reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. IDAPA 18.04.08, "Individual and Group Supplementary
			 Disability Insurance Minimum Standards Rule." (3-31-22)
02.
Purpose
. The purpose of this
			 chapter is to implement Title 41, Chapters 21, 22, 34, and 42, Idaho Code, to
			 standardize and simplify the terms and coverages of individual and group
			 supplementary disability insurance, to facilitate public understanding and
			 comparison of coverage, to eliminate provisions that may be misleading or
			 confusing in connection with the purchase of the coverages or with the
			 settlement of claims, and to provide for full disclosure in the marketing and
			 sale of such insurance. (3-31-22)
03.
Applicability and Scope
.
			 This chapter applies to all individual and group policies and certificates
			 providing hospital confinement indemnity, disability income protection,
			 accident only, specified disease, specified accident, or limited benefit health
			 coverage, referred to collectively in this chapter as "supplementary disability
			 insurance," offered, delivered, issued for delivery, or renewed in this state
			 or to a resident of this state, unless specifically exempted. (3-31-22)
a. This chapter applies to dental plans and
			 vision plans only as specified. (3-31-22)
b. This chapter applies to group
			 supplementary plans whether issued to supplement a group health benefit plan,
			 or as a supplementary plan that pays benefits regardless of other coverage.
			 (3-31-22)
c. This chapter does not
			 apply to: (3-31-22)
i. Individual policies or
			 contracts issued pursuant to a conversion privilege under a group policy or
			 certificate. (3-31-22)
ii. Policies
			 issued to employees or members as additions to franchise plans.
			 (3-31-22)
iii. Medicare supplement
			 policies subject to Title 41, Chapter 44, Idaho Code, Medicare Supplement
			 Insurance Minimum Standards. (3-31-22)
iv. Long-term care insurance policies subject
			 to Title 41, Chapter 46, Idaho Code, Long Term Care Insurance.
			 (3-31-22)
v. Civilian Health and
			 Medical Program of the Uniformed Services, Title 10, Chapter 55, of the United
			 States Code, (CHAMPUS) supplement insurance policies. (3-31-22)
vi. Individual or group major medical expense
			 coverage, including short-term coverage.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.002 - INCORPORATION BY REFERENCE

Current through August 31, 2023
01.
Copies
. May be obtained from the Idaho Department of Insurance.
			 (3-31-22)
02.
Documents
			 Incorporated by Reference
. The following Outlines of Coverage and
			 notices are incorporated by reference from the April 1999 version of the NAIC
			 Model Regulation to Implement the Accident and Sickness Insurance Minimum
			 Standards Act: (3-31-22)
a. Hospital
			 Confinement Indemnity Coverage. (3-31-22)
b. Disability Income Protection Coverage.
			 (3-31-22)
c. Accident Only
			 Coverage. (3-31-22)
d. Specified
			 Disease. (3-31-22)
e. Specified
			 Accident. (3-31-22)
f. Limited
			 Benefit Health Coverage. (3-31-22)
g. Dental Plans. (3-31-22)
h. Vision Plans. (3-31-22)
i. Notice to Applicant Regarding Replacement
			 of Accident and Sickness Insurance (direct sales). (3-31-22)
j. Notice to Applicant Regarding Placement of
			 Accident and Sickness Insurance (other than direct sales).
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.010 - DEFINITIONS

Current through August 31, 2023
01.
Accident Only Coverage
.
			 "Accident Only Coverage" means a policy or certificate that provides coverage,
			 singly or in combination, for death, dismemberment, disability or hospital and
			 medical care caused by an accident, and does not provide coverage for
			 non-accidents. (3-31-22)
02.
Dental Coverage
. "Dental Coverage" means a policy or certificate
			 that primarily provides benefits for dental expenses. (3-31-22)
03.
Disability Income Protection
			 Coverage
. "Disability Income Protection Coverage" means a policy or
			 certificate that provides for periodic payments, weekly or monthly, for a
			 specified period during the continuance of disability resulting from either
			 sickness or injury or a combination of both. (3-31-22)
04.
Hospital Confinement Indemnity
			 Coverage
. "Hospital Confinement Indemnity Coverage" means a policy or
			 certificate of accident and sickness insurance that provides daily benefits for
			 hospital confinement on an indemnity basis, meaning the benefit is a fixed
			 dollar amount per day of confinement, regardless of the expenses incurred.
			 (3-31-22)
05.
Limited Benefit
			 Health Coverage
. "Limited Benefit Health Coverage" means a policy or
			 certificate that provides benefits that are less than the minimum standards
			 under Sections 035 through
			 039 of this chapter.
			 (3-31-22)
06.
Major Medical
			 Expense Coverage
. "Major Medical Expense Coverage" means a policy of
			 accident and sickness insurance that provides hospital, medical and surgical
			 expense coverage. (3-31-22)
07.
Specified Accident Coverage
. "Specified Accident Coverage" means a
			 policy or certificate that provides coverage for a specifically identified kind
			 of accident (or accidents) for each person insured under the coverage for
			 accidental death or accidental death and dismemberment combined.
			 (3-31-22)
08.
Specified
			 Disease Coverage
. "Specified Disease Coverage" means a policy or
			 certificate that pays benefits only after the diagnosis of a specifically named
			 disease or diseases. (3-31-22)
09.
Vision Coverage
. "Vision Coverage" means a policy or certificate
			 that primarily provides benefits for vision expenses. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.011 - POLICY DEFINITIONS AND TERMS

Current through August 31, 2023
Except as provided in this chapter, an insurance policy or
				certificate to which this chapter applies will not include definitions more
				restrictive than the following: (3-31-22)
01.
Accident
. "Accident,"
			 "accidental injury," and "accidental" is to employ "result" language and does
			 not include words that establish an accidental means test or use words such as
			 "external, violent, visible wounds" or similar words of description or
			 characterization. (3-31-22)
a. "Injury" or
			 "injuries" means accidental bodily injury sustained by the insured person that
			 is the direct cause of the condition for which benefits are provided,
			 independent of disease or bodily infirmity or any other cause, and that occurs
			 while the insurance is in force. (3-31-22)
b. It may exclude injuries for which benefits
			 are provided: (3-31-22)
i. Under workers'
			 compensation, employers' liability, or similar law; or (3-31-22)
ii. Under a motor vehicle no-fault plan,
			 unless the motor vehicle no-fault plan provides for coordination of benefits;
			 or (3-31-22)
iii. For injuries
			 occurring while the insured person is engaged in any activity pertaining to a
			 trade, business, employment or occupation for wage or profit.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.020 - BANNED POLICY PROVISIONS

Current through August 31, 2023
01.
Probationary or Waiting Period
. Except as provided in Subsection
			 011.10 pertaining to the
			 definition of a preexisting condition or Paragraph 038.02.e. of this chapter
			 regarding specified disease coverage, a policy or certificate will not contain
			 provisions establishing a probationary or waiting period during which no
			 coverage is provided under the policy or certificate. Accident policies will
			 not contain probationary or waiting periods. (3-31-22)
02.
Additional Coverage as
			 Dividend
. A policy or rider for additional coverage will not be issued
			 as a dividend unless an equivalent cash payment is offered as an alternative to
			 the dividend policy or rider. A dividend policy or rider for additional
			 coverage will not be issued for an initial term of less than six (6) months.
			 (3-31-22)
a. The initial renewal subsequent to
			 the issuance of a policy or rider as a dividend will clearly disclose that the
			 policyholder is renewing the coverage that was provided as a dividend for the
			 previous term and that the renewal is optional. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.035 - HOSPITAL CONFINEMENT INDEMNITY COVERAGE

Current through August 31, 2023
01.
Minimum Standards for Benefits
. The following minimum standards
			 apply: (3-31-22)
a. Provides daily benefits
			 for hospital confinement on an indemnity basis in an amount not less than forty
			 dollars ($40) per day; and (3-31-22)
b. Provides benefits for not less than
			 thirty-one (31) days during each period of confinement for each person insured
			 under the policy. (3-31-22)
c.
			 Benefits will be paid regardless of other coverage.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.036 - DISABILITY INCOME PROTECTION COVERAGE

Current through August 31, 2023
01.
Minimum
			 Standards for Benefits
. The following minimum standards apply to
			 disability income protection coverage: (3-31-22)
a. Provides that periodic payments that are
			 payable at ages after sixty-two (62) and reduced solely on the basis of age are
			 at least fifty percent (50%) of amounts payable immediately prior to sixty-two
			 (62); (3-31-22)
b. Contains an
			 elimination period no greater than: (3-31-22)
i. Ninety (90) days in the case of a coverage
			 providing a benefit of one year (1) or less; (3-31-22)
ii. One hundred and eighty (180) days in the
			 case of coverage providing a benefit of more than one (1) year but not greater
			 than two (2) years; or (3-31-22)
iii. Three hundred sixty-five (365) days in
			 all other cases during the continuance of disability resulting from sickness or
			 injury; (3-31-22)
c. Has
			 a maximum period of time for which it is payable during disability of at least
			 six (6) months. No reduction in benefits is put into effect because of an
			 increase in Social Security or similar benefits during a benefit period.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.037 - ACCIDENT ONLY COVERAGE

Current through August 31, 2023
01.
Minimum
			 Standards for Benefits
. The following minimum standards apply to
			 accident only coverage: (3-31-22)
a.
			 Accidental death and double dismemberment amounts under the policy or
			 certificate are at least one thousand dollars ($1,000); (3-31-22)
b. A single dismemberment amount is at least
			 five hundred dollars ($500); and (3-31-22)
c. Benefits for disability, hospital or
			 medical care will be as defined in the policy or certificate.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.039 - SPECIFIED ACCIDENT COVERAGE

Current through August 31, 2023
01.
Minimum
			 Standards for Benefits
. The following minimum standards apply to
			 specified accident coverage: (3-31-22)
a. A
			 benefit amount not less than one thousand dollars ($1,000) for accidental
			 death; (3-31-22)
b. A benefit
			 amount not less than one thousand dollars ($1,000) for double dismemberment;
			 and (3-31-22)
c. A benefit amount
			 not less than five hundred dollars ($500) for single dismemberment.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.040 - LIMITED BENEFIT HEALTH COVERAGE

Current through August 31, 2023
01.
Minimum
			 Standards
. (3-31-22)
a. Limited Benefit
			 Health Coverage will not be offered, delivered, issued for delivery, or renewed
			 in this state or to a resident of this state unless approved by the Director
			 prior to use. (3-31-22)
b. A policy
			 covering a single specified disease or combination of diseases will not be
			 offered for sale as "limited benefit" coverage. (3-31-22)
c. Section
			 040 does not apply to policies
			 designed to provide coverage for long-term care or to Medicare supplement
			 insurance, as defined in Title 41, Chapter 46, Idaho Code, "Long-Term Care
			 Insurance" and Title 41, Chapter 44, Idaho Code, "Medicare Supplement Insurance
			 Minimum Standards." (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.041 - DENTAL COVERAGE

Current through August 31, 2023
01.
Disclosure Provisions
. Dental coverage will include the following
			 disclosures; (3-31-22)
a. All applications
			 will contain a prominent statement in either contrasting color or in boldface
			 type at least equal to the size type used for the headings or captions of
			 sections of the application and in close conjunction with the applicant's
			 signature block on the application as follows: "The (policy) (certificate)
			 provides dental benefits only. Review your (policy) (certificate) carefully."
			 (3-31-22)
b. All dental plan
			 policies and certificates will display prominently on the first page of the
			 policy or certificate, in either contrasting color or in boldface type at least
			 equal to the size type used for headings or captions of sections in the policy
			 or certificate the following: "Notice to Buyer: This (policy) (certificate)
			 provides dental benefits only." (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.042 - VISION COVERAGE

Current through August 31, 2023
01.
Disclosure Provisions
. Vision coverage will include the following
			 disclosures; (3-31-22)
a. All applications
			 will contain a prominent statement in either contrasting color or in boldface
			 type at least equal to the size type used for the headings or captions of
			 sections of the application and in close conjunction with the applicant's
			 signature block on the application as follows: "The (policy) (certificate)
			 provides vision benefits only. Review your (policy) (certificate) carefully."
			 (3-31-22)
b. All vision plan
			 policies and certificates will display prominently on the first page of the
			 policy or certificate in either contrasting color or in boldface type at least
			 equal to the size type used for headings or captions of sections in the policy
			 or certificate the following: "Notice to Buyer: This (policy) (certificate)
			 provides vision benefits only." (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.08 - INDIVIDUAL AND GROUP SUPPLEMENTARY DISABILITY INSURANCE MINIMUM STANDARDS RULE › Section 18.04.08.201 - REQUIREMENTS FOR REPLACEMENT OF INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE

Current through August 31, 2023
01.
Application Form
. An
			 application form will include a question designed to elicit information as to
			 whether the insurance to be issued is intended to replace any other accident
			 and sickness insurance presently in force. A supplementary application or other
			 form to be signed by the applicant containing the question may be used.
			 (3-31-22)
02. Prescribed
Notice
. Notices prescribed under this chapter will conform to the
			 model outlines of coverage incorporated herein in Section
			 002 of this chapter, and set forth
			 at the Idaho Department of Insurance website. Upon determining that a sale will
			 involve replacement, an insurer, or its agent will furnish the applicant, prior
			 to issuance or delivery of the policy, the "Notice To Applicant Regarding
			 Replacement Of Accident And Sickness Insurance," taking into consideration the
			 requirement for direct response or other than direct response. A direct
			 response insurer will deliver to the applicant upon issuance of the policy, the
			 notice described in this section. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.001 - SCOPE

Current through August 31, 2023
a. Except as specifically provided in
			 Sections 046,
			 051,
			 066, and
			 077, this chapter applies to:
			 (3-31-22)
i. All Medicare supplement policies
			 delivered or issued for delivery in this state; and (3-31-22)
ii. All certificates issued under group
			 Medicare supplement policies, which certificates have been delivered or issued
			 for delivery in this state. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.002 - INCORPORATION BY REFERENCE

Current through August 31, 2023
This chapter incorporates by reference Appendixes A (Refund
				Calculation and Calculation of Benchmark forms Model Regulation 651 pages
				651-94 to
				651-97 ), B (Form for Reporting
				Medicare Supplement Policies, page 651-98), and C (Disclosure Statements pages
				651-99 to
				651-108 ), and all other outlines
				of coverage and specific plan designs of the National Association of Insurance
				Commissioners (NAIC) Model Regulation 651 (pages
				651-42 to
				651-85 ) implementing the
				Medicare supplement insurance minimum standards (2018). The Model Regulation is
				available from the National Association of Insurance Commissioners and from the
				Idaho Department of Insurance. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.010 - DEFINITIONS

Current through August 31, 2023
01.
Applicant
. (3-31-22)
a. In the case of an individual Medicare
			 supplement policy, the person who seeks to contract for insurance benefits; and
			 (3-31-22)
b. In the case of a group
			 Medicare supplement policy, the proposed certificate holder.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.011 - POLICY DEFINITIONS AND TERMS

Current through August 31, 2023
No policy or certificate may be advertised, solicited or issued
				for delivery in this state as a Medicare supplement policy or certificate
				unless the policy or certificate contains definitions or terms which conform to
				the requirements of this section. (3-31-22)
01.
Accident, Accidental Injury, or
			 Accidental Means
. To employ "result" language and does not include words
			 that establish an accidental means test or use words such as "external,
			 violent, visible wounds" or similar words of description or characterization.
			 (3-31-22)
a. The definition will not be more
			 restrictive than the following: "Injury or injuries for which benefits are
			 provided means accidental bodily injury sustained by the insured person which
			 is the direct result of an accident, independent of disease or bodily infirmity
			 or any other cause, and occurs while insurance coverage is in force."
			 (3-31-22)
b. The definition may
			 provide that injuries cannot include injuries for which benefits are provided
			 or available under any workers' compensation, employer's liability or similar
			 law, or motor vehicle no-fault plan, unless banned by law.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.012 - POLICY PROVISIONS

Current through August 31, 2023
01.
Medicare
			 Supplement Policy
. Except for permitted preexisting condition clauses as
			 described in Paragraph 022.01.a., no policy or certificate may be advertised,
			 solicited, or issued for delivery in this state as a Medicare supplement policy
			 if the policy or certificate contains limitations or exclusions on coverage
			 that are more restrictive than those of Medicare. (3-31-22)
02.
Waivers
. No Medicare
			 supplement policy or certificate may use waivers to exclude, limit or reduce
			 coverage or benefits for specifically named or described preexisting diseases
			 or physical conditions. (3-31-22)
03.
Duplicate Benefits
. No
			 Medicare supplement policy or certificate in force in this state may contain
			 benefits which duplicate benefits provided by Medicare. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.025 - STANDARD MEDICARE SUPPLEMENT BENEFIT PLANS FOR 2020 STANDARDIZED BENEFIT PLAN POLICIES OR CERTIFICATES ISSUED FOR DELIVERY TO INDIVIDUALS NEWLY ELIGIBLE FOR MEDICARE ON OR AFTER JANUARY 1, 2020

Current through August 31, 2023
The Medicare Access and CHIP Reauthorization Act of 2015
				(MACRA) requires the following standards are applicable to all Medicare
				supplement policies or certificates delivered or issued for delivery in this
				state to individuals newly eligible for Medicare on or after January 1, 2020.
				No policy or certificate that provides coverage of the Medicare Part B
				deductible may be advertised, solicited, delivered or issued for delivery in
				this state as a Medicare supplement policy or certificate to individuals newly
				eligible for Medicare on or after January 1, 2020. All policies need to comply
				with the following benefit standards. Benefit plan standards applicable to
				Medicare supplement policies and certificates issued to individuals eligible
				for Medicare before January 1, 2020, remain subject to the requirements of
				Section 022.
				(3-31-22)
01.
Benefit
			 Requirements
. The standards and requirements of Section
			 024 apply to all Medicare
			 supplement policies or certificates delivered or issued for delivery to
			 individuals newly eligible for Medicare on or after January 1, 2020, with the
			 following exceptions: (3-31-22)
a.
			 Standardized benefit Plan C is redesignated as Plan D and provides the benefits
			 contained in Paragraph 022.04.c. but will not provide coverage for one hundred
			 percent (100%) or any portion of the Medicare Part B deductible.
			 (3-31-22)
b. Standardized benefit
			 Plan F is redesignated as Plan G and provides the benefits contained in
			 Paragraph 022.04.e. but will not provide coverage for one hundred percent
			 (100%) or any portion of the Medicare Part B deductible. (3-31-22)
c. Standardized benefit plans C, F, and F
			 with High Deductible will not be offered to individuals newly eligible for
			 Medicare on or after January 1, 2020. (3-31-22)
d. Standardized benefit Plan F With High
			 Deductible is redesignated as Plan G With High Deductible and provides the
			 benefits contained in Paragraph 022.04.f., but will not provide coverage for
			 one hundred percent (100%) or any portion of the Medicare Part B deductible;
			 provided further that, the Medicare Part B deductible paid by the beneficiary
			 is considered an out-of-pocket expense in meeting the annual high deductible.
			 (3-31-22)
e. The reference to Plans
			 C or F contained in Paragraph 022.01.i. is deemed a reference to Plans D or G
			 for purposes of this section. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.036 - OPEN ENROLLMENT

Current through August 31, 2023
01.
Offer of
			 Coverage
. (3-31-22)
a. An issuer cannot
			 deny or condition the issuance or effectiveness of any Medicare supplement
			 policy or certificate available for sale in this state, nor discriminate in the
			 pricing of a policy or certificate because of the health status, claims
			 experience, receipt of health care, or medical condition of an applicant in the
			 case of an application for a policy or certificate that is submitted prior to
			 or during the six (6) month period beginning with: (3-31-22)
i. The first day of the first month in which
			 an individual is both sixty-five (65) years of age or older and is enrolled for
			 benefits under Medicare Part B. (3-31-22)
ii. The first day of the first month of
			 Medicare Part B eligibility due to disability or end stage renal disease, for
			 an individual that is both under sixty-five (65) years of age and enrolled for
			 benefits under Medicare Part B; or (3-31-22)
iii. The first day of the first month after
			 the individual receives written notice of retroactive enrollment under Medicare
			 Part B due to a retroactive eligibility decision made by the Social Security
			 Administration. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.041 - GUARANTEED ISSUE FOR ELIGIBLE PERSONS

Current through August 31, 2023
01.
Guaranteed Issue
. (3-31-22)
a.
			 Eligible persons are those individuals described in Subsection
			 041.02 who seek to enroll under
			 the policy during the period specified in Subsection
			 041.03, and who submit evidence
			 of the date of termination or disenrollment or Medicare Part D enrollment with
			 the application for a Medicare supplement policy. (3-31-22)
b. With respect to eligible persons, an
			 issuer cannot deny or condition the issuance or effectiveness of a Medicare
			 supplement policy described in Subsection
			 041.05 that is offered and is
			 available for issuance to new enrollees by the issuer, cannot discriminate in
			 the pricing of such a Medicare supplement policy because of health status,
			 claims experience, receipt of health care, or medical condition, and will not
			 impose an exclusion of benefits based on a preexisting condition under such a
			 Medicare supplement policy. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.046 - STANDARDS FOR CLAIMS PAYMENT

Current through August 31, 2023
01.
Compliance
. An issuer will comply with Section
			 1882(c)(3)  of
			 the Social Security Act (as enacted by Section
			 4081(b)(2)(C)  of
			 the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987,
			 Pub. L. No.
			 100-203) by: (3-31-22)
a. Accepting a notice from a Medicare carrier
			 on dually assigned claims submitted by participating physicians and suppliers
			 as a claim for benefits in place of any other claim form needed and making a
			 payment determination on the basis of the information contained in that notice;
			 (3-31-22)
b. Notifying the
			 participating physician or supplier and the beneficiary of the payment
			 determination; (3-31-22)
c. Paying
			 the participating physician or supplier directly; (3-31-22)
d. Furnishing, at the time of enrollment,
			 each enrollee with a card listing the policy name, number and a central mailing
			 address to which notices from a Medicare carrier may be sent;
			 (3-31-22)
e. Paying user fees for
			 claim notices; and (3-31-22)
f.
			 Providing to the Secretary, at least annually, a central mailing address to
			 which all claims may be sent by Medicare carriers.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.051 - LOSS RATIO STANDARDS AND REFUND OR CREDIT OF PREMIUM

Current through August 31, 2023
01.
Loss Ratio Standards
.
			 (3-31-22)
a. A Medicare supplement policy form
			 or certificate form will not be delivered or issued for delivery unless the
			 policy form or certificate form can be expected, as estimated for the entire
			 period for which rates are computed to provide coverage, to return to
			 policyholders and certificateholders in the form of aggregate benefits (not
			 including anticipated refunds or credits) provided under the policy form or
			 certificate form. (3-31-22)
i. At least
			 seventy-five percent (75%) of the aggregate amount of premiums earned in the
			 case of group policies; or (3-31-22)
ii. At least sixty-five percent (65%) of the
			 aggregate amount of premiums earned in the case of individual policies;
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.056 - FILING AND APPROVAL OF POLICIES AND CERTIFICATES AND PREMIUM RATES

Current through August 31, 2023
01.
Filing of Policy Forms
.
			 (3-31-22)
a. An issuer cannot deliver or issue
			 for delivery a policy or certificate to a resident of this state unless the
			 policy form or certificate form has been filed with and approved by the
			 director in accordance with filing requirements and procedures prescribed by
			 the director. (3-31-22)
b. An
			 issuer would file any riders or amendments to policy or certificate forms to
			 delete outpatient prescription drug benefits as prescribed by the Medicare
			 Prescription Drug, Improvement, and Modernization Act of 2003 only with the
			 director in the state in which the policy or certificate was issued.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.061 - PERMITTED COMPENSATION ARRANGEMENTS

Current through August 31, 2023
01.
Commissions
. An issuer or other entity may provide commission or
			 other compensation to an agent or other representative for the sale of a
			 Medicare supplement policy or certificate only if the first-year commission or
			 other first-year compensation is no more than two hundred percent (200%) of the
			 commission or other compensation paid for selling or servicing the policy or
			 certificate in the second year or period. An issuer or other entity may not
			 vary commission or otherwise pay commission differentials based upon variables
			 such as age, guarantee issue status, or on any other basis. (3-31-22)
02.
Compensation in Subsequent
			 Years
. The commission or other compensation provided in subsequent
			 renewal years needs to be the same as that provided in the second year or
			 period and be provided for no fewer than five (5) renewal years.
			 (3-31-22)
03.
Renewal
			 Compensation
. No issuer or other entity provides compensation to its
			 agent or other producers and no agent or producer receives compensation greater
			 than the renewal compensation payable by the replacing issuer on renewal
			 policies or certificates if an existing policy or certificate is replaced.
			 (3-31-22)
04.
Compensation
. For purposes of Section
			 061, compensation includes
			 pecuniary or non-pecuniary remuneration of any kind relating to the sale or
			 renewal of the policy or certificate, including but not limited to bonuses,
			 gifts, prizes, awards, and finder's fees. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.072 - FILING REQUIREMENTS FOR ADVERTISING

Current through August 31, 2023
An issuer provides a copy of any Medicare supplement
				advertisement intended for use in this state whether through written, radio, or
				television medium to the director for review or approval by the director.
				(3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.073 - STANDARDS FOR MARKETING

Current through August 31, 2023
01.
Issuer
. An issuer, directly or through its producers: (3-31-22)
a. Establishes marketing procedures to assure
			 that any comparison of policies by its agents or other producers will be fair
			 and accurate. (3-31-22)
b.
			 Establishes marketing procedures to assure excessive insurance is not sold or
			 issued. (3-31-22)
c. Displays
			 prominently by type, stamp, or other appropriate means, on the first page of
			 the policy the following:
"Notice to buyer: This policy may not cover all
			 of your medical expenses."
(3-31-22)
d. Inquires and makes every reasonable effort
			 to identify whether a prospective applicant or enrollee for Medicare supplement
			 insurance already has accident and sickness insurance and the types and amounts
			 of any such insurance. (3-31-22)
e.
			 Establishes auditable procedures for verifying compliance with this Subsection
			 073.01.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.076 - APPROPRIATENESS OF RECOMMENDED PURCHASE AND EXCESSIVE INSURANCE

Current through August 31, 2023
In recommending the purchase or replacement of any Medicare
				supplement policy or certificate, an agent makes reasonable efforts to
				determine the appropriateness of a recommended purchase or replacement. Any
				sale of Medicare supplement policy or certificate that will provide an
				individual more than one Medicare supplement policy or certificate is banned.
				An issuer cannot issue a Medicare supplement policy or certificate to an
				individual enrolled in Medicare Part C unless the effective date of the
				coverage is after the termination date of the individual's Part C coverage.
				(3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.077 - REPORTING OF MULTIPLE POLICIES

Current through August 31, 2023
01.
Reporting
. On or before March 1 of each year, an issuer reports
			 the following information for every individual resident of this state for which
			 the issuer has in force more than one (1) Medicare supplement policy or
			 certificate: (3-31-22)
a. Policy and
			 certificate number, and (3-31-22)
b. Date of issuance.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.081 - PROHIBITION AGAINST PREEXISTING CONDITIONS, WAITING PERIODS, ELIMINATION PERIODS AND PROBATIONARY PERIODS IN REPLACEMENT POLICIES OR CERTIFICATES

Current through August 31, 2023
01.
Waiving of Time Periods
. If
			 a Medicare supplement policy or certificate replaces another Medicare
			 supplement policy or certificate, the replacing issuer waives any time periods
			 applicable to preexisting conditions, waiting periods, elimination periods and
			 probationary periods in the new Medicare supplement policy or certificate for
			 similar benefits to the extent such time was spent under the original policy.
			 (3-31-22)
02.
Replacing
			 Policy
. If a Medicare supplement policy or certificate replaces another
			 Medicare supplement policy or certificate which has been in effect for at least
			 six (6) months, the replacing policy does not provide any time period
			 applicable to preexisting conditions, waiting periods, elimination periods, and
			 probationary periods for benefits similar to those contained in the original
			 policy or certificate. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.10 - MEDICARE SUPPLEMENT INSURANCE STANDARDS › Section 18.04.10.082 - PROHIBITION AGAINST USE OF GENETIC INFORMATION AND REQUESTS FOR GENETIC TESTING

Current through August 31, 2023
01.
Banned
			 Provisions
. An issuer of a Medicare supplement policy or certificate:
			 (3-31-22)
a. Does not deny or condition the
			 issuance of effectiveness of the policy or certificate (including the
			 imposition of any exclusion of benefits under the policy based on a preexisting
			 condition) on the basis of the genetic information with respect to such
			 individual; and (3-31-22)
b. Does
			 not discriminate in the pricing of the policy or certificate (including the
			 adjustment of premium rates) of an individual on the basis of the genetic
			 information with respect to such individual. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.001 - TITLE AND SCOPE

Current through August 31, 2023
01.
Title
. IDAPA 18.04.11, "Long-Term Care Insurance Minimum
			 Standards." (3-31-22)
02.
Purpose
. The purpose of this chapter is to promote the public
			 interest, to promote the availability of long-term care insurance coverage, to
			 protect applicants for long-term care insurance, as defined, from unfair or
			 deceptive sales or enrollment practices, to facilitate public understanding and
			 comparison of long-term care insurance coverages, and to facilitate flexibility
			 and innovation in the development of long-term care insurance.
			 (3-31-22)
03.
Scope and
			 Applicability
. Except as specifically provided, this chapter applies to
			 all long-term care insurance policies including qualified long-term care
			 insurance contracts and life insurance policies that accelerate benefits for
			 long-term care delivered or issued for delivery in this state; certain
			 provisions of this chapter apply only to qualified long-term care insurance.
			 Additionally, this chapter is intended to apply to policies having indemnity
			 benefits that are triggered by activities of daily living and sold as
			 disability income insurance, if: (3-31-22)
a.
			 The benefits of the disability income policy are dependent upon or vary in
			 amount based on the receipt of long-term care services; (3-31-22)
b. The disability income policy is
			 advertised, marketed or offered as insurance for long-term care services; or
			 (3-31-22)
c. Benefits under the
			 policy may commence after the policyholder has reached Social Security's normal
			 retirement age unless benefits are designed to replace lost income or pay for
			 specific expenses other than long-term 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 18.04.11.002 - INCORPORATION OF DOCUMENTS BY REFERENCE

Current through August 31, 2023
01.
Forms
. Documents incorporated by reference may be obtained from
			 the Idaho Department of Insurance website. (3-31-22)
02.
Documents Incorporated by
			 Reference
. This chapter incorporates by reference the following
			 documents, appendices, and attachments of the National Association of Insurance
			 Commissioners (NAIC) Long Term Care Model Regulation. The Model Regulation is
			 available from the NAIC and from the Idaho Department of Insurance. (3-31-22)
a. Rescission Reporting Form for Long-Term
			 Care, Appendix A. (3-31-22)
b.
			 Personal Worksheet, Appendix B. (3-31-22)
c. Things You Should Know Before You Buy
			 Long-Term Care Insurance, Appendix C. (3-31-22)
d. Suitability Letter, Appendix D.
			 (3-31-22)
e. Claims Denial
			 Reporting Form, Appendix E. (3-31-22)
f. Instructions, Appendix F.
			 (3-31-22)
g. Replacement and Lapse
			 Reporting Form, Appendix G. (3-31-22)
h. Outline of Coverage. (3-31-22)
i. Notice to Applicant Regarding Replacement
			 of Individual Accident and Sickness or Long-Term Care Insurance, Attachment I.
			 (3-31-22)
j. Notice to Applicant
			 Regarding Replacement of Accident and Sickness or Long-Term Care Insurance,
			 Attachment II. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.010 - DEFINITIONS

Current through August 31, 2023
For the purpose of this rule, the following definitions apply
				in addition to those found in Title 41, Chapter 46, Idaho Code.
				(3-31-22)
01.
Exceptional
			 Increase
. Means only those increases filed by an insurer as exceptional
			 for which the director determines the need for the premium rate increase is
			 justified due to changes in Idaho laws or rules applicable to long-term care
			 coverage, or due to increased and unexpected utilization that affects the
			 majority of insurers of similar products. (3-31-22)
a. Except as provided in Section
			 025, Premium Rate Schedule
			 Increases, exceptional increases are subject to the same requirements as other
			 premium rate schedule increases. (3-31-22)
b. The director may request a review by an
			 independent actuary or a professional actuarial body of the basis for a request
			 that an increase be considered an exceptional increase. (3-31-22)
c. The director, in determining that the
			 necessary basis for an exceptional increase exists, will determine any
			 potential offsets to higher claims costs. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.012 - POLICY PRACTICES AND PROVISIONS

Current through August 31, 2023
01.
Renewability
. The terms "guaranteed renewable" and
			 "noncancellable" cannot be used in any individual long-term care insurance
			 policy without further explanatory language in accordance with the disclosure
			 requirements of Section
			 014 of this rule. (3-31-22)
a. A policy issued to an individual cannot
			 contain renewal provisions other than "guaranteed renewable" or
			 "noncancellable." (3-31-22)
b. The
			 term "guaranteed renewable" may be used only when the insured has the right to
			 continue the long-term care insurance in force by the timely payment of
			 premiums and when the insurer has no unilateral right to make any change in any
			 provision of the policy or rider while the insurance is in force, and cannot
			 decline to renew, except that rates may be revised by the insurer on a class
			 basis. (3-31-22)
c. The term
			 "noncancellable" may be used only when the insured has the right to continue
			 the long-term care insurance in force by the timely payment of premiums during
			 which period the insurer has no right to unilaterally make any change in any
			 provision of the insurance or in the premium rate. (3-31-22)
d. The term "level premium" may only be used
			 when the insurer does not have the right to change the premium for a specified
			 period for the life of the policy. (3-31-22)
e. In addition to the other requirements of
			 Subsection 011.01, a qualified long-term
			 care insurance contract is guaranteed renewable, within the meaning of Section
			 7702B(b)(1)(C) 
			 of the Internal Revenue Code of 1986 as amended. (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.014 - REQUISITE DISCLOSURE PROVISIONS

Current through August 31, 2023
01.
Renewability
. Individual long-term care insurance policies will
			 contain a renewability provision. (3-31-22)
a.
			 The provision is appropriately captioned, appears on the first page of the
			 policy, and clearly states that the coverage is guaranteed renewable or
			 noncancellable. This provision cannot apply to policies that do not contain a
			 renewability provision, and under which the right to nonrenew is reserved
			 solely to the policyholder. (3-31-22)
b. A long-term care insurance policy or
			 certificate, other than one where the insurer does not have the right to change
			 the premium, includes a statement that the premium rates may change.
			 (3-31-22)
Idaho Administrative Code › Title IDAPA 18 - Insurance, Department of › Rule 18.04.11 - LONG-TERM CARE INSURANCE MINIMUM STANDARDS › Section 18.04.11.015 - PROHIBITION AGAINST POST-CLAIMS UNDERWRITING

Current through August 31, 2023
01.
Health Conditions
. All applications for long-term care insurance
			 policies or certificates except those that are guaranteed issue contains clear
			 and unambiguous questions designed to ascertain the health condition of the
			 applicant. (3-31-22)
02.
Medication
. If an application for long-term care insurance
			 contains a question that asks whether the applicant has had medication
			 prescribed by a physician, it will also ask the applicant to list the
			 medication that has been prescribed. If the medications listed in the
			 application were known by the insurer, or should have been known at the time of
			 application, to be directly related to a medical condition for which coverage
			 would be denied, then the policy or certificate cannot be rescinded for that
			 condition. (3-31-22)
03.
Non-Guaranteed Issue
. Except for policies or certificates which
			 are guaranteed issue: (3-31-22)
a. The
			 following language is set out conspicuously and in close conjunction with the
			 applicant's signature block on an application for a long-term care insurance
			 policy or certificate: Caution: If your answers on this application are
			 incorrect or untrue, (company) has the right to deny benefits or rescind your
			 policy. (3-31-22)
b. The following
			 language, or language substantially similar to the following, is set out
			 conspicuously on the long-term care insurance policy or certificate at the time
			 of delivery: "Caution: The issuance of this long-term care insurance (policy)
			 (certificate) is based upon your responses to the questions on your
			 application. A copy of your (application) (enrollment form) (is enclosed) (was
			 retained by you when you applied). If your answers are incorrect or untrue, the
			 company has the right to deny benefits or rescind your policy. The best time to
			 clear up any questions is now, before a claim arises! If, for any reason, any
			 of your answers are incorrect, contact the company at this address: (insert
			 address)." (3-31-22)
c. Prior to
			 issuance of a long-term care policy or certificate to an applicant age eighty
			 (80) or older, the insurer obtains one (1) of the following: (3-31-22)
i. A report of a physical examination;
			 (3-31-22)
ii. An assessment of
			 functional capacity; (3-31-22)
iii.
			 An attending physician's statement; or (3-31-22)
iv. Copies of medical records.
			 (3-31-22)