Iowa Administrative Code

35.21(1) Nondiscretionary groups. A certificate of coverage delivered in this state under a group life or accident and health insurance policy issued to a group substantially as described in Iowa Code sections 509.1(1) to 509.1(7) may not be reviewed by the commissioner if the po…

the Health Insurance Portability and Accountability Act of 1996 and Iowa Code section 509.3 for large group health insurance coverage.

“Affiliation period” means a period of time that must expire before health insurance coverage provided by an HMO becomes effective, and during which the HMO is not required to provide benefits. “Beneficiary” has the meaning given the term under Section 3(8) of the Employee Retire…

35.24(1) A carrier offering group health insurance coverage shall not establish rules for eligibility, including continued eligibility, of an individual to enroll under the terms of the coverage based on any of the following health status-related factors in relation to the indivi…

35.25(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 insurance coverage, if an eligible employee requests enrollment or, if the group health insurance cov…

35.26(1) Group health insurance coverage subject to the rules in this division is renewable with respect to all eligible employees or their dependents at the option of the employer, except for one or more of the following reasons: a. The health insurance coverage sponsor fails to…

condition exclusion period, a group health plan or carrier offering group health insurance coverage shall determine the amount of an individual’s creditable coverage by using the standard method described in subrule 35.27(1) except that the plan or carrier may use the alternative…

35.28(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…

35.29(1) A group health plan or carrier shall provide written notice to the employee and dependents that includes the following: a. The existence of any preexisting condition exclusions. b. A determination that the group health plan or carrier intends to impose a preexisting cond…

35.3(1) Blanket accident and sickness insurance is hereby declared to be that form of accident, sickness or accident and sickness insurance designed to insure against specified hazards incident to or defined by reference to a particular activity or activities and covering groups …

coverage forms a statement disclosing the existence of any prescription drug formularies. Upon request, all carriers offering health insurance coverage that includes a prescription drug formulary shall inform enrollees of the coverage, and prospective enrollees of the coverage du…

35.32(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 …

outpatient emergency services. Since carriers may not contract with every emergency care provider in an area, carriers shall make every effort to inform members of participating providers. 35.33(1) The term “emergency services” means, with respect to an individual enrolled with a…

access to obstetrical and gynecological services from network or participating providers. The carrier 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 2/2/22] These rules are intended to impleme…

35.35(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…

commissioner and the director of public health to annually publish a consumer guide. These rules apply to all carriers providing health insurance coverage in the individual, small employer group and large group markets that utilize a preferred provider arrangement and to all heal…

35.37(1) Each health maintenance organization shall annually file with the division no later than July 1 the following information by plan as requested by the division: a. Health plan employer data information set (HEDIS). b. Network composition. c. Other information determined t…

be collected and published in the event the division believes the information is not statistically relevant and would not be beneficial to consumers. [ARC 6121C, IAB 12/29/21, effective 2/2/22] These rules are intended to implement Iowa Code section 514K.1(2).

35.39(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 …

this state unless a copy of the policy and brochure if required, has been approved by the commissioner of insurance in accordance with the provisions set forth in rule 191—35.7(509). All policies of blanket accident or sickness insurance or combination thereof issued in this stat…

35.40(1) Purpose. This rule implements Iowa Code section 514C.28, relating to autism spectrum disorder coverage in a group plan established pursuant to Iowa Code chapter 509A for employees of the state that provides for third-party payment or prepayment of health, medical, and su…

required from a person covered under a blanket accident and sickness policy, nor shall it be necessary for the insurer to furnish each person a certificate; however, a brochure as herein defined shall be issued to the policyholder for delivery to each person insured as defined in…

payable to the person insured, to a designated beneficiary or beneficiaries, or to their estate, except that if the person insured be a minor or otherwise not competent to give a valid release, such benefits may be made payable to their parent, guardian or other person actually s…

35.7(1) Insurance companies required to file rates or forms with the division shall submit required rate and form filings pursuant to rule 191—20.1(505,509,514A,515,515A,515F). 35.7(2) Each filing must be submitted to the division of insurance not less than 60 days prior to the e…

35.8(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 insurers and group policyholders, while guaranteeing that individual plan members still receive the important informatio…

insurance. 35.9(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, issuer, employer, group policyholder, or carrier, so as to implement the various…

provide reasonable standardization and simplification of terms and coverages of individual accident and sickness insurance policies and individual subscriber contracts of hospital, medical, and dental service corporations in order to facilitate public understanding and comparison…

36.10(1) Average annual premium. a. New forms. With respect to a new form under which the average annual premium (as defined below) is expected to be at least $200 benefits shall be deemed reasonable in relation to premiums provided the anticipated loss ratio is at least as great…

is subject to Iowa Code chapter 514D shall be in conformance with the applicable requirements of Iowa Code chapter 514D and with the filing requirements set forth in rule 191—20.1(505,509,514A,515,515A,515F).

or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby.

36.13(1) Purpose, applicability and effective date. a. The purpose of this rule is to set forth the requirements and procedures to be followed for individual health insurance coverage for children under the age of 19. b. This rule shall apply to all “carriers” as defined in Iowa …

These rules are intended to implement Iowa Code chapters 507B, 510, 513C and 514D. DIVISION II RATE HEARINGS

insurance policies and subscriber contracts of service corporations, organized under Iowa Code chapter 514, delivered or issued for delivery to any person in this state on and after the effective date hereof, except it shall not apply to individual policies or contracts issued pu…

36.20(1) Purpose, applicability and effective date. a. Purpose. The purpose of this rule is to set forth a procedure to be followed for hearings about certain health insurance policy premium rate increases. b. Applicability. This rule applies to all individual health insurance po…

applicable to all new filings of individual accident and sickness insurance policies and nonprofit hospital, medical and dental service contracts made after that date, and all other policies and contracts covered by this chapter and delivered or issued for delivery after June 30,…

insurance policy or hospital, medical, or dental service corporation subscriber contract delivered or issued for delivery to any person in this state shall contain definitions respecting the matters set forth below unless such definitions comply with the requirements of this rule…

36.5(1) Except as provided in subrule 36.4(7), no policy shall contain provisions establishing a probationary or waiting period during which no coverage is provided under the policy subject to the further exception that a policy may specify a probationary or waiting period not to…

standards for benefits are prescribed for the categories of coverage noted in the following subrules. No individual policy of accident and sickness insurance or nonprofit hospital, medical or dental service corporation contract shall be delivered or issued for delivery in this st…

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…

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 policies which may be misleading or confusing in connection with the…

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…