31A-29-113. Benefits -- Additional types of pool insurance -- Preexisting conditions
-- Waiver -- Maximum benefits.
(1) (a) The pool policy shall pay for eligible medical expenses rendered or furnished for
the diagnoses or treatment of illness or injury that:
(i) exceed the deductible and copayment amounts applicable under Section 31A-29-114;
and
(ii) are not otherwise limited or excluded.
(b) Eligible medical expenses are the allowed charges established by the board for the
health care services and items rendered during times for which benefits are extended under the
pool policy.
(2) The coverage to be issued by the pool, its schedule of benefits, exclusions, and other
limitations shall be established by the board.
(3) The commissioner shall approve the benefit package developed by the board to
ensure its compliance with this chapter.
(4) The pool shall offer at least one benefit plan through a managed care program as
authorized under Section 31A-29-106.
(5) This chapter may not be construed to prohibit the pool from issuing additional types
of pool policies with different types of benefits which in the opinion of the board may be of
benefit to the citizens of Utah.
(6) (a) The board shall design and require an administrator to employ cost containment
measures and requirements including preadmission certification and concurrent inpatient review
for the purpose of making the pool more cost effective.
(b) Sections 31A-22-617 and 31A-22-618 do not apply to coverage issued under this
chapter.
(7) (a) A pool policy may contain provisions under which coverage for a preexisting
condition is excluded if:
(i) the exclusion relates to a condition, regardless of the cause of the condition, for which
medical advice, diagnosis, care, or treatment was recommended or received, from an individual
licensed or similarly authorized to provide such services under state law and operating within the
scope of practice authorized by state law, within the six-month period ending on the effective
date of plan coverage; and
(ii) except as provided in Subsection (8), the exclusion extends for a period no longer
than the six-month period following the effective date of plan coverage for a given individual.
(b) Subsection (7)(a) does not apply to a HIPAA eligible individual.
(8) (a) A pool policy may contain provisions under which coverage for a preexisting
pregnancy is excluded during a ten-month period following the effective date of plan coverage
for a given individual.
(b) Subsection (8)(a) does not apply to a HIPAA eligible individual.
(9) (a) The pool will waive the preexisting condition exclusion described in Subsections
(7)(a) and (8)(a) for an individual that is changing health coverage to the pool, to the extent to
which similar exclusions have been satisfied under any prior health insurance coverage if the
individual applies not later than 63 days following the date of involuntary termination, other than
for nonpayment of premiums, from health coverage.
(b) If this Subsection (9) applies, coverage in the pool shall be effective from the date on
which the prior coverage was terminated.
(10) Covered benefits available from the pool may not exceed a $1,500,000 lifetime
maximum, which includes a per enrollee calendar year maximum established by the board.
Amended by Chapter 40, 2007 General Session
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Last revised: Thursday, May 28, 2009