S.B. 164 Enrolled

MEDICAL EXCLUSIONS IN INDIVIDUAL
HEALTH INSURANCE POLICIES
2000 GENERAL SESSION
STATE OF UTAH
Sponsor: Howard C. Nielson
AN ACT RELATING TO INSURANCE; PERMITTING AN INSURER AND AN INSURED TO
AGREE TO EXCLUDE A SPECIFIC HEALTH CARE CONDITION FROM COVERAGE IN
AN INDIVIDUAL HEALTH INSURANCE POLICY; CLARIFYING THAT FOR INSURANCE
PURPOSES, AN EXCLUDED HEALTH CARE CONDITION IS AN UNCOVERED
PREEXISTING CONDITION; AND PROVIDING AN EFFECTIVE DATE.
This act affects sections of Utah Code Annotated 1953 as follows:
AMENDS:
31A-30-107, as last amended by Chapter 329, Laws of Utah 1998
Be it enacted by the Legislature of the state of Utah:
Section 1. Section 31A-30-107 is amended to read:
31A-30-107. Renewal -- Limitations -- Exclusions.
(1) A health benefit plan subject to this chapter is renewable with respect to all covered
individuals at the option of the covered insured except in any of the following cases:
(a) nonpayment of the required premiums;
(b) fraud or misrepresentation of the employer or, with respect to coverage of individual
insureds, the insureds or their representatives;
(c) noncompliance with the covered carrier's minimum participation requirements;
(d) noncompliance with the covered carrier's employer contribution requirements;
(e) repeated misuse of a provider network provision; or
(f) an election by the covered carrier to nonrenew all of its health benefit plans issued to
covered insureds in this state, in which case the covered carrier shall:
(i) provide advanced notice of its decision under this subsection to the commissioner in
each state in which it is licensed; and
(ii) provide notice of the decision not to renew coverage to all affected covered insureds

and to the commissioner in each state in which an affected insured individual is known to reside at
least 180 days prior to the nonrenewal of any health benefit plans by the covered carrier. Notice to
the commissioner under this subsection shall be provided at least three working days prior to the
notice to the affected covered insureds.
(2) A covered carrier that elects not to renew a health benefit plan under Subsection (1)(f)
is prohibited from writing new business subject to this chapter in this state for a period of five years
from the date of notice to the commissioner.
(3) When a covered carrier is doing business subject to this chapter in one service area of this
state, Subsections (1) and (2) apply only to the covered carrier's operations in that service area.
(4) Health benefit plans covering covered insureds shall comply with the following provisions:
(a) (i) A health benefit plan may not deny, exclude, or limit benefits for a covered individual
for losses incurred more than 12 months, or 18 months in the case of a late enrollee, as defined in P.L.
104-191, 110 Stat. 1940, Sec. 101, following the effective date of the individual's coverage due to
a preexisting condition.
(ii) A health benefit plan may not define a preexisting condition more restrictively than:
(A) a condition for which medical advice, diagnosis, care, or treatment was recommended
or received during the six months immediately preceding enrollment date or the effective date of
coverage, whichever comes first; or
(B) for an individual insurance policy, a pregnancy existing on the effective date of coverage.
(iii) An individual insurer shall offer a health benefit plan in compliance with Subsections
(4)(a)(i) and (ii), and may, when the insurer and the insured mutually agree in writing to a
condition-specific exclusion rider, offer to issue an individual policy that excludes a specific physical
condition consistent with Subsections (4)(a)(iv) and (v).
(iv) The commissioner shall establish, in rule, a list of nonlife threatening and nondegenerative
physical conditions that may be the subject of a condition-specific exclusion rider.
(v) A condition-specific exclusion rider shall be limited to the excluded condition and may
not extend to any secondary medical condition that may or may not be directly related to the excluded
condition.

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(b) (i) A covered carrier shall waive any time period applicable to a preexisting condition
exclusion or limitation period with respect to particular services in a health benefit plan for the period
of time the individual was previously covered by public or private health insurance or by any other
health benefit arrangement that provided benefits with respect to such services, provided that:
(A) the previous coverage was continuous to a date not more than [62] 63 days prior to the
effective date of the new coverage; and
(B) the insured provides notification of previous coverage to the covered carrier within 36
months of the coverage effective date if the insurer has previously requested such notification.
(ii) The period of continuous coverage under Subsection (4)(b)(i)(A) shall not include any
waiting period for the effective date of the new coverage applied by the employer or the carrier. This
Subsection (4) does not preclude application of any waiting period applicable to all new enrollees
under such plan.
(iii) Credit for previous coverage as provided under Subsection (4)(b)(i)(A) need not be given
for any condition which was previously excluded under a condition-specific exclusion rider. A new
preexisting waiting period may be applied to any condition that was excluded by a rider under the
terms of previous individual coverage.
Section 2. Effective date.
This act takes effect on July 1, 2000.

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