Iowa Administrative Code

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…

39.28(1) This rule applies to any 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 on February 1, 2003, the provisions of this rule shall apply o…

39.29(1) Except as provided in subrule 39.29(2), a long-term care insurance policy may not be delivered or issued for delivery in this state unless the policyholder or certificate holder has been offered the option of purchasing a policy or certificate including a nonforfeiture b…

to all long-term care insurance policies and long-term care coverage arrangements delivered or issued for delivery in this state on or after the effective date hereof, by insurers, fraternal benefit societies, nonprofit health, hospital and medical service corporations, prepaid h…

39.30(1) A long-term care insurance policy shall condition the payment of benefits on a determination of the insured’s ability to perform activities of daily living and on cognitive impairment. Eligibility for the payment of benefits shall not be more restrictive than requiring e…

contracts. 39.31(1) For purposes of this rule, the following definitions apply: “Chronically ill individual” has the meaning prescribed for this term by Section 7702B(c)(2) of the Internal Revenue Code of 1986. Under this provision, a chronically ill individual means any individu…

Iowa Code chapter 507B.

39.33(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, so as to implement the various policyholder protections intended by Iowa Code section 514G…

DIVISION II INDEPENDENT REVIEW OF BENEFIT TRIGGER DETERMINATIONS

insurance,” “Commissioner,” “Applicant,” “Policy,” “Preexisting condition” and “Certificate” shall have the meanings set forth in Iowa Code chapter 514G, “Long-Term Care Insurance Act.” “Long-term care insurance” means an insurance policy, insurance contract, insurance certificat…

uniform process for insureds covered under long-term care insurance to request an independent review of a denial of coverage based on a benefit trigger determination. [ARC 5598C, IAB 5/5/21, effective 6/9/21]

benefit trigger determinations made on or after January 1, 2009.

514G.103 shall apply. [ARC 5598C, IAB 5/5/21, effective 6/9/21]

Code section 514G.109 shall contain the following information: 1. The reason that the insurer determined that the policy benefit trigger has not been met by the insured. 2. A description of the internal appeal mechanism provided under the long-term care policy. 3. A description o…

conclusion of the internal appeal mechanism specified in Iowa Code section 514G.109(2), the notice required in Iowa Code section 514G.110(2)“b” and “c” shall contain the following information: 39.45(1) A description of additional internal appeal rights, if any, offered by the ins…

explaining why the benefit trigger has not been met, with the insured’s request for an independent review, to the insurance commissioner within 60 days of receipt of the benefit trigger determination. The notice shall be sent to the commissioner at the Iowa Insurance Division, 19…

39.47(1) The commissioner shall provide written notice of the certification decision to the insurer and the insured within the two-business-day period specified in Iowa Code section 514G.110. 39.47(2) The insurer may appeal the commissioner’s certification decision within three b…

39.48(1) Within three business days of receiving the commissioner’s certification decision, the insurer shall: a. Select an independent review entity from the list certified by the commissioner; b. Notify the insured in writing of the name, address, and telephone number of the in…

39.49(1) Within five business days of receiving either the notice provided in paragraph 39.48(1)“b,” or the denial of an objection made pursuant to subrule 39.48(3), whichever is later, the insured may submit any additional information or documentation in support of the insured’s…

in this state shall use the terms set forth below, unless the terms are defined in the policy and the definitions satisfy the following requirements: 39.5(1) “Medicare” shall be defined as “The Health Insurance for the Aged Act, Title XVIII of the Social Security Amendments of 19…

39.50(1) The independent review entity shall immediately notify the insurer, the insured, and the commissioner of the independent review decision either affirming or overturning the insurer’s benefit trigger determination. The initial notification shall be delivered by telephone …

39.51(1) No later than January 1, 2009, each insurer delivering or issuing for delivery long-term care insurance policies in this state on or after July 1, 2008, and each insurer that has active long-term care policies or riders under which claims for benefits may be made on or a…

required for certification as an independent review entity: 39.52(1) The entity shall ensure that any licensed health care professional on its staff who participates in an independent review proceeding holds a current unrestricted license or certification to practice a health car…

written policies and procedures governing all aspects of the independent review process. The written policies and procedures include, but are not limited to, the following: 39.53(1) Procedures to ensure that independent reviews are conducted within the time frames specified in th…

telephone service to receive information relating to independent reviews pursuant to this division and Iowa Code chapter 514G. The system shall include a procedure to ensure the capability of accepting, recording, or providing instruction to respond to incoming telephone calls du…

commissioner such data, information, and reports as the commissioner determines necessary to evaluate the independent review process established under Iowa Code chapter 514G. An application for certification as an independent review entity must be submitted in duplicate to the Io…

DIVISION III LONG-TERM CARE PARTNERSHIP PROGRAM

39.6(1) Renewability. The terms “guaranteed renewable” and “noncancellable” shall not be used in any individual long-term care insurance policy without further explanatory language in accordance with the disclosure requirements of this chapter. No such policy issued to an individ…

39.7(1) Renewability. a. Individual long-term care insurance policies shall contain a renewability provision. Such provision shall be appropriately captioned, shall appear on the first page of the policy, and shall clearly state the duration of the term of coverage for which the …

39.75(1) This division is intended to implement Iowa Code chapter 514H and Section 6021 of the federal Deficit Reduction Act of 2005, Public Law 109-171, to establish, in conjunction with the department of human services, a long-term care partnership program in Iowa to provide fo…

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]

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 insurance benefit payments that are made to or on behalf of an individual w…

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…

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 was discontinued shall be eligible to r…

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…