reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.016 - MINIMUM STANDARDS FOR HOME HEALTH AND COMMUNITY CARE BENEFITS IN LONG-TERM CARE INSURANCE POLICIES

Current through August 31, 2023
01.
Limitations or Exclusions
. A long-term care insurance policy or
			 certificate cannot, if it provides benefits for home health care or community
			 care services, limit or exclude benefits: (3-31-22)
a. By requiring that the insured or claimant
			 would need care in a skilled nursing facility if home health care services were
			 not provided; (3-31-22)
b. By
			 requiring that the insured or claimant first or simultaneously receive nursing
			 or therapeutic services, or both, in a home, community, or institutional
			 setting before home health care services are covered; (3-31-22)
c. By limiting eligible services to services
			 provided by registered nurses or licensed practical nurses; (3-31-22)
d. By requiring that a nurse or therapist
			 provide services covered by the policy that can be provided by a home health
			 aide, or other licensed or certified home care worker acting within the scope
			 of their licensure or certification; (3-31-22)
e. By excluding coverage for personal care
			 services provided by a home health aide; (3-31-22)
f. By requiring that the provision of home
			 health care services be at a level of certification or licensure greater than
			 that prescribed by the eligible service; (3-31-22)
g. By requiring that the insured or claimant
			 have an acute condition before home health care services are covered;
			 (3-31-22)
h. By limiting benefits
			 to services provided by Medicare-certified agencies or providers; or
			 (3-31-22)
i. By excluding coverage
			 for adult day care services. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.017 - REQUIREMENT TO OFFER INFLATION PROTECTION

Current through August 31, 2023
01.
Inflation Protection Offer
. No insurer may offer a long-term care
			 insurance policy unless the insurer also offers to the policyholder in addition
			 to any other inflation protection the option to purchase a policy that provides
			 for benefit levels to increase with benefit maximums or reasonable durations
			 which are meaningful to account for reasonably anticipated increases in the
			 costs of long-term care services covered by the policy. Insurers will offer to
			 each policyholder, at the time of purchase, the option to purchase a policy
			 with an inflation protection feature no less favorable than one (1) of the
			 following: (3-31-22)
a. Increases benefit
			 levels annually in a manner so that the increases are compounded annually at a
			 rate not less than five percent (5%); (3-31-22)
b. Guarantees the insured individual the
			 right to periodically increase benefit levels without providing evidence of
			 insurability or health status as long as the option for the previous period has
			 not been declined. The amount of the additional benefit is no less than the
			 difference between the existing policy benefit and that benefit compounded
			 annually at a rate of at least five percent (5%) for the period beginning with
			 the purchase of the existing benefit and extending until the year in which the
			 offer is made; or (3-31-22)
c.
			 Covers a specified percentage of actual or reasonable charges and does not
			 include a maximum specified indemnity amount or limit. (3-31-22)
d. With respect to inflation protection for a
			 Partnership policy only: (3-31-22)
i. If the
			 policy is sold to an individual who has not attained age sixty-one (61) as of
			 the date of purchase, the policy will provide some level of automatic compound
			 annual inflation protection; (3-31-22)
ii. If the policy is sold to an individual
			 who has attained age sixty-one (61) but has not attained age 76 as of the date
			 of purchase, the policy will provide some level of automatic annual inflation
			 protection; and (3-31-22)
iii. If
			 the policy is sold to an individual who has attained age seventy-six (76) as of
			 the date of purchase, the policy may (but is not prescribed to) provide some
			 level of inflation protection. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.018 - REQUIREMENTS FOR APPLICATION FORMS AND REPLACEMENT COVERAGE

Current through August 31, 2023
01.
Application Forms
.
			 Application forms include the following questions designed to elicit
			 information as to whether, as of the date of the application, the applicant has
			 another long-term care insurance policy or certificate in force or whether a
			 long-term care policy or certificate is intended to replace any other accident
			 and sickness or long-term care policy or certificate presently in force. A
			 supplementary application or other form to be signed by the applicant and
			 producer, except where the coverage is sold without a producer, containing the
			 questions may be used. With regard to a replacement policy issued to a group
			 defined by Section
			 41-4603(a), Idaho
			 Code, the following questions may be modified only to the extent necessary to
			 elicit information about health or long-term care insurance policies other than
			 the group policy being replaced, provided that the certificateholder has been
			 notified of the replacement. (3-31-22)
a. Do
			 you have another long-term care insurance policy or certificate in force
			 (including insurance, Fraternal Benefit Societies, Managed Care Organization)
			 or other similar organizations? (3-31-22)
b. Did you have another long-term care
			 insurance policy or certificate in force during the last twelve (12) months?
			 (3-31-22)
i. If so, with which company?
			 (3-31-22)
ii. If that policy
			 lapsed, when did it lapse? (3-31-22)
c. Are you covered by Medicaid?
			 (3-31-22)
d. Do you intend to
			 replace any of your medical or health insurance coverage with this policy
			 (certificate)? (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.019 - REPORTING REQUIREMENTS

Current through August 31, 2023
01.
Maintenance of Producer Records
. Every insurer maintains records
			 for each producer of that producer's amount of replacement sales as a percent
			 of the producer's total annual sales and the number of lapses of long-term care
			 insurance policies sold by the producer as a percent of the producer's total
			 annual sales, in the format of Appendix G. (3-31-22)
02.
Producers Experiencing Lapses and
			 Replacements
. Every insurer reports annually by June 30 the ten percent
			 (10%) of its producers with the greatest percentages of lapses and replacements
			 as measured by Subsection
			 019.01. (3-31-22)
03.
Purpose of Reports
. Reported
			 replacement and lapse rates do not alone constitute a violation of insurance
			 laws or necessarily imply wrongdoing. The reports are for the purpose of
			 reviewing more closely producer activities regarding the sale of long-term care
			 insurance. (3-31-22)
04.
Lapsed Policies
. Every insurer reports annually by June 30 the
			 number of lapsed policies as a percent of its total annual sales and as a
			 percent of its total number of policies in force as of the end of the preceding
			 calendar year. (3-31-22)
05.
Replacement Policies
. Every insurer reports annually by June 30
			 the number of replacement policies sold as a percent of its total annual sales
			 and as a percent of its total number of policies in force as of the preceding
			 calendar year. (3-31-22)
06.
Claims Denied
. Every insurer reports annually by June 30, for
			 qualified long-term care insurance contracts, the number of claims denied for
			 each class of business, expressed as a percentage of claims denied, other than
			 claims denied for failure to meet the waiting period or because of an
			 applicable preexisting condition, in the format of Appendix E.
			 (3-31-22)
07.
Policies and
			 Reports
. For purposes of Section
			 019, "policy" means only long-term
			 care insurance and "report" means on a statewide basis. (3-31-22)
a. Policy means only long-term care
			 insurance; (3-31-22)
b. Claim means
			 any request for payment of benefits under a policy regardless of whether the
			 benefit claimed is covered under the policy or any terms or conditions of the
			 policy have been met; (3-31-22)
c.
			 Denied means the insurer refused to pay a claim for any reason; and
			 (3-31-22)
d. Report means on a
			 statewide basis. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.020 - LICENSING

Current through August 31, 2023
No producer is authorized to sell, solicit, or negotiate with
				respect to long-term care insurance except as authorized by Title 41, Chapter
				10, Producer Licensing. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.021 - DISCRETIONARY POWERS OF DIRECTOR

Current through August 31, 2023
The director may upon written request and after an
				administrative hearing, issue an order to modify or suspend a specific
				provision or provisions of this rule with respect to a specific long-term care
				insurance policy or certificate upon a written finding that: (3-31-22)
01.
General Requirement
. The
			 modification or suspension would be in the best interest of the insureds; the
			 purposes to be achieved could not be effectively or efficiently achieved
			 without the modification or suspension; and the modification or suspension is
			 necessary to the development of an innovative and reasonable approach for
			 insuring long-term care; or (3-31-22)
02.
Residential Care Community
.
			 The policy or certificate is to be issued to residents of a life care or
			 continuing care retirement community or some other residential community for
			 the elderly and the modification or suspension is reasonably related to the
			 special needs or nature of such a community; or (3-31-22)
03.
Other Insurance Products
.
			 The modification or suspension is necessary to permit long-term care insurance
			 to be sold as part of, or in conjunction with, another insurance product.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.022 - RESERVE STANDARDS

Current through August 31, 2023
01.
Acceleration of Benefits Under Life Policies
. When long-term care
			 benefits are provided through the acceleration of benefits under group or
			 individual life policies or riders to such policies, policy reserves for the
			 benefits are determined in accordance with Section
			 41-612, Idaho Code, Standard
			 Valuation Law - Life Insurance. Claim reserves will also be established in the
			 case when the policy or rider is in claim status. (3-31-22)
02.
Decrement Models
. Reserves
			 for policies and riders subject to Section
			 022 should be based on the multiple
			 decrement model utilizing all relevant decrements except for voluntary
			 termination rates. Single decrement approximations are acceptable if the
			 calculation produces essentially similar reserves, if the reserve is clearly
			 more conservative, or if the reserve is immaterial. The calculations may take
			 into account the reduction in life insurance benefits due to the payment of
			 long-term care benefits. However, in no event can the reserves for the
			 long-term care benefit and the life insurance benefit be less than the reserves
			 for the life insurance benefit assuming no long-term care benefit.
			 (3-31-22)
03.
Considerations
			 Impacting Projected Claim Costs
. Any applicable valuation morbidity
			 table is certified as appropriate as a statutory valuation table by a member of
			 the American Academy of Actuaries. In the development and calculation of
			 reserves for policies and riders subject to Section
			 022, due regard is given to the
			 applicable policy provisions, marketing methods, administrative procedures and
			 all other considerations which have an impact on projected claim costs,
			 including, but not limited to, the following: (3-31-22)
a. Definition of insured events;
			 (3-31-22)
b. Covered long-term care
			 facilities; (3-31-22)
c. Existence
			 of home convalescence care coverage; (3-31-22)
d. Definition of facilities;
			 (3-31-22)
e. Existence or absence
			 of barriers to eligibility; (3-31-22)
f. Premium waiver provision;
			 (3-31-22)
g. Renewability;
			 (3-31-22)
h. Ability to raise
			 premiums; (3-31-22)
i. Marketing
			 method; (3-31-22)
j. Underwriting
			 procedures; (3-31-22)
k. Claims
			 adjustment procedures; (3-31-22)
l.
			 Waiting period; (3-31-22)
m.
			 Maximum benefit; (3-31-22)
n.
			 Availability of eligible facilities; (3-31-22)
o. Margins in claim costs;
			 (3-31-22)
p. Optional nature of
			 benefit; (3-31-22)
q. Delay in
			 eligibility for benefit; (3-31-22)
r. Inflation protection provisions; and
			 (3-31-22)
s. Guaranteed
			 insurability option. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.023 - LOSS RATIO

Current through August 31, 2023
Section
				023 applies to all (group and
				individual) long-term care insurance policies or certificates except those
				covered under Sections
				024 and
				025 of this chapter.
				(3-31-22)
01.
Expected Loss
			 Ratios
. Benefits under long-term care insurance policies are reasonable
			 in relation to premiums provided the expected loss ratio is at least sixty
			 percent (60%), calculated in a manner which provides for adequate reserving of
			 the long-term care insurance risk. In evaluating the expected loss ratio, due
			 consideration is given to all relevant factors, including: (3-31-22)
a. Statistical credibility of incurred claims
			 experience and earned premiums; (3-31-22)
b. The period for which rates are computed to
			 provide coverage; (3-31-22)
c.
			 Experienced and projected trends; (3-31-22)
d. Concentration of experience within early
			 policy duration; (3-31-22)
e.
			 Expected claim fluctuation; (3-31-22)
f. Experience refunds, adjustments or
			 dividends; (3-31-22)
g.
			 Renewability features; (3-31-22)
h.
			 All appropriate expense factors; (3-31-22)
i. Interest; (3-31-22)
j. Experimental nature of the coverage;
			 (3-31-22)
k. Policy reserves;
			 (3-31-22)
l. Mix of business by
			 risk classification; and (3-31-22)
m. Product features such as long elimination
			 periods, high deductibles and high maximum limits.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.025 - PREMIUM RATE SCHEDULE INCREASES

Current through August 31, 2023
01.
Premium
			 Rate Increase Notice
. An insurer provides notice of a pending premium
			 rate schedule increase, including an exceptional increase, to the director at
			 least thirty (30) days prior to the notice to the policyholders and includes:
			 (3-31-22)
a. Information prescribed by Section
			 014. (3-31-22)
b. Certification by a qualified actuary that:
			 (3-31-22)
i. If the requested premium rate
			 schedule increase is implemented and the underlying assumptions, which reflect
			 moderately adverse conditions, are realized, no further premium rate schedule
			 increases are anticipated; and (3-31-22)
ii. The premium rate filing is in compliance
			 with the provisions of this Section
			 025.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.026 - FILING REQUIREMENTS FOR ADVERTISING

Current through August 31, 2023
01.
Filing
			 and Retention
. Every Insurer, Fraternal Benefit Society, Managed Care
			 Organization, or other similar organization providing long-term care insurance
			 or benefits in this state provides a copy of any long-term care insurance
			 advertisement intended for use in this state whether through written, radio, or
			 television medium to the Director of Insurance of this state for review and
			 approval by the Director. In addition, all advertisements are retained by the
			 insurer or other entity for at least five (5) years from the date the
			 advertisement was first used; or until the filing of the next regular report of
			 examination of the insurer, whichever is the longer period of time.
			 (3-31-22)
02.
Exemptions
. The director may exempt from these requirements any
			 advertising form or material when, in the director's opinion, this requirement
			 cannot be reasonably applied. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.027 - STANDARDS FOR MARKETING AND PRODUCER TRAINING

Current through August 31, 2023
01.
General Provisions
. Every Insurer, Fraternal Benefit Society,
			 Managed Care Organization or other similar organization marketing long-term
			 care insurance coverage in this state, directly or through its producers, will:
			 (3-31-22)
a. Establish marketing procedures
			 and producer training requirements to assure that any marketing activities,
			 including any comparison of policies by its producers will be fair and
			 accurate. (3-31-22)
b. Establish
			 marketing procedures to assure excessive insurance is not sold or issued.
			 (3-31-22)
c. Display prominently by
			 type, stamp or other appropriate means, on the first page of the outline of
			 coverage and policy the following: "Notice to buyer: This policy cannot cover
			 all of the costs associated with long-term care incurred by the buyer during
			 the period of coverage. The buyer is advised to review carefully all policy
			 limitations." (3-31-22)
d. Provide
			 copies of the disclosure forms prescribed in Subsection
			 014.10. (3-31-22)
e. Provide an explanation of contingent
			 benefit upon lapse as provided for in Subsection
			 032.04.b. and if applicable,
			 the additional contingent benefit upon lapse provided to policies with fixed or
			 limited premium paying period in Subsection
			 032.04.c. (3-31-22)
f. Inquire and make every reasonable effort
			 to identify whether a prospective applicant or enrollee for long-term care
			 insurance already has accident and sickness or long-term care insurance and the
			 types and amounts of any such insurance, except that in the case of qualified
			 long-term care insurance contracts, an inquiry into whether a prospective
			 applicant or enrollee for long-term care insurance has accident and sickness
			 insurance is not prescribed. (3-31-22)
g. Establish auditable procedures for
			 verifying compliance with Subsection
			 027.01. (3-31-22)
h. At solicitation, provide written notice to
			 the prospective policyholder and certificateholder that Senior Health Insurance
			 Benefits Advisors/SHIBA the program is available and the name, address and
			 telephone number of the program. (3-31-22)
i. For long-term care insurance policies and
			 certificates, use the terms "noncancellable" or "level premium" only when the
			 policy or certificate conforms to Subsection
			 011.01.c. of this chapter.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.028 - SUITABILITY

Current through August 31, 2023
01.
Life Insurance Policies That
			 Accelerate Benefits
. Section
			 028 cannot apply to life insurance
			 policies that accelerate benefits for long-term care. (3-31-22)
02.
General Provisions
. Every
			 Insurer, Fraternal Benefit Society, Managed Care Organization or other similar
			 organization marketing long-term care insurance (the "issuer") will: (3-31-22)
a. Develop and use suitability standards to
			 determine whether the purchase or replacement of long-term care insurance is
			 appropriate for the needs of the applicant; (3-31-22)
b. Train its producers in the use of its
			 suitability standards; and (3-31-22)
c. Maintain a copy of its suitability
			 standards and make them available for inspection upon request by the director.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.029 - PROHIBITION AGAINST PREEXISTING CONDITIONS AND PROBATIONARY PERIODS IN REPLACEMENT POLICIES OR CERTIFICATES

Current through August 31, 2023
If a long-term care insurance policy or certificate replaces
				another long-term care policy or certificate, the replacing insurer waives any
				time periods applicable to preexisting conditions and probationary periods in
				the new long-term care policy for similar benefits to the extent that similar
				exclusions have been satisfied under the original policy. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.030 - AVAILABILITY OF NEW SERVICES OR PROVIDERS

Current through August 31, 2023
01.
Notification to Policyholder
. An insurer notifies the policyholder
			 of the availability of a new long term care policy that provides coverage for
			 new long-term care services or providers material in nature and not previously
			 available through the insurer to the general public. The notice is provided
			 within twelve (12) months of the date the new policy is made available for sale
			 in this state. (3-31-22)
02.
Exceptions to Notification Requirements
. Notwithstanding
			 Subsection 030.01, notification is not
			 prescribed for any policy issued prior to the effective date of this Section
			 030 or to any policyholder who is
			 currently eligible for benefits, within an elimination period or on claim, or
			 who previously has been in claim status, or who would not be eligible to apply
			 for coverage due to issue age limitations under the new policy. The insurer may
			 require that policyholders meet all eligibility requirements, including
			 underwriting and payment of the prescribed premium to add such new services or
			 providers. (3-31-22)
03.
New
			 Coverage
. The insurer makes the new coverage available in one of the
			 following ways: (3-31-22)
a. By adding a rider
			 to the existing policy and charging a separate premium for the new rider based
			 on the insured's attained age; (3-31-22)
b. By exchanging the existing policy or
			 certificate for one with an issue age based on the present age of the insured
			 and recognizing past insured status by granting premium credits toward the
			 premiums for the new policy or certificate. The premium credits are based on
			 premiums paid or reserves held for the prior policy or certificate.
			 (3-31-22)
c. By exchanging the
			 existing policy or certificate for a new policy or certificate in which
			 consideration for past insured status is recognized by setting the premium for
			 the new policy or certificate at the issue age of the policy or certificate
			 being exchanged. The cost of the new policy or certificate may recognize the
			 difference in reserves between the new policy or certificate and the original
			 policy or certificate; or (3-31-22)
d. By an alternative program developed by the
			 insurer that meets the intent of Section
			 030 if the program is filed with
			 and approved by the Director. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.031 - RIGHT TO REDUCE COVERAGE AND LOWER PREMIUMS

Current through August 31, 2023
01.
Reduction of Coverage
. Every long-term care insurance policy and
			 certificate includes a provision that allows the policyholder or
			 certificateholder to reduce coverage and lower the policy or certificate
			 premium in at least one of the following ways: (3-31-22)
a. Reducing the maximum benefit; or
			 (3-31-22)
b. Reducing the daily,
			 weekly or monthly benefit amount. (3-31-22)
c. The insurer may also offer other reduction
			 options that are consistent with the policy or certificate design or the
			 carrier's administrative processes. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.032 - NONFORFEITURE BENEFIT REQUIREMENT

Current through August 31, 2023
01.
Life
			 Insurance Policies That Accelerate Benefits
. Section
			 032 does not apply to life
			 insurance policies or riders containing accelerated long-term care benefits.
			 (3-31-22)
02.
Nonforfeiture
			 Benefits
. To comply with the requirement to offer a nonforfeiture
			 benefit pursuant to the provisions of Section
			 41-4607, Idaho Code, every
			 Insurer, Fraternal Benefit Society, Managed Care Organization, or other similar
			 organization marketing long-term care insurance coverage in this state
			 satisfies the following: (3-31-22)
a. A policy
			 or certificate offered with nonforfeiture benefits will have coverage elements,
			 eligibility, benefit triggers and benefit length that are the same as coverage
			 to be issued without nonforfeiture benefits. The nonforfeiture benefit included
			 in the offer is the benefit described in Subsection
			 032.04.e. (3-31-22)
b. The offer is in writing if the
			 nonforfeiture benefit is not described in the Outline of Coverage or other
			 materials given to the prospective policyholder. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.033 - STANDARDS FOR BENEFIT TRIGGERS

Current through August 31, 2023
01.
Conditions of Benefits Payment
. A long-term care insurance policy
			 conditions the payment of benefits on a determination of the insured's ability
			 to perform activities of daily living and on cognitive impairment. Eligibility
			 for the payment of benefits is not more restrictive than requiring either a
			 deficiency in the ability to perform not more than three (3) of the activities
			 of daily living or the presence of cognitive impairment. (3-31-22)
02.
Activities of Daily Living
.
			 Insurers may use activities of daily living to trigger covered benefits in
			 addition to those contained in Subsection
			 033.02 as long as they are
			 defined in the policy. Activities of daily living includes at least the
			 following as defined in Section
			 010 and in the policy. (3-31-22)
a. Bathing; (3-31-22)
b. Continence; (3-31-22)
c. Dressing; (3-31-22)
d. Eating; (3-31-22)
e. Toileting; and (3-31-22)
f. Transferring.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.034 - ADDITIONAL STANDARDS FOR BENEFIT TRIGGERS FOR QUALIFIED LONG-TERM CARE INSURANCE CONTRACTS

Current through August 31, 2023
01.
Definitions
. For purposes of Section
			 034 the following definitions
			 apply: (3-31-22)
a. Qualified long-term care
			 services means services that meet the requirements of Section
			 7702B(a)(1)  of
			 the Internal Revenue Code of 1986, as amended, as follows: necessary
			 diagnostic, preventive, therapeutic, curative, treatment, mitigation, and
			 rehabilitative services and maintenance or personal care services which are
			 prescribed by a chronically ill individual, and are provided pursuant to a plan
			 of care prescribed by a licensed health care practitioner. (3-31-22)
b. Chronically ill individual has the meaning
			 prescribed for this term by Section
			 7702B(c)(2)  of
			 the Internal Revenue Code of 1986, as amended. Under this provision, a
			 chronically ill individual means any individual who has been certified by a
			 licensed health care practitioner as: (3-31-22)
i. Being unable to perform (without
			 substantial assistance from another individual) at least two (2) activities of
			 daily living for a period of at least ninety (90) days due to a loss of
			 functional capacity; or (3-31-22)
ii. Requiring substantial supervision to
			 protect the individual from threats to health and safety due to severe
			 cognitive impairment. (3-31-22)
c. The term chronically ill individual cannot
			 include an individual meeting these requirements unless within the preceding
			 twelve (12) month period a licensed health care practitioner has certified that
			 the individual meets these requirements. (3-31-22)
d. Licensed health care practitioner means a
			 physician, as defined in Section
			 1861(r)(1)  of
			 the Social Security Act, and a registered professional nurse, licensed social
			 worker, or other individual who meets requirements prescribed by the Secretary
			 of the Treasury. (3-31-22)
e.
			 Maintenance or personal care services means any care, the primary purpose of
			 which is the provision of needed assistance with any of the disabilities, the
			 existence of which leads to the conclusion that the individual is a chronically
			 ill individual (including the protection from threats to health and safety due
			 to severe cognitive impairment). (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.035 - STANDARD FORMAT OUTLINE OF COVERAGE

Current through August 31, 2023
Section
				035 of the rule implements,
				interprets and makes specific, the provisions of Section
				41-4605(7)(a),
				Idaho Code, in prescribing a standard format and the content of an outline of
				coverage. (3-31-22)
01.
Format
. The outline of coverage is a freestanding document, using
			 no smaller than ten (10) point type. Text that is capitalized or underscored in
			 the standard format outline of coverage may be emphasized by other means that
			 provide prominence equivalent to the capitalization or underscoring.
			 (3-31-22)
02.
Content
.
			 The outline of coverage contains no material of an advertising nature.
			 (3-31-22)
03.
Standard
			 Form
. Use of the text and sequence of text of the standard format
			 outline of coverage is mandatory, unless otherwise specifically indicated.
			 Format for the outline of coverage is published on the Department of Insurance
			 website. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.036 - REQUIREMENT TO DELIVER SHOPPER'S GUIDE

Current through August 31, 2023
01.
Approved
			 Format
. A long-term care insurance shopper's guide in the format
			 developed by the National Association of Insurance Commissioners, or a guide
			 developed or approved by the director, is provided to all prospective
			 applicants of a long-term care insurance policy or certificate. (3-31-22)
a. In the case of producer solicitations, a
			 producer will deliver the shopper's guide prior to the presentation of an
			 application or enrollment form. (3-31-22)
b. In the case of direct response
			 solicitations, the shopper's guide will be presented in conjunction with any
			 application or enrollment form. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.037 - PENALTIES

Current through August 31, 2023
In addition to any other penalties provided by the laws of this
				state any insurer and any producer found to have violated any requirement of
				this state relating to the marketing of such insurance or of IDAPA 18.04.11,
				"Long-Term Care Insurance Minimum Standards," is subject to an administrative
				penalty of up to three (3) times the amount of any commissions paid for each
				policy involved in the violation or up to ten thousand dollars ($10,000),
				whichever is greater. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. IDAPA 18.04.12, "The Small Employer Health Insurance and
			 Availability Act." (3-31-22)
02.
Scope
. The Act and this chapter are intended to promote broader
			 spreading of risk in the small employer marketplace and to regulate all health
			 benefit plans sold to small employers, whether sold directly or through
			 associations or other groupings of small employers. Carriers that provide
			 health benefit plans to small employers are intended to be subject to all of
			 the provisions of the Act and this chapter. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.010 - DEFINITIONS

Current through August 31, 2023
As used in this chapter: (3-31-22)
01.
Associate Member
. Any
			 individual who participates in an employee benefit plan (as defined in
			 29 U.S.C. Section
			 1002(1) ) that is a
			 multi-employer plan (as defined in
			 29 U.S.C. Section
			 1002(37A) ), other than the
			 following: (3-31-22)
a. An individual (or the
			 beneficiary of such individual) who is employed by a participating employer
			 within a bargaining unit covered by at least one (1) of the collective
			 bargaining agreements under or pursuant to which the employee benefit plan is
			 established or maintained; or (3-31-22)
b. An individual who is a present or former
			 employee (or a beneficiary of such employee) of the sponsoring employee
			 organization, of an employer who is or was a party to at least one (1) of the
			 collective bargaining agreements under or pursuant to which the employee
			 benefit plan is established or maintained, or of the employee benefit plan (or
			 of a related plan). (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.011 - ASSESSMENTS

Current through August 31, 2023
Prior to March 1st of each year the Board determines and files
				with the Director an estimate of the assessments needed to fund the losses
				incurred by the Idaho Small Employer Reinsurance Program in the previous
				calendar year. This interim assessment is based on the assessment formula set
				forth in Section
				41-4711(12)(c),
				Idaho Code. Initial or interim assessments paid will be credited to each
				carrier's account when the amounts needed to fund losses and pay program
				expenses are known. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.015 - APPLICABILITY

Current through August 31, 2023
01.
Applicability
. This chapter
			 applies to any health benefit plan provided on a group basis, that: (3-31-22)
a. Meets one (1) or more of the conditions
			 set forth in Section
			 41-4704, Idaho Code; and
			 (3-31-22)
b. Offers coverage to two
			 (2) or more eligible employees of a small employer located in this state,
			 without regard to whether the policy or certificate was issued in this state.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.021 - ESTABLISHMENT OF CLASSES OF BUSINESS

Current through August 31, 2023
01.
Supporting Documentation for Establishment of Classes of Business
.
			 A small employer carrier that establishes more than one class of business
			 pursuant to the provisions of Section
			 41-4705, Idaho Code, maintains on
			 file for inspection by the Director the following information with respect to
			 each class of business so established: (3-31-22)
a. A description of each criterion employed
			 by the carrier (or any of its agents) for determining membership in the class
			 of business; (3-31-22)
b. A
			 statement describing the justification for establishing the class as a separate
			 class of business and documentation that the establishment of the class of
			 business is intended to reflect substantial differences in expected claims
			 experience or administrative costs related to the reasons set forth in Section
			 41-4705, Idaho Code; and
			 (3-31-22)
c. A statement disclosing
			 that, if any, health benefit plans are currently available for purchase in the
			 class and any significant limitations related to the purchase of such plans.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.028 - TRANSITION FOR ASSUMPTIONS OF BUSINESS FROM ANOTHER CARRIER

Current through August 31, 2023
01.
Conditions for Transfer or
			 Assumption of Entire Insurance Obligation
. A small employer carrier will
			 not transfer or assume the entire insurance obligation and/or risk of a health
			 benefit plan covering a small employer in this state unless: (3-31-22)
a. The transaction received any necessary
			 approval of the insurance supervisory official of the state of domicile of the
			 assuming carrier; (3-31-22)
b. The
			 transaction received any necessary approval of the insurance supervisory
			 official of the state of domicile of the ceding carrier; and,
			 (3-31-22)
c. The transaction meets
			 the other requirements of this Section. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.036 - RESTRICTIONS RELATING TO PREMIUM RATES

Current through August 31, 2023
The following provisions are applicable for all small employer
				health benefit plans. (3-31-22)
01.
Separate Rate Manual for Each Class of Business
. A small employer
			 carrier develops a separate rate manual for each class of business. Base
			 premium rates and new business premium rates charged to small employers by the
			 small employer carrier are computed solely from the applicable rate manual
			 developed pursuant to this Section. To the extent that a portion of the premium
			 rates charged by a small employer carrier is based on the carrier's discretion,
			 the manual specifies the criteria and factors considered by the carrier in
			 exercising such discretion. (3-31-22)
02.
Requirements for Adjustments to
			 Rating Method
. A small employer carrier will not modify the rating
			 method used in the rate manual for a class of business until the change has
			 been approved as provided in this Section. The Director may approve a change to
			 a rating method if the Director finds that the change is reasonable,
			 actuarially appropriate, and consistent with the purposes of the Act and this
			 chapter. (3-31-22)
03.
Information for Review of Modification of Rating Method
. A carrier
			 may modify the rating method for a class of business only with prior approval
			 of the Director. A carrier requesting to change the rating method for a class
			 of business makes a filing with the Director at least thirty (30) days prior to
			 the proposed date of the change. The filing contains at least the following
			 information: (3-31-22)
a. The reasons the
			 change in rating method is being requested; (3-31-22)
b. A complete description of each of the
			 proposed modifications to the rating method; (3-31-22)
c. A description of how the change in rating
			 method would affect the premium rates currently charged to small employers in
			 the class of business, including an estimate from a qualified actuary of the
			 number of groups or individuals (and a description of the types of groups or
			 individuals) whose premium rates may change by more than ten percent (10%) due
			 to the proposed change in rating method (not generally including increases in
			 premium rates applicable to all small employers in a health benefit plan);
			 (3-31-22)
d. A certification from a
			 qualified actuary that the new rating method would be based on objective and
			 credible data and would be actuarially sound and appropriate; and
			 (3-31-22)
e. A certification from a
			 qualified actuary that the proposed change in rating method would not produce
			 premium rates for small employers that would be in violation of Section
			 41-4706, Idaho Code.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.055 - APPLICATION TO REENTER STATE

Current through August 31, 2023
Restrictions on offering small group health insurance. A
				carrier that has been banned from writing coverage for small employers in this
				state pursuant to Section
				41-4707(2), Idaho
				Code, will not resume offering health benefit plans to small employers in this
				state until the carrier has made a petition to the Director to be reinstated as
				a small employer carrier and the petition has been approved by the Director. In
				reviewing a petition, the Director may ask for such information and assurances
				as the Director finds reasonable and appropriate. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.060 - QUALIFYING PREVIOUS AND QUALIFYING EXISTING COVERAGES

Current through August 31, 2023
01.
Previous Coverage or Existing
			 Coverage
. In determining whether a health benefit plan or other health
			 benefit arrangement (whether public or private) is considered qualifying
			 previous coverage or qualifying existing coverage for the purposes of Sections
			 41-4703(17),
			 41-4703(23), and
			 41-4708(3)(c),
			 Idaho Code, a small employer carrier interprets the Act no less favorably to an
			 insured individual than the following: (3-31-22)
a. A health benefit plan, certificate, or
			 other health benefit arrangement is considered employer-based if an employer
			 sponsors the plan or arrangement or makes a contribution to the plan or
			 arrangement. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.067 - RESTRICTIVE RIDERS

Current through August 31, 2023
Except as permitted in Section
				41-4708(3), Idaho
				Code, a small employer carrier will not modify or restrict any health benefit
				plan with respect to any eligible employee or dependent of an eligible
				employee, through riders, endorsements or otherwise, for the purpose of
				restricting or excluding the coverage or benefits provided to such employee or
				dependent for specific diseases, medical conditions, including but not limited
				to pregnancy, or services otherwise covered by the plan. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.12 - THE SMALL EMPLOYER HEALTH INSURANCE AND AVAILABILITY ACT › Section 18.04.12.075 - RULES RELATED TO FAIR MARKETING

Current through August 31, 2023
01.
Small
			 Employer Carrier to Actively Market
. A small employer carrier actively
			 markets each of its health benefit plans to small employers in this state.
			 (3-31-22)
02.
Marketing
			 Mandated Plans
. In marketing the mandated health benefit plans to small
			 employers, a small employer carrier uses at least the same sources and methods
			 of distribution that it uses to market other health benefit plans to small
			 employers. Any producer authorized by a small employer carrier to market health
			 benefit plans to small employers in the state is also authorized to market the
			 mandated health benefit plans. (3-31-22)
03.
Offer in Writing
. A small
			 employer carrier offers all small group health benefit plans to any small
			 employer that applies for or makes an inquiry regarding health insurance
			 coverage from the small employer carrier. The offer may be provided directly to
			 the small employer or delivered through a producer. The offer is in writing and
			 includes at least the following information: (3-31-22)
a. A general description of the benefits and
			 base rates contained in all actively marketed, including but not limited to the
			 mandated, health benefit plans; and (3-31-22)
b. Information describing how the small
			 employer may enroll in the plans. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.13 - THE INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT › Section 18.04.13.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. IDAPA 18.04.13, "The Individual Health Insurance
			 Availability Act." (3-31-22)
02.
Scope
. The Act and this chapter are intended to promote broader
			 spreading of risk in the individual marketplace. The Act and chapter are
			 intended to regulate all health benefit plans sold to eligible individuals.
			 Carriers that provide health benefit plans to eligible individuals are intended
			 to be subject to all of the provisions of the Act and this chapter.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.13 - THE INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT › Section 18.04.13.002 - INCORPORATION BY REFERENCE

Current through August 31, 2023
The Outline of Coverage for Individual Major Medical Expense
				Coverage is incorporated by reference into this chapter from the April 1999
				version of the National Association of Insurance Commissioners Model Regulation
				to Implement the Accident and Sickness Insurance Minimum Standards Act.
				(3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.13 - THE INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT › Section 18.04.13.010 - DEFINITIONS

Current through August 31, 2023
As used in this chapter: (3-31-22)
01.
Geographic Area
. Geographic
			 areas are limited to six (6) designated areas, with no area being smaller than
			 a county. (3-31-22)
02.
Risk
			 Characteristic
. Risk Characteristic means the health status, claims
			 experience, duration of coverage, or any similar characteristic related to the
			 health status or claims experience of an individual. Such characteristics can
			 include family composition. (3-31-22)
03.
Risk Load
. Risk Load means
			 the percentage above the applicable base premium rate that is charged by an
			 individual carrier to the rates of the eligible individual, to reflect the risk
			 characteristics of the eligible individual. (3-31-22)
04.
Idaho Resident
. Idaho
			 resident means a person who is able to provide satisfactory proof of having
			 resided in Idaho, as their place of domicile for a continuous six (6) month
			 period, for purposes of being an eligible individual pursuant to Section
			 41-5203(10),
			 Idaho Code. The six (6) month residency requirements would be waived for
			 eligible individuals based on the Health Insurance Portability and
			 Accountability Act of 1996. (3-31-22)