Minimum Standards For Benefits

01. Minimum Covered Benefits. The following covered benefits and limitations are to be provided, consistent with the Benchmark Medical Plan. (4-2-26) IDAHO ADMINISTRATIVE CODE IDAPA 18.04.15 – Rules Governing Department of Insurance Short-Term Health Insurance Coverage Section 040 Page 5 a. Ambulatory (outpatient) patient services; (3-31-22) b. Emergency services; (3-31-22) c. Hospitalization; (3-31-22) d. Generic prescription drugs; (4-2-26) e. Rehabilitative and habilitative services and devices; and (4-2-26) f. Laboratory services. (4-2-26) 02. Prescription Drug Formulary. If a prescription drug coverage formulary is applied, the applicable formulary drug list is to: (3-31-22) a. Include at least one drug in every United States Pharmacopeia (USP) category and class; (3-31-22) b. Cover a range of drugs across a broad distribution of therapeutic categories and classes and recommended drug treatment regimens that treat all covered disease states, and does not discourage enrollment by any group of enrollees; and (3-31-22) c. Provide appropriate access to drugs included in broadly accepted treatment guidelines and indicative of then-current general best practices. (3-31-22) 03. Cost Sharing. (3-31-22) a. Except for out-of-network benefits offered as part of a managed care plan, a coinsurance percentage is not to exceed fifty percent (50%) of covered charges. A coinsurance percentage for out-of-network benefits offered as part of a managed care plan is not to exceed sixty percent (60%) of covered charges. (3-31-22) b. The maximum out-of-pocket is to be stated in the policy and in aggregate is not to exceed the limits for QHPs. All deductibles, copayments, coinsurance and any other cost-sharing are applicable to the maximum out- of-pocket. Within the aggregate maximum, the policy may include separate out-of-pocket limits applicable to particular services. (4-2-26) c. The annual limit is no less than one million dollars ($1,000,000) for each insured. (4-2-26) 04. Benefit Requirements. The minimum benefits imposed by Subsection 030.01 may be subject to all applicable deductibles, coinsurance and general policy exceptions and limitations. Except as allowed by Subsection 030.03, a policy will cover the usual, customary and reasonable charges, as determined consistently by the carrier or another rate agreed to between the insurer and provider, for covered services up to the annual limit. (4-2-26) 031. -- 039. (RESERVED)