Iowa Administrative Code

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…

71.4(1) A small employer carrier that establishes more than one class of business as defined in Iowa Code section 513B.2 shall maintain on file for inspection by the commissioner the following information with respect to each class of business so established: a. A description of …

71.5(1) a. A small employer carrier shall not transfer or assume the entire insurance obligation or risk of health insurance coverage covering a small employer in this state unless: (1) The transaction has been approved by the commissioner of the state of domicile of the assuming…

71.6(1) a. A small employer carrier shall develop a separate rate manual for each class of business. Base premium rates and new business premium rates charged to small employers by the small employer carrier shall be computed solely from the applicable rate manual developed pursu…

71.7(1) a. A small employer carrier that offers coverage to a small employer shall offer to provide coverage to each eligible employee and to each dependent of an eligible employee. The small employer carrier shall provide the same health insurance coverage to each employee and d…

71.8(1) A small employer carrier may use age, geographic area, family composition, and group size in establishing premium rates, subject to Iowa Code section 513B.4(2). 71.8(2) Additional rating factors are not allowed without the prior approval of the commissioner.

71.9(1) A carrier prohibited from writing coverage for small employers in this state pursuant to Iowa Code section 513B.5(2) may not resume offering health insurance coverage to small employers in this state until the carrier has made a petition to the commissioner or director to…

care insurance policies sold prior to December 31, 2009, that participate in the Iowa long-term care asset preservation program; establish documentation and reporting requirements for issuers of policies or certificates to qualify under the Iowa long-term care asset preservation …

72.10(1) Each issuer shall maintain information as stipulated in 72.10(6) on all policyholders or certificate holders who have ever received any benefit under the policy or certificate. Such information shall be updated at least quarterly. This requirement for updating shall not …

72.11(1) Each issuer shall send an asset protection report at least quarterly to each policyholder or certificate holder who has received any benefits since the last asset protection report sent to the policyholder or certificate holder. Each asset protection report shall include…

72.12(1) Each issuer shall prepare a service summary at the client’s request specifically for the policyholder or certificate holder applying for Medicaid. The issuer shall also prepare a service summary when the policyholder or certificate holder has exhausted benefits under the…

72.13(1) Each issuer shall, prior to qualification by the division of insurance, submit to the department of human services a plan for complying with the information maintenance and documentation requirements set forth in rules 191—72.9(514H) and 191—72.10(514H). No policy or cer…

72.14(1) Within one year of the first date that any policyholder or certificate holder of a particular issuer’s policy or certificate has met the criteria for the insured event, and as often as the commissioner of insurance or department of human services deems necessary thereaft…

circumstance is for any reason held to be invalid or unenforceable, the remainder of the chapter and the application of such provision to other persons or circumstances shall not be affected thereby. [ARC 5598C, IAB 5/5/21, effective 6/9/21] These rules are intended to implement …

insurance policy or certificate that was authorized for sale by the division of insurance as qualifying under the Iowa long-term care asset preservation program under former Iowa Code chapter 249G. No long-term care insurance policy or certificate which has been approved by the d…

“Asset disregard” means a $1 increase in the amount of assets an individual who purchases a certified long-term care policy may retain, upon qualification for Medicaid, for each $1 of benefit paid out under the individual’s certified long-term care policy for Medicaid-eligible lo…

insurance policy or certificate shall qualify for participation in the Iowa long-term care asset preservation program unless the long-term care insurance policy or certificate complies with this chapter. Long-term care insurance policies and certificates in force on July 1, 1994,…

not meet the requirements of this chapter and has not been approved by the division of insurance as a certified long-term care insurance policy or certificate may be advertised, solicited, or issued for delivery in this state as a certified long-term care insurance policy or cert…

care insurance policy or certificate may be advertised, solicited, or issued for delivery in this state as a qualified long-term care insurance policy or certificate which does not meet the minimum benefit standards in this rule, and which has not been approved by the division of…

72.7(1) All qualified policies and certificates shall meet the following requirements: a. Have premiums: (1) Based on the issue age of the applicant; or (2) Level for the life of the policy or certificate with an adjustment only for the increased benefits resulting from the infla…

may not be included in a certified policy or certificate: a restoration of benefits; a second elimination period; any cap on the daily (as opposed to monthly) home- and community-based care benefits. [ARC 5598C, IAB 5/5/21, effective 6/9/21]

issuer documentation and reporting requirements for qualified policies and certificates. The reports shall be submitted for each person entitled to benefits under a qualified policy or certificate. Each issuer shall do the following: 72.9(1) Maintain a registry and submit on a qu…

an employer to provide access to health care or health insurance to an employer’s eligible employees. The employer shall, at a minimum, make health care information or health insurance information available to the employer’s eligible employees by a written referral. However, the …

the state of Iowa.

74.3(1) “Division” means the insurance division of the state of Iowa. 74.3(2) “Eligible employee” means a natural person who is employed in this state for wages by an employer and works on a regular full-time or regular part-time basis. An eligible employee may include a commissi…

74.4(1) Access to health care or health insurance means any of the following: a. An employer provides a written referral to an eligible employee as to where the eligible employee can receive information concerning health care or health insurance. b. An employer offers coverage or…

employee’s contributions to the health care program or health insurance program to which the employer referred the eligible employee. However, payroll deduction shall occur only if the eligible employee has adequate wages to pay the cost of the health care or health insurance. In…

bureau of the division. The division, upon finding that the employer has failed to offer an eligible employee access to health care or health insurance, may do any of the following: 1. Issue a cease and desist order instructing the employer to cure the failure to provide access t…

513C to promote the availability of health insurance coverage to individuals, regardless of their health status or claims experience; to prevent abusive rating practices; to require disclosure of rating practices to purchasers; to establish rules regarding the renewal of coverage…

75.10(1) The form and level of coverage of the basic health benefit plan and the standard health benefit plan are contained in the rules and table. 75.10(2) Termination of pregnancy is to be covered when performed for therapeutic reasons. Elective termination of pregnancy is not …

maternity benefit rider for the basic and standard health benefit plans providing benefits, as any other illness, for a pregnancy and delivery without complications with a 12-month waiting period. Credit toward meeting the waiting period shall be given for prior coverage of a pre…

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…

75.13(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.

benefit plan for the cost associated with equipment, supplies, and education for the treatment of diabetes pursuant to Iowa Code section 514C.18. [ARC 6121C, IAB 12/29/21, effective 2/2/22] These rules are intended to implement Iowa Code chapters 513C and 514C.