1. (1) A contract may not impose a preexisting condition limitation or exclusion provision.

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 services;
   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) applied behavioral analysis therapy, except as required under Section 31A-22-642;
   6. (f) aviation, to a non-fare-paying passenger;
   7. (g) axillary hyperhidrosis;

   8. (h) benefits paid for under:

      1. (i) employers' liability or occupational disease law;
      2. (ii) Medicare or another governmental program except Medicaid; or
      3. (iii) state or federal workers' compensation;
      4. (i) charge for a missed appointment;
   9. (j) chiropractic care;

   10. (k) complementary or alternative medicine;

       1. (l) corrective lenses, including examination for the prescription or fitting, except:
       2. (i) lens implant following cataract surgery; and
       3. (ii) as required under Rule R590-266;

   11. (m) 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; or
       2. (ii) due to a congenital disease or anomaly of a covered dependent child that has resulted in a functional defect;
   12. (n) custodial care;
   13. (o) dental care or treatment, except as required under Section R590-266-4;
   14. (p) dietary products, except as required under Rule R590-194;
   15. (q) educational or nutritional training, except as required under Rule R590-200;
   16. (r) experimental or investigational services;
   17. (s) expenses before coverage begins or after coverage ends;
   18. (t) felony, riot, or insurrection, when it is determined the enrollee was a voluntary participant;

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

       1. (v)(i) foot care for a corn, a callus, flat feet, a fallen arch, a weak foot, chronic foot strain, or symptomatic complaints of a foot, including an orthotic; and
       2. (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;

   20. (w)(i) gastric or intestinal bypass service, including lap banding, gastric stapling, or a similar procedure to facilitate weight loss;

       1. (ii) the reversal or revision of a procedure under Subsection (2)(w)(i); or
       2. (iii) a service required for the treatment of a complication from a procedure in Subsection (2)(w)(i);
       3. (x) gender reassignment, except as required under Section 1557 of PPACA;
   21. (y) gene therapy;
   22. (z) genetic testing;
   23. (aa) hearing aid, including examination for the prescription or fitting;
   24. (bb) infertility services, except as required under Subsection 31A-22-610.1(1);
   25. (cc) 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;
   26. (dd) mental health condition or substance use disorder services, except as required under Section 31A-22-625 and Rule R590-266;
   27. (ee) nuclear release;
   28. (ff) refractive eye surgery;
   29. (gg) rehabilitation or habilitative therapy services, such as physical, speech, and occupational, unless required to correct an impairment caused by a covered accident, injury, or illness, or as required under Rule R590-266;

   30. (hh) respite care;

       1. (ii) rest cures;
   31. (jj) services performed by an enrollee's parent, spouse, sibling, or child, including a step or in-law relationship;

   32. (kk) services performed by an employee of a hospital, laboratory, or other institution;

       1. (ll) services that are not medically necessary;
   33. (mm) services for which no charge is normally made in the absence of insurance;
   34. (nn) services while in the armed forces or an auxiliary unit;
   35. (oo) services in connection with a prearranged surrogacy agreement, except for services for the baby, where the covered person relinquishes a baby and receives payment or other compensation arising out of such services;
   36. (pp) sexual dysfunction procedures, equipment, or drugs;
   37. (qq) shipping or handling;
   38. (rr) telephone or electronic consultation, except as required under Sections 31A-22-649 and 31A-22-649.5;
   39. (ss) territorial limitations outside the United States, except as required under Section 31A-22-627;
   40. (tt) terrorism, including acts of terrorism;

   41. (uu) transplants, except as required by Rule R590-266;

       1. (vv) transportation, except medically necessary ambulance services;

   42. (ww) war or act of war, whether declared or undeclared;

       1. (xx) except under Subsection (2)(yy), a loss directly related to the enrollee's voluntary participation in an activity when the enrollee:
       2. (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
       3. (ii) is found liable for the activity in a civil proceeding;

   43. (yy) a loss established under Subsection (3) 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
   44. (zz) 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)(yy) 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 managed care organization;
      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 managed care organization.

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

         1. (A) the managed care organization;
         2. (B) an officer, director, or management employee of the managed care organization;
         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)(yy) does not apply to an enrollee who is under 18 years of age.
4. (4) A contract 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: insurance, health insurance

Date of Last Change: June 10, 2025

Notice of Continuation: August 9, 2024

Authorizing, and Implemented or Interpreted Law: 31A-45-103; 31A-2-201(3)(a); 31A-23a-402(8); 31A-23a-412; 31A-2-202