Section 41-3901 – SHORT TITLE.
41-3901. SHORT TITLE. This chapter may be cited as the Idaho "Managed Care Reform Act." History: [41-3901, added 1974, ch. 177, sec. 1, p. 1444; am. 1997, ch. 204, sec. 2, p. 582.]
Section 41-3902 – INTENT AND PURPOSE.
41-3902. INTENT AND PURPOSE. As a guide to the interpretation and application of this chapter, the public policy of this state is declared as follows: The legislature wishes to eliminate legal barriers to the establishment of managed care plans which provide readily available, accessible and quality health care to their members and to encourage their […]
Section 41-3903 – DEFINITIONS.
41-3903. DEFINITIONS. (1) "Basic health care services" means the following services: preventive care, emergency care, inpatient and outpatient hospital and physician care, hospital-based rehabilitation treatment, diagnostic laboratory and diagnostic and therapeutic radiological services. It does not include mental health services or services for alcohol or drug abuse, dental or vision services or long-term rehabilitation treatment. […]
Section 41-3904 – CERTIFICATE OF AUTHORITY REQUIRED — EXCEPTIONS — APPLICATION OF CERTAIN PROVISIONS.
41-3904. CERTIFICATE OF AUTHORITY REQUIRED — EXCEPTIONS — APPLICATION OF CERTAIN PROVISIONS. (1) No person shall in this state offer a managed care plan on a predetermined and prepaid basis, unless authorized under a certificate of authority issued by the director. A person offering a managed care plan on a predetermined and prepaid basis is […]
Section 41-3905 – QUALIFICATIONS FOR CERTIFICATE OF AUTHORITY.
41-3905. QUALIFICATIONS FOR CERTIFICATE OF AUTHORITY. The director shall not issue or permit to remain in force a certificate of authority authorizing the transaction of managed care plans unless the organization offering the managed care plan is qualified therefor as follows: (1) It must be empowered to engage in business as a managed care organization […]
Section 41-3906 – APPLICATION FOR CERTIFICATE OF AUTHORITY.
41-3906. APPLICATION FOR CERTIFICATE OF AUTHORITY. (1) The application for a certificate of authority shall be in writing in the form prescribed by the director. It shall be verified by an officer of an applicant corporation or association, or member of an applicant firm, or by the applicant if an individual. The application shall set […]
Section 41-3909 – RECORDS.
41-3909. RECORDS. (1) Every managed care organization shall establish and at all times maintain adequate records of its financial and business transactions. (2) The managed care organization shall retain its general records with respect to a particular transaction for a period of not less than seven (7) years after termination of the transaction, and health […]
Section 41-3910 – REPORTS TO THE DIRECTOR.
41-3910. REPORTS TO THE DIRECTOR. (1) Every managed care organization offering a managed care plan for which a certificate of authority is required shall annually, on or before the first day of June, file a report with the director showing its audited financial condition on the last day of the preceding December. The report shall […]
Section 41-3911 – EXAMINATIONS.
41-3911. EXAMINATIONS. (1) The director shall make an examination of the affairs and operations of any organization offering a managed care plan for which a certificate of authority is required as often as he deems necessary but not less frequently than once every five (5) years. (2) Every such organization shall upon the director’s request […]
Section 41-3912 – SUSPENSION OR REVOCATION OF CERTIFICATE OF AUTHORITY.
41-3912. SUSPENSION OR REVOCATION OF CERTIFICATE OF AUTHORITY. The director may initiate proceedings to suspend or revoke a certificate of authority to offer a managed care plan for the reasons and in the manner provided in title 41, Idaho Code, for mutual insurers. In addition to any other penalties, the director may impose a penalty […]
Section 41-3914 – ANNUAL DISCLOSURES.
41-3914. ANNUAL DISCLOSURES. (1) Every managed care organization shall provide to its enrollees and make available for inspection by the general public on an annual basis: (a) an audited statement of financial condition including a balance sheet and a summary of receipts and disbursements; (b) a description of the accessibility and availability of services, including […]
Section 41-3915 – HEALTH CARE CONTRACTS.
41-3915. HEALTH CARE CONTRACTS. (1) All health care contracts or other marketing documents describing health care services offered by any managed care organization shall contain: (a) A complete description of the health care services and other benefits to which the member is entitled; (b) A description of the accessibility and availability of services, including a […]
Section 41-3916 – ADVISORY PANELS.
41-3916. ADVISORY PANELS. Every managed care organization shall establish a mechanism to provide members an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions, or through the use of other reasonable mechanisms. As a minimum, such an advisory panel […]
Section 41-3917 – CERTAIN WORDS PROHIBITED IN NAME OF ORGANIZATION.
41-3917. CERTAIN WORDS PROHIBITED IN NAME OF ORGANIZATION. No person or organization offering a health care plan not qualified as a managed care plan under the provisions of this chapter shall use in its name, logo, contracts or literature the phrase, "health maintenance organization," "managed care organization," "general managed care organization" or "limited managed care […]
Section 41-3918 – GRIEVANCE SYSTEM.
41-3918. GRIEVANCE SYSTEM. (1) Every managed care organization shall establish a grievance system to resolve grievances initiated by members concerning health care services. The system shall provide reasonable procedures for the resolution of grievances, and shall include an appeals process which affords the member the right to a prompt review by a grievance panel before […]
Section 41-3919 – OPEN ENROLLMENT.
41-3919. OPEN ENROLLMENT. (1) Requirement of an open enrollment period is intended to provide the benefits of managed care to the general public or to all members of the class of persons the managed care organization serves. Such requirement is not intended to prohibit a managed care organization from establishing administrative procedures that protect the […]
Section 41-3920 – DISCRIMINATION AGAINST HEALTH PROFESSIONALS ASSOCIATED WITH MANAGED CARE ORGANIZATIONS.
41-3920. DISCRIMINATION AGAINST HEALTH PROFESSIONALS ASSOCIATED WITH MANAGED CARE ORGANIZATIONS. It shall be unlawful for any health service institution or associations of health professionals to exclude other health professionals from working privileges, membership, or association solely on the basis that such other person is employed by or contracts with a managed care organization pursuant to […]
Section 41-3921 – STATUTORY CONSTRUCTION AND RELATIONSHIP TO OTHER LAWS.
41-3921. STATUTORY CONSTRUCTION AND RELATIONSHIP TO OTHER LAWS. (1) Except as stated in this chapter, provisions of title 41, Idaho Code, applicable to disability insurers shall be applicable to the lawful transactions and business of an organization offering a managed care plan for which a certificate of authority is required pursuant to this chapter. (2) […]
Section 41-3922 – TAXATION — PENALTY FOR FAILURE TO FILE.
41-3922. TAXATION — PENALTY FOR FAILURE TO FILE. (1) Each organization offering a managed care plan for which a certificate of authority is required under this chapter shall be subject to taxation as provided in chapter 4, title 41, Idaho Code. (2) Any managed care organization failing to file any documents required to be filed […]
Section 41-3923 – COVERAGE OF ADOPTED NEWBORN CHILDREN — COVERAGE OF MATERNITY AND COMPLICATIONS OF PREGNANCY.
41-3923. COVERAGE OF ADOPTED NEWBORN CHILDREN — COVERAGE OF MATERNITY AND COMPLICATIONS OF PREGNANCY. (1) Any contract delivered or issued for delivery in this state by an organization offering a managed care plan for which a certificate of authority is required, which provides coverage for injury or sickness for newborn dependent children of the members […]