T41CH52

Title 41 > T41CH52

Sections (12)

41-5201

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5201. Short title. This chapter shall be known and may be cited as the Individual Health Insurance Availability Act. History: [41-5201, added 1994, ch. 427, sec. 1, p. 1338.]

41-5202

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5202. Purpose. The purpose and intent of this chapter is to promote the availability of health insurance coverage to persons not covered by employment based insurance regardless of their health status or claims experience, to prevent abusive rating practices, to require disclosure of rating practices to purchasers, to establish rules regarding renewability of coverage, to establish limitations on the use of preexisting condition exclusions, and to improve the overall fairness and efficiency of the individual health insurance market. This chapter is not intended to provide a comprehensive solution to the problem of affordability of health care or health insurance. History: [41-5202, added 1994, ch. 427, sec. 1, p. 1338; am. 1997, ch. 321, sec. 19, p. 980; am. 2000, ch. 472, sec. 10, p. 1623.]

41-5203

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5203. Definitions. As used in this chapter: (1) Actuarial certification means a written statement by a member of the American academy of actuaries or other individual acceptable to the director that an individual carrier is in compliance with the provisions of section 41-5206 , Idaho Code, based upon the person’s examination and including a review of the appropriate records and the actuarial assumptions and methods used by the individual carrier in establishing premium rates for applicable health benefit plans. (2) Affiliate or affiliated means any entity or person who directly or indirectly through one (1) or more intermediaries, controls or is controlled by, or is under common control with, a specified entity or person. (3) Agent means a producer as defined in section 41-1003 (8), Idaho Code. (4) Base premium rate means, as to a rating period, the lowest premium rate charged or that could have been charged under a rating system by the individual carrier to individuals with similar case characteristics for health benefit plans with the same or similar coverage. (5) Carrier means any entity that provides health insurance in this state. For purposes of this chapter, carrier includes an insurance company, a hospital or professional service corporation, a fraternal benefit society, a health maintenance organization, any entity providing health insurance coverage or benefits to residents of this state as certificate holders under a group policy issued or delivered outside of this state, and any other entity providing a plan of health insurance or health benefits subject to state insurance regulation. (6) Case characteristics means demographic or other objective characteristics of an individual that are considered by the individual carrier in the determination of premium rates for the individual, provided that claim experience, health status and duration of coverage shall not be case characteristics for the purposes of this chapter. (7) Control shall be defined in the same manner as in section 41-3802 (2), Idaho Code. (8) Dependent in any new or renewing plan means a spouse, an unmarried child under the age of twenty-five (25) years and who receives more than one-half (1/2) of his financial support from the parent, or an unmarried child of any age who is medically certified as disabled and dependent upon the parent. (9) Director means the director of the department of insurance of the state of Idaho. (10) Eligible individual means an Idaho resident individual or dependent of an Idaho resident: (a) Who is under the age of sixty-five (65) years, is not eligible for coverage under a group health plan, part A or part B of title XVIII of the social security act (medicare), or a state plan under title XIX (medicaid) or any successor program, and who does not have other health insurance coverage; or (b) Who is a federally eligible individual (one who meets the eligibility criteria

41-5204

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5204. Applicability and scope. To the extent permitted by federal law, the provisions of this chapter shall apply to any health benefit plan delivered or issued for delivery in the state of Idaho that provides coverage to eligible individuals or their dependents if not otherwise subject to the provisions of chapter 22, 40, 47 or 55, title 41 , Idaho Code. (1) Except as provided in subsection (2) of this section, for the purposes of this chapter, carriers that are affiliated companies or that are eligible to file a consolidated tax return shall be treated as one (1) carrier and any restrictions or limitations imposed in this chapter shall apply as if all health benefit plans delivered or issued for delivery to individuals in this state by such affiliated carriers were insured by one (1) carrier. (2) An affiliated carrier that is a managed care organization having a certificate of authority pursuant to the provisions of chapter 39, title 41 , Idaho Code, may be considered to be a separate carrier for the purposes of this chapter. (3) Unless otherwise authorized by the director, an individual carrier shall not enter into one (1) or more ceding arrangements with respect to health benefit plans delivered or issued for delivery to individuals in this state if such arrangements would result in less than fifty percent (50%) of the insurance obligation or risk for such health benefit plans being retained by the ceding carrier. The provisions of sections 41-510 , 41-511 and 41-515 , Idaho Code, shall apply if an individual carrier cedes or assumes all of the insurance obligation or risk with respect to one (1) or more health benefit plans delivered or issued for delivery to individuals in this state. History: [41-5204, added 1994, ch. 427, sec. 1, p. 1340; am. 2000, ch. 472, sec. 12, p. 1626; am. 2017, ch. 76, sec. 3, p. 208.]

41-5206

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5206. Restrictions relating to premium rates. (1) Premium rates for health benefit plans subject to the provisions of this chapter shall be subject to the following provisions: (a) The premium rates charged during a rating period to individuals with similar case characteristics for the same or similar coverage, or the rates that could be charged to such individuals under the rating system, shall not vary from the index rate by more than fifty percent (50%) of the index rate. (b) The percentage increase in the premium rate charged to an individual for a new rating period may not exceed the sum of the following: (i) The percentage change in the new business premium rate measured from the first day of the prior rating period to the first day of the new rating period. In the case of a health benefit plan into which the individual carrier is no longer enrolling new individuals, the individual carrier shall use the percentage change in the base premium rate, provided that such change does not exceed, on a percentage basis, the change in the new business premium rate for the most similar health benefit plan into which the individual carrier is actively enrolling new individuals. (ii) Any adjustment, not to exceed fifteen percent (15%) annually and adjusted pro rata for rating periods of less than one (1) year, due to the claim experience, health status or duration of coverage of the individual or dependents as determined from the individual carrier’s rate manual; and (iii) Any adjustment due to change in coverage or change in the case characteristics of the individual as determined from the individual carrier’s rate manual. (c) Premium rates for health benefit plans shall comply with the requirements of this section notwithstanding any assessments paid or payable by carriers pursuant to chapter 55, title 41 , Idaho Code. (d)(i) Individual carriers shall apply rating factors, including case characteristics, consistently with respect to all individuals. Rating factors shall produce premiums for identical individuals which differ only by the amounts attributable to plan design and do not reflect differences due to the nature of the individuals assumed to select particular health benefit plans; and (ii) An individual carrier shall treat all health benefit plans issued or renewed in the same calendar month as having the same rating period. (e) For purposes of this subsection, a health benefit plan that utilizes a restricted provider network shall not be considered similar coverage to a health benefit plan that does not utilize such a network, provided that utilization of the restricted provider network results in substantial differences in claims costs. (f) The individual carrier shall not use case characteristics, other than age, individual tobacco use, geography as defined by rule of the director, or gender, without prior approval of the director. (g) An individual carrier may ut

41-5207

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5207. Renewability of coverage. (1) A health benefit plan subject to the provisions of this chapter shall be renewable with respect to the individual or dependents, at the option of the individual, except in any of the following cases: (a) Nonpayment of the required premiums; (b) Fraud or intentional misrepresentation of material fact by the individual insured or his representatives. An individual whose coverage is terminated for fraud or misrepresentation shall not be deemed to be an eligible individual for a period of twelve (12) months from the effective date of the termination of the individual’s coverage and shall not be deemed to have qualifying previous coverage under chapter 22, 47 or 52, title 41 , Idaho Code; (c) The individual ceases to be an eligible individual as defined in section 41-5203 (10), Idaho Code; (d) In the case of health benefit plans that are made available in the individual market only through one (1) or more associations, as defined in section 41-2202 , Idaho Code, the membership of an individual in the association, on the basis of which the coverage is provided ceases, but only if the coverage is terminated under this paragraph uniformly without regard to any health status-related factor relating to any covered individual; (e) The individual carrier elects, at the time of coverage renewal, to discontinue offering a particular health benefit plan delivered or issued for delivery to individuals in this state. Unless otherwise authorized in advance by the department of insurance, a carrier may discontinue a product only after the product has been in use for at least thirty-six (36) consecutive months, provided the carrier may not discontinue more than fifteen percent (15%) of its total number of individuals and dependents in all lines of business regulated by this chapter in a twelve (12) month period. The carrier shall: (i) Provide advance written or electronic notice of its decision under this paragraph to the director; (ii) Provide notice of the discontinuation to all affected individuals at least ninety (90) calendar days prior to the date the particular health benefit plan will be discontinued by the carrier, provided that notice to the director under the provisions of this paragraph shall be provided at least fourteen (14) calendar days prior to the notice to the affected individuals; (iii) Offer to each affected individual, on a guaranteed issue basis, the option to purchase all other health benefit plans currently being offered by the carrier to individuals in this state; (iv) Act uniformly without regard to any health status-related factor of an affected individual or dependent of an affected individual who may become eligible for the coverage; and (v) Offer the new products at rates that comply with section 41-5206 (1)(b), Idaho Code. (f) The individual carrier elects to nonrenew all of its health benefit plans delivered or issued for

41-5208

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5208. Availability of coverage — Preexisting conditions — Portability. (1) (a) Every individual carrier shall, as a condition of offering health benefit plans in this state to individuals, actively offer health benefit plans to individuals, including the individual basic health benefit plan, the individual standard health benefit plan, the individual catastrophic A health benefit plan, the individual catastrophic B health benefit plan and the individual HSA compatible health benefit plan. (b) An individual carrier shall issue an individual basic, standard, catastrophic A, catastrophic B or HSA compatible health benefit plan to any eligible individual that applies for such plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the health benefit plan not inconsistent with the provisions of this chapter. (2) (a) An individual carrier shall file with the director, in a format and manner prescribed by the director, the basic, standard, catastrophic, and HSA compatible health benefit plans to be used by the carrier. A health benefit plan filed pursuant to the provisions of this paragraph may be used by an individual carrier beginning thirty (30) days after it is filed unless the director disapproves its use. (b) The director at any time may, after providing notice and an opportunity for a hearing to the individual carrier, disapprove the continued use by an individual carrier of a basic, standard, catastrophic, or HSA compatible health benefit plan on the grounds that the plan does not meet the requirements of this chapter. (3) Health benefit plans covering eligible individuals shall comply with the following provisions: (a) A health benefit plan shall not deny, exclude or limit benefits for a covered individual for covered expenses incurred more than twelve (12) months following the effective date of the individual’s coverage due to a preexisting condition. A health benefit plan shall not define a preexisting condition more restrictively than: (i) A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care or treatment during the six (6) months immediately preceding the effective date of coverage; (ii) A condition for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the effective date of coverage; or (iii) A pregnancy existing on the effective date of coverage. (b) A health benefit plan shall waive any time period applicable to a preexisting condition exclusion or limitation period for the period of time an individual was previously covered by qualifying previous coverage, provided that the qualifying previous coverage was continuous to a date not more than sixty-three (63) days prior to the effective date of the new coverage. As provided in section 2741(b) of the federal health insurance portability and a

41-5209

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5209. Notice of intent to operate as a risk-assuming carrier or a reinsuring carrier. (1) (a) Each individual carrier shall notify the director within thirty (30) days of the effective date of this chapter of the carrier’s intention to operate as a risk-assuming carrier or a reinsuring carrier. An individual carrier seeking to operate as a risk-assuming carrier shall make an application pursuant to the provisions of section 41-5210 , Idaho Code. (b) The decision shall be binding for a five (5) year period except that the initial decision shall be binding for two (2) years. The director may permit a carrier to modify its decision at any time for good cause shown. (c) The director shall establish an application process for individual carriers seeking to change their status under the provisions of this subsection. (2) A reinsuring carrier that applies and is approved to operate as a risk-assuming carrier shall not be permitted to continue to reinsure any health benefit plan with the program. Such a carrier shall pay a prorated assessment based upon business issued as a reinsuring carrier for any portion of the year that the business was reinsured. History: [41-5209, added 1994, ch. 427, sec. 1, p. 1346.]

41-5210

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5210. Application to become a risk-assuming carrier. (1) An individual carrier may apply to become a risk-assuming carrier by filing an application with the director in a form and manner prescribed by the director. (2) The director shall consider the following factors in evaluating an application filed under the provisions of subsection (1) of this section: (a) The carrier’s financial condition; (b) The carrier’s history of rating and underwriting individuals; (c) The carrier’s commitment to market fairly to all individuals in the state or its established geographic service area, as applicable; (d) The carrier’s experience with managing the risk of individuals; and (e) The extent to which a carrier has and will be able to maintain reinsurance pursuant to the provisions of subsection (3) of section 41-5204 , Idaho Code. (3) The director shall provide public notice of an application by an individual carrier to be a risk-assuming carrier and shall provide at least a sixty (60) day period for public comment prior to making a decision on the application. If the application is not acted on within ninety (90) days of the receipt of the application by the director, the carrier may request a hearing. (4) The director may rescind the approval granted to a risk-assuming carrier under the provisions of this section if the director finds that: (a) The carrier’s financial condition will no longer support the assumption of risk from issuing coverage to individuals in compliance with the provisions of section 41-5208 , Idaho Code, without the protection afforded by the program; (b) The carrier has failed to market fairly to all individuals in the state or its established geographic service area, as applicable; or (c) The carrier has failed to provide coverage to eligible individuals as required in section 41-5208 , Idaho Code. History: [41-5210, added 1994, ch. 427, sec. 1, p. 1347; am. 2025, ch. 49, sec. 12, p. 253.]

41-5211

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5211. Administrative procedures. The director shall promulgate rules in accordance with the provisions of chapter 52, title 67 , Idaho Code, for the implementation and administration of the individual health coverage reform act. History: [41-5211, added 1994, ch. 427, sec. 1, p. 1347.]

41-5212

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5212. Standards to assure fair marketing. (1) Each individual carrier shall actively market health benefit plan coverage, including the individual basic, standard, catastrophic A, catastrophic B, and HSA compatible health benefit plans, to eligible individuals in the state. If an individual carrier denies coverage to an individual on the basis of the health status or claims experience of the individual or dependents, the individual carrier shall offer the individual the opportunity to purchase an individual basic, standard, catastrophic A, catastrophic B, or HSA compatible health benefit plan. (2) (a) Except as provided in subsection (2)(b) of this section, no individual carrier or agent shall, directly or indirectly, engage in the following activities: (i) Encouraging or directing individuals to refrain from filing an application for coverage with the individual carrier because of the health status, claims experience, industry, occupation or geographic location of the individual or dependents. (ii) Encouraging or directing individuals to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the individual. (b) The provisions of subsection (2)(a) of this section shall not apply with respect to information provided by an individual carrier or agent to an individual regarding the established geographic service area or a restricted network provision of an individual carrier. (3) (a) Except as provided in subsection (2)(b) of this section, no individual carrier shall, directly or indirectly, enter into any contract, agreement or arrangement with an agent that provides for or results in the compensation paid to an agent for the sale of a health benefit plan to be carried because of the health status, claims experience, industry, occupation or geographic location of the individual. (b) The provisions of paragraph (a) of this subsection shall not apply with respect to a compensation arrangement that provides compensation to an agent on the basis of percentage of premium, provided that the percentage shall not vary because of the health status, claims experience, industry, occupation or geographic area of the individual. (4) An individual carrier shall provide reasonable compensation, as provided under the plan of operation of the individual high risk reinsurance pool, to an agent, if any, for the sale of an individual basic, standard, catastrophic A, catastrophic B, or HSA compatible health benefit plan. (5) No individual carrier may terminate, fail to renew or limit its contract or agreement of representation with an agent for any reason related to the health status, claims experience, occupation or geographic location of the individuals placed by the agent with the individual carrier. (6) Denial by an individual carrier of an application for coverage from an individual shall be in writing and shall

41-5214

TITLE 41 INSURANCE CHAPTER 52 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT 41-5214. enhanced short-term PLANS. The director shall adopt reasonable rules to establish specific standards for enhanced short-term plans. The standards shall be in addition to and in accordance with applicable laws of this state, including this chapter. The standards: (1) Shall include requirements for renewability that are consistent with federal law regarding short-term, limited duration insurance; and (2) May include, but need not be limited to: (a) A scope of covered benefits, which may be as broad as the scope of covered benefits required to be included in individual health benefit plans that are not deemed short-term, limited duration insurance under federal law; (b) Restrictions on premium rate increases when an enhanced short-term plan ceases to be renewable and the individual policyholder reapplies for coverage from the same carrier; and (c) Conversion of enhanced short-term plans into fully renewable coverage upon a finding by the director that the conversion complies with law and is in the best interests of the public. History: [41-5214, added 2019, ch. 301, sec. 3, p. 897.]