Health insurance

Group Medical Insurance

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Group Medical Insurance

Idaho Code, Title 41, Chapter 47, the Small Employer Health Insurance Availability Act is a law that requires every health insurance firm must be necessary, to conduct business with small employers in Idaho and actively provide health benefit plans offered by the company* to Idaho small-sized businesses.

“Small employer” means a company that has at least two, but not more than 50 employees who are eligible who, for the most part, work in Idaho. “Eligible employee” means an employee who is employed full-time and is employed for a regular schedule of at least 30 hours (or up to 20 hours if there is a mutual agreement between the insurance company).

The act applies to all health benefit plans that offer coverage to employees of a small-sized employer when:

  • A portion of the cost or benefits is paid for by, or on behalf of, the smaller employer.
  • A qualified employee or dependent is reimbursed through wage adjustments or any other method on behalf of the employer of a small size for any part of the cost; or
  • The employer, employee, or dependents consider the health benefits plan as a component of a program or plan following specific IRS rules.

All insurance companies that offer coverage in the small-employer market must be actively marketing all health benefits plans to small businesses regardless of the health status of their eligible employees. They are not allowed to apply medical underwriting to denial of coverage. They must adhere to the fairness of marketing guidelines defined by the law. Insurance companies can provide small-sized employer health benefit programs through the Idaho insurance market, Your Health Idaho, outside the marketplace, or both.

An agent or company should not encourage a group of eligible applicants not to apply or to join a different business due to their health status, experience with claims or work experience, or the geographical place of employment of the employer. The agent or company cannot influence or incentivize a small-sized employer to exclude or separate an employee or a dependent eligible for insurance coverage. Insurance companies may set minimum levels of participation or contributions and apply these levels equally to all small-sized employers.

The law and Department’s Rules, IDAPA 18.04.12, require companies to reveal their rating practices to a small-sized employer purchasing a health plan. The law and the rule provide the Department control to ensure no abuse in rating practices. From January 1, 2014, the only rates that an insurance company is allowed to employ are:

  • A person’s age
  • Geography
  • Tobacco use
  • Family composition

Insurance companies cannot deny insurance, charge higher rates for those with medical conditions, or set different premiums for both genders.

After January 1st and 1st, 2014, health benefits plans for small businesses may not follow Idaho’s existing conditions and transferability laws. (SS41-4708)

The law states that a health plan can be renewed at the discretion of the small employer in the event of a situation like non-payment of premium, fraud or misrepresentation made by the small employer, or the small employer failing to meet the minimum contribution or participation obligations. (SS41-4707)

The Idaho Department of Insurance maintains the list of insurers that offer health insurance licensed to offer small-sized employer health benefits.

*”Health benefits plan” is a hospital or medical insurance policy.
“Health benefit plan” does not contain a policy, certificate for a specific illness, hospital confinement indemnity accident-only, credit vision Medicare Supplement, longer-term healthcare disability income insurance health benefits for students only, and is issued as an addition to liability insurance or workers’ compensation similar insurance, car health insurance for medical payments, and any nonrenewable short-term coverage that is valid for twelve months or more. (SS 41-4703)

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