26B-3-904. Program benefits.

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A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Effective 5/3/2023

(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:

(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

(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:

(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.

Renumbered and Amended by Chapter 306 , 2023 General Session