CHAPTER 35ACCIDENT AND HEALTH INSURANCEBLANKET ACCIDENT AND SICKNESS INSURANCE[Prior to 10/22/86, Insurance Department[510]]191—35.1(509)  Purpose.  The purpose of this regulation is to establish guidelines for insurers to make special risk coverage available to particular groups that will be exposed to specific hazards for a certain period of time.191—35.2(509)  Scope.  These rules shall apply to all insurance companies holding a certificate of authority to transact the business of insurance under the provisions of Iowa Code chapters 508 and 515.191—35.3(509)  Definitions.    35.3(1)  Blanket accident and sickness insurance is hereby declared to be that form of accident, sickness or accident and sickness insurance designed to insure against specified hazards incident to or defined by reference to a particular activity or activities and covering groups of persons as enumerated in the following subparagraphs:  a.  Under a policy issued to an employer, who shall be deemed the policyholder covering any group of employees defined by reference to specific hazards incident to an activity or activities of the policyholder.  b.  Under a policy issued to a college, high school, junior high school, grade school, school district, school jurisdictional unit or other institution of learning; or to the head, principal, governing board of any such educational unit who or which shall be deemed the policyholder covering students, teachers or employees.  c.  Under a policy issued to any religious, charitable or educational organization, or branch thereof, which shall be deemed the policyholder covering any group of members or participants defined by reference to specified hazards incident to an activity or activities sponsored or supervised by such policyholder.  d.  Under a policy issued to a sports team, youth camp, recreational organization or sponsor thereof, which shall be deemed the policyholder, covering members, campers, participants, employees, officials or supervisors.  e.  Under a policy issued to any volunteer fire department, first aid, civil defense or other such volunteer organizations, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by such policyholder.  f.  Under a policy issued to a newspaper or other publisher, which shall be deemed the policyholder, covering its carriers.  g.  Under a policy issued to an association, other than a labor union, trade association or industrial association, which shall have a constitution and bylaws and which has been organized and is maintained in good faith for purposes other than that of obtaining insurance, which shall be deemed the policyholder, covering any group of members or participants defined by reference to specified hazards incident to an activity or activities or operations sponsored or supervised by such policyholder.  h.  Under a policy issued to cover any other risk or class of risks which, in the discretion of the commissioner, may be properly eligible for blanket accident and sickness insurance. The discretion of the commissioner may be exercised on an individual risk basis or class of risks, or both.  35.3(2)  Brochure shall mean an instrument, booklet or pamphlet setting forth a statement as to the insurance protection provided, to whom the insurance benefits are payable, sufficient information on the procedure an insured shall follow in filing a claim and such other provisions as are in the opinion of the commissioner of insurance necessary to inform the holder thereof as to rights under the policy.  35.3(3)  For purposes of Iowa Code section 514C.22 relating to biologically based mental illness coverage in a group policy, contract or plan providing for third-party payment of health, medical, and surgical coverage benefits issued by a carrier, “biologically based mental illness” shall mean the following mental disorders as they are defined under the following diagnostic classes within the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, edition DSM-IV-TR:  a.  Schizophrenia. Diagnostic codes 295.xx and 293.xx, including all specific subtypes of schizophrenia listed under those two diagnostic codes and using an appropriate extension. Schizophrenia also includes diagnostic codes 295.40, 295.70, 297.1, 298.8, 297.3 and 298.9.  b.  Bipolar disorders. Diagnostic code 296.xx including all specific subtypes of bipolar disorders listed under that diagnostic code and using an appropriate extension. Bipolar disorders also includes diagnostic codes 286.89, 301.13, 296.80, 293.83 and 296.90.  c.  Major depressive disorders. Diagnostic codes 296.2x and 296.3x including all specific subtypes of major depressive disorders listed under those two diagnostic codes and using an appropriate extension.  d.  Schizo-affective disorders. Diagnostic code 295.70.  e.  Obsessive-compulsive disorders. Diagnostic code 300.3.  f.  Pervasive development disorders. Diagnostic codes 299.00, 299.80 and 299.10.  g.  Autistic disorders. Diagnostic code 299.00.Related ARC(s): 3682C191—35.4(509)  Required provisions.  No blanket policy as herein defined shall be issued or delivered in this state unless a copy of the policy and brochure if required, has been approved by the commissioner of insurance in accordance with the provisions set forth in rule 191—35.7(509). All policies of blanket accident or sickness insurance or combination thereof issued in this state shall contain in substance the following provisions:  35.4(1)  A provision that the policy including endorsements and a copy of the application, if any, of the policyholder and the persons insured shall constitute the entire contract between the parties, and that any statement made by the policyholder or by a person insured shall in the absence of fraud, be deemed a representation and not a warranty. No such statement shall be used in defense of a claim under the policy, unless it is contained in a written application. If a copy of such application is not delivered to the person insured the insurer shall be precluded from introducing such application as evidence in any action involving any statements contained therein.  35.4(2)  A provision that written notice of sickness or of injury must be given to the insurer within 20 days of the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible.  35.4(3)  A provision that the insurer will furnish either to the claimant or to the policyholder for delivery to the claimant such forms as are usually furnished by it for filing proof of loss. If such forms are not furnished before the expiration of 15 days after giving such notice, the claimant shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, the character and the extent of the loss for which claim is made.  35.4(4)  A provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within 90 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within 90 days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible.  35.4(5)  A provision that all benefits payable under the policy other than benefits for loss of time will be payable immediately upon receipt of due written proof of such loss, and that, subject to due proof of loss, all accrued benefits payable under the policy for loss of time will be paid not less frequently than monthly during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof.  35.4(6)  A provision that the insurer at its own expense, shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy where it is not prohibited by law.  35.4(7)  A provision that no action at law or in equity shall be brought to recover under the policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of the policy and that no such action shall be brought after the expiration of three years after the time written proof of loss is required to be furnished.191—35.5(509)  Application and certificates not required.  An individual application need not be required from a person covered under a blanket accident and sickness policy, nor shall it be necessary for the insurer to furnish each person a certificate; however, a brochure as herein defined shall be issued to the policyholder for delivery to each person insured as defined in 35.3(1)“b” and “g.”191—35.6(509)  Facility of payment.  All benefits under any blanket accident and sickness policy shall be payable to the person insured, to a designated beneficiary or beneficiaries, or to their estate, except that if the person insured be a minor or otherwise not competent to give a valid release, such benefits may be made payable to their parent, guardian or other person actually supporting the insured, designated beneficiary, or beneficiaries. The policy may also provide that all or a portion of any indemnities provided by any such policy on account of hospital, nursing, medical or surgical services may with the consent of the insured be paid directly to the hospital or person rendering such services, but the policy may not require that the services be rendered by a particular hospital or person. Payment so made shall discharge the obligation of the insurer with respect to the amount of insurance so paid.These rules are intended to implement Iowa Code section 509.6.191—35.7(509)  General filing requirements.    35.7(1)  Insurance companies required to file rates or forms with the division shall submit required rate and form filings pursuant to rule 191—20.1(505,509,514A,515,515A,515F).  35.7(2)  Each filing must be submitted to the division of insurance not less than 60 days prior to the effective date of the filing. Any deficiencies or discrepancies in the filing will delay final approval. In case of disapproval, the company will be notified by the division.191—35.8(509)  Electronic delivery of accident and health group insurance certificates.    35.8(1)    Purpose.  The purpose of this rule is to authorize the electronic delivery of accident and health group insurance certificates in an efficient manner by insurers and group policyholders, while guaranteeing that individual plan members still receive the important information contained in such group insurance certificates, as required by Iowa Code section 509.3(2), and as allowed by the uniform electronic transactions Act, Iowa Code chapter 554D.  35.8(2)    Scope.  This rule shall apply to all insurance companies holding a certificate of authority to transact the business of insurance under the provisions of Iowa Code chapters 508 and 515.  35.8(3)    Electronic delivery—insurance companies.  The insurer will be deemed to comply with the requirements of Iowa Code section 509.3(2) if the group insurance certificate is delivered to the group policyholder electronically and if:  a.  The insurer takes appropriate and necessary measures to ensure that the system for furnishing group insurance certificates results in actual receipt of transmitted information by group policyholders, which may be done by:  (1)  Using return-receipt electronic mail features;  (2)  Periodic reviews or surveys to confirm receipt of the transmitted information; or  (3)  Any other method approved by the insurance commissioner.  b.  The electronic documents contain the same content and appear in reasonably the same format as the certificates previously approved by the insurance commissioner.  c.  Each group policyholder is provided notice, through electronic means or in writing, apprising the group policyholder of the fact that the certificate will be furnished electronically, of the significance of the certificate and the group policyholder’s obligations under this rule, and of the group policyholder’s right to request and receive a paper copy of the document for each participant.  d.  Upon request of any group policyholder, the insurer furnishes paper copies of the group insurance certificate that was delivered to the group policyholder electronically, so that the group policyholder may provide them to participants that have requested paper copies.  35.8(4)    Electronic delivery—group policyholders.  The group policyholder will be deemed to comply with the requirements of Iowa Code section 509.3(2) if the group insurance certificate is delivered to the individual plan member electronically and if:  a.  The group policyholder takes appropriate and necessary measures to ensure that the system for furnishing group insurance certificates results in actual receipt of transmitted information by participants, which may be done by:  (1)  Using return-receipt electronic mail features;  (2)  Periodic reviews or surveys to confirm receipt of the transmitted information; or  (3)  Any other method approved by the insurance commissioner.  b.  The electronic documents contain the same content and appear in reasonably the same format as the certificates previously approved by the insurance commissioner.  c.  Each participant is provided notice, through electronic means or in writing, apprising the participant of the fact that the certificate will be furnished electronically, of the significance of the certificate, and of the participant’s right to request and receive, free of charge, a paper copy of the document.  d.  Upon request of any participant, the group policyholder furnishes, free of charge, a paper copy of the group insurance certificate that was delivered to the participant electronically.This rule is intended to implement Iowa Code chapter 509.GENERAL ACCIDENT AND HEALTH INSURANCE REQUIREMENTS191—35.9(509B, 513B, 514D)  Notice of cancellation, nonrenewal or termination of accident and health insurance.    35.9(1)    Purpose and definitions.    a.    Purpose.  The purpose of this rule is to clarify the authorized methods of delivery for notices of cancellation, nonrenewal or termination by an insurer, issuer, employer, group policyholder, or carrier, so as to implement the various policyholder protections intended by Iowa Code sections 509B.5, 513B.5, 514D.3, 515.125 and 515.129A and chapter 505B.  b.    Definitions.  As used in Iowa Code section 505B.1 and this rule:
"Commissioner" means the Iowa insurance commissioner or insurance division.
"Notice of cancellation, nonrenewal or termination" means:
  1. Notice of termination of an insurance policy at the end of a term or before the termination date;
  2. Notice of a decision or intention not to renew a policy; and
  3. For purposes of notices required by Iowa Code sections 509B.5, 513B.5, 514D.3, 515.125 and 515.129A and chapter 505B, “notice of cancellation, nonrenewal or termination” includes but is not limited to the following:
  4. An employer’s or group policyholder’s notification to employees or members of the termination or substantial modification of the continuation of an employer group accident or health policy pursuant to Iowa Code section 509B.5;
  5. A carrier’s advance notice to all affected small employers, participants, and beneficiaries of its decision to discontinue offering a particular type of small group health insurance plan pursuant to Iowa Code section 513B.5(1)“e”(2);
  6. An insurance company’s notice of termination of an individual accident and sickness policy, pursuant to rules promulgated pursuant to Iowa Code section 514D.3;
  7. An insurance company’s notice of forfeiture, suspension, cancellation, or intention not to renew, pursuant to Iowa Code section 515.125; or
  8. An insurance company’s notice of cancellation of personal lines policies or contracts pursuant to Iowa Code section 515.129A.
  35.9(2)    Scope.  This rule shall apply to all insurance companies holding a certificate of authority to transact the business of insurance under the provisions of Iowa Code chapters 508, 512B, 515, and 520.  35.9(3)    Delivery.  For any notice of cancellation, nonrenewal or termination by an insurer, employer, group policyholder, or carrier to be effective, an insurer, employer, group policyholder, or carrier must, within the time frame established by law, deliver the notice to the person to whom notice is required to be provided either in person or by mail through the U.S. Postal Service to the last-known address of the person to whom notice is required to be provided. The use of U.S. Postal Service Intelligent Mail® fulfills any requirement in the Iowa Code sections cited in this subrule for certified mail or certificate of mailing as proof of mailing.  35.9(4)    Electronic transmissions.  Notwithstanding the requirements of subrule 35.9(3), if an insurer, issuer, employer, group policyholder, or carrier receives, pursuant to 191—subrule 4.24(2), approval from the commissioner of a manner of electronic delivery of a notice of cancellation, nonrenewal or termination of a policy, the approved manner shall satisfy the notice requirements of Iowa Code sections 509B.5, 513B.5, 514D.3, 515.125 and 515.129A and chapter 505B.This rule is intended to implement Iowa Code chapters 505B, 509B, 513B, 514D, and 515.
Related ARC(s): 1999C, 2415C, 3682C191—35.10    Reserved.191—35.11    Reserved.191—35.12    Reserved.191—35.13    Reserved.191—35.14    Reserved.191—35.15    Reserved.191—35.16    Reserved.191—35.17    Reserved.191—35.18    Reserved.191—35.19    Reserved.191—35.20(509A)  Life and health self-funded plans.    35.20(1)  Scope. This rule shall apply to life and health self-funded plans for political subdivisions of the state, school corporations, and all other public bodies of the state. This rule shall not apply to life and health self-funded plans for the state of Iowa.  35.20(2)  Iowa Code chapter 28E agreements—certificate of registration. Public entities seeking to pool risk through a joint exercise of power under Iowa Code chapter 28E shall apply for and obtain a certificate of registration from the commissioner. This subrule shall not apply to single-employer public entities with self-insured plans.  a.  An application for a certificate of registration shall contain the following:  (1)  A copy of the proposed agreement entered into pursuant to Iowa Code chapter 28E, to be executed by all plan participants;  (2)  A copy of the articles of incorporation, bylaws, agreements, or other documents or instruments describing the rights and obligations of employers, employees and beneficiaries;  (3)  A copy of all contracts with insurance companies, consultants and third-party administrators;  (4)  A business plan, including a copy of all contracts or other instruments which the 28E agreement proposes to make with or sell to its members, a copy of its plan description and the printed matter to be used in the solicitation of members; and  (5)  A current list of all participating public entities.  b.  Iowa Code chapter 28E agreements shall contain the following provisions:  (1)  If the plan is in a deficit position, a participant cannot terminate from the plan without the prior written consent of the commissioner;  (2)  If a participant in the plan terminates, the terminating participant shall be assessed its proportionate share of the plan’s deficit, if any;  (3)  Deficit assessments shall be mandatory for all plan participants within a time frame acceptable to the commissioner;  (4)  Plan participants have no individual interest in the accumulated surplus of a plan; and  (5)  Upon termination of the plan, surplus remaining after the payment of all liabilities shall be distributed proportionately to plan participants that were active members of the plan on the termination date.  c.  Reporting requirements. In addition to the requirements of subrule 35.20(3), all public entities pooling risk shall submit:  (1)  Quarterly financial statement. A plan shall file with the commissioner of insurance within 60 days of the end of each quarter a report which has been verified by at least two of its principal officers and which covers the preceding calendar quarter. The report shall be on a form prescribed by the commissioner. The commissioner of insurance may request additional reports and information from a plan as often as is deemed necessary.  (2)  Amendments. A plan shall submit copies of any proposed amendment to the documents submitted in accordance with subrule 35.20(2), paragraph “a,” 30 days in advance of the amendment’s proposed effective date.  (3)  Other documents. A plan shall submit any other documents deemed necessary by the commissioner.  35.20(3)  Minimum plan standards for both pooled and single-employer public entities. Self-funded life plans subject to this rule shall meet the requirements of Iowa Code sections 509.1, 509.2, 509.4, and 509.15 and rules thereunder. Self-funded health plans subject to this rule shall meet the requirements of Iowa Code sections 509.1 and 509.3 and rules thereunder. In order to ensure that a self-funded life or health plan is able to cover all reasonably anticipated expenses and to avoid liability for the public body, a self-funded life or health plan shall provide that:  a.  An annual report showing the starting and ending balance of the fund, deposits of monthly accrual rates and other assets of the fund, and the amount and nature of all disbursements from the fund shall be prepared and submitted to the governing body of the public body. An annual report shall be made to show a separate accounting to reflect all required reserves.  b.  Monthly accrual rates shall be established at a satisfactory level to provide funds to cover all claims, reserves, and expenses to operate the plan. Accrual rates shall be reevaluated annually. Accrual rates shall be funded solely through public body contributions or through a combination of employer and employee contributions.  c.  A plan fund shall be established exclusively for the deposit of monthly accrual rates and other assets pertaining to the plan. After a self-funded life or health plan is established and as long as any claims may be made against the plan fund, all contributions shall be deposited as collected in the plan fund. The plan fund shall be disbursed only for plan expenses.  d.  The following reserves shall be established in the plan fund:  (1)  A reserve for claims that have been incurred by participants under the plan, but have not yet been presented for payment. The appropriate amount of this reserve shall be on an actuarially sound basis as determined by an independent actuary, an insurance company, or a nonprofit health service corporation authorized pursuant to Iowa Code chapter 514.  (2)  A claims fluctuation reserve for setting aside funds that become available during a month when claims are less than projected for that month. Funds shall be maintained and available for a month in which claims exceed those projected for that month. For public entities that require a certificate of registration under subrule 35.20(2), the claims fluctuation reserve shall equal or exceed a minimum of two months of paid claims.  e.  The public body shall obtain a fidelity bond as a guaranty of faithful operation of the self-funded plan by the public body, its officers, agents, and employees.  f.  Disbursements from the plan fund shall be made only for the following specified plan expenses:  (1)  Payment of claims.  (2)  Cost of aggregate excess loss coverage.  (3)  Cost of specific excess loss coverage.  (4)  Bonding expenses.  (5)  Payment of service fees applicable to plan design, payment of claims, materials explaining plan benefits, actuarial assistance, legal assistance, and accounting assistance.  (6)  Other expenses directly related to the operation of the plan.  g.  Aggregate excess loss coverage shall be obtained which will limit a public body’s total claim liability for each year to not more than 125 percent of the level of claims liability as projected by an independent actuary or insurance company. A public body shall fund this potential additional liability of 25 percent either by allocating necessary funds from the operating fund of the general fund or by setting up an additional reserve in the operating fund. Specific excess loss coverage may also be obtained if a public body wishes to limit its total annual liability on claims for any one claimant.  h.  The commissioner may retain an independent actuary, at the commissioner’s discretion, to review the adequacy of a plan’s reserves. The cost of such review shall be paid by the plan. Examples that illustrate when the commissioner may retain an independent actuary include, but are not limited to, negative trends in the plan’s financial statements, an increase in consumer complaints about the plan’s failing to timely pay claims and material changes to the plan’s operations.  35.20(4)  Plan shortfalls. If the resources of any self-funded plan subject to this rule are not adequate to fully cover all claims under that plan, then the public body sponsoring that plan shall make up the shortfall from other resources.  35.20(5)  Confidentiality. Information held by the plan administrator of a self-funded plan shall be kept confidential. An employee or agent of the plan administrator shall not use or disclose any information to any person, except to the extent necessary to administer claims or as otherwise authorized by law.  35.20(6)  A health self-funded plan subject to this rule shall not prohibit a participating provider from or penalize a participating provider for discussing treatment options with covered persons, irrespective of a self-funded plan’s position on the treatment options, or from advocating on behalf of covered persons within the utilization review or grievance processes established by the self-funded plan or a person contracting with the self-funded plan.The self-funded plan shall not penalize a provider because the provider, in good faith, reports to state or federal authorities any act or practice by the self-funded plan that, in the opinion of the provider, jeopardizes patient health or welfare.  35.20(7)  Benefits shall be made available by the health self-funded plan for inpatient and outpatient emergency services. Since self-funded plans may not contract with every emergency care provider in an area, self-funded plans shall make every effort to inform members of participating providers.The term “emergency services” means, with respect to an individual enrolled with an organization, covered inpatient and outpatient services that are furnished by a provider who is qualified to furnish the services that are needed to evaluate or stabilize an emergency medical condition.The term “emergency medical condition” means a medical condition manifesting itself by symptoms of sufficient severity, including but not limited to severe pain, that an ordinarily prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in one of the following:
  1. Placing the health of the individual or, with respect to a pregnant woman, the health of the woman and her unborn child in serious jeopardy;
  2. Serious impairment to bodily function; or
  3. Serious dysfunction of any bodily organ or part.
Reimbursement to a provider of “emergency services” shall not be denied by any health maintenance organization without that organization’s review of the patient’s medical history, presenting symptoms, and admitting or initial diagnosis as well as final diagnosis, submitted by the provider, in determining whether, by definition, emergency services could reasonably have been expected to be provided. Reimbursement for emergency services shall not be denied solely on the grounds that a noncontracted provider performed services. If reimbursement for emergency services is denied, the enrollee may file a complaint with the self-funded plan. Upon denial of reimbursement for emergency services, the self-funded plan shall notify the enrollee and the provider that they may register a complaint with the commissioner of insurance.
  35.20(8)  A health self-funded plan subject to this rule shall allow a female member direct access to obstetrical or gynecological services from network and participating providers. The plan shall also allow a pediatrician to be the primary care provider for a child through the age of 18.This rule is intended to implement Iowa Code chapter 509A and 2003 Iowa Acts, chapter 83.
191—35.21(509)  Review of certificates issued under group policies.    35.21(1)    Nondiscretionary groups.  A certificate of coverage delivered in this state under a group life or accident and health insurance policy issued to a group substantially as described in Iowa Code section 509.1, subsections (1) to (7), shall not be reviewed by the commissioner if the policy is issued outside of this state.  35.21(2)    Discretionary groups.  A certificate of coverage delivered in this state under a group life or accident and health insurance policy issued to a group not substantially as described in Iowa Code section 509.1, subsections (1) to (7), shall not be reviewed by the commissioner if the policy is issued outside of this state and if the policy is issued or offered in a state which has reviewed and approved the policy under a statute substantially similar to Iowa Code section 509.1(8).These rules are intended to implement Iowa Code sections 509.1, 509.6, and 509A.14.LARGE GROUP HEALTH INSURANCE COVERAGE191—35.22(509)  Purpose.  This division of Chapter 35 implements the requirements of Pub.L. 104-191, the Health Insurance Portability and Accountability Act of 1996 and Iowa Code section 509.3 for large group health insurance coverage.191—35.23(509)  Definitions.  
"Affiliation period" means a period of time that must expire before health insurance coverage provided by an HMO becomes effective, and during which the HMO is not required to provide benefits.
"Beneficiary" has the meaning given the term under Section 3(8) of the Employee Retirement Income Security Act of 1974 (ERISA), which states, “a person designated by a participant, or by the terms of an employee benefit plan, who is or may become entitled to a benefit” under the plan.
"Bona fide association" means, with respect to group health insurance coverage offered in Iowa, an association that meets the following conditions:
  1. Has been actively in existence for at least five years.
  2. Has been formed and maintained in good faith for purposes other than obtaining insurance.
  3. Does not condition membership in the association on any health status-related factor relating to an individual including an employee of an employer or a dependent of any employee.
  4. Makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members or individuals eligible for coverage through a member.
  5. Does not make health insurance coverage offered through the association available other than in connection with a member of the association.
"Carrier" means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, or any other entity providing a plan of health insurance, health benefits or health services.
"COBRA" means Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.
"Commissioner" means the commissioner of insurance.
"Continuation coverage" means coverage under a COBRA continuation provision or a similar state program. Coverage provided by a plan that is subject to a COBRA continuation provision or similar state program, but that does not satisfy all the requirements of that provision or program, will be deemed to be continuation coverage if it allows an individual to elect to continue coverage for a period of at least 18 months. Continuation coverage does not include coverage under a conversion policy required to be offered to an individual upon exhaustion of continuation coverage, nor does it include continuation coverage under the Federal Employees Health Benefits Program.
"Creditable coverage" means health benefits or coverage provided to an individual under any of the following:
  1. A group health plan.
  2. Health insurance coverage.
  3. Part A or Part B Medicare pursuant to Title XVIII of the federal Social Security Act.
  4. Medicaid pursuant to Title XIX of the federal Social Security Act, other than coverage consisting solely of benefits under Section 1928 of that Act.
  5. 10 U.S.C. ch.55.
  6. A health or medical care program provided through the Indian Health Service or a tribal organization.
  7. A state health benefits risk pool.
  8. A health plan offered under 5 U.S.C. ch.89.
  9. A public health plan as defined under federal regulations.
  10. A health benefit plan under Section 5(e) of the Peace Corps Act, 22 U.S.C. 2504(e).
  11. A short-term limited-duration policy.
"Director" means the director of public health appointed pursuant to Iowa Code section 135.2.
"Division" means the division of insurance.
"Eligible employee" means an individual who is eligible to enroll in group health insurance coverage offered to a group health plan maintained by an employer, in accordance with the terms of the group health plan.
"Employee" means any individual employed by an employer.
"Enrollment date" means the first day of coverage or, if there is a waiting period, the first day of the waiting period.
"Exhaustion of continuation coverage" means that an individual’s continuation coverage ceases for any reason other than either failure of the individual to pay premiums on a timely basis, or for cause such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan. An individual is considered to have exhausted continuation coverage if:
  1. Coverage ceases due to the failure of the employer or other responsible entity to remit premiums on a timely basis, or
  2. When the individual no longer resides, lives, or works in a service area of an HMO or similar program, whether or not within the choice of the individual, and there is no other continuation coverage available to the individual.
"Group health plan" means an employee welfare benefit plan as defined in Section 3(1) of the federal Employee Retirement Income Security Act of 1974, to the extent that the plan provides medical care including items and services paid for as medical care to employees or their dependents as defined under the terms of the plan directly or through insurance, reimbursement, or otherwise.
  1. For purposes of this rule, “medical care” means amounts paid for any of the following:
  • The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting a structure or function of the body.
  • Transportation primarily for and essential to medical care referred to in this definition.
  • Insurance covering medical care referred to in this definition.
    1. For purposes of this division, a plan, fund, or program established or maintained by a partnership which, but for this paragraph, would not be an employee welfare benefit plan, shall be treated as an employee welfare benefit plan which is a group health plan to the extent that the plan, fund, or program provides medical care, including items and services paid for as medical care, for present or former partners in the partnership or to the dependents of such partners, as defined under the terms of the plan, fund, or program, either directly or through insurance, reimbursement, or otherwise.
    1. With respect to a group health plan, the term “employer” includes a partnership with respect to a partner.
    2. With respect to a group health plan the term “participant” includes the following:
  • With respect to a group health plan maintained by a partnership, an individual who is a partner in the partnership.
  • With respect to a group health plan maintained by a self-employed individual, under which one or more of the self-employed individual’s employees are participants, the self-employed individual, if that individual is, or may become, eligible to receive benefits under the plan or the individual’s dependents may be eligible to receive benefits under the plan.
  • "Health insurance coverage" " health insurance plan" means benefits consisting of health care provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as health care under a hospital or health service policy or certificate, hospital or health service plan contract, or health maintenance organization contract offered by a carrier.
    1. “Health insurance coverage” does not include any of the following:
    2. Coverage for accident only, or disability income insurance.
    3. Coverage issued as a supplement to liability insurance.
    4. Liability insurance, including general liability insurance and automobile liability insurance.
    5. Workers’ compensation or similar insurance.
    6. Automobile medical payment insurance.
    7. Credit-only insurance.
    8. Coverage for on-site medical clinic care.
    9. Other similar insurance coverage, specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.
    10. Flexible spending accounts.
    1. “Health insurance coverage” does not include benefits provided under a separate policy as follows:
    2. Limited scope dental or vision benefits.
    3. Benefits for long-term care, nursing home care, home health care, or community-based care.
    4. Short-term limited-duration insurance.
    5. Any other similar, limited benefits as provided by rule of the commissioner.
    6. Stop loss insurance coverage.
    1. “Health insurance coverage” does not include benefits offered as independent noncoordinated benefits as follows:
    2. Coverage only for a specified disease or illness;
    3. Hospital indemnity or other fixed indemnity insurance.
    1. “Health insurance coverage” does not include Medicare supplemental health insurance as defined under Section 1882(g)(1) of the federal Social Security Act, coverage supplemental to the coverage provided under 10 U.S.C. ch.55, and similar supplemental coverage provided under insurance coverage.
    1. “Group health insurance coverage” means health insurance coverage offered in connection with a group health plan.
    "Health maintenance organization" "HMO" means a federally qualified health maintenance organization as defined in Section 1301(a) of the Public Health Services Act or an organization licensed under Iowa Code section 514B.5.
    "Large employer" means an employer employing two or more employees and which does not meet the definition of small employer under Iowa Code section 513B.2(16).
    "Late enrollee" means an individual, other than one who enrolls during a special enrollment period, who enrolls under a health benefit plan or health insurance coverage in connection with which it is issued, other than during the first period in which the individual is eligible to enroll under terms of the health benefit plan or health insurance coverage.
    "Network plan" means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care including items and services paid for as medical care are provided, in whole or in part, through a defined set of providers under contract with the carrier.
    "Plan year" means the year that is designated as the plan year in the plan document of a group health plan, except that if the plan document does not designate a plan year or if there is no plan document, the plan year is:
    1. The deductible/limit year used under the plan.
    2. If the plan does not impose deductibles or limits on a yearly basis, the plan year is the policy year.
    3. If the plan does not impose deductibles or limits on a yearly basis, and either the plan is not insured or the insurance policy is not renewed on an annual basis, the plan year is the employer’s taxable year.
    "Preexisting condition exclusion" means, with respect to health insurance coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date. A preexisting condition exclusion includes any exclusion applicable to an individual as a result of information that is obtained relating to an individual’s health status before the individual’s first day of coverage, such as a condition identified as a result of a preenrollment questionnaire or physical examination given to the individual, or review of medical records relating to the preenrollment period.
    "Short-term limited-duration insurance" means health coverage provided pursuant to a contract with an issuer that has an expiration date specified in the contract that is less than 12 months after the original effective date of the contract and, taking into account renewals or extensions, has a duration of no longer than 36 months in total.
    "Significant break in coverage" means a period of 63 consecutive days during all of which the individual does not have any creditable coverage, except that neither a waiting period nor an affiliation period is taken into account in determining a significant break in coverage.
    "Special enrollment period" means a period other than the first period in which an eligible employee or a dependent is eligible to enroll under the terms of group health insurance coverage in connection with which it is issued, without regard to other enrollment periods defined under the health insurance coverage.
    "Waiting period" means, with respect to group health insurance coverage and an eligible employee or a dependent who is potentially eligible for coverage under the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan.
    Related ARC(s): 3682C, 4332C191—35.24(509)  Eligibility to enroll.    35.24(1)  A carrier offering group health insurance coverage shall not establish rules for eligibility, including continued eligibility, of an individual to enroll under the terms of the coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:  a.  Health status.  b.  Medical condition, including both physical and mental conditions.  c.  Claims experience.  d.  Receipt of health care.  e.  Medical history.  f.  Genetic information.  g.  Evidence of insurability, including conditions arising out of acts of domestic violence.  h.  Disability.  35.24(2)  Subrule 35.24(1) does not require group health insurance coverage to provide particular benefits other than those provided under the terms of the coverage, and does not prevent a coverage from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the coverage.  35.24(3)  Rules for eligibility to enroll under group health insurance coverage include rules defining any applicable waiting or affiliation periods for such enrollment.  35.24(4)  A carrier offering health insurance coverage shall not require an individual, as a condition of enrollment or continued enrollment under the coverage, to pay a premium or contribution which is greater than a premium or contribution for a similarly situated individual enrolled in the coverage on the basis of a health status-related factor in relation to the individual or to a dependent of an individual enrolled under the coverage. This subrule shall not be construed to do either of the following:  a.  Restrict the amount that an employer may be charged for health insurance coverage.  b.  Prevent a carrier offering group health insurance coverage from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.  35.24(5)  A carrier shall not modify a health insurance coverage with respect to an employer or any eligible employee or dependent through riders, endorsements or other means, to restrict or exclude coverage or benefits for specific diseases, medical conditions, or services otherwise covered by the health insurance coverage.Related ARC(s): 3682C191—35.25(509)  Special enrollments.    35.25(1)  A carrier shall permit individuals to enroll for coverage under terms of a health benefit plan, without regard to other enrollment dates permitted under the group health insurance coverage, if an eligible employee requests enrollment or, if the group health insurance coverage makes coverage available to dependents, on behalf of a dependent who is eligible but not enrolled under the group health insurance coverage, during the special enrollment period, which shall be 30 days following an event described in subrule 35.25(2) or 35.25(3) with respect to the individual for whom enrollment is requested. A carrier may impose enrollment requirements that are otherwise applicable under terms of the group health insurance coverage to individuals requesting immediate enrollment.  35.25(2)  An individual, who previously had other coverage for medical care and for whom an eligible employee declined coverage under the group health insurance coverage, may be enrolled during a special enrollment period if the individual has lost the other coverage for medical care and:  a.  If required by the group health insurance coverage, the eligible employee stated in writing when declining the coverage, after being given a notice of the requirement form, and the consequences of failure to submit a written statement that coverage was declined because the individual had coverage for medical care under another group health insurance coverage, group health plan, or otherwise; and  b.  When enrollment was declined for the individual:  (1)  The individual had coverage under a COBRA continuation provision and the coverage has been exhausted; or   (2)  The individual had coverage other than under a COBRA continuation provision and the coverage has been terminated due to loss of eligibility for the coverage, including loss of coverage as a result of legal separation, divorce, death, termination of employment, reduction in the number of hours of employment and any loss of eligibility after a period that is measured by reference to any of the foregoing, or termination of employer contributions toward the other coverage.  c.  For purposes of subparagraph 35.25(2)“b”(2):  (1)  Loss of eligibility for the coverages does not include loss of eligibility due to the eligible employee’s or dependent’s failure to make timely premium payments or termination of coverage for cause such as making a fraudulent claim or intentional misrepresentation of material fact in connection with the group health insurance coverage; and  (2)  Employer contributions include contributions by any current or former employer of the individual or another person that was contributing to coverage for the individual.  (3)  Exhaustion of COBRA continuation coverage means that an individual’s COBRA continuation coverage ceases for any reason other than either failure of the individual to pay premiums on a timely basis, or for cause, such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan. An individual is considered to have exhausted COBRA continuation coverage if the coverage ceases.  35.25(3)  If the eligible employee has previously declined enrollment under the group health insurance coverage but acquires a dependent through marriage, birth, adoption or placement for adoption, the eligible employee or dependent may be enrolled during the special enrollment period with respect to the individual.  35.25(4)  Enrollment of the eligible employee or dependent is effective not later than the first day of the calendar month or, for a newborn or adopted child, on the date of birth, adoption, or placement for adoption.Related ARC(s): 3682C191—35.26(509)  Group health insurance coverage policy requirements.    35.26(1)  Group health insurance coverage subject to the rules in this division is renewable with respect to all eligible employees or their dependents at the option of the employer, except for one or more of the following reasons:  a.  The health insurance coverage sponsor fails to pay or to make timely payments of premiums or contributions pursuant to the terms of the health insurance coverage.  b.  The health insurance coverage sponsors, performs an act or practice constituting fraud or makes an intentional misrepresentation of a material fact under the terms of the coverage.  c.  Noncompliance with the carrier’s minimum participation requirements or employer contribution requirements.  d.  For a network plan, no enrollees connected to the plan live, reside, or work in the service area of the issuer.  e.  A carrier may choose to discontinue offering and cease to renew a particular type of health insurance coverage in the large group market if the carrier does all of the following:  (1)  Provides advance notice of its decision to discontinue the plan to the commissioner or director a minimum of three days prior to the notice for affected employers, participants, and beneficiaries.  (2)  Provides notice of its decision not to renew a plan to all affected employers, participants, and beneficiaries no less than 90 days prior to nonrenewal of a plan.  (3)  Offers to each plan sponsor of the discontinued coverage the option to purchase any other coverage currently offered by the carrier to other employers in this state.  (4)  Acts uniformly, in opting to discontinue the coverage and in offering the option under subparagraph 35.26(1)“e”(3), without regard to the claims experience of the sponsors under the discontinued coverage or to a health status-related factor relating to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for the coverage.  f.  A decision by the carrier to discontinue offering and cease to renew all of its health insurance delivered or issued for delivery to employers in this state shall do all of the following:  (1)  Provide advance notice of its decision to discontinue such coverage to the commissioner or director. Notice to the commissioner or director, at a minimum, shall be no less than three days prior to the notice provided for in subparagraph 35.26(1)“f”(2) to affected employers, participants, and beneficiaries.  (2)  Provide notice of its decision not to renew such coverage to all affected employers, participants, and beneficiaries no less than 180 days prior to the nonrenewal of the coverage.  (3)  Discontinue all health insurance coverage issued or delivered for issuance to employers in this state and cease renewal of such coverage.  g.  The membership of an employer in a bona fide association, which is the basis for the coverage which is provided through such association, ceases, but only if the termination of coverage under this subrule occurs uniformly without regard to any health status-related factor relating to any covered individual.  h.  The commissioner or director finds that the continuation of the coverage is not in the best interests of the policyholders or certificate holders, or would impair the carrier’s ability to meet its contractual obligations.  i.  At the time of coverage renewal, a carrier may modify the health insurance coverage for a product offered under group health insurance coverage in the group market, if such modification is consistent with the laws of this state and is effective on a uniform basis among group health insurance coverage with that product.  35.26(2)  A carrier that elects not to renew health insurance coverage under 35.26(1)“f” shall not write any new business in the group market in this state for a period of five years after the date of notice to the commissioner or director.  35.26(3)  This rule applies only to a carrier doing business in one established geographic service area of the state and the carrier’s operations in that service area.  35.26(4)  Preexisting condition exclusions.  a.  A carrier, with respect to a participant or beneficiary, may impose a preexisting condition exclusion only as follows:  (1)  The exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date. However, genetic information shall not be treated as a condition under this subparagraph in the absence of a diagnosis of the condition related to such information.  (2)  The exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date.  (3)  The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.  b.  A carrier offering group health insurance coverage shall not impose any preexisting condition as follows:  (1)  In the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This subparagraph shall not apply to coverage before the date of such adoption or placement for adoption.  (2)  In the case of an individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage.  (3)  Relating to pregnancy as a preexisting condition.  c.  A carrier shall waive any waiting period applicable to a preexisting condition exclusion or limitation period with respect to particular services under health insurance coverage for the period of time an individual was covered by creditable coverage, provided that the creditable coverage was continuous to a date not more than 63 days prior to the effective date of the new coverage. Any period that an individual is in a waiting period for any coverage under group health insurance coverage, or is in an affiliation period, shall not be taken into account in determining the period of continuous coverage. A health maintenance organization that does not use preexisting condition limitations in any of its health insurance coverage may impose an affiliation period. For purposes of this paragraph, “affiliation period” means a period of time not to exceed 60 days for new entrants and not to exceed 90 days for late enrollees during which no premium shall be collected and coverage issued is not effective, so long as the affiliation period is applied uniformly, without regard to any health status-related factors.  d.  A group health plan or carrier offering group health insurance under the plan may not impose a preexisting condition exclusion with respect to a participant or dependent of the participant before notifying the participant under rule 191—35.29(509).Related ARC(s): 3682C191—35.27(509)  Methods of counting creditable coverage.  For purposes of reducing any preexisting condition exclusion period, a group health plan or carrier offering group health insurance coverage shall determine the amount of an individual’s creditable coverage by using the standard method described in subrule 35.27(1) except that the plan or carrier may use the alternative method under subrule 35.27(2) with respect to any or all of the categories of benefits described under subrule 35.27(4).  35.27(1)  Under the standard method, a group health plan or health insurance carrier offering group health insurance coverage shall determine the amount of creditable coverage without regard to the specific benefits included in the coverage.  a.  For purposes of reducing the preexisting condition exclusion period, a group health plan or health insurance carrier offering group health insurance coverage shall determine the amount of creditable coverage by counting all the days that the individual has under one or more types of creditable coverage. If on a particular day, an individual has creditable coverage from more than one source, all the creditable coverage on that day is counted as one day. Further, any days in a waiting period for a plan or policy are not creditable coverage under the plan or policy.  b.  Days of creditable coverage that occur before a significant break in coverage are not required to be counted.  c.  Notwithstanding any other provisions of subrule 35.27(2) for purposes of reducing a preexisting condition exclusion period, a group health plan or a health insurance carrier offering group health insurance coverage may determine the amount of creditable coverage in any other manner that is at least as favorable to the individual as the method set forth in subrule 35.27(2).  35.27(2)  Under the alternative method, a group health plan or a health insurance carrier offering group health insurance coverage shall determine the amount of creditable coverage based on coverage within any category of benefits described in subrule 35.27(4) and not based on coverage. The plan may apply a different preexisting condition exclusion period with respect to each category and may apply a different preexisting condition exclusion period for benefits that are not within any category. The creditable coverage determined for a category of benefits applies only for purposes of reducing the preexisting condition exclusion period with respect to that category. An individual’s creditable coverage for benefits that are not within any category for which the alternative method is being used is determined under the standard method of subrule 35.27(1).  35.27(3)  A plan or carrier using the alternative method is required to apply it uniformly to all participants and beneficiaries in the plan or policy. The use of the alternative method must be set forth in the plan.  35.27(4)  The alternative method for counting creditable coverage may be used for coverage for any of the following categories of benefits:  a.  Mental health.  b.  Substance abuse treatment.  c.  Prescription drugs.  d.  Dental care.  e.  Vision care.  35.27(5)  If the alternative method is used, the plan is required to:  a.  State prominently that the plan is using the alternative method of counting creditable coverage in disclosure statements concerning the plan, and state this to each enrollee at the time of enrollment under the plan;  b.  Include in these statements a description of the effect of using the alternative method, including an identification of the category’s uses; and  c.  Count creditable coverage within a category if any level of benefits is provided within the category.Related ARC(s): 3682C191—35.28(509)  Certificates of creditable coverage.    35.28(1)  Group health plans or carriers shall issue certificates of creditable coverage to persons losing coverage. A group health plan or carrier required to provide a certificate under this rule for an individual is deemed to have satisfied the certification requirements for that individual if another party provides the certificate, but only to the extent that information relating to the individual’s creditable coverage and waiting or affiliation period is provided by the other party. Certificates shall be issued within a reasonable amount of time following termination to employees and dependents:  a.  Automatically upon the termination of an individual’s group coverage;  b.  Automatically upon the termination of COBRA coverage;  c.  Upon request within 24 months after coverage ends.  35.28(2)  Certificates in writing. Certificates of coverage must be in writing unless all of the following conditions are met:  a.  The individual requesting the certificate is not entitled to receive a certificate;  b.  The individual requests that the certificate be sent to another plan or carrier;  c.  The plan or carrier receiving the certificate agrees to accept the information through means other than a written certificate;  d.  The plan or carrier receiving the certificate receives the certificate within a reasonable amount of time.  35.28(3)  Required information. The certificate shall include the following information:  a.  The date the certificate is issued;  b.  The name of the group plan providing coverage;  c.  The name of the employee or dependent to whom the certificate applies, other relevant identifying information, and the name of the employee if the certificate is for a dependent;  d.  The plan administrator’s name, address and telephone number;  e.  A telephone number to call for further information if different from above;  f.  Either a statement that the person has at least 18 months’ creditable coverage without a significant break of coverage or the date any waiting period and creditable coverage began;  g.  The date creditable coverage ended or an indication that the coverage is in force.  35.28(4)  Family information. Information for families may be combined on one certificate. Any differences in creditable coverages shall be clearly delineated.  35.28(5)  Dependent coverage transition rule. A group health plan or carrier that does not maintain dependent data is deemed to have satisfied the requirement to issue dependent certificates by naming the employee and specifying that the coverage on the certificate is for dependent coverage.  35.28(6)  Delivering certificates. The certificate shall be given to the individual, plan or carrier requesting the certificate. The certificates may be sent by first-class mail. When a dependent’s last-known address differs from the employee’s last-known address, a separate certificate shall be provided to the dependent at the dependent’s last-known address. Separate certificates may be mailed together to the same location.  35.28(7)  A group health plan or carrier shall establish a procedure for individuals to request and receive certificates.  35.28(8)  A certificate is not required to be furnished until the group health plan or carrier knows or should have known that the dependent’s coverage terminated.  35.28(9)  Demonstrating creditable coverage. An individual has the right to demonstrate creditable coverage, waiting periods, and affiliation periods when the accuracy of the certificate is contested or a certificate is unavailable. A group health plan or carrier shall consider information obtained by it or presented on behalf of an individual to determine whether the individual has creditable coverage.Related ARC(s): 3682C191—35.29(509)  Notification requirements.    35.29(1)  A group health plan or carrier shall provide written notice to the employee and dependents that includes the following:  a.  The existence of any preexisting condition exclusions.  b.  A determination that the group health plan or carrier intends to impose a preexisting condition exclusion and:  (1)  The basis for the decision to do so;  (2)  The length of time to which the exclusion will apply;  (3)  The right of the employee or dependent to appeal a decision to impose a preexisting condition exclusion;  (4)  The right of the person to demonstrate creditable coverage including the right of the person to request a certificate from a prior group health plan or carrier and a statement that the current group health plan or carrier will assist in obtaining the certificate.  c.  That the group health plan, carrier, or ODS will use the alternative method of counting creditable coverage.  d.  Special enrollment rights when an employee declines coverage for the employee or dependents.  35.29(2)  A group health plan or carrier shall provide written notice to the employee and dependents of a modification of a prior creditable coverage decision when the group health plan or carrier subsequently determines either no or less creditable coverage existed provided that the group health plan or carrier acts according to its initial determination until the final determination is made.Related ARC(s): 3682C191—35.30(509)  Mental health benefits.  Rescinded IAB 12/7/05, effective 1/11/06.191—35.31(509)  Disclosure requirements.  All carriers shall include in contracts and evidence of coverage forms a statement disclosing the existence of any prescription drug formularies. Upon request, all carriers offering health insurance coverage that includes a prescription drug formulary shall inform enrollees of the coverage, and prospective enrollees of the coverage during any open enrollment period, whether a prescription drug specified in the request is included in such formulary.All carriers shall also disclose the existence of any contractual arrangements providing rebates received by them for prescription drugs or durable medical equipment. Durable medical equipment means equipment that can stand repeated use and is primarily and customarily used to serve a medical purpose and is generally not useful to a person who is not sick or injured or used by other family members and is appropriate for home use for the purpose of improving bodily functions or preventing further deterioration of the medical condition caused by sickness or injury.Related ARC(s): 3682C191—35.32(514C)  Treatment options.    35.32(1)  A carrier shall not prohibit a participating provider from or penalize a participating provider for discussing treatment options with covered persons, irrespective of the carrier’s position on the treatment options, or from advocating on behalf of covered persons within the utilization review or grievance processes established by the carrier or a person contracting with the carrier.  35.32(2)  A carrier shall not penalize a provider because the provider, in good faith, reports to state or federal authorities any act or practice by the carrier that, in the opinion of the provider, jeopardizes patient health or welfare.191—35.33(514C)  Emergency services.  Benefits shall be available by the carrier for inpatient and outpatient emergency services. Since carriers may not contract with every emergency care provider in an area, carriers shall make every effort to inform members of participating providers.  35.33(1)  The term “emergency services” means, with respect to an individual enrolled with an organization, covered inpatient and outpatient services that are furnished by a provider who is qualified to furnish the services that are needed to evaluate or stabilize an emergency medical condition.  35.33(2)  The term “emergency medical condition” means a medical condition manifesting itself by symptoms of sufficient severity, including but not limited to severe pain, that an ordinarily prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in one of the following:  a.  Placing the health of the individual or, with respect to a pregnant woman, the health of the woman and her unborn child in serious jeopardy;  b.  Serious impairment to bodily function; or  c.  Serious dysfunction of any bodily organ or part.  35.33(3)  Reimbursement to a provider of “emergency services” shall not be denied by any carrier without that organization’s review of the patient’s medical history, presenting symptoms, and admitting or initial as well as final diagnosis, submitted by the provider, in determining whether, by definition, emergency services could reasonably have been expected to be provided. Reimbursement for emergency services shall not be denied solely on the grounds that services were performed by a noncontracted provider. If reimbursement for emergency services is denied, the enrollee may file a complaint with the carrier. Upon denial of reimbursement for emergency services, the carrier shall notify the enrollee and the provider that they may register a complaint with the commissioner of insurance.191—35.34(514C)  Provider access.  A carrier subject to this chapter shall allow a female enrollee direct access to obstetrical and gynecological services from network or participating providers. The carrier shall also allow a pediatrician to be the primary care provider for a child through the age of 18.These rules are intended to implement Iowa Code chapters 509 and 514C and 1999 Iowa Acts, Senate File 276.191—35.35(509)  Reconstructive surgery.    35.35(1)  A carrier that provides medical and surgical benefits with respect to a mastectomy shall provide the following coverage in the event an enrollee receives benefits in connection with a mastectomy and elects breast reconstruction:  a.  Reconstruction of the breast on which the mastectomy has been performed;  b.  Surgery and reconstruction of the other breast to produce a symmetrical appearance; and  c.  Prostheses and coverage of physical complications at all stages of a mastectomy including lymphedemas.  35.35(2)  The benefits under this rule shall be provided in a manner determined in consultation with the attending physician and the enrollee. The coverage may be subject to annual deductibles and coinsurance provisions that are consistent with other benefits under the plan or coverage.  35.35(3)  Written notice of the availability of coverage in this rule shall be provided to the enrollee upon enrollment and then annually.  35.35(4)  A carrier shall not deny an enrollee eligibility or continued eligibility to enroll or renew coverage under the terms of the health insurance solely for the purpose of avoiding the requirements of this rule. A carrier shall not penalize, reduce or limit the reimbursement of an attending provider or induce the provider to provide care in a manner inconsistent with this rule.This rule is intended to implement Public Law 105-277.Related ARC(s): 3682CCONSUMER GUIDE191—35.36(514K)  Purpose.  These rules implement Iowa Code Supplement section 514K.1(2) which requires the commissioner and the director of public health to annually publish a consumer guide. These rules apply to all carriers providing health insurance coverage in the individual, small employer group and large group markets that utilize a preferred provider arrangement and to all health maintenance organizations.191—35.37(514K)  Information filing requirements.    35.37(1)  Each health maintenance organization shall annually file with the division no later than July 1 the following information by plan as requested by the division:  a.  Health plan employer data information set (HEDIS).  b.  Network composition.  c.  Other information determined to be beneficial to consumers including but not limited to consumer survey information.  35.37(2)  Each preferred provider organization health network shall annually file with the division no later than July 1 the following information by plan as requested by the division:  a.  Reportable information as defined by a nationally recognized accreditation organization for preferred provider organization health networks.  b.  Network composition.  c.  Other information determined to be beneficial to consumers including but not limited to consumer survey information.  35.37(3)  Each health maintenance organization and insurer using a preferred provider organization health network shall transmit the requested information by electronic mail or diskette in a format prescribed by the division.191—35.38(514K)  Limitation of information published.  The division may establish limits on the data to be collected and published in the event the division believes the information is not statistically relevant and would not be beneficial to consumers.These rules are intended to implement Iowa Code Supplement section 514K.1(2).191—35.39(514C)  Contraceptive coverage.    35.39(1)  A carrier that provides benefits for outpatient prescription drugs or devices shall provide benefits for prescription contraceptive drugs or prescription contraceptive devices which prevent conception and are approved by the United States Food and Drug Administration or generic equivalents approved as substitutable by the United States Food and Drug Administration.  35.39(2)  A carrier is not required to provide benefits for over-the-counter contraceptive drugs or contraceptive devices that do not require a prescription for purchase.  35.39(3)  A contraceptive drug or contraceptive device does not include surgical services intended for sterilization, including, but not limited to, tubal ligation or vasectomy.  35.39(4)  A carrier shall be required to provide benefits for services related to outpatient contraceptive services for the purpose of preventing conception if the policy or contract provides benefits for other outpatient services provided by a health care professional.  35.39(5)  If a carrier does not provide benefits for a routine physical examination, the carrier is not required to provide benefits for a routine physical examination provided in the course of prescribing a contraceptive drug or contraceptive device.This rule is intended to implement Iowa Code chapter 514C.Related ARC(s): 3682C191—35.40(514C)  Autism spectrum disorders coverage.    35.40(1)    Purpose.  This rule implements Iowa Code section 514C.28, relating to autism spectrum disorders coverage in a group plan established pursuant to Iowa Code chapter 509A for employees of the state that provides for third-party payment or prepayment of health, medical, and surgical coverage benefits.  35.40(2)    Definitions.  For purposes of this rule, the definitions found in Iowa Code section 514C.28(2) shall apply. In addition, the following definitions shall apply:
    "Autism spectrum disorders" means the following neurological disorders as defined under the following diagnostic classes within the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, edition DSM-IV-TR:
    1. Autistic disorders. Diagnostic code 299.00.
    2. Rett’s Disorder. Diagnostic code 299.80.
    3. Childhood Disintegrative Disorder. Diagnostic code 299.10.
    4. Asperger’s Disorder. Diagnostic code 299.80.
    5. Pervasive Developmental Disorder NOS. Diagnostic code 299.80.
    "Commissioner" means the commissioner of insurance.
    "Group plan" "group health plan" means a group health plan established for the employees of the state of Iowa under Iowa Code chapter 509A.
      35.40(3)    Services.  A group plan is not required to provide coverage for any of the following:  a.  Acupuncture.  b.  Animal-based therapy including hippotherapy.  c.  Auditory integration training.  d.  Chelation therapy.  e.  Child care.  f.  Cranial sacral therapy.   g.  Custodial or respite care.  h.  Hyperbaric oxygen therapy.  i.  Special diets or supplements.  35.40(4)    Parents or legal guardians of children diagnosed with autism spectrum disorders.  A group plan shall not be required to pay for treatment rendered by parents or legal guardians who are otherwise qualified providers, supervising providers, therapists, professionals or paraprofessionals for treatment rendered to their own children.  35.40(5)    Locations for services.    a.  A group plan shall provide coverage for treatments, therapies and services to an insured diagnosed with autism spectrum disorders by an autism service provider in locations including the provider’s office or clinic or in a setting conducive to the acquisition of the target skill. Treatments may be provided in schools when the treatments, therapies, and services are related to the goals of the treatment plan and do not duplicate services provided by a school.  b.  A group health plan is not required to provide coverage for therapy, treatment or services when the therapy, treatment or services are provided to an insured who is residing in a residential treatment center or inpatient treatment or day treatment facility.  35.40(6)    Verification of qualified provider.  A group health plan is required to verify the licensure, certification and all training or other credentials of a qualified provider or health professional. A group health plan shall not deny payment or reimbursement for the necessary diagnosis or treatment provided by a certified behavior analyst or a health professional licensed under Iowa Code chapter 147.  35.40(7)    Annual publication CPI adjustment.  The commissioner shall publish on or before April 1 of each year beginning April 1, 2014, an adjustment to the required maximum benefit equal to the percentage change in the United States Department of Labor Consumer Price Index for all urban consumers in the preceding year. The adjusted maximum benefit published each April shall be used by group health plans in order to comply with this rule and shall be effective January 1 for group plans issued or renewed on or after January 1 of the following calendar year.  35.40(8)    Notice to insureds.  A group plan shall provide written notice to the insured regarding claims submitted and processed for the treatment of autism spectrum disorders and shall include the total amount expended to date for the current policy year. The notice may be included with the explanation of benefits form or in a separate communication provided on a periodic basis during the course of treatment.This rule is intended to implement Iowa Code section 514C.28.
    Related ARC(s): 9500B
    Related ARC(s): 9500B, 1999C, 2415C, 3682C, 4332C