Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 75 - Iowa Individual Health Benefit Plans › Rule 191-75.10 - Basic Health Benefit Plan and Standard Health Benefit Plan Policy Forms

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The form and
				level of coverage of the basic health benefit plan and the standard health
				benefit plan are contained in the rules and table.
(2) Termination of pregnancy is to be covered
				when performed for therapeutic reasons. Elective termination of pregnancy is
				not to be covered in either the basic or standard plan.
(3) A provision shall be made in the basic
				health benefit plan and the standard health benefit plan covering diagnosis and
				treatment of human ailments for payment or reimbursement for necessary
				diagnosis and treatment provided by a chiropractor licensed under Iowa Code
				chapter 151, if the diagnosis or treatment is provided within the scope of the
				chiropractor's license.
(4)
				Prescription oral contraceptives and contraceptive devices that are approved by
				the United States Food and Drug Administration are to be covered in both policy
				forms.
(5) The division of
				insurance and the department of health have available "safe harbor" policy
				forms for the basic and standard health benefit plans required pursuant to Iowa
				Code chapter 513C.
Iowa Individual Products
Hospital Services
MANDATED INDEMNITY
MANDATED HMO
BASIC
STANDARD
PPO
BASIC
STANDARD
In
Out
Inpatient Outpatient
60%
80%
80%
60%
60% $400/admit
80% $200/admit
Prostheses
60%
80%
80%
60%
60%
80%
DME-including medical supplies
60%
80%
80%
60%
60%
80%
Ambulance- Emergency
60%
80%
80%
60%
60%
80%
Hospice
60%
80%
80%
60%
60%
80%
Home Health and Physician House Calls
60%
80%
80%
60%
60%
80%
Alcoliolism Substance Abuse
MANDATED INDEMNITY
MANDATED HMO
BASIC
STANDARD
PPO
BASIC
STANDARD
In
Out
Inpatient
-
80%(1)
80%(1)
60%(1)
-
80%
Outpatient
-
80%(1) ($50 max. eligible
							 fee)
80%(1)
60%(1)
-
80% ($50 max. eligible fee)
Mental Health
MANDATED INDEMNITY
MANDATED HMO
BASIC
STANDARD
PPO
BASIC
STANDARD
In
Out
Inpatient
-
80%(1)
80%(1)
60%(1)
-
80%
Outpatient
-
80%(1) ($50 max. eligible
							 fee)
80%(1) ($50 max. eligible
							 fee)
60%(1) ($50 max. eligible
							 fee)
-
80%
($50 max. eligible fee)
Iowa Individual Products
General
MANDATED INDEMNITY
MANDATED HMO
BASIC
STANDARD
PPO
BASIC
STANDARD
In
Out
Calendar year deductibles (S/F)
$1,500x3
$1,000x3
$1,000 X 3
$1,000 X 3
-
-
E.R. Copayment
-
-
-
-
$50 (waived if admitted)
$50 (waived if admitted)
Coinsurance
60%
80%
80%
60%
60%
80%
Annual out-of-pocket max. (1)
$4,800/ $14,400
$2,000/ $4,000
$2,000/ $4,000
$3,000/ $6,000
$4,000/ $8,000
$2,000/ $4,000
Lifetime Maximum
$250,000
$1,000,000
$1,000,000
$1,000,000
$250,000
$1,000,000
Pre-existing
513C.7(4) (a)&(b)
513C.7(4) (a)&(b)
513C.7(4) (a)&(b)
513C.7(4) (a)&(b)
513C.7(4) (a)&(b)
513C.7(4) (a)&(b)
Rx
60%
80%
80%
60%
Copayment of > $30 or 25%
Copayment of > $20 or 25%
Transplants
None
80%
80%
80%
None
80%
Physician Services
MANDATED INDEMNITY
MANDATED HMO
BASIC
STANDARD
PPO
BASIC
STANDARD
In
Out
Office visits including wellness
60%
80%
$20 copay 100%
$40 copay 60%
$20 copay per office visit
$15 copay per office visit
Urgent Care
60%
80%
80%
60%
60%
80%
Inpatient
60%
80%
80%
60%
60%
80%
Outpatient
60%
80%
80%
60%
60%
80%
ACCEPTABLE EXCLUSIONS FOR USE IN BASIC AND STANDARD
				  POLICIES
(6) Except as
				specifically provided for, no benefits will be provided for services, supplies
				or charges:
1. Which are not prescribed by,
				performed by, or upon the direction of a provider;
2. Which are not medically
				necessary;
3. Rendered by other
				than a hospital or a provider;
4.
				Which are investigational in nature; including any service, procedure, or
				treatment directly related to an investigational treatment;
5. For any condition, disease, illness, or
				bodily injury which occurs in the course of employment if benefits or
				compensation is carried or required, in whole or in part, under the provisions
				of any legislation or governmental unit. This exclusion applies whether or not
				the insured claims the benefits or compensation;
6. To the extent benefits are provided by any
				governmental unit except as required by federal law for the treatment of
				veterans in Veterans Administration or armed forces facilities for
				non-service-related medical conditions;
7. For any illness or injury suffered as a
				result of any act of war, declared or undeclared, or military
				service;
8. For which the insured
				would have no legal obligation to pay in the absence of this or any similar
				coverage;
9. For which no expense
				is incurred;
10. Surgery and any
				related services intended solely to improve appearance including but not
				limited to the restoration of hair and appearance of skin. This does not
				include those services or surgeries that restore bodily function or correct
				deformity resulting from disease, trauma, congenital or developmental anomalies
				of a newborn;
11. Rendered by a
				provider that is a member of the insured's immediate family;
12. Incurred prior to the effective date or
				during an inpatient admission that commenced prior to the insured's effective
				date of coverage;
13. Incurred
				after the date of termination of the insured's coverage;
14. For personal hygiene and convenience
				items such as, but not limited to, air conditioners, humidifiers, or physical
				fitness equipment;
15. For
				telephone consultations, charges for failure to keep scheduled appointments,
				charges for completion of any form or charges for medical
				information;
16. For inpatient
				admissions which are primarily for diagnostic studies or physical
				therapy;
17. For whole blood, blood
				components and blood derivatives which are not classified as drugs in the
				official formularies;
18. For
				custodial care, domiciliary care or rest cures;
19. For treatment in a facility, or part of a
				facility, that is mainly a place for:
* Rest;
* Convalescence;
* Custodial care;
* Aged;
* Care or treatment of alcoholism or drug addiction;
* Rehabilitation; or
* Training, schooling or occupational therapy;
20. For screening examinations
				including X-ray examinations made without film;
21. For sterilization or reversal of
				sterilizations, or both;
22. For
				dental work or treatment except for removal of malignant tumors and cysts or
				accidental injury (eating and chewing mishaps are not accidental injuries for
				the purposes of this policy) to natural teeth, if the accident occurs while the
				person is insured and the treatment is received within 12 months after the
				accident;
23. For treatment of
				weak, strained or flat feet, including orthopedic shoes or other supportive
				devices, or for cutting, removal or treatment of corns, calluses or nails,
				other than with corrective surgery, or for metabolic or peripheral vascular
				disease;
24. For eyeglasses or
				contact lenses and the visual examination for prescribing or fitting eyeglasses
				or contact lenses (except for aphasic patients and soft lenses or sclera shells
				intended for use in the treatment of disease or injury);
25. For radial keratotomy, myopic
				keratomileusis and any surgery which involves corneal tissue for the purpose of
				altering, modifying or correcting myopia, hyperopia or stigmatic
				error;
26. For hearing aids and
				supplies, tinnitus maskers, or examinations for the prescription or fitting of
				hearing aids;
27. For any treatment
				leading to or in connection with transsexualism, sex changes or modifications,
				including but not limited to surgery or the treatment of sexual dysfunction not
				related to organic disease;
28. For
				any treatment or regimen, medical or surgical, for the purpose of reducing or
				controlling the insured's weight or for the treatment of obesity;
29. For conditions related to autistic
				disease of childhood, hyperkinetic syndromes, learning disabilities, behavioral
				problems, or for inpatient confinement for environmental change;
30. For services and supplies for and related
				to fertility testing, treatment of infertility and conception by artificial
				means, including but not limited to: artificial insemination, in vitro
				fertilization, ovum or embryo placement or transfer, gamete intrafallopian tube
				transfer, or cryogenic or other preservation techniques used in such or similar
				procedures;
31. For travel whether
				or not recommended by a physician;
32. For complications or side effects arising
				from services, procedures, or treatments excluded by this policy;
33. For maternity care except for
				complications of pregnancy which is covered as any other illness;
34. For services to the extent that those
				services are covered by Medicare;
35. For or related to organ transplants
				(unless a benefit is specifically provided and then only to the limits
				provided);
36. For or related to
				the transplantation of animal or artificial organs or tissues;
37. For the care or treatment of any injury
				that is intentionally self-inflicted, while sane or insane;
38. For the care or treatment of any injury
				incurred during the commission of, or an attempt to commit, a felony or any
				injury or sickness incurred while engaging in an illegal act or occupation or
				participation in a riot;
39. For
				lifestyle improvements including smoking cessation, nutrition counseling or
				physical fitness programs;
40. For
				the purchase of wigs or cranial prosthesis;
41. For weekend admission charges, except for
				emergencies;
42. For orthomolecular
				therapy including nutrients, vitamins and food supplements;
43. For speech therapy, except to restore
				speech abilities which were lost due to sickness or injury.