See bold text below:
In addition to the definitions of Section 31A-1-301 and Subsection 31A-22-605(2), the following definitions shall apply for the purpose of this rule.
(1) “Accident,” “accidental injury,” and “accidental means” shall be defined to employ result language and shall not include words that establish an accidental means test or use words such as “external, violent, visible wounds” or similar words of description or characterization.
(a) The definition shall not be more restrictive than the following: “injury” or “injuries” means accidental bodily injury sustained by the insured person that is the direct cause of the condition for which benefits are provided, independent of disease or bodily infirmity or any other cause and that occurs while the insurance is in force.
(b) Unless otherwise prohibited by law, the definition may exclude injuries for which benefits are paid under worker’s compensation, any employer’s liability or similar law, or a motor vehicle no-fault plan.
(2) “Adult Day Care” shall mean a facility duly licensed and operating within the scope of such license. Adult Day Care facility may not be defined more restrictively than providing continuous care and supervision for three or more adults 18 years of age and over for at least four but less than 24 hours a day, that meets the needs of functionally impaired adults through a comprehensive program that provides a variety of health, social, recreational, and related support services in a protective setting.
(3) “Certificate of Completion” shall mean a document issued by the Utah Board of Education to a person who completes an approved course of study not leading to a diploma, or to one who passes a challenge for that same course of study, or to one whose out-of-state credentials and certificate are acceptable to the Board.
(4) “Complications of Pregnancy” shall mean diseases or conditions the diagnoses of which are distinct from pregnancy but are adversely affected or caused by pregnancy and not associated with a normal pregnancy.
(a) “Complications of Pregnancy” include acute nephritis, nephrosis, cardiac decompensation, ectopic pregnancy which is terminated, a spontaneous termination of pregnancy when a viable birth is not possible, puerperal infection, eclampsia, pre-eclampsia and toxemia.
(b) This definition does not include false labor, occasional spotting, doctor prescribed rest during the period of pregnancy, morning sickness, and conditions of comparable severity associated with management of a difficult pregnancy.
(5) “Conditionally Renewable” means renewal can be declined by class, by geographic area or for stated reasons other than deterioration of health.
(6) “Convalescent Nursing Home,” “extended care facility,” or “skilled nursing facility” shall mean a facility duly licensed and operating within the scope of such license.
(7) “Cosmetic Surgery” or “Reconstructive Surgery” shall mean any surgical procedure performed primarily to improve physical appearance.
(a) This definition does not include surgery, which 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.
(b) This provision does not require coverage for preexisting conditions otherwise excluded.
(8) “Custodial Care” shall mean a Plan of Care, which does not provide treatment for sickness or injury, but is only for the purpose of meeting personal needs and maintaining physical condition when there is no prospect of effecting remission or restoration of the patient to a condition in which care would not be required. Such care may be provided by persons without nursing skills or qualifications. If a nursing care facility is only providing custodial or residential care, the level of care may be so characterized.
(9) “Disability Income” shall mean income replacement as defined in Section 31A-1-301.
(10) “Elimination Period” or “Waiting Period” means the length of time an insured shall wait before benefits are paid under the policy.
(11) “Enrollment Form” shall mean application as defined in Section 31A-1-301.
(12) “Experimental Treatment” is defined as medical treatment, services, supplies, medications, drugs, or other methods of therapy or medical practices, which are not accepted as a valid course of treatment by the Utah Medical Association, the U.S. Food and Drug Administration, the American Medical Association, or the Surgeon General.
(13) “Group Supplemental Health Insurance” means group accident and health insurance policies and certificates providing hospital confinement indemnity, accident only, specified disease, specified accident or limited benefit health coverage.
(14) “Guaranteed Renewable” means renewal cannot be declined by the insurance company for any reasons, but the insurance company can revise rates on a class basis.
(15) “Home Health Agency” shall mean a public agency or private organization, or subdivision of a health care facility, licensed and operating within the scope of such license.
(16) “Home Health Aide” shall mean a person who obtains a Certificate of Completion, as required by law, which allows performance of health care and other related services under the supervision of a registered nurse from the home health agency, or performance of simple procedures as an extension of physical, speech, or occupational therapy under the supervision of licensed therapists.
(17) “Home Health Care” shall mean services provided by a home health agency.
(18) “Homemaker” shall mean a person who cares for the environment in the home through performance of duties such as housekeeping, meal planning and preparation, laundry, shopping and errands.
(19) “Homemaker/Home Health Aide” shall mean a person who has obtained a Certificate of Completion, as required by law, which allows performance of both homemaker and home health aide services, and who provides health care and other related services under the supervision of a registered nurse from the home health agency or under the supervision of licensed therapists.
(20) “Hospice” shall mean a program of care for the terminally ill and their families which occurs in a home or in a health care facility and which provides medical, palliative, psychological, spiritual, or supportive care and treatment and is licensed and operating within the scope of such license.
(21) “Hospital” means a facility that is licensed and operating within the scope of such license. This definition may not preclude the requirement of medical necessity of hospital confinement or other treatment.
(22) “Intermediate Nursing Care” shall mean nursing services provided by, or under the supervision of, a registered nurse. Such care shall be for the purpose of treating the condition for which confinement is required.
(23) “Medical Necessity” means:
(a) health care services or products that a prudent health care professional would provide to a patient for the purpose of preventing, diagnosing or treating 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) when 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.
(i) For interventions not yet in widespread use, the effectiveness shall be based on scientific evidence.
(ii) For established interventions, the effectiveness shall be based on:
(A) scientific evidence;
(B) professional standards; and
(C) expert opinion.
(24) “Medicare” means the “Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 1965 as Then Constituted or Later Amended.”
(25) “Medicare Supplement Policy” shall mean an individual, franchise, or group policy of accident and health insurance, other than a policy issued pursuant to a contract under section 1876 of the federal Social Security Act, 42 U.S.C. section 1395 et seq., or an issued policy under a demonstration project specified in 41 U.S.C. Section 1395ss(g)(1), that is advertised, marketed, or primarily designed as a supplement to reimbursements under Medicare for hospital, medical, or surgical expenses of persons eligible for Medicare.
(26) “Mental or Nervous Disorders” may not be defined more restrictively than a definition including neurosis, psychoneurosis, psychosis, or any other mental or emotional disease or disorder which does not have a demonstrable organic cause.
(27) “Non-Cancelable” means renewal cannot be declined nor can rates be revised by the insurance company.
(28) “Nurse” may be defined so that the description of nurse is restricted to a type of nurse, such as registered nurse, or licensed practical nurse. If the words “nurse” or “registered nurse” are used without specific instruction, then the use of such terms requires the insurer to recognize the services of any individual who qualifies under such terminology in accordance with applicable statutes or administrative rules.
(29) “Nurse, Licensed Practical” shall mean a person who is registered and licensed to practice as a practical nurse.
(30) “Nurse, Registered” shall mean any person who is registered and licensed to practice as a registered nurse.
(31) “Nursing Care” shall mean assistance provided for the health care needs of sick or disabled individuals, by or under the direction of licensed nursing personnel.
(32) “One Period of Confinement” shall mean 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 time of not more than 90 days or three times the maximum number of days of in-hospital coverage provided by the policy up to a maximum of 180 days.
(33) “Optionally Renewable” means renewal is at the option of the insurance company.
(34) “Partial Disability” shall be defined in relation to the individual’s inability to perform one or more, but not all, of; the major, important, or essential duties of employment or occupation; customary duties of a homemaker or dependent; or may be related to a percentage of time worked or to a specified number of hours or to compensation.
(35) “Personal Care” shall mean assistance, under a plan of care by a home health agency, provided to persons in activities of daily living.
(36) “Personal Care Aide” shall mean a person who obtains a Certificate of Completion, as required by law, which allows that person to assist in the activities of daily living and emergency first aid, and who must be supervised by a registered nurse from the home health agency.
(37) “Physician” may be defined by including words such as qualified physician or licensed physician. The use of such terms requires an insurer to recognize and to accept, to the extent of its obligation under the contract, all providers of medical care and treatment when such services are within the scope of the provider’s licensed authority and are provided pursuant to applicable laws.
(38) “Preexisting Condition.”
(a) Except as provided in Section (b), a preexisting condition shall not be defined more restrictively than the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a two year period preceding the effective date of the coverage of the insured person or a condition for which medical advice or treatment was recommended by a physician or received from a physician within a two year period preceding the effective date of the coverage of the insured person.
(b) A specified disease insurance policy shall not define preexisting condition more restrictively than a condition which first manifested itself within six months prior to the effective date of coverage or which was diagnosed by a physician at any time prior to the effective date of coverage.
(39) “Probationary Period” shall mean the period of time following the date of issuance or effective date of the policy before coverage begins for all or certain conditions.
(40) “Residential Health Care Facility” shall mean a publicly or privately operated and maintained facility providing personal care to residents who require protected living arrangements which is licensed and operating within the scope of such license.
(41) “Residual Disability” shall be defined in relation to the individual’s reduction in earnings and may be related either to the inability to perform some part of the major, important, or essential duties of employment or occupation, or to the inability to perform all usual duties for as long as is usually required.
(42) “Respite Care” shall mean provision of temporary support to the primary caregiver of the aged, disabled, or handicapped individual insured, by taking over the tasks of that person for a limited period of time. The insured may receive care in the home, or other appropriate community location, or in an appropriate institutional setting.
(43)(a) “Scientific evidence” means:
(i) scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff; or
(ii) findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes.
(b) Scientific evidence shall not include published peer-reviewed literature sponsored to a significant extent by a pharmaceutical manufacturing company or medical device manufacturer or a single study without other supportable studies.
(44) “Sickness” means illness, disease, or disorder of an insured person.
(45) “Skilled Nursing Care” shall mean nursing services provided by, or under the supervision of, a registered nurse. Such care shall be for the purpose of treating the condition for which the confinement is required and not for the purpose of providing intermediate or custodial care.
(46) “Therapist” may be defined as a professionally trained or duly licensed or registered person, 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.
(47)(a) “Total Disability” shall mean an individual who:
(i) is not engaged in employment or occupation for which he is or becomes qualified by reason of education, training or experience; and
(ii) is unable to perform all of the substantial and material duties of his or her regular occupation or words of similar import.
(b) An insurer may require care by a physician other than the insured or a member of the insured’s immediate family.
(c) The definition may not exclude benefits based on the individual’s:
(i) ability to engage in any employment or occupation for wage or profit;
(ii) inability to perform any occupation whatsoever, any occupational duty, or any and every duty of his occupation; or
(iii) inability to engage in any training or rehabilitation program.
Out-of-Network Payment Issues
(48)(a) “Usual and Customary” shall mean the most common charge for similar services, medicines or supplies within the area in which the charge is incurred.
(b) In determining whether a charge is usual and customary, insurers shall consider one or more of the following factors:
(i) the level of skill, extent of training, and experience required to perform the procedure or service;
(ii) the length of time required to perform the procedure or services as compared to the length of time required to perform other similar services;
(iii) the severity or nature of the illness or injury being treated;
(iv) the amount charged for the same or comparable services, medicines or supplies in the locality; the amount charged for the same or comparable services, medicines or supplies in other parts of the country;
(v) the cost to the provider of providing the service, medicine or supply; and
(vi) other factors determined by the insurer to be appropriate.
(49) “Waiting Period” shall mean “Elimination Period.”