Self-Funded Employee Health Care Plans
The forms and procedures of the application process are designed to facilitate our review of the application. Therefore, it is extremely important that your application conforms fully to the instructions and requirements set forth below. This list may not provide all the information or requirements that will be needed to register the self-funded plan, based upon your particular situation. You will be advised of any additional registration information that is required. Please submit the following:
- The attached signed by at least one (1) employer or, if applicable, by a person authorized by a postsecondary educational institution to sign the application, and at least one (1) plan trustee. If employer, postsecondary educational institution, or trustee is a corporation, the verification shall be by a duly authorized corporate officer or by a managing member of the plan sponsor if the plan sponsor is a limited liability company.
- A copy of the irrevocable trust agreement under which the trust fund is to exist and operate. The trust agreement should comply with Idaho Code Title 41, Chapter 40 and contain the conditions set forth in sections 41-4004(1)(e) and 41-4004(1)(d), Idaho Code.
- A copy of the proposed written statement of benefits referenced in section 41-4004(1)(d), Idaho Code. The statement should include a table of the rates charged. The policy forms should be in compliance with all requirements of Title 41, Chapter 40 and other code sections as required under Idaho Code section 41-4021. The policies should not include any terms that could be misconstrued to imply that the policy is one of insurance, including, but not limited to, references to words such as “insurance,” “reinsurance”, “premium”, or other common insurance terms. Each form should clearly state that the policy is not insurance and not subject to the Idaho Guaranty Association. Additionally, all updates or future changes to the policies must be re-filed with the DOI for review.
- Copies of all materials used in marketing or the solicitation of business.
- A financial statement of the trust fund, if already in existence and operating at the time of application, certified by an independent certified public accountant and in accordance with generally accepted accounting principles. The statement should be accompanied by an actuarial opinion certifying the reserve liabilities, prepared in accordance with Idaho Code section 41-4011(3). The income statement should provide enough detail to identify specific significant expenses of the trust.
- If the trust fund is not in existence at the time of application or is undergoing substantial changes in benefits or number of beneficiaries, a pro forma balance sheet is required for the start of operation of the plan and a pro forma balance sheet, by month, is required for the first twelve (12) months of operation of the plan, commencing with the expected start date of the plan’s operations, and showing the amount projected as of the end of each period for claims incurred but not paid and incurred but not reported as certified by a qualified actuary. In order to verify compliance with Idaho Code and Rules, the balance sheet should include: 1) a detailed list of the type and amount of investments of the plan; 2) reserves for claims and other items, per Idaho Rule , which have been certified by an actuary; and 3) other liabilities.
- A written statement of reasonably projected income and disbursements of the Fund, by month, for the twelve (12) month period commencing with the expected effective date of registration, and including changes to claims liabilities fully set forth in the monthly expenses as calculated by a qualified actuary. Please provide enough detail that the DOI can identify specific significant expenses of the trust, by month. Do NOT use the annual estimated expense and allocate the expense monthly, unless the estimated expense will be paid or accrued monthly, in practice. The Trust should have enough surplus to cover fluctuations in expenses and claims and still meet the minimum surplus requirements at all times. A copy of a business plan. Include the amount of initial funding planned by the employer or plan sponsor that will be in addition to the monthly contributions. This amount cannot be a loan, prepayment, or encumbered in any way.
- A certified statement attesting to actuarial soundness of contribution rates. Include the actuarial study prepared by a qualified actuary certifying that the rates for the plan are sufficient to cover moderately adverse experience and all costs of operation. The study shall include the development and justification of the assumptions used by the actuary in determining the rates. Also, include the employer and employee contribution percentages, or, for a student health plan, the student and school contribution percentages, and the period of time for which rates may be deemed valid. A qualified actuary must certify the statement.
- A copy of any study made of the proposed self-funded health care plan by a consultant for the information or guidance of an employer or employees.
- A certified copy of the fidelity bond or coverage deemed to be equivalent by the director of the Department of Insurance, in compliance with Idaho code section 41-4014(3).). This bond is required for the plan regardless of any other TPA (third party administrator) under Title 41, Chapter 9. The bond or equivalent coverage should be in the name of the Trust (not an employer or school) and contain the language outlined in , “Cancellation of Bond Requirements.” The bond must contain specific language stating “that it is noncancellable except upon not less than thirty (30) days advance notice in writing to the trustee and the Director. A copy of any notice cancelling a bond required under Chapter 40, Title 41, Idaho Code, is to be forwarded to the Director by the surety at the same time it is forwarded to the trustee.”
- A copy of every contract between the plan and any administrator, trustee, service company, or other person or entity.
- A biographical affidavit, on a form prescribed by the director, for each of the plan’s trustees with original signatures and notarizations.
- With regard to a single employer or multiple employer welfare arrangement or plan, if the plan is domiciled out of state, a letter or other written evidence of good standing from the plan’s regulator in the state of domicile, and evidence that it is regulated and examined a minimum of once every five years by its state of domicile.
- A copy of all stop loss agreements that include applicable stop-loss insurance provided, or to be provided, the plan by an insurer duly authorized to transact disability insurance in this state. [The plan must maintain aggregate stop-loss coverage and specific stop-loss coverage provided by an insurance company authorized to transact insurance in this state.]
- The application shall also include: (a) with regard to an employer plan sponsor, a copy of any articles of incorporation and bylaws or any founding documents and bylaws of any entity acting as a plan sponsor; and (b) a list of the names, addresses, and official capacities concerning the plan of the individuals who will be responsible for the management and conduct of the affairs of the plan, including all trustees, officers, and directors.
- The management of the trust shall be experienced and competent to ensure the trust’s compliance with Idaho laws and rules; the management of the trust and trustees shall fully disclose the extent and nature of any contracts or arrangements between them and the plan, including any possible conflicts of interest; and a copy of the articles of incorporation, bylaws, if any, and irrevocable trust agreement of the plan, as well as any other document concerning the operation of the plan.
- Completion of the , if the plan has been in existence prior to registration.
Prior to registration, the Board of the proposed self-funded plan will meet with Department of Insurance personnel to review the requirements of Idaho Code as it relates to self-funded plans, financial responsibilities, and fiduciary duties. Contact the DOI to arrange a meeting.