reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. IDAPA 18.04.03, "Advertisement of Disability (Accident and
			 Sickness) Insurance." (3-31-22)
02.
Scope
. To protect consumers by assuring truthful and adequate
			 disclosure of all material and relevant information in the advertising of
			 accident and sickness insurance, including Medicare supplement accident and
			 sickness insurance and long-term care insurance. This is accomplished by the
			 establishment of, and adherence to, certain minimum standards and guidelines of
			 conduct in the advertising of disability (accident and sickness) insurance in a
			 manner that prevents unfair competition among insurers and promotes an accurate
			 presentation and description to the insurance buying public.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.002 - APPLICABILITY

Current through August 31, 2023
01.
Disability and Medicare Supplement
			 Insurance
. Any disability (accident and sickness) insurance
			 "advertisement," including Medicare supplement and long-term care insurance
			 "advertisement," as that term is defined, intended for presentation,
			 distribution or dissemination in this state when such presentation,
			 distribution or dissemination is made either directly or indirectly by or on
			 behalf of an insurer or producer. (3-31-22)
02.
Control over Advertisement
.
			 Every insurer will establish and at all times maintain a system of control over
			 the content, form and method of dissemination of all advertisements of its
			 policies. All such advertisements created, designed or presented, are the
			 responsibility of the insurer whose policies are so advertised.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.010 - DEFINITIONS

Current through August 31, 2023
01.
Advertisement
. Includes:
			 (3-31-22)
a. Printed and published material,
			 audio visual material, and descriptive literature of an insurer used in direct
			 mail, newspapers, magazines, radio scripts, TV scripts, web sites and other
			 internet displays or communications, other forms of electronic communications,
			 billboards and similar displays; (3-31-22)
b. Descriptive literature and sales aids of
			 all kinds issued by an insurer or producer for presentation to members of the
			 insurance buying public; and (3-31-22)
c. Prepared sales talks, presentations and
			 material for use by producers whether prepared by the insurer or the producer.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.011 - METHOD OF DISCLOSURE OF REQUISITE INFORMATION

Current through August 31, 2023
All information needed to be disclosed by these rules will be
				set out conspicuously and closely associated with the statements to which such
				information relates or under appropriate captions of such prominence that it
				will not be minimized, rendered obscure or presented in an ambiguous fashion or
				intermingled with the context of the advertisement so as to be confusing or
				misleading. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.012 - FORM AND CONTENT OF ADVERTISEMENTS

Current through August 31, 2023
The format and content of an advertisement of an accident or
				sickness insurance policy will be sufficiently complete, not misleading, and
				clear to avoid deception. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.014 - NECESSITY FOR DISCLOSING POLICY PROVISIONS RELATING TO RENEWABILITY, CANCELLATION AND TERMINATION

Current through August 31, 2023
When an advertisement refers to either a dollar amount or a
				period of time for which any benefit is payable, or the cost of the policy, or
				specific policy benefit, or the loss for which such benefit is payable, it will
				disclose the provisions relating to renewability, cancellation and termination
				and any modification of benefits, losses covered or premiums because of age or
				for other reasons, in a manner that will not minimize or render obscure the
				qualifying conditions. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.015 - TESTIMONIALS OR ENDORSEMENTS BY THIRD PARTIES

Current through August 31, 2023
01.
Testimonials
. Testimonials used in advertisements will be genuine,
			 represent the current opinion of the author, be applicable to the policy
			 advertised and be accurately reproduced. The insurer, in using a testimonial,
			 makes as its own all of the statements contained therein, and the
			 advertisement, including such statement, is subject to all the provisions of
			 this chapter. (3-31-22)
02.
Disclosure of Financial Interest
. If the person making a
			 testimonial, an endorsement or an appraisal has a financial interest in the
			 insurer or a related entity as a stockholder, director, officer, employee, or
			 otherwise, such fact will be disclosed in the advertisement. If a person is
			 compensated for making a testimonial, endorsement or appraisal, such fact will
			 be disclosed in the advertisement by language substantially as follows: "Paid
			 Endorsement." This chapter does not require disclosure of union "scale" wages
			 set by union rules if the payment is actually for such "scale" for TV or radio
			 performances. The payment of substantial amounts, directly or indirectly, for
			 "travel and entertainment" for filming or recording of TV or radio
			 advertisements requires disclosure of such compensation. (3-31-22)
03.
Limitations and
			 Restrictions
. An advertisement will not state or imply that an insurer
			 or a policy has been approved or endorsed by any individual, group of
			 individuals, society, association or other organizations, unless such is the
			 fact, and unless any proprietary relationship between an organization and the
			 insurer is disclosed. If the entity making the endorsement or testimonial has
			 been formed by the insurer or is owned or controlled by the insurer or the
			 person or persons who own or control the insurer, such fact will be disclosed
			 in the advertisement. (3-31-22)
04.
Retention of Data
. When a testimonial refers to benefits received
			 under a policy, the specific claim data, including claim number, date of loss,
			 and other pertinent information is retained by the insurer for inspection for a
			 period of four (4) years or until the filing of the next regular report on
			 examination of the insurer, whichever is the longer period of time.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.016 - USE OF STATISTICS

Current through August 31, 2023
01.
Requests
			 for Use of Statistical Information
. An advertisement relating to the
			 dollar amounts of claims paid, the number of persons insured, or similar
			 statistical information relating to any insurer or policy cannot use irrelevant
			 facts, and cannot be used unless it accurately reflects all relevant facts.
			 Such an advertisement will not imply that such statistics are derived from the
			 policy advertised unless such is the fact, and when applicable to other
			 policies or plans will specifically so state. (3-31-22)
02.
Restrictions on
			 Representations
. An advertisement will not represent or imply that claim
			 settlements by the insurer are "liberal" or "generous," or use words of similar
			 import, or that claim settlements are or will be beyond the actual terms of the
			 contract. An unusual amount paid for a unique claim for the policy advertised
			 is misleading and cannot be used. (3-31-22)
03.
Source of Statistics
. The
			 source of any statistics used in an advertisement will be identified in such
			 advertisement. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.017 - IDENTIFICATION OF PLAN OR NUMBER OF POLICIES

Current through August 31, 2023
01.
Disclosure Requirements
. When a choice of the amount of benefits
			 is referred to, an advertisement will disclose that the amount of benefits
			 provided depends upon the plan selected and that the premium will vary with the
			 amount of the benefits selected. (3-31-22)
02.
Disclosure Based on Combination of
			 Policies
. When an advertisement refers to various benefits that may be
			 contained in two (2) or more policies, other than group master policies, the
			 advertisement will disclose that such benefits are provided only through a
			 combination of such policies. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.018 - DISPARAGING COMPARISONS AND STATEMENTS

Current through August 31, 2023
An advertisement will not directly or indirectly make unfair or
				incomplete comparisons of policies or benefits or comparisons of non-comparable
				policies of other insurers, and will not disparage competitors, their policies,
				services or business methods, and will not disparage or unfairly minimize
				competing methods of marketing insurance. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.019 - JURISDICTION LICENSING AND STATUS OF INSURER

Current through August 31, 2023
01.
Restrictions on Licensing Jurisdiction
. An advertisement intended
			 to be seen or heard beyond the limits of the jurisdiction in which the insurer
			 is licensed will not imply licensing beyond those limits. (3-31-22)
02.
Restrictions on
			 Endorsements
. An advertisement will not create the impression directly
			 or indirectly that the insurer, its financial condition or status, or the
			 payment of its claims, or the merits, desirability, or advisability of its
			 policy forms or kinds or plans of insurance are approved, endorsed, or
			 accredited by any division or agency of this state or the United States
			 Government. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.020 - IDENTITY OF INSURER

Current through August 31, 2023
01.
Name of
			 Insurer to Be Identified
. The name of the actual insurer is clearly
			 identified and the policy or policies advertised is identified by form number
			 or otherwise described. An advertisement will not use a trade name, any
			 insurance group designation, name of the parent company of the insurer, name of
			 a particular division of the insurer, service mark, slogan, symbol or other
			 device that, without disclosing the name of the actual insurer.
			 (3-31-22)
02.
Identity of
			 Insurer Not to Be Misrepresented
. No advertisement can use any
			 combination of words, symbols, or physical materials that by their content,
			 phraseology, shape, color or other characteristics are so similar to
			 combinations of words, symbols, or physical materials used by agencies of the
			 federal government or of this state, or appear to be of such a nature that it
			 tends to confuse or mislead prospective insureds into believing that the
			 solicitation is in some manner connected with an agency of the municipal,
			 state, or federal government. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.021 - GROUP OR QUASI-GROUP IMPLICATIONS

Current through August 31, 2023
An advertisement of a particular policy will not state or imply
				that prospective insureds become group or quasi-group members covered under a
				group policy and as such enjoy special rates or underwriting privileges, unless
				such is the fact. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.022 - INTRODUCTORY, INITIAL OR SPECIAL OFFERS

Current through August 31, 2023
01.
Restrictions on Introductory, Initial or Special Offers
. (3-31-22)
a. An advertisement of an individual policy
			 will not represent that a contract or combination of contracts is an
			 introductory, initial or special offer, or that applicants will receive
			 substantial advantages not available at a later date, or that the offer is
			 available only to a specified group of individuals, unless such is the fact. An
			 advertisement cannot contain phrases describing an enrollment period as
			 "special," "limited," or similar words. (3-31-22)
b. An enrollment period during which a
			 particular insurance product may be purchased on an individual basis cannot be
			 offered within this state unless there has been a lapse of not less than three
			 (3) months between the close of the immediately preceding enrollment period for
			 the same product and the opening of the new enrollment period. The
			 advertisement will indicate the date by which the applicant need mail the
			 application, which is not less than ten (10) days and not more than forty (40)
			 days from the date that such enrollment period is advertised for the first
			 time. This chapter applies to all advertising media, i.e., mail, newspapers,
			 radio, television, magazines and periodicals, by any one (1) insurer. It is
			 inapplicable to solicitations of employees or members of a particular group or
			 association that would be eligible under specific provisions of the Insurance
			 Code for group, blanket or franchise insurance. The phrase "any one (1)
			 insurer" includes all the affiliated companies of a group of insurance
			 companies under common management or control. (3-31-22)
c. This chapter prohibits any statement or
			 implication to the effect that only a specific number of policies will be sold,
			 or that a time is fixed for the discontinuance of the sale of the particular
			 policy advertised because of special advantages available in the policy, unless
			 such is the fact. (3-31-22)
d. The
			 phrase "a particular insurance product" in paragraph(s) of this Section means
			 an insurance policy that provides substantially different benefits than those
			 contained in any other policy. Different terms of renewability; and increase or
			 decrease in the dollar amounts of benefits; and increase or decrease in any
			 elimination period or waiting period from those available during an enrollment
			 period for another policy will not be sufficient to constitute the product
			 being offered as a different product eligible for concurrent or overlapping
			 enrollment periods. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.023 - STATEMENTS ABOUT AN INSURER

Current through August 31, 2023
An advertisement will not contain statements that are untrue in
				fact, or by implication misleading, with respect to the assets, corporate
				structure, financial standing, age or relative position of the insurer in the
				insurance business. An advertisement will not contain a recommendation by any
				commercial rating system unless it clearly indicates the purpose of the
				recommendation and the limitations of the scope and extent of the
				recommendation. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.024 - ENFORCEMENT PROCEDURES

Current through August 31, 2023
Each insurer will maintain at its home or principal office a
				complete file containing every printed, published or prepared advertisement of
				its individual policies and typical printed, published or prepared
				advertisements of its blanket, franchise and group policies hereafter
				disseminated in this or any other state whether or not licensed in such other
				state, with a notation attached to each such advertisement that will indicate
				the manner and extent of distribution and the form number of any policy
				advertised. Such file is subject to regular and periodical inspection by this
				Department. All such advertisements will be maintained in said file for a
				period of either four (4) years or until the filing of the next regular report
				on examination of the insurer, whichever period is longer. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.03 - ADVERTISEMENT OF DISABILITY (ACCIDENT AND SICKNESS) INSURANCE › Section 18.04.03.025 - FILING FOR PRIOR REVIEW

Current through August 31, 2023
The Director may, at their discretion, require the filing of
				any accident and sickness insurance advertising material for review prior to
				use. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.04 - THE MANAGED CARE REFORM ACT RULE › Section 18.04.04.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. IDAPA 18.04.04, "The Managed Care Reform Act Rule."
			 (3-31-22)
02.
Scope
.
			 The Act and this chapter define procedures to be followed in establishing and
			 operating a Managed Care Organization. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.04 - THE MANAGED CARE REFORM ACT RULE › Section 18.04.04.010 - DEFINITIONS

Current through August 31, 2023
01.
Balance Billing
. The
			 practice whereby a provider bills an individual covered under the benefit plan
			 for the difference between the amount the provider normally charges for a
			 service and the amount the plan, policy, or contract recognizes as the
			 allowable charge or negotiated price for the service delivered.
			 (3-31-22)
02.
MCO
.
			 Managed Care Organizations is abbreviated to MCO in this rule.
			 (3-31-22)
03.
MCO
			 Provider
. MCO provider means any provider owned, managed, employed by,
			 or under contract with an MCO to provide health care services to MCO members.
			 An MCO provider includes a physician, hospital, or other person licensed or
			 authorized to furnish health care services. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.04 - THE MANAGED CARE REFORM ACT RULE › Section 18.04.04.011 - APPLICATION FOR CERTIFICATE OF AUTHORITY

Current through August 31, 2023
01.
Certificate of Authority
. Any person offering a managed care plan
			 on a predetermined and prepaid basis is transacting the business of insurance
			 and needs to be authorized under a Certificate of Authority issued by the
			 Director of Insurance. (3-31-22)
02.
Application Requirements
.
			 The application for a Certificate of Authority will include the affidavits,
			 statements, and other information as enumerated in Idaho Code, Sections
			 41-319,
			 41-3904,
			 41-3905, and
			 41-3906. After receiving these
			 completed documents, the Director has the authority to request any supplemental
			 information before final approval or disapproval is given. (3-31-22)
03.
Capital Surplus and Deposit
			 Requirements
. (3-31-22)
a. The
			 Director has established the following minimum capital fund requirements as per
			 Section 41-3905(8), Idaho
			 Code, based on the number of enrolled members:
Enrolled Members
Capital Funds
0-100
$200,000
101-300
$300,000
301-500
$400,000
501-700
$500,000
701-1,000
$1,000,000
1,001-2,000
$1,500,000
2,001-3,000
$2,000,000
b. In no
			 event will the organization's capital funds be less than the following:
One year after the organization becomes subject to
							 the Act
$1,000,000
Two years after the date the organization becomes
							 subject to the Act
$1,500,000
Three years after the date the organization becomes
							 subject to the Act
$2,000,000
c.
			 Immediately upon becoming subject to the Act, the MCO's minimum statutory
			 deposit requirements is calculated as fifty percent (50%) of the amount of the
			 organization's Capital funds as calculated above up to a maximum of one million
			 dollars ($1,000,000), but not less than two hundred thousand dollars
			 ($200,000). The amount of the deposit so held by the Department is adjusted
			 based on the organization's December 31st and June 30th financial statement
			 filings each year. In no event will the minimum prescribed statutory deposit
			 amount be reduced. Upon notification by the Department of the necessary
			 increase in the deposit amount, the organization will have no more than thirty
			 (30) days to come into compliance with the prescribed amount. Failure to
			 increase the deposit as prescribed will subject the organization to suspension
			 or revocation of its certificate of authority pursuant to Section
			 41-326, Idaho Code.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.04 - THE MANAGED CARE REFORM ACT RULE › Section 18.04.04.012 - SOLICITATION PRIOR TO ISSUANCE OF CERTIFICATE OF AUTHORITY

Current through August 31, 2023
01.
Permission for Solicitation
			 Requisite
. In accordance with Section
			 41-3904, Idaho Code, a proposed
			 MCO, after filing its application for a Certificate of Authority, may request
			 permission from the Director to inform potential enrollees concerning its
			 proposed managed care services. (3-31-22)
02.
Solicitation Materials
.
			 Before contacting potential enrollees or subscribers, the proposed MCO will
			 submit its request for permission to the Director in writing, with copies of
			 brochures, advertising or solicitation materials, sales talks or any other
			 procedures or methods to be used. (3-31-22)
03.
Methods of Solicitation
.
			 Advertising and solicitation materials used by a proposed MCO need to meet the
			 following minimum requirements: (3-31-22)
a.
			 The prospective enrollee will clearly be advised that: (3-31-22)
i. The proposed MCO is not as yet authorized
			 to offer health care services in this state; (3-31-22)
ii. Coverage for health care services is not
			 being provided at the time of the solicitation; (3-31-22)
iii. The solicitation is not a guarantee that
			 any services will be provided at a future date. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.04 - THE MANAGED CARE REFORM ACT RULE › Section 18.04.04.013 - ANNUAL DISCLOSURE, FILING WITH DIRECTOR

Current through August 31, 2023
The annual disclosure material prescribed to be filed with the
				Director pursuant to Section
				41-3914, Idaho Code, is filed with
				the reports to the Director on or before March 1 each year. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.04 - THE MANAGED CARE REFORM ACT RULE › Section 18.04.04.014 - ANNUAL REPORT TO THE DIRECTOR

Current through August 31, 2023
In accordance with Sections
				41-3910 and
				41-335, Idaho Code, every managed
				care organization will annually on or before the first day of March, file with
				the Director a full and true statement of its financial condition, transactions
				and affairs as of the preceding December 31. Unless otherwise prescribed by the
				Director, the statement is to be prepared in accordance with the annual
				statement instructions and the accounting practices and procedures manual
				adopted by the National Association of Insurance Commissioners (NAIC) and is to
				be submitted on the NAIC annual convention blank form. The managed care
				organization will also file its annual audited financial report in accordance
				with IDAPA 18.07.04, "Annual Audited Financial Reports." (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.04 - THE MANAGED CARE REFORM ACT RULE › Section 18.04.04.015 - PERSONNEL AND FACILITIES LISTING

Current through August 31, 2023
01.
Current
			 Listing
. The MCO will at all times keep a current list of all personnel,
			 providers and facilities employed, retained or under contract to furnish health
			 care services to enrollees. This list is to be made available to the Director
			 upon request. (3-31-22)
02.
Allowable Expense -- No Balance Billing
. No MCO provider or other
			 provider accepting a referral from an MCO, who treats or provides services to
			 an individual covered by the MCO, may charge to or collect from any member or
			 other beneficiary any amount in excess of that amount of compensation
			 determined or allowed for a particular service by the MCO or by the
			 administrator for the MCO. Nothing in this section prevents the collection of
			 any copayments, coinsurance, or deductibles allowed for in the plan design.
			 (3-31-22)
03.
Procedures for
			 Basic Care and Referrals
. The MCO will provide basic health care to
			 enrollees through an organized system of health care providers. In plans in
			 which referrals to specialty physicians and ancillary services are prescribed,
			 the MCO provider or the MCO will initiate the referrals. The MCO will inform
			 its providers of their responsibility to provide written referrals and any
			 specific procedures that need to be followed in providing referrals, including
			 prohibition of balance billing. (3-31-22)
04.
Health Care Services to Be
			 Accessible
. The MCO, either directly or through its organized system of
			 health care providers, will arrange for covered health care services, including
			 referrals to providers within the organized system of health care providers and
			 noncontracting providers, to be accessible to enrollees on a timely basis in
			 accordance with medically appropriate guidelines consistent with generally
			 accepted practice parameters. (3-31-22)
05.
Out of Network Services
. In
			 the case of provider care which is delivered outside of the organized system of
			 health care providers or defined referral system, the MCO will alert those
			 covered under health benefit plans to the fact that providers which are not MCO
			 providers, or have not accepted written referrals, may balance bill the
			 customer for amounts above the MCO's maximum allowance. Consumers should be
			 encouraged to discuss the issue with their providers (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. IDAPA 18.04.05, "Self-Funded Health Care Plans Rule."
			 (3-31-22)
02.
Scope
.
			 This rule supplements the provisions of Title 41, Chapter 40, Idaho Code,
			 Self-Funded Health Care Plans. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.010 - DEFINITIONS

Current through August 31, 2023
01.
"All Contributions to Be Paid in
			 Advance."
All contributions are to be paid in advance of the period of
			 time for which the contribution is made. (3-31-22)
02.
"Deposited in and Disbursed from a
			 Trust Fund."
All contributions based on calculated rates in accordance
			 with Section 028 of this
			 rule are deposited into the trust fund and all expenses are paid out of the
			 trust fund. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.021 - QUALIFICATION OF PLAN

Current through August 31, 2023
In order for a plan to qualify under Title 41, Chapter 40,
				Idaho Code, the plan's trust will be established by agreement between the
				employer or employers or a postsecondary education institution and the trustee
				of the trust, for the sole purpose of providing health care benefits to
				employees of the employer or employers or to students of the postsecondary
				educational institution. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.022 - REGISTRATION

Current through August 31, 2023
01.
Registration Requisite
. No
			 self-funded plan, unless exempted from registration by Section
			 41-4003, Idaho Code, will be
			 organized and permitted to operate in the state of Idaho without securing a
			 Certificate of Registration from the Director. (3-31-22)
02.
Specific Plans
. Any plans
			 covering the employees of a common employer are a single plan in respect to the
			 exemption for registration allowed in Section
			 41-4003, Idaho Code. Any
			 combinations of plans under the effective control of a single administrator,
			 trustee, and/or employer, or group of administrators, trustees and/or employers
			 utilizing or attempting to utilize the exempt dollar amounts permitted under
			 Section 41-4003, Idaho Code in order to
			 avoid registration of any such plans are deemed to be contrary to the intent of
			 Title 41, Chapter 40, Idaho Code, and are expressly banned by this rule.
			 (3-31-22)
03.
Beneficiary
			 Within State
. Registration is mandatory of plans that cover any
			 beneficiary working or residing within this state, unless the plans are
			 otherwise exempted by Section
			 41-4003(2), Idaho
			 Code. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.024 - INVESTIGATION OF PROPOSED APPLICATION FOR REGISTRATION

Current through August 31, 2023
The Director may make an investigation of matters accompanying
				the application for registration including an examination specified in Section
				41-4013, Idaho Code. Costs of any
				investigation or examination, or both, will be borne by the trust fund of the
				plan. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.025 - CONTRIBUTIONS RECEIVABLE

Current through August 31, 2023
The trust fund may take credit in any financial statement for
				contributions receivable which are not in excess of ninety (90) days past due.
				(3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.026 - TRUST FUND RESERVES AND SURPLUS

Current through August 31, 2023
01.
Reserve
			 Requirements
. The trust fund of the plan is to continuously maintain
			 reserves sufficient, as certified by a qualified actuary as being necessary, to
			 fully fund payment of all benefits in effect at the time a claim arises. This
			 reserve needs to adequately provide for all reasonably estimated future claim
			 payments, adjustment expenses, and litigation expenses on claims which have
			 arisen, including claims incurred but not reported, extended benefits and
			 maternity benefits, if any. (3-31-22)
02.
Reserves for Disability Income
			 Benefits
. Reserves established for disability income benefits cannot be
			 less than the Minimum Reserve Standards for Group Health Insurance Contracts
			 set forth the in the NAIC's Accounting Practices and Procedures Manual unless
			 it can be proven to the satisfaction of the Director that a lower reserve can
			 be actuarially justified. (3-31-22)
03.
Certification by Actuary
.
			 Reserves needs to be certified annually by a qualified actuary. Such
			 certification needs to be accompanied by a statement describing bases used in
			 reserve determination. The certification will be in a form acceptable to the
			 Director. (3-31-22)
04.
Insolvent Condition
. If determination of surplus reveals a
			 deficiency in surplus, the Director may allow the plan up to ninety (90) days
			 to accumulate prescribed surplus. The plan is deemed insolvent when it is
			 either unable to pay its obligations or its assets do not exceed all its
			 liabilities, including prescribed reserves. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.027 - BONDING

Current through August 31, 2023
01.
Certified Copy of Bond
. The
			 plan will submit to the Director a certified copy of the fidelity bond or
			 equivalent coverage, as prescribed under Section
			 41-4014(3), Idaho
			 Code. (3-31-22)
02.
Scope of
			 Coverage
. The fidelity bond or equivalent coverage will cover every
			 trustee, officer, director, and employee of the plan. (3-31-22)
03.
Cancellation of Bond
			 Requirements
. The fidelity bond or equivalent coverage needs to contain
			 language stating that it is noncancellable except upon not less than thirty
			 (30) days advance notice in writing to the trustee and the Director. A copy of
			 any notice cancelling a bond prescribed under Title 41, Chapter 40, Idaho Code,
			 is to be forwarded to the Director by the surety at the same time it is
			 forwarded to the trustee. (3-31-22)
04.
Third Party Administrator
.
			 Any party that provides any one of the following services to the plan needs to
			 be licensed as a third party administrator: (3-31-22)
a. Directly or indirectly underwrites;
			 (3-31-22)
b. Collects or handles
			 charges or contributions; or (3-31-22)
c. Adjusts or settles claims on members or
			 beneficiaries of the plan. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.028 - CONTRIBUTION RATES

Current through August 31, 2023
01.
Contribution Rate Calculation
. Contribution rates will be
			 calculated at least annually by a qualified actuary. The contribution rate
			 calculations should break down and designate the rate for the employer and the
			 rate per employee, or the rate for the postsecondary educational institution
			 and the rate per student. (3-31-22)
02.
Employer Contributions
.
			 Employer contributions will be based on filed rates, paid in advance on a
			 periodic basis during the period of coverage or at the beginning of the period
			 of coverage. (3-31-22)
03.
Annual Filing of Rates
. The annual filing of rates with the
			 Director will include a breakdown as prescribed under Subsection
			 028.01. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.029 - CONTRACTS AND SERVICES

Current through August 31, 2023
01.
Affiliated Contracts
. All contracts for goods or services provided
			 to the plan by any plan sponsor, employer, third party administrator, or other
			 affiliated entity or employee or agent thereof, will be in writing, setting
			 forth in detail the rights and duties of each party to the writing; regardless
			 of whether compensation, fees, or other consideration is paid or exchanged
			 directly or indirectly. (3-31-22)
02.
Contracts for Services
. All
			 contracts for services directly affecting the plan including, but not limited
			 to, accounting services, legal services, custodial agreements, and agreements
			 for lease, rent, or insurance coverage to be performed or entered into on
			 behalf of the plan will be agreed to by the board of trustees and the other
			 party. (3-31-22)
03.
Recordkeeping and Writing
. Contracts and agreements valued at
			 greater than five hundred dollars ($500.00) entered into by the plan, will be
			 in writing and approved by resolution of the board of trustees, and placed in
			 the minutes and records of the plan. (3-31-22)
04.
Fiduciary Duty
. By entering
			 into contracts and agreements, the trustees are not permitted to transfer or
			 avoid their statutory fiduciary responsibilities. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.030 - RECORDS

Current through August 31, 2023
01.
Board Actions
. Any and all
			 acts, resolutions, appointments, or delegations, or other decisions of the
			 board of trustees will be in writing and placed in the minutes and records of
			 the plan. (3-31-22)
02.
Complete Records
. The full and accurate records and accounts of the plan
			 include, but are not limited to, minutes of the meetings of the board of
			 trustees that document the acts, resolutions, appointments or delegations of
			 the trustees; any and all correspondence between the board of trustees and
			 contractors; accounting and actuarial records; and any and all records,
			 correspondence, minutes, or statements as prescribed by law or the trust
			 agreement. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.05 - SELF-FUNDED HEALTH CARE PLANS RULE › Section 18.04.05.031 - ANNUAL STATEMENT

Current through August 31, 2023
The trustee will file an annual statement within ninety (90)
				days after the close of each fiscal year of the Plan and at such other time as
				may be determined by the Director. A quarterly statement will be filed with the
				Director within sixty (60) days of the end of each quarter in a form acceptable
				to the Director. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. IDAPA 18.04.06, "Governmental Self-Funded Employee Health
			 Care Plans Rule." (3-31-22)
02.
Scope
. The purpose of this rule is to supplement the provisions of
			 Title 41, Chapter 41, Idaho Code, Joint Public Agency Self-Funded Health Care
			 Plans by providing: (3-31-22)
a. Dates of
			 application for registration; (3-31-22)
b. Requirements for application for
			 registration; (3-31-22)
c. Rules
			 regarding investigation of applications; (3-31-22)
d. Definition of needed liabilities; and
			 establishment of reserve bases; and (3-31-22)
e. To provide an effective date.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.021 - QUALIFICATION OF PLAN

Current through August 31, 2023
In order to qualify under Title 41, Chapter 41, Idaho Code, the
				plan's trust needs to be established by agreement between the public agency
				employers or joint powers entity and the trustee of the trust, for the sole
				purpose of providing health care benefits to employees of the public agency
				employer or employers. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.022 - REGISTRATION

Current through August 31, 2023
01.
Registration Requisite
. No
			 joint public agency self-funded plan, unless exempted from registration by
			 Section 41-4103, Idaho Code, will be
			 organized and permitted to operate in the state of Idaho without securing a
			 certificate of registration from the Director of insurance. (3-31-22)
02.
Beneficiary Within State
.
			 Registration is mandatory of plans that cover any beneficiary working or
			 residing within this state, unless the plans are exempted by Section
			 41-4103, Idaho Code.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.023 - APPLICATION FOR REGISTRATION

Current through August 31, 2023
01.
Application
. The application needs to include each of the
			 requirements set out in Section
			 41-4105, Idaho Code. The projected
			 income and disbursement statement referenced in Section
			 41-4105(2)(d),
			 Idaho Code, needs to be certified by an actuary meeting the qualifications of
			 Section 41-4105(2)(d),
			 Idaho Code, and accompanied by a description of assumptions used in projecting
			 income and disbursements together with bases used to estimate amounts reserved
			 for claims. (3-31-22)
02.
Joint Powers Agreement
. The joint powers agreement needs to comply
			 with Title 41, Chapter 41 and, to the extent not in conflict with Title 41, the
			 joint powers agreement needs to also comply with Title 67, Chapter 23, Idaho
			 Code. The joint powers agreement needs to contain, at a minimum, the conditions
			 set forth in Section
			 41-4104, Idaho Code.
			 (3-31-22)
03.
Trust
			 Agreement.
(3-31-22)
a. The trust
			 agreement will comply with Title 41, Chapter 41, Idaho Code, and, to the extent
			 not in conflict with Title 41, the trust agreement needs to also comply with
			 Title 68, Idaho Code, and Title 15, Chapter 7, Idaho Code. The trust agreement
			 will contain, at a minimum, the conditions set forth in Section
			 41-4104, Idaho Code.
			 (3-31-22)
b. The term irrevocable
			 as used in Section
			 41-4104(1), Idaho
			 Code, means that the plan sponsor cannot retain a power to alter, amend, revoke
			 or terminate the transfer in trust. The trustee may, pursuant to the terms of
			 the trust agreement, amend the terms of the trust agreement for the purpose of
			 complying with applicable law. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.024 - INVESTIGATION OF PROPOSED APPLICATION FOR REGISTRATION

Current through August 31, 2023
The Director may make an investigation of matters accompanying
				the application for registration as deemed necessary including an examination
				specified in Section
				41-4113, Idaho Code.
				(3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.025 - CONTRIBUTIONS RECEIVABLE

Current through August 31, 2023
The trust fund may take credit in any financial statement for
				contributions receivable which are not in excess of ninety (90) days past due.
				(3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.026 - TRUST FUND RESERVES

Current through August 31, 2023
01.
Reserve
			 Requirements
. The trust fund of a plan needs to continuously maintain
			 reserves, pursuant to Section
			 41-4110, Idaho Code, from
			 inception of the plan, sufficient to fully fund payment of all benefits at the
			 time a claim arises. This reserve needs to adequately provide for all
			 reasonably estimated future claim payments, adjustment expenses, and litigation
			 expenses on claims which have arisen, including claims incurred but not
			 reported, extended benefits and maternity benefits, if any. (3-31-22)
02.
Reserves for Disability Income
			 Benefits
. Reserves established for disability income benefits cannot be
			 less than reserves determined by the Minimum Reserve Standards for Group Health
			 Insurance Contracts set forth the in the NAIC's Accounting Practices and
			 Procedures Manual unless it can be proven to the satisfaction of the Director
			 that a lower reserve can be actuarially justified. (3-31-22)
03.
Certification by Actuary
.
			 Reserves needs to be certified annually by an actuary who meets the
			 requirements of Section
			 41-4105(2)(d),
			 Idaho Code, and such certification needs to be accompanied by a statement
			 describing bases used in reserve determination. The certification will be in a
			 form acceptable to the Director. (3-31-22)
04.
Insolvent Condition
.
			 (3-31-22)
a. Insolvency means that the plan is
			 unable to pay its obligations when they are due, or when its admitted assets do
			 not exceed its liabilities, including needed reserves. (3-31-22)
b. If the determination of reserves reveals
			 an insolvent condition, the Director may allow the plan a period of time not
			 exceeding ninety (90) days to accumulate needed reserves.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.027 - BONDING OR DISHONESTY INSURANCE

Current through August 31, 2023
01.
Certified
			 Copy of Bond
. A certified copy of the fidelity bond or dishonesty
			 policy, as prescribed under Section
			 41-4114(3), Idaho
			 Code, will be furnished to the Director by the plan. (3-31-22)
02.
Cancellation of Bond
			 Requirements
. The bond or dishonesty policy will contain language
			 stating that the bond or policy is noncancellable except upon not less than
			 thirty (30) days advance notice in writing to the trustee and the Director. A
			 copy of any notice cancelling a bond or dishonesty policy prescribed under
			 Chapter 41 is to be forwarded to the Director by the surety or policy provider
			 at the same time it is forwarded to the board. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.06 - GOVERNMENTAL SELF-FUNDED EMPLOYEE HEALTH CARE PLANS RULE › Section 18.04.06.028 - ANNUAL STATEMENT

Current through August 31, 2023
The trustee will file an annual statement within ninety (90)
				days after the close of each fiscal year of the plan and at such other time as
				may be determined by the Director. A quarterly statement will be filed with the
				Director within sixty (60) days of the end of each quarter in a form acceptable
				to the Director. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.07 - RESTRICTIONS ON DISCRETIONARY CLAUSES IN HEALTH INSURANCE CONTRACTS › Section 18.04.07.001 - SCOPE

Current through August 31, 2023
This rule sets forth uniform requirements regarding the use of
				discretionary clauses to be followed by health carriers transacting insurance
				in Idaho. This chapter does not apply to a health insurance contract for group
				coverage offered by or through an employer to its employees. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.07 - RESTRICTIONS ON DISCRETIONARY CLAUSES IN HEALTH INSURANCE CONTRACTS › Section 18.04.07.010 - DEFINITIONS

Current through August 31, 2023
01.
Discretionary Clause
. Any
			 health insurance contract provision that provides the health carrier with sole
			 discretionary authority to determine eligibility for benefits or to interpret
			 the terms and provisions of the health insurance contract. (3-31-22)
03.
Health Care Services
.
			 Services for the diagnosis, prevention, treatment, cure or relief of a health
			 condition, illness, injury, or disease. (3-31-22)
04.
Health Carrier
. An entity
			 subject to regulation under Title 41, Chapters 21, 22, 32, 34, 39, 40, 41, 47,
			 52 or 55, Idaho Code. (3-31-22)
05.
Health Insurance Contract
. Any policy, contract, certificate,
			 agreement, or other form or document providing, defining, or explaining
			 coverage for health care services offered, delivered, issued for delivery,
			 continued, or renewed in this state by a health carrier. (3-31-22)