State Law

Utah Admin Code-Title R590- Rule R590-126. Accident and Health Insurance Standards

05/12/2025 Utah Section R590-126-3

Definitions

Medical Necessity-Definition, OON-Payment Issues

See bold text below:

Terms used in this rule are defined in Sections 31A-1-301, 31A-22-605, 31A-22-620, and 31A-22-625. Additional terms are defined as follows:

(1) “Assisted living facility,” “continued care retirement community,” “convalescent nursing home,” “extended care facility,” “hospital,” “residential health care facility,” or “skilled nursing facility” means a facility licensed and operating within the scope of that license.

(2) “Buyer’s guide” means the NAIC’s Shopper’s Guide to Cancer Insurance.

(3) “Certificate of completion” means a document issued by the Utah State Board of Education, or similar organization in another state, to an individual:

(a) who completes an approved course of study not leading to a diploma;

(b) who passes a challenge for the course of study in Subsection (3)(a); or

(4) “Complication of pregnancy” means a disease or condition that is distinct from pregnancy but is adversely affected or caused by pregnancy and is not associated with a normal pregnancy.

(a) “Complication of pregnancy” includes:

(i) acute nephritis;

(ii) nephrosis;

(iii) cardiac decompensation;

(iv) terminated ectopic pregnancy;

(v) spontaneous termination of pregnancy when a viable birth is not possible;

(vi) puerperal infection;

(vii) eclampsia;

(viii) pre-eclampsia; or

(ix) toxemia.

(b) “Complication of pregnancy” does not include:

(i) false labor;

(ii) occasional spotting;

(iii) doctor prescribed rest during pregnancy;

(iv) morning sickness; or

(v) a condition of comparable severity associated with management of a difficult pregnancy.

(5) “Contract” means a policy or certificate.

(6)(a) “Cosmetic surgery” or “reconstructive surgery” means a surgical procedure performed primarily to improve physical appearance.

(b) “Cosmetic surgery” or “reconstructive surgery” does not include surgery that is necessary:

(i) to correct damage caused by injury or sickness;

(ii) for reconstructive treatment following medically necessary surgery;

(iii) to provide or restore normal bodily function; or

(iv) to correct a congenital disorder that has resulted in a functional defect.

(7)(a) “Custodial care” means a plan of care that does not provide treatment for sickness or injury, but is for meeting personal needs and maintaining physical condition when there is no prospect of remission or restoration of the patient to a condition when care would not be required, and that may be provided by a person without nursing skills or qualifications.

(8) “Elimination period” or “waiting period” means the length of time an insured shall wait before benefits are paid under the contract.

(9) “Enrollment form” means an application as defined in Section 31A-1-301.

(10) Experimental treatment” means a medical treatment, service, supply, medication, drug, or other method of therapy or medical practice that is not accepted as a valid course of treatment by the U.S. Food and Drug Administration, the American Medical Association, or the Surgeon General.

(11) “Home health agency” means a public agency, a private organization, or a subdivision of a health care facility that is licensed and operating within the scope of that license.

(12) “Home health aide” means an individual who obtains a certificate of completion, as required by law, that allows performance of:

(a) health care and other related services under the supervision of a registered nurse from the home health agency; or

(b) a simple procedure as an extension of physical, speech, or occupational therapy under the supervision of a licensed therapist.

(13) “Home health care” means a service provided by a home health agency.

(14) “Homemaker” means an individual who cares for the home through duties such as housekeeping, meal planning and preparation, laundry, shopping, and errands.

(15) “Hospice” means a program of care for the terminally ill and their families that occurs in a home or health care facility and provides medical, palliative, psychological, spiritual, or supportive care and treatment and is licensed and operating within the scope of that license.

(16)(a) “Injury” means a bodily injury resulting from an accident, independent of disease, that occurs while the coverage is in force.

(b) “Injury” is not limited to an injury with external, violent, visible wound or similar description.

(17) “Immediate family” means an insured’s parent, spouse, sibling, or child, including a step or in-law relationship.

(18) “Intermediate nursing care” means a nursing service provided by, or under the supervision of, a nurse to treat a condition when confinement is required.

(19) “Licensed practical nurse” means a licensed practical nurse who provides services within the scope of their license.

Medical Necessity-Definition

(20)(a) “Medical necessity” means a health care service or product that a prudent health care provider would provide to a patient to prevent, diagnose, or treat an illness, injury, disease, or its symptoms in a manner that is:

(i) in accordance with generally accepted standards of medical practice in the United States;

(ii) clinically appropriate in terms of type, frequency, extent, site, and duration;

(iii) not primarily for the convenience of the patient, physician, or other health care provider; and

(iv) covered under the contract.

(b) If a medical question-of-fact exists, “medical necessity” shall include the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual, and known to be effective.

(c)(i) For an intervention not yet in widespread use, the effectiveness shall be based on scientific evidence.

(ii) For an established intervention, the effectiveness shall be based on:

(A) scientific evidence;

(B) professional standards; and

(C) expert opinion.

(21)(a) “Nurse” means a type of licensed nurse, such as an advanced practice nurse, a registered nurse, or a licensed practical nurse.

(b) If the word “nurse” is used without specific instruction, then the use of this term requires the insurer to recognize the services of any individual who qualifies under this terminology under applicable laws.

(22) “Nursing care” means assistance provided for the health care needs of a sick or disabled individual, by or under the direction of a nurse.

(23) “One period of confinement” means consecutive days of in-hospital service received as an inpatient, or successive confinements when discharge from and readmission to the hospital occurs within a period of not more than 90 days or three times the maximum number of days of in-hospital coverage provided by the contract up to a maximum of 180 days.

(24) “Partial disability” means an individual’s inability to:

(a) perform some, but not all, of the major, important, or essential duties of the individual’s employment or existing occupation;

(b) work a specified:

(i) percentage of time; or

(ii) number of hours; or

(25) “Personal care” means assistance in the activities of daily living provided to an individual under a plan of care by a home health agency.

(26) “Personal care aide” means an individual who obtains a certificate of completion, as required by law, that allows that individual to assist in the activities of daily living and emergency first aid, and who must be supervised by a registered nurse from a home health agency.

(27) “Physician,” “qualified physician,” or “licensed physician” means a physician who provides services within the scope of their license.

(28)(a) “Preexisting condition” means:

(i) the existence of a symptom or condition that would cause an ordinarily prudent person to seek diagnosis, care, or treatment within the 24-month period before the effective date of coverage; or

(ii) a condition for which medical advice or treatment was recommended or received from a health care provider within the 24-month period before the effective date of the coverage of the insured.

(b) This definition does not apply to a specified disease insurance contract.

(29) “Probationary period” means the length of time following the date of issuance or effective date of the contract before a benefit is paid under the contract.

(30) “Registered nurse” means a registered nurse who provides services within the scope of their license.

(31) “Residual disability” means an individual’s relative reduction in earnings and may be related to the inability to perform either:

(a) some part of the major, important, or essential duties of the individual’s employment or existing occupation; or

(b) the individual’s usual work duties for as long as is usually required.

(32) “Respite care” means providing temporary support to the primary caregiver of an aged or disabled insured by taking over the tasks of that insured for a limited time period, whether in the home, an appropriate community location, or an appropriate institutional setting.

(33)(a) “Scientific evidence” means:

(i) a scientific study published or accepted by a medical journal that meets nationally recognized standards for scientific manuscripts and that submits its published articles for review by experts who are not part of the editorial staff; or

(ii) a finding, study, or research conducted by or under the auspices of a federal government agency or nationally recognized federal research institute.

(b) “Scientific evidence” does not include:

(i) published peer-reviewed literature sponsored by:

(A) a pharmaceutical manufacturing company; or

(B) a medical device manufacturer; or

(ii) a single study without other supportable studies.

(34) “Sickness” means illness, disease, or disorder of an insured.

(35) “Skilled nursing care” means nursing services provided by, or under the supervision of, a registered nurse to treat the condition for which the

confinement is required and for not providing intermediate nursing care or custodial care.

(36) “Therapist” means a professionally trained or licensed individual, such as a physical therapist, occupational therapist, or speech therapist, who is skilled in applying treatment techniques and procedures under the general direction of a physician.

(37) “Total disability” means an individual who:

(a) is not engaged in employment or occupation for which the individual is or becomes qualified, by reason of education, training, or experience; and

(b) is unable to perform each substantial and material duty of the individual’s regular occupation.

Out-of-Network Payment Issues

(38) “Usual and customary” means the most common charge for a similar service, medicine, or supply within the geographical area in which a charge is incurred, considering one or more of the following factors:

(a) the level of skill, extent of training, and experience required to perform the procedure or service;

(b) the length of time required to perform the procedure or service as compared to the length of time required to perform a similar service;

(c) the severity or nature of the illness or injury being treated;

(d) the amount charged for the same or comparable service, medicine, or supply in the geographical area or in other parts of the country;

(e) the cost to the provider of providing the service, medicine, or supply; or

(f) another factor determined by the insurer to be appropriate.

See https://adminrules.utah.gov/public/rule/R590-126/Current%20Rules