Title 31A, Insurance Code

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 i…

31A-22-629. Adverse benefit determination review process. (1) As used in this section: (a)(i) "Adverse benefit determination" means the: (A) denial of a benefit; (B) reduction of a benefit; (C) termination of a benefit; or (D) failure to provide or make payment, in whole or in pa…

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 ma…

31A-22-630.1. Mobile mammography screening coverage. (1) As used in this section: (a) "Approved mobile mammography unit" means a mobile mammography bus or vehicle that is: (i) equipped with mammography equipment to perform a mobile mammography screening; and (ii) approved by an a…

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 sup…

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)…

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 Departme…

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 organiz…

31A-22-635. Uniform application -- Uniform waiver of coverage. (1) For purposes of this section, "insurer": (a) is defined in Subsection 31A-22-634(1); and (b) includes the state employee's risk pool under Section 49-20-202. (2)(a) Insurers offering a health benefit plan to an in…

31A-22-636. Standardized health insurance information cards. (1) As used in this section, "insurer" means: (a) an insurer governed by this part as described in Section 31A-22-600; (b) a health maintenance organization governed by Chapter 8, Health Maintenance Organizations and Li…

31A-22-637. Health care provider payment information -- Notice of admissions. (1) For purposes of this section, "insurer" is as defined in Section 31A-22-636. (2)(a) An insurer shall provide its health care providers who are under contract with the insurer access to current infor…

31A-22-638. Coverage for prosthetic devices. (1) For purposes of this section: (a) "Orthotic device" means a rigid or semirigid device supporting a weak or deformed leg, foot, arm, hand, back, or neck, or restricting or eliminating motion in a diseased or injured leg, foot, arm, …

31A-22-639. Statement of preauthorization. (1) An insurer who requires preauthorization or preapproval for coverage under accident and health insurance shall, beginning January 1, 2011, provide an enrollee with a statement of preauthorization if: (a) the applicable CPT codes have…

31A-22-641. Cancer treatment parity. (1) For purposes of this section: (a) "Cost sharing" means the enrollee's maximum out-of-pocket costs as defined by the health benefit plan. (b) "Health insurer" is as defined in Subsection 31A-22-634(1). (c) "Intravenously administered chemot…

31A-22-642. Insurance coverage for autism spectrum disorder. (1) As used in this section: (a) "Applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant im…

31A-22-643. Prescription synchronization -- Copay and dispensing fee restrictions -- Rebate requirements -- Pharmacy networks. (1) For purposes of this section: (a) "Administrative fee" means the same as that term is defined in Section 31A-46-102. (b) "Copay" means the copay norm…

31A-22-644. Denial of coverage under a health benefit plan because of life expectancy or terminal condition. (1) As used in this section: (a) "Health benefit plan" means the same as that term is defined in Section 31A-1-301. (b) "Terminal condition" means an irreversible conditio…

31A-22-645. Alcohol and drug dependency treatment. (1) An insurer offering a health benefit plan providing coverage for alcohol or drug dependency treatment may require an inpatient facility to be licensed by: (a)(i) the Department of Health and Human Services, under Title 26B, C…

31A-22-646. Dental insurance -- Contract provision for noncovered services. (1) For purposes of this section: (a) "Covered services" means dental services for which reimbursement: (i) is available or would be reimbursable under an enrollee's dental plan but for the application of…

31A-22-646.1. Leasing requirements for dental plans. (1) As used in this section: (a) "Contracting entity" means a person that enters into a direct contract with a provider for the delivery of dental services in the ordinary course of business, including a third party administrat…

31A-22-646.2. Dental services jurisdiction. (1)(a) Notwithstanding Section 31A-1-103, an insurer that provides coverage for dental services that are completed in Utah to a patient that is a Utah resident shall comply with all Utah laws related to covered services, non-covered ser…

31A-22-647. Insurer shared savings program. (1) As used in this section: (a) "Insurer" means a person who offers health care insurance, including a health maintenance organization as that term is defined in Section 31A-8-101. (b) "PEHP" means the Public Employees' Benefit and Ins…

31A-22-648. Vision insurance -- Contract provisions. (1) As used in this section: (a) "Covered individual" means an individual who has insurance coverage under a vision plan. (b) "Covered service" means a vision service that: (i) is reimbursable under or would be reimbursable und…

31A-22-649. Coverage of telepsychiatric consultations. (1) As used in this section: (a) "Telehealth services" means the same as that term is defined in Section 26B-4-704. (b) "Telepsychiatric consultation" means a consultation between a physician and a board certified psychiatris…

31A-22-649.5. Insurance parity for telemedicine services -- Method of technology used. (1) As used in this section: (a) "Mental health condition" means a mental disorder or a substance-related disorder that falls under a diagnostic category listed in the Diagnostic and Statistica…

31A-22-650. Health care preauthorization requirements -- Notice -- Reporting -- Retroactive denial prohibited. (1) As used in this section: (a) "Adverse preauthorization determination" means a determination by an insurer that health care does not meet the preauthorization require…

31A-22-650. Health care preauthorization requirements. (1) As used in this section: (a) "Adverse preauthorization determination" means a determination by an insurer that health care does not meet the preauthorization requirement for the health care. (b) "Authorization" means a de…

31A-22-651. Insurance coverage for assisted outpatient treatment. (1) As used in this section, "assisted outpatient treatment" means the same as that term is defined in Section 26B-5-301. (2) A health insurance provider may not deny an insured the benefits of the insured's policy…

31A-22-652. Coverage for mental health services in schools. (1) As used in this section, "local education agency" means: (a) a school district; (b) a charter school; or (c) the Utah Schools for the Deaf and the Blind. (2) A health benefit plan that is entered into or renewed on o…

31A-22-654. Study of coverage for in vitro fertilization and genetic testing -- Reporting -- Coverage requirements. (1) As used in this section: (a) "Qualified condition" means the same as that term is defined in Section 49-20-420. (b) "Qualified insurer" means an insurer that pr…

31A-22-655. Living organ donor coverage. (1) For the purposes of this section, "living organ donor" means an individual who has donated all or part of an organ and is not deceased. (2) An insurer may not: (a) deny eligibility for coverage or limit coverage of a individual under a…

31A-22-656. Coverage of epinephrine auto-injector. A health benefit plan entered into or renewed on or after July 1, 2021, that provides coverage of an epinephrine auto-injector is not required to reimburse a participant, as that term is defined in Section 49-20-421, for an epine…

31A-22-657. Application of health insurance mandates. (1) As used in this section: (a) "Cost-sharing mandate" means a statutory requirement limiting a cost-sharing requirement. (b) "Cost-sharing requirement" means a copayment, coinsurance, or deductible required by or on behalf o…

31A-22-658. Health care provider behavioral health treatment -- Single case agreement. (1) As used in this section: (a) "Mental health condition" means the same as that term is defined in Section 31A-22-649.5. (b) "Mental health provider" means: (i) a mental health therapist, as …

31A-22-659. Provider administered drugs. (1) As used in this section: (a) "Clinician-administered drug" means an outpatient prescription drug as defined in Section 58-17b-102 that: (i) cannot reasonably be self-administered by the patient to whom the drug is prescribed or by an i…

31A-22-660. Definitions -- Prohibitions concerning organ harvesting -- Severability. (1) As used in this section, "forced organ harvesting" means the removal of one or more organs from a living individual, or from an individual killed for the purpose of removal of one or more of …

31A-22-661. Health benefit plan procedures related to prescription drugs. (1) As used in this section, "long-term drug" means an enrollee's prescription drug where the prescription has been active for at least 180 days with the health benefit plan. (2)(a) Except as provided in Su…

31A-22-662. Pharmacist as a health care provider. (1) As used in this section, "pharmacist" means the same as that term is defined in Section 58-17b-102. (2) An insurer that provides a health benefit plan shall consider a pharmacist as a health care provider for a consultation th…

31A-22-663. Timely access to behavioral health services -- Single case agreement. (1) As used in this section: (a) "Covered insurer" means an insurer that offers health insurance that includes coverage for behavioral health services. (b)(i) "Behavioral health services" means: (A)…

31A-22-664. Health care provider directories. (1) As used in this section: (a) "Division" means the Division of Professional Licensing created in Section 58-1-103. (b) "Exempt health care professional" means a person exempt from licensure under a title listed in Subsection 58-13-…

31A-22-665. Continuity of mental health treatment and services for a child leaving foster care. (1) As used in this section: (a)(i) "Covered child" means an insured child who: (A) while in the custody of the Division of Child and Family Services, was receiving mental health treat…

31A-22-666. Coverage for reversal of sex transition procedures. (1) As used in this section: (a) "Hormonal transgender treatment" means the same as that term is defined in Section 58-1-603. (b) "Primary sex characteristic surgical procedure" means the same as that term is defined…

31A-22-667. Anesthesia services. (1) A health benefit plan shall provide coverage for medically necessary anesthesia services, regardless of the duration, for any procedure covered by the health benefit plan. (2) A health benefit plan is prohibited from denying payment or reimbur…

31A-22-701. Groups eligible for group or blanket insurance. (1) A group insurance policy offering accident and health insurance may be issued to: (a) a group: (i) to which a group life insurance policy may be issued under Section 31A-22-502, 31A-22-503, 31A-22-504, 31A-22-505, 31…

31A-22-702. Adjustment of premium rate and application of dividends or rate reductions. Any group accident and health insurance policy may provide for the adjustment of the rate of premium based upon the experience under the contract. If a policy dividend is declared or a reducti…

31A-22-716. Required provision for notice of termination. (1) A group insurance policy offering accident and health insurance or a blanket insurance policy offering accident and health insurance shall include a provision that obligates the policyholder: (a) to give written notice…