Iowa Administrative Code

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…

39.80(1) An insurer or a producer soliciting or offering to sell a partnership policy shall provide to each prospective applicant a Partnership Program Notice. The notice must be substantially similar to Appendix H of this chapter. The Partnership Program Notice shall be provided…

39.81(1) A partnership policy shall not be issued or issued for delivery in Iowa unless filed with and approved by the division. Any policy submitted for certification as a partnership policy shall be accompanied by a Partnership Issuer Certification. The Partnership Issuer Certi…

39.82(1) An insurer must offer, on a one-time basis, in writing, to all existing policyholders that were issued long-term care policies between February 1, 2003, and January 1, 2010, the option to exchange their existing long-term care policies for an Iowa long-term care partners…

39.83(1) A policy or certificate designed or marketed as a long-term care insurance policy or certificate must prominently disclose on the schedule page the following statements: “Some long-term care insurance [policies or certificates] may qualify under the state’s Long-Term Car…

191—39.15(514D,514G) and the suitability requirements of rule 191—39.16(514D,514G) shall apply to the marketing and sale of long-term care partnership policies. [ARC 8271B, IAB 11/4/09, effective 12/9/09; ARC 5598C, IAB 5/5/21, effective 6/9/21]

39.85(1) Each issuer of partnership-qualified long-term care insurance in this state shall provide regular reports to the Secretary of the United States Department of Health and Human Services in accordance with federal law and regulations and to the Iowa department of human serv…

insurance policies. 39.9(1) A long-term care insurance policy or certificate may not, if it provides benefits for home health care services, limit or exclude benefits: a. By requiring that the insured/claimant would need skilled care in a nursing facility if home health care serv…

4.8(3) The petition must be typewritten or legibly handwritten in ink and must substantially conform to the following form: BEFORE THE IOWA INSURANCE COMMISSIONER Petition by (Name of Petitioner) for a Declaratory Order on (Cite provisions of law involved). } PETITION FOR DECLARA…

proposed or adopted by the division are subject to the provisions of Iowa Code chapter 17A and the provisions of this chapter. [ARC 7732C, IAB 3/20/24, effective 4/24/24]

4.10(1) Persons who qualify under any applicable provision of law as an intervenor and who file a petition for intervention within 20 days of the filing of a petition for declaratory order (after time for notice under rule 191—4.9(17A) and before 30-day time for division action u…

The division may request a brief from the petitioner, any intervenor, or any other person concerning the questions raised. [ARC 7732C, IAB 3/20/24, effective 4/24/24]

division at the address disclosed in rule 191—1.4(502,505). [ARC 7732C, IAB 3/20/24, effective 4/24/24] 191—4.13(17A) Service and filing of petitions and other papers. 4.13(1) When service required. Except where otherwise provided by law, every petition for declaratory order, pet…

any other persons deemed appropriate. [ARC 7732C, IAB 3/20/24, effective 4/24/24]

meeting between the original petitioner, all intervenors, and the commissioner, or a member of the commissioner’s staff, to discuss the questions raised. [ARC 7732C, IAB 3/20/24, effective 4/24/24]

4.15(1) Within the time allowed by Iowa Code section 17A.9(5), after receiving a petition for a declaratory order, the division shall take action on the petition as required by Iowa Code section 17A.9(5). 4.15(2) The date of issuance of an order is as defined in rule 191—3.2(17A)…

4.16(1) The division shall not issue a declaratory order where prohibited by Iowa Code section 17A.9(1) and may refuse to issue a declaratory order on some or all questions raised for any of the following reasons: a. The petition does not substantially comply with the required fo…