Iowa Administrative Code

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…

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…