Iowa Administrative Code

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,…

supplement policies or certificates. 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…

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…

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 issued on or after January 1, 1992, and with an effective date for coverag…

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…

and probationary periods in replacement policies or certificates. 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 …

testing. 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, a…

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 this rule shall be deemed a…

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…

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,” or “accidental means” shall be defined to employ “resu…

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…

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 4/10/19, effective 5/15/19] These rules are intended to implement Iowa Code ch…

policies or certificates issued for delivery prior to January 1, 1992 (prestandardized plans). 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 minim…

or certificates issued for delivery on or after January 1, 1992, and with an effective date for coverage prior to June 1, 2010 (1990 plans). The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state o…

or certificates issued for delivery with an effective date for coverage on or after June 1, 2010 (2010 plans). 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 cove…

supplement benefit plan policies or certificates issued for delivery to individuals newly eligible for Medicare on or after January 1, 2020. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires that the following standards are applicable to all Medicare suppl…

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…

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 and without reduction for any applicable deductible, that is cover…

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…

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 and the secondary plan is not a closed panel plan…

claim. 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…

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…

APPENDIX A MODEL COB CONTRACT PROVISIONS COORDINATION OF THIS CONTRACT’S BENEFITS WITH OTHER BENEFITS The Coordination of Benefits (COB) provision applies when a person has health care coverage under more than one Plan. Plan is defined below. The order of benefit determination ru…

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 understanding and comparison of long-term care insurance coverages, and to f…

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…

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 state having statutory or regulatory long-term care insurance requirem…

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…

replacement policies or certificates. 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 c…

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 coverage shall be delivered to a prospective app…

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…

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…

by acceleration of the death benefit. 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 c…

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 …

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 available all information directly related to the denial.

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…