reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 56 - Workers' Compensation Group Self-insurance › Rule 191-56.18 - Deficits and Insolvencies

Current through Register Vol. 47, No. 3, July 24, 2024
(1) If the
				assets of an association are at any time insufficient to enable the association
				to discharge its legal liabilities and other obligations and to maintain the
				reserves required of it under this Act, it shall forthwith make up the
				deficiency or levy an assessment upon its members for the amount needed to make
				up the deficiency.
(2) In the event
				of a deficiency in any fund year, such deficiency shall be made up immediately,
				by one or more of the methods described in subrule 56.18(1). The commissioner
				shall be notified prior to any transfer of surplus funds from one fund year to
				another.
(3) If the association
				fails to assess its members or to otherwise make up such deficit within 30
				days, the commissioner shall order it to do so.
(4) If the association fails to make the
				required assessment of its members within 30 days after the commissioner orders
				it to do so, or if the deficiency is not fully made up within 60 days after the
				date on which such assessment is made, or within such longer period of time as
				may be specified by the commissioner, the association shall be deemed to be
				insolvent.
(5) The commissioner
				shall proceed against an insolvent association in the same manner as the
				commissioner would proceed against an insolvent domestic insurer in this state
				as prescribed in Iowa Code sections 515.85 to 515.87 regarding liquidation,
				conservation, etc. The commissioner shall have the same powers and limitations
				in such proceedings as are provided under those sections, except as otherwise
				provided in this chapter
(6) In the
				event of the liquidation of an association, the commissioner shall levy an
				assessment upon its members for such an amount as the commissioner determines
				to be necessary to discharge all liabilities of the association, including the
				reasonable cost of liquidation.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 56 - Workers' Compensation Group Self-insurance › Rule 191-56.19 - Grounds for Nonrenewal or Revocation of a Certificate of Relief From Insurance

Current through Register Vol. 47, No. 3, July 24, 2024
The following constitute grounds for nonrenewal or revocation
				  of a certificate of relief from insurance:
(1) Failure to comply with any provisions of
				these rules or of Iowa Code chapter 85, 85A, 85B, 86 or 87;
(2) Failure to comply with any lawful order
				of the commissioner;
(3) Failure to
				promptly pay lawful compensation claims;
(4) Committing an unfair or deceptive act or
				practice;
(5) Deterioration of
				financial condition adversely affecting the certificate holder's ability to pay
				expected losses;
(6) The
				application or any necessary forms that have been filed with the division
				contain fraudulent information or omissions;
(7) The association or its administrator has
				misappropriated, converted, illegally withheld, or refused to pay over upon
				proper demand any moneys that belong to a member, an employee of a member, or a
				person otherwise entitled thereto and that have been entrusted to the
				association or its administrator in its fiduciary capacities;
(8) Failure to remit the proper amount of
				premium tax in a timely manner, as required by Iowa Code section
				4321..
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 56 - Workers' Compensation Group Self-insurance › Rule 191-56.20 - Hearing and Appeal

Current through Register Vol. 47, No. 3, July 24, 2024
Prior to denying a renewal application or revoking a
				  certificate issued under this chapter, a certificate holder shall be given a
				  hearing and a right to appeal as provided in rule 3.1(17A,502,505) et
				  seq.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 56 - Workers' Compensation Group Self-insurance › Rule 191-56.21 - Existing Approved Self-insurers

Current through Register Vol. 47, No. 3, July 24, 2024
(1) All mutual associations which were given
				a certificate of relief from insurance or some other approval to group
				self-insure from the commissioner prior to the effective date of these rules
				shall bring themselves into full compliance with these rules within 90 days
				after their effective date or by the filing time set out for renewals,
				whichever comes later
(2) An
				existing association may petition the commissioner for a waiver of a rule or
				rules. The commissioner may grant such waiver upon showing to the
				commissioner's satisfaction that the association is solvent and has the ability
				to pay workers' compensation benefits as required by law.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 56 - Workers' Compensation Group Self-insurance › Rule 191-56.22 - Severability Clause

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 subsequently held to be invalid, such
				  invalidity shall not affect other provisions or applications of this
				  chapter.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.1 - General Provisions

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The
				purpose of this chapter is to provide general guidelines for the approval of
				self-insurance for workers' compensation liability for individual
				employers.
(2) The authority to
				promulgate these rules is found in Iowa Code section
				5058..
(3) Certificates of relief from insurance
				shall not exempt an employer from Iowa Code chapters 85, 85A, 85B, 86 and
				87.
(4) The state of Iowa shall be
				exempt from the requirements of this chapter
(5) A political subdivision of the state
				filing for a certificate of relief from insurance under this chapter shall be
				exempt from the requirements of subrule 57.3(1), but must comply with the other
				provisions of this chapter
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
"Commissioner"
shall mean the commissioner of the insurance
				division of Iowa, appointed by the governor pursuant to Iowa Code section
				5052..
(2)
"Division "
shall mean
				the insurance division of Iowa.
(3)
"Employer"
shall be defined as set forth in Iowa Code section
				8561..
(4)
"Self-insurer"
shall mean
				an employer who has been granted relief from the requirement of insurance by
				the commissioner after having complied with the relevant portions of this
				chapter but shall not include an employer who is a member of a group of
				employers under 191-chapter 56.
(5)
"Insolvent"
or
"insolvency"
means the inability of a workers' compensation
				self-insurer to pay its outstanding lawful obligations as they mature in the
				regular course of business, as may be shown either by an excess of its
				liabilities over its assets or by its not having sufficient assets to insure
				all of its outstanding liabilities after paying all accrued claims owed by
				it.
(6)
"Parent company
				"
shall mean a company that owns at least 20 percent of the
				outstanding stock of another company.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.3 - Requirements for Self-insurance

Current through Register Vol. 47, No. 3, July 24, 2024
To qualify to receive a certificate of relief from insurance,
				  an employer must satisfy the following requirements:
(1) File with the division an annual surety
				bond issued by an insurance company licensed to do business in the state of
				Iowa in an amount determined by applying the formula below, but in no case
				shall the bond be less than $200,000 or, if an employer cannot obtain a bond,
				then any other security such as cash or negotiable securities which is
				agreeable to the commissioner, in an equal amount. Such surety bond shall be in
				the form prescribed by the commissioner and, in the event of insolvency of the
				employer, shall be payable to the division to ensure the payment of the
				employer's workers' compensation liabilities in the same manner as if the
				division were such employer, subject to the dollar limitation of such surety
				bond.
The following formula will be used to determine the
				  appropriate amount of security required:
a. Determine the following three ratios:
(1) Current assets: Current
				liabilities
(2) Capital + retained
				earning (net of treasury stock) as a percentage of sales (less
				discounts)
(3) Long term debt:
				Capital + retained earnings
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.4 - Additional Security Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
(1) If at any time the commissioner feels
				additional security is necessary because any one or more of the following
				factors are present, the commissioner may require such additional security as
				provided in subrule 57.4(2):
a. Insufficient
				liquid assets or retained earnings;
b. A deteriorating financial condition, as
				evidenced by a comparison of current financial statements to recent past
				financial statements;
c. The
				workers' compensation loss experience is significantly higher than the average
				for the industry the company is in;
d. The loss potential within and without the
				state is higher than what the company can apparently withstand;
e. Any other relevant
				consideration(s).
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.5 - Application for an Individual Self-insurer

Current through Register Vol. 47, No. 3, July 24, 2024
(1) An applicant for a certificate of relief
				from insurance shall submit a completed application to the division together
				with the following:
a. A surety bond or other
				security, in the amount determined under rule 57.3(87,505);
b. Parental guarantee from the ultimate
				controlling parent, if applicable;
c. Most recent audited financial statement,
				such as that included in the shareholders annual report. If such statement is
				over six months old, also include the latest unaudited financial statement and
				an affidavit signed by the treasurer of the company stating that there has been
				no material lessening of net worth or other adverse changes since the last
				audited statement, or, if there were, an explanation of such changes. For
				subsidiaries, this information is to be furnished on the ultimate controlling
				parent company;
d. Data from the
				immediate past five years on paid and outstanding Iowa workers' compensation
				losses subject to self-insurance; and
e. A fee of $100 per application review and
				$100 per certificate issued, paid in separate checks. If the application is
				denied, the fee for the issuance of a certificate will be returned to the
				applicant. The division will either issue one certificate for each parent and
				each subsidiary or the division will issue one certificate only for the
				approved parent and all approved subsidiaries, at the applicant's
				option.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.7 - Excess Insurance

Current through Register Vol. 47, No. 3, July 24, 2024
No contract or policy of per occurrence or aggregate excess
				  insurance shall be recognized in considering the ability of an applicant to
				  fulfill its financial obligations under the workers' compensation Act, unless
				  such contract or policy complies with the following:
(1) Is issued by a company:
a. Licensed to transact casualty business in
				this state; or
b. Listed in the
				most recent NAIC publication "Financial Review of Alien Insurers" (commonly
				known as the white list); or
c.
				Listed on the most recent List of Acceptable Non-Admitted Insurers prepared by
				this department.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.8 - Insolvency

Current through Register Vol. 47, No. 3, July 24, 2024
If the individual employer becomes insolvent, the
				  commissioner may appoint a party to receive funds on the surety bond or other
				  posted security to be dispersed to individual claimants.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.9 - Renewals

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Individual employers.
a. A certificate of relief from insurance is
				valid for one year, unless sooner revoked under the provisions of rule
				57.11(87,505). Such certificate is effective from August 1 to July
				31.
b. By June 1 of each year, each
				individual employer must submit:
(1) A
				completed application;
(2) A
				statement of financial condition audited by an independent certified public
				accountant as of the end of the most recently completed fiscal year. The
				financial statement shall be on a form prescribed by the commissioner and shall
				include, but not be limited to, actuarially appropriate reserves for (a) known
				claims and expenses associated therewith, (b) claims incurred but not reported
				and expenses associated therewith, (c) unearned premiums and (d) bad debts,
				which reserves shall be shown as liabilities. An actuarial opinion regarding
				reserves for items (a) and (b) above shall be included in the audited financial
				statement. The actuarial opinion shall be given by a member of the American
				Academy of Actuaries or other qualified loss reserve specialist as defined in
				the annual statement adopted by the National Association of Insurance
				Commissioners;
(3) Any additional
				relevant information required by the division; and
(4) The required fee.
c. Depending on any change in financial
				condition, the commissioner may require additional security, as provided in
				rule 57.4(87,505).
d. The
				commissioner reserves the right to require financial reports more frequently
				than once each year if a deterioration in financial security warrants a closer
				scrutiny of an individual employer
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.10 - Periodic Examination

Current through Register Vol. 47, No. 3, July 24, 2024
The commissioner reserves the right to examine an employer as
				  often as it deems necessary. Cost of the examination is to be paid by the
				  employer Examination shall include but not be limited to adequacy of loss
				  reserves and claims handling practices.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.11 - Grounds for Nonrenewal or Revocation of a Certificate of Relief From Insurance

Current through Register Vol. 47, No. 3, July 24, 2024
The following constitute grounds for nonrenewal or revocation
				  of a certificate of relief from insurance:
(1) Failure to comply with any provisions of
				these rules or of Iowa Code chapter 85, 85A, 85B, 86 or 87;
(2) Failure to comply with any lawful order
				of the commissioner;
(3) Failure to
				promptly pay lawful compensation claims;
(4) Committing an unfair or deceptive act or
				practice;
(5) Deterioration of
				financial condition adversely affecting the certificate holder's ability to pay
				expected losses.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.12 - Hearing and Appeal

Current through Register Vol. 47, No. 3, July 24, 2024
Prior to denying a renewal application or revoking a
				  certificate issued under this chapter, a certificate holder shall be given a
				  hearing and a right to appeal as provided in rule
				  191-31.
				  (17A,502,505) et seq.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.13 - Existing Approved Self-insurers

Current through Register Vol. 47, No. 3, July 24, 2024
(1) All individual employers which were given
				a certificate of relief from insurance or some other approval to self-insure
				from the division prior to the effective date of these rules shall bring
				themselves into full compliance with these rules within 90 days after their
				effective date or by the filing time set out for renewals, whichever comes
				later
(2) An existing individual
				self-insurer may petition the commissioner for a waiver of a rule, or rules.
				The commissioner may grant such waiver upon showing to the commissioner's
				satisfaction that the employer is solvent and has the ability to pay workers'
				compensation benefits as required by law.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 57 - Workers' Compensation Self-insurance for Individual Employers › Rule 191-57.14 - Severability Clause

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 subsequently held to be invalid, such
				  invalidity shall not affect other provisions or applications of this
				  chapter.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.3 - Registration Required

Current through Register Vol. 47, No. 3, July 24, 2024
A third-party administrator shall not operate as a
				  third-party administrator in Iowa without an approved certificate of
				  registration from the division. A third-party administrator that has a home
				  state other than Iowa must apply for and obtain a nonresident third-party
				  administrator certificate of registration from the division before operating as
				  a third-party administrator in Iowa.
(1)
Exceptions.
a. The following persons doing the following
				corresponding actions shall not be required to have approved certificates of
				registration from the division if these are the only actions by the persons
				that would otherwise cause the persons to be considered third-party
				administrators:
(1) An employer administering
				its employee benefit plan or the plan of an affiliated employer under common
				management and control;
(2) A trust
				exempt from taxation under Section 507(a) of the Internal Revenue Code and its
				trustees and employees acting pursuant to such trust, or a custodian and the
				custodian's agents or employees acting pursuant to a custodian account that
				meets the requirements of Section 401(f) of the Internal Revenue Code;
				or
(3) A person licensed as a
				managing general agent in this state when acting within the scope of activities
				conveyed under such a license.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.4 - Third-party Administrator Duties

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				A third-party administrator registered or applying for a certificate of
				registration or renewal under Iowa Code section
				51021.
				and this chapter shall:
a. Make available for
				inspection on request by the commissioner copies of all contracts with insurers
				or other persons utilizing the services of the third-party
				administrator.
b. As often as
				reasonably required by the commissioner, produce its accounts, records and
				files for examination and make its officers available to give information with
				respect to its affairs.
c.
				Immediately notify the commissioner of any material change in its ownership,
				control, or other fact or circumstance affecting its qualification for a
				certificate of registration in this state.
d. Notify the commissioner in writing of any
				change in the information required to be filed under these rules including, but
				not limited to, a change of address or name, not later than 30 days after the
				change.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.5 - Renewal Procedure

Current through Register Vol. 47, No. 3, July 24, 2024
A third-party administrator that wants to maintain its
				  certificate of registration in Iowa shall file a completed request for renewal
				  within 60 days prior to the expiration date on the certificate of
				  registration.
(1) The division shall
				provide notice to the third-party administrator of the upcoming renewal
				date.
(2) The renewal form shall be
				filed in a manner as prescribed by the division. The renewal form shall be
				accompanied by the fee specified in rule
				191-58.18 (510).
(3) Renewal requests filed after the
				certificate expiration date must include the late fee specified in rule
				191-58.18(510).
(4) A third-party
				administrator that allows the certificate of registration to lapse and does not
				renew within one year from the expiration date must apply for a new certificate
				of registration.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.6 - Responsibilities of the Insurer

Current through Register Vol. 47, No. 3, July 24, 2024
(1) If
				an insurer utilizes the services of a third-party administrator, the insurer
				shall be responsible for determining the benefits, premium rates, underwriting
				criteria, and claims payment procedures applicable to the coverage.
(2) An insurer must supervise its contracted
				third-party administrators to ensure that its programs are administered in a
				competent and appropriate manner.
(3) In cases where a third-party
				administrator administers benefits for more than 100 certificate holders,
				subscribers, claimants or policyholders on behalf of an insurer, the insurer
				shall, at least annually, conduct a reasonable review of the operations of the
				third-party administrator If a third-party administrator has an independent
				party conduct a review of the third-party administrator's operations and has
				provided that review to the insurer, and the insurer has determined that the
				review was reasonable for purposes of this subrule, the review may, at the
				discretion of the division, meet the requirement of this subrule.
(4) The requirements of rule 191-58.6
				(505,510) also apply to any insurer that contracts with a person exempt from
				licensure, pursuant to the exceptions set forth in subrule 58.3(1), to act as a
				third-party administrator.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.7 - Written Agreement

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The
				written agreement required by Iowa Code section
				51012.
				shall include a statement of duties that the third-party administrator is
				expected to perform on behalf of the insurer and the lines, classes or types of
				insurance for which the third-party administrator is to be authorized to
				administer The agreement shall make provision with respect to underwriting,
				claims handling and other standards pertaining to the business underwritten by
				the insurer The rules pertaining to these matters shall be provided, in
				writing, by the insurer to the third-party administrator, pursuant to Iowa Code
				section
				51012.
				and rule 191-58.7 (505,510).
(2)
				The insurer or third-party administrator may, with written notice, terminate
				the written agreement for cause as provided in the agreement. The insurer may
				suspend the underwriting authority of the third-party administrator during the
				pendency of any dispute regarding the cause for termination of the written
				agreement. The insurer shall fulfill any lawful obligations with respect to
				policies affected by the written agreement, regardless of any dispute between
				the insurer and the third-party administrator
(3) The requirements of this rule shall also
				apply to any insurer that contracts with a person exempt from licensure,
				pursuant to the exceptions set forth in subrule 58.3(1), to act as a
				third-party administrator, unless that person and the insurer are the
				same.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.8 - Compensation to the Third-party Administrator

Current through Register Vol. 47, No. 3, July 24, 2024
A third-party administrator and an insurer shall not enter
				  into an agreement or understanding that makes the amount of the third-party
				  administrator's commissions, fees, or charges contingent upon savings effected
				  in the adjustment, settlement and payment of losses covered by the insurer's
				  obligations. Third-party administrators are not prohibited from receiving
				  performance-based compensation for providing to the insurer cost control
				  services, including hospital auditing or other auditing services, subrogation
				  services, contractual discounting services, or claim negotiation with
				  providers.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.9 - Disclosure of Charges and Fees

Current through Register Vol. 47, No. 3, July 24, 2024
The third-party administrator shall disclose to the insurer
				  all charges, fees and commissions received from all services in connection with
				  the provision of administrative services for the insurer, including any fees or
				  commissions paid by insurers providing reinsurance. Additional charges may not
				  be made for services to the extent the insurer has paid for those
				  services.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.10 - Delivery of Materials to Covered Individuals

Current through Register Vol. 47, No. 3, July 24, 2024
Any policies, certificates, booklets, termination notices or
				  other written communications delivered by the insurer to the third-party
				  administrator for delivery to insured parties or covered individuals shall be
				  delivered by the third-party administrator promptly after receipt of delivery
				  instructions from the insurer
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.11 - Annual Report and Fee

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Each
				registered third-party administrator shall file by July 1 an annual report in a
				form and manner as prescribed by the commissioner The report shall:
a. Be verified by at least two officers of
				the third-party administrator;
b.
				Include audited financial statements prepared by an independent certified
				public accountant using generally accepted accounting principles;
c. Be prepared on a consolidated basis;
				and
d. Include a columnar
				consolidating or combining worksheet that shall be filed with the report and
				include the following:
(1) amounts shown on
				the consolidated audited financial report shall be shown on the
				worksheet;
(2) amounts for each
				entity shall be stated separately; and
(3) Explanations of consolidating and
				eliminating entries shall be included.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.12 - Change of Information

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A
				third-party administrator shall notify the commissioner within 30 days of any
				change in the information required to be filed under these rules including, but
				not limited to, a change of original application content. Reports of changes
				shall be filed electronically as instructed on the division's website. Failure
				to timely file changes is grounds for suspension of a certificate of
				registration and imposition of a $100 civil penalty.
(2) A third-party administrator may not do
				business under any name other than the name on the original application unless
				the third-party administrator notifies the commissioner prior to using the
				assumed name. The notice shall include a detailed explanation of the manner in
				which the name will be used.
(3) A
				third-party administrator who ceases doing business in Iowa may either allow
				its certificate of registration to expire or file a request to withdraw its
				certificate of registration. A request for withdrawal must include information
				demonstrating that the third-party administrator will no longer be acting in
				Iowa as a third-party administrator.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.13 - Inquiry by Commissioner

Current through Register Vol. 47, No. 3, July 24, 2024
A third-party administrator shall promptly respond in writing
				  to inquiries from the commissioner A third-party administrator's actions are
				  deemed untimely under this rule if the third-party administrator fails to
				  respond to an inquiry from the commissioner within 30 days of the receipt of
				  the inquiry, unless good cause exists for delay and the commissioner has given
				  the third-party administrator a time extension in writing.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.14 - Complaints

Current through Register Vol. 47, No. 3, July 24, 2024
A third-party administrator shall keep all complaints on file
				  for a period of five years. Complaint information shall be made available to
				  the division by the third-party administrator at any time upon the
				  commissioner's request.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.15 - Periodic Examination

Current through Register Vol. 47, No. 3, July 24, 2024
The commissioner reserves the right to examine a third-party
				  administrator or require the most recent audited financial statements from the
				  third-party administrator and such other interim evidence as the commissioner
				  deems appropriate.
(1) Reasonable
				costs of the examination or audited financial statements shall be paid by the
				third-party administrator.
(2)
				Examination shall include, but not be limited to: financial condition, premium
				collection, claims processing, and marketing practices.
(3) If one or more of the following factors
				are present, the commissioner may require and determine an amount of additional
				security:
a. Insufficient liquid assets or
				retained earnings;
b. A
				deteriorating financial condition, as evidenced through an examination by the
				commissioner or any other insurance commissioner;
c. Any other relevant
				considerations.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.16 - Grounds for Denial, Nonrenewal, Suspension or Revocation of Certificate of Registration

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The commissioner
				may, at the commissioner's discretion and without advance notice or hearing,
				immediately suspend the certificate of registration of a third-party
				administrator if the commissioner finds that one or more of the following
				circumstances exist:
a. The third-party
				administrator is insolvent or impaired;
b. A proceeding for receivership,
				conservatorship, rehabilitation or other delinquency proceeding regarding the
				third-party administrator has been commenced in any state; or
c. The financial condition or business
				practices of the third-party administrator otherwise pose an imminent threat to
				the public health, safety or welfare of the residents of this state.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.17 - Confidential Information

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Neither
				the commissioner nor any person who received documents, materials or other
				information while acting under the authority of the commissioner shall be
				permitted or required to testify in any private civil action concerning any
				confidential documents, materials or information subject to Iowa Code section
				51014..
(2) In order to assist in the performance of
				the commissioner's duties, the commissioner:
a. May share documents, materials or other
				information, including the confidential and privileged documents, materials or
				information subject to Iowa Code section
				51014.,
				with other state, federal and international regulatory agencies, with the
				National Association of Insurance Commissioners, its affiliates or subsidiaries
				and with state, federal and international law enforcement authorities, provided
				that the recipient agrees to maintain the confidentiality and privileged status
				of the documents, materials or other information;
b. May receive documents, materials or
				information, including otherwise confidential and privileged documents,
				materials or information, from the National Association of Insurance
				Commissioners, its affiliates or subsidiaries, and from regulatory and law
				enforcement officials of other foreign or domestic jurisdictions, and shall
				maintain as confidential or privileged any document, material or information
				received with notice or the understanding that it is confidential or privileged
				under the laws of the jurisdiction that is the source of the document, material
				or information; and
c. May enter
				into agreements governing the sharing and use of information consistent with
				this subrule.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.18 - Fees

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Fees to be paid
				directly to the division shall be paid by check. Fees accompanying electronic
				filings shall be paid in a manner as directed by the commissioner.
(2) Fees related to this chapter are as
				follows:
a. The fee to accompany an
				application for a certificate of registration is $100.
b. The fee to accompany the filing of an
				annual report is $50.
c. The fee to
				renew a certificate of registration is $100.
d. The fee for the late filing of an annual
				report or of an application to renew a certificate of registration is
				$100.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 58 - Third-party Administrators › Rule 191-58.19 - Severability Clause

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 subsequently held to be invalid, such
				  invalidity shall not affect other provisions or applications of this
				  chapter.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.2 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
The terms defined in Iowa Code sections
				  510.11,
				  510B.1, and
				  510C.1 shall have the same
				  meaning for the purposes of this chapter. The definitions contained in
				  191-Chapter 58, "Third-Party Administrators," and 191-Chapter 78, "Uniform
				  Prescription Drug Information Card," are incorporated by reference. As used in
				  this chapter:
"Complaint"
means a written communication
				  from a pharmacy or the commissioner to a pharmacy benefits manager that makes
				  an inquiry or expresses a grievance and includes, but is not limited to, the
				  following:
1. A comment on, contest or
				appeal by a pharmacy of a pharmacy benefits manager's maximum allowable cost,
				maximum allowable cost list or other pricing methodology used to pay a
				pharmacy.
2. Any pharmacy's appeal
				or request for an independent third-party review of an audit report pursuant to
				subrules 59.4(4) and 59.4(5).
3.
				Any request by a pharmacy for an independent third-party review of a
				termination or suspension decision pursuant to paragraph
				59.6(3)
"d."
4. Any
				inquiries from the commissioner pursuant to subrule 59.8(3).
"Day"
means a calendar day, unless otherwise
				  defined or limited.
"Dosage unit"
means the same as defined in
				  45 CFR Section
				  149.710.
"Ingredient costs"
means the costs of the
				  component of the prescription drug for prescriptions dispensed. Ingredient
				  costs do not include dispensing fees, copayments received by the pharmacy,
				  service fees or any other type of reimbursement paid to the pharmacy by a
				  pharmacy benefits manager.
"Paid"
means the later of either the day on
				  which the payment is mailed by the pharmacy benefits manager or the day on
				  which the electronic payment is processed by the pharmacy benefits manager's
				  bank.
"Prescription drug cost reimbursement fee"
means the dollar amount reimbursed by a third-party payor to the pharmacy
				  benefits manager for the ingredient costs of a prescription drug. The
				  prescription drug cost reimbursement fee may be a type of third-party payor
				  administrative service fee.
"Wholesale acquisition cost"
means the same
				  as defined in 42 U.S.C.
				  Section
				  1395w-3a(c)(6)(B).
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.3 - Timely Payment of Pharmacy Claims

Current through Register Vol. 47, No. 3, July 24, 2024
(1) All benefits
				payable under a pharmacy benefits management plan shall be paid as soon as
				feasible but within 20 days after receipt of a clean claim when the claim is
				submitted electronically and shall be paid within 30 days after receipt of a
				clean claim when the claim is submitted in paper format.
(2) A payment to the pharmacy for a clean
				claim is considered to be overdue and not timely if not paid within 20 or 30
				days, whichever is applicable. If a clean claim is not timely paid, the
				pharmacy benefits manager must pay the pharmacy interest at the rate of 10
				percent per annum commencing the day after any claim payment or portion thereof
				was due until the claim is finally settled or adjudicated in full.
(3) A pharmacy benefits manager may
				demonstrate the date a claim is paid by a mail record or a bank
				statement.
(4) Pursuant to Iowa
				Code section 510B.4 and paragraph
				59.4(1)
"j,"
a pharmacy benefits manager shall not
				retroactively reduce or increase reimbursement, through adjustment or
				reconciliation or any other means, of a clean claim paid to
				pharmacies.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.6 - Termination or Suspension of Contracts With Pharmacies by Pharmacy Benefits Managers

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A contract
				between a pharmacy benefits manager and a pharmacy shall include a provision
				describing notification procedures for contract termination. The contract shall
				require no less than 60 days' prior written notice by either party that wishes
				to terminate the contract.
(2)
				Termination of a contract between a pharmacy benefits manager and a pharmacy or
				termination of a pharmacy from the network of the pharmacy benefits manager
				shall not release the pharmacy benefits manager from the obligation to make
				payments due to the pharmacy for contract-covered services rendered before the
				contract of the pharmacy was terminated.
(3) The following apply to a termination or
				suspension of a contract with a pharmacy by a pharmacy benefits manager:
a. If the pharmacy benefits manager has
				evidence that the pharmacy has engaged in fraudulent conduct or poses a
				significant risk to patient care or safety, the pharmacy benefits manager may
				suspend the pharmacy from further performance under the contract only if
				written notice of the suspension and reasoning therefor is provided to the
				pharmacy, the third-party payor and the commissioner.
b. A pharmacy benefits manager shall neither
				take action, nor imply or state that it may or will take action, to decrease
				reimbursement or to terminate, suspend, cancel or limit a pharmacy's
				participation in a pharmacy benefits manager's provider network solely or
				mainly because the pharmacy files a complaint with any entity.
c. A pharmacy shall not be terminated or
				suspended from a network of a pharmacy benefits manager due to any disagreement
				with a decision of the pharmacy benefits manager to deny or limit benefits to a
				covered person or due to any assistance provided to a covered person by the
				pharmacy in obtaining reconsideration of a decision of the pharmacy benefits
				manager.
d. The pharmacy may
				request an independent third-party review of the final decision to terminate or
				suspend the contract between the pharmacy benefits manager and the pharmacy by
				filing with the pharmacy benefits manager a written request for an independent
				third-party review of the decision. This written request must be filed with the
				pharmacy benefits manager within 30 days of receipt of the final termination or
				suspension decision.
e. If a
				pharmacy requests an independent third-party review of a termination or
				suspension decision and the termination is found to be substantiated, the cost
				of the third-party review shall be paid by the pharmacy. If a pharmacy requests
				an independent third-party review of a termination or suspension decision and
				the termination is found to be unsubstantiated, the cost of the third-party
				review shall be paid by the pharmacy benefits manager.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.8 - Complaints

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
System
				to record complaints.
Each pharmacy benefits manager shall develop an
				internal system to record and report complaints. This system shall include but
				not be limited to the following information regarding each complaint:
a. The reason for the complaint and any
				factual documentation submitted by the complainant to support the
				complaint;
b. Contact name, address
				and telephone number of the pharmacy;
c. Prescription number;
d. Prescription reimbursement amount for any
				disputed claim;
e. Any disputed
				prescription claim payment date of fill;
f. Third-party payor benefits
				certificate;
g. The justification
				for final determination and outcome of the complaint, including but not limited
				to the section and language of the contract or provider manual that was used in
				making the determination;
h. The
				name of any pharmacy services administrative organization, if known by the
				pharmacy benefits manager, with which the pharmacy or the pharmacy benefits
				manager has a contract and that is involved in the matter; and
i. For complaints related to the maximum
				allowable cost or other pricing methodology used to pay a pharmacy,
				documentation demonstrating compliance with Iowa Code section
				510B.8A as appropriate based on
				the nature of the complaint.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.9 - Duty to Notify Commissioner of Fraud

Current through Register Vol. 47, No. 3, July 24, 2024
A third-party payor that contracts with a pharmacy benefits
				  manager to perform the third-party payor's services shall require the pharmacy
				  benefits manager to follow Iowa Code section
				  507E.6 in notifying the
				  commissioner of any detection of fraud, including but not limited to
				  prescription drug diversion activity. "Prescription drug diversion activity,"
				  for purposes of this rule, means the diversion of prescription drugs from legal
				  and medically necessary uses to uses that are illegal and not medically
				  authorized or necessary. A pharmacy benefits manager shall follow the fraud
				  detection protocol developed by the third-party payor or shall allow the
				  third-party payor to review and agree to the pharmacy benefits manager's
				  protocol.
Iowa Administrative Code › Agency 191 - Insurance Division › Securities › Chapter 59 - Pharmacy Benefits Managers › Rule 191-59.10 - Commissioner Examinations of Pharmacy Benefits Managers

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Cooperation of pharmacy benefits managers with the
				commissioner.
A pharmacy benefits manager shall cooperate with the
				commissioner and comply with the commissioner's requests to aid with the
				commissioner's administration of Iowa Code chapters 507, 507B, 510, and 510B
				and this chapter, including cooperation and compliance with the commissioner in
				conducting an examination ofa pharmacy benefits manager pursuant to Iowa Code
				chapter 507, and cooperation with the commissioner in conducting an
				investigation pursuant to Iowa Code chapter 507B.
(2)
Maintenance of records.
A pharmacy benefits manager shall maintain the records necessary to demonstrate
				to the commissioner compliance with this chapter for the duration of any
				written agreement plus five years. A pharmacy benefits manager shall provide
				the commissioner easy accessibility to records for examination, audit and
				inspection to verify compliance with this chapter, including but not limited to
				all contracts and provider manuals governing pharmacies and pharmacy
				networks.
(3)
Disclosure of
				payments received by the pharmacy benefits manager.
a. The commissioner may request, and a
				pharmacy benefits manager shall disclose to the commissioner, the amount of all
				payments received by the pharmacy benefits manager, and the nature, type, and
				amounts of all other revenues that the pharmacy benefits manager
				receives.
b. For purposes of this
				subrule, "payments received by the pharmacy benefits manager" includes but is
				not limited to the aggregate amount of the following types of payments:
(1) A remuneration collected by the pharmacy
				benefits manager that is allocated to a third-party payor;
(2) An administrative fee collected from the
				manufacturer in consideration of an administrative service provided by the
				pharmacy benefits manager to the manufacturer; and
(3) Any other fee or amount collected by the
				pharmacy benefits manager from a manufacturer or other entity for a drug switch
				program, a formulary management program, a mail service pharmacy, educational
				support, data sales related to a covered person, or any other administrative
				function.
(4)
Disclosure of
				pricing methodology used to pay a pharmacy.
The commissioner may
				require, and a pharmacy benefits manager shall submit to the commissioner,
				pursuant to Iowa Code section
				510B.8A, information related to
				the pharmacy benefits manager's pricing methodology for maximum allowable cost
				or other pricing methodology used to pay a pharmacy.
(5)
Confidentiality.
Information provided by a pharmacy benefits manager to the commissioner under
				this rule or under rule
				191-59.8 (510B) shall be deemed
				confidential under Iowa Code sections
				22.7(2),
				22.7(3),
				22.7(6),
				505.8(8),
				505.8(9), 507.14, and
				510B.10, as
				applicable.