CHAPTER 514K
HEALTH CARE PLAN INFORMATION

Referred to in §87.4, 296.7, 331.301, 364.4, 505.28, 505.29, 669.14, 670.7

  
     
514K.1  Health care plan disclosures — information to enrollees.
  1.  A health maintenance organization or an insurer using a preferred provider arrangement shall provide to each of its enrollees at the time of enrollment, and shall make available to each prospective enrollee upon request, written information as required by rules adopted by the commissioner. The information required by rule shall include but not be limited to all of the following:
  a.  A description of the plan’s benefits and exclusions.
  b.  Enrollee cost-sharing requirements.
  c.  A list of participating providers.
  d.  Disclosure of the existence of any drug formularies used and, upon request, information about the specific drugs included in the formulary.
  e.  An explanation for accessing emergency care services.
  f.  Any policies addressing investigational or experimental treatments.
  g.  The methodologies used to compensate providers.
  h.  Performance measures as determined by the commissioner and the director.
  i.  Information on how to access internal and external grievance procedures.
  2.  The commissioner shall annually publish a consumer guide providing a comparison by plan on performance measures, network composition, and other key information to enable consumers to better understand plan differences.
99 Acts, ch 41, §21; 2017 Acts, ch 148, §95, 96

  
     
514K.2  Health carrier disclosures — public internet sites.
  1.  A carrier that provides small group health coverage pursuant to chapter 513B or individual health coverage pursuant to chapter 513C and that offers for sale a policy, contract, or plan that covers the essential health benefits required pursuant to section 1302 of the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and its implementing regulations, shall provide to each of its enrollees at the time of enrollment, and shall make available to prospective enrollees and enrollees, insurance producers licensed under chapter 522B, and the general public, on the carrier’s internet site, all of the following information in a clear and understandable form for use in comparing policies, contracts, and plans, and coverage and premiums:
  a.  Any items or services, including prescription drugs, that have a coinsurance requirement where the cost-sharing required depends on the cost of the item or service.
  b.  The specific prescription drugs available on the carrier’s formulary, the specific prescription drugs covered when furnished by a physician or clinic, and any clinical prerequisites or prior authorization requirements for coverage of the drugs.
  c.  How medications will specifically be included in or excluded from the deductible, including a description of all out-of-pocket costs that may not apply to the deductible for a prescription drug.
  2.  A carrier that provides a summary of benefits and coverage to its enrollees in accordance with 26 C.F.R. §54.9815-2715, 29 C.F.R. §2590.715-2715, and 45 C.F.R. §147.200 is deemed to be in compliance with this section unless the commissioner of insurance determines that these federal regulations, or the successors to any of these federal regulations, fail to require the information required pursuant to this section in a clear and understandable form.
2016 Acts, ch 1122, §6, 14
Section is applicable to health insurance policies, contracts, or plans that are delivered, issued for delivery, continued, or renewed on or after January 1, 2017; 
2016 Acts, ch 1122, §14