IDAPA 18.04.02
This rule applies to health carriers providing coverage to newborn and newly adopted children.
The purpose of this rule sets forth uniform requirements for providing coverage to newborn and newly adopted children in accordance with Sections 41-2140, 41-2210, 41-3437, 41-3923, 41-4023, and 41-4123, Idaho Code.
This rule implements the following statute passed by the Idaho Legislature:
700 W. State Street, 3rd Floor Boise, ID 83720-0043
P.O. Box 83720
Boise, ID 83720-0043
Phone: 1(800) 721-3272 or (208) 334-4250
Fax: (208) 334-4398
Email: rulesreview@doi.idaho.gov
Web: https://doi.idaho.gov/
This rule chapter will be reviewed in compliance with Section 67-5292, Idaho Code, and in accordance with the 8-year rule review schedule linked here.
18.04.02 – Complications of Pregnancy, Newborn, and Adopted Children Coverage
000. Legal Authority. ... 3
001. Scope. ... 3
002. -- 009. (Reserved) ... 3
010. Definitions. ... 3
011. Coverage Requirements of newborn and newly adopted children. ... 3
012. -- 020. (Reserved) ... 4
021. Coverage Of Involuntary Complications Of Pregnancy. ... 4
022. -- 999. (Reserved) ... 4
Title 41, Chapter 2, Idaho Code.
(3-31-22)
This rule sets forth uniform definitions and requirements to be followed by health plans regarding involuntary complications of pregnancy and coverage to newborn and newly adopted children. (3-31-22)
As used in this chapter the following terms have the following meanings.
(3-31-22)
01. Congenital Anomaly. A condition existing at or from birth that is a significant deviation from the common form or function of the body, impairing the function of the body, whether caused by a hereditary or developmental defect or disease. (3-31-22)
02. Health Plan. Any type of benefit plan or contract of coverage subject to the requirements of Title 41, Chapters 21, 22, 34, 39, 40, or 41, Idaho Code, which provides coverage for injury or sickness. (3-31-22)
03. Health Plan Member. A person entitled to benefits as a member, subscriber or insured under a health plan and who, under the terms of the health plan contract, may add dependents for coverage under the health plan. (3-31-22)
01. Coverage. A health plan will provide coverage to:
(3-31-22)
a. A newborn child and
(3-31-22)
b. A newly adopted child.
(3-31-22)
02. Coverage Requirements. Coverage of newborn and newly adopted children will be at least equivalent to the coverage afforded other health plan members under the health plan and include coverage for the medically necessary care and treatment of congenital anomalies. (3-31-22)
03. Pre-Existing Conditions. A health plan cannot apply a pre-existing condition exclusion to a newborn or newly adopted child. (3-31-22)
04. Reconstructive Surgery. A health plan will not exclude reconstructive surgery for congenital anomalies. (3-31-22)
05. Limitations on Coverage for Congenital Anomalies. A health plan may apply exclusions, requirements or benefit limitations, including cost sharing requirements, to coverage for congenital anomalies that are consistent with the requirements of this chapter and no more restrictive than exclusions, requirements or benefit limitations applied to coverage for similar treatments, conditions and services provided under the health plan. (3-31-22)
06. Notification and Payment.
(3-31-22)
a. If notice and payment of additional premium are needed for dependent coverage under the health plan contract, the contract may request notice of birth, placement or adoption and payment of associated premium as a condition of coverage for newborn and newly adopted children. The notification period cannot be less than sixty (60) days from the date of birth for a newborn child or, for newly adopted children, sixty (60) days from the earlier of the date of adoption or placement for adoption. The due date for payment of any additional premium, if requested, cannot be not less than thirty-one (31) days following receipt by the health plan member of a billing for the premium. (3-31-22)
b. All requirements for notice and payment of premium applied by the health plan for the enrollment of newborn or newly adopted children are to be clearly set forth in the health plan contract and provided to the health plan members in a manner reasonably calculated to provide notice to the members of the requirements. (3-31-22)
c. If the health plan member fails to provide the requested notification, or make the associated premium payment, the health plan may decline to enroll a dependent child as a newborn or newly adopted child, but will treat a newborn or newly adopted child no less favorably than it treats other applicants who seek coverage at a time other than when first eligible for coverage. (3-31-22)
d. For self-funded health care plans subject to Title 41, Chapter 40 or 41, Idaho Code, any references to premium in this chapter should be recognized to be applying to contributions. (3-31-22)
07. Portability. The coverage provided by this section applies to any subsequent health plans providing coverage to the newborn or newly adopted child. (3-31-22)
012. -- 020. (RESERVED)
Involuntary complications of pregnancy, as that term is used in Title 41, Idaho Code, also includes but is not limited to: ectopic pregnancy which is terminated; spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible; and conditions requiring hospital confinement (when the pregnancy is not terminated), whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, but not false labor, occasional spotting, physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy. (3-31-22)
022. -- 999. (RESERVED)