An insurer may issue a basic benefit coverage policy or subscription contract meeting the criteria set forth in this subchapter.
For purposes of this subchapter, a basic benefit coverage policy or subscription contract means a policy or subscription contract which the insurer may choose to offer to individuals, spouses, families, or groups of twenty-five or less formed for purposes other than obtaining insurance coverage, and which meets the following criteria:
1. The individual, spouse, family, or group obtaining coverage under the policy or subscription contract has been without hospital and medical insurance coverage, a health services plan, or employer-sponsored health care coverage for all of the twelve-month period immediately preceding the effective date of the basic hospital and medical coverage policy or subscription contract, provided that for groups in existence for less than twelve months, the group has been without hospital and medical insurance coverage, a health services plan, or employer-sponsored health care coverage since inception of the group.
2. The insurer may include any or all of the following managed care provisions, subject to the approval of the commissioner, to control costs:
a. A procedure for preauthorization by the insurer, or its designees.
b. An exclusion for services that are not medically necessary or are not covered preventive health services.
c. First-dollar coverage for preventive and emergency care.
d. Except as otherwise provided, copayments for all other physician visits.
e. Exclusions or limitations upon benefits or direct pay requirements otherwise mandated.
f. Deductibles or copayments which vary based upon the service provided.
3. The insurer may include any or all of the following managed care provisions to control costs:
a. A preferred panel of providers who have entered into written agreements with the insurer to provide services at specified levels of reimbursement. Any such written agreement between a provider and an insurer shall contain a provision under which the parties agree that the insured individual or covered member will have no obligation to make payment for any medical service rendered by the provider that is determined not to be medically necessary.
b. Provisions requiring a second surgical opinion.
c. A procedure for utilization review by the insurer or its designees.
This section does not prohibit an insurer from including in its policy or subscription contract additional managed care and cost control provisions which, subject to the approval of the commissioner, have the potential to control costs in a manner which does not result in inequitable treatment of insureds or subscribers.
4. The policy or subscription contract shall provide basic levels of primary, preventive, and hospital care for covered individuals, including, but not limited to, all of the following:
a. A minimum of thirty days of inpatient hospitalization coverage per policy year.
b. Prenatal care, including a minimum of one prenatal office visit per month during the first two trimesters of pregnancy, two office visits per month during the seventh and eighth months of pregnancy, and one office visit per week during the ninth month and until term. Coverage for each such visit shall include necessary and appropriate screening, including history, physical examination, and such laboratory and diagnostic procedures as may be deemed appropriate by the physician based upon recognized medical criteria for the risk group of which the patient is a member.
c. Obstetrical care, including physician's services, delivery room, and other medically necessary hospital services.
d. For covered individuals, a basic level of primary and preventive care, including but not limited to, two physician office visits per calendar year.
e. Such other coverages as the commissioner may determine are cost-effective pursuant to section 513B.37.
5. The commissioner may also authorize the issuance of a basic benefit coverage family plan for spouses or dependents of employees, even if the employer currently provides individual health benefits exclusively for employees. The commissioner may also authorize the issuance of a basic benefit coverage plan for part-time employees or full-time, part-year employees, even if the employer currently offers health benefits for full-time employees.
91 Acts, ch 244, §12
CS91, § 514H.2
93 Acts, ch 80, § 20
CS93, § 513B.32
Referred to in § 513B.33, 513B.39
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