Idaho Admin. Code r. 18.04.15.030

Current through September 2, 2024

Section 18.04.15.030 - MINIMUM STANDARDS FOR BENEFITS

01.Minimum Covered Benefits.

a. Daily hospital room and board expenses subject only to limitations based on average daily cost of the semiprivate room rate in the area where the insured resides;

b. Miscellaneous hospital services;

c. Surgical services;

d. Anesthesia services;

e. In-hospital medical services; and

f. Out-of-hospital care, consisting of physicians' services rendered on an ambulatory basis where coverage is not provided elsewhere in the policy for diagnosis and treatment of sickness or injury, diagnostic x-ray, laboratory services, radiation therapy, and hemodialysis ordered by a physician.

02.Minimum Additional Benefits. A separate premium corresponding to additional benefits offered through a rider is to be filed and actuarially justified. A policy is to provide not fewer than three (3) of the following additional benefits:

a. In-hospital private duty registered nurse services;

b. Convalescent nursing home care;

c. Diagnosis and treatment by a radiologist or physiotherapist;

d. Rental of special medical equipment, as defined by the insurer in the policy;

e. Artificial limbs or eyes, casts, splints, trusses or braces;

f. Treatment for functional nervous disorders, and mental and emotional disorders; or

g. Out-of-hospital prescription drugs and medications.

03.Enhanced Short-term Plans Covered Benefits. The following covered benefits and limitations are to be provided consistent with the Benchmark Medical Plan, including:

a. Ambulatory (outpatient) patient services;

b. Emergency services;

c. Hospitalization;

d. Maternity and newborn care;

e. Mental health and substance use disorder services, including behavioral health treatment;

f. Prescription drugs;

g. Rehabilitative and habilitative services and devices;

h. Laboratory services; and

i. Preventive and wellness services and chronic disease management.

04.Prescription Drug Formulary. If a prescription drug coverage formulary is applied, the applicable formulary drug list is to:

a. Include at least one drug in every United States Pharmacopeia (USP) category and class;

b. Cover a range of drugs across a broad distribution of therapeutic categories and classes and recommended drug treatment regimens that treat all covered disease states, and does not discourage enrollment by any group of enrollees; and

c. Provide appropriate access to drugs included in broadly accepted treatment guidelines and indicative of then-current general best practices.

05.Cost Sharing.

a. Except for out-of-network benefits offered as part of a managed care plan, a coinsurance percentage is not to exceed fifty percent (50%) of covered charges. A coinsurance percentage for out-of-network benefits offered as part of a managed care plan is not to exceed sixty percent (60%) of covered charges.

b. The maximum out-of-pocket is to be stated in the policy and in aggregate is not to exceed four percent (4%) of the aggregate annual limit under the policy for each covered person. All deductibles, copayments, coinsurance and any other cost-sharing are applicable to the maximum out-of-pocket. Within the aggregate maximum, the policy may include separate out-of-pocket limits applicable to particular services.

c. The annual limit is no less than one million dollars ($1,000,000) for each covered person.

d. Enhanced short-term plans are to provide coverage for and not impose any cost sharing requirements for preventive and wellness services consistent with QHP requirements.

06.Applicability of Mental Health Parity. Enhanced short-term plans are to meet the requirements of Section 2726 of the Public Health Service Act (Mental Health Parity and Addiction Equity Act) in the same manner and extent as QHPs.

07.Benefit Requirements. The minimum benefits imposed by Subsections 030.01, 030.02, and 030.03 may be subject to all applicable deductibles, coinsurance and general policy exceptions and limitations. Except as disallowed by Subsections 030.03, 030.05, and 030.06, a policy may also have special or internal limitations for nursing facilities, transplants, experimental treatments, services covered under Subsection 030.02, and other special or internal limitations authorized by the Director. Except as authorized by this Subsection through the application of special or internal limitations, a policy will cover, after any deductibles or coinsurance provisions are met, the usual, customary and reasonable charges, as determined consistently by the carrier and as subject to prior written approval by the Director or another rate agreed to between the insurer and provider, for covered services up to the annual limit.

Idaho Admin. Code r. 18.04.15.030

Effective March 31, 2022