1. (1) "Essential health benefits" means the following health care service categories:

   1. (a) ambulatory patient services;
   2. (b) emergency services;
   3. (c) hospitalization;
   4. (d) pregnancy, maternity, and newborn care;
   5. (e) mental health and substance use disorder services, including behavioral health treatment;
   6. (f) prescription drugs;
   7. (g) rehabilitative and habilitative services and devices;

   8. (h) laboratory services;

      1. (i) preventive and wellness services and chronic disease management; and
   9. (j) pediatric services, including oral and vision care.

2. (2) "Grandfathered health plan" means an individual or small employer health benefit plan that:

   1. (a) was in existence when the PPACA was enacted on March 23, 2010;

   2. (b) has not had any significant changes that reduce benefits or increase costs to the consumer including:

      1. (i) a significant cut or reduction in benefits;
      2. (ii) an increase in co-pays by more than $5, adjusted annually for medical inflation, or a percentage equal to medical inflation plus 15%;
      3. (iii) an employer reduction in contributions by more than five percentage points; or
      4. (iv) a reduction of annual dollar limits, or addition of a new limit; and
   3. (c) the insured has received notification from the insurer that their health benefit plan is a grandfathered plan.

3. (3)(a) "Habilitative" means health care services that help a person keep, learn, or improve skills and functioning for daily living.

   1. (b) Habilitative services may include:

      1. (i) physical therapy;
      2. (ii) occupational therapy;
      3. (iii) speech-language pathology; or
      4. (iv) other services.

4. (4) "Non-grandfathered health plan" means an individual or small employer health benefit plan:

   1. (a) that is issued after the PPACA was enacted on March 23, 2010; or

   2. (b) a grandfathered health plan that has made significant changes that:

      1. (i) reduce benefits or increase costs to the consumer; and
      2. (ii) caused the plan to lose the grandfathered status as provided in Subsection (2)(b).
5. (5) "Rehabilitative" means the treatment of disease, injury, developmental delay, or other cause, by physical agents and methods to assist in the rehabilitation of normal physical bodily function, that is goal-oriented and where the person has potential for functional improvement and ability to progress.
6. (6) "Utah essential health benefits package" means the benefits designated in this rule by the commissioner as essential health benefits.

Terms used in this rule are defined in Sections 31A-1-301 and 31A-30-103. Additional terms are defined as follows:

KEY: essential health benefit, insurance

Date of Last Change: June 9, 2023

Notice of Continuation: October 14, 2022

Authorizing, and Implemented or Interpreted Law: 31A-30-201(3)(a); 31A-2-212(5)