31A-29-113 - Benefits -- Additional types of pool insurance -- Preexisting conditions -- Waiver -- Maximum benefits.
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 forthe 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 thehealth care services and items rendered during times for which benefits are extended under thepool policy.
(2) The coverage to be issued by the pool, its schedule of benefits, exclusions, and otherlimitations shall be established by the board.
(3) The commissioner shall approve the benefit package developed by the board toensure its compliance with this chapter.
(4) The pool shall offer at least one benefit plan through a managed care program asauthorized under Section 31A-29-106.
(5) This chapter may not be construed to prohibit the pool from issuing additional typesof pool policies with different types of benefits which in the opinion of the board may be ofbenefit to the citizens of Utah.
(6) (a) The board shall design and require an administrator to employ cost containmentmeasures and requirements including preadmission certification and concurrent inpatient reviewfor 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 thischapter.
(7) (a) A pool policy may contain provisions under which coverage for a preexistingcondition is excluded if:
(i) the exclusion relates to a condition, regardless of the cause of the condition, for whichmedical advice, diagnosis, care, or treatment was recommended or received, from an individuallicensed or similarly authorized to provide such services under state law and operating within thescope of practice authorized by state law, within the six-month period ending on the effectivedate of plan coverage; and
(ii) except as provided in Subsection (8), the exclusion extends for a period no longerthan 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 preexistingpregnancy is excluded during a ten-month period following the effective date of plan coveragefor 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 towhich similar exclusions have been satisfied under any prior health insurance coverage if theindividual applies not later than 63 days following the date of involuntary termination, other thanfor nonpayment of premiums, from health coverage.
(b) If this Subsection (9) applies, coverage in the pool shall be effective from the date onwhich the prior coverage was terminated.
(10) Covered benefits available from the pool may not exceed a $1,500,000 lifetimemaximum, which includes a per enrollee calendar year maximum established by the board.
Amended by Chapter 40, 2007 General Session