§ 31A-22-658 — Health care provider behavioral health treatment -- Single case agreement.

Utah § 31A-22-658

• Jurisdiction: Utah
• Title 31A: Insurance Code
• Ch. 31A-22: Contracts in Specific Lines
• Part 31A-22-6: Accident and Health Insurance

Text

(1) As used in this section:

(1)(a) "Mental health condition" means the same as that term is defined in Section 31A-22-649.5.
(1)(b) "Mental health provider" means:
(1)(b)(i) a mental health therapist, as defined in Section 58-60-102; or
(1)(b)(ii) an individual practicing within the scope of practice described in Title 58, Chapter 60, Part 5, Substance Use Disorder Counselor Act.
(1)(c) "Mental health treatment" means treatment for a mental health condition.
(2) (2)(a) Except as provided in Subsection (3), and subject to Subsections (4) and (5), beginning January 1, 2024, a health benefit plan that offers coverage for mental health treatment shall, upon request of a health benefit plan enrollee who is employed as a health care provider, offer a single case agreement that allows the enrollee to receive covered mental health treatment from an out-of-network mental health provider selected by the enrollee.
(2)(b) A single case agreement described in Subsection (2)(a) shall:
(2)(b)(i) reimburse the out-of-network mental health provider for the covered mental health treatment at the equivalent out-of-network rate set by the health benefit plan, subject to the member cost-sharing requirements imposed by the health benefit plan;
(2)(b)(ii) include the same coinsurance, copayments, and deductibles that would be applied for the mental health treatment if the mental health treatment was provided by a mental health provider who is a network provider;
(2)(b)(iii) include the terms that a network provider is subject to under the health benefit plan; and
(2)(b)(iv) define the length and scope of the single case agreement.
(3) (3)(a) Subsection (2) does not apply if:
(3)(a)(i) (3)(a)(i)(A) the health benefit plan has network providers for the covered mental health treatment; and
(3)(a)(i)(B) the network providers described in Subsection (3)(a)(i) do not provide the covered mental health treatment in the location where the enrollee works as a health care provider; or
(3)(a)(ii) the enrollee selects a mental health provider for the covered mental health treatment who the health benefit plan knows or reasonably suspects has committed a fraudulent insurance act as described in Section 31A-31-103.
(3)(b) For purposes of this Subsection (3), the location where an enrollee works as a health care provider includes all locations or facilities of the enrollee's employer.
(4) Mental health treatment provided pursuant to a single case agreement under this section:

(4)(a) shall be:
(4)(a)(i) within the out-of-network mental health provider's scope of practice; and
(4)(a)(ii) a service that is otherwise covered under the enrollee's health benefit plan; and
(4)(b) may not be experimental.
(5) (5)(a) An enrollee shall request a single case agreement under Subsection (2) prior to receiving mental health treatment from an out-of-network mental health provider.
(5)(b) With a request for a single case agreement under Subsection (2), an enrollee shall provide information about where the enrollee works as a health care provider sufficient for the health benefit plan to determine whether the circumstances described in Subsection (3)(a)(i) exist.

Legislative History

Enacted by Chapter 449, 2023 General Session