ID| The Idaho Department of Insurance Bulletin No. 26-14 (reissuing Bulletin 16-04) addresses disability/health insurance carriers in the group and individual markets and clarifies when carriers must accept third party payments of premiums or cost sharing for health benefit plans and Medicare supplement plans. While neither Idaho Insurance Code nor federal law generally prohibits or compels acceptance of third party payments, the bulletin establishes a minimum floor of circumstances in which acceptance and crediting are mandatory, framing refusal as unfairly prejudicial to insureds and grounds for form disapproval under Idaho Code § 41-1813(2).
Key Points:
- Contract language and notice duties — Any plan limitation on third party payments must appear in the insured’s contract and be no more restrictive than this minimum standard; upon rejecting a third party payment, the carrier must notify the insured in writing of the reason and of the right to file a Department complaint. Provider-funded payments remain limited by Idaho Code § 41-348(2), and obligations under 45 CFR § 147.104 and 42 USC § 18116 are unaffected.
- Mandatory acceptance categories — Carriers must accept payments from Ryan White HIV/AIDS Programs, Indian tribes/tribal or urban Indian organizations, and local, state or federal government programs (per 45 CFR § 156.1250, extended beyond QHPs to all health benefit plans), plus individuals such as family and friends, and religious/not-for-profit organizations that give based on financial need, are not healthcare providers, and are not financially interested.
- Crediting, verification, and Medicare supplement — Required third party cost sharing payments must be credited to the insured’s deductible and out-of-pocket maximum accumulators as if paid directly by the insured; payments made directly by the insured must be accepted without any certification or verification of fund source; and Medicare supplement carriers must accept third party payments so long as they don’t violate Social Security Act anti-kickback provisions (42 USC § 1320a-7b).