Iowa Administrative Code

Partnership Program Notice Important Consumer Information Regarding the Iowa Long-Term Care Partnership Program Some long-term care insurance policies or certificates sold in Iowa may qualify for the Iowa Long- Term Care Partnership Program (the Partnership Program). The Partners…

Partnership Status Disclosure Notice Important Information Regarding Your Policy’s or Certificate’s Long-Term Care Partnership Status This disclosure notice is issued in conjunction with your long-term care policy. Some long-term care insurance policies or certificates sold in Io…

approval to use as a substitute for Appendix J. [ARC 8271B, IAB 11/4/09, effective 12/9/09; ARC 5598C, IAB 5/5/21, effective 6/9/21]

The purpose of this chapter is to implement Iowa Code chapter 514G, to promote the availability of long-term care insurance coverage, to protect applicants for long-term care insurance, as defined, from unfair or deceptive sales or enrollment practices, to facilitate public under…

39.10(1) No insurer may offer a long-term care insurance policy unless the insurer also offers to the policyholder, in addition to any other inflation protection offers, the option to purchase a policy that provides for benefit levels to increase with benefit maximums or reasonab…

39.11(1) Application forms shall include the following questions designed to elicit information whether, as of the date of the application, the applicant has another long-term care insurance policy or certificate in force or whether a long-term care policy or certificate is inten…

39.12(1) When long-term care benefits are provided through the acceleration of benefits under group or individual life policies or riders to such policies, policy reserves for such benefits shall be determined in accordance with Iowa Code section 508.36(3)“a”(7). Claim reserves m…

39.13(1) Applicability. This rule shall apply to all long-term care insurance policies or certificates except those covered under rules 191—39.26(514G) and 191—39.28(514G). 39.13(2) Minimum loss ratio. Benefits under long-term care insurance policies shall be deemed reasonable in…

Prior to an insurer or similar organization’s offering group long- term care insurance to a resident of this state pursuant to Iowa Code section 514G.103(9)“d,” it shall file with the commissioner evidence that the group policy or certificate thereunder has been approved by a sta…

39.15(1) Every insurer, health care service plan or other entity marketing long-term care insurance coverage in this state, directly or through its producers, shall: a. Establish marketing procedures to ensure that any comparison of policies by its producers or by other producers…

39.16(1) This rule shall not apply to life insurance policies that accelerate benefits for long-term care. 39.16(2) Every insurer, health care service plan or other entity marketing long-term care insurance (the “issuer”) shall: a. Develop and use suitability standards to determi…

If a long-term care insurance policy or certificate replaces another long-term care policy or certificate, the replacing insurer shall waive any time periods applicable to preexisting conditions and probationary periods in the new long-term care policy for similar benefits to the…

This rule, which is not applicable to life policies with long-term care riders attached, implements, interprets and makes specific the provisions of Iowa Code section 514G.105 in prescribing a standard format and the content of an outline of coverage. 39.18(1) An outline of cover…

39.19(1) A long-term care insurance shopper’s guide in the format developed by the National Association of Insurance Commissioners, the Blue Cross and Blue Shield Association, the Health Insurance Association of America or the senior health insurance information program of the in…

This chapter is issued pursuant to the authority vested in the commissioner under Iowa Code section 514G.105 in accordance with the procedures set forth in Iowa Code chapter 17A. [ARC 5598C, IAB 5/5/21, effective 6/9/21]

39.20(1) If an application for a long-term care insurance contract or certificate is approved, the issuer shall deliver the contract or certificate of insurance to the applicant no later than 30 days after the date of approval. 39.20(2) At the time of policy delivery, a policy su…

Any time a long-term care benefit, funded through life insurance which by the acceleration of the death benefit is in benefit payment status, a monthly report shall be provided to the policyholder. The report shall include: 1. Any long-term care benefits paid out during the month…

39.22(1) Notice before lapse or termination. No individual long-term care policy or certificate shall be issued until the insurer has received from the applicant either: a written designation of at least one person, in addition to the applicant, who is to receive notice of lapse …

If a claim under a long-term care insurance contract is denied, the issuer shall, within 60 days of the date of a written request by the policyholder or certificate holder, or a representative thereof, provide a written explanation of the reasons for the denial; and make availabl…

39.24(1) For a policy or certificate that has been in force for less than six months, an insurer may rescind a long-term care insurance policy or certificate or deny an otherwise valid long-term care insurance claim upon a showing of misrepresentation that is material to the acce…

39.25(1) Applicability. This rule applies to any new long-term care policy or certificate issued in this state on or after February 1, 2003. For certificates issued under a group long-term care insurance policy which policy was in force prior to February 1, 2003, the provisions o…

39.26(1) Effective date. This rule applies to any long-term care policy issued in this state on or after February 1, 2003. 39.26(2) Required filing. An insurer shall provide the information listed in this subrule to the commissioner pursuant to rule 191—20.1(505,509,514A,515,515A…

39.27(1) Every insurer shall maintain for each producer records of that producer’s amount of replacement sales as a percent of the producer’s total annual sales and the amount of lapses of long-term care insurance policies sold by the producer as a percent of the producer’s total…

39.28(1) This rule applies to any long-term care policy or certificate issued in this state on or after February 1, 2003. For certificates issued under a group long-term care insurance policy which policy was in force on February 1, 2003, the provisions of this rule shall apply o…

39.29(1) Except as provided in subrule 39.29(2), a long-term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture b…

Except as otherwise specifically provided, this chapter applies to all long-term care insurance policies and long-term care coverage arrangements delivered or issued for delivery in this state on or after the effective date hereof, by insurers, fraternal benefit societies, nonpro…

39.30(1) A long-term care insurance policy shall condition the payment of benefits on a determination of the insured’s ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits shall not be more restrictive than requiring e…

39.31(1) For purposes of this rule, the following definitions apply: “Chronically ill individual” has the meaning prescribed for this term by Section 7702B(c)(2) of the Internal Revenue Code of 1986. Under this provision, a chronically ill individual means any individual who has …

Violations of this chapter shall be subject to the penalties imposed under Iowa Code chapter 507B.

39.33(1) Purpose and definitions. a. Purpose. The purpose of this rule is to clarify the authorized methods of delivery for notices of cancellation, nonrenewal or termination by an insurer, so as to implement the various policyholder protections intended by Iowa Code section 514G…

For the purpose of these rules, the terms “Group long-term care insurance,” “Commissioner,” “Applicant,” “Policy,” “Preexisting condition” and “Certificate” shall have the meanings set forth in Iowa Code chapter 514G, “Long-Term Care Insurance Act.” “Long-term care insurance” mea…

This division is intended to implement Iowa Code chapter 514G to provide a uniform process for insureds covered under long-term care insurance to request an independent review of a denial of coverage based on a benefit trigger determination. [ARC 5598C, IAB 5/5/21, effective 6/9/…

The rules contained in this division shall apply to all requests for benefit trigger determinations made on or after January 1, 2009.

For purposes of this division, the definitions found in Iowa Code section 514G.103 shall apply. [ARC 5598C, IAB 5/5/21, effective 6/9/21]

The notice required by Iowa Code section 514G.109 shall contain the following information: 1. The reason that the insurer determined that the policy benefit trigger has not been met by the insured. 2. A description of the internal appeal mechanism provided under the long-term car…

Upon the conclusion of the internal appeal mechanism specified in Iowa Code section 514G.109(2), the notice required in Iowa Code section 514G.110(2)“b” and “c” shall contain the following information: 39.45(1) A description of additional internal appeal rights, if any, offered b…

The insured shall send a copy of the insurer’s notice explaining why the benefit trigger has not been met, with the insured’s request for an independent review, to the insurance commissioner within 60 days of receipt of the benefit trigger determination. The notice shall be sent …

39.47(1) The commissioner shall provide written notice of the certification decision to the insurer and the insured within the two-business-day period specified in Iowa Code section 514G.110. 39.47(2) The insurer may appeal the commissioner’s certification decision within three b…

39.48(1) Within three business days of receiving the commissioner’s certification decision, the insurer shall: a. Select an independent review entity from the list certified by the commissioner; b. Notify the insured in writing of the name, address, and telephone number of the in…

39.49(1) Within five business days of receiving either the notice provided in paragraph 39.48(1)“b,” or the denial of an objection made pursuant to subrule 39.48(3), whichever is later, the insured may submit any additional information or documentation in support of the insured’s…

No long-term care insurance policy delivered or issued for delivery in this state shall use the terms set forth below, unless the terms are defined in the policy and the definitions satisfy the following requirements: 39.5(1) “Medicare” shall be defined as “The Health Insurance f…

39.50(1) The independent review entity shall immediately notify the insurer, the insured, and the commissioner of the independent review decision either affirming or overturning the insurer’s benefit trigger determination. The initial notification shall be delivered by telephone …

39.51(1) No later than January 1, 2009, each insurer delivering or issuing for delivery long-term care insurance policies in this state on or after July 1, 2008, and each insurer that has active long-term care policies or riders under which claims for benefits may be made on or a…

The following minimum standards are required for certification as an independent review entity: 39.52(1) The entity shall ensure that any licensed health care professional on its staff who participates in an independent review proceeding holds a current unrestricted license or ce…

The independent review entity shall develop and maintain written policies and procedures governing all aspects of the independent review process. The written policies and procedures include, but are not limited to, the following: 39.53(1) Procedures to ensure that independent rev…

The independent review entity shall establish a toll-free telephone service to receive information relating to independent reviews pursuant to this division and Iowa Code chapter 514G. The system shall include a procedure to ensure the capability of accepting, recording, or provi…

The independent review entity shall provide the commissioner such data, information, and reports as the commissioner determines necessary to evaluate the independent review process established under Iowa Code chapter 514G. An application for certification as an independent review…