Title 41, INSURANCE

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…

41-4001. Declaration of purpose. (1) The purpose of this chapter is to recognize and provide reasonable supervision of self-funded or partially self-funded plans for provision of health care service benefits to employees or to students of a postsecondary educational institution i…

41-4002. Definitions. For the purposes of this chapter unless context otherwise requires: (1) "Administrator" is a person, if other than the trustee, employed or contracted by the trustee to provide administrative services to a self-funded plan. (2) "Beneficiary" is any individua…

41-4003. Registration required — Exemptions — Not subject to insurance code. (1) No person shall offer or operate a self-funded plan in this state unless the plan is registered with the director as hereinafter provided. (2) No registration shall be required of: (a) Any self-funde…

41-4004. Plan requirements. (1) The director shall not register any self-funded plan under this chapter unless the following requirements are met: (a) The plan must require all contributions to be paid in advance and to be deposited in and disbursed from a trust fund duly created…

41-4005. Application for registration — Fee. (1) Application for registration of a self-funded plan shall be made to the director, on forms prescribed by the director, seeking such information concerning whether, in the opinion of the director, the plan is qualified for registrat…

41-4006. Grant or denial of registration. (1) The director shall act upon an application for registration of a self-funded plan with all reasonable promptness, but not more than ninety (90) days from the date of submission of a complete application to the director. Failure to act…

41-4007. Trust fund — authority. The trust fund of a self-funded plan shall have the authority: (1) To have and use an appropriate descriptive name; (2) To sue and be sued in its own name; (3) To contract in its own name. All such contracts shall be in writing and shall be signed…

41-4008. Trust fund liability — fiduciary funds. (1) The trust fund of a self-funded plan shall be legally liable for payment of all applicable benefits stated in the schedule of benefits for such plan in effect at the time a claim thereunder arises. (2) Funds in the trust fund a…

41-4009. Investment of trust fund. (1) The trustee may invest trust funds available for that purpose in the following kinds of investments only: (a) General obligations of the United States government, or of any state, district, commonwealth, or territory of the United States, or…

41-4010. Reserves and surplus. (1) The trustee of a self-funded plan shall establish and maintain in the trust fund the following reserves: (a) A reserve in an amount as certified by a qualified actuary as being necessary for payment of claims liability. The reserve shall be reas…

41-4011. Records and accounts — Annual statement. (1) The trustee of a self-funded plan shall cause full and accurate records and accounts to be entered and maintained during all times of the existence of the trust covering all financial transactions and affairs of the trust fund…

41-4012. Taxes. (1) Each self-funded plan required to be registered under this chapter is subject to the tax as provided in this section. Each registered self-funded plan, and each formerly registered plan with respect to beneficiaries in this state while so registered, shall sim…

41-4013. Examination of books, records and accounts. (1) The books, records, accounts and affairs of a self-funded plan shall be subject to examination by the director, by qualified examiners duly authorized by him in writing, at such times or intervals as the director deems appr…

41-4014. Trustees — Administrators — Bonding. (1) Either an individual or a corporation or other legal entity may be a trustee of the trust fund. Any person acting as a trustee is a fiduciary acting on behalf of the beneficiaries of the plan and the trust fund in such capacity. A…

41-4015. Prohibited pecuniary interests in plan management. (1) No plan sponsor, trustee, administrator, or other person having responsibility for the management of a self-funded plan or the investment or other handling of trust funds shall: (a) Receive directly or indirectly or …

41-4016. Political contributions prohibited. No trustee shall make or knowingly permit the making, directly or indirectly, of any political contribution by or from any self-funded plan trust fund.

41-4017. Recovery of depleted funds. If after notice and the opportunity for a hearing the director finds that any self-funded plan trust fund has been depleted by reason of any wrongful or negligent act or omission of a trustee or any other person, he shall transmit a copy of hi…

41-4018. Termination of registration. (1) The director shall terminate the registration of a self-funded plan upon written request of the trustee, or if he finds, after an inquiry or an examination, that the trust fund is insolvent. For the purposes of this chapter, "insolvent" m…

41-4019. Liquidation of trust fund. (1) Upon termination of registration of the plan, the trust fund of a self-funded plan shall be liquidated as soon as practicable. (2) Liquidation of a solvent self-funded plan shall be conducted by its trustee under a plan of liquidation in wr…

41-4020. Rules. (1) The director may promulgate reasonable rules necessary for or as an aid to effectuation of any provision of this chapter. No such rule shall extend, modify, or conflict with any provision of this chapter and the reasonable implications thereof. (2) Such rules,…

41-4021. Other provisions applicable. Chapter 2, title 41, Idaho Code, (the director of the department of insurance), chapter 9, title 41, Idaho Code, (insurance administrators), chapter 13, title 41, Idaho Code, (trade practices and frauds), chapter 56, title 41, Idaho Code, (pr…

41-4022. Penalties. (1) Any person who violates or causes or induces violation of any provision of this chapter, or any lawful rule of the director issued thereunder, shall be subject to an administrative penalty for each violation of not more than one thousand dollars ($1,000) f…

41-4023. Coverage from moment of birth — Complications of pregnancy. (1) Every self-funded plan issued pursuant to this chapter in this state, or providing coverage to any covered family residing within this state, shall contain a provision granting immediate accident and sicknes…

41-4024. Services provided by governmental entities. (1) From and after July 1, 1990, no self-funded plan shall be issued in Idaho which excludes from coverage services rendered the subscriber while a resident in an Idaho state institution, provided the services to the subscriber…

41-4025. Mammography coverage. (1) From and after July 1, 1992, all self-funded plans which provide coverage for the surgical procedure known as a mastectomy which are delivered, issued for delivery, continued or renewed in this state shall provide minimum mammography examination…

41-4101. Declaration of purpose. It is the purpose of this chapter to recognize and provide reasonable public supervision of self-funded plans established by public agencies pursuant to a joint powers agreement in accordance with chapter 23, title 67, Idaho Code, for provision of…

41-4102. Definitions. As used in this chapter: (1) "Administrator" means a person, other than a board member, employed by the board to administer a joint public agency self-funded plan. (2) "Beneficiary" means any individual entitled, under the joint public agency self-funded pla…

41-4103. Registration required — Exemptions — Not subject to insurance code. (1) No joint public agency self-funded plan shall operate in this state except while registered with the director as hereinafter provided. Joint public agency self-funded plans already in operation as of…

41-4104. Qualifications for registration. No joint public agency self-funded plan shall register, and the director shall not register a joint public agency self-funded plan, which is not qualified as provided in this section. (1) The joint powers agreement must require all contri…

41-4105. Application for registration. (1) Application for registration of a joint public agency self-funded plan for public agencies shall be made to the director, on forms furnished and designed by him. The application shall be signed and verified by at least two (2) of the boa…

41-4106. Grant or denial of application. The director shall act upon an application for registration of a joint public agency self-funded plan with all reasonable promptness. He may make a reasonable investigation of the proposal from the public agency. If the director finds that…

41-4107. Trust fund — Powers. In addition to the inherent applicable powers of its public agency members and those of a joint powers entity, the trust fund of a joint public agency self-funded plan shall have power: (1) To have and use an appropriate descriptive name; (2) To sue …

41-4108. Trust fund liability. (1) The trust fund of a joint public agency self-funded plan shall be legally liable for payment of all applicable benefits stated in the statement or schedule of benefits in effect at the time a claim thereunder arises and subject to the terms of t…

41-4109. Investment of trust fund. (1) The board may invest reserves and other funds available for the purpose in the trust fund of a joint public agency self-funded plan in the following kinds of investments only: (a) General obligations of the United States government, or of an…

41-4110. Reserves. (1) A joint public agency self-funded plan shall establish and maintain in its trust fund the following reserves: (a) A reserve in an amount as certified by a member of the American academy of actuaries as being necessary for payment of claims against the trust…

41-4111. Records and accounts — Annual statement. (1) The board of a joint public agency self-funded plan shall cause full and accurate records and accounts to be entered and maintained covering all financial transactions and affairs of the trust fund. (2) Within ninety (90) days…

41-4112. Taxes — Exemption. Any plan established under this chapter is not subject to any state tax, including a premium or maintenance tax.

41-4113. Examination of books, records and accounts. (1) The books, records, accounts and affairs of a joint public agency self-funded plan shall be subject to examination by the director, by competent examiners duly authorized by him in writing, at such times or intervals as the…

41-4114. Board of trustees — Administrators. (1) The trust shall be governed and managed by a board of trustees. This board shall consist of members elected by the governing boards of the member public agencies. The composition and membership of the board shall be established in …

41-4115. Prohibited pecuniary interests in plan management. No board member, administrator or other person having responsibility for the management of a joint public agency self-funded plan or the investment or other handling of plan funds shall: (1) Receive directly or indirectl…

41-4116. Political contributions prohibited. No board shall make or knowingly permit the making, directly or indirectly, of any political contribution by or from any joint public agency self-funded plan trust fund.