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H.B. 326

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COVERAGE FOR DENTAL PROCEDURES

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1997 GENERAL SESSION

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STATE OF UTAH

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Sponsor: Robert H. M. Killpack

5    AN ACT RELATING TO HEALTH; REQUIRING THAT HEALTH INSURANCE DENTAL
6    CARE COVERAGE INCLUDE GENERAL ANESTHESIA AND HOSPITALIZATION AS
7    NECESSARY TO PROVIDE APPROPRIATE DENTAL CARE TO A PERSON COVERED
8    BY THE INSURANCE.
9    This act affects sections of Utah Code Annotated 1953 as follows:
10    AMENDS:
11         31A-22-605, as last amended by Chapter 224, Laws of Utah 1992
12    ENACTS:
13         31A-8-105.7, Utah Code Annotated 1953
14         31A-22-719, Utah Code Annotated 1953
15    Be it enacted by the Legislature of the state of Utah:
16        Section 1. Section 31A-8-105.7 is enacted to read:
17         31A-8-105.7. Special needs dental care coverage.
18        (1) Organizations operating under this chapter that offer dental care as a part of any health
19    care plan shall provide as a part of that coverage general anesthesia and hospital charges for dental
20    care for any enrollee who:
21        (a) is a child five years of age or younger;
22        (b) is disabled by a physical or mental impairment to an extent that general anesthesia,
23    hospitalization, or both, are necessary in order to provide dental care; or
24        (c) has a medical condition that requires hospitalization or general anesthesia, or both, for
25    dental care treatment.
26        (2) An organization offering any health care plan under Subsection (1) shall include
27    coverage for general anesthesia and treatment regarding dental care:


1        (a) provided in a health care facility by a dentist; and
2        (b) for a medical condition covered by the health plan, including when the services are
3    provided in a hospital or a dental office.
4        (3) An organization offering any health care plan under Subsection (1) may require prior
5    authorization of hospitalization for dental care in the same manner the organization requires
6    hospitalization for other covered conditions.
7        Section 2. Section 31A-22-605 is amended to read:
8         31A-22-605. Disability insurance standards.
9        (1) The purposes of this section include:
10        (a) reasonable standardization and simplification of terms and coverages of individual and
11    franchise disability insurance policies, including disability insurance contracts of insurers licensed
12    under Chapters 7 and 8, to facilitate public understanding and comparison in purchasing;
13        (b) elimination of provisions contained in individual and franchise disability insurance
14    contracts which may be misleading or confusing in connection with either the purchase of those
15    types of coverages or the settlement of claims; and
16        (c) full disclosure in the sale of individual and franchise disability insurance contracts.
17        (2) As used in this section:
18        (a) "Direct response insurance policy" means an individual insurance policy solicited and
19    sold without the policyholder having direct contact with a natural person intermediary.
20        (b) "Medicare" is defined in Subsection 31A-22-620 (1)(e).
21        (c) "Medicare supplement policy" is defined in Subsection 31A-22-620 (1)(f).
22        (3) This section applies to all individual and franchise disability policies.
23        (4) The commissioner shall adopt rules relating to the following matters:
24        (a) standards for the manner and content of policy provisions, and disclosures to be made
25    in connection with the sale of policies covered by this section, dealing with at least the following
26    matters:
27        (i) terms of renewability;
28        (ii) initial and subsequent conditions of eligibility;
29        (iii) nonduplication of coverage provisions;
30        (iv) coverage of dependents;
31        (v) preexisting conditions;

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1        (vi) termination of insurance;
2        (vii) probationary periods;
3        (viii) limitations;
4        (ix) exceptions;
5        (x) reductions;
6        (xi) elimination periods;
7        (xii) requirements for replacement;
8        (xiii) recurrent conditions;
9        (xiv) coverage of persons eligible for Medicare; and
10        (xv) definition of terms;
11        (b) minimum standards for benefits under each of the following categories of coverage in
12    policies covered in this section:
13        (i) basic hospital expense coverage;
14        (ii) basic medical-surgical expense coverage;
15        (iii) hospital confinement indemnity coverage;
16        (iv) major medical expense coverage;
17        (v) disability income protection coverage;
18        (vi) accident only coverage;
19        (vii) specified disease or specified accident coverage;
20        (viii) limited benefit health coverage; and
21        (ix) nursing home and long-term care coverage;
22        (c) the content and format of the outline of coverage, in addition to that required under
23    Subsection (6); and
24        (d) the method of identification of policies and contracts based upon coverages provided.
25        (5) Nothing in Subsection (4)(b) precludes the issuance of policies that combine categories
26    of coverage in that subsection provided that any combination of categories meets the standards of
27    a component category of coverage.
28        (6) The commissioner may adopt rules relating to the following matters:
29        (a) establishing disclosure requirements for insurance policies covered in this section,
30    designed to adequately inform the prospective insured of the need for and extent of the coverage
31    offered, and requiring that this disclosure be furnished to the prospective insured with the

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1    application form, unless it is a direct response insurance policy;
2        (b) (i) prescribing caption or notice requirements designed to inform prospective insureds
3    that particular insurance coverages are not Medicare Supplement coverages;
4        (ii) the requirements of Subsection (b)(i) apply to all disability insurance policies and
5    certificates sold to persons eligible for Medicare; and
6        (c) requiring the disclosures or information brochures to be furnished to the prospective
7    insured on direct response insurance policies, upon his request or, in any event, no later than the
8    time of the policy delivery.
9        (7) A policy covered by this section may be issued only if it meets the minimum standards
10    established by the commissioner under Subsection (4), an outline of coverage accompanies the
11    policy or is delivered to the applicant at the time of the application, and, except with respect to
12    direct response insurance policies, an acknowledged receipt is provided to the insurer. The outline
13    of coverage shall include:
14        (a) a statement identifying the applicable categories of coverage provided by the policy
15    as prescribed under Subsection (4);
16        (b) a description of the principal benefits and coverage;
17        (c) a statement of the exceptions, reductions, and limitations contained in the policy;
18        (d) a statement of the renewal provisions, including any reservation by the insurer of a
19    right to change premiums;
20        (e) a statement that the outline is a summary of the policy issued or applied for and that
21    the policy should be consulted to determine governing contractual provisions; and
22        (f) any other contents the commissioner prescribes.
23        (8) If a policy is issued on a basis other than that applied for, the outline of coverage shall
24    accompany the policy when it is delivered and it shall clearly state that it is not the policy for
25    which application was made.
26        (9) (a) Notwithstanding Subsection 31A-22-609 (2), and except as provided under
27    Subsection (9)(b), an insurer that elects to use an application form without questions concerning
28    the insured's health history or medical treatment history, shall provide coverage under the policy
29    for any loss which occurs more than 12 months after the effective date of the policy due to a
30    preexisting condition which is not specifically excluded from coverage.
31        (b) (i) An insurer that issues a specified disease policy, regardless of whether the basis of

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1    issuance is a detailed application form, a simplified application form, or an enrollment form, may
2    not deny a claim for loss due to a preexisting condition which occurs more than six months after
3    the effective date of coverage.
4        (ii) A specified disease policy may not define a preexisting condition more restrictively
5    than a condition which first manifested itself within six months prior to the effective date of
6    coverage or which was diagnosed by a physician at any time prior to the effective date of coverage.
7        (iii) A specified disease policy may not include wording that provides a defense based
8    upon a preexisting condition except as allowed under this subsection.
9        (10) Notwithstanding Subsection 31A-22-606 (1), limited accident and health policies or
10    certificates issued to persons eligible for Medicare shall contain a notice prominently printed on
11    or attached to the cover or front page which states that the policyholder or certificate holder has
12    the right to return the policy for any reason within 30 days after its delivery and to have the
13    premium refunded.
14        (11) (a) Organizations operating under this part that offer dental care as a part of any health
15    care plan shall provide as a part of that coverage general anesthesia and hospital charges for dental
16    care for any enrollee who:
17        (i) is a child five years of age or younger;
18        (ii) is disabled by a physical or mental impairment to an extent that general anesthesia,
19    hospitalization, or both are necessary in order to provide dental care; or
20        (iii) has a medical condition that requires hospitalization or general anesthesia, or both,
21    for dental care treatment.
22        (b) An organization offering any health care plan under Subsection (11)(a) shall include
23    coverage for general anesthesia and treatment regarding dental care:
24        (i) provided in a health care facility by a dentist; and
25        (ii) for a medical condition covered by the health plan, including when the services are
26    provided in a hospital or a dental office.
27        (c) An organization offering any health care plan under Subsection (11)(a) may require
28    prior authorization of hospitalization for dental care in the same manner the organization requires
29    hospitalization for other covered conditions.
30        Section 3. Section 31A-22-719 is enacted to read:
31         31A-22-719. Special needs dental care coverage.

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1        (1) Organizations operating under this chapter that offer dental care as a part of any health
2    care plan shall provide as a part of that coverage general anesthesia and hospital charges for dental
3    care for any enrollee who:
4        (a) is a child five years of age or younger;
5        (b) is disabled by a physical or mental impairment to an extent that general anesthesia,
6    hospitalization, or both, are necessary in order to provide dental care; or
7        (c) has a medical condition that requires hospitalization or general anesthesia, or both, for
8    dental care treatment.
9        (2) An organization offering any health care plan under Subsection (1) shall include
10    coverage for general anesthesia and treatment regarding dental care:
11        (a) provided in a health care facility by a dentist; and
12        (b) for a medical condition covered by the health plan, including when the services are
13    provided in a hospital or a dental office.
14        (3) An organization offering any health care plan under Subsection (1) may require prior
15    authorization of hospitalization for dental care in the same manner the organization requires
16    hospitalization for other covered conditions.




Legislative Review Note
    as of 2-3-97 8:14 AM


A limited legal review of this bill raises no obvious constitutional or statutory concerns.

Office of Legislative Research and General Counsel


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