H.B. 211

1

INSURANCE COVERAGE FOR AMINO ACID-BASED
2 FORMULA
3 2012 GENERAL SESSION
4 STATE OF UTAH
5 Chief Sponsor: Carol Spackman Moss
6 Senate Sponsor: ____________
7
8 LONG TITLE
9 General Description:
10 This bill amends the Insurance Code to require coverage for the use of an amino
11 acid-based elemental formula, regardless of the delivery method of the formula, for the
12 diagnosis or treatment of an eosinophilic gastrointestinal disorder.
13 Highlighted Provisions:
14 This bill:
15 . defines terms;
16 . requires that a health benefit plan shall provide coverage for the use of an amino
17 acid-based elemental formula, regardless of the delivery method of the formula, for
18 the diagnosis or treatment of an eosinophilic gastrointestinal disorder if a licensed
19 physician issues a written order stating that the formula is medically necessary;
20 . grants rulemaking authority to the insurance commissioner;
21 . requires the coverage described in this bill to be similar to, or identical to, the
22 coverage provided for other illnesses or diseases;
23 . provides that exemptions to insurance coverage mandates for health benefit plans do
24 not apply to the insurance coverage described in this bill; and
25 . makes technical changes.
26 Money Appropriated in this Bill:
27 None

28 Other Special Clauses:
29 None
30 Utah Code Sections Affected:
31 AMENDS:
32 31A-22-618.5, as last amended by Laws of Utah 2011, Chapters 284 and 297
33 31A-22-724, as last amended by Laws of Utah 2011, Chapter 400
34 ENACTS:
35 31A-22-640, Utah Code Annotated 1953
36
37 Be it enacted by the Legislature of the state of Utah:
38 Section 1. Section 31A-22-618.5 is amended to read:
39 31A-22-618.5. Health benefit plan offerings.
40 (1) The purpose of this section is to increase the range of health benefit plans available
41 in the small group, small employer group, large group, and individual insurance markets.
42 (2) A health maintenance organization that is subject to Chapter 8, Health Maintenance
43 Organizations and Limited Health Plans:
44 (a) shall offer to potential purchasers at least one health benefit plan that is subject to
45 the requirements of Chapter 8, Health Maintenance Organizations and Limited Health Plans;
46 and
47 (b) may offer to a potential purchaser one or more health benefit plans that:
48 (i) are not subject to one or more of the following:
49 (A) the limitations on insured indemnity benefits in Subsection 31A-8-105 (4);
50 (B) the limitation on point of service products in Subsections 31A-8-408 (3) through
51 (6);
52 (C) except as provided in Subsection (2)(b)(ii), basic health care services as defined in
53 Section 31A-8-101 ; or
54 (D) except for the insurance coverage required in Section 31A-22-640 , coverage
55 mandates enacted after January 1, 2009, that are not required by federal law, provided that the
56 insurer offers one plan under Subsection (2)(a) that covers the mandate enacted after January 1,
57 2009; and
58 (ii) when offering a health plan under this section, provide coverage for an emergency

59 medical condition as required by Section 31A-22-627 as follows:
60 (A) within the organization's service area, covered services shall include health care
61 services from non-affiliated providers when medically necessary to stabilize an emergency
62 medical condition; and
63 (B) outside the organization's service area, covered services shall include medically
64 necessary health care services for the treatment of an emergency medical condition that are
65 immediately required while the enrollee is outside the geographic limits of the organization's
66 service area.
67 (3) An insurer that offers a health benefit plan that is not subject to Chapter 8, Health
68 Maintenance Organizations and Limited Health Plans:
69 (a) notwithstanding Subsection 31A-22-617 (2), may offer a health benefit plan that
70 groups providers into the following reimbursement levels:
71 (i) tier one contracted providers;
72 (ii) tier two contracted providers who the insurer shall reimburse at least 75% of tier
73 one providers; and
74 (iii) one or more tiers of non-contracted providers;
75 (b) notwithstanding Subsection 31A-22-617 (9) may offer a health benefit plan that is
76 not subject to Section 31A-22-618 ;
77 (c) beginning July 1, 2012, may offer health benefit plans that:
78 (i) are not subject to Subsection 31A-22-617 (2); and
79 (ii) are subject to the reimbursement requirements in Section 31A-8-501 ;
80 (d) when offering a health plan under this Subsection (3), shall provide coverage of
81 emergency care services as required by Section 31A-22-627 by providing coverage at a
82 reimbursement level of at least 75% of the health benefit plan's highest contracted provider
83 category; and
84 (e) except for insurance coverage required in Section 31A-22-640 , are not subject to
85 coverage mandates enacted after January 1, 2009, that are not required by federal law, provided
86 that an insurer offers one plan that covers a mandate enacted after January 1, 2009.
87 (4) Section 31A-8-106 does not prohibit the offer of a health benefit plan under
88 Subsection (2)(b).
89 (5) (a) Any difference in price between a health benefit plan offered under Subsections

90 (2)(a) and (b) shall be based on actuarially sound data.
91 (b) Any difference in price between a health benefit plan offered under Subsections
92 (3)(a) and (b) shall be based on actuarially sound data.
93 (6) Nothing in this section limits the number of health benefit plans that an insurer may
94 offer.
95 Section 2. Section 31A-22-640 is enacted to read:
96 31A-22-640. Insurance coverage for amino acid-based formula.
97 (1) As used in this section:
98 (a) "Amino acid-based elemental formula" means a nutrition formula:
99 (i) made from individual non-allergenic amino acids that are broken down to enhance
100 absorption and digestion; and
101 (ii) designed for individuals who have a dysfunctional gastrointestinal tract and are
102 unable to tolerate and absorb whole foods or formulas composed of whole proteins, fats, or
103 carbohydrates.
104 (b) (i) "Eosinophilic gastrointestinal disorder" means a disorder characterized by
105 having above normal amounts of eosinophils in one or more specific places anywhere in the
106 digestive system.
107 (ii) "Eosinophilic gastrointestinal disorder" includes:
108 (A) eosinophilic esophagitis;
109 (B) eosinophilic gastritis;
110 (C) eosinophilic gastroenteritis;
111 (D) eosinophilic enteritis; and
112 (E) eosinophilic colitis.
113 (2) A health benefit plan shall provide coverage for the use of an amino acid-based
114 elemental formula, regardless of the delivery method of the formula, for the diagnosis or
115 treatment of an eosinophilic gastrointestinal disorder if a licensed physician issues a written
116 order stating that the use of an amino acid-based elemental formula is medically necessary.
117 (3) The commissioner shall make rules, in accordance with Title 63G, Chapter 3, Utah
118 Administrative Rulemaking Act, that set minimum standards for the coverage described in
119 Subsection (2).
120 (4) The rules described in Subsection (3) shall require that all cost sharing provisions

121 for the coverage described in Subsection (2), including deductibles, coinsurance, annual
122 maximums, and lifetime maximums, are similar to, or identical to, the coverage provided for
123 other illnesses or diseases.
124 Section 3. Section 31A-22-724 is amended to read:
125 31A-22-724. Offer of alternative coverage -- Utah NetCare Plan.
126 (1) For purposes of this section, "alternative coverage" means:
127 (a) a high deductible or low deductible Utah NetCare Plan described in Subsection (2)
128 for a conversion health benefit plan policy offered under Section 31A-22-723 ; and
129 (b) a high deductible and low deductible Utah NetCare Plans described in Subsection
130 (2) as an alternative to COBRA and mini-COBRA health benefit plan coverage offered under
131 Section 31A-22-722 .
132 (2) A Utah NetCare Plan under this section is subject to Section 31A-2-212 and shall,
133 except when prohibited by federal law, include:
134 (a) healthy lifestyle and wellness incentives;
135 (b) the benefits described in this Subsection (2) or at least the actuarial equivalent of
136 the benefits described in this Subsection (2);
137 (c) a lifetime maximum benefit per person of not less than $1,000,000;
138 (d) an annual maximum benefit per person of not less than $250,000;
139 (e) the following deductibles:
140 (i) for a low deductible plan:
141 (A) $2,000 for an individual plan;
142 (B) $4,000 for a two party plan; and
143 (C) $6,000 for a family plan;
144 (ii) for a high deductible plan:
145 (A) $4,000 for an individual plan;
146 (B) $8,000 for a two party plan; and
147 (C) $12,000 for a family plan;
148 (f) the following out-of-pocket maximum costs, including deductibles, copayments,
149 and coinsurance:
150 (i) for a low deductible plan:
151 (A) $5,000 for an individual plan;

152 (B) $10,000 for a two party plan; and
153 (C) $15,000 for a family plan; and
154 (ii) for a high deductible plan:
155 (A) $10,000 for an individual plan;
156 (B) $20,000 for a two party plan; and
157 (C) $30,000 for a family plan;
158 (g) the following benefits before applying a deductible requirement and in accordance
159 with Section 223, Internal Revenue Code, and 42 U.S.C. Sec. 300gg-13:
160 (i) all well child exams and immunizations up to age five, with no annual maximum;
161 (ii) preventive care up to a $500 annual maximum;
162 (iii) primary care and specialist and urgent care not covered under Subsection (2)(g)(i)
163 or (ii) up to a $300 annual maximum; and
164 (iv) supplemental accident coverage up to a $500 annual maximum;
165 (h) the following copayments for each exam:
166 (i) $15 for preventive care and well child exams;
167 (ii) $25 for primary care; and
168 (iii) $50 for urgent care and specialist care;
169 (i) a $200 copayment for an emergency room visit after applying the deductible;
170 (j) no more than a 30% coinsurance after deductible for covered plan benefits for:
171 (i) hospital services;
172 (ii) maternity;
173 (iii) laboratory work;
174 (iv) x-rays;
175 (v) radiology;
176 (vi) outpatient surgery services;
177 (vii) injectable medications not otherwise covered under a pharmacy benefit;
178 (viii) durable medical equipment;
179 (ix) ambulance services;
180 (x) in-patient mental health services; and
181 (xi) out-patient mental health services; and
182 (k) the following cost-sharing features for a prescription drug:

183 (i) up to a $15 copayment for a generic drug; and
184 (ii) up to a 50% coinsurance for a name brand drug.
185 (3) A Utah NetCare Plan may exclude:
186 (a) the benefit mandates described in Subsections 31A-22-618.5 (2)(b) and (3)(b); and
187 (b) unless required by federal law, mandated coverage required by the following
188 sections and related administrative rules:
189 (i) Section 31A-22-610.1 , Adoption indemnity benefit;
190 (ii) Section 31A-22-623 , Coverage of inborn metabolic errors;
191 (iii) Section 31A-22-624 , Primary care physician;
192 (iv) Section 31A-22-626 , Coverage of diabetes;
193 (v) Section 31A-22-628 , Standing referral to a specialist; and
194 (vi) except for the insurance coverage required in Section 31A-22-640 , a mandated
195 coverage enacted after January 1, 2009, that is not required by federal law.
196 (4) A Utah NetCare Plan may include a formulary or preferred drug list.
197 (5) (a) Except as provided in Subsection (6), a person may elect alternative coverage
198 under this section if the person is eligible for:
199 (i) continuation of employer group health benefit plan coverage under federal COBRA
200 laws;
201 (ii) continuation of employer group health benefit plan coverage under state
202 mini-COBRA under Section 31A-22-722 ; or
203 (iii) a conversion to an individual health benefit plan after the exhaustion of benefits
204 under:
205 (A) alternative coverage elected in place of federal COBRA; or
206 (B) state mini-COBRA under Section 31A-22-722 .
207 (b) The right to extend coverage under Subsection (5)(a) applies to spouse or
208 dependent coverages, including a surviving spouse or dependent whose coverage under the
209 policy terminates by reason of the death of the employee or member.
210 (6) If a person elects federal COBRA or state mini-COBRA health benefit plan
211 coverage under Section 31A-22-722 , the person is not eligible to elect alternative coverage
212 under this section until the person is eligible to convert coverage to an individual policy under
213 Section 31A-22-723 and Subsection (1)(a).

214 (7) (a) (i) If alternative coverage is selected as an alternative to COBRA or
215 mini-COBRA health benefit plan coverage under Section 31A-22-722 , Section 31A-22-722
216 applies to the alternative coverage.
217 (ii) If an employee of a small employer selects alternative coverage as an alternative to
218 COBRA or mini-COBRA health benefit plan coverage, the insurer may not use a risk factor
219 greater than the employer's most current risk factor for purposes of Subsection 31A-22-722 (5).
220 (b) If alternative coverage is selected as a conversion policy under Section
221 31A-22-723 , Section 31A-22-723 applies.
222 (8) The commissioner shall adopt administrative rules in accordance with Title 63G,
223 Chapter 3, Utah Administrative Rulemaking Act, to develop a model letter for employers to
224 use to notify an employee of the employee's options for alternative coverage.




Legislative Review Note
as of 10-3-11 6:35 AM

Office of Legislative Research and General Counsel