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SB 175

Health Insurance Revisions

2026 General Session Introduced by Karen Kwan and 1 co-sponsor

Utah SB 175 expands and standardizes autism coverage in health plans, ensuring diagnosis and evidence-based ASD treatments (including ABA) with defined providers, networks, and rev

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Bill Summary · SB 175

Summary of SB 175 (Health Insurance Revisions) — Utah, 2026 General Session

Main purpose and intent

  • Update health insurance requirements related to autism spectrum disorder (ASD) coverage.
  • Expand and standardize how autism diagnosis and treatment are covered by health benefit plans.
  • Align autism coverage with refinements to benchmark–based program benefits while ensuring ASD services are accessible, evidence-based, and adequately funded.

Key provisions and changes

  • Autism coverage within benchmarked benefits (Section 1, 26B-3-904)

    • Medical and dental program benefits must continue to be benchmarked every three years, with special ASD consideration.
    • The ASD treatment requirement remains included for program enrollees, defined in statute as autism spectrum disorder treatment, including applied behavior analysis (ABA).
    • If the benchmark plan for medical benefits does not include ASD coverage, the department must exclude ASD coverage from the benchmark solely for the purpose of providing program benefits.
    • The ASD treatment components must be provided consistent with the definition of autism spectrum disorder treatment in the amended statute.

  • Expanded and clarified ASD coverage definitions (Section 2, 31A-22-642)

    • Provides precise definitions for:
    • Autism spectrum disorder and diagnosis.
    • Autism spectrum disorder treatment, including what constitutes evidence-based care and related equipment.
    • Behavioral health treatment (including ABA), pharmacy care, psychiatric care, psychological care, and therapeutic care.
    • Qualified health care providers who can diagnose ASD and provide required treatment (e.g., physicians, advanced practice registered nurses, clinical social workers, marriage and family therapists, clinical mental health counselors, psychologists, physician assistants, and more).
    • Therapeutic care (e.g., speech, occupational, and physical therapy).
    • Establishes who is eligible to provide ASD-related services and what constitutes medically necessary assessments, evaluations, and tests.

  • Coverage requirements for ASD diagnosis and treatment (Section 2)

    • Requires health benefit plans in the individual and large group markets (entered into or renewed on/after Jan 1, 2016 through Jan 1, 2020; and after Jan 1, 2020, respectively) to provide:
    • Diagnosis of ASD and ASD treatment for individuals, in line with the statute's definitions and rules established by the commissioner.
    • The commissioner may adopt rules to set minimum standards for ASD treatment coverage.

  • Coverage levels and constraints (Section 2)

    • Rules will set duration limits, monetary limits, deductibles, copayments, and coinsurance for ASD treatment, aligned with coverage for other illnesses/diseases.
    • Behavioral health treatment for ASD must cover at least 600 hours per year, with separate rules ensuring no hourly limit for plans in the individual or large group market renewed after Jan 1, 2020.
    • Plans must include network providers for both board-certified behavior analysts (BCBA) and mental health providers qualified under the statute.
    • Other plan terms for existing coverages apply to ASD coverage; plans may apply cost-containment tools (e.g., prior authorization) as allowed, with specific exceptions noted.

  • Treatment timeline and review (Section 2)

    • Providers must submit an ASD treatment plan within 14 business days of starting treatment.
    • Insurers may review ongoing ASD treatment no more than once every three months, including goals and progress.
    • If treatment is stopped following a review, the decision can be appealed under the existing administrative-review process.

Who is affected

  • Individuals with Autism Spectrum Disorder and their families who have health insurance through Utah’s individual market or large group market, now with clarified and potentially expanded ASD coverage requirements.
  • Health plans and insurers offering medical, dental, or state-subsidized programs, which must align with the ASD coverage rules, network requirements, and rule-based standards.
  • Healthcare providers delivering ASD-related diagnosis and treatment (e.g., physicians, licensed psychologists, BCBA, speech/occupational/physical therapists, and other licensed clinicians listed as qualified providers).
  • Utah Department of Health and Human Services or Insurance Department responsible for setting rules, publishing benchmarks, and ensuring compliance.

Procedural and timeline aspects

  • Effective date: May 6, 2026.
  • The bill directs the commissioner to adopt rules under Section 63G-3 to establish minimum ASD coverage standards, including duration and cost-sharing parameters.
  • Annual benchmarking process for program benefits continues, with ASD treatment explicitly incorporated.
  • Affected plans entering into or renewing in the post-2020 markets must conform to the new ASD coverage rules, with timeline-driven compliance to 600-hour annual behavioral health treatment and related provider-network requirements.

Fiscal and administrative notes (highlights)

  • The fiscal note indicates some modest ongoing and one-time costs to the Insurance Department related to reporting and administration:
    • Ongoing expenditures of about $2,000 annually plus a one-time $700 in a given year, starting around FY 2027.
    • Potential impacts include reduced year-end transfers to the General Fund by up to $2,700 (one-time and ongoing combined) due to increased reporting requirements.
  • No direct new charges or taxes on individuals or businesses are anticipated; regulatory burden may increase modestly due to new reporting and network requirements.

Overall assessment

SB 175 modernizes and clarifies Utah’s autism insurance coverage, reinforcing access to diagnosis and a broad range of ASD treatments (including ABA) while ensuring coverage levels and provider networks are sufficient. It emphasizes evidence-based care, reasonable review processes, and parity with coverage for other illnesses, subject to regulatory standards and budget considerations. Effective mid-2026, the bill aims to improve consistency and predictability of ASD benefits for insured Utahns and streamline oversight for insurers and providers.

Compiled from official sources — confirm details with the bill’s official record.

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