Iowa Administrative Code

36.7(1) General rules. a. Each individual policy of accident and sickness insurance or hospital, medical, or dental service corporation subscriber contract shall include a renewal, continuation, or nonrenewal provision. The language or specifications of the provision must be cons…

36.8(1) Application forms shall include a question designed to elicit information as to whether the insurance to be issued is intended to replace any other accident and sickness insurance presently in force. A supplementary application or other form to be signed by the applicant …

36.9(1) Rate filing. Every policy, rider or endorsement form affecting benefits which is submitted for approval shall be accompanied by a rate filing unless such rider or endorsement form does not require a change in a rate. Any subsequent addition to or change in rates applicabl…

MEDICARE SUPPLEMENT REFUND CALCULATION FORM FOR CALENDAR YEAR ______ TYPE1 __________________________________________ SMSBP2 ___________________________ For the State of ___________________________________ Company Name _____________________ NAIC Group Code _______________________…

DISCLOSURE STATEMENTS Instructions for Use of the Disclosure Statements for Health Insurance Policies Sold to Medicare Beneficiaries that Duplicate Medicare Benefits 1. Section 1882(d) of the federal Social Security Act [42 U.S.C. 1395ss] prohibits the sale of a health insurance …

STATEMENTS AND QUESTIONS FOR APPLICATION FORMS RELATED TO DUPLICATE OR REPLACEMENT COVERAGE Statements (1) You do not need more than one Medicare supplement policy. (2) If you purchase this [policy or certificate], you may want to evaluate your existing health coverage and decide…

NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE [Insurance company’s name and address] SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to [your application] [information you have furnished], you intend to term…

[ARC 4394C, IAB 4/10/19, effective 5/15/19]

FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES OR CERTIFICATES Pursuant to Iowa Administrative Code rule 191—37.32(514D) Company Name: ___________________________________________ Address: ___________________________________________ ___________________________________________ Pho…

The purpose of this chapter is to provide for the reasonable standardization of coverage and simplification of terms and benefits of Medicare supplement policies; to facilitate public understanding and comparison of such policies; to eliminate provisions contained in such policie…

37.2(1) Applicability and scope. a. Except as otherwise specifically provided in rules 191—37.6(514D), 191—37.22(514D), 191—37.23(514D), 191—37.28(514D) and 191—37.32(514D), this chapter shall apply to: (1) All Medicare supplement individual or group policies delivered or issued …

37.20(1) Applicability of this rule. a. Rule 191—37.20(514D) shall apply to Medicare Select policies and certificates, as defined in this rule. b. No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this rule. …

37.21(1) Denial of policy for health reason prohibited. No issuer shall deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this state, or discriminate in the pricing of such a Medicare supplement policy or certif…

37.22(1) Compliance with OBRA. An issuer shall comply with Section 1882(c)(3) of the Social Security Act (as enacted by Section 4081(b)(2)(C) of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203) by: a. Accepting a notice from an issuer on dually assi…

37.23(1) Definitions. For the purposes of this rule: “Health care expenses” means expenses of health maintenance organizations associated with the delivery of health care services, which expenses are analogous to incurred losses of issuers. “Type” means one of the following: an i…

37.24(1) Definition. For the purposes of this rule: “Type” means one of the following: an individual policy, a group policy, an individual Medicare Select policy, or a group Medicare Select policy. 37.24(2) Form filing and approval required. An issuer shall not deliver or issue f…

37.25(1) Definition of “compensation.” For purposes of this rule: “Compensation” includes pecuniary or nonpecuniary remuneration of any kind relating to the sale or renewal of the Medicare supplement or Medicare Select policy or certificate including, but not limited to, bonuses,…

37.26(1) Issuer required to disclose that a policy is not a Medicare supplement policy. An issuer of any accident and sickness insurance policy or certificate issued for delivery in this state to a person eligible for Medicare shall notify the insured under the policy that the po…

37.27(1) Application to include Appendix C. Application forms for Medicare supplement policies or certificates shall include in the outline of coverage the “statements and questions for application forms related to duplicate or replacement coverage” set forth in Appendix C, in th…

37.28(1) General rules. a. A Medicare supplement policy or certificate shall include renewal or continuation provisions. The language or specifications of such provisions shall be consistent with the type of Medicare supplement policy issued. Such provisions shall be appropriatel…

For purposes of this chapter, in addition to the definitions in Iowa Code section 514D.2, the following definitions shall apply, unless otherwise specified: “1990 standardized Medicare supplement benefit plan” or “1990 plan” means a group or individual Medicare supplement policy …

37.30(1) Requirements for marketing. An issuer, directly or through its producers, shall: a. Establish marketing procedures to ensure that any comparison of policies or certificates by its producers will be fair and accurate. b. Establish marketing procedures to ensure excessive …

37.31(1) Appropriateness. In recommending the purchase or replacement of any Medicare supplement policy or certificate, a producer shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement. 37.31(2) No duplication. Any sale of a Medic…

37.32(1) Report of in-force Medicare supplement covered individuals. On or before March 1 of each year, an issuer shall report, using the format of Appendix F, the following information for every covered individual resident of this state for which the issuer has in force more tha…

37.33(1) Time credited from prior policy or certificate. If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination…

This rule applies to all Medicare supplement policies or certificates with policy years beginning on or after May 21, 2009. 37.34(1) Definitions. For the purposes of this rule, the following definitions shall apply: “Family member” means, with respect to an individual, any other …

The Senior Health Insurance Information Program (SHIIP) may prepare a consumer Medicare supplement insurance premium guide and benefits comparison guide. This guide and the SHIIP name or logo shall not be used in the solicitation or sale of health insurance products. Violation of…

37.36(1) Definition of “Medicare Advantage organization.” For purposes of this rule: “Medicare Advantage organization” means a private company that has a contract with Medicare to provide Medicare Advantage plans and benefits to individuals. 37.36(2) Guaranteed issue. a. Eligible…

No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this rule. “Accident,” “accidental injury…

37.5(1) Coverage restrictions related to Medicare. Except for permitted preexisting condition clauses as described in paragraphs 37.6(1)“a,” 37.7(1)“d,” and 37.8(1)“d,” no policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supple…

37.50(1) Purpose. The purpose of this rule is to provide prospective purchasers with clear and unambiguous statements in the advertisement of Medicare supplement insurance and to ensure the clear and truthful disclosure of the benefits, limitations and exclusions of policies sold…

If any provisions of this chapter or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the chapter and the application of such provision to other persons or circumstances shall not be affected thereby. [ARC 4394C, IAB 4/1…

No policy or certificate may be advertised, solicited or issued for delivery in this state as a prestandardized plan policy or certificate unless it meets or exceeds the following minimum standards. These are minimum standards and do not preclude the inclusion of other provisions…

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state on or after January 1, 1992, and with an effective date for coverage prior to June 1, 2010. No policy or certificate may be advertised, solici…

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy or certificate was to be advertised, solicited, delivered, or issued f…

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires that the following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state to individuals newly eligible for Medicare on or after January …

38.12(1) The purpose of this chapter is to adopt the new model provisions for coordination of benefits (COB) as promulgated by the National Association of Insurance Commissioners (NAIC). 38.12(2) This division is intended to establish a uniform order of benefit determination unde…

As used in this division, these terms have the following meanings, unless the context clearly indicates otherwise: “Allowable expense,” except as set forth below or where a statute requires a different definition, means any health care expense, including coinsurance or copayments…

38.14(1) Appendix A of this division contains a model COB provision for use in contracts. The use of this model COB provision is subject to the provisions of subrules 38.14(2) through 38.14(4) and to rule 38.15(509,514). 38.14(2) Appendix B of this division is a plain language de…

When a person is covered by two or more plans, the order of benefit payments shall be determined as follows: 38.15(1) Primary plans. The primary plan shall pay or provide its benefits as if the secondary plan or plans do not exist. a. If the primary plan is a closed panel plan an…

In determining the amount to be paid by the secondary plan on a claim, should the plan wish to coordinate benefits, the secondary plan shall calculate the benefits it would have paid on the claim in the absence of other health care coverage and apply that calculated amount to any…

A plan shall, in its explanation of benefits provided to covered persons, include the following language: “If you are covered by more than one health benefit plan, you should file all your claims with each plan.”

38.18(1) A secondary plan that provides benefits in the form of services may recover the reasonable cash value of the services from the primary plan, to the extent that benefits for the services are covered by the primary plan and have not already been paid or provided by the pri…

[ARC 5598C, IAB 5/5/21, effective 6/9/21]

Long-Term Care Insurance Personal Worksheet People buy long-term care insurance for many reasons. Some don’t want to use their own assets to pay for long-term care. Some buy insurance to make sure they can choose the type of care they get. Others don’t want their family to have t…

Things You Should Know Before You Buy Long-Term Care Insurance Long-Term Care • A long-term care insurance policy may pay most of the costs for your care in a nursing home. Many policies also pay for care at home or Insurance other community settings. Since policies can vary in c…

Long-Term Care Insurance Suitability Letter Dear [Applicant]: Your recent application for long-term care insurance included a “personal worksheet,” which asked questions about your finances and your reasons for buying long-term care insurance. For your protection, state law requi…