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House Study Bill 25 - IntroducedA Bill ForAn Act 1relating to programs and activities under the purview
2of the department of public health, and including effective
3date provisions.
4BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1DIVISION I
2Program Flexibility and Efficiencies
3 Section 1. Section 125.59, subsection 1, paragraph b, Code
42017, is amended to read as follows:
5b. If the transferred amount for this subsection exceeds
6grant requests funded to the ten thousand dollar maximum, the
7Iowa department of public health may use the remainder for
8activities and public information resources that align with
9best practices for substance-related disorder prevention or to
10increase grants pursuant to subsection 2.
11 Sec. 2. Section 135.11, subsection 31, Code 2017, is amended
12by striking the subsection.
13 Sec. 3. Section 135.150, subsection 2, Code 2017, is amended
14to read as follows:
152. The department shall report semiannually annually to the
16general assembly’s standing committees on government oversight
17regarding the operation of the gambling treatment program.
18The report shall include but is not limited to information on
19the moneys expended and grants awarded for operation of the
20gambling treatment program.
21DIVISION II
22Medical home and Patient-centered health advisory council
23 Sec. 4. Section 135.159, Code 2017, is amended by striking
24the section and inserting in lieu thereof the following:
25135.159 Patient-centered health advisory council.
261. The department shall establish a patient-centered health
27advisory council which shall include but is not limited to
28all of the following members, selected by their respective
29organizations, and any other members the department determines
30necessary:
31a. The director of human services, or the director’s
32designee.
33b. The commissioner of insurance, or the commissioner’s
34designee.
35c. A representative of the federation of Iowa insurers.
-1- 1d. A representative of the Iowa dental association.
2e. A representative of the Iowa nurses association.
3f. A physician and an osteopathic physician licensed
4pursuant to chapter 148 who are family physicians and members
5of the Iowa academy of family physicians.
6g. A health care consumer.
7h. A representative of the Iowa collaborative safety net
8provider network established pursuant to section 135.153.
9i. A representative of the Iowa developmental disabilities
10council.
11j. A representative of the Iowa chapter of the American
12academy of pediatrics.
13k. A representative of the child and family policy center.
14l. A representative of the Iowa pharmacy association.
15m. A representative of the Iowa chiropractic society.
16n. A representative of the university of Iowa college of
17public health.
182. The patient-centered health advisory council may utilize
19the assistance of other relevant public health and health care
20expertise when necessary to carry out the council’s purposes
21and responsibilities.
223. A public member of the patient-centered health advisory
23council shall receive reimbursement for actual expenses
24incurred while serving in the member’s official capacity
25only if the member is not eligible for reimbursement by the
26organization the member represents.
274. The purposes of the patient-centered health advisory
28council shall include all of the following:
29a. To serve as a resource on emerging health care
30transformation initiatives in Iowa.
31b. To convene stakeholders in Iowa to streamline efforts
32that support state-level and community-level integration and
33focus on reducing fragmentation of the health care system.
34c. To encourage partnerships and synergy between community
35health care partners in the state who are working on new
-2-1system-level models to provide better health care at lower
2costs by focusing on shifting from volume-based to value-based
3health care.
4d. To lead discussions on the transformation of the
5health care system to a patient-centered infrastructure that
6integrates and coordinates services and supports to address
7social determinants of health and to meet population health
8goals.
9e. To provide a venue for education and information
10gathering for stakeholders and interested parties to learn
11about emerging health care initiatives across the state.
12f. To develop recommendations for submission to the
13department related to health care transformation issues.
14 Sec. 5. Section 136.3, subsection 13, Code 2017, is amended
15to read as follows:
1613. Perform those duties authorized pursuant to sections
17 section 135.156 and 135.159 and other provisions of law.
18 Sec. 6. Section 249N.2, subsections 15 and 19, Code 2017,
19are amended to read as follows:
2015. “Medical home” means medical home as defined in
21section 135.157. a team approach to providing health care that
22originates in a primary care setting; fosters a partnership
23among the patient, the personal provider, and other health care
24professionals, and where appropriate, the patient’s family;
25utilizes the partnership to access and integrate all medical
26and nonmedical health-related services across all elements of
27the health care system and the patient’s community as needed by
28the patient and the patient’s family to achieve maximum health
29potential; maintains a centralized, comprehensive record of all
30health-related services to promote continuity of care; and has
31all of the following characteristics:
32a. A personal provider.
33b. A provider-directed team-based medical practice.
34c. Whole person orientation.
35d. Coordination and integration of care.
-3- 1e. Quality and safety.
2f. Enhanced access to health care.
3g. A payment system that appropriately recognizes the added
4value provided to patients who have a patient-centered medical
5home.
619. “Primary medical provider” means the personal provider
7as defined in section 135.157 trained to provide first contact
8and continuous and comprehensive care to a member, chosen by
9a member or to whom a member is assigned under the Iowa health
10and wellness plan.
11 Sec. 7. Section 249N.2, Code 2017, is amended by adding the
12following new subsection:
13 NEW SUBSECTION. 17A. “Personal provider” means the
14patient’s first point of contact in the health care system
15with a primary care provider who identifies the patient’s
16health-related needs and, working with a team of health
17care professionals and providers of medical and nonmedical
18health-related services, provides for and coordinates
19appropriate care to address the health-related needs
20identified.
21 Sec. 8. Section 249N.6, subsection 2, paragraph c, Code
222017, is amended to read as follows:
23c. The department shall develop a mechanism for primary
24medical providers, medical homes, and participating accountable
25care organizations to jointly facilitate member care
26coordination. The Iowa health and wellness plan shall provide
27for reimbursement of care coordination services provided
28under the plan consistent with the reimbursement methodology
29developed pursuant to section 135.159.
30 Sec. 9. Section 249N.6, subsection 3, paragraph a, Code
312017, is amended to read as follows:
32a. The department shall provide procedures for accountable
33care organizations that emerge through local markets to
34participate in the Iowa health and wellness plan provider
35network. Such accountable care organizations shall incorporate
-4-1the medical home as defined and specified in chapter 135,
2division XXII, as a foundation and shall emphasize whole-person
3orientation and coordination and integration of both clinical
4services and nonclinical community and social supports that
5address social determinants of health. A participating
6accountable care organization shall enter into a contract with
7the department to ensure the coordination and management of the
8health of attributed members, to produce quality health care
9outcomes, and to control overall cost.
10 Sec. 10. REPEAL. Sections 135.157 and 135.158, Code 2017,
11are repealed.
12DIVISION III
13workforce programming
14 Sec. 11. Section 84A.11, subsection 4, Code 2017, is amended
15to read as follows:
164. The nursing workforce data clearinghouse shall be
17established and maintained in a manner consistent with the
18health care delivery infrastructure and health care workforce
19resources strategic plan developed pursuant to section 135.164
20 135.163.
21 Sec. 12. Section 135.107, subsection 3, Code 2017, is
22amended to read as follows:
233. The center for rural health and primary care shall
24establish a primary care provider recruitment and retention
25endeavor, to be known as PRIMECARRE. The endeavor shall
26include a health care workforce and community support grant
27program, and a primary care provider loan repayment program,
28and a primary care provider community scholarship program.
29The endeavor shall be developed and implemented in a manner
30to promote and accommodate local creativity in efforts to
31recruit and retain health care professionals to provide
32services in the locality. The focus of the endeavor shall
33be to promote and assist local efforts in developing health
34care provider recruitment and retention programs. The center
35for rural health and primary care may enter into an agreement
-5-1under chapter 28E with the college student aid commission for
2the administration of the center’s grant and loan repayment
3programs.
4a. Community Health care workforce and community support
5 grant program.
6(1) The center for rural health and primary care shall adopt
7rules establishing an flexible application process processes
8based upon the department’s strategic plan to be used by the
9center to establish a grant assistance program as provided
10in this paragraph “a”, and establishing the criteria to be
11used in evaluating the applications. Selection criteria
12shall include a method for prioritizing grant applications
13based on illustrated efforts to meet the health care provider
14needs of the locality and surrounding area. Such assistance
15may be in the form of a forgivable loan, grant, or other
16nonfinancial assistance as deemed appropriate by the center.
17An application submitted shall may contain a commitment of at
18least a dollar-for-dollar match of matching funds for the grant
19assistance. Application may be made for assistance by a single
20community or group of communities or in response to programs
21recommended in the strategic plan to address health workforce
22shortages.
23(2) Grants awarded under the program shall be subject to the
24following limitations:
25(a) Ten thousand dollars for a single community or region
26with a population of ten thousand or less. An award shall not
27be made under this program to a community with a population of
28more than ten thousand.
29(b) An amount not to exceed one dollar per capita for a
30region in which the population exceeds ten thousand. For
31purposes of determining the amount of a grant for a region,
32the population of the region shall not include the population
33of any community with a population of more than ten thousand
34located in the region awarded to rural, underserved areas or
35special populations as identified by the department’s strategic
-6-1plan or evidence-based documentation.
2b. Primary care provider loan repayment program.
3(1) A primary care provider loan repayment program is
4established to increase the number of health professionals
5practicing primary care in federally designated health
6professional shortage areas of the state. Under the program,
7loan repayment may be made to a recipient for educational
8expenses incurred while completing an accredited health
9education program directly related to obtaining credentials
10necessary to practice the recipient’s health profession.
11(2) The center for rural health and primary care shall adopt
12rules relating to the establishment and administration of the
13primary care provider loan repayment program. Rules adopted
14pursuant to this paragraph shall provide, at a minimum, for all
15of the following:
16(a) Determination of eligibility requirements and
17qualifications of an applicant to receive loan repayment under
18the program, including but not limited to years of obligated
19service, clinical practice requirements, and residency
20requirements. One year of obligated service shall be provided
21by the applicant in exchange for each year of loan repayment,
22unless federal requirements otherwise require. Loan repayment
23under the program shall not be approved for a health provider
24whose license or certification is restricted by a medical
25regulatory authority of any jurisdiction of the United States,
26other nations, or territories.
27(b) Identification of federally designated health
28professional shortage areas of the state and prioritization of
29such areas according to need.
30(c) Determination of the amount and duration of the loan
31repayment an applicant may receive, giving consideration to the
32availability of funds under the program, and the applicant’s
33outstanding educational loans and professional credentials.
34(d) Determination of the conditions of loan repayment
35applicable to an applicant.
-7- 1(e) Enforcement of the state’s rights under a loan repayment
2program contract, including the commencement of any court
3action.
4(f) Cancellation of a loan repayment program contract for
5reasonable cause unless federal requirements otherwise require.
6(g) Participation in federal programs supporting repayment
7of loans of health care providers and acceptance of gifts,
8grants, and other aid or amounts from any person, association,
9foundation, trust, corporation, governmental agency, or other
10entity for the purposes of the program.
11(h) Upon availability of state funds, determination of
12eligibility criteria and qualifications for participating
13communities and applicants not located in federally designated
14shortage areas.
15(i) Other rules as necessary.
16(3) The center for rural health and primary care may enter
17into an agreement under chapter 28E with the college student
18aid commission for the administration of this program.
19c. Primary care provider community scholarship program.
20(1) A primary care provider community scholarship program
21is established to recruit and to provide scholarships to train
22primary health care practitioners in federally designated
23health professional shortage areas of the state. Under
24the program, scholarships may be awarded to a recipient for
25educational expenses incurred while completing an accredited
26health education program directly related to obtaining the
27credentials necessary to practice the recipient’s health
28profession.
29(2) The department shall adopt rules relating to the
30establishment and administration of the primary care provider
31community scholarship program. Rules adopted pursuant to
32this paragraph shall provide, at a minimum, for all of the
33following:
34(a) Determination of eligibility requirements and
35qualifications of an applicant to receive scholarships under
-8-1the program, including but not limited to years of obligated
2service, clinical practice requirements, and residency
3requirements. One year of obligated service shall be provided
4by the applicant in exchange for each year of scholarship
5receipt, unless federal requirements otherwise require.
6(b) Identification of federally designated health
7professional shortage areas of the state and prioritization of
8such areas according to need.
9(c) Determination of the amount of the scholarship an
10applicant may receive.
11(d) Determination of the conditions of scholarship to be
12awarded to an applicant.
13(e) Enforcement of the state’s rights under a scholarship
14contract, including the commencement of any court action.
15(f) Cancellation of a scholarship contract for reasonable
16cause.
17(g) Participation in federal programs supporting
18scholarships for health care providers and acceptance of gifts,
19grants, and other aid or amounts from any person, association,
20foundation, trust, corporation, governmental agency, or other
21entity for the purposes of the program.
22(h) Upon availability of state funds, determination of
23eligibility criteria and qualifications for participating
24communities and applicants not located in federally designated
25shortage areas.
26(i) Other rules as necessary.
27(3) The center for rural health and primary care may enter
28into an agreement under chapter 28E with the college student
29aid commission for the administration of this program.
30 Sec. 13. Section 135.107, subsection 4, paragraphs a, b, and
31c, Code 2017, are amended to read as follows:
32a. Eligibility under any of the programs established under
33the primary care provider recruitment and retention endeavor
34shall be based upon a community health services assessment
35completed under subsection 2, paragraph “a”. A community
-9-1or region, as applicable, shall submit a letter of intent
2to conduct a community health services assessment and to
3apply for assistance under this subsection. The letter shall
4be in a form and contain information as determined by the
5center. A letter of intent shall be submitted to the center by
6January 1 preceding the fiscal year for which an application
7for assistance is to be made. Participation in a community
8health services assessment process shall be documented by the
9community or region.
10b. Assistance under this subsection shall not be granted
11until such time as the community or region making application
12has completed the a community health services assessment and
13adopted a long-term community health services assessment and
14developmental plan. In addition to any other requirements, a
15developmental an applicant’s plan shall include, to the extent
16possible, a clear commitment to informing high school students
17of the health care opportunities which may be available to such
18students.
19c. The center for rural health and primary care shall
20seek additional assistance and resources from other state
21departments and agencies, federal agencies and grant programs,
22private organizations, and any other person, as appropriate.
23The center is authorized and directed to accept on behalf of
24the state any grant or contribution, federal or otherwise,
25made to assist in meeting the cost of carrying out the purpose
26of this subsection. All federal grants to and the federal
27receipts of the center are appropriated for the purpose set
28forth in such federal grants or receipts. Funds appropriated
29by the general assembly to the center for implementation of
30this subsection shall first be used for securing any available
31federal funds requiring a state match, with remaining funds
32being used for the health care workforce and community support
33 grant program.
34 Sec. 14. Section 135.107, subsection 5, paragraph a, Code
352017, is amended to read as follows:
-10- 1a. There is established an advisory committee to the
2center for rural health and primary care consisting of one
3representative, approved by the respective agency, of each
4of the following agencies: the department of agriculture
5and land stewardship, the Iowa department of public health,
6the department of inspections and appeals, the a national or
7regional institute for rural health policy, the rural health
8resource center, the institute of agricultural medicine
9and occupational health, and the Iowa state association of
10counties. The governor shall appoint two representatives
11of consumer groups active in rural health issues and a
12representative of each of two farm organizations active within
13the state, a representative of an agricultural business in
14the state, a representative of a critical needs hospital,
15a practicing rural family physician, a practicing rural
16physician assistant, a practicing rural advanced registered
17nurse practitioner, and a rural health practitioner who is
18not a physician, physician assistant, or advanced registered
19nurse practitioner, as members of the advisory committee. The
20advisory committee shall also include as members two state
21representatives, one appointed by the speaker of the house of
22representatives and one by the minority leader of the house,
23and two state senators, one appointed by the majority leader of
24the senate and one by the minority leader of the senate.
25 Sec. 15. Section 135.163, Code 2017, is amended to read as
26follows:
27135.163 Health and long-term care access.
28The department shall coordinate public and private efforts
29to develop and maintain an appropriate health care delivery
30infrastructure and a stable, well-qualified, diverse, and
31sustainable health care workforce in this state. The health
32care delivery infrastructure and the health care workforce
33shall address the broad spectrum of health care needs of Iowans
34throughout their lifespan including long-term care needs. The
35department shall, at a minimum, do all of the following:
-11- 11. Develop a strategic plan for health care delivery
2infrastructure and health care workforce resources in this
3state.
42. Provide for the continuous collection of data to provide
5a basis for health care strategic planning and health care
6policymaking.
73. Make recommendations regarding the health care delivery
8infrastructure and the health care workforce that assist
9in monitoring current needs, predicting future trends, and
10informing policymaking.
11 Sec. 16. Section 135.175, subsection 1, paragraph b, Code
122017, is amended to read as follows:
13b. A health care workforce shortage fund is created in
14the state treasury as a separate fund under the control of
15the department, in cooperation with the entities identified
16in this section as having control over the accounts within
17the fund. The fund and the accounts within the fund shall
18be controlled and managed in a manner consistent with the
19principles specified and the strategic plan developed pursuant
20to sections section 135.163 and 135.164.
21 Sec. 17. Section 135.175, subsections 6 and 7, Code 2017,
22are amended to read as follows:
236. a. Moneys in the fund and the accounts in the fund shall
24only be appropriated in a manner consistent with the principles
25specified and the strategic plan developed pursuant to sections
26 section 135.163 and 135.164 to support the medical residency
27training state matching grants program, the fulfilling Iowa’s
28need for dentists matching grant program, and to provide
29funding for state health care workforce shortage programs as
30provided in this section.
31b. State programs that may receive funding from the fund
32and the accounts in the fund, if specifically designated for
33the purpose of drawing down federal funding, are the primary
34care recruitment and retention endeavor (PRIMECARRE), the Iowa
35affiliate of the national rural recruitment and retention
-12-1network, the oral and health delivery systems bureau of the
2department, the primary care office and shortage designation
3program, and the state office of rural health, and the Iowa
4health workforce center, administered through the oral and
5health delivery systems bureau of health care access of the
6department of public health; the area health education centers
7programs at Des Moines university — osteopathic medical center
8and the university of Iowa; the Iowa collaborative safety net
9provider network established pursuant to section 135.153; any
10entity identified by the federal government entity through
11which federal funding for a specified health care workforce
12shortage initiative is received; and a program developed in
13accordance with the strategic plan developed by the department
14of public health in accordance with sections section 135.163
15and 135.164.
16c. State appropriations to the fund shall be allocated in
17equal amounts to each of the accounts within the fund, unless
18otherwise specified in the appropriation or allocation. Any
19federal funding received for the purposes of addressing state
20health care workforce shortages shall be deposited in the
21health care workforce shortage national initiatives account,
22unless otherwise specified by the source of the funds, and
23shall be used as required by the source of the funds. If use
24of the federal funding is not designated, the funds shall be
25used in accordance with the strategic plan developed by the
26department of public health in accordance with sections section
27 135.163 and 135.164, or to address workforce shortages as
28otherwise designated by the department of public health. Other
29sources of funding shall be deposited in the fund or account
30and used as specified by the source of the funding.
317. No more than five percent of the moneys in any of the
32accounts within the fund, not to exceed one hundred thousand
33dollars in each account, shall be used for administrative
34purposes, unless otherwise provided by the appropriation,
35allocation, or source of the funds.
-13-1 Sec. 18. REPEAL. Sections 135.164 and 135.180, Code 2017,
2are repealed.
3DIVISION IV
4unfunded OR outdated program PROVISIONS
5 Sec. 19. Section 135.11, subsection 25, Code 2017, is
6amended by striking the subsection.
7 Sec. 20. Section 135.141, subsection 2, paragraph c, Code
82017, is amended by striking the paragraph.
9 Sec. 21. Section 135.141, subsection 2, paragraph e, Code
102017, is amended to read as follows:
11e. For the purpose of paragraphs “c” and paragraph “d”,
12an employee or agent of the department may enter into and
13examine any premises containing potentially dangerous agents
14with the consent of the owner or person in charge of the
15premises or, if the owner or person in charge of the premises
16refuses admittance, with an administrative search warrant
17obtained under section 808.14. Based on findings of the risk
18assessment and examination of the premises, the director may
19order reasonable safeguards or take any other action reasonably
20necessary to protect the public health pursuant to rules
21adopted to administer this subsection.
22 Sec. 22. Section 901B.1, subsection 4, paragraph a, Code
232017, is amended to read as follows:
24a. The district department of correctional services shall
25place an individual committed to it under section 907.3 to the
26sanction and level of supervision which is appropriate to the
27individual based upon a current risk assessment evaluation.
28Placements may be to levels two and three of the corrections
29continuum. The district department may, with the approval of
30the Iowa department of public health and the department of
31corrections, place an individual in a level three substance
32abuse treatment facility established pursuant to section
33135.130, to assist the individual in complying with a condition
34of probation. The district department may, with the approval
35of the department of corrections, place an individual in a
-14-1level four violator facility established pursuant to section
2904.207 only as a penalty for a violation of a condition
3imposed under this section.
4 Sec. 23. REPEAL. Sections 135.26, 135.29, 135.130, and
5135.152, Code 2017, are repealed.
6DIVISION V
7miscellaneous provisions
8 Sec. 24. Section 135A.2, subsection 6, Code 2017, is amended
9to read as follows:
106. “Local board of health” means a county or district board
11of health the same as defined in section 137.102.
12 Sec. 25. REPEAL. Section 135.132, Code 2017, is repealed.
13DIVISION VI
14iowa health information network
15 Sec. 26. Section 136.3, subsection 13, Code 2017, is amended
16to read as follows:
1713. Perform those duties authorized pursuant to sections
18135.156 and section 135.159 and other provisions of law.
19 Sec. 27. EFFECTIVE DATE. This division of this Act
20takes effect upon the assumption of the administration and
21governance, including but not limited to the assumption of the
22assets and liabilities, of the Iowa health information network
23by the designated entity as defined in 2015 Iowa Acts, ch.73,
24section 2. The department of public health shall notify the
25Code editor of the date of such assumption by the designated
26entity.
27DIVISION VII
28ORGANIZED DELIVERY SYSTEMS
29 Sec. 28. Section 135H.3, subsection 2, Code 2017, is amended
30to read as follows:
312. If a child is diagnosed with a biologically based mental
32illness as defined in section 514C.22 and meets the medical
33assistance program criteria for admission to a psychiatric
34medical institution for children, the child shall be deemed
35to meet the acuity criteria for medically necessary inpatient
-15-1benefits under a group policy, contract, or plan providing
2for third-party payment or prepayment of health, medical, and
3surgical coverage benefits issued by a carrier, as defined in
4section 513B.2, or by an organized delivery system authorized
5under 1993 Iowa Acts, ch.158, that is subject to section
6514C.22. Such medically necessary benefits shall not be
7excluded or denied as care that is substantially custodial in
8nature under section 514C.22, subsection 8, paragraph “b”.
9 Sec. 29. Section 505.32, subsection 2, paragraph h, Code
102017, is amended by striking the paragraph.
11 Sec. 30. Section 505.32, subsection 4, paragraph b,
12subparagraphs (1) and (2), Code 2017, are amended to read as
13follows:
14(1) The commissioner may establish methodologies to provide
15uniform and consistent side-by-side comparisons of the health
16care coverage options that are offered by carriers, organized
17delivery systems, and public programs in this state including
18but not limited to benefits covered and not covered, the amount
19of coverage for each service, including copays and deductibles,
20administrative costs, and any prior authorization requirements
21for coverage.
22(2) The commissioner may require each carrier, organized
23delivery system, and public program in this state to describe
24each health care coverage option offered by that carrier,
25organized delivery system, or public program in a manner
26so that the various options can be compared as provided in
27subparagraph (1).
28 Sec. 31. Section 507B.4, subsection 1, Code 2017, is amended
29to read as follows:
301. For purposes of subsection 3, paragraph “p”, “insurer”
31means an entity providing a plan of health insurance, health
32care benefits, or health care services, or an entity subject
33to the jurisdiction of the commissioner performing utilization
34review, including an insurance company offering sickness and
35accident plans, a health maintenance organization, an organized
-16-1delivery system authorized under 1993 Iowa Acts, ch.158, and
2licensed by the department of public health, a nonprofit health
3service corporation, a plan established pursuant to chapter
4509A for public employees, or any other entity providing a
5plan of health insurance, health care benefits, or health care
6services. However, “insurer” does not include an entity that
7sells disability income or long-term care insurance.
8 Sec. 32. Section 507B.4A, subsection 2, paragraph a, Code
92017, is amended to read as follows:
10a. An insurer providing accident and sickness insurance
11under chapter 509, 514, or 514A; a health maintenance
12organization; an organized delivery system authorized under
131993 Iowa Acts, ch.158, and licensed by the department of
14public health; or another entity providing health insurance or
15health benefits subject to state insurance regulation shall
16either accept and pay or deny a clean claim.
17 Sec. 33. Section 509.3A, subsection 11, Code 2017, is
18amended by striking the subsection.
19 Sec. 34. Section 509.19, subsection 2, paragraph d, Code
202017, is amended by striking the paragraph.
21 Sec. 35. Section 509A.6, Code 2017, is amended to read as
22follows:
23509A.6 Contract with insurance carrier, or health maintenance
24organization, or organized delivery system.
25The governing body may contract with a nonprofit corporation
26operating under the provisions of this chapter or chapter
27514 or with any insurance company having a certificate of
28authority to transact an insurance business in this state with
29respect of a group insurance plan, which may include life,
30accident, health, hospitalization and disability insurance
31during period of active service of such employees, with the
32right of any employee to continue such life insurance in force
33after termination of active service at such employee’s sole
34expense; may contract with a nonprofit corporation operating
35under and governed by the provisions of this chapter or chapter
-17-1514 with respect of any hospital or medical service plan; and
2may contract with a health maintenance organization or an
3organized delivery system authorized to operate in this state
4with respect to health maintenance organization or organized
5delivery system activities.
6 Sec. 36. Section 513B.2, subsection 8, paragraph k, Code
72017, is amended by striking the paragraph.
8 Sec. 37. Section 513B.5, Code 2017, is amended to read as
9follows:
10513B.5 Provisions on renewability of coverage.
111. Health insurance coverage subject to this chapter is
12renewable with respect to all eligible employees or their
13dependents, at the option of the small employer, except for one
14or more of the following reasons:
15a. The health insurance coverage sponsor fails to pay, or to
16make timely payment of, premiums or contributions pursuant to
17the terms of the health insurance coverage.
18b. The health insurance coverage sponsor performs an
19act or practice constituting fraud or makes an intentional
20misrepresentation of a material fact under the terms of the
21coverage.
22c. Noncompliance with the carrier’s or organized delivery
23system’s minimum participation requirements.
24d. Noncompliance with the carrier’s or organized delivery
25system’s employer contribution requirements.
26e. A decision by the carrier or organized delivery system
27 to discontinue offering a particular type of health insurance
28coverage in the state’s small employer market. Health
29insurance coverage may be discontinued by the carrier or
30organized delivery system in that market only if the carrier or
31organized delivery system does all of the following:
32(1) Provides advance notice of its decision to discontinue
33such plan to the commissioner or director of public health.
34Notice to the commissioner or director, at a minimum, shall be
35no less than three days prior to the notice provided for in
-18-1subparagraph (2) to affected small employers, participants, and
2beneficiaries.
3(2) Provides notice of its decision not to renew such
4plan to all affected small employers, participants, and
5beneficiaries no less than ninety days prior to the nonrenewal
6of the plan.
7(3) Offers to each plan sponsor of the discontinued
8coverage, the option to purchase any other coverage currently
9offered by the carrier or organized delivery system to other
10employers in this state.
11(4) Acts uniformly, in opting to discontinue the coverage
12and in offering the option under subparagraph (3), without
13regard to the claims experience of the sponsors under the
14discontinued coverage or to a health status-related factor
15relating to any participants or beneficiaries covered or new
16participants or beneficiaries who may become eligible for the
17coverage.
18f. A decision by the carrier or organized delivery system to
19discontinue offering and to cease to renew all of its health
20insurance coverage delivered or issued for delivery to small
21employers in this state. A carrier or organized delivery
22system making such decision shall do all of the following:
23(1) Provide advance notice of its decision to discontinue
24such coverage to the commissioner or director of public health.
25Notice to the commissioner or director, at a minimum, shall be
26no less than three days prior to the notice provided for in
27subparagraph (2) to affected small employers, participants, and
28beneficiaries.
29(2) Provide notice of its decision not to renew such
30coverage to all affected small employers, participants, and
31beneficiaries no less than one hundred eighty days prior to the
32nonrenewal of the coverage.
33(3) Discontinue all health insurance coverage issued or
34delivered for issuance to small employers in this state and
35cease renewal of such coverage.
-19- 1g. The membership of an employer in an association, which
2is the basis for the coverage which is provided through such
3association, ceases, but only if the termination of coverage
4under this paragraph occurs uniformly without regard to
5any health status-related factor relating to any covered
6individual.
7h. The commissioner or director of public health finds that
8the continuation of the coverage is not in the best interests
9of the policyholders or certificate holders, or would impair
10the carrier’s or organized delivery system’s ability to meet
11its contractual obligations.
12i. At the time of coverage renewal, a carrier or organized
13delivery system may modify the health insurance coverage for
14a product offered under group health insurance coverage in
15the small group market, for coverage that is available in
16such market other than only through one or more bona fide
17associations, if such modification is consistent with the laws
18of this state, and is effective on a uniform basis among group
19health insurance coverage with that product.
202. A carrier or organized delivery system that elects not to
21renew health insurance coverage under subsection 1, paragraph
22“f”, shall not write any new business in the small employer
23market in this state for a period of five years after the date
24of notice to the commissioner or director of public health.
253. This section, with respect to a carrier or organized
26delivery system doing business in one established geographic
27service area of the state, applies only to such carrier’s or
28organized delivery system’s operations in that service area.
29 Sec. 38. Section 513B.6, unnumbered paragraph 1, Code 2017,
30is amended to read as follows:
31A small employer carrier or organized delivery system shall
32make reasonable disclosure in solicitation and sales materials
33provided to small employers of all of the following:
34 Sec. 39. Section 513B.6, subsection 2, Code 2017, is amended
35to read as follows:
-20- 12. The provisions concerning the small employer carrier’s
2or organized delivery system’s right to change premium rates
3and factors, including case characteristics, which affect
4changes in premium rates.
5 Sec. 40. Section 513B.7, Code 2017, is amended to read as
6follows:
7513B.7 Maintenance of records.
81. A small employer carrier or organized delivery system
9 shall maintain at its principal place of business a complete
10and detailed description of its rating practices and renewal
11underwriting practices, including information and documentation
12which demonstrate that its rating methods and practices are
13based upon commonly accepted actuarial assumptions and are in
14accordance with sound actuarial principles.
152. A small employer carrier or organized delivery system
16 shall file each March 1 with the commissioner or the director
17of public health an actuarial certification that the small
18employer carrier or organized delivery system is in compliance
19with this section and that the rating methods of the small
20employer carrier or organized delivery system are actuarially
21sound. A copy of the certification shall be retained by the
22small employer carrier or organized delivery system at its
23principal place of business.
243. A small employer carrier or organized delivery system
25 shall make the information and documentation described in
26subsection 1 available to the commissioner or the director of
27public health upon request. The information is not a public
28record or otherwise subject to disclosure under chapter 22,
29and is considered proprietary and trade secret information
30and is not subject to disclosure by the commissioner or the
31director of public health to persons outside of the division or
32department except as agreed to by the small employer carrier or
33organized delivery system or as ordered by a court of competent
34jurisdiction.
35 Sec. 41. Section 513B.9A, subsection 1, unnumbered
-21-1paragraph 1, Code 2017, is amended to read as follows:
2A carrier or organized delivery system offering group health
3insurance coverage shall not establish rules for eligibility,
4including continued eligibility, of an individual to enroll
5under the terms of the coverage based on any of the following
6health status-related factors in relation to the individual or
7a dependent of the individual:
8 Sec. 42. Section 513B.9A, subsection 4, paragraph a, Code
92017, is amended to read as follows:
10a. A carrier or organized delivery system offering health
11insurance coverage shall not require an individual, as a
12condition of enrollment or continued enrollment under the
13coverage, to pay a premium or contribution which is greater
14than a premium or contribution for a similarly situated
15individual enrolled in the coverage on the basis of a health
16status-related factor in relation to the individual or to a
17dependent of an individual enrolled under the coverage.
18 Sec. 43. Section 513B.9A, subsection 4, paragraph b,
19subparagraph (2), Code 2017, is amended to read as follows:
20(2) Prevent a carrier or organized delivery system
21 offering group health insurance coverage from establishing
22premium discounts or rebates or modifying otherwise applicable
23copayments or deductibles in return for adherence to programs
24of health promotion and disease prevention.
25 Sec. 44. Section 513B.10, Code 2017, is amended to read as
26follows:
27513B.10 Availability of coverage.
281. a. A carrier or an organized delivery system that offers
29health insurance coverage in the small group market shall
30accept every small employer that applies for health insurance
31coverage and shall accept for enrollment under such coverage
32every eligible individual who applies for enrollment during the
33period in which the individual first becomes eligible to enroll
34under the terms of the health insurance coverage and shall not
35place any restriction which is inconsistent with eligibility
-22-1rules established under this chapter.
2b. A carrier or organized delivery system that offers health
3insurance coverage in the small group market through a network
4plan may do either of the following:
5(1) Limit employers that may apply for such coverage to
6those with eligible individuals who live, work, or reside in
7the service area for such network plan.
8(2) Deny such coverage to such employers within the service
9area of such plan if the carrier or organized delivery system
10 has demonstrated to the applicable state authority both of the
11following:
12(a) The carrier or organized delivery system will not have
13the capacity to deliver services adequately to enrollees of any
14additional groups because of its obligations to existing group
15contract holders and enrollees.
16(b) The carrier or organized delivery system is applying
17this subparagraph uniformly to all employers without regard to
18the claims experience of those employers and their employees
19and their dependents, or any health status-related factor
20relating to such employees or dependents.
21c. A carrier or organized delivery system, upon denying
22health insurance coverage in any service area pursuant to
23paragraph “b”, subparagraph (2), shall not offer coverage in the
24small group market within such service area for a period of one
25hundred eighty days after the date such coverage is denied.
26d. A carrier or organized delivery system may deny health
27insurance coverage in the small group market if the issuer has
28demonstrated to the commissioner or director of public health
29 both of the following:
30(1) The carrier or organized delivery system does not have
31the financial reserves necessary to underwrite additional
32coverage.
33(2) The carrier or organized delivery system is applying the
34provisions of this paragraph uniformly to all employers in the
35small group market in this state consistent with state law and
-23-1without regard to the claims experience of those employers and
2the employees and dependents of such employers, or any health
3status-related factor relating to such employees and their
4dependents.
5e. A carrier or organized delivery system, upon denying
6health insurance coverage pursuant to paragraph “d”, shall not
7offer coverage in connection with health insurance coverages
8in the small group market in this state for a period of one
9hundred eighty days after the date such coverage is denied or
10until the carrier or organized delivery system has demonstrated
11to the commissioner or director of public health that the
12carrier or organized delivery system has sufficient financial
13reserves to underwrite additional coverage, whichever is later.
14The commissioner or director may provide for the application of
15this paragraph on a service area-specific basis.
16f. Paragraph “a” shall not be construed to preclude
17a carrier or organized delivery system from establishing
18employer contribution rules or group participation rules for
19the offering of health insurance coverage in the small group
20market.
212. A carrier or organized delivery system, subject to
22subsection 1, shall issue health insurance coverage to an
23eligible small employer that applies for the coverage and
24agrees to make the required premium payments and satisfy the
25other reasonable provisions of the health insurance coverage
26not inconsistent with this chapter. A carrier or organized
27delivery system is not required to issue health insurance
28coverage to a self-employed individual who is covered by, or is
29eligible for coverage under, health insurance coverage offered
30by an employer.
313. Health insurance coverage for small employers shall
32satisfy all of the following:
33a. A carrier or organized delivery system offering group
34health insurance coverage, with respect to a participant or
35beneficiary, may impose a preexisting condition exclusion only
-24-1as follows:
2(1) The exclusion relates to a condition, whether physical
3or mental, regardless of the cause of the condition, for
4which medical advice, diagnosis, care, or treatment was
5recommended or received within the six-month period ending on
6the enrollment date. However, genetic information shall not be
7treated as a condition under this subparagraph in the absence
8of a diagnosis of the condition related to such information.
9(2) The exclusion extends for a period of not more than
10twelve months, or eighteen months in the case of a late
11enrollee, after the enrollment date.
12(3) The period of any such preexisting condition exclusion
13is reduced by the aggregate of the periods of creditable
14coverage applicable to the participant or beneficiary as of the
15enrollment date.
16b. A carrier or organized delivery system offering group
17health insurance coverage shall not impose any preexisting
18condition exclusion as follows:
19(1) In the case of a child who is adopted or placed for
20adoption before attaining eighteen years of age and who, as of
21the last day of the thirty-day period beginning on the date
22of the adoption or placement for adoption, is covered under
23creditable coverage. This subparagraph shall not apply to
24coverage before the date of such adoption or placement for
25adoption.
26(2) In the case of an individual who, as of the last day
27of the thirty-day period beginning with the date of birth, is
28covered under creditable coverage.
29(3) Relating to pregnancy as a preexisting condition.
30c. A carrier or organized delivery system shall waive
31any waiting period applicable to a preexisting condition
32exclusion or limitation period with respect to particular
33services under health insurance coverage for the period
34of time an individual was covered by creditable coverage,
35provided that the creditable coverage was continuous to a
-25-1date not more than sixty-three days prior to the effective
2date of the new coverage. Any period that an individual
3is in a waiting period for any coverage under group health
4insurance coverage, or is in an affiliation period, shall not
5be taken into account in determining the period of continuous
6coverage. A health maintenance organization that does not
7use preexisting condition limitations in any of its health
8insurance coverage may impose an affiliation period. For
9purposes of this section, “affiliation period” means a period
10of time not to exceed sixty days for new entrants and not to
11exceed ninety days for late enrollees during which no premium
12shall be collected and coverage issued is not effective, so
13long as the affiliation period is applied uniformly, without
14regard to any health status-related factors. This paragraph
15does not preclude application of a waiting period applicable
16to all new enrollees under the health insurance coverage,
17provided that any carrier or organized delivery system-imposed
18 carrier-imposed waiting period is no longer than sixty days and
19is used in lieu of a preexisting condition exclusion.
20d. Health insurance coverage may exclude coverage for late
21enrollees for preexisting conditions for a period not to exceed
22eighteen months.
23e. (1) Requirements used by a carrier or organized delivery
24system in determining whether to provide coverage to a small
25employer shall be applied uniformly among all small employers
26applying for coverage or receiving coverage from the carrier
27or organized delivery system.
28(2) In applying minimum participation requirements with
29respect to a small employer, a carrier or organized delivery
30system shall not consider employees or dependents who have
31other creditable coverage in determining whether the applicable
32percentage of participation is met.
33(3) A carrier or organized delivery system shall not
34increase any requirement for minimum employee participation
35or modify any requirement for minimum employer contribution
-26-1applicable to a small employer at any time after the small
2employer has been accepted for coverage.
3f. (1) If a carrier or organized delivery system offers
4coverage to a small employer, the carrier or organized delivery
5system shall offer coverage to all eligible employees of the
6small employer and the employees’ dependents. A carrier or
7organized delivery system shall not offer coverage to only
8certain individuals or dependents in a small employer group or
9to only part of the group.
10(2) Except as provided under paragraphs “a” and “d”, a
11carrier or organized delivery system shall not modify health
12insurance coverage with respect to a small employer or any
13eligible employee or dependent through riders, endorsements, or
14other means, to restrict or exclude coverage or benefits for
15certain diseases, medical conditions, or services otherwise
16covered by the health insurance coverage.
17g. A carrier or organized delivery system offering coverage
18through a network plan shall not be required to offer coverage
19or accept applications pursuant to subsection 1 with respect to
20a small employer where any of the following apply applies:
21(1) The small employer does not have eligible individuals
22who live, work, or reside in the service area for the network
23plan.
24(2) The small employer does have eligible individuals who
25live, work, or reside in the service area for the network plan,
26but the carrier or organized delivery system, if required, has
27demonstrated to the commissioner or the director of public
28health that it will not have the capacity to deliver services
29adequately to enrollees of any additional groups because of its
30obligations to existing group contract holders and enrollees
31and that it is applying the requirements of this lettered
32paragraph uniformly to all employers without regard to the
33claims experience of those employers and their employees and
34the employees’ dependents, or any health status-related factor
35relating to such employees and dependents.
-27- 1(3) A carrier or organized delivery system, upon denying
2health insurance coverage in a service area pursuant to
3subparagraph (2), shall not offer coverage in the small
4employer market within such service area for a period of one
5hundred eighty days after the coverage is denied.
64. A carrier or organized delivery system shall not be
7required to offer coverage to small employers pursuant to
8subsection 1 for any period of time where the commissioner or
9director of public health determines that the acceptance of the
10offers by small employers in accordance with subsection 1 would
11place the carrier or organized delivery system in a financially
12impaired condition.
135. A carrier or organized delivery system shall not be
14required to provide coverage to small employers pursuant to
15subsection 1 if the carrier or organized delivery system elects
16not to offer new coverage to small employers in this state.
17However, a carrier or organized delivery system that elects not
18to offer new coverage to small employers under this subsection
19shall be allowed to maintain its existing policies in the
20state, subject to the requirements of section 513B.5.
216. A carrier or organized delivery system that elects not to
22offer new coverage to small employers pursuant to subsection 5
23shall provide notice to the commissioner or director of public
24health and is prohibited from writing new business in the small
25employer market in this state for a period of five years from
26the date of notice to the commissioner or director.
27 Sec. 45. Section 513C.3, subsection 5, Code 2017, is amended
28to read as follows:
295. “Carrier” means any entity that provides individual
30health benefit plans in this state. For purposes of this
31chapter, carrier includes an insurance company, a group
32hospital or medical service corporation, a fraternal benefit
33society, a health maintenance organization, and any other
34entity providing an individual plan of health insurance
35or health benefits subject to state insurance regulation.
-28-1“Carrier” does not include an organized delivery system.
2 Sec. 46. Section 513C.3, subsection 7, Code 2017, is amended
3by striking the subsection.
4 Sec. 47. Section 513C.3, subsection 9, Code 2017, is amended
5to read as follows:
69. “Established service area” means a geographic area,
7as approved by the commissioner and based upon the carrier’s
8certificate of authority to transact business in this state,
9within which the carrier is authorized to provide coverage or
10a geographic area, as approved by the director and based upon
11the organized delivery system’s license to transact business
12in this state, within which the organized delivery system is
13authorized to provide coverage.
14 Sec. 48. Section 513C.3, subsection 12, Code 2017, is
15amended by striking the subsection.
16 Sec. 49. Section 513C.3, subsection 15, paragraph a,
17subparagraph (3), Code 2017, is amended by striking the
18subparagraph.
19 Sec. 50. Section 513C.3, subsection 18, Code 2017, is
20amended to read as follows:
2118. “Restricted network provision” means a provision of an
22individual health benefit plan that conditions the payment
23of benefits, in whole or in part, on the use of health care
24providers that have entered into a contractual arrangement with
25the carrier or the organized delivery system to provide health
26care services to covered individuals.
27 Sec. 51. Section 513C.5, subsection 1, unnumbered paragraph
281, Code 2017, is amended to read as follows:
29Premium rates for any block of individual health benefit
30plan business issued on or after January 1, 1996, or the date
31rules are adopted by the commissioner of insurance and the
32director of public health and become effective, whichever
33date is later, by a carrier subject to this chapter shall be
34limited to the composite effect of allocating costs among the
35following:
-29-1 Sec. 52. Section 513C.6, Code 2017, is amended to read as
2follows:
3513C.6 Provisions on renewability of coverage.
41. An individual health benefit plan subject to this
5chapter is renewable with respect to an eligible individual or
6dependents, at the option of the individual, except for one or
7more of the following reasons:
8a. The individual fails to pay, or to make timely payment
9of, premiums or contributions pursuant to the terms of the
10individual health benefit plan.
11b. The individual performs an act or practice constituting
12fraud or makes an intentional misrepresentation of a material
13fact under the terms of the individual health benefit plan.
14c. A decision by the individual carrier or organized
15delivery system to discontinue offering a particular type
16of individual health benefit plan in the state’s individual
17insurance market. An individual health benefit plan may be
18discontinued by the carrier or organized delivery system in
19that market with the approval of the commissioner or the
20director and only if the carrier or organized delivery system
21 does all of the following:
22(1) Provides advance notice of its decision to discontinue
23such plan to the commissioner or director. Notice to the
24commissioner or director, at a minimum, shall be no less than
25three days prior to the notice provided for in subparagraph (2)
26to affected individuals.
27(2) Provides notice of its decision not to renew such plan
28to all affected individuals no less than ninety days prior
29to the nonrenewal date of any discontinued individual health
30benefit plans.
31(3) Offers to each individual of the discontinued plan the
32option to purchase any other health plan currently offered by
33the carrier or organized delivery system to individuals in this
34state.
35(4) Acts uniformly in opting to discontinue the plan and
-30-1in offering the option under subparagraph (3), without regard
2to the claims experience of any affected eligible individual
3or beneficiary under the discontinued plan or to a health
4status-related factor relating to any covered individuals or
5beneficiaries who may become eligible for the coverage.
6d. A decision by the carrier or organized delivery system
7 to discontinue offering and to cease to renew all of its
8individual health benefit plans delivered or issued for
9delivery to individuals in this state. A carrier or organized
10delivery system making such decision shall do all of the
11following:
12(1) Provide advance notice of its decision to discontinue
13such plan to the commissioner or director. Notice to the
14commissioner or director, at a minimum, shall be no less than
15three days prior to the notice provided for in subparagraph (2)
16to affected individuals.
17(2) Provide notice of its decision not to renew such plan
18to all individuals and to the commissioner or director in each
19state in which an individual under the discontinued plan is
20known to reside, no less than one hundred eighty days prior to
21the nonrenewal of the plan.
22e. The commissioner or director finds that the continuation
23of the coverage is not in the best interests of the
24individuals, or would impair the carrier’s or organized
25delivery system’s ability to meet its contractual obligations.
262. At the time of coverage renewal, a carrier or organized
27delivery system may modify the health insurance coverage for
28a policy form offered to individuals in the individual market
29so long as such modification is consistent with state law and
30effective on a uniform basis among all individuals with that
31policy form.
323. An individual carrier or organized delivery system that
33elects not to renew an individual health benefit plan under
34subsection 1, paragraph “d”, shall not write any new business in
35the individual market in this state for a period of five years
-31-1after the date of notice to the commissioner or director.
24. This section, with respect to a carrier or organized
3delivery system doing business in one established geographic
4service area of the state, applies only to such carrier’s or
5organized delivery system’s operations in that service area.
65. A carrier or organized delivery system offering coverage
7through a network plan is not required to renew or continue in
8force coverage or to accept applications from an individual who
9no longer resides or lives in, or is no longer employed in,
10the service area of such carrier or organized delivery system,
11or no longer resides or lives in, or is no longer employed
12in, a service area for which the carrier is authorized to do
13business, but only if coverage is not offered or terminated
14uniformly without regard to health status-related factors of a
15covered individual.
166. A carrier or organized delivery system offering coverage
17through a bona fide association is not required to renew or
18continue in force coverage or to accept applications from an
19individual through an association if the membership of the
20individual in the association on which the basis of coverage
21is provided ceases, but only if the coverage is not offered or
22terminated under this paragraph uniformly without regard to
23health status-related factors of a covered individual.
247. An individual who has coverage as a dependent under a
25basic or standard health benefit plan may, when that individual
26is no longer a dependent under such coverage, elect to continue
27coverage under the basic or standard health benefit plan if
28the individual so elects immediately upon termination of the
29coverage under which the individual was covered as a dependent.
30 Sec. 53. Section 513C.7, subsection 1, Code 2017, is amended
31to read as follows:
321. a. (1) A carrier shall file with the commissioner, in
33a form and manner prescribed by the commissioner, the basic
34or standard health benefit plan. A basic or standard health
35benefit plan filed pursuant to this paragraph may be used by
-32-1a carrier beginning thirty days after it is filed unless the
2commissioner disapproves of its use.
3(2) b. The commissioner may at any time, after providing
4notice and an opportunity for a hearing to the carrier,
5disapprove the continued use by a carrier of a basic or
6standard health benefit plan on the grounds that the plan does
7not meet the requirements of this chapter.
8b. (1) An organized delivery system shall file with the
9director, in a form and manner prescribed by the director,
10the basic or standard health benefit plan to be used by the
11organized delivery system. A basic or standard health benefit
12plan filed pursuant to this paragraph may be used by the
13organized delivery system beginning thirty days after it is
14filed unless the director disapproves of its use.
15(2) The director may at any time, after providing notice and
16an opportunity for a hearing to the organized delivery system,
17disapprove the continued use by an organized delivery system of
18a basic or standard health benefit plan on the grounds that the
19plan does not meet the requirements of this chapter.
20 Sec. 54. Section 513C.7, subsection 3, Code 2017, is amended
21to read as follows:
223. A carrier or an organized delivery system shall not
23modify a basic or standard health benefit plan with respect
24to an individual or dependent through riders, endorsements,
25or other means to restrict or exclude coverage for certain
26diseases or medical conditions otherwise covered by the health
27benefit plan.
28 Sec. 55. Section 513C.9, subsections 1, 2, 3, 6, and 8, Code
292017, are amended to read as follows:
301. A carrier, an organized delivery system, or an agent
31shall not do either of the following:
32a. Encourage or direct individuals to refrain from
33filing an application for coverage with the carrier or the
34organized delivery system because of the health status, claims
35experience, industry, occupation, or geographic location of the
-33-1individuals.
2b. Encourage or direct individuals to seek coverage from
3another carrier or another organized delivery system because of
4the health status, claims experience, industry, occupation, or
5geographic location of the individuals.
62. Subsection 1, paragraph “a”, shall not apply with respect
7to information provided by a carrier or an organized delivery
8system or an agent to an individual regarding the established
9geographic service area of the carrier or the organized
10delivery system, or the restricted network provision of the
11carrier or the organized delivery system.
123. A carrier or an organized delivery system shall not,
13directly or indirectly, enter into any contract, agreement, or
14arrangement with an agent that provides for, or results in, the
15compensation paid to an agent for a sale of a basic or standard
16health benefit plan to vary because of the health status or
17permitted rating characteristics of the individual or the
18individual’s dependents.
196. Denial by a carrier or an organized delivery system of an
20application for coverage from an individual shall be in writing
21and shall state the reason or reasons for the denial.
228. If a carrier or an organized delivery system enters into
23a contract, agreement, or other arrangement with a third-party
24administrator to provide administrative, marketing, or other
25services related to the offering of individual health benefit
26plans in this state, the third-party administrator is subject
27to this section as if it were a carrier or an organized
28delivery system.
29 Sec. 56. Section 513C.10, subsection 1, paragraph a, Code
302017, is amended to read as follows:
31a. All persons that provide health benefit plans in this
32state including insurers providing accident and sickness
33insurance under chapter 509, 514, or 514A, whether on an
34individual or group basis; fraternal benefit societies
35providing hospital, medical, or nursing benefits under chapter
-34-1512B; and health maintenance organizations, organized delivery
2systems, other entities providing health insurance or health
3benefits subject to state insurance regulation, and all other
4insurers as designated by the board of directors of the Iowa
5comprehensive health insurance association with the approval of
6the commissioner shall be members of the association.
7 Sec. 57. Section 513C.10, subsection 2, paragraph a, Code
82017, is amended to read as follows:
9a. Rates for basic and standard coverages as provided in
10this chapter shall be determined by each carrier or organized
11delivery system as the product of a basic and standard factor
12and the lowest rate available for issuance by that carrier or
13organized delivery system adjusted for rating characteristics
14and benefits. Basic and standard factors shall be established
15annually by the Iowa comprehensive health insurance association
16board with the approval of the commissioner. Multiple basic
17and standard factors for a distinct grouping of basic and
18standard policies may be established. A basic and standard
19factor is limited to a minimum value defined as the ratio
20of the average of the lowest rate available for issuance and
21the maximum rate allowable by law divided by the lowest rate
22available for issuance. A basic and standard factor is limited
23to a maximum value defined as the ratio of the maximum rate
24allowable by law divided by the lowest rate available for
25issuance. The maximum rate allowable by law and the lowest
26rate available for issuance is determined based on the rate
27restrictions under this chapter. For policies written after
28January 1, 2002, rates for the basic and standard coverages
29as provided in this chapter shall be calculated using the
30basic and standard factors and shall be no lower than the
31maximum rate allowable by law. However, to maintain assessable
32loss assessments at or below one percent of total health
33insurance premiums or payments as determined in accordance
34with subsection 6, the Iowa comprehensive health insurance
35association board with the approval of the commissioner may
-35-1increase the value for any basic and standard factor greater
2than the maximum value.
3 Sec. 58. Section 513C.10, subsections 3, 4, 7, 8, 9, and 10,
4Code 2017, are amended to read as follows:
53. Following the close of each calendar year, the
6association, in conjunction with the commissioner, shall
7require each carrier or organized delivery system to report
8the amount of earned premiums and the associated paid losses
9for all basic and standard plans issued by the carrier or
10organized delivery system. The reporting of these amounts must
11be certified by an officer of the carrier or organized delivery
12system.
134. The board shall develop procedures and assessment
14mechanisms and make assessments and distributions as required
15to equalize the individual carrier and organized delivery
16system gains or losses so that each carrier or organized
17delivery system receives the same ratio of paid claims to
18ninety percent of earned premiums as the aggregate of all
19basic and standard plans insured by all carriers and organized
20delivery systems in the state.
217. The board shall develop procedures for distributing
22the assessable loss assessments to each carrier and organized
23delivery system in proportion to the carrier’s and organized
24delivery system’s respective share of premium for basic and
25standard plans to the statewide total premium for all basic and
26standard plans.
278. The board shall ensure that procedures for collecting
28and distributing assessments are as efficient as possible
29for carriers and organized delivery systems. The board may
30establish procedures which combine, or offset, the assessment
31from, and the distribution due to, a carrier or organized
32delivery system.
339. A carrier or an organized delivery system may
34petition the association board to seek remedy from writing a
35significantly disproportionate share of basic and standard
-36-1policies in relation to total premiums written in this state
2for health benefit plans. Upon a finding that a carrier or
3organized delivery system has written a disproportionate share,
4the board may agree to compensate the carrier or organized
5delivery system either by paying to the carrier or organized
6delivery system an additional fee not to exceed two percent
7of earned premiums from basic and standard policies for that
8carrier or organized delivery system or by petitioning the
9commissioner or director, as appropriate, for remedy.
1010. a. The commissioner, upon a finding that the acceptance
11of the offer of basic and standard coverage by individuals
12pursuant to this chapter would place the carrier in a
13financially impaired condition, shall not require the carrier
14to offer coverage or accept applications for any period of time
15the financial impairment is deemed to exist.
16b. The director, upon a finding that the acceptance of the
17offer of basic and standard coverage by individuals pursuant
18to this chapter would place the organized delivery system in a
19financially impaired condition, shall not require the organized
20delivery system to offer coverage or accept applications for
21any period of time the financial impairment is deemed to exist.
22 Sec. 59. Section 514A.3B, subsection 3, paragraph k, Code
232017, is amended by striking the paragraph.
24 Sec. 60. Section 514B.25A, Code 2017, is amended to read as
25follows:
26514B.25A Insolvency protection — assessment.
271. Upon a health maintenance organization or organized
28delivery system authorized to do business in this state and
29licensed by the director of public health being declared
30insolvent by the district court, the commissioner may levy an
31assessment on each health maintenance organization or organized
32delivery system doing business in this state and licensed by
33the director of public health, as applicable, to pay claims
34for uncovered expenditures for enrollees. The commissioner
35shall not assess an amount in any one calendar year which is
-37-1more than two percent of the aggregate premium written by each
2health maintenance organization or organized delivery system.
32. The commissioner may use funds obtained through an
4assessment under subsection 1 to pay claims for uncovered
5expenditures for enrollees of an insolvent health maintenance
6organization or organized delivery system and administrative
7costs. The commissioner, by rule, may prescribe the time,
8manner, and form for filing claims under this section. The
9commissioner may require claims to be allowed by an ancillary
10receiver or the domestic receiver or liquidator.
113. a. A receiver or liquidator of an insolvent health
12maintenance organization or organized delivery system shall
13allow a claim in the proceeding in an amount equal to uncovered
14expenditures and administrative costs paid under this section.
15b. A person receiving benefits under this section for
16uncovered expenditures is deemed to have assigned the rights
17under the covered health care plan certificates to the
18commissioner to the extent of the benefits received. The
19commissioner may require an assignment of such rights by a
20payee, enrollee, or beneficiary, to the commissioner as a
21condition precedent to the receipt of such benefits. The
22commissioner is subrogated to these rights against the assets
23of the insolvent health maintenance organization or organized
24delivery system that are held by a receiver or liquidator of
25a foreign jurisdiction.
26c. The assigned subrogation rights of the commissioner and
27allowed claims under this subsection have the same priority
28against the assets of the insolvent health maintenance
29organization or organized delivery system as those claims of
30persons entitled to receive benefits under this section or for
31similar expenses in the receivership or liquidation.
324. If funds assessed under subsection 1 are unused
33following the completion of the liquidation of an insolvent
34health maintenance organization or organized delivery system,
35the commissioner shall distribute the remaining amounts, if
-38-1such amounts are not de minimis, to the health maintenance
2organizations or organized delivery systems that were assessed.
35. The aggregate coverage of uncovered expenditures under
4this section shall not exceed three hundred thousand dollars
5with respect to one individual. Continuation of coverage
6shall cease after the lesser of one year after the health
7maintenance organization or organized delivery system is
8terminated by insolvency or the remaining term of the contract.
9The commissioner may provide continuation of coverage on a
10reasonable basis, including, but not limited to, continuation
11of the health maintenance organization or organized delivery
12system contract or substitution of indemnity coverage in a form
13as determined by the commissioner.
146. The commissioner may waive an assessment of a health
15maintenance organization or organized delivery system if such
16organization or system is impaired financially or would be
17impaired financially as a result of such assessment. A health
18maintenance organization or organized delivery system that
19fails to pay an assessment within thirty days after notice of
20the assessment is subject to a civil forfeiture of not more
21than one thousand dollars for each day the failure continues,
22and suspension or revocation of its certificate of authority.
23An action taken by the commissioner to enforce an assessment
24under this section may be appealed by the health maintenance
25organization or organized delivery system pursuant to chapter
2617A.
27 Sec. 61. Section 514C.10, subsection 2, paragraph e, Code
282017, is amended by striking the paragraph.
29 Sec. 62. Section 514C.11, Code 2017, is amended to read as
30follows:
31514C.11 Services provided by licensed physician assistants
32and licensed advanced registered nurse practitioners.
331. Notwithstanding section 514C.6, a policy or contract
34providing for third-party payment or prepayment of health or
35medical expenses shall include a provision for the payment of
-39-1necessary medical or surgical care and treatment provided by
2a physician assistant licensed pursuant to chapter 148C, or
3provided by an advanced registered nurse practitioner licensed
4pursuant to chapter 152 and performed within the scope of the
5license of the licensed physician assistant or the licensed
6advanced registered nurse practitioner if the policy or
7contract would pay for the care and treatment if the care and
8treatment were provided by a person engaged in the practice
9of medicine and surgery or osteopathic medicine and surgery
10under chapter 148. The policy or contract shall provide that
11policyholders and subscribers under the policy or contract may
12reject the coverage for services which may be provided by a
13licensed physician assistant or licensed advanced registered
14nurse practitioner if the coverage is rejected for all
15providers of similar services. A policy or contract subject
16to this section shall not impose a practice or supervision
17restriction which is inconsistent with or more restrictive than
18the restriction already imposed by law.
192. This section applies to services provided under a policy
20or contract delivered, issued for delivery, continued, or
21renewed in this state on or after July 1, 1996, and to an
22existing policy or contract, on the policy’s or contract’s
23anniversary or renewal date, or upon the expiration of the
24applicable collective bargaining contract, if any, whichever
25is later. This section does not apply to policyholders or
26subscribers eligible for coverage under Tit.XVIII of the
27federal Social Security Act or any similar coverage under a
28state or federal government plan.
293. For the purposes of this section, third-party payment or
30prepayment includes an individual or group policy of accident
31or health insurance or individual or group hospital or health
32care service contract issued pursuant to chapter 509, 514, or
33514A, an individual or group health maintenance organization
34contract issued and regulated under chapter 514B, an organized
35delivery system contract regulated under rules adopted by the
-40-1director of public health, or a preferred provider organization
2contract regulated pursuant to chapter 514F.
34. Nothing in this section shall be interpreted to require
4an individual or group health maintenance organization, an
5organized delivery system, or a preferred provider organization
6or arrangement to provide payment or prepayment for services
7provided by a licensed physician assistant or licensed advanced
8registered nurse practitioner unless the physician assistant’s
9supervising physician, the physician-physician assistant team,
10the advanced registered nurse practitioner, or the advanced
11registered nurse practitioner’s collaborating physician has
12entered into a contract or other agreement to provide services
13with the individual or group health maintenance organization,
14the organized delivery system, or the preferred provider
15organization or arrangement.
16 Sec. 63. Section 514C.13, subsection 1, paragraph h, Code
172017, is amended by striking the paragraph.
18 Sec. 64. Section 514C.13, subsection 2, Code 2017, is
19amended to read as follows:
202. A carrier or organized delivery system which offers to
21a small employer a limited provider network plan to provide
22health care services or benefits to the small employer’s
23employees shall also offer to the small employer a point of
24service option to the limited provider network plan.
25 Sec. 65. Section 514C.13, subsection 3, unnumbered
26paragraph 1, Code 2017, is amended to read as follows:
27A carrier or organized delivery system which offers to a
28large employer a limited provider network plan to provide
29health care services or benefits to the large employer’s
30employees shall also offer to the large employer one or more
31of the following:
32 Sec. 66. Section 514C.14, subsections 1 and 3, Code 2017,
33are amended to read as follows:
341. Except as provided under subsection 2 or 3, a carrier,
35as defined in section 513B.2, an organized delivery system
-41-1authorized under 1993 Iowa Acts, ch.158, or a plan established
2pursuant to chapter 509A for public employees, which terminates
3its contract with a participating health care provider,
4shall continue to provide coverage under the contract to a
5covered person in the second or third trimester of pregnancy
6for continued care from such health care provider. Such
7persons may continue to receive such treatment or care through
8postpartum care related to the child birth and delivery.
9Payment for covered benefits and benefit levels shall be
10according to the terms and conditions of the contract.
113. A carrier, organized delivery system, or a plan
12established under chapter 509A, which terminates the contract
13of a participating health care provider for cause shall not
14be liable to pay for health care services provided by the
15health care provider to a covered person following the date of
16termination.
17 Sec. 67. Section 514C.15, Code 2017, is amended to read as
18follows:
19514C.15 Treatment options.
20A carrier, as defined in section 513B.2,; an organized
21delivery system authorized under 1993 Iowa Acts, ch.158,
22and licensed by the director of public health; or a plan
23established pursuant to chapter 509A for public employees,
24shall not prohibit a participating provider from, or penalize a
25participating provider for, doing either of the following:
261. Discussing treatment options with a covered individual,
27notwithstanding the carrier’s, organized delivery system’s, or
28plan’s position on such treatment option.
292. Advocating on behalf of a covered individual within
30a review or grievance process established by the carrier,
31organized delivery system, or chapter 509A plan, or established
32by a person contracting with the carrier, organized delivery
33system, or chapter 509A plan.
34 Sec. 68. Section 514C.16, subsection 1, Code 2017, is
35amended to read as follows:
-42- 11. A carrier, as defined in section 513B.2,; an organized
2delivery system authorized under 1993 Iowa Acts, ch.158,
3and licensed by the director of public health; or a plan
4established pursuant to chapter 509A for public employees,
5which provides coverage for emergency services, is responsible
6for charges for emergency services provided to a covered
7individual, including services furnished outside any
8contractual provider network or preferred provider network.
9Coverage for emergency services is subject to the terms and
10conditions of the health benefit plan or contract.
11 Sec. 69. Section 514C.17, subsections 1 and 3, Code 2017,
12are amended to read as follows:
131. Except as provided under subsection 2 or 3, if a carrier,
14as defined in section 513B.2, an organized delivery system
15authorized under 1993 Iowa Acts, ch.158, or a plan established
16pursuant to chapter 509A for public employees, terminates its
17contract with a participating health care provider, a covered
18individual who is undergoing a specified course of treatment
19for a terminal illness or a related condition, with the
20recommendation of the covered individual’s treating physician
21licensed under chapter 148 may continue to receive coverage for
22treatment received from the covered individual’s physician for
23the terminal illness or a related condition, for a period of
24up to ninety days. Payment for covered benefits and benefit
25levels shall be according to the terms and conditions of the
26contract.
273. Notwithstanding subsections 1 and 2, a carrier,
28organized delivery system, or a plan established under chapter
29509A which terminates the contract of a participating health
30care provider for cause shall not be required to cover health
31care services provided by the health care provider to a covered
32person following the date of termination.
33 Sec. 70. Section 514C.18, subsection 2, paragraph a,
34subparagraph (6), Code 2017, is amended by striking the
35subparagraph.
-43-1 Sec. 71. Section 514C.19, subsection 7, paragraph a,
2subparagraph (6), Code 2017, is amended by striking the
3subparagraph.
4 Sec. 72. Section 514C.20, subsection 3, paragraph f, Code
52017, is amended by striking the paragraph.
6 Sec. 73. Section 514C.21, subsection 2, paragraph d, Code
72017, is amended by striking the paragraph.
8 Sec. 74. Section 514C.22, subsection 1, unnumbered
9paragraph 1, Code 2017, is amended to read as follows:
10Notwithstanding the uniformity of treatment requirements of
11section 514C.6, a group policy, contract, or plan providing
12for third-party payment or prepayment of health, medical, and
13surgical coverage benefits issued by a carrier, as defined in
14section 513B.2, or by an organized delivery system authorized
15under 1993 Iowa Acts, ch.158, shall provide coverage benefits
16for treatment of a biologically based mental illness if either
17of the following is satisfied:
18 Sec. 75. Section 514C.22, subsection 6, Code 2017, is
19amended to read as follows:
206. A carrier, organized delivery system, or plan
21established pursuant to chapter 509A may manage the benefits
22provided through common methods including, but not limited to,
23providing payment of benefits or providing care and treatment
24under a capitated payment system, prospective reimbursement
25rate system, utilization control system, incentive system for
26the use of least restrictive and least costly levels of care,
27a preferred provider contract limiting choice of specific
28providers, or any other system, method, or organization
29designed to assure services are medically necessary and
30clinically appropriate.
31 Sec. 76. Section 514C.25, subsection 2, paragraph a,
32subparagraph (5), Code 2017, is amended by striking the
33subparagraph.
34 Sec. 77. Section 514C.26, subsection 5, paragraph a,
35subparagraph (6), Code 2017, is amended by striking the
-44-1subparagraph.
2 Sec. 78. Section 514C.27, subsection 1, unnumbered
3paragraph 1, Code 2017, is amended to read as follows:
4Notwithstanding the uniformity of treatment requirements
5of section 514C.6, a group policy or contract providing for
6third-party payment or prepayment of health or medical expenses
7issued by a carrier, as defined in section 513B.2, or by an
8organized delivery system authorized under 1993 Iowa Acts, ch.
9158, shall provide coverage benefits to an insured who is a
10veteran for treatment of mental illness and substance abuse if
11either of the following is satisfied:
12 Sec. 79. Section 514C.27, subsection 6, Code 2017, is
13amended to read as follows:
146. A carrier, organized delivery system, or plan
15established pursuant to chapter 509A may manage the benefits
16provided through common methods including but not limited to
17providing payment of benefits or providing care and treatment
18under a capitated payment system, prospective reimbursement
19rate system, utilization control system, incentive system for
20the use of least restrictive and least costly levels of care,
21a preferred provider contract limiting choice of specific
22providers, or any other system, method, or organization
23designed to assure services are medically necessary and
24clinically appropriate.
25 Sec. 80. Section 514C.29, subsection 2, paragraph e, Code
262017, is amended by striking the paragraph.
27 Sec. 81. Section 514C.30, subsection 2, paragraph e, Code
282017, is amended by striking the paragraph.
29 Sec. 82. Section 514E.1, subsection 6, paragraph k, Code
302017, is amended by striking the paragraph.
31 Sec. 83. Section 514E.1, subsection 17, Code 2017, is
32amended by striking the subsection.
33 Sec. 84. Section 514E.2, subsection 1, paragraph a, Code
342017, is amended to read as follows:
35a. All carriers and all organized delivery systems licensed
-45-1by the director of public health providing health insurance or
2health care services in Iowa, whether on an individual or group
3basis, and all other insurers designated by the association’s
4board of directors and approved by the commissioner shall be
5members of the association.
6 Sec. 85. Section 514E.2, subsection 2, paragraph a,
7subparagraph (3), Code 2017, is amended to read as follows:
8(3) Two members selected by the members of the association,
9one of whom shall be a representative from a corporation
10operating pursuant to chapter 514 on July 1, 1989, or
11any successor in interest, and one of whom shall be a
12representative of an organized delivery system or an insurer
13providing coverage pursuant to chapter 509 or 514A.
14 Sec. 86. Section 514E.7, subsection 1, paragraph a,
15subparagraphs (1) and (2), Code 2017, are amended to read as
16follows:
17(1) A notice of rejection or refusal to issue substantially
18similar insurance for health reasons by one carrier or
19organized delivery system.
20(2) A refusal by a carrier or organized delivery system to
21issue insurance except at a rate exceeding the plan rate.
22 Sec. 87. Section 514E.7, subsection 1, paragraph b, Code
232017, is amended to read as follows:
24b. A rejection or refusal by a carrier or organized delivery
25system offering only stoploss, excess of loss, or reinsurance
26coverage with respect to an applicant under paragraph “a”,
27 subparagraphs (1) and (2), is not sufficient evidence for
28purposes of this subsection.
29 Sec. 88. Section 514E.9, Code 2017, is amended to read as
30follows:
31514E.9 Rules.
32Pursuant to chapter 17A, the commissioner and the director
33of public health shall adopt rules to provide for disclosure
34by carriers and organized delivery systems of the availability
35of insurance coverage from the association, and to otherwise
-46-1implement this chapter.
2 Sec. 89. Section 514E.11, Code 2017, is amended to read as
3follows:
4514E.11 Notice of association policy.
5Every carrier, including a health maintenance organization
6subject to chapter 514B and an organized delivery system,
7authorized to provide health care insurance or coverage for
8health care services in Iowa, shall provide a notice of the
9availability of coverage by the association to any person
10who receives a rejection of coverage for health insurance
11or health care services, or a rate for health insurance or
12coverage for health care services that will exceed the rate of
13an association policy, and that person is eligible to apply
14for health insurance provided by the association. Application
15for the health insurance shall be on forms prescribed by the
16association’s board of directors and made available to the
17carriers and organized delivery systems and other entities
18providing health care insurance or coverage for health care
19services regulated by the commissioner.
20 Sec. 90. Section 514F.5, Code 2017, is amended to read as
21follows:
22514F.5 Experimental treatment review.
231. A carrier, as defined in section 513B.2, an organized
24delivery system authorized under 1993 Iowa Acts, ch.158, or a
25plan established pursuant to chapter 509A for public employees,
26that limits coverage for experimental medical treatment, drugs,
27or devices, shall develop and implement a procedure to evaluate
28experimental medical treatments and shall submit a description
29of the procedure to the division of insurance. The procedure
30shall be in writing and must describe the process used to
31determine whether the carrier, organized delivery system,
32 or chapter 509A plan will provide coverage for new medical
33technologies and new uses of existing technologies. The
34procedure, at a minimum, shall require a review of information
35from appropriate government regulatory agencies and published
-47-1scientific literature concerning new medical technologies, new
2uses of existing technologies, and the use of external experts
3in making decisions. A carrier, organized delivery system,
4 or chapter 509A plan shall include appropriately licensed
5or qualified professionals in the evaluation process. The
6procedure shall provide a process for a person covered under
7a plan or contract to request a review of a denial of coverage
8because the proposed treatment is experimental. A review of
9a particular treatment need not be reviewed more than once a
10year.
112. A carrier, organized delivery system, or chapter 509A
12plan that limits coverage for experimental treatment, drugs, or
13devices shall clearly disclose such limitations in a contract,
14policy, or certificate of coverage.
15 Sec. 91. Section 514I.2, subsection 10, Code 2017, is
16amended to read as follows:
1710. “Participating insurer” means any entity licensed by the
18division of insurance of the department of commerce to provide
19health insurance in Iowa or an organized delivery system
20licensed by the director of public health that has contracted
21with the department to provide health insurance coverage to
22eligible children under this chapter.
23 Sec. 92. Section 514J.102, subsection 24, Code 2017, is
24amended to read as follows:
2524. “Health carrier” means an entity subject to the
26insurance laws and regulations of this state, or subject
27to the jurisdiction of the commissioner, including an
28insurance company offering sickness and accident plans, a
29health maintenance organization, a nonprofit health service
30corporation, a plan established pursuant to chapter 509A
31for public employees, or any other entity providing a plan
32of health insurance, health care benefits, or health care
33services. “Health carrier” includes, for purposes of this
34chapter, an organized delivery system.
35 Sec. 93. Section 514J.102, subsection 29, Code 2017, is
-48-1amended by striking the subsection.
2 Sec. 94. Section 514K.1, subsection 1, unnumbered paragraph
31, Code 2017, is amended to read as follows:
4A health maintenance organization, an organized delivery
5system, or an insurer using a preferred provider arrangement
6shall provide to each of its enrollees at the time of
7enrollment, and shall make available to each prospective
8enrollee upon request, written information as required by rules
9adopted by the commissioner and the director of public health.
10The information required by rule shall include, but not be
11limited to, all of the following:
12 Sec. 95. Section 514K.1, subsection 2, Code 2017, is amended
13to read as follows:
142. The commissioner and the director shall annually publish
15a consumer guide providing a comparison by plan on performance
16measures, network composition, and other key information to
17enable consumers to better understand plan differences.
18 Sec. 96. Section 514L.1, subsection 3, Code 2017, is amended
19to read as follows:
203. “Provider of third-party payment or prepayment of
21prescription drug expenses” or “provider” means a provider of an
22individual or group policy of accident or health insurance or
23an individual or group hospital or health care service contract
24issued pursuant to chapter 509, 514, or 514A, a provider of a
25plan established pursuant to chapter 509A for public employees,
26a provider of an individual or group health maintenance
27organization contract issued and regulated under chapter 514B,
28a provider of an organized delivery system contract regulated
29under rules adopted by the director of public health, a
30provider of a preferred provider contract issued pursuant to
31chapter 514F, a provider of a self-insured multiple employer
32welfare arrangement, and any other entity providing health
33insurance or health benefits which provide for payment or
34prepayment of prescription drug expenses coverage subject to
35state insurance regulation.
-49-1 Sec. 97. Section 514L.2, subsection 1, paragraph a,
2unnumbered paragraph 1, Code 2017, is amended to read as
3follows:
4A provider of third-party payment or prepayment of
5prescription drug expenses, including the provider’s agents or
6contractors and pharmacy benefits managers, that issues a card
7or other technology for claims processing and an administrator
8of the payor, excluding administrators of self-funded employer
9sponsored health benefit plans qualified under the federal
10Employee Retirement Income Security Act of 1974, shall issue
11to its insureds a card or other technology containing uniform
12prescription drug information. The commissioner of insurance
13shall adopt rules for the uniform prescription drug information
14card or technology applicable to those entities subject to
15regulation by the commissioner of insurance. The director of
16public health shall adopt rules for the uniform prescription
17drug information card or technology applicable to organized
18delivery systems. The rules shall require at least both of the
19following regarding the card or technology:
20 Sec. 98. Section 521F.2, subsection 7, Code 2017, is amended
21to read as follows:
227. “Health organization” means a health maintenance
23organization, limited service organization, dental or vision
24plan, hospital, medical and dental indemnity or service
25corporation or other managed care organization licensed under
26chapter 514, or 514B, or 1993 Iowa Acts, ch.158, or any other
27entity engaged in the business of insurance, risk transfer,
28or risk retention, that is subject to the jurisdiction of the
29commissioner of insurance or the director of public health.
30“Health organization” does not include an insurance company
31licensed to transact the business of insurance under chapter
32508, 515, or 520, and which is otherwise subject to chapter
33521E.
34 Sec. 99. 1993 Iowa Acts, chapter 158, section 4, is amended
35to read as follows:
-50- 1SEC. 4. EMERGENCY RULES. Pursuant to sections 1, and 2, and
23 of this Act, the commissioner of insurance or the director of
3public health shall adopt administrative rules under section
417A.4, subsection 2, and section 17A.5, subsection 2, paragraph
5“b”, to implement the provisions of this Act and the rules
6shall become effective immediately upon filing, unless a later
7effective date is specified in the rules. Any rules adopted in
8accordance with the provisions of this section shall also be
9published as notice of intended action as provided in section
1017A.4.
11 Sec. 100. REPEAL. Section 135.120, Code 2017, is repealed.
12 Sec. 101. REPEAL. 1993 Iowa Acts, chapter 158, section 3,
13is repealed.
14 Sec. 102. CODE EDITOR’S DIRECTIVE. The Code editor shall
15correct and eliminate any references to the term “organized
16delivery system” or other forms of the term anywhere else in
17the Iowa Code or Iowa Code Supplement, in any bills awaiting
18codification, in this Act, and in any bills enacted by the
19Eighty-seventh General Assembly, 2017 Regular Session, or any
20extraordinary session.
21EXPLANATION
22The inclusion of this explanation does not constitute agreement with
23the explanation’s substance by the members of the general assembly.
24This bill relates to programs and activities under the
25purview of the department of public health (DPH).
26Division I of the bill relates to program funding
27flexibility and reporting.
28The bill provides that if the amount of estimated moneys to
29be received from certain liquor fees and retail beer permit
30fees that is transferred to DPH annually for grants to counties
31operating a substance abuse program exceeds grant requests,
32in addition to using the remainder for grants to entities to
33operate a substance abuse prevention program, DPH may also use
34the remainder for activities and public information resources
35that align with best practices for substance-related disorder
-51-1prevention.
2The bill eliminates the requirement under Code section
3135.11, subsection 31, that DPH report to the chairpersons and
4ranking members of the joint appropriations subcommittee on
5health and human services, the legislative services agency, the
6legislative caucus staffs, and the department of management
7within 60 calendar days of applying for or renewing a federal
8grant which requires a state match or maintenance of effort
9and has a value of over $100,000, including a listing of
10the federal funding source and the potential need for the
11commitment of state funding in the present or future.
12The bill amends Code section 135.150 to require DPH to report
13annually rather than semiannually to the general assembly’s
14standing committees on government oversight regarding
15the operation of the gambling treatment program including
16information on the moneys expended and grants awarded for
17operation of the program.
18Division II of the bill relates to medical home and the
19patient-centered health advisory council.
20The bill amends provisions relating to medical homes.
21Code sections 135.157 and 135.158, providing definitions and
22describing the purposes and characteristics of medical homes,
23are repealed by the bill. Code section 135.159 provides
24parameters for the development and implementation of a medical
25home system in the state, as well as the establishment of the
26patient-centered health advisory council. The bill amends
27Code section 135.159 to provide for the continuation of the
28patient-centered health advisory council and to revise the
29purposes of the council.
30The bill also makes conforming changes throughout the Code,
31including those relative to the definitions of “medical home”,
32“personal provider”, and “primary medical provider”, due to
33elimination of certain definitions and concepts based upon the
34repeal of Code sections 135.157 and 135.158.
35Division III of the bill includes provisions relating to
-52-1workforce programming.
2The bill amends Code section 135.107 relating to the center
3for rural health and primary care. Of the programs that
4constitute the primary care provider recruitment and retention
5endeavor or PRIMECARRE, the bill eliminates the primary care
6provider community scholarship program, but retains the primary
7care loan repayment program and the community grant program
8that is renamed the health care workforce and community support
9grant program. The bill amends the application and matching
10funds requirements for a grant under the health care workforce
11and community support grant program and specifies that the
12target areas for awarding of such grants are rural, underserved
13areas or special populations identified by the department’s
14strategic plan or evidence-based documentation.
15The bill provides that the primary care provider loan
16repayment program may cancel a loan repayment program contract
17for reasonable cause unless federal requirements otherwise
18require and provides that the center for rural health and
19primary care may enter into an agreement under Code chapter 28E
20with the college student aid commission for administration of
21the center’s grant and loan repayment programs.
22The bill eliminates the requirement that a community or
23region applying for assistance under any of the programs
24established under PRIMECARRE submit a letter of intent to
25conduct a community health services assessment and instead
26requires that the community or region shall document
27participation in the community health services assessment. In
28addition to any other requirements, an applicant’s plan is
29also to include, to the extent possible, a clear commitment to
30informing high school students of the health care opportunities
31which may be available to such students.
32The bill removes the representation by the obsolete rural
33health resource center on the advisory committee to the center
34for rural health and primary care and corrects the reference to
35a national or regional institute for rural health policy.
-53- 1The bill eliminates the reference to “long-term care” in
2Code section 135.163 which directs DPH to coordinate public and
3private efforts to develop and maintain an appropriate health
4care delivery infrastructure and a stable, well-qualified,
5diverse, and sustainable health care workforce in this state.
6Under this section, DPH is required, at a minimum, to develop
7a strategic plan for health care delivery infrastructure and
8health care workforce resources in this state; provide for
9the continuous collection of data to provide a basis for
10health care strategic planning and health care policymaking;
11and make recommendations regarding the health care delivery
12infrastructure and the health care workforce that assist
13in monitoring current needs, predicting future trends, and
14informing policymaking.
15The bill amends Code section 135.175 relating to the health
16care workforce support initiative, the workforce shortage fund,
17and the accounts within the fund. The bill provides that
18state programs that may receive moneys from the fund or the
19accounts in the fund, if specifically designated for drawing
20down federal funding, include PRIMECARRE, the Iowa affiliate
21of the national rural recruitment and retention network, the
22oral and health delivery systems bureau of the department,
23the primary care office and shortage designation program, and
24the state office of rural health, but eliminates inclusion of
25the Iowa health workforce center, the area health education
26centers programs at Des Moines university osteopathic medical
27center and the university of Iowa, and the Iowa collaborative
28safety net provider network as potential recipients. The bill
29also eliminates the requirement that state appropriations to
30the fund shall be allocated in equal amounts to each of the
31accounts within the fund, unless otherwise specified in the
32appropriation or allocation, and eliminates the restriction
33that moneys in each of the accounts in the fund used for
34administrative purposes are not to exceed $100,000 in each
35account, but retains the limitation that no more than 5 percent
-54-1of the moneys in any of the accounts within the fund shall be
2used for administrative purposes unless otherwise provided in
3the appropriation, allocation, or source of the funds.
4The bill repeals Code section 135.164 which relates to the
5health care delivery infrastructure and health care workforce
6resources strategic plan to be developed by DPH including the
7specific elements of the strategic plan and the requirements
8for developing the strategic plan.
9The bill repeals Code section 135.180, the mental health
10professional shortage area program, which provides stipends to
11support psychiatrist positions with an emphasis on securing and
12retaining medical directors at community mental health centers
13designated under Code chapter 230A and hospital psychiatric
14units that are located in mental health professional shortage
15areas.
16Division IV of the bill relates to unfunded or outdated
17program provisions.
18The bill eliminates the provision under Code section 135.11
19requiring DPH to establish and administer a substance abuse
20treatment facility for persons on probation, repeals Code
21section 135.130, and strikes the conforming provision in Code
22section 901B.1. The substance abuse treatment facility for
23persons on probation was authorized in 2001 but was never
24established.
25The bill strikes the directive in Code section 135.141 for
26the division of acute disease prevention and emergency response
27of DPH to conduct and maintain a statewide risk assessment
28of any present or potential danger to the public health from
29biological agents.
30The bill repeals Code section 135.26 establishing the
31automated external defibrillator (AED) grant program to provide
32matching fund grants to local boards of health, community
33organizations, or cities to implement AED programs.
34The bill repeals Code section 135.29, relating to local
35substitute medical decision-making boards, which authorized
-55-1each county to establish and fund a local substituted medical
2decision-making board to act as a substitute decision maker for
3patients incapable of making their own medical care decisions
4if no other substitute decision maker is available to act.
5The bill repeals Code section 135.120, relating to the
6taxation of organized delivery systems (ODSs). 1993 Iowa
7Acts, chapter 158, section 3, directs DPH to adopt rules and a
8licensing procedure for the establishment of ODSs. The bill
9only eliminates the provision for taxation of ODSs, not all
10other provisions relating to ODSs.
11The bill repeals Code section 135.152, the statewide
12obstetrical and newborn indigent patient care program. The
13program acts as a payer of last resort for eligible individuals
14but has not been utilized since 2009 due to other options
15for coverage including through the Medicaid program and the
16Affordable Care Act for otherwise eligible individuals.
17Division V includes miscellaneous provisions.
18The bill amends the definition of “local board of health” in
19Code section 135A.2 under the public health modernization Act
20to be consistent with the definition under Code chapter 137,
21relating to local boards of health.
22The bill repeals Code section 135.132, the interagency
23pharmaceuticals bulk purchasing council. The provision was
24enacted in 2003, but the council was never established.
25Division VI relates to the Iowa health information
26network. Legislation was enacted in 2015 Iowa Acts, chapter
2773, to provide for the future assumption of the Iowa health
28information network by a designated entity. The bill
29includes a conforming change that would take effect upon
30future assumption of the Iowa health information network by a
31designated entity.
32Division VII relates to organized delivery systems that are
33regulated by DPH. Organized delivery systems were created
34pursuant to 1993 Iowa Acts, chapter 158. Rules adopted
35under the provision define an organized delivery system as
-56-1“an organization with defined governance that is responsible
2for delivering or arranging to deliver the full range of
3health care services covered under a standard benefit plan
4and is accountable to the public for the cost, quality and
5access of its services and for the effect of its services
6on their health.” (641 IAC 201.2) An organization operating
7as an organized delivery system is required to assume risk
8and be subject to solvency standards. The bill eliminates
9all references to organized delivery systems in the Code and
10repeals the provision in the Acts authorizing the establishment
11of organized delivery systems. The most recent application for
12licensure was received by DPH in 1998. Since being authorized
13in 1993, only two entities applied for licensure as organized
14delivery systems and both of these entities have since ceased
15operations.
-57-pf/nh
2of the department of public health, and including effective
3date provisions.
4BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
1DIVISION I
2Program Flexibility and Efficiencies
3 Section 1. Section 125.59, subsection 1, paragraph b, Code
42017, is amended to read as follows:
5b. If the transferred amount for this subsection exceeds
6grant requests funded to the ten thousand dollar maximum, the
7Iowa department of public health may use the remainder for
8activities and public information resources that align with
9best practices for substance-related disorder prevention or to
10increase grants pursuant to subsection 2.
11 Sec. 2. Section 135.11, subsection 31, Code 2017, is amended
12by striking the subsection.
13 Sec. 3. Section 135.150, subsection 2, Code 2017, is amended
14to read as follows:
152. The department shall report semiannually annually to the
16general assembly’s standing committees on government oversight
17regarding the operation of the gambling treatment program.
18The report shall include but is not limited to information on
19the moneys expended and grants awarded for operation of the
20gambling treatment program.
21DIVISION II
22Medical home and Patient-centered health advisory council
23 Sec. 4. Section 135.159, Code 2017, is amended by striking
24the section and inserting in lieu thereof the following:
25135.159 Patient-centered health advisory council.
261. The department shall establish a patient-centered health
27advisory council which shall include but is not limited to
28all of the following members, selected by their respective
29organizations, and any other members the department determines
30necessary:
31a. The director of human services, or the director’s
32designee.
33b. The commissioner of insurance, or the commissioner’s
34designee.
35c. A representative of the federation of Iowa insurers.
-1- 1d. A representative of the Iowa dental association.
2e. A representative of the Iowa nurses association.
3f. A physician and an osteopathic physician licensed
4pursuant to chapter 148 who are family physicians and members
5of the Iowa academy of family physicians.
6g. A health care consumer.
7h. A representative of the Iowa collaborative safety net
8provider network established pursuant to section 135.153.
9i. A representative of the Iowa developmental disabilities
10council.
11j. A representative of the Iowa chapter of the American
12academy of pediatrics.
13k. A representative of the child and family policy center.
14l. A representative of the Iowa pharmacy association.
15m. A representative of the Iowa chiropractic society.
16n. A representative of the university of Iowa college of
17public health.
182. The patient-centered health advisory council may utilize
19the assistance of other relevant public health and health care
20expertise when necessary to carry out the council’s purposes
21and responsibilities.
223. A public member of the patient-centered health advisory
23council shall receive reimbursement for actual expenses
24incurred while serving in the member’s official capacity
25only if the member is not eligible for reimbursement by the
26organization the member represents.
274. The purposes of the patient-centered health advisory
28council shall include all of the following:
29a. To serve as a resource on emerging health care
30transformation initiatives in Iowa.
31b. To convene stakeholders in Iowa to streamline efforts
32that support state-level and community-level integration and
33focus on reducing fragmentation of the health care system.
34c. To encourage partnerships and synergy between community
35health care partners in the state who are working on new
-2-1system-level models to provide better health care at lower
2costs by focusing on shifting from volume-based to value-based
3health care.
4d. To lead discussions on the transformation of the
5health care system to a patient-centered infrastructure that
6integrates and coordinates services and supports to address
7social determinants of health and to meet population health
8goals.
9e. To provide a venue for education and information
10gathering for stakeholders and interested parties to learn
11about emerging health care initiatives across the state.
12f. To develop recommendations for submission to the
13department related to health care transformation issues.
14 Sec. 5. Section 136.3, subsection 13, Code 2017, is amended
15to read as follows:
1613. Perform those duties authorized pursuant to sections
17 section 135.156 and 135.159 and other provisions of law.
18 Sec. 6. Section 249N.2, subsections 15 and 19, Code 2017,
19are amended to read as follows:
2015. “Medical home” means medical home as defined in
21section 135.157. a team approach to providing health care that
22originates in a primary care setting; fosters a partnership
23among the patient, the personal provider, and other health care
24professionals, and where appropriate, the patient’s family;
25utilizes the partnership to access and integrate all medical
26and nonmedical health-related services across all elements of
27the health care system and the patient’s community as needed by
28the patient and the patient’s family to achieve maximum health
29potential; maintains a centralized, comprehensive record of all
30health-related services to promote continuity of care; and has
31all of the following characteristics:
32a. A personal provider.
33b. A provider-directed team-based medical practice.
34c. Whole person orientation.
35d. Coordination and integration of care.
-3- 1e. Quality and safety.
2f. Enhanced access to health care.
3g. A payment system that appropriately recognizes the added
4value provided to patients who have a patient-centered medical
5home.
619. “Primary medical provider” means the personal provider
7as defined in section 135.157 trained to provide first contact
8and continuous and comprehensive care to a member, chosen by
9a member or to whom a member is assigned under the Iowa health
10and wellness plan.
11 Sec. 7. Section 249N.2, Code 2017, is amended by adding the
12following new subsection:
13 NEW SUBSECTION. 17A. “Personal provider” means the
14patient’s first point of contact in the health care system
15with a primary care provider who identifies the patient’s
16health-related needs and, working with a team of health
17care professionals and providers of medical and nonmedical
18health-related services, provides for and coordinates
19appropriate care to address the health-related needs
20identified.
21 Sec. 8. Section 249N.6, subsection 2, paragraph c, Code
222017, is amended to read as follows:
23c. The department shall develop a mechanism for primary
24medical providers, medical homes, and participating accountable
25care organizations to jointly facilitate member care
26coordination. The Iowa health and wellness plan shall provide
27for reimbursement of care coordination services provided
28under the plan consistent with the reimbursement methodology
29developed pursuant to section 135.159.
30 Sec. 9. Section 249N.6, subsection 3, paragraph a, Code
312017, is amended to read as follows:
32a. The department shall provide procedures for accountable
33care organizations that emerge through local markets to
34participate in the Iowa health and wellness plan provider
35network. Such accountable care organizations shall incorporate
-4-1the medical home as defined and specified in chapter 135,
2division XXII, as a foundation and shall emphasize whole-person
3orientation and coordination and integration of both clinical
4services and nonclinical community and social supports that
5address social determinants of health. A participating
6accountable care organization shall enter into a contract with
7the department to ensure the coordination and management of the
8health of attributed members, to produce quality health care
9outcomes, and to control overall cost.
10 Sec. 10. REPEAL. Sections 135.157 and 135.158, Code 2017,
11are repealed.
12DIVISION III
13workforce programming
14 Sec. 11. Section 84A.11, subsection 4, Code 2017, is amended
15to read as follows:
164. The nursing workforce data clearinghouse shall be
17established and maintained in a manner consistent with the
18health care delivery infrastructure and health care workforce
19resources strategic plan developed pursuant to section 135.164
20 135.163.
21 Sec. 12. Section 135.107, subsection 3, Code 2017, is
22amended to read as follows:
233. The center for rural health and primary care shall
24establish a primary care provider recruitment and retention
25endeavor, to be known as PRIMECARRE. The endeavor shall
26include a health care workforce and community support grant
27program, and a primary care provider loan repayment program,
28and a primary care provider community scholarship program.
29The endeavor shall be developed and implemented in a manner
30to promote and accommodate local creativity in efforts to
31recruit and retain health care professionals to provide
32services in the locality. The focus of the endeavor shall
33be to promote and assist local efforts in developing health
34care provider recruitment and retention programs. The center
35for rural health and primary care may enter into an agreement
-5-1under chapter 28E with the college student aid commission for
2the administration of the center’s grant and loan repayment
3programs.
4a. Community Health care workforce and community support
5 grant program.
6(1) The center for rural health and primary care shall adopt
7rules establishing an flexible application process processes
8based upon the department’s strategic plan to be used by the
9center to establish a grant assistance program as provided
10in this paragraph “a”, and establishing the criteria to be
11used in evaluating the applications. Selection criteria
12shall include a method for prioritizing grant applications
13based on illustrated efforts to meet the health care provider
14needs of the locality and surrounding area. Such assistance
15may be in the form of a forgivable loan, grant, or other
16nonfinancial assistance as deemed appropriate by the center.
17An application submitted shall may contain a commitment of at
18least a dollar-for-dollar match of matching funds for the grant
19assistance. Application may be made for assistance by a single
20community or group of communities or in response to programs
21recommended in the strategic plan to address health workforce
22shortages.
23(2) Grants awarded under the program shall be subject to the
24following limitations:
25(a) Ten thousand dollars for a single community or region
26with a population of ten thousand or less. An award shall not
27be made under this program to a community with a population of
28more than ten thousand.
29(b) An amount not to exceed one dollar per capita for a
30region in which the population exceeds ten thousand. For
31purposes of determining the amount of a grant for a region,
32the population of the region shall not include the population
33of any community with a population of more than ten thousand
34located in the region awarded to rural, underserved areas or
35special populations as identified by the department’s strategic
-6-1plan or evidence-based documentation.
2b. Primary care provider loan repayment program.
3(1) A primary care provider loan repayment program is
4established to increase the number of health professionals
5practicing primary care in federally designated health
6professional shortage areas of the state. Under the program,
7loan repayment may be made to a recipient for educational
8expenses incurred while completing an accredited health
9education program directly related to obtaining credentials
10necessary to practice the recipient’s health profession.
11(2) The center for rural health and primary care shall adopt
12rules relating to the establishment and administration of the
13primary care provider loan repayment program. Rules adopted
14pursuant to this paragraph shall provide, at a minimum, for all
15of the following:
16(a) Determination of eligibility requirements and
17qualifications of an applicant to receive loan repayment under
18the program, including but not limited to years of obligated
19service, clinical practice requirements, and residency
20requirements. One year of obligated service shall be provided
21by the applicant in exchange for each year of loan repayment,
22unless federal requirements otherwise require. Loan repayment
23under the program shall not be approved for a health provider
24whose license or certification is restricted by a medical
25regulatory authority of any jurisdiction of the United States,
26other nations, or territories.
27(b) Identification of federally designated health
28professional shortage areas of the state and prioritization of
29such areas according to need.
30(c) Determination of the amount and duration of the loan
31repayment an applicant may receive, giving consideration to the
32availability of funds under the program, and the applicant’s
33outstanding educational loans and professional credentials.
34(d) Determination of the conditions of loan repayment
35applicable to an applicant.
-7- 1(e) Enforcement of the state’s rights under a loan repayment
2program contract, including the commencement of any court
3action.
4(f) Cancellation of a loan repayment program contract for
5reasonable cause unless federal requirements otherwise require.
6(g) Participation in federal programs supporting repayment
7of loans of health care providers and acceptance of gifts,
8grants, and other aid or amounts from any person, association,
9foundation, trust, corporation, governmental agency, or other
10entity for the purposes of the program.
11(h) Upon availability of state funds, determination of
12eligibility criteria and qualifications for participating
13communities and applicants not located in federally designated
14shortage areas.
15(i) Other rules as necessary.
16(3) The center for rural health and primary care may enter
17into an agreement under chapter 28E with the college student
18aid commission for the administration of this program.
19c. Primary care provider community scholarship program.
20(1) A primary care provider community scholarship program
21is established to recruit and to provide scholarships to train
22primary health care practitioners in federally designated
23health professional shortage areas of the state. Under
24the program, scholarships may be awarded to a recipient for
25educational expenses incurred while completing an accredited
26health education program directly related to obtaining the
27credentials necessary to practice the recipient’s health
28profession.
29(2) The department shall adopt rules relating to the
30establishment and administration of the primary care provider
31community scholarship program. Rules adopted pursuant to
32this paragraph shall provide, at a minimum, for all of the
33following:
34(a) Determination of eligibility requirements and
35qualifications of an applicant to receive scholarships under
-8-1the program, including but not limited to years of obligated
2service, clinical practice requirements, and residency
3requirements. One year of obligated service shall be provided
4by the applicant in exchange for each year of scholarship
5receipt, unless federal requirements otherwise require.
6(b) Identification of federally designated health
7professional shortage areas of the state and prioritization of
8such areas according to need.
9(c) Determination of the amount of the scholarship an
10applicant may receive.
11(d) Determination of the conditions of scholarship to be
12awarded to an applicant.
13(e) Enforcement of the state’s rights under a scholarship
14contract, including the commencement of any court action.
15(f) Cancellation of a scholarship contract for reasonable
16cause.
17(g) Participation in federal programs supporting
18scholarships for health care providers and acceptance of gifts,
19grants, and other aid or amounts from any person, association,
20foundation, trust, corporation, governmental agency, or other
21entity for the purposes of the program.
22(h) Upon availability of state funds, determination of
23eligibility criteria and qualifications for participating
24communities and applicants not located in federally designated
25shortage areas.
26(i) Other rules as necessary.
27(3) The center for rural health and primary care may enter
28into an agreement under chapter 28E with the college student
29aid commission for the administration of this program.
30 Sec. 13. Section 135.107, subsection 4, paragraphs a, b, and
31c, Code 2017, are amended to read as follows:
32a. Eligibility under any of the programs established under
33the primary care provider recruitment and retention endeavor
34shall be based upon a community health services assessment
35completed under subsection 2, paragraph “a”. A community
-9-1or region, as applicable, shall submit a letter of intent
2to conduct a community health services assessment and to
3apply for assistance under this subsection. The letter shall
4be in a form and contain information as determined by the
5center. A letter of intent shall be submitted to the center by
6January 1 preceding the fiscal year for which an application
7for assistance is to be made. Participation in a community
8health services assessment process shall be documented by the
9community or region.
10b. Assistance under this subsection shall not be granted
11until such time as the community or region making application
12has completed the a community health services assessment and
13adopted a long-term community health services assessment and
14developmental plan. In addition to any other requirements, a
15developmental an applicant’s plan shall include, to the extent
16possible, a clear commitment to informing high school students
17of the health care opportunities which may be available to such
18students.
19c. The center for rural health and primary care shall
20seek additional assistance and resources from other state
21departments and agencies, federal agencies and grant programs,
22private organizations, and any other person, as appropriate.
23The center is authorized and directed to accept on behalf of
24the state any grant or contribution, federal or otherwise,
25made to assist in meeting the cost of carrying out the purpose
26of this subsection. All federal grants to and the federal
27receipts of the center are appropriated for the purpose set
28forth in such federal grants or receipts. Funds appropriated
29by the general assembly to the center for implementation of
30this subsection shall first be used for securing any available
31federal funds requiring a state match, with remaining funds
32being used for the health care workforce and community support
33 grant program.
34 Sec. 14. Section 135.107, subsection 5, paragraph a, Code
352017, is amended to read as follows:
-10- 1a. There is established an advisory committee to the
2center for rural health and primary care consisting of one
3representative, approved by the respective agency, of each
4of the following agencies: the department of agriculture
5and land stewardship, the Iowa department of public health,
6the department of inspections and appeals, the a national or
7regional institute for rural health policy, the rural health
8resource center, the institute of agricultural medicine
9and occupational health, and the Iowa state association of
10counties. The governor shall appoint two representatives
11of consumer groups active in rural health issues and a
12representative of each of two farm organizations active within
13the state, a representative of an agricultural business in
14the state, a representative of a critical needs hospital,
15a practicing rural family physician, a practicing rural
16physician assistant, a practicing rural advanced registered
17nurse practitioner, and a rural health practitioner who is
18not a physician, physician assistant, or advanced registered
19nurse practitioner, as members of the advisory committee. The
20advisory committee shall also include as members two state
21representatives, one appointed by the speaker of the house of
22representatives and one by the minority leader of the house,
23and two state senators, one appointed by the majority leader of
24the senate and one by the minority leader of the senate.
25 Sec. 15. Section 135.163, Code 2017, is amended to read as
26follows:
27135.163 Health and long-term care access.
28The department shall coordinate public and private efforts
29to develop and maintain an appropriate health care delivery
30infrastructure and a stable, well-qualified, diverse, and
31sustainable health care workforce in this state. The health
32care delivery infrastructure and the health care workforce
33shall address the broad spectrum of health care needs of Iowans
34throughout their lifespan including long-term care needs. The
35department shall, at a minimum, do all of the following:
-11- 11. Develop a strategic plan for health care delivery
2infrastructure and health care workforce resources in this
3state.
42. Provide for the continuous collection of data to provide
5a basis for health care strategic planning and health care
6policymaking.
73. Make recommendations regarding the health care delivery
8infrastructure and the health care workforce that assist
9in monitoring current needs, predicting future trends, and
10informing policymaking.
11 Sec. 16. Section 135.175, subsection 1, paragraph b, Code
122017, is amended to read as follows:
13b. A health care workforce shortage fund is created in
14the state treasury as a separate fund under the control of
15the department, in cooperation with the entities identified
16in this section as having control over the accounts within
17the fund. The fund and the accounts within the fund shall
18be controlled and managed in a manner consistent with the
19principles specified and the strategic plan developed pursuant
20to sections section 135.163 and 135.164.
21 Sec. 17. Section 135.175, subsections 6 and 7, Code 2017,
22are amended to read as follows:
236. a. Moneys in the fund and the accounts in the fund shall
24only be appropriated in a manner consistent with the principles
25specified and the strategic plan developed pursuant to sections
26 section 135.163 and 135.164 to support the medical residency
27training state matching grants program, the fulfilling Iowa’s
28need for dentists matching grant program, and to provide
29funding for state health care workforce shortage programs as
30provided in this section.
31b. State programs that may receive funding from the fund
32and the accounts in the fund, if specifically designated for
33the purpose of drawing down federal funding, are the primary
34care recruitment and retention endeavor (PRIMECARRE), the Iowa
35affiliate of the national rural recruitment and retention
-12-1network, the oral and health delivery systems bureau of the
2department, the primary care office and shortage designation
3program, and the state office of rural health, and the Iowa
4health workforce center, administered through the oral and
5health delivery systems bureau of health care access of the
6department of public health; the area health education centers
7programs at Des Moines university — osteopathic medical center
8and the university of Iowa; the Iowa collaborative safety net
9provider network established pursuant to section 135.153; any
10entity identified by the federal government entity through
11which federal funding for a specified health care workforce
12shortage initiative is received; and a program developed in
13accordance with the strategic plan developed by the department
14of public health in accordance with sections section 135.163
15and 135.164.
16c. State appropriations to the fund shall be allocated in
17equal amounts to each of the accounts within the fund, unless
18otherwise specified in the appropriation or allocation. Any
19federal funding received for the purposes of addressing state
20health care workforce shortages shall be deposited in the
21health care workforce shortage national initiatives account,
22unless otherwise specified by the source of the funds, and
23shall be used as required by the source of the funds. If use
24of the federal funding is not designated, the funds shall be
25used in accordance with the strategic plan developed by the
26department of public health in accordance with sections section
27 135.163 and 135.164, or to address workforce shortages as
28otherwise designated by the department of public health. Other
29sources of funding shall be deposited in the fund or account
30and used as specified by the source of the funding.
317. No more than five percent of the moneys in any of the
32accounts within the fund, not to exceed one hundred thousand
33dollars in each account, shall be used for administrative
34purposes, unless otherwise provided by the appropriation,
35allocation, or source of the funds.
-13-1 Sec. 18. REPEAL. Sections 135.164 and 135.180, Code 2017,
2are repealed.
3DIVISION IV
4unfunded OR outdated program PROVISIONS
5 Sec. 19. Section 135.11, subsection 25, Code 2017, is
6amended by striking the subsection.
7 Sec. 20. Section 135.141, subsection 2, paragraph c, Code
82017, is amended by striking the paragraph.
9 Sec. 21. Section 135.141, subsection 2, paragraph e, Code
102017, is amended to read as follows:
11e. For the purpose of paragraphs “c” and paragraph “d”,
12an employee or agent of the department may enter into and
13examine any premises containing potentially dangerous agents
14with the consent of the owner or person in charge of the
15premises or, if the owner or person in charge of the premises
16refuses admittance, with an administrative search warrant
17obtained under section 808.14. Based on findings of the risk
18assessment and examination of the premises, the director may
19order reasonable safeguards or take any other action reasonably
20necessary to protect the public health pursuant to rules
21adopted to administer this subsection.
22 Sec. 22. Section 901B.1, subsection 4, paragraph a, Code
232017, is amended to read as follows:
24a. The district department of correctional services shall
25place an individual committed to it under section 907.3 to the
26sanction and level of supervision which is appropriate to the
27individual based upon a current risk assessment evaluation.
28Placements may be to levels two and three of the corrections
29continuum. The district department may, with the approval of
30the Iowa department of public health and the department of
31corrections, place an individual in a level three substance
32abuse treatment facility established pursuant to section
33135.130, to assist the individual in complying with a condition
34of probation. The district department may, with the approval
35of the department of corrections, place an individual in a
-14-1level four violator facility established pursuant to section
2904.207 only as a penalty for a violation of a condition
3imposed under this section.
4 Sec. 23. REPEAL. Sections 135.26, 135.29, 135.130, and
5135.152, Code 2017, are repealed.
6DIVISION V
7miscellaneous provisions
8 Sec. 24. Section 135A.2, subsection 6, Code 2017, is amended
9to read as follows:
106. “Local board of health” means a county or district board
11of health the same as defined in section 137.102.
12 Sec. 25. REPEAL. Section 135.132, Code 2017, is repealed.
13DIVISION VI
14iowa health information network
15 Sec. 26. Section 136.3, subsection 13, Code 2017, is amended
16to read as follows:
1713. Perform those duties authorized pursuant to sections
18135.156 and section 135.159 and other provisions of law.
19 Sec. 27. EFFECTIVE DATE. This division of this Act
20takes effect upon the assumption of the administration and
21governance, including but not limited to the assumption of the
22assets and liabilities, of the Iowa health information network
23by the designated entity as defined in 2015 Iowa Acts, ch.73,
24section 2. The department of public health shall notify the
25Code editor of the date of such assumption by the designated
26entity.
27DIVISION VII
28ORGANIZED DELIVERY SYSTEMS
29 Sec. 28. Section 135H.3, subsection 2, Code 2017, is amended
30to read as follows:
312. If a child is diagnosed with a biologically based mental
32illness as defined in section 514C.22 and meets the medical
33assistance program criteria for admission to a psychiatric
34medical institution for children, the child shall be deemed
35to meet the acuity criteria for medically necessary inpatient
-15-1benefits under a group policy, contract, or plan providing
2for third-party payment or prepayment of health, medical, and
3surgical coverage benefits issued by a carrier, as defined in
4section 513B.2, or by an organized delivery system authorized
5under 1993 Iowa Acts, ch.158, that is subject to section
6514C.22. Such medically necessary benefits shall not be
7excluded or denied as care that is substantially custodial in
8nature under section 514C.22, subsection 8, paragraph “b”.
9 Sec. 29. Section 505.32, subsection 2, paragraph h, Code
102017, is amended by striking the paragraph.
11 Sec. 30. Section 505.32, subsection 4, paragraph b,
12subparagraphs (1) and (2), Code 2017, are amended to read as
13follows:
14(1) The commissioner may establish methodologies to provide
15uniform and consistent side-by-side comparisons of the health
16care coverage options that are offered by carriers, organized
17delivery systems, and public programs in this state including
18but not limited to benefits covered and not covered, the amount
19of coverage for each service, including copays and deductibles,
20administrative costs, and any prior authorization requirements
21for coverage.
22(2) The commissioner may require each carrier, organized
23delivery system, and public program in this state to describe
24each health care coverage option offered by that carrier,
25organized delivery system, or public program in a manner
26so that the various options can be compared as provided in
27subparagraph (1).
28 Sec. 31. Section 507B.4, subsection 1, Code 2017, is amended
29to read as follows:
301. For purposes of subsection 3, paragraph “p”, “insurer”
31means an entity providing a plan of health insurance, health
32care benefits, or health care services, or an entity subject
33to the jurisdiction of the commissioner performing utilization
34review, including an insurance company offering sickness and
35accident plans, a health maintenance organization, an organized
-16-1delivery system authorized under 1993 Iowa Acts, ch.158, and
2licensed by the department of public health, a nonprofit health
3service corporation, a plan established pursuant to chapter
4509A for public employees, or any other entity providing a
5plan of health insurance, health care benefits, or health care
6services. However, “insurer” does not include an entity that
7sells disability income or long-term care insurance.
8 Sec. 32. Section 507B.4A, subsection 2, paragraph a, Code
92017, is amended to read as follows:
10a. An insurer providing accident and sickness insurance
11under chapter 509, 514, or 514A; a health maintenance
12organization; an organized delivery system authorized under
131993 Iowa Acts, ch.158, and licensed by the department of
14public health; or another entity providing health insurance or
15health benefits subject to state insurance regulation shall
16either accept and pay or deny a clean claim.
17 Sec. 33. Section 509.3A, subsection 11, Code 2017, is
18amended by striking the subsection.
19 Sec. 34. Section 509.19, subsection 2, paragraph d, Code
202017, is amended by striking the paragraph.
21 Sec. 35. Section 509A.6, Code 2017, is amended to read as
22follows:
23509A.6 Contract with insurance carrier, or health maintenance
24organization, or organized delivery system.
25The governing body may contract with a nonprofit corporation
26operating under the provisions of this chapter or chapter
27514 or with any insurance company having a certificate of
28authority to transact an insurance business in this state with
29respect of a group insurance plan, which may include life,
30accident, health, hospitalization and disability insurance
31during period of active service of such employees, with the
32right of any employee to continue such life insurance in force
33after termination of active service at such employee’s sole
34expense; may contract with a nonprofit corporation operating
35under and governed by the provisions of this chapter or chapter
-17-1514 with respect of any hospital or medical service plan; and
2may contract with a health maintenance organization or an
3organized delivery system authorized to operate in this state
4with respect to health maintenance organization or organized
5delivery system activities.
6 Sec. 36. Section 513B.2, subsection 8, paragraph k, Code
72017, is amended by striking the paragraph.
8 Sec. 37. Section 513B.5, Code 2017, is amended to read as
9follows:
10513B.5 Provisions on renewability of coverage.
111. Health insurance coverage subject to this chapter is
12renewable with respect to all eligible employees or their
13dependents, at the option of the small employer, except for one
14or more of the following reasons:
15a. The health insurance coverage sponsor fails to pay, or to
16make timely payment of, premiums or contributions pursuant to
17the terms of the health insurance coverage.
18b. The health insurance coverage sponsor performs an
19act or practice constituting fraud or makes an intentional
20misrepresentation of a material fact under the terms of the
21coverage.
22c. Noncompliance with the carrier’s or organized delivery
23system’s minimum participation requirements.
24d. Noncompliance with the carrier’s or organized delivery
25system’s employer contribution requirements.
26e. A decision by the carrier or organized delivery system
27 to discontinue offering a particular type of health insurance
28coverage in the state’s small employer market. Health
29insurance coverage may be discontinued by the carrier or
30organized delivery system in that market only if the carrier or
31organized delivery system does all of the following:
32(1) Provides advance notice of its decision to discontinue
33such plan to the commissioner or director of public health.
34Notice to the commissioner or director, at a minimum, shall be
35no less than three days prior to the notice provided for in
-18-1subparagraph (2) to affected small employers, participants, and
2beneficiaries.
3(2) Provides notice of its decision not to renew such
4plan to all affected small employers, participants, and
5beneficiaries no less than ninety days prior to the nonrenewal
6of the plan.
7(3) Offers to each plan sponsor of the discontinued
8coverage, the option to purchase any other coverage currently
9offered by the carrier or organized delivery system to other
10employers in this state.
11(4) Acts uniformly, in opting to discontinue the coverage
12and in offering the option under subparagraph (3), without
13regard to the claims experience of the sponsors under the
14discontinued coverage or to a health status-related factor
15relating to any participants or beneficiaries covered or new
16participants or beneficiaries who may become eligible for the
17coverage.
18f. A decision by the carrier or organized delivery system to
19discontinue offering and to cease to renew all of its health
20insurance coverage delivered or issued for delivery to small
21employers in this state. A carrier or organized delivery
22system making such decision shall do all of the following:
23(1) Provide advance notice of its decision to discontinue
24such coverage to the commissioner or director of public health.
25Notice to the commissioner or director, at a minimum, shall be
26no less than three days prior to the notice provided for in
27subparagraph (2) to affected small employers, participants, and
28beneficiaries.
29(2) Provide notice of its decision not to renew such
30coverage to all affected small employers, participants, and
31beneficiaries no less than one hundred eighty days prior to the
32nonrenewal of the coverage.
33(3) Discontinue all health insurance coverage issued or
34delivered for issuance to small employers in this state and
35cease renewal of such coverage.
-19- 1g. The membership of an employer in an association, which
2is the basis for the coverage which is provided through such
3association, ceases, but only if the termination of coverage
4under this paragraph occurs uniformly without regard to
5any health status-related factor relating to any covered
6individual.
7h. The commissioner or director of public health finds that
8the continuation of the coverage is not in the best interests
9of the policyholders or certificate holders, or would impair
10the carrier’s or organized delivery system’s ability to meet
11its contractual obligations.
12i. At the time of coverage renewal, a carrier or organized
13delivery system may modify the health insurance coverage for
14a product offered under group health insurance coverage in
15the small group market, for coverage that is available in
16such market other than only through one or more bona fide
17associations, if such modification is consistent with the laws
18of this state, and is effective on a uniform basis among group
19health insurance coverage with that product.
202. A carrier or organized delivery system that elects not to
21renew health insurance coverage under subsection 1, paragraph
22“f”, shall not write any new business in the small employer
23market in this state for a period of five years after the date
24of notice to the commissioner or director of public health.
253. This section, with respect to a carrier or organized
26delivery system doing business in one established geographic
27service area of the state, applies only to such carrier’s or
28organized delivery system’s operations in that service area.
29 Sec. 38. Section 513B.6, unnumbered paragraph 1, Code 2017,
30is amended to read as follows:
31A small employer carrier or organized delivery system shall
32make reasonable disclosure in solicitation and sales materials
33provided to small employers of all of the following:
34 Sec. 39. Section 513B.6, subsection 2, Code 2017, is amended
35to read as follows:
-20- 12. The provisions concerning the small employer carrier’s
2or organized delivery system’s right to change premium rates
3and factors, including case characteristics, which affect
4changes in premium rates.
5 Sec. 40. Section 513B.7, Code 2017, is amended to read as
6follows:
7513B.7 Maintenance of records.
81. A small employer carrier or organized delivery system
9 shall maintain at its principal place of business a complete
10and detailed description of its rating practices and renewal
11underwriting practices, including information and documentation
12which demonstrate that its rating methods and practices are
13based upon commonly accepted actuarial assumptions and are in
14accordance with sound actuarial principles.
152. A small employer carrier or organized delivery system
16 shall file each March 1 with the commissioner or the director
17of public health an actuarial certification that the small
18employer carrier or organized delivery system is in compliance
19with this section and that the rating methods of the small
20employer carrier or organized delivery system are actuarially
21sound. A copy of the certification shall be retained by the
22small employer carrier or organized delivery system at its
23principal place of business.
243. A small employer carrier or organized delivery system
25 shall make the information and documentation described in
26subsection 1 available to the commissioner or the director of
27public health upon request. The information is not a public
28record or otherwise subject to disclosure under chapter 22,
29and is considered proprietary and trade secret information
30and is not subject to disclosure by the commissioner or the
31director of public health to persons outside of the division or
32department except as agreed to by the small employer carrier or
33organized delivery system or as ordered by a court of competent
34jurisdiction.
35 Sec. 41. Section 513B.9A, subsection 1, unnumbered
-21-1paragraph 1, Code 2017, is amended to read as follows:
2A carrier or organized delivery system offering group health
3insurance coverage shall not establish rules for eligibility,
4including continued eligibility, of an individual to enroll
5under the terms of the coverage based on any of the following
6health status-related factors in relation to the individual or
7a dependent of the individual:
8 Sec. 42. Section 513B.9A, subsection 4, paragraph a, Code
92017, is amended to read as follows:
10a. A carrier or organized delivery system offering health
11insurance coverage shall not require an individual, as a
12condition of enrollment or continued enrollment under the
13coverage, to pay a premium or contribution which is greater
14than a premium or contribution for a similarly situated
15individual enrolled in the coverage on the basis of a health
16status-related factor in relation to the individual or to a
17dependent of an individual enrolled under the coverage.
18 Sec. 43. Section 513B.9A, subsection 4, paragraph b,
19subparagraph (2), Code 2017, is amended to read as follows:
20(2) Prevent a carrier or organized delivery system
21 offering group health insurance coverage from establishing
22premium discounts or rebates or modifying otherwise applicable
23copayments or deductibles in return for adherence to programs
24of health promotion and disease prevention.
25 Sec. 44. Section 513B.10, Code 2017, is amended to read as
26follows:
27513B.10 Availability of coverage.
281. a. A carrier or an organized delivery system that offers
29health insurance coverage in the small group market shall
30accept every small employer that applies for health insurance
31coverage and shall accept for enrollment under such coverage
32every eligible individual who applies for enrollment during the
33period in which the individual first becomes eligible to enroll
34under the terms of the health insurance coverage and shall not
35place any restriction which is inconsistent with eligibility
-22-1rules established under this chapter.
2b. A carrier or organized delivery system that offers health
3insurance coverage in the small group market through a network
4plan may do either of the following:
5(1) Limit employers that may apply for such coverage to
6those with eligible individuals who live, work, or reside in
7the service area for such network plan.
8(2) Deny such coverage to such employers within the service
9area of such plan if the carrier or organized delivery system
10 has demonstrated to the applicable state authority both of the
11following:
12(a) The carrier or organized delivery system will not have
13the capacity to deliver services adequately to enrollees of any
14additional groups because of its obligations to existing group
15contract holders and enrollees.
16(b) The carrier or organized delivery system is applying
17this subparagraph uniformly to all employers without regard to
18the claims experience of those employers and their employees
19and their dependents, or any health status-related factor
20relating to such employees or dependents.
21c. A carrier or organized delivery system, upon denying
22health insurance coverage in any service area pursuant to
23paragraph “b”, subparagraph (2), shall not offer coverage in the
24small group market within such service area for a period of one
25hundred eighty days after the date such coverage is denied.
26d. A carrier or organized delivery system may deny health
27insurance coverage in the small group market if the issuer has
28demonstrated to the commissioner or director of public health
29 both of the following:
30(1) The carrier or organized delivery system does not have
31the financial reserves necessary to underwrite additional
32coverage.
33(2) The carrier or organized delivery system is applying the
34provisions of this paragraph uniformly to all employers in the
35small group market in this state consistent with state law and
-23-1without regard to the claims experience of those employers and
2the employees and dependents of such employers, or any health
3status-related factor relating to such employees and their
4dependents.
5e. A carrier or organized delivery system, upon denying
6health insurance coverage pursuant to paragraph “d”, shall not
7offer coverage in connection with health insurance coverages
8in the small group market in this state for a period of one
9hundred eighty days after the date such coverage is denied or
10until the carrier or organized delivery system has demonstrated
11to the commissioner or director of public health that the
12carrier or organized delivery system has sufficient financial
13reserves to underwrite additional coverage, whichever is later.
14The commissioner or director may provide for the application of
15this paragraph on a service area-specific basis.
16f. Paragraph “a” shall not be construed to preclude
17a carrier or organized delivery system from establishing
18employer contribution rules or group participation rules for
19the offering of health insurance coverage in the small group
20market.
212. A carrier or organized delivery system, subject to
22subsection 1, shall issue health insurance coverage to an
23eligible small employer that applies for the coverage and
24agrees to make the required premium payments and satisfy the
25other reasonable provisions of the health insurance coverage
26not inconsistent with this chapter. A carrier or organized
27delivery system is not required to issue health insurance
28coverage to a self-employed individual who is covered by, or is
29eligible for coverage under, health insurance coverage offered
30by an employer.
313. Health insurance coverage for small employers shall
32satisfy all of the following:
33a. A carrier or organized delivery system offering group
34health insurance coverage, with respect to a participant or
35beneficiary, may impose a preexisting condition exclusion only
-24-1as follows:
2(1) The exclusion relates to a condition, whether physical
3or mental, regardless of the cause of the condition, for
4which medical advice, diagnosis, care, or treatment was
5recommended or received within the six-month period ending on
6the enrollment date. However, genetic information shall not be
7treated as a condition under this subparagraph in the absence
8of a diagnosis of the condition related to such information.
9(2) The exclusion extends for a period of not more than
10twelve months, or eighteen months in the case of a late
11enrollee, after the enrollment date.
12(3) The period of any such preexisting condition exclusion
13is reduced by the aggregate of the periods of creditable
14coverage applicable to the participant or beneficiary as of the
15enrollment date.
16b. A carrier or organized delivery system offering group
17health insurance coverage shall not impose any preexisting
18condition exclusion as follows:
19(1) In the case of a child who is adopted or placed for
20adoption before attaining eighteen years of age and who, as of
21the last day of the thirty-day period beginning on the date
22of the adoption or placement for adoption, is covered under
23creditable coverage. This subparagraph shall not apply to
24coverage before the date of such adoption or placement for
25adoption.
26(2) In the case of an individual who, as of the last day
27of the thirty-day period beginning with the date of birth, is
28covered under creditable coverage.
29(3) Relating to pregnancy as a preexisting condition.
30c. A carrier or organized delivery system shall waive
31any waiting period applicable to a preexisting condition
32exclusion or limitation period with respect to particular
33services under health insurance coverage for the period
34of time an individual was covered by creditable coverage,
35provided that the creditable coverage was continuous to a
-25-1date not more than sixty-three days prior to the effective
2date of the new coverage. Any period that an individual
3is in a waiting period for any coverage under group health
4insurance coverage, or is in an affiliation period, shall not
5be taken into account in determining the period of continuous
6coverage. A health maintenance organization that does not
7use preexisting condition limitations in any of its health
8insurance coverage may impose an affiliation period. For
9purposes of this section, “affiliation period” means a period
10of time not to exceed sixty days for new entrants and not to
11exceed ninety days for late enrollees during which no premium
12shall be collected and coverage issued is not effective, so
13long as the affiliation period is applied uniformly, without
14regard to any health status-related factors. This paragraph
15does not preclude application of a waiting period applicable
16to all new enrollees under the health insurance coverage,
17provided that any carrier or organized delivery system-imposed
18 carrier-imposed waiting period is no longer than sixty days and
19is used in lieu of a preexisting condition exclusion.
20d. Health insurance coverage may exclude coverage for late
21enrollees for preexisting conditions for a period not to exceed
22eighteen months.
23e. (1) Requirements used by a carrier or organized delivery
24system in determining whether to provide coverage to a small
25employer shall be applied uniformly among all small employers
26applying for coverage or receiving coverage from the carrier
27or organized delivery system.
28(2) In applying minimum participation requirements with
29respect to a small employer, a carrier or organized delivery
30system shall not consider employees or dependents who have
31other creditable coverage in determining whether the applicable
32percentage of participation is met.
33(3) A carrier or organized delivery system shall not
34increase any requirement for minimum employee participation
35or modify any requirement for minimum employer contribution
-26-1applicable to a small employer at any time after the small
2employer has been accepted for coverage.
3f. (1) If a carrier or organized delivery system offers
4coverage to a small employer, the carrier or organized delivery
5system shall offer coverage to all eligible employees of the
6small employer and the employees’ dependents. A carrier or
7organized delivery system shall not offer coverage to only
8certain individuals or dependents in a small employer group or
9to only part of the group.
10(2) Except as provided under paragraphs “a” and “d”, a
11carrier or organized delivery system shall not modify health
12insurance coverage with respect to a small employer or any
13eligible employee or dependent through riders, endorsements, or
14other means, to restrict or exclude coverage or benefits for
15certain diseases, medical conditions, or services otherwise
16covered by the health insurance coverage.
17g. A carrier or organized delivery system offering coverage
18through a network plan shall not be required to offer coverage
19or accept applications pursuant to subsection 1 with respect to
20a small employer where any of the following apply applies:
21(1) The small employer does not have eligible individuals
22who live, work, or reside in the service area for the network
23plan.
24(2) The small employer does have eligible individuals who
25live, work, or reside in the service area for the network plan,
26but the carrier or organized delivery system, if required, has
27demonstrated to the commissioner or the director of public
28health that it will not have the capacity to deliver services
29adequately to enrollees of any additional groups because of its
30obligations to existing group contract holders and enrollees
31and that it is applying the requirements of this lettered
32paragraph uniformly to all employers without regard to the
33claims experience of those employers and their employees and
34the employees’ dependents, or any health status-related factor
35relating to such employees and dependents.
-27- 1(3) A carrier or organized delivery system, upon denying
2health insurance coverage in a service area pursuant to
3subparagraph (2), shall not offer coverage in the small
4employer market within such service area for a period of one
5hundred eighty days after the coverage is denied.
64. A carrier or organized delivery system shall not be
7required to offer coverage to small employers pursuant to
8subsection 1 for any period of time where the commissioner or
9director of public health determines that the acceptance of the
10offers by small employers in accordance with subsection 1 would
11place the carrier or organized delivery system in a financially
12impaired condition.
135. A carrier or organized delivery system shall not be
14required to provide coverage to small employers pursuant to
15subsection 1 if the carrier or organized delivery system elects
16not to offer new coverage to small employers in this state.
17However, a carrier or organized delivery system that elects not
18to offer new coverage to small employers under this subsection
19shall be allowed to maintain its existing policies in the
20state, subject to the requirements of section 513B.5.
216. A carrier or organized delivery system that elects not to
22offer new coverage to small employers pursuant to subsection 5
23shall provide notice to the commissioner or director of public
24health and is prohibited from writing new business in the small
25employer market in this state for a period of five years from
26the date of notice to the commissioner or director.
27 Sec. 45. Section 513C.3, subsection 5, Code 2017, is amended
28to read as follows:
295. “Carrier” means any entity that provides individual
30health benefit plans in this state. For purposes of this
31chapter, carrier includes an insurance company, a group
32hospital or medical service corporation, a fraternal benefit
33society, a health maintenance organization, and any other
34entity providing an individual plan of health insurance
35or health benefits subject to state insurance regulation.
-28-1“Carrier” does not include an organized delivery system.
2 Sec. 46. Section 513C.3, subsection 7, Code 2017, is amended
3by striking the subsection.
4 Sec. 47. Section 513C.3, subsection 9, Code 2017, is amended
5to read as follows:
69. “Established service area” means a geographic area,
7as approved by the commissioner and based upon the carrier’s
8certificate of authority to transact business in this state,
9within which the carrier is authorized to provide coverage or
10a geographic area, as approved by the director and based upon
11the organized delivery system’s license to transact business
12in this state, within which the organized delivery system is
13authorized to provide coverage.
14 Sec. 48. Section 513C.3, subsection 12, Code 2017, is
15amended by striking the subsection.
16 Sec. 49. Section 513C.3, subsection 15, paragraph a,
17subparagraph (3), Code 2017, is amended by striking the
18subparagraph.
19 Sec. 50. Section 513C.3, subsection 18, Code 2017, is
20amended to read as follows:
2118. “Restricted network provision” means a provision of an
22individual health benefit plan that conditions the payment
23of benefits, in whole or in part, on the use of health care
24providers that have entered into a contractual arrangement with
25the carrier or the organized delivery system to provide health
26care services to covered individuals.
27 Sec. 51. Section 513C.5, subsection 1, unnumbered paragraph
281, Code 2017, is amended to read as follows:
29Premium rates for any block of individual health benefit
30plan business issued on or after January 1, 1996, or the date
31rules are adopted by the commissioner of insurance and the
32director of public health and become effective, whichever
33date is later, by a carrier subject to this chapter shall be
34limited to the composite effect of allocating costs among the
35following:
-29-1 Sec. 52. Section 513C.6, Code 2017, is amended to read as
2follows:
3513C.6 Provisions on renewability of coverage.
41. An individual health benefit plan subject to this
5chapter is renewable with respect to an eligible individual or
6dependents, at the option of the individual, except for one or
7more of the following reasons:
8a. The individual fails to pay, or to make timely payment
9of, premiums or contributions pursuant to the terms of the
10individual health benefit plan.
11b. The individual performs an act or practice constituting
12fraud or makes an intentional misrepresentation of a material
13fact under the terms of the individual health benefit plan.
14c. A decision by the individual carrier or organized
15delivery system to discontinue offering a particular type
16of individual health benefit plan in the state’s individual
17insurance market. An individual health benefit plan may be
18discontinued by the carrier or organized delivery system in
19that market with the approval of the commissioner or the
20director and only if the carrier or organized delivery system
21 does all of the following:
22(1) Provides advance notice of its decision to discontinue
23such plan to the commissioner or director. Notice to the
24commissioner or director, at a minimum, shall be no less than
25three days prior to the notice provided for in subparagraph (2)
26to affected individuals.
27(2) Provides notice of its decision not to renew such plan
28to all affected individuals no less than ninety days prior
29to the nonrenewal date of any discontinued individual health
30benefit plans.
31(3) Offers to each individual of the discontinued plan the
32option to purchase any other health plan currently offered by
33the carrier or organized delivery system to individuals in this
34state.
35(4) Acts uniformly in opting to discontinue the plan and
-30-1in offering the option under subparagraph (3), without regard
2to the claims experience of any affected eligible individual
3or beneficiary under the discontinued plan or to a health
4status-related factor relating to any covered individuals or
5beneficiaries who may become eligible for the coverage.
6d. A decision by the carrier or organized delivery system
7 to discontinue offering and to cease to renew all of its
8individual health benefit plans delivered or issued for
9delivery to individuals in this state. A carrier or organized
10delivery system making such decision shall do all of the
11following:
12(1) Provide advance notice of its decision to discontinue
13such plan to the commissioner or director. Notice to the
14commissioner or director, at a minimum, shall be no less than
15three days prior to the notice provided for in subparagraph (2)
16to affected individuals.
17(2) Provide notice of its decision not to renew such plan
18to all individuals and to the commissioner or director in each
19state in which an individual under the discontinued plan is
20known to reside, no less than one hundred eighty days prior to
21the nonrenewal of the plan.
22e. The commissioner or director finds that the continuation
23of the coverage is not in the best interests of the
24individuals, or would impair the carrier’s or organized
25delivery system’s ability to meet its contractual obligations.
262. At the time of coverage renewal, a carrier or organized
27delivery system may modify the health insurance coverage for
28a policy form offered to individuals in the individual market
29so long as such modification is consistent with state law and
30effective on a uniform basis among all individuals with that
31policy form.
323. An individual carrier or organized delivery system that
33elects not to renew an individual health benefit plan under
34subsection 1, paragraph “d”, shall not write any new business in
35the individual market in this state for a period of five years
-31-1after the date of notice to the commissioner or director.
24. This section, with respect to a carrier or organized
3delivery system doing business in one established geographic
4service area of the state, applies only to such carrier’s or
5organized delivery system’s operations in that service area.
65. A carrier or organized delivery system offering coverage
7through a network plan is not required to renew or continue in
8force coverage or to accept applications from an individual who
9no longer resides or lives in, or is no longer employed in,
10the service area of such carrier or organized delivery system,
11or no longer resides or lives in, or is no longer employed
12in, a service area for which the carrier is authorized to do
13business, but only if coverage is not offered or terminated
14uniformly without regard to health status-related factors of a
15covered individual.
166. A carrier or organized delivery system offering coverage
17through a bona fide association is not required to renew or
18continue in force coverage or to accept applications from an
19individual through an association if the membership of the
20individual in the association on which the basis of coverage
21is provided ceases, but only if the coverage is not offered or
22terminated under this paragraph uniformly without regard to
23health status-related factors of a covered individual.
247. An individual who has coverage as a dependent under a
25basic or standard health benefit plan may, when that individual
26is no longer a dependent under such coverage, elect to continue
27coverage under the basic or standard health benefit plan if
28the individual so elects immediately upon termination of the
29coverage under which the individual was covered as a dependent.
30 Sec. 53. Section 513C.7, subsection 1, Code 2017, is amended
31to read as follows:
321. a. (1) A carrier shall file with the commissioner, in
33a form and manner prescribed by the commissioner, the basic
34or standard health benefit plan. A basic or standard health
35benefit plan filed pursuant to this paragraph may be used by
-32-1a carrier beginning thirty days after it is filed unless the
2commissioner disapproves of its use.
3(2) b. The commissioner may at any time, after providing
4notice and an opportunity for a hearing to the carrier,
5disapprove the continued use by a carrier of a basic or
6standard health benefit plan on the grounds that the plan does
7not meet the requirements of this chapter.
8b. (1) An organized delivery system shall file with the
9director, in a form and manner prescribed by the director,
10the basic or standard health benefit plan to be used by the
11organized delivery system. A basic or standard health benefit
12plan filed pursuant to this paragraph may be used by the
13organized delivery system beginning thirty days after it is
14filed unless the director disapproves of its use.
15(2) The director may at any time, after providing notice and
16an opportunity for a hearing to the organized delivery system,
17disapprove the continued use by an organized delivery system of
18a basic or standard health benefit plan on the grounds that the
19plan does not meet the requirements of this chapter.
20 Sec. 54. Section 513C.7, subsection 3, Code 2017, is amended
21to read as follows:
223. A carrier or an organized delivery system shall not
23modify a basic or standard health benefit plan with respect
24to an individual or dependent through riders, endorsements,
25or other means to restrict or exclude coverage for certain
26diseases or medical conditions otherwise covered by the health
27benefit plan.
28 Sec. 55. Section 513C.9, subsections 1, 2, 3, 6, and 8, Code
292017, are amended to read as follows:
301. A carrier, an organized delivery system, or an agent
31shall not do either of the following:
32a. Encourage or direct individuals to refrain from
33filing an application for coverage with the carrier or the
34organized delivery system because of the health status, claims
35experience, industry, occupation, or geographic location of the
-33-1individuals.
2b. Encourage or direct individuals to seek coverage from
3another carrier or another organized delivery system because of
4the health status, claims experience, industry, occupation, or
5geographic location of the individuals.
62. Subsection 1, paragraph “a”, shall not apply with respect
7to information provided by a carrier or an organized delivery
8system or an agent to an individual regarding the established
9geographic service area of the carrier or the organized
10delivery system, or the restricted network provision of the
11carrier or the organized delivery system.
123. A carrier or an organized delivery system shall not,
13directly or indirectly, enter into any contract, agreement, or
14arrangement with an agent that provides for, or results in, the
15compensation paid to an agent for a sale of a basic or standard
16health benefit plan to vary because of the health status or
17permitted rating characteristics of the individual or the
18individual’s dependents.
196. Denial by a carrier or an organized delivery system of an
20application for coverage from an individual shall be in writing
21and shall state the reason or reasons for the denial.
228. If a carrier or an organized delivery system enters into
23a contract, agreement, or other arrangement with a third-party
24administrator to provide administrative, marketing, or other
25services related to the offering of individual health benefit
26plans in this state, the third-party administrator is subject
27to this section as if it were a carrier or an organized
28delivery system.
29 Sec. 56. Section 513C.10, subsection 1, paragraph a, Code
302017, is amended to read as follows:
31a. All persons that provide health benefit plans in this
32state including insurers providing accident and sickness
33insurance under chapter 509, 514, or 514A, whether on an
34individual or group basis; fraternal benefit societies
35providing hospital, medical, or nursing benefits under chapter
-34-1512B; and health maintenance organizations, organized delivery
2systems, other entities providing health insurance or health
3benefits subject to state insurance regulation, and all other
4insurers as designated by the board of directors of the Iowa
5comprehensive health insurance association with the approval of
6the commissioner shall be members of the association.
7 Sec. 57. Section 513C.10, subsection 2, paragraph a, Code
82017, is amended to read as follows:
9a. Rates for basic and standard coverages as provided in
10this chapter shall be determined by each carrier or organized
11delivery system as the product of a basic and standard factor
12and the lowest rate available for issuance by that carrier or
13organized delivery system adjusted for rating characteristics
14and benefits. Basic and standard factors shall be established
15annually by the Iowa comprehensive health insurance association
16board with the approval of the commissioner. Multiple basic
17and standard factors for a distinct grouping of basic and
18standard policies may be established. A basic and standard
19factor is limited to a minimum value defined as the ratio
20of the average of the lowest rate available for issuance and
21the maximum rate allowable by law divided by the lowest rate
22available for issuance. A basic and standard factor is limited
23to a maximum value defined as the ratio of the maximum rate
24allowable by law divided by the lowest rate available for
25issuance. The maximum rate allowable by law and the lowest
26rate available for issuance is determined based on the rate
27restrictions under this chapter. For policies written after
28January 1, 2002, rates for the basic and standard coverages
29as provided in this chapter shall be calculated using the
30basic and standard factors and shall be no lower than the
31maximum rate allowable by law. However, to maintain assessable
32loss assessments at or below one percent of total health
33insurance premiums or payments as determined in accordance
34with subsection 6, the Iowa comprehensive health insurance
35association board with the approval of the commissioner may
-35-1increase the value for any basic and standard factor greater
2than the maximum value.
3 Sec. 58. Section 513C.10, subsections 3, 4, 7, 8, 9, and 10,
4Code 2017, are amended to read as follows:
53. Following the close of each calendar year, the
6association, in conjunction with the commissioner, shall
7require each carrier or organized delivery system to report
8the amount of earned premiums and the associated paid losses
9for all basic and standard plans issued by the carrier or
10organized delivery system. The reporting of these amounts must
11be certified by an officer of the carrier or organized delivery
12system.
134. The board shall develop procedures and assessment
14mechanisms and make assessments and distributions as required
15to equalize the individual carrier and organized delivery
16system gains or losses so that each carrier or organized
17delivery system receives the same ratio of paid claims to
18ninety percent of earned premiums as the aggregate of all
19basic and standard plans insured by all carriers and organized
20delivery systems in the state.
217. The board shall develop procedures for distributing
22the assessable loss assessments to each carrier and organized
23delivery system in proportion to the carrier’s and organized
24delivery system’s respective share of premium for basic and
25standard plans to the statewide total premium for all basic and
26standard plans.
278. The board shall ensure that procedures for collecting
28and distributing assessments are as efficient as possible
29for carriers and organized delivery systems. The board may
30establish procedures which combine, or offset, the assessment
31from, and the distribution due to, a carrier or organized
32delivery system.
339. A carrier or an organized delivery system may
34petition the association board to seek remedy from writing a
35significantly disproportionate share of basic and standard
-36-1policies in relation to total premiums written in this state
2for health benefit plans. Upon a finding that a carrier or
3organized delivery system has written a disproportionate share,
4the board may agree to compensate the carrier or organized
5delivery system either by paying to the carrier or organized
6delivery system an additional fee not to exceed two percent
7of earned premiums from basic and standard policies for that
8carrier or organized delivery system or by petitioning the
9commissioner or director, as appropriate, for remedy.
1010. a. The commissioner, upon a finding that the acceptance
11of the offer of basic and standard coverage by individuals
12pursuant to this chapter would place the carrier in a
13financially impaired condition, shall not require the carrier
14to offer coverage or accept applications for any period of time
15the financial impairment is deemed to exist.
16b. The director, upon a finding that the acceptance of the
17offer of basic and standard coverage by individuals pursuant
18to this chapter would place the organized delivery system in a
19financially impaired condition, shall not require the organized
20delivery system to offer coverage or accept applications for
21any period of time the financial impairment is deemed to exist.
22 Sec. 59. Section 514A.3B, subsection 3, paragraph k, Code
232017, is amended by striking the paragraph.
24 Sec. 60. Section 514B.25A, Code 2017, is amended to read as
25follows:
26514B.25A Insolvency protection — assessment.
271. Upon a health maintenance organization or organized
28delivery system authorized to do business in this state and
29licensed by the director of public health being declared
30insolvent by the district court, the commissioner may levy an
31assessment on each health maintenance organization or organized
32delivery system doing business in this state and licensed by
33the director of public health, as applicable, to pay claims
34for uncovered expenditures for enrollees. The commissioner
35shall not assess an amount in any one calendar year which is
-37-1more than two percent of the aggregate premium written by each
2health maintenance organization or organized delivery system.
32. The commissioner may use funds obtained through an
4assessment under subsection 1 to pay claims for uncovered
5expenditures for enrollees of an insolvent health maintenance
6organization or organized delivery system and administrative
7costs. The commissioner, by rule, may prescribe the time,
8manner, and form for filing claims under this section. The
9commissioner may require claims to be allowed by an ancillary
10receiver or the domestic receiver or liquidator.
113. a. A receiver or liquidator of an insolvent health
12maintenance organization or organized delivery system shall
13allow a claim in the proceeding in an amount equal to uncovered
14expenditures and administrative costs paid under this section.
15b. A person receiving benefits under this section for
16uncovered expenditures is deemed to have assigned the rights
17under the covered health care plan certificates to the
18commissioner to the extent of the benefits received. The
19commissioner may require an assignment of such rights by a
20payee, enrollee, or beneficiary, to the commissioner as a
21condition precedent to the receipt of such benefits. The
22commissioner is subrogated to these rights against the assets
23of the insolvent health maintenance organization or organized
24delivery system that are held by a receiver or liquidator of
25a foreign jurisdiction.
26c. The assigned subrogation rights of the commissioner and
27allowed claims under this subsection have the same priority
28against the assets of the insolvent health maintenance
29organization or organized delivery system as those claims of
30persons entitled to receive benefits under this section or for
31similar expenses in the receivership or liquidation.
324. If funds assessed under subsection 1 are unused
33following the completion of the liquidation of an insolvent
34health maintenance organization or organized delivery system,
35the commissioner shall distribute the remaining amounts, if
-38-1such amounts are not de minimis, to the health maintenance
2organizations or organized delivery systems that were assessed.
35. The aggregate coverage of uncovered expenditures under
4this section shall not exceed three hundred thousand dollars
5with respect to one individual. Continuation of coverage
6shall cease after the lesser of one year after the health
7maintenance organization or organized delivery system is
8terminated by insolvency or the remaining term of the contract.
9The commissioner may provide continuation of coverage on a
10reasonable basis, including, but not limited to, continuation
11of the health maintenance organization or organized delivery
12system contract or substitution of indemnity coverage in a form
13as determined by the commissioner.
146. The commissioner may waive an assessment of a health
15maintenance organization or organized delivery system if such
16organization or system is impaired financially or would be
17impaired financially as a result of such assessment. A health
18maintenance organization or organized delivery system that
19fails to pay an assessment within thirty days after notice of
20the assessment is subject to a civil forfeiture of not more
21than one thousand dollars for each day the failure continues,
22and suspension or revocation of its certificate of authority.
23An action taken by the commissioner to enforce an assessment
24under this section may be appealed by the health maintenance
25organization or organized delivery system pursuant to chapter
2617A.
27 Sec. 61. Section 514C.10, subsection 2, paragraph e, Code
282017, is amended by striking the paragraph.
29 Sec. 62. Section 514C.11, Code 2017, is amended to read as
30follows:
31514C.11 Services provided by licensed physician assistants
32and licensed advanced registered nurse practitioners.
331. Notwithstanding section 514C.6, a policy or contract
34providing for third-party payment or prepayment of health or
35medical expenses shall include a provision for the payment of
-39-1necessary medical or surgical care and treatment provided by
2a physician assistant licensed pursuant to chapter 148C, or
3provided by an advanced registered nurse practitioner licensed
4pursuant to chapter 152 and performed within the scope of the
5license of the licensed physician assistant or the licensed
6advanced registered nurse practitioner if the policy or
7contract would pay for the care and treatment if the care and
8treatment were provided by a person engaged in the practice
9of medicine and surgery or osteopathic medicine and surgery
10under chapter 148. The policy or contract shall provide that
11policyholders and subscribers under the policy or contract may
12reject the coverage for services which may be provided by a
13licensed physician assistant or licensed advanced registered
14nurse practitioner if the coverage is rejected for all
15providers of similar services. A policy or contract subject
16to this section shall not impose a practice or supervision
17restriction which is inconsistent with or more restrictive than
18the restriction already imposed by law.
192. This section applies to services provided under a policy
20or contract delivered, issued for delivery, continued, or
21renewed in this state on or after July 1, 1996, and to an
22existing policy or contract, on the policy’s or contract’s
23anniversary or renewal date, or upon the expiration of the
24applicable collective bargaining contract, if any, whichever
25is later. This section does not apply to policyholders or
26subscribers eligible for coverage under Tit.XVIII of the
27federal Social Security Act or any similar coverage under a
28state or federal government plan.
293. For the purposes of this section, third-party payment or
30prepayment includes an individual or group policy of accident
31or health insurance or individual or group hospital or health
32care service contract issued pursuant to chapter 509, 514, or
33514A, an individual or group health maintenance organization
34contract issued and regulated under chapter 514B, an organized
35delivery system contract regulated under rules adopted by the
-40-1director of public health, or a preferred provider organization
2contract regulated pursuant to chapter 514F.
34. Nothing in this section shall be interpreted to require
4an individual or group health maintenance organization, an
5organized delivery system, or a preferred provider organization
6or arrangement to provide payment or prepayment for services
7provided by a licensed physician assistant or licensed advanced
8registered nurse practitioner unless the physician assistant’s
9supervising physician, the physician-physician assistant team,
10the advanced registered nurse practitioner, or the advanced
11registered nurse practitioner’s collaborating physician has
12entered into a contract or other agreement to provide services
13with the individual or group health maintenance organization,
14the organized delivery system, or the preferred provider
15organization or arrangement.
16 Sec. 63. Section 514C.13, subsection 1, paragraph h, Code
172017, is amended by striking the paragraph.
18 Sec. 64. Section 514C.13, subsection 2, Code 2017, is
19amended to read as follows:
202. A carrier or organized delivery system which offers to
21a small employer a limited provider network plan to provide
22health care services or benefits to the small employer’s
23employees shall also offer to the small employer a point of
24service option to the limited provider network plan.
25 Sec. 65. Section 514C.13, subsection 3, unnumbered
26paragraph 1, Code 2017, is amended to read as follows:
27A carrier or organized delivery system which offers to a
28large employer a limited provider network plan to provide
29health care services or benefits to the large employer’s
30employees shall also offer to the large employer one or more
31of the following:
32 Sec. 66. Section 514C.14, subsections 1 and 3, Code 2017,
33are amended to read as follows:
341. Except as provided under subsection 2 or 3, a carrier,
35as defined in section 513B.2, an organized delivery system
-41-1authorized under 1993 Iowa Acts, ch.158, or a plan established
2pursuant to chapter 509A for public employees, which terminates
3its contract with a participating health care provider,
4shall continue to provide coverage under the contract to a
5covered person in the second or third trimester of pregnancy
6for continued care from such health care provider. Such
7persons may continue to receive such treatment or care through
8postpartum care related to the child birth and delivery.
9Payment for covered benefits and benefit levels shall be
10according to the terms and conditions of the contract.
113. A carrier, organized delivery system, or a plan
12established under chapter 509A, which terminates the contract
13of a participating health care provider for cause shall not
14be liable to pay for health care services provided by the
15health care provider to a covered person following the date of
16termination.
17 Sec. 67. Section 514C.15, Code 2017, is amended to read as
18follows:
19514C.15 Treatment options.
20A carrier, as defined in section 513B.2,; an organized
21delivery system authorized under 1993 Iowa Acts, ch.158,
22and licensed by the director of public health; or a plan
23established pursuant to chapter 509A for public employees,
24shall not prohibit a participating provider from, or penalize a
25participating provider for, doing either of the following:
261. Discussing treatment options with a covered individual,
27notwithstanding the carrier’s, organized delivery system’s, or
28plan’s position on such treatment option.
292. Advocating on behalf of a covered individual within
30a review or grievance process established by the carrier,
31organized delivery system, or chapter 509A plan, or established
32by a person contracting with the carrier, organized delivery
33system, or chapter 509A plan.
34 Sec. 68. Section 514C.16, subsection 1, Code 2017, is
35amended to read as follows:
-42- 11. A carrier, as defined in section 513B.2,; an organized
2delivery system authorized under 1993 Iowa Acts, ch.158,
3and licensed by the director of public health; or a plan
4established pursuant to chapter 509A for public employees,
5which provides coverage for emergency services, is responsible
6for charges for emergency services provided to a covered
7individual, including services furnished outside any
8contractual provider network or preferred provider network.
9Coverage for emergency services is subject to the terms and
10conditions of the health benefit plan or contract.
11 Sec. 69. Section 514C.17, subsections 1 and 3, Code 2017,
12are amended to read as follows:
131. Except as provided under subsection 2 or 3, if a carrier,
14as defined in section 513B.2, an organized delivery system
15authorized under 1993 Iowa Acts, ch.158, or a plan established
16pursuant to chapter 509A for public employees, terminates its
17contract with a participating health care provider, a covered
18individual who is undergoing a specified course of treatment
19for a terminal illness or a related condition, with the
20recommendation of the covered individual’s treating physician
21licensed under chapter 148 may continue to receive coverage for
22treatment received from the covered individual’s physician for
23the terminal illness or a related condition, for a period of
24up to ninety days. Payment for covered benefits and benefit
25levels shall be according to the terms and conditions of the
26contract.
273. Notwithstanding subsections 1 and 2, a carrier,
28organized delivery system, or a plan established under chapter
29509A which terminates the contract of a participating health
30care provider for cause shall not be required to cover health
31care services provided by the health care provider to a covered
32person following the date of termination.
33 Sec. 70. Section 514C.18, subsection 2, paragraph a,
34subparagraph (6), Code 2017, is amended by striking the
35subparagraph.
-43-1 Sec. 71. Section 514C.19, subsection 7, paragraph a,
2subparagraph (6), Code 2017, is amended by striking the
3subparagraph.
4 Sec. 72. Section 514C.20, subsection 3, paragraph f, Code
52017, is amended by striking the paragraph.
6 Sec. 73. Section 514C.21, subsection 2, paragraph d, Code
72017, is amended by striking the paragraph.
8 Sec. 74. Section 514C.22, subsection 1, unnumbered
9paragraph 1, Code 2017, is amended to read as follows:
10Notwithstanding the uniformity of treatment requirements of
11section 514C.6, a group policy, contract, or plan providing
12for third-party payment or prepayment of health, medical, and
13surgical coverage benefits issued by a carrier, as defined in
14section 513B.2, or by an organized delivery system authorized
15under 1993 Iowa Acts, ch.158, shall provide coverage benefits
16for treatment of a biologically based mental illness if either
17of the following is satisfied:
18 Sec. 75. Section 514C.22, subsection 6, Code 2017, is
19amended to read as follows:
206. A carrier, organized delivery system, or plan
21established pursuant to chapter 509A may manage the benefits
22provided through common methods including, but not limited to,
23providing payment of benefits or providing care and treatment
24under a capitated payment system, prospective reimbursement
25rate system, utilization control system, incentive system for
26the use of least restrictive and least costly levels of care,
27a preferred provider contract limiting choice of specific
28providers, or any other system, method, or organization
29designed to assure services are medically necessary and
30clinically appropriate.
31 Sec. 76. Section 514C.25, subsection 2, paragraph a,
32subparagraph (5), Code 2017, is amended by striking the
33subparagraph.
34 Sec. 77. Section 514C.26, subsection 5, paragraph a,
35subparagraph (6), Code 2017, is amended by striking the
-44-1subparagraph.
2 Sec. 78. Section 514C.27, subsection 1, unnumbered
3paragraph 1, Code 2017, is amended to read as follows:
4Notwithstanding the uniformity of treatment requirements
5of section 514C.6, a group policy or contract providing for
6third-party payment or prepayment of health or medical expenses
7issued by a carrier, as defined in section 513B.2, or by an
8organized delivery system authorized under 1993 Iowa Acts, ch.
9158, shall provide coverage benefits to an insured who is a
10veteran for treatment of mental illness and substance abuse if
11either of the following is satisfied:
12 Sec. 79. Section 514C.27, subsection 6, Code 2017, is
13amended to read as follows:
146. A carrier, organized delivery system, or plan
15established pursuant to chapter 509A may manage the benefits
16provided through common methods including but not limited to
17providing payment of benefits or providing care and treatment
18under a capitated payment system, prospective reimbursement
19rate system, utilization control system, incentive system for
20the use of least restrictive and least costly levels of care,
21a preferred provider contract limiting choice of specific
22providers, or any other system, method, or organization
23designed to assure services are medically necessary and
24clinically appropriate.
25 Sec. 80. Section 514C.29, subsection 2, paragraph e, Code
262017, is amended by striking the paragraph.
27 Sec. 81. Section 514C.30, subsection 2, paragraph e, Code
282017, is amended by striking the paragraph.
29 Sec. 82. Section 514E.1, subsection 6, paragraph k, Code
302017, is amended by striking the paragraph.
31 Sec. 83. Section 514E.1, subsection 17, Code 2017, is
32amended by striking the subsection.
33 Sec. 84. Section 514E.2, subsection 1, paragraph a, Code
342017, is amended to read as follows:
35a. All carriers and all organized delivery systems licensed
-45-1by the director of public health providing health insurance or
2health care services in Iowa, whether on an individual or group
3basis, and all other insurers designated by the association’s
4board of directors and approved by the commissioner shall be
5members of the association.
6 Sec. 85. Section 514E.2, subsection 2, paragraph a,
7subparagraph (3), Code 2017, is amended to read as follows:
8(3) Two members selected by the members of the association,
9one of whom shall be a representative from a corporation
10operating pursuant to chapter 514 on July 1, 1989, or
11any successor in interest, and one of whom shall be a
12representative of an organized delivery system or an insurer
13providing coverage pursuant to chapter 509 or 514A.
14 Sec. 86. Section 514E.7, subsection 1, paragraph a,
15subparagraphs (1) and (2), Code 2017, are amended to read as
16follows:
17(1) A notice of rejection or refusal to issue substantially
18similar insurance for health reasons by one carrier or
19organized delivery system.
20(2) A refusal by a carrier or organized delivery system to
21issue insurance except at a rate exceeding the plan rate.
22 Sec. 87. Section 514E.7, subsection 1, paragraph b, Code
232017, is amended to read as follows:
24b. A rejection or refusal by a carrier or organized delivery
25system offering only stoploss, excess of loss, or reinsurance
26coverage with respect to an applicant under paragraph “a”,
27 subparagraphs (1) and (2), is not sufficient evidence for
28purposes of this subsection.
29 Sec. 88. Section 514E.9, Code 2017, is amended to read as
30follows:
31514E.9 Rules.
32Pursuant to chapter 17A, the commissioner and the director
33of public health shall adopt rules to provide for disclosure
34by carriers and organized delivery systems of the availability
35of insurance coverage from the association, and to otherwise
-46-1implement this chapter.
2 Sec. 89. Section 514E.11, Code 2017, is amended to read as
3follows:
4514E.11 Notice of association policy.
5Every carrier, including a health maintenance organization
6subject to chapter 514B and an organized delivery system,
7authorized to provide health care insurance or coverage for
8health care services in Iowa, shall provide a notice of the
9availability of coverage by the association to any person
10who receives a rejection of coverage for health insurance
11or health care services, or a rate for health insurance or
12coverage for health care services that will exceed the rate of
13an association policy, and that person is eligible to apply
14for health insurance provided by the association. Application
15for the health insurance shall be on forms prescribed by the
16association’s board of directors and made available to the
17carriers and organized delivery systems and other entities
18providing health care insurance or coverage for health care
19services regulated by the commissioner.
20 Sec. 90. Section 514F.5, Code 2017, is amended to read as
21follows:
22514F.5 Experimental treatment review.
231. A carrier, as defined in section 513B.2, an organized
24delivery system authorized under 1993 Iowa Acts, ch.158, or a
25plan established pursuant to chapter 509A for public employees,
26that limits coverage for experimental medical treatment, drugs,
27or devices, shall develop and implement a procedure to evaluate
28experimental medical treatments and shall submit a description
29of the procedure to the division of insurance. The procedure
30shall be in writing and must describe the process used to
31determine whether the carrier, organized delivery system,
32 or chapter 509A plan will provide coverage for new medical
33technologies and new uses of existing technologies. The
34procedure, at a minimum, shall require a review of information
35from appropriate government regulatory agencies and published
-47-1scientific literature concerning new medical technologies, new
2uses of existing technologies, and the use of external experts
3in making decisions. A carrier, organized delivery system,
4 or chapter 509A plan shall include appropriately licensed
5or qualified professionals in the evaluation process. The
6procedure shall provide a process for a person covered under
7a plan or contract to request a review of a denial of coverage
8because the proposed treatment is experimental. A review of
9a particular treatment need not be reviewed more than once a
10year.
112. A carrier, organized delivery system, or chapter 509A
12plan that limits coverage for experimental treatment, drugs, or
13devices shall clearly disclose such limitations in a contract,
14policy, or certificate of coverage.
15 Sec. 91. Section 514I.2, subsection 10, Code 2017, is
16amended to read as follows:
1710. “Participating insurer” means any entity licensed by the
18division of insurance of the department of commerce to provide
19health insurance in Iowa or an organized delivery system
20licensed by the director of public health that has contracted
21with the department to provide health insurance coverage to
22eligible children under this chapter.
23 Sec. 92. Section 514J.102, subsection 24, Code 2017, is
24amended to read as follows:
2524. “Health carrier” means an entity subject to the
26insurance laws and regulations of this state, or subject
27to the jurisdiction of the commissioner, including an
28insurance company offering sickness and accident plans, a
29health maintenance organization, a nonprofit health service
30corporation, a plan established pursuant to chapter 509A
31for public employees, or any other entity providing a plan
32of health insurance, health care benefits, or health care
33services. “Health carrier” includes, for purposes of this
34chapter, an organized delivery system.
35 Sec. 93. Section 514J.102, subsection 29, Code 2017, is
-48-1amended by striking the subsection.
2 Sec. 94. Section 514K.1, subsection 1, unnumbered paragraph
31, Code 2017, is amended to read as follows:
4A health maintenance organization, an organized delivery
5system, or an insurer using a preferred provider arrangement
6shall provide to each of its enrollees at the time of
7enrollment, and shall make available to each prospective
8enrollee upon request, written information as required by rules
9adopted by the commissioner and the director of public health.
10The information required by rule shall include, but not be
11limited to, all of the following:
12 Sec. 95. Section 514K.1, subsection 2, Code 2017, is amended
13to read as follows:
142. The commissioner and the director shall annually publish
15a consumer guide providing a comparison by plan on performance
16measures, network composition, and other key information to
17enable consumers to better understand plan differences.
18 Sec. 96. Section 514L.1, subsection 3, Code 2017, is amended
19to read as follows:
203. “Provider of third-party payment or prepayment of
21prescription drug expenses” or “provider” means a provider of an
22individual or group policy of accident or health insurance or
23an individual or group hospital or health care service contract
24issued pursuant to chapter 509, 514, or 514A, a provider of a
25plan established pursuant to chapter 509A for public employees,
26a provider of an individual or group health maintenance
27organization contract issued and regulated under chapter 514B,
28a provider of an organized delivery system contract regulated
29under rules adopted by the director of public health, a
30provider of a preferred provider contract issued pursuant to
31chapter 514F, a provider of a self-insured multiple employer
32welfare arrangement, and any other entity providing health
33insurance or health benefits which provide for payment or
34prepayment of prescription drug expenses coverage subject to
35state insurance regulation.
-49-1 Sec. 97. Section 514L.2, subsection 1, paragraph a,
2unnumbered paragraph 1, Code 2017, is amended to read as
3follows:
4A provider of third-party payment or prepayment of
5prescription drug expenses, including the provider’s agents or
6contractors and pharmacy benefits managers, that issues a card
7or other technology for claims processing and an administrator
8of the payor, excluding administrators of self-funded employer
9sponsored health benefit plans qualified under the federal
10Employee Retirement Income Security Act of 1974, shall issue
11to its insureds a card or other technology containing uniform
12prescription drug information. The commissioner of insurance
13shall adopt rules for the uniform prescription drug information
14card or technology applicable to those entities subject to
15regulation by the commissioner of insurance. The director of
16public health shall adopt rules for the uniform prescription
17drug information card or technology applicable to organized
18delivery systems. The rules shall require at least both of the
19following regarding the card or technology:
20 Sec. 98. Section 521F.2, subsection 7, Code 2017, is amended
21to read as follows:
227. “Health organization” means a health maintenance
23organization, limited service organization, dental or vision
24plan, hospital, medical and dental indemnity or service
25corporation or other managed care organization licensed under
26chapter 514, or 514B, or 1993 Iowa Acts, ch.158, or any other
27entity engaged in the business of insurance, risk transfer,
28or risk retention, that is subject to the jurisdiction of the
29commissioner of insurance or the director of public health.
30“Health organization” does not include an insurance company
31licensed to transact the business of insurance under chapter
32508, 515, or 520, and which is otherwise subject to chapter
33521E.
34 Sec. 99. 1993 Iowa Acts, chapter 158, section 4, is amended
35to read as follows:
-50- 1SEC. 4. EMERGENCY RULES. Pursuant to sections 1, and 2, and
23 of this Act, the commissioner of insurance or the director of
3public health shall adopt administrative rules under section
417A.4, subsection 2, and section 17A.5, subsection 2, paragraph
5“b”, to implement the provisions of this Act and the rules
6shall become effective immediately upon filing, unless a later
7effective date is specified in the rules. Any rules adopted in
8accordance with the provisions of this section shall also be
9published as notice of intended action as provided in section
1017A.4.
11 Sec. 100. REPEAL. Section 135.120, Code 2017, is repealed.
12 Sec. 101. REPEAL. 1993 Iowa Acts, chapter 158, section 3,
13is repealed.
14 Sec. 102. CODE EDITOR’S DIRECTIVE. The Code editor shall
15correct and eliminate any references to the term “organized
16delivery system” or other forms of the term anywhere else in
17the Iowa Code or Iowa Code Supplement, in any bills awaiting
18codification, in this Act, and in any bills enacted by the
19Eighty-seventh General Assembly, 2017 Regular Session, or any
20extraordinary session.
21EXPLANATION
22The inclusion of this explanation does not constitute agreement with
23the explanation’s substance by the members of the general assembly.
24This bill relates to programs and activities under the
25purview of the department of public health (DPH).
26Division I of the bill relates to program funding
27flexibility and reporting.
28The bill provides that if the amount of estimated moneys to
29be received from certain liquor fees and retail beer permit
30fees that is transferred to DPH annually for grants to counties
31operating a substance abuse program exceeds grant requests,
32in addition to using the remainder for grants to entities to
33operate a substance abuse prevention program, DPH may also use
34the remainder for activities and public information resources
35that align with best practices for substance-related disorder
-51-1prevention.
2The bill eliminates the requirement under Code section
3135.11, subsection 31, that DPH report to the chairpersons and
4ranking members of the joint appropriations subcommittee on
5health and human services, the legislative services agency, the
6legislative caucus staffs, and the department of management
7within 60 calendar days of applying for or renewing a federal
8grant which requires a state match or maintenance of effort
9and has a value of over $100,000, including a listing of
10the federal funding source and the potential need for the
11commitment of state funding in the present or future.
12The bill amends Code section 135.150 to require DPH to report
13annually rather than semiannually to the general assembly’s
14standing committees on government oversight regarding
15the operation of the gambling treatment program including
16information on the moneys expended and grants awarded for
17operation of the program.
18Division II of the bill relates to medical home and the
19patient-centered health advisory council.
20The bill amends provisions relating to medical homes.
21Code sections 135.157 and 135.158, providing definitions and
22describing the purposes and characteristics of medical homes,
23are repealed by the bill. Code section 135.159 provides
24parameters for the development and implementation of a medical
25home system in the state, as well as the establishment of the
26patient-centered health advisory council. The bill amends
27Code section 135.159 to provide for the continuation of the
28patient-centered health advisory council and to revise the
29purposes of the council.
30The bill also makes conforming changes throughout the Code,
31including those relative to the definitions of “medical home”,
32“personal provider”, and “primary medical provider”, due to
33elimination of certain definitions and concepts based upon the
34repeal of Code sections 135.157 and 135.158.
35Division III of the bill includes provisions relating to
-52-1workforce programming.
2The bill amends Code section 135.107 relating to the center
3for rural health and primary care. Of the programs that
4constitute the primary care provider recruitment and retention
5endeavor or PRIMECARRE, the bill eliminates the primary care
6provider community scholarship program, but retains the primary
7care loan repayment program and the community grant program
8that is renamed the health care workforce and community support
9grant program. The bill amends the application and matching
10funds requirements for a grant under the health care workforce
11and community support grant program and specifies that the
12target areas for awarding of such grants are rural, underserved
13areas or special populations identified by the department’s
14strategic plan or evidence-based documentation.
15The bill provides that the primary care provider loan
16repayment program may cancel a loan repayment program contract
17for reasonable cause unless federal requirements otherwise
18require and provides that the center for rural health and
19primary care may enter into an agreement under Code chapter 28E
20with the college student aid commission for administration of
21the center’s grant and loan repayment programs.
22The bill eliminates the requirement that a community or
23region applying for assistance under any of the programs
24established under PRIMECARRE submit a letter of intent to
25conduct a community health services assessment and instead
26requires that the community or region shall document
27participation in the community health services assessment. In
28addition to any other requirements, an applicant’s plan is
29also to include, to the extent possible, a clear commitment to
30informing high school students of the health care opportunities
31which may be available to such students.
32The bill removes the representation by the obsolete rural
33health resource center on the advisory committee to the center
34for rural health and primary care and corrects the reference to
35a national or regional institute for rural health policy.
-53- 1The bill eliminates the reference to “long-term care” in
2Code section 135.163 which directs DPH to coordinate public and
3private efforts to develop and maintain an appropriate health
4care delivery infrastructure and a stable, well-qualified,
5diverse, and sustainable health care workforce in this state.
6Under this section, DPH is required, at a minimum, to develop
7a strategic plan for health care delivery infrastructure and
8health care workforce resources in this state; provide for
9the continuous collection of data to provide a basis for
10health care strategic planning and health care policymaking;
11and make recommendations regarding the health care delivery
12infrastructure and the health care workforce that assist
13in monitoring current needs, predicting future trends, and
14informing policymaking.
15The bill amends Code section 135.175 relating to the health
16care workforce support initiative, the workforce shortage fund,
17and the accounts within the fund. The bill provides that
18state programs that may receive moneys from the fund or the
19accounts in the fund, if specifically designated for drawing
20down federal funding, include PRIMECARRE, the Iowa affiliate
21of the national rural recruitment and retention network, the
22oral and health delivery systems bureau of the department,
23the primary care office and shortage designation program, and
24the state office of rural health, but eliminates inclusion of
25the Iowa health workforce center, the area health education
26centers programs at Des Moines university osteopathic medical
27center and the university of Iowa, and the Iowa collaborative
28safety net provider network as potential recipients. The bill
29also eliminates the requirement that state appropriations to
30the fund shall be allocated in equal amounts to each of the
31accounts within the fund, unless otherwise specified in the
32appropriation or allocation, and eliminates the restriction
33that moneys in each of the accounts in the fund used for
34administrative purposes are not to exceed $100,000 in each
35account, but retains the limitation that no more than 5 percent
-54-1of the moneys in any of the accounts within the fund shall be
2used for administrative purposes unless otherwise provided in
3the appropriation, allocation, or source of the funds.
4The bill repeals Code section 135.164 which relates to the
5health care delivery infrastructure and health care workforce
6resources strategic plan to be developed by DPH including the
7specific elements of the strategic plan and the requirements
8for developing the strategic plan.
9The bill repeals Code section 135.180, the mental health
10professional shortage area program, which provides stipends to
11support psychiatrist positions with an emphasis on securing and
12retaining medical directors at community mental health centers
13designated under Code chapter 230A and hospital psychiatric
14units that are located in mental health professional shortage
15areas.
16Division IV of the bill relates to unfunded or outdated
17program provisions.
18The bill eliminates the provision under Code section 135.11
19requiring DPH to establish and administer a substance abuse
20treatment facility for persons on probation, repeals Code
21section 135.130, and strikes the conforming provision in Code
22section 901B.1. The substance abuse treatment facility for
23persons on probation was authorized in 2001 but was never
24established.
25The bill strikes the directive in Code section 135.141 for
26the division of acute disease prevention and emergency response
27of DPH to conduct and maintain a statewide risk assessment
28of any present or potential danger to the public health from
29biological agents.
30The bill repeals Code section 135.26 establishing the
31automated external defibrillator (AED) grant program to provide
32matching fund grants to local boards of health, community
33organizations, or cities to implement AED programs.
34The bill repeals Code section 135.29, relating to local
35substitute medical decision-making boards, which authorized
-55-1each county to establish and fund a local substituted medical
2decision-making board to act as a substitute decision maker for
3patients incapable of making their own medical care decisions
4if no other substitute decision maker is available to act.
5The bill repeals Code section 135.120, relating to the
6taxation of organized delivery systems (ODSs). 1993 Iowa
7Acts, chapter 158, section 3, directs DPH to adopt rules and a
8licensing procedure for the establishment of ODSs. The bill
9only eliminates the provision for taxation of ODSs, not all
10other provisions relating to ODSs.
11The bill repeals Code section 135.152, the statewide
12obstetrical and newborn indigent patient care program. The
13program acts as a payer of last resort for eligible individuals
14but has not been utilized since 2009 due to other options
15for coverage including through the Medicaid program and the
16Affordable Care Act for otherwise eligible individuals.
17Division V includes miscellaneous provisions.
18The bill amends the definition of “local board of health” in
19Code section 135A.2 under the public health modernization Act
20to be consistent with the definition under Code chapter 137,
21relating to local boards of health.
22The bill repeals Code section 135.132, the interagency
23pharmaceuticals bulk purchasing council. The provision was
24enacted in 2003, but the council was never established.
25Division VI relates to the Iowa health information
26network. Legislation was enacted in 2015 Iowa Acts, chapter
2773, to provide for the future assumption of the Iowa health
28information network by a designated entity. The bill
29includes a conforming change that would take effect upon
30future assumption of the Iowa health information network by a
31designated entity.
32Division VII relates to organized delivery systems that are
33regulated by DPH. Organized delivery systems were created
34pursuant to 1993 Iowa Acts, chapter 158. Rules adopted
35under the provision define an organized delivery system as
-56-1“an organization with defined governance that is responsible
2for delivering or arranging to deliver the full range of
3health care services covered under a standard benefit plan
4and is accountable to the public for the cost, quality and
5access of its services and for the effect of its services
6on their health.” (641 IAC 201.2) An organization operating
7as an organized delivery system is required to assume risk
8and be subject to solvency standards. The bill eliminates
9all references to organized delivery systems in the Code and
10repeals the provision in the Acts authorizing the establishment
11of organized delivery systems. The most recent application for
12licensure was received by DPH in 1998. Since being authorized
13in 1993, only two entities applied for licensure as organized
14delivery systems and both of these entities have since ceased
15operations.
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