31A-30-107.5 - Preexisting condition exclusion -- Condition-specific exclusion riders -- Limitation periods.
31A-30-107.5. Preexisting condition exclusion -- Condition-specific exclusion riders-- Limitation periods.
(1) A health benefit plan may impose a preexisting condition exclusion only if theprovision complies with Subsection 31A-22-605.1(4).
(2) (a) In accordance with Subsection (2)(b), an individual carrier:
(i) may, when the individual carrier and the insured mutually agree in writing to acondition-specific exclusion rider, offer to issue an individual policy that excludes all treatmentand prescription drugs related to:
(A) a specific physical condition;
(B) a specific disease or disorder; and
(C) any specific or class of prescription drugs; and
(ii) may offer an individual policy that may establish separate cost sharing requirementsincluding, deductibles and maximum limits that are specific to covered services and supplies,including drugs, when utilized for the treatment and care of the conditions, diseases, or disorderslisted in Subsection (2)(b).
(b) (i) Except as provided in Section 31A-22-630 and Subsection (2)(b)(ii), the followingmay be the subject of a condition-specific exclusion rider:
(A) conditions, diseases, and disorders of the bones or joints of the ankle, arm, elbow,fingers, foot, hand, hip, knee, leg, mandible, mastoid, wrist, shoulder, spine, and toes, includingbone spurs, bunions, carpal tunnel syndrome, club foot, cubital tunnel syndrome, hammertoe,syndactylism, and treatment and prosthetic devices related to amputation;
(B) anal fistula, anal fissure, anal stricture, breast implants, breast reduction, chroniccystitis, chronic prostatitis, cystocele, rectocele, enuresis, hemorrhoids, hydrocele, hypospadius,interstitial cystitis, kidney stones, uterine leiomyoma, varicocele, spermatocele, endometriosis;
(C) allergic rhinitis, nonallergic rhinitis, hay fever, dust allergies, pollen allergies,deviated nasal septum, and sinus related conditions, diseases, and disorders;
(D) hemangioma, keloids, scar revisions, and other skin related conditions, diseases, anddisorders;
(E) goiter and other thyroid related conditions, diseases, or disorders;
(F) cataracts, cornea transplant, detached retina, glaucoma, keratoconus, maculardegeneration, strabismus and other eye related conditions, diseases, and disorders;
(G) otitis media, cholesteatoma, otosclerosis, and other internal/external ear conditions,diseases, and disorders;
(H) Baker's cyst, ganglion cyst;
(I) abdominoplasty, esophageal reflux, hernia, Meniere's disease, migraines, TICDoulourex, varicose veins, vestibular disorders;
(J) sleep disorders and speech disorders; and
(K) any specific or class of prescription drugs.
(ii) Subsection (2)(b)(i) does not apply:
(A) for the treatment of asthma; or
(B) when the condition is due to cancer.
(iii) A condition-specific exclusion rider:
(A) shall be limited to the excluded condition, disease, or disorder and any complicationsfrom that condition, disease, or disorder;
(B) may not extend to any secondary medical condition; and
(C) must include the following informed consent paragraph: "I agree by signing below, tothe terms of this rider, which excludes coverage for all treatment, including medications, relatedto the specific condition(s), disease(s), and/or disorder(s) stated herein and that if treatment ormedications are received that I have the responsibility for payment for those services and items. Ifurther understand that this rider does not extend to any secondary medical condition, disease, ordisorder."
(c) If an individual carrier issues a condition-specific exclusion rider, thecondition-specific exclusion rider shall remain in effect for the duration of the policy at theindividual carrier's option.
(d) An individual policy issued in accordance with this Subsection (2) is not subject toSubsection 31A-26-301.6(7).
(3) Notwithstanding the other provisions of this section, a health benefit plan mayimpose a limitation period if:
(a) each policy that imposes a limitation period under the health benefit plan specifies thephysical condition, disease, or disorder that is excluded from coverage during the limitationperiod;
(b) the limitation period does not exceed 12 months;
(c) the limitation period is applied uniformly; and
(d) the limitation period is reduced in compliance with Subsections 31A-22-605.1(4)(a)and (4)(b).
Amended by Chapter 307, 2007 General Session