Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.046 - REQUIREMENT TO INSURE ENTIRE GROUPS

Current through August 31, 2023
01.
Offer of
			 Coverage
. A small employer carrier that offers coverage to a small
			 employer will offer to provide coverage to each eligible employee and to each
			 dependent of an eligible employee. Except as provided in Subsection
			 046.02, the small employer
			 carrier provides the same health benefit plan to each such employee and
			 dependent. (3-31-22)
02.
Choice of Health Benefit Plans
. A small employer carrier may offer
			 the employees of a small employer the option of choosing among one (1) or more
			 health benefit plans, provided that each eligible employee may choose any of
			 the offered plans. The choice among benefit plans will not be limited,
			 restricted or conditioned based upon the risk characteristics of the eligible
			 employees or their dependents. (3-31-22)
03.
Participation Requirement
.
			 The small employer carrier may impose reasonable minimum participation
			 requirements for issuance of coverage to small employers, subject to prior
			 approval from the Director. (3-31-22)
04.
Employer Census and Supporting
			 Documentation
. A small employer carrier will require each small employer
			 that applies for coverage, as part of the application process, to prepare or
			 provide an employer census of dependents and eligible employees as defined in
			 Sections 41-4703(11)  and
			 41-4703(13),
			 Idaho Code. The small employer carrier may require the small employer to
			 provide appropriate supporting documentation (such as the W-2 Summary Wage and
			 Tax Form) or a certification of information by a Small Employer as to the
			 current census information. (3-31-22)
05.
Waiver for Documentation of
			 Coverage
. A small employer carrier will secure a waiver with respect to
			 each eligible employee and each dependent of such an eligible employee who
			 declines an offer of coverage under a health benefit plan provided to a small
			 employer. The waiver is signed by the eligible employee (on behalf of such
			 employee or the dependent of such employee) and certifies that the individual
			 who declined coverage was informed of the availability of coverage under the
			 health benefit plan. The waiver form requires that the reason for declining
			 coverage be stated on the form, and includes a statement informing the eligible
			 employee of the special enrollment rights provided within the Section
			 41-4703(17)(d) and
			 (e), Idaho Code, and includes a written
			 warning of the penalties imposed on late enrollees. Waivers are maintained by
			 the small employer carrier for a period of six (6) years. (3-31-22)
06.
Refusal to Provide
			 Information
. A small employer carrier will not issue coverage to a small
			 employer that refuses to provide the list prescribed under Subsection
			 046.04 or a waiver prescribed
			 under Subsection 046.05,
			 except if the excluded individual has coverage under a health benefit plan or
			 other health benefit arrangement that provides benefits similar to or exceeding
			 benefits provided under the basic health benefit plan. (3-31-22)
07.
Induced Declinations
. A
			 small employer carrier will not issue coverage to a small employer if the
			 carrier, or an agent for such carrier, has reason to believe that the small
			 employer has induced or pressured an eligible employee (or dependent of an
			 eligible employee) to decline coverage due to a health status related factor of
			 the individual. (3-31-22)
08.
Agent Notification to Small Employer Carrier
. An agent will notify
			 a small employer carrier, prior to submitting an application for coverage with
			 the carrier on behalf of a small employer, of any circumstances that would
			 indicate that the small employer has induced or pressured an eligible employee
			 (or dependent of an eligible employee) to decline coverage due to the
			 individual's risk characteristics. (3-31-22)
09.
New Entrants
. New entrants
			 to a small employer group are offered an opportunity to enroll in the health
			 benefit plan currently held by such group based upon the provisions of Section
			 41-4708, Idaho Code. A new entrant
			 that does not exercise the opportunity to enroll in the health benefit plan
			 within the period provided by the small employer carrier may be treated as a
			 late enrollee by the carrier, provided that the period provided to enroll in
			 the health benefit plan extends at least thirty (30) days after the date the
			 new entrant is notified of their opportunity to enroll. The period of
			 continuous coverage will not include any waiting period for the effective date
			 of the new coverage applied by the employer to all new enrollees under the
			 Employee Benefit Plan. If a small employer carrier has offered more than one
			 health benefit plan to a small employer group pursuant to Subsection
			 046.02, the new entrant is
			 offered the same choice of health benefit plans as the other members of the
			 group. (3-31-22)
10.
Waiting
			 Period
. A small employer carrier will not apply a waiting period,
			 elimination period or other similar limitation of coverage (other than an
			 exclusion for pre-existing medical conditions consistent with Section
			 41-4708(3), Idaho
			 Code). (3-31-22)
11.
Risk
			 Characteristics
. New entrants to a group are accepted for coverage by
			 the small employer carrier without any restrictions or limitations on coverage
			 related to the risk characteristics of the employees or their dependents,
			 except that a carrier may exclude or limit coverage for pre-existing medical
			 conditions, consistent with the provisions provided in Section
			 41-4708(3), Idaho
			 Code. (3-31-22)
12.
Risk
			 Load
. A small employer carrier may assess a risk load to the premium
			 rate associated with a new entrant, consistent with the requirements of Section
			 41-4706, Idaho Code. The risk load
			 is the same risk load charged to the small employer group immediately prior to
			 acceptance of the new entrant into the group. (3-31-22)
13.
Rescission Employer
			 Misstatements
. When material application misstatements are found,
			 rescission action by the carrier may be taken at the carrier's option against
			 the coverage of an entire small employer (including employees and dependents)
			 and is limited to circumstances under which the application misstatements have
			 been made by the small employer. When rescission action is taken, per Section
			 41-4707(1)(b),
			 Idaho Code, premiums are refunded less any claims which had been paid prior to
			 the date the rescission was initiated. At the carrier's option, the carrier may
			 seek to recover any amounts of claims paid in excess of premiums paid. The
			 applicable contract or coverage is considered null and void.
			 (3-31-22)