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Individual Health Insurance Availability Act

Idaho Code, Title 41, Chapter 52, is the Individual Health Insurance Availability Act. The purpose of this act is to make health insurance coverage available to Idaho “eligible individuals” not covered by employment-based insurance. Idaho residents may be eligible for coverage regardless of their health status or claims experience.

An “eligible individual” means an Idaho resident individual or dependent of an Idaho resident:

• Who is under the age of 65, is not eligible for coverage under a group health plan, for Part A or Part B of Medicare or for Medicaid, and who does not have other health insurance coverage; or
• Who is a federally eligible individual under the federal law known as HIPAA (1996 Public Law 104-191).

Every insurance company that is approved to market individual health benefit plans* in Idaho must actively offer health benefit plans to individuals, including the five High Risk Reinsurance Pool Plans (HRP Plans) as described below. Companies must follow fair marketing standards set by the act. Companies may deny coverage under a plan other than an HRP Plan on the basis of:

• The health status or claims experience of the individual or dependents; or
• If the coverage offered is substantially similar to an HRP Plan except at a higher premium rate.

Any denial of coverage must be in writing and state the reason(s) for the denial. The company must then offer that individual his or her choice of the five HRP Plans. A company or agent may not encourage an individual to refrain from applying or to apply with another company due to the health status, claims experience, industry, occupation, or geographic location of the individual.

The act and the Department’s Rule, IDAPA 18.01.72, require a company to disclose its rating practices to an individual purchasing a health benefit plan. The act and rule give the Department oversight to prevent abusive rating practices.

Idaho Code, Title 41, Chapter 55, enacted the Idaho Individual High Risk Reinsurance Pool, effective January 1, 2001. This act provided for the development of four High Risk Reinsurance Pool Plans (HRP Plans): Basic, Standard, Catastrophic A, and Catastrophic B.  A fifth plan, an HSA Compatible Plan, was added as of January 1, 2006.  An Idaho resident who meets the eligibility requirements can be insured for one of these plans through the insurance carriers that are approved to offer individual health benefit plans in Idaho.

For more information on the HRP Plans for Idaho residents, refer to our brochure. The five plan designs are included in the Department’s Rule, IDAPA 18.01.73., and in the sample policy of insurance.

ALL health benefit plans for individuals must comply with laws regarding preexisting conditions and portability.

ALL health benefit plans are renewable at the insured’s option, except due to circumstances such as: nonpayment of premium; fraud or misrepresentation; or the insured ceases to be an “eligible individual”.

The Idaho Department of Insurance maintains a list of the health insurance companies approved to offer individual health benefit plans.

* “Health benefit plan” means a hospital or medical policy or certificate.
“Health benefit plan” does not include a policy or certificate for specific disease, hospital confinement indemnity, accident-only, credit, dental, vision, Medicare supplement, long-term care, disability income insurance, student health benefits-only coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, automobile medical payment insurance, or nonrenewable short-term coverage issued for a period of 12 months or less. (§ 41-5203)