Credit for Preexisting Conditions for Individual Health Benefit Plans (Portability)
Idaho Code, Title 41, Chapter 52, applies to individual health benefit plans* for Idaho residents.
An individual health benefit plan may define a “preexisting condition” to mean:
- A condition that would have caused an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment during the six months immediately preceding the effective date of coverage;
- A condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six months immediately preceding the effective date of coverage; or
- A pregnancy existing on the effective date of coverage.
A health benefit plan may deny, exclude, or limit benefits for covered expenses incurred for preexisting conditions for 12 months following an individual’s effective date of coverage.
However, if an individual was covered under qualifying previous coverage** within 63 days before the effective date of a new individual health benefit plan, the new plan must provide credit for the time insured under the qualifying previous coverage towards satisfaction of the 12-month preexisting condition exclusion or limitation.
No preexisting condition limitation or exclusion may be applied to:
- A person determined to be a “federally eligible individual” under the federal law known as HIPAA, if the person applies for coverage within the 63 days of the date of termination of the prior creditable coverage; or
- A person who is eligible for Trade Adjustment Act assistance, if the person had prior creditable coverage for at least three months and had no break in coverage of more than 63 days.
* “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)
** “Qualifying previous coverage” means benefits or coverage provided under:
- Medicare or Medicaid, civilian health and medical program for uniformed services (CHAMPUS), the Indian health service program, a state health benefit risk pool, or any other similar publicly sponsored program; or
- Any group or individual health insurance policy or health benefit arrangement whether or not subject to the state insurance laws, including coverage provided by a managed care organization, hospital or professional service corporation, or a fraternal benefit society, that provides benefits similar to or exceeding benefits provided under the basic health benefit plan. (§41-5203)
