Utah Admin. Code R590-286-3 - Definitions

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

(1) "Certificate" means a short-term limited duration health insurance certificate.

(2) "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) ectopic pregnancy;

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

(vi) puerperal infection;

(vii) eclampsia;

(viii) pre-eclampsia; and

(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.

(3) "Contract" means a short-term limited duration health insurance policy or certificate.

(4) "Cosmetic surgery" or "reconstructive surgery" means a surgical procedure performed primarily to improve physical appearance.

(a) "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 a normal bodily function; or

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

(b) "Cosmetic surgery" or "reconstructive surgery" does not require coverage for a preexisting condition that is otherwise excluded.

(5) "Custodial care" means a plan of care that does not provide treatment for sickness or injury, 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.

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

(7) "Enrollment form" means an application as defined in Section 31A-1-301.

(8) "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.

(9) "Hospital" means a facility that is licensed and operating within the scope of that license.

(10)

(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 wounds, or similar words of characterization or description.

(11)

(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.

(12) "Policy" means a short-term limited duration health insurance policy.

(13) "Preexisting condition" means:

(a) the existence of a symptom or a 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 of the insured; or

(b) a condition for which medical advice or treatment was recommended or received from a health care provider within a 12-month period before the effective date of the coverage of the insured person.

(14)

(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.

(15) "Sickness" means illness, disease, or disorder of an insured person.

(16) "Usual and customary" means the most common charge for a similar service, medicine, or supply within the 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.

(17) "Waiting period" means "elimination period."

Notes

Utah Admin. Code R590-286-3

Adopted by Utah State Bulletin Number 2021-07, effective 3/11/2021 Adopted by Utah State Bulletin Number 2025-07, effective 3/24/2025