R590. Insurance, Administration.R590-266. Utah Essential Health Benefits Package.
R590-266-1. Authority.
This rule is promulgated by the commissioner pursuant to Sections 31A-2-201 and 31A-2-212.
R590-266-2. Purpose and Scope.
(1) The purpose of this rule is to designate an essential health benefits package as required by PPACA.
(2) This rule applies to a non-grandfathered individual or small employer health benefit plan issued or renewed on or after January 1, 2014.
R590-266-3. Definitions.
Terms used in this rule are defined in Sections 31A-1-301 and 31A-30-103. Additional terms are defined as follows:
(1) "Essential health benefits" means the following health care service categories:
(a) ambulatory patient services;
(b) emergency services;
(c) hospitalization;
(d) pregnancy, maternity, and newborn care;
(e) mental health and substance use disorder services, including behavioral health treatment;
(f) prescription drugs;
(g) rehabilitative and habilitative services and devices;
(h) laboratory services;
(i) preventive and wellness services and chronic disease management; and
(j) pediatric services, including oral and vision care.
(2) "Grandfathered health plan" means an individual or small employer health benefit plan that:
(a) was in existence when the PPACA was enacted on March 23, 2010;
(b) has not had any significant changes that reduce benefits or increase costs to the consumer including:
(i) a significant cut or reduction in benefits;
(ii) an increase in co-pays by more than $5, adjusted annually for medical inflation, or a percentage equal to medical inflation plus 15%;
(iii) an employer reduction in contributions by more than five percentage points; or
(iv) a reduction of annual dollar limits, or addition of a new limit; and
(c) the insured has received notification from the insurer that their health benefit plan is a grandfathered plan.
(3)(a) "Habilitative" means health care services that help a person keep, learn, or improve skills and functioning for daily living.
(b) Habilitative services may include:
(i) physical therapy;
(ii) occupational therapy;
(iii) speech-language pathology; or
(iv) other services.
(4) "Non-grandfathered health plan" means an individual or small employer health benefit plan:
(a) that is issued after the PPACA was enacted on March 23, 2010; or
(b) a grandfathered health plan that has made significant changes that:
(i) reduce benefits or increase costs to the consumer; and
(ii) caused the plan to lose the grandfathered status as provided in Subsection (2)(b).
(5) "Rehabilitative" means the treatment of disease, injury, developmental delay, or other cause, by physical agents and methods to assist in the rehabilitation of normal physical bodily function, that is goal-oriented and where the person has potential for functional improvement and ability to progress.
(6) "Utah essential health benefits package" means the benefits designated in this rule by the commissioner as essential health benefits.
R590-266-4. Utah Essential Health Benefits.
(1)(a) The PEHP Utah Basic Plus 2013 plan is designated as the Utah essential health benefits package.
(b) The PEHP Utah Basic Plus 2013 Plan is available at https://insurance.utah.gov/consumer/health/reform.
(c) The PEHP Utah Basic Plus 2013 Plan was issued on July 1, 2013, and some of the benchmark plan benefits may not comply with current state or federal requirements.
(2)(a) Except as provided in Subsections (2)(b) and (2)(c), an individual or small employer insurer who issues or renews a non-grandfathered plan on or after January 1, 2014, must include at least the benefits of the Utah essential health benefits package.
(b) An insurer may substitute coverage provided in the Utah essential health benefits package if the substitution is actuarially equivalent and complies with 42 CFR 457.431.
