26B-3-904. Program benefits.
| (1) |
Except as provided in Subsection (3), medical and dental program benefits shall be benchmarked, in accordance with 42 U.S.C. § 1397cc, as follows:
Terms Used In Utah Code 26B-3-904- Plan: means the department's plan submitted to the United States Department of Health and Human Services pursuant to 42 U. See Utah Code 26B-3-901
- Program: means the Utah Children's Health Insurance Program created by this part. See Utah Code 26B-3-901
- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
| (a) |
medical program benefits, including behavioral health care benefits, shall be benchmarked effective July 1, 2019, and on July 1 every third year thereafter, to:
| (i) |
be substantially equal to a health benefit plan with the largest insured commercial enrollment offered by a health maintenance organization in the state; and |
| (ii) |
comply with the Mental Health Parity and Addiction Equity Act, Pub. L. No. 110-343; and |
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| (b) |
dental program benefits shall be benchmarked effective July 1, 2019, and on July 1 every third year thereafter in accordance with the Children’s Health Insurance Program Reauthorization Act of 2009, to be substantially equal to a dental benefit plan that has the largest insured, commercial, non-Medicaid enrollment of covered lives that is offered in the state, except that the utilization review mechanism for orthodontia shall be based on medical necessity. |
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| (2) |
On or before July 1 of each year, the department shall publish the benchmark for dental program benefits established under Subsection (1)(b). |
| (3) |
The program benefits:
| (a) |
for enrollees who are at or below 100% of the federal poverty level are exempt from the benchmark requirements of Subsections (1) and (2); and |
| (b) |
shall include treatment for autism spectrum disorder as defined in Section 31A-22-642, which:
| (i) |
shall include coverage for applied behavioral analysis; and |
| (ii) |
if the benchmark described in Subsection (1)(a) does not include the coverage described in this Subsection (3)(b), the department shall exclude from the benchmark described in Subsection (1)(a) for any purpose other than providing benefits under the program. |
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Renumbered and Amended by Chapter 306, 2023 General Session
