CurrentIdaho Department of InsurancePolicy N/A

Self-Funded Health Care Plans Rule

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This rule applies to Idaho employers offering self-funded health care plans and establishes requirements for qualification, registration, reserves, contributions, contracts, records, bonding, and financial statements.

Policy Summary

PayerIdaho Department of Insurance

PolicySelf-Funded Health Care Plans Rule

Policy CodePolicy N/A

Change TypeAdministrative and operational requirements

Effective DateN/A

Next Review DateN/A

Key ActionObtain a Certificate of Registration before organizing and operating a self-funded plan in Idaho unless an exemption applies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysContributions receivable

30 daysBond cancellation notice

$500Written contract threshold

90 daysAnnual statement deadline

60 days

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CurrentIdaho Department of InsurancePolicy N/A

Self-Funded Health Care Plans Rule

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

PolicySelf-Funded Health Care Plans Rule

Policy CodePolicy N/A

Change TypeAdministrative and operational requirements

Effective DateN/A

Next Review DateN/A

Key ActionObtain a Certificate of Registration before organizing and operating a self-funded plan in Idaho unless an exemption applies.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysContributions receivable

30 daysBond cancellation notice

$500Written contract threshold

90 daysAnnual statement deadline

60 days

Quarterly statement deadline

Plan Qualification and Compliance Criteria

Plan qualification and registration

A self-funded plan must satisfy all of the following qualification and registration conditions:

ALL of the following

The trust is established by agreement between the employer or employers, or a postsecondary educational institution, and the trustee of the trust.
The trust is established solely to provide health care benefits to the employer's employees or the postsecondary educational institution's students.
The plan secures a Certificate of Registration from the Director before being organized and permitted to operate in Idaho, unless exempt from registration under Idaho Code Section 41-4003.
The plan is registered if it covers any beneficiary working or residing in Idaho, unless an applicable statutory exemption applies.

Financial and operational safeguards

The plan must maintain all of the following financial protections and administrative controls:

ALL of the following

The trust fund continuously maintains reserves, certified by a qualified actuary, sufficient to fully fund benefits in effect when a claim arises and to provide for reasonably estimated future claim payments, claim-adjustment expenses, litigation expenses, claims incurred but not reported, extended benefits, and maternity benefits, if any.
Reserve certification is required annually and must include a statement describing the bases used to determine the reserves, in a form acceptable to the Director.
The plan submits to the Director a certified copy of its fidelity bond or equivalent coverage.
The coverage must cover every trustee, officer, director, and employee of the plan.
The fidelity bond or equivalent coverage is noncancellable except upon at least 30 days' advance written notice to the trustee and the Director.
Any party that directly or indirectly underwrites, collects or handles charges or contributions, or adjusts or settles claims for plan members or beneficiaries, is licensed as a third-party administrator.

Administrative compliance requirements

The plan must comply with all of the following contribution, contracting, recordkeeping, and reporting requirements:

ALL of the following

Contribution rates are calculated at least annually by a qualified actuary and filed with the Director.
The rate calculation must separately designate the employer and employee rates, or the postsecondary educational institution and student rates.
Employer contributions are based on filed rates and paid in advance on a periodic basis during the coverage period or at the beginning of the coverage period.
Contracts for services directly affecting the plan are agreed to by the board of trustees and the other party.
Contracts and agreements valued at greater than $500 are in writing, approved by resolution of the board of trustees, and placed in the plan's minutes and records.> $500

Key Regulatory Thresholds and Filing Deadlines

Contributions Receivable

RequirementThe trust fund may take credit for contributions receivable only when they are not more than ninety (90) days past due.

Applies toContributions receivable reported in the plan’s financial statements.

Responsible partyThe plan’s trust fund.

Bond Cancellation Notice

Minimum noticeNot less than thirty (30) days advance notice in writing.

Notice recipientsThe trustee and the Director.

Coverage affected

Required Plan Actions

Prior Authorization

Obtain plan registration

Obtain a Certificate of Registration from the Director before organizing or operating a self-funded plan in Idaho, unless the plan is exempt under Idaho Code Section 41-4003. Registration is mandatory for plans covering any beneficiary working or residing in Idaho unless an applicable exemption applies.

Documentation Required

Meet plan qualification requirements

Establish the plan trust by agreement between the employer or employers, or a postsecondary educational institution, and the trustee. The trust must exist solely to provide health care benefits to covered employees or students.

Documentation Required

Support registration investigation

Key Plan Administration Definitions

All Contributions to Be Paid in Advance

Payment timingAll contributions are to be paid in advance of the period of time for which the contribution is made.

ScopeThe requirement applies to all contributions.

Definition contextThis is a defined requirement under the self-funded health care plan rule.

Deposited in and Disbursed from a Trust Fund

Deposit requirementAll contributions based on calculated rates under Section 028 are deposited into the trust fund.

Expense paymentAll expenses are paid out of the trust fund.

Applies to

Policy Summary

PayerIdaho Department of Insurance

PolicySelf-Funded Health Care Plans Rule

Policy CodePolicy N/A

Change TypeAdministrative and operational requirements

Effective DateN/A

Next Review DateN/A

Key ActionObtain a Certificate of Registration before organizing and operating a self-funded plan in Idaho unless an exemption applies.

SourceLink

On This Page

All acts, resolutions, appointments, delegations, and other decisions of the board of trustees are in writing and placed in the plan's minutes and records.

The plan maintains full and accurate records and accounts, including board minutes, correspondence with contractors, accounting and actuarial records, and other records, correspondence, minutes, or statements required by law or the trust agreement.

The trustee files an annual statement with the Director within 90 days after the close of each fiscal year, and files a quarterly statement within 60 days after the end of each quarter, in a form acceptable to the Director.90 days annually; 60 days quarterly

The fidelity bond or equivalent coverage must be noncancellable except upon the required notice.

Surplus Deficiency Cure Period

Maximum cure periodUp to ninety (90) days.

When it appliesWhen a determination of surplus reveals a deficiency.

DiscretionThe Director may allow the plan to accumulate the prescribed surplus during this period.

Written Contract and Board-Record Requirement

Value thresholdContracts and agreements valued at greater than five hundred dollars ($500.00).

Required formThe contract or agreement must be in writing.

Board recordIt must be approved by resolution of the board of trustees and placed in the plan’s minutes and records.

Annual Statement Filing Deadline

Filing deadlineWithin ninety (90) days after the close of each fiscal year of the Plan.

Filed byThe trustee.

Additional timingThe Director may require filing at another time.

Quarterly Statement Filing Deadline

Filing deadlineWithin sixty (60) days of the end of each quarter.

Filed withThe Director.

Required formatThe statement must be in a form acceptable to the Director.

Cooperate with the Director’s investigation of the registration application, including any examination authorized by statute. The plan’s trust fund must bear the costs of the investigation or examination.

Documentation Required

Maintain actuarial reserves

Continuously maintain reserves sufficient to fully fund benefits and reasonably estimated future claim, adjustment, litigation, incurred-but-not-reported, extended-benefit, and maternity-benefit expenses. A qualified actuary must certify the reserves annually, with a statement describing the bases used in determining them.

Documentation Required

Submit fidelity bond documentation

Submit to the Director a certified copy of the plan’s fidelity bond or equivalent coverage. The coverage must include every trustee, officer, director, and employee of the plan.

The bond or equivalent coverage must provide for cancellation only upon at least 30 days’ advance written notice to the trustee and the Director.

Prior Authorization

Use licensed third-party administrators

Use a party licensed as a third-party administrator when that party directly or indirectly underwrites, collects or handles charges or contributions, or adjusts or settles claims for plan members or beneficiaries.

Billing Rule

Calculate and file contribution rates

Have contribution rates calculated at least annually by a qualified actuary and file the rates with the Director. The calculations must separately designate the employer and employee rates, or the postsecondary educational institution and student rates.

Employer contributions must be based on filed rates and paid in advance on a periodic basis during, or at the beginning of, the coverage period.

Documentation Required

Approve and document contracts

Ensure that contracts directly affecting the plan are agreed to by the board of trustees and the other party. Contracts valued at greater than $500 must be in writing, approved by board resolution, and placed in the plan’s minutes and records.

Board acts, resolutions, appointments, delegations, and other decisions must be in writing and placed in the plan’s minutes and records.

Documentation Required

File financial statements

The trustee must file an annual statement with the Director within 90 days after the close of each fiscal year and a quarterly statement within 60 days after the end of each quarter. Statements must be in a form acceptable to the Director.

Contributions based on calculated rates under Section 028 of the rule.