07/14/2020 14:5325:22B1C889-B5A8-45BD-9B24-4B286AC82D9025:971E2FE0-44D7-4529-98EC-B9893AC00A7225:72463BD5-5DD5-4929-B030-F0F182B08BD561514CSPECIAL HEALTH AND ACCIDENT INSURANCE COVERAGES514C.1Supplemental coverage for adopted or newly born children.1Any policy of individual or group accident and sickness insurance providing coverage on an expense incurred basis, and any individual or group hospital or medical service contracts issued pursuant to chapters 509, 514, and 514A, which provide coverage for a family member of the insured or subscriber shall also provide that the health insurance benefits applicable for children shall, subject to the enrollment requirements of this section, be payable with respect to a newly born child of the insured or subscriber from the moment of birth, or, in the situation of a newly adopted child of a covered person, such child shall be covered from the earlier of any of the following:aThe date of placement of the child for the purpose of adoption and continuing in the same manner as for other dependents of the covered person, unless the placement is disrupted prior to legal adoption and the child is removed from placement.bThe date of entry of an order granting the covered person custody of the child for purposes of adoption.cThe effective date of adoption.2The coverage for adopted or newly born children shall consist of coverage for injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and is not subject to any preexisting condition exclusion.3If payment of a specific premium or subscription fee is required to provide coverage for a newly born child, the policy or contract may require that notification of birth of a newly born child and payment of the required premium or fees must be furnished to the insurer or nonprofit service or indemnity corporation within sixty days after the date of birth.4If payment of a specific premium or subscription fee is not required to provide coverage for a newly born child, the policy or contract may require that notification of birth of a newly born child must be furnished to the insurer or nonprofit service or indemnity corporation within sixty days after the date of birth in order for coverage to be provided for the child from the date of birth.5aIf payment of a specific premium or subscription fee is required to provide coverage for a newly adopted child or child placed for adoption, the policy or contract may require that notification of the adoption or placement for adoption and payment of the required premium or fees must be furnished to the insurer or nonprofit service or indemnity corporation within sixty days after the coverage is required to begin under this section.bIf payment of a specific premium or subscription fee is not required to provide coverage for a newly adopted child or child placed for adoption, the policy or contract may require that notification of the adoption or placement for adoption must be furnished to the insurer or nonprofit service or indemnity corporation within sixty days after the coverage is required to begin under this section.cIf a covered person fails to provide the required notice or to make payment of premium or subscription fees within the sixty-day period required in this subsection, the newly adopted child or child placed for adoption shall be treated no less favorably by a health carrier than other dependents of the covered person, other than newly born children, who seek coverage under a policy or contract at a time other than the time when the dependent is first eligible to apply for coverage.[C75, 77, 79, 81, §514C.1]2006 Acts, ch 1117, §62514C.2Skilled nursing care covered in hospitals.An insurer, a hospital service corporation, or a medical service corporation, which covers the costs of skilled nursing care under an individual or group policy of accident and health insurance regulated under chapter 509 or 514A, a nonprofit hospital or medical and surgical service plan regulated under chapter 514, or a health care service contract regulated under chapter 514B, shall also cover the costs of skilled nursing care in a hospital if the level of care needed by the insured or subscriber has been reclassified from acute care to skilled nursing care and no designated skilled nursing care beds or swing beds are available in the hospital or in another hospital or health care facility within a thirty-mile radius of the hospital. The insurer or corporation shall reimburse the insured or subscriber based on the skilled nursing care rate.84 Acts, ch 1034, §1; 95 Acts, ch 185, §12514C.3Dentist’s services under accident and sickness insurance policies.A policy of accident and sickness insurance issued in this state which provides payment or reimbursement for any service which is within the lawful scope of practice of a licensed dentist shall provide benefits for the service whether the service is performed by a licensed physician or a licensed dentist. As used in this section, “licensed physician” includes persons licensed under chapter 148, and “policy of accident and sickness insurance” includes individual policies or contracts issued pursuant to chapter 514, 514A, or 514B, and group policies as defined in section 509B.1, subsection 3.88 Acts, ch 1127, §1; 2006 Acts, ch 1117, §63; 2008 Acts, ch 1088, §129514C.3ADisclosures relating to dental coverage reimbursement rates.1An individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 514, or 514A, and delivered, amended, or renewed on or after July 1, 1995, that provides dental care benefits with a base payment for those benefits determined upon a usual and customary fee charged by licensed dentists, shall disclose all of the following:aThe frequency of the determination of the usual and customary fee.bA general description of the methodology used to determine usual and customary fees, including geographic considerations.cThe percentile that determines the maximum benefit that the insurer or nonprofit health service corporation will pay for any dental procedure, if the usual and customary fee is determined by taking a sample of fees submitted on actual claims from licensed dentists and then determining the benefit by selecting a percentile of those fees.2The disclosure shall be provided upon request to all group and individual policyholders and subscribers. All proposals for dental care benefits shall inform the prospective policyholder or subscriber that information regarding usual and customary fee determinations is available from the insurer or nonprofit health service corporation. All employee benefit descriptions or supplemental documents shall notify the employee that information regarding reimbursement rates is available from the employer.95 Acts, ch 78, §1; 95 Acts, ch 209, §26514C.3BDental coverage fee schedules.1A contract between a dental plan and a dentist for the provision of services to covered individuals under the plan shall not require that a dentist provide services to those covered individuals at a fee set by the dental plan unless such services are covered services under the dental plan.2A person or entity providing third-party administrator services shall not make available any dentists in its dentist network to a dental plan that sets fees for dental services that are not covered services.3For the purposes of this section:a“Covered services” means services reimbursed under the dental plan.b“Dental plan” means any policy or contract of insurance which provides for coverage of dental services not in connection with a medical plan that provides for the coverage of medical services.4Nothing in this section shall be construed as limiting the ability of an insurer or a third-party administrator to restrict any of the following as they relate to covered services:aBalance billing.bWaiting periods.cFrequency limitations.dDeductibles.eMaximum annual benefits.2010 Acts, ch 1179, §1514C.3CDental care service plan contracts.1Definitions.As used in this section unless the context otherwise provides:a“Commissioner” means the commissioner of insurance.b“Contracting entity” means any person, third-party administrator, health carrier, or dental carrier that enters into a contract with a dental care provider for the delivery of dental care services.c“Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a dental care service plan or health benefit plan that provides for dental care services.d“Dental care provider” means any person licensed to practice dentistry pursuant to chapter 153, and who provides dental care services pursuant to a dental care service plan or health benefit plan.e“Dental care service plan” means a policy, contract, plan, certificate, or agreement that provides for third-party payment or prepayment of dental care services and that is delivered or issued for delivery by or through a dental carrier on a stand-alone basis. “Dental care service plan” includes a health benefit plan that provides for dental care services.f“Dental care services” means the same as defined in section 514J.102. “Dental care services” does not include services that are billed as medical expenses under a health benefit plan.g“Dental carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering dental care service plans, or any other entity that provides a dental care service plan.h“Dental service contractor” means any person who accepts a prepayment from, or for the benefit of, another person as consideration for the provision of future dental care services. “Dental service contractor” does not include a dental care provider that accepts prepayment on a fee-for-service basis for providing specific dental services to individual patients for whom such services have been prediagnosed.i“Dentist agent” means a person that contracts with a dental care provider to establish an agency relationship for purposes of processing bills for services provided by the dental care provider under the terms and conditions of a contract between the dentist agent and a health care provider. A contract between a dentist agent and a health care provider may permit the dentist agent to submit bills, request reconsideration, and receive reimbursement.j“Health benefit plan” means the same as defined in section 514J.102.k“Health carrier” means the same as defined in section 514J.102.l“Network contract” means a contract between a contracting entity and a dental care provider that specifies the rights and responsibilities of the contracting entity and provides for the delivery and payment of dental services to a covered person.m“Third party” means a person, not including a covered person, that enters into a contract with a contracting entity to access the dental services or contractual discounts of a network contract. “Third party” does not include an employer or other group for whom the dental carrier or contracting entity provides administrative services.n“Virtual credit card payment” means an electronic funds transfer in which a dental care service plan, or a contracted vendor, issues a single-use series of numbers associated with the payment of dental care services performed by a dental care provider and chargeable to a predetermined dollar amount, where the dental care provider is responsible for processing the payment by a credit card terminal or internet portal. “Virtual credit card payment” includes only electronic or virtual credit card payments, where no physical credit card is used and the single-use electronic credit card expires upon payment processing.2Third-party access to network contracts.aA contracting entity may grant a third party access to a network contract, or to a dental care provider’s dental care services or contractual discounts provided pursuant to a network contract, if all of the following requirements are met:1If the contracting entity is a dental carrier or health carrier, at the time the network contract is entered into, renewed, or material modifications relevant to granting access to a third party are made, the contracting entity allows any dental care provider that is part of the contracting entity’s network contract to choose not to participate in third-party access to the network contract, or to enter into a contract directly with the third party. If a dental care provider opts out of lease arrangements, a contracting entity shall not cancel or terminate a contractual relationship with, or refuse to contract with, the dental care provider.2The network contract specifically states that the contracting entity may enter into an agreement with a third party to allow the third party to obtain the contracting entity’s rights and responsibilities under the network contract as if the third party were the contracting entity. If the contracting entity is a dental carrier, the network contract must specifically state that the dental care provider may choose not to participate in third-party access to the network contract, and that the dental care provider chose to participate in third-party access at the time the network contract was entered into or renewed.3The third party accessing the network contract agrees to comply with all of the network contract’s terms.4The contracting entity identifies to the dental care provider, in writing, all third parties participating in the network contract as of the date the network contract is entered into or renewed.5The contracting entity provides a list of all third parties participating in the network contract on the contracting entity’s internet site and the list of third parties is updated at least once every ninety days.6The contracting entity notifies a dental care provider under the network contract at least thirty days prior to a new third party leasing or purchasing the network contract.7The contracting entity requires a third party to identify, for all remittance advice or explanations of payment under which a discount applies, the source of the discount. This subparagraph does not apply to an electronic transaction mandated by the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191.8The contracting entity notifies a third party of the termination of a network contract no later than thirty days from the termination date of the network contract.9A third party’s right to a dental care provider’s discounted rate is terminated as of the termination date of the network contract.10In the adjudication of a claim under the network contract, the contracting entity makes available to the dental care provider a copy of the network contract no later than thirty days after a request for the network contract is received.bThis section shall not apply to access to a network contract provided to a third party that is either an affiliate of, or operating under the same brand licensing as, the contracting entity. A contracting entity shall provide a list of all affiliates on the contracting entity’s internet site.cNo dental care provider shall be bound by, or required to perform, dental care services under a network contract that has been granted to a third party in violation of this section.3Dental care service plans method of payment.aA dental care service plan shall not require payments to be made to dental care providers by virtual credit card payment.bA dental care service plan, when initiating payments to a dental care provider via virtual credit card payment, or when changing the method of payment for a dental care provider to virtual credit card payments, shall do all of the following:1Notify the dental care provider of any fees associated with each payment method.2Inform the dental care provider of the available options for methods of payment and provide clear instructions to the dental care provider for the selection of an alternative payment method.cA dental care service plan that transmits payments to a dental care provider in accordance with the standards of 45 C.F.R. §162.1601 and 162.1602 shall not charge a fee solely for the transmission of the payment to the dental care provider unless the dental care provider has consented to payment of the fee. When transmitting a national automated clearinghouse payment, a dentist agent may charge a reasonable fee related to bank transmittal, transaction management, data management, portal services, and other value-added services.4Waiver prohibited.The requirements of this section shall not be waived by contract. Any contractual arrangement contrary to this section shall be null and void.5Rules.The commissioner may adopt rules pursuant to chapter 17A to administer this section.2024 Acts, ch 1041, §1; 2024 Acts, ch 1154, §16514C.3DPrior authorization for dental care services.1Definitions.As used in this section unless the context otherwise provides:a“Commissioner” means the commissioner of insurance.b“Covered person” means the same as defined in section 514C.3C.c“Dental care provider” means the same as defined in section 514C.3C.d“Dental care service plan” means the same as defined in section 514C.3C.e“Dental care services” means the same as defined in section 514C.3C.f“Dental carrier” means the same as defined in section 514C.3C.g“Prior authorization” means a determination by a dental carrier in response to a request submitted by a dental care provider as to whether a specific dental care service proposed by the dental care provider for a covered person will be reimbursed at a specified amount, subject to any applicable coinsurance or deductible required under the covered person’s dental care service plan.2Prior authorization.aA dental carrier shall not deny a claim submitted by a dental care provider for dental care services approved by prior authorization.bA dental carrier shall reimburse a dental care provider at the contracted reimbursement rate for a dental care service provided by the dental care provider to a covered person per a prior authorization.3Exceptions.Subsection 2 shall not apply if any of the following apply for each dental care service for which a dental care provider is denied reimbursement:aOn the date that the dental care service was provided by the dental care provider to the covered person per a prior authorization, a benefit limitation including but not limited to an annual maximum or a frequency limitation that was not applicable at the time of the prior authorization had been reached due to utilization of the dental care service plan subsequent to the dental carrier issuing the prior authorization.bThe dental care provider submits a claim for dental care services approved by prior authorization and the documentation of dental care services fails to support the claim for dental care services as originally authorized by the prior authorization.cSubsequent to the issuance of a prior authorization, and prior to the provision of dental care services authorized by the prior authorization, a covered person receives additional dental care services, or a change in the dental condition of the covered person occurs, such that the dental care services authorized by the prior authorization are no longer considered medically necessary based on the prevailing standard of care.dSubsequent to the issuance of a prior authorization, and prior to the provision of dental care services authorized by the prior authorization, a covered person receives additional dental care services, or a change in the dental condition of the covered person occurs, such that on the date that the dental care service is to be provided a request for prior authorization of the dental care service would require disapproval pursuant to the terms and conditions for coverage under the covered person’s current dental care service plan.eA payor other than the dental carrier is responsible for payment for the dental care service.fA dental care provider has already received payment from the dental carrier for the dental care services identified in the claim for reimbursement.gThe claim was submitted fraudulently to the dental carrier. hThe dental care provider, covered person, or other person not related to the dental carrier provided inaccurate information that the dental carrier relied on, in whole or in part, for the dental carrier’s prior authorization determination.iOn the date that the dental care service was provided by the dental care provider to the covered person per the prior authorization, the covered person was ineligible to receive the dental care service and the dental carrier did not know, and with the exercise of reasonable care could not have known, of the covered person’s ineligibility.jPrior to providing a dental care service approved by prior authorization, the dental care provider terminated participation in the dental carrier’s network under which the dental carrier issued the prior authorization for such dental care service.4Waiver prohibited.The requirements of this section shall not be waived by contract. Any contractual arrangement contrary to this section shall be null and void.5Rules.The commissioner may adopt rules pursuant to chapter 17A to administer this section.2025 Acts, ch 37, §1NEW section514C.3EState-regulated dental care service plans.1Definitions.As used in this section, unless the context otherwise provides:a“Commissioner” means the commissioner of insurance.b“Covered person” means the same as defined in section 514C.3C.c“Dental care provider” means the same as defined in section 514C.3C.d“Dental care service plan” means the same as defined in section 514C.3C.e“Dental carrier” means the same as defined in section 514C.3C.2Required disclosures.If a covered person’s dental care service plan is subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, a dental carrier shall do all of the following:aDisclose to a dental care provider through an online dental care provider portal, or other easily accessible means, that a covered person’s dental care service plan is state-regulated.bInclude the statement “state-regulated” on an electronic or physical identification card issued to a covered person on or after July 1, 2025.3Waiver prohibited.The requirements of this section shall not be waived by contract. Any contract contrary to this section shall be null and void.4Rules.The commissioner may adopt rules pursuant to chapter 17A to administer this section.2025 Acts, ch 37, §2NEW section514C.3FDental carrier recovery of claim overpayment.1Definitions.As used in this section, unless the context otherwise provides:a“Dental care provider” means the same as defined in section 514C.3C.b“Dental care services” means the same as defined in section 514C.3C.c“Dental carrier” means the same as defined in section 514C.3C.d“Overpayment” means a payment made in error by a dental carrier to a dental provider for a dental care service. 2Appeals.A dental carrier shall establish written policies and procedures for a dental care provider to appeal an overpayment recovery or overpayment recovery request made by the dental carrier. The dental carrier shall notify the dental care provider of the policies and procedures to appeal an overpayment recovery or overpayment recovery request at the time that the dental carrier makes the overpayment recovery or overpayment recovery request. The policies and procedures must allow a dental care provider to appeal an overpayment recovery or overpayment recovery request within a minimum of ninety calendar days after the dental care provider receives such notice. The policies and procedures must allow the dental care provider to access the claim information that is the subject of the overpayment dispute.3Notice.A dental carrier shall not attempt to recover an overpayment, in whole or in part, unless the dental carrier provides written notice of the overpayment to the dental care provider no later than three hundred sixty-five calendar days after the date the dental care provider received the overpayment. The written notice of overpayment must identify the error made in the processing or payment of the claim. The written notice must state a request for recovery of the overpayment or notify the dental care provider of withholding or reducing a payment as required in subsection 4. If a recovery attempt is made pursuant to subsection 4, then the dental carrier shall be deemed to have met the notice requirements of this subsection.4Withholding or reducing payments.A dental carrier may attempt to recover an overpayment by withholding or reducing a payment to a dental care provider for a different claim if the dental carrier provides the dental care provider with written notice within twenty-eight calendar days after the date of withholding or reducing the payment for the other claim. The notice must identify the original claim that was overpaid, the amount being withheld or reduced for the overpayment and recovery, and the payment from which such amount is being withheld or reduced. A dental carrier may include the notice required by this subsection as part of the notice required by subsection 3.5Applicability.Subsections 3 and 4 shall not apply, and a dental carrier shall be entitled to recover an overpayment, if the overpayment recovery efforts are based on a reasonable belief of fraud, abuse, or other intentional misconduct.6Waiver prohibited.The requirements of this section shall not be waived by contract. Any contract contrary to this section shall be null and void.7Rules.The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.2025 Acts, ch 37, §3NEW section514C.4Mandated coverage for mammography.1aA policy or contract providing for third-party payment or prepayment of health or medical expenses shall provide minimum mammography examination coverage, including, but not limited to, the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state.1Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.2An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.3An individual or group health maintenance organization contract regulated under chapter 514B.4An individual or group Medicare supplemental policy, unless coverage pursuant to such policy is preempted by federal law.bA long-term care policy or contract is specifically excluded from regulation under this section.2As used in this section, “minimum mammography examination coverage” means benefits which are better than or equal to the following minimum requirements:aOne baseline mammogram for any woman who is thirty-five through thirty-nine years of age, or more frequent mammograms if recommended by the woman’s physician.bA mammogram every two years for any woman who is forty through forty-nine years of age, or more frequently if recommended by the woman’s physician.cA mammogram every year for any woman who is fifty years of age or older, or more frequently if recommended by the woman’s physician.3Mammogram benefits may be subject to any policy or contract provisions which apply generally to other services covered by the policy or contract.4The commissioner of insurance shall adopt rules under chapter 17A necessary to implement this section.89 Acts, ch 289, §1; 92 Acts, ch 1162, §32, 33; 2003 Acts, ch 135, §1 – 3; 2012 Acts, ch 1023, §157514C.4ASupplemental and diagnostic breast examinations.1As used in this section, unless the context otherwise requires:a“Breast magnetic resonance imaging” or “breast MRI” means an examination of a breast, following administration of intravenous contrast, using a powerful magnetic field, radio waves, and a computer to produce detailed pictures of the structures within the breast.b“Breast ultrasound” means a noninvasive examination of a breast using high-frequency sound waves to produce detailed images of the breast.c“Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses.d“Diagnostic breast examination” means a medically necessary and appropriate examination of the breast that may include a diagnostic mammogram, breast magnetic resonance imaging, breast ultrasound, or other breast imaging, and that is performed for any of the following reasons:1To evaluate an abnormality seen or suspected during a screening examination for breast cancer.2To evaluate an abnormality detected by another means of examination.e“Diagnostic mammogram” means a detailed examination of a breast abnormality using X ray.f“Health care professional” means the same as defined in section 514J.102.g“Health care services” means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.h“Screening mammogram” means an examination of a breast that aids in the early detection and diagnosis of breast abnormalities including breast cancer.i“Supplemental breast examination” means a medically necessary and appropriate examination of the breast that may include breast magnetic resonance imaging, breast ultrasound, contrast-enhanced mammography, or examination for dense breast tissue as described by the breast imaging reporting and data system of the American college of radiology, and that is performed to screen for breast cancer when there is no abnormality seen or suspected and based on an individual’s personal or family medical history, or additional factors that may increase the individual’s risk of breast cancer.2aNotwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall provide coverage for supplemental breast examinations and diagnostic breast examinations.bCoverage required under this section shall not be less favorable than coverage a health carrier offers for screening mammograms.3aThis section applies to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2025:1Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.2An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.3An individual or group health maintenance organization contract regulated under chapter 514B.4A plan established for public employees pursuant to chapter 509A.bThis section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner of insurance, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.4The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.2024 Acts, ch 1115, §1514C.5Prescription drug benefit restrictions.1A group policy or contract providing for third-party payment or prepayment for prescription drugs shall not require a person covered under the policy or contract to obtain prescription drugs from a mail order pharmacy as a condition of obtaining benefits for prescription drugs if the pharmacy selected by the covered person agrees to provide pharmaceutical services under the same terms and conditions as those provided by the mail order pharmacy.2Group third-party payor policies or contracts delivered, issued for delivery, continued, or renewed in this state on or after July 1, 1990, are subject to this section, including but not limited to the following classes:aA group accident and sickness insurance policy.bA group hospital or medical service contract.cA group health maintenance organization contract.dA group Medicare supplemental policy.90 Acts, ch 1130, §1514C.6Uniformity of treatment — employee welfare benefit plans.1A statutory provision to mandate a health care coverage or service, or to mandate the offering of a health care coverage or service, applies to all state-regulated third-party payors and to employee welfare benefit plans described in 29 U.S.C. §1001 et seq. However, if an employee welfare benefit plan subject to federal regulation is not subject to a substantially similar requirement, the statutory provision does not apply to a state-regulated third-party payor until the employee welfare benefit plans are subject to a substantially similar standard under federal regulations as determined by the commissioner.2For purposes of this section unless the context otherwise requires, a third-party payor means:aAn accident and sickness insurer, subject to chapter 509 or 514A.bA nonprofit health service corporation, subject to chapter 514.cA health maintenance organization, subject to chapter 514B.dAny other entity engaged in the business of insurance, risk transfer, or risk retention, which is subject to the jurisdiction of the commissioner.91 Acts, ch 213, §20514C.7Prohibition on restricting coverage in certain instances involving a diagnosis of a fibrocystic condition.Notwithstanding the uniformity of treatment requirements of section 514C.6, a third-party payor as defined in that section shall not deny or fail to renew, or include an exception to or exclusion of benefits in, a policy or contract of individual or group accident and sickness insurance solely based upon an insured being diagnosed as having a fibrocystic condition.92 Acts, ch 1046, §1514C.8Coordination of health care benefits with state medical assistance.1An insurer, health maintenance organization, or hospital and medical service plan providing health care coverage to individuals in this state shall not consider the availability of or eligibility for medical assistance under Tit. XIX of the federal Social Security Act and chapter 249A, when determining eligibility of the individual for coverage or calculating payments to the individual under the health care coverage plan.2The state acquires the rights of an individual to payment from an insurer, health maintenance organization, or hospital or medical service plan to the extent payment for covered expenses is made pursuant to chapter 249A for health care items or services provided to the individual. Upon presentation of proof that payment was made pursuant to chapter 249A for covered expenses, the insurer, health maintenance organization, or hospital or medical service plan shall make payment to the state medical assistance program to the extent of the coverage provided in the policy or contract.3An insurer shall not impose requirements on the state with respect to the assignment of rights pursuant to this section that are different from the requirements applicable to an agent or assignee of a covered individual.4For purposes of this section, “insurer” means an entity which offers a health benefit plan, including a group health plan under the federal Employee Retirement Income Security Act of 1974.95 Acts, ch 185, §13; 2010 Acts, ch 1061, §180514C.9Medical support — insurance requirements.1An insurer shall not deny coverage or enrollment of a child under the health plan of the obligor upon any of the following grounds:aThe child is born out of wedlock.bThe child is not claimed as a dependent on the obligor’s federal income tax return.cThe child does not reside with the obligor or in the insurer’s service area. This section shall not be construed to require a health maintenance organization regulated under chapter 514B to provide any services or benefits for treatment outside of the geographic area described in its certificate of authority which would not be provided to a member outside of that geographic area pursuant to the terms of the health maintenance organization’s contract.2An insurer of an obligor providing health care coverage to the child for which the obligor is legally responsible to provide support shall do all of the following:aProvide information to the obligee or other legal custodian of the child as necessary for the child to obtain benefits through the coverage of the insurer.bAllow the obligee or other legal custodian of the child, or the provider with the approval of the obligee or other legal custodian of the child, to submit claims for covered services without the approval of the obligor.cMake payment on a claim submitted in paragraph “b” directly to the obligee or other legal custodian of the child, the provider, or the state medical assistance agency for claims submitted by the obligee or other legal custodian of the child, by the provider with the approval of the obligee or other legal custodian of the child, or by the state medical assistance agency.3If an obligor is required by a court order or administrative order to provide health coverage for a child and the obligor is eligible for dependent health coverage, the insurer shall do all of the following:aAllow the obligor to enroll under dependent coverage a child who is eligible for coverage pursuant to the applicable terms and conditions of the health benefit plan and the standard enrollment guidelines of the insurer without regard to an enrollment season restriction.bEnroll a child who is eligible for coverage under the applicable terms and conditions of the health benefit plan and the standard enrollment guidelines of the insurer, without regard to any time of enrollment restriction, under dependent coverage upon application by the obligee or other legal custodian of the child or by the department of health and human services in the event an obligor required by a court order or administrative order fails to apply for coverage for the child.cMaintain coverage and not cancel the child’s enrollment unless the insurer obtains satisfactory written evidence of any of the following:1The court order or administrative order is no longer in effect.2The child is eligible for or will enroll in comparable health coverage through an insurer which shall take effect not later than the effective date of the cancellation of enrollment of the original coverage.3The employer has eliminated dependent health coverage for its employees.4The obligor is no longer paying the required premium because the employer no longer owes the obligor compensation, or because the obligor’s employment has terminated and the obligor has not elected to continue coverage.4A group health plan shall establish reasonable procedures to determine whether a child is covered under a qualified medical child support order issued pursuant to chapter 252E. The procedures shall be in writing, provide for prompt notice of each person specified in the medical child support order as eligible to receive benefits under the group health plan upon receipt by the plan of the medical child support order, and allow an obligee or other legal custodian of the child under chapter 252E to designate a representative for receipt of copies of notices in regard to the medical child support order that are sent to the obligee or other legal custodian of the child and the department of health and human services’ child support services.5For purposes of this section, unless the context otherwise requires:a“Child” means a person, other than an obligee’s spouse or former spouse, who is recognized under a qualified medical child support order as having a right to enrollment under a group health plan as the obligor’s dependent.b“Court order” or “administrative order” means a ruling by a court or administrative agency in regard to the support an obligor shall provide to the obligor’s child.c“Insurer” means an entity which offers a health benefit plan.d“Obligee” means an obligee as defined in section 252E.1.e“Obligor” means an obligor as defined in section 252E.1.f“Qualified medical child support order” means a child support order which creates or recognizes a child’s right to receive health benefits for which the child is eligible under a group health benefit plan, describes or determines the type of coverage to be provided, specifies the length of time for which the order applies, and specifies the plan to which the order applies.95 Acts, ch 185, §142023 Acts, ch 19, §1198, 1199514C.10Coverage for adopted child.1Definitions.For purposes of this section, unless the context otherwise requires:a“Child” means, with respect to an adoption or a placement for adoption of a child, an individual who has not attained age eighteen as of the date of the issuance of a final adoption decree, or upon an interlocutory adoption decree becoming a final adoption decree, as provided in chapter 600, or as of the date of the placement for adoption.b“Placement for adoption” means the assumption and retention of a legal obligation for the total or partial support of the child in anticipation of the adoption of the child. The child’s placement with a person terminates upon the termination of such legal obligation.2Coverage required.A policy or contract providing for third-party payment or prepayment of health or medical expenses shall provide coverage benefits to a dependent child adopted by, or placed for adoption with, an insured or enrollee under the same terms and conditions as apply to a biological, dependent child of the insured or enrollee. The issuer of the policy or contract shall not restrict coverage under the policy or contract for a dependent child adopted by, or placed for adoption with, the insured or enrollee solely on the basis of a preexisting condition of such dependent child at the time that the child would otherwise become eligible for coverage under the plan, if the adoption or placement occurs while the insured or enrollee is eligible for coverage under the policy or contract. This section applies to the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after July 1, 1995:aIndividual or group accident and sickness insurance providing coverage on an expense-incurred basis.bAn individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.cAn individual or group health maintenance organization contract regulated under chapter 514B.dAn individual or group Medicare supplemental policy, unless coverage pursuant to such policy is preempted by federal law.95 Acts, ch 185, §15; 2017 Acts, ch 148, §62514C.11Services provided by licensed physician assistants and licensed advanced registered nurse practitioners.1Notwithstanding section 514C.6, a policy or contract providing for third-party payment or prepayment of health or medical expenses shall include a provision for the payment of necessary medical or surgical care and treatment provided by a physician assistant licensed pursuant to chapter 148C, or provided by an advanced registered nurse practitioner licensed pursuant to chapter 152 and performed within the scope of the license of the licensed physician assistant or the licensed advanced registered nurse practitioner if the policy or contract would pay for the care and treatment if the care and treatment were provided by a person engaged in the practice of medicine and surgery or osteopathic medicine and surgery under chapter 148. The policy or contract shall provide that policyholders and subscribers under the policy or contract may reject the coverage for services which may be provided by a licensed physician assistant or licensed advanced registered nurse practitioner if the coverage is rejected for all providers of similar services. A policy or contract subject to this section shall not impose a practice or supervision restriction which is inconsistent with or more restrictive than the restriction already imposed by law.2This section applies to services provided under a policy or contract delivered, issued for delivery, continued, or renewed in this state on or after July 1, 1996, and to an existing policy or contract, on the policy’s or contract’s anniversary or renewal date, or upon the expiration of the applicable collective bargaining contract, if any, whichever is later. This section does not apply to policyholders or subscribers eligible for coverage under Tit. XVIII of the federal Social Security Act or any similar coverage under a state or federal government plan.3For the purposes of this section, third-party payment or prepayment includes an individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 514, or 514A, an individual or group health maintenance organization contract issued and regulated under chapter 514B, or a preferred provider organization contract regulated pursuant to chapter 514F.4Nothing in this section shall be interpreted to require an individual or group health maintenance organization or a preferred provider organization or arrangement to provide payment or prepayment for services provided by a licensed physician assistant or licensed advanced registered nurse practitioner unless the physician assistant’s supervising physician, the physician-physician assistant team, the advanced registered nurse practitioner, or the advanced registered nurse practitioner’s collaborating physician has entered into a contract or other agreement to provide services with the individual or group health maintenance organization or the preferred provider organization or arrangement.96 Acts, ch 1169, §1; 2008 Acts, ch 1088, §130; 2017 Acts, ch 148, §63514C.12Postdelivery benefits and care.1Notwithstanding section 514C.6, a person who provides an individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 509A, 514, or 514A or an individual or group health maintenance organization contract issued and regulated under chapter 514B, which is delivered, amended, or renewed on or after July 1, 1996, and which provides maternity benefits, which are not limited to complications of pregnancy, or newborn care benefits, shall not terminate inpatient benefits or require discharge of a mother or the newborn from a hospital following delivery earlier than determined to be medically appropriate by the attending physician after consultation with the mother and in accordance with guidelines adopted by rule by the commissioner. The guidelines adopted by rule shall be consistent with or may adopt by reference the guidelines for perinatal care established by the American academy of pediatrics and the American college of obstetricians and gynecologists which provide that when complications are not present, the postpartum hospital stay ranges from a minimum of forty-eight hours for a vaginal delivery to a minimum of ninety-six hours for a cesarean birth, excluding the day of delivery. The guidelines adopted by rule by the commissioner shall also provide that in the event of a discharge from the hospital prior to the minimum stay established in the guidelines, a postdischarge follow-up visit shall be provided to the mother and newborn by providers competent in postpartum care and newborn assessment if determined medically appropriate as directed by the attending physician, in accordance with the guidelines.2When performing utilization review of inpatient hospital services related to maternity and newborn care, including but not limited to length of postdelivery stay and postdischarge follow-up care, any person who provides an individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 509A, 514, or 514A, or an individual or group health maintenance organization contract issued and regulated under chapter 514B, shall use the guidelines adopted by rule by the commissioner, and shall not deselect, require additional documentation, require additional utilization review, terminate services to, reduce payment to, or in any manner provide a disincentive to an attending physician solely on the basis that the attending physician provided or directed the provision of services in compliance with the guidelines adopted by rule.3Preauthorization or precertification for a hospital stay or for a postdischarge follow-up visit in accordance with the guidelines adopted by rule by the commissioner shall not be required.96 Acts, ch 1202, §1514C.12ALicensed midwife services.1Notwithstanding section 514C.6, a person who provides an individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 509A, 514, or 514A or an individual or group health maintenance organization contract issued and regulated under chapter 514B, which is delivered, amended, or renewed on or after July 1, 2023, and which provides maternity benefits, which are not limited to complications of pregnancy, or newborn care benefits, shall provide coverage for maternity services rendered by a midwife licensed pursuant to chapter 148I, regardless of the site of services, in accordance with guidelines adopted by rule by the commissioner.2Coverage for maternity services provided by a licensed midwife shall not be subject to any greater copayment, deductible, or coinsurance than is applicable to any other similar benefits provided by the plan.3A person who provides an individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 509A, 514, or 514A or an individual or group health maintenance organization contract issued and regulated under chapter 514B may require that maternity services be provided by a licensed midwife under contract with the person.4This section does not require payment for any cost, charge, or fee relating to the location at which maternity services were provided by a certified professional midwife.2023 Acts, ch 127, §12; 2025 Acts, ch 30, §88Subsection 1 amended514C.13Group managed care health plans — requirements attached to limited provider network plan offers.1As used in this section, unless the context otherwise requires:a“Carrier” means an entity that provides health benefit plans in this state. “Carrier” includes an insurance company, group hospital or medical service corporation, health maintenance organization, multiple employer welfare arrangement, and any other person providing health benefit plans in this state subject to regulation by the commissioner of insurance.b“Health benefit plan” means a policy, certificate, or contract providing hospital or medical coverage, benefits, or services rendered by a health care provider. “Health benefit plan” does not include a group conversion plan, accident-only, specific-disease, short-term hospital or medical hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, or disability income insurance, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.c“Health care provider” means a hospital licensed pursuant to chapter 135B, a person licensed under chapter 148, 148C, 149, 151, or 154, or a person licensed as an advanced registered nurse practitioner under chapter 152.d“Indemnity plan” means a hospital or medical expense-incurred policy, certificate, or contract, major medical expense insurance, or hospital or medical service plan contract.e“Large employer” means a person actively engaged in business who, during at least fifty percent of the employer’s working days during the preceding calendar year, employed more than fifty full-time equivalent employees.f“Limited provider network plan” means a managed care health plan which limits access to or coverage for services to selected health care providers who are under contract with the managed care health plan.g“Managed care health plan” means a health benefit plan that selects and contracts with health care providers; manages and coordinates health care delivery; monitors necessity, appropriateness, and quality of health care delivered by health care providers; and performs utilization review and cost control.h“Point of service plan option” means a provision in a managed care health plan that permits insureds, enrollees, or subscribers access to health care from health care providers who have not contracted with the managed care health plan.i“Small employer” means a person actively engaged in business who, during at least fifty percent of the employer’s working days during the preceding calendar year, employed at least one and not more than fifty full-time equivalent employees.2A carrier which offers to a small employer a limited provider network plan to provide health care services or benefits to the small employer’s employees shall also offer to the small employer a point of service option to the limited provider network plan.3A carrier which offers to a large employer a limited provider network plan to provide health care services or benefits to the large employer’s employees shall also offer to the large employer one or more of the following:aA point of service plan option to the limited provider network plan. The price of the point of service plan option shall be actuarially determined.bA managed care health plan that is not a limited provider network plan.cAn indemnity plan.4A large employer that offers a limited provider network plan to its employees shall also offer to its employees one or more of the following:aA point of service plan option to the limited provider network plan.bA managed care health plan that is not a limited provider network plan.cAn indemnity plan.97 Acts, ch 88, §1; 2008 Acts, ch 1088, §131; 2011 Acts, ch 70, §27, 49; 2017 Acts, ch 148, §64 – 66514C.14Continuity of care — pregnancy.1Except as provided under subsection 2 or 3, a carrier, as defined in section 513B.2, or a plan established pursuant to chapter 509A for public employees, that terminates its contract with a participating health care provider, shall continue to provide coverage under the contract to a covered person in the second or third trimester of pregnancy for continued care from such health care provider. Such persons may continue to receive such treatment or care through postpartum care related to the child birth and delivery. Payment for covered benefits and benefit levels shall be according to the terms and conditions of the contract.2A covered person who makes an involuntary change in health plans may request that the new health plan cover the services of the covered person’s physician specialist who is not a participating health care provider under the new health plan, if the covered person is in the second or third trimester of pregnancy. Continuation of such coverage shall continue through postpartum care related to the child birth and delivery. Payment for covered benefits and benefit levels shall be according to the terms and conditions of the new health plan contract.3A carrier or a plan established under chapter 509A, that terminates the contract of a participating health care provider for cause shall not be liable to pay for health care services provided by the health care provider to a covered person following the date of termination.99 Acts, ch 41, §1; 2017 Acts, ch 148, §67; 2018 Acts, ch 1026, §157514C.15Treatment options.A carrier, as defined in section 513B.2, or a plan established pursuant to chapter 509A for public employees, shall not prohibit a participating provider from, or penalize a participating provider for, doing either of the following:1Discussing treatment options with a covered individual, notwithstanding the carrier’s or plan’s position on such treatment option.2Advocating on behalf of a covered individual within a review or grievance process established by the carrier or chapter 509A plan, or established by a person contracting with the carrier or chapter 509A plan.99 Acts, ch 41, §2; 2017 Acts, ch 148, §68; 2018 Acts, ch 1041, §103514C.16Emergency room services.1A carrier, as defined in section 513B.2, or a plan established pursuant to chapter 509A for public employees, which provides coverage for emergency services, is responsible for charges for emergency services provided to a covered individual, including services furnished outside any contractual provider network or preferred provider network. Coverage for emergency services is subject to the terms and conditions of the health benefit plan or contract.2Prior authorization for emergency services shall not be required. All services necessary to evaluate and stabilize an emergency medical condition shall be considered covered emergency services.3For purposes of this section, unless the context otherwise requires:a“Emergency medical condition” means a medical condition that manifests itself by symptoms of sufficient severity, including but not limited to severe pain, that an ordinarily prudent person, possessing average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in one of the following:1Placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy.2Serious impairment to bodily function.3Serious dysfunction of a bodily organ or part.b“Emergency services” means covered inpatient and outpatient health care services that are furnished by a health care provider who is qualified to provide the services that are needed to evaluate or stabilize an emergency medical condition.99 Acts, ch 41, §3; 2017 Acts, ch 148, §69514C.17Continuity of care — terminal illness.1Except as provided under subsection 2 or 3, if a carrier, as defined in section 513B.2, or a plan established pursuant to chapter 509A for public employees, terminates its contract with a participating health care provider, a covered individual who is undergoing a specified course of treatment for a terminal illness or a related condition, with the recommendation of the covered individual’s treating physician licensed under chapter 148 or treating physician assistant licensed under chapter 148C may continue to receive coverage for treatment received from the covered individual’s physician or physician assistant for the terminal illness or a related condition, for a period of up to ninety days. Payment for covered benefits and benefit levels shall be according to the terms and conditions of the contract.2A covered person who makes a change in health plans involuntarily may request that the new health plan cover services of the covered person’s treating physician licensed under chapter 148 or treating physician assistant licensed under chapter 148C who is not a participating health care provider under the new health plan, if the covered person is undergoing a specified course of treatment for a terminal illness or a related condition. Continuation of such coverage shall continue for up to ninety days. Payment for covered benefits and benefit levels shall be according to the terms and conditions of the contract.3Notwithstanding subsections 1 and 2, a carrier or a plan established under chapter 509A which terminates the contract of a participating health care provider for cause shall not be required to cover health care services provided by the health care provider to a covered person following the date of termination.99 Acts, ch 41, §4; 2008 Acts, ch 1088, §132; 2017 Acts, ch 148, §70; 2022 Acts, ch 1066, §46514C.18Diabetes coverage.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy or contract providing for third-party payment or prepayment of health or medical expenses shall provide coverage benefits for the cost associated with equipment, supplies, and self-management training and education for the treatment of all types of diabetes mellitus when prescribed by a physician licensed under chapter 148 or a physician assistant licensed under chapter 148C. Coverage benefits shall include coverage for the cost associated with all of the following:aEquipment and supplies.bPayment for diabetes self-management training and education only under all of the following conditions:1The physician or physician assistant managing the individual’s diabetic condition certifies that such services are needed under a comprehensive plan of care related to the individual’s diabetic condition to ensure therapy compliance or to provide the individual with necessary skills and knowledge to participate in the management of the individual’s condition.2The diabetes self-management training and education program is certified by the department of health and human services. The department shall consult with the American diabetes association, Iowa affiliate, in developing the standards for certification of diabetes education programs that cover at least ten hours of initial outpatient diabetes self-management training within a continuous twelve-month period and up to two hours of follow-up training for each subsequent year for each individual diagnosed by a physician or physician assistant with any type of diabetes mellitus.2aThis section applies to the following classes of third-party payment provider contracts or policies that are delivered, issued for delivery, continued, or renewed in this state:1Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.2An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.3An individual or group health maintenance organization contract regulated under chapter 514B.4Any other entity engaged in the business of insurance, risk transfer, or risk retention, which is subject to the jurisdiction of the commissioner.5A plan established pursuant to chapter 509A for public employees.bThis section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.99 Acts, ch 75, §1; 99 Acts, ch 208, §58; 2008 Acts, ch 1088, §133; 2009 Acts, ch 139, §1, 2; 2011 Acts, ch 70, §28; 2017 Acts, ch 148, §71; 2022 Acts, ch 1066, §47, 48; 2023 Acts, ch 19, §1200; 2023 Acts, ch 66, §120514C.19Prescription contraceptive coverage.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a group policy or contract providing for third-party payment or prepayment of health or medical expenses shall not do either of the following:aExclude or restrict benefits for prescription contraceptive drugs or prescription contraceptive devices which prevent conception and which are approved by the United States food and drug administration, or generic equivalents approved as substitutable by the United States food and drug administration, if such policy or contract provides benefits for other outpatient prescription drugs or devices.bExclude or restrict benefits for outpatient contraceptive services which are provided for the purpose of preventing conception if such policy or contract provides benefits for other outpatient services provided by a health care professional.2A person who provides a group policy or contract providing for third-party payment or prepayment of health or medical expenses which is subject to subsection 1 shall not do any of the following:aDeny to an individual eligibility, or continued eligibility, to enroll in or to renew coverage under the terms of the policy or contract because of the individual’s use or potential use of such prescription contraceptive drugs or devices, or use or potential use of outpatient contraceptive services.bProvide a monetary payment or rebate to a covered individual to encourage such individual to accept less than the minimum benefits provided for under subsection 1.cPenalize or otherwise reduce or limit the reimbursement of a health care professional because such professional prescribes contraceptive drugs or devices, or provides contraceptive services.dProvide incentives, monetary or otherwise, to a health care professional to induce such professional to withhold from a covered individual contraceptive drugs or devices, or contraceptive services.3This section shall not be construed to prevent a third-party payor from including deductibles, coinsurance, or copayments under the policy or contract, as follows:aA deductible, coinsurance, or copayment for benefits for prescription contraceptive drugs shall not be greater than such deductible, coinsurance, or copayment for any outpatient prescription drug for which coverage under the policy or contract is provided.bA deductible, coinsurance, or copayment for benefits for prescription contraceptive devices shall not be greater than such deductible, coinsurance, or copayment for any outpatient prescription device for which coverage under the policy or contract is provided.cA deductible, coinsurance, or copayment for benefits for outpatient contraceptive services shall not be greater than such deductible, coinsurance, or copayment for any outpatient health care services for which coverage under the policy or contract is provided.4This section shall not be construed to require a third-party payor under a policy or contract to provide benefits for experimental or investigational contraceptive drugs or devices, or experimental or investigational contraceptive services, except to the extent that such policy or contract provides coverage for other experimental or investigational outpatient prescription drugs or devices, or experimental or investigational outpatient health care services.5This section shall not be construed to limit or otherwise discourage the use of generic equivalent drugs approved by the United States food and drug administration, whenever available and appropriate. This section, when a brand name drug is requested by a covered individual and a suitable generic equivalent is available and appropriate, shall not be construed to prohibit a third-party payor from requiring the covered individual to pay a deductible, coinsurance, or copayment consistent with subsection 3, in addition to the difference of the cost of the brand name drug less the maximum covered amount for a generic equivalent.6A person who provides an individual policy or contract providing for third-party payment or prepayment of health or medical expenses shall make available a coverage provision that satisfies the requirements in subsections 1 through 5 in the same manner as such requirements are applicable to a group policy or contract under those subsections. The policy or contract shall provide that the individual policyholder may reject the coverage provision at the option of the policyholder.7aThis section applies to the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2000:1Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.2An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.3An individual or group health maintenance organization contract regulated under chapter 514B.4Any other entity engaged in the business of insurance, risk transfer, or risk retention, which is subject to the jurisdiction of the commissioner.5A plan established pursuant to chapter 509A for public employees.bThis section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.2000 Acts, ch 1120, §1; 2017 Acts, ch 148, §72514C.20Mandated coverage for dental care — anesthesia and certain hospital charges.1Notwithstanding section 514C.6, and subject to the terms and conditions of the policy or contract, a policy or contract providing for third-party payment or prepayment of health or medical expenses shall provide coverage for the administration of general anesthesia and hospital or ambulatory surgical center charges related to the provision of dental care services provided to any of the following covered individuals:aA child under five years of age upon a determination by a licensed dentist and the child’s treating physician licensed pursuant to chapter 148 or treating physician assistant licensed pursuant to chapter 148C, that such child requires necessary dental treatment in a hospital or ambulatory surgical center due to a dental condition or a developmental disability for which patient management in the dental office has proved to be ineffective.bAny individual upon a determination by a licensed dentist and the individual’s treating physician licensed pursuant to chapter 148 or treating physician assistant licensed pursuant to chapter 148C, that such individual has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center.2Prior authorization of hospitalization or ambulatory surgical center for dental care procedures may be required in the same manner that prior authorization is required for hospitalization for other coverages under the contract or policy.3This section applies to the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2000:aIndividual or group accident and sickness insurance providing coverage on an expense-incurred basis.bAn individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.cAn individual or group health maintenance organization contract regulated under chapter 514B.dAny other entity engaged in the business of insurance, risk transfer, or risk retention, which is subject to the jurisdiction of the commissioner.eA plan established pursuant to chapter 509A for public employees.4This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.2000 Acts, ch 1193, §1; 2008 Acts, ch 1088, §134; 2017 Acts, ch 148, §73; 2022 Acts, ch 1066, §49514C.21Coverage for immunizations — mercury.1Third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2006, that provide reimbursement for immunizations shall provide reimbursement for immunizations containing no more than trace amounts of mercury at the acquisition cost rate for immunizations containing no more than trace amounts of mercury. For the purposes of this section, “trace amounts” means trace amounts as defined by the United States food and drug administration.2For the purposes of this section, “third-party payment provider contracts or policies” includes:aIndividual or group accident and sickness insurance providing coverage on an expense-incurred basis.bAn individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.cAn individual or group health maintenance organization contract regulated under chapter 514B.2004 Acts, ch 1159, §2; 2017 Acts, ch 148, §74514C.22Biologically based mental illness coverage.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a group policy, contract, or plan providing for third-party payment or prepayment of health, medical, and surgical coverage benefits issued by a carrier, as defined in section 513B.2, shall provide coverage benefits for treatment of a biologically based mental illness if either of the following is satisfied:aThe policy, contract, or plan is issued to an employer who on at least fifty percent of the employer’s working days during the preceding calendar year employed more than fifty full-time equivalent employees. In determining the number of full-time equivalent employees of an employer, employers who are affiliated or who are able to file a consolidated tax return for purposes of state taxation shall be considered one employer.bThe policy, contract, or plan is issued to a small employer as defined in section 513B.2, and such policy, contract, or plan provides coverage benefits for the treatment of mental illness.2Notwithstanding the uniformity of treatment requirements of section 514C.6, a plan established pursuant to chapter 509A for public employees shall provide coverage benefits for treatment of a biologically based mental illness.3For purposes of this section, “biologically based mental illness” means the following psychiatric illnesses:aSchizophrenia.bBipolar disorders.cMajor depressive disorders.dSchizo-affective disorders.eObsessive-compulsive disorders.fPervasive developmental disorders.gAutism spectrum disorder.4The definitions of the biologically based mental illnesses identified in subsection 3 shall be consistent with definitions provided in the most recent edition of the American psychiatric association’s diagnostic and statistical manual of mental disorders, as such definitions may be amended from time to time. 5This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance, or individual accident and sickness policies issued to individuals or to individual members of a member association.6A carrier or plan established pursuant to chapter 509A may manage the benefits provided through common methods, including but not limited to providing payment of benefits or providing care and treatment under a capitated payment system, prospective reimbursement rate system, utilization control system, incentive system for the use of least restrictive and least costly levels of care, a preferred provider contract limiting choice of specific providers, or any other system, method, or organization designed to assure services are medically necessary and clinically appropriate.7aA group policy, contract, or plan covered under this section shall not impose an aggregate annual or lifetime limit on biologically based mental illness coverage benefits unless the policy, contract, or plan imposes an aggregate annual or lifetime limit on substantially all health, medical, and surgical coverage benefits.bA group policy, contract, or plan covered under this section that imposes an aggregate annual or lifetime limit on substantially all health, medical, and surgical coverage benefits shall not impose an aggregate annual or lifetime limit on biologically based mental illness coverage benefits that is less than the aggregate annual or lifetime limit imposed on substantially all health, medical, and surgical coverage benefits.cNotwithstanding paragraphs “a” and “b”, a group policy, contract, or plan covered under this section shall not impose an aggregate annual or lifetime limit on biologically based mental illness coverage benefits for autism spectrum disorder.8A group policy, contract, or plan covered under this section shall at a minimum allow for thirty inpatient days and fifty-two outpatient visits annually, and shall not limit the number of outpatient visits a covered individual may have with a practitioner for applied behavior analysis under section 514C.31, or with an autism service provider for treatment of autism spectrum disorder under section 514C.28. The policy, contract, or plan may also include deductibles, coinsurance, or copayments, provided the amounts and extent of such deductibles, coinsurance, or copayments applicable to other health, medical, or surgical services coverage under the policy, contract, or plan are the same. It is not a violation of this section if the policy, contract, or plan excludes entirely from coverage benefits for the cost of providing the following:aMarital, family, educational, developmental, or training services.bCare that is substantially custodial in nature.cServices and supplies that are not medically necessary or clinically appropriate.dExperimental treatments.9This section applies to third-party payment provider policies or contracts and to plans established pursuant to chapter 509A that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2006.2005 Acts, ch 91, §1; 2017 Acts, ch 148, §75, 76; 2025 Acts, ch 162, §1 – 4, 102025 amendments to section apply to third-party payment provider policies, contracts, and plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2026; 2025 Acts, ch 162, §10Subsection 3, paragraph g amendedSubsection 4 amendedSubsection 7, NEW paragraph cSubsection 8, unnumbered paragraph 1 amended514C.23Human papilloma virus vaccinations — coverage.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a contract, policy, or plan providing for third-party payment or prepayment of health or medical expenses that provides coverage benefits for any vaccination or immunization shall provide coverage benefits for a vaccination for human papilloma virus, including but not limited to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2009:aIndividual or group accident and sickness insurance providing coverage on an expense-incurred basis.bAn individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.cAn individual or group health maintenance organization contract regulated under chapter 514B.dAn individual or group Medicare supplemental policy, unless coverage pursuant to such policy is preempted by federal law.eA plan established pursuant to chapter 509A for public employees.2This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.3As used in this section, “human papilloma virus” means the human papilloma virus as defined by the centers for disease control and prevention of the United States department of health and human services.4The commissioner of insurance shall adopt rules pursuant to chapter 17A as necessary to administer this section.2008 Acts, ch 1108, §1514C.24Cancer treatment — coverage.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a contract, policy, or plan providing for third-party payment or prepayment for cancer treatment shall not discriminate between coverage benefits for prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells and intravenously administered or injected cancer medications that are covered, regardless of formulation or benefit category determination by the contract, policy, or plan.2The provisions of this section shall apply to all of the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2009:aIndividual or group accident and sickness insurance providing coverage on an expense-incurred basis.bAn individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.cAn individual or group health maintenance organization contract regulated under chapter 514B.dAn individual or group Medicare supplemental policy, unless coverage pursuant to such policy is preempted by federal law.eA plan established pursuant to chapter 509A for public employees.3This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, long-term care, basic hospital, and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.4The commissioner of insurance shall adopt rules pursuant to chapter 17A as necessary to administer this section.2009 Acts, ch 179, §183514C.25Coverage for prosthetic devices.1aNotwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall provide coverage benefits for medically necessary prosthetic devices when prescribed by a physician licensed under chapter 148 or physician assistant licensed under chapter 148C. Such coverage benefits for medically necessary prosthetic devices shall provide coverage for medically necessary prosthetic devices that, at a minimum, equals the coverage and payment for medically necessary prosthetic devices provided under the most recent federal laws for health insurance for the aged and disabled pursuant to 42 U.S.C. §1395k, 13951, and 1395m, and 42 C.F.R. §410.100, 414.202, 414.210, and 414.228, as applicable.bFor the purposes of this section, “prosthetic device” means an artificial limb device to replace, in whole or in part, an arm or leg.2aThis section applies to the following classes of third-party payment provider policies, contracts, or plans delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2009:1Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.2An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.3An individual or group health maintenance organization contract regulated under chapter 514B.4A plan established pursuant to chapter 509A for public employees.bThis section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.3Notwithstanding subsection 1, paragraph “a”, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses that is issued for use in connection with a health savings account as authorized under Tit. XII of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. No. 108-173, may impose the same deductibles and out-of-pocket limits on the prosthetics coverage benefits required in this section that apply to substantially all health, medical, and surgical coverage benefits under the policy, contract, or plan.2009 Acts, ch 89, §1; 2017 Acts, ch 148, §77; 2022 Acts, ch 1066, §50514C.26Approved cancer clinical trials coverage.1Definitions.For purposes of this section, unless the context otherwise requires:a“Approved cancer clinical trial” means a scientific study of a new therapy for the treatment of cancer in human beings that meets the requirements set forth in subsection 3 and consists of a scientific plan of treatment that includes specified goals, a rationale and background for the plan, criteria for patient selection, specific directions for administering therapy and monitoring patients, a definition of quantitative measures for determining treatment response, and methods for documenting and treating adverse reactions.b“Institutional review board” means a board, committee, or other group formally designated by an institution and approved by the national institutes of health, office for protection from research risks, to review, approve the initiation of, and conduct periodic review of biomedical research involving human subjects. “Institutional review board” means the same as “institutional review committee” as used in section 520(g) of the Federal Food, Drug, and Cosmetic Act, as codified in 21 U.S.C. §301 et seq.c1“Routine patient care costs” means medically necessary services or treatments that are a benefit under a contract or policy providing for third-party payment or prepayment of health or medical expenses that would be covered if the patient were receiving standard cancer treatment.2“Routine patient care costs” does not include any of the following:aCosts of any treatments, procedures, drugs, devices, services, or items that are the subject of the approved cancer clinical trial or any other investigational treatments, procedures, drugs, devices, services, or items.bCosts of nonhealth care services that the patient is required to receive as a result of participation in the approved cancer clinical trial.cCosts associated with managing the research that is associated with the approved cancer clinical trial.dCosts that would not be covered by the third-party payment provider if noninvestigational treatments were provided.eCosts of any services, procedures, or tests provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient participating in an approved cancer clinical trial.fCosts paid for, or not charged for, by the approved cancer clinical trial providers.gCosts for transportation, lodging, food, or other expenses for the patient, a family member, or a companion of the patient that are associated with travel to or from a facility where an approved cancer clinical trial is conducted.hCosts for services, items, or drugs that are eligible for reimbursement from a source other than a patient’s contract or policy providing for third-party payment or prepayment of health or medical expenses, including the sponsor of the approved cancer clinical trial.iCosts associated with approved cancer clinical trials designed exclusively to test toxicity or disease pathophysiology.jCosts of extra treatments, services, procedures, tests, or drugs that would not be performed or administered except for participation in the cancer clinical trial. Nothing in this subparagraph division shall limit payment for treatments, services, procedures, tests, or drugs that are otherwise a covered benefit under subparagraph (1).d“Therapeutic intent” means that a treatment is aimed at improving a patient’s health outcome relative to either survival or quality of life.2Coverage required.Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy or contract providing for third-party payment or prepayment of health or medical expenses shall provide coverage benefits for routine patient care costs incurred for cancer treatment in an approved cancer clinical trial to the same extent that such policy or contract provides coverage for treating any other sickness, injury, disease, or condition covered under the policy or contract, if the insured has been referred for such cancer treatment by two physicians who specialize in oncology and the cancer treatment is given pursuant to an approved cancer clinical trial that meets the criteria set forth in subsection 3. Services that are furnished without charge to a participant in the approved cancer clinical trial are not required to be covered as routine patient care costs pursuant to this section.3Criteria.Routine patient care costs for cancer treatment given pursuant to an approved cancer clinical trial shall be covered pursuant to this section if all of the following requirements are met:aThe treatment is provided with therapeutic intent and is provided pursuant to an approved cancer clinical trial that has been authorized or approved by one of the following:1The national institutes of health.2The United States food and drug administration.3The United States department of defense.4The United States department of veterans affairs.bThe proposed treatment has been reviewed and approved by the applicable qualified institutional review board.cThe available clinical or preclinical data indicate that the treatment that will be provided pursuant to the approved cancer clinical trial will be at least as effective as the standard therapy and is anticipated to constitute an improvement in therapeutic effectiveness for the treatment of the disease in question.4Notice.As soon as practical after the insured provides written consent to participate in an approved cancer clinical trial, the physician shall provide notice to the third-party payment provider of the insured’s intent to participate in an approved cancer clinical trial. Failure to provide such notice to the third-party payment provider shall not be the basis for denying the coverage required under subsection 2.5Applicability.aThis section applies to the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2010:1Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.2An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.3An individual or group health maintenance organization contract regulated under chapter 514B.4Any other entity engaged in the business of insurance, risk transfer, or risk retention, which is subject to the jurisdiction of the commissioner.5A plan established pursuant to chapter 509A for public employees.bThis section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.2010 Acts, ch 1013, §1; 2010 Acts, ch 1193, §61; 2017 Acts, ch 148, §78; 2025 Acts, ch 30, §105Code editor directive applied514C.27Mental illness and substance use disorder treatment coverage for veterans.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a group policy or contract providing for third-party payment or prepayment of health or medical expenses issued by a carrier, as defined in section 513B.2, shall provide coverage benefits to an insured who is a veteran for treatment of mental illness and substance use disorder if either of the following is satisfied:aThe policy or contract is issued to an employer who on at least fifty percent of the employer’s working days during the preceding calendar year employed more than fifty full-time equivalent employees. In determining the number of full-time equivalent employees of an employer, employers who are affiliated or who are able to file a consolidated tax return for purposes of state taxation shall be considered one employer.bThe policy or contract is issued to a small employer as defined in section 513B.2, and such policy or contract provides coverage benefits for the treatment of mental illness and substance use disorder.2Notwithstanding the uniformity of treatment requirements of section 514C.6, a plan established pursuant to chapter 509A for public employees shall provide coverage benefits to an insured who is a veteran for treatment of mental illness and substance use disorder as defined in subsection 3.3For purposes of this section:a“Mental illness” means mental disorders as defined by the commissioner by rule.b“Substance use disorder” means a pattern of pathological use of alcohol or a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when the alcohol or drug is withdrawn.c“Veteran” means the same as defined in section 35.1.4The commissioner, by rule, shall define “mental illness” consistent with definitions provided in the most recent edition of the American psychiatric association’s diagnostic and statistical manual of mental disorders, as the definitions may be amended from time to time. The commissioner may adopt the definitions provided in such manual by reference.5This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance, or individual accident and sickness policies issued to individuals or to individual members of a member association.6A carrier or plan established pursuant to chapter 509A may manage the benefits provided through common methods, including but not limited to providing payment of benefits or providing care and treatment under a capitated payment system, prospective reimbursement rate system, utilization control system, incentive system for the use of least restrictive and least costly levels of care, a preferred provider contract limiting choice of specific providers, or any other system, method, or organization designed to assure services are medically necessary and clinically appropriate.7aA group policy or contract or plan covered under this section shall not impose an aggregate annual or lifetime limit on mental illness or substance use disorder coverage benefits unless the policy or contract or plan imposes an aggregate annual or lifetime limit on substantially all medical and surgical coverage benefits.bA group policy or contract or plan covered under this section that imposes an aggregate annual or lifetime limit on substantially all medical and surgical coverage benefits shall not impose an aggregate annual or lifetime limit on mental illness or substance use disorder coverage benefits which is less than the aggregate annual or lifetime limit imposed on substantially all medical and surgical coverage benefits.8A group policy or contract or plan covered under this section shall at a minimum allow for thirty inpatient days and fifty-two outpatient visits annually. The policy or contract or plan may also include deductibles, coinsurance, or copayments, provided the amounts and extent of such deductibles, coinsurance, or copayments applicable to other medical or surgical services coverage under the policy or contract or plan are the same. It is not a violation of this section if the policy or contract or plan excludes entirely from coverage benefits for the cost of providing the following:aCare that is substantially custodial in nature.bServices and supplies that are not medically necessary or clinically appropriate.cExperimental treatments.9This section applies to third-party payment provider policies or contracts and plans established pursuant to chapter 509A delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2011.2010 Acts, ch 1121, §15; 2014 Acts, ch 1026, §143; 2016 Acts, ch 1011, §95; 2017 Acts, ch 148, §79, 80; 2023 Acts, ch 19, §1201514C.28Autism spectrum disorder coverage.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a group plan established pursuant to chapter 509A for employees of the state providing for third-party payment or prepayment of health, medical, and surgical coverage benefits shall provide coverage benefits to covered individuals for the diagnostic assessment of autism spectrum disorder and for the treatment of autism spectrum disorder.2As used in this section, unless the context otherwise requires:a“Applied behavioral analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior or to prevent loss of attained skill or function, including the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.b“Autism service provider” means a person, or group providing treatment of autism spectrum disorder. An autism service provider that provides treatment of autism spectrum disorder that includes applied behavioral analysis shall be certified as a behavior analyst by the behavior analyst certification board or shall be a health professional licensed under chapter 147.c“Autism spectrum disorder” means the same as defined in section 514C.22, subsection 4.d“Diagnostic assessment of autism spectrum disorder” means medically necessary assessment, evaluations, or tests performed by a licensed physician, licensed physician assistant, licensed psychologist, or licensed registered nurse practitioner to diagnose whether an individual has autism spectrum disorder.e “Pharmacy care” means medications prescribed by a licensed physician, licensed physician assistant, or licensed registered nurse practitioner and any assessment, evaluation, or test prescribed or ordered by a licensed physician, licensed physician assistant, or licensed registered nurse practitioner to determine the need for or effectiveness of such medications.f “Psychiatric care” means direct or consultative services provided by a licensed physician who specializes in psychiatry.g “Psychological care” means direct or consultative services provided by a licensed psychologist.h “Rehabilitative care” means professional services and treatment programs, including applied behavioral analysis, provided by an autism service provider to produce socially significant improvement in human behavior or to prevent loss of attained skill or function.i “Therapeutic care” means services provided by a licensed speech pathologist, licensed occupational therapist, or licensed physical therapist.j“Treatment of autism spectrum disorder” means treatment that is identified in a treatment plan and includes medically necessary pharmacy care, psychiatric care, psychological care, rehabilitative care, and therapeutic care that is one of the following:1Prescribed, ordered, or provided by a licensed physician, licensed physician assistant, licensed psychologist, licensed social worker, or licensed registered nurse practitioner.2Provided by an autism service provider.3Provided by a person, entity, or group that works under the direction of an autism service provider.k“Treatment plan” means a plan for the treatment of autism spectrum disorder developed by a licensed physician or licensed psychologist pursuant to a comprehensive evaluation or reevaluation performed in consultation with the patient and the patient’s representative.3Coverage required pursuant to this section shall not be subject to any limits on the number of visits a covered individual may have with an autism service provider for treatment of autism spectrum disorder. 4Coverage required pursuant to this section shall be subject to copayment, deductible, and coinsurance provisions, and any other general exclusions or limitations of a group plan to the same extent as other medical or surgical services covered by the group plan.5Coverage required by this section shall be provided in coordination with coverage required for the treatment of autism spectrum disorder pursuant to section 514C.22.6 This section shall not be construed to limit benefits which are otherwise available to an individual under a group plan.7This section shall not be construed to require coverage by a group plan of any service solely based on inclusion of the service in an individualized education program. Consistent with federal or state law and upon consent of the parent or guardian of a covered individual, the treatment of autism spectrum disorder may be coordinated with any services included in an individualized education program. However, coverage for the treatment of autism spectrum disorder shall not be contingent upon coordination of services with an individualized education program.8 This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance, or individual accident and sickness policies issued to individuals or to individual members of a member association.9A plan established pursuant to chapter 509A for employees of the state may manage the benefits provided through common methods including but not limited to providing payment of benefits or providing care and treatment under a capitated payment system, prospective reimbursement rate system, utilization control system, incentive system for the use of least restrictive and costly levels of care, a preferred provider contract limiting choice of specific providers, or any other system, method, or organization designed to assure services are medically necessary and clinically appropriate.10An insurer may review a treatment plan for treatment of autism spectrum disorder once every six months, subject to its utilization review requirements, including case management, concurrent review, and other managed care provisions. A more or less frequent review may be agreed upon by the insured and the licensed physician or licensed psychologist developing the treatment plan.11For the purposes of this section, the results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of not less than twelve months, unless a licensed physician or licensed psychologist determines that a more frequent assessment is necessary.12The commissioner shall adopt rules pursuant to chapter 17A to implement and administer this section.13 This section applies to plans established pursuant to chapter 509A for employees of the state that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2011.2010 Acts, ch 1193, §131; 2022 Acts, ch 1026, §4 – 6, 8; 2025 Acts, ch 162, §5, 6, 102022 amendments to subsections 1 – 3, 7, and 10 apply to plans established pursuant to chapter 509A for employees of the state that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2023; 2022 Acts, ch 1026, §82025 amendments to section apply to a group plan established pursuant to chapter 509A for employees of the state that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2026; 2025 Acts, ch 162, §10Subsections 1, 3, and 5 amendedSubsection 2, paragraph c amended514C.29Services provided by a doctor of chiropractic.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall not impose a copayment or coinsurance amount on an insured for services provided by a doctor of chiropractic licensed pursuant to chapter 151 that is greater than the copayment or coinsurance amount imposed on the insured for services provided by a person engaged in the practice of medicine and surgery or osteopathic medicine and surgery under chapter 148 for the same or a similar diagnosed condition even if a different nomenclature is used to describe the condition for which the services are provided.2This section applies to the following classes of third-party payment provider policies, contracts, or plans delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2012:aIndividual or group accident and sickness insurance providing coverage on an expense-incurred basis.bAn individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.cAn individual or group health maintenance organization contract regulated under chapter 514B.dA plan established pursuant to chapter 509A for public employees.3This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.2012 Acts, ch 1138, §36; 2017 Acts, ch 148, §81514C.30Services provided by a physical therapist, occupational therapist, or speech pathologist.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall not impose a copayment or coinsurance amount on an insured for services provided by a physical therapist licensed pursuant to chapter 148A, by an occupational therapist licensed pursuant to chapter 148B, or by a speech pathologist licensed pursuant to chapter 154F that is greater than the copayment or coinsurance amount imposed on the insured for services provided by a person engaged in the practice of medicine and surgery or osteopathic medicine and surgery under chapter 148 for the same or a similar diagnosed condition even if a different nomenclature is used to describe the condition for which the services are provided.2This section applies to the following classes of third-party payment provider policies, contracts, or plans delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2015:aIndividual or group accident and sickness insurance providing coverage on an expense-incurred basis.bAn individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.cAn individual or group health maintenance organization contract regulated under chapter 514B.dA plan established pursuant to chapter 509A for public employees.3This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.2015 Acts, ch 137, §101, 162, 163; 2017 Acts, ch 148, §82514C.31Applied behavior analysis for treatment of autism spectrum disorder coverage.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a group policy, contract, or plan providing for third-party payment or prepayment of health, medical, and surgical coverage benefits shall provide coverage benefits for applied behavior analysis provided by a practitioner to covered individuals for the treatment of autism spectrum disorder pursuant to a treatment plan if the policy, contract, or plan is either of the following:aA policy, contract, or plan issued by a carrier, as defined in section 513B.2, to an employer who on at least fifty percent of the employer’s working days during the preceding calendar year employed more than fifty full-time equivalent employees. In determining the number of full-time equivalent employees of an employer, employers who are affiliated or who are able to file a consolidated tax return for purposes of state taxation shall be considered one employer.bA plan established pursuant to chapter 509A for public employees other than employees of the state.2As used in this section, unless the context otherwise requires:a“Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior.b“Autism spectrum disorder” means the same as defined in section 514C.28, subsection 2.c“Practitioner” means any of the following:1A physician licensed pursuant to chapter 148.2A psychologist licensed pursuant to chapter 154B.3A behavior analyst licensed pursuant to chapter 154D.d“Treatment plan” means a plan for the treatment of autism spectrum disorder developed by a licensed physician or licensed psychologist after a comprehensive evaluation or reevaluation performed in a manner consistent with the most recent clinical report or recommendations of the American academy of pediatrics. “Treatment plan” includes supervisory services, subject to the provisions of subsection 4.3Coverage required pursuant to this section may be subject to deductibles, copayments, or coinsurance provisions that apply to other medical and surgical services under the policy, contract, or plan.4Coverage required pursuant to this section may be subject to care management provisions of the applicable policy, contract, or plan, including prior authorization and prior approval.5A carrier or plan may request a review of a treatment plan for a covered individual not more than once every three months during the first year of the treatment plan and not more than once every six months during every year thereafter, unless the carrier or plan and the covered individual’s treating physician or psychologist execute an agreement that a more frequent review is necessary. An agreement giving a carrier or plan the right to review the treatment plan of a covered individual more frequently applies only to a particular covered individual receiving applied behavior analysis and does not apply to other individuals receiving applied behavior analysis from a practitioner. The cost of conducting a review under this section shall be paid by the carrier or plan. A carrier or plan shall not change the provisions of a treatment plan until the completion of a review of the treatment plan.6This section shall not be construed to limit benefits which are otherwise available to an individual under a group policy, contract, or plan.7This section shall not be construed as affecting any obligation to provide services to an individual under an individualized family service plan, an individualized education program, or an individualized service plan.8This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance, or individual accident and sickness policies issued to individuals or to individual members of a member association.9This section applies to third-party provider payment contracts, policies, or plans specified in subsection 1, paragraph “a” or to plans established pursuant to chapter 509A for public employees other than employees of the state, that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2018.2017 Acts, ch 18, §4; 2017 Acts, ch 148, §103; 2018 Acts, ch 1106, §13, 14; 2022 Acts, ch 1026, §7, 8; 2025 Acts, ch 162, §7 – 102022 amendment to subsection 2, paragraphs b and d applies to third-party provider payment contracts, policies, or plans specified in subsection 1, paragraph a, or to plans established pursuant to chapter 509A for public employees other than employees of the state, that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2023; 2022 Acts, ch 1026, §82025 amendments to section apply to third-party provider payment contracts, policies, or plans specified in subsection 1, paragraph a, or to plans established pursuant to chapter 509A for public employees other than employees of the state, that are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2026; 2025 Acts, ch 162, §10Subsection 1, unnumbered paragraph 1 amendedSubsection 3 strickenFormer subsections 4 and 5 amended and renumbered as 3 and 4Former subsections 6 – 10 renumbered as 5 – 9514C.32Services provided by certain licensed master social workers, licensed mental health counselors, and licensed marital and family therapists.1Notwithstanding section 514C.6, a policy or contract providing for third-party payment or prepayment of health or medical expenses shall include a provision for the payment of necessary behavioral health services provided by any of the following:aA licensed master social worker who is licensed by the board of behavioral health professionals as a master social worker pursuant to section 154C.3, subsection 1, paragraph “b”, and who provides services under the supervision of an independent social worker licensed pursuant to section 154C.3, subsection 1, paragraph “c”.bA licensed mental health counselor or a licensed marital and family therapist who holds a temporary license to practice mental health counseling or marital and family therapy pursuant to section 154D.7, and who provides services under the supervision of a qualified supervisor as determined by the board of behavioral health professionals by rule.2A policy or contract subject to this section shall not impose a practice or supervision restriction which is inconsistent with or more restrictive than the authority already granted by law, including the authority to provide supervision in person or remotely through electronic means as specified by rule of the applicable licensing board.3The requirements of this section apply to and supersede any conflicting requirements regarding services provided under a policy or contract, which is delivered, issued for delivery, continued, or renewed in this state on or after June 1, 2018, and apply to and supersede any conflicting requirements regarding services contained in an existing policy or contract on the policy’s or contract’s anniversary or renewal date, whichever is later.4For the purposes of this section, third-party payment or prepayment includes an individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 514, or 514A, an individual or group health maintenance organization contract issued and regulated under chapter 514B, or a preferred provider organization contract regulated pursuant to chapter 514F.5Nothing in this section shall be interpreted to require an individual or group health maintenance organization or a preferred provider organization or arrangement to provide payment or prepayment for services provided by a licensed master social worker providing behavioral health services under the supervision of an independent social worker, or to a licensed mental health counselor or licensed marital and family therapist who holds a temporary license to practice mental health counseling or marital and family therapy providing behavioral health services under the supervision of a qualified supervisor, as specified in this section, unless the supervising independent social worker or the qualified supervisor, respectively, has entered into a contract or other agreement to provide behavioral health services with the individual or group health maintenance organization or the preferred provider organization or arrangement.2018 Acts, ch 1165, §137, 139; 2019 Acts, ch 59, §235, 240; 2024 Acts, ch 1170, §510514C.33Services provided by provisionally licensed psychologists.1Notwithstanding section 514C.6, a policy or contract providing for third-party payment or prepayment of health or medical expenses shall include a provision for the payment of necessary behavioral health services provided by a person who holds a provisional license to practice psychology pursuant to section 154B.6, and who practices under the supervision of a supervisor who meets the qualifications determined by the board of behavioral health professionals by rule.2A policy or contract subject to this section shall not impose a practice or supervision restriction which is inconsistent with or more restrictive than the authority already granted by law, including the authority to provide supervision in person or remotely through electronic means as specified by rule of the board of behavioral health professionals.3The requirements of this section apply to and supersede any conflicting requirements regarding services provided under a policy or contract which is delivered, issued for delivery, continued, or renewed in this state on or after June 1, 2018, and apply to and supersede any conflicting requirements regarding services contained in an existing policy or contract on the policy’s or contract’s anniversary or renewal date, whichever is later.4For the purposes of this section, third-party payment or prepayment includes an individual or group policy of accident or health insurance or individual or group hospital or health care service contract issued pursuant to chapter 509, 514, or 514A, an individual or group health maintenance organization contract issued and regulated under chapter 514B, or a preferred provider organization contract regulated pursuant to chapter 514F.5Nothing in this section shall be interpreted to require an individual or group health maintenance organization or a preferred provider organization or arrangement to provide payment or prepayment for services provided by a provisionally licensed psychologist providing behavioral health services under the supervision of a supervisor as specified in this section, unless the supervisor has entered into a contract or other agreement to provide behavioral health services with the individual or group health maintenance organization or the preferred provider organization or arrangement.2018 Acts, ch 1165, §138, 139; 2019 Acts, ch 59, §236, 240; 2024 Acts, ch 1170, §511514C.34Health care services delivered by telehealth coverage.1As used in this section, unless the context otherwise requires:a“Covered person” means the same as defined in section 514J.102.b“Facility” means the same as defined in section 514J.102.c“Health care professional” means the same as defined in section 514J.102.d“Health care services” means the same as defined in section 514J.102 and includes services for mental health conditions, illnesses, injuries, or diseases.e“Health carrier” means the same as defined in section 514J.102.f“Telehealth” means the delivery of health care services through the use of real-time interactive audio and video, or other real-time interactive electronic media, regardless of where the health care professional and the covered person are each located. “Telehealth” does not include the delivery of health care services delivered solely through an audio-only telephone, electronic mail message, or facsimile transmission. 2Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall not discriminate between coverage benefits for health care services that are provided in person and the same health care services that are delivered through telehealth.3aHealth care services that are delivered by telehealth must be appropriate and delivered in accordance with applicable law and generally accepted health care practices and standards prevailing at the time the health care services are provided, including all rules adopted by the appropriate professional licensing board, pursuant to chapter 147, having oversight of the health care professional providing the health care services. bA health carrier shall not exclude a health care professional who provides services for mental health conditions, illnesses, injuries, or diseases and who is physically located out-of-state from participating as a provider, via telehealth, under a policy, plan, or contract offered by the health carrier in the state if all of the following requirements are met:1The health care professional is licensed in this state by the appropriate professional licensing board and is able to deliver health care services for mental health conditions, illnesses, injuries, or diseases via telehealth in compliance with paragraph “a”.2The health care professional is able to satisfy the same criteria that the health carrier uses to qualify a health care professional who is located in the state, and who holds the same license as the out-of-state professional, to participate as a provider, via telehealth, under a policy, plan, or contract offered by the health carrier in the state.4aA health carrier shall reimburse a health care professional and a facility for health care services provided by telehealth to a covered person for a mental health condition, illness, injury, or disease on the same basis and at the same rate as the health carrier would apply to the same health care services for a mental health condition, illness, injury, or disease provided in person to a covered person by the health care professional or the facility.bAs a condition of reimbursement pursuant to paragraph “a”, a health carrier shall not require that an additional health care professional be located in the same room as a covered person while health care services for a mental health condition, illness, injury, or disease are provided via telehealth by another health care professional to the covered person.5This section applies to the following classes of third-party payment provider policies, contracts, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2019:aIndividual or group accident and sickness insurance providing coverage on an expense-incurred basis.bAn individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.cAn individual or group health maintenance organization contract regulated under chapter 514B.dA plan established pursuant to chapter 509A for public employees.6This section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.7The commissioner of insurance may adopt rules pursuant to chapter 17A as necessary to administer this section.2018 Acts, ch 1055, §1; 2021 Acts, ch 177, §20 – 24; 2022 Acts, ch 1131, §76 – 78For applicability of 2022 amendment to subsection 3 to health carriers that deliver, issue for delivery, continue, or renew a policy, contract, or plan in this state, see 2022 Acts, ch 1131, §78;; 2023 Acts, ch 66, §157, 159, 160514C.35Behavioral health services provided in a school coverage.1Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of health or medical expenses shall not deny coverage or payment for behavioral health services, including behavioral health services provided via telehealth, solely because the services are delivered in a school.2Nothing in this section shall be interpreted to do any of the following:aRequire an insurer to pay for behavioral health services that are otherwise excluded from coverage under a policy, contract, or plan.bRequire an insurer to pay for behavioral health services that are provided by an individual employed by or under contract with a school district or an educational service agency in a regular full-time or part-time position, or any other party that has not entered into a provider agreement with the insurer.cPrevent application of any other provision of a policy, contract, or plan.3This section applies to third-party payment provider policies, contracts, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2021, and to claims for reimbursement under such policies, contracts, or plans incurred on or after January 1, 2021.4For the purposes of this section:a“Behavioral health services” means services provided by a health care professional operating within the scope of the health care professional’s practice which address mental, emotional, medical, or behavioral conditions, illnesses, diseases, or problems.b“Educational service agency” means a governmental agency or government entity which is established and operated exclusively for the purpose of providing educational services to one or more educational institutions.c“Health care professional” means a physician or other health care practitioner licensed, accredited, registered, or certified to perform specified health care services consistent with state law.d“School” means all of the following:1Any school, other than a public school, that is accredited pursuant to section 256.11 for any and all levels for grades one through twelve.2Any school directly supported in whole or in part by taxation.3An area education agency established pursuant to chapter 273.e“School district” means a school district described in chapter 274.f“Telehealth” means the same as defined in section 514C.34.2020 Acts, ch 1105, §5; 2020 Acts, ch 1121, §66, 70514C.36Biomarker testing coverage.1As used in this section, unless the context otherwise requires:a“Biomarker” means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including but not limited to genetic mutations or protein expression.b“Biomarker testing” means the analysis of an individual’s tissue, blood, or other biospecimen for the presence of a biomarker, including but not limited to single-analyte tests, multiplex panel tests, or whole genome sequencing.c“Clinical utility” means sufficient medical and scientific evidence indicating that the use of a biomarker test will provide meaningful information that affects treatment decisions and guides improvement of net health outcomes, including an improved quality of life or longer survival.d“Consensus statement” means a statement developed by an independent, multidisciplinary panel of experts, none of whom have a conflict of interest, who utilize a transparent methodology and reporting structure. A consensus statement concerns specific clinical circumstances and is based on the best available evidence for the purpose of optimizing the outcomes of clinical care.e“Covered person” means a policyholder, subscriber, or other person participating in a policy, contract, or plan that provides for third-party payment or prepayment of health or medical expenses.f“Health care professional” means the same as defined in section 514J.102.g“Local coverage determinations” means the same as defined in section 1869(f)(2)(B) of the federal Social Security Act.h“National coverage determinations” means the same as defined in section 1869(f)(1)(B) of the federal Social Security Act.i“Nationally recognized clinical practice guidelines” means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies, none of which have a conflict of interest, that utilize a transparent methodology and reporting structure. Clinical practice guidelines establish standards of care informed by a systematic review of evidence and assessment of the costs and benefits of alternative care options and include recommendations intended to optimize patient care.2Notwithstanding the uniformity of treatment requirements of section 514C.6, a policy, contract, or plan providing for third-party payment or prepayment of medical expenses shall provide coverage for biomarker testing for the purposes of diagnosing, treating, appropriately managing, or monitoring a disease or condition in a covered person when the biomarker testing has demonstrated clinical utility, including but not limited to any of the following:aLabeled indications for a test approved or cleared by the United States food and drug administration or indicated tests for a drug approved by the United States food and drug administration.bCenters for Medicare and Medicaid services of the United States department of health and human services national coverage determinations or Medicare administrative contractor local coverage determinations.cNationally recognized clinical practice guidelines and consensus statements.3Coverage required under this section shall limit disruptions in care, including mitigating the need for a covered person to undergo multiple biopsies or to provide multiple biospecimen samples.4A covered person and the covered person’s health care professional shall have access to a clear and convenient process available on the health carrier’s internet site to request an exception to coverage provided under this section.5aThis section applies to the following classes of third-party payment provider policies, contracts, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2025:1Individual or group accident and sickness insurance providing coverage on an expense-incurred basis.2An individual or group hospital or medical service contract issued pursuant to chapter 509, 514, or 514A.3An individual or group health maintenance organization contract regulated under chapter 514B.4A plan established pursuant to chapter 509A for public employees.bThis section shall apply to all of the following:1The medical assistance program under chapter 249A.2The healthy and well kids in Iowa (Hawki) program under chapter 514I.3A managed care organization acting pursuant to a contract with the department of health and human services under chapter 249A, or with the healthy and well kids in Iowa (Hawki) program under chapter 514I.cThis section shall not apply to accident-only, specified disease, short-term hospital or medical, hospital confinement indemnity, credit, dental, vision, Medicare supplement, long-term care, basic hospital and medical-surgical expense coverage as defined by the commissioner, disability income insurance coverage, coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, or automobile medical payment insurance.6The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.2024 Acts, ch 1129, §1