Print Friendly HOUSE BILL NO. 803 – Health insurnce, coverage/eligiblty
HOUSE BILL NO. 803
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H0803......................................................by STATE AFFAIRS
HEALTH INSURANCE - Amends existing law relating to insurance to provide
that the preexisting condition limitation shall not apply to certain
individuals; to further define "eligible individual"; to provide that
certain persons shall be eligible for health benefit plans; and to provide
that certain limitations and requirements shall not apply if such persons
have maintained creditable health insurance coverage for a specified period
03/02 House intro - 1st rdg - to printing
03/03 Rpt prt - to Bus
03/10 Rpt out - rec d/p - to 2nd rdg
03/11 2nd rdg - to 3rd rdg
03/12 3rd rdg - PASSED - 65-0-5
AYES -- Andersen, Barraclough, Barrett, Bauer, Bayer, Bedke, Black,
Block, Boe, Bolz, Bradford, Campbell, Cannon, Clark, Collins, Crow,
Cuddy, Deal, Denney, Douglas, Eberle, Edmunson, Ellsworth, Eskridge,
Field(18), Field(23), Gagner, Garrett, Harwood, Jaquet, Jones,
Kellogg, Kulczyk, Lake, Langford, Langhorst, Martinez, McKague,
Meyer, Miller, Mitchell, Moyle, Naccarato, Nielsen, Pasley-Stuart,
Raybould, Ridinger, Ring, Ringo, Roberts, Robison, Rydalch, Sali,
Sayler, Schaefer, Shepherd, Skippen, Smith(30), Smith(24), Smylie,
Snodgrass, Trail, Wills, Wood, Mr. Speaker
NAYS -- None
Absent and excused -- Bell, Henbest, McGeachin, Shirley, Stevenson
Floor Sponsor - Collins
Title apvd - to Senate
03/15 Senate intro - 1st rdg - to Com/HuRes
03/17 Rpt out - rec d/p - to 2nd rdg
03/18 2nd rdg - to 3rd rdg
03/19 3rd rdg - PASSED - 35-0-0
AYES -- Andreason, Bailey, Brandt, Bunderson, Burkett(Maxand),
Burtenshaw, Calabretta, Cameron, Compton, Darrington, Davis, Gannon,
Geddes, Goedde, Hill, Ingram, Kennedy, Keough, Little, Lodge,
Malepeai, Marley, McKenzie, McWilliams, Noble, Noh, Pearce,
Richardson, Schroeder, Sorensen, Stegner, Stennett, Sweet, Werk,
NAYS -- None
Absent and excused -- None
Floor Sponsor - Cameron
Title apvd - to House
03/20 To enrol - Rpt enrol - Sp signed - Pres signed
03/22 To Governor
03/24 Governor signed
Session Law Chapter 332
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]]
Fifty-seventh Legislature Second Regular Session - 2004
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 803
BY STATE AFFAIRS COMMITTEE
1 AN ACT
2 RELATING TO INSURANCE; AMENDING SECTION 41-5208, IDAHO CODE, TO PROVIDE THAT
3 THE PREEXISTING CONDITION LIMITATION SHALL NOT APPLY TO CERTAIN INDIVIDU-
4 ALS; AMENDING SECTION 41-5501, IDAHO CODE, TO FURTHER DEFINE "ELIGIBLE
5 INDIVIDUAL" AND TO MAKE A TECHNICAL CORRECTION; AND AMENDING SECTION
6 41-5510, IDAHO CODE, TO PROVIDE THAT CERTAIN PERSONS SHALL BE ELIGIBLE FOR
7 HEALTH BENEFIT PLANS AND TO PROVIDE THAT CERTAIN LIMITATIONS AND REQUIRE-
8 MENTS SHALL NOT APPLY IF SUCH PERSONS HAVE MAINTAINED CREDITABLE HEALTH
9 INSURANCE COVERAGE FOR A SPECIFIED PERIOD OF TIME.
10 Be It Enacted by the Legislature of the State of Idaho:
11 SECTION 1. That Section 41-5208, Idaho Code, be, and the same is hereby
12 amended to read as follows:
13 41-5208. AVAILABILITY OF COVERAGE -- PREEXISTING CONDITIONS -- PORTABIL-
15 (1) (a) Every individual carrier shall, as a condition of offering health
16 benefit plans in this state to individuals, actively offer health benefit
17 plans to individuals, including the individual basic health benefit plan,
18 the individual standard health benefit plan, the individual catastrophic A
19 health benefit plan and the individual catastrophic B health benefit plan.
20 (b) An individual carrier shall issue an individual basic, standard, cat-
21 astrophic A or catastrophic B health benefit plan to any eligible individ-
22 ual that applies for such plan and agrees to make the required premium
23 payments and to satisfy the other reasonable provisions of the health ben-
24 efit plan not inconsistent with the provisions of this chapter.
25 (2) (a) An individual carrier shall file with the director, in a format
26 and manner prescribed by the director, the basic, standard and cata-
27 strophic health benefit plans to be used by the carrier. A health benefit
28 plan filed pursuant to the provisions of this paragraph may be used by an
29 individual carrier beginning thirty (30) days after it is filed unless the
30 director disapproves its use.
31 (b) The director at any time may, after providing notice and an opportu-
32 nity for a hearing to the individual carrier, disapprove the continued use
33 by an individual carrier of a basic, standard, or catastrophic health ben-
34 efit plan on the grounds that the plan does not meet the requirements of
35 this chapter.
36 (3) Health benefit plans covering individuals shall comply with the fol-
37 lowing provisions:
38 (a) A health benefit plan shall not deny, exclude or limit benefits for a
39 covered individual for covered expenses incurred more than twelve (12)
40 months following the effective date of the individual's coverage due to a
41 preexisting condition. A health benefit plan shall not define a preexist-
42 ing condition more restrictively than:
43 (i) A condition that would have caused an ordinarily prudent person
1 to seek medical advice, diagnosis, care or treatment during the six
2 (6) months immediately preceding the effective date of coverage;
3 (ii) A condition for which medical advice, diagnosis, care or treat-
4 ment was recommended or received during the six (6) months immedi-
5 ately preceding the effective date of coverage; or
6 (iii) A pregnancy existing on the effective date of coverage.
7 (b) A health benefit plan shall waive any time period applicable to a
8 preexisting condition exclusion or limitation period with respect to par-
9 ticular services for the period of time an individual was previously cov-
10 ered by qualifying previous coverage to the extent such previous coverage
11 provided benefits with respect to such services, provided that the quali-
12 fying previous coverage was continuous to a date not more than sixty-three
13 (63) days prior to the effective date of the new coverage.
14 (c) An individual carrier shall not modify a basic, standard, or cata-
15 strophic health benefit plan with respect to an individual or any depend-
16 ent through riders, endorsements, or otherwise, to restrict or exclude
17 coverage for certain diseases or medical conditions otherwise covered by
18 the health benefit plan.
19 (d) In the case of an individual who is eligible for the credit for
20 health insurance costs under section 35 of the Internal Revenue Code of
21 1986, the preexisting condition limitation shall not apply only if the
22 individual maintained creditable health insurance coverage for an aggre-
23 gate period of three (3) months as of the date on which the individual
24 seeks to enroll in pool coverage, not counting any period prior to a
25 sixty-three (63) day break in coverage.
26 (4) (a) An individual carrier shall not be required to offer coverage or
27 accept applications pursuant to the provisions of subsection (1) of this
28 section in the case of the following:
29 (i) To an individual, where the individual is not residing in the
30 carrier's established geographic service area;
31 (ii) Within an area where the individual carrier reasonably antici-
32 pates, and demonstrates to the satisfaction of the director, that it
33 will not have the capacity within its established geographic service
34 area to deliver service adequately to individuals because of its
35 obligations to existing groups or individuals.
36 (b) An individual carrier that cannot offer coverage pursuant to the pro-
37 visions of subsection (4)(a)(ii) of this section may not offer coverage in
38 the applicable area to new employer groups with more than fifty (50) eli-
39 gible employees or to any small employer groups or to any individuals
40 until the later of one hundred eighty (180) days following each such
41 refusal or the date on which the carrier notifies the director that it has
42 regained capacity to deliver services to individuals and groups.
43 (5) An individual carrier shall not be required to provide coverage to
44 individuals pursuant to the provisions of subsection (1) of this section for
45 any period of time for which the director determines that requiring the accep-
46 tance of individuals in accordance with the provisions of subsection (1) of
47 this section would place the individual carrier in a financially impaired con-
49 SECTION 2. That Section 41-5501, Idaho Code, be, and the same is hereby
50 amended to read as follows:
51 41-5501. DEFINITIONS. As used in this chapter:
52 (1) "Agent" means a producer as defined in section 41-1003( 98), Idaho
1 (2) "Board" means the board of directors of the Idaho high risk individ-
2 ual reinsurance pool established in this chapter and the Idaho small employer
3 reinsurance program established in section 41-4711, Idaho Code.
4 (3) "Carrier" means any entity that provides, or is authorized to pro-
5 vide, health insurance in this state. For purposes of this chapter, carrier
6 includes an insurance company, any other entity providing reinsurance includ-
7 ing excess or stop loss coverage, a hospital or professional service corpora-
8 tion, a fraternal benefit society, a managed care organization, any entity
9 providing health insurance coverage or benefits to residents of this state as
10 certificate holders under a group policy issued or delivered outside of this
11 state, and any other entity providing a plan of health insurance or health
12 benefits subject to state insurance regulation.
13 (4) "Dependent" means a spouse, an unmarried child under the age of nine-
14 teen (19) years, an unmarried child who is a full-time student under the age
15 of twenty-three (23) years and who is financially dependent upon the parent,
16 and an unmarried child of any age who is medically certified as disabled and
17 dependent upon the parent.
18 (5) "Director" means the director of the department of insurance of the
19 state of Idaho.
20 (6) "Eligible individual" means:
21 (a) A an Idaho resident individual or dependent of an Idaho resident who
22 is under the age of sixty-five (65) years, is not eligible for coverage
23 under a group health plan, part A or part B of title XVIII of the social
24 security act (medicare), or a state plan under title XIX (medicaid) or any
25 successor program, and who does not have other health insurance coverage;
27 (b) An individual who is legally domiciled in Idaho on the date of appli-
28 cation to the pool and is eligible for the credit for health insurance
29 costs under section 35 of the Internal Revenue Code of 1986. Coverage
30 under a basic, standard, catastrophic A or catastrophic B health benefit
31 plan shall not be available to any individual who is covered under other
32 health insurance coverage. For purposes of this chapter, to be eligible,
33 an individual must also meet the requirements of section 41-5510, Idaho
35 (7) "Health benefit plan" means any hospital or medical policy or certif-
36 icate, any subscriber contract provided by a hospital or professional service
37 corporation, or health maintenance organization subscriber contract. Health
38 benefit plan does not include policies or certificates of insurance for spe-
39 cific disease, hospital confinement indemnity, accident-only, credit, dental,
40 vision, medicare supplement, long-term care, or disability income insurance,
41 student health benefits only, coverage issued as a supplement to liability
42 insurance, worker's compensation or similar insurance, automobile medical pay-
43 ment insurance, or nonrenewable short-term coverage issued for a period of
44 twelve (12) months or less.
45 (8) "Individual basic health benefit plan" means a lower cost health ben-
46 efit plan developed pursuant to section 41-5511, Idaho Code.
47 (9) "Individual carrier" means a carrier that offers health benefit plans
48 covering eligible individuals and their dependents.
49 (10) "Individual catastrophic A health benefit plan" means a higher limit
50 health benefit plan developed pursuant to section 41-5511, Idaho Code.
51 (11) "Individual catastrophic B health benefit plan" means a health bene-
52 fit plan offering limits higher than a catastrophic A health benefit plan
53 developed pursuant to section 41-5511, Idaho Code.
54 (12) "Individual standard health benefit plan" means a health benefit plan
55 developed pursuant to section 41-5511, Idaho Code.
1 (13) "Plan" or "pool plan" means the individual basic, standard, cata-
2 strophic A or catastrophic B plan established pursuant to section 41-5511,
3 Idaho Code.
4 (14) "Plan of operation" means the plan of operation of the individual
5 high risk reinsurance pool established pursuant to this chapter.
6 (15) "Pool" means the Idaho high risk reinsurance pool.
7 (16) "Premium" means all moneys paid by an individual and eligible depend-
8 ents as a condition of receiving coverage from a carrier, including any fees
9 or other contributions associated with the health benefit plan.
10 (17) "Qualifying previous coverage" and "qualifying existing coverage"
11 mean benefits or coverage provided under:
12 (a) Medicare or medicaid, civilian health and medical program for
13 uniformed services (CHAMPUS), the Indian health service program, a state
14 health benefit risk pool, or any other similar publicly sponsored program;
16 (b) Any group or individual health insurance policy or health benefit
17 arrangement whether or not subject to the state insurance laws, including
18 coverage provided by a managed care organization, hospital or professional
19 service corporation, or a fraternal benefit society, that provides bene-
20 fits similar to or exceeding benefits provided under the basic health ben-
21 efit plan.
22 (18) "Reinsurance premium" means the premium set by the board pursuant to
23 section 41-5506, Idaho Code, to be paid by a reinsuring carrier for plans
24 issued under the pool.
25 (19) "Reinsuring carrier" means a carrier participating in the individual
26 high risk reinsurance pool established by this chapter.
27 (20) "Restricted network provision" means any provision of a health bene-
28 fit plan that conditions the payment of benefits, in whole or in part, on the
29 use of health care providers that have entered into a contractual arrangement
30 with the carrier to provide health care services to covered individuals.
31 SECTION 3. That Section 41-5510, Idaho Code, be, and the same is hereby
32 amended to read as follows:
33 41-5510. ELIGIBILITY. (1) Any individual eligible person, who is and con-
34 tinues to be a resident shall be eligible for coverage under an individual
35 basic, standard, catastrophic A or catastrophic B health benefit plan if evi-
36 dence is provided that:
37 (a) Such person has been rejected by one (1) individual carrier on the
38 basis of health status or claims experience; or
39 (b) An individual carrier refuses to issue a health benefit plan provid-
40 ing coverage substantially similar to coverage offered under an equivalent
41 pool plan except at a rate exceeding the rate for the pool plan; or
42 (c) Such person is legally domiciled in Idaho on the date of application
43 to the pool and is eligible for the credit for health insurance costs
44 under section 35 of the Internal Revenue Code of 1986. In addition, if
45 such person maintained creditable health insurance coverage for an aggre-
46 gate period of three (3) months as of the date on which the individual
47 seeks to enroll in pool coverage, not counting any period prior to a
48 sixty-three (63) day break in coverage:
49 (i) The preexisting condition limitation set forth in section
50 41-5208, Idaho Code, shall not apply; and
51 (ii) The requirement for exhaustion of any available COBRA or state
52 continuation benefits is waived.
53 (2) A rejection or refusal by a carrier offering only stop loss, excess
1 of loss or reinsurance coverage with respect to an applicant under subsection
2 (1) of this section shall not constitute sufficient evidence for purposes of
3 subsection (1) of this section.
4 (3) Each resident dependent of a person who is eligible for coverage
5 under the pool shall also be eligible for coverage under the pool.
6 (4) A person shall not be eligible for coverage under a pool plan if:
7 (a) The person has or obtains health insurance coverage substantially
8 similar to or more comprehensive than a pool plan, or would be eligible to
9 have coverage if the person elected to obtain it;
10 (b) The person is determined to be eligible for health care benefits
11 under medicaid;
12 (c) The person has previously terminated pool plan coverage unless twelve
13 (12) months have lapsed since such termination; provided however, that
14 this provision shall not apply with respect to an applicant who is a fed-
15 erally defined eligible individual;
16 (d) The person is an inmate or resident of a state or other public insti-
17 tution, or a state, local or private correctional facility; provided how-
18 ever, that this provision shall not apply with respect to an applicant who
19 is a federally defined eligible individual.
20 (5) Coverage shall cease:
21 (a) On the first day of the month following the date a person is no
22 longer a resident of this state;
23 (b) On the first day of the month following the date a person requests
24 coverage to end;
25 (c) Upon the death of the covered person;
26 (d) At the option of the board, thirty (30) days after the plan makes any
27 inquiry concerning the person's eligibility or place of residence to which
28 the person does not reply.
29 (6) A person who ceases to meet the eligibility requirements of this sec-
30 tion may be terminated on the first day of the month following the date when
31 the individual becomes ineligible.
STATEMENT OF PURPOSE
The Federal Trade Act of 2002 includes provisions to help certain
categories of individuals who have lost their jobs purchase
health insurance. Under the federal act, persons participating
in the Trade Adjustment Assistance Program or receiving payments
from the Pension Benefit Guaranty Corporation are eligible for a
federal tax credit that is equal to 65 percent of the premium
cost of a state qualified health insurance plan. To be a
qualified health insurance plan for purpose of the act, the plan
must meet certain minimum federal requirements. Currently, there
are no qualified plans in Idaho, and individuals who would
otherwise qualify for the federal tax credit are unable to take
advantage of the credit. The amendments made by this bill will
allow the Idaho Individual High Risk Reinsurance Pool plans to be
designated as state qualified health benefit plans for purposes
of the Trade Act of 2002.
The Individual High Risk Reinsurance Pool receives a statutorily
set percentage of premium tax receipts. The changes made by this
bill will not change that percentage and, therefore, this bill
will have no fiscal impact on the general fund.
Name: Rep. W.W."Bill" Deal
STATEMENT OF PURPOSE/FISCAL NOTE H 803