Iowa Administrative Code › Agency 191 - Insurance Division › Insurance Coverage for Pediatric Preventive Services › Chapter 85 - Regulation of Navigators › Rule 191-85.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
As used in this chapter:
"ACA "
means, collectively, the Patient
				  Protection and Affordable Care Act (Pub. L. 111-148) and Health Care and
				  Education Reconciliation Act (Pub. L. 111-152).
"Applicant"
means an individual or entity
				  applying or intending to apply for a navigator license.
"Business entity"
means a corporation,
				  association, partnership, limited liability company, limited liability
				  partnership or other legal entity.
"Commissioner "
means the Iowa commissioner
				  of insurance.
"Credit"
means continuing education credit.
				  One credit is 50 minutes of instruction or reading material in an acceptable
				  topic.
"Division "
means the Iowa insurance
				  division.
"Health insurance "
means insurance that is
				  primarily for the diagnosis, cure, mitigation, treatment, or prevention of
				  disease or amounts paid for the purpose of affecting any structure of the body,
				  including transportation that is essential to obtaining medical care, but
				  excluding:
1. Coverage only for
				accident or disability income insurance, or any combination thereof;
2. Coverage issued as a supplement to
				liability insurance;
3. Liability
				insurance, including general liability insurance and automobile liability
				insurance;
4. Workers' compensation
				or similar insurance;
5. Automobile
				medical payment insurance;
6.
				Credit-only insurance;
7. Coverage
				for on-site medical clinics;
8.
				Coverage only for limited-scope vision benefits;
9. Benefits for long-term care, nursing home
				care, home health care, community-based care, or any combination
				thereof;
10. Coverage for specified
				disease or critical illness;
11.
				Hospital indemnity or other fixed indemnity insurance;
12. Medicare supplement policies;
13. Medicare, Medicaid, or the Federal
				Employee Health Benefit Program, 5 U.S.C. §§ 8901 -8914, as it
				existed on January 1, 2013;
14.
				Coverage only for medical and surgical outpatient benefits;
15. Excess or stop-loss insurance;
				and
16. Other similar insurance
				coverage under which benefits for health insurance are secondary or incidental
				to other insurance benefits.
"Individual"
means a private or natural
				  person, as distinguished from a partnership, corporation or association.
"License "
means the authorization by the
				  commissioner for a person to act as a navigator in the state of Iowa.
"Market place "
means any health benefit
				  exchange authorized under the ACA and established or operating in this state,
				  including any exchange established or operated by the U.S. Department of Health
				  and Human Services.
"Navigator"
means the individual or business
				  entity that is granted the title, duties, and responsibilities under 45 CFR
				  § 155.210 of a navigator by the granting or appointing authority. A
				  navigator would engage in the activities and meet the standards described in 45
				  CFR § 155.210, including:
1.
				Maintaining expertise in eligibility, enrollment, and program
				specification;
2. Conducting public
				education activities to raise awareness about the marketplace;
3. Providing information and services in a
				fair, accurate, and impartial manner, including information that acknowledges
				other health programs such as Medicaid and the healthy and well kids in Iowa
				program;
4. Facilitating selection
				of a qualified health plan;
5.
				Providing referrals for consumers with questions, complaints, or grievances to
				any applicable office of health insurance consumer assistance or health
				insurance ombudsman established under Section 2793 of the Public Health Service
				Act, or other appropriate state agency or agencies;
6. Providing information in a culturally and
				linguistically appropriate manner, including to persons with limited English
				proficiency; and
7. Ensuring
				accessibility and usability of navigator tools and functions for persons with
				disabilities.
"Navigator renewal notice"
means a written
				  or electronic communication issued by the division to inform a navigator about
				  license renewal.
"Negotiate"
means the act of advising a
				  purchaser or prospective purchaser of a particular contract of insurance
				  concerning any of the substantive benefits, terms or conditions of the contract
				  provided that the person engaged in that act either sells insurance or obtains
				  insurance for purchasers. The definition of "negotiate" shall not
				  include:
1. Impartially informing a
				purchaser or prospective purchaser about substantive benefits, terms or
				conditions of a contract while facilitating the enrollment in a qualified
				health plan by providing fair, impartial, and accurate information that assists
				a purchaser or prospective purchaser with submitting an eligibility
				application;
2. Clarifying the
				distinctions among qualified health plans; and
3. Helping qualified individuals make
				informed decisions during a health plan selection process.
"Person"
means an individual or
				  entity.
"Producer"
means a person required to be
				  licensed in this state to sell, solicit or negotiate insurance.
"Qualified health plan"
means a health
				  benefit plan that has in effect a certification that the plan meets the
				  criteria for certification described in Section 1311(c) of the ACA.
"Sell"
means to exchange a contract of
				  insurance by any means, for money or its equivalent, on behalf of an
				  insurer.
"Solicit"
means attempting to sell insurance
				  or asking or urging a person to apply for a particular kind of insurance from a
				  particular company.
"U.S. Department of Health and Human
				  Services"
means the United States Department of Health and Human
				  Services and any of its subsidiaries.