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Idaho Filing Submission Documentation Form

Health Benefit Plans (Major Medical)

The following companies have met the statutory requirements to offer individual health benefit plans under Idaho Code Title 41, Chapter 52. These types of plans meet the requirements of the Affordable Care Act (ACA) for essential health benefits.

CompanyPhoneWebsite
*Blue Cross of Idaho Health Services, Inc.(888) 462-7677bcidaho.com 
*Mountain Health Co-Op(855) 447-2900mhc.coop 
*PacificSource Health Plans(855) 330-2792pacificsource.com 
*Regence BlueShield of Idaho, Inc.(800) 632-2022regence.com 
*SelectHealth, Inc.(800) 538-5038selecthealth.org 

*These companies offer plans through Idaho’s health insurance exchange, Your Health Idaho.

As defined in Idaho Code, “health benefit plan” means a hospital or medical policy or certificate. “Health benefit plan” does not include a policy or certificate for specific disease, hospital confinement indemnity, accident-only, credit, dental, vision, Medicare supplement, long-term care, disability income insurance, student health benefits-only coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, automobile medical payment insurance, or nonrenewable short-term coverage issued for a period of 12 months or less. (§ 41-5203)

The list above are for information only and should in no way be interpreted as a recommendation by the Idaho Department of Insurance.

The following companies have met the statutory requirements to offer small employer health benefit plans under Idaho Code Title 41, Chapter 47. These types of plans meet the requirements of the Affordable Care Act (ACA) for essential health benefits for small businesses.

CompanyPhoneWebsite
*Blue Cross of Idaho Health Services, Inc.(888) 462-7677bcidaho.com 
*Mountain Health Co-Op(855) 447-2900mhc.coop
*PacificSource Health Plans(855) 330-2792pacificsource.com
Regence BlueShield of Idaho, Inc.(800) 632-2022regence.com
*SelectHealth, Inc.(800) 538-5038selecthealth.org 
UnitedHealthcare(866) 452-8546uhc.com

*These companies offer plans through Idaho’s health insurance exchange, Your Health Idaho.

As defined in Idaho Code, “health benefit plan” means a hospital or medical policy or certificate. “Health benefit plan” does not include a policy or certificate for specific disease, hospital confinement indemnity, accident-only, credit, dental, vision, Medicare supplement, long-term care, disability income insurance, student health benefits-only coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, automobile medical payment insurance, or nonrenewable short-term coverage issued for a period of 12 months or less. (§ 41-4703)

The list above are for information only and should in no way be interpreted as a recommendation by the Idaho Department of Insurance.

Short-term Limited-duration Health Plans

Background: Idaho and Pre-ACA Federal Law

Idaho statute (Title 41, Chapter 22, Chapter 47 and Chapter 52) limits short-term coverage to 12 months or less in duration. The same chapters also define short-term coverage as non-renewable. Because they are non-renewable, short-term coverage does not meet the definition of a “health benefit plan” and is not subject to all of the requirements that health benefit plans must meet.

Bulletin No. 03-1, Sale of Short-Term Health Insurance Coverage, addressed the issue of renewability. The Bulletin clarified that Idaho insurance law prohibits the renewal or reissuance of short-term coverage; any renewals or reissuances of short-term coverage have the effect of causing the plan to become subject to all of Idaho’s requirements applicable to individual and small group coverage, including guaranteed renewability and prohibitions against preexisting condition exclusions.

Until late 2016, federal law and regulation also defined short-term coverage (“Short-term, limited-duration insurance” or “STLDI”) as having a duration of less than 12 months after the original effective date of the contract. Such coverage is not considered to be individual health insurance coverage and is not subject to federal provisions specific to the individual health insurance market.

Post-ACA Related Changes to Federal Law

2016: On October 31, 2016, a final rule was published that changed the federal definition of STLDI, found at 45 CFR 144.103. Such coverage was newly defined as “having an expiration date…that is less than 3 months after the original effective date of the contract.” Additionally, the updated regulation imposed a requirement for the carrier to include a disclosure, in the contract and any application materials, that short-term coverage does not constitute minimum essential coverage (MEC), and that the consumer could face a tax penalty due to the lack of MEC.

2018: On August 3, 2018, a final rule concerning STLDI was published in the Federal Register. The effective date of the final rule is October 2, 2018.

This federal rule accomplishes the following:

  • Changes the federal definition of STLDI back to the pre-2016 language to allow for coverage lasting less than 12 months, rather than less than 3 months.
  • Allows for renewals of STLDI if state law permits; if renewals are allowed, the total duration of the coverage must be no longer than 36 months.
  • Requires a written disclosure that the STLDI coverage is not considered Minimum Essential Coverage (MEC), and therefore a tax penalty could result from not having MEC in 2018.

Current Guidance for Idaho Carriers

Maximum duration of short-term coverage: The 2018 final rule states that a STLDI may provide coverage for a period of “less than 12 months” while Idaho Code considers short term plans to be a duration of “twelve (12) months or less.” See Idaho Code §§ 41-2221(2)(a), -4703(15) and -5203(12). Idaho law is preempted to the extent that the maximum term for a short term plan is “less than 12 months.” Thus short-term plans may provide coverage for a maximum period of 364 days or less than 12 months.

Prohibition of renewals: In accordance with Idaho statutes, administrative rule and bulletin, short-term coverage must NOT be renewed or reissued. A carrier cannot renew, reissue or otherwise extend short-term coverage to provide continuous coverage for 12 months or longer. Likewise, a carrier cannot issue to an individual a short-term policy with an effective date within 60 days of the termination of short-term coverage of the individual by the same carrier; such issuance is considered to be a renewal or reissuance.

Disclosure requirementsBulletin No. 03-1, citing IDAPA 18.01.30, requires that short-term policies include a nonrenewal provision of the first page of the policy, so that consumers understand that they cannot renew the policy. Short-term policies issued to Idaho consumers must also contain the required federal disclosure language, in at least 14 point type, informing consumers that these policies are not MEC. For short-term policies with an effective date prior to January 1, 2019, the required language is:

This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage. Also, this coverage is not “minimum essential coverage.” If you don’t have minimum essential coverage for any month in 2018, you may have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

For short-term policies effective January 1, 2019 or later, the federal disclosure language is as follows:

This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.

Licensing and filing requirements: Prior to offering short-term plans to Idaho residents, all carriers must be licensed for disability with the Idaho Department of Insurance. All short term insurance plans forms and rates must be filed with the Department before being offered or advertised for sale to Idahoans. View the Idaho Filing Submission Documentation Form.

Required benefits: Short-term coverage is not required to provide Essential Health Benefits, nor is it subject to any other requirements of the ACA. Short-term insurance plans must comply with all requirements applicable to major medical health insurance plans found in Title 41, Idaho Code, including (but not limited to) Chapters 18, 21, 22, 42 and 59, as well as IDAPAs 18.04.02, 18.04.03, 18.04.08, 18.04.09, except where specifically exempted from compliance.

Supplemental Benefits

In an effort to provide better service and faster review of health/disability policy filings, the Idaho Department of Insurance has prepared the following checklist and filing instructions. Idaho is a “file and use” state. This means that it is the company’s responsibility to review all statutes, rules and bulletins, which may be pertinent to its filings prior to submission of a filing. A company representative must sign the Idaho Submission Documentation Form, which certifies the filing is in compliance with all Idaho laws and administrative rules. Forms that are submitted that do not meet Idaho’s legal requirements will be disapproved and returned to the company, which results in significant delays in the filing process.

To assist companies in determining that a filing meets the requirements of Idaho’s laws and rules, the Department has created a checklist of specific legal requirements applicable to health/disability products that have been a recurring source of returned filings. Beginning October 1, 2004, the company representative certifying the filing will be expected to complete the checklist below to certify that he or she has reviewed the filing for compliance with the listed requirement. If a listed requirement is not applicable to the filing, the representative should designate by inserting “N/A” instead of an initial. After October 1, 2004, a filing will be considered incomplete without the required checklist.

Filing Requirements

  • As of April 9, 2009, there will be a $20.00 fee for each rate or form filed in excess of ten (10) per calendar year.
  • Idaho Code Section 41-1812 requires the filing of all policy forms for health insurance.
  • Each filing must include:
    (1) A cover letter describing the filing and explaining the purpose of the filing.
    (2) A detailed forms list, including the name of the form, the form number and the form number of the form the filing replaces, if applicable.
    (3) The ID-FF Certification form, signed by a company representative. Filings will be returned disapproved if the signed certification form is not included in the filing along with the initialed Individual Health/Disability and Group Supplemental Checklist.
    (4) Either a duplicate set of the forms or a copy of the cover letter to be returned to the company notifying it of the status of the filing.

Once you have reviewed the appropriate department checklist, you can download from the Department’s website the required ID-FF Certification form that must be submitted with all filings.

Health/Disability

The Health/Disability and Group Supplemental Checklist apply to individual policies and group supplemental policies providing disability coverage. Idaho Code §41-503 defines “disability insurance” as:

  1. Insurance of human beings against bodily injury, disablement, or death by accident or accidental means, or the expense thereof, or against disablement or expense resulting from sickness, and every insurance appertaining thereto. Disability insurance does not include worker’s compensation coverages; and
  2. A managed care plan for which a certificate of authority is required pursuant to chapter 39, title 41, Idaho Code.

Health/disability plans are subject to the provisions of Chapter 21 and Chapter 42, Idaho Code and IDAPA 18.04.08. If the plan is an individual health benefit plan, as defined in Title 41, Chapter 52, Idaho Code, then Chapter 52 and IDAPA 18.04.12 and 18.04.13 also apply. Title 41, Chapter 55, Idaho Code applies to Idaho individual high-risk pool contracts. Individual managed care plans are also subject to Title 41, Chapter 39, Idaho Code. If the plan is a group supplemental plan, Chapter 22, of Title 41, Idaho Code and IDAPA 18.04.08 apply. The Idaho Code and the Department’s Administrative Rules (IDAPA) can be accessed through this website under Regulation and Guidance.

Types of Contracts

IDAPA 18.04.08 defines the guidelines for the following types of contracts:

Accident Only PoliciesMajor Medical Plans
DentalDisability Income
Home Health Care OnlyIndemnity
Short Term CoveragesVision
Basic Medical Surgical Expense CoverageBasic Hospital Medical Surgical Expense
Hospital Confinement Indemnity CoverageSpecified Disease
Hospice CareNon-Cancer Coverage
Cancer Only or Combination PoliciesBasic Hospital Expense Coverage
Per Diem Cancer CoveragesLump Sum Indemnity Coverage
Specified AccidentLimited Benefit Health Coverage
Group Supplemental Plans

Association Health Plans

Additional Health Guidance

Idaho Code, Title 41*, permits an insured individual or an insured dependent with an existing “major medical” plan to request a transfer to another “major medical” plan with the same insurance carrier. This right to request a transfer applies to individual and group policies. For group policies, this right must be made available after the insured’s declination or expiration of COBRA continuation coverage, if applicable, otherwise upon termination of group coverage.

“Major medical” means policies, contracts or certificates that are issued to provide hospital and medical-surgical coverage, including Medicare supplement coverage.

When an insurance carrier receives a transfer request from an insured, the carrier must offer equal or lesser benefits than the insured has under the existing policy with the carrier. The carrier may not use underwriting criteria where coverage is denied or subject to cancellation or nonrenewal, in whole or in part, due to the insured’s:

  • Age;
  • Health;
  • Medical history;
  • Employment status; or
  • If employed, industry or job classification.

However, if the insured requests Medicare supplement benefits in excess of the insured’s current Medicare supplement policy, the carrier may use health underwriting criteria in its determination to accept the request.

“Benefits in excess of the current policy” may include, but are not limited to, lower deductibles, lower coinsurance or copayments, and lower maximum out-of-pocket limits. Excess benefits do not include the addition of pharmacy cards to replace existing prescription drug benefits, supplemental accident insurance, chiropractic services or vision services.

Insurance carriers must provide a simplified application to an insured who makes a transfer request. That application may not exceed one page in length and six medical questions.

* Idaho Code § 41-2146 for individual insurance; § 41-2220 for group insurance.

Insurance policies that provide medical expense maternity benefits for Idaho residents may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child in a manner that would conflict with the federal Newborns’ and Mothers’ Health Protection Act of 1996 (P.L. 104-204).

In general, the federal law provides that plans subject to this law may not restrict benefits for a hospital stay in connection with childbirth to less than:

  • 48 hours following a vaginal delivery; or
  • 96 hours following a delivery by cesarean section.

If the mother delivers in the hospital, the time period starts at the time of delivery. If the mother delivers outside of the hospital and is later admitted to a hospital, the time period starts at the time of admission.

If an attending provider, after speaking with the mother, determines that either the mother or newborn can be discharged before the end of the time period, the plan does not have to continue covering the stay for whichever person is eligible for discharge.

* Idaho Code §41-2140(4) for individual health plans; §41-2210(4) for group health plans; §41-3923(4) for managed care organization plans.

See Administrative Rules, IDAPA 18.04.14 Attachments:

  • Coordination of This Contract’s Benefits with Other Benefits, Appendix A
  • Consumer Explanatory Booklet, Appendix B

Rate Filing Requirements

The Idaho Department of Insurance has revised the templates of required content for the annual actuarial certifications which are required each March 15 for all small employer health insurance carriers and each September 15 for all individual health insurance carriers.The templates are also available through SERFF. The Department expects that all applicable actuarial certifications which are submitted to the Department on or after March 1, 2013 will conform to the updated template.

ACA FAQs

(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.

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.

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