CHAPTER 82
IOWA STOPGAP MEASURE
191—82.1(505,513C,514E) Purpose. This chapter is intended to establish a temporary health program providing for a single, standard individual health insurance plan available to eligible residents, premium credits based on age and income, and a reinsurance program to support the costs of high-cost claimants. The operations of this Iowa Stopgap Measure shall be facilitated by the Iowa Individual Health Benefit Reinsurance Association (IIHBRA) and the Iowa Comprehensive Health Association (HIPIOWA) pursuant to the powers and authority afforded to the associations and the insurance commissioner under Iowa Code sections 513C.10 and 514E.2.
[ARC 3281C, IAB 8/30/17, effective 8/4/17]
191—82.2(505,513C,514E) Authority to request waiver. The insurance commissioner may, on behalf of the state of Iowa, apply to the United States Secretary of Health and Human Services and the United States Secretary of the Treasury under 42 U.S.C. Section 18052 for the waiver of applicable provisions of P.L. 111-148 (Patient Protection and Affordable Care Act) with respect to health insurance coverage for a plan year beginning on or after January 1, 2018. The insurance commissioner may implement a state plan meeting the waiver requirements in a manner consistent with state and federal law and as approved by the United States Secretary of Health and Human Services and the United States Secretary of the Treasury.
[ARC 3281C, IAB 8/30/17, effective 8/4/17]
191—82.3(505,513C,514E) Funding. The Iowa Stopgap Measure shall be funded by the Centers for Medicare and Medicaid Services (CMS). If no funding or an insufficient amount of funding is received from CMS, the Iowa Stopgap Measure shall not be established. If funding for the Iowa Stopgap Measure is insufficient to completely fund all premium credits and the reinsurance program, a carrier participating in the Iowa Stopgap Measure may cancel and nonrenew a standard individual health insurance plan issued thereunder by giving 30 days’ written notice of cancellation to the consumer.
[ARC 3281C, IAB 8/30/17, effective 8/4/17]
191—82.4(505,513C,514E) Authority. These rules are adopted pursuant to the general rule-making authority of the insurance commissioner in Iowa Code chapters 505, 513C, and 514E to establish the Iowa Stopgap Measure.
[ARC 3281C, IAB 8/30/17, effective 8/4/17]
191—82.5(505,513C,514E) Scope. This chapter and the definitions and rules set forth herein shall apply only to the Iowa Stopgap Measure.
[ARC 3281C, IAB 8/30/17, effective 8/4/17]
191—82.6(505,513C,514E) Duties of IIHBRA and HIPIOWA to amend their plans of operation.
	82.6(1) Pursuant to Iowa Code sections 513C.10 and 514E.2(3), the IIHBRA and the HIPIOWA shall develop amendments to their plans of operation that:
	a. 	Establish a procedure for implementation of the Iowa Stopgap Measure as set forth in the State of Iowa’s Section 1332 waiver;
	b. 	Set forth the benefits, the deductible, and the cost-sharing amounts to be offered in the standard individual health insurance plan; and
	c. 	Undertake, directly or through contracts with other persons, the procedure for implementation of the Iowa Stopgap Measure.
	82.6(2) The amendments to the plans of operation are subject to review and approval by the insurance commissioner.
[ARC 3281C, IAB 8/30/17, effective 8/4/17]
191—82.7(505,513C,514E) Definitions. As used in this chapter, unless the context otherwise requires:
“Benefit year” means a period of time in which health benefits are to be provided, beginning on or after January 1 and ending December 31.
“Eligible consumer” means a consumer who meets the following criteria:
	1.	Is a resident of Iowa;
	2.	Is a citizen or national of the United States, or is considered an alien lawfully present;
	3.	Is not enrolled in Medicaid, Children’s Health Insurance Program (CHIP), or Medicare;
	4.	Does not receive minimum essential coverage; and
	5.	Is not incarcerated.
“Eligible health carrier” means any health insurer which the commissioner approves to offer the Iowa Stopgap Measure.
“Household income” means an amount equal to the sum of:
	1.	The 2017 modified adjusted gross income of the individual; and
	2.	The 2017 modified adjusted gross income of all individuals, including a spouse and dependents, who are on the same federal income tax filing, regardless of whether or not these individuals reside in the same household and whether or not coverage is being purchased for each of the individuals.
“Iowa Comprehensive Health Association” or “HIPIOWA” means the association established by Iowa Code section 514E.
“Iowa Individual Health Benefit Reinsurance Association” or “IIHBRA” means the association established by Iowa Code section 513C.10.
“Lawfully present” has the meaning given in 45 CFR Section 155.20.
“Minimum essential coverage” has the meaning given in 26 U.S.C. Section 5000A(f). “Minimum essential coverage” also includes coverage offered by an employer that is affordable as defined in 26 U.S.C. Section 36B(c)(2)(C)(i) and meets the minimum value standards as defined in 26 U.S.C. Section 36B(c)(2)(C)(ii).
“Standard plan” means the group of individual health benefits developed and offered to all eligible consumers under the Iowa Stopgap Measure.
[ARC 3349C, IAB 10/11/17, effective 9/14/17]
191—82.8(505,513C,514E) Eligibility determination.
	82.8(1) Any individual intending to purchase the standard plan offered by the Iowa Stopgap Measure must provide the following information to determine the individual’s eligibility to participate and the amount of the individual’s premium credit:
	a. 	The name, address, date of birth, and social security number for each individual in the household and for each dependent for whom coverage is sought;
	b. 	The individual’s 2017 household income;
	c. 	An attestation that the individual does not receive minimum essential coverage;
	d. 	An attestation that the individual is not incarcerated;
	e. 	An attestation that the individual is not enrolled in Medicare;
	f. 	Consent for information to be provided to any necessary state or federal agencies and third-party entities contracted by state or federal agencies for the purpose of determining whether an individual is an eligible consumer; and
	g. 	An attestation that the information submitted by the individual is true, correct, and complete subject to penalty of perjury. Submission of false information may subject the consumer to felony prosecution under Iowa Code chapter 507E.
	82.8(2) Any person or entity who receives information provided by an individual under this chapter, or receives information from a state or federal agency related to this information, shall use the information only for the purposes of, and to the extent necessary in, ensuring the efficient operation of the Iowa Stopgap Measure, including premium credit verification and enrollment eligibility verification.
	82.8(3) In the event individuals are enrolled following submission of a completed attested application and through subsequent data matching are determined not to be eligible for the standard plan, the standard plan for such individuals may be prospectively terminated by the carrier.
[ARC 3349C, IAB 10/11/17, effective 9/14/17]
191—82.9(505,513C,514E) Covered benefits.
	82.9(1) The standard plan shall provide the following benefits:
	a. 	All essential health benefits set forth in 45 CFR Section 156.110, and
	b. 	Benefits required to be provided pursuant to Iowa Code chapter 514C.
	82.9(2) The standard plan shall have an actuarial value between 68 percent and 72 percent.
[ARC 3349C, IAB 10/11/17, effective 9/14/17]
191—82.10(505,513C,514E) Enrollment.
	82.10(1) For calendar year 2018, eligible individuals who wish to enroll in the Iowa Stopgap Measure must submit all information required to determine eligibility for open enrollment between November 1, 2017, and December 15, 2017.
	82.10(2) November 1 through December 15 shall be the open enrollment period for any future years should the Iowa Stopgap Measure be renewed by the commissioner and CMS.
	82.10(3) Individuals who qualify for one of the special enrollment periods defined in rule 191—82.11(505,513C,514E) may enroll in the Iowa Stopgap Measure if they meet the requirements described in rule 191—82.8(505,513C,514E).
[ARC 3349C, IAB 10/11/17, effective 9/14/17]
191—82.11(505,513C,514E) Special enrollment periods.
	82.11(1) An individual may purchase the standard plan outside of the defined open enrollment period via a special enrollment period when the individual experiences one of the following qualifying events:
	a. 	Loss of qualifying health coverage as defined in 45 CFR Section 155.420(d)(1) and 45 CFR Section 155.420(d)(6)(iii).
	b. 	Change in household size as defined in 45 CFR Section 155.420(d)(2).
	c. 	Becoming newly eligible for coverage due to gaining status as a citizen, national, or lawfully present individual or being released from incarceration as defined in 45 CFR Section 155.420(d)(3).
	d. 	Change in primary place of living as defined in 45 CFR Section 155.420(d)(7).
	e. 	Gaining membership in a federally recognized tribe or status as an Alaskan Native Claims Settlement Act Corporate shareholder as defined in 45 CFR Section 155.420(d)(8).
	f. 	Loss of eligibility for Medicaid or CHIP as defined in 45 CFR Section 155.420(d)(11).
	g. 	Experiencing a plan contract violation as defined in 45 CFR Section 155.420(d)(5).
	h. 	Domestic abuse or spousal abandonment as defined in 45 CFR Section 155.420(d)(10).
	i. 	Experiencing an exceptional circumstance as defined in 45 CFR Section 155.420(d)(9).
	82.11(2) To qualify for a special enrollment period, an individual must demonstrate that the individual has not been without minimum essential coverage for more than 60 days in the immediately preceding 12 months.
	82.11(3) Individuals qualifying for a special enrollment period defined in paragraphs 82.11(1)“a” to 82.11(1)“e” will not be required to meet the qualifications of subrule 82.11(2).
	82.11(4) An individual seeking to purchase the standard plan during a special enrollment period will be required to submit documentation to verify eligibility for the Iowa Stopgap Measure.
[ARC 3349C, IAB 10/11/17, effective 9/14/17]
191—82.12(505,513C,514E) Rate schedule and premium credits.
	82.12(1) Premium rates charged by an eligible health carrier under the Iowa Stopgap Measure shall vary based on an individual’s age, except that such rate shall not vary by more than 3 to 1 for adults as set forth in 45 CFR Section 147.102(a)(1)(iii).
	82.12(2) A per-member, per-month premium credit shall be allocated to an eligible individual based on a combination of the individual’s age and, if applicable, 2017 household income as a percentage of the federal poverty level. The premium credit shall be based on the individual’s age as of the first date of the benefit year.
	82.12(3) The value of the monthly per-member, per-month premium credit shall be as set forth in the State of Iowa’s Section 1332 waiver application.
	82.12(4) The premium credit amount for each individual will be reconciled based on the 2017 tax filing.
[ARC 3349C, IAB 10/11/17, effective 9/14/17]
191—82.13(505,513C,514E) Reinsurance program.
	82.13(1) The Iowa Stopgap Measure will coordinate reinsurance reimbursement with the Federal High-Cost Risk Pooling Program (FHCRP), to the extent adequate funding for the FHCRP exists. Subject to the availability of sufficient FHCRP funding, reinsurance shall be available for eligible health carriers for individuals with aggregate claims incurred during the 2018 benefit year at the following amounts:
	a. 	For claims that are greater than $100,000 and up to $1,000,000, the Iowa Stopgap Measure program will reimburse 85 percent.
	b. 	For claims that are greater than $1,000,000 and up to $3,000,000, the Iowa Stopgap Measure program will reimburse 25 percent.
	c. 	For claims that are greater than $3,000,000, the Iowa Stopgap Measure program will reimburse 40 percent.
	d. 	For claims that are greater than $1,000,000, the FHCRP is expected to reimburse 60 percent. In the event sufficient funding for the FHCRP does not exist to contribute the 60 percent share, any shortfall shall be paid to the carriers from funding for the Iowa Stopgap Measure.
	82.13(2) Reinsurance payments will be paid to the eligible health carrier in the time and manner defined by the amendment to the plan of operations developed by HIPIOWA. The amendment to the plan of operations shall also include a description of the data that an eligible health carrier submitting a reinsurance payment must provide and the manner and time period in which such data should be provided.
	82.13(3) The reinsurance program will not supersede any payments made pursuant to the FHCRP as set forth in the HHS Notice of Benefit and Payment Parameters for 2018.
[ARC 3349C, IAB 10/11/17, effective 9/14/17]
191—82.14(505,513C,514E) Term of Iowa Stopgap Measure. The Iowa Stopgap Measure shall provide coverage to enrollees through December 31, 2018, unless the commissioner and CMS renew the program.
[ARC 3349C, IAB 10/11/17, effective 9/14/17]
These rules are intended to implement Iowa Code chapters 505, 513C, and 514E.
[Filed Emergency ARC 3281C, IAB 8/30/17, effective 8/4/17]
[Filed Emergency ARC 3349C, IAB 10/11/17, effective 9/14/17]