Iowa Administrative Code

As used in this chapter, unless the context otherwise requires: “Commissioner” means the commissioner of insurance. “Enrollee” means an individual who has contracted for or who participates in health benefits coverage provided through any third-party payor. “Third-party payor” me…

70.3(1) A third-party payor which provides health benefits to enrollees residing in the state of Iowa shall not conduct utilization review, either directly or indirectly, by contract with a third party that does not meet the requirements established for accreditation by the Utili…

For the purpose of certification and compliance under rule 191—70.3(505,514F), the most recently available utilization review standards adopted by URAC shall be used. A copy of the standards and application for accreditation may be obtained from the Utilization Review Accreditati…

A third-party payor shall not impose a retroactive change in procedure that creates an impossibility or impracticability of compliance that would result in a refusal of payment.

Upon application by a third-party payor, the commissioner may approve a variance from the URAC standards for good cause shown, provided such conditions are consistent with the purpose of this chapter. The commissioner shall require the third-party payor to provide reasonable writ…

A third-party payor shall require a contract utilization review agent to adhere to the same standards of patient medical record confidentiality as are directly applicable to the third-party payor.

When performing utilization review of inpatient hospital services related to maternity and newborn care, including but not limited to length of postdelivery stay and postdelivery follow-up care, a third-party payor shall use the guidelines adopted under the provisions of rule 191…

The remedy for noncompliance with this chapter shall be those remedies authorized by Iowa Code chapters 505 and 507B, including, upon order of the commissioner, payment of outstanding charges, as determined to be reasonable by the commissioner. Upon a finding of a pattern or prac…

This chapter is intended to implement the provisions of Iowa Code chapter 513B to provide for the guaranteed issue of all health insurance products in the small group market, regardless of their health status or claims experience; to regulate insurer rating practices and establis…

For purposes of this chapter, creditable coverage shall have the same definition as Iowa Code section 513B.2. [ARC 6121C, IAB 12/29/21, effective 2/2/22]

71.11(1) a. A small employer carrier shall actively market health insurance coverages including one basic and one standard health benefit plan to small employers in this state. A small employer carrier may not suspend the marketing or issuance of the basic and standard health ben…

71.12(1) Subject to 71.12(2), a carrier shall not offer health insurance coverages to small employers or continue to provide coverage under health insurance coverages previously issued to small employers in this state unless the carrier has made a filing with the commissioner or …

71.13(1) a. Except as provided in 71.13(1)“b,” a small employer carrier shall, as a condition of continuing to transact business in this state with small employers, offer to provide health insurance coverage as described in 71.13(3) to any small employer carrier after January 1, …

71.14(1) The form and level of coverage of the basic health benefit plan and the standard health benefit plan are contained in this rule. This rule provides the minimum benefit levels allowed and does not prevent carriers from voluntarily providing additional services to the basi…

71.15(1) For purposes of reducing any preexisting condition exclusion period, a group health plan or a carrier offering group health insurance coverage shall determine the amount of an individual’s creditable coverage by using the standard method described in subrule 71.15(2), ex…

71.16(1) Group health plans or carriers shall issue certificates of creditable coverage to persons losing coverage. A group health plan or carrier required to provide a certificate under this rule for an individual is deemed to have satisfied the certification requirements for th…

71.17(1) A group health plan or carrier shall provide written notice to the employee and dependents of: a. The existence of any preexisting condition exclusions. b. The length of time to which the exclusions will apply. c. The right of the employee or dependent to appeal a decisi…

71.18(1) A carrier shall permit individuals to enroll for coverage under terms of a health benefit plan, without regard to other enrollment dates permitted under the group health plan, if an eligible employee requests enrollment or, if the group health plan makes coverage availab…

All carriers shall include in contracts and evidence of coverage forms a statement disclosing the existence of any drug formularies. Upon request, a carrier offering health insurance coverage that includes a prescription drug formulary shall inform enrollees of the coverage, and …

As used in this chapter: “Associate member of an employee organization” means any individual who participates in an employee benefit plan (as defined in 29 U.S.C. 1002(1)) that is a multiemployer plan (as defined in 29 U.S.C. 1002(37A)), other than the following: 1. An individual…

71.20(1) A carrier shall not prohibit a participating provider from or penalize a participating provider for discussing treatment options with covered persons, irrespective of the carrier’s position on the treatment options, or from advocating on behalf of covered persons within …

Benefits shall be available by the carrier 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 carriers may not contract with every emergency care…

A carrier shall allow a female enrollee direct access to obstetrical or gynecological services from network and participating providers. The plan shall also allow a pediatrician to be the primary care provider for a child through the age of 18. [ARC 6121C, IAB 12/29/21, effective…

71.23(1) A carrier that provides medical and surgical benefits with respect to a mastectomy shall provide the following coverage in the event an enrollee receives benefits in connection with a mastectomy and elects breast reconstruction: a. Reconstruction of the breast on which t…

71.24(1) A carrier that provides benefits for outpatient prescription drugs or devices shall provide benefits for prescription contraceptive drugs or prescription contraceptive devices which prevent conception and are approved by the United States Food and Drug Administration or …

Upon the recommendation of the board of directors of the Iowa small employer health reinsurance program and the findings of the commissioner that the operation of the Iowa small employer health reinsurance program pursuant to Iowa Code chapter 513B is not currently cost-effective…

71.26(1) Small employer carriers shall use the small employer uniform health insurance application form as the only acceptable form when small employers apply for new health insurance coverage from small employer carriers. Small employer carriers shall implement procedures and po…

71.3(1) a. Except as provided herein, this chapter shall apply to any health insurance coverage, whether provided on a group or individual basis, which: (1) Meets one or more of the conditions set forth in Iowa Code sections 513B.3(1) to 513B.3(3); (2) Provides coverage to one or…

71.4(1) A small employer carrier that establishes more than one class of business as defined in Iowa Code section 513B.2 shall maintain on file for inspection by the commissioner the following information with respect to each class of business so established: a. A description of …

71.5(1) a. A small employer carrier shall not transfer or assume the entire insurance obligation or risk of health insurance coverage covering a small employer in this state unless: (1) The transaction has been approved by the commissioner of the state of domicile of the assuming…

71.6(1) a. A small employer carrier shall develop a separate rate manual for each class of business. Base premium rates and new business premium rates charged to small employers by the small employer carrier shall be computed solely from the applicable rate manual developed pursu…

71.7(1) a. A small employer carrier that offers coverage to a small employer shall offer to provide coverage to each eligible employee and to each dependent of an eligible employee. The small employer carrier shall provide the same health insurance coverage to each employee and d…

71.8(1) A small employer carrier may use age, geographic area, family composition, and group size in establishing premium rates, subject to Iowa Code section 513B.4(2). 71.8(2) Additional rating factors are not allowed without the prior approval of the commissioner.

71.9(1) A carrier prohibited from writing coverage for small employers in this state pursuant to Iowa Code section 513B.5(2) may not resume offering health insurance coverage to small employers in this state until the carrier has made a petition to the commissioner or director to…

The purpose of this chapter is to set forth the minimum standards for long-term care insurance policies sold prior to December 31, 2009, that participate in the Iowa long-term care asset preservation program; establish documentation and reporting requirements for issuers of polic…

72.10(1) Each issuer shall maintain information as stipulated in 72.10(6) on all policyholders or certificate holders who have ever received any benefit under the policy or certificate. Such information shall be updated at least quarterly. This requirement for updating shall not …

72.11(1) Each issuer shall send an asset protection report at least quarterly to each policyholder or certificate holder who has received any benefits since the last asset protection report sent to the policyholder or certificate holder. Each asset protection report shall include…

72.12(1) Each issuer shall prepare a service summary at the client’s request specifically for the policyholder or certificate holder applying for Medicaid. The issuer shall also prepare a service summary when the policyholder or certificate holder has exhausted benefits under the…

72.13(1) Each issuer shall, prior to qualification by the division of insurance, submit to the department of human services a plan for complying with the information maintenance and documentation requirements set forth in rules 191—72.9(514H) and 191—72.10(514H). No policy or cer…

72.14(1) Within one year of the first date that any policyholder or certificate holder of a particular issuer’s policy or certificate has met the criteria for the insured event, and as often as the commissioner of insurance or department of human services deems necessary thereaft…

If any provision of this chapter or the application thereof to any person or circumstance is for any reason held to be invalid or unenforceable, the remainder of the chapter and the application of such provision to other persons or circumstances shall not be affected thereby. [AR…

The requirements of this chapter apply to any long-term care insurance policy or certificate that was authorized for sale by the division of insurance as qualifying under the Iowa long-term care asset preservation program under former Iowa Code chapter 249G. No long-term care ins…

“Asset disregard” means a $1 increase in the amount of assets an individual who purchases a certified long-term care policy may retain, upon qualification for Medicaid, for each $1 of benefit paid out under the individual’s certified long-term care policy for Medicaid-eligible lo…

No long-term care insurance policy or certificate shall qualify for participation in the Iowa long-term care asset preservation program unless the long-term care insurance policy or certificate complies with this chapter. Long-term care insurance policies and certificates in forc…

No long-term care insurance policy or certificate which does not meet the requirements of this chapter and has not been approved by the division of insurance as a certified long-term care insurance policy or certificate may be advertised, solicited, or issued for delivery in this…

No long-term care insurance policy or certificate may be advertised, solicited, or issued for delivery in this state as a qualified long-term care insurance policy or certificate which does not meet the minimum benefit standards in this rule, and which has not been approved by th…

72.7(1) All qualified policies and certificates shall meet the following requirements: a. Have premiums: (1) Based on the issue age of the applicant; or (2) Level for the life of the policy or certificate with an adjustment only for the increased benefits resulting from the infla…