Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.14 - Auditing and Correcting Deficiencies in Issuer Record Keeping

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Within one year
				of the first date that any policyholder or certificate holder of a particular
				issuer's policy or certificate has met the criteria for the insured event, and
				as often as the commissioner of insurance or department of human services deems
				necessary thereafter, the commissioner of insurance or department of human
				services shall conduct a systems audit of that company's records. The issuer
				shall be responsible for advising the department of human services and the
				division of insurance when this one-year period has begun. The commissioner or
				department of human services shall promptly inform each issuer of inaccuracies
				and other potential problems discovered in its systems audits and shall
				instruct the issuer of the methods necessary to correct any problems in the
				issuer's methods of operation.
(2)
				The department of human services shall periodically reconcile a sample of
				individual applications to Medicaid of persons who have submitted documentation
				for qualification for asset protection with the reports submitted by issuers.
				The department of human services shall have the final decision concerning
				sample sizes and other auditing methods. The department of human services shall
				promptly advise issuers of any problems discovered and shall instruct the
				issuer of the methods necessary to correct any problems in the issuer's method
				of operation. The department of human services shall also notify the issuer of
				any obligations described in this subrule to hold clients harmless.
(3) The department of human services may
				enter into voluntary arrangements with issuers of qualified long-term care
				insurance policies and certificates under which the department of human
				services would issue binding determinations as to whether or not services
				qualify for asset protection. Policyholders or certificate holders may submit
				requests for information and advice through their issuer or case management
				agency. When the following procedures are followed in all material respects,
				the written determinations of the department of human services concerning
				whether services qualify for asset protection shall be binding upon the
				department of human services in all subsequent actions, and the department of
				human services shall not make any assertion contradicting these determinations
				in any action arising in this subrule:
a. All
				requests for determinations as to whether or not services qualify for asset
				protection shall be submitted to the department of human services in writing.
				These requests may include, but are not limited to, requests for determinations
				in the following areas:
(1) Whether the
				insured event has occurred and has been adequately documented.
(2) Whether a care plan is
				required.
(3) Whether a revision of
				a care plan is required.
(4)
				Whether a service or services are in accord with the care plan.
(5) Whether a service is of such a nature as
				to qualify for asset protection.
(6) Whether the applicable amount is the
				amount paid by the issuer or the amount charged for the service.