Health

(7/23/2018, revised 7/19/2019) Unlike some other states, Idaho does not currently have a specific licensing requirement for ABA practitioners. As Idaho Code requires that covered health care services must be readily available and accessible, carriers must undertake reasonable efforts in good faith to contract with sufficient qualified providers to offer meaningful coverage of ABA and other ASD services. The Department will allow carriers to impose licensing/certification requirements for providers of ABA services that are no more stringent than a Board Certified Behavioral Analysis (BCBA) certification issued by the Behavioral Analyst Certification Board. Carriers must of course comply with all applicable state and federal laws and requirements related to network adequacy and provider contracting, including Idaho Code 41-3927. These requirements are subject to change for the 2020 and future plan years based on any future legislation or other factors affecting ASD services or providers.

(9/5/2018) In the group market, per Idaho Code § 41-2214, if an individual is pregnant at the time the group policy is discontinued by either the employer or the carrier, and the policy covers pregnancy, child birth or miscarriage benefits, the carrier must continue to provide such benefits for up to 12 months after the date of discontinuance. The carrier cannot require the former policyholder (the employer) or certificate holder (employee) to continue to pay premiums during the period in which the pregnant individual receives the maternity extension of benefits. The carrier can require the pregnant individual to pay cost-sharing toward any deductible or other cost-sharing requirement as such cost-sharing would have been required had the policy not been discontinued.

However, if the employer enrolls with a new carrier within 60 days of the discontinuance and the pregnant individual is eligible for that replacement group coverage, the new carrier must assume responsibility for claims related to the pregnancy.

In the individual market, per IDAPA 18.04.13.082.05, if a carrier cancels or refuses to renew a health benefit plan which covers pregnancy, child birth or miscarriage benefits, the carrier must continue to provide such benefits to an individual who is enrolled in the plan and pregnant at the time the policy would have renewed; in this context, to “cancel or refuse to renew” means the carrier discontinues offering the health plan for sale or renewal to eligible individuals. The extension of benefits as to the pregnancy must be provided as if the policy were still in force and at the same benefit levels as prior to the discontinuation. The carrier must not require or accept additional premium payments during the extension. The carrier can require the pregnant individual to pay cost-sharing toward any deductible or other cost-sharing requirement as such cost-sharing would have been required had the plan not been discontinued.

If the carrier provides automatic enrollment (e.g., enrollment occurs similarly to a renewal, upon continued payment of premium without requiring a new application) of the individual into a substantially similar health benefit plan, this requirement for pregnancy benefit extension does not apply.

(9/5/2018) In the group market, per Idaho Code § 41-2213, if an employee or dependent is totally disabled when a health insurance policy is discontinued by the employer or carrier, the group policy must continue to provide benefits related to the total disability for not less than 12 months following the discontinuation. The carrier cannot require the former policyholder (the employer) or the employee to continue to pay premiums during the extension of benefits. If the extension bridges the end of the policy’s benefit year, the carrier can require the disabled individual to pay cost-sharing toward the reset deductible or other cost-sharing requirements as such cost-sharing would have been required had the policy not been discontinued.

If the totally disabled individual elects to enroll with a new carrier, the new carrier assumes responsibility for claims other than those related to the disability, per Idaho Code § 41-2215 while the former carrier continues to be responsible for claims related to the disability until the extension period of not less than 12 months ends. Once the extension period expires, the new carrier is responsible for claims related to the total disability for employees and dependents validly insured under the prior carrier’s policy.

In the individual market, per IDAPA 18.04.13.082.04, if a policy terminates for any reason while a covered person is experiencing a continuous loss that commenced while the policy was in force, the carrier must continue to provide benefits after the termination date for covered expenses incurred during the continuous loss. Termination for this purpose includes situations in which the carrier terminates due to fraud, non-payment of premium, or withdrawal of the plan from the individual market, as well as situations in which the member terminates the policy or chooses not to renew for any reason. In the case of a retroactive termination, the policy would not be considered in force for any period after the retroactive termination date.

A continuous loss for this purpose is temporally identified as an inpatient stay plus any inpatient readmissions within 30 days of discharge. The rule also allows the extension to be “limited to the duration of the benefit period, if any,” which in context must be understood to mean that any day or visit maximums for specific covered expenses are still applicable, such as a 30-day limit for skilled nursing care after which the benefit is exhausted. The carrier must not require or accept additional premium payments during the extension, nor can the carrier reset the deductible accumulation or other cost-sharing provisions applicable to the loss if the extension bridges the benefit year of the policy.

If the individual experiencing the continuous loss enrolls with a new carrier, the former carrier continues to be responsible for claims incurred during the continuous loss as described above. The new carrier may coordinate coverage of any claims incurred during the continuous loss but after the original policy’s termination date, such as provider surgical fees or anesthesia, when such claims are billed separately from the inpatient stay.

The following examples illustrate the application of IDAPA 18.04.08:

Example A – Member A terminates her insurance policy as of June 30. On June 29th, Member A is admitted to the hospital for an otherwise covered event. Member A remains in the hospital from June 29 through July 10. The premium for the month of June was paid for the purpose of covering the risk, if any, incurred throughout the month of June. Since Member A was admitted to the hospital prior to the policy’s termination date for an event covered by the benefits stated in the policy, the carrier is obligated to cover the costs associated with Member A’s entire stay in the hospital, i.e., June 29 through July 10.

Example B – Member B pays premium for the month of September to cover the benefits defined by the policy, but terminates the policy as of September 30. Member B incurs an event that requires care at a skilled nursing facility starting September 20. The policy provides a benefit for skilled nursing, but limits the benefit to 30 days. Member B is entitled to exhaust the benefit period, i.e., 30 days, by utilizing skilled nursing from September 20 through October 20, even though the use runs past the September 30 termination date of the policy.

Example C – Member C pays premium through December, and enrolls with a new carrier as of January 1. Member C was admitted to the hospital December 29 and discharged January 5. On January 7, Member C was readmitted to the hospital for complications from the same event, and remained in the hospital through January 12. Since the readmission was within 30 days of the discharge for the first hospitalization, the former carrier is responsible for the costs of both the December 29 through January 5 inpatient stay and the January 7 through January 12 stay.

Below is sample contract language that the Department would find acceptable under and in compliance with IDAPA 18.04.13:

Extension of benefits for continuous loss. Termination of this policy will not discontinue benefits for a continuous loss covered under this policy if your continuous loss commenced while the policy was in force. The extension of benefits for your continuous loss applies to a single inpatient stay where you are admitted prior to the policy termination date and your stay extends after the policy termination date, including any inpatient readmission that occurs within 30 days of your initial discharge. The extension of benefits for your continuous loss is also subject to any quantitative benefit limitations in the policy that you have not exhausted as of the termination date, such as day or visit limitations or maximum dollar amounts allotted for benefits.

(7/15/2014) On July 8, 2014, CMS approved the small group composite premium method described below:

The Idaho specific method is equivalent to the required per-member rating methodology. The total premium is allocated back to employees based on a four-tier structure with standard tier factors, assigning any allowable tobacco use load separately to the corresponding individual. Since the Idaho-specific method was approved, carriers cannot use the federally defined method. The tiers and factors are as follows:

Employee Only = 1.0

Employee and Spouse = 2.0

Employee and Child(ren) = 1.9

Employee, Spouse and Child)ren) = 2.9