US Laws, Codes, Statutes & Cases

                                  TITLE  41
                                  INSURANCE
                                  CHAPTER 18
                            THE INSURANCE CONTRACT
    41-1846.  HEALTH CARE POLICIES -- APPLICABILITY -- REQUIREMENT. (1) An
insurer offering a health care policy that does not meet the definition of a
managed care plan as provided in section 41-3903(15), Idaho Code:
    (a)  Must have the intent to render and the capability for rendering or
    providing coverage for good quality health care services, which will be
    and are readily available and accessible to its insureds both within and
    outside the state of Idaho, and such services must be reasonably
    responsive to the needs of insureds;
    (b)  When "emergency services" are provided, they shall be provided as set
    forth in section 41-3903(7), Idaho Code, and shall not require prior
    authorization;
    (c)  Shall include on its website and/or send annually to its
    policyholders:
         (i)   A statement as to whether the plan includes a limited formulary
         of medications and a statement that the formulary will be made
         available to any member on request;
         (ii)  Notification of any change in benefits; and
         (iii) A description of all prior authorization review procedures for
         health care services;
    (d)  Shall adopt procedures for a timely review by a licensed physician,
    peer provider or peer review panel when a claim has been denied as not
    medically necessary or as experimental. The procedure shall provide for a
    written statement of the reasons the service was denied and transmittal of
    that information to the appropriate provider for inclusion in the
    insured's permanent medical record;
    (e)  When prior approval for a covered service is required of and obtained
    by or on behalf of an insured, the approval for the specific procedure
    shall be final and may not be rescinded after the covered service has been
    provided except in cases of fraud, misrepresentation, nonpayment of
    premium, exhaustion of benefits or if the insured for whom the prior
    approval was granted is not enrolled at the time the covered service was
    provided; and
    (f)  Shall not offer a provider any incentive that includes a specific
    payment made, in any type or form, to the provider as an inducement to
    deny, reduce, limit, or delay specific, medically necessary, and
    appropriate services covered by the health care policy.
    (2)  No health care provider shall require an insured to make additional
payments for covered services under a policy subject to subsection (1) of this
section, other than specified deductibles, copayments or coinsurance once a
provider has agreed in writing to accept the insurer's reimbursement rate to
provide a covered service.