Insurance, Administration

Rule R590-175

Basic Health Care Plan Rule

Notice of Proposed Rule

(Repeal)

DAR File No.: 33558
Filed: 04/14/2010 10:12:47 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule is being repealed due to H.B. 188, Health System Reform, that passed in 2009. This bill eliminated the requirement for the department to adopt a Basic Health Care Plan. (DAR NOTE: H.B. 188 (2009) is found at Chapter 12, Laws of Utah 2009, and was effective 03/11/2009.)

Summary of the rule or change:

This rule is repealed in its entirety.

State statutory or constitutional authorization for this rule:

• Section 31A-2-201
• Section 31A-22-613.5

Anticipated cost or savings to:

the state budget:

This rule will have no fiscal effect on the department or the state budget. Instead of the basic health care plan being set in a rule it is now in the code. The department will regulate it either way with no change in work load.

local governments:

The repeal of this rule will have no effect on local government since it deals solely with the relationship of the department with its licensees.

small businesses:

The basic health care plan standards are now in the code rather than the rule, which insurers are already aware of. The basic health care plan now has the same benefits as Netcare, which, on average, is offered with lower benefits reducing the cost of coverage approximately 30%. This affects large and small employers and individual consumers the same.

persons other than small businesses, businesses, or local governmental entities:

The basic health care plan standards are now in the code rather than the rule, which insurers are already aware of. The basic health care plan now has the same benefits as Netcare, which, on average, is offered with lower benefits reducing the cost of coverage approximately 30%. This affects large and small employers and individual consumers the same.

Compliance costs for affected persons:

The basic health care plan standards are now in the code rather than the rule, which insurers are already aware of. The basic health care plan now has the same benefits as Netcare, which, on average, is offered with lower benefits reducing the cost of coverage approximately 30%. This affects large and small employers and individual consumers the same.

Comments by the department head on the fiscal impact the rule may have on businesses:

The repeal of this rule will have no fiscal impact on insurers. The new law will reduce cost and benefits to those that purchase the basic health care plan, which would include businesses.

Neal T. Gooch, Acting Commissioner

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Insurance
Administration
450 N MAIN ST
SALT LAKE CITY, UT 84114-1201

Direct questions regarding this rule to:

• Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

05/31/2010

This rule may become effective on:

06/07/2010

Authorized by:

Jilene Whitby, Information Specialist

R590. Insurance, Administration.

[R590-175. Basic Health Care Plan Rule.

R590-175-1. Authority.

This rule is issued pursuant to Subsection 31A-22-613.5(2) and the general rulemaking authority vested in the commissioner by Section 31A-2-201. Section 31A-22-613.5(2)(a) requires that the commissioner adopt a Basic Health Care Plan.

 

R590-175-2. Statement of Purpose and Scope.

(1) The purpose of this rule is to adopt a Basic Health Care Plan as:

(a) a conversion plan per Section 31A-22-723; or

(b) a basic coverage plan per Section 31A-30-109.

(2)(a) This rule applies to all insurers marketing health insurance policies subject to the open enrollment provisions of Chapter 30; and

(b) to all insurers subject to 31A-22-723.

 

R590-175-3. General Requirements.

(1) Each insurer who is required to offer a health care plan under the open enrollment provisions of Chapter 30 shall file with the department at least one basic health care plan which is specified by the insurer as complying with the provisions of this rule and which must be offered for sale to anyone qualifying for open enrollment under Chapter 30.

(2) The basic health care plan shall not be designed or marketed in a manner that tends to discourage its purchase by anyone under the open enrollment provisions of Chapter 30.

(3) A plan having actuarial equivalence may be considered, at the sole discretion of the commissioner.

(4) Each insurer must use the language in this rule to present covered services, limitations and exclusions.

(5) A plan offered in compliance with the open enrollment provisions of Chapter 30 must contain at least the benefits set forth in the Basic Health Care Plan as adopted by the commissioner.

(6) The basic health care plan is to be offered as a package, in its entirety, and is mutually exclusive of and not comparable on a line by line basis to an insurer's other plans.

(7) If the basic health care plan is offered by a preferred provider organization, PPO, the benefit levels shown in the plan are for contracting providers; benefit levels for non-contracting providers' services may be reduced in accordance with Section 31A-22-617.

(8) Each insurer is to include its usual contracting provisions in its basic health care plan including submission of claims, coordination of benefits, eligibility and coverage termination, grievance procedures general terms and conditions, etc.

(9) Each insurer who is required to offer a group conversion plan under Subsection 31A-33-723 shall file with the department at least one basic health care plan that complies with the provisions of this rule and must be offered for sale to anyone qualifying for conversion.

(10) The form to follow for the Basic Health Care Plan is as follows:

 

TABLE
BASIC HEALTH CARE PLAN

  1.  MAXIMUM BENEFIT. The maximum benefit per person for the

entire period for which this policy coverage is in effect shall

be $1,000,000.

  2.  ANNUAL MAXIMUM BENEFIT. The maximum annual benefit per

person shall not be less than $250,000.

  3.  OUT OF POCKET MAXIMUM PER PERSON.  The annual out of

pocket maximum per person not to exceed $5,000, including

any deductibles, copayments or coinsurances in the plan,

for family coverage, not to exceed three times the per person

out-of-pocket maximum.

  4.  PREEXISTING CONDITION LIMITATION.

  (a)  Any preexisting condition limitation shall be in

compliance with Utah Code Subsection 31A-22-605.1(4); and

  (b)  Any waiting period shall not exceed 12 months, or 18

months in the case of a late enrollee, with credit for prior

coverage when applicable.

  5.  GENERAL COST-SHARING FOR MEDICAL BENEFITS.

  Cost-sharing shall be based on eligible expenses. The cost-

sharing features of the plan shall be the following:

  (a)  Annual Deductible.

  (i)  A major medical deductible of not less than $1,000

per person, for family coverage not to exceed three times the per

person deductible for major medical expenses; and

  (ii)  an annual deductible for prescription benefits not to

exceed $1000 per person, for family coverage not to exceed three

times the per person deductible.

  (b)  Copayment and Coinsurance.

  (i)(A)  A copayment of not less than $25 per visit for office

visits, including preventive care services; and

  (B)  A copayment of not less than $150 per visit to the emergency

room; or

  (ii)  less than 20% coinsurance per

visit for office services and 20% per emergency room visits.

  6.  PREVENTIVE SERVICES. Preventive services covered under a

managed care plan shall not be subject to the annual deductible.

Covered preventive services shall consist of at least the following:

  (a)  childhood immunizations in accordance with guidelines as

recommended by the Centers for Disease Control, as directed and

modified from time to time;

  (b)  well-baby care through age five in accordance with

guidelines recommended by the American Academy of Pediatrics, as

directed and modified from time to time;

  (c)  for adults and adolescents, age, sex and risk appropriate

preventive and screening services in accordance with

Classification A guidelines recommended by the U.S. Preventive

Services Task Force, as directed and modified from time to time.

  7.  COST SHARING FOR PRESCRIPTION DRUGS. Benefits for

prescription drugs, other than self injectable drugs, except

insulin, shall be subject to either:

  (a)  a copayment of not more than:

  (i)  the lesser of the cost of the prescription drug or $15

for the lowest level of cost for prescription drugs;

  (ii)  the lesser of the cost of the prescription drug or $25

for the second level of cost for prescription drugs; and

  (iii)  the lesser of the cost of the prescription drug or $35

for the highest level of cost for prescription drugs; or

  (b)  a coinsurance of not less than:

  (i)  the lesser of the cost of the prescription drug or 25% for

the lowest level of cost for prescription;

  (ii)  the lesser of the cost of the prescription drug or 40% for

the second level of cost for prescription drugs; and

  (iii)  the lesser of the cost of the prescription drug or 60% for

the highest level of cost for prescription drugs.

  8.  COST SHARING FOR MENTAL HEALTH BENEFITS AND/OR SUBSTANCE

ABUSE SERVICES.

  Benefits for mental health and substance abuse services shall

provide:

  (i) for individual policies:

  (A) coinsurance of 50% of eligible expenses;

  (B) inpatient services limited to 10 days annually per person; and

  (C) benefits for outpatient services limited to 20 visits annually

per person;

  (ii) small employer group policies shall be subject to Sections

31A-22-625 and 31A-22-715; and

  (iii) large employer group policies shall be subject to the Paul

Wellstone and Pete Domenici Mental Health Parity and Addiction Equity

Act of 2008.

  9.  OUTPATIENT REHABILITATION SERVICES. Benefits for outpatient

rehabilitation services, e.g., physical therapy, occupational

therapy, and speech therapy, shall be limited to not less than 10

visits for each illness or injury.

  10.  HOME HEALTH CARE. Benefits for home health care shall be

limited to not less than 30 days in any 12 month period and shall

consist of services provided, in accordance with a plan of care,

in the home by a licensed community home health agency or an

approved hospital program for home health care when the person

is physically unable to obtain necessary medical care on an

outpatient basis, would otherwise be confined as an inpatient,

and is under the care of a physician. A "plan of care" means a

written plan that:

  (a)  is approved by the physician prior to commencement of

treatment, unless it is continuity of care under the same

physician;

  (b)  is based on the assessment data or physician orders; and

  (c)  identifies the patient's needs, who will provide needed

services, how often, treatment goals, and anticipated outcomes.

  Covered services shall not include health aide services

furnished when the person is not receiving professional services

of a registered nurse (RN), licensed practical nurse (LPN), or

licensed vocational nurse (LVN), nor shall it include

housekeeping services.

  11.  DURABLE MEDICAL EQUIPMENT. Benefits for durable

medical equipment, rental or purchase, at the option of the

insurer.  Prosthetics and orthotics shall be limited to

not less than $5,000 per person for the entire period for which

coverage is in effect.

  12.  COVERED SERVICES. Subject to medical necessity,

provider network, and prior approval criteria established by the

insurer, and subject to the limitations and exclusions and

other terms and conditions of the policy, the following shall be

covered services under the basic health care plan:

  (a)  inpatient hospital services:

  (i)  semi-private room accommodations;

  (ii)  ICU;

  (iii)  hospital services and supplies;

  (b)  ambulatory service facility services:

  (i)  birthing center services, when maternity care is covered;

  (ii)  surgical facility services;

  (c)  office preventive services;

  (d)  office medical services:

  (i)  diagnostic services; e.g., x-ray, lab tests;

  (ii)  therapeutic services; e.g., injection of medication;

  (e)  outpatient hospital services:

  (i)  emergency room services;

  (ii)  diagnostic services;

  (iii)  therapeutic services; e.g., chemotherapy, radiation

therapy;

  (iv)  surgical facility services;

  (f)  inpatient medical services; e.g., physician visits;

  (g)  surgery;

  (h)  assistant-at-surgery;

  (i)  anesthesia, including children's general anesthesia for

dental, if necessary;

  (j)  consultation;

  (k)  dental care for accidental injury to sound natural teeth;

  (l)  limited home health care;

  (m)  emergency ambulance transportation;

  (n)  prescription drugs;

  (o)  durable medical equipment, prosthetics and orthotics, as

limited; and medical supplies;

  (p)  maternity services:

  (i)  for employer group conversion plans, maternity benefits

are provided on the same basis as benefits for sickness;

  (ii)  for individual plans, there are no maternity benefits;

  (iii)  benefits for complications of pregnancy are provided on

the same basis as benefits for sickness. Complications of

pregnancy will not be excluded solely because the pregnancy is a

preexisting condition. "Complications of pregnancy" means

diseases or conditions, the diagnoses of which are distinct from

pregnancy but are adversely affected or caused by pregnancy and

not associated with a normal pregnancy.

  Complications of pregnancy does not include false labor,

occasional spotting, doctor prescribed rest during the period

of pregnancy, morning sickness, and conditions of comparable

severity associated with management of a difficult pregnancy.

In no event will the presence of complications of pregnancy

result in benefits being provided for services normal to care

and treatment of pregnancy and childbirth. Such normal services

include but are not limited to hospitalization for childbirth or

termination of pregnancy by any means, anesthesia services,

ultrasound examinations, prenatal diagnostic laboratory

services, antepartum and postpartum care, vaginal or cesarean

delivery, threatened premature termination, premature

termination, and routine nursery care of the newborn;

  (iv)  newborn and maternity inpatient time limits will conform

to Subsection 31A-22-610.2.  For conversion plans, maternity

will be covered with the lesser of benefits originally on plan

prior to conversion or the basic benefit plan.  This coverage

benefit is only for existing pregnancies, known or unknown at

the time of conversion. Additional premium for pregnancy is not

allowed;

  (q)  limited outpatient rehabilitation services;

  (r)  limited mental illness/substance abuse services;

  (s)  diabetes as required by Section 31A-22-626.

  (t)  inborn metabolic errors, PKU, nutritional benefits as

required by Section 31A-22-623; and

  (u)  mastectomy as required by Sections 31A-22-630 and

31A-22-719.

  13.  EXCLUSIONS. Benefits will not be provided for any of the

following:

  (a)  services, supplies, or treatment provided prior to the

effective date or after the termination date of coverage;

  (b)  charges in connection with a work-related injury or

sickness for which coverage is provided under any state or

federal workers' compensation, employer's liability, or

occupational disease law;

  (c)  services, supplies, or treatment for which coverage is

provided under any motor vehicle no-fault plan. When the person

is required by law to have no-fault insurance in effect, this

exclusion applies to charges up to the minimum coverage required

by law whether or not such coverage is in effect;

  (d)  services, supplies, or treatment for injury or sickness

resulting from war or any act of war whether declared or

undeclared;

  (e)  services, supplies, or treatment for injury or sickness

resulting from service in the military of any country;

  (f)  services, supplies, or treatment for which benefits are

provided under Medicare or any other government program except

Medicaid;

  (g)  services, supplies, or treatment for which no charge is

made or for which the person is not required to pay;

  (h)  services or supplies not incident to or necessary for the

treatment of injury or sickness or which are not medically

necessary, as determined by the insurer;

  (i)  treatment or prevention of an injury or sickness,

including mental illness, by means of treatments, procedures,

techniques, or therapy outside generally accepted health care

practice;

  (j)  services, supplies, or treatment required as a result of

an injury or sickness sustained while committing a felony or

engaging in an illegal occupation;

  (k)  services to the extent benefits are provided by any

governmental unit except as required by federal law for

treatment of veterans in Veterans Administration or armed

forces facilities for non-service related medical conditions;

  (l)  examinations, reports, or appearances in connection with

legal proceedings; and services, supplies, or accommodations

pursuant to a court order, whether or not injury or sickness is

involved;

  (m)  investigative/experimental technology, treatment,

procedure, facility, equipment, drug, device or supply,

"technology," which does not, as determined by the insurer on a

case by case basis, meet all of the following criteria:

  (i)  the technology must have final approval from appropriate

governmental regulatory bodies, if applicable;

  (ii)  the technology must be available in significant number

outside the clinical trial or research setting;

  (iii)  the available research regarding the technology must

be substantial. For purposes of this definition, "substantial"

means sufficient to allow the insurer to conclude that:

  (A)  the technology is both medically necessary and

appropriate for the person's treatment;

  (B)  the technology is safe and efficacious; and

  (C)  more likely than not, the technology will be beneficial

to the person's health;

  (iv)  the regional medical community as a whole must generally

recognize the technology as appropriate;

  (n)  services in connection with any transplant of any whole

organ or part thereof, live or cadaver, bone marrow, either as

donor or recipient, or any artificial organ, except for the

following:

  (i)  cornea transplants;

  (ii)  kidney transplants;

  (iii)  liver transplants for children under age 18 years;

  (iv)  bone marrow transplants for children under age 18 years;

and

  (v)  evaluation, treatment and therapy involving the use of

myeloablative chemotherapy with autologous hematopoietic stem

cell and/or colony stimulating factor support for children under

age 18 years;

  (o)  custodial care;

  (i)  "Custodial care" means:

  (A)  institutional care, consisting mainly of room and board,

which is for the primary purpose of controlling the person's

environment; and

  (B)  professional or personal care, consisting mainly

of non-skilled nursing services with or without medical

supervision, which is for the primary purpose of managing the

person's disability or maintaining the person's degree of

recovery already attained without reasonable expectation of

significant further recovery.

  (ii)  "Custodial care" does not mean outpatient palliative

and supportive care provided by a hospice program to a person

who is terminally ill with a life expectancy of not more than

six months and is in lieu of institutional or inpatient hospital

care;

  (p)  services, supplies, or treatment in connection with

cosmetic or reconstructive procedures which alter appearance but

do not restore or improve impaired physical function or which

are performed for psychological or emotional purposes, except

when performed while a person is covered under this policy for

the following:

  (i)  repair of defects resulting from an accident occurring

within 90 days of the effective date of this policy under

creditable coverage or occurring during this policy;

  (ii)  replacement of diseased tissue surgically removed for

illness occurring within 90 days of this policy under creditable

coverage or occurring during this policy;

  (iii)  treatment of a birth defect in a child who has met the

pre-existing conditions requirement since birth or date of

placement for adoption; and

  (iv)  mastectomy reconstruction as required by Sections

31A-22-630 and 31A-22-719;

  (q)  dental services. This exclusion will not apply if dental

services are required as a result of an accidental injury which

occurs while coverage is in force, dental services are received

within two years following the accidental injury, and the person

has been continuously covered from the date of the accidental

injury through the date the dental services are provided;

  (r)  eyeglasses, contact lenses and/or servicing of eyeglasses

and/or contact lenses. This exclusion does not apply to contact

lenses in the case of keratoconus or post-cataract surgery when

the contact lenses are medically necessary in the treatment of

the condition;

  (s)  medical, non-surgical, care of weak, strained, flat,

unstable or unbalanced feet routine foot care. The exclusion of

routine foot care does not apply to cutting or removal of corns,

calluses, or nails when provided to a person who has a systemic

disease, such as diabetes with peripheral neuropathy or

circulatory insufficiency, of such severity that unskilled

performance of the procedure would be hazardous;

  (t)  orthopedic or corrective shoes, foot orthotics, or any

other supportive devices for the feet;

  (u)  drugs and medicines which do not bear the legend

"Caution - federal law prohibits dispensing without a

prescription" and/or which are not dispensed by a licensed

pharmacist;

  (v)  charges in connection with jaw realignment procedures

including, but not limited to, osteotomy, upper or lower jaw

augmentation or reduction procedures, and orthognathic surgery;

charges in connection with treatment of temporomandibular joint

(TMJ) dysfunction, including surgical procedures and injections

of the TMJ, physical therapy, splints, and orthodontic

appliances. This exclusion will not apply to:

  (i)  the initial diagnostic evaluation of TMJ dysfunction;

  (ii)  surgical correction of the TMJ required as a result of

an accidental injury which occurs while this coverage is in

force; and

  (iii)  physical therapy services related to and subsequent to

covered TMJ surgery;

  (w)  treatment of obesity by means of surgical, medical

or medication services and regardless of associated medical,

emotional, or psychological conditions;

  (x)  services or supplies in connection with genetic studies;

  (y)  implantable contraceptives (hormonal or other);

  (z)  reversal of a sterilization procedure;

  (aa)  any treatment for or diagnosis of infertility,

artificial insemination, in vitro fertilization, and any other

male or female dysfunction, except as required by Section

31A-8-101;

  (bb)  vision testing, vision training;

  (cc)  radial keratotomy, laser and any surgical correction of

errors of refraction;

  (dd)  educational service or counseling, including weight

control clinics, stop smoking clinics, cholesterol counseling,

exercise programs or other types of physical fitness training,

except for those benefits required by Section 31A-22-626;

  (ee)  marriage counseling; family counseling; counseling

for educational, social, occupational, religious, or other

similar maladjustment; behavior modification, biofeedback, or

rest cures as treatment for mental disorders; sensitivity or

stress-management training; self-help training; and residential

treatment;

  (ff)  treatment for mental disorders which are irreversible or

for which there is little or no reasonable expectation for

improvement, including mental retardation, personality

disorders, and chronic organic brain disease. This exclusion

does not apply to the initial assessment for diagnosis of the

condition;

  (gg)  psychotherapy, counseling, or other services in

connection with learning disabilities, disruptive behavior

disorders, conduct disorders, psychosexual disorders, or

transexualism. This exclusion does not apply to the initial

assessment for diagnosis of the condition;

  (hh)  vitamins, special formulas, special diets, and food

supplements except as provided by a hospital or skilled nursing

facility during a confinement for which benefits are available,

except as outlined in Section 31A-22-623;

  (ii)  any devices used to aid hearing, including cochlear

implants, the fitting of such devices and any routine hearing

tests;

  (jj)  acupuncture or acupressure;

  (kk)  speech therapy for psychosocial speech delays;

  (ll)  all shipping, handling, or postage charges except as

incidentally provided, without a separate charge, in connection

with covered services or supplies;

  (mm)  interest or finance charges except as specifically

required by law;

  (nn)  charges for missed appointments, telephone

consultations, and clerical services for completion of special

reports or claim forms;

  (oo)  travel expenses, whether or not prescribed;

  (pp)  care, except urgent or emergency care, rendered outside

the United States;

  (qq)  services provided by a member of the person's immediate

family or household; and

  (rr)  autopsy procedures.

 

(11) The basic health care plan is to be filed with the department before use.

(12) Conversion coverage provided pursuant to Section 31A-22-723, may provide additional benefits in addition to the Basic Health Care Plan.

 

R590-175-4. Enforcement Date.

The commissioner will begin enforcing the revised provisions of this rule 45 days from the rule's effective date.

 

R590-175-5. Severability.

If a provision of this rule or its application to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of these provisions shall not be affected.

 

KEY: insurance

Date of Enactment or Last Substantive Amendment: August 13, 2009

Notice of Continuation: November 8, 2005

Authorizing, and Implemented or Interpreted Law: 31A-22-613.5]