The national Medical Plans guide covers plan types, cost sharing and the ACA. This guide covers the Utah rules for health benefit plans: dependent and newborn coverage, emergency and maternity mandates, renewability, claim deadlines and coordination of benefits. Policy provisions are in the Utah Individual A&H Provisions guide. Group continuation is in the Utah Group Health guide.

Dependents (Utah Code 31A-22-610 to 31A-22-612)

• Unmarried dependents must be covered up to age 26. Coverage runs through the last day of the month in which the person stops being a dependent (31A-22-610.5).
• Newborns are covered from the moment of birth, with no preexisting-condition limit (31A-22-610). That includes congenital defects, birth abnormalities and prematurity.
  • If a specific premium is required, the child must be enrolled within 30 days of birth.
• Adopted children are covered from birth if placed within 30 days of birth. Otherwise, coverage starts from placement.
• Disabled dependents: proof may be required within 30 days of reaching the limiting age. After the following 2 years, it may be required no more than once a year (31A-22-611).
• Enrollment of a child under a court order can't be denied because the child (31A-22-610.5):
  • was born out of wedlock
  • isn't a tax dependent
  • doesn't live with the parent
  • lives outside the service area
• Spouses (31A-22-612):
  • A spouse's coverage ends only on a decree of divorce, separation or annulment.
  • A former spouse who applies and pays within 30 days after notice gets individual coverage without proof of insurability.

Required benefits

Individual market rules

• Renewal: individual health benefit plans renew at the enrollee's option, except for reasons such as nonpayment or fraud (31A-22-618.7).
  • When an insurer discontinues a plan, it gives 90 days' notice and offers its other plans on a guaranteed-issue basis.
• Individual and small-employer plans use a uniform application with no health history questions (31A-22-635).
• The health information card shows whether the plan is state-regulated (31A-22-636).
• Open enrollment outside the exchange matches the exchange's. Enrolling by December 15 starts coverage January 1 (R590-269).
• Only a licensed HMO may use the term "HMO" (31A-23a-402).

Claims (R590-192; 31A-26-301.5)

• If information is missing, the claimant gets at least 45 days to provide it.
• Insurers notify the insured of payments made to providers.
• The insured remains ultimately responsible for paying for services, except as HMO law provides.

Coordination of benefits (R590-131)

• The plan covering the person as an employee (non-dependent) pays first.
• For children, the birthday rule applies: the parent whose birthday comes earlier in the year has the primary plan.

Common exam traps

• Dependents are covered to 26. Newborns are covered from birth. Enroll within 30 days if a premium is due.
• Maternity minimums: 48 / 96 hours.
• Emergency care: no preauthorization, and in-network cost sharing.
• Post-service claims: 30 days. Pre-service claims: 15 days.
• Birthday rule: the earlier birthday in the year, not the older parent.