including age restrictions or any reservation of right to change premiums.

(4) An insurer shall deliver an outline of coverage to an applicant or enrollee before or upon the sale of an individual accident and health insurance contract as required in this rule.

(5) If an outline of coverage was delivered at the time of application or enrollment and the contract is issued on a basis that would require revision of the outline of coverage, a substitute outline of coverage describing the contract shall accompany the contract when it is delivered and shall include the following statement in no less than 12-point font, immediately above the company name, "NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application, and the coverage originally applied for has not been issued."

(6) If the outline of coverage is inappropriate for the coverage provided by the contract, an alternate outline of coverage shall be submitted to the commissioner for prior approval.

(7) An advertisement may fulfill the requirement for an outline of coverage if the advertisement satisfies the standards specified in this rule.

R590-233-9. Replacement of Accident and Health Insurance Requirements.

(1)(a) Upon determining that a sale will involve replacement, an insurer or its producer, other than a direct response insurer or its producer, shall furnish to the applicant, before issuance or delivery of the contract, the notice in Table 4.

(b) The insurer shall retain a copy of the notice.

(2) A direct response insurer shall deliver to the applicant, upon issuance of the contract, the notice in Table 5.

TABLE 4

Notice to Applicant Regarding Replacement of Accident and Health Insurance

NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND HEALTH INSURANCE

According to (your application)(information you have furnished), you intend to lapse or otherwise terminate existing accident and health insurance and replace it with a policy to be issued by (insert company name) Insurance Company. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy.

Health conditions that you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

You may wish to secure the advice of your present insurer or its producer regarding the proposed replacement of your present policy. This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage.

If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical/health history. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force.

After the application has been completed and before you sign it, reread it carefully to be certain that all information has been properly recorded.

The above "Notice to Applicant" was delivered to me on:

Date:

Applicant's Signature

TABLE 5

Direct Response Notice to Applicant Regarding Replacement of Accident and Health Insurance

NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND HEALTH INSURANCE

According to (your application)(information you have furnished), you intend to lapse or otherwise terminate existing accident and health insurance and replace it with the policy delivered herewith issued by (insert company name) Insurance Company. Your new policy provides 30 days within which you may decide without cost whether you desire to keep the policy. For your own information and protection, you should be aware of and seriously consider certain factors that may affect the insurance protection available to you under the new policy.

You may wish to secure the advice of your present insurer or its producer regarding the proposed replacement of your present policy.

This is not only your right, but it is also in your best interests to make sure you understand all the relevant factors involved in replacing your present coverage.

(To be included only if the application is attached to the policy.) If, after due consideration, you still wish to terminate your present policy and replace it with new coverage, read the copy of the application attached to your new policy and be sure that all questions are answered fully and correctly. Omissions or misstatements in the application could cause an otherwise valid claim to be denied. Carefully check the application and write to (insert company name and address) within ten days if any information is not correct and complete, or if any past medical history has been left out of the application.

COMPANY NAME

R590-233-10. Severability.

If any provision of this rule, Rule R590-233, or its application to any person or situation is held invalid, such invalidity does not affect any other provision or application of this rule that can be given effect without the invalid provision or application. The remainder of this rule shall be given effect without the invalid provision or application.

KEY: health insurance

Date of Last Change: March 24, 2025

Notice of Continuation: November 25, 2024

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