Iowa Administrative Code

60.4(1) Every insurer, either on its own or via a licensed rating organization, shall file with the division, pursuant to provisions of Iowa Code chapter 515A, every manual, minimum, class rate, rating schedule or rating plan and every other rating rule, and every modification of…

this chapter shall be deemed to have committed an unfair trade practice under Iowa Code chapter 507B and shall be subject to the penalties set forth in Iowa Code chapter 507B. [ARC 7740C, IAB 3/20/24, effective 4/24/24]

circumstance is held invalid for any reason, the invalidity shall not affect the other provisions or any other application of these rules that can be given effect without the invalid provisions or application. To this end, all provisions of these rules are declared to be severabl…

practices committed on or after January 1, 2009. [ARC 7740C, IAB 3/20/24, effective 4/24/24] These rules are intended to implement Iowa Code section 515A.7. [Filed 8/20/08, Notice 7/2/08—published 9/10/08, effective 1/1/09] [Filed ARC 7740C (Notice ARC 7355C, IAB 1/24/24), IAB 3/…

having 100 or more stockholders; provided, however, that this regulation shall not apply to any insurer if 95 percent or more of its stock is owned or controlled by a parent or an affiliated insurer and the remaining shares are held by less than 500 stockholders. A domestic stock…

7.10(1) Applicability. This rule shall apply to any solicitation subject to this regulation by any person or group for the purpose of opposing a solicitation subject to this regulation by any other person or group with respect to the election or removal of directors at any annual…

months prior to such meeting or election for which said proxy was given, and such proxy shall be limited to 30 days subsequent to the date of such meeting or election, and may be revoked at any time by the policyholder who executed the said proxy.

meeting or election at which they are to be used.

either for personal use, or for the use of officers of the company or for any other person or persons, is forbidden. Company funds shall not be expended in procuring proxies.

STOCK TRANSACTION REPORTING

or employee of such insurer subject to 7.1(523) hereof, or any other person, shall solicit, or permit the use of the person’s name to solicit, by mail or otherwise, any proxy, consent or authorization in respect of any stock of such insurer in contravention of this regulation and…

7.20(1) Directors, executive officers, and principal stockholders of domestic insurers required to file. Every person who is directly or indirectly the beneficial owner of more than 10 percent of any class of any equity security of an insurer exempt from the filing requirements o…

respect of a stock of a domestic insurer subject to 7.1(523) hereof are solicited by or on behalf of the management of such insurer from the holders of record of stock of such insurer in accordance with this regulation and the schedules thereunder prior to any annual or other mee…

7.4(1) The definitions and instructions set out in Schedule SIS, as promulgated by the National Association of Insurance Commissioners, shall be applicable for purposes of this regulation. 7.4(2) The terms “solicit” and “solicitation” for purposes of this regulation shall include…

7.5(1) No solicitation subject to this regulation shall be made unless each person solicited is concurrently furnished or has previously been furnished with a written proxy statement containing the information specified in Schedule A. 7.5(2) If the solicitation is made on behalf …

7.6(1) The form of proxy (a) shall indicate in bold-face type whether or not the proxy is solicited on behalf of the management, (b) shall provide a specifically designated blank space for dating the proxy, and (c) shall identify clearly and impartially each matter or group of re…

7.7(1) Two preliminary copies of the proxy statement and form of proxy and any other soliciting material to be furnished to stockholders concurrently therewith shall be filed with the commissioner at least ten days prior to the date definitive copies of such material are first se…

means of any proxy statement, form of proxy, notice of meeting, or other communication, written or oral, containing any statement which at the time and in the light of the circumstances under which it is made, is false or misleading with respect to any material fact, or which omi…

this regulation shall solicit any undated or postdated proxy or any proxy which provides that it shall be deemed to be dated as of any date subsequent to the date on which it is signed by the stockholder.

1. Promote the delivery of appropriate health care in a cost-effective manner. 2. Ensure that any utilization review system used by a third-party payor adheres to reasonable standards for conducting orderly and efficient utilization review processes. 3. Ensure that any utilizatio…

70.10(1) Purpose. This rule implements Iowa Code section 514F.6, which provides for the retrospective payment of clean claims for covered services provided by a physician, advanced registered nurse practitioner or physician assistant during the credentialing period, once the phys…

“Commissioner” means the commissioner of insurance. “Enrollee” means an individual who has contracted for or who participates in health benefits coverage provided through any third-party payor. “Third-party payor” means any of the following entities: 1. An insurer subject to Iowa…

70.3(1) A third-party payor which provides health benefits to enrollees residing in the state of Iowa shall not conduct utilization review, either directly or indirectly, by contract with a third party that does not meet the requirements established for accreditation by the Utili…

191—70.3(505,514F), the most recently available utilization review standards adopted by URAC shall be used. A copy of the standards and application for accreditation may be obtained from the Utilization Review Accreditation Commission at www.urac.org. A copy of the standards shal…

in procedure that creates an impossibility or impracticability of compliance that would result in a refusal of payment.

approve a variance from the URAC standards for good cause shown, provided such conditions are consistent with the purpose of this chapter. The commissioner shall require the third-party payor to provide reasonable written notice to providers of any approved variance. 70.6(1) Noti…

to adhere to the same standards of patient medical record confidentiality as are directly applicable to the third-party payor.

review of inpatient hospital services related to maternity and newborn care, including but not limited to length of postdelivery stay and postdelivery follow-up care, a third-party payor shall use the guidelines adopted under the provisions of rule 191—81.3(514C) and shall not de…

remedies authorized by Iowa Code chapters 505 and 507B, including, upon order of the commissioner, payment of outstanding charges, as determined to be reasonable by the commissioner. Upon a finding of a pattern or practice of noncompliance with this chapter, the commissioner may …

513B to provide for the guaranteed issue of all health insurance products in the small group market, regardless of their health status or claims experience; to regulate insurer rating practices and establish limits on differences in rates between health insurance coverages; to en…

same definition as Iowa Code section 513B.2. [ARC 6121C, IAB 12/29/21, effective 2/2/22]

71.11(1) a. A small employer carrier shall actively market health insurance coverages including one basic and one standard health benefit plan to small employers in this state. A small employer carrier may not suspend the marketing or issuance of the basic and standard health ben…

71.12(1) Subject to 71.12(2), a carrier shall not offer health insurance coverages to small employers or continue to provide coverage under health insurance coverages previously issued to small employers in this state unless the carrier has made a filing with the commissioner or …

71.13(1) a. Except as provided in 71.13(1)“b,” a small employer carrier shall, as a condition of continuing to transact business in this state with small employers, offer to provide health insurance coverage as described in 71.13(3) to any small employer carrier after January 1, …

71.14(1) The form and level of coverage of the basic health benefit plan and the standard health benefit plan are contained in this rule. This rule provides the minimum benefit levels allowed and does not prevent carriers from voluntarily providing additional services to the basi…

71.15(1) For purposes of reducing any preexisting condition exclusion period, a group health plan or a carrier offering group health insurance coverage shall determine the amount of an individual’s creditable coverage by using the standard method described in subrule 71.15(2), ex…

71.16(1) Group health plans or carriers shall issue certificates of creditable coverage to persons losing coverage. A group health plan or carrier required to provide a certificate under this rule for an individual is deemed to have satisfied the certification requirements for th…

71.17(1) A group health plan or carrier shall provide written notice to the employee and dependents of: a. The existence of any preexisting condition exclusions. b. The length of time to which the exclusions will apply. c. The right of the employee or dependent to appeal a decisi…

71.18(1) A carrier shall permit individuals to enroll for coverage under terms of a health benefit plan, without regard to other enrollment dates permitted under the group health plan, if an eligible employee requests enrollment or, if the group health plan makes coverage availab…

coverage forms a statement disclosing the existence of any drug formularies. Upon request, a carrier offering health insurance coverage that includes a prescription drug formulary shall inform enrollees of the coverage, and prospective enrollees of the coverage during any open en…

“Associate member of an employee organization” means any individual who participates in an employee benefit plan (as defined in 29 U.S.C. 1002(1)) that is a multiemployer plan (as defined in 29 U.S.C. 1002(37A)), other than the following: 1. An individual (or the beneficiary of s…

71.20(1) A carrier shall not prohibit a participating provider from or penalize a participating provider for discussing treatment options with covered persons, irrespective of the carrier’s position on the treatment options, or from advocating on behalf of covered persons within …

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

gynecological services from network and participating providers. The plan shall also allow a pediatrician to be the primary care provider for a child through the age of 18. [ARC 6121C, IAB 12/29/21, effective 2/2/22] These rules are intended to implement Iowa Code chapters 513B a…

71.23(1) A carrier that provides medical and surgical benefits with respect to a mastectomy shall provide the following coverage in the event an enrollee receives benefits in connection with a mastectomy and elects breast reconstruction: a. Reconstruction of the breast on which t…

71.24(1) A carrier that provides benefits for outpatient prescription drugs or devices shall provide benefits for prescription contraceptive drugs or prescription contraceptive devices which prevent conception and are approved by the United States Food and Drug Administration or …

recommendation of the board of directors of the Iowa small employer health reinsurance program and the findings of the commissioner that the operation of the Iowa small employer health reinsurance program pursuant to Iowa Code chapter 513B is not currently cost-effective, the com…

71.26(1) Small employer carriers shall use the small employer uniform health insurance application form as the only acceptable form when small employers apply for new health insurance coverage from small employer carriers. Small employer carriers shall implement procedures and po…

71.3(1) a. Except as provided herein, this chapter shall apply to any health insurance coverage, whether provided on a group or individual basis, which: (1) Meets one or more of the conditions set forth in Iowa Code sections 513B.3(1) to 513B.3(3); (2) Provides coverage to one or…