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Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.11 - Reporting on Asset Protection

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Each issuer shall send an asset protection report at least quarterly to each
				policyholder or certificate holder who has received any benefits since the last
				asset protection report sent to the policyholder or certificate holder Each
				asset protection report shall include the following information:
a. The amount of asset protection for which
				the policyholder or certificate holder had qualified prior to the quarter
				covered by the report.
b. The total
				benefits paid by the issuer for services rendered during the quarter.
c. A statement of the amount of benefits paid
				by the issuer for services rendered during the quarter which qualify for asset
				protection.
d. A summary total of
				the amount paid to date under the policy or certificate which qualifies for
				asset protection.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.12 - Preparing a Service Summary

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				Each issuer shall prepare a service summary at the client's request
				specifically for the policyholder or certificate holder applying for Medicaid.
				The issuer shall also prepare a service summary when the policyholder or
				certificate holder has exhausted benefits under the policy or certificate or
				when the policy or certificate ceases to be in force for a reason other than
				the death of the policyholder or certificate holder, whichever occurs
				first.
(2) The service summary
				shall identify the following:
a. The specific
				qualified policy or certificate.
b.
				The total benefits paid for services rendered to date.
c. The amount qualifying for asset
				protection.
This service summary is separate and in addition to any other
				  information requirement in this chapter.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.13 - Plan of Action

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Each issuer
				shall, prior to qualification by the division of insurance, submit to the
				department of human services a plan for complying with the information
				maintenance and documentation requirements set forth in rules
				191-72.9 (514H) and
				191-72.10 (514H). No policy or
				certificate shall be qualified until the department of human services has
				approved the issuer's documentation plan for the policy or certificate. The
				documentation plan will include the following:
a. The location where records will be kept.
				Records required for purposes of the Iowa long-term care asset preservation
				program must be available at no more than three locations, each of which shall
				be easily accessible to the division of insurance.
b. The issuer shall agree to give the
				commissioner access to all information described in rule
				191-72.10 (514H) on an aggregate
				basis for all policyholders or certificate holders and on an individual basis
				for all policyholders or certificate holders who have ever received any
				benefits. Access to information on persons who have not applied for Medicaid is
				required in order for the commissioner to determine if an issuer's system for
				documenting asset protection is functioning correctly. The commissioner shall
				have the final decision concerning the frequency of access to the data and the
				size of samples for auditing or other purposes.
c. The name, job title, address, and
				telephone number of the person primarily responsible for the maintenance of the
				information required and for acting as liaison with the department of human
				services and the division of insurance concerning the information.
d. Methods for determining when insurance
				benefits or prepaid benefits qualify for asset protection, including the
				following:
(1) Documentation of the insured
				event.
(2) Description of
				services.
(3) Documentation of
				charges and benefits paid.
(4)
				Documentation of plans of care, when required.
e. Description of electronic and manual
				systems which will be used in maintaining the required information.
f. Information that will be retained which is
				needed to comply with this rule.
g.
				Copies of forms and descriptions of standard procedures for maintaining and
				reporting the information required, including the specific electronic medium
				which will be used to report required information and a description of the
				relevant files.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 72 - Long-term Care Asset Preservation Program › Rule 191-72.15 - Separability

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 for any reason held to be invalid or
				  unenforceable, the remainder of the chapter and the application of such
				  provision to other persons or circumstances shall not be affected
				  thereby.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to implement 1993 Iowa Acts,
				  chapter 158, section 2, authorizing the creation of privately established and
				  operated health insurance purchasing cooperatives, subject to regulation by the
				  division of insurance. The purpose of the health insurance purchasing
				  cooperatives is to improve the quality, access, and affordability of health
				  care by more effectively representing the interests of buyers and consumers and
				  creating a value conscious market. Health insurance purchasing cooperatives as
				  described in the Insurance Division's oral and written briefings, the Pooled
				  Purchasing Group Subcommittee Report, and Jackson Hole papers relied upon by
				  the legislature effectively organize buyers of insurance, risk management, and
				  health care services to negotiate price and quality with sellers of insurance,
				  risk management, and health care services, whether the sellers are organized as
				  insurance companies, health maintenance organizations, or other legally
				  permissible structures.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.2 - Applicability and Scope

Current through Register Vol. 47, No. 3, July 24, 2024
(1) This
				chapter shall apply to all health insurance purchasing cooperatives operating
				in this state. However, this chapter shall not apply to any other health
				insurance or health care marketing, distribution or purchasing mechanism
				otherwise permitted by law.
(2) A
				health insurance purchasing cooperative under this chapter is exempt from any
				law in this state relating to the creation of groups for the purchase of
				insurance, prohibition of group purchasing, or any law that discriminates
				against a purchasing group or its members. An insurer is exempt from any law of
				the state that prohibits providing or offering to provide, to a purchasing
				group or its members, advantages based upon their loss and expense experience
				not afforded to other persons with respect to rates, policy forms, coverage, or
				other matters. A purchasing group is subject to all other applicable laws of
				this state including Iowa Code chapter 522.
(3) An entity not approved by the division as
				a HIPC and engaged in the purchase, sale, marketing or distribution of health
				insurance or health care plans shall not hold itself out as a HIPC, health
				insurance purchasing cooperative, purchasing cooperative, or otherwise use a
				confusingly similar name or marketing materials; and a nonapproved entity that
				does so shall be in violation of this chapter and subject to penalties under
				Iowa Code chapter 507B. This subrule is not intended to restrict the activities
				of a purchasing coalition of ERISA-qualified, self-funded employers engaged in
				the purchase of health care from providers on a nonrisk-bearing
				basis.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.3 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
As used in this chapter:
"Adjusted community rating"
means a method
				  used to develop a carrier's premiums which spreads financial risk across a
				  large population and allows adjustments only for certain demographic factors
				  and family composition as provided by state law for insurance carriers
				  providing services to the same consumer or as otherwise approved by the
				  commissioner to accommodate the unique characteristics of a health insurance
				  purchasing cooperative.
"Business plan"
means the plan of operation
				  of the health insurance purchasing cooperative.
"Carrier"
means any entity that provides
				  health benefit plans in this state. For purposes of this chapter, carrier
				  includes an insurance company, a hospital or medical service corporation, a
				  fraternal benefit society, a health maintenance organization, and any other
				  entity providing a plan of health insurance or health benefits subject to state
				  regulation.
"Commissioner"
means the commissioner of
				  insurance for the state of Iowa.
"Division"
means the insurance division of
				  the state of Iowa.
"Health insurance purchasing cooperative"
means a group of individuals, a group of employers and employees, or a
				  combination of individuals and employers and employees who join together to
				  purchase health insurance or health care benefits.
"HIPC"
means health insurance purchasing
				  cooperative. This acronym shall be used interchangeably with the words "health
				  insurance purchasing cooperative" throughout this chapter.
"HIPC administrator"
means a person or
				  organization charged with overseeing the day-to-day operations of a
				  HIPC.
"HIPC sponsor"
means an employer, group of
				  employers, or private agent authorized under this chapter to facilitate the
				  purchase of insurance and health care services for participating employers and
				  employees.
"Service territory"
means any of the
				  following:
1. A regional HIPC as identified by the commissioner. A
				  regional HIPC serves a defined regional market which shall at minimum include
				  the surrounding rural market of any city included in the regional HIPC.
2. A statewide HIPC as identified by the commissioner shall
				  offer service throughout the state. A statewide HIPC may establish regional
				  service areas, governance and negotiations, provided those structures conform
				  to the provisions of paragraph "1."
"Small employer"
means an employer as
				  defined in Iowa Code section
				  513B2..
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.5 - Fidelity Bond-letter of Credit

Current through Register Vol. 47, No. 3, July 24, 2024
A HIPC shall maintain in force a fidelity bond on
				  administrators, employees and officers in an amount not less than $1,000,000 or
				  such greater sum as may be prescribed by the commissioner The fidelity bond
				  shall be in the form prescribed by the commissioner In the event a HIPC employs
				  a contract administrator, the administrator shall maintain a $250,000 letter of
				  credit for the life of the contract payable to the HIPC sponsor. This letter of
				  credit shall be in addition to the fidelity bond.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.6 - Annual Report

Current through Register Vol. 47, No. 3, July 24, 2024
The commissioner shall submit an annual report to the general
				  assembly no later than February 1 of each year. The report shall include a
				  description of the operations of all health insurance purchasing cooperatives,
				  a review of the success of health insurance purchasing cooperatives as it
				  pertains to improving the quality, access or affordability of health insurance.
				  The commissioner may require HIPCs to provide information in uniform format for
				  use in compliance with this report and for other public
				  purposes.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.8 - Participants

Current through Register Vol. 47, No. 3, July 24, 2024
A HIPC may offer services to any of the following
				  participants:
1.
				Individuals.
2. A small business as
				defined in 191-Chapter 71.
3. A
				business with more than 50 employees.
4. An association and its members.
5. The state or a local government
				unit.
6. Any other purchaser on a
				voluntary basis.
Underwriting standards shall be no more restrictive than
				  required of small group health insurance under 191-Chapter 71.
A HIPC's business plan may impose conditions or limitations
				  on members leaving the HIPC to protect against adverse selection. A HIPC shall
				  accept all entities within its chosen market segment in accordance with the
				  regulations governing marketing of insurance to that market segment, e.g.,
				  individual, small group, or large group.
A HIPC may provide services to participants out-of-state or
				  out-of-region who elect to join for the benefit of representation and
				  participation in health insurance or health care benefits only when an employer
				  out-of-state or out-of-region has employees within the state or region or an
				  individual is required to have coverage in the state or region due to specific
				  circumstance.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.9 - Health Insurance Purchasing Cooperative-product Offerings-exemptions

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A HIPC shall
				offer at least one indemnity plan which provides an unrestricted choice of a
				physician. However, the indemnity plan may require an appropriate utilization
				review, preauthorization of treatments, or other reasonable cost and
				utilization oversight.
(2) All
				small employer group carriers participating in a HIPC shall offer a basic and a
				standard benefit plan.
(3) A HIPC
				is not required but may offer an employer-choice managed health care plan. The
				HIPC may also offer other indemnity plans.
(4) A HIPC cannot offer insurance from a risk
				retention group not chartered in the state nor a carrier not admitted in the
				state.
(5) A HIPC shall retain
				agents who are licensed pursuant to Iowa law if the HIPC markets the products
				of the HIPC through agents or sales representatives. Alternatively, if the HIPC
				does not use sales agents or representatives, the HIPC must demonstrate to the
				satisfaction of the commissioner that the alternative will provide consumer
				service meeting the same standards as that required of agents.
(6) A participating health plan is not
				required to be offered outside of the HIPC but may be offered through other
				distribution or marketing channels. An entity may not be licensed as a HIPC if
				it offers only one health plan or the products of only one carrier, or related
				carriers.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.10 - Insurance Risk

Current through Register Vol. 47, No. 3, July 24, 2024
A HIPC shall bear no insurance risk. The HIPC shall
				  facilitate the purchase of insurance and health care services. Provisions for
				  participants to retain risk through deductibles, retention levels, or partial
				  or complete self-funding shall be disclosed and shall be subject to approval by
				  the commissioner prior to implementation to ensure that risk is not borne by
				  the HIPC.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.11 - Rates

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A carrier shall
				use rate restrictions and regulations applicable to each market
				segment.
(2) The HIPC may collect a
				different premium within the HIPC. This difference is predicated on marketing
				and administrative expenses which the HIPC would assume. Therefore, the carrier
				could offer the HIPC a lower final rate than the carrier would charge outside
				of the HIPC.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.12 - Election-disclosure and Confidentiality

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				A HIPC may elect to preclude for a period of time a participant who leaves the
				HIPC from returning to the HIPC to purchase health insurance or health care
				benefits. However, a HIPC shall not use this subrule to discriminate against
				high-risk participants.
(2) Subject
				to review and approval by the commissioner, a HIPC may provide restricted
				access to information in its possession which is essential to the operation of
				the HIPC.
Confidentiality must:
a. Be an inducement for voluntary
				participation in the program;
b.
				Protect the privacy of participants;
c. Protect negotiating strategy from
				disclosure to contractors or competitors; or
d. Protect proprietary information in like
				circumstances as for insurance.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.13 - Structure-merger and Consolidation

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				A HIPC shall be a legal entity which operates on behalf of its sponsor or
				participants.
(2) A HIPC shall
				disclose its total administrative cost in its annual report to the commissioner
				in the same manner and on the same basis as insurance carriers.
(3) The change in control, merger or
				acquisition of a HIPC is subject to the prior review and approval of the
				commissioner on the same terms as a change in control, merger or acquisition of
				an Iowa domestic insurance company.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.14 - Conflict of Interest

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Health care
				providers or insurers offering competing products within the same service
				territory shall not participate in a HIPC as a sponsor A HIPC sponsor employing
				a HIPC administrator that offers competing products within the same service
				territory shall demonstrate to the satisfaction of the commissioner precautions
				to protect the HIPC from unfair competition or disclosure of proprietary
				information.
(2) A HIPC sponsor
				shall not be an employee or be affiliated with or a subsidiary of a health care
				provider or insurer offering competing products within the same service
				territory.
(3) The employees of a
				health care provider or insurer may receive services through a HIPC. The
				employer may vote in corporate governance elections of officers and directors.
				However, a health care provider or insurer or an employee of a health care
				provider or insurer may not serve as an officer of a HIPC. A health care
				provider or insurer or the employee of a health care provider or insurer may be
				a director of a HIPC or HIPC sponsor, but such persons shall not constitute a
				majority of the governing board or body of a HIPC or HIPC sponsor
(4) Compensation to the HIPC's sponsor,
				administrator, or agents shall not vary based upon the plan selected by
				participating members.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.15 - Nondiscrimination and Retaliatory Protections

Current through Register Vol. 47, No. 3, July 24, 2024
An insurer shall not discriminate against or take retaliatory
				  action against a participant employer, employee, agent, sponsor, or
				  administrator of a HIPC. A HIPC shall not discriminate against or take
				  retaliatory actions against an insurer or agent for activities relating to the
				  HIPC.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.16 - Annual Health Insurance or Health Care Benefits Plan Selection

Current through Register Vol. 47, No. 3, July 24, 2024
A HIPC shall offer participants an opportunity at least once
				  annually to change health insurance or health care benefits. The HIPC shall
				  determine whether the change in health insurance or health care benefits may be
				  made by the individual employees of an employer participant or by the employer
				  participant on behalf of the employer's employees. The HIPC shall provide
				  pertinent available information including cost and quality of risk management
				  services on health insurance and health care benefits offered to assist the
				  participants in making an informed decision in the selection of health
				  insurance or health care benefits.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.17 - License Subject to Conditions-waivers

Current through Register Vol. 47, No. 3, July 24, 2024
A new participating buyer shall join when the plan is offered
				  to them or at the annual open enrollment.
(1) The commissioner may limit the number of
				HIPCs licensed within a geographic service territory. A HIPC must demonstrate
				probable success in representing a substantial share of the purchasers within
				the proposed service territory and that it is likely to largely represent
				purchasers not already served by existing HIPCs within the same service
				territory. The commissioner may refuse to renew or condition the license of a
				HIPC that fails in actual operations to achieve these requirements.
(2) Existing HIPCs may present evidence of
				the anticipated impact of a new HIPC within their geographic service territory
				to resist an additional licensee. This shall include but is not limited to
				evidence that the new HIPC will use risk selection against an existing HIPC and
				the new HIPC will adversely dilute the market leverage of an existing HIPC. The
				division shall provide notice to existing HIPCs of an applicant's filing.
				Existing HIPCs must file notice of intent to submit evidence within ten days of
				the notice. Existing HIPCs may request a hearing or submit evidence in
				writing.
(3) The commissioner may
				impose risk adjustments between HIPCs within a geographic service area or
				between all HIPCs within the state to ensure competition based upon service and
				effective cost and quality control and not based upon risk selection.
(4) The commissioner may impose additional
				conditions to protect the interests of participating buyers and consumers,
				ensure fair and efficient conduct of HIPC duties, and to protect HIPCs from
				adverse selection or bearing insurance risk.
(5) The commissioner may impose additional
				conditions or waive restrictions for a specified period of time to facilitate
				orderly market transition to reform upon a showing of necessity by the
				applicant HIPC or upon the commissioner's own initiative.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.19 - Data Collection-quality Evaluation

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The HIPC shall conform to any pertinent
				reporting provisions of the community health management information
				system.
(2) A HIPC shall conduct a
				qualitative review of plans offered through the HIPC in order to provide
				participating employers and employees an accurate comparative analysis of cost,
				quality, access, relative value, service, and customer satisfaction. The
				division may require HIPCs to cooperate in establishing a common basis and
				methodology for plan evaluation and customer education to facilitate informed
				choice between plans. A HIPC shall detail in its proposed business plan the
				methodologies and resources it intends to employ to satisfy this requirement.
				The HIPC must produce an annual report card on the performance of participating
				plans.
(3) The division may
				establish data reporting standards to permit the objective evaluation of HIPCs
				and their impact on health care costs, quality and access.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.20 - Examination-costs

Current through Register Vol. 47, No. 3, July 24, 2024
The commissioner shall examine a HIPC and may require the
				  most recent audited financial statements from the administrator and such other
				  interim evidence as the commissioner deems appropriate. Reasonable costs of the
				  examination or audit are to be paid by the HIPC. Examination shall include, but
				  not be limited to, premium collection, marketing practices, and financial
				  condition.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.22 - Grounds for Denial, Nonrenewal, Suspension or Revocation of Certificate

Current through Register Vol. 47, No. 3, July 24, 2024
The following constitute grounds for denial, nonrenewal,
				  suspension or revocation of the HIPC's certificate following notice and an
				  opportunity for hearing:
1. Failure to
				comply with any provisions of the rules of this chapter;
2. Failure to comply with any lawful order of
				the commissioner;
3. Committing an
				unfair or deceptive act or practice as defined in Iowa Code chapter
				507B;
4. Filing any necessary form
				with the division which contains fraudulent information or omission;
5. Misappropriation, conversion, illegal
				withholding, or refusal to pay over upon proper demand any moneys that belong
				to a person or health care carrier otherwise not entitled to the HIPC and that
				have been entrusted to the HIPC in its fiduciary capacity;
6. Failure to demonstrate through clear and
				convincing evidence that it will extend HIPC services to a significant group of
				buyers not currently being served by a HIPC; or
7. Failure to demonstrate through clear and
				convincing evidence that it will reduce the cost, improve the quality, and
				improve access to or choice of affordable health insurance or health care
				services.
In addition, the application for certification to be a HIPC
				  may be denied upon a finding by the commissioner that a sufficient number of
				  HIPCs are licensed within a geographic service area and an additional HIPC
				  would adversely affect existing HIPCs.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.23 - Hearing and Appeal

Current through Register Vol. 47, No. 3, July 24, 2024
Prior to denying an application or a renewal application or
				  suspending or revoking a certificate issued under this chapter, a certificate
				  holder shall be provided with written notice of the commissioner's decision and
				  provided an opportunity for a hearing and a right to appeal as provided in rule
				  191-31.
				  (17A,502,505) and Iowa Code chapter 17A.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 73 - Health Insurance Purchasing Cooperatives › Rule 191-73.24 - Solvency

Current through Register Vol. 47, No. 3, July 24, 2024
In the event a HIPC becomes insolvent, the division shall
				  maintain jurisdiction of the HIPC for purposes of protection of the interests
				  of the HIPC participants and the health insurance carriers and health benefit
				  plans pursuant to the pertinent sections of Iowa Code chapter
				  507C.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 74 - Health Care Access › Rule 191-74.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
The purpose of this chapter is to implement Iowa Code section
				  50521.
				  requiring an employer to provide access to health care or health insurance to
				  an employer's eligible employees. The employer shall, at a minimum, make health
				  care information or health insurance information available to the employer's
				  eligible employees by a written referral. However, the employer may also
				  satisfy the health care access requirement by offering or paying for health
				  care or health insurance.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 74 - Health Care Access › Rule 191-74.3 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
As used in this chapter:
(1)
"Division"
means the
				insurance division of the state of Iowa.
(2)
"Eligible employee"
means a natural person who is employed in this state for wages by an employer
				and works on a regular full-time or regular part-time basis. An eligible
				employee may include a commission salesperson who takes orders or performs
				services on behalf of a principal and who is paid on the basis of commissions
				but does not include persons who purchase for their own account for resale.
For purposes of this chapter:
a. An eligible employee does not include a
				temporary employee which means an employee who works for a limited period of
				time, or an employee with seasonal, intermittent, internship, trainee, or
				temporary status.
b. A minor as
				defined in Iowa Code chapter 599 is not an eligible employee.
c. The following persons engaged in
				agriculture are not eligible employees:
(1)
				The spouse of the employer and relatives of either the employer or spouse
				including relatives employed by a family farm corporation, a family farm
				partnership or family farm limited liability company.
(2) A person engaged in agriculture as an
				owner-operator or tenant-operator and the spouse or relatives of
				either
(3) Neighboring persons
				engaged in agriculture who are exchanging labor or other services.
d. An independent contractor is
				not an eligible employee.
e. An
				individual working in vocational rehabilitation programs and receiving health
				care coverage through governmental programs is not an eligible
				employee.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 74 - Health Care Access › Rule 191-74.4 - Access to Health Care or Health Insurance for an Employee.

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Access to
				health care or health insurance means any of the following:
a. An employer provides a written referral to
				an eligible employee as to where the eligible employee can receive information
				concerning health care or health insurance.
b. An employer offers coverage or contributes
				to health insurance or a health benefit plan.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 74 - Health Care Access › Rule 191-74.5 - Employer Participation

Current through Register Vol. 47, No. 3, July 24, 2024
The employer shall offer payroll deduction of the eligible
				  employee's contributions to the health care program or health insurance program
				  to which the employer referred the eligible employee. However, payroll
				  deduction shall occur only if the eligible employee has adequate wages to pay
				  the cost of the health care or health insurance. In the event that the
				  insurance carrier or health care organization does not provide for payment
				  through payroll deduction, an automatic withdrawal from the employee's savings
				  or checking account shall comply with Iowa Code section
				  50521..
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 74 - Health Care Access › Rule 191-74.6 - Violation of Chapter

Current through Register Vol. 47, No. 3, July 24, 2024
A violation of this chapter may be reported to the market
				  regulation bureau of the division. The division, upon finding that the employer
				  has failed to offer an eligible employee access to health care or health
				  insurance, may do any of the following:
1. Issue a cease and desist order instructing
				the employer to cure the failure to provide access to health care and desist
				from future violations of this chapter.
2. Issue an order requiring the employer who
				has previously been the subject of a cease and desist order to pay an eligible
				employee's reasonable health insurance premiums necessary to prevent or cure a
				lapse in health care coverage due to the employer's failure to offer access to
				health care.
3. Assess the
				reasonable costs of the division's investigation and enforcement to the
				employer.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.1 - Purpose

Current through Register Vol. 47, No. 3, July 24, 2024
This chapter is intended to implement the provisions of Iowa
				  Code chapter 513C to promote the availability of health insurance coverage to
				  individuals, regardless of their health status or claims experience; to prevent
				  abusive rating practices; to require disclosure of rating practices to
				  purchasers; to establish rules regarding the renewal of coverage; to establish
				  limitations on the use of preexisting condition exclusions; to assure fair
				  access to health benefit plans; to improve the overall fairness and efficiency
				  of the individual health insurance market; and to provide for development of
				  "basic" and "standard" health insurance plans to be offered to individuals.
				  Carriers that provide individual health insurance benefit plans, as that term
				  is defined in Iowa Code chapter 513C, to individuals are subject to all
				  provisions of chapter 513C and this Chapter 75.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
As used in this chapter:
"Eligible resident"
means an individual who
				  has been legally domiciled in this state for a period of 60 days. For purposes
				  of this chapter, legal domicile is established by living in this state and
				  obtaining an Iowa motor vehicle operator's license, registering to vote in
				  Iowa, or filing an Iowa income tax return. A child is legally domiciled in this
				  state if the child lives in this state and if at least one of the child's
				  parents or the child's guardian is legally domiciled in this state for a period
				  of 60 days. A person with a developmental disability or another disability
				  which prevents the person from obtaining an Iowa motor vehicle operator's
				  license, registering to vote in Iowa, or filing an Iowa income tax return, is
				  legally domiciled in this state by living in the state for 60 days.
"Insured group health plan"
as that term is
				  referenced in Iowa Code section
				  513C.3 includes a
				  health benefit plan offered directly through an employer with two or more
				  employees and a plan offered through an employer with two or more employees
				  under a group discretionary trust or association plan.
"Risk characteristic"
means the health
				  status, claims experience or any similar characteristic related to the health
				  status or experience of an individual under a health benefit plan.
"Risk load"
means the percentage above the
				  applicable base premium rate that is charged by a carrier to an individual to
				  reflect the risk characteristics of such individual.
Other terms shall be defined pursuant to Iowa Code chapter
				  513C.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.3 - Applicability and Scope

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Except
				as otherwise specifically provided, this chapter shall apply to any individual
				health benefit plan applied for on or after April 1, 1996.
(2) Iowa Code chapter 513C and this chapter
				shall apply to an individual health benefit plan provided to an eligible
				individual.
(3) An entity that is
				not operating as an individual health benefit plan carrier in this state shall
				not become subject to the provisions of the Act and this rule solely because an
				individual that was issued a health benefit plan in another state by that
				entity becomes a resident of this state.
(4) This chapter shall not apply to health
				insurance policies or certificates that are subject to Iowa Code chapter
				513B.
(5) Except for basic or
				standard health benefit plans, nothing in Iowa Code chapter 513C or this
				chapter is applicable to underwriting practices, substandard ratings, or the
				addition of waivers or riders to policies or certificates.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.4 - Establishment of Blocks of Business

Current through Register Vol. 47, No. 3, July 24, 2024
A carrier shall file with the commissioner the following
				  information with respect to each established block of business, as defined in
				  Iowa Code section
				  513C3..
1. A description of each criterion employed
				by the carrier for determining membership in the block of business;
2. A statement describing the justification
				for establishing the block as a separate block of business;
3. A statement disclosing which, if any,
				health benefit plans are currently available for purchase in the block and any
				significant limitations related to the purchase of such plans.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.6 - Restrictions Relating to Premium Rates

Current through Register Vol. 47, No. 3, July 24, 2024
(1) As provided by Iowa Code section
				513C5.,
				each carrier must limit differences in premium due to such factors as
				experience and duration to the composite effect of 20 percent, 30 percent, and
				30 percent. Allocation of cost differences due to experience and duration among
				the categories outlined in Iowa Code section
				513C5.
				may be determined by each carrier.
(2) Nothing in this rule shall require rates
				be filed absent any other statutory requirements.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.7 - Availability of Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Except as
				provided in Iowa Code section
				513C7.,
				the choice between the basic and standard health benefit plans may not be
				limited, restricted or conditioned upon the risk characteristics of the
				individuals or their dependents.
(2) Insurers shall not require eligible
				family members to accept a basic or standard health benefit plan covering all
				family members. Those family members who qualify for an underwritten plan may
				be issued separate coverage from those who do not qualify for the underwritten
				plan but are eligible for guaranteed issue of the basic or standard
				plan.
(3) Qualifying previous
				coverage for a newborn shall be the greater of the period or periods of
				qualifying previous coverage established by either of the newborn's parents
				prior to the date of birth.
(4)
				Benefits paid under a basic or standard health benefit plan shall not duplicate
				benefits paid under any other health insurance coverage. Other coverage means
				benefits paid for hospital, surgical or other medical care or expenses for a
				covered person by any of the following:
a.
				Insurance plan or policy; or
b.
				Health benefit plan; or
c. Welfare
				plan; or
d. Prepayment plan;
				or
e. Hospital service corporation
				plan or policy; or
f. Medicare;
whether provided on an individual, family, or group basis or
				  through an employer, union or association. If such other coverage is on a
				  provision of service basis, the amount of benefits will be the amount that the
				  services provided would have cost without such other coverage.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.8 - Disclosure of Information

Current through Register Vol. 47, No. 3, July 24, 2024
(1) General
				rules. In connection with the offering for sale of a health benefit plan to
				individuals, each carrier shall make a reasonable disclosure, as part of its
				solicitation and sales materials, of the following:
a. The extent to which premium rates for a
				specified individual are established or adjusted in part based upon the actual
				or expected variation in claims costs or the actual or expected variation in
				health conditions of the individual and the individual's dependents, if
				any.
b. The provisions of such plan
				concerning the carrier's ability to change premium rates and the factors, other
				than claim experience, which affect changes in premium rates.
c. The provisions of such plan relating to
				the renewability of policies and contracts.
d. The provisions of such plan relating to
				the effect of any preexisting condition provision. The expression "preexisting
				conditions" shall not be used unless appropriately defined in the policy or
				contract.
e. The availability, upon
				request, of descriptive information about the benefits and premiums available
				under individual health benefit plans offered by the carrier for which the
				individual is qualified. For purposes of Iowa Code section
				513C7.,
				carriers will be permitted to exclude from disclosure of plans those plans
				within the following categories:
(1) Plans
				distributed through a separate marketing channel.
(2) Plans offered through a membership
				association.
(3) Plans offered
				through a trust in which membership is otherwise limited.
(4) Other plans as reviewed and approved by
				the commissioner or director.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.9 - Standards to Ensure Fair Marketing

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A carrier shall make available at least
				one basic and one standard health benefit plan to eligible individuals in this
				state.
(2) The written information
				described in this subrule may be provided directly to the individual or
				delivered through an authorized producer:
a. A
				carrier shall not apply more stringent requirements related to the application
				process for the basic and standard health benefit plans than applied for other
				health benefit plans offered by the carrier.
b. A carrier shall supply a price quote for
				basic or standard plans to an eligible individual upon request.
c. If a carrier denies coverage under a
				health benefit plan to an individual on the basis of a risk characteristic, the
				denial shall be in writing and state with specificity the reasons for the
				denial subject to any restrictions related to confidentiality of medical
				information. The denial shall be accompanied by a written explanation of the
				availability of the basic and standard health benefit plans from the carrier
				and may be combined with the notification requirements of Iowa Code chapter
				514E. The explanation shall include the following information about the basic
				and standard benefit plans:
(1) A general
				description of the benefits and policy provisions contained in each
				plan;
(2) A price quote for each
				plan; and
(3) Information
				describing eligibility and how an eligible individual may enroll in such
				plans.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.11 - Maternity Benefit Rider

Current through Register Vol. 47, No. 3, July 24, 2024
Every individual insurance carrier shall offer an optional
				  maternity benefit rider for the basic and standard health benefit plans
				  providing benefits, as any other illness, for a pregnancy and delivery without
				  complications with a 12-month waiting period. Credit toward meeting the waiting
				  period shall be given for prior coverage of a pregnancy without complications
				  provided there was no more than a 63-day break in coverage. A maternity rider
				  offered under this rule shall only be offered when the basic or standard plan
				  is initially purchased. Premiums for the rider shall be calculated based upon
				  generally accepted actuarial principles and shall not be subject to the premium
				  restrictions in Iowa Code subsection
				  513C10(6)..
				  The earned premiums and paid losses associated with the rider shall not be
				  considered by the Iowa Individual Health Benefit Reinsurance Association for
				  purposes of Iowa Code section 513C.10.
Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.12 - 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 75 - Iowa Individual Health Benefit Plans › Rule 191-75.13 - 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.