IDAHO INDIVIDUAL HIGH RISK REINSURANCE POOL
41-5510. Eligibility. (1) Any eligible individual person, who is and continues to be a resident shall be eligible for coverage under an individual basic, standard, catastrophic A, catastrophic B, and HSA compatible health benefit plan if evidence is provided that:
(a) Such person has been rejected by one (1) individual carrier on the basis of health status or claims experience; or
(b) An individual carrier refuses to issue a health benefit plan providing coverage substantially similar to coverage offered under an equivalent pool plan except at a rate exceeding the rate for the pool plan; or
(c) Such person is a federally eligible individual; or
(d) Such person is legally domiciled in Idaho on the date of application to the pool and is eligible for the credit for health insurance costs under section 35 of the Internal Revenue Code of 1986. In addition, if such person maintained creditable health insurance coverage for an aggregate period of three (3) months as of the date on which the individual seeks to enroll in pool coverage, not counting any period prior to a sixty-three (63) day break in coverage:
(i) The preexisting condition limitation set forth in section 41-5208, Idaho Code, shall not apply; and
(ii) The requirement for exhaustion of any available coverage under title X of the consolidated omnibus budget reconciliation act of 1986, public law 99-272 (COBRA) or state continuation benefits is waived.
(2) A rejection or refusal by a carrier offering only stop loss, excess of loss or reinsurance coverage with respect to an applicant under subsection (1) of this section shall not constitute sufficient evidence for purposes of subsection (1) of this section.
(3) Each resident dependent of a person who is eligible for coverage under the pool shall also be eligible for coverage under the pool.
(4) Any eligible individual person meeting the eligibility requirements of subsection (1), (2) or (3) of this section shall be eligible for coverage under a pool plan even though the person has existing coverage under other health insurance or under a group health plan provided: (a) there is a reasonable probability that the lifetime benefit maximum of the existing coverage will be exceeded within ninety (90) days; and (b) the lifetime benefit maximum under the existing coverage is at least five hundred thousand dollars ($500,000). In all cases, coverage under a pool plan is secondary to the existing coverage and all other insurance.
(5) A person shall not be eligible for coverage under a pool plan if:
(a) The person is not a federally eligible individual and, except as provided otherwise in subsection (4) of this section, has or obtains health insurance coverage substantially similar to or more comprehensive than a pool plan, or would be eligible to have such coverage at a rate not exceeding the rate for the pool plan if the person elected to obtain it;
(b) The person is determined to be eligible for health care benefits under medicaid;
(c) The person has previously terminated pool plan coverage unless twelve (12) months have lapsed since such termination; provided however, that this provision shall not apply with respect to an applicant who is a federally eligible individual;
(d) The person is an inmate or resident of a state or other public institution, or a state, local or private correctional facility; provided however, that this provision shall not apply with respect to an applicant who is a federally eligible individual.
(6) Notwithstanding any other provision of this chapter, eligibility for continuation of coverage under COBRA shall not render a person ineligible for coverage under a pool plan.
(7) Coverage shall cease:
(a) On the first day of the month following the date a person is no longer a resident of this state;
(b) On the first day of the month following the date a person requests coverage to end;
(c) Upon the death of the covered person;
(d) At the option of the board, thirty (30) days after the plan makes any inquiry concerning the person's eligibility or place of residence to which the person does not reply.
(8) A person who ceases to meet the eligibility requirements of this section may be terminated on the first day of the month following the date when the individual becomes ineligible.
[41-5510, added 2000, ch. 472, sec. 17, p. 1640; am. 2004, ch. 285, sec. 4, p. 808; am. 2004, ch. 332, sec. 3, p. 992; am. 2005, ch. 71, sec. 1, p. 247; am. 2005, ch. 353, sec. 8, p. 1120; am. 2008, ch. 297, sec. 2, p. 832.]
The Idaho Code is the property of the state of Idaho and is made available on the Internet as a public service. Any person who reproduces or distributes the Idaho Code for commercial purposes is in violation of the provisions of Idaho law and shall be deemed to be an infringer of the state of Idaho's copyright.