Title 27
Insurance

Chapter 18.5
Individual Health Insurance Coverage

§ 27-18.5-11. Essential health benefits — Individual.

(a) The following words and phrases as used in this section have the following meanings consistent with federal law and regulations adopted thereunder, as long as they remain in effect. If such authorities are determined by the commissioner to no longer be in effect, the laws and regulations in effect as of the date immediately prior to their legislative repeal or their being declared invalid or nullified by final federal judicial or executive branch action, as identified by the commissioner shall govern, unless a different meaning is required by the context:

(1) “Essential health benefits” means the following general categories, and the services covered within those categories as defined pursuant to the processes described in 42 U.S.C. § 18022 and implementing regulations and guidance:

(i) Ambulatory patient services;

(ii) Emergency services;

(iii) Hospitalization;

(iv) Maternity and newborn care;

(v) Mental health and substance use disorder services, including behavioral health treatment;

(vi) Prescription drugs;

(vii) Rehabilitative and habilitative services and devices;

(viii) Laboratory services;

(ix) Preventive services, wellness services, and chronic disease management; and

(x) Pediatric services, including oral and vision care.

(2) “Preventive services” means those services described in 42 U.S.C. § 300gg-13 and implementing regulations and guidance.

(b) If any provision of the federal Patient Protection and Affordable Care Act and implementing regulations relating to coverage for essential health benefits and/or for preventive services without cost sharing are determined by the commissioner to have been repealed or to have been declared invalid or nullified by the final judgment of a federal court applicable to the state or by executive or administrative action, which shall be deemed to include an action of the federal executive or judicial branch that nullifies the effectiveness of the obligation to provide coverage without cost sharing for a meaningful range of preventive services substantially similar to those preventive services required under 42 U.S.C. § 300gg-13 as of January 1, 2023, then the following shall apply:

(1) A health insurance policy, subscriber contract, or health plan offered, issued, renewed, issued for delivery, or issued to cover a resident of this state, by a health insurance company licensed pursuant to this title and/or chapter shall provide coverage of at least the essential health benefits categories set forth in this section, and shall further provide coverage of preventive services from in-network providers without applying any copayments, deductibles, coinsurance, or other cost sharing, as described in 42 U.S.C. § 300gg-13 and related regulations and guidance, including existing exemptions, in effect as of the date immediately prior to their repeal, revocation, or nullification, as set forth above.

(2) To the extent that the U.S. Preventive Services Taskforce revises its recommendations with respect to grade “A” or “B” preventive services, or other expert advisory panel designated in 42 U.S.C. § 300gg-13 similarly provides new or revised recommendations, the office of the health insurance commissioner shall have the authority to issue guidance clarifying the services that shall qualify as preventive services under this section, consistent with said recommendations and in accordance with the processes as had been described by the version of 42 U.S.C. § 300gg-13(b) and related regulations and guidance in effect as of the date immediately prior to their repeal, revocation, or nullification, as set forth above.

(c) If a health insurance policy, subscriber contract, or health plan offered, issued, renewed, issued for delivery, or issued to cover a resident of this state, by a health insurance company licensed pursuant to this title and/or chapter, was not subject to the requirements described in subsection (b) of this section prior to their repeal, revocation, or nullification, then such policy, contract, or plan shall remain so exempt and the provisions of this section shall not apply.