Print Friendly SENATE BILL NO. 1395
– Individual high-risk insurance pool
SENATE BILL NO. 1395
View Bill Status
View Bill Text
View Statement of Purpose / Fiscal Impact
Text to be added within a bill has been marked with Bold and
Underline. Text to be removed has been marked with
Strikethrough and Italic. How these codes are actually displayed will
vary based on the browser software you are using.
This sentence is marked with bold and underline to show added text.
This sentence is marked with strikethrough and italic, indicating
text to be removed.
S1395.......................................by COMMERCE AND HUMAN RESOURCES
INSURANCE - Amends existing law relating to the Idaho Individual High Risk
Reinsurance Pool to revise definitions; to provide for coverage for certain
eligible persons; and to provide for exceptions.
02/08 Senate intro - 1st rdg - to printing
02/11 Rpt prt - to Com/HuRes
02/13 Rpt out - rec d/p - to 2nd rdg
02/14 2nd rdg - to 3rd rdg
02/21 3rd rdg - PASSED - 34-0-1
AYES -- Andreason, Bair, Bastian, Bilyeu, Broadsword, Cameron,
Coiner, Corder, Darrington, Davis, Fulcher, Gannon, Geddes, Goedde,
Hammond, Heinrich, Hill, Jorgenson, Kelly, Keough, Langhorst, Little,
Lodge, Malepeai(Sagness), McGee, McKague, McKenzie, Pearce,
Richardson, Schroeder, Siddoway, Stegner, Stennett, Werk
NAYS -- None
Absent and excused -- Burkett
Floor Sponsor - Cameron
Title apvd - to House
02/22 House intro - 1st rdg - to Bus
03/14 Rpt out - rec d/p - to 2nd rdg
03/17 2nd rdg - to 3rd rdg
03/19 3rd rdg - PASSED - 67-0-3
AYES -- Anderson, Andrus, Barrett, Bayer, Bedke, Bell, Bilbao, Black,
Block, Bock, Boe, Bolz, Bowers, Brackett, Bradford, Chadderdon,
Chavez, Chew, Clark, Collins, Crane, Durst, Eskridge, Hagedorn, Hart,
Harwood, Henbest, Henderson, Jaquet, Killen, King, Kren, Labrador,
Lake, LeFavour, Loertscher, Luker, Marriott, Mathews, McGeachin,
Mortimer, Moyle, Nielsen, Pasley-Stuart, Patrick, Pence, Raybould,
Ringo, Ruchti, Rusche, Sayler, Schaefer, Shepherd(02), Shepherd(08),
Shirley, Shively, Smith(30), Smith(24), Snodgrass, Stevenson, Thayn,
Thomas, Vander Woude, Wills, Wood(27), Wood(35), Mr. Speaker
NAYS -- None
Absent and excused -- Nonini, Roberts, Trail
Floor Sponsor - Collins
Title apvd - to Senate
03/20 To enrol - Rpt enrol - Pres signed
03/21 Sp signed
03/24 To Governor
03/28 Governor signed
Session Law Chapter 297
]]]] LEGISLATURE OF THE STATE OF IDAHO ]]]]
Fifty-ninth Legislature Second Regular Session - 2008
IN THE SENATE
SENATE BILL NO. 1395
BY COMMERCE AND HUMAN RESOURCES COMMITTEE
1 AN ACT
2 RELATING TO THE IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL; AMENDING SECTION
3 41-5501, IDAHO CODE, TO REVISE DEFINITIONS; AND AMENDING SECTION 41-5510,
4 IDAHO CODE, TO PROVIDE CORRECT TERMINOLOGY, TO PROVIDE FOR COVERAGE FOR
5 CERTAIN ELIGIBLE PERSONS AND TO PROVIDE FOR EXCEPTIONS.
6 Be It Enacted by the Legislature of the State of Idaho:
7 SECTION 1. That Section 41-5501, Idaho Code, be, and the same is hereby
8 amended to read as follows:
9 41-5501. DEFINITIONS. As used in this chapter:
10 (1) "Agent" means a producer as defined in section 41-1003(8), Idaho
12 (2) "Board" means the board of directors of the Idaho high risk individ-
13 ual reinsurance pool established in this chapter and the Idaho small employer
14 reinsurance program established in section 41-4711, Idaho Code.
15 (3) "Carrier" means any entity that provides, or is authorized to pro-
16 vide, health insurance in this state. For purposes of this chapter, carrier
17 includes an insurance company, any other entity providing reinsurance includ-
18 ing excess or stop loss coverage, a hospital or professional service corpora-
19 tion, a fraternal benefit society, a managed care organization, any entity
20 providing health insurance coverage or benefits to residents of this state as
21 certificate holders under a group policy issued or delivered outside of this
22 state, and any other entity providing a plan of health insurance or health
23 benefits subject to state insurance regulation.
24 (4) "Dependent" means a spouse, an unmarried child under the age of
25 twenty-one (21) years, an unmarried child who is a full-time student under the
26 age of twenty-five (25) years and who is financially dependent upon the par-
27 ent, and an unmarried child of any age who is medically certified as disabled
28 and dependent upon the parent.
29 (5) "Director" means the director of the department of insurance of the
30 state of Idaho.
31 (6) "Eligible individual" means:
32 (a) An Idaho resident individual or dependent of an Idaho resident who is
33 under the age of sixty-five (65) years, is not eligible for coverage under
34 a group health plan, part A or part B of title XVIII of the social secu-
35 rity act (medicare), or a state plan under title XIX (medicaid) or any
36 successor program, and who does not have other health insurance coverage;
38 (b) An individual who is legally domiciled in Idaho on the date of appli-
39 cation to the pool and is eligible for the credit for health insurance
40 costs under section 35 of the Internal Revenue Code of 1986; or
41 (c) An Idaho resident individual or a dependent of an Idaho resident who
42 is a federally eligible individual (one who meets the eligibility criteria
43 set forth in the federal health insurance portability and accountability
1 act of 1996 Public Law 104-191, Sec. 2741(b) (HIPAA)).
2 Coverage under a basic, standard, catastrophic A, catastrophic B, or HSA com-
3 patible health benefit plan shall not be available to any individual who is
4 covered under other health insurance coverage, except as provided in section
5 41-5510(4), Idaho Code. For purposes of this chapter, to be eligible, an indi-
6 vidual must also meet the requirements of section 41-5510, Idaho Code.
7 (7) "Health benefit plan" means any hospital or medical policy or certif-
8 icate, any subscriber contract provided by a hospital or professional service
9 corporation, or health maintenance organization subscriber contract. Health
10 benefit plan does not include policies or certificates of insurance for spe-
11 cific disease, hospital confinement indemnity, accident-only, credit, dental,
12 vision, medicare supplement, long-term care, or disability income insurance,
13 student health benefits only, coverage issued as a supplement to liability
14 insurance, worker's compensation or similar insurance, automobile medical pay-
15 ment insurance, or nonrenewable short-term coverage issued for a period of
16 twelve (12) months or less.
17 (8) "Individual basic health benefit plan" means a lower cost health ben-
18 efit plan developed pursuant to section 41-5511, Idaho Code.
19 (9) "Individual carrier" means a carrier that offers health benefit plans
20 covering eligible individuals and their dependents.
21 (10) "Individual catastrophic A health benefit plan" means a higher limit
22 health benefit plan developed pursuant to section 41-5511, Idaho Code.
23 (11) "Individual catastrophic B health benefit plan" means a health bene-
24 fit plan offering limits higher than a catastrophic A health benefit plan
25 developed pursuant to section 41-5511, Idaho Code.
26 (12) "Individual HSA compatible health benefit plan" means a health sav-
27 ings account compatible health benefit plan developed pursuant to section
28 41-5511, Idaho Code.
29 (13) "Individual standard health benefit plan" means a health benefit plan
30 developed pursuant to section 41-5511, Idaho Code.
31 (14) "Plan" or "pool plan" means the individual basic, standard, cata-
32 strophic A, catastrophic B, or HSA compatible health benefit plan established
33 pursuant to section 41-5511, Idaho Code.
34 (15) "Plan of operation" means the plan of operation of the individual
35 high risk reinsurance pool established pursuant to this chapter.
36 (16) "Pool" means the Idaho high risk reinsurance pool.
37 (17) "Premium" means all moneys paid by an individual and eligible depend-
38 ents as a condition of receiving coverage from a carrier, including any fees
39 or other contributions associated with the health benefit plan.
40 (18) "Qualifying previous coverage" and "qualifying existing coverage"
41 mean benefits or coverage provided under:
42 (a) Medicare or medicaid, civilian health and medical program for
43 uniformed services (CHAMPUS), the Indian health service program, a state
44 health benefit risk pool, or any other similar publicly sponsored program;
46 (b) Any group or individual health insurance policy or health benefit
47 arrangement whether or not subject to the state insurance laws, including
48 coverage provided by a managed care organization or a fraternal benefit
50 (19) "Reinsurance premium" means the premium set by the board pursuant to
51 section 41-5506, Idaho Code, to be paid by a reinsuring carrier for plans
52 issued under the pool.
53 (20) "Reinsuring carrier" means a carrier participating in the individual
54 high risk reinsurance pool established by this chapter.
55 (21) "Restricted network provision" means any provision of a health bene-
1 fit plan that conditions the payment of benefits, in whole or in part, on the
2 use of health care providers that have entered into a contractual arrangement
3 with the carrier to provide health care services to covered individuals.
4 SECTION 2. That Section 41-5510, Idaho Code, be, and the same is hereby
5 amended to read as follows:
6 41-5510. ELIGIBILITY. (1) Any eligible individual eligible person, who is
7 and continues to be a resident shall be eligible for coverage under an indi-
8 vidual basic, standard, catastrophic A, catastrophic B, and HSA compatible
9 health benefit plan if evidence is provided that:
10 (a) Such person has been rejected by one (1) individual carrier on the
11 basis of health status or claims experience; or
12 (b) An individual carrier refuses to issue a health benefit plan provid-
13 ing coverage substantially similar to coverage offered under an equivalent
14 pool plan except at a rate exceeding the rate for the pool plan; or
15 (c) Such person is a federally eligible individual; or
16 (d) Such person is legally domiciled in Idaho on the date of application
17 to the pool and is eligible for the credit for health insurance costs
18 under section 35 of the Internal Revenue Code of 1986. In addition, if
19 such person maintained creditable health insurance coverage for an aggre-
20 gate period of three (3) months as of the date on which the individual
21 seeks to enroll in pool coverage, not counting any period prior to a
22 sixty-three (63) day break in coverage:
23 (i) The preexisting condition limitation set forth in section
24 41-5208, Idaho Code, shall not apply; and
25 (ii) The requirement for exhaustion of any available coverage under
26 title X of the consolidated omnibus budget reconciliation act of
27 1986, public law 99-272 (COBRA) or state continuation benefits is
29 (2) A rejection or refusal by a carrier offering only stop loss, excess
30 of loss or reinsurance coverage with respect to an applicant under subsection
31 (1) of this section shall not constitute sufficient evidence for purposes of
32 subsection (1) of this section.
33 (3) Each resident dependent of a person who is eligible for coverage
34 under the pool shall also be eligible for coverage under the pool.
35 (4) Any eligible individual person meeting the eligibility requirements
36 of subsection (1), (2) or (3) of this section shall be eligible for coverage
37 under a pool plan even though the person has existing coverage under other
38 health insurance or under a group health plan provided: (a) there is a reason-
39 able probability that the lifetime benefit maximum of the existing coverage
40 will be exceeded within ninety (90) days; and (b) the lifetime benefit maximum
41 under the existing coverage is at least five hundred thousand dollars
42 ($500,000). In all cases, coverage under a pool plan is secondary to the
43 existing coverage and all other insurance.
44 (5) A person shall not be eligible for coverage under a pool plan if:
45 (a) The person is not a federally eligible individual and, except as pro-
46 vided otherwise in subsection (4) of this section, has or obtains health
47 insurance coverage substantially similar to or more comprehensive than a
48 pool plan, or would be eligible to have such coverage at a rate not
49 exceeding the rate for the pool plan if the person elected to obtain it;
50 (b) The person is determined to be eligible for health care benefits
51 under medicaid;
52 (c) The person has previously terminated pool plan coverage unless twelve
53 (12) months have lapsed since such termination; provided however, that
1 this provision shall not apply with respect to an applicant who is a fed-
2 erally eligible individual;
3 (d) The person is an inmate or resident of a state or other public insti-
4 tution, or a state, local or private correctional facility; provided how-
5 ever, that this provision shall not apply with respect to an applicant who
6 is a federally eligible individual.
7 ( 56) Notwithstanding any other provision of this chapter, eligibility for
8 continuation of coverage under COBRA shall not render a person ineligible for
9 coverage under a pool plan.
10 ( 67) Coverage shall cease:
11 (a) On the first day of the month following the date a person is no
12 longer a resident of this state;
13 (b) On the first day of the month following the date a person requests
14 coverage to end;
15 (c) Upon the death of the covered person;
16 (d) At the option of the board, thirty (30) days after the plan makes any
17 inquiry concerning the person's eligibility or place of residence to which
18 the person does not reply.
19 ( 78) A person who ceases to meet the eligibility requirements of this
20 section may be terminated on the first day of the month following the date
21 when the individual becomes ineligible.
STATEMENT OF PURPOSE
In 2000, the Idaho Legislature created the Idaho High Risk
Pool. The purpose of the High Risk Pool was to provide every
Idahoan who has serious health conditions an opportunity to
purchase insurance through a reinsurance mechanism. As part of
the original bill, we prohibited individuals who currently had
insurance from applying to the High Risk Pool. There are good
reasons for that public policy decision.
However, an inadvertent result is that individuals who reach
their lifetime maximum cannot apply to the High Risk Pool until
their coverage is terminated. This causes the person to go
through a period of being uninsured, while building up large
dollars of claims. County indigent funds and property taxes are
affected as well as the State's Catastrophic Health Care Fund,
not to mention the health and well being of the individual.
This bill attempts to remedy that situation by allowing an
individual who would otherwise qualify for the High Risk Pool to
apply for coverage if there is reasonable probability that they
will exceed their lifetime maximum within 90 days.
None to the General Fund, except a potential savings in the
Catastrophic Health Care Fund. The High Risk Pool may be
adversely impacted by large claims; however, we expect that to be
minimal. The Fund is actuarially financially stable.
Name: Senator Dean Cameron
Name: Representative Gary Collins, Phone: 332-1063
Hyatt Erstad, Chairman, Idaho High Risk Pool Board
Bill Deal, Director, Idaho Department of Insurance
STATEMENT OF PURPOSE/FISCAL NOTE S 1395