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Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 35 - Accident and Health Insurance › Rule 191-35.40 - Autism Spectrum Disorder Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Purpose.
This rule implements Iowa Code section
				514C.28,
				relating to autism spectrum disorder coverage in a group plan established
				pursuant to Iowa Code chapter 509A for employees of the state that provides for
				third-party payment or prepayment of health, medical, and surgical coverage
				benefits.
(2)
Definitions.
For purposes of this rule, the definitions found
				in Iowa Code section
				514C.28(2)
				 shall apply. In addition, the following
				definitions shall apply:
"Autism spectrum disorder"
means a mental
				  health condition that meets the diagnostic criteria for such disorder as
				  published in the most recent edition of the Diagnostic and Statistical Manual
				  of Mental Disorders as published by the American Psychiatric
				  Association.
"Commissioner"
means the commissioner of
				  insurance.
"Group plan"
or
"group health
				  plan"
means a group health plan established for the employees of the
				  state of Iowa under Iowa Code chapter 509A.
(3)
Services.
A group plan
				is not required to provide coverage for any of the following:
a. Acupuncture.
b. Animal-based therapy including
				hippotherapy.
c. Auditory
				integration training.
d. Chelation
				therapy.
e. Child care.
f. Cranial sacral therapy.
g. Custodial or respite care.
h. Hyperbaric oxygen therapy.
i. Special diets or supplements.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to implement Iowa Code chapter
				  514D so as to provide reasonable standardization and simplification of terms
				  and coverages of individual accident and sickness insurance policies and
				  individual subscriber contracts of hospital, medical, and dental service
				  corporations in order to facilitate public understanding and comparison and to
				  eliminate provisions contained in individual accident and sickness insurance
				  policies and individual subscriber contracts of hospital, medical, and dental
				  service corporations which may be misleading or confusing in connection either
				  with the purchase of the coverages or with the settlement of claims and to
				  provide for full disclosure in the sale of the coverages.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.2 - Applicability and Scope

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter shall apply to all individual accident and
				  sickness insurance policies and subscriber contracts of service corporations,
				  organized under Iowa Code chapter 514, delivered or issued for delivery to any
				  person in this state on and after the effective date hereof, except it shall
				  not apply to individual policies or contracts issued pursuant to a conversion
				  privilege under a policy or contract of group or individual insurance when the
				  group or individual policy or contract includes provisions which are
				  inconsistent with the requirements of this chapter, nor to policies being
				  issued to employees or members as additions to franchise plans in existence on
				  the effective date of this chapter The requirements contained in this chapter
				  shall be in addition to any other applicable regulations previously
				  adopted.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.3 - Effective Date

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter shall be effective on December 31, 1981, and
				  shall be applicable to all new filings of individual accident and sickness
				  insurance policies and nonprofit hospital, medical and dental service contracts
				  made after that date, and all other policies and contracts covered by this
				  chapter and delivered or issued for delivery after June 30, 1982, shall be in
				  compliance with this chapter
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.4 - Policy Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
Except as provided hereafter, no individual accident or
				  sickness insurance policy or hospital, medical, or dental service corporation
				  subscriber contract delivered or issued for delivery to any person in this
				  state shall contain definitions respecting the matters set forth below unless
				  such definitions comply with the requirements of this rule.
(1)
"One period of
				confinement"
means consecutive days of in-hospital service received as
				an inpatient, or successive confinements when discharge from and readmission to
				the hospital occurs within a period of time not more than 90 days or three
				times the maximum number of days of in-hospital coverage provided by the policy
				to a maximum of 180 days.
(2)
"Hospital"
may be defined in relation to its status,
				facilities and available services or to reflect its accreditation by the Joint
				Commission on Accreditation of Hospitals.
a.
				The definition of the term "hospital" shall not be more restrictive than one
				requiring that the hospital:
(1) Be an
				institution operated pursuant to law; and
(2) Be primarily and continuously engaged in
				providing or operating, either on its premises or in facilities available to
				the hospital on a prearranged basis and under the supervision of a staff of
				duly licensed physicians, medical, diagnostic and major surgical facilities for
				the medical care and treatment of sick or injured persons on an inpatient basis
				for which a charge is made; and
(3)
				Provide 24-hour nursing service by or under the supervision of registered
				graduate professional nurses (R.N.s).
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.5 - Prohibited Policy Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Except as provided in subrule 36.4(7), no policy shall contain provisions
				establishing a probationary or waiting period during which no coverage is
				provided under the policy subject to the further exception that a policy may
				specify a probationary or waiting period not to exceed six months for specified
				diseases or conditions and losses resulting therefrom for hernia, disorder of
				reproductive organs, varicose veins, adenoids, appendix, and tonsils. However,
				the permissible six months' exception shall not be applicable where such
				specified diseases or conditions are treated on an emergency basis. Accident
				policies shall not contain probationary or waiting periods.
(2) No policy or rider for additional
				coverage may be issued as a dividend unless an equivalent cash payment is
				offered to the policyholder as an alternative to such dividend policy or rider
				No such dividend policy or rider shall be issued for an initial term of less
				than six months. The initial renewal subsequent to the issuance of any policy
				or rider as a dividend shall clearly disclose that the policyholder is renewing
				the coverage that was provided as a dividend for the previous term and that the
				renewal is optional with the policyholder
(3) No policy shall exclude coverage for a
				loss due to a preexisting condition for a period greater than 12 months
				following policy issue where the application for the insurance does not seek
				disclosure of prior illness, disease or physical conditions or prior medical
				care and treatment and preexisting condition is not specifically excluded by
				the terms of the policy.
(4) A
				disability income policy may contain a "return of premium" or "cash value
				benefit" so long as:
a. Such return of premium
				or cash value benefit is not reduced by an amount greater than the aggregate of
				any claims paid under the policy; and
b. The insurer demonstrates that the reserve
				basis for such policies is adequate. No other policy shall provide a return of
				premium or cash value benefit, except return of unearned premium upon
				termination or suspension of coverage, retroactive waiver of premium paid
				during disability, payment of dividends on participating policies, or
				experience rating refunds.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.9 - Filing Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Rate filing.
Every policy, rider or endorsement form affecting
				benefits which is submitted for approval shall be accompanied by a rate filing
				unless such rider or endorsement form does not require a change in a rate. Any
				subsequent addition to or change in rates applicable to such policy, rider or
				endorsement shall also be filed.
(2)
Contents of rate
				filings.
Each rate submission shall include an actuarial memorandum
				describing the basis on which rates were determined and shall indicate and
				describe the calculation of the ratio, hereinafter called "anticipated
				creditable loss ratio," of the present value of the expected benefits to the
				present value of the expected premiums over the entire period for which rates
				are computed to provide coverage. Interest shall be used in the calculation of
				these present values only if it is a significant factor in the calculation of
				this loss ratio. Each rate submission must also include a certification by a
				qualified actuary that to the best of the actuary's knowledge and judgment the
				rate filing is in compliance with the applicable laws and regulations of Iowa
				and that the benefits are reasonable in relation to premiums.
(3)
Previously approved
				forms.
Filings of rate revisions for a previously approved policy,
				rider or endorsement form shall also include the following:
a. A statement of the scope and reason for
				the revision, and an estimate of the expected average effect on premiums,
				including the anticipated loss ratio for the form.
b. A statement as to whether the filing
				applies only to new business, only to in force business, or both, and the
				reasons therefor.
c. A history of
				the experience under existing rates, including at least the data indicated in
				36.9(4). The history may also include, if available and appropriate, the ratios
				of actual claims to the claims expected according to the assumptions underlying
				the existing rates. Additional data might include: substitution of actual claim
				runoffs for claim reserves and liabilities; determination of loss ratios with
				the increase in policy reserves (other than unearned premium reserves) added to
				benefits rather than subtracted from premiums; accumulations of experience
				funds; substitution of net level policy reserves for preliminary term policy
				reserves; adjustment of premiums to an annual mode basis; or other adjustments
				or schedules suited to the form and to the records of the company. All
				additional data must be reconciled, as appropriate, to the required
				data.
d. The date and magnitude of
				each previous rate change, if any.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.10 - Loss Ratios

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Average annual premium.
a.
				New forms. With respect to a new form under which the average annual premium
				(as defined below) is expected to be at least $200 benefits shall be deemed
				reasonable in relation to premiums provided the anticipated loss ratio is at
				least as great as shown in the following table:
Type of
Renewal Clause
Coverage
OR
CR
GR
NC
Medical Expense
60%
55%
55%
50%
Loss of Income and other
60%
55%
50%
45%
For a policy form, including riders and endorsements, under
				  which the expected average annual premium per policy is $100 or more but less
				  than $200, subtract five percentage points from the numbers in the table above,
				  or if less than $100, subtract ten percentage points.
b. The average annual premium per policy
				shall be computed by the insurer based on an anticipated distribution of
				business by all applicable criteria having a price difference, such as age,
				sex, amount, dependent status, rider frequency, etc., except assuming an annual
				mode for all policies (i.e., the fractional premium loading shall not affect
				the average annual premium or anticipated loss ratio calculation).
The above anticipated loss ratio standards do not apply to a
				  class of business where such standards are in conflict with specific statutes
				  or regulations.
c.
				Definitions of renewal clause.
OR-Optionally Renewable: Renewal is at the option of the
				  insurance company.
CR-Conditionally Renewable: Renewal can be declined by the
				  insurance company only for stated reasons other than deterioration of
				  health.
GR-Guaranteed Renewable: Renewal cannot be declined by the
				  insurance company for any reason, but the insurance company can revise rates on
				  a class basis.
NC-Non-Cancelable: Renewal cannot be declined nor can rates
				  be revised by the insurance company.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.11 - Certification

Current through Register Vol. 47, No. 3, July 24, 2024
Any policy form submitted to the insurance division for
				  approval which is subject to Iowa Code chapter 514D shall be in conformance
				  with the applicable requirements of Iowa Code chapter 514D and with the filing
				  requirements set forth in rule
				  191-201.
				  (505,509,514A,515,515A,515F).
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.12 - Severability

Current through Register Vol. 47, No. 3, July 24, 2024
If any provision of this regulation or the application
				  thereof to any person or circumstance is for any reason held to be invalid, the
				  remainder of the regulation and the application of such provision to other
				  persons or circumstances shall not be affected thereby.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.13 - Individual Health Insurance Coverage for Children Under the Age of 19

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Purpose, applicability and effective date.
a. The purpose of this rule is to set forth
				the requirements and procedures to be followed for individual health insurance
				coverage for children under the age of 19.
b. This rule shall apply to all "carriers" as
				defined in Iowa Code subsection
				513C3(5).. For
				purposes of this rule, "carrier" means the same as it is defined in Iowa Code
				subsection
				513C3(5)..
c. For purposes of this rule, a "child-only"
				policy means a health benefit plan delivered or issued for delivery to an
				individual who is the primary subscriber on the policy and who is under the age
				of 19. A "child-only" policy does not include a health benefit plan that is
				delivered or issued for delivery to a primary subscriber who is 19 years of age
				and older but that insures persons under the age of 19.
d. This rule shall become effective June 8,
				2011, for policies sold or issued on or after that date.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 36 - Accident and Health Insurance › Rule 191-36.20 - Rate Hearings

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Purpose, applicability and effective date.
a.
Purpose.
The purpose of
				this rule is to set forth a procedure to be followed for hearings about certain
				health insurance policy premium rate increases.
b.
Applicability.
This rule
				applies to all individual health insurance policies issued or to be issued in
				Iowa except those excluded by Iowa Code section
				505.19(5)
"a."
c.
Effective date.
This rule became effective October 1, 2010.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.1 - Purpose and Authority

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to provide for the reasonable
				  standardization of coverage and simplification of terms and benefits of
				  Medicare supplement policies; to facilitate public understanding and comparison
				  of such policies; to eliminate provisions contained in such policies which may
				  be misleading or confusing in connection with the purchase of such policies or
				  with the settlement of claims; and to provide for full disclosures in the sale
				  of accident and sickness insurance coverages to persons eligible for Medicare.
				  This chapter is issued pursuant to the authority vested in the commissioner
				  under Iowa Code chapter 514D.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.2 - Applicability, Scope, and Appendices

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Applicability and scope.
a. Except as otherwise specifically provided
				in rules 191-376. (514D),
				191-3722. (514D),
				191-3723. (514D),
				191-3728. (514D) and
				191-3732. (514D), this chapter
				shall apply to:
(1) All Medicare supplement
				individual or group policies delivered or issued for delivery in this state on
				or after May 15, 2019, unless otherwise stated; and
(2) All certificates issued under group
				Medicare supplement policies, which certificates have been delivered or issued
				for delivery in this state on or after May 15, 2019, unless otherwise
				stated.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.5 - Policy Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Coverage restrictions related to Medicare.
Except for
				permitted preexisting condition clauses as described in paragraphs
				37.6(1)
"a,"
37.7(1)
"d,"
and
				37.8(1)
"d,"
no policy or certificate may be advertised,
				solicited or issued for delivery in this state as a Medicare supplement policy
				or certificate if such Medicare supplement policy or certificate contains
				limitations or exclusions on coverage that are more restrictive than those
				permitted by Medicare.
(2)
Waivers of preexisting conditions.
No Medicare supplement
				policy or certificate may use waivers to exclude, limit or reduce coverage or
				benefits for specifically named or described preexisting diseases or physical
				conditions.
(3)
Duplicate
				benefits.
No Medicare supplement policy or certificate in force in the
				state shall contain benefits which duplicate benefits provided by Medicare
				insurance.
(4)
Renewal of
				pre-2006 coverage.
Subject to paragraphs 37.6(1)
"d,""e,"
and
"g"
and
				37.7(1)
"d"
and
"e,"
a Medicare supplement
				policy or certificate with benefits for outpatient prescription drugs in
				existence prior to January 1, 2006, shall, at the option of a currently covered
				individual who does not enroll in Medicare Part D, be renewed for that covered
				individual.
(5)
Coverage of
				prescription drugs after 2005.
A Medicare supplement policy or
				certificate with benefits for outpatient prescription drugs shall not be issued
				after December 31, 2005.
(6)
Renewal of coverage of prescription drugs after 2005 for enrollees of
				Part D.
After December 31,2005, a Medicare supplement policy or
				certificate with benefits for outpatient prescription drugs may not be renewed
				after the covered individual enrolls in Medicare Part D unless:
a. The policy or certificate is modified to
				eliminate outpatient prescription coverage for expenses of outpatient
				prescription drugs incurred after the effective date of the covered
				individual's coverage under a Medicare Part D plan; and
b. Premiums are adjusted to reflect the
				elimination of outpatient prescription drug coverage at the time of Medicare
				Part D enrollment, accounting for any claims paid, if applicable.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.9 - Standard Medicare Supplement Benefit Plans for 2020 Standardized Medicare Supplement Benefit Plan Policies or Certificates Issued for Delivery to Individuals Newly Eligible for Medicare on or After January 1, 2020

Current through Register Vol. 47, No. 3, July 24, 2024
The Medicare Access and CHIP Reauthorization Act of 2015
				  (MACRA) requires that the following standards are applicable to all Medicare
				  supplement policies or certificates delivered or issued for delivery in this
				  state to individuals newly eligible for Medicare on or after January 1, 2020.
				  No policy or certificate that provides coverage of the Medicare Part B
				  deductible may be advertised, solicited, delivered or issued for delivery in
				  this state as a Medicare supplement policy or certificate to individuals newly
				  eligible for Medicare on or after January 1, 2020. All policies must comply
				  with the following benefit standards. Benefit plan standards applicable to
				  Medicare supplement policies and certificates issued to individuals eligible
				  for Medicare before January 1,2020, remain subject to the requirements of rules
				  191-37.6(514D), 191-377. (514D) and
				  191-378. (514D).
(1)
Benefit requirements.
The standards and requirements of rule
				191-378. (514D) shall apply to
				all Medicare supplement policies or certificates delivered or issued for
				delivery to individuals newly eligible for Medicare on or after January 1,
				2020, with the following exceptions:
a. Plan C
				is redesignated as Plan D and shall provide the benefits contained in paragraph
				37.8(4)
"c"
but shall not provide coverage for 100 percent or
				any portion of the Medicare Part B deductible.
b. Plan F is redesignated as Plan G and shall
				provide the benefits contained in paragraph 37.8(4)
"e"
but
				shall not provide coverage for 100 percent or any portion of the Medicare Part
				B deductible.
c. Plans C, F, and F
				with high deductible may not be offered to individuals newly eligible for
				Medicare on or after January 1, 2020.
d. Plan F with high deductible is
				redesignated as Plan G with high deductible and shall provide the benefits
				contained in paragraph 37.8(4)
"f "
but shall not provide
				coverage for 100 percent or any portion of the Medicare Part B deductible;
				provided further that the Medicare Part B deductible paid by the covered
				individual shall be considered an out-of-pocket expense in meeting the annual
				high deductible.
e. The reference
				to Plan C or F contained in paragraph 37.8(2)
"b "
is deemed a
				reference to Plan D or G for purposes of this rule.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.20 - Medicare Select Policies and Certificates

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Applicability of this
				rule.
a. Rule 191-37.20 (514D) shall
				apply to Medicare Select policies and certificates, as defined in this
				rule.
b. No policy or certificate
				may be advertised as a Medicare Select policy or certificate unless it meets
				the requirements of this rule.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.21 - Open Enrollment

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Denial of policy for health reason prohibited.
No issuer shall
				deny or condition the issuance or effectiveness of any Medicare supplement
				policy or certificate available for sale in this state, or discriminate in the
				pricing of such a Medicare supplement policy or certificate, because of the
				health status, claims experience, receipt of health care, or medical condition
				of an applicant in the case of an application for a Medicare supplement policy
				or certificate that is submitted prior to or during the six-month period
				beginning with the first day of the first month in which an individual is both
				65 years of age or older and is enrolled for benefits under Medicare Part B.
				Each Medicare supplement policy and certificate currently available from an
				issuer shall be made available to all applicants who qualify under this subrule
				without regard to age.
(2)
When preexisting condition exclusion cannot be applied.
a.
Definition of "continuous period
				of creditable coverage."
For purposes of this subrule, "continuous
				period of creditable coverage" means the period during which a covered
				individual was covered by creditable coverage, if during the period of the
				coverage the covered individual had no breaks in coverage greater than 63
				days.
b.
No preexisting
				condition exclusion.
If an applicant under subrule 37.21(1) submits an
				application during the time period referenced in subrule 37.21(1) and, as of
				the date of application, has had a continuous period of creditable coverage of
				at least six months, the issuer shall not exclude benefits based on a
				preexisting condition.
c.
Reduced time of preexisting condition exclusion.
If the applicant
				qualifies under subrule 37.21(1) and submits an application during the time
				period referenced in subrule 37.21(1) and, as of the date of application, has
				had a continuous period of creditable coverage that is less than six months,
				the Medicare Select issuer shall reduce the period of any preexisting condition
				exclusion by the aggregate of the period of creditable coverage applicable to
				the applicant as of the enrollment date. The Secretary shall specify the manner
				of the reduction under this subrule.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.22 - Standards for Claims Payment

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Compliance with OBRA.
An issuer shall comply with Section
				1882(c)(3) of the Social Security Act (as enacted by Section 4081(b)(2)(C) of
				the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203
				) by:
a. Accepting a notice from an issuer on
				dually assigned claims submitted by participating providers and suppliers as a
				claim for benefits in place of any other claim form otherwise required and
				making a payment determination on the basis of the information contained in
				that notice;
b. Notifying the
				participating provider or supplier and the beneficiary of the payment
				determination;
c. Paying the
				participating provider or supplier directly;
d. Furnishing, at the time of enrollment,
				each covered individual with a card listing the policy name, number and a
				central mailing address to which notices from an issuer may be sent;
e. Paying user fees for claim notices that
				are transmitted electronically or otherwise; and
f. Providing to the Secretary, at least
				annually, the issuer's central mailing address to which all claims may be sent
				by other issuers.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.23 - Loss Ratio Standards and Refund or Credit of Premium

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definitions.
For the
				purposes of this rule:
"Health care expenses"
means expenses of
				  health maintenance organizations associated with the delivery of health care
				  services, which expenses are analogous to incurred losses of issuers.
"Type"
means one of the following: an
				  individual policy, a group policy, an individual Medicare Select policy, or a
				  group Medicare Select policy.
(2)
Loss ratio standards.
a.
Calculations.
(1) A Medicare supplement policy form or
				certificate form shall not be delivered or issued for delivery unless the
				Medicare supplement policy form or certificate form can be expected, as
				estimated for the entire period for which rates are computed to provide
				coverage, to return to covered individuals one of the following amounts in the
				form of aggregate benefits (not including anticipated refunds or credits)
				provided under the policy form or certificate form:
1. At least 75 percent of the aggregate
				amount of premiums earned in the case of group Medicare supplement policies,
				or
2. At least 65 percent of the
				aggregate amount of premiums earned in the case of individual Medicare
				supplement policies.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.24 - Filing and Approval of Policies and Certificates and Premium Rates

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definition.
For the purposes of this rule:
"Type"
means one of the following: an
				  individual policy, a group policy, an individual Medicare Select policy, or a
				  group Medicare Select policy.
(2)
Form filing and approval
				required.
An issuer shall not deliver or issue for delivery a policy
				or certificate to a resident of this state unless the SMSBP policy form or
				certificate form has been filed pursuant to rule
				191-201.
				(505,509,514A,515,515A,515F) and approved by the commissioner.
(3)
MMA requirements to be filed with
				state of issue.
An issuer shall file any riders or amendments to SMSBP
				policy or certificate forms to delete outpatient prescription drug benefits as
				required by the MMA only with the commissioner in the state in which the policy
				or certificate was issued.
(4)
Rate filing and approval required.
An issuer shall not use or
				change premium rates for a Medicare supplement policy or certificate unless the
				rates, rating schedule and supporting documentation have been filed with and
				approved by the commissioner in accordance with the filing requirements and
				procedures prescribed by the commissioner.
(5)
One form per type.
a. Except as provided in paragraph
				37.24(5)
"b,"
an issuer shall not file for approval more than
				one form of a policy or certificate of each type for each SMSBP.
b. An issuer may offer, with the approval of
				the commissioner, up to four additional policy forms or certificate forms of
				the same type for the same SMSBP, one for each of the following cases:
(1) The inclusion of new or innovative
				benefits;
(2) The addition of
				either direct response or producer marketing methods;
(3) The addition of either guaranteed issue
				or underwritten coverage;
(4) The
				offering of coverage to individuals eligible for Medicare by reason of
				disability.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.25 - Permitted Compensation Arrangements

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definition of
				"compensation."
For purposes of this rule:
"Compensation "
includes pecuniary or
				  nonpecuniary remuneration of any kind relating to the sale or renewal of the
				  Medicare supplement or Medicare Select policy or certificate including, but not
				  limited to, bonuses, gifts, prizes, awards and finder's fees.
(2)
Compensation to producer for
				sales.
An issuer or other entity may provide a commission or other
				compensation to a producer or other representative for the sale of a Medicare
				supplement policy or certificate only if the first-year commission or other
				first-year compensation is no more than 200 percent of the commission or other
				compensation paid for selling or servicing the Medicare supplement policy or
				certificate in the second year or period.
(3)
Compensation to producer for
				renewals.
The commission or other compensation provided in subsequent
				(renewal) years must be the same as that provided in the second year or period
				and must be provided for no fewer than five renewal years.
(4)
Compensation for renewals
				involving replacement.
No issuer or other entity shall provide
				compensation to its producers and no producer shall receive compensation
				greater than the renewal compensation payable by the replacing issuer on
				renewal Medicare supplement policies or certificates if an existing Medicare
				supplement policy or certificate is replaced.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.26 - Required Notice Regarding Policies or Certificates Which Are Not Medicare Supplement Policies or Certificates

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Issuer required to disclose that
				a policy is not a Medicare supplement policy.
An issuer of any
				accident and sickness insurance policy or certificate issued for delivery in
				this state to a person eligible for Medicare shall notify the insured under the
				policy that the policy is not a Medicare supplement policy or certificate, if
				the policy or certificate is not a Medicare supplement policy or certificate.
a. The notice shall either be printed or
				attached to the first page of the outline of coverage delivered to the insured
				under the accident and sickness policy or, if no outline of coverage is
				delivered, to the first page of the policy or certificate delivered to the
				insured.
b. The notice shall be in
				no less than 12-point type and shall contain the following language:
"THIS [POLICY OR CERTIFICATE] IS NOT A MEDICARE SUPPLEMENT
				  [POLICY OR CONTRACT]. If you are eligible for Medicare, review the [insert name
				  of most recent version
of 2019 Choosing a Medigap Policy: Guide to
				  Health Insurance for People with Medicare,
issued by Centers for
				  Medicare and Medicaid Services] available from the company."
c. The notice requirement of this subrule
				37.26(1) shall not apply to an accident and sickness insurance policy or
				certificate that is a Medicare supplement policy or certificate, a policy
				issued pursuant to a contract under Section 1876 of the federal Social Security
				Act (
				42 U.S.C. Section
				1395 et seq.), a disability income policy, or
				any other policy excepted by rule
				191-372. (514D).
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.27 - Requirements for Application Forms and Replacement Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Application to include Appendix C.
Application forms for
				Medicare supplement policies or certificates shall include in the outline of
				coverage the "statements and questions for application forms related to
				duplicate or replacement coverage" set forth in Appendix C, in the order
				prescribed in Appendix C, designed to elicit the following information, as of
				the date of the application: whether the applicant currently has a Medicare
				supplement policy or certificate, a Medicare Advantage policy or certificate,
				or other Medicaid coverage; whether the applicant has another health insurance
				policy or certificate in force; or whether the applicant intends a Medicare
				supplement policy or certificate to replace any other accident and sickness
				policy or certificate presently in force. An additional page or form containing
				such questions and statements and the applicant's responses may be used, but it
				must be signed by the applicant and producer, attached to the application, and
				kept together with the issuer's records.
(2)
List of policies sold to
				applicant.
Producers shall list on the form or on an attachment to the
				form of Appendix C any other health insurance policies they have sold to the
				applicant, including the following:
a.
				Policies sold which are still in force.
b. Policies sold in the prior five years
				which are no longer in force.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.30 - Standards for Marketing

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Requirements for marketing.
An issuer, directly or through its
				producers, shall:
a. Establish marketing
				procedures to ensure that any comparison of policies or certificates by its
				producers will be fair and accurate.
b. Establish marketing procedures to ensure
				excessive insurance is not sold or issued.
c. Display prominently by type, stamp or
				other appropriate means, on the first page of the policy or certificate, the
				following:
"Notice to buyer: This policy may not cover all of your
				  medical expenses."
d. Inquire and otherwise make every
				reasonable effort to identify whether a prospective covered individual for
				Medicare supplement policy or certificate already has accident and sickness
				insurance and the types and amounts of any such insurance.
e. Establish auditable procedures for
				certifying compliance with this subrule.
f. At solicitation, provide written notice to
				the prospective covered individual of the name, address, and telephone number
				of the senior health insurance information program, part of the insurance
				division. The written notice shall be in a form prescribed by the
				commissioner.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.31 - Appropriateness of Recommended Purchase and Excessive Insurance

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Appropriateness.
In recommending the purchase or replacement
				of any Medicare supplement policy or certificate, a producer shall make
				reasonable efforts to determine the appropriateness of a recommended purchase
				or replacement.
(2)
No
				duplication.
Any sale of a Medicare supplement policy or certificate
				that will provide an individual more than one Medicare supplement policy or
				certificate is prohibited.
(3)
No Medicare supplement for enrollee in Part C.
An issuer shall
				not issue a Medicare supplement policy or certificate to an individual enrolled
				in Medicare Part C unless the effective date of the coverage is after the
				termination date of the individual's Medicare Part C coverage.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.32 - Reporting of Multiple Policies

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Report of in-force Medicare supplement covered individuals.
On
				or before March 1 of each year, an issuer shall report, using the format of
				Appendix F, the following information for every covered individual resident of
				this state for which the issuer has in force more than one Medicare supplement
				policy or certificate:
a. Policy and
				certificate number; and
b. Date of
				issuance.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.33 - Prohibition Against Preexisting Conditions, Waiting Periods, Elimination Periods and Probationary Periods in Replacement Policies or Certificates

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Time
				credited from prior policy or certificate.
If a Medicare supplement
				policy or certificate replaces another Medicare supplement policy or
				certificate, the replacing issuer shall waive any time periods applicable to
				preexisting conditions, waiting periods, elimination periods and probationary
				periods in the new replacing Medicare supplement policy or certificate to the
				extent such time was spent under the replaced policy.
(2)
Similar benefits credited from
				prior policy or certificate.
If a Medicare supplement policy or
				certificate replaces another Medicare supplement policy or certificate which
				has been in effect for at least six months, the replacing Medicare supplement
				policy or certificate shall not provide any time period applicable to
				preexisting conditions, waiting periods, elimination periods and probationary
				periods for benefits similar to those contained in the replaced policy or
				certificate.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.35 - Prohibition Against Using Materials Prepared by Shiip

Current through Register Vol. 47, No. 3, July 24, 2024
The Senior Health Insurance Information Program (SHIIP) may
				  prepare a consumer Medicare supplement insurance premium guide and benefits
				  comparison guide. This guide and the SHIIP name or logo shall not be used in
				  the solicitation or sale of health insurance products. Violation of this rule
				  shall be deemed an unfair trade practice under Iowa Code chapter
				  507B.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.36 - Guaranteed Issue for Eligible Persons

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definition of "Medicare Advantage
				organization."
For purposes of this rule:
"Medicare Advantage organization"
means a
				  private company that has a contract with Medicare to provide Medicare Advantage
				  plans and benefits to individuals.
(2)
Guaranteed issue.
a. Eligible persons for guaranteed issue of a
				Medicare supplement policy or certificate are those individuals described in
				subrule 37.36(3) who seek to enroll under the Medicare supplement policy during
				the period specified in subrule 37.36(4) and who submit evidence of the date of
				termination, disenrollment, or Medicare Part D enrollment with the application
				for a Medicare supplement policy or certificate.
b. With respect to eligible individuals for
				guaranteed issue of a Medicare supplement policy or certificate, an issuer:
				shall not deny or condition the issuance or effectiveness of a Medicare
				supplement policy or certificate described in subrule 37.36(6) that is offered
				by the issuer and is available for issuance to new enrollees; shall not
				discriminate in the pricing of such Medicare supplement policy or certificate
				because of health status, claims experience, receipt of health care, or medical
				condition; and shall not impose an exclusion of benefits based on a preexisting
				condition under such Medicare supplement policy or certificate.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.50 - Medicare Supplement Advertising

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Purpose.
The purpose of
				this rule is to provide prospective purchasers with clear and unambiguous
				statements in the advertisement of Medicare supplement insurance and to ensure
				the clear and truthful disclosure of the benefits, limitations and exclusions
				of policies sold as Medicare supplement insurance. This purpose is intended to
				be accomplished by the establishment of guidelines and permissible and
				impermissible standards of conduct in the advertising of Medicare supplement
				insurance in a manner which prevents unfair, deceptive and misleading
				advertising and which is conducive to accurate presentation and description to
				the insurance-buying public through the advertising media and material used by
				producers and companies.
(2)
Applicability.
a. This rule
				shall apply to any "advertisement" of Medicare supplement insurance, as that
				term is defined in subrule 37.50(3), unless otherwise specified in this rule,
				that the issuer or producer knows or reasonably should know is intended for
				presentation, distribution or dissemination in this state when the
				presentation, distribution or dissemination is made either directly or
				indirectly by or on behalf of an issuer or producer.
b. The requirements of Iowa Code chapter 507B
				and 191-Chapter 15 also shall apply to issuers and producers to which this rule
				191-37.50 (507B,514D) applies, unless specifically exempted therein.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.51 - Severability

Current through Register Vol. 47, No. 3, July 24, 2024
If any provisions of this chapter or the application thereof
				  to any person or circumstance is for any reason held to be invalid, the
				  remainder of the chapter and the application of such provision to other persons
				  or circumstances shall not be affected thereby.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.53 - Form and Content of Advertisements

Current through Register Vol. 47, No. 3, July 24, 2024
An insurer must clearly identify its Medicare supplement
				  insurance policy as an insurance policy. A policy trade name must be followed
				  by the words "Insurance Policy" or similar words clearly identifying the fact
				  that an insurance policy or health benefits product (in the case of health
				  maintenance organizations, prepaid health plans and other direct service
				  organizations) is being offered.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 37 - Medicare Supplement Insurance › Rule 191-37.54 - Testimonials or Endorsements by Third Parties

Current through Register Vol. 47, No. 3, July 24, 2024
In addition to complying with 191-subrule 15.3(7), when a
				  testimonial refers to benefits received under a Medicare supplement insurance
				  policy, the insurer shall retain the specific claim data, including claim
				  number, date of loss, and other pertinent information, for a period of four
				  years or until the filing of the next regular report of examination of the
				  insurer, whichever is the longer period of time. The use of testimonials that
				  do not correctly reflect the present practices of the insurer or that are not
				  applicable to the policy or benefit being advertised is not
				  permissible.