Iowa Administrative Code

76.4(1) Except for requests for expedited review, the covered person or the covered person’s authorized representative shall submit a written request for external review (completed Appendix B) to the commissioner by personal delivery, by mail, by fax or by electronic transmission…

organization and the commissioner. 76.5(1) Notices or other communications required by Iowa Code chapter 514J between the commissioner, the health carrier and the independent review organization shall be by email or facsimile, unless otherwise specified, and shall be documented t…

76.6(1) The assignment by the commissioner of an independent review organization pursuant to Iowa Code chapter 514J shall be by rotation among approved independent review organizations. 76.6(2) Upon assignment by the commissioner of an independent review organization, in addition…

copy of a draft of the decision to the commissioner for review. The commissioner shall review the draft of the decision to verify that the independent review organization has included in its draft of the decision the requirements set forth in Iowa Code section 514J.107, 514J.108,…

76.8(1) Each health carrier shall provide to the commissioner the name, title, telephone number, fax number and email address of the individual who shall be the health carrier’s contact person for external review procedures. The carrier’s contact person or an appointed alternate …

76.9(1) In addition to the minimum qualifications set forth in Iowa Code section 514J.112, the following minimum standards are required for certification as an independent review organization: a. The applicant shall provide a description of the procedures employed to comply with …

amount set forth below. In addition to the requirements set forth below, the commissioner may increase the amount required to be deposited based on the commissioner’s written determination that such an increase is necessary to adequately secure any potential liability of the self…

of multiple employer welfare arrangements that intend to offer an employee welfare benefit plan to, and maintain the plan for, any resident of this state. [ARC 4039C, IAB 9/26/18, effective 9/12/18]

following definitions shall apply to this chapter: “Association health plan” or “AHP” means a group health plan or an employee welfare benefit plan established by a bona fide group or association of employers. “Authorized representative” means an individual designated by a MEWA o…

77.3(1) Certificate of registration. A person shall not establish or maintain a self-insured employee welfare benefit plan that is a self-insured MEWA in this state unless the MEWA obtains and maintains a certificate of registration pursuant to this rule. Such certificate of regi…

77.4(1) Certificate of registration. A person shall not establish or maintain a fully insured employee welfare benefit plan that is a fully insured MEWA in this state unless the MEWA obtains and maintains a certificate of registration pursuant to this rule. Such certificate of re…

77.5(1) Certificate of registration. A person shall not establish or maintain a self-insured association health plan in this state unless the self-insured AHP obtains and maintains a certificate of registration pursuant to this rule. Such certificate of registration is required f…

77.6(1) Certificate of registration. A person shall not establish or maintain a fully insured association health plan in this state unless the group or association of employers obtains and maintains a certificate of registration pursuant to this rule. Such certificate of registra…

drug information card or other technology by the providers of third-party payment or prepayment of prescription drug expenses, by the providers’ contractors or agents and pharmacy benefit managers, and by administrators of the providers and payors. The purpose of the uniform pres…

“Administrator” or “administrator of the payor” means the claims administrator or administrators to which claims for prescription drug benefits are submitted, processed and adjudicated, and includes pharmacy benefit managers, and excludes administrators for self-funded employer-s…

78.3(1) Cards or other technology for prescription claims processing issued by providers, administrators, pharmacy benefit managers, and other entities shall contain data elements and other required information that is substantially consistent with the most recent National Counci…

commissioner to adopt rules to provide for a single prior authorization form and prior authorization process for approval of prescription drug benefits by health carriers and pharmacy benefits managers. [ARC 2348C, IAB 1/6/16, effective 2/10/16; ARC 6121C, IAB 12/29/21, effective…

505.26 shall apply. In addition, the following definitions shall apply: “Commissioner” means the Iowa insurance commissioner. “Division” means the Iowa insurance division. “Exigent” means circumstances as defined under federal regulations relating to the Affordable Care Act, as p…

benefits managers must accept the approved prior authorization form from health care providers. 79.3(1) Duration of approved prior authorization request. Health carriers, health benefit plans, and pharmacy benefits managers shall provide that approval of a prior authorization req…

79.4(1) A prior authorization form approved by the commissioner shall meet all of the following requirements: a. Not exceed two pages in length, except that a prior authorization form may exceed that length as determined to be appropriate by the commissioner. Exceptions to the tw…

hearing to have violated a provision of this chapter shall be subject to the penalties set forth in Iowa Code chapter 505. [ARC 2348C, IAB 1/6/16, effective 2/10/16]

[ARC 2348C, IAB 1/6/16, effective 2/10/16] These rules are intended to implement Iowa Code section 505.26. [Filed ARC 2348C (Notice ARC 2228C, IAB 10/28/15), IAB 1/6/16, effective 2/10/16] [Filed ARC 6121C (Notice ARC 6002C, IAB 10/20/21), IAB 12/29/21, effective 2/2/22] APPENDIX…

its board of directors at all times and shall have more than one person act as corporate officer.

stock owned by more than one stockholder.

and records in accordance with normally accepted accounting procedures. Such books and records shall be used to supply the information requested in the annual statement provided each year by the insurance commissioner. These rules are intended to implement Iowa Code chapter 512A.…

it shall first file with the commissioner for examination and approval one copy of its general plan of organization and operation, an original and two copies of its articles of incorporation, an original and one copy of any bylaws, and two copies of its certificate of membership …

more than 1250 members per group or unit who may make voluntary contributions to the association for distribution to the beneficiary of a deceased member or to the members as contributions toward expenses incurred by accident or sickness. 8.4(1) If membership in the association i…

membership in the form of benefit assessments, enrollment fees or dues and operational expense fees. 8.5(1) An enrollment fee or dues to cover initial expenses may be charged but such fees or dues shall not exceed $10 per enrollee membership. If two or more enrollees are in one f…

except the expense contribution and any reasonable corporate dividends or undivided profits, shall be maintained as a reserve fund to be used only for the benefit of the members of the specific group or unit from which it was collected. Such reserve funds shall be used periodical…

the membership certificates, said certificates shall also contain sufficient information to inform a member or a member’s beneficiary on the proper procedure in the filing of a claim, including any limitations or exclusions affecting the claim.

beneficiary or beneficiaries. If no beneficiary is named or the named beneficiary or beneficiaries do not survive the member, the estate shall become the beneficiary. Each association shall have forms to provide for the change of beneficiary in the event a member wishes to change…

established size as set forth in the plan of operation, such group or unit shall be merged into another existing group in the association and any funds of the depleted membership group shall become the reserve funds of the group into which it is merged. If the entire membership o…

by the commissioner for the general provision of coverage for benefits for routine well-child care. [ARC 6121C, IAB 12/29/21, effective 2/2/22]

insurance, group nonprofit health service plans and prepaid group plans of health maintenance organizations delivered or issued for delivery in this state after March 1, 1993. However, this chapter shall not apply to those basic benefit policies approved under Iowa Code chapter 5…

all new filings of group accident and sickness insurance, group nonprofit health service plans and prepaid group plans of health maintenance organizations made after that date and all other policies and contracts covered by this chapter delivered or issued for delivery prior to J…

service plan or prepaid group plan of a health maintenance organization delivered or issued for delivery in this state shall contain definitions respecting the matters set forth unless such definitions comply with the requirements of this rule. 80.4(1) “Well-child care” means ped…

80.5(1) Every group accident and sickness insurance policy, group nonprofit health service plan or prepaid group plan of a health maintenance organization shall provide benefits for well-child care for any child covered by the policy or contract at approximately the following age…

thereby setting forth those requirements deemed appropriate by the commissioner for the general provision of coverage for benefits for postdelivery care.

health insurance, individual or group hospital or health care service contracts issued pursuant to Iowa Code chapter 509, 509A, 514, or 514A, and individual or group health maintenance organization contracts issued and regulated under chapter 514B, which are delivered, amended, o…

providing maternity benefits, which are not limited to complications of pregnancy, or newborn care benefits, shall not terminate inpatient benefits or require discharge of a mother or the newborn from a hospital following delivery earlier than determined to be medically appropria…

85.1(1) The purpose of these rules is to set out the requirements, procedures and fees relating to the qualification, licensure, training, continuing education and regulation of navigators. 85.1(2) These rules are established based upon the authority provided in Iowa Code section…

85.10(1) Individual navigators shall complete a minimum of 32 credits of initial training in courses approved by the commissioner. Initial training must include a minimum of 2 credits of Iowa-specific training on Medicaid and healthy and well kids in Iowa program training, as wel…

85.11(1) Prior to each renewal term, individual navigators must complete a minimum of 36 continuing education credits for each continuing education term in courses approved by the commissioner on subjects relevant to navigators, including health insurance, tax credits, tax penalt…

85.12(1) The commissioner will enter into a contractual relationship with an outside testing service to provide the licensing examinations for individual navigators. 85.12(2) The outside testing service will administer all examinations for applicants. 85.12(3) The testing service…

85.13(1) Fees may be paid by check or credit card. 85.13(2) The fee for issuance or renewal of a navigator license is $20 for three years. 85.13(3) The fee for reinstatement of a navigator license is a total of the renewal fee plus $100. 85.13(4) The division may charge a reasona…

85.14(1) Prior to the issuance by the division of a license as a navigator and for the duration of the license, including any renewal thereof, a navigator shall secure and maintain evidence of financial responsibility in the form of a surety bond or other alternative financial re…

85.15(1) Navigators shall comply with all federal and state statutes, regulations, and rules affecting insurance and navigators. 85.15(2) Navigators shall comply with any inquiries or requests submitted by the commissioner. Navigators shall respond to requests by the commissioner…

circumstance is held invalid by a court of competent jurisdiction or by federal law, the invalidity does not affect other provisions or applications of the chapter that can be given effect without the invalid provision or application, and to this end the provisions of this chapte…

“ACA” means, collectively, the Patient Protection and Affordable Care Act (Pub. L. 111-148) and Health Care and Education Reconciliation Act (Pub. L. 111-152). “Applicant” means an individual or entity applying or intending to apply for a navigator license. “Business entity” mean…