§ 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. Sec. 1397cc, as follows:

(1)(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:
(1)(a)(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
(1)(a)(ii) comply with the Mental Health Parity and Addiction Equity Act, Pub. L. No. 110-343; and
(1)(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.
(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:

(3)(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
(3)(b) shall include treatment for autism spectrum disorder as defined in Section 31A-22-642, which:
(3)(b)(i) shall include coverage for applied behavioral analysis; and
(3)(b)(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.

Legislative History

Renumbered and Amended by Chapter 306, 2023 General Session