reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.14 - 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 75 - Iowa Individual Health Benefit Plans › Rule 191-75.15 - 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 75 - Iowa Individual Health Benefit Plans › Rule 191-75.16 - Diabetic Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
All carriers shall provide benefits in the standard health
				  benefit plan for the cost associated with equipment, supplies, and education
				  for the treatment of diabetes pursuant to Iowa Code section
				  514C.18.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.17 - 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 75 - Iowa Individual Health Benefit Plans › Rule 191-75.18 - 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 offer
				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 make available 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 chapter
				  514C.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter is intended to implement Iowa Code chapter 514J
				  and the federal Patient Protection and Affordable Care Act,
				  Pub. L. No.
				  111-148 as amended by the federal Health Care and
				  Education Reconciliation Act of 2010,
				  Pub. L. No.
				  111-152, which amends the Public Health Service
				  Act and adopts, in part,
				  42 U.S.C. Section
				  300gg-19. These rules address issues which
				  are unique to the external review process in this state and provide a uniform
				  process for covered persons of health carriers providing health insurance
				  coverage or the covered persons' authorized representatives to request and
				  receive an external review of adverse determinations and final adverse
				  determinations as defined in Iowa Code sections
				  514J.102(1)
				   and
				  514J.102(18)
				   and as referenced in Iowa Code section
				  514J.109(1).
				  Health carriers defined in Iowa Code section
				  514J.102(23),
				  and included in paragraph 76.2(2)
"c"
are subject to these
				  rules.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.2 - Applicable Law and Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The
				rules contained in this chapter shall apply to any health benefit plan as
				defined in Iowa Code section
				514J.102 other than
				those excluded under Iowa Code section 514J.103(2), for any plan that is
				offered or issued by a health carrier as defined in Iowa Code section 514J.102,
				if the plan was issued in Iowa, and if the external review request is filed
				with the commissioner on or after July 1, 2011.
(2) For purposes of this chapter, the
				definitions in Iowa Code chapter 514J shall apply. In addition:
a. For purposes of applying the exemption in
				Iowa Code section
				514J.103(2)
"b,"
"Medicare supplement policy of insurance" shall mean the
				same as "Medicare supplement policy" as defined in rule
				191-37.3 (514D).
b. For purposes of this chapter, the
				definition of "adverse determination" in Iowa Code section
				514J.102 shall
				include experimental or investigational treatment adverse determinations, as
				set forth in Iowa Code section
				514J.109.
c. For purposes of this chapter, the
				definition of "health carrier" may include an employer self-funded plan if the
				employer chooses to opt in to comply with these rules.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.3 - Disclosure Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
The description of external review procedures required by
				  Iowa Code section
				  514J116.
				  shall be in the form of Appendix A or substantially similar language approved
				  by the commissioner.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.4 - External Review Request

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Except for
				requests for expedited review, the covered person or the covered person's
				authorized representative shall submit a written request for external review
				(completed Appendix B) to the commissioner by personal delivery, by mail, by
				fax or by electronic transmission, including a copy of the health carrier's
				written notice containing the final adverse determination, within the time
				periods specified in Iowa Code section
				514J.107(1)
				 or
				514J.109(1),
				as applicable. The request form and notice shall be submitted to the
				commissioner at Iowa Insurance Division, 1963 Bell Avenue, Suite 100, Des
				Moines, Iowa 50315; fax (515)654-6500; or email
iid.marketregulation@iid.iowa.gov
.
(2) Requests for expedited review may be made
				orally to initiate the process, and the commissioner may require submission of
				additional documentation such as physician certifications and medical
				information releases as is deemed practicable under the time
				constraints.
(3) There is no charge
				or fee for submitting a request for external review.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.5 - Communication Between Covered Person, Health Carrier, Independent Review Organization and the Commissioner

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Notices or other communications required by Iowa Code chapter 514J between the
				commissioner, the health carrier and the independent review organization shall
				be by e-mail or facsimile, unless otherwise specified, and shall be documented
				to prove transmission and receipt of the communication.
(2) Notices or other communications required
				by Iowa Code chapter 514J from the commissioner, the health carrier or the
				independent review organization to the covered person shall be by e-mail,
				facsimile or overnight mail, and shall be documented to prove transmission and
				receipt of the communication.
(3)
				The covered person or covered person's representative may provide notifications
				and communications to the health carrier, independent review organization and
				the commissioner as required by Iowa Code chapter 514J by e-mail, facsimile or
				overnight mail, but also may do so by first-class mail or personal
				delivery.
(4) Any time periods or
				deadlines specified in Iowa Code chapter 514J shall commence upon receipt of
				the notice or communication and cease upon the transmission of the subsequent
				notice or communication.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.6 - Assignment of Independent Review Organization by the Commissioner

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The assignment
				by the commissioner of an independent review organization pursuant to Iowa Code
				chapter 514J shall be by rotation among approved independent review
				organizations.
(2) Upon assignment
				by the commissioner of an independent review organization, in addition to
				providing notice to the health carrier and the covered person or covered
				person's representative as required by Iowa Code chapter 514J, the commissioner
				shall provide notice of the assignment to the independent review
				organization.
(3) Within two
				business days of receipt by the independent review organization of notice from
				the commissioner pursuant to subrule 76.6(2), the independent review
				organization shall make a determination of its ability to perform the external
				review and advise the commissioner if the independent review organization is
				unable to perform the review due to conflict of interest or due to lack of
				expertise or qualification for the particular subject matter of the
				review.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.7 - Decision Notification

Current through Register Vol. 47, No. 3, July 24, 2024
The independent review organization shall immediately provide
				  a copy of a draft of the decision to the commissioner for review. The
				  commissioner shall review the draft of the decision to verify that the
				  independent review organization has included in its draft of the decision the
				  requirements set forth in Iowa Code section
				  514J107.,
				  514J108.,
				  or
				  514J109..
				  The commissioner shall make any suggestions for changes to make the draft of
				  the decision comply with the requirements. The independent review organization
				  shall make such required changes within two business days. Once the
				  commissioner determines that the decision meets the requirements of Iowa Code
				  section
				  514J107.,
				  514J108.,
				  or
				  514J109.,
				  as applicable, the independent review organization shall immediately send the
				  decision to the commissioner, the health carrier, and the covered person or
				  covered person's authorized representative. The decision approved by the
				  commissioner shall be delivered by telephone, fax or electronic transmission to
				  the health carrier, the commissioner and the covered person or covered person's
				  authorized representative, and a hard copy of the decision also shall be
				  delivered by mail to the covered person or covered person's authorized
				  representative.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.8 - Health Carrier Information

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Each
				health carrier shall provide to the commissioner the name, title, telephone
				number, fax number and e-mail address of the individual who shall be the health
				carrier's contact person for external review procedures. The carrier's contact
				person or an appointed alternate shall be available to the commissioner during
				the Iowa insurance division's normal business hours, 8 a.m. to 4:30 p.m.,
				Monday through Friday, central time, excluding state holidays. Any change in
				personnel or contact information shall be immediately sent to the
				commissioner.
(2) Each health
				carrier shall make available to the commissioner upon request within five
				business days a detailed description of the process the health carrier has in
				place to ensure compliance with the requirements found in this chapter and in
				Iowa Code chapter 514J. The description shall include:
a. An explanation of how the carrier
				determines when a person has qualified for external review and should receive a
				notice from the carrier, and
b. A
				copy of the notice sent to persons who fall within the scope of the
				law.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.9 - Certification of Independent Review Organization

Current through Register Vol. 47, No. 3, July 24, 2024
(1) In addition to the minimum qualifications
				set forth in Iowa Code section
				514J.112,
				the following minimum standards are required for certification as an
				independent review organization:
a. The
				applicant shall provide a description of the procedures employed to comply with
				Iowa Code section
				514J.112(1)
"a."
b. The
				applicant shall provide the number of reviewers retained by the independent
				review organization and a description of the areas of expertise available from
				such reviewers and the types of cases such reviewers are qualified to
				review.
c. The applicant shall
				provide the names and rÃ©sumÃ©s of all directors, officers, and
				executives of the independent review organization.
d. The applicant shall provide a description
				of the fees to be charged to the carrier by the independent review organization
				for external reviews.
e. The
				applicant shall provide the name of the medical director or health professional
				director responsible for the supervision and oversight of the independent
				review procedure.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.10 - Fees Charged by Independent Review Organizations

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Fees charged by independent review
				organizations shall be reasonable.
(2) A health carrier objecting to the fee
				charged by an independent review organization shall file a written notice with
				the commissioner and the independent review organization indicating the health
				carrier's objections to the fee and the reasons and any documentation for the
				objections.
(3) Five days after
				receipt of the notice, the independent review organization may submit to the
				commissioner written documentation supporting the fee.
(4) If the parties do not come to an
				agreement within 30 days of the initial notice, the commissioner or the
				commissioner's designee shall conduct a review of the fee and submissions and
				issue a written decision within 60 days. Factors to consider in determining
				whether a fee is unreasonable may include the following:
a. The time and labor required to perform the
				independent review;
b. The novelty
				and difficulty of the issues;
c.
				The skill requisite to perform the independent review properly;
d. The customary fee;
e. The experience, reputation and ability of
				the independent review organization and those performing the independent
				review.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Rule 191-76.11 - Penalties

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Independent review organizations.
The commissioner may
				withdraw the approval of an independent review organization for any of the
				following reasons:
a. Failure to maintain the
				minimum standards set forth in Iowa Code sections
				514J111.
				and
				514J112.
				or in subrule 76.9(1).
b. Failure
				to comply with any of the requirements in subrules 76.9(2) through 76.9(5) or
				rule 191-76.10 (514J).
c. Failure
				to meet any time requirements for conducting a standard, an experimental or
				investigational, or an expedited external review.
d. Failure to comply with any other
				requirements set forth in this chapter or in Iowa Code chapter 514J.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Appendix C - Iowa Insurance Division Independent Review Organization External Review Annual Report Form

Current through Register Vol. 47, No. 3, July 24, 2024
(Attach information to this form if
				  necessary.)
External Review Annual Summary for 20__
Each independent review organization (IRO) shall submit upon
				  request of the Commissioner an annual report with information for each health
				  carrier in the aggregate for Iowa on external reviews performed and by type of
				  health benefit plan.
1. IRO name:
Filing date:
2. IRO address:
3. IRO Web site:
4. Name, email address, telephone number and fax number of
				  the person completing this form:
5. Name, title, email address, telephone number and fax
				  number of the person responsible for regulatory compliance and quality of
				  external reviews:
6. Total number of requests for external review received from
				  the Iowa Insurance Division during the reporting period:
7. Number of standard external reviews:
8. Average number of days the IRO required to reach a final
				  decision in standard reviews:
9. Number of expedited reviews completed to a final
				  decision:
10. Average number of days the IRO required to reach a final
				  decision in expedited reviews:
11. Number of medical necessity reviews decided in favor of
				  the health carrier:
Briefly list procedures denied:
12. Number of medical necessity reviews decided in favor of
				  the covered person/patient:
Briefly list procedures approved:
13. Number of experimental/investigational reviews decided in
				  favor of the health carrier:
Briefly list procedures denied:
14. Number of experimental/investigational reviews decided in
				  favor of the covered person/patient:
Briefly list procedures approved:
15. Number of reviews terminated as the result of a
				  reconsideration by the health carrier:
16. Number of reviews terminated by the covered
				  person/patient prior to issuance by the IRO of external review decision:
17. Number of reviews declined due to possible conflict
				  with:
Health carrier:
Covered person/patient:
Health care provider:
Describe possible conflicts of interest:
18. Number of reviews declined due to other reasons not
				  reflected in #17 above:
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Appendix D - Iowa Insurance Division Health Carrier External Review Annual Report Form

Current through Register Vol. 47, No. 3, July 24, 2024
(Attach information to this form if
				  necessary.)
External Review Annual Summary for 20__
Each health carrier shall submit upon request of the
				  Commissioner an annual report with information in the aggregate for Iowa and by
				  type of health benefit plan.
1. Health carrier name:
2. Health carrier address:
3. Health carrier Web site:
4. Name, email address, telephone number and fax number of
				  the person completing this form:
5. Name, title, email address, telephone number and fax
				  number of the person responsible for regulatory compliance:
6. Total number of external review requests of the health
				  carrier's adverse determinations and final adverse determinations received from
				  the Iowa Insurance Division during the reporting period:
7. From the total number of external review requests provided
				  in Question 6, the number of requests determined eligible for an external
				  review:
8. Total number of external review requests resolved and, of
				  those resolved, the number resolved upholding the adverse determination or
				  final adverse determination of the health carrier and the number resolved
				  reversing the adverse determination or final adverse determination of the
				  health carrier:
9. Total number of external review requests that were
				  terminated as the result of a reconsideration by the health carrier of its
				  adverse determination or final adverse determination after the receipt of
				  additional information from the covered person or the covered person's
				  authorized representative:
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 77 - Multiple Employer Welfare Arrangements › Rule 191-77.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter is intended to establish rules for the
				  establishment and registration of multiple employer welfare arrangements that
				  intend to offer an employee welfare benefit plan to, and maintain the plan for,
				  any resident of this state.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 77 - Multiple Employer Welfare Arrangements › Rule 191-77.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
In addition to the definitions set forth in Iowa Code section
				  507A.3, the following definitions shall apply to this chapter:
"Association health plan"
or
"AHP"
means a group health plan or an employee welfare benefit
				  plan established by a bona fide group or association of employers.
"Authorized representative"
means an
				  individual designated by a MEWA or AHP to act for the MEWA or AHP in completion
				  of the duties described in this chapter and may include an officer, director or
				  legal representative.
"Beneficiary"
means as it is defined in
				  29
				  U.S.C. Section 1002(8).
"Commissioner"
means the Iowa insurance
				  commissioner or, as delegated by the commissioner, the insurance
				  division.
"Employee"
means as it is defined in
				  29
				  U.S.C. Section 1002(6).
"Employee welfare benefit plan"
means as it
				  is defined in
				  29
				  U.S.C. Section 1002(1).
"Employer member"
means an employer
				  participating in a MEWA or AHP.
"Health coverage"
means a policy or
				  certificate that provides coverage for medical, dental, optical, surgical,
				  hospital, accident and sickness, prescription, or disability benefits or life
				  insurance.
"Insurer"
means as it is defined in Iowa
				  Code section
				  5071(2).
"e."
"MEWA"
means a multiple employer welfare
				  arrangement as defined in
				  29
				  U.S.C. Section 1002(40).
"Participant"
means an enrollee or other
				  beneficiary covered under a MEWA or AHP.
"Person"
means an individual, partnership,
				  joint venture, corporation, mutual company, joint-stock company, trust, estate,
				  unincorporated organization, association, or employee organization, or as
				  "person" is defined in
				  29
				  U.S.C. Section 1002(9).
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 77 - Multiple Employer Welfare Arrangements › Rule 191-77.7 - Agreements and Management Contracts

Current through Register Vol. 47, No. 3, July 24, 2024
Any agreement between the MEWA and any administrator, service
				  company, or other entity shall be made available for review in the office of
				  the commissioner upon request by the commissioner
This rule is intended to implement Iowa Code section
				  507A4..
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 77 - Multiple Employer Welfare Arrangements › Rule 191-77.8 - Examination

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Each MEWA shall
				be subject to examination by the commissioner in accordance with Iowa Code
				chapter 507. Chapter 507 shall govern all aspects of the examination.
(2) The commissioner may make an examination
				of a MEWA as often as the commissioner considers it necessary, but not less
				frequently than once every five years. The expenses of the examination shall be
				assessed against the MEWA being examined in a manner in which expenses of
				examinations are assessed against an insurance company under Iowa Code chapter
				507.
This rule is intended to implement Iowa Code section
				  507A.4.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 77 - Multiple Employer Welfare Arrangements › Rule 191-77.9 - Trade Practices

Current through Register Vol. 47, No. 3, July 24, 2024
MEWAs are subject to applicable provisions of the unfair
				  trade practices Act, Iowa Code chapter 507B.
This rule is intended to implement Iowa Code section
				  507A4..
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 77 - Multiple Employer Welfare Arrangements › Rule 191-77.10 - Insolvency

Current through Register Vol. 47, No. 3, July 24, 2024
The provisions of Iowa Code chapter 507C shall apply to MEWAs
				  which shall be considered insurers for purposes of that chapter However, a MEWA
				  shall not be subject to Iowa Code chapter 508C.
This rule is intended to implement Iowa Code section
				  507A4..
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 77 - Multiple Employer Welfare Arrangements › Rule 191-77.11 - Suspension or Revocation of Certificate

Current through Register Vol. 47, No. 3, July 24, 2024
The commissioner may sanction a MEWA or suspend or revoke any
				  certificate issued to a MEWA upon any of the following grounds:
1. Failure to comply with any provision of
				these rules or any applicable provision of the Iowa Code;
2. Failure to comply with any lawful order of
				the commissioner;
3. Failure to
				promptly pay lawful benefit claims;
4. Committing an unfair or deceptive act or
				practice;
5. Deterioration of
				financial condition adversely affecting the MEWA's ability to pay
				claims;
6. A finding that the
				application or any necessary forms that have been filed with the division
				contain fraudulent information or omissions;
7. A finding that the MEWA or its
				administrator has misappropriated, converted, illegally withheld, or refused to
				pay over upon proper demand any moneys that belong to a member, a participant,
				or a person otherwise entitled thereto and that have been entrusted to the MEWA
				or its administrator in its fiduciary capacity;
8. Rescinded lAB 9/19/01, effective 10/24/01.
This rule is intended to implement Iowa Code section
				  507A.4.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 78 - Uniform Prescription Drug Information Card › Rule 191-78.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to implement the use of a
				  uniform prescription drug information card or other technology by the providers
				  of third-party payment or prepayment of prescription drug expenses, by the
				  providers' contractors or agents and pharmacy benefit managers, and by
				  administrators of the providers and payors. The purpose of the uniform
				  prescription drug information card or other technology is to benefit patients,
				  insurers, pharmacy benefit managers and pharmacists through enhanced patient
				  convenience and processing of claims for prescription benefits, decreased calls
				  to help desks due to missing or incorrect card information, and improved
				  delivery of prescription benefit services to consumers.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 78 - Uniform Prescription Drug Information Card › Rule 191-78.3 - Implementation

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Cards or other
				technology for prescription claims processing issued by providers,
				administrators, pharmacy benefit managers, and other entities shall contain
				data elements and other required information that is substantially consistent
				with the most recent National Council for Prescription Drug Programs Pharmacy
				ID Card Implementation Guide. The location of the data elements and information
				shall be substantially consistent with the guide, and the cards or other
				technology shall at a minimum contain the following:
a. The BIN number labeled as "BIN" or
				"RxBIN."
b. The processor control
				number labeled as "PCN" or "RxPCN" if required for claims processing.
c. The group identification number labeled as
				"Grp" or "RxGrp" if required for claims processing.
d. The card issuer's identification number if
				available.
e. The cardholder's
				name.
f.The card issuer's name or
				logo.
g. The help desk name and
				telephone number for claims submission, processing and other assistance clearly
				labeled as "Help Desk" or "Pharmacy Service," except that this information may
				be excluded from the card if the name and telephone number is provided
				electronically in a readable manner to the pharmacy computer at the time of
				claims processing and submission. Notwithstanding the foregoing, nothing in
				this rule shall be interpreted to preclude the inclusion of additional data
				elements and information.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 79 - Prior Authorization-prescription Drug Benefits › Rule 191-79.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
These rules implement Iowa Code section
				  50526.
				  as amended by 2015 Iowa Acts, House File 632, section 9, which requires the
				  commissioner to adopt rules to provide for a single prior authorization form
				  and prior authorization process for approval of prescription drug benefits by
				  health carriers and pharmacy benefits managers.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 79 - Prior Authorization-prescription Drug Benefits › Rule 191-79.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
For purposes of this chapter, the definitions found in Iowa
				  Code section
				  50526.
				  as amended by 2015 Iowa Acts, House File 632, section 9, shall apply. In
				  addition, the following definitions shall apply:
"Commissioner "
means the Iowa insurance
				  commissioner.
"Division "
means the Iowa insurance
				  division.
"Exigent"
means circumstances as defined
				  under federal regulations relating to the Affordable Care Act, as provided in
				  45 CFR
				  156122..
"Prescription drug prior authorization "
means requests for preapproval from a payor for specified medications or
				  quantities of medications.
"Qualified health plan "
or
"QHP
				  "
means a health insurance plan under the Affordable Care Act, which
				  is certified by the health insurance marketplace.
"Urgent"
means any claim for medical care or
				  treatment to which the application of time periods that either could seriously
				  jeopardize the life or health of the patient or the ability of the patient to
				  regain maximum function or, in the opinion of the physician or health care
				  professional, as defined in Iowa Code chapter 514J, with knowledge of the
				  patient's medical condition, would subject the patient to severe pain that
				  cannot be adequately managed without the care or treatment that is the subject
				  of the claim.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 79 - Prior Authorization-prescription Drug Benefits › Rule 191-79.3 - Prior Authorization Protocols

Current through Register Vol. 47, No. 3, July 24, 2024
All health carriers, health benefit plans and pharmacy
				  benefits managers must accept the approved prior authorization form from health
				  care providers.
(1)
Duration of
				approved prior authorization request.
Health carriers, health benefit
				plans, and pharmacy benefits managers shall provide that approval of a prior
				authorization request shall be valid for a minimum of 12 months or for a
				duration that is clinically appropriate for the condition being treated, in
				accordance with the rules adopted pursuant to Iowa Code section
				505.26.
				Updates on disease progression must be provided with each renewal
				request.
(2)
Posting of
				prior authorization form.
The approved prior authorization form shall
				be made available electronically on the website of the division and on the
				website of each health carrier, health benefit plan or pharmacy benefits
				manager that uses the form. Health carriers, health benefit plans and pharmacy
				benefits managers shall allow health care providers to submit a prior
				authorization request electronically.
(3)
Assignment of identification
				number.
The health carrier, health benefit plan or pharmacy benefits
				manager shall assign to each prior authorization request a unique electronic
				identification number that a provider may use during the prior authorization
				process to track the request electronically, through a call center, or by fax.
				This unique identifier may include a format that consists of a patient's first
				name, last name and date of birth.
(4)
Posting of required
				information.
Health carriers, health benefit plans, and pharmacy
				benefits managers shall make the following available and accessible on their
				Internet sites:
a. Prior authorization
				requirements and restrictions, including a list of drugs that require prior
				authorization.
b. Clinical criteria
				that are easily understandable to health care providers, including clinical
				criteria for reauthorization of a previously approved drug after the prior
				authorization period has expired.
c. Standards for submitting and considering
				requests, including evidence-based guidelines, when possible, for making prior
				authorization determinations.
d.
				Health carriers shall provide a process for health care providers to appeal a
				prior authorization determination as provided in Iowa Code chapter 514J.
				Pharmacy benefits managers shall provide a process for health care providers to
				appeal a prior authorization determination that is consistent with the process
				provided in Iowa Code chapter 514J. Appeal standards as provided in Iowa Code
				chapter 514J are set out in Appendix A herein.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 79 - Prior Authorization-prescription Drug Benefits › Rule 191-79.4 - Filing With the Division

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A prior
				authorization form approved by the commissioner shall meet all of the following
				requirements:
a. Not exceed two pages in
				length, except that a prior authorization form may exceed that length as
				determined to be appropriate by the commissioner. Exceptions to the two-page
				limit shall consider clinical differences and complexity of the requested
				prescription drugs.
b. Be available
				in electronic format.
c. Be
				transmissible in an electronic format or a fax transmission.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 79 - Prior Authorization-prescription Drug Benefits › Rule 191-79.5 - Violations

Current through Register Vol. 47, No. 3, July 24, 2024
A health carrier, health benefit plan or pharmacy benefits
				  manager found after hearing to have violated a provision of this chapter shall
				  be subject to the penalties set forth in Iowa Code chapter
				  505.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 80 - Well-child Care › Rule 191-80.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to set forth those
				  requirements deemed appropriate by the commissioner for the general provision
				  of coverage for benefits for routine well-child care.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 80 - Well-child Care › Rule 191-80.2 - Applicability and Scope

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter shall apply to all group accident and sickness
				  insurance, group nonprofit health service plans and prepaid group plans of
				  health maintenance organizations delivered or issued for delivery in this state
				  after March 1, 1993. However, this chapter shall not apply to those basic
				  benefit policies approved under Iowa Code chapter 513C.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 80 - Well-child Care › Rule 191-80.3 - Effective Date

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter shall be effective on July 2, 1993, and shall be
				  applicable to all new filings of group accident and sickness insurance, group
				  nonprofit health service plans and prepaid group plans of health maintenance
				  organizations made after that date and all other policies and contracts covered
				  by this chapter delivered or issued for delivery prior to July 2, 1993, upon
				  the date of renewal.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 80 - Well-child Care › Rule 191-80.4 - Policy Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
No group accident and sickness insurance, group nonprofit
				  health service plan or prepaid group plan of a health maintenance organization
				  delivered or issued for delivery in this state shall contain definitions
				  respecting the matters set forth unless such definitions comply with the
				  requirements of this rule.
(1)
"Well-child care"
means pediatric preventive services
				appropriate to the age of a child from birth to age seven as defined by current
				Recommendations for Preventive Pediatric Health Care of the American Academy of
				Pediatrics. The Recommendations may be obtained by contacting the American
				Academy of Pediatrics at 141 Northwest Point Boulevard, P.O. Box 927, Elk Grove
				Village, Illinois 60009-0927. Pediatric preventive services shall include, at a
				minimum, a history and complete physical examination as well as developmental
				assessment, anticipatory guidance, immunizations, vision and hearing screening,
				and laboratory services including, but not limited to, screening for lead
				exposure as well as blood levels.
(2)
"Developmental
				assessment"
and
"anticipatory guidance"
mean the
				services described in the Guidelines for Health Supervision II, published by
				and obtainable from the American Academy of Pediatrics.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 80 - Well-child Care › Rule 191-80.5 - Benefit Plan

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Every group
				accident and sickness insurance policy, group nonprofit health service plan or
				prepaid group plan of a health maintenance organization shall provide benefits
				for well-child care for any child covered by the policy or contract at
				approximately the following age intervals: birth, 2 weeks, 2 months, 4 months,
				6 months, 9 months, 12 months, 15 months, 18 months, 24 months or two years,
				three years, four years, five years and six years.
(2) Minimum benefits may be limited to one
				visit payable to one provider for all services provided at each visit cited in
				this rule.
(3) Benefits shall be
				subject to any policy provisions which apply to other services covered by such
				policy, except as set forth in 80.5(5).
(4) This rule does not apply to disability
				income, specified disease, Medicare supplement, hospital indemnity, long-term
				care or trip/travel policies.
(5)
				The provisions of this benefit will supersede any deductible
				requirements.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 81 - Postdelivery Benefits and Care › Rule 191-81.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to implement Iowa Code section
				  514C12.,
				  thereby setting forth those requirements deemed appropriate by the commissioner
				  for the general provision of coverage for benefits for routine well-child
				  care.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 81 - Postdelivery Benefits and Care › Rule 191-81.2 - Applicability and Scope

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter shall apply to all individual or group accident
				  and health insurance, individual or group hospital or health care service
				  contracts issued pursuant to Iowa Code chapter 509, 509A, 514, or 514A, and
				  individual or group health maintenance organization contracts issued and
				  regulated under chapter 514B, which are delivered, amended, or renewed on or
				  after July 1, 1996.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 81 - Postdelivery Benefits and Care › Rule 191-81.3 - Postdelivery Benefits

Current through Register Vol. 47, No. 3, July 24, 2024
Every person issuing contracts under the scope of this
				  chapter providing maternity benefits, which are not limited to complications of
				  pregnancy, or newborn care benefits, shall not terminate inpatient benefits or
				  require discharge of a mother or the newborn from a hospital following delivery
				  earlier than determined to be medically appropriate by the attending physician
				  after consultation with the mother and in accordance with the most recent
				  edition of the Guidelines for Perinatal Care, by the American Academy of
				  Pediatrics and the American College of Obstetricians and Gynecologists, which
				  provide that when complications are not present, the postpartum hospital stay
				  ranges from a minimum of 48 hours for a vaginal delivery to a minimum of 96
				  hours for a Cesarean birth, excluding the day of delivery. In accordance with
				  those guidelines, in the event of a discharge from the hospital prior to the
				  minimum stay established in the guidelines, a postdischarge follow-up visit
				  shall be provided to the mother and newborn by providers competent in
				  postpartum care and newborn assessment if determined medically appropriate as
				  directed by the attending physician. Copies of this publication may be obtained
				  through the Iowa Insurance Division, 1963 Bell Avenue, Suite 100, Des Moines,
				  Iowa 50315, telephone (515)654-6600.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 85 - Regulation of Navigators › Rule 191-85.1 - Purpose and Authority

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The
				purpose of these rules is to set out the requirements, procedures and fees
				relating to the qualification, licensure, training, continuing education and
				regulation of navigators.
(2)
				These rules are established based upon the authority provided in Iowa Code
				sections
				5058(19).
				and
				522D10..
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 85 - Regulation of Navigators › Rule 191-85.3 - Requirement to Hold a License

Current through Register Vol. 47, No. 3, July 24, 2024
No person may act as a navigator in Iowa until that person
				  has been issued an Iowa navigator license.
(1) To be licensed as a navigator, a person
				must satisfy the following requirements:
a. Be
				at least 18 years of age;
b.
				Demonstrate compliance with the initial training and certification requirements
				set forth in rule
				191-8510.
				(505,522D);
c. Have not committed
				any act that is grounds for denial, suspension or revocation under Iowa Code
				section
				522D7.;
d. Submit a completed uniform
				application;
e. Pass an examination
				on the duties and responsibilities of a navigator and the insurance laws and
				regulations of Iowa with a score of 70 percent or higher;
f. Pay the nonrefundable navigator license
				fee of $20; and
g. Pass a
				background check or security screening.
Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 85 - Regulation of Navigators › Rule 191-85.4 - Issuance of License

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A person
				that meets the requirements of this chapter and of Iowa Code sections
				522D4. and
				522D5.,
				unless otherwise denied licensure pursuant to Iowa Code section
				522D7.,
				shall be issued a navigator license. A navigator license shall be valid for
				three years. A navigator license remains in effect unless revoked or suspended
				as long as all required fees are paid and continuing education requirements are
				met. A renewal term is three years. If not renewed, a navigator license
				automatically terminates on the last day of the month of the initial or renewal
				term.
(2) An individual navigator
				whose license has expired may seek reinstatement as set forth in rule
				191-856.
				(505,522D).
(3) The license shall
				contain the navigator's name and address, the date of issuance, the date of
				expiration and any other information the division deems necessary.
(4) If the division issues or renews a
				navigator license and subsequently determines that payment for the license or
				renewal was returned without payment to the division by a bank, or that the
				credit card company does not approve or cancels or refuses amounts charged to
				the credit card, the license shall be immediately suspended until the payments
				are made and any fees or penalties charged by the division are paid, at which
				time the license may be reinstated. The individual may request a hearing within
				30 days of receipt of notice by the division that the license was
				suspended.