2005 Idaho Code - 41-4708 — AVAILABILITY OF COVERAGE -- PREEXISTING CONDITIONS -- PORTABILITY

                                  TITLE  41
                                  INSURANCE
                                  CHAPTER 47
                            SMALL EMPLOYER HEALTH
                          INSURANCE AVAILABILITY ACT
    41-4708.  AVAILABILITY OF COVERAGE -- PREEXISTING CONDITIONS --
PORTABILITY. (1) Every small employer carrier shall, as a condition of
offering health benefit plans in this state to small employers, actively offer
to small employers all benefit plans, including the small employer basic
health benefit plan, the small employer standard health benefit plan, and the
small employer catastrophic health benefit plan.
    (2)  (a) A small employer carrier shall file with the director, in a
    format and manner prescribed by the director, the small employer basic,
    standard and catastrophic health benefit plans to be used by the carrier.
    A health benefit plan filed pursuant to the provisions of this paragraph
    may be used by a small employer carrier beginning thirty (30) days after
    it is filed unless the director disapproves its use.
    (b)  The director at any time may, after providing notice and an
    opportunity for a hearing to the small employer carrier, disapprove the
    continued use by a small employer carrier of a basic, standard or
    catastrophic health benefit plan on the grounds that the plan does not
    meet the requirements of this chapter.
    (3)  Health benefit plans covering small employers shall comply with the
following provisions:
    (a)  A health benefit plan shall not deny, exclude or limit benefits for a
    covered individual for covered expenses incurred more than twelve (12)
    months following the effective date of the individual's coverage due to a
    preexisting condition. A  health benefit plan shall not define a
    preexisting condition more restrictively than a condition, whether
    physical or mental, regardless of the cause of the condition, for which
    medical advice, diagnosis, care or treatment was recommended or received
    during the six (6) months immediately preceding the effective date of
    coverage.
    (b)  Genetic information shall not be considered as a condition described
    in this subsection in the absence of a diagnosis of the condition related
    to such information.
    (c)  A health benefit plan shall waive any time period applicable to a
    preexisting condition exclusion or limitation period with respect to
    particular services for the period of time an individual was previously
    covered by qualifying previous coverage that provided benefits with
    respect to such services, provided that the qualifying previous coverage
    was continuous to a date not more than sixty-three (63) days prior to the
    effective date of the new coverage. The period of continuous coverage
    shall not include any waiting period for the effective date of the new
    coverage applied by the employer or the carrier. This paragraph does not
    preclude application of any waiting period applicable to all new enrollees
    under the health benefit plan.
    (d)  A health benefit plan may exclude coverage for late enrollees for the
    greater of twelve (12) months or for a twelve (12) month preexisting
    condition exclusion; provided that if both a period of exclusion from
    coverage and a preexisting condition exclusion are applicable to a late
    enrollee, the combined period shall not exceed twelve (12) months from the
    date the individual enrolls for coverage under the health benefit plan.
    (e)  (i) Except as provided in paragraph (e)(iv) of this subsection,
         requirements used by a small employer carrier in determining whether
         to provide coverage to a small employer, including requirements for
         minimum participation of eligible employees and minimum employer
         contributions, shall be applied uniformly among all small employers
         with the same number of eligible employees applying for coverage or
         receiving coverage from the small employer carrier.
         (ii)  A small employer carrier may vary application of minimum
         participation requirements and minimum employer contribution
         requirements only by the size of the small employer group.
         (iii) In applying minimum participation requirements with respect to
         a small employer, a small employer carrier shall not consider
         employees or dependents who have qualifying existing coverage in
         determining whether the applicable percentage of participation is
         met.
         (iv)  A small employer carrier shall not increase any requirement for
         minimum employee participation or any requirement for minimum
         employer contribution applicable to a small employer at any time
         after the small employer has been accepted for coverage.
    (f)  (i) If a small employer carrier offers coverage to a small employer,
         the small employer carrier shall offer coverage to all of the
         eligible employees of a small employer and their dependents. A small
         employer carrier shall not offer coverage to only certain individuals
         in a small employer group or to only part of the group, except in the
         case of late enrollees as provided in paragraph (d) of this
         subsection.
         (ii)  A small employer carrier shall not modify a basic, standard or
         catastrophic health benefit plan with respect to a small employer or
         any eligible employee or dependent through riders, endorsements or
         otherwise, to restrict or exclude coverage for certain diseases or
         medical conditions otherwise covered by the health benefit plan.
    (4)  (a) A small employer carrier shall not be required to offer coverage
    or accept applications pursuant to the provisions of subsection (1) of
    this section in the case of the following:
         (i)   To a small employer, where the small employer is not physically
         located in the carrier's established geographic service area;
         (ii)  To an employee, when the employee does not work or reside
         within the carrier's established geographic service area; or
         (iii) Within an area where the small employer carrier reasonably
         anticipates, and demonstrates to the satisfaction of the director,
         that it will not have the capacity within its established geographic
         service area to deliver service adequately to the members of such
         groups because of its obligations to existing group policyholders and
         enrollees.
    (b)  A small employer carrier that cannot offer coverage pursuant to the
    provisions of subsection (4)(a)(iii) of this section may not offer
    coverage in the applicable area to new cases of employer groups with more
    than fifty (50) eligible employees or to any small employer groups until
    the later of one hundred eighty (180) days following each such refusal or
    the date on which the carrier notifies the director that it has regained
    capacity to deliver services to small employer groups.
    (5)  A small employer carrier shall not be required to provide coverage to
small employers pursuant to the provisions of subsection (1) of this section
for any period of time for which the director determines that requiring the
acceptance of small employers in accordance with the provisions of subsection
(1) of this section would place the small employer carrier in a financially
impaired condition.