reglab/housing_qa huggingface dataset:
ID Code § 41-5502 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 55 - IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL|Section 41-5502 - CREATION OF THE INDIVIDUAL HIGH RISK REINSURANCE POOL — BOARD.

41-5502. CREATION OF THE INDIVIDUAL HIGH RISK REINSURANCE POOL — BOARD. (1) There is hereby created an independent public body corporate and politic to be known as the Idaho individual high risk reinsurance pool. The pool will perform an essential governmental function in the exercise of powers conferred upon it in this chapter. The pool and any assessments imposed or collected pursuant to the operation of the pool shall at all times be free from taxation of every kind. (2) The pool created by this chapter and the small employer reinsurance program established in section 41-4711, Idaho Code, shall operate subject to the supervision and control of the board. The board shall consist of ten (10) members. Eight (8) members shall be appointed by the director and serve at the pleasure of the director. The director or his designated representative shall serve as an ex officio member of the board. In selecting the members of the board the director shall appoint four (4) members representing carriers, two (2) disability agents and two (2) members representing consumer interests. One (1) member shall be a member of the senate appointed by the president pro tempore of the senate and one (1) member shall be a member of the house of representatives appointed by the speaker of the house. (3) The initial nonlegislative board members shall be appointed as follows: two (2) of the members to serve a term of two (2) years; three (3) of the members to serve a term of four (4) years; and three (3) of the members to serve a term of six (6) years. Subsequent nonlegislative board members shall serve for a term of three (3) years. Legislative members of the board shall serve for a term of two (2) years. A vacancy in a legislative member’s position on the board shall be filled in the same manner as the original appointment. All other vacancies on the board shall be filled by the director. A nonlegislative board member may be removed by the director for cause.  History: [41-5502, added 2000, ch. 472, sec. 17, p. 1635.]
ID Code § 41-5503 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 55 - IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL|Section 41-5503 - PLAN OF OPERATION.

41-5503. PLAN OF OPERATION. (1) The board shall submit to the director a plan of operation and thereafter any amendments thereto necessary or suitable to assure the fair, reasonable and equitable administration of the pool. The director may, after notice and hearing, approve the plan of operation if the director determines it to be suitable to assure the fair, reasonable and equitable administration of the pool, and to provide for the sharing of pool gains or losses on an equitable and proportionate basis in accordance with the provisions of this chapter. The plan of operation shall become effective upon written approval by the director. (2) If the board fails to submit a suitable plan of operation, the director shall, after notice and hearing, adopt and promulgate a temporary plan of operation. The director shall approve the plan of operation submitted by the board, or adopt a temporary plan of operation if the board fails to submit a suitable plan. The director shall amend or rescind any plan adopted under the provisions of this section at the time a plan of operation is submitted by the board and approved by the director. (3) The plan of operation shall: (a) Establish procedures for handling and accounting of pool assets and moneys and for an annual fiscal reporting to the director; (b) Establish procedures for selecting an administrator, and setting forth the powers and duties of the administrator; (c) Establish procedures for reinsuring risks in accordance with the provisions of this chapter; (d) Establish procedures and conditions for a carrier to cede individuals with certain high risk medical conditions; (e) Define the high risk medical conditions for which carriers are allowed to cede for reinsurance; (f) Set forth the reinsurance parameters including, but not limited to, the initial level of claims for which the reinsuring carrier is responsible, the coinsurance percentage at which claims above the initial level are reinsured by the pool, and the maximum claims limit above which the pool no longer reimburses; (g) Establish procedures for collecting assessments from carriers to fund claims and administrative expenses incurred or estimated to be incurred by the pool; and (h) Provide for any additional matters necessary for the implementation and administration of the pool.  History: [41-5503, added 2000, ch. 472, sec. 17, p. 1636; am. 2017, ch. 281, sec. 2, p. 735.]
ID Code § 41-5505 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 55 - IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL|Section 41-5505 - REINSURANCE.

41-5505. REINSURANCE. (1) Any individual carrier issuing a health benefit plan shall be liable to the pool for the reinsurance premium and shall be reinsured by the pool for each eligible individual ceded in accordance with section 41-5509, Idaho Code, and the plan of operation. (2) The pool shall reimburse a reinsuring carrier with respect to the claims of a ceded eligible individual incurred during the calendar year and paid by the reinsuring carrier for benefits covered by the health benefit plan, in accordance with the reinsurance parameters set forth in the plan of operation. (a) The board may annually adjust the reinsurance parameters by submitting an amendment to the plan of operation in accordance with section 41-5503(1), Idaho Code. The adjustments may reflect increases in costs and utilization within the individual market for health benefit plans but must consider the availability of pool funding and the stability of the individual health insurance market, as well as any objectives stated in the plan of operation. (b) The board shall not submit for approval by the director a plan of operation or an amendment thereto with an initial level of less than twenty-five thousand dollars ($25,000) or a reinsuring carrier coinsurance percentage of less than twenty percent (20%). (3) A reinsuring carrier shall apply all managed care and claims handling techniques, including utilization review, individual case management, preferred provider provisions, and other managed care provisions or methods of operation consistently with respect to reinsured and nonreinsured business. (4) Each carrier shall make a filing with the director containing the carrier’s earned health insurance premium derived from health benefit plans delivered or issued for delivery in this state in the previous calendar year. (5) Each carrier shall file with the director, in a form and manner to be prescribed by the director, an annual report. The report shall state the number of resident persons insured under the carrier’s health benefit plan, or through excess or stop loss coverage. (6) Carriers shall permit individuals and their dependents covered by a high risk pool plan to remain on the high risk pool plan as long as the individual continues to meet the conditions of section 41-5501(6)(a), Idaho Code.  History: [41-5505, added 2000, ch. 472, sec. 17, p. 1637; am. 2003, ch. 267, sec. 4, p. 717; am. 2005, ch. 353, sec. 5, p. 1119; am. 2017, ch. 281, sec. 4, p. 737.]
ID Code § 41-5506 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 55 - IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL|Section 41-5506 - REINSURANCE PREMIUM RATES.

41-5506. REINSURANCE PREMIUM RATES. (1) The board, as part of the plan of operation, shall establish a methodology for determining reinsurance premium rates to be charged reinsuring carriers to reinsure individuals under this chapter. The methodology shall include a system for classification of individuals that reflects the types of case characteristics commonly used by individual carriers in the state. The methodology shall provide for the development of base reinsurance premium rates, subject to the approval of the director, which shall be set at levels which reasonably approximate gross premiums charged to individuals by individual carriers for health benefit plans. Rate adjustments under the provisions of this subsection shall not be subject to the provisions of section 41-5206, Idaho Code. (2) The board periodically shall review the methodology established under the provisions of subsection (1) of this section, including the system of classification and any rating factors, to assure that it reasonably reflects the claims experience of the pool. The board may propose changes to the methodology which shall be subject to the approval of the director. (3) The board may consider adjustments to the reinsurance premium rates charged by the pool to reflect the use of effective cost containment and managed care arrangements.  History: [41-5506, added 2000, ch. 472, sec. 17, p. 1638; am. 2017, ch. 281, sec. 5, p. 738.]
ID Code § 41-5507 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 55 - IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL|Section 41-5507 - PREMIUM RATES FOR HIGH RISK POOL PLAN COVERAGE.

41-5507. PREMIUM RATES FOR HIGH RISK POOL PLAN COVERAGE. (1) For high risk pool plans issued prior to April 1, 2017, the board shall establish premium rates for coverage under the individual basic, standard, catastrophic A, catastrophic B, and HSA compatible high risk pool plans. (2) Separate schedules of premium rates based on age, individual tobacco use, geography as defined by rule of the director, gender and benefit plan design shall apply for individual risks. (3) The board, with the assistance of the director and in accordance with appropriate actuarial principles, shall determine a standard risk rate by using the average rates that individual standard risks in this state are charged by at least five (5) of the largest health insurance carriers providing individual health insurance coverage to residents of Idaho that is substantially similar to the coverage offered by each high risk pool plan. In determining the average rate or charges of those health insurance carriers, the rates charged by those carriers shall be actuarially adjusted to determine the rate that would have been charged for benefits similar to those provided by each plan. The standard risk rates shall be established using reasonable actuarial techniques and shall reflect anticipated claims experience, expenses, and other appropriate risk factors for such coverage. (4) Rates for plan coverage shall not be less than one hundred twenty-five percent (125%) nor more than one hundred fifty percent (150%) of rates established as applicable for individual standard risks pursuant to subsection (3) of this section. (5) Carriers shall not issue high risk pool plans as defined in section 41-5501(9), Idaho Code, after April 1, 2017.  History: [41-5507, added 2000, ch. 472, sec. 17, p. 1638; am. 2005, ch. 353, sec. 6, p. 1119; am. 2017, ch. 281, sec. 6, p. 738.]
ID Code § 41-5508 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 55 - IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL|Section 41-5508 - ASSESSMENTS.

41-5508. ASSESSMENTS. (1) Prior to March 1 of each year, the board shall determine and report to the director the pool’s net loss for the previous calendar year, including administrative expenses and incurred losses for the year, taking into account investment income and other appropriate gains and losses, and any premium tax funds appropriated to the pool pursuant to section 41-406, Idaho Code. (2) Any net loss for the year may be recouped by assessments of carriers. (3) (a) For the assessment of March 1, 2001, and prior to March 1 of each succeeding year, the board shall determine and file with the director an estimate of the assessments needed to fund the losses incurred by the pool in the previous calendar year. (b) The individual assessments shall be determined by multiplying net losses, if net earnings are negative, as defined by subsection (1) of this section, by a fraction, the numerator of which shall be the carrier’s total premiums earned in the preceding calendar year from all health benefit plans and policies or certificates of insurance for specific disease, and hospital confinement indemnity in this state as reported in the carrier’s reports filed pursuant to section 41-5505(4) and (5), Idaho Code, including reinsurance by way of excess or stop loss coverage, and the denominator of which shall be the total premiums earned in the preceding calendar year from all health benefit plans and policies or certificates of insurance for specific disease and hospital confinement indemnity in this state, including reinsurance by way of excess or stop loss coverage. (4) If assessments exceed net losses of the pool, the excess shall be held at interest and used by the board to offset future losses or to reduce pool premiums. As used in this paragraph, "future losses" includes reserves for incurred but not reported claims. (5) Each carrier’s proportion of the assessment shall be determined annually by the board based on annual statements and other reports deemed necessary by the board and filed by the carriers with the director. (6) The plan of operation shall provide for the imposition of an interest penalty for late payment of assessments. (7) A carrier may seek from the director a deferment from all or part of an assessment imposed by the board. The director may defer all or part of the assessment if the director determines that the payment of the assessment would place the carrier in a financially impaired condition. If all or part of an assessment against a carrier is deferred the amount deferred shall be assessed against the other carriers in a manner consistent with the basis for assessment set forth in this section. The carrier receiving the deferment shall remain liable to the pool for the amount deferred and shall be prohibited from reinsuring any individuals with the pool until such time as it pays the assessments.  History: [41-5508, added 2000, ch. 472, sec. 17, p. 1639; am. 2017, ch. 281, sec. 7, p. 739.]
ID Code § 41-5509 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 55 - IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL|Section 41-5509 - CEDING ELIGIBILITY.

41-5509. CEDING ELIGIBILITY. (1) The pool shall provide reinsurance to any eligible individual who qualifies for reinsurance pursuant to this chapter if evidence is provided that such person has a qualifying high risk medical condition as defined by section 41-5501(8), Idaho Code. (2) Notwithstanding any other provision of this chapter, eligibility for continuation of coverage under COBRA shall not render a person ineligible for reinsurance coverage under this chapter. (3) Reinsurance through the pool shall cease: (a) On the first day of the month following the date a person is no longer a resident of this state; (b) On the date coverage under the individual health benefit plan ends; (c) Upon the death of the covered person; (d) At the option of the board, thirty (30) days after the plan makes any inquiry concerning the person’s eligibility or place of residence to which the person does not reply. (4) Reinsurance for a person who ceases to meet the eligibility requirements of this chapter may be terminated on the first day of the month following the date when the individual becomes ineligible.  History: [(41-5509) 41-5510, added 2000, ch. 472, sec. 17, p. 1640; am. 2004, ch. 285, sec. 4, p. 808; am. 2004, ch. 332, sec. 3, p. 992; am. 2005, ch. 71, sec. 1, p. 247; am. 2005, ch. 353, sec. 8, p. 1120; am. 2008, ch. 297, sec. 2, p. 832; am. and redesig. 2017, ch. 281, sec. 9, p. 740.]
ID Code § 41-5601 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 56 - PROMPT PAYMENT OF CLAIMS|Section 41-5601 - DEFINITIONS.

41-5601. DEFINITIONS. As used in this chapter: (1) "Beneficiary" means a policyholder, subscriber, member, employer or other person who is eligible for benefits under a contract providing hospital, surgical, or medical expense coverage or a managed care organization policy or agreement under which a third party payer agrees to reimburse for covered health care services rendered to beneficiaries in accordance with the benefits contract. (2) "Date of payment" means the date the payment is sent as indicated by the mail stamp on the envelope, by the insurer to the practitioner or facility or to the beneficiary in the event there is not a contract for direct payment by the insurer to the practitioner or facility, or, in the event of a wire or other electronic funds transfer, upon acceptance by the insurer’s bank of a payment order. (3) "Department" means the department of insurance. (4) "Director" means the director of the department of insurance. (5) "Electronic claim" means a claim that is transmitted through the use of electronic media, which includes the internet, extranet, leased lines, dial-up lines, private networks, and those transmissions that are physically moved from one (1) location to another using magnetic tape, disk or compact disk media. The claim shall contain the proper format and code sets in accordance with the applicable implementation specifications under 45 CFR 160 et seq., and 45 CFR 162 et seq. (6) "Insurer" means any insurer that sells hospital, medical, long-term care, or vision insurance policies or certificates and managed care organizations. For the purpose of this chapter only, "insurer" also includes a third party administrator who makes payments to beneficiaries, practitioners or facilities on behalf of an insurer and a hospital or professional service corporation that provides hospital, medical, long-term care or vision health care services. (7) "Practitioner or facility" means any physician, hospital or other person or facility licensed or otherwise authorized to furnish health care services. (8) "Receipt of claim" means the date the claim is actually received by the insurer from the practitioner or facility or the beneficiary. (9) "Submission of claim" means the date the claim is sent as indicated by the mail stamp on the envelope, by the beneficiary, practitioner or facility, to the insurer or the date an electronic claim is transmitted to an insurer.  History: [41-5601, added 2004, ch. 290, sec. 1, p. 812.]
ID Code § 41-5602 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 56 - PROMPT PAYMENT OF CLAIMS|Section 41-5602 - PROMPT PAYMENT OF CLAIMS.

41-5602. PROMPT PAYMENT OF CLAIMS. (1) Except as otherwise specifically provided in this chapter, an insurer shall process a claim for payment for health care services rendered by a practitioner or facility to a beneficiary in accordance with this section. (2) If a beneficiary, practitioner or facility submits an electronic claim to an insurer within thirty (30) days of the date on which service was delivered, an insurer shall pay or deny the claim not later than thirty (30) days after receipt of the claim. (3) If a beneficiary, practitioner or facility submits a paper claim for payment to an insurer within forty-five (45) days of the date on which service was delivered, an insurer shall pay or deny the claim not later than forty-five (45) days after receipt of the claim. (4) If an insurer denies the claim or needs additional information to process the claim, the insurer shall notify the practitioner or facility and the beneficiary in writing within thirty (30) days of receipt of an electronic claim or within forty-five (45) days of receipt of a paper claim. The notice shall state why the insurer denied the claim. (5) If the claim was denied because more information was required to process the claim, the notice shall specifically describe all information and supporting documentation needed to evaluate the claim for processing. If the practitioner or facility submits the information and documentation identified by the insurer within thirty (30) days of receipt of the written notice, the insurer shall process and pay the claim within thirty (30) days of receipt of the additional information or, if appropriate, deny the claim. (6) Any claim submitted pursuant to this chapter shall use the current procedural terminology (CPT) code in effect, as published by the American medical association, the international classification of disease (ICD) code in effect, as published by the United States department of health and human services, or the healthcare common procedural coding system (HCPCS) code in effect, as published by the United States centers for medicaid and medicare services (CMS). (7) This chapter shall not apply to claims submitted under policies or certificates of insurance for specific disease, hospital confinement indemnity, accident-only, credit, medicare supplement, disability income insurance, student health benefits only coverage issued as a supplement to liability insurance, worker’s compensation or similar insurance, automobile medical payment insurance or nonrenewable short-term coverage issued for a period of twelve (12) months or less.  History: [41-5602, added 2004, ch. 290, sec. 1, p. 813; am. 2005, ch. 66, sec. 1, p. 231.]
ID Code § 41-5603 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 56 - PROMPT PAYMENT OF CLAIMS|Section 41-5603 - INTEREST PAYMENTS.

41-5603. INTEREST PAYMENTS. An insurer that fails to pay, request additional information or documentation or deny a claim from a beneficiary, practitioner or facility within the time periods established in this chapter shall pay interest at the contract statutory rate pursuant to section 28-22-104, Idaho Code, on the unpaid amount of a claim that is determined to be due and owing. The interest shall accrue from the date payment was due, pursuant to the provisions of this chapter, until the claim is paid. Payment of any interest amount of less than four dollars ($4.00) shall not be required. Insurers may add any interest due to a future payment to the beneficiary, practitioner or facility.  History: [41-5603, added 2004, ch. 290, sec. 1, p. 814.]
ID Code § 41-5604 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 56 - PROMPT PAYMENT OF CLAIMS|Section 41-5604 - ASSIGNMENT.

41-5604. ASSIGNMENT. Nothing in this chapter requires an insurer to accept an assignment of payment by the beneficiary to the practitioner or facility.  History: [41-5604, added 2004, ch. 290, sec. 1, p. 814.]
ID Code § 41-5605 (2021)
2021 Idaho Code|Title 41 - INSURANCE|Chapter 56 - PROMPT PAYMENT OF CLAIMS|Section 41-5605 - EXCEPTIONS.

41-5605. EXCEPTIONS. (1) The time periods set forth in section 41-5602, Idaho Code, shall not apply to claims that the insurer reasonably believes involve fraud or misrepresentation by the practitioner or facility or the beneficiary or to instances where the insurer has not been provided the information necessary to evaluate the claim after notice has been given requesting additional information by the insurer as required by section 41-5602(5), Idaho Code. (2) The time periods set forth in section 41-5602, Idaho Code, shall not apply to claims that the insurer reasonably believes require medical records, including accident reports, for the purpose of investigating whether a claim is valid for subrogation, or the coordination of benefits payable by the insurer with benefits payable by another insurer or payable under federal or state law. (3) An insurer is not required to comply with the time periods set forth in section 41-5602, Idaho Code, if the insurer is in compliance with a contract with the practitioner or facility which specifies different payment requirements. Payments made within the time periods set forth in section 41-5602, Idaho Code, for the purpose of this chapter, shall be deemed to be made in a reasonable and timely manner. (4) An insurer is not required to comply with the periods set forth in section 41-5602, Idaho Code, if the fee or premium entitling a beneficiary to insurance benefits has not been paid in full. (5) An insurer is not required to comply with the time periods set forth in section 41-5602, Idaho Code, if failure to comply is due to an act of God, bankruptcy, an act of a governmental authority responding to an act of God or emergency or the result of a strike, walkout or other labor dispute, or act of terrorism.  History: [41-5605, added 2004, ch. 290, sec. 1, p. 814.]