Rep. Norm Thurston — Voting Record

Bill

Number

H.B. 495 (2025GS)

Sponsor

Rep. Dunnigan, James A.

Final action

Governor Signed 3/25/2025

Outcome

Became law — signed by Gov. Spencer J. Cox

Summary

What it does

• This bill:
• amends provisions regarding the use of credit card payments to health care providers;
• amends provisions related to dental claims practices; and
• allows dentists to dispense medications under certain circumstances.

Every vote on this bill

Bill text

15
31A-26-301.6
31A-26-301.7
58-88-201
58-88-202
31A-26-301.6
31A-26-301.7
58-88-201
58-88-202
0
Health Care Amendments
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: James A. Dunnigan
Senate Sponsor: Evan J. Vickers
LONG TITLE
General Description:
This bill amends provisions related to health care practices.
Highlighted Provisions:
This bill:
amends provisions regarding the use of credit card payments to health care providers;
amends provisions related to dental claims practices; and
allows dentists to dispense medications under certain circumstances.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
31A-26-301.6
, as last amended by Laws of Utah 2024, Chapter 120
31A-26-301.7
, as enacted by Laws of Utah 2021, Chapter 288
58-88-201
, as last amended by Laws of Utah 2023, Chapter 329
58-88-202
, as last amended by Laws of Utah 2024, Chapter 210
Be it enacted by the Legislature of the state of Utah:
Section 1, Section 
31A-26-301.6
 is amended to read:
31A-26-301.6
. Health care claims practices.
(1)
As used in this section:
(a)
"Health care provider" means a person licensed to provide health care under:
(i)
Title 26B, Chapter 2, Part 2, Health Care Facility Licensing and Inspection; or
(ii)
Title 58, Occupations and Professions.
(b)
"Insurer" means an admitted or authorized insurer, as defined in Section 
31A-1-301
, 
and includes:
(i)
a health maintenance organization; and
(ii)
a third party administrator that is subject to this title, provided that nothing in this 
section may be construed as requiring a third party administrator to use its own 
funds to pay claims that have not been funded by the entity for which the third 
party administrator is paying claims.
(c)
"Provider" means a health care provider to whom an insurer is obligated to pay 
directly in connection with a claim by virtue of:
(i)
an agreement between the insurer and the provider;
(ii)
an accident and health insurance policy or contract of the insurer; or
(iii)
state or federal law.
(2)
An insurer shall timely pay every valid insurance claim submitted by a provider in 
accordance with this section.
(3)
(a)
Except as provided in Subsection (4), within 30 days of the day on which the 
insurer receives a written claim, an insurer shall:
(i)
pay the claim; or
(ii)
deny the claim and provide a written explanation for the denial.
(b)
(i)
Subject to Subsection (3)(b)(ii), the time period described in Subsection (3)(a) 
may be extended by 15 days if the insurer:
(A)
determines that the extension is necessary due to matters beyond the control 
of the insurer; and
(B)
before the end of the 30-day period described in Subsection (3)(a), notifies the 
provider and insured in writing of:
(I)
the circumstances requiring the extension of time; and
(II)
the date by which the insurer expects to pay the claim or deny the claim 
with a written explanation for the denial.
(ii)
If an extension is necessary due to a failure of the provider or insured to submit 
the information necessary to decide the claim:
(A)
the notice of extension required by this Subsection (3)(b) shall specifically 
describe the required information; and
(B)
the insurer shall give the provider or insured at least 45 days from the day on 
which the provider or insured receives the notice before the insurer denies the 
claim for failure to provide the information requested in Subsection 
(3)(b)(ii)(A).
(4)
(a)
In the case of a claim for income replacement benefits, within 45 days of the day 
on which the insurer receives a written claim, an insurer shall:
(i)
pay the claim; or
(ii)
deny the claim and provide a written explanation of the denial.
(b)
Subject to Subsections (4)(d) and (e), the time period described in Subsection (4)(a) 
may be extended for 30 days if the insurer:
(i)
determines that the extension is necessary due to matters beyond the control of the 
insurer; and
(ii)
before the expiration of the 45-day period described in Subsection (4)(a), notifies 
the insured of:
(A)
the circumstances requiring the extension of time; and
(B)
the date by which the insurer expects to pay the claim or deny the claim with a 
written explanation for the denial.
(c)
Subject to Subsections (4)(d) and (e), the time period for complying with Subsection 
(4)(a) may be extended for up to an additional 30 days from the day on which the 
30-day extension period provided in Subsection (4)(b) ends if before the day on 
which the 30-day extension period ends, the insurer:
(i)
determines that due to matters beyond the control of the insurer a decision cannot 
be rendered within the 30-day extension period; and
(ii)
notifies the insured of:
(A)
the circumstances requiring the extension; and
(B)
the date as of which the insurer expects to pay the claim or deny the claim 
with a written explanation for the denial.
(d)
A notice of extension under this Subsection (4) shall specifically explain:
(i)
the standards on which entitlement to a benefit is based; and
(ii)
the unresolved issues that prevent a decision on the claim.
(e)
If an extension allowed by Subsection (4)(b) or (c) is necessary due to a failure of the 
insured to submit the information necessary to decide the claim:
(i)
the notice of extension required by Subsection (4)(b) or (c) shall specifically 
describe the necessary information; and
(ii)
the insurer shall give the insured at least 45 days from the day on which the 
insured receives the notice before the insurer denies the claim for failure to 
provide the information requested in Subsection (4)(b) or (c).
(5)
If a period of time is extended as permitted under Subsection (3)(b), (4)(b), or (4)(c), 
due to an insured or provider failing to submit information necessary to decide a claim, 
the period for making the benefit determination shall be tolled from the date on which 
the notification of the extension is sent to the insured or provider until the date on which 
the insured or provider responds to the request for additional information.
(6)
An insurer shall pay all sums to the provider or insured that the insurer is obligated to 
pay on the claim, and provide a written explanation of the insurer's decision regarding 
any part of the claim that is denied within 20 days of receiving the information requested 
under Subsection (3)(b), (4)(b), or (4)(c).
(7)
(a)
Whenever an insurer makes a payment to a provider on any part of a claim under 
this section, the insurer shall also send to the insured an explanation of benefits paid.
(b)
Whenever an insurer denies any part of a claim under this section, the insurer shall 
also send to the insured:
(i)
a written explanation of the part of the claim that was denied; and
(ii)
notice of the adverse benefit determination review process established under 
Section 
31A-22-629
.
(c)
This Subsection (7) does not apply to a person receiving benefits under the state 
Medicaid program as defined in Section 
26B-3-101
, unless required by the 
Department of Health and Human Services or federal law.
(8)
(a)
A late fee shall be imposed on:
(i)
an insurer that fails to timely pay a claim in accordance with this section; and
(ii)
a provider that fails to timely provide information on a claim in accordance with 
this section.
(b)
The late fee described in Subsection (8)(a) shall be determined by multiplying 
together:
(i)
the total amount of the claim the insurer is obliged to pay;
(ii)
the total number of days the response or the payment is late; and
(iii)
0.033% daily interest rate.
(c)
Any late fee paid or collected under this Subsection (8) shall be separately identified 
on the documentation used by the insurer to pay the claim.
(d)
For purposes of this Subsection (8), "late fee" does not include an amount that is less 
than $1.
(9)
Each insurer shall establish a review process to resolve claims-related disputes between 
the insurer and providers.
(10)
An insurer or person representing an insurer may not engage in any unfair claim 
settlement practice with respect to a provider. Unfair claim settlement practices include:
(a)
knowingly misrepresenting a material fact or the contents of an insurance policy in 
connection with a claim;
(b)
failing to acknowledge and substantively respond within 15 days to any written 
communication from a provider relating to a pending claim;
(c)
denying or threatening to deny the payment of a claim for any reason that is not 
clearly described in the insured's policy;
(d)
failing to maintain a payment process sufficient to comply with this section;
(e)
failing to maintain claims documentation sufficient to demonstrate compliance with 
this section;
(f)
failing, upon request, to give to the provider written information regarding the 
specific rate and terms under which the provider will be paid for health care services;
(g)
failing to timely pay a valid claim in accordance with this section as a means of 
influencing, intimidating, retaliating, or gaining an advantage over the provider with 
respect to an unrelated claim, an undisputed part of a pending claim, or some other 
aspect of the contractual relationship;
(h)
failing to pay the sum when required and as required under Subsection (8) when a 
violation has occurred;
(i)
threatening to retaliate or actual retaliation against a provider for the provider 
applying this section;
(j)
any material violation of this section; and
(k)
any other unfair claim settlement practice established in rule or law.
(11)
(a)
The provisions of this section shall apply to each contract between an insurer and 
a provider for the duration of the contract.
(b)
Notwithstanding Subsection (11)(a), this section may not be the basis for a bad faith 
insurance claim.
(c)
Nothing in Subsection (11)(a) may be construed as limiting the ability of an insurer 
and a provider from including provisions in their contract that are more stringent than 
the provisions of this section.
(12)
(a)
Pursuant to Chapter 2, Part 2, Duties and Powers of Commissioner, the 
commissioner may conduct examinations to determine an insurer's level of 
compliance with this section and impose sanctions for each violation.
(b)
The commissioner may adopt rules only as necessary to implement this section.
(c)
The commissioner may establish rules to facilitate the exchange of electronic 
confirmations when claims-related information has been received.
(d)
Notwithstanding Subsection (12)(b), the commissioner may not adopt rules 
regarding the review process required by Subsection (9).
(13)
Nothing in this section may be construed as limiting the collection rights of a provider 
under Section 
31A-26-301.5
.
(14)
Nothing in this section may be construed as limiting the ability of an insurer to:
(a)
recover any amount improperly paid to a provider or an insured:
(i)
in accordance with Section 
31A-31-103
 or any other provision of state or federal 
law;
(ii)
within 24 months of the amount improperly paid for a coordination of benefits 
error;
(iii)
within 12 months of the amount improperly paid for any other reason not 
identified in Subsection (14)(a)(i) or (ii); or
(iv)
within 36 months of the amount improperly paid when the improper payment 
was due to a recovery by Medicaid, Medicare, the Children's Health Insurance 
Program, or any other state or federal health care program;
(b)
take any action against a provider that is permitted under the terms of the provider 
contract and not prohibited by this section;
(c)
report the provider to a state or federal agency with regulatory authority over the 
provider for unprofessional, unlawful, or fraudulent conduct; or
(d)
enter into a mutual agreement with a provider to resolve alleged violations of this 
section through mediation or binding arbitration.
(15)
A provider may only seek recovery from the insurer for an amount improperly paid by 
the insurer within the same time frames as Subsections (14)(a) and (b).
(16)
(a)
An insurer may offer the remittance of payment through a credit card or other 
similar arrangement.
(b)
(i)
A provider may elect not to receive remittance through a credit card or other 
similar arrangement.
(ii)
An insurer:
(A)
shall permit a provider's election described in Subsection (16)(b)(i) to apply to 
the provider's entire practice;
 and
(B)
may not require a provider's election described in Subsection (16)(b)(i) to be 
made on a patient-by-patient basis
.
; and
(C)
shall allow a provider to opt out of all credit card or other similar 
arrangements for every plan offered by the insurer through a single opt out 
process.
(iii)
If a provider elects not to receive remittance through a credit card or other 
similar arrangement, that decision remains in effect until:
(A)
the provider affirmatively elects to receive remittance through credit card or 
similar arrangement; or
(B)
a new contract is issued.
(c)
An insurer may not require a provider or insured to accept remittance through a 
credit card or other similar arrangement.
(d)
An insurer shall allow a tangible check as a form of acceptable payment.
Section 2, Section 
31A-26-301.7
 is amended to read:
31A-26-301.7
. Dental claim transparency and practices.
(1)
As used in this section:
(a)
"Bundling" means the practice of combining distinct dental procedures into one 
procedure for billing purposes.
(b)
"Dental plan" means the same as that term is defined in Section 
31A-22-646
.
(c)
"Downcoding" means the adjustment of a claim submitted to a dental plan to a less 
complex or lower cost procedure code.
(d)
"Covered services" means the same as that term is defined in Section 
31A-22-646
.
(e)
"Material change" means a change to:
(i)
a dental plan's rules, guidelines, policies, or procedures concerning payment for 
dental services;
(ii)
the general policies of the dental plan that affect a reimbursement paid to 
providers; or
(iii)
the manner by which a dental plan adjudicates and pays a claim for services.
(2)
An insurer that contracts or renews a contract with a dental provider shall:
(a)
make a copy of the insurer's current dental plan policies available online; and
(b)
if requested by a provider, send a copy of the policies to the provider through mail or 
electronic mail.
(3)
Dental policies described in Subsection 
(2)
 shall include:
(a)
a summary of all material changes made to a dental plan since the policies were last 
updated;
(b)
the downcoding and bundling policies that the insurer reasonably expects to be 
applied to the dental provider or provider's services as a matter of policy; and
(c)
a description of the dental plan's utilization review procedures, including:
(i)
a procedure for an enrollee of the dental plan to obtain review of an adverse 
determination in accordance with Section 
31A-22-629
; and
(ii)
a statement of a provider's rights and responsibilities regarding the procedures 
described in Subsection 
(3)(c)(i)
.
(4)
An insurer may not maintain a dental plan that:
(a)
based on the provider's contracted fee for covered services, uses downcoding in a 
manner that prevents a dental provider from collecting the 
contracted 
fee for the 
actual service performed from either the plan or the patient;
 or
(b)
uses bundling in a manner where a procedure code is labeled as nonbillable to the 
patient unless, under generally accepted practice standards, the procedure code is for 
a procedure that may be provided in conjunction with another procedure
.
;
(c)
does not allow a dental provider to seek payment of the contracted fee for a covered 
service from the patient when the insurer denies payment for the service, unless 
under generally accepted practice standards, the service performed should not be 
billed; or
(d)
beginning January 1, 2026, automatically recoups an overpayment unless:
(i)
the recoupment occurs more than 60 days from the day the insurer sends a notice 
of the overpayment; or
(ii)
the dental provider affirmatively elects to have recoupment occur earlier than 60 
days from the day the insurer sends a notice of the overpayment.
(5)
(a)
An insurer shall ensure that an explanation of benefits for a dental plan includes 
the reason for any downcoding or bundling result.
(b)
A dental provider who receives an overpayment from a dental plan shall return the 
amount of the overpayment through check or other means to the dental plan within 
60 days from the day the insurer sends a notice of the overpayment.
(c)
A dental provider shall make reasonable efforts to inform patients of services that 
may not be covered by the patient's dental plan if the dental provider will perform a 
service that may not be covered.
Section 3, Section 
58-88-201
 is amended to read:
58-88-201
. Definitions.
As used in this part:
(1)
(a)
"Dispense" means the delivery by a prescriber of a prescription drug or device to a 
patient, including the packaging, labeling, and security necessary to prepare and 
safeguard the drug or device for supplying to a patient.
(b)
"Dispense" does not include:
(i)
prescribing or administering a drug or device; or
(ii)
delivering to a patient a sample packaged for individual use by a licensed 
manufacturer or re-packager of a drug or device.
(2)
"Dispensing practitioner" means an individual who:
(a)
is currently licensed as:
(i)
a physician and surgeon under 
Chapter 67, Utah Medical Practice Act
;
(ii)
an osteopathic physician and surgeon under 
Chapter 68, Utah Osteopathic 
Medical Practice Act
;
(iii)
an advanced practice registered nurse under Subsection 
58-31b-301(2)(d)
;
 or
(iv)
a physician assistant under 
Chapter 70a, Utah Physician Assistant Act
;
 or
(v)
a dentist under Chapter 69, Dentist and Dental Hygienist Practice Act;
(b)
is authorized by state law to prescribe and administer drugs in the course of 
professional practice; and
(c)
practices at a licensed dispensing practice.
(3)
"Drug" means the same as that term is defined in Section 
58-17b-102
.
(4)
"Health care practice" means:
(a)
a health care facility as defined in Section 
26B-2-201
; or
(b)
the offices of one or more private prescribers, whether for individual or group 
practice.
(5)
"Licensed dispensing practice" means a health care practice that is licensed as a 
dispensing practice under Section 
58-88-202
.
Section 4, Section 
58-88-202
 is amended to read:
58-88-202
. Dispensing practice -- Drugs that may be dispensed -- Limitations 
and exceptions.
(1)
Notwithstanding Section 
58-17b-302
, a dispensing practitioner may dispense a drug at a 
licensed dispensing practice if the drug is:
(a)
packaged in a fixed quantity per package by:
(i)
the drug manufacturer;
(ii)
a pharmaceutical wholesaler or distributor; or
(iii)
a pharmacy licensed under Chapter 17b, Pharmacy Practice Act;
(b)
dispensed:
(i)
at a licensed dispensing practice at which the dispensing practitioner regularly 
practices; and
(ii)
under a prescription issued by the dispensing practitioner to the dispensing 
practitioner's patient;
(c)
except as provided in Subsection 
(6)
, 
for a condition that is not expected to last 
longer than 30 days; and
(d)
for a condition for which the patient has been evaluated by the dispensing 
practitioner on the same day on which the dispensing practitioner dispenses the drug.
(2)
A dispensing practitioner may not dispense:
(a)
a controlled substance as defined in Section 
58-37-2
;
(b)
a drug or class of drugs that is designated by the division under Subsection 
58-88-205
(2);
 or
(c)
gabapentin; or
(d)
(c)
a supply of a drug under this part that exceeds a 30-day supply.
(3)
A dispensing practitioner may not make a claim against workers' compensation or 
automobile insurance for a drug dispensed under this part for outpatient use unless the 
dispensing practitioner is contracted with a pharmacy network established by the claim 
payor.
(4)
When a dispensing practitioner dispenses a drug to the patient under this part, a 
dispensing practitioner shall:
(a)
disclose to the patient verbally and in writing that the patient is not required to fill the 
prescription through the licensed dispensing practice and that the patient has a right 
to fill the prescription through a pharmacy; and
(b)
if the patient will be responsible to pay cash for the drug, disclose:
(i)
that the patient will be responsible to pay cash for the drug; and
(ii)
the amount that the patient will be charged by the licensed dispensing practice for 
the drug.
(5)
This part does not:
(a)
require a dispensing practitioner to dispense a drug under this part;
(b)
limit a health care prescriber from dispensing under Chapter 17b, Part 8, Dispensing 
Medical Practitioner and Dispensing Medical Practitioner Clinic Pharmacy; or
(c)
apply to a physician who dispenses:
(i)
a drug sample, as defined in Section 
58-17b-102
, to a patient in accordance with 
Section 
58-1-501.3
 or Section 
58-17b-610
; or
(ii)
a drug in an emergency situation as defined by the division in rule under Chapter 
17b, Pharmacy Practice Act.
(6)
A dispensing practitioner that is a dentist may dispense prescription fluoride medication 
regardless of whether the condition the fluoride is treating will last longer than 30 days.
Section 5. 
Effective Date.
This bill takes effect on 
May 7, 2025
.
3-13-25 2:32 PM