reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.27 - Reporting Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Every insurer shall maintain for each producer records of that producer's
				amount of replacement sales as a percent of the producer's total annual sales
				and the amount of lapses of long-term care insurance policies sold by the
				producer as a percent of the producer's total annual sales.
(2) Every insurer shall report annually by
				June 30 the 10 percent of its producers with the greatest percentages of lapses
				and replacements as measured by subrule 39.27(1) in the format prescribed in
				Appendix G.
(3) Reported
				replacement and lapse rates do not alone constitute a violation of insurance
				laws or necessarily imply wrongdoing. The reports are for the purpose of
				reviewing more closely producer activities regarding the sale of long-term care
				insurance.
(4) Every insurer shall
				report annually by June 3 0 the number of lapsed policies as a percent of its
				total annual sales and as a percent of its total number of policies in force as
				of the end of the preceding calendar year in the format prescribed in Appendix
				G.
(5) Every insurer shall report
				annually by June 30 the number of replacement policies sold as a percent of its
				total annual sales and as a percent of its total number of policies in force as
				of the preceding calendar year in the format prescribed in Appendix
				G.
(6) Every insurer shall report
				annually by Jime 30, for qualified long-term care insurance contracts, the
				number of claims denied for each class of business, expressed as a percentage
				of claims denied in the format prescribed in Appendix E.
(7) For purposes of rule
				191-3927.
				(514G):
a. "Policy" means only long-term care
				insurance;
b. Subject to
				paragraph
"c"
below, "claim" means a request for payment of
				benefits under an in-force policy regardless of whether the benefit claimed is
				covered under the policy or any terms or conditions of the policy have been
				met;
c. "Denied" means the insurer
				refuses to pay a claim for any reason other than for claims not paid for
				failure to meet the waiting period or because of an applicable preexisting
				condition; and
d. "Report" means on
				a statewide basis.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.29 - Nonforfeiture

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Except as
				provided in subrule 39.29(2), a long-term care insurance policy may 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 including a nonforfeiture benefit. The offer of a nonforfeiture
				benefit may be in the form of a rider that is attached to the policy. In the
				event the policyholder or certificate holder declines the nonforfeiture
				benefit, the insurer shall provide a contingent benefit upon lapse that shall
				be available for a specified period of time following a substantial increase in
				premium rates.
(2) When a group
				long-term care insurance policy is issued, the offer required in subrule
				39.29(1) shall be made to the group policyholder. However, if the policy is
				issued as group long-term care insurance to a group as defined in Iowa Code
				section
				514G.103(9)
"d,"
other than to a continuing care retirement community or
				other similar entity, the offering shall be made to each proposed certificate
				holder.
(3) This rule does not
				apply to life insurance policies or riders containing accelerated long-term
				care benefits.
(4) To comply with
				the requirement to offer a nonforfeiture benefit pursuant to the provisions of
				subrule 39.29(1):
a. A policy or certificate
				offered with nonforfeiture benefits shall have coverage elements, eligibility,
				benefit triggers and benefit length that are the same as coverage to be issued
				without nonforfeiture benefits. The nonforfeiture benefit included in the offer
				shall be the benefit described in subrule 39.29(7); and
b. The offer shall be in writing if the
				nonforfeiture benefit is not otherwise described in the outline of coverage or
				other materials given to the prospective policyholder.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.30 - Standards for Benefit Triggers

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				long-term care insurance policy shall condition the payment of benefits on a
				determination of the insured's ability to perform activities of daily living
				and on cognitive impairment. Eligibility for the payment of benefits shall not
				be more restrictive than requiring either a deficiency in the ability to
				perform not more than three of the activities of daily living or the presence
				of cognitive impairment.
(2)
				Activities of daily living.
a. Activities of
				daily living shall include at least the following as defined in rule
				191"39.5(514G) and in the policy:
(1)
				Bathing;
(2) Continence;
(3) Dressing;
(4) Eating;
(5) Toileting; and
(6) Transferring.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.33 - Notice of Cancellation, Nonrenewal or Termination of Long-term Care Insurance

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Purpose and definitions.
a.
Purpose.
The purpose of this rule is to clarify the authorized
				methods of delivery for notices of cancellation, nonrenewal or termination by
				an insurer, so as to implement the various policyholder protections intended by
				Iowa Code section
				514G111.
				and rule
				191-3922.
				(514G).
b.
Definitions.
As used in Iowa Code section
				505B1.
				and this rule:
"Commissioner "
means the Iowa insurance
				  commissioner or insurance division.
"Notice of cancellation, nonrenewal or
				  termination"
means:
1. Notice
				of an insurance company's termination of an insurance policy at the end of a
				term or before the termination date;
2. Notice of an insurance company's decision
				or intention not to renew a policy; and
3. For purposes of notices required by Iowa
				Code section
				514G111.
				and rule
				191-3922.
				(514G), at a minimum, an insurance company's notice of lapse or termination of
				a long-term care insurance policy.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.41 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
This division is intended to implement Iowa Code chapter 514G
				  to provide a uniform process for insureds covered under long-term care
				  insurance to request an independent review of a denial of coverage based on a
				  benefit trigger determination.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.44 - Notice of Benefit Trigger Determination and Content

Current through Register Vol. 47, No. 3, July 24, 2024
The notice required by Iowa Code section
				  514G.109
				  shall contain the following information:
1. The reason that the insurer determined
				that the policy benefit trigger has not been met by the insured.
2. A description of the internal appeal
				mechanism provided under the long-term care policy.
3. A description of how the insured, after
				exhausting the insurer's internal appeal process, has the right to have the
				benefit trigger determination reviewed under the independent review process
				required by Iowa Code section
				514G.110.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.45 - Notice of Internal Appeal Decision and Right to Independent Review

Current through Register Vol. 47, No. 3, July 24, 2024
Upon the conclusion of the internal appeal mechanism
				  specified in Iowa Code section
				  514G109(2).,
				  the notice required in Iowa Code section 514G.110(2)
"b"
and
"c"
shall contain the following information:
(1) A description of additional internal
				appeal rights, if any, offered by the insurer.
(2) A description of how the insured can
				request independent review of the benefit trigger determination. Such
				description must specify the following:
a.
				The insured must submit a written request within 60 days of the insured's
				receiving written notice of the insurer's internal appeal decision;
b. The request must be made to the Iowa
				Insurance Division, Two Ruan Center, Fourth Floor, 601 Locust Street, Des
				Moines, Iowa 50309-3738;
c. A copy
				of the insurer's benefit trigger determination letter must accompany the
				written request for an independent review.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.46 - Independent Review Request

Current through Register Vol. 47, No. 3, July 24, 2024
The insured shall send a copy of the insurer's notice
				  explaining why the benefit trigger has not been met, with the insured's request
				  for an independent review, to the insurance commissioner within 60 days of
				  receipt of the benefit trigger determination. The notice shall be sent to the
				  commissioner at the Iowa Insurance Division, Two Ruan Center, Fourth Floor, 601
				  Locust Street, Des Moines, Iowa 50309-3738.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.47 - Certification Process

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The
				commissioner shall provide written notice of the certification decision to the
				insurer and the insured within the two-business-day period specified in Iowa
				Code section
				514G.110.
(2) The insurer may appeal the commissioner's
				certification decision within three business days after receiving notice of the
				decision. The commissioner shall review any such appeal and promptly notify the
				insured and the insurer of the commissioner's decision.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.48 - Selection of Independent Review Entity

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Within three business days of receiving
				the commissioner's certification decision, the insurer shall:
a. Select an independent review entity from
				the list certified by the commissioner;
b. Notify the insured in writing of the name,
				address, and telephone number of the independent review entity;
c. Notify the independent review entity of
				its selection and provide the independent review entity with sufficient
				information to allow selection of qualified licensed health care professionals
				to conduct the independent review;
d. Provide the commissioner with copies of
				the notices required by this subrule.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.49 - Independent Review Process

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Within five business days of receiving either the notice provided in paragraph
				39.48(1)
"b,''
or the denial of an objection made pursuant to
				subrule 39.48(3), whichever is later, the insured may submit any additional
				information or documentation in support of the insured's claim to both the
				independent review entity and the insurer
(2) Within 15 days of receiving the notice
				provided in paragraph 39.48(1)
"b,"
or within three business
				days of receiving notice of the denial of an objection made pursuant to subrule
				39.48(3), whichever is later, an insurer shall:
a. Provide the independent review entity with
				any information submitted to the insurer by the insured during the insurer's
				internal appeal process relating to the benefit trigger determination that is
				the subject of the independent review proceeding;
b. Provide the independent review entity with
				any other relevant documents used by the insurer in making its benefit trigger
				determination; and
c. Provide the
				commissioner and the insured with confirmation that the information required by
				this subrule was submitted to the independent review entity, including the date
				such information was submitted.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.50 - Decision Notification

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The
				independent review entity shall immediately notify the insurer, the insured,
				and the commissioner of the independent review decision either affirming or
				overturning the insurer's benefit trigger determination. The initial
				notification shall be delivered by telephone or fax transmission, and a written
				copy of the decision notification delivered by regular mail. The written copy
				of the decision shall include a description of the basis for the independent
				review entity's decision.
(2) If
				the independent review entity overturns the insurer's decision, the independent
				review entity shall include all of the following in the decision:
a. The precise date that the benefit trigger
				was deemed to have been met;
b. The
				specific period of time under review for which the insurer declined eligibility
				but during which the independent review entity determined that the benefit
				trigger was met;
c. For qualified
				long-term care insurance contracts, a certification made only by a licensed
				health care practitioner that the insured is a chronically ill
				individual.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.51 - Insurer Information

Current through Register Vol. 47, No. 3, July 24, 2024
(1) No
				later than January 1, 2009, each insurer delivering or issuing for delivery
				long-term care insurance policies in this state on or after July 1, 2008, and
				each insurer that has active long-term care policies or riders under which
				claims for benefits may be made on or after July 1, 2008, shall provide the
				commissioner the name or title, telephone and fax numbers and email address of
				an individual who shall be the insurer's contact person for independent review
				procedures and matters. Any changes in personnel or communication numbers shall
				be immediately communicated to the commissioner.
(2) Each insurer shall provide the
				commissioner a detailed description of the process that the insurer has in
				place to ensure compliance with the requirements of this division and of Iowa
				Code sections
				514G.109
				and 514G.110. The description required by this subrule shall be filed in a
				format as directed by the commissioner on or before March 1, 2009, and
				thereafter as requested by the commissioner. The description shall include:
a. An explanation of how the insurer
				determines when an insured has qualified for independent review of the benefit
				trigger decision and should receive a notice from the insurer,
b. A copy of the notice sent to insureds who
				fall within the scope of the law, and
c. An explanation of the internal appeal
				process.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.53 - Additional Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
The independent review entity shall develop and maintain
				  written policies and procedures governing all aspects of the independent review
				  process. The written policies and procedures include, but are not limited to,
				  the following:
(1) Procedures to
				ensure that independent reviews are conducted within the time frames specified
				in this division and Iowa Code chapter 514G as amended by 2008 Iowa Acts, House
				File 2694, and that any required notices are provided in a timely
				manner.
(2) Procedures to ensure
				the selection of qualified and impartial reviewers. The reviewers shall be
				qualified to render impartial determinations relating to the benefit trigger
				which is the subject of the benefit trigger decision under review (e.g.,
				assessment of cognitive impairment or inability to perform activities of daily
				living due to a loss of functional capacity) and be deemed experts in the
				assessment of such benefit trigger.
(3) Procedures to ensure that the insured is
				notified in writing of the insured's right to object to the independent review
				entity selected by the insurer or to the licensed health care professional
				designated by the independent review entity to conduct the review by filing a
				notice of objection, along with the reasons for the objection, with the
				commissioner at the Iowa Insurance Division, 1963 Bell Avenue, Suite 100, Des
				Moines, Iowa 50315, within ten days of the receipt of a notice from the
				independent review entity.
(4)
				Procedures to ensure the confidentiality of protected health information
				records and review materials, in accordance with federal and state
				law.
(5) Procedures to ensure
				adherence to the requirements of this division and Iowa Code chapter 514G by
				any contractor, subcontractor, subvendor, agent or employee affiliated with the
				independent review entity.
(6)
				Policies and procedures establishing a quality assurance program. The program
				shall include a written description to be provided to all individuals involved
				in the program, the organizational arrangements, and the ongoing procedures for
				the identification, evaluation, resolution and follow-up of potential and
				actual problems in independent reviews performed by the independent review
				entity and procedures to ensure the maintenance of program standards pursuant
				to this requirement.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.54 - Toll-free Telephone Number

Current through Register Vol. 47, No. 3, July 24, 2024
The independent review entity shall establish a toll-free
				  telephone service to receive information relating to independent reviews
				  pursuant to this division and Iowa Code chapter 514G. The system shall include
				  a procedure to ensure the capability of accepting, recording, or providing
				  instruction to respond to incoming telephone calls during other than normal
				  business hours. The independent review entity shall also establish a facsimile
				  and electronic mail service.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.55 - Division Application and Reports

Current through Register Vol. 47, No. 3, July 24, 2024
The independent review entity shall provide the commissioner
				  such data, information, and reports as the commissioner determines necessary to
				  evaluate the independent review process established under Iowa Code chapter
				  514G. An application for certification as an independent review entity must be
				  submitted in duplicate to the Iowa Insurance Division, Two Ruan Center, 601
				  Locust Street, Fourth Floor, Des Moines, Iowa 50309. An application must be
				  submitted in full to be considered. Every applicant will be notified of the
				  certification decision. A list of certified independent review entities shall
				  be maintained at the division and shall be available through the division's
				  website.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.75 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
(1) This division
				is intended to implement Iowa Code chapter 514H and Section 6021 of the federal
				Deficit Reduction Act of 2005,
				Public
				Law 109-171, to establish, in conjunction with the
				department of human services, a long-term care partnership program in Iowa to
				provide for financing of long-term care through a combination of private
				insurance and Iowa Medicaid. This program is also known as the long-term care
				asset disregard incentive program.
(2) The Iowa long-term care partnership
				program shall:
a. Provide incentive for
				individuals to insure against the costs of providing for long-term care
				needs;
b. Provide a mechanism for
				individuals to qualify for coverage under Iowa Medicaid while having certain
				assets disregarded for eligibility determinations and recovery; and
c. Reduce the financial burden on the state's
				Medicaid program by encouraging the pursuit of private initiatives using
				qualified long-term care partnership policies or certificates.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.76 - Effective Date

Current through Register Vol. 47, No. 3, July 24, 2024
The rules in this division shall apply to all long-term care
				  partnership policies or certificates sold or issued for delivery on or after
				  January 1, 2010.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.78 - Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
(1) An individual
				who is a beneficiary of an Iowa long-term care partnership policy or
				certificate may be eligible for assistance under the state's Medicaid program
				using the asset disregard as provided under Iowa Code chapter 514H as amended
				by 2009 Iowa Acts, House File 723.
(2) An individual who is a beneficiary of a
				long-term care partnership policy or certificate issued in another state which
				grants reciprocity to an Iowan who moves to that state is eligible for benefits
				under Iowa's Medicaid program using the asset disregard as provided in Iowa
				Code chapter 514H as amended by 2009 Iowa Acts, House File 723. For purposes of
				this subrule, "reciprocity" means the granting of all the benefits by one state
				to an individual who becomes a resident of that state but who purchased a
				long-term care partnership policy while residing in another state.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.79 - Discontinuance of Partnership Program

Current through Register Vol. 47, No. 3, July 24, 2024
If the Iowa long-term care partnership program established by
				  this division and Iowa Code chapter 514H as amended by 2009 Iowa Acts, House
				  File 723, is discontinued, any individual who purchased an Iowa long-term care
				  partnership policy or certificate before the date the program was discontinued
				  shall be eligible to receive asset disregard if allowed as provided by Title
				  VI, Section 6021 of the federal Deficit Reduction Act of 2005,
				  Public Law
				  109-171.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.80 - Required Disclosures

Current through Register Vol. 47, No. 3, July 24, 2024
(1) An
				insurer or a producer soliciting or offering to sell a partnership policy shall
				provide to each prospective applicant a Partnership Program Notice. The notice
				must be substantially similar to Appendix H of this chapter. The Partnership
				Program Notice shall be provided with the required outline of
				coverage.
(2) An insurer or a
				producer soliciting or offering to sell a partnership policy shall provide to
				each prospective applicant a copy of the Iowa Long-Term Care Partnership
				Program Consumer Guide. The Iowa Long-Term Care Partnership Program Consumer
				Guide may be found at
shiip.iowa.gov
.
(3) A partnership policy or certificate
				issued or issued for delivery in Iowa shall be accompanied by a Partnership
				Status Disclosure Notice (Appendix I). A similar notice may be used if filed
				with and approved by the division.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.81 - Form Filings

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				partnership policy shall not be issued or issued for delivery in Iowa unless
				filed with and approved by the division. Any policy submitted for certification
				as a partnership policy shall be accompanied by a Partnership Issuer
				Certification. The Partnership Issuer Certification form may be found on the
				division's Web site,
www.iid.state.ia.us
. Insurance companies
				required to file rates or forms with the division shall submit required rate
				and form filings and any fees required for the filings electronically using the
				System for Electronic Rate and Form Filing (SERFF). Insurance companies must
				comply with the division's requirements, including both the Iowa general
				instructions and the specific submission requirements for the type of insurance
				for which the companies are submitting forms or rates, as set forth on the
				SERFF Web site at
www.serfforg
.
(2) Insurers may request to make use of a
				previously approved policy form as a qualified state long-term care partnership
				policy. Requests shall be filed electronically via SERFF and according to
				instructions on the SERFF Web site.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.83 - Required Policy Terms and Disclosures

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A policy or certificate designed or
				marketed as a long-term care insurance policy or certificate must prominently
				disclose on the schedule page the following statements:
"Some long-term care insurance [policies or certificates] may
				  qualify under the state's Long-Term Care Partnership Program. Under this
				  Program the [policyholder or certificate holder] may be able to protect some of
				  the [policyholder's or certificate holder's] assets from Medicaid spend-down
				  requirements through a feature known as 'Asset Disregard.' Nothing in this
				  [policy or certificate] is a guarantee of Medicaid eligibility nor is it a
				  guarantee of any ability to disregard assets for purposes of Medicaid
				  eligibility. If you have questions about whether or not your policy currently
				  qualifies under the Long-Term Care Partnership Program, please contact [the
				  insurer at ###-###-####] and request a long-term care partnership program
				  policy summary."
(2) If a
				policyholder or certificate holder or that person's representative requests a
				long-term care partnership program policy summary, as provided in subrule
				39.83(1), the information the insurer shall provide and the format of the
				long-term care partnership program policy summary shall be as set forth in
				Appendix J. An insurer may submit a form substantially similar to Appendix J to
				the commissioner for approval to use as a substitute for Appendix J.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.84 - Standards for Marketing and Suitability

Current through Register Vol. 47, No. 3, July 24, 2024
The standards for marketing found in rule
				  191-3915.
				  (514D,514G) and the suitability requirements of rule
				  191-3916. (514D,514G)
				  shall apply to the marketing and sale of long-term care partnership
				  policies.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.85 - Required Reports

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Each issuer
				of partnership-qualified long-term care insurance in this state shall provide
				regular reports to the Secretary of the United States Department of Health and
				Human Services in accordance with federal law and regulations and to the Iowa
				department of human services and the division as provided in Section 6021 of
				the federal Deficit Reduction Act of 2005, Public Law 109-171. The report shall
				include information as required by the United States Department of Health and
				Human Services, Office of the Assistant Secretary for Planning and Evaluation.
				Submission of the report to the Iowa department of human services or the
				division is not required if the issuer files the report through the Centers for
				Medicare and Medicaid Services filing system.
(2) When a policyholder or certificate holder
				begins receiving any benefits under a policy, the issuer shall begin providing
				to the policyholder or certificate holder statements of benefits either monthly
				or within a reasonable time after benefits have been paid. The statements of
				benefits shall include, at a minimum, detailed information regarding benefits
				paid and dates of service.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.1 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Act"
when used in these rules shall mean
				  Iowa Code chapter 5146.
"Complaint"
means a written communication
				  expressing a grievance concerning a health maintenance organization.
"Dental care"
means care by licensed
				  dentists or by appropriate auxiliary dental personnel working under the
				  supervision of a dentist. It includes the necessary diagnostic, treatment, and
				  preventive services required to maintain proper oral health.
"Governing body"
means the persons in which
				  the ultimate responsibility and authority for the conduct of the HMO is
				  vested.
"HMO"
means health maintenance organization
				  and shall be abbreviated as HMO in these rules.
"Inpatient hospital care"
means inpatient
				  hospital care provided through a licensed hospital on a 24-hour basis.
"Outpatient medical services"
means
				  outpatient medical services provided within or outside of a hospital. This
				  shall include, but not be limited to, laboratory and diagnostic X-ray with
				  emphasis directed toward primary care.
"Physician care"
means care by a licensed
				  physician or by paramedical or other ancillary health personnel under the
				  direction of the licensed physician. It shall be of sufficient type and amount
				  to adequately provide for the contracted services including emergency care,
				  inpatient hospital care, and outpatient medical services.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.2 - Application

Current through Register Vol. 47, No. 3, July 24, 2024
An application on forms provided by the insurance division
				  accompanied by a filing fee of $100 payable to State Treasurer, State of Iowa,
				  shall be completed by an officer or authorized representative of the health
				  maintenance organization. The application with copies in duplicate shall be
				  verified and shall be accompanied by the information found in Iowa Code section
				  514B.3(1).
				  An application shall not be deemed to be filed until all information necessary
				  to properly process said application has been received by the commissioner. See
				  191-40.11 (514B).
An amendment to the application form shall be filed in the
				  same manner as the application and approved by the commissioner before the
				  change proposed by the amendment is effective.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.3 - Inspection of Evidence of Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
An enrollee may, if evidence of coverage is not satisfactory
				  for any reason, return evidence of coverage within ten days of receipt of same
				  and receive full refund of the deposit paid, if any. This right shall not act
				  as a cure for misleading or deceptive advertising or marketing methods, nor may
				  it be exercised if the enrollee utilizes the services of the HMO within the
				  ten-day period.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.4 - Governing Body and Enrollee Representation

Current through Register Vol. 47, No. 3, July 24, 2024
An HMO shall have a basic written organizational document
				  setting forth its scheme of organization and establishing a governing body
				  appropriate to its form of organization. The governing body shall be
				  responsible for matters of policy and operation.
The HMO shall develop bylaws or guidelines which describe the
				  scope of the health care services the HMO renders to enrollees either directly
				  by its medical staff or dental staff, if dental care is provided, or through
				  arrangements with others outside of the organization. Initial bylaws,
				  guidelines, and revisions thereto shall be submitted to the commissioner of
				  insurance for review and approval.
The bylaws, guidelines, or similar document shall provide for
				  "reasonable representation" on the governing body by enrollees. "Reasonable
				  representation" as used in Iowa Code section 5146.7 shall require not less than
				  30 percent of the governing board members be enrollees who are not providers or
				  are not associated with a provider Enrollees shall have the opportunity to
				  nominate said enrollee representatives.
The HMO may provide upon its initial formation that all
				  representatives on the governing board shall be selected by the organizers of
				  the HMO. Such members shall serve until the first annual meeting or election.
				  If there are no enrollee representatives on the initial governing board, they
				  shall be elected at the first annual meeting or election.
The nomination procedures for enrollee representatives should
				  provide for the following to assure an adequate opportunity for participation
				  by enrollees:
(1) An opportunity for
				adult enrollees to nominate candidates for the governing body.
(2) Notice to all adult enrollees of the
				nomination and election procedures.
The HMO shall be deemed to have complied with these
				  requirements if it provides notice in its regular newsletter to enrollees of
				  the opportunity to and the procedures for nomination of enrollee
				  representatives.
Nomination procedures may be waived by the commissioner for a
				  period of up to three years from the HMO's commencement of delivery of services
				  to enrollees.
For purposes of this rule, an HMO operated directly by a
				  corporation or corporations subject to Iowa Code chapter 514 and rule
				  191-34.7(514) shall be deemed to be in compliance with this rule if it is or
				  they are in compliance with Iowa Code section
				  5144. and rule
				  191-34.7(514).
This rule is intended to implement Iowa Code section
				  514B.7.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.7 - Change of Ownership

Current through Register Vol. 47, No. 3, July 24, 2024
Each HMO which desires to transfer ownership of more than 10
				  percent of the stock or ownership interest in the HMO shall not do so without
				  first submitting a proposed plan to the division for review and approval or
				  disapproval.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.8 - Termination of Services

Current through Register Vol. 47, No. 3, July 24, 2024
When an HMO desires to cease offering a service, such service
				  may not be terminated without prior approval of the division. Arrangements
				  equitable to the enrollees providing for a rate adjustment or substitution of
				  an equivalent service satisfactory to the division must be
				  made.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.9 - Complaints

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Each health
				maintenance organization shall provide in its bylaws for a system to resolve
				and record complaints.
(2) The
				complaint system shall provide for the resolution of the following kinds of
				complaints and the recording of the information required to be reported to the
				commissioner:
a. Complaints about the quality
				of health care services provided by the health maintenance
				organization.
b. Complaints about
				the availability of such services.
c. Complaints relating to enrollee
				participation in the operation of the health maintenance
				organization.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.10 - Cancellation of Enrollees

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Membership of an enrollee in a health maintenance organization may be
				terminated by the health maintenance organization for the following reasons and
				no other:
a. Nonpayment of charges when
				due.
b. Termination of the
				conditions, other than a change in the health of the enrollee, under which the
				enrollee became eligible to be enrolled under a group contract.
c. Termination of the group contract under
				which the enrollee was enrolled.
d.
				Change of place of residence of the enrollee from the geographic area served by
				the health maintenance organization.
e. Failure of the enrollee to pay deductible
				or coinsurance charges permitted under Iowa Code section
				514B.5(l)
				"c."
f. Unreasonable refusal of the
				enrollee to follow a prescribed course of treatment.
g. A materially false statement or
				misrepresentation by the enrollee in an application for membership or
				benefits.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.12 - Net Worth

Current through Register Vol. 47, No. 3, July 24, 2024
(1) An HMO shall not
				be authorized to transact business with a net worth less than $1
				million.
(2) No HMO incorporated by
				or organized under the laws of any other state or government shall transact
				business in this state unless it possesses the net worth required of an HMO
				organized by the laws of this state and is authorized to do business in this
				state.
(3) As deemed necessary by
				the division, each health maintenance organization that is a subsidiary of
				another person shall file with the division, in a form satisfactory to it, a
				guarantee of the HMO's obligations issued by the ultimate controlling parent or
				such other person satisfactory to the division.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.13 - Fidelity Bond

Current through Register Vol. 47, No. 3, July 24, 2024
A health maintenance organization shall maintain in force a
				  fidelity bond on employees and officers in an amoimt not less than $100,000 or
				  such other sum as may be prescribed by the commissioner All such bonds shall be
				  written with at least a one-year discovery period and if written with less than
				  a three-year discovery period shall contain a provision that no cancellation or
				  termination of the bond, whether by or at the request of the insured or by the
				  underwriter, shall take effect prior to the expiration of 90 days after written
				  notice of cancellation or termination has been filed with the commissioner
				  unless an earlier date of cancellation or termination is approved by the
				  commissioner.
This rule is intended to implement Iowa Code section
				  514B5(1)..
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.14 - Annual Report

Current through Register Vol. 47, No. 3, July 24, 2024
A health maintenance organization shall annually, on or
				  before the first day of March, file with the commissioner of insurance a report
				  verified by at least two of its principal officers and covering the preceding
				  calendar year
The report shall be on the form designated by the National
				  Association of Insurance Commissioners (NAIC) as the report form for health
				  maintenance organizations. The report shall be completed using "statutory
				  accounting practices" (SAP), and shall include any other information required
				  under law or rule.
The commissioner of insurance may request additional reports
				  and information from a health maintenance organization as often as is deemed
				  necessary to enable the commissioner to carry out the duties of Iowa Code
				  chapter 514B.
This rule is intended to implement Iowa Code section
				  5146.12.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.15 - Cash or Asset Management Agreements

Current through Register Vol. 47, No. 3, July 24, 2024
If an HMO utilizes a cash or asset management arrangement
				  with its parent, affiliate, or any other person, the arrangement shall be
				  written and subject to prior approval by the commissioner Cash or asset
				  management agreements shall meet the following minimum requirements:
(1) Cash receipts shall be under the direct
				control of the HMO that generated the receipts. If the system is under the
				control of the HMO's parent or affiliate, then receipts shall be transferred to
				the HMO within five working days.
(2) Securities purchased shall be in the name
				of the HMO generating the funds for the security purchase.
(3) An HMO's investments shall not be pooled
				with other entities' investments unless there is an agreement which vests an
				undivided interest in the pooled arrangement to the HMO. Such an agreement
				shall be subject to prior approval by the commissioner
(4) An HMO's cash or investments shall not be
				commingled with the cash or investments of any other person.
(5) Investments made on behalf of an HMO
				shall be subject to the limitations imposed by Iowa Code sections
				5118.
				and 5146.15.
(6) The agreement
				shall provide for prompt notice and verification of investments, establish
				responsibility for brokerage and other fees and provide for periodic reports on
				earnings and expenses.
(7) A
				parent, affiliate, person, and employees thereof providing cash or asset
				management services shall be bonded and responsible for any physical loss of
				investments.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.17 - Reinsurance

Current through Register Vol. 47, No. 3, July 24, 2024
Reinsurance contracts and stop-loss agreements entered into
				  by an HMO shall be subject to prior approval and shall meet the following
				  minimum requirements:
(1) Reinsurance
				contracts and stop-loss agreements shall provide that the commissioner of
				insurance be given notice of termination by certified mail at least 30 days
				prior to the effective date of termination of the reinsurance contract or
				stop-loss agreement.
(2) Retention
				levels shall be reasonable in light of the HMO's financial condition and
				potential liabilities.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.18 - Provider Contracts

Current through Register Vol. 47, No. 3, July 24, 2024
An HMO's arrangements for health care services shall be by
				  written contract. Initial provider contracts shall be subject to prior
				  approval. Thereafter, any provider contract deviating from previously submitted
				  or approved contracts shall be submitted to the division within 30 days of
				  execution for informational purposes. In all instances, all provider contracts
				  shall include the following provision:
(Provider), or its assignee or subcontractor, hereby agrees
				  that in no event, including, but not limited to nonpayment by the HMO, HMO
				  insolvency or breach of this agreement, shall (Provider), or its assignee or
				  subcontractor, bill, charge, collect a deposit from, seek compensation,
				  remuneration or reimbursement from, or have any recourse against
				  subscriber/enrollee or persons other than the HMO acting on their behalf for
				  services provided pursuant to this Agreement. This provision shall not prohibit
				  collection of supplemental charges or copayments on HMO's behalf made in
				  accordance with terms of (applicable Agreement) between HMO and
				  subscriber/enrollee.
(Provider), or its assignee or subcontractor, further agrees
				  that (1) this provision shall survive the termination of this Agreement
				  regardless of the cause giving rise to termination and shall be construed to be
				  for the benefit of the HMO subscriber/enrollee and that (2) this provision
				  supersedes any oral or written contrary agreement now existing or hereafter
				  entered into between (Provider) and subscriber/enrollee or persons acting on
				  their behalf.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.19 - Producers' Duties

Current through Register Vol. 47, No. 3, July 24, 2024
In order to qualify for solicitation, enrollment, or delivery
				  of a certificate of membership or policy in a health maintenance organization,
				  a producer must comply with the licensing rules set forth in 191-Chapter 10 and
				  in particular pass the accident and health or sickness insurance lines of
				  authority examination.
Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 40 - Health Maintenance Organizations › Rule 191-40.20 - Emergency Services

Current through Register Vol. 47, No. 3, July 24, 2024
Benefits shall be available by the HMO for inpatient and
				  outpatient emergency services. A physician and sufficient other licensed and
				  ancillary personnel shall be readily available at all times to render such
				  services. Since HMOs may not contract with every emergency care provider in an
				  area, HMOs shall make every effort to inform members of participating
				  providers.
(1) The term "emergency
				services" means, with respect to an individual enrolled with an organization,
				covered inpatient and outpatient services that are furnished by a provider that
				is qualified to furnish such services and are needed to evaluate or stabilize
				an emergency medical condition.
(2)
				The term "emergency medical condition" means a medical condition manifesting
				itself by acute symptoms of sufficient severity, including severe pain, that a
				prudent layperson, who possesses an average knowledge of health and medicine,
				could reasonably expect that absence of immediate medical attention to result
				in one of the following:
a. Placing the health
				of the individual or, with respect to a pregnant woman, the health of the woman
				and her unborn child, in serious jeopardy;
b. Serious impairment to bodily function;
				or
c. Serious dysfunction of any
				bodily organ or part.