Title 41 — INSURANCE

41-6301. purpose and scope. (1) The purpose of this chapter is to provide the requirements for maintaining a risk management framework and completing an own risk and solvency assessment (ORSA) and provide guidance and instructions for filing an ORSA summary report with the direct…

41-6302. definitions. For purposes of this chapter: (1) "Department" means the state department of insurance. (2) "Director" means the director of the state department of insurance. (3) "Insurance group" means, for the purpose of conducting an ORSA, those insurers and affiliates …

41-6303. risk management framework. An insurer shall maintain a risk management framework to assist the insurer with identifying, assessing, monitoring, managing and reporting on its material and relevant risks. This requirement may be satisfied if the insurance group of which th…

41-6304. orsa requirement. Subject to section 41-6306, Idaho Code, an insurer, or the insurance group of which the insurer is a member, shall regularly conduct an ORSA consistent with a process comparable to the ORSA guidance manual. The ORSA shall be conducted no less than annua…

41-6305. orsa summary report. (1) Upon the director’s request, and no more than once each year, an insurer shall submit to the director an ORSA summary report or any combination of reports that together contain the information described in the ORSA guidance manual, applicable to …

41-6306. exemption. (1) An insurer shall be exempt from the requirements of this chapter if: (a) The insurer has an annual direct written and unaffiliated assumed premium, including international direct and assumed premium, but excluding premiums reinsured with the federal crop i…

41-6307. contents of orsa summary report. (1) The ORSA summary report shall be prepared consistent with the ORSA guidance manual, subject to the requirements of subsection (2) of this section. Documentation and supporting information shall be maintained and made available upon ex…

41-6308. confidentiality. (1) Documents, materials or other information, including the ORSA summary report, in the possession of or control of the department that are obtained by, created by or disclosed to the director or any other person under this chapter are recognized by thi…

41-6401. PURPOSE AND SCOPE. (1) The purpose and scope of this chapter are to: (a) Provide the insurance director a summary of an insurer or insurance group’s corporate governance structure, policies and practices to permit the director to gain and maintain an understanding of the…

41-6402. definitions. As used in this chapter: (1) "Corporate governance annual disclosure" or "CGAD" means a confidential report filed by the insurer or insurance group made in accordance with the requirements of this chapter. (2) "Insurance group" means those insurers and affil…

41-6403. DISCLOSURE REQUIREMENT. (1) A domestic insurer, or the insurance group of which the domestic insurer is a member, shall, no later than June 1 of each calendar year, submit to the director a corporate governance annual disclosure (CGAD) that contains the information descr…

41-6404. CONTENTS OF CORPORATE GOVERNANCE ANNUAL DISCLOSURE. (1) The insurer or insurance group shall have discretion over the responses to the CGAD inquiries, provided the CGAD shall contain the material information necessary to permit the director to gain an understanding of th…

41-6405. CONFIDENTIALITY. (1) Documents, materials or other information, including the CGAD, in the possession or control of the department of insurance that are obtained by, created by or disclosed to the director or any other person under this chapter are recognized by this sta…

41-6406. NAIC AND THIRD-PARTY CONSULTANTS. (1) The director may retain third-party consultants not otherwise part of the director’s staff as may be reasonably necessary to assist the director in reviewing the CGAD and related information or the insurer’s compliance with this chap…

41-6501. "ROUTINE PATIENT CARE costs" defined. "Routine patient care costs" means the costs of any medically necessary health care service for which benefits are provided under a health benefit plan, without regard to whether the enrollee is participating in a clinical trial. Rou…

41-6502. required coverage. The issuer of a health benefit plan shall provide benefits for routine patient care costs to an enrollee in connection with an approved clinical trial. For purposes of this chapter, "approved clinical trial" means a phase I, phase II, phase III, or pha…

41-6503. research institutions. The issuer of a health benefit plan is not required to: (1) Reimburse a research institution conducting a clinical trial for the cost of routine patient care provided through the research institution unless the research institution, and each health…

41-6504. limitations on coverage. The issuer of a health benefit plan is not required to provide benefits for routine patient care services provided outside: (1) Of the plan’s health care provider network, unless out-of-network benefits are otherwise provided under the plan; or (…

41-6505. insurer liability. An insurer that provides coverage required by this chapter is not, based on that coverage, liable for any adverse effects of the approved clinical trial.

41-6506. deductible, coinsurance, and copayment requirements. Benefits may be made subject to a deductible, coinsurance, or copayment requirement comparable to other deductible, coinsurance, or copayment requirements applicable under the health benefit plan.

41-6507. cancellation or nonrenewal prohibited. The issuer of a health benefit plan may not cancel or refuse to renew coverage under a plan solely because an enrollee in the plan participates in a clinical trial.

41-6601. SHORT TITLE. This chapter shall be known and may be cited as the "Fair Pharmacy Audits Act."

41-6602. purpose and applicability. (1) The purpose of this chapter is to establish minimum and uniform standards and criteria for the audit of pharmacies. (2) The provisions of this chapter shall apply to any audit of a pharmacy conducted on or after July 1, 2023, unless: (a) Co…

41-6603. requirements and prohibitions for pharmacy audits. (1) Any person or entity conducting an audit of a pharmacy shall: (a) If performing the audit pursuant to a contract, identify and specifically describe the contract provisions authorizing the audit, including provisions…

41-6604. Appeals process. (1) Each person or entity conducting an audit shall establish a written appeals process under which a pharmacy may appeal an unfavorable preliminary audit report or final audit report to the person or entity. The pharmacy must submit documentation or oth…

41-6605. Extrapolation audit prohibited. (1) As used in this section, "extrapolation audit" means an audit of a sample of prescription drug benefit claims submitted by a pharmacy to the person or entity conducting an audit that is then used to estimate audit results for a larger …