reglab/statecodes huggingface dataset:
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.3B - Certificate of authority — renewal.

514B.3B Certificate of authority — renewal.
A certificate of authority of a health maintenance organization formed under this chapter expires on June 1 succeeding its issue and shall be renewed annually so long as the organization transacts its business in accordance with all legal requirements. A health maintenance organization shall submit annually, on or before March 1, a completed application for renewal of its certificate of authority. A health maintenance organization that fails to timely file an application for renewal shall pay an administrative penalty of five hundred dollars to the treasurer of state for deposit as provided in section 505.7. A duly certified copy or duplicate of the certificate is admissible in evidence for or against the organization with the same effect as the original.
2006 Acts, ch 1117, §58; 2009 Acts, ch 181, §73
Referred to in §514B.33
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.4 - Applicant for certificate of authority.

514B.4 Applicant for certificate of authority.
1. The commissioner shall determine whether the applicant for a certificate of authority, with respect to health care services to be furnished:
a. Has demonstrated the willingness and potential ability to assure the availability, accessibility, and continuity of service through adequate personnel and facilities.
b. Has arrangements established in accordance with rules adopted by the commissioner for a continuous review of health care processes and outcomes. If a health maintenance organization is accredited by the national committee on quality assurance, or another accreditation entity approved by the commissioner, an external peer review under rules of the commissioner shall not be applicable. However, at the discretion of the commissioner, an on-site inspection of the health maintenance organization may be conducted.
c. Has a procedure established in accordance with rules adopted by the commissioner to develop, compile, evaluate, and report statistics relating to the cost of its operations, the pattern of utilization of its services, the availability and accessibility of its services, and other matters as may be reasonably required by the commissioner.
2. The commissioner, in administering this section and sections 514B.25 and 514B.26, may contract with qualified persons to make recommendations concerning the determinations required to be made by the commissioner. Such recommendations may be accepted in full or in part by the commissioner.
[C75, 77, 79, 81, §514B.4]
92 Acts, ch 1162, §21; 99 Acts, ch 165, §11; 2012 Acts, ch 1023, §157
Referred to in §514B.3, 514B.5
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.4A - Direct provision of health care services.

514B.4A Direct provision of health care services.
1. An application for a certificate of authority to provide health care services, directly, shall be forwarded by the commissioner to the director of public health for review, comment, and recommendation, with respect to the health care services to be provided directly, to assure that the applicant has demonstrated the willingness and potential ability to provide the health care services through adequate personnel and facilities.
2. Rules proposed by the commissioner for adoption for the direct provision of health care services by a health maintenance organization, shall be forwarded by the commissioner to the director of public health for review, comment, and recommendation, prior to submission to the administrative rules coordinator pursuant to section 17A.4.
3. The director of public health shall respond to the commissioner, with respect to an application or proposed rule, with any comments or recommendations within thirty days of the forwarding of the application or proposed rules to the director of public health.
92 Acts, ch 1237, §12
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.5 - Issuance and denial of a certificate of authority.

514B.5 Issuance and denial of a certificate of authority.
1. The commissioner shall issue or deny a certificate of authority to any person filing an application pursuant to section 514B.3 within a reasonable period of time. Issuance of a certificate of authority shall be granted upon payment of the application fee prescribed in section 514B.22 if the commissioner is satisfied that the following conditions are met:
a. The persons responsible for the conduct of the affairs of the applicant are competent and trustworthy.
b. The commissioner finds that the health maintenance organization’s proposed plan of operation meets the requirements of section 514B.4.
c. The health maintenance organization provides or arranges for the provision of basic health care services on a prepaid basis, except that the health maintenance organization may impose deductible and coinsurance charges subject to approval by the commissioner. The commissioner has the authority to promulgate rules pursuant to chapter 17A establishing reasonable maximum deductible and coinsurance charges which may be imposed by health maintenance organizations.
d. The health maintenance organization is fiscally sound and may reasonably be expected to meet its obligations to enrollees. In making this determination, the commissioner may consider:
(1) The financial soundness of the health maintenance organization’s arrangements for health care services in relation to its schedule of charges.
(2) The adequacy of the health maintenance organization’s working capital.
(3) Any agreement made by the health maintenance organization with an insurer, a corporation authorized under chapter 514 or any other organization for insuring the payment of the cost of health care services or for providing immediate alternative coverage in the event of discontinuance of the health maintenance organization.
(4) Any agreement made with providers for the provision of health care services.
(5) Any surety bond or deposit of cash or securities submitted in accordance with section 514B.16.
e. The enrollees may participate in matters of policy and operation pursuant to section 514B.7.
f. Nothing in the proposed method of operation as shown by the information submitted pursuant to section 514B.3 or by independent investigation is contrary to the public interest.
2. A certificate of authority shall be denied only after compliance with the requirements of section 514B.26.
[C75, 77, 79, 81, §514B.5]
92 Acts, ch 1162, §22, 23; 2012 Acts, ch 1023, §117
Referred to in §513C.4, 514B.3, 514B.9
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.6 - Powers of health maintenance organizations.

514B.6 Powers of health maintenance organizations.
1. The powers of a health maintenance organization include, but are not limited to, the following:
a. The purchase, lease, construction, renovation, operation or maintenance of hospitals, medical facilities, or both, and their ancillary equipment, and such property as may reasonably be required for transacting the business of the organization.
b. The making of loans to a medical group under contract with it or to a corporation under its control for the purpose of acquiring or constructing medical facilities and hospitals or in furtherance of a program providing health care services to enrollees.
c. The furnishing of health care services to the public through providers which are under contract with or employed by the health maintenance organization.
d. The contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment and administration.
e. The contracting with an insurance company authorized to insure groups or individuals in this state for the cost of health care or with a corporation authorized under chapter 514 for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization.
f. The offering, in addition to basic health care services, of health care services and indemnity benefits to enrollees or groups of enrollees.
g. The acceptance from any person of payments covering all or part of the charges made to enrollees of the health maintenance organization.
2. A health maintenance organization shall file notice with the commissioner before the exercise of any power granted in subsection 1, paragraphs “a” and “b”. The commissioner shall disapprove the exercise of power if in the commissioner’s opinion it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. The commissioner may adopt rules exempting from the filing requirement of this section those activities having a minimum effect.
[C75, 77, 79, 81, §514B.6]
92 Acts, ch 1162, §24; 2012 Acts, ch 1023, §118
Referred to in §514B.15
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.7 - Governing body.

514B.7 Governing body.
The governing body of a health maintenance organization may include providers, other individuals, or both, but it shall establish a mechanism to allow a reasonable representation of enrollees to participate in matters of policy and operation. The commissioner shall establish guidelines to implement this section.
[C75, 77, 79, 81, §514B.7]
86 Acts, ch 1180, §8
Referred to in §514B.3, 514B.5
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.8 - Fiduciary responsibilities.

514B.8 Fiduciary responsibilities.
Any director, officer or partner of a health maintenance organization who receives, collects, disburses or invests funds in connection with the activities of a health maintenance organization shall be responsible for these funds in a fiduciary relationship to the enrollees.
[C75, 77, 79, 81, §514B.8]
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.9 - Evidence of coverage.

514B.9 Evidence of coverage.
1. Every enrollee shall receive an evidence of coverage and any amendments. If the enrollee obtains coverage through an insurance policy or a contract issued by a corporation authorized under chapter 514, the insurer or the corporation shall issue the evidence of coverage. No evidence of coverage or amendment shall be issued or delivered to any person in this state until a copy of the form of the evidence of coverage or amendment has been filed with and approved by the commissioner.
2. An evidence of coverage shall contain a clear and complete statement of:
a. The health care services and the insurance or other benefits, if any, to which the enrollee is entitled in the total context of the organizational structure of the health maintenance organization.
b. Any limitations on the services or benefits to be provided, including any deductible or coinsurance charges permitted under section 514B.5, subsection 1, paragraph “c”.
c. The manner in which information is available on the method of obtaining health care services.
d. The total amount of payment for health care services and indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan offered through the health maintenance organization is contributory or noncontributory with respect to group contracts.
e. The health maintenance organization’s method for resolving enrollee complaints.
f. The mechanism by which enrollees shall be allowed to participate in matters of policy and operation.
3. A copy of the form of the evidence of coverage to be used in this state and any amendment shall be subject to the filing and approval requirements of this section unless it is subject to the jurisdiction of the commissioner under the laws governing health insurance or corporations authorized under chapter 514 in which event the filing and approval provisions of such laws apply. To the extent, however, that those provisions are less strict than those provided under this section, then the requirements of this section shall apply.
4. Enrollees shall be entitled to receive the most recent annual statement of the financial condition of the health maintenance organization in which they are enrolled, which statement shall include a balance sheet and summary of receipts and disbursements.
[C75, 77, 79, 81, §514B.9]
2012 Acts, ch 1023, §119
Referred to in §514B.11
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.9A - Coverage of children — continuation or reenrollment.

514B.9A Coverage of children — continuation or reenrollment.
A health maintenance organization which provides health care coverage pursuant to an individual or group health maintenance organization contract regulated under this chapter for children of an enrollee shall permit continuation of existing coverage or reenrollment in previously existing coverage for an individual who meets the requirements of section 513B.2, subsection 14, paragraph “a”, “b”, “c”, “d”, or “e”, and who is an unmarried child of an enrollee who so elects, at least through the policy anniversary date on or after the date the child marries, ceases to be a resident of this state, or attains the age of twenty-five years old, whichever occurs first, or so long as the unmarried child maintains full-time status as a student in an accredited institution of postsecondary education.
2009 Acts, ch 118, §10, 11
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.10 - Charges.

514B.10 Charges.
Charges to enrollees may be established in accordance with actuarial principles for various categories of enrollees, but the charges shall not be determined according to the status of an individual enrollee’s health or sex and shall not be excessive, inadequate, or unfairly discriminatory.
[C75, 77, 79, 81, §514B.10]
95 Acts, ch 185, §10
Referred to in §514B.11, 514B.17
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.11 - Disapproval of filings.

514B.11 Disapproval of filings.
If the commissioner disapproves a filing made pursuant to sections 514B.9 and 514B.10, the commissioner shall notify the filer and in the notice specify the reasons for the disapproval. A hearing shall be granted by the commissioner within a reasonable period of time from the request for the hearing, which request must be made within thirty days after receipt by the filer of the notice of disapproval. The commissioner may require the submission of whatever relevant information the commissioner deems necessary in determining whether to disapprove a filing.
[C75, 77, 79, 81, §514B.11]
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.12 - Annual report.

514B.12 Annual report.
1. A health maintenance organization shall annually on or before the first day of March file with the commissioner or a depository designated by the commissioner a report verified by at least two of the principal officers of the health maintenance organization and covering the preceding calendar year. The report shall be on forms prescribed by the commissioner and shall include:
a. Financial statements of the organization including a balance sheet as of the end of the preceding calendar year and statement of profit and loss for the year then ended, certified by a certified public accountant or an independent public accountant.
b. Any material changes in the information submitted pursuant to section 514B.3.
c. The number of persons enrolled during the year, the number of enrollees as of the end of the year and the number of enrollments terminated during the year.
d. Other information relating to the performance of the health maintenance organization as is necessary to enable the commissioner to carry out the commissioner’s duties under this chapter.
2. The commissioner shall refuse to renew a certificate of authority of a health maintenance organization that fails to comply with the provisions of this section and the organization’s right to transact new business in this state shall immediately cease until the organization has so complied.
3. A health maintenance organization that fails to timely file the report required under subsection 1 is in violation of this section and shall pay an administrative penalty of five hundred dollars to the treasurer of state for deposit as provided in section 505.7.
4. The commissioner may give notice to a health maintenance organization that the organization has not timely filed the report required under subsection 1 and is in violation of this section. If the organization fails to file the required report and comply with this section within ten days of the date of the notice, the organization shall pay an additional administrative penalty of one hundred dollars for each day that the failure continues to the treasurer of state for deposit as provided in section 505.7.
[C75, 77, 79, 81, §514B.12]
92 Acts, ch 1162, §25; 2003 Acts, ch 91, §29; 2004 Acts, ch 1101, §73; 2006 Acts, ch 1117, §59; 2009 Acts, ch 181, §74
Referred to in §514B.33
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.13 - Open enrollment.

514B.13 Open enrollment.
1. After a health maintenance organization has been in operation twenty-four months, it shall have an annual open enrollment period of at least one month during which it accepts enrollees up to the limits of its capacity, as determined by the health maintenance organization, in the order in which the prospective enrollees apply for enrollment. A health maintenance organization may apply to the commissioner for authorization to impose such underwriting restrictions upon enrollment as are necessary to preserve its financial stability, to prevent excessive adverse selection by prospective enrollees, or to avoid unreasonably high or unmarketable charges for enrollee coverage for health care services. The commissioner shall approve or deny the application made pursuant to this section within a reasonable period of time from the receipt of the application.
2. Health maintenance organizations providing services exclusively on a group contract basis may limit the open enrollment provided for in this section to all members of the group covered by the contract, including those members of the group who previously waived coverage.
[C75, 77, 79, 81, §514B.13]
2005 Acts, ch 70, §13; 2018 Acts, ch 1041, §127; 2019 Acts, ch 59, §186
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.14 - Complaint system.

514B.14 Complaint system.
1. A health maintenance organization shall establish and maintain a complaint system which has been approved by the commissioner and which shall provide for the resolution of written complaints initiated by enrollees concerning health care services. A health maintenance organization shall submit to the commissioner an annual report in a form prescribed by the commissioner which shall include:
a. A description of the procedures of the complaint system.
b. The total number of complaints handled through the complaint system and a compilation of causes underlying the complaints filed.
c. The number, amount and disposition of malpractice claims settled during the year by the health maintenance organization and any of its providers.
2. The health maintenance organization shall maintain statistical information of written complaints filed with it concerning benefits over which the health maintenance organization does not have control and shall submit to the commissioner a summary report at the time and in the format that the commissioner may require. Complaints involving other persons shall be referred to those persons and a copy of the complaint sent to the commissioner.
[C75, 77, 79, 81, §514B.14]
92 Acts, ch 1162, §26; 2012 Acts, ch 1023, §157
Referred to in §514B.3
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.15 - Investments.

514B.15 Investments.
With the exception of investments made in accordance with section 514B.6, the investable funds of a health maintenance organization shall be invested only in securities or other investments permitted by section 511.8 for the investment of assets constituting the legal reserves of life insurance companies or such other securities or investments as the commissioner may permit. For purposes of this section, investable funds of a health maintenance organization are all moneys held in trust for the purpose of fulfilling the obligations incurred by a health maintenance organization in providing health care services to enrollees.
[C75, 77, 79, 81, §514B.15]
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.16 - Protection against insolvency.

514B.16 Protection against insolvency.
A health maintenance organization shall furnish a surety bond in an amount satisfactory to the commissioner, or deposit with the commissioner cash or securities acceptable to the commissioner in at least the same amount, as a guarantee that its obligations to enrollees will be performed. The commissioner may waive this requirement when satisfied that the assets of the organization or its contracts with other organizations are sufficient to reasonably assure the performance of its obligations.
[C75, 77, 79, 81, §514B.16]
Referred to in §514B.5
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.17 - Cancellation of enrollees.

514B.17 Cancellation of enrollees.
1. An enrollee enrolled in a prepaid individual plan shall not be canceled except for the failure to pay the charges permitted under section 514B.10 or for other reasons stated in the rules adopted by the commissioner and subject to review in accordance with chapter 17A. Except as provided in subsection 2 concerning prepaid group plans, notice of cancellation to an enrollee shall not be effective unless delivered to the enrollee by the health maintenance organization in a manner prescribed by the commissioner and at least thirty days before the effective date of cancellation and unless accompanied by a statement of reason for cancellation. At any time before cancellation of the policy for nonpayment, the enrollee may pay to the health maintenance organization the full amount due, including court costs if any, and from the date of payment by the enrollee or the collection of the judgment, coverage shall revive and be in full force and effect.
2. The effect of cancellation of a prepaid group plan providing health care services to enrollees, and the duty to provide notice and liability for benefits, is the same as provided under section 509B.5, subsection 2, for the termination of accident or health insurance for employees or members.
[C75, 77, 79, 81, §514B.17]
95 Acts, ch 185, §11
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.17A - Rescission.

514B.17A Rescission.
1. A health maintenance organization may rescind an enrollee’s membership in the health maintenance organization if the enrollee makes a material false statement or misrepresentation in the enrollee’s application for membership. A written notice of rescission shall be sent to the enrollee by certified mail addressed to the enrollee and sent to the enrollee’s last address known to the health maintenance organization and shall state the reason for the rescission. The enrollee may appeal the rescission to the commissioner as provided by the commissioner by rules adopted under chapter 17A.
2. An enrollee’s membership in a health maintenance organization shall not be rescinded as provided in subsection 1 more than two years after the date of the enrollee’s enrollment in the health maintenance organization.
2008 Acts, ch 1123, §24; 2017 Acts, ch 54, §76
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.18 - False representation.

514B.18 False representation.
A health maintenance organization, unless licensed as an insurer, shall not use in its name, contracts, or literature any words descriptive of an insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in this state. No health maintenance organization or any person on its behalf shall advertise or merchandise its services in a manner to misrepresent its services or capacity for service, nor shall it engage in misleading, deceptive or unfair practices with respect to advertising or merchandising. This section does not exempt health maintenance organizations which are engaged in the business of insurance from regulation under the provisions of chapter 507B.
[C75, 77, 79, 81, §514B.18]
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.19 - Regulation of insurance producers.

514B.19 Regulation of insurance producers.
The commissioner may, after notice and hearing, promulgate such reasonable rules under the provisions of chapter 522B that are necessary to provide for the licensing of insurance producers who engage in solicitation or enrollment for a health maintenance organization.
[C75, 77, 79, 81, §514B.19]
2001 Acts, ch 16, §14, 37
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.20 - Powers of insurers and hospital and medical service corporations.

514B.20 Powers of insurers and hospital and medical service corporations.
1. An insurance company authorized to engage in insuring individuals or groups for the cost of health care in this state or a corporation authorized under chapter 514 may either directly or through a subsidiary or affiliate do one or more of the following:
a. Organize and operate a health maintenance organization under the provisions of this chapter.
b. Contract with a health maintenance organization to provide insurance or similar protection against the cost of care provided through the health maintenance organization.
c. Contract with a health maintenance organization to provide coverage in the event of the failure of the health maintenance organization to meet its obligations.
2. Any two or more insurance companies, corporations, or their subsidiaries or affiliates may jointly organize and operate a health maintenance organization.
[C75, 77, 79, 81, §514B.20]
2012 Acts, ch 1023, §157
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.21 - Public employees included.

514B.21 Public employees included.
Any employee of the state, political subdivision of the state, or of any institution supported in whole or in part by public funds may authorize the deduction from the employee’s salary or wages of the amount charged to the employee for any health care services provided through health maintenance organizations under this chapter in the manner provided in section 514.16.
[C75, 77, 79, 81, §514B.21]
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.22 - Fees.

514B.22 Fees.
When not otherwise provided, a foreign or domestic health maintenance organization doing business in this state shall pay the commissioner of insurance the fees as required in section 511.24.
[C75, 77, 79, 81, §514B.22]
2006 Acts, ch 1117, §60
Referred to in §514B.5
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.24 - Examinations permitted.

514B.24 Examinations permitted.
1. The commissioner shall make an examination of the affairs of a health maintenance organization and its providers as often as the commissioner deems necessary for the protection of the interests of the people of this state, but not less frequently than once every five years.
2. Every health maintenance organization and provider shall submit its books and records to the commissioner and in every way facilitate the examination. For the purpose of examinations, the commissioner may administer oaths to and examine the officers and agents of the health maintenance organization and the principals of its providers concerning their business. The expenses of examinations under this section shall be assessed against the organization being examined and remitted to the commissioner.
3. In lieu of the examination required by this section, the commissioner may accept the report of an examination made by the appropriate departments in other states.
[C75, 77, 79, 81, §514B.24]
92 Acts, ch 1162, §28; 2000 Acts, ch 1023, §25; 2018 Acts, ch 1041, §127
Referred to in §514B.30
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.25 - Financially impaired or insolvent health maintenance organizations.

514B.25 Financially impaired or insolvent health maintenance organizations.
The provisions of chapter 507C shall apply to health maintenance organizations, which shall be considered insurers for the purposes of chapter 507C.
[C75, 77, 79, 81, §514B.25]
91 Acts, ch 26, §39
Referred to in §514B.4
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.25A - Impairment and insolvency protection.

514B.25A Impairment and insolvency protection.
The provisions of chapter 508C shall apply to health maintenance organizations.
2000 Acts, ch 1023, §26; 2017 Acts, ch 148, §61; 2019 Acts, ch 12, §34, 35, 36
2019 amendment applies beginning March 29, 2019; 2019 Acts, ch 12, §35, 36
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.26 - Administrative procedures.

514B.26 Administrative procedures.
1. When the commissioner has cause to believe that grounds for the denial, suspension, or revocation of a certificate of authority exist, the commissioner shall notify the health maintenance organization in writing of the particular grounds for denial, suspension, or revocation and shall issue a notice of a time fixed for a hearing, which shall be held not less than ten days after the receipt by the health maintenance organization of the notice.
2. At the time and place fixed for a hearing, the person charged shall have an opportunity to be heard and to show cause why the order should not be made by the commissioner. Upon good cause shown, the commissioner may permit any person to intervene, appear, and be heard at the hearing by counsel or in person. Nothing contained in this chapter shall require the observance at any hearing of formal rules of pleading or evidence. The provisions of section 507B.6, subsections 4 and 5, relating to the powers and duties of the commissioner in relation to the hearing and relating to the rights and obligations of persons upon whom the commissioner has served notice shall apply to this chapter.
3. After the hearing, or upon the failure of the health maintenance organization to appear at the hearing, the commissioner shall take action as the commissioner deems advisable and which is permitted by the commissioner under the provisions of this chapter and shall reduce the findings to writing. Copies of the written findings shall be mailed to the health maintenance organization charged with violation of this chapter.
[C75, 77, 79, 81, §514B.26]
92 Acts, ch 1162 §29; 2018 Acts, ch 1041, §127; 2019 Acts, ch 24, §78
Referred to in §514B.4, 514B.5, 514B.27
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.27 - Judicial review.

514B.27 Judicial review.
The action of the commissioner under section 514B.26 is subject to judicial review in accordance with chapter 17A.
[C75, 77, 79, 81, §514B.27]
92 Acts, ch 1162, §30
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.28 - Injunction.

514B.28 Injunction.
The commissioner may, in the manner provided by law, maintain an action in the name of the state for injunction or other process against the person violating any provision of this chapter.
[C75, 77, 79, 81, §514B.28]
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.30 - Communications in professional confidence.

514B.30 Communications in professional confidence.
1. An officer, director, trustee, partner, or employee of a health maintenance organization shall not testify as to or make other public disclosure of any communication made to a provider and deemed privileged under section 622.10, and which communication has come into the knowledge or possession of such officer, director, trustee, partner, or employee by reason of employment with the health maintenance organization. To the extent necessary to effectuate the examinations provided in section 514B.24 only, the commissioner may examine medical or hospital records of a person receiving basic health care services under the provisions of this chapter but shall not testify as to such confidential communications or make other public disclosure thereof without the express consent of the person or the person’s legal representative, if the person is deceased or incompetent. The provisions of section 622.10 respecting waiver shall apply to this section.
2. A health maintenance organization is hereby prohibited from releasing the names of its membership list of enrollees, whether or not for value or consideration, except to the extent necessary to effectuate the provisions of this chapter or to conduct research or analyses regarding cost or quality issues.
[C75, 77, 79, 81, §514B.30]
92 Acts, ch 1162, §31; 92 Acts, ch 1206, §6; 2018 Acts, ch 1041, §127
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.31 - Taxation.

514B.31 Taxation.
Payments received by a health maintenance organization for health care services, insurance, indemnity, or other benefits to which an enrollee is entitled through a health maintenance organization authorized under this chapter and payments by a health maintenance organization to providers for health care services, to insurers, or corporations authorized under chapter 514 for insurance, indemnity, or other service benefits authorized under this chapter are not premiums received and taxable under the provisions of section 432.1 for the first five years of the existence of the health maintenance organization, its successors or assigns. After the first five years, the payments received shall be considered premiums received and shall be taxable under the provisions of section 432.1, subsection 1. However, payments made by the United States secretary of health and human services under contracts issued under section 1833 or 1876 of the federal Social Security Act, section 4015 of the federal Omnibus Budget Reconciliation Act of 1987, or chapter 249A for enrolled members shall not be considered premiums received and shall not be taxable under section 432.1.
[C75, 77, 79, 81, §514B.31]
90 Acts, ch 1173, §1; 2002 Acts, ch 1158, §8
Referred to in §514E.1
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.32 - Construction.

514B.32 Construction.
1. Except as otherwise provided in this chapter, laws regulating the insurance business in this state and the operations of corporations authorized under chapter 514 shall not be applicable to any health maintenance organization granted a certificate of authority under this chapter with respect to its health maintenance organization activities authorized and regulated pursuant to this chapter.
2. Solicitation of enrollees by a health maintenance organization granted a certificate of authority or its representatives does not violate any provision of law prohibiting solicitation or advertising by health professionals. Upon a prospective enrollee’s request, a list of locations of services and a list of providers who have current agreements with the health maintenance organization shall be made available.
3. Any health maintenance organization authorized under this chapter is not practicing medicine and shall not be subject to the limitations provided in section 135B.26 on types of contracts entered into between doctors and hospitals.
4. A health maintenance organization authorized under this chapter shall be considered a person for purposes of chapter 507B.
5. The provisions of this chapter shall be applicable to a managed care organization acting pursuant to a contract with the department of human services to administer the medical assistance program under chapter 249A, or the healthy and well kids in Iowa (hawk-i) program under chapter 514I, only with respect to licensure and solvency standards as evidenced by the managed care organization obtaining and maintaining a certificate of authority, and maintaining compliance with the solvency standards set forth in this chapter.
[C75, 77, 79, 81, §514B.32]
83 Acts, ch 28, §1; 93 Acts, ch 88, §16; 2022 Acts, ch 1131, §64
NEW subsection 5
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS › Section 514B.33 - Establishment of limited service organizations.

514B.33 Establishment of limited service organizations.
1. A person may apply to the commissioner for and obtain a certificate of authority to establish and operate a limited service organization in compliance with this chapter. A person shall not establish or operate a limited service organization in this state, or sell, offer to sell, or solicit offers to purchase or receive advance or periodic consideration in conjunction with a limited service organization without obtaining a certificate of authority under this chapter.
2. When not otherwise provided, a foreign or domestic limited service organization doing business in this state shall pay the commissioner the fees as required in section 511.24.
3. The commissioner shall adopt rules pursuant to chapter 17A establishing a certification process for limited service organizations.
4. Sections 514B.3B and 514B.12 apply to all foreign and domestic limited service organizations authorized to do business in this state.
5. a. For purposes of this section, “limited service organization” means an organization providing dental care services, vision care services, mental health services, substance abuse services, pharmaceutical services, podiatric care services, or such other services as may be determined by the commissioner.
b. “Limited service organization” does not include an organization providing hospital, medical, surgical, or emergency services, except as such services are provided incident to those services identified in paragraph “a”.
97 Acts, ch 186, §9; 2003 Acts, ch 91, §30; 2006 Acts, ch 1117, §61
Referred to in §507C.3, 508C.3
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514C - SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES › Section 514C.2 - Skilled nursing care covered in hospitals.

514C.2 Skilled nursing care covered in hospitals.
An insurer, a hospital service corporation, or a medical service corporation, which covers the costs of skilled nursing care under an individual or group policy of accident and health insurance regulated under chapter 509 or 514A, a nonprofit hospital or medical and surgical service plan regulated under chapter 514, or a health care service contract regulated under chapter 514B, shall also cover the costs of skilled nursing care in a hospital if the level of care needed by the insured or subscriber has been reclassified from acute care to skilled nursing care and no designated skilled nursing care beds or swing beds are available in the hospital or in another hospital or health care facility within a thirty-mile radius of the hospital. The insurer or corporation shall reimburse the insured or subscriber based on the skilled nursing care rate.
84 Acts, ch 1034, §1; 95 Acts, ch 185, §12
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514C - SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES › Section 514C.3 - Dentist’s services under accident and sickness insurance policies.

514C.3 Dentist’s services under accident and sickness insurance policies.
A policy of accident and sickness insurance issued in this state which provides payment or reimbursement for any service which is within the lawful scope of practice of a licensed dentist shall provide benefits for the service whether the service is performed by a licensed physician or a licensed dentist. As used in this section, “licensed physician” includes persons licensed under chapter 148, and “policy of accident and sickness insurance” includes individual policies or contracts issued pursuant to chapter 514, 514A, or 514B, and group policies as defined in section 509B.1, subsection 3.
88 Acts, ch 1127, §1; 2006 Acts, ch 1117, §63; 2008 Acts, ch 1088, §129
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514C - SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES › Section 514C.3A - Disclosures relating to dental coverage reimbursement rates.

514C.3A Disclosures relating to dental coverage reimbursement rates.
1. An individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 514, or 514A, and delivered, amended, or renewed on or after July 1, 1995, that provides dental care benefits with a base payment for those benefits determined upon a usual and customary fee charged by licensed dentists, shall disclose all of the following:
a. The frequency of the determination of the usual and customary fee.
b. A general description of the methodology used to determine usual and customary fees, including geographic considerations.
c. The percentile that determines the maximum benefit that the insurer or nonprofit health service corporation will pay for any dental procedure, if the usual and customary fee is determined by taking a sample of fees submitted on actual claims from licensed dentists and then determining the benefit by selecting a percentile of those fees.
2. The disclosure shall be provided upon request to all group and individual policyholders and subscribers. All proposals for dental care benefits shall inform the prospective policyholder or subscriber that information regarding usual and customary fee determinations is available from the insurer or nonprofit health service corporation. All employee benefit descriptions or supplemental documents shall notify the employee that information regarding reimbursement rates is available from the employer.
95 Acts, ch 78, §1; 95 Acts, ch 209, §26
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514C - SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES › Section 514C.3B - Dental coverage — fee schedules.

514C.3B Dental coverage — fee schedules.
1. A contract between a dental plan and a dentist for the provision of services to covered individuals under the plan shall not require that a dentist provide services to those covered individuals at a fee set by the dental plan unless such services are covered services under the dental plan.
2. A person or entity providing third-party administrator services shall not make available any dentists in its dentist network to a dental plan that sets fees for dental services that are not covered services.
3. For the purposes of this section:
a. “Covered services” means services reimbursed under the dental plan.
b. “Dental plan” means any policy or contract of insurance which provides for coverage of dental services not in connection with a medical plan that provides for the coverage of medical services.
4. Nothing in this section shall be construed as limiting the ability of an insurer or a third-party administrator to restrict any of the following as they relate to covered services:
a. Balance billing.
b. Waiting periods.
c. Frequency limitations.
d. Deductibles.
e. Maximum annual benefits.
2010 Acts, ch 1179, §1
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514C - SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES › Section 514C.4 - Mandated coverage for mammography.

514C.4 Mandated coverage for mammography.
1. a. A policy or contract providing for third-party payment or prepayment of health or medical expenses shall provide minimum mammography examination coverage, including, but not limited to, the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state.
(1) Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.
(2) An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.
(3) An individual or group health maintenance organization contract regulated under chapter 514B.
(4) An individual or group Medicare supplemental policy, unless coverage pursuant to such policy is preempted by federal law.
b. A long-term care policy or contract is specifically excluded from regulation under this section.
2. As used in this section, “minimum mammography examination coverage” means benefits which are better than or equal to the following minimum requirements:
a. One baseline mammogram for any woman who is thirty-five through thirty-nine years of age, or more frequent mammograms if recommended by the woman’s physician.
b. A mammogram every two years for any woman who is forty through forty-nine years of age, or more frequently if recommended by the woman’s physician.
c. A mammogram every year for any woman who is fifty years of age or older, or more frequently if recommended by the woman’s physician.
3. Mammogram benefits may be subject to any policy or contract provisions which apply generally to other services covered by the policy or contract.
4. The commissioner of insurance shall adopt rules under chapter 17A necessary to implement this section.
89 Acts, ch 289, §1; 92 Acts, ch 1162, §32, 33; 2003 Acts, ch 135, §1 – 3; 2012 Acts, ch 1023, §157
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514C - SPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES › Section 514C.5 - Prescription drug benefit restrictions.

514C.5 Prescription drug benefit restrictions.
1. A group policy or contract providing for third-party payment or prepayment for prescription drugs shall not require a person covered under the policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for prescription drugs if the pharmacy selected by the covered person agrees to provide pharmaceutical services under the same terms and conditions as those provided by the mail order pharmacy.
2. Group third-party payor policies or contracts delivered, issued for delivery, continued, or renewed in this state on or after July 1, 1990, are subject to this section, including but not limited to the following classes:
a. A group accident and sickness insurance policy.
b. A group hospital or medical service contract.
c. A group health maintenance organization contract.
d. A group Medicare supplemental policy.
90 Acts, ch 1130, §1