CurrentIdaho Department of InsurancePolicy N/A

Addendum 1 - 2026 Idaho Standards for ACA Individual and Small Group Health Benefit Plans and Qualified Dental Plans

Customize your policy alerts

Sign up for all Idaho Department of Insurance policy alerts

Know when Idaho Department of Insurance releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This addendum establishes additional 2026 requirements and guidance for issuers submitting rates and offering ACA-compliant individual and small group health benefit plans and qualified dental plans in Idaho. It addresses reinsurance impacts, actuarial rate documentation, off-Exchange silver plans, actuarial value changes, and producer compensation structures.

Policy Summary

PayerIdaho Department of Insurance

PolicyAddendum 1 - 2026 Idaho ACA Plan Standards

Policy CodePolicy N/A

Change TypeAdded and clarified requirements

Effective DateN/A

Next Review DateN/A

Key ActionIssuers must incorporate the Idaho 1332 Reinsurance Waiver's 18% impact into 2026 individual-market rate development and document the full reduction to consumer premiums.

SourceLink

POLICY UPDATE CHANGES

Issuers must account for the Idaho 1332 Reinsurance Waiver and document an 18% reduction to consumer premiums in 2026 individual-market rate development.

Issuers must provide expanded actuarial memorandum documentation for CSR loading, including actual CSRs paid for PY 2024 and development of the PY 2026 CSR load.

Issuers must submit a scenario analysis showing market- or plan-level rate impacts if federal CSR payments are funded.

The prohibition on compensation differences applies to producer bonuses and other compensation structures, not only direct commission schedules.

Issuers may offer an exclusively off-Exchange silver plan without a CSR load only if the plan is meaningfully different from the issuer's on-Exchange silver plans and has a unique HIOS plan identifier.

Reducing a plan's actuarial value below its PY 2025 level solely under the federal AV Calculator allowances does not qualify as a uniform modification of coverage.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentIdaho Department of InsurancePolicy N/A

Addendum 1 - 2026 Idaho Standards for ACA Individual and Small Group Health Benefit Plans and Qualified Dental Plans

Customize your policy alerts

Sign up for all Idaho Department of Insurance policy alerts

Know when Idaho Department of Insurance releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerIdaho Department of Insurance

PolicyAddendum 1 - 2026 Idaho ACA Plan Standards

Policy CodePolicy N/A

Change TypeAdded and clarified requirements

Effective DateN/A

Next Review DateN/A

Key ActionIssuers must incorporate the Idaho 1332 Reinsurance Waiver's 18% impact into 2026 individual-market rate development and document the full reduction to consumer premiums.

SourceLink

POLICY UPDATE CHANGES

Issuers must account for the Idaho 1332 Reinsurance Waiver and document an 18% reduction to consumer premiums in 2026 individual-market rate development.

Issuers must provide expanded actuarial memorandum documentation for CSR loading, including actual CSRs paid for PY 2024 and development of the PY 2026 CSR load.

Issuers must submit a scenario analysis showing market- or plan-level rate impacts if federal CSR payments are funded.

The prohibition on compensation differences applies to producer bonuses and other compensation structures, not only direct commission schedules.

Reducing a plan's actuarial value below its PY 2025 level solely under the federal AV Calculator allowances does not qualify as a uniform modification of coverage.

Plan Design and Compensation Standards

Off-Exchange-Only Silver Plan Criteria

Approval requires ALL of the following conditions for a silver plan offered exclusively off-Exchange without a CSR load:

ALL of the following

The plan is offered exclusively off-Exchange as a non-QHP silver plan and does not include a cost-sharing reduction (CSR) load.
The plan is meaningfully different, as defined in the 2026 Idaho Standards (page 19), from any silver plan offered by the issuer, including the issuer's on-Exchange silver plans.
The plan has a unique HIOS plan identifier.

Actuarial Value Modification Criteria

Any modification to a plan's cost-sharing structure must satisfy the uniform-modification standard. Reliance solely on an allowance in the federal AV Calculator is not sufficient.

ALL of the following

The cost-sharing variation is solely related to ONE of the following
- Changes in the cost and utilization of medical care.
- Maintaining the same metal tier.
The modification does not reduce the plan's actuarial value below the level it had in PY 2025.
A cost-sharing modification that reduces actuarial value below the PY 2025 level does not meet the criteria for a uniform modification of coverage.

Producer Compensation Criteria

Issuer commission schedules and bonus structures for ACA products must be consistent so that producer compensation does not create incentives that conflict with consumers' best interests.

ALL of the following compensation standards apply

Direct commission schedules and any bonus structures available to producers do not distinguish based on whether coverage is purchased through the Exchange or directly from the issuer off-Exchange.
Compensation for plans sold on-Exchange and off-Exchange is consistent.
Schedules do not distinguish between special enrollment and open enrollment, or any other enrollment period.
Schedules do not distinguish based on metal level.
Schedules do not distinguish based on age.

Issuer Filing and Operational Requirements

Documentation Required

Document the 1332 Waiver impact

When submitting calendar year 2026 individual-market rates, incorporate Idaho’s 1332 Reinsurance Waiver and document the full 18% reduction to consumer premiums in rate development. Include an Excel rate table template showing rates without the 18% savings as supporting documentation.

Documentation Required

Document CSR and rate assumptions

The rate-filing actuarial memorandum must clearly document the assumptions used to develop rates, including CSR loading, changes to Advanced Premium Tax Credits (APTC), actual CSRs paid for enrollees in PY 2024, and development of the PY 2026 CSR load. Explain how additional revenue from the CSR load compares with expected PY 2026 CSR costs.

Documentation Required

Submit funded-CSR scenario analysis

Prepare an actuarial memorandum addendum showing market- or plan-level rate impacts and resulting rates under a scenario in which federal CSR payments are funded. The documentation must support evaluation of rate reasonableness and be added to the SERFF rate filing by July 16, 2025, the final day for submitting rate-filing corrections.