Free Medical Plans Study Guide
Idaho Life, Accident & Health exam — Medical Plans.
The national guide covers medical plan design:
- Plan types: HMOs, PPOs and POS plans.
- Cost sharing: deductibles, coinsurance, copays and out-of-pocket maximums.
- Accounts: HSAs.
- The ACA.
Idaho's state questions on medical plans focus on four areas:
- Idaho's minimum standards for disability (health) policies (Idaho Code chapter 41-42; IDAPA 18.04.08);
- a few mandated benefits;
- external review (Idaho Code chapter 41-59);
- enhanced short-term plans.
In Idaho statutes, "disability insurance" means accident and health insurance.
National concepts in brief
- HMO: network care coordinated by a primary care physician.
- PPO: lower cost sharing in network, with out-of-network care still covered.
- POS: a blend of HMO and PPO.
- Cost sharing: the deductible comes first, then coinsurance or copays, up to the out-of-pocket maximum.
Minimum standards for health coverage
- Purpose: reasonable standardization, removal of misleading provisions, and full disclosure in the sale of these coverages (Idaho Code 41-4201).
- Categories of coverage (Idaho Code 41-4204):
- basic hospital;
- basic medical-surgical;
- hospital confinement indemnity;
- major medical;
- disability income;
- accident only;
- specified disease.
- Outline of coverage: delivered at the time of application, with the applicant acknowledging receipt. Direct-response products are the exception (Idaho Code 41-4205).
- Accident-only policies (IDAPA 18.04.08.037):
- at least $1,000 for accidental death and double dismemberment, and $500 for single dismemberment;
- no waiting or probationary periods.
- AD&D benefits must be paid if the loss occurs within 90 days of the accident (IDAPA 18.04.08.030).
- Renewability: a guaranteed renewable policy can't be changed by the insurer except for rates by class. A noncancellable policy can't be changed at all, including the premium (IDAPA 18.04.08.030).
Mandated benefits
| Mandate | Idaho rule |
|---|---|
| Newborns | Covered from the moment of birth, including congenital anomalies (Idaho Code 41-2140) |
| Adopted children | Covered from birth if placed within 60 days of birth. Otherwise covered from placement (Idaho Code 41-2140, 41-2210) |
| Complications of pregnancy | May not be excluded or limited unless the limit applies to all benefits (Idaho Code 41-2140(3)) |
| Mammography | A baseline at 35–39, every two years at 40–49 (or more often if recommended), and every year from 50 (Idaho Code 41-2144) |
| Disabled dependents | Coverage continues past the limiting age with proof within 31 days (Idaho Code 41-2139) |
| Genetic information | Insurers may not discriminate based on a genetic test or private genetic information in issuing or rating health coverage (Idaho Code 41-1313(3)) |
External review (Idaho Code 41-5901 to 41-5917)
- What it is: an insured may have an adverse benefit determination reviewed by an independent review organization.
- How to request: in writing to the director, within four months of the final adverse determination (Idaho Code 41-5906, 41-5908).
- Decision deadlines:
- standard review: within 42 days;
- expedited review: within 72 hours (Idaho Code 41-5908, 41-5909).
- Cost: the health carrier pays for the review (Idaho Code 41-5915).
- Effect: the decision binds the carrier and the covered person for non-ERISA plans (Idaho Code 41-5910).
Enhanced short-term plans
An enhanced short-term plan is an individual plan with an initial period of less than 12 months. It is renewable at the individual's option, as the rules permit (Idaho Code 41-5203).
Common exam traps
- Idaho calls accident and health insurance "disability insurance" in its statutes.
- The outline of coverage is due at application.
- Mammograms: baseline at 35–39, every 2 years at 40–49, then annual from 50.
- External review must be requested within 4 months. The carrier pays, and expedited decisions come within 72 hours.
- Accident-only policies may not have waiting periods.
Practice Medical Plans questions All Life, Accident & Health topics
Practice questions are study aids generated for exam preparation and are not actual exam questions. Content is provided for educational purposes and is not legal advice. Verify current statutes, rules, and exam specifications with the Insurance Department and the exam administrator before relying on it.
