House Amendment to Senate File 2293 S-5183 Amend Senate File 2293, as amended, passed, and 1 reprinted by the Senate, as follows: 2 1. Page 3, line 34, by striking < premium > and 3 inserting < premium, less claims paid, > 4 2. By striking page 11, line 8, through page 15, 5 line 14, and inserting: 6 < Sec. ___. Section 514J.102, subsections 1 and 10, 7 Code Supplement 2011, are amended to read as follows: 8 1. “Adverse determination” means a determination 9 by a health carrier that an admission, availability 10 of care, continued stay, or other health care service 11 that is a covered benefit has been reviewed and, 12 based upon the information provided, does not meet the 13 health carrier’s requirements for medical necessity, 14 appropriateness, health care setting, level of 15 care, or effectiveness, and the requested service or 16 payment for the service is therefore denied, reduced, 17 or terminated. “Adverse determination” includes a 18 denial of coverage for a dental care service that is 19 a covered benefit that has been reviewed and, based 20 upon the information provided, does not meet the health 21 carrier’s requirements for medical necessity, and 22 the requested service or payment for the dental care 23 service is therefore denied, reduced, or terminated, 24 in whole or in part. “Adverse determination” does not 25 include a denial of coverage for a service or treatment 26 specifically listed in plan or evidence of coverage 27 documents as excluded from coverage. 28 10. “Covered benefits” or “benefits” means those 29 health care services and dental care services to which 30 a covered person is entitled under the terms of a 31 health benefit plan. 32 Sec. ___. Section 514J.102, Code Supplement 2011, 33 is amended by adding the following new subsection: 34 NEW SUBSECTION . 11A. “Dental care services” means 35 services for diagnostic, preventive, maintenance, and 36 therapeutic dental care that is provided under chapter 37 153. > 38 3. Page 18, after line 12 by inserting: 39 < Sec. ___. Section 522B.12, Code 2011, is amended 40 by adding the following new subsection: 41 NEW SUBSECTION . 5. A person who enrolls in a 42 qualified health benefit plan offered in this state 43 pursuant to federal law has the option to utilize the 44 services of an insurance producer licensed pursuant 45 to chapter 522B. Qualified health benefit plans 46 offered pursuant to federal law shall pay licensed 47 insurance producers for their services at a level that 48 is commensurate with the compensation paid to insurance 49 producers for the placement, renewal, or enrollment of 50 -1- SF2293.5701.H (1) 84 md 1/ 8 #1. #2. #3.
persons in health benefit plans offered pursuant to 1 state law. > 2 4. Page 19, after line 14 by inserting: 3 < Sec. ___. NEW SECTION . 522D.1 Definitions. 4 As used in this chapter, unless the context 5 otherwise requires: 6 1. “Commissioner” means the commissioner of 7 insurance. 8 2. “ Navigator ” means a public or private entity 9 or an individual that is qualified and licensed, if 10 appropriate, to engage in the activities and meet the 11 standards described in 45 C.F.R. § 155.210. 12 Sec. ___. NEW SECTION . 522D.2 License required. 13 A person shall not act as a navigator in this state 14 unless the person is licensed by the commissioner as 15 required in this chapter. 16 Sec. ___. NEW SECTION . 522D.3 Actions prohibited. 17 A navigator shall not perform the functions of a 18 person required to be licensed as an insurance producer 19 under chapter 522B unless the navigator is licensed 20 as a navigator pursuant to this chapter and as an 21 insurance producer pursuant to chapter 522B. 22 Sec. ___. NEW SECTION . 522D.4 Application for 23 examination. 24 1. An individual applying for a navigator license 25 shall pass a written examination. The examination 26 shall test the knowledge of the individual concerning 27 the duties and responsibilities of a navigator and the 28 insurance laws and regulations of this state. The 29 commissioner shall adopt rules pursuant to chapter 30 17A related to the development and conduct of the 31 examination. 32 2. The commissioner may make arrangements, 33 including contracting with an outside testing service 34 or other appropriate entity, for administering 35 examinations and collecting fees. 36 3. An individual applying for an examination shall 37 remit a nonrefundable fee as established by rule of the 38 commissioner. 39 4. An individual who fails to appear for the 40 examination as scheduled or fails to pass the 41 examination shall reapply for an examination and remit 42 all required fees and forms before being rescheduled 43 for another examination. 44 Sec. ___. NEW SECTION . 522D.5 Application for 45 license. 46 1. A person applying for a navigator license shall 47 make application to the commissioner on an application 48 form approved by the commissioner and declare under 49 penalty of refusal, suspension, or revocation of the 50 -2- SF2293.5701.H (1) 84 md 2/ 8 #4.
license that the statements made on the application 1 are true, correct, and complete to the best of the 2 individual’s knowledge and belief. Before approving 3 the application, the commissioner shall find all of the 4 following: 5 a. The individual is at least eighteen years of 6 age. 7 b. The individual has not committed any act that is 8 a ground for denial, suspension, or revocation as set 9 forth in section 522D.7. 10 c. The individual has paid the license fee, as 11 established by the commissioner by rule. 12 d. The individual has successfully completed the 13 initial training and education program for a license as 14 established by the commissioner by rule. 15 e. The individual has successfully passed the 16 examination as provided in section 522D.4. 17 f. In order to protect the public interest, the 18 individual has the requisite character and competence 19 to receive a license as a navigator. 20 2. A public or private entity acting as a navigator 21 may elect to obtain a navigator license. Application 22 shall be made using the application form approved by 23 the commissioner. Prior to approving the application, 24 the commissioner shall find both of the following: 25 a. The entity has paid the appropriate fees. 26 b. The entity has designated a licensed navigator 27 responsible for the entity’s compliance with this 28 chapter. 29 Sec. ___. NEW SECTION . 522D.6 License. 30 1. A person who meets the requirements of sections 31 522D.4 and 522D.5, unless otherwise denied licensure 32 pursuant to section 522D.7, shall be issued a navigator 33 license. A navigator license is valid for three years. 34 2. A navigator license remains in effect unless 35 revoked or suspended as long as all required fees are 36 paid and continuing education requirements are met by 37 any applicable due date. A navigator is required to 38 complete continuing education requirements required by 39 law in order to be eligible for license renewal. 40 3. A licensed navigator who is unable to comply 41 with license renewal procedures due to military service 42 or other extenuating circumstances may request a waiver 43 of those procedures. The licensed navigator may also 44 request a waiver of any examination requirement or any 45 other penalty or sanction imposed for failure to comply 46 with renewal procedures. 47 4. The license shall contain the licensee’s 48 name, address, personal identification number, the 49 date of issuance, the expiration date, and any other 50 -3- SF2293.5701.H (1) 84 md 3/ 8
information the commissioner deems necessary. 1 5. A licensee shall inform the commissioner by any 2 means acceptable to the commissioner of a change of 3 legal name or address within thirty days of the change. 4 Failure to timely inform the commissioner of a change 5 of legal name or address may result in a penalty as 6 specified in section 522D.7. 7 6. The commissioner shall require by rule that 8 a licensed navigator furnish a surety bond or other 9 evidence of financial responsibility that protects all 10 persons against wrongful acts, misrepresentations, 11 errors, omissions, or negligence of the navigator. 12 7. In order to assist with the commissioner’s 13 duties, the commissioner may contract with a 14 nongovernmental entity, including the national 15 association of insurance commissioners or any affiliate 16 or subsidiary the national association of insurance 17 commissioners oversees, to perform any ministerial 18 functions, including the collection of fees, related 19 to navigator licensing that the commissioner deems 20 appropriate. 21 Sec. ___. NEW SECTION . 522D.7 License denial, 22 nonrenewal, or revocation. 23 1. The commissioner may place on probation, 24 suspend, revoke, or refuse to issue or renew a 25 navigator’s license or may levy a civil penalty as 26 provided in section 522D.8 for any one or more of the 27 following causes: 28 a. Providing incorrect, misleading, incomplete, 29 or materially untrue information in the license 30 application. 31 b. Violating any insurance laws, or violating any 32 regulation, subpoena, or order of the commissioner or 33 of a commissioner of another state. 34 c. Obtaining or attempting to obtain a license 35 through misrepresentation or fraud. 36 d. Improperly withholding, misappropriating, or 37 converting any moneys or properties received in the 38 course of doing insurance business. 39 e. Intentionally misrepresenting the terms of an 40 actual or proposed insurance contract or application 41 for insurance. 42 f. Having been convicted of a felony. 43 g. Having admitted or been found to have committed 44 any unfair insurance trade practice or fraud. 45 h. Using fraudulent, coercive, or dishonest 46 practices, or demonstrating incompetence, 47 untrustworthiness, or financial irresponsibility 48 in the conduct of business in this state or elsewhere. 49 i. Having a navigator license, or its equivalent, 50 -4- SF2293.5701.H (1) 84 md 4/ 8
denied, suspended, or revoked in any other state, 1 province, district, or territory. 2 j. Forging another’s name to an application for 3 insurance or to any document related to an insurance 4 transaction. 5 k. Improperly using notes or any other reference 6 material to complete an examination for a navigator 7 license. 8 l. Failing to comply with an administrative or 9 court order imposing a child support obligation. 10 m. Failing to comply with an administrative or 11 court order related to repayment of loans to the 12 college student aid commission. 13 n. Failing to pay state income tax or comply with 14 any administrative or court order directing payment of 15 state income tax. 16 o. Failing or refusing to cooperate in an 17 investigation by the commissioner. 18 2. If the commissioner does not renew a license or 19 denies an application for a license, the commissioner 20 shall notify the applicant or licensee and advise, 21 in writing, the licensee or applicant of the reason 22 for the nonrenewal of the license or denial of the 23 application for a license. The licensee or applicant 24 may request a hearing on the nonrenewal or denial. A 25 hearing shall be conducted according to section 507B.6. 26 3. The license of a public or private entity 27 operating as a navigator may be suspended, revoked, 28 or refused if the commissioner finds, after hearing, 29 that an individual navigator licensee’s violation was 30 known or should have been known by a partner, officer, 31 or manager acting on behalf of the entity and the 32 violation was not reported to the commissioner and 33 corrective action was not taken. 34 4. In addition to, or in lieu of, any applicable 35 denial, suspension, or revocation of a license, a 36 person, after hearing, may be subject to a civil 37 penalty as provided in section 522D.8. 38 5. The commissioner may conduct an investigation 39 of any suspected violation of this chapter pursuant 40 to section 507B.6 and may enforce the provisions and 41 impose any penalty or remedy authorized by this chapter 42 and chapter 507B against any person who is under 43 investigation for, or charged with, a violation of 44 either chapter even if the person’s license has been 45 surrendered or has lapsed by operation of law. 46 6. a. In order to assure a free flow of 47 information for accomplishing the purposes of this 48 section, all complaint files, investigation files, 49 other investigation reports, and other investigative 50 -5- SF2293.5701.H (1) 84 md 5/ 8
information in the possession of the commissioner or 1 the commissioner’s employees or agents that relates to 2 licensee discipline are privileged and confidential, 3 and are not subject to discovery, subpoena, or 4 other means of legal compulsion for their release 5 to a person other than the licensee, and are not 6 admissible in evidence in a judicial or administrative 7 proceeding other than the proceeding involving 8 licensee discipline. A final written decision of the 9 commissioner in a disciplinary proceeding is a public 10 record. 11 b. Investigative information in the possession 12 of the commissioner or the commissioner’s employees 13 or agents that relates to licensee discipline may 14 be disclosed, in the commissioner’s discretion, to 15 appropriate licensing authorities within this state, 16 the appropriate licensing authority in another state, 17 the District of Columbia, or a territory or country in 18 which the licensee is licensed or has applied for a 19 license. 20 c. If the investigative information in the 21 possession of the commissioner or the commissioner’s 22 employees or agents indicates a crime has been 23 committed, the information shall be reported to the 24 proper law enforcement agency. 25 d. Pursuant to the provisions of section 17A.19, 26 subsection 6, upon an appeal by the licensee, the 27 commissioner shall transmit the entire record of the 28 contested case to the reviewing court. 29 e. Notwithstanding the provisions of section 30 17A.19, subsection 6, if a waiver of privilege has 31 been involuntary and evidence has been received at a 32 disciplinary hearing, the court shall issue an order to 33 withhold the identity of the individual whose privilege 34 was waived. 35 Sec. ___. NEW SECTION . 522D.8 Cease and desist 36 orders —— penalties. 37 1. A navigator who, after hearing, is found to have 38 violated this chapter, may be ordered to cease and 39 desist from engaging in the conduct resulting in the 40 violation and may be assessed a civil penalty pursuant 41 to chapter 507B. 42 2. If a person does not comply with an order issued 43 pursuant to this section, the commissioner may petition 44 a court of competent jurisdiction to enforce the order. 45 The court shall not require the commissioner to post 46 a bond in an action or proceeding under this section. 47 If the court finds, after notice and opportunity for 48 hearing, that the person is not in compliance with an 49 order, the court may adjudge the person to be in civil 50 -6- SF2293.5701.H (1) 84 md 6/ 8
contempt of the order. The court may impose a civil 1 penalty against the person for contempt in an amount 2 not less than three thousand dollars but not greater 3 than ten thousand dollars for each violation and may 4 grant any other relief that the court determines is 5 just and proper in the circumstances. 6 Sec. ___. NEW SECTION . 522D.9 Injunctive relief. 7 1. A person may bring an action in district court 8 to enjoin another person from acting as a navigator in 9 violation of section 522D.2. However, before bringing 10 an action in district court to enjoin a person pursuant 11 to this section, the person shall file a complaint with 12 the insurance division alleging that another person is 13 acting as a navigator in violation of section 522D.2. 14 2. If the division makes a determination to proceed 15 administratively against the person for a violation 16 of section 522D.2, the complainant shall not bring an 17 action in district court against the person pursuant to 18 this section based upon the allegations contained in 19 the complaint filed with the division. 20 3. If the division does not make a determination 21 to proceed administratively against the person for 22 a violation of section 522D.2, the division shall 23 issue, by ninety days from the date of filing of the 24 complaint, a release to the complainant that permits 25 the complainant to bring an action in district court 26 pursuant to this section. 27 4. The filing of a complaint with the division 28 pursuant to this section tolls the statute of 29 limitations pursuant to section 614.1 as to the alleged 30 violation for a period of one hundred twenty days from 31 the date of filing the complaint. 32 5. Any action brought in district court by a 33 complainant against a person pursuant to this section, 34 based upon the allegations contained in the complaint 35 filed with the division, shall be brought within one 36 year after the ninety-day period following the filing 37 of the complaint with the division, or the date of the 38 issuance of a release by the division, whichever is 39 earlier. 40 6. If the court finds that the person is in 41 violation of section 522D.2 and enjoins the person from 42 acting as a navigator in violation of that section, 43 the court’s findings of fact and law, and the judgment 44 and decree, when final, shall be admissible in any 45 proceeding initiated pursuant to section 522D.8 by the 46 commissioner against the person enjoined and the person 47 enjoined shall be precluded from contesting in that 48 proceeding the court’s determination that the person 49 acted as a navigator in violation of section 522D.2. 50 -7- SF2293.5701.H (1) 84 md 7/ 8
Sec. ___. NEW SECTION . 522D.10 Rules. 1 The commissioner may adopt rules pursuant to 2 chapter 17A as are necessary or proper to carry out the 3 purposes of this chapter. 4 Sec. ___. NEW SECTION . 522D.11 Severability. 5 If any provision of this chapter or its application 6 to any person or circumstance is held invalid by a 7 court of competent jurisdiction or by federal law, 8 the invalidity does not affect other provisions or 9 applications of the chapter that can be given effect 10 without the invalid provision or application, and to 11 this end the provisions of the chapter are severable 12 and the valid provisions or applications shall remain 13 in full force and effect. 14 Sec. ___. NEW SECTION . 522D.12 Future repeal. 15 If the federal law requiring the establishment 16 of an exchange in each state is repealed by federal 17 legislation or is ruled invalid by a decision of the 18 United States supreme court, the commissioner shall 19 notify the Iowa Code editor of the effective date of 20 the repeal or the date of the ruling. This chapter 21 is repealed on the effective date of such federal 22 legislation or the date of the United States supreme 23 court decision. > 24 5. Page 21, by striking lines 1 through 12. 25 6. Page 21, by striking lines 17 and 18. 26 7. Page 21, after line 18 by inserting: 27 Sec. ___. EFFECTIVE DATE. The following provision 28 or provisions of this Act take effect July 1, 2013: 29 1. The sections of this Act enacting chapter 522D. > 30 8. By renumbering as necessary. 31 -8- SF2293.5701.H (1) 84 md 8/ 8 #5. #6. #7.