H.B. 205

1

INSURANCE COVERAGE FOR METABOLIC
2 DISEASE
3 1998 GENERAL SESSION
4 STATE OF UTAH
5 Sponsor: Trisha S. Beck
6 AN ACT RELATING TO INSURANCE; REQUIRING AN INSURANCE POLICY TO COVER
7 DIETARY PRODUCTS FOR TREATMENT OF INBORN ERRORS OF AMINO ACID OR
8 UREA CYCLE METABOLISM h [ TO THE SAME EXTENT AS PRESCRIPTION DRUGS ] h .
9 This act affects sections of Utah Code Annotated 1953 as follows:
10 AMENDS:
11 31A-22-613, as last amended by Chapter 38, Laws of Utah 1996
12 Be it enacted by the Legislature of the state of Utah:
13 Section 1. Section 31A-22-613 is amended to read:
14 31A-22-613. Permitted provisions for disability insurance policies.
15 The following provisions may be contained in a disability insurance policy, but if they are
16 in that policy, they shall conform to at least the following minimum requirements for the
17 policyholder:
18 (1) Any provision respecting change of occupation may provide only for a lower
19 maximum benefit payment and for reduction of loss payments proportionate to the change in
20 appropriate premium rates, if the change is to a higher rated occupation, and this provision shall
21 provide for retroactive reduction of premium rates from the date of change of occupation or the
22 last policy anniversary date, whichever is the more recent, if the change is to a lower rated
23 occupation.
24 (2) Section 31A-22-405 applies to misstatement of age in disability policies, with the
25 appropriate modifications of terminology.
26 (3) Any policy which contains a provision establishing, as an age limit or otherwise, a date
27 after which the coverage provided by the policy is not effective, and if that date falls within a

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1 period for which a premium is accepted by the insurer or if the insurer accepts a premium after that
2 date, the coverage provided by the policy continues in force, subject to any right of cancellation,
3 until the end of the period for which the premium was accepted. This subsection does not apply
4 if the acceptance of premium would not have occurred but for a misstatement of age by the
5 insured.
6 (4) Any provision dealing with preexisting conditions shall be consistent with Subsections
7 31A-22-605(9)(a) and 31A-22-609(2), and any applicable rule adopted by the commissioner.
8 (5) (a) If an insured is otherwise eligible for maternity benefits, a policy may not contain
9 language which requires an insured to obtain any additional preauthorization or preapproval for
10 customary and reasonable maternity care expenses or for the delivery of the child after an initial
11 preauthorization or preapproval has been obtained from the insurer for prenatal care. A
12 requirement for notice of admission for delivery is not a requirement for preauthorization or
13 preapproval, however, the maternity benefit may not be denied or diminished for failure to provide
14 admission notice. The policy may not require the provision of admission notice by only the
15 insured patient.
16 (b) This subsection does not prohibit an insurer from:
17 (i) requiring a referral before maternity care can be obtained;
18 (ii) specifying a group of providers or a particular location from which an insured is
19 required to obtain maternity care; or
20 (iii) limiting reimbursement for maternity expenses and benefits in accordance with the
21 terms and conditions of the insurance contract so long as such terms do not conflict with
22 Subsection (a).
23 (6) (a) As used in this Subsection (6):
24 (i) "Dietary products" means medical food or a low protein modified food product that:
25 (A) is specifically formulated to treat inborn errors of amino acid or urea cycle
26 metabolism;
27 (B) is not a natural food that is naturally low in protein; and
28 (C) is used under the direction of a physician.
29 h [ (ii) "Drug" is defined in Section 58-37-2. ] h
30 h [ (iii) ] (ii) h "Inborn errors of amino acid or urea cycle metabolism" means a disease caused by
30a an
31 inherited abnormality of body chemistry which is treatable by the dietary restriction of one or more

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1 amino acid.
2 h [ (iv) "Prescription" is defined in Section 58-37-2. ]
3 [ (b) A policy that provides a benefit for prescription drugs shall cover dietary products used
4 under the direction of a physician for the treatment of inborn errors of amino acid or urea cycle
5 metabolism to the same extent that it covers prescription drugs and subject to the same
6 co-payment, deductible, and out-of-pocket limit, if any. ]
6a (b) THE COMMISSIONER SHALL ESTABLISH, BY RULE, MINIMUM STANDARDS OF COVERAGE
6b FOR DIETARY PRODUCTS USED FOR THE TREATMENT OF INBORN ERRORS OF AMINO ACID OR
6c UREA CYCLE METABOLISM AT LEVELS CONSISTENT WITH THE MAJOR MEDICAL BENEFIT PROVIDED
6d UNDER A DISABILITY INSURANCE POLICY. h



Legislative Review Note
as of 12-5-97 7:29 AM

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

Office of Legislative Research and General Counsel

Committee Note

The Health and Human Services Interim Committee recommended this bill.

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Lilac-January 21, 1998