Title XIII, COMMERCE (Ch. 505 - 554I)

Participating insurers shall meet the qualifying standards established by rule under this chapter and shall perform all of the following functions: 1. Provide plan cards and membership booklets to qualifying families. 2. Provide or reimburse accessible, quality medical or dental …

1. a. Effective July 1, 1998, and notwithstanding any medical assistance program eligibility criteria to the contrary, medical assistance shall be provided to, or on behalf of, an eligible child under the age of nineteen whose family income does not exceed one hundred thirty-thre…

The department shall provide coverage to individuals under nineteen years of age who meet the income eligibility requirements for the Hawki program and for whom federal financial participation is or becomes available for the cost of such coverage. 2009 Acts, ch 118, §14 ; 2023 Ac…

1. Following the first thirty days of commitment, the department shall suspend, but not terminate, the eligibility of an eligible child who is an inmate of a public institution as defined in 42 C.F.R. §435.1010 , who is enrolled in the medical assistance program under this chapte…

1. The advisory council shall review the benefits package annually and shall determine additions to or deletions from the benefits package offered. The advisory council shall submit the recommendations to the general assembly for any amendment to the benefits package. 2. Benefits…

The purpose of this chapter is to provide uniform standards for the establishment and maintenance of external review procedures to assure that covered persons have the opportunity for an independent review of an adverse determination or final adverse determination made by a healt…

As used in this chapter , unless the context otherwise requires: 1. a. “Adverse determination” means a determination by a health carrier that an admission, availability of care, continued stay, or other health care service, other than a dental care service, that is a covered bene…

1. Except as provided in subsection 2 , this chapter shall apply to all health carriers. 2. This chapter shall not apply to any of the following: a. A policy or certificate that provides coverage only for a specified disease, specified accident or accident-only, credit, disabilit…

1. A health carrier shall notify a covered person or the covered person’s authorized representative, if known, in writing of the covered person’s right to request an external review and include the appropriate statements and information set forth in this chapter at the time the h…

A covered person or the covered person’s authorized representative may make a request for an external review of a final adverse determination. Except for a request for an expedited external review, all requests for external review shall be made in writing to the commissioner. The…

1. Except as otherwise provided in this section , a request for an external review shall not be made until the covered person or the covered person’s authorized representative has exhausted the health carrier’s internal grievance process and received a final adverse determination…

1. A covered person or the covered person’s authorized representative may file a written request for an external review with the commissioner within four months after any of the following events: a. The date of receipt of a final adverse determination. b. The failure of a health …

1. Notwithstanding section 514J.107 , a covered person or the covered person’s authorized representative may make an oral or written request to the commissioner for an expedited external review at the time the covered person or the covered person’s authorized representative recei…

1. Within four months after the date of receipt of a notice of an adverse determination or final adverse determination that involves a denial of coverage based on a determination that the health care service or treatment recommended or requested is experimental or investigational…

1. An external review decision pursuant to this chapter is binding on the health carrier except to the extent the health carrier has other remedies available under applicable Iowa law. The external review process shall not be considered a contested case under chapter 17A . 2. a. …

1. The commissioner shall approve applications submitted by independent review organizations to conduct external reviews under this chapter . The commissioner may retain an outside expert to perform reviews of such applications. 2. In order to be eligible for approval by the comm…

1. To be approved to conduct external reviews pursuant to this chapter , an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process and t…

An independent review organization, a clinical reviewer working on behalf of an independent review organization, or an employee, agent, or contractor of an independent review organization shall not be liable in damages to any person for any opinions rendered or acts or omissions …

1. a. An independent review organization assigned to conduct an external review shall maintain written records in the aggregate by state and by health carrier of all requests for external review for which it conducted an external review during a calendar year. b. Each independent…

The health carrier against which a request for a standard external review or an expedited external review is filed shall pay the costs of retaining an independent review organization to conduct the external review. 2011 Acts, ch 101, §15

1. Each health carrier shall include a description of the external review procedures contained in this chapter in or attached to any policy, certificate, membership booklet, outline of coverage, or other evidence of coverage that is provided to a covered person. The description s…

The commissioner may adopt rules pursuant to chapter 17A to carry out the provisions of this chapter . 2011 Acts, ch 101, §17

If any provision of this chapter , or the application of the provision to any person or circumstance is held invalid, the remainder of the chapter, and the application of the provision to persons or circumstances other than those to which it is held invalid, shall not be affected…

A person who fails to comply with the provisions of this chapter or the rules adopted pursuant to this chapter is subject to the penalties provided under chapter 507B . 2011 Acts, ch 101, §19

1. This chapter applies to all requests for external review filed on or after July 1, 2011. 2. Section 514J.116 applies to all health benefit plans delivered, issued for delivery, continued, or renewed in this state on or after July 1, 2011. 2011 Acts, ch 101, §20

1. A health maintenance organization or an insurer using a preferred provider arrangement shall provide to each of its enrollees at the time of enrollment, and shall make available to each prospective enrollee upon request, written information as required by rules adopted by the …

1. A carrier that provides small group health coverage pursuant to chapter 513B or individual health coverage pursuant to chapter 513C and that offers for sale a policy, contract, or plan that covers the essential health benefits required pursuant to section 1302 of the federal P…

As used in this chapter , unless the context otherwise requires: 1. “Guide” means the most recent national council for prescription drug programs pharmacy identification card implementation guide, or its successor. 2. “Prescription drug” means prescription drug as defined in sect…

1. a. A provider of third-party payment or prepayment of prescription drug expenses, including the provider’s agents or contractors and pharmacy benefits managers, that issues a card or other technology for claims processing and an administrator of the payor, excluding administra…

1. A health insurance or health benefits policy or contract issued and delivered, amended, or renewed on or after July 1, 2003, shall comply with this chapter . 2. The commissioner of insurance shall enforce this chapter and shall adopt rules necessary to implement this chapter .…

Corporations formed for the purpose of insurance, other than life insurance, shall be governed by the provisions of chapter 490 , chapter 491 , or chapter 504 , except as modified by the provisions of this chapter . The provisions of this chapter relative to insurance companies s…

After compliance by the incorporators with sections 515.1 and 515.2 , the secretary of state shall certify the articles of incorporation to the commissioner of insurance. When the commissioner of insurance is satisfied that all provisions of law in relation to the promotion and o…

Every domestic and foreign insurance company organized and doing business under this chapter shall indicate upon the first page of every policy and renewal receipt that the policy is issued by a mutual company in case of a mutual company, and by a stock company in case of a stock…

1. Any condition or stipulation in an application, policy, or contract of insurance making the policy void before the loss occurs shall not prevent recovery on the policy by the insured, if the plaintiff shows that the failure to observe such provision or the violation thereof di…

1. The form of all policies, and of applications, and of agreements or endorsements modifying the provisions of policies, and of all permits and riders used generally throughout the state, that are issued or proposed to be issued by any insurance company doing business in this st…

1. Definitions. As used in this section unless the context otherwise requires: a. “Adverse action” means a denial of issuance, cancellation, or refusal to renew, an increase in any charge for, or a reduction or other unfavorable change in the terms of coverage or amount of any pe…

Contracts of insurance against loss or damage by fire or other perils may contain a coinsurance or contribution clause or clause having similar effect, provided the form setting up the terms of the same has been approved by the commissioner of insurance. [C97, §1746; S13, §1746; …

Any officer, insurance producer, or representative of an insurance company doing business in this state who may solicit insurance, procure applications, issue policies, adjust losses, or transact the business generally of such companies, shall be held to be the agent of such insu…

An insurance company organized under this chapter or authorized to do business in this state shall not terminate a contract of an insurance producer who is an independent contractor but who is not an exclusive insurance producer as defined in section 522B.1 without at least one h…

No action shall be maintained in any court in the state upon any policy or contract of fire insurance issued upon any property situated in the state by any company, association, partnership, individual, or individuals that have not been authorized by the commissioner of insurance…

1. The printed form of a policy of fire insurance as set forth in subsection 6 shall be known and designated as the “standard policy” to be used in the state of Iowa. 2. Standard policy, additions, riders, and clauses. a. It shall be unlawful for any insurance company to issue an…

Nothing contained in section 515.109 shall be so construed as to prohibit any insurance company not required by the statutes of Iowa to issue a standard form of policy, from embodying, with the approval of the commissioner of insurance, in any insurance contract issued by it, pro…

Insurers issuing the standard policy pursuant to section 515.109 are authorized to affix to or include within a policy a written statement that the policy does not cover loss or damage caused by nuclear reaction or nuclear radiation or radioactive contamination, all whether direc…

It shall be unlawful for any insurance company, its officers or agents, or either of them, to violate any of the provisions of section 515.109 by issuing, delivering, or offering to issue or deliver any policy of fire insurance on property in this state other than the standard fo…

Nothing contained in sections 515.109 and 515.112 , nor any provisions or conditions in the standard form of policy provided for in section 515.109 , shall be deemed to repeal or in any way modify any existing statutes or to prevent any insurance company issuing such policy, from…

1. Every fire insurance company and association authorized to transact business in this state shall conduct its business in the name under which it is incorporated, and the policies issued by it shall be headed or entitled only by such name. There shall not appear on the face of …