Iowa Administrative Code

4.17(1) In addition to the order itself, a declaratory order must contain the date of its issuance; the name of the petitioner and all intervenors; the specific statutes, rules, policies, decisions, or orders involved; the particular facts upon which it is based; and the reasons …

order must be mailed or emailed by the division promptly to the original petitioner and all intervenors. [ARC 7732C, IAB 3/20/24, effective 4/24/24]

as a final order issued in a contested case proceeding. It is binding on the division, the petitioner, and any intervenors who consent to be bound and is applicable only in circumstances where the relevant facts and the law involved are indistinguishable from those on which the o…

by this reference. In addition to those definitions and the definitions in rule 191—1.1(502,505), the following definitions apply: “Commissioner” means the commissioner of insurance or the commissioner’s designee. For the purposes of this chapter, “commissioner” includes both the…

any such rule to any person or circumstance, is for any reason held to be invalid, illegal or unenforceable by any court of law, the validity, legality and enforceability of the remainder of the rule and its application to other persons or circumstances shall not be affected or i…

public rulemaking docket listing each pending rulemaking proceeding and relevant rulemaking information, including the information required by Iowa Code sections 17A.3(1)“d” and 17A.6A(2). If a rulemaking docket for all agencies is maintained on the Iowa legislature’s website, th…

4.5(1) Scope. This chapter outlines generally applicable standards and a uniform process for the granting of individual waivers from rules adopted by the division in situations when no other more specifically applicable law provides for waivers. This chapter shall not preclude th…

follows: 4.6(1) Applications. If the petition relates to an application or license, the petition must be made in accordance with the filing requirements for the application or license in question. 4.6(2) Contested cases. If the petition relates to a pending contested case, the pe…

4.7(1) Procedures. The provisions of Iowa Code sections 17A.10 through 17A.18A regarding contested case hearings shall apply to any petition for a waiver filed within a contested case and shall otherwise apply to agency proceedings for a waiver only when the division so provides …

4.8(1) Any person or agency may file a petition with the division for a declaratory order as to the applicability to specified circumstances of a statute, rule or order within the primary jurisdiction of the division. 4.8(2) The petition must be submitted to the division at the a…

division must give notice of the petition to all persons not served by the petitioner pursuant to rule

“Act” when used in these rules shall mean Iowa Code chapter 514B. “Complaint” means a written communication expressing a grievance concerning a health maintenance organization. “Dental care” means care by licensed dentists or by appropriate auxiliary dental personnel working unde…

40.10(1) Membership of an enrollee in a health maintenance organization may be terminated by the health maintenance organization for the following reasons and no other: a. Nonpayment of charges when due. b. Termination of the conditions, other than a change in the health of the e…

shall be in the following form: HEALTH MAINTENANCE ORGANIZATION APPLICATION FOR CERTIFICATE OF AUTHORITY ______________________________________________________________________________________ (Name of Health Maintenance Organization) Organized as _________________________________…

40.12(1) An HMO shall not be authorized to transact business with a net worth less than $1 million. 40.12(2) No HMO incorporated by or organized under the laws of any other state or government shall transact business in this state unless it possesses the net worth required of an …

bond on employees and officers in an amount not less than $100,000 or such other sum as may be prescribed by the commissioner. All such bonds shall be written with at least a one-year discovery period and if written with less than a three-year discovery period shall contain a pro…

day of March, file with the commissioner of insurance a report verified by at least two of its principal officers and covering the preceding calendar year. The report shall be on the form designated by the National Association of Insurance Commissioners (NAIC) as the report form …

management arrangement with its parent, affiliate, or any other person, the arrangement shall be written and subject to prior approval by the commissioner. Cash or asset management agreements shall meet the following minimum requirements: 40.15(1) Cash receipts shall be under the…

shall be subject to prior approval and shall meet the following minimum requirements: 40.17(1) Reinsurance contracts and stop-loss agreements shall provide that the commissioner of insurance be given notice of termination by certified mail at least 30 days prior to the effective …

written contract. Initial provider contracts shall be subject to prior approval. Thereafter, any provider contract deviating from previously submitted or approved contracts shall be submitted to the division within 30 days of execution for informational purposes. In all instances…

certificate of membership or policy in a health maintenance organization, a producer must comply with the licensing rules set forth in 191—Chapter 10 and in particular pass the accident and health or sickness insurance lines of authority examination. [ARC 5515C, IAB 3/10/21, effe…

by a filing fee of $100 payable to State Treasurer, State of Iowa, shall be completed by an officer or authorized representative of the health maintenance organization. The application with copies in duplicate shall be verified and shall be accompanied by the information found in…

outpatient emergency services. A physician and sufficient other licensed and ancillary personnel shall be readily available at all times to render such services. Since HMOs may not contract with every emergency care provider in an area, HMOs shall make every effort to inform memb…

191—40.1(514B), shall not be denied by any health maintenance organization without that organization’s review of the patient’s medical history, presenting symptoms, and admitting or initial as well as final diagnosis, submitted by the provider, in determining whether, by definiti…

40.22(1) A health maintenance organization shall not prohibit a participating provider from or penalize a participating provider for discussing treatment options with covered persons, irrespective of the health maintenance organization’s position on the treatment options, or from…

coverage forms a statement disclosing the existence of any prescription drug formularies. Upon request, an HMO offering a plan that includes a prescription drug formulary shall inform enrollees of the plan, and prospective enrollees of the plan during any open enrollment period, …

direct access to obstetrical and gynecological services from network or participating providers. The plan shall also allow a pediatrician to be the primary care provider for a child through the age of 18.

40.25(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 health maintenance organizations and group policyholders, while guaranteeing that individual plan members still receive…

40.26(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 a health maintenance organization, so as to implement the various consumer protections intended by Iow…

satisfactory for any reason, return evidence of coverage within ten days of receipt of same and receive full refund of the deposit paid, if any. This right shall not act as a cure for misleading or deceptive advertising or marketing methods, nor may it be exercised if the enrolle…

organizational document setting forth its scheme of organization and establishing a governing body appropriate to its form of organization. The governing body shall be responsible for matters of policy and operation. The HMO shall develop bylaws or guidelines which describe the s…

40.5(1) Provide primary care physicians’ services commensurate with the need of the enrollees, but at a level of not less than that established in the community. 40.5(2) Advise the insurance division annually pursuant to Iowa Code section 514B.12 of the ratio of full-time equival…

name of the HMO may not be changed without prior approval of the division.

percent of the stock or ownership interest in the HMO shall not do so without first submitting a proposed plan to the division for review and approval or disapproval.

may not be terminated without prior approval of the division. Arrangements equitable to the enrollees providing for a rate adjustment or substitution of an equivalent service satisfactory to the division must be made.

40.9(1) Each health maintenance organization shall provide in its bylaws for a system to resolve and record complaints. 40.9(2) The complaint system shall provide for the resolution of the following kinds of complaints and the recording of the information required to be reported …

“Act” when used in these rules shall mean Iowa Code chapter 514B. “Complaint” means a written communication expressing a grievance concerning a limited service organization. “Governing body” means the persons in which the ultimate responsibility and authority for the conduct of t…

shall be in the following form: LIMITED SERVICE ORGANIZATION APPLICATION FOR CERTIFICATE OF AUTHORITY (Name of Limited Service Organization) Organized as ___________________________________ under the laws of the state of ________________________, makes application to the commissi…

41.11(1) Net equity requirements. a. Each LSO shall, at all times, have and maintain a tangible net equity at least equal to the greater of: (1) $100,000 at the inception of the first year of operation, $200,000 at the inception of the second year of operation and thereafter; or …

officers in an amount not less than $100,000 or such other sum as may be prescribed by the commissioner. All such bonds shall be written with at least a one-year discovery period and if written with less than a three-year discovery period shall contain a provision that no cancell…

the commissioner of insurance a report verified by at least two of its principal officers and covering the preceding calendar year. The report shall be on the form designated by the National Association of Insurance Commissioners (NAIC) as the report form for LSOs. The report sha…

management arrangement with its parent, affiliate, or any other person, the arrangement shall be written and subject to prior approval by the commissioner. Cash or asset management agreements shall meet the following minimum requirements: 1. Cash receipts shall be under the direc…

shall be subject to prior approval and shall meet the following minimum requirements: 1. Reinsurance contracts and stop-loss agreements shall provide that the commissioner of insurance be given notice of termination by certified mail at least 30 days prior to the effective date o…

contract. Initial provider contracts shall be subject to prior approval. Thereafter, any provider contract deviating from previously submitted or approved contracts shall be submitted to the division for approval. In all instances, all provider contracts shall include the followi…

certificate of membership or policy in an LSO, a producer must comply with the licensing rules set forth in 191—Chapter 10 and in particular pass the accident and health or sickness insurance line of authority examination. [ARC 5515C, IAB 3/10/21, effective 4/14/21]

rule 191—40.20(514B), shall be provided by the LSO, either through its own facilities or through guaranteed arrangements with other providers, on a 24-hour basis unless a waiver from such services is approved by the commissioner. A provider and sufficient other licensed and ancil…

rule 191— 40.20(514B), shall not be denied by any LSO without that organization’s review of the patient’s provider history, presenting symptoms, and admitting or initial as well as final diagnosis, submitted by the provider, in determining whether, by definition, emergency servic…

by a filing fee of $100 payable to State Treasurer, State of Iowa, shall be completed by an officer or authorized representative of the LSO. The application with copies in duplicate shall be executed in conformance with rule 191—41.10(514B) and shall be accompanied by the informa…

restrict a participating provider from advising a covered person about the health status of the covered person or medical care or treatment of the covered person’s condition or disease, regardless of whether benefits for such care or treatment are provided under the plan, if the …