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PAG LIN
1 1 Section 1. NEW SECTION. 514C.8 COORDINATION OF HEALTH
1 2 CARE BENEFITS WITH STATE MEDICAL ASSISTANCE.
1 3 1. An insurer, health maintenance organization, or
1 4 hospital and medical service plan providing health care
1 5 coverage to individuals in this state shall not consider the
1 6 availability of or eligibility for medical assistance under
1 7 Title XIX of the federal Social Security Act and chapter 249A,
1 8 when determining eligibility of the individual for coverage or
1 9 calculating payments to the individual under the health care
1 10 coverage plan.
1 11 2. The state acquires the rights of an individual to
1 12 payment from an insurer, health maintenance organization, or
1 13 hospital or medical service plan to the extent payment for
1 14 covered expenses is made pursuant to chapter 249A for health
1 15 care items or services provided to the individual. Upon
1 16 presentation of proof that payment was made pursuant to
1 17 chapter 249A for covered expenses, the insurer, health
1 18 maintenance organization, or hospital or medical service plan
1 19 shall make payment to the state medical assistance program to
1 20 the extent of the coverage provided in the policy or contract.
1 21 3. An insurer shall not impose requirements on the state
1 22 with respect to the assignment of rights pursuant to this
1 23 section that are different from the requirements applicable to
1 24 an agent or assignee of a covered individual.
1 25 4. For purposes of this section, "insurer" means an entity
1 26 which offers a health benefit plan, including a group health
1 27 plan under the federal Employee Retirement Income Security Act
1 28 of 1974.
1 29 Sec. 2. NEW SECTION. 514C.9 MEDICAL SUPPORT &endash; INSURANCE
1 30 REQUIREMENTS.
1 31 1. An insurer shall not deny coverage or enrollment of a
1 32 child under the health plan of the obligor upon any of the
1 33 following grounds:
1 34 a. The child is born out of wedlock.
1 35 b. The child is not claimed as a dependent on the
2 1 obligor's federal income tax return.
2 2 c. The child does not reside with the obligor or in the
2 3 insurer's service area. This section shall not be construed
2 4 to require a health maintenance organization regulated under
2 5 chapter 514B to provide any services or benefits for treatment
2 6 outside of the geographic area described in its certificate of
2 7 authority which would not be provided to a member outside of
2 8 that geographic area pursuant to the terms of the health
2 9 maintenance organizations contract.
2 10 2. An insurer of an obligor providing health care coverage
2 11 to the child for which the obligor is legally responsible to
2 12 provide support shall do all of the following:
2 13 a. Provide information to the obligee or other legal
2 14 custodian of the child as necessary for the child to obtain
2 15 benefits through the coverage of the insurer.
2 16 b. Allow the obligee or other legal custodian of the
2 17 child, or the provider with the approval of the obligee or
2 18 other legal custodian of the child, to submit claims for
2 19 covered services without the approval of the obligor.
2 20 c. Make payment on a claim submitted in paragraph "b"
2 21 directly to the obligee or other legal custodian of the child,
2 22 the provider, or the state medical assistance agency for
2 23 claims submitted by the obligee or other legal custodian of
2 24 the child, by the provider with the approval of the obligee or
2 25 other legal custodian of the child, or by the state medical
2 26 assistance agency.
2 27 3. If an obligor is required by a court order or
2 28 administrative order entered pursuant to chapter 252E to
2 29 provide health coverage for a child and the obligor is
2 30 eligible for dependent health coverage, the insurer shall do
2 31 all of the following:
2 32 a. Allow the obligor to enroll under dependent coverage a
2 33 child who is eligible for coverage pursuant to the applicable
2 34 terms and conditions of the health benefit plan and the
2 35 standard enrollment guidelines of the insurer without regard
3 1 to an enrollment season restriction.
3 2 b. Enroll a child who is eligible for coverage under the
3 3 applicable terms and conditions of the health benefit plan and
3 4 the standard enrollment guidelines of the insurer, without
3 5 regard to any time of enrollment restriction, under dependent
3 6 coverage upon application by the obligee or other legal
3 7 custodian of the child or by the department of human services
3 8 in the event an obligor required by a court order or
3 9 administrative order fails to apply for coverage for the
3 10 child.
3 11 c. Maintain coverage and not cancel the child's enrollment
3 12 unless the insurer obtains satisfactory written evidence of
3 13 any of the following:
3 14 (1) The court order or administrative order is no longer
3 15 in effect.
3 16 (2) The child is eligible for or will enroll in comparable
3 17 health coverage through an insurer which shall take effect not
3 18 later than the effective date of the cancellation of
3 19 enrollment of the original coverage.
3 20 (3) The employer has eliminated dependent health coverage
3 21 for its employees.
3 22 (4) The obligor is no longer paying the required premium
3 23 because the employer no longer owes the obligor compensation,
3 24 or because the obligor's employment has terminated and the
3 25 obligor has not elected to continue coverage.
3 26 4. A group health plan shall establish reasonable
3 27 procedures to determine whether a child is covered under a
3 28 qualified medical child support order issued pursuant to
3 29 chapter 252E. The procedures shall be in writing, provide for
3 30 prompt notice of each person specified in the medical child
3 31 support order as eligible to receive benefits under the group
3 32 health plan upon receipt by the plan of the medical child
3 33 support order, and allow an obligee or other legal custodian
3 34 of the child under chapter 252E to designate a representative
3 35 for receipt of copies of notices in regard to the medical
4 1 child support order that are sent to the obligee or other
4 2 legal custodian of the child and the department of human
4 3 services' child support recovery unit.
4 4 5. For purposes of this section, unless the context
4 5 otherwise requires:
4 6 a. "Child" means a person, other than an obligee's spouse
4 7 or former spouse, who is recognized under a qualified medical
4 8 child support order as having a right to enrollment under a
4 9 group health plan as the obligor's dependent.
4 10 b. "Court order" or "administrative order" means a ruling
4 11 by a court or administrative agency in regard to the support
4 12 an obligor shall provide to the obligor's child.
4 13 c. "Insurer" means an entity which offers a health benefit
4 14 plan.
4 15 d. "Obligee" means an obligee as defined in section
4 16 252E.1.
4 17 e. "Obligor" means an obligor as defined in section
4 18 252E.1.
4 19 f. "Qualified medical child support order" means a child
4 20 support order which creates or recognizes a child's right to
4 21 receive health benefits for which the child is eligible under
4 22 a group health benefit plan, describes or determines the type
4 23 of coverage to be provided, specifies the length of time for
4 24 which the order applies, and specifies the plan to which the
4 25 order applies.
4 26 Sec. 3. NEW SECTION. 514C.10 COVERAGE FOR ADOPTED CHILD.
4 27 1. DEFINITIONS. For purposes of this section, unless the
4 28 context otherwise requires:
4 29 a. "Child" means, with respect to an adoption or a
4 30 placement for adoption of a child, an individual who has not
4 31 attained age eighteen as of the date of the issuance of a
4 32 final adoption decree, or upon an interlocutory adoption
4 33 decree becoming a final adoption decree, as provided in
4 34 chapter 600, or as of the date of the placement for adoption.
4 35 b. "Placement for adoption" means the assumption and
5 1 retention of a legal obligation for the total or partial
5 2 support of the child in anticipation of the adoption of the
5 3 child. The child's placement with a person terminates upon
5 4 the termination of such legal obligation.
5 5 2. COVERAGE REQUIRED. A policy or contract providing for
5 6 third-party payment or prepayment of health or medical
5 7 expenses shall provide coverage benefits to a dependent child
5 8 adopted by, or placed for adoption with, an insured or
5 9 enrollee under the same terms and conditions as apply to a
5 10 biological, dependent child of the insured or enrollee. The
5 11 issuer of the policy or contract shall not restrict coverage
5 12 under the policy or contract for a dependent child adopted by,
5 13 or placed for adoption with, the insured or enrollee solely on
5 14 the basis of a preexisting condition of such dependent child
5 15 at the time that the child would otherwise become eligible for
5 16 coverage under the plan, if the adoption or placement occurs
5 17 while the insured or enrollee is eligible for coverage under
5 18 the policy or contract. This section applies to the following
5 19 classes of third-party payment provider contracts or policies
5 20 delivered, issued for delivery, continued, or renewed in this
5 21 state on or after July 1, 1995:
5 22 a. Individual or group accident and sickness insurance
5 23 providing coverage on an expense-incurred basis.
5 24 b. An individual or group hospital or medical service
5 25 contract issued pursuant to chapter 509, 514, or 514A.
5 26 c. An individual or group health maintenance organization
5 27 contract regulated under chapter 514B.
5 28 d. An individual or group Medicare supplemental policy,
5 29 unless coverage pursuant to such policy is preempted by
5 30 federal law.
5 31 e. An organized delivery system licensed by the director
5 32 of public health.
5 33 EXPLANATION
5 34 This bill creates several new sections relating to the
5 35 coordination of health care benefits with state medical
6 1 assistance, providing health care coverage pursuant to a
6 2 medical child support order, and providing health care
6 3 benefits to an adopted child.
6 4 New section 514C.8 is created and provides that an insurer,
6 5 health maintenance organization, or hospital or medical
6 6 service plan, which provides health coverage in this state, is
6 7 not to consider the availability to an individual or an
6 8 individual's eligibility for state or federal medical
6 9 assistance when determining eligibility for coverage or the
6 10 amount to be paid pursuant to the health coverage provided.
6 11 The section also provides that the state acquires the right of
6 12 the individual to any payment from the health care coverage
6 13 provider to the extent of payment by the state for health care
6 14 services covered by the health care coverage plan.
6 15 New section 514C.9 is created which provides that an
6 16 insurer shall not deny coverage or enrollment of a child under
6 17 the health plan of a person obligated to provide support to
6 18 the child on the basis that the child is born out of wedlock,
6 19 is not claimed as a dependent on the obligor's federal income
6 20 tax return, or does not reside with the obligor or in the
6 21 insurer's service area.
6 22 Section 514C.10 is created and provides for coverage of an
6 23 adopted child under the policy or contract of group or
6 24 individual health benefit coverage of the adopting individual.
6 25 LSB 1177HV 76
6 26 mj/cf/24
Text: HF00204 Text: HF00206 Text: HF00200 - HF00299 Text: HF Index Bills and Amendments: General Index Bill History: General Index
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