Iowa Administrative Code

75.3(1) Except as otherwise specifically provided, this chapter shall apply to any individual health benefit plan applied for on or after April 1, 1996. 75.3(2) Iowa Code chapter 513C and this chapter shall apply to an individual health benefit plan provided to an eligible indivi…

following information with respect to each established block of business, as defined in Iowa Code section 513C.3. 1. A description of each criterion employed by the carrier for determining membership in the block of business; 2. A statement describing the justification for establ…

75.5(1) Transfer or assumption of insurance obligation. a. A carrier shall not transfer or assume the entire insurance obligation or risk of a health benefit plan covering a block of business in this state unless the transaction has been approved by the commissioner of the state …

75.6(1) As provided by Iowa Code section 513C.5, each carrier must limit differences in premium due to such factors as experience and duration to the composite effect of 20 percent, 30 percent, and 30 percent. Allocation of cost differences due to experience and duration among th…

75.7(1) Except as provided in Iowa Code section 513C.7, the choice between the basic and standard health benefit plans may not be limited, restricted or conditioned upon the risk characteristics of the individuals or their dependents. 75.7(2) Insurers shall not require eligible f…

75.8(1) General rules. In connection with the offering for sale of a health benefit plan to individuals, each carrier shall make a reasonable disclosure, as part of its solicitation and sales materials, of the following: a. The extent to which premium rates for a specified indivi…

75.9(1) A carrier shall make available at least one basic and one standard health benefit plan to eligible individuals in this state. 75.9(2) The written information described in this subrule may be provided directly to the individual or delivered through an authorized producer: …

Patient Protection and Affordable Care Act, Pub. L. No. 111-148 as amended by the federal Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, which amends the Public Health Service Act and adopts, in part, 42 U.S.C. Section 300gg-19. These rules address iss…

76.10(1) Fees charged by independent review organizations shall be reasonable. 76.10(2) A health carrier objecting to the fee charged by an independent review organization shall file a written notice with the commissioner and the independent review organization indicating the hea…

76.11(1) Independent review organizations. The commissioner may withdraw the approval of an independent review organization for any of the following reasons: a. Failure to maintain the minimum standards set forth in Iowa Code sections 514J.111 and 514J.112 or in subrule 76.9(1). …

76.2(1) The rules contained in this chapter shall apply to any health benefit plan as defined in Iowa Code section 514J.102 other than those excluded under Iowa Code section 514J.103(2), for any plan that is offered or issued by a health carrier as defined in Iowa Code section 51…

Iowa Code section 514J.116 shall be in the form of Appendix A or substantially similar language approved by the commissioner. [ARC 9637B, IAB 7/27/11, effective 7/8/11; ARC 9979B, IAB 1/25/12, effective 2/29/12; ARC 2601C, IAB 6/22/16, effective 7/27/16]

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…