reglab/statecodes huggingface dataset:
2023 Idaho Code › Title 41 - INSURANCE › Chapter 39 - MANAGED CARE REFORM › Section 41-3925 - SERVICES PROVIDED BY GOVERNMENTAL ENTITIES.

41-3925. SERVICES PROVIDED BY GOVERNMENTAL ENTITIES. (1) From and after July 1, 1990, no contract shall be issued in Idaho by an organization offering a managed care plan for which a certificate of authority is required which excludes from coverage services rendered the member while a resident in an Idaho state institution, provided the services to the member would be covered by the contract if rendered to him outside an Idaho state institution.
(2) From and after July 1, 1990, no contract issued by an organization offering a managed care plan for which a certificate of authority is required may contain any provision denying or reducing benefits otherwise provided under the policy for the reason that the person insured is receiving health or mental health care or developmental services provided by the department of health and welfare, whether or not the department of health and welfare bases its charges for such services on the recipient’s ability to pay. Provided, nothing in this section shall prevent the issuance of a contract which excludes or reduces benefits where the charge level or amount of the charge levied by a governmental entity for such services would vary or be affected in any way by the existence of coverage under the managed care plan.
History:
[(41-3925), added 1990, ch. 300, sec. 4, p. 829; am. and redesig. 1997, ch. 204, sec. 28, p. 599.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 39 - MANAGED CARE REFORM › Section 41-3926 - MAMMOGRAPHY COVERAGE.

41-3926. MAMMOGRAPHY COVERAGE. (1) From and after July 1, 1992, all policies, contracts, plans or certificates issued by an organization offering a managed care plan which provide coverage for the surgical procedure known as a mastectomy which are delivered, issued for delivery, continued or renewed in this state shall provide minimum mammography examination or equivalent examination coverage. Such coverage shall include at least the following benefits:
(a) One (1) baseline mammogram for any woman who is thirty-five (35) through thirty-nine (39) years of age.
(b) A mammogram every two (2) years for any woman who is forty (40) through forty-nine (49) years of age, or more frequently if recommended by the woman’s physician.
(c) A mammogram every year for any woman who is fifty (50) years of age or older.
(d) A mammogram for any woman desiring a mammogram for medical cause.
Such coverage shall not exceed the cost of the examination.
(2) As used in this section, "mastectomy" means the removal of all or part of the breast for medically necessary reasons as determined by a licensed physician.
(3) Nothing in this section shall apply to specified accident, specified disease, hospital indemnity, medicare supplement, long-term care or other limited benefit health insurance policies.
History:
[(41-3926), added 1992, ch. 132, sec. 4, p. 415; am. 1993, ch. 113, sec. 4, p. 290; am. and redesig. 1997, ch. 204, sec. 29, p. 599.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 39 - MANAGED CARE REFORM › Section 41-3928 - INCENTIVES TO WITHHOLD CARE PROHIBITED.

41-3928. INCENTIVES TO WITHHOLD CARE PROHIBITED. (1) No managed care organization shall offer a provider and no contract between a managed care organization and a provider shall contain any incentive plan that includes a specific payment made, in any type or form, to the provider as an inducement to deny, reduce, limit, or delay specific, medically necessary, and appropriate services covered by the health care contract and provided with respect to a specific member or group of members with similar medical conditions.
(2) Nothing in this section shall be construed to prohibit contracts that contain incentive plans that involve general payments such as capitation payments or shared risk agreements that are not tied to specific medical decisions involving specific members or groups of members with similar medical conditions.
History:
[41-3928, added 1997, ch. 204, sec. 31, p. 601.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 39 - MANAGED CARE REFORM › Section 41-3930 - UTILIZATION MANAGEMENT PROGRAM REQUIREMENTS.

41-3930. UTILIZATION MANAGEMENT PROGRAM REQUIREMENTS. (1) All managed care organizations performing utilization management or contracting with third parties for the performance of utilization management shall:
(a) Adopt utilization management criteria based on sound patient care and scientific principles developed in cooperation with licensed physicians and other providers as deemed appropriate by the managed care organization. Such criteria shall be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis;
(b) Adopt procedures for a timely review by a licensed physician, peer provider or peer review panel when a claim has been denied as not medically necessary or as experimental. The procedure shall provide for a written statement of the reasons the service was denied and transmittal of that information to the appropriate provider for inclusion in the member’s permanent medical record;
(c) Upon enrollment, require members to provide written authorization for the release of medical information to the managed care organization;
(d) Adopt procedures which protect the confidentiality of patient health records. Such procedures may permit a managed care organization to record a telephone conversation in the course of requesting patient medical information only if it complies with existing state and federal laws and the other party to the conversation is notified by voice message that he is being recorded. Upon written request and within a reasonable time, a copy of such recordings shall be provided to the other party to the conversation if the recorded conversation becomes an issue in a formal grievance procedure, and the other party agrees to reimburse the managed care organization for reasonable costs associated with providing the requested copy.
(2) If emergency services are offered, no managed care organization shall require prior authorization for emergency services. In addition, a managed care organization shall respond to member or provider requests for prior authorization of a nonemergency service within two (2) business days after complete member medical information is provided to the managed care organization unless exceptional circumstances warrant a longer period to evaluate a request. Qualified medical personnel shall be available during normal business hours for telephone responses to inquiries about medical necessity, including certification of continued length of stay.
(3) When prior approval for a covered service is required of and obtained by or on behalf of a member, the approval shall be final and may not be rescinded by the managed care organization after the covered service has been provided except in cases of fraud, misrepresentation, nonpayment of premium, exhaustion of benefits or if the member for whom the prior approval was granted is not enrolled at the time the covered service was provided.
History:
[41-3930, added 1997, ch. 204, sec. 33, p. 605.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 39 - MANAGED CARE REFORM › Section 41-3931 - PARTICIPATION IN IDAHO LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION.

41-3931. PARTICIPATION IN IDAHO LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION. (1) Each organization offering a managed care plan for which a certificate of authority is required under this chapter shall, as a condition of its authority to offer managed care plans in this state, be a member insurer of the Idaho life and health insurance guaranty association established under chapter 43, title 41, Idaho Code.
(2) The director may take such actions and promulgate such rules as may be necessary to effectuate the provisions of this section.
History:
[41-3931, added 1997, ch. 204, sec. 34, p. 606; am. 2000, ch. 371, sec. 2, p. 1225.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 39 - MANAGED CARE REFORM › Section 41-3932 - EXEMPTIONS FROM APPLICATION OF CHAPTER.

41-3932. EXEMPTIONS FROM APPLICATION OF CHAPTER. This chapter shall not apply to managed care programs operated under contract with the federal government under title XVIII of the federal social security act, as amended (medicare), or under contract with a plan otherwise exempt from operation of this chapter pursuant to the employee retirement income security act of 1974, as amended (ERISA). This chapter shall not apply to programs administered by the department of health and welfare under contract with the department of health and welfare under title XIX of the federal social security act, as amended (medicaid) or under programs administered by the department of health and welfare substance use disorder bureau or its contracted managed care organization.
History:
[41-3932, added 1997, ch. 204, sec. 35, p. 606; am. 2008, ch. 317, sec. 1, p. 879.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 39 - MANAGED CARE REFORM › Section 41-3940 - PREEXISTING CONDITIONS.

41-3940. PREEXISTING CONDITIONS. A general managed care plan shall comply with the following provisions:
(1) A general managed care 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 general managed care plan shall not define a preexisting condition more restrictively than a condition, whether physical or mental, regardless of the cause of the 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.
(2) Genetic information shall not be considered as a condition described in subsection (1) of this section in the absence of a diagnosis of the condition related to such information.
(3) A managed care organization that does not use preexisting condition limitations in any of its general managed care plans may impose an affiliation period. "Affiliation period" means a period of time not to exceed sixty (60) days for new entrants and not to exceed ninety (90) days for late enrollees during which no premiums shall be collected and coverage issued shall not become effective. Such period shall begin on the enrollment date. This subsection does not preclude application of any waiting period applicable to all new enrollees under the general managed care plan, provided that any carrier-imposed waiting period is no longer than sixty (60) days and is used in lieu of a preexisting condition exclusion. An affiliation period under a plan shall run concurrently with any waiting period under the plan.
History:
[41-3940, added 1997, ch. 321, sec. 6, p. 957.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4001 - DECLARATION OF PURPOSE.

41-4001. DECLARATION OF PURPOSE. (1) The purpose of this chapter is to recognize and provide reasonable supervision of self-funded or partially self-funded plans for provision of health care service benefits to employees or to students of a postsecondary educational institution in connection with or as an alternative to insurance and other prepayment plans, to provide standards for financial soundness of such plans, to protect the interests of employees or students covered thereby and to provide for the establishment of financially viable alternatives to traditional health care plans. The legislature of the state of Idaho declares that the existence and operation of such self-funded plans are matters of legislative concern, vitally affecting the rights and interests of the citizens of this state.
(2) The provisions of this chapter shall apply to any single employer or multiple employer plan or any postsecondary educational institution that provides a fully or partially self-funded health benefit plan for beneficiaries residing in this state to the extent that state regulation of such plan is not preempted by the employee retirement income security act of 1974, as amended.
History:
[41-4001, added 1974, ch. 248, sec. 1, p. 1624; am. 2006, ch. 414, sec. 1, p. 1257; am. 2013, ch. 181, sec. 1, p. 419.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4006 - GRANT OR DENIAL OF REGISTRATION.

41-4006. GRANT OR DENIAL OF REGISTRATION. (1) The director shall act upon an application for registration of a self-funded plan with all reasonable promptness, but not more than ninety (90) days from the date of submission of a complete application to the director. Failure to act within the ninety (90) day time period shall be deemed as registration of such self-funded plan by the director.
(2) The director may make such investigation of the application for registration as he deems advisable. If the director finds that the application is complete and that the plan meets the qualifications stated in sections 41-4004 and 41-4005, Idaho Code, and is otherwise consistent with the provisions of this chapter, he shall issue and deliver a certificate of registration in appropriate form to the applicant.
(3) In the event the director denies an applicant’s application for registration, the director shall notify the applicant in writing of the basis for the denial. Within twenty-one (21) days of the issuance of the notice of denial, the applicant may submit to the director a written request for a hearing before the director or his duly appointed representative addressing the basis for the denial of the application and requesting that the director reexamine the applicant’s qualifications for registration. An applicant’s failure to request a hearing in writing within twenty-one (21) days of the issuance of the notice of denial shall be deemed a waiver of the opportunity for hearing.
History:
[41-4006, added 1974, ch. 248, sec. 6, p. 1624; am. 2006, ch. 414, sec. 6, p. 1262; am. 2013, ch. 181, sec. 6, p. 425.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4007 - TRUST FUND — AUTHORITY.

41-4007. TRUST FUND — AUTHORITY. The trust fund of a self-funded plan shall have the authority:
(1) To have and use an appropriate descriptive name;
(2) To sue and be sued in its own name;
(3) To contract in its own name. All such contracts shall be in writing and shall be signed by the trustee of the fund, and if there is more than one (1) trustee, the contract may be so executed by one (1) trustee if so authorized by all trustees;
(4) To borrow money and give security therefor; and
(5) To engage exclusively in transactions authorized or required by this chapter, or reasonably incidental thereto.
History:
[41-4007, added 1974, ch. 248, sec. 7, p. 1624; am. 2006, ch. 414, sec. 7, p. 1262; am. 2013, ch. 181, sec. 7, p. 425.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4008 - TRUST FUND LIABILITY — FIDUCIARY FUNDS.

41-4008. TRUST FUND LIABILITY — FIDUCIARY FUNDS. (1) The trust fund of a self-funded plan shall be legally liable for payment of all applicable benefits stated in the schedule of benefits for such plan in effect at the time a claim thereunder arises.
(2) Funds in the trust fund are fiduciary funds, and are not liable to any obligation of any plan sponsor, including any employer participant or postsecondary educational institution, nor are fiduciary funds held in the trust subject to garnishment or levy. The prohibition on garnishment or levy shall not be deemed to prohibit levy upon the trust fund by any provider thereof (or its assignee) for health care services rendered to a beneficiary.
(3) All funds and moneys received by the self-funded plan and all funds billed and paid as contributions to the trust fund shall be timely deposited in the trust account and shall be held in no other name than the name of the self-funded plan.
History:
[41-4008, added 1974, ch. 248, sec. 8, p. 1624; am. 2013, ch. 181, sec. 8, p. 426.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4009 - INVESTMENT OF TRUST FUND.

41-4009. INVESTMENT OF TRUST FUND. (1) The trustee may invest trust funds available for that purpose in the following kinds of investments only:
(a) General obligations of the United States government, or of any state, district, commonwealth, or territory of the United States, or of any municipality, county, or other political subdivision or agency thereof.
(b) Obligations, including the payment of principal and interest thereon of which are guaranteed by any such government or agency.
(c) Corporate bonds and similar obligations meeting the requirements specified for investment of funds of insurers under section 41-711, Idaho Code.
(d) Collateral loans, including payment of principal and interest of which are adequately secured by securities in which the trust fund could lawfully invest directly.
(e) Deposits, savings accounts, and share accounts in chartered banks and savings and loan associations located in the United States. An investment in any one (1) such institution may not be in excess of the amount covered by applicable deposit, savings, and share account insurance, unless otherwise authorized by the director.
(f) Investments as permitted by sections 41-714 and 41-716, Idaho Code, provided that the combined amount of such investments shall not exceed ten percent (10%) of the total assets of the trust fund.
(2) In addition to investments excluded under subsection (1) of this section, the trustee is expressly prohibited from investing trust fund moneys in:
(a) Any loan to or security of any plan sponsor including any employer or postsecondary educational institution participating in the plan, or to or of any trustee, officer, director, subsidiary or affiliate of any such plan sponsor, employer or postsecondary educational institution.
(b) The security of any person in which the trustee, administrator, or any consultant of the plan has a direct or indirect material pecuniary interest.
(c) Real property or loans thereon.
(d) Any personal loan.
(3) All such investments shall be made and held in the name of the trust fund, and the interest and yield thereon shall inure to the benefit of the trust fund.
(4) No investment shall be made by or on behalf of the trust fund unless authorized in writing by the trustee and included in the records of the trust fund.
(5) Any person who authorizes any investment of trust fund moneys in violation of this section shall, in addition to other penalties that may be applicable therefor, be liable for all loss suffered by the trust fund on account of the investment.
(6) No investment made in violation of this section shall constitute an "asset" in any determination of the financial condition of the trust fund.
History:
[41-4009, added 1974, ch. 248, sec. 9, p. 1624; am. 2006, ch. 414, sec. 8, p. 1263; am. 2013, ch. 181, sec. 9, p. 426.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4012 - TAXES.

41-4012. TAXES. (1) Each self-funded plan required to be registered under this chapter is subject to the tax as provided in this section. Each registered self-funded plan, and each formerly registered plan with respect to beneficiaries in this state while so registered, shall simultaneously with the filing of its annual statement with the director, pay to the director a tax computed at the rate of four cents (4¢) per month per beneficiary covered by the plan during the fiscal year of the annual statement with respect to all beneficiaries working or resident in this state. Any plans operating in Idaho without proper registration shall be subject to back taxes for all years the plan was in operation plus all other sanctions authorized by law.
(2) All excise, privilege, franchise, income, license and similar taxes, licenses and fees are hereby preempted from imposition upon self-funded plans and on the intangible property of their trust funds; and no county, city, municipality, district, school district, or other political subdivision or agency of Idaho shall levy upon such plans or trust funds any such tax, license or fee additional to those set forth in this chapter.
(3) The tax imposed on self-funded plans in subsection (1) of this section, together with the fees imposed on such plans as set forth in this chapter, shall be in lieu of any and all income taxes and other excise taxes, licenses and fees payable to the state of Idaho. No self-funded plan shall be required to file any tax returns or comply with any provisions governing such income taxes and other excise taxes, licenses and fees payable to the state of Idaho.
(4) The director shall promptly remit all such tax payments received by him pursuant to this section to the state treasurer for credit to the state general fund.
History:
[41-4012, added 1974, ch. 248, sec. 12, p. 1624; am. 1982, ch. 252, sec. 3, p. 645; am. 2006, ch. 414, sec. 11, p. 1265; am. 2013, ch. 181, sec. 12, p. 429.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4013 - EXAMINATION OF BOOKS, RECORDS AND ACCOUNTS.

41-4013. EXAMINATION OF BOOKS, RECORDS AND ACCOUNTS. (1) The books, records, accounts and affairs of a self-funded plan shall be subject to examination by the director, by qualified examiners duly authorized by him in writing, at such times or intervals as the director deems appropriate. The purposes of the examination shall be to determine compliance of the plan with applicable laws, the plan’s financial condition, the adequacy of the plan’s trust fund, the treatment accorded by the plan to its beneficiaries and any other factors deemed materially relevant by the director to the plan’s management and operation.
(2) The trustee shall promptly make the books, records and accounts of the plan and trust fund available to the department’s examiner in Idaho and otherwise facilitate the examination.
(3) The examiner shall conduct the examination expeditiously, prepare the report of the examination in writing, and deliver a copy thereof to the trustee and the director as soon as practicable. The trustee shall have no longer than four (4) weeks after receipt of the report within which to recommend to the director such corrections or changes therein as the trustee may deem appropriate. After making such corrections or changes, if any, as he deems appropriate, the director shall file the report in his office as a document open to public inspection, and deliver to the trustee a copy of the report, including any modifications made to the examiner’s original report as submitted to the director.
(4) At the direction of the director, the costs of the examination shall be borne by the trust fund of the plan, and shall be paid by the trustee in accordance with section 41-228, Idaho Code.
History:
[41-4013, added 1974, ch. 248, sec. 13, p. 1624; am. 2001, ch. 85, sec. 12, p. 219; am. 2006, ch. 414, sec. 12, p. 1265; am. 2013, ch. 181, sec. 13, p. 429.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4014 - TRUSTEES — ADMINISTRATORS — BONDING.

41-4014. TRUSTEES — ADMINISTRATORS — BONDING. (1) Either an individual or a corporation or other legal entity may be a trustee of the trust fund. Any person acting as a trustee is a fiduciary acting on behalf of the beneficiaries of the plan and the trust fund in such capacity. An individual, firm, corporation or other legal entity may be an administrator of a plan.
(2) An employer participant in the plan shall be neither a trustee nor the administrator. A postsecondary educational institution as a plan sponsor of a self-funded plan shall be neither a trustee nor an administrator of such plan. However, this subsection shall not prohibit an individual who is otherwise an employee of such an employer or a postsecondary educational institution from being trustee or administrator.
(3) The trustee shall obtain a fidelity bond, or coverage deemed by the director to be equivalent to a fidelity bond, in the name of the self-funded plan, the purpose of which is to protect against acts of fraud and dishonesty by the plan’s trustees, directors, officers and employees in connection with the trust fund or plan. Such bond shall be in an amount equal to the greater of ten percent (10%) of the contributions received by the plan or ten percent (10%) of the benefits paid during the preceding calendar year. If the plan was not in operation during the preceding calendar year, the bond shall be in an amount equal to ten percent (10%) of the contributions projected to be received by the plan during its first year of operation. The amount of any bond required under this section shall be not less than twenty-five thousand dollars ($25,000) or more than five hundred thousand dollars ($500,000).
(4) Any administrator that is retained by a self-funded plan must be licensed and bonded as an administrator pursuant to chapter 9, title 41, Idaho Code.
History:
[41-4014, added 1974, ch. 248, sec. 14, p. 1624; am. 2006, ch. 414, sec. 13, p. 1266; am. 2013, ch. 181, sec. 14, p. 430.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4015 - PROHIBITED PECUNIARY INTERESTS IN PLAN MANAGEMENT.

41-4015. PROHIBITED PECUNIARY INTERESTS IN PLAN MANAGEMENT. (1) No plan sponsor, trustee, administrator, or other person having responsibility for the management of a self-funded plan or the investment or other handling of trust funds shall:
(a) Receive directly or indirectly or have a pecuniary interest, either directly or indirectly, in any fee, commission, compensation, or emolument, other than salary or other similar compensation regularly fixed and authorized for services duly rendered to the plan, arising out of any transaction to which the trust fund is or may become a party.
(b) Receive compensation as a consultant to the plan while also acting as a trustee or administrator, or as an employee of either the trust fund or the plan.
(c) Have any direct or indirect material pecuniary interest in any loan or investment related to the trust fund.
(2) No consultant to the plan or trust fund shall directly or indirectly receive or have a pecuniary interest, either directly or indirectly, in any commission or other compensation arising out of any contract or transaction between the plan or trust fund and any insurer, health care service corporation, health maintenance organization or other provider of health care services or of drugs or other health care needs and supplies.
(3) The director may, after reasonable notice and the opportunity for a hearing, require removal of a trustee or prohibit the trustee from employing or retaining or continuing to employ or retain any person in the administration of the trust fund or plan, upon finding that continuation of the trustee or such employment or retention involves a conflict of interest or an interest with the potential to adversely affect plan beneficiaries.
History:
[41-4015, added 1974, ch. 248, sec. 15, p. 1624; am. 2006, ch. 414, sec. 14, p. 1266; am. 2013, ch. 181, sec. 15, p. 431.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4016 - POLITICAL CONTRIBUTIONS PROHIBITED.

41-4016. POLITICAL CONTRIBUTIONS PROHIBITED. No trustee shall make or knowingly permit the making, directly or indirectly, of any political contribution by or from any self-funded plan trust fund.
History:
[41-4016, added 1974, ch. 248, sec. 16, p. 1624.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4017 - RECOVERY OF DEPLETED FUNDS.

41-4017. RECOVERY OF DEPLETED FUNDS. If after notice and the opportunity for a hearing the director finds that any self-funded plan trust fund has been depleted by reason of any wrongful or negligent act or omission of a trustee or any other person, he shall transmit a copy of his findings to the attorney general of this state, who may bring an action in the name of the people of this state, or intervene in any action brought by or on behalf of an employer or beneficiary, for the recovery of the amount of such depletion, for the benefit of the trust fund, and to impose any sanctions as authorized by law.
History:
[41-4017, added 1974, ch. 248, sec. 17, p. 1624; am. 2013, ch. 181, sec. 16, p. 431.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4018 - TERMINATION OF REGISTRATION.

41-4018. TERMINATION OF REGISTRATION. (1) The director shall terminate the registration of a self-funded plan upon written request of the trustee, or if he finds, after an inquiry or an examination, that the trust fund is insolvent. For the purposes of this chapter, "insolvent" means the plan is unable to pay its obligations when they are due or that its assets do not exceed its liabilities. As used in this chapter, "assets" means all investments held in the name of the trust as permitted by section 41-4009, Idaho Code.
(2) The director may terminate the registration of a plan for violation of this chapter, or failure of the trustee to timely file with the director the annual statement or actuarial opinion and timely pay the tax required under sections 41-4011 and 41-4012, Idaho Code, or if he finds, after an inquiry or an examination of the trust fund and the plan or notice from the trustee:
(a) That the plan no longer meets the qualifications required by sections 41-4004 and 41-4005, Idaho Code, and that such deficiency will not or cannot be remedied within a reasonable time;
(b) That there is a pattern of benefits promised by the plan that are not being fairly and promptly paid;
(c) That the cost of administering the plan is excessive in relation to the character and volume of service being rendered in the administration;
(d) That the trust fund has been subject to fraudulent, incompetent or dishonest practices on the part of the trustee, administrator, consultant, any participating employer, any postsecondary educational institution, beneficiaries or others; or
(e) That the trust fund does not meet the minimum surplus requirements under this chapter.
(3) The director shall terminate the plan’s registration by his written order provided to the trustee last of record with the department and to each employer or postsecondary educational institution last of record with the department. Such order shall state the grounds upon which it is based and its effective date. The order shall be subject to judicial review in the same manner as applies to official orders of the director in general.
History:
[41-4018, added 1974, ch. 248, sec. 18, p. 1624; am. 2006, ch. 414, sec. 15, p. 1267; am. 2013, ch. 181, sec. 17, p. 431.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4019 - LIQUIDATION OF TRUST FUND.

41-4019. LIQUIDATION OF TRUST FUND. (1) Upon termination of registration of the plan, the trust fund of a self-funded plan shall be liquidated as soon as practicable.
(2) Liquidation of a solvent self-funded plan shall be conducted by its trustee under a plan of liquidation in writing filed with and approved by the director as fair and equitable to all persons having a pecuniary interest in the trust fund. Any balance remaining after payment or adequate provision for all claims and charges against the trust fund shall be disposed of in such manner as is provided for in the plan of liquidation. Unless the plan of liquidation provides that liability for all unpaid claims and obligations of the trust fund has been unconditionally assumed by other financially responsible person or persons and the third party contract has been submitted to the department for its review, the existence of surplus funds for such disposition shall not be determined prior to expiration of two (2) years after termination of the registration.
(3) The liquidation of an insolvent self-funded plan shall be carried out by the director in accordance with chapter 33, title 41, Idaho Code (rehabilitation and liquidation). For this purpose, the self-funded plan shall be deemed to be an insolvent domestic insurer and subject to all statutes and rules applicable to the same.
History:
[41-4019, added 1974, ch. 248, sec. 19, p. 1624; am. 2006, ch. 414, sec. 16, p. 1268; am. 2013, ch. 181, sec. 18, p. 432.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4020 - RULES.

41-4020. RULES. (1) The director may promulgate reasonable rules necessary for or as an aid to effectuation of any provision of this chapter. No such rule shall extend, modify, or conflict with any provision of this chapter and the reasonable implications thereof.
(2) Such rules, or any amendment thereof, shall be made by the director in accordance with chapter 52, title 67, Idaho Code.
History:
[41-4020, added 1974, ch. 248, sec. 20, p. 1624; am. 2006, ch. 414, sec. 17, p. 1268; am. 2013, ch. 181, sec. 19, p. 432.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4021 - OTHER PROVISIONS APPLICABLE.

41-4021. OTHER PROVISIONS APPLICABLE. Chapter 2, title 41, Idaho Code, (the director of the department of insurance), chapter 9, title 41, Idaho Code, (insurance administrators), chapter 13, title 41, Idaho Code, (trade practices and frauds), chapter 56, title 41, Idaho Code, (prompt payment of claims), chapter 59, title 41, Idaho Code, (external review), section 41-1845, Idaho Code, (recreational-related activities), sections 41-2141 and 41-2216, Idaho Code, (coordination with social security benefits), and section 41-2841, Idaho Code, (borrowed surplus), to the extent applicable and not in conflict with the express provisions of this chapter, shall also apply with respect to self-funded plans, and for the purpose such plans shall be deemed to be "insurers."
History:
[41-4021, added 1974, ch. 248, sec. 21, p. 1624; am. 1978, ch. 10, sec. 6, p. 22; am. 2006, ch. 414, sec. 18, p. 1269; am. 2013, ch. 181, sec. 20, p. 433.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4022 - PENALTIES.

41-4022. PENALTIES. (1) Any person who violates or causes or induces violation of any provision of this chapter, or any lawful rule of the director issued thereunder, shall be subject to an administrative penalty for each violation of not more than one thousand dollars ($1,000) for an individual and not more than five thousand dollars ($5,000) for any entity for each violation.
(2) Any person who makes a false statement or representation of a material fact, knowing it to be false, or who knowingly fails to disclose a material fact in any application, examination or statement relating to self-funded plans, trust accounts, administration of a plan or any matter materially related thereto, shall be subject to penalty as provided in subsection (4) of this section.
(3) Any person who makes a false entry in any book, record, statement, or report required by this chapter or any rule of the director promulgated thereunder, with intent to injure or defraud the trust fund or any beneficiary thereunder, or to deceive anyone authorized or entitled to examine the affairs of the plan, shall be subject to penalty as provided in subsection (4) of this section.
(4) For each such violation, act or omission referred to in subsections (2) and (3) of this section, unless greater penalty is provided therefor under any other applicable law, the offender shall upon conviction thereof be subject to a fine of not more than fifteen thousand dollars ($15,000) and to imprisonment for not more than fifteen (15) years, or to both such fine and imprisonment.
(5) Further, the director may in his discretion:
(a) Order the person to cease and desist from the violation of such provision;
(b) Issue an order revoking or suspending the registration of the plan that engaged in such violation;
(c) Bring an action in the fourth district court in and for Ada county or in such other court as the director deems appropriate to seek appropriate injunctive relief and impose a civil penalty not to exceed five thousand dollars ($5,000) for each violation.
History:
[41-4022, added 1974, ch. 248, sec. 22, p. 1624; am. 2006, ch. 414, sec. 19, p. 1269; am. 2013, ch. 181, sec. 21, p. 433.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4024 - SERVICES PROVIDED BY GOVERNMENTAL ENTITIES.

41-4024. SERVICES PROVIDED BY GOVERNMENTAL ENTITIES. (1) From and after July 1, 1990, no self-funded plan shall be issued in Idaho which excludes from coverage services rendered the subscriber while a resident in an Idaho state institution, provided the services to the subscriber would be covered by the contract if rendered to him outside an Idaho state institution.
(2) From and after July 1, 1990, no self-funded plan may contain any provision denying or reducing benefits otherwise provided under the policy for the reason that the person insured is receiving health or mental health care or developmental services provided by the department of health and welfare, whether or not the department of health and welfare bases its charges for such services on the recipient’s ability to pay. Provided, nothing in this section shall prevent the issuance of a contract which excludes or reduces benefits where the charge level or amount of the charge levied by a governmental entity for such services would vary or be affected in any way by the existence of coverage under a self-funded plan.
History:
[41-4024, added 1990, ch. 300, sec. 5, p. 830.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 40 - SELF-FUNDED HEALTH CARE PLANS › Section 41-4025 - MAMMOGRAPHY COVERAGE.

41-4025. MAMMOGRAPHY COVERAGE. (1) From and after July 1, 1992, all self-funded plans which provide coverage for the surgical procedure known as a mastectomy which are delivered, issued for delivery, continued or renewed in this state shall provide minimum mammography examination or equivalent examination coverage. Such coverage shall include at least the following benefits:
(a) One (1) baseline mammogram for any woman who is thirty-five (35) through thirty-nine (39) years of age.
(b) A mammogram every two (2) years for any woman who is forty (40) through forty-nine (49) years of age, or more frequently if recommended by the woman’s physician.
(c) A mammogram every year for any woman who is fifty (50) years of age or older.
(d) A mammogram for any woman desiring a mammogram for medical cause.
Such coverage shall not exceed the cost of the examination.
(2) As used in this section, "mastectomy" means the removal of all or part of the breast for medically necessary reasons as determined by a licensed physician.
(3) Nothing in this section shall apply to specified accident, specified disease, hospital indemnity, medicare supplement, long-term care or other limited benefit health insurance policies.
History:
[41-4025, added 1992, ch. 132, sec. 5, p. 415; am. 1993, ch. 113, sec. 5, p. 290.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 41 - JOINT PUBLIC AGENCY SELF-FUNDED HEALTH CARE PLANS › Section 41-4101 - DECLARATION OF PURPOSE.

41-4101. DECLARATION OF PURPOSE. It is the purpose of this chapter to recognize and provide reasonable public supervision of self-funded plans established by public agencies pursuant to a joint powers agreement in accordance with chapter 23, title 67, Idaho Code, for provision of health care service benefits to employees of public agencies in connection with or as an alternative to insurance and other prepayment plans.
History:
[41-4101, added 2006, ch. 415, sec. 1, p. 1271.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 41 - JOINT PUBLIC AGENCY SELF-FUNDED HEALTH CARE PLANS › Section 41-4102 - DEFINITIONS.

41-4102. DEFINITIONS. As used in this chapter:
(1) "Administrator" means a person, other than a board member, employed by the board to administer a joint public agency self-funded plan.
(2) "Beneficiary" means any individual entitled, under the joint public agency self-funded plan, to payment by the trust fund of any part of all of the cost of any health care service rendered to him.
(3) "Board of trustees" or "board" is the board of trustees of the trust fund.
(4) "Contribution" means the amount paid or payable by the employer or employee into the trust fund.
(5) "Director" means the director of the department of insurance of this state.
(6) "Joint powers agreement" means an agreement entered into between public agencies pursuant to chapter 23, title 67, Idaho Code.
(7) "Joint public agency self-funded plan" or "self-funded plan" or "plan" means any public agency plan established by a joint powers agreement and under which payment for any disability benefits not otherwise provided for under title 72, Idaho Code (worker’s compensation and related laws — industrial commission), medical, surgical, hospital, and other services for prevention, diagnosis, or treatment of any disease, injury, or bodily condition of an employee is, or is to be, regularly provided for or promised from funds created or maintained in whole or in part by contributions or payments thereto by a public agency employer, or by a public agency employer and the employees of the public agency, and not otherwise covered by insurance or contract with a health care service corporation, health maintenance organization, or similar other third party prepayment plan.
(8) "Person" means any individual, corporation, association, firm, syndicate, organization or other entity.
(9) "Public agency" means any city, county or political subdivision of this state, including, but not limited to: counties; school districts; highway districts; port authorities; instrumentalities of counties, county hospitals, cities or any political subdivision created under the laws of the state of Idaho; and the state of Idaho and any agency of the state government. "Public agency" also means any group of more than one (1) of the above public agencies acting together pursuant to a joint powers agreement in accordance with chapter 23, title 67, Idaho Code.
(10) "Surplus" means the excess of the assets of a self-funded plan minus the liabilities of the plan, provided the liabilities of a self-funded plan shall include the claims liability of the plan.
(11) "Trust fund" means a fund established under a joint public agency self-funded plan for receipt of contributions of employers and employees and payment of or with respect to health care service costs of beneficiaries.
History:
[41-4102, added 2006, ch. 415, sec. 1, p. 1272; am. 2018, ch. 61, sec. 1, p. 151.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 41 - JOINT PUBLIC AGENCY SELF-FUNDED HEALTH CARE PLANS › Section 41-4103 - REGISTRATION REQUIRED — EXEMPTIONS — NOT SUBJECT TO INSURANCE CODE.

41-4103. REGISTRATION REQUIRED — EXEMPTIONS — NOT SUBJECT TO INSURANCE CODE. (1) No joint public agency self-funded plan shall operate in this state except while registered with the director as hereinafter provided. Joint public agency self-funded plans already in operation as of July 1, 2006, shall so register within ninety (90) days of the effective date of this act.
(2) No registration shall be required of:
(a) Any plan established and maintained for the purpose of complying with any worker’s compensation law or unemployment compensation disability insurance law; or
(b) Any plan that is primarily for the purpose of providing first aid care and treatment, at a dispensary of an employer, for injury or sickness of employees while engaged in their employment.
(3) Plans while so registered shall not be deemed to be engaged in the business of insurance and shall not be subject to provisions of the Idaho insurance code except as expressly provided in this chapter.
(4) The plan shall provide to each employer participant and to each prospective employer participant a written notice stating that the plan is not insurance and does not participate in the state guaranty association.
History:
[41-4103, added 2006, ch. 415, sec. 1, p. 1272.]
2023 Idaho Code › Title 41 - INSURANCE › Chapter 41 - JOINT PUBLIC AGENCY SELF-FUNDED HEALTH CARE PLANS › Section 41-4104 - QUALIFICATIONS FOR REGISTRATION.

41-4104. QUALIFICATIONS FOR REGISTRATION. No joint public agency self-funded plan shall register, and the director shall not register a joint public agency self-funded plan, which is not qualified as provided in this section.
(1) The joint powers agreement must require all contributions to be paid in advance and to be deposited in and disbursed from a trust fund duly created and existing under an adequate written irrevocable trust agreement between the employer or employers and the board.
(2) The plan must:
(a) Have, or provide for, a board of trustees in accordance with this chapter for the administration of the plan;
(b) Require that all members of the joint powers agreement comply with the provisions of the joint powers agreement;
(c) Provide that the administrator or board on behalf of the plan, as the case may be, shall furnish to each employee-beneficiary of the plan a written statement or schedule adequately and clearly stating all benefits currently allowable under the plan, together with all applicable restrictions, limitations, and exclusions, and the procedure for filing a claim for benefits; and
(d) Otherwise be in compliance with the provisions of this chapter.
(3) The allocated trust fund must be actuarially sound; that is, assets and income of the fund must be adequate under reasonable estimates for payment of all benefits promised to beneficiaries by the plan. In determining actuarial soundness the director shall also give due consideration to:
(a) Applicable stop-loss insurance provided or to be provided the plan by an insurer duly authorized to transact disability insurance in this state;
(b) Contracts with health care service corporations or health maintenance organizations authorized to conduct such operations in this state and covering certain of the promised benefits;
(c) Other applicable insurance or guarantys; and
(d) The nature of the participating entities and other plan factors or provisions for prevention or reduction of adverse selection against the plan by those otherwise eligible to become beneficiaries.
(4) The plan shall maintain aggregate stop-loss coverage and specific stop-loss coverage provided by an insurance company authorized to transact insurance in this state in accordance with the annual actuarial opinion of the plan, unless waived pursuant to section 41-4110(3), Idaho Code.
History:
[41-4104, added 2006, ch. 415, sec. 1, p. 1273; am. 2018, ch. 61, sec. 2, p. 152.]