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Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.11 - Pharmacy Benefits Manager Annual Report

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Filing
				of annual report.
In addition to submitting the third-party
				administrator annual report required under rule
				191-58.11 (510), each pharmacy
				benefits manager shall submit to the commissioner on or before February 15 of
				each year the annual report required by Iowa Code section
				510C.2 (PBM annual report). The
				pharmacy benefits manager shall follow the instructions and use the online
				submission form provided on the Iowa insurance division's website
				(iid.iowa.gov) to file the PBM annual report.
(2)
Verification.
At least
				two officers of the pharmacy benefits manager shall certify in writing that
				they verified the accuracy of the PBM annual report.
(3)
Electronic filing.
Each
				pharmacy benefits manager shall submit the PBM annual report electronically as
				set forth in the instructions, unless otherwise specifically authorized by the
				commissioner.
(4)
Report
				content.
a. Reporting requirement
				elements.
(1) A pharmacy benefits manager
				shall provide information about all rebates, as defined in Iowa Code section
				510C.1, which shall include but not be limited to any consideration, incentive,
				disbursement, discount, payment and any other pecuniary transaction that is
				provided directly or indirectly to the pharmacy benefits manager from a
				pharmaceutical manufacturer that adjusts the price of the wholesale acquisition
				cost of a prescription drug.
(2) An
				administrative fee, as defined in Iowa Code section 5 IOC. 1, shall include but
				not be limited to any consideration, incentive, disbursement, payment and any
				other pecuniary transaction, other than a rebate, that is provided directly or
				indirectly to the pharmacy benefits manager from a pharmaceutical
				manufacturer.
(3) The aggregate
				dollar amount of a rebate shall be reported as the wholesale acquisition cost
				of a prescription drug minus the price negotiated by the pharmacy benefits
				manager for the same prescription drug.
(4) Aggregate dollar amounts reported shall
				be reported as gross aggregate dollar amounts using generally accepted
				accounting principles (GAAP).
(5)
				Information requested about pharmacies shall include any pharmacy services
				administrative organizations that may represent pharmacies.
(6) A third-party payor administrative
				service fee, as defined in Iowa Code section
				510C.1, shall include but not be
				limited to any consideration, incentive, disbursement, payment and any other
				pecuniary transaction that is provided directly or indirectly to the pharmacy
				benefits manager from a third-party payor.
(7) A third-party payor administrative
				service fee, as defined in Iowa Code section
				510C.1, shall not be reported as
				a benefit or incurred claim provided under a health benefit plan.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.12 - Failure to Comply

Current through Register Vol. 47, No. 3, July 24, 2024
Failure to comply with the provisions of this chapter or with
				  Iowa Code chapters 510, 510B and 510C or failure to comply with 191-Chapters 58
				  and 78 or Iowa Code chapters 507 and 514L as they are relevant to the
				  administration of this chapter shall subject the pharmacy benefits manager to
				  the penalties of Iowa Code chapter 507B. No provision of these rules or the
				  Iowa Code chapters mentioned herein may be waived or modified by
				  contract.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 60 - Workers' Compensation Insurance Rate Filing Procedures › Rule 191-60.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The purpose of
				this chapter is to set forth filing procedures and parameters for rates as
				required by Iowa Code chapter 515A.
(2) Nothing herein shall be construed to
				create or imply a private cause of action for a violation of this
				chapter.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 60 - Workers' Compensation Insurance Rate Filing Procedures › Rule 191-60.2 - Definitions, Scope, Authority

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The definitions
				in Iowa Code section 515A.2 are incorporated into
				this chapter by this reference. In addition, the following definitions shall
				apply:
"Division"
means the Iowa insurance
				  division.
"SERFF"
means the National Association of
				  Insurance Commissioners' System for Electronic Rate and Form Filing.
(2) This chapter shall apply only
				to workers' compensation liability insurance.
(3) This chapter is issued under the
				authority of Iowa Code section
				505.8 and chapter
				515A.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 60 - Workers' Compensation Insurance Rate Filing Procedures › Rule 191-60.3 - General Filing Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Insurers
				required to file rates with the division shall submit required rate filings and
				any fees required for the filings electronically using SERFF. Insurers 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 out on the SERFF
				website at
serff.com
.
(2) No rate filing shall include any
				adjustment designed to recover underwriting or operating losses incurred out of
				state. Upon request by the division, insurers doing business in Iowa shall
				segregate in their rate filings data from any state identified by the division,
				and the filings shall include a certification that no portion of any rate
				increase is designed to recover underwriting or operating losses incurred in
				another state.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 60 - Workers' Compensation Insurance Rate Filing Procedures › Rule 191-60.4 - Rate or Manual Rule Filing

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Every insurer,
				either on its own or via a licensed rating organization, shall file with the
				division, pursuant to provisions of Iowa Code chapter 515A, every manual,
				minimum, class rate, rating schedule or rating plan and every other rating
				rule, and every modification of any of the foregoing that it proposes to use.
Every insurer shall adhere to the filings made on its behalf
				  by a rating organization except that any such insurer may file a deviation from
				  the class rates, schedules, rating plans, or rules, or a combination thereof,
				  at any time during the year and, once approved, the deviation need only be
				  refiled to propose changes to any filing.
(2) An insurer may file for approval by the
				division a uniform percentage rate deviation to be applied to the class rates
				of the rating organization's filing.
a. A rate
				deviation from the approved class rates of a rating organization shall not
				exceed 15 percent nor shall it cause the rate charged a policyholder to exceed
				the approved assigned risk rates but must state whether or not the proposed
				deviation is to be applied to minimum premiums.
b. In the event that an insurer has an
				existing approved filing for which the deviation results in rates above those
				approved for the assigned risk, the insurer must use the same deviation as
				approved for the assigned risk effective the same date as the approval of the
				assigned risk rates. A filing must be made confirming use of the new deviation
				on that date.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 60 - Workers' Compensation Insurance Rate Filing Procedures › Rule 191-60.5 - Violation and Penalties

Current through Register Vol. 47, No. 3, July 24, 2024
Any insurer found after hearing to have violated a provision
				  of this chapter shall be deemed to have committed an unfair trade practice
				  under Iowa Code chapter 507B and shall be subject to the penalties set forth in
				  Iowa Code chapter 507B.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 60 - Workers' Compensation Insurance Rate Filing Procedures › Rule 191-60.6 - Severability

Current through Register Vol. 47, No. 3, July 24, 2024
If any provision of this chapter or the application thereof
				  to any person or circumstance is held invalid for any reason, the invalidity
				  shall not affect the other provisions or any other application of these rules
				  that can be given effect without the invalid provisions or application. To this
				  end, all provisions of these rules are declared to be
				  severable.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to:
1. Promote the delivery of appropriate health
				care in a cost-effective manner
2.
				Ensure that any utilization review system used by a third-party payor adheres
				to reasonable standards for conducting orderly and efficient utilization review
				processes.
3. Ensure that any
				utilization review system used by a third-party payor does not result in an
				unfair discrimination between enrollees of essentially the same class or risk
				in the benefits payable under a contract for health benefits.
4. Foster greater coordination and
				cooperation between health care providers and utilization reviewers.
5. Improve communications and knowledge of
				benefits among all parties concerned before expenses are incurred.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
As used in this chapter, unless the context otherwise
				  requires:
"Commissioner "
means the commissioner of
				  insurance.
"Enrollee"
means an individual who has
				  contracted for or who participates in health benefits coverage provided through
				  any third-party payor
"Third-party payor"
means any of the
				  following entities:
1. An insurer subject to Iowa Code chapter 509 or
				  514A.
2. A health service corporation subject to Iowa Code chapter
				  514.
3. A health maintenance organization subject to Iowa Code
				  chapter 5I4B.
4. A preferred provider arrangement subject to 191-Chapter
				  27, Iowa Administrative Code.
5. A multiple employer welfare arrangement.
6. A third-party administrator
7. A fraternal benefit society.
8. Any other benefit program providing payment,
				  reimbursement, or indemnification for health care costs for an enrollee or an
				  enrollee's eligible dependents.
"Utilization review "
means a program or
				  process by which an evaluation is made of the necessity, appropriateness and
				  efficiency of the use of health care services, procedures, or facilities given
				  or proposed to be given to an individual within this state. These standards do
				  not apply to requests by any person or provider for a clarification, guarantee
				  or statement of an individual's health insurance coverage or benefits provided
				  under a health insurance policy, nor to claims adjudication. Unless it is
				  specifically so stated, verification of benefits, preauthorization, and
				  prospective or concurrent utilization review programs shall not be construed in
				  any context as a guarantee or statement of insurance coverage or benefits for
				  any individual under a health insurance policy.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.3 - Application

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A third-party
				payor which provides health benefits to enrollees residing in the state of Iowa
				shall not conduct utilization review, either directly or indirectly, by
				contract with a third party that does not meet the requirements established for
				accreditation by the Utilization Review Accreditation Commission (URAC) or
				another national accreditation entity recognized and approved by the
				commissioner
(2) On or before March
				1 of each year, a third-party payor conducting utilization review shall provide
				the commissioner with a certification that it is in compliance with this
				chapter, and shall continuously meet all requirements of the relevant standards
				in addition to the following information:
a.
				Name, address, telephone number and normal business hours of the third-party
				payor and of the utilization review agent if not the same as the third-party
				payor
b. Name, address, and
				telephone number of a person for the commissioner to contact in connection with
				utilization review compliance.
Any material changes in the information filed in accordance
				  with this rule shall be filed with the commissioner within 30 days of the
				  change.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.4 - Standards

Current through Register Vol. 47, No. 3, July 24, 2024
For the purpose of certification and compliance under rule
				  191-70.3 (505,514F), the most
				  recently available utilization review standards adopted by URAC shall be
				  used.
A copy of the standards and application for accreditation may
				  be obtained from the Utilization Review Accreditation Commission at
www.urac.org
. A copy of the standards shall
				  be readily available and maintained on the premises of any third-party payor
				  conducting utilization review.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.5 - Retroactive Application

Current through Register Vol. 47, No. 3, July 24, 2024
A third-party payor shall not impose a retroactive change in
				  procedure that creates an impossibility or impracticability of compliance that
				  would result in a refusal of payment.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.6 - Variances Allowed

Current through Register Vol. 47, No. 3, July 24, 2024
Upon application by a third-party payor, the commissioner may
				  approve a variance from the URAC standards for good cause shown, provided such
				  conditions are consistent with the purpose of this chapter The commissioner
				  shall require the third-party payor to provide reasonable written notice to
				  providers of any approved variance.
(1) Notification of allowed coverage and
				denials. Notification of the attending physician and treatment facility (as
				used and defined in the URAC standards) by telephone within one working day is
				not required provided a documented communication with the physician or the
				physician's staff and treatment facility is made within one working day of a
				determination not to certify an admission or extension of a hospital
				stay.
(2) Individuals who are not
				licensed health care professionals, but who are otherwise qualified, may
				perform routine utilization review under the following conditions:
a. They have received full orientation by the
				utilization review organization relating to administrative practices and
				policies;
b. They have been fully
				trained in the application of the medical and/or benefit screening criteria
				established or endorsed by the utilization review organization;
c. They are trained to refer review requests
				to licensed health care professionals when the required review exceeds their
				own expertise, when not addressed in the criteria established or endorsed by
				the utilization review organization, or when requested by the provider;
				and
d. They are under the direct
				supervision of a licensed health care professional.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.7 - Confidentiality

Current through Register Vol. 47, No. 3, July 24, 2024
A third-party payor shall require a contract utilization
				  review agent to adhere to the same standards of patient medical record
				  confidentiality as are directly applicable to the third-party
				  payor.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.8 - Utilization Review of Postdelivery Benefits and Care

Current through Register Vol. 47, No. 3, July 24, 2024
When performing utilization review of inpatient hospital
				  services related to maternity and newborn care, including but not limited to
				  length of postdelivery stay and postdelivery follow-up care, a third-party
				  payor shall use the guidelines adopted under the provisions of rule
				  191-81.3 (514C) and shall not
				  deselect, require additional documentation, require additional utilization
				  review, terminate services to, reduce payment to, or in any manner provide a
				  disincentive to an attending physician solely on the basis that the attending
				  physician provided or directed the provision of services in compliance with
				  those guidelines. This does not preclude a third-party payor from monitoring a
				  patient's stay or making reasonable inquiries necessary to assess patient
				  progress in accordance with the guidelines and to coordinate discharge planning
				  or postdischarge care.
This rule is intended to implement Iowa Code section
				  514C.11.
Iowa Administrative Code › Agency 191 - Insurance Division › Managed Health Care › Chapter 70 - Utilization Review › Rule 191-70.9 - Enforcement

Current through Register Vol. 47, No. 3, July 24, 2024
The remedy for noncompliance with this chapter shall be those
				  remedies authorized by Iowa Code chapters 505 and 507B, including, upon order
				  of the commissioner, payment of outstanding charges, as determined to be
				  reasonable by the commissioner Upon a finding of a pattern or practice of
				  noncompliance with this chapter, the commissioner may also suspend a person's
				  authority to conduct utilization review.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter is intended to implement the provisions of Iowa
				  Code chapter 513B to provide for the guaranteed issue of all health insurance
				  products in the small group market, regardless of their health status or claims
				  experience; to regulate insurer rating practices and establish limits on
				  differences in rates between health insurance coverages; to ensure renewability
				  of coverage; to establish limitations on underwriting practices, eligibility
				  requirements and the use of preexisting condition exclusions; to provide for
				  development of "basic" and "standard" health insurance plans to be offered to
				  all small employers; to provide for establishment of a reinsurance program; to
				  direct the basis of market competition away from risk selection and toward the
				  efficient management of health care; to improve the overall fairness and
				  efficiency of the small group health insurance market and to promote broader
				  spreading of risk in the small employer marketplace. Carriers that provide
				  basic and standard health benefit plans, as herein set forth, to small
				  employers are intended to be subject to all provisions of Iowa Code chapter
				  513B and this chapter.
(1) Health
				insurance coverage subject to this chapter is available or renewable with
				respect to all eligible employees or their dependents, at the option of the
				employer, except for reasons set forth in Iowa Code section
				513B5..
(2) A carrier subject to this chapter is
				required to guarantee issue small employer plans except for reasons set forth
				in Iowa Code chapter 513B.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.3 - Applicability and Scope

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
a. Except as provided herein, this chapter
				shall apply to any health insurance coverage, whether provided on a group or
				individual basis, which:
(1) Meets one or more
				of the conditions set forth in Iowa Code sections
				513B3(l).
				to513B.3(3);
(2) Provides coverage
				to one or more employees of a small employer located in this state without
				regard to whether the policy or certificate was issued in this state;
				and
(3) Is in effect on or after
				July 1, 1991.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.4 - Establishment of Classes of Business

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A small employer carrier that establishes
				more than one class of business as defined in Iowa Code section
				513B2. shall maintain
				on file for inspection by the commissioner the following information with
				respect to each class of business so established:
a. A description of each criterion employed
				by the carrier (or any of its agents) for determining membership in the class
				of business;
b. A statement
				describing the justification for establishing the class as a separate class of
				business and documentation that the establishment of the class of business is
				intended to reflect substantial differences in expected claims experience or
				administrative costs related to the reasons as set forth in the definition of
				"class of business" in Iowa Code section
				513B2.;
c. A statement disclosing which, if any,
				health insurance coverages are currently available for purchase in the class
				and any significant limitations related to the purchase of such
				plans.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.5 - Transition for Assumptions of Business From Another Carrier

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
a. A
				small employer carrier shall not transfer or assume the entire insurance
				obligation or risk of health insurance coverage covering a small employer in
				this state unless:
(1) The transaction has
				been approved by the commissioner of the state of domicile of the assuming
				carrier;
(2) The transaction has
				been approved by the commissioner of the state of domicile of the ceding
				carrier; and
(3) The transaction
				otherwise meets the requirements of this rule and Iowa Code section
				513B3(4).
"c."
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.7 - Requirement to Insure Entire Groups

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
a. A
				small employer carrier that offers coverage to a small employer shall offer to
				provide coverage to each eligible employee and to each dependent of an eligible
				employee. The small employer carrier shall provide the same health insurance
				coverage to each employee and dependent.
b. Except as provided in Iowa Code section
				513B. 10(4) (with respect to exclusions for preexisting conditions), the choice
				among insurance coverages may not be limited, restricted or conditioned upon
				the risk characteristics of the employees or their
				dependents.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.8 - Case Characteristics

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				small employer carrier may use age, geographic area, family composition, and
				group size in establishing premium rates, subject to Iowa Code section
				5136.4(2).
(2) Additional rating
				factors are not allowed without the prior approval of the
				commissioner.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.9 - Application to Reenter State

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				carrier prohibited from writing coverage for small employers in this state
				pursuant to Iowa Code section
				513B5(2).
				may not resume offering health insurance coverage to small employers in this
				state until the carrier has made a petition to the commissioner or director to
				be reinstated as a small employer carrier and the petition has been approved by
				the commissioner or director. In reviewing a petition, the commissioner or
				director may ask for such information and assurances as the commissioner or
				director finds reasonable and appropriate.
(2) In the case of a small employer carrier
				doing business in only one established geographic service area of the state, if
				the small employer carrier elects to nonrenew health insurance coverage under
				Iowa Code section
				513B5.,
				the small employer carrier shall be prohibited from offering health insurance
				coverages to small employers in any other geographic area of the state without
				the prior approval of the commissioner or director. In considering whether to
				grant approval, the commissioner or director may ask for such information and
				assurances as the commissioner or director finds reasonable and
				appropriate.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.11 - Rules Related to Fair Marketing

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
a. A small employer carrier shall actively
				market health insurance coverages including one basic and one standard health
				benefit plan to small employers in this state. A small employer carrier may not
				suspend the marketing or issuance of the basic and standard health benefit
				plans unless the carrier has good cause and has received the prior approval of
				the commissioner or director.
b. In
				marketing the basic and standard health benefit plans to small employers, a
				small employer carrier shall use at least the same sources and methods of
				distribution that it uses to market other health insurance coverages to small
				employers.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.12 - Status of Carriers as Small Employer Carriers

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Subject to 71.12(2), a carrier shall not
				offer health insurance coverages to small employers or continue to provide
				coverage under health insurance coverages previously issued to small employers
				in this state unless the carrier has made a filing with the commissioner or
				director that the carrier intends to operate as a small employer carrier in
				this state under the terms of this chapter.
(2)
a. If a
				carrier does not intend to operate as a small employer carrier in this state,
				the carrier may continue to provide coverage under health insurance coverages
				previously issued to small employers in this state only if the carrier complies
				with the following provisions:
(1) The
				carrier complies with the requirements of Iowa Code chapter 513B (other than
				Iowa Code sections
				513B11.
				to
				513B13.
				) with respect to each of the health insurance coverages previously issued to
				small employers by the carrier.
(2)
				The carrier provides coverage to each new entrant to health insurance coverage
				previously issued to a small employer by the carrier. The provisions of Iowa
				Code chapter 513B (other than Iowa Code sections
				513B11.
				to
				513B13.
				) and this chapter shall apply to the coverage issued new entrants.
(3) The carrier complies with the
				requirements of Iowa Code section
				513B17A., and rule
				191-7113.
				(513B), as they apply to small employers whose coverage has been terminated by
				the carrier, and to individuals and small employers whose coverage has been
				limited or restricted by the carrier.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.13 - Restoration of Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
a. Except as provided in
				71.13(1)
"b,"
a small employer carrier shall, as a condition of
				continuing to transact business in this state with small employers, offer to
				provide health insurance coverage as described in 71.13(3) to any small
				employer carrier after January 1,1993, unless the carrier's termination is
				pursuant to Iowa Code section
				513B5..
b. The offer required under 71.13(1)
"a"
shall not be required with respect to health insurance
				coverage that was not renewed if:
(1) The
				health insurance coverage was not renewed for reasons permitted in Iowa Code
				section
				513B5(1).,
				or
(2) The nonrenewal was a result
				of the small employer voluntarily electing coverage under different health
				insurance coverage.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.15 - Methods of Counting Creditable Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1) For purposes of reducing any preexisting
				condition exclusion period, a group health plan or a carrier offering group
				health insurance coverage shall determine the amount of an individual's
				creditable coverage by using the standard method described in subrule 71.15(2),
				except that the plan or carrier may use the alternative method under subrule
				71.15(3) with respect to any or all of the categories of benefits described
				under paragraph 71.15(3)
"b."
(2) Under the standard method, a group health
				plan and a health insurance carrier offering group health insurance coverage
				shall determine the amount of creditable coverage without regard to the
				specific benefits included in the coverage.
a.
				For purposes of reducing the preexisting condition exclusion period, a group
				health plan or a health insurance carrier offering group health insurance
				coverage shall determine the amount of creditable coverage by counting all the
				days that the individual has under one or more types of creditable coverage. If
				on a particular day, an individual has creditable coverage from more than one
				source, all the creditable coverage on that day is counted as one day. Further,
				any days in a waiting period for a plan or policy are not creditable coverage
				under the plan or policy.
b. Days
				of creditable coverage that occur before a significant break in coverage are
				not required to be counted.
c.
				Notwithstanding any other provision of paragraph 71.15(2)
"b,"
for purposes of reducing a preexisting condition exclusion period, a group
				health plan and a health insurance carrier offering group health insurance
				coverage may determine the amount of creditable coverage in any other manner
				that is at least as favorable to the individual as the method set forth in
				paragraph 71.15(2)
"b."
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.16 - Certificates of Creditable Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Group health plans or carriers shall
				issue certificates of creditable coverage to persons losing coverage. A group
				health plan or carrier required to provide a certificate under this rule for an
				individual is deemed to have satisfied the certification requirements for that
				individual if another party provides the certificate, but only to the extent
				that information relating to the individual's creditable coverage and waiting
				or affiliation period is provided by the other party. Certificates shall be
				issued within a reasonable amount of time following termination to employees
				and dependents:
a. Automatically upon the
				termination of an individual's group coverage;
b. Automatically upon the termination of
				COBRA coverage;
c. Upon request
				within 24 months after coverage ends.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.17 - Notification Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				group health plan or carrier shall provide written notice to the employee and
				dependents of:
a. The existence of any
				preexisting condition exclusions.
b. The length of time to which the exclusions
				will apply.
c. The right of the
				employee or dependent to appeal a decision to impose a preexisting condition
				exclusion.
d. The right of the
				person to demonstrate creditable coverage including:
(1) The right of the person to request a
				certificate from a prior group health plan or carrier;
(2) A statement that the current group health
				plan or carrier will assist in obtaining the certificate;
(3) That the group health plan or carrier
				will use the alternative method of counting creditable coverage; and
(4) Special enrollment rights when an
				employee declines coverage for the employee or dependents.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.19 - Disclosure Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
All carriers shall include in contracts and evidence of
				  coverage forms a statement disclosing the existence of any drug formularies.
				  Upon request, a carrier offering health insurance coverage that includes a
				  prescription drug formulary shall inform enrollees of the coverage, and
				  prospective enrollees of the coverage during any open enrollment period,
				  whether a prescription drug specified in the request is included in such
				  formulary.
All carriers shall also disclose the existence of any
				  contractual arrangements providing rebates received by them for prescription
				  drugs or durable medical equipment. Durable medical equipment means equipment
				  that can stand repeated use and is primarily and customarily used to serve a
				  medical purpose and is generally not useful to a person who is not sick or
				  injured or used by other family members and is appropriate for home use for the
				  purpose of improving bodily functions or preventing further deterioration of
				  the medical condition caused by sickness or injury.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.20 - Treatment Options

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A carrier
				shall not prohibit a participating provider from or penalize a participating
				provider for discussing treatment options with covered persons, irrespective of
				the carrier's position on the treatment options, or from advocating on behalf
				of covered persons within the utilization review or grievance processes
				established by the carrier or a person contracting with the carrier
(2) A carrier shall not penalize a provider
				because the provider, in good faith, reports to state or federal authorities
				any act or practice by the carrier that, in the opinion of the provider,
				jeopardizes patient health or welfare.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.21 - Emergency Services

Current through Register Vol. 47, No. 3, July 24, 2024
Benefits shall be available by the carrier 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 carriers may not contract with every emergency care provider in
				  an area, carriers 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 who
				is qualified to furnish the services that are needed to evaluate or stabilize
				an emergency medical condition.
(2)
				The term "emergency medical condition" means a medical condition manifesting
				itself by symptoms of sufficient severity, including but not limited to severe
				pain, that an ordinarily prudent layperson, who possesses an average knowledge
				of health and medicine, could reasonably expect the 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.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.22 - Provider Access

Current through Register Vol. 47, No. 3, July 24, 2024
A carrier shall allow a female enrollee direct access to
				  obstetrical or gynecological services from network and participating providers.
				  The plan shall also allow a pediatrician to be the primary care provider for a
				  child through the age of 18.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.23 - Reconstructive Surgery

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A carrier
				that provides medical and surgical benefits with respect to a mastectomy shall
				provide the following coverage in the event an enrollee receives benefits in
				connection with a mastectomy and elects breast reconstruction:
a. Reconstruction of the breast on which the
				mastectomy has been performed;
b.
				Surgery and reconstruction of the other breast to produce a symmetrical
				appearance; and
c. Prostheses and
				coverage of physical complications at all stages of a mastectomy including
				lymphedemas.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.24 - Contraceptive Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				carrier that provides benefits for outpatient prescription drugs or devices
				shall provide benefits for prescription contraceptive drugs or prescription
				contraceptive devices which prevent conception and are approved by the United
				States Food and Drug Administration or generic equivalents approved as
				substitutable by the United States Food and Drug Administration.
(2) A carrier is not required to provide
				benefits for over-the-counter contraceptive drugs or contraceptive devices that
				do not require a prescription for purchase.
(3) A contraceptive drug or contraceptive
				device does not include surgical services intended for sterilization,
				including, but not limited to, tubal ligation or vasectomy.
(4) A carrier shall be required to provide
				benefits for services related to outpatient contraceptive services for the
				purpose of preventing conception if the policy or contract provides benefits
				for other outpatient services provided by a health care professional.
(5) If a carrier does not provide benefits
				for a routine physical examination, the carrier is not required to provide
				benefits for a routine physical examination provided in the course of
				prescribing a contraceptive drug or contraceptive device.
This rule is intended to implement Iowa Code section
				  514C.19.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.25 - Suspension of the Small Employer Health Reinsurance Program

Current through Register Vol. 47, No. 3, July 24, 2024
Upon the recommendation of the board of directors of the Iowa
				  small employer health reinsurance program and the findings of the commissioner
				  that the operation of the Iowa small employer health reinsurance program
				  pursuant to Iowa Code chapter 513B is not currently cost-effective, the
				  commissioner suspends the operation of the program, effective January 30, 2004,
				  until further notice. After the effective date of the suspension, the program
				  may continue its administration with regard to handling claims and refunds
				  related to activities prior to the suspension as well as other administrative
				  matters.
This rule is intended to implement Iowa Code section
				  5136.13(14).
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.26 - Uniform Health Insurance Application Form

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Small employer carriers shall use the
				small employer uniform health insurance application form as the only acceptable
				form when small employers apply for new health insurance coverage from small
				employer carriers. Small employer carriers shall implement procedures and
				policies necessary to use the small employer uniform health insurance
				application form.
(2) Small
				employer carriers shall treat and accept a copy of the uniform health insurance
				application form as an original.
(3) Use of the uniform health insurance
				application form shall not be required:
a.
				Upon renewal of an existing small employer group policy, or
b. When adding or removing employees or
				dependents under an existing small employer group policy.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to set forth the minimum
				  standards for long-term care insurance policies sold prior to December 31,
				  2009, that participate in the Iowa long-term care asset preservation program;
				  establish documentation and reporting requirements for issuers of policies or
				  certificates to qualify under the Iowa long-term care asset preservation
				  program; provide full disclosures in the sale of long-term care insurance
				  policies and certificates which qualify under the Iowa long-term care asset
				  preservation program; and facilitate public understanding regarding long-term
				  care insurance and long-term care insurance policies and certificates which
				  qualify under the Iowa long-term care asset preservation
				  program.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.2 - Applicability and Scope

Current through Register Vol. 47, No. 3, July 24, 2024
The requirements of this chapter apply to any long-term care
				  insurance policy or certificate that was authorized for sale by the division of
				  insurance as qualifying under the Iowa long-term care asset preservation
				  program under former Iowa Code chapter 249G. No long-term care insurance policy
				  or certificate which has been approved by the division of insurance as a
				  certified long-term care insurance policy or certificate under this chapter may
				  be advertised, solicited, or issued for delivery in this state after December
				  31, 2009.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.4 - Qualification of Long-term Care Insurance Policies and Certificates

Current through Register Vol. 47, No. 3, July 24, 2024
No long-term care insurance policy or certificate shall
				  qualify for participation in the Iowa long-term care asset preservation program
				  unless the long-term care insurance policy or certificate complies with this
				  chapter Long-term care insurance policies and certificates in force on July 1,
				  1994, may, with the signed acceptance of the policyholder or certificate
				  holder, be amended to meet the requirements for
				  qualification.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.7 - Required Policy and Certificate Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
(1) All qualified policies and certificates
				shall meet the following requirements:
a.
				Have premiums:
(1) Based on the issue age of
				the applicant; or
(2) Level for the
				life of the policy or certificate with an adjustment only for the increased
				benefits resulting from the inflation protection requirements of subrule
				72.6(4). Nothing in this rule shall preclude an issuer from reducing premiums
				of a policy or certificate or using a policy form or certificate form in which
				the premiums are no longer required to be paid after a specified period of
				time.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.8 - Prohibited Provisions in Certified Policies or Certificates

Current through Register Vol. 47, No. 3, July 24, 2024
The following provisions may not be included in a certified
				  policy or certificate: a restoration of benefits; a second elimination period;
				  any cap on the daily (as opposed to monthly) home- and community-based care
				  benefits.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.9 - Reporting Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
Unless otherwise noted, the requirements of this rule refer
				  to issuer documentation and reporting requirements for qualified policies and
				  certificates. The reports shall be submitted for each person entitled to
				  benefits under a qualified policy or certificate. Each issuer shall do the
				  following:
(1) Maintain a registry and
				submit on a quarterly basis and in a format specified by the state of Iowa, a
				report to the department of human services that will include the following
				information on all individuals who purchased a qualified policy or certificate
				during the reporting period:
a. Name,
				address, telephone number, date of birth, sex, marital status, and social
				security number
b. Policy or
				certificate identification information, including the following:
(1) The policy or certificate form
				number
(2) The policy or
				certificate number
(3) The policy
				or certificate category.
(4) The
				effective date of coverage.
c. Policy or certificate elimination period
				in days by type of service.
d. The
				maximum daily benefit for nursing facility care and for home- and
				community-based care.
e. Maximum
				lifetime benefit amounts.
f. Any
				options and riders in force.
g.
				Purchase type (upgrade, conversion or new issue).
h. Method used for calculation of the
				inflation protection benefit.
i.
				For expense incurred policies or certificates, the percentage of expenses
				payable.
j. The annual premium for
				the policy or certificate, the premium mode (monthly, bank draft, quarterly),
				and the type of premium calculation (level, issue age, other).