benefit: means the health care services to which a covered person is entitled under the terms of a health care insurance plan offered by a managed care organization. See Utah Code 31A-45-102
a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;
(ii)
a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and
(iii)
a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301
Managed care organization: means :
(a)
a managed care organization as that term is defined in Section 31A-1-301; and
Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
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)
The requirements of Subsection (2) apply to a managed care organization if the managed care organization:
(i)
restricts coverage for nonemergency services to services provided by contracted providers within the organization’s service area; and
(ii)
does not offer a benefit that permits members the option of obtaining covered services from a non-network provider.
(b)
The requirements of Subsection (2) do not apply to a managed care organization if:
(i)
the child is no longer the subject of a court or administrative support order; or
(ii)
a parent’s employer offers the parent a choice to select health insurance coverage that is not a managed care organization plan either at the time of the court or administrative support order, or at a subsequent open enrollment period. This exemption from Subsection (2) applies even if the parent ultimately chooses the managed care organization plan.
(2)
If a parent is required by a court or administrative support order to provide health insurance coverage for a child who resides outside of a managed care organization’s service area, the managed care organization shall:
(a)
comply with the provisions of Section 31A-22-610.5;
(b)
allow the enrollee parent to enroll the child on the organization plan;
(c)
pay for otherwise covered health care services rendered to the child outside of the service area by a non-network provider:
(i)
if the child, noncustodial parent, or custodial parent has complied with prior authorization or utilization review otherwise required by the organization; and
(ii)
in an amount equal to the dollar amount the organization pays under a noncapitated arrangement for comparable services to a network provider in the same class of health care providers as the provider who rendered the services; and
(d)
make payments on claims submitted in accordance with Subsection (2)(c) directly to the provider, custodial parent, the child who obtained benefits, or state Medicaid agency.
(3)
(a)
The parents of the child who is the subject of the court or administrative support order are responsible for any charges billed by the provider in excess of those paid by the organization.
(b)
This section does not affect any court or administrative order regarding the responsibilities between the parents to pay any medical expenses not covered by accident and health insurance or a managed care organization plan.
(4)
The commissioner shall adopt rules as necessary to administer this section and Section 31A-22-610.5.
