CHAPTER 41
LIMITED SERVICE ORGANIZATIONS
191—41.1(514B) Definitions.
“Act” when used in these rules shall mean Iowa Code chapter 514B.
“Complaint” means a written communication expressing a grievance concerning a limited service organization.
“Governing body” means the persons in which the ultimate responsibility and authority for the conduct of the LSO is vested.
“Limited health services” include dental care services, vision care services, mental health services, behavioral health care services, substance abuse services, pharmaceutical services, podiatric care services, chiropractic services, nursing services, services of a licensed dietitian, physical therapy services, or any other category of services approved by the commissioner. “Limited health services” do not include employee assistance programs which provide only assessment and referral services or intermediate or long-term care facilities.
“Limited service organization” or “LSO” means any corporation or limited liability company or other entity which, in return for prepayment, undertakes to provide or arrange for the provision of one or more limited health services to enrollees. Entities authorized to do business pursuant to Iowa Code chapters 508, 512B, 514, 514B (health maintenance organizations), 515, and 520 shall not be required to obtain separate licensure as an LSO.
“Outpatient provider services” means outpatient provider services provided within or outside of a hospital. These services shall include, but not be limited to, laboratory and diagnostic X-ray with emphasis directed toward primary care.
“Producer” means a person engaged in solicitation or enrollment for an LSO and who ultimately delivers the certificate of membership or policy to a member.
“Provider” means any person or institution duly licensed or otherwise authorized to deliver or furnish limited health services.
[ARC 3682C, IAB 3/14/18, effective 4/18/18]
191—41.2(514B) Application. An application on forms provided by the insurance division accompanied by a filing fee of $100 payable to State Treasurer, State of Iowa, shall be completed by an officer or authorized representative of the LSO. The application with copies in duplicate shall be executed in conformance with rule 191—41.10(514B) and shall be accompanied by the information found in Iowa Code sections 514B.3(1) to 514B.3(14). An application shall not be deemed to be filed until all information necessary to properly process said application has been received by the commissioner, as indicated in rule 191—41.10(514B). Amendments to the application form shall be filed in the same manner as the application and approved by the commissioner before the change proposed by the amendment is effective.
191—41.3(514B) Inspection of evidence of coverage. Except for groups which maintain a cafeteria plan pursuant to Section 125 of the Internal Revenue Code (28 U.S.C.A. § 125), an enrollee may, if evidence of coverage is not satisfactory for any reason, return evidence of coverage within ten days of receipt of same and receive full refund of the deposit paid, if any. This right shall not act as a cure for misleading or deceptive advertising or marketing methods, nor may it be exercised if the enrollee utilizes the services of the LSO within the ten-day period. Enrollees in cafeteria plans must adhere to the plan provisions concerning termination or changes in coverage.
191—41.4(514B) Governing body and enrollee representation. An LSO shall have a basic written organizational document setting forth its scheme of organization and establishing a governing body appropriate to its form of organization. The governing body shall be responsible for matters of policy and operation.
The LSO shall develop bylaws or guidelines which describe the scope of the health care services the LSO renders to enrollees directly by a provider. Initial articles of incorporation, bylaws, guidelines of the LSO and revisions thereto shall be submitted to the commissioner of insurance for review and approval.
The articles of incorporation, bylaws, guidelines, or similar document shall provide for “reasonable representation” on the governing body by enrollees. “Reasonable representation” as used in Iowa Code section 514B.7 shall require that not less than 30 percent of the governing board members be enrollees who are not providers or are not associated with a provider. Enrollees shall have the opportunity to nominate said enrollee representatives.
The LSO may provide upon its initial formation that all representatives on the governing board shall be selected by the organizers of the LSO. Such members shall serve until the first annual meeting or election. If there are no enrollee representatives on the initial governing board, they shall be elected at the first annual meeting or election. The nomination procedures for enrollee representatives should provide for the following to ensure an adequate opportunity for participation by enrollees:
	41.4(1) An opportunity for adult enrollees to nominate candidates for the governing body.
	41.4(2) Notice to all adult enrollees of the nomination and elective procedures. The LSO shall be deemed to have complied with these requirements if it provides notice in its regular newsletter to enrollees of the opportunity to and the procedures for nomination of enrollee representatives. Nomination procedures may be waived by the commissioner for a period of up to three years from the LSO’s commencement of delivery of services to enrollees.
191—41.5(514B) Quality of care. Each LSO shall:
	41.5(1) Advise the insurance division annually of the ratio of full-time providers and ancillary health personnel to enrollees to ensure an adequate network. Changes in the provider ratios shall be immediately reported together with action taken to correct any deficiencies in the ratios.
	41.5(2) Provide assurance that all personnel engaged in the provision of health services to enrollees are currently licensed or certified by the appropriate state agency where the providers are located to practice their respective professions. These personnel shall be no less qualified in their respective professions than the current level of qualification, which is maintained in the providers’ communities.
	41.5(3) Provide assurance that any health care facilities utilized by the LSO are licensed by the appropriate state agency where the facilities are located. These facilities shall be accredited by the Joint Commission on Accreditation of Hospitals or the American Osteopathic Association; or they shall be certified as a provider for Medicare or Medicaid; or as otherwise accredited or licensed in accordance with state or federal law.
	41.5(4) Have a qualified administrator designated by the governing body who shall be responsible for the management of the LSO.
	41.5(5) Provide for an ongoing internal peer review program.
	41.5(6) Maintain a provider records system which includes at a minimum the following information:
	a. 	Documentation of utilization rates for every enrollee.
	b. 	Patient’s name, identification number, age, sex, and place of residence, and place of employment, if applicable.
	c. 	Services provided, when provided, where provided, and by whom.
	d. 	Provider diagnosis, treatment prescribed, therapy prescribed and drugs administered.
	e. 	Statement in regard to the status of the patient’s health, as appropriate.
	41.5(7) Provide by contract or other arrangement for peer review. The plans for internal and external peer review shall be submitted to the commissioner of insurance for approval.
	a. 	Internal peer review shall be conducted by the LSO staff on a continuing basis using standards adopted by the applicable accrediting body as a general guide. Internal peer review shall be structured to review the specific type of services for which the LSO is responsible. This review shall include but not be limited to the following:
	(1)	Utilization review and evaluation of the quality of services provided enrollees.
	(2)	The process or method by which services are provided.
	(3)	The outcome of services.
	b. 	External review may be satisfied either by NCQA certification or meeting the requirements of the external review group appointed by the commissioner. The criteria and methodology for selection of an external review group (ERG) are as follows:
	(1)	The commissioner will appoint an ERG based on the following criteria:
	1.	The group’s experience in evaluating the quality of service provided.
	2.	The degree to which the group is representative of the LSOs to be reviewed.
	3.	The degree to which the group is knowledgeable about the delivery of the services provided by the LSO in Iowa.
	4.	The group’s ability to coordinate its activities with other review groups and with practitioners and providers of health services in Iowa.
	5.	The group’s knowledge of current and accepted provider opinion and its ability to make qualitative evaluations of clinical practice.
	(2)	No provider shall review an LSO of which the provider is a member.
	(3)	Appointment of an ERG will be for a four-year period, and only one ERG will be appointed at a time. Applications for appointment or reappointment will be accepted between 180 days and 90 days before the expiration of the acting ERG’s four-year term.
	c. 	The following are criteria and methodology by which an ERG will evaluate the effectiveness of an LSO’s peer review program:
	(1)	The ERG will conduct an on-site inspection of each Iowa-certified LSO every two years.
	(2)	The inspection will consist of an interview with LSO staff and providers and a review of records (including clinical records of LSO patients) the ERG determines are necessary to conduct its inspection. The records may include any records or parts thereof maintained by the LSO or any of its provider members which pertain to LSO quality assurance operations or LSO patients, excluding financial records.
	(3)	The function of the ERG will be to make a qualitative evaluation of the effectiveness of an LSO’s internal peer review program and to report its findings to the insurance division.
	(4)	The following items will be considered by the ERG in making its determination:
	1.	The extent and acuity of the LSO’s peer review program in evaluating the clinical management of enrollees provided by LSO providers.
	2.	The ability of the LSO’s program to identify aberrant practices in clinical management and to take appropriate disciplinary action.
	3.	The method within the LSO by which the peer review program reports its findings to the provider staff and the governing body.
	4.	The authority within the LSO to correct practices which the peer review program has found to be detrimental.
	5.	The system developed within the LSO to facilitate the work of the peer review program.
	6.	The commitment on the part of the LSO governing body and provider staff toward an active peer review program with a goal of quality assurance.
	d. 	The following are procedures to be followed upon completion of an ERG’s inspection:
	(1)	Within 30 days of the completion of its inspection, the ERG will submit a written report of its findings to the LSO.
	(2)	The LSO will have 45 days to respond to the ERG.
	(3)	The ERG must file its final report with the insurance division within 90 days of the completion of its inspection. The final report must include any comments received from the LSO.
	(4)	The insurance division may extend the time periods referred to in subparagraphs 41.5(7)“d”(1) to (3).
	(5)	After considering the report of the ERG, the insurance commissioner shall determine if the LSO’s certificate of authority is to be continued, suspended or revoked.
191—41.6(514B) Change of name. No name other than that certified by the division may be used. The name of the LSO may not be changed without prior approval of the division.
191—41.7(514B) Change of ownership. Each LSO which desires to transfer ownership of more than 10 percent of the stock or ownership interest in the LSO shall not do so without first submitting a proposed plan to the division for review and approval or disapproval.
191—41.8(514B) Complaints.
	41.8(1) Each LSO shall provide in its bylaws for a system to resolve and record complaints.
	41.8(2) The complaint system shall provide for the resolution of the following kinds of complaints and the recording of the information required to be reported to the commissioner.
	a. 	Complaints about the quality of health care services provided by the LSO.
	b. 	Complaints about the availability of such services.
	c. 	Complaints relating to enrollee participation in the operation of the LSO.
	41.8(3) The complaints record shall be included in the annual report to the commissioner.
	41.8(4) All complaint files shall be retained by the LSO until the examination for the period during which the complaint was received has been completed.
191—41.9(514B) Cancellation of enrollees.
	41.9(1) Membership of an enrollee in an LSO may be terminated by the LSO for the following reasons and no other:
	a. 	Nonpayment of charges when due.
	b. 	Termination of the conditions, other than a change in the health of the enrollee, under which the enrollee became eligible to be enrolled under a group contract.
	c. 	Termination of the group contract under which the enrollee was enrolled.
	d. 	Change of place of residence of the enrollee from the geographic area served by the LSO.
	e. 	Failure of the enrollee to pay deductible or coinsurance charges permitted under Iowa Code section 514B.5(3).
	f. 	Unreasonable refusal of the enrollee to follow a prescribed course of treatment.
	g. 	A materially false statement or misrepresentation by the enrollee in an application for membership or benefits.
	h. 	Withdrawal of licensure by the LSO from the state. Upon withdrawal, an LSO has no obligation to secure replacement coverage for enrollees.
	41.9(2) Membership of an enrollee in an LSO may be terminated only upon giving a notice of cancellation not less than 30 days before the date of termination. Such notice shall:
	a. 	Be given by delivery of the notice in duplicate to the enrollee in person or by certified mail addressed to the enrollee at the last address known to the LSO.
	b. 	State the date and hour upon which the enrollment shall terminate.
	c. 	State the reason for cancellation.
	d. 	If cancellation is for nonpayment of charges, state the amount of charges due, the cost of preparing and serving the notice, and the total cost of charges and preparing the notice, and that if the enrollee pays the amount of charges due plus the cost of preparing and serving the notice at any time before the cancellation date, the coverage will remain in force.
	e. 	State that the enrollee has the right to a hearing before the commissioner if requested by the enrollee within 20 days after receipt of notice of cancellation.
	f. 	Provide for the enrollee to indicate on the notice that the enrollee requests such hearing.
	g. 	State that the enrollee may request such hearing by forwarding one copy of the notice of cancellation, marked to request a hearing, to the Commissioner of Insurance, 330 E. Maple Street, Des Moines, Iowa 50319.
	41.9(3) When a hearing is requested, the commissioner may require the LSO to continue to provide coverage during the pendency of the hearing and a period of not more than ten days after the decision is made known. The commissioner may require the enrollee, as a condition of granting continued coverage, to pay the LSO the charges for such period of coverage.
	41.9(4) The hearing shall be held before the commissioner or the delegated administrative law judge in the following manner:
	a. 	Upon receipt of a request for hearing, the commissioner shall notify the LSO and the enrollee of the time and place of hearing.
	b. 	Formal rules of evidence need not be observed, but no evidence shall be received which does not relate to the issue.
	c. 	The burden of proof shall be upon the LSO to show by a preponderance of the evidence that it had good cause for cancellation for one or more of the reasons stated in the notice and provided herein, except that when the cancellation is for nonpayment of charges, the burden of proof shall be upon the enrollee to show a tender of payment before the date of cancellation.
	d. 	At the close of the hearing, or as soon thereafter as possible, the commissioner shall advise the parties of the commissioner’s decision.
191—41.10(514B) Application for certificate of authority. The application for certificate of authority shall be in the following form:
LIMITED SERVICE ORGANIZATION
APPLICATION FOR CERTIFICATE OF AUTHORITY
(Name of Limited Service Organization)
Organized as ___________________________________ under the laws of the state of ________________________, makes application to the commissioner of insurance for a certificate of authority to establish and operate a limited service organization in compliance with Iowa Code chapter 514B.
Attached and made a part of this application are exhibits bearing numbers corresponding to the following:
	1.	A copy of the basic organizational document of the applicant, such as the articles of incorporation, articles of association or other applicable documents and all of its amendments.
	2.	A copy of the bylaws, rules or similar document regulating the conduct of the internal affairs of the applicant.
	3.	A list of the names, addresses, and official positions of the persons who are to be responsible for the conduct of the affairs of the applicant, including all members of the board of directors, board of trustees, executive committee, or other governing board or committee, the principal officers if a corporation and the partners or members if a partnership or association.
3.1 A list of the names and addresses of each owner of 5 percent or more of the LSO.
4. A copy of any contract made or to be made between any providers and the applicant.
4.1 A copy of any contract made or to be made between the applicant and any person listed in paragraph “3” above.
4.2 A copy of any contract made or to be made between the applicant and any person for management services.
5. A statement generally describing the LSO including, but not limited to, a description of its facilities and personnel.
	6.	A copy of the form of evidence of coverage.
	7.	A copy of the form of the group contract, if any, which is to be issued to employers, unions, trustees or other organizations.
	8.	Financial statements showing the applicant’s assets, liabilities, and sources of financial support. If the applicant’s financial affairs are audited by an independent certified public accountant, a copy of the applicant’s most recent regular certified financial statement is attached.
8.1 A copy of any contract made or to be made between the applicant and its reinsurer.
8.2 A copy of any contract made or to be made between the applicant and any person for cash or asset management services.
9. A description of the proposed method of marketing the plan, a financial plan which includes a three-year projection of operating results anticipated, and a statement as to the sources of funding.
	10.	A power of attorney executed by the applicant, if not domiciled in this state, appointing the commissioner, the commissioner’s successors in office and deputies as the true and lawful attorney of the applicant for this state upon whom all lawful process in any legal action or proceeding against the LSO on a cause of action arising in this state may be served.
	11.	A statement reasonably describing the geographic area to be served and assessing in detail the economic feasibility of the LSO’s projected operation.
	12.	A description of the complaint procedures to be utilized as required under Iowa Code section 514B.14.
	13.	A description of the procedures and programs to be implemented to meet the requirements for quality of health care as determined by the commissioner of insurance under Iowa Code section 514B.4.
	14.	A description of the mechanism by which enrollees shall be allowed to participate in matters of policy and operation as required by Iowa Code section 514B.7.
14.1 A copy of the notice to be given to enrollees of the procedure for nomination and election of members of the governing body.
15. A schedule of the liability and workers’ compensation insurance to be maintained in force by the LSO.
VERIFICATION
The undersigned deposes and states that deponent has duly executed the attached application
dated ________________________, ____________, for and on behalf of __________________; that
(Year)	(Name of Applicant)
the deponent is the ______________________________ of such company, and that deponent is
(Title of Officer)
authorized to execute and file such instrument. Deponent further states that deponent is familiar with such instrument and the contents thereof, and that the facts therein set forth are true to the best of deponent’s knowledge, information and belief.
(Signature)
(type or print name beneath)
Subscribed and sworn to before me by _______________on this ________ day of _________________, _________.
(Year)
(Notary Public)
191—41.11(514B) Net equity and deposit requirements.
	41.11(1) Net equity requirements.
	a. 	Each LSO shall, at all times, have and maintain a tangible net equity at least equal to the greater of:
	(1)	$100,000 at the inception of the first year of operation, $200,000 at the inception of the second year of operation and thereafter; or
	(2)	Two percent of the organization’s annual gross premium income, up to a maximum of the required capital and surplus of an accident and health insurer.
	b. 	An LSO that has uncovered expenses in excess of $500,000, as reported on the most recent annual financial statement filed with the commissioner, shall maintain tangible net equity equal to 25 percent of the uncovered expense in excess of $500,000 in addition to the tangible net equity required by paragraph 41.11(1)“a.”
	c. 	For the purpose of this rule, “net equity” shall mean the excess of total assets over total liabilities, excluding liabilities which have been subordinated in a manner acceptable to the commissioner; and “net equity” shall mean net equity reduced by the value assigned to intangible assets, including, but not limited to:
	(1)	Goodwill;
	(2)	Going-concern value;
	(3)	Organizational expense;
	(4)	Start-up costs;
	(5)	Obligations of officers, directors or affiliates, except short-term obligations of affiliates for goods or services arising in the normal course of business which are payable on the same terms as equivalent transactions with nonaffiliates and which are not past due;
	(6)	Long-term prepayments of deferred charges; and
	(7)	Nonreturnable deposits.
	41.11(2) Deposits.
	a. 	Each LSO shall deposit with the commissioner or with any organization or trustee meeting the requirements of rule 191—32.4(508) cash, securities or any combination of these that is acceptable to the commissioner having a fair market value equal to the minimum net worth of the LSO as determined by paragraph 41.11(1)“a.” The amount on deposit shall remain as an admitted asset of the organization in the determination of its net worth.
	b. 	All income from deposits shall be an asset of the LSO. An LSO may withdraw a deposit or any part thereof, first having deposited, in lieu thereof, a deposit of cash, securities, or any combination of these in an amount and value equal to that to be withdrawn. Securities shall be approved by the commissioner before being substituted.
	41.11(3) No LSO organized under the laws of another state shall, directly or indirectly, assume risks or provide the services of an LSO, as defined in Iowa Code section 514B.33, subsection (3), unless it first obtains licensure from the commissioner and complies with the requirements of rule 191—41.11(514B).
	41.11(4) As deemed necessary by the division, each LSO that is a subsidiary of another person shall file with the division, in a form satisfactory to the division, a guarantee of the LSO’s obligations issued by the ultimate controlling parent or such other person satisfactory to the division.
	41.11(5) Each LSO shall, at the time of application, pay to the division a one-time, nonrefundable fee of $10,000 to be used by the division to create a special fund solely for the payment of administrative expenses in connection with the insolvency of an LSO.
191—41.12(514B) Fidelity bond. An LSO shall maintain in force a fidelity bond on employees and officers in an amount not less than $100,000 or such other sum as may be prescribed by the commissioner. All such bonds shall be written with at least a one-year discovery period and if written with less than a three-year discovery period shall contain a provision that no cancellation or termination of the bond, whether by or at the request of the insured or by the underwriter, shall take effect prior to the expiration of 90 days after written notice of cancellation or termination has been filed with the commissioner unless an earlier date of cancellation or termination is approved by the commissioner.
191—41.13(514B) Annual report. An LSO shall annually, on or before the first day of March, file with the commissioner of insurance a report verified by at least two of its principal officers and covering the preceding calendar year. The report shall be on the form designated by the National Association of Insurance Commissioners (NAIC) as the report form for LSOs. The report shall be completed using statutory accounting practices (SAP), and shall include any other information required under law or rule.
The commissioner of insurance may request additional reports and information from an LSO as often as is deemed necessary to enable the commissioner to carry out the duties of Iowa Code chapter 514B.
191—41.14(514B) Cash or asset management agreements. If an LSO utilizes a cash or asset management arrangement with its parent, affiliate, or any other person, the arrangement shall be written and subject to prior approval by the commissioner. Cash or asset management agreements shall meet the following minimum requirements:
	1.	Cash receipts shall be under the direct control of the LSO that generated the receipts. If the system is under the control of the LSO’s parent or affiliate, then receipts shall be transferred to the LSO within five working days.
	2.	Securities purchased shall be in the name of the LSO generating the funds for the security purchase.
	3.	An LSO’s investments shall not be pooled with other entities’ investments unless there is an agreement which vests an undivided interest in the pooled arrangement to the LSO. Such an agreement shall be subject to prior approval by the commissioner.
	4.	An LSO’s cash or investments shall not be commingled with the cash or investments of any other person.
	5.	Investments made on behalf of an LSO shall be subject to the limitations imposed by Iowa Code sections 511.8 and 514B.15.
	6.	The agreement shall provide for prompt notice and verification of investments, establish responsibility for brokerage and other fees and provide for periodic reports on earnings and expenses.
	7.	A parent, affiliate, person, and employees thereof providing cash or asset management services shall be bonded and responsible for any physical loss of investments.
191—41.15(514B) Reinsurance. Reinsurance contracts and stop-loss agreements entered into by an LSO shall be subject to prior approval and shall meet the following minimum requirements:
	1.	Reinsurance contracts and stop-loss agreements shall provide that the commissioner of insurance be given notice of termination by certified mail at least 30 days prior to the effective date of termination of the reinsurance contract or stop-loss agreement.
	2.	Retention levels shall be reasonable in light of the LSO’s financial condition and potential liabilities.
191—41.16(514B) Provider contracts. An LSO’s arrangements for health care services shall be by written contract. Initial provider contracts shall be subject to prior approval. Thereafter, any provider contract deviating from previously submitted or approved contracts shall be submitted to the division for approval. In all instances, all provider contracts shall include the following provision:
(Provider), or its assignee or subcontractor, hereby agrees that in no event, including, but not limited to, nonpayment by the LSO, LSO insolvency or breach of this agreement, shall (Provider), or its assignee or subcontractor, bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against subscriber/enrollee or persons other than the LSO acting on the providers’ behalf for services provided pursuant to this agreement. This provision shall not prohibit collection of supplemental charges or copayments on LSO’s behalf made in accordance with terms of (applicable agreement) between LSO and subscriber/enrollee.
(Provider), or its assignee or subcontractor, further agrees that (1) this provision shall survive the termination of this agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the LSO subscriber/enrollee and that (2) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between (Provider) and subscriber/enrollee or persons acting on their behalf.
191—41.17(514B) Producers’ duties. In order to qualify for solicitation, enrollment, or delivery of a certificate of membership or policy in an LSO, a producer must comply with the licensing rules set forth in 191—Chapter 10 of the Iowa Administrative Code and in particular submit to an examination to determine the applicant’s competence to sell accident and health insurance as described in rule 191—10.7(522), qualification 6.
191—41.18(514B) Emergency services. “Emergency services” (inpatient and outpatient), as defined in rule 191—40.20(514B), shall be provided by the LSO, either through its own facilities or through guaranteed arrangements with other providers, on a 24-hour basis unless a waiver from such services is approved by the commissioner. A provider and sufficient other licensed and ancillary personnel shall be readily available at all times to render such services. Since LSOs may not contract with every emergency care provider in an area, LSOs shall make every effort to inform members of participating providers.
191—41.19(514B) Reimbursement. Reimbursement to a provider of “emergency services,” as defined in rule 191— 40.20(514B), shall not be denied by any LSO without that organization’s review of the patient’s provider history, presenting symptoms, and admitting or initial as well as final diagnosis, submitted by the provider, in determining whether, by definition, emergency services could reasonably have been expected to be provided. Reimbursement for emergency services shall not be denied solely on the grounds that services were performed by a noncontracted provider. If reimbursement for emergency services is denied, the enrollee may file a complaint with the LSO as outlined in rule 191—40.9(514B). Upon denial of reimbursement for emergency services, the LSO shall notify the enrollee and the provider that they may register a complaint with the commissioner of insurance.
191—41.20(514B) Limited service organization requirements. An LSO shall not prohibit or otherwise restrict a participating provider from advising a covered person about the health status of the covered person or medical care or treatment of the covered person’s condition or disease, regardless of whether benefits for such care or treatment are provided under the plan, if the provider is acting within the lawful scope of practice.
An LSO shall not penalize a provider because the provider, in good faith, reports to state or federal authorities any act or practice by the LSO that, in the opinion of the provider, jeopardizes patient health or welfare.
191—41.21(514B) Disclosure requirements. All LSOs shall include in contracts and evidence of coverage forms a statement disclosing the existence of any prescription drug formularies. Upon request, all LSOs offering policies under this chapter that include a prescription drug formulary shall inform policyholders, and prospective policyholders at time of issuance, whether a prescription drug specified in the request is included in such formulary.
All LSOs shall also disclose the existence of any contractual arrangements providing rebates received by them for drugs or durable medical equipment. Durable medical equipment means equipment that can stand repeated uses and is primarily and customarily used to serve a medical purpose and is generally not useful to a person who is not sick or injured or used by other family members and is appropriate for home use for the purpose of improving bodily function or preventing further deterioration of the medical condition caused by sickness or injury.
These rules are intended to implement Iowa Code section 514B.33.
[Filed 4/30/99, Notice 1/13/99—published 5/19/99, effective 8/18/99]
[Filed ARC 3682C (Notice ARC 3571C, IAB 1/17/18), IAB 3/14/18, effective 4/18/18]