2005 Idaho Code - 41-5208 — AVAILABILITY OF COVERAGE -- PREEXISTING CONDITIONS -- PORTABILITY

                                  TITLE  41
                                  INSURANCE
                                  CHAPTER 52
                 INDIVIDUAL HEALTH INSURANCE AVAILABILITY ACT
    41-5208.  AVAILABILITY OF COVERAGE --  PREEXISTING CONDITIONS --
PORTABILITY.
    (1)  (a) Every individual carrier shall, as a condition of offering health
    benefit plans in this state to individuals, actively offer health benefit
    plans to individuals, including the individual basic health benefit plan,
    the individual standard health benefit plan, the individual catastrophic A
    health benefit plan, the individual catastrophic B health benefit plan and
    the individual HSA compatible health benefit plan.
    (b)  An individual carrier shall issue an individual basic, standard,
    catastrophic A, catastrophic B or HSA compatible health benefit plan to
    any eligible individual that applies for such plan and agrees to make the
    required premium payments and to satisfy the other reasonable provisions
    of the health benefit plan not inconsistent with the provisions of this
    chapter.
    (2)  (a) An individual carrier shall file with the director, in a format
    and manner prescribed by the director, the basic, standard, catastrophic,
    and HSA compatible 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 an individual 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 individual carrier, disapprove the
    continued use by an individual carrier of a basic, standard, catastrophic,
    or HSA compatible health benefit plan on the grounds that the plan does
    not meet the requirements of this chapter.
    (3)  Health benefit plans covering eligible individuals 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:
         (i)   A condition that would have caused an ordinarily prudent person
         to seek medical advice, diagnosis, care or treatment during the six
         (6) months immediately preceding the effective date of coverage;
         (ii)  A 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; or
         (iii) A pregnancy existing on the effective date of coverage.
    (b)  A health benefit plan shall waive any time period applicable to a
    preexisting condition exclusion or limitation period for the period of
    time an individual was previously covered by qualifying previous coverage,
    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. As provided in section 2741(b) of the federal health insurance
    portability and accountability act of 1996 (42 U.S.C. 300gg-41(b)), with
    regard to federally eligible individuals under HIPAA, any limitation or
    exclusion of benefits relating to a condition based on the fact that the
    condition was present before the first day of coverage shall not apply,
    whether or not any medical advice, diagnosis, care or treatment was
    recommended or received before that day, and whether or not the condition
    would have caused an ordinarily prudent person to seek medical advice,
    diagnosis, care or treatment before that day.
    (c)  An individual carrier shall not modify a basic, standard,
    catastrophic A, catastrophic B or HSA compatible health benefit plan with
    respect to an individual or any dependent through riders, endorsements, or
    otherwise, to restrict or exclude coverage for certain diseases or medical
    conditions otherwise covered by the health benefit plan.
    (d)  In the case of an individual who is eligible for the credit for
    health insurance costs under section 35 of the Internal Revenue Code of
    1986, the preexisting condition limitation shall not apply only if the
    individual maintained creditable health insurance coverage for an
    aggregate period of three (3) months as of the date on which the
    individual seeks to enroll in pool coverage, not counting any period prior
    to a sixty-three (63) day break in coverage.
    (4)  (a) An individual 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 an individual, where the individual is not residing in the
         carrier's established geographic service area;
         (ii)  Within an area where the individual 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 individuals because of
         its obligations to existing groups or individuals.
    (b)  An individual carrier that cannot offer coverage pursuant to the
    provisions  of subsection (4)(a)(ii) of this section may not offer
    coverage in the applicable area to new employer groups with more than
    fifty (50) eligible employees or to any small employer groups or to any
    individuals 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 individuals and
    groups.
    (5)  An individual carrier shall not be required to provide coverage to
individuals 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 individuals in accordance with the provisions of subsection (1)
of this section would place the individual carrier in a financially impaired
condition.