1. (1) For the entire term of the contract, including any renewal or re-issuance, coverage may not exclude a loss due to a preexisting condition for a period greater than 12 months following the initial issuance of the contract.

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

   1. (a) abortion;
   2. (b) acupuncture and acupressure;
   3. (c) administrative charges for completing an insurance form, duplication service, interest, finance charge, or other administrative charge, unless otherwise required by law;
   4. (d) administrative exam or service;
   5. (e) applied behavioral analysis therapy;
   6. (f) aviation, to a non-fare-paying passenger;
   7. (g) axillary hyperhidrosis;

   8. (h) benefits paid for under:

      1. (i) employer's 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 lens, including an examination for prescription or fitting, except lens implant following cataract surgery;

   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 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;
   12. (n) custodial care;
   13. (o) dental care or treatment;
   14. (p) dietary products, except as required under Rule R590-194;
   15. (q) educational and nutritional training, except as required under Rule R590-200;
   16. (r) experimental or investigational service;
   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, a flat foot, 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 in 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) gene therapy;
   21. (y) genetic testing;
   22. (z) hearing aid, including examination for the prescription or fitting;
   23. (aa) infertility services;
   24. (bb) injury as a result of a motor vehicle, to the extent the covered person is required to have no-fault coverage, up to the minimum coverage required by law whether or not coverage is in effect;
   25. (cc) mental health condition or substance use disorder services;
   26. (dd) nuclear release;

   27. (ee) preexisting condition, except:

       1. (i) as required under Sections 31A-22-605.1 and R590-286-5, and Subsection 31A-22-610(2); and
       2. (ii) for coverage of a congenital anomaly as required under Section 31A-22-610;
   28. (ff) pregnancy, except for a complication of pregnancy;
   29. (gg) refractive eye surgery;

   30. (hh) rehabilitation or habilitative therapy services, such as physical, speech, and occupational, except as required to correct an impairment caused by a covered injury or illness;

       1. (ii) respite care;
   31. (jj) rest cure;

   32. (kk) services while in the armed forces or an auxiliary unit;

       1. (ll) services performed by an enrollee's parent, spouse, sibling, or child, including a step or in-law relationship;
   33. (mm) services performed by an employee of a hospital, laboratory, or other institution;
   34. (nn) services that are not medically necessary;
   35. (oo) services for which no charge is normally made in the absence of insurance;
   36. (pp) sexual dysfunction procedure, equipment, or drug;
   37. (qq) shipping or handling, except as required by law;
   38. (rr) telephone or electronic consultation;
   39. (ss) territorial limitation outside the United States, except as required under Section 31A-22-627;
   40. (tt) terrorism, including an act of terrorism;

   41. (uu) transplant;

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

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

       1. (xx) except as provided in Subsection (2)(yy), a loss directly related to an 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)(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
   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 of Subsection R590-286-4(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 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 R592-286-4(2)(yy) does not apply to an enrollee who is under 18 years of age.
4. (5) 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 the commissioner finds is unjust, unfair, or unfairly discriminatory to an enrollee.

KEY: insurance, health, short-term limited duration

Date of Last Change: March 24, 2025

Notice of Continuation: March 9, 2026

Authorizing, and Implemented or Interpreted Law: 31A-2-201(3)(a); 31A-2-202; 31A-22-605(4); 31A-22-605(6); 31A-22-605.1(1); 31A-45-103