Title 41 — INSURANCE

41-3901. Short title. This chapter may be cited as the Idaho "Managed Care Reform Act."

41-3902. Intent and purpose. As a guide to the interpretation and application of this chapter, the public policy of this state is declared as follows: The legislature wishes to eliminate legal barriers to the establishment of managed care plans which provide readily available, ac…

41-3903. Definitions. (1) "Basic health care services" means the following services: preventive care, emergency care, inpatient and outpatient hospital and physician care, hospital-based rehabilitation treatment, diagnostic laboratory and diagnostic and therapeutic radiological s…

41-3904. Certificate of authority required — Exceptions — Application of certain provisions. (1) No person shall in this state offer a managed care plan on a predetermined and prepaid basis, unless authorized under a certificate of authority issued by the director. A person offer…

41-3905. Qualifications for certificate of authority. The director shall not issue or permit to remain in force a certificate of authority authorizing the transaction of managed care plans unless the organization offering the managed care plan is qualified therefor as follows: (1…

41-3906. Application for certificate of authority. (1) The application for a certificate of authority shall be in writing in the form prescribed by the director. It shall be verified by an officer of an applicant corporation or association, or member of an applicant firm, or by t…

41-3909. Records. (1) Every managed care organization shall establish and at all times maintain adequate records of its financial and business transactions. (2) The managed care organization shall retain its general records with respect to a particular transaction for a period of…

41-3910. Reports to the director. (1) Every managed care organization offering a managed care plan for which a certificate of authority is required shall annually, on or before the first day of June, file a report with the director showing its audited financial condition on the l…

41-3911. Examinations. (1) The director shall make an examination of the affairs and operations of any organization offering a managed care plan for which a certificate of authority is required as often as he deems necessary but not less frequently than once every five (5) years.…

41-3912. Suspension or revocation of certificate of authority. The director may initiate proceedings to suspend or revoke a certificate of authority to offer a managed care plan for the reasons and in the manner provided in title 41, Idaho Code, for mutual insurers. In addition t…

41-3914. Annual disclosures. (1) Every managed care organization shall provide to its enrollees and make available for inspection by the general public on an annual basis: (a) an audited statement of financial condition including a balance sheet and a summary of receipts and disb…

41-3915. Health care contracts. (1) All health care contracts or other marketing documents describing health care services offered by any managed care organization shall contain: (a) A complete description of the health care services and other benefits to which the member is enti…

41-3916. Advisory panels. Every managed care organization shall establish a mechanism to provide members an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions, or t…

41-3917. Certain words prohibited in name of organization. No person or organization offering a health care plan not qualified as a managed care plan under the provisions of this chapter shall use in its name, logo, contracts or literature the phrase, "health maintenance organiza…

41-3918. Grievance system. (1) Every managed care organization shall establish a grievance system to resolve grievances initiated by members concerning health care services. The system shall provide reasonable procedures for the resolution of grievances, and shall include an appe…

41-3919. Open enrollment. (1) Requirement of an open enrollment period is intended to provide the benefits of managed care to the general public or to all members of the class of persons the managed care organization serves. Such requirement is not intended to prohibit a managed …

41-3920. Discrimination against health professionals associated with managed care organizations. It shall be unlawful for any health service institution or associations of health professionals to exclude other health professionals from working privileges, membership, or associati…

41-3921. Statutory construction and relationship to other laws. (1) Except as stated in this chapter, provisions of title 41, Idaho Code, applicable to disability insurers shall be applicable to the lawful transactions and business of an organization offering a managed care plan …

41-3922. Taxation — Penalty for failure to file. (1) Each organization offering a managed care plan for which a certificate of authority is required under this chapter shall be subject to taxation as provided in chapter 4, title 41, Idaho Code. (2) Any managed care organization f…

41-3923. Coverage of adopted newborn children — Coverage of maternity and complications of pregnancy. (1) Any contract delivered or issued for delivery in this state by an organization offering a managed care plan for which a certificate of authority is required, which provides c…

41-3924. Limitation of benefits for elective abortions. All policies, contracts, plans or certificates delivered, issued for delivery or renewed in this state by an organization offering a managed care plan for which a certificate of authority is required shall exclude coverage f…

41-3925. Services provided by governmental entities. (1) From and after July 1, 1990, no contract shall be issued in Idaho by an organization offering a managed care plan for which a certificate of authority is required which excludes from coverage services rendered the member wh…

41-3926. Mammography coverage. (1) From and after July 1, 1992, all policies, contracts, plans or certificates issued by an organization offering a managed care plan which provide coverage for the surgical procedure known as a mastectomy which are delivered, issued for delivery, …

41-3927. Health care providers — Participation by any qualified, willing provider — Contracts — Grievance procedure. (1) Any managed care organization issuing benefits pursuant to the provisions of this chapter shall be ready and willing at all times to enter into care provider s…

41-3928. Incentives to withhold care prohibited. (1) No managed care organization shall offer a provider and no contract between a managed care organization and a provider shall contain any incentive plan that includes a specific payment made, in any type or form, to the provider…

41-3930. Utilization management program requirements. (1) All managed care organizations performing utilization management or contracting with third parties for the performance of utilization management shall: (a) Adopt utilization management criteria based on sound patient care …

41-3931. Participation in Idaho life and health insurance guaranty association. (1) Each organization offering a managed care plan for which a certificate of authority is required under this chapter shall, as a condition of its authority to offer managed care plans in this state,…

41-3932. Exemptions from application of chapter. This chapter shall not apply to managed care programs operated under contract with the federal government under title XVIII of the federal social security act, as amended (medicare), or under contract with a plan otherwise exempt f…

41-3940. Preexisting conditions. A general managed care plan shall comply with the following provisions: (1) A general managed care plan shall not deny, exclude or limit benefits for a covered individual for covered expenses incurred more than twelve (12) months following the eff…