Iowa Administrative Code

The rules in this division shall apply to all long-term care partnership policies or certificates sold or issued for delivery on or after January 1, 2010. [ARC 8271B, IAB 11/4/09, effective 12/9/09; ARC 5598C, IAB 5/5/21, effective 6/9/21]

For purposes of this division, the definitions in Iowa Code chapter 514H and rule 191—39.4(514G) shall apply. In addition, the following definitions shall apply: “Asset disregard” means, with regard to the state’s Medicaid program, disregarding assets in an amount equal to the in…

39.78(1) An individual who is a beneficiary of an Iowa long-term care partnership policy or certificate may be eligible for assistance under the state’s Medicaid program using the asset disregard as provided under Iowa Code chapter 514H as amended by 2009 Iowa Acts, House File 72…

If the Iowa long-term care partnership program established by this division and Iowa Code chapter 514H as amended by 2009 Iowa Acts, House File 723, is discontinued, any individual who purchased an Iowa long-term care partnership policy or certificate before the date the program …

39.8(1) All applications for long-term care insurance policies or certificates except those which are guaranteed issue shall contain clear and unambiguous questions designed to ascertain the health condition of the applicant. 39.8(2) If an application for long-term care insurance…

39.80(1) An insurer or a producer soliciting or offering to sell a partnership policy shall provide to each prospective applicant a Partnership Program Notice. The notice must be substantially similar to Appendix H of this chapter. The Partnership Program Notice shall be provided…

39.81(1) A partnership policy shall not be issued or issued for delivery in Iowa unless filed with and approved by the division. Any policy submitted for certification as a partnership policy shall be accompanied by a Partnership Issuer Certification. The Partnership Issuer Certi…

39.82(1) An insurer must offer, on a one-time basis, in writing, to all existing policyholders that were issued long-term care policies between February 1, 2003, and January 1, 2010, the option to exchange their existing long-term care policies for an Iowa long-term care partners…

39.83(1) A policy or certificate designed or marketed as a long-term care insurance policy or certificate must prominently disclose on the schedule page the following statements: “Some long-term care insurance [policies or certificates] may qualify under the state’s Long-Term Car…

The standards for marketing found in rule 191—39.15(514D,514G) and the suitability requirements of rule 191—39.16(514D,514G) shall apply to the marketing and sale of long-term care partnership policies. [ARC 8271B, IAB 11/4/09, effective 12/9/09; ARC 5598C, IAB 5/5/21, effective …

39.85(1) Each issuer of partnership-qualified long-term care insurance in this state shall provide regular reports to the Secretary of the United States Department of Health and Human Services in accordance with federal law and regulations and to the Iowa department of human serv…

39.9(1) A long-term care insurance policy or certificate may not, if it provides benefits for home health care services, limit or exclude benefits: a. By requiring that the insured/claimant would need skilled care in a nursing facility if home health care services were not provid…

“Act” when used in these rules shall mean Iowa Code chapter 514B. “Complaint” means a written communication expressing a grievance concerning a health maintenance organization. “Dental care” means care by licensed dentists or by appropriate auxiliary dental personnel working unde…

40.10(1) Membership of an enrollee in a health maintenance organization may be terminated by the health maintenance organization for the following reasons and no other: a. Nonpayment of charges when due. b. Termination of the conditions, other than a change in the health of the e…

The application for certificate of authority shall be in the following form: HEALTH MAINTENANCE ORGANIZATION APPLICATION FOR CERTIFICATE OF AUTHORITY ______________________________________________________________________________________ (Name of Health Maintenance Organization) O…

40.12(1) An HMO shall not be authorized to transact business with a net worth less than $1 million. 40.12(2) No HMO incorporated by or organized under the laws of any other state or government shall transact business in this state unless it possesses the net worth required of an …

A health maintenance organization shall maintain in force a fidelity bond on employees and officers in an amount not less than $100,000 or such other sum as may be prescribed by the commissioner. All such bonds shall be written with at least a one-year discovery period and if wri…

A health maintenance organization shall annually, on or before the first day of March, file with the commissioner of insurance a report verified by at least two of its principal officers and covering the preceding calendar year. The report shall be on the form designated by the N…

If an HMO utilizes a cash or asset management arrangement with its parent, affiliate, or any other person, the arrangement shall be written and subject to prior approval by the commissioner. Cash or asset management agreements shall meet the following minimum requirements: 40.15(…

Reinsurance contracts and stop-loss agreements entered into by an HMO shall be subject to prior approval and shall meet the following minimum requirements: 40.17(1) Reinsurance contracts and stop-loss agreements shall provide that the commissioner of insurance be given notice of …

An HMO’s arrangements for health care services shall be by written contract. Initial provider contracts shall be subject to prior approval. Thereafter, any provider contract deviating from previously submitted or approved contracts shall be submitted to the division within 30 day…

In order to qualify for solicitation, enrollment, or delivery of a certificate of membership or policy in a health maintenance organization, a producer must comply with the licensing rules set forth in 191—Chapter 10 and in particular pass the accident and health or sickness insu…

An application on forms provided by the insurance division accompanied by a filing fee of $100 payable to State Treasurer, State of Iowa, shall be completed by an officer or authorized representative of the health maintenance organization. The application with copies in duplicate…

Benefits shall be available by the HMO for inpatient and outpatient emergency services. A physician and sufficient other licensed and ancillary personnel shall be readily available at all times to render such services. Since HMOs may not contract with every emergency care provide…

Reimbursement to a provider of “emergency services,” as defined in 191—40.1(514B), shall not be denied by any health maintenance organization without that organization’s review of the patient’s medical history, presenting symptoms, and admitting or initial as well as final diagno…

40.22(1) A health maintenance organization shall not prohibit a participating provider from or penalize a participating provider for discussing treatment options with covered persons, irrespective of the health maintenance organization’s position on the treatment options, or from…

All HMOs shall include in contracts and evidence of coverage forms a statement disclosing the existence of any prescription drug formularies. Upon request, an HMO offering a plan that includes a prescription drug formulary shall inform enrollees of the plan, and prospective enrol…

A health maintenance organization shall allow a female enrollee direct access to obstetrical and gynecological services from network or participating providers. The plan shall also allow a pediatrician to be the primary care provider for a child through the age of 18.

40.25(1) Purpose. The purpose of this rule is to authorize the electronic delivery of accident and health group insurance certificates in an efficient manner by health maintenance organizations and group policyholders, while guaranteeing that individual plan members still receive…

40.26(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 a health maintenance organization, so as to implement the various consumer protections intended by Iow…

An enrollee may, if evidence of coverage is not satisfactory for any reason, return evidence of coverage within ten days of receipt of same and receive full refund of the deposit paid, if any. This right shall not act as a cure for misleading or deceptive advertising or marketing…

An HMO shall have a basic written organizational document setting forth its scheme of organization and establishing a governing body appropriate to its form of organization. The governing body shall be responsible for matters of policy and operation. The HMO shall develop bylaws …

Each HMO shall: 40.5(1) Provide primary care physicians’ services commensurate with the need of the enrollees, but at a level of not less than that established in the community. 40.5(2) Advise the insurance division annually pursuant to Iowa Code section 514B.12 of the ratio of f…

No name other than that certified by the division may be used. The name of the HMO may not be changed without prior approval of the division.

Each HMO which desires to transfer ownership of more than 10 percent of the stock or ownership interest in the HMO shall not do so without first submitting a proposed plan to the division for review and approval or disapproval.

When an HMO desires to cease offering a service, such service may not be terminated without prior approval of the division. Arrangements equitable to the enrollees providing for a rate adjustment or substitution of an equivalent service satisfactory to the division must be made.

40.9(1) Each health maintenance organization shall provide in its bylaws for a system to resolve and record complaints. 40.9(2) The complaint system shall provide for the resolution of the following kinds of complaints and the recording of the information required to be reported …

“Act” when used in these rules shall mean Iowa Code chapter 514B. “Complaint” means a written communication expressing a grievance concerning a limited service organization. “Governing body” means the persons in which the ultimate responsibility and authority for the conduct of t…

The application for certificate of authority shall be in the following form: LIMITED SERVICE ORGANIZATION APPLICATION FOR CERTIFICATE OF AUTHORITY (Name of Limited Service Organization) Organized as ___________________________________ under the laws of the state of ______________…

41.11(1) Net equity requirements. a. Each LSO shall, at all times, have and maintain a tangible net equity at least equal to the greater of: (1) $100,000 at the inception of the first year of operation, $200,000 at the inception of the second year of operation and thereafter; or …

An LSO shall maintain in force a fidelity bond on employees and officers in an amount not less than $100,000 or such other sum as may be prescribed by the commissioner. All such bonds shall be written with at least a one-year discovery period and if written with less than a three…

An LSO shall annually, on or before the first day of March, file with the commissioner of insurance a report verified by at least two of its principal officers and covering the preceding calendar year. The report shall be on the form designated by the National Association of Insu…

If an LSO utilizes a cash or asset management arrangement with its parent, affiliate, or any other person, the arrangement shall be written and subject to prior approval by the commissioner. Cash or asset management agreements shall meet the following minimum requirements: 1. Cas…

Reinsurance contracts and stop-loss agreements entered into by an LSO shall be subject to prior approval and shall meet the following minimum requirements: 1. Reinsurance contracts and stop-loss agreements shall provide that the commissioner of insurance be given notice of termin…

An LSO’s arrangements for health care services shall be by written contract. Initial provider contracts shall be subject to prior approval. Thereafter, any provider contract deviating from previously submitted or approved contracts shall be submitted to the division for approval.…

In order to qualify for solicitation, enrollment, or delivery of a certificate of membership or policy in an LSO, a producer must comply with the licensing rules set forth in 191—Chapter 10 and in particular pass the accident and health or sickness insurance line of authority exa…

“Emergency services” (inpatient and outpatient), as defined in rule 191—40.20(514B), shall be provided by the LSO, either through its own facilities or through guaranteed arrangements with other providers, on a 24-hour basis unless a waiver from such services is approved by the c…