reglab/statecodes huggingface dataset:
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514E - IOWA COMPREHENSIVE HEALTH INSURANCE ASSOCIATION › Section 514E.8 - Policies — renewal provisions — election to continue coverage upon death of policyholder.

514E.8 Policies — renewal provisions — election to continue coverage upon death of policyholder.
1. An association policy shall contain provisions under which the association is obligated to renew the coverage for an individual until the day the individual becomes eligible for Medicare coverage based on age, provided that any individual who is covered by an association policy and is eligible for Medicare coverage based on age prior to January 1, 2005, may continue to renew the coverage under the association policy.
2. The association shall not change the rates for association policies except on a class basis with a clear disclosure in the policy of the association’s right to do so.
3. An association policy shall provide that upon the death of the individual in whose name the policy is issued, every other individual then covered under the contract may elect, within a period specified in the policy, to continue coverage under the same or a different policy until such time as the person would have ceased to be entitled to coverage had the individual in whose name the policy was issued lived.
86 Acts, ch 1156, §8; 2004 Acts, ch 1110, §50; 2004 Acts, ch 1158, §18; 2005 Acts, ch 70, §18, 51; 2006 Acts, ch 1030, §84
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514E - IOWA COMPREHENSIVE HEALTH INSURANCE ASSOCIATION › Section 514E.9 - Rules.

514E.9 Rules.
Pursuant to chapter 17A, the commissioner shall adopt rules to provide for disclosure by carriers of the availability of insurance coverage from the association, and to otherwise implement this chapter.
86 Acts, ch 1156, §9; 97 Acts, ch 103, §54; 2017 Acts, ch 148, §89
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514E - IOWA COMPREHENSIVE HEALTH INSURANCE ASSOCIATION › Section 514E.10 - Collective action — immunity.

514E.10 Collective action — immunity.
Neither the participation by carriers or members in the association, the establishment of rates, forms, or procedures for coverage issued by the association, nor any joint or collective action required by this chapter shall be the basis of any legal civil action, or criminal liability against the association or members of it either jointly or separately.
86 Acts, ch 1156, §10
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514E - IOWA COMPREHENSIVE HEALTH INSURANCE ASSOCIATION › Section 514E.11 - Notice of association policy.

514E.11 Notice of association policy.
Every carrier, including a health maintenance organization subject to chapter 514B, authorized to provide health care insurance or coverage for health care services in Iowa, shall provide a notice of the availability of coverage by the association to any person who receives a rejection of coverage for health insurance or health care services, or a rate for health insurance or coverage for health care services that will exceed the rate of an association policy, and that person is eligible to apply for health insurance provided by the association. Application for the health insurance shall be on forms prescribed by the association’s board of directors and made available to the carriers and other entities providing health care insurance or coverage for health care services regulated by the commissioner.
86 Acts, ch 1156, §11; 97 Acts, ch 103, §55; 2004 Acts, ch 1110, §51; 2004 Acts, ch 1158, §19; 2017 Acts, ch 148, §90
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514F - UTILIZATION AND COST CONTROL › Section 514F.1 - Utilization and cost control review committees.

514F.1 Utilization and cost control review committees.
The licensing boards under chapters 148, 149, 151, and 152 shall establish utilization and cost control review committees of licensees under the respective chapters, selected from licensees who have practiced in Iowa for at least the previous five years, or shall accredit and designate other utilization and cost control organizations as utilization and cost control committees under this section, for the purposes of utilization review of the appropriateness of levels of treatment and of giving opinions as to the reasonableness of charges for diagnostic or treatment services of licensees. Persons governed by the various chapters of Title XIII, subtitle 1, of the Code and self-insurers for health care benefits to employees may utilize the services of the utilization and cost control review committees upon the payment of a reasonable fee for the services, to be determined by the respective boards. The respective boards under chapters 148, 149, 151, and 152 shall adopt rules necessary and proper for the administration of this section pursuant to chapter 17A. It is the intent of this general assembly that conduct of the utilization and cost control review committees authorized under this section shall be exempt from challenge under federal or state antitrust laws or other similar laws in regulation of trade or commerce.
86 Acts, ch 1180, §10; 87 Acts, ch 115, §63; 88 Acts, ch 1199, §6; 89 Acts, ch 164, §6; 90 Acts, ch 1233, §32; 2007 Acts, ch 10, §177; 2008 Acts, ch 1088, §135
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514F - UTILIZATION AND COST CONTROL › Section 514F.2 - Utilization and cost control.

514F.2 Utilization and cost control.
Nothing contained in the chapters of Title XIII, subtitle 1, of the Code shall be construed to prohibit or discourage insurers, nonprofit service corporations, health maintenance organizations, or self-insurers for health care benefits to employees from providing payments of benefits or providing care and treatment under capitated payment systems, prospective reimbursement rate systems, utilization control systems, incentive systems for the use of least restrictive and least costly levels of care, preferred provider contracts limiting choice of specific provider, or other systems, methods or organizations designed to contain costs without sacrificing care or treatment outcome, provided these systems do not limit or make optional payment or reimbursement for health care services on a basis solely related to the license under or the practices authorized by chapter 151 or on a basis that is dependent upon a method of classification, categorization, or description based upon differences in terminology used by different licensees under the chapters of Title IV, subtitle 3, of the Code in describing human ailments or their diagnosis or treatment.
86 Acts, ch 1180, §10
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514F - UTILIZATION AND COST CONTROL › Section 514F.3 - Preferred providers.

514F.3 Preferred providers.
The commissioner of insurance shall adopt rules for preferred provider contracts and organizations, both those that limit choice of specific provider and those that do not. The rules adopted shall include, but not be limited to, the following subjects: preferred provider arrangements and participation requirements, health benefit plans, and civil penalties.
88 Acts, ch 1112, §604
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514F - UTILIZATION AND COST CONTROL › Section 514F.4 - Utilization review requirements.

514F.4 Utilization review requirements.
1. A third-party payor which provides health benefits to a covered individual residing in this state shall not conduct utilization review, either directly or indirectly, under a contract with a third-party who does not meet the requirements established for accreditation by the utilization review accreditation commission, national committee on quality assurance, or another national accreditation entity recognized and approved by the commissioner.
2. This section does not apply to any utilization review performed solely under contract with the federal government for review of patients eligible for services under any of the following:
a. Tit. XVIII of the federal Social Security Act.
b. The civilian health and medical program of the uniformed services.
c. Any other federal employee health benefit plan.
3. For purposes of this section, unless the context otherwise requires:
a. “Third-party payor” means:
(1) An insurer subject to chapter 509 or 514A.
(2) A health service corporation subject to chapter 514.
(3) A health maintenance organization subject to chapter 514B.
(4) A preferred provider arrangement.
(5) A multiple employer welfare arrangement.
(6) A third-party administrator.
(7) A fraternal benefit society.
(8) A plan established pursuant to chapter 509A for public employees.
(9) Any other benefit program providing payment, reimbursement, or indemnification for health care costs for an enrollee or an enrollee’s eligible dependents.
b. “Utilization review” means a program or process by which an evaluation is made of the necessity, appropriateness, and efficiency of the use of health care services, procedures, or facilities given or proposed to be given to an individual within this state. Such evaluation does not apply to requests by an individual or provider for a clarification, guarantee, or statement of an individual’s health insurance coverage or benefits provided under a health insurance policy, nor to claims adjudication. Unless it is specifically stated, verification of benefits, preauthorization, or a prospective or concurrent utilization review program or process shall not be construed as a guarantee or statement of insurance coverage or benefits for any individual under a health insurance policy.
99 Acts, ch 41, §5; 2010 Acts, ch 1061, §180
Referred to in §514F.8
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514F - UTILIZATION AND COST CONTROL › Section 514F.5 - Experimental treatment review.

514F.5 Experimental treatment review.
1. A carrier, as defined in section 513B.2, or a plan established pursuant to chapter 509A for public employees, that limits coverage for experimental medical treatment, drugs, or devices, shall develop and implement a procedure to evaluate experimental medical treatments and shall submit a description of the procedure to the division of insurance. The procedure shall be in writing and must describe the process used to determine whether the carrier or chapter 509A plan will provide coverage for new medical technologies and new uses of existing technologies. The procedure, at a minimum, shall require a review of information from appropriate government regulatory agencies and published scientific literature concerning new medical technologies, new uses of existing technologies, and the use of external experts in making decisions. A carrier or chapter 509A plan shall include appropriately licensed or qualified professionals in the evaluation process. The procedure shall provide a process for a person covered under a plan or contract to request a review of a denial of coverage because the proposed treatment is experimental. A review of a particular treatment need not be reviewed more than once a year.
2. A carrier or chapter 509A plan that limits coverage for experimental treatment, drugs, or devices shall clearly disclose such limitations in a contract, policy, or certificate of coverage.
99 Acts, ch 41, §6; 2017 Acts, ch 148, §91
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514F - UTILIZATION AND COST CONTROL › Section 514F.6 - Credentialing — retrospective payment.

514F.6 Credentialing — retrospective payment.
1. The commissioner shall adopt rules to provide for the retrospective payment of clean claims for covered services provided by a physician, advanced registered nurse practitioner, or physician assistant during the credentialing period, once the physician, advanced registered nurse practitioner, or physician assistant is credentialed.
2. For purposes of this section:
a. “Advanced registered nurse practitioner” means a person currently licensed as a registered nurse under chapter 152 or 152E who is licensed by the board of nursing as an advanced registered nurse practitioner.
b. “Clean claim” means the same as defined in section 507B.4A, subsection 2, paragraph “b”.
c. “Credentialing” means a process through which a health insurer makes a determination based on criteria established by the health insurer concerning whether a physician, advanced registered nurse practitioner, or physician assistant is eligible to provide health care services to an insured and to receive reimbursement for the health care services provided under an agreement entered into between the physician, advanced registered nurse practitioner, or physician assistant and the health insurer.
d. “Credentialing period” means the time period between the health insurer’s receipt of a physician’s, advanced registered nurse practitioner’s, or physician assistant’s application for credentialing and approval of that application by the health insurer.
e. “Physician” means a licensed doctor of medicine and surgery or a licensed doctor of osteopathic medicine and surgery.
f. “Physician assistant” means a person who is licensed to practice as a physician assistant under the supervision of one or more physicians.
2008 Acts, ch 1123, §28; 2010 Acts, ch 1121, §16; 2013 Acts, ch 90, §155; 2015 Acts, ch 56, §24
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.101 - Title and purpose.

514G.101 Title and purpose.
This chapter may be known and cited as the “Long-term Care Insurance Act”. The purpose of this chapter is to promote the public interest, to promote the availability of long-term care insurance, to protect applicants for long-term care insurance from unfair or deceptive sales or enrollment practices, to establish standards for long-term care insurance, to facilitate public understanding and comparison of long-term care insurance policies, and to facilitate flexibility and innovation in the development of long-term care insurance coverage.
2008 Acts, ch 1175, §2
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.102 - Scope.

514G.102 Scope.
The requirements of this chapter apply to policies delivered or issued for delivery in this state on or after July 1, 2008. The requirements of this chapter related to independent review of benefit trigger determinations apply to all claims made on or after January 1, 2009. The requirements of this chapter related to prompt payment of claims and the payment of interest apply to all long-term care insurance policies. This chapter is not intended to supersede the obligations of entities subject to this chapter to comply with the substance of other applicable insurance laws not in conflict with this chapter, except that laws and regulations designed and intended to apply to Medicare supplement insurance policies shall not be applied to long-term care insurance.
2008 Acts, ch 1175, §3; 2009 Acts, ch 145, §11, 55; 2015 Acts, ch 128, §21, 50, 51
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.104 - Extraterritorial jurisdiction — group long-term care insurance.

514G.104 Extraterritorial jurisdiction — group long-term care insurance.
Group long-term care insurance coverage shall not be offered to a resident of this state under a group policy issued in another state unless either this state or another state with statutory and regulatory requirements for long-term care insurance that are substantially similar to those adopted in this state has made a determination that the group to which the policy is issued meets the requirements of section 514G.103, subsection 9, paragraph “d”.
2008 Acts, ch 1175, §5; 2009 Acts, ch 145, §12
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.106 - Incontestability period.

514G.106 Incontestability period.
1. An insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim if the policy or certificate has been in force for less than six months upon a showing of misrepresentation that is material to the insurer’s acceptance for coverage.
2. An insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim if the policy or certificate has been in force for at least six months but less than two years, upon a showing of misrepresentation that is both material to the acceptance for coverage and pertains to the condition for which benefits are sought.
3. An insurer shall not contest a long-term care insurance policy or certificate that has been in force for two or more years solely upon the grounds of misrepresentation. Such a policy or certificate may be contested only upon a showing that the insured knowingly and intentionally misrepresented relevant facts relating to the insured’s health.
4. A long-term care insurance policy or certificate may be field-issued if the compensation paid to the field issuer is not based on the number of policies or certificates issued. For the purposes of this subsection, a “field-issued” policy means a policy or certificate issued by a producer or third-party administrator pursuant to the underwriting authority granted to the producer or third-party administrator by an insurer and using the insurer’s underwriting guidelines.
5. An insurer that has paid benefits under a long-term care insurance policy or certificate shall not recover such benefit payments if the policy or certificate is rescinded.
6. The provisions of this section are applicable to life insurance policies or certificates that accelerate benefits for long-term care. However, if an insured dies, the remaining death benefits of a life insurance policy that accelerates benefits for long-term care are not governed by this section but by the provisions of section 508.28. In all other situations, this section shall apply to life insurance policies that accelerate benefits for long-term care.
2008 Acts, ch 1175, §7
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.107 - Nonforfeiture benefits.

514G.107 Nonforfeiture benefits.
1. Except as otherwise provided in subsection 2, a long-term care insurance policy or certificate shall not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate that includes a nonforfeiture benefit. A nonforfeiture benefit may be offered in the form of a rider that is attached to the policy or certificate. If the policyholder or certificate holder declines the nonforfeiture benefit, the insurer shall provide a contingent benefit upon lapse that is available for a specified period of time following a substantial increase in premium rates.
2. When a group long-term care insurance policy or certificate is delivered or issued for delivery in this state, an offer of benefits shall be made to the group policyholder that meets the requirements of subsection 1. However, if the policy is delivered or issued for delivery to a group as described in section 514G.103, subsection 9, paragraph “d”, that is not a continuing care retirement community or other similar entity, the offer of benefits shall be made to each proposed certificate holder.
3. The commissioner shall, by rule, specify the type or types of nonforfeiture benefits to be offered as part of long-term care insurance policies and certificates, the standards for such nonforfeiture benefits, and the standards for contingent benefit upon lapse including a specified period of time during which a contingent benefit upon lapse will be available and what constitutes a substantial premium rate increase that will trigger a contingent benefit upon lapse as provided in subsection 1.
2008 Acts, ch 1175, §8
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.108 - Prompt payment of claims — requirements.

514G.108 Prompt payment of claims — requirements.
1. An insurer providing long-term care insurance under this chapter and subject to state insurance regulation shall either accept and pay or deny a clean claim. For the purposes of this section, “clean claim” means a properly completed paper or electronic request for payment that contains all necessary information for the insurer to timely adjudicate and pay claims for long-term care benefits under the policy, does not involve coordination of benefits for third-party liability or subrogation, and does not involve the existence of particular circumstances requiring special treatment that prevents a prompt payment from being made.
2. The commissioner shall adopt rules establishing processes for timely adjudication and payment of claims for long-term care benefits by insurers.
3. Payment of a clean claim shall include interest at the rate of ten percent per annum when an insurer or other entity that administers or processes claims on behalf of the insurer fails to timely pay a clean claim.
2008 Acts, ch 1175, §9
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.109 - Benefit trigger determinations — notice — appeals.

514G.109 Benefit trigger determinations — notice — appeals.
1. Notice. When a long-term care insurer determines that the benefit trigger in an insured’s long-term care insurance policy has not been met, the insurer shall provide a clear, written notice to the insured of all of the following:
a. The reason that the insurer determined that the insured’s benefit trigger has not been met.
b. The insurer’s internal appeal process provided under the insured’s long-term care insurance policy.
c. The insured’s right, after exhaustion of the insurer’s internal appeal process, to have the benefit trigger determination reviewed under the independent review process set forth in section 514G.110.
2. Internal appeal.
a. An insured may request an internal appeal of a benefit trigger determination by sending a written request to the insurer, along with any additional supporting information, within sixty days after the insured receives the notice described in subsection 1. The internal appeal shall be considered by an individual or group of individuals designated by the insurer, provided that the individual or individuals making the internal appeal decision shall not be the same individual or individuals who made the initial benefit trigger determination. All internal appeals shall be completed and written notice of the internal appeal decision sent to the insured within sixty days of the insurer’s receipt of all necessary information upon which a final determination can be made.
b. If the determination that the benefit trigger was not met is upheld upon internal appeal, the notice of the appeal decision shall describe additional internal appeal rights that are offered by the insurer, if any. Nothing in this paragraph shall require an insurer to offer any internal appeal rights other than those described in paragraph “a”.
c. If the determination that the benefit trigger was not met is upheld after the internal appeal process has been exhausted and there is no new information not previously provided to the insurer for consideration, the insurer shall provide the insured with a written description of the insured’s right to request an independent review of the benefit trigger determination.
3. Receipt of notice. Notices required by this section shall be deemed received within five days after the date of mailing.
2008 Acts, ch 1175, §10, 18
Referred to in §514G.110
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.111 - Authority to promulgate rules.

514G.111 Authority to promulgate rules.
The commissioner may adopt rules pursuant to chapter 17A related to long-term care insurance and to the administration and enforcement of this chapter, including but not limited to the following:
1. Promoting adequate premiums and protecting policyholders in the event of substantial rate increases.
2. Establishing minimum standards for producer education, compensation, and testing; marketing practices; reporting practices; and penalties related to the sale of long-term care insurance in this state.
3. Establishing loss ratio standards for long-term care insurance policies with specific reference to such policies.
4. Providing standards for full and fair disclosure by setting forth the manner and content of disclosures required for the sale of long-term care insurance policies including terms of renewability; initial and subsequent conditions of eligibility; nonduplication of coverage provisions; coverage of dependents; effect of preexisting conditions; termination, continuation, or conversion of policies; probationary periods; limitations, exceptions, and reductions; elimination periods; requirements for replacement; recurrent conditions; and definitions of terms.
5. Requiring certain remedial actions necessitated by changes in the long-term care insurance market to provide fair and reasonable protections for long-term care insurance purchasers and beneficiaries.
6. Ensuring the prompt payment of clean claims.
7. Administering the independent review process of insurers’ benefit trigger determinations.
2008 Acts, ch 1175, §12
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.112 - Severability.

514G.112 Severability.
If any provision of this chapter or the application of this chapter to any person or circumstance is for any reason held to be invalid, the remainder of the chapter and the application of the provision to other persons or circumstances shall not be affected.
2008 Acts, ch 1175, §13
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514G - LONG-TERM CARE INSURANCE ACT › Section 514G.113 - Penalties.

514G.113 Penalties.
In addition to any other penalties provided by the laws of this state, any insurer or any producer found to have violated a provision of this chapter or any other requirement of this state relating to the regulation of long-term care insurance or the marketing of such insurance shall be subject to a fine of up to three times the amount of any commission paid for each policy involved in the violation, or up to ten thousand dollars, whichever is greater. A fine collected under this section shall be deposited as provided in section 505.7.
2008 Acts, ch 1175, §14; 2009 Acts, ch 181, §75
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.1 - Definitions.

514H.1 Definitions.
As used in this chapter, unless the context otherwise requires:
1. “Deficit Reduction Act of 2005” means section 6021(a)(1)(A) of Pub. L. No. 109-171 as it pertains to the expansion of state long-term care insurance partnership programs.
2. “Long-term care facility” means a facility licensed under chapter 135C or an assisted living program certified under chapter 231C.
3. “Long-term care insurance” means long-term care insurance as defined in section 514G.103 and regulated in section 514G.105.
4. “Qualified long-term care insurance policy” means a long-term care insurance contract that is issued by an insurer or other person who complies with section 514H.4.
5. “Qualified long-term care services” means qualified long-term care services as defined in section 7702B(c) of the Internal Revenue Code.
6. “Qualified state long-term care insurance partnership” means an approved state plan amendment, according to the Deficit Reduction Act of 2005 that provides for the disregard of any assets or resources in an amount equal to the insurance benefit payments that are made to or on behalf of an individual who is a beneficiary.
2005 Acts, ch 166, §2, 13; 2008 Acts, ch 1175, §15; 2009 Acts, ch 145, §13, 14
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.2 - Iowa long-term care asset disregard incentive program — establishment and administration.

514H.2 Iowa long-term care asset disregard incentive program — establishment and administration.
1. The Iowa long-term care asset disregard incentive program is established to do all of the following:
a. Provide incentives for individuals to insure against the costs of providing for their long-term care needs.
b. Provide a mechanism for individuals to qualify for coverage of the costs of their long-term care needs under the medical assistance program without first being required to substantially exhaust all their resources.
c. Assist in developing methods for increasing access to and the affordability of long-term care insurance.
d. Alleviate the financial burden on the state’s medical assistance program by encouraging the pursuit of private initiatives.
2. The insurance division of the department of commerce shall administer the program in cooperation with the division responsible for medical services within the department of human services. Each agency shall take all necessary actions, including filing an appropriate medical assistance state plan amendment to the state Medicaid plan to take full advantage of the benefits and features of the Deficit Reduction Act of 2005.
2005 Acts, ch 166, §3, 13; 2009 Acts, ch 145, §15
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.3 - Eligibility.

514H.3 Eligibility.
An individual who is the beneficiary of a qualified long-term care insurance policy approved by the insurance division may be eligible for assistance under the medical assistance program using the asset disregard provisions pursuant to section 514H.5.
2005 Acts, ch 166, §4, 13; 2009 Acts, ch 145, §16
Referred to in §514H.5
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.4 - Insurer requirements.

514H.4 Insurer requirements.
An insurer or other person who wishes to issue a qualified long-term care insurance policy in Iowa shall conform with all policy guidelines as expressed in the Deficit Reduction Act of 2005 and in Iowa law and rules.
2005 Acts, ch 166, §5, 13; 2009 Acts, ch 145, §17
Referred to in §514H.1
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.5 - Asset disregard adjustment.

514H.5 Asset disregard adjustment.
1. As used in this section, “asset disregard” means a one dollar increase in the amount of assets an individual who is the beneficiary of a qualified long-term care insurance policy and meets the requirements of section 514H.3 may retain under section 249A.35 for each one dollar of benefit paid out under the individual’s qualified long-term care insurance policy for qualified long-term care services.
2. When the division responsible for medical services within the department of human services determines whether an individual is eligible for medical assistance under chapter 249A, the division shall make an asset disregard adjustment for any individual who meets the requirements of section 514H.3. The asset disregard shall be available after benefits of the qualified long-term care insurance policy have been applied to the cost of qualified long-term care services as required under this chapter.
2005 Acts, ch 166, §6, 13; 2009 Acts, ch 145, §18
Referred to in §249A.35, 514H.3, 514H.6, 514H.7, 514H.8
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.6 - Application of asset disregard to determination of individual’s assets.

514H.6 Application of asset disregard to determination of individual’s assets.
A public program administered by the state that provides long-term care services and bases eligibility upon the amount of the individual’s assets shall apply the asset disregard under section 514H.5 in determining the amount of the individual’s assets.
2005 Acts, ch 166, §7, 13
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.7 - Prior program — discontinuation of program.

514H.7 Prior program — discontinuation of program.
1. If the Iowa long-term care asset disregard incentive program is discontinued, an individual who is covered by a qualified long-term care insurance policy prior to the date the program is discontinued is eligible to continue to receive an asset disregard as defined under section 514H.5.
2. An individual who is covered by a long-term care insurance policy under the long-term care asset preservation program established pursuant to chapter 249G, Code 2005, on or before November 17, 2005, is eligible to continue to receive the asset adjustment as defined under that chapter.
3. The insurance division, in cooperation with the department of human services, shall adopt rules to provide an asset disregard to individuals who are covered by a long-term care insurance policy prior to November 17, 2005, consistent with the Iowa long-term care asset disregard incentive program.
2005 Acts, ch 166, §8, 13; 2009 Acts, ch 145, §19
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.8 - Reciprocal agreements to extend asset disregard.

514H.8 Reciprocal agreements to extend asset disregard.
The division responsible for medical services within the department of human services may enter into reciprocal agreements with other states to extend the asset disregard under section 514H.5 to Iowa residents who had purchased or were covered by qualified long-term care insurance policies in other states.
2005 Acts, ch 166, §9, 13; 2009 Acts, ch 145, §20
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514H - LONG-TERM CARE ASSET DISREGARD INCENTIVES › Section 514H.9 - Rules.

514H.9 Rules.
The insurance division of the department of commerce in cooperation with the department of human services shall adopt rules pursuant to chapter 17A as necessary to administer this chapter.
2005 Acts, ch 166, §10, 13; 2009 Acts, ch 145, §21
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514I - HEALTHY AND WELL KIDS IN IOWA PROGRAM › Section 514I.1 - Intent of the general assembly.

514I.1 Intent of the general assembly.
1. It is the intent of the general assembly to provide health care coverage to eligible children that improves access to preventive, diagnostic, and treatment health services which result in improved health status using in part resources made available from the passage of Tit. XXI of the federal Social Security Act.
2. It is the intent of the general assembly that the program be implemented and administered in compliance with Tit. XXI of the federal Social Security Act. If, as a condition of receiving federal funds for the program, federal law requires implementation and administration of the program in a manner not provided in this chapter, during a period when the general assembly is not in session, the department, with the approval of the hawk-i board, shall proceed to implement and administer those provisions, subject to review by the next regular session of the general assembly.
3. It is the intent of the general assembly, recognizing the importance of outreach to the successful utilization of the program by eligible children, that within the limitations of funding allowed for outreach and administration expenses, the maximum amount possible be used for outreach.
4. It is the intent of the general assembly that the hawk-i program be an integral part of the continuum of health insurance coverage and that the program be developed and implemented in such a manner as to facilitate movement of families between health insurance providers and to facilitate the transition of families to private sector health insurance coverage.
5. It is the intent of the general assembly that if federal reauthorization of the state children’s health insurance program provides sufficient federal allocations to the state and authorization to cover such children as an option under the state children’s health insurance program, the department shall expand coverage under the state children’s health insurance program to cover children with family incomes at or below three hundred percent of the federal poverty level.
98 Acts, ch 1196, §2, 16; 2003 Acts, ch 108, §131; 2008 Acts, ch 1188, §5, 6; 2009 Acts, ch 118, §23
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514I - HEALTHY AND WELL KIDS IN IOWA PROGRAM › Section 514I.2 - Definitions.

514I.2 Definitions.
As used in this chapter, unless the context otherwise requires:
1. “Benchmark benefit package” means any of the following:
a. The standard blue cross/blue shield preferred provider option service benefit plan, described in and offered under 5 U.S.C. §8903(1).
b. A health benefits coverage plan that is offered and generally available to state employees in this state.
c. The plan of a health maintenance organization as defined in 42 U.S.C. §300e, with the largest insured commercial, nonmedical assistance enrollment of covered lives in the state.
2. “Cost sharing” means the payment of a premium or copayment as provided for by Tit. XXI of the federal Social Security Act and section 514I.10.
3. “Department” means the department of human services.
4. “Director” means the director of human services.
5. “Eligible child” means an individual who meets the criteria for participation in the program under section 514I.8.
6. “Hawk-i board” or “board” means the entity which adopts rules and establishes policy for, and directs the department regarding, the hawk-i program.
7. “Hawk-i program” or “program” means the healthy and well kids in Iowa program created in this chapter to provide health insurance coverage to eligible children.
8. “Health insurance coverage” means health insurance coverage as defined in 42 U.S.C. §300gg-91.
9. “Participating insurer” means any of the following:
a. An entity licensed by the division of insurance of the department of commerce to provide health insurance in Iowa that has contracted with the department to provide health insurance coverage to eligible children under this chapter.
b. A managed care organization acting pursuant to a contract with the department of human services to administer the hawk-i program.
10. “Qualified child health plan” or “plan” means health insurance coverage provided by a participating insurer under this chapter.
98 Acts, ch 1196, §3, 16; 2003 Acts, ch 108, §131; 2008 Acts, ch 1188, §7; 2009 Acts, ch 118, §24; 2014 Acts, ch 1092, §184; 2017 Acts, ch 148, §92; 2019 Acts, ch 124, §1; 2022 Acts, ch 1131, §65
Subsection 9 amended
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514I - HEALTHY AND WELL KIDS IN IOWA PROGRAM › Section 514I.3 - Hawk-i program — established.

514I.3 Hawk-i program — established.
1. The hawk-i program, a statewide program designed to improve the health of children and to provide health insurance coverage to eligible children on a regional basis which complies with Tit. XXI of the federal Social Security Act, is established and shall be implemented January 1, 1999.
2. Health insurance coverage under the program shall be provided by participating insurers and through qualified child health plans.
3. The department of human services is designated to receive the state and federal funds appropriated or provided for the program, and to submit and maintain the state plan for the program, which is approved by the centers for Medicare and Medicaid services of the United States department of health and human services.
4. Nothing in this chapter shall be construed or is intended as, or shall imply, a grant of entitlement for services to persons who are eligible for participation in the program based upon eligibility consistent with the requirements of this chapter. Any state obligation to provide services pursuant to this chapter is limited to the extent of the funds appropriated or provided for this chapter.
5. Participating insurers under this chapter are not subject to the requirements of chapters 513B and 513C.
6. Health care coverage provided under this chapter in accordance with Tit. XXI of the federal Social Security Act shall be recognized as prior creditable coverage for the purposes of private individual and group health insurance coverage.
98 Acts, ch 1196, §4, 16; 2002 Acts, ch 1050, §45; 2003 Acts, ch 108, §131; 2009 Acts, ch 118, §25
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514I - HEALTHY AND WELL KIDS IN IOWA PROGRAM › Section 514I.6 - Participating insurers.

514I.6 Participating insurers.
Participating insurers shall meet the qualifying standards established by rule under this chapter and shall perform all of the following functions:
1. Provide plan cards and membership booklets to qualifying families.
2. Provide or reimburse accessible, quality medical or dental services.
3. Require that any plan provided by the participating insurer establishes and maintains a conflict management system that includes methods for both preventing and resolving disputes involving the health or dental care needs of eligible children, and a process for resolution of such disputes.
4. Provide the department with all of the following information pertaining to the participating insurer’s plan:
a. A list of providers of medical or dental services under the plan.
b. Information regarding plan rules relating to referrals to specialists.
c. Information regarding the plan’s conflict management system.
d. Other information as directed by the board.
5. Submit a plan for a health improvement program to the department, for approval by the board.
6. Develop a plan for provider network development including criteria for access to pediatric subspecialty services.
7. Permit any chiropractor licensed under chapter 151 who is located in the geographic coverage area served by the plan and who agrees to abide by the plan’s terms, conditions, reimbursement rates, and quality standards to serve as a participating provider in any plan offered to eligible children under this chapter, including but not limited to a limited provider network plan as defined in section 514C.13.
98 Acts, ch 1196, §7, 16; 2003 Acts, ch 108, §131; 2003 Acts, ch 124, §8; 2009 Acts, ch 118, §32, 33; 2010 Acts, ch 1133, §2; 2019 Acts, ch 124, §8
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514I - HEALTHY AND WELL KIDS IN IOWA PROGRAM › Section 514I.8A - Hawk-i — all income-eligible children.

514I.8A Hawk-i — all income-eligible children.
The department shall provide coverage to individuals under nineteen years of age who meet the income eligibility requirements for the hawk-i program and for whom federal financial participation is or becomes available for the cost of such coverage.
2009 Acts, ch 118, §14
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514I - HEALTHY AND WELL KIDS IN IOWA PROGRAM › Section 514I.9 - Program benefits.

514I.9 Program benefits.
1. The hawk-i board shall review the benefits package annually and shall determine additions to or deletions from the benefits package offered. The hawk-i board shall submit the recommendations to the general assembly for any amendment to the benefits package.
2. Benefits, in addition to those required by rule, may be provided to eligible children by a participating insurer if the benefits are provided at no additional cost to the state.
98 Acts, ch 1196, §10, 16; 2003 Acts, ch 108, §131; 2010 Acts, ch 1061, §180; 2013 Acts, ch 138, §104
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514I - HEALTHY AND WELL KIDS IN IOWA PROGRAM › Section 514I.10 - Cost sharing.

514I.10 Cost sharing.
1. Cost sharing for eligible children whose family income is below one hundred fifty percent of the federal poverty level shall not exceed the standards permitted under 42 U.S.C. §1396o(a)(3) or §1396o(b)(1).
2. Cost sharing for eligible children whose family income equals one hundred fifty percent but does not exceed two hundred percent of the federal poverty level may include a premium or copayment amount which does not exceed five percent of the annual family income. The amount of any premium or the copayment amount shall be based on family income and size.
3. Cost sharing for an eligible child whose family income exceeds two hundred percent but does not exceed three hundred percent of the federal poverty level may include copayments and graduated premium amounts which do not exceed the limitations of federal law.
4. The payment to and acceptance by an automated case management system or the department of the premium required under this section shall not automatically confer initial or continuing program eligibility on an individual. A premium paid to and accepted through the department’s premium payment process that is subsequently determined to be untimely or to have been paid on behalf of an individual ineligible for the program shall be refunded to the remitter in accordance with rules adopted by the department.
98 Acts, ch 1196, §11, 16; 2000 Acts, ch 1221, §10; 2003 Acts, ch 124, §12; 2008 Acts, ch 1014, §4; 2008 Acts, ch 1188, §12; 2009 Acts, ch 118, §36; 2014 Acts, ch 1026, §115
Referred to in §514I.2
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514I - HEALTHY AND WELL KIDS IN IOWA PROGRAM › Section 514I.11 - Hawk-i trust fund.

514I.11 Hawk-i trust fund.
1. A hawk-i trust fund is created in the state treasury under the authority of the department of human services, in which all appropriations and other revenues of the program such as grants, contributions, and participant payments shall be deposited and used for the purposes of the program. The moneys in the fund shall not be considered revenue of the state, but rather shall be funds of the program.
2. The trust fund shall be separate from the general fund of the state and shall not be considered part of the general fund of the state. The moneys in the trust fund are not subject to section 8.33 and shall not be transferred, used, obligated, appropriated, or otherwise encumbered, except to provide for the purposes of this chapter and except as provided in subsection 4. Notwithstanding section 12C.7, subsection 2, interest or earnings on moneys deposited in the trust fund shall be credited to the trust fund.
3. Moneys in the fund are appropriated to the department and shall be used to offset any program costs.
4. The department may transfer moneys appropriated from the fund to be used for the purpose of expanding health care coverage to children under the medical assistance program.
5. The department shall provide periodic updates to the general assembly regarding expenditures from the fund.
99 Acts, ch 203, §52; 2003 Acts, ch 108, §131; 2005 Acts, ch 175, §124, 125; 2008 Acts, ch 1188, §13; 2009 Acts, ch 118, §37
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514J - EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS › Section 514J.101 - Purpose — applicability.

514J.101 Purpose — applicability.
The purpose of this chapter is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination made by a health carrier as required by the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, which amends the Public Health Service Act and adopts, in part, 42 U.S.C. §300gg-19, and to address issues which are unique to the external review process in this state.
2011 Acts, ch 101, §1; 2022 Acts, ch 1032, §87
Section amended
2023 Iowa Code › Title XIII - COMMERCE › Chapter 514J - EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS › Section 514J.103 - Applicability and scope.

514J.103 Applicability and scope.
1. Except as provided in subsection 2, this chapter shall apply to all health carriers.
2. This chapter shall not apply to any of the following:
a. A policy or certificate that provides coverage only for a specified disease, specified accident or accident-only, credit, disability income, hospital indemnity, long-term care, vision care, or any other limited supplemental benefit.
b. A Medicare supplement policy of insurance, as defined by the commissioner by rule.
c. Coverage under a plan through Medicare, Medicaid, or the federal employees health benefits program, any coverage issued under 10 U.S.C. ch. 55, and any coverage issued as supplemental to that coverage.
d. Any coverage issued as supplemental to liability insurance.
e. Workers’ compensation or similar insurance.
f. Automobile medical-payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket or individual basis.
2011 Acts, ch 101, §3; 2014 Acts, ch 1140, §111