CurrentIdaho Department of InsurancePolicy 26-1

Third-Party Payments of Premiums or Cost Sharing for Health Benefit Plans and Medicare Supplement Plans

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Establishes minimum circumstances for accepting third-party premium and cost-sharing payments and crediting qualifying cost-sharing payments toward deductibles and out-of-pocket maximums.

Policy Summary

PayerIdaho Department of Insurance

PolicyThird-Party Payments of Premiums or Cost Sharing for Health Benefit Plans and Medicare Supplement Plans

Policy CodePolicy N/A

Change TypeReissuance and clarification

Effective DateJuly 29, 2026

Next Review DateN/A

Key ActionAccept qualifying third-party premium or cost-sharing payments and credit qualifying cost-sharing payments toward the insured’s deductible and out-of-pocket maximum.

SourceLink

POLICY UPDATE CHANGES

Third-party payment acceptance and accumulator crediting requirements were clarified.

3Federal program or entity categories

2Additional payer categories

2Required accumulator types

1Written notice requirement

Policy Summary

PayerIdaho Department of Insurance

PolicyThird-Party Payments of Premiums or Cost Sharing for Health Benefit Plans and Medicare Supplement Plans

Policy CodePolicy N/A

Change TypeReissuance and clarification

Effective DateJuly 29, 2026

Next Review DateN/A

Key ActionAccept qualifying third-party premium or cost-sharing payments and credit qualifying cost-sharing payments toward the insured’s deductible and out-of-pocket maximum.

SourceLink

On This Page

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CurrentIdaho Department of InsurancePolicy 26-1

Third-Party Payments of Premiums or Cost Sharing for Health Benefit Plans and Medicare Supplement Plans

Customize your policy alerts

Sign up for Idaho Department of Insurance Policy 26-1 alerts

Get alerted when Policy 26-1 changes without checking for updates manually.

Monitor payer policy activity

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

Establishes minimum circumstances for accepting third-party premium and cost-sharing payments and crediting qualifying cost-sharing payments toward deductibles and out-of-pocket maximums.

Policy Summary

PayerIdaho Department of Insurance

PolicyThird-Party Payments of Premiums or Cost Sharing for Health Benefit Plans and Medicare Supplement Plans

Policy CodePolicy N/A

Change TypeReissuance and clarification

Effective DateJuly 29, 2026

Next Review DateN/A

Key ActionAccept qualifying third-party premium or cost-sharing payments and credit qualifying cost-sharing payments toward the insured’s deductible and out-of-pocket maximum.

SourceLink

POLICY UPDATE CHANGES

Third-party payment acceptance and accumulator crediting requirements were clarified.

3Federal program or entity categories

2Additional payer categories

2Required accumulator types

1Written notice requirement

Policy Summary

PayerIdaho Department of Insurance

PolicyThird-Party Payments of Premiums or Cost Sharing for Health Benefit Plans and Medicare Supplement Plans

Policy CodePolicy N/A

Change TypeReissuance and clarification

Effective DateJuly 29, 2026

Next Review DateN/A

Key ActionAccept qualifying third-party premium or cost-sharing payments and credit qualifying cost-sharing payments toward the insured’s deductible and out-of-pocket maximum.

SourceLink

On This Page

Key federal regulation

Third-Party Payment Requirements

Required Acceptance of Qualifying Third-Party Payments

Carriers must accept qualifying third-party payments toward an insured's premium or cost sharing.

Qualifying payment source

A Ryan White HIV/AIDS Program.
An Indian tribe, tribal organization, or urban Indian organization.
A local, state, or federal government program, including a grantee directed by a government program to make payments on its behalf.
An individual, such as a family member or friend.
A religious institution or other not-for-profit organization, when the assistance is provided based on the insured's financial need, the third party is not a healthcare provider, and the third party is not financially interested.

Accumulator Crediting

When a required third-party payment is applied to cost sharing, it must be credited as though the insured paid it directly.

ALL of the following

Credit the qualifying third-party cost-sharing payment toward the insured's deductible accumulator.
Credit the qualifying third-party cost-sharing payment toward the insured's out-of-pocket maximum accumulator.

Payment Limitations and Refusal Notice

Third-party payment limits and refusals must comply with applicable law and the insured's contract.

ALL of the following

Any limitation on third-party payments in a health benefit plan must be included in the insured's contract and may be no more restrictive than the minimum standard described in this bulletin.
Apply the legal limitation on payments made by service providers under Idaho Code § 41-348(2), which prohibits providers, as defined by law, from waiving, rebating, giving, paying, or offering to waive, rebate, give, or pay all or part of a claimant's deductible or claim for health insurance.
If a carrier rejects a third-party payment or otherwise refuses to treat it as a payment from the insured, inform the insured in writing of the reason for the decision.
The written refusal notice must also inform the insured of the right to file a complaint with the Idaho Department of Insurance.

Medicare Supplement Payment Condition

Medicare supplement carriers must accept third-party payments toward Medicare supplement policies unless acceptance would violate applicable federal anti-kickback provisions.

ALL of the following

Accept a third-party payment toward a Medicare supplement policy.
The acceptance requirement does not apply when acceptance would violate the anti-kickback provisions of the Social Security Act § 1128B, codified at 42 U.S.C. § 1320a-7b.

Authorities and Regulatory References

Authorities governing third-party payment acceptance and provider payment waiversmixed

Idaho Code § 41-348(2)	Prohibits service providers from waiving, rebating, giving, paying, or offering to waive, rebate, give, or pay all or part of a claimant's deductible or claim for specified insurance, including health insurance.
45 CFR § 156.1250	Requires QHP carriers to accept and apply specified third-party payments of premiums or cost sharing.
Idaho Code § 41-1813(2)	Cited as the basis for disapproval of unfairly prejudicial carrier practices.

Additional federal limitations and obligationsmixed

42 USC § 1320a-7b	Social Security Act anti-kickback provisions applicable to Medicare supplement third-party payments.
45 CFR § 147.104	Guaranteed availability requirements that remain applicable.
42 USC § 18116	Nondiscrimination requirements that remain applicable.

Operational Requirements

Billing Rule

Accept Qualifying Third-Party Payments

Accept qualifying third-party payments toward an insured’s premiums or cost sharing when made by an eligible source. This requirement applies to carriers offering health benefit plans, including payments accepted under the federal QHP rule and the additional categories identified in this bulletin.

Ryan White HIV/AIDS Program
Indian tribe, tribal organization, or urban Indian organization
Local, state, or federal government programs, including grantees directed by a government program to make payments on its behalf
Individuals, such as family and friends
Religious institutions and other not-for-profit organizations that satisfy the applicable financial-need, provider, and financial-interest conditions

Billing Rule

Credit Cost-Sharing Payments to Accumulators

Defined Terms

Service provider

Statutory referenceA service provider is the type of provider referenced in Idaho Code § 41-348(2).

Prohibited conductThe statute prohibits waiving, rebating, giving, paying, or offering to waive, rebate, give, or pay all or part of a claimant’s deductible or claim.

Insurance coveredThe restriction applies to specified insurance, including casualty, disability, workers’ compensation, health, and property insurance.

Health benefit plan

Statutory definitionHealth benefit plans are defined under Idaho Code § 41-4703(13).

Additional statutory definitionHealth benefit plans are also defined under Idaho Code § 41-5203(13).

When a required third party makes a cost-sharing payment, credit it toward the insured’s deductible and out-of-pocket maximum accumulators as if the insured made the payment directly.

Apply the payment to the same cost-sharing accumulators used for direct insured payments.

Documentation Required

Do Not Require Source-of-Funds Verification

Accept any payment made directly by the insured without requiring the insured to certify or verify the source of the funds.

Do not require source-of-funds documentation, certification, or verification from the insured.

Billing Rule

Contractual Limits on Third-Party Payments

If a health benefit plan limits third-party payments, include the limitation in the insured’s contract. The contractual language may be no more restrictive than the minimum standard described in this bulletin.

Payment limitations must be stated in the insured’s contract.
Do not impose contractual limits more restrictive than the bulletin’s minimum requirements.

Documentation Required

Provide Written Notice of Rejected or Uncredited Payments

If a third-party payment is rejected or is not treated as a payment from the insured, provide the insured written notice explaining the reason and the insured’s right to file a complaint with the Department.

Written notice is required for both rejection and refusal to credit or treat the payment as an insured payment.
Include the reason for the decision and complaint rights with the Idaho Department of Insurance.

Billing Rule

Conditions for Nonprofit and Religious-Organization Assistance

Accept assistance from religious institutions and other not-for-profit organizations only when the required qualification conditions are satisfied.

The assistance is provided on the basis of the insured’s financial need.
The third party is not a healthcare provider.
The third party is not financially interested in the payment of health insurance claims.
A financially interested organization includes one receiving the majority of its funding from entities with a pecuniary interest in claim payments or subject to direct or indirect control by such entities.

Denial Risk

Medicare Supplement Payment Limitation

Accept third-party payments toward Medicare supplement policies unless acceptance would violate the anti-kickback provisions of the Social Security Act, § 1128B, codified at 42 U.S.C. § 1320a-7b.

Medicare supplement policies are outside the statutory definition of health benefit plans, but this payment-acceptance requirement still applies subject to the anti-kickback limitation.

Note

Apply the Bulletin as a Minimum Standard

This bulletin establishes the minimum circumstances under which a carrier must accept and credit third-party payments. It does not authorize or require acceptance or rejection of payments outside those circumstances and does not relieve the carrier of obligations under other applicable state or federal law.

Continue compliance with applicable law, including guaranteed availability requirements under 45 CFR § 147.104 and nondiscrimination requirements under 42 U.S.C. § 18116.
The bulletin is an agency interpretation of existing law, except as authorized by law or incorporated into a contract.

ApplicationThe Department’s payment-acceptance requirement applies to carriers offering health benefit plans as defined by these statutes.

Financially interested third party

Funding sourceAn organization is financially interested when it receives the majority of its funding from entities with a pecuniary interest in payment of health insurance claims.

Control relationshipAn organization is also financially interested when it is subject to direct or indirect control by entities with a pecuniary interest in payment of health insurance claims.

Relevant financial interestThe pecuniary interest must relate to payment of health insurance claims.

Insured

PolicyholderAn insured may be the policyholder.

Certificate holderAn insured may be the certificate holder.

Payment contextThe bulletin uses “insured” to refer to a policyholder or certificate holder whose premium or cost-sharing payment is at issue.