Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 71 - Small Group Health Benefit Plans* › Rule 191-71.14 - Basic Health Benefit Plan and Standard Health Plan Policy Forms

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The form and
				level of coverage of the basic health benefit plan and the standard health
				benefit plan are contained in this rule. This rule provides the minimum benefit
				levels allowed and does not prevent carriers from voluntarily providing
				additional services to the basic health benefit plan or the standard health
				benefit plan.
(2) The matrix and
				acceptable exclusions following this chapter are a guideline for the minimum
				benefit levels in a basic and standard health policy form.
(3) Termination of pregnancy is to be covered
				in both policy forms when performed for therapeutic reasons. Elective
				termination of pregnancy is not to be covered in either the basic or standard
				form.
(4) A provision shall be made
				in the basic health benefit plan and the standard health benefit plan covering
				diagnosis and treatment of human ailments for payment or reimbursement for
				necessary diagnosis and treatment provided by a chiropractor licensed under
				Iowa Code chapter 151, if the diagnosis or treatment is provided within the
				scope of the chiropractor's license.
(5) Prosthetic devices are covered when
				medically necessary.
(6)
				Prescription oral contraceptives and contraceptive devices that are approved by
				the United States Food and Drug Administration are to be covered in both policy
				forms.
(7) Both policy forms shall
				cover well baby care consistent with Iowa Administrative Code 191-Chapter
				80.
(8) The division has available
				"safe harbor" policy forms for the basic and standard health insurance plans
				required pursuant to Iowa Code chapter 513B. These are model forms approved by
				the division as meeting the minimum requirements of a basic and a standard
				policy.
SMALL EMPLOYER PRODUCTS
MANDATED INDEMNITY
MANDATED HMOs
BASIC
STANDARD
BASIC
STANDARD
Calendar Year Deductibles (S/F)
$500 x 3
$500 x 2
E.R. Copayment
$50 (waived if admitted)
$50 (waived if admitted)
$50 (waived if admitted)
$50 (waived if admitted)
Coinsurance
60%
80%
60%
80%
Out-of-pocket per insured/family
								maximum
$4,800/$14,400
$2,000/$4,000
$4,000/$8,000
(excludes deductibles and copays)
$2,000/$4,000
Annual Maximum
Lifetime Maximum
$250,000
$1,000,000
$250,000
$1,000,000
Pre-Existing
513B.10(3)
513B.10(3)
513B.10(3)
513B.10(3)
Late Entrant
513B.2(12)
513B.2(12)
513B.2(12)
513B.2(12)
Wellness
100% first $100
60% over $100
100% first $150
80% over $150
100% after $20 copay per visit
100% after $15 copay per visit
Maternity
60% Enrollee or Spouse Only
80% Enrollee or Spouse
60%
80%
PHYSICIAN SERVICES
Office Visits
60%(1)
80%(2)
$20 copay per office visit
$15 copay per office visit
Urgent Care
60%
80%
60%
80%
Inpatient
60%
80%
60%
80%
Outpatient
60%(1)
80%(2)
60%
80%
Vision Screening
Vision Examinations
Immunizations
60%(1)
80%(2)
60%
80%
Well Child
60%(1) (Deductible does
								not apply)
80%(2) (Deductible does
								not apply)
100% after $20 copay/visit
100% after $15 copay/visit
Pre-Natal/Post-Natal Outpatient
								Visits
60%(1)
80%(2)
100% after $50 copay/pregnancy
100% after $50 copay/pregnancy
Inpatient
60%
80%
60% of $400/admit
80% $200/admit
Prostheses
60%
80%
60%
80%
DME-including medical supplies
60%
80%
60%
80%
Ambulance-Emergency
60%
80%
60%
80%
Hospice
60%
80%
60%
80%
Home Health and
Physician House Calls
60%
80%
60%
80%
ALCOHOLISM/SUBSTANCE ABUSE
Inpatient
80%(3)
80%(3)
Outpatient
80%(3) ($50 max.
								eligible fee)
80%(3)
MENTAL HEALTH
Inpatient
80%(3)
80%(3)
Outpatient
80%(3) ($50 max.
								eligible fee)
80%(3)
RX
60%
80%
Copayment greater of $15 or 25%
Copayment greater of $10 or 25%
Transplants
80%
80%
(1) For wellness services, covered
				  100% first $100 and 60% over $100
(2) For wellness services, covered
				  100% first $150 and 80% over $150
(3) $50,000 lifetime max.
ACCEPTABLE EXCLUSIONS FOR USE IN BASIC AND STANDARD
				  POLICIES
Except as specifically provided for, no benefits will be
				  provided for services, supplies or charges:
1. Which are not prescribed by, performed by,
				or upon the direction of a provider;
2. Which are not medically
				necessary;
3. Rendered by other
				than a hospital or a provider;
4.
				Which are investigational in nature; including any service, procedure, or
				treatment directly related to an investigational treatment;
5. For any condition, disease, illness, or
				bodily injury which occurs in the course of employment if benefits or
				compensation is carried or required, in whole or in part, under the provisions
				of any legislation or governmental unit. This exclusion applies whether or not
				the insured claims the benefits or compensation;
6. To the extent benefits are provided by any
				governmental unit except as required by federal law for the treatment of
				veterans in Veterans Administration or armed forces facilities for non-service-
				related medical conditions;
7. For
				any illness or injury suffered as a result of any act of war or while in the
				military service;
8. For which the
				insured would have no legal obligation to pay in the absence of this or any
				similar coverage;
9. Received from
				a dental or medical department maintained by or on behalf of an employer, a
				mutual benefit association, labor union, trust, or similar person or
				group;
10. Surgery and any related
				services intended solely to improve appearance including but not limited to the
				restoration of hair and appearance of skin. This does not include those
				services or surgeries that restore bodily function or correct deformity
				resulting from disease, trauma, congenital or developmental anomalies of a
				newborn;
11. Rendered by a provider
				that is a member of the insured's immediate family;
12. Incurred prior to the effective date or
				during an inpatient admission that commenced prior to the insured's effective
				date of coverage;
13. Incurred
				after the date of termination of the insured's coverage;
14. For personal hygiene and convenience
				items such as, but not limited to, air conditioners, humidifiers, or physical
				fitness equipment;
15. For
				telephone consultations, charges for failure to keep scheduled appointments,
				charges for completion of any form or charges for medical
				information;
16. For inpatient
				admissions which are primarily for diagnostic studies or physical
				therapy;
17. For whole blood, blood
				components and blood derivatives which are not classified as drugs in the
				official formularies;
18. For
				custodial care, domiciliary care or rest cures;
19. For treatment in a facility, or part of a
				facility, that is mainly a place for:
(a)
				rest;
(b) convalescence;
(c) custodial care;
(d) the aged;
(e) the care or treatment of alcoholism or
				drug addiction;
(f) rehabilitation;
				or
(g) training, schooling or
				occupational therapy;
20. For screening examinations including
				X-ray examinations made without film;
21. For sterilization or reversal of
				sterilizations, or both;
22. For
				dental work or treatment except for removal of malignant tumors and cysts or
				accidental injury (eating and chewing mishaps are not accidental injuries for
				the purposes of this policy) to natural teeth, if the accident occurs while the
				person is insured and the treatment is received within 12 months after the
				accident;
23. For treatment of
				weak, strained or flat feet, including orthopedic shoes or other supportive
				devices, or for cutting, removal or treatment of corns, callouses or nails,
				other than with corrective surgery, or for metabolic or peripheral vascular
				disease;
24. For eyeglasses or
				contact lenses and the visual examination for prescribing or fitting eyeglasses
				or contact lenses (except for aphasic patients and soft lenses or sclera shells
				intended for use in the treatment of disease or injury);
25. For radial keratotomy, myopic
				keratomileusis and any surgery which involves corneal tissue for the purpose of
				altering, modifying or correcting myopia, hyperopia or stigmatic
				error;
26. For hearing aids and
				supplies, tinnitus maskers, or examinations for the prescription or fitting of
				hearing aids;
27. For any treatment
				leading to or in connection with transsexualism, sex changes or modifications,
				including but not limited to surgery or the treatment of sexual dysfunction not
				related to organic disease;
28. For
				any treatment or regimen, medical or surgical, for the purpose of reducing or
				controlling the insured's weight or for the treatment of obesity;
29. For conditions related to autistic
				disease of childhood, hyperkinetic syndromes, learning disabilities, behavioral
				problems, or for inpatient confinement for environmental change;
30. For services and supplies for and related
				to fertility testing, treatment of infertility and conception by artificial
				means, including but not limited to: artificial insemination, in vitro
				fertilization, ovum or embryo placement or transfer, gamete intra-fallopian
				tube transfer, or cryogenic or other preservation techniques used in such or
				similar procedures;
31. For travel
				whether or not recommended by a physician;
32. For complications or side effects arising
				from services, procedures, or treatments excluded by this policy;
33. For maternity care of dependent children
				except for complications of pregnancy which is covered as any other
				illness;
34. For services to the
				extent that those services are covered by Medicare;
35. For or related to organ transplants
				(unless a benefit is specifically provided and then only to the limits
				provided);
36. For or related to
				the transplantation of animal or artificial organs or tissues;
37. For the care or treatment of any injury
				that is intentionally self-inflicted, while sane or insane;
38. For the care or treatment of any injury
				incurred during the commission of, or an attempt to commit, a felony or any
				injury or sickness incurred while engaging in an illegal act or occupation or
				participation in a riot;
39. For
				lifestyle improvements including smoking cessation, nutrition counseling or
				physical fitness programs;
40. For
				the purchase of wigs or cranial prosthesis;
41. For weekend admission charges, except for
				emergencies and nonscheduled maternity admissions;
42. For orthomolecular therapy including
				nutrients, vitamins and food supplements;
43. For speech therapy, except to restore
				speech abilities which were lost due to sickness or injury.