1. (1)(a) A contract may not establish a probationary period when coverage is not provided, except under Subsections (1)(b) and (1)(c).

   1. (b) A contract may specify a probationary period not to exceed 12 months for a loss resulting from:

      1. (i) amenorrhea;
      2. (ii) cataracts;
      3. (iii) a congenital deformity, except as required under Subsection 31A-22-610(2);
      4. (iv) cystocele;
      5. (v) dysmenorrhea;
      6. (vi) enterocele;
      7. (vii) infertility;
      8. (viii) rectocele;
      9. (ix) seasonal allergy, limited to testing and treatment;
      10. (x) sleep disorder, including sleep studies;

      11. (xi) surgical treatment for:

          1. (A) adenoidectomy;
          2. (B) bunionectomy;
          3. (C) carpal tunnel;
          4. (D) hysterectomy, except in a case of malignancy;
          5. (E) joint replacement;
          6. (F) reduction mammoplasty;
          7. (G) Morton's neuroma;
          8. (H) myringotomy and tympanotomy, with or without tubes inserted;
          9. (I) nasal septal repair, except for an injury after the effective date of coverage;
          10. (J) retained hardware removal;
          11. (K) sterilization; and
          12. (L) tonsillectomy;
      12. (xii) urethrocele;
      13. (xiii) uterine prolapse; and
      14. (xiv) varicose veins.
   2. (c) Coverage shall be provided for a disease, condition, or procedure in Subsection (1)(b) if the disease, condition, or procedure is treated on an emergency basis.

2. (2) Unless otherwise required by law, a contract may not limit or exclude coverage or benefits by type of illness, accident, injury, treatment, or medical condition, except:

   1. (a) abortion;
   2. (b) acupuncture or acupressure;
   3. (c) administrative charge for completing an insurance form, duplication service, interest, finance charge, or other administrative charge;
   4. (d) administrative exam or service;
   5. (e) allergy test or treatment;
   6. (f) applied behavioral analysis therapy, except as required under Section 31A-22-642;
   7. (g) aviation, to a non-fare-paying passenger;

   8. (h) axillary hyperhidrosis;

      1. (i) benefits paid for under:
      2. (i) employer's liability or occupational disease law;
      3. (ii) Medicare or another governmental program, except Medicaid; or
      4. (iii) state or federal workers' compensation;
   9. (j) charge for a missed appointment;

   10. (k) chiropractic care;

       1. (l) complementary or alternative medicine;
   11. (m) corrective lens, including an examination for prescription or fitting, except lens implant following cataract surgery;

   12. (n) cosmetic surgery, including reversal, revision, repair, complication, or treatment related to a non-covered cosmetic surgery, except reconstructive surgery:

       1. (i) when the service is incidental to or follows surgery resulting from trauma, infection, or other disease of the involved part; or
       2. (ii) due to a congenital disease or anomaly of a covered dependent child that resulted in a functional defect;
   13. (o) custodial care;
   14. (p) dental care or treatment;
   15. (q) dietary products, except as required under Rule R590-194;
   16. (r) educational or nutritional training, except as required under Rule R590-200;
   17. (s) expenses before coverage begins or after coverage ends;
   18. (t) experimental or investigational service;

   19. (u) felony, riot, or insurrection, when it is determined the enrollee was a voluntary participant;

       1. (v) fitness training, exercise equipment, or a membership fee to a spa or health club;

   20. (w)(i) foot care for a corn, a callus, a flat foot, a fallen arch, a weak foot, chronic foot strain, or symptomatic complaints of a foot, including an orthotic; and

       1. (ii) the cutting or removal of a corn, a callus, or a nail may not be excluded when provided to an enrollee who has a systemic disease, such as diabetes with peripheral neuropathy or circulatory insufficiency, if unskilled performance of the procedure would be hazardous;
       2. (x)(i) gastric or intestinal bypass service, including lap banding, gastric stapling, or a similar procedure to facilitate weight loss;
       3. (ii) the reversal or revision of a procedure in Subsection (2)(x)(i); or
       4. (iii) a service required for the treatment of a complication from a procedure in Subsection (2)(x)(i);
   21. (y) gender reassignment, except as required under Section 1557 of PPACA;
   22. (z) gene therapy;
   23. (aa) genetic testing;
   24. (bb) hearing aid, including examination for the prescription or fitting;
   25. (cc) infertility service, except as required under Subsection 31A-22-610.1(1);
   26. (dd) injury as a result of a motor vehicle, to the extent the enrollee is required to have no-fault coverage, up to the minimum coverage required by law whether or not coverage is in effect;
   27. (ee) mental health condition or substance use disorder, except as required under 45 CFR 147.160 and Section 31A-22-625;
   28. (ff) nuclear release;
   29. (gg) preexisting condition, except as required under Section 31A-22-605.1 and Subsection 31A-22-610(2);

   30. (hh) pregnancy, except for a complication of pregnancy;

       1. (ii) refractive eye surgery;
   31. (jj) rehabilitation therapy service, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident, injury, or illness;

   32. (kk) respite care;

       1. (ll) rest cure;
   33. (mm) routine physical examination;
   34. (nn) services performed by an enrollee's parent, spouse, sibling, or child, including a step or in-law relationship;
   35. (oo) services performed by an employee of a hospital, laboratory, or other institution;
   36. (pp) services that are not medically necessary;
   37. (qq) services for which no charge is normally made in the absence of insurance;
   38. (rr) services while in the armed forces or an auxiliary unit;
   39. (ss) sexual dysfunction procedure, equipment, or drug;
   40. (tt) shipping or handling;

   41. (uu) suicide, sane or insane, attempted suicide, or intentionally self-inflicted injury;

       1. (vv) telephone or electronic consultation, except as required under Sections 31A-22-649 and 31A-22-649.5;

   42. (ww) territorial limitation outside the United States, except as required under Section 31A-22-627;

       1. (xx) terrorism, including an act of terrorism;
   43. (yy) transplant;
   44. (zz) transportation, except medically necessary ambulance services;
   45. (aaa) war or act of war, whether declared or undeclared;

   46. (bbb) except under Subsection (2)(ccc), a loss directly related to the enrollee's voluntary participation in an activity when the enrollee:

       1. (i) is found guilty of an illegal activity in a criminal proceeding, including a plea of guilty, a no contest plea, and a plea in abeyance; or
       2. (ii) is found liable for the activity in a civil proceeding;

   47. (ccc) a loss established under Subsection (3)(a) that is directly related to the enrollee violating:

       1. (i) Section 41-6a-502, if the loss occurred in Utah; or
       2. (ii) a law in a state other than Utah that prohibits operating a motor vehicle while exceeding the legal limit of concentration of alcohol, drugs, or a combination of both in the blood, if the loss occurred in the other state; or
   48. (ddd) any other exclusion that, in the opinion of the commissioner, is not inequitable, misleading, deceptive, obscure, unjust, unfair, or unfairly discriminatory to an enrollee.

3. (3)(a) A violation under Subsection (2)(ccc) shall be established:

   1. (i) in a criminal proceeding in which the enrollee is found guilty, enters a no contest plea or a plea in abeyance, or enters into a diversion agreement; or

      1. (ii) by a request for an independent review when the findings support a decision to deny coverage based on the exclusion.

   2. (b)(i) For purposes of Subsection (3)(a)(ii), an independent review means a process that:

      1. (A) is conducted by an independent entity designated by the insurer;
      2. (B) renders an independent and impartial decision on a decision to deny coverage based on the exclusion; and
      3. (C) is paid for by the insurer.

      4. (ii) The independent review entity may not have a material professional, familial, or financial conflict of interest with:

         1. (A) the insurer;
         2. (B) an officer, director, or management employee of the insurer;
         3. (C) the enrollee;
         4. (D) the enrollee's health care provider;
         5. (E) the health care provider's medical group or independent practice association; or
         6. (F) a health care facility where services were provided.
   3. (c) The exclusion in Subsection (2)(ccc) does not apply to an enrollee who is under age 18.

4. (4)(a) A waiver shall comply with Section 31A-30-107.5.

   1. (b) A signed acceptance by the enrollee is required if a waiver is required as a condition of issuance, renewal, or reinstatement.
5. (5) A contractual provision precluded in this section may not be construed as a limitation on the commissioner's authority to prohibit a contract provision that, in the opinion of the commissioner, is unjust, unfair, or unfairly discriminatory to an enrollee.

KEY: health insurance

Date of Last Change: March 24, 2025

Notice of Continuation: November 25, 2024

Authorizing, and Implemented or Interpreted Law: 31A-2-201; 31A-2-202; 31A-22-605; 31A-22-623; 31A-22-626; 31A-23a-402; 31A-23a-412; 31A-26-301