Health Insurance Benefit Coverage Law Summaries

Health Insurance Benefit Coverage Law Summaries

Iowa, Health Insurance Benefit Coverage Law Summaries

Iowa's mandated health care law is located in the Code of Iowa at Title XIII, Subtitle 1. Coordination of benefits provisions are located in the Iowa Administrative Code at Chapter 38.

DEFINITIONS

A “small employer” is a person actively engaged in business who, on at least 50 percent of its working days during the preceding year, employed not less than two and not more than 50 full-time equivalent eligible employees. Companies that are affiliated companies or that are eligible to file a combined tax return for the state are considered one employer (Sec. 513B.2(16)).

“Preexisting condition exclusion” means, with respect to health insurance coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date (Sec. 513B.2(13A), as added by H. 701, L. 1997).

WHAT THE EMPLOYER MUST DO

Iowa does not require employers to provide health insurance for their employers. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.

Dependent care coverage.- Any policy of individual or group accident and sickness insurance providing coverage on an expense-incurred basis, and any individual or group hospital or medical service contracts that provide coverage for a family member of the insured or subscriber must also provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured or subscriber from the moment of birth. The coverage for newly born children must consist of coverage for injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities (Sec. 514C.1).

An insurer must permit continuation of existing coverage for an unmarried child of an insured or enrollee who so elects, at least through the policy anniversary date on or after the date the child marries, ceases to be a resident of this state, or attains the age of 25 years old, whichever occurs first, or so long as the unmarried child maintains full-time status as a student in an accredited institution of postsecondary education (Sec. 509.3, as added by H.F.2539, L. 2008).

Adoption.- A policy or contract providing for third-party payment or prepayment of health or medical expenses must provide coverage benefits to a dependent child adopted by, or placed for adoption with, an insured or enrollee under the same terms and conditions as apply to a biological, dependent child of the insured or enrollee (Sec. 514C.10, as added by H.F. 247, L. 1995).

Mental health coverage.- A group policy, contract, or plan providing for third-party payment or prepayment of health, medical, and surgical coverage benefits issued by a carrier or by an authorized organized delivery system shall provide coverage benefits for treatment of a biologically based mental illness (schizophrenia; bipolar disorders; major depressive disorders; shizo-affective disorders; obsessive-compulsive disorders; pervasive developmental disorders; and autistic disorders) if either of the following is satisfied (Sec. 514C.22, as added by H. 420, L. 2005):

1. The policy, contract, or plan is issued to an employer who on at least 50 percent of the employer's working days during the preceding calendar year employed more than 50 full-time equivalent employees.

2. The policy, contract, or plan is issued to a small employer, and such policy, contract, or plan provides coverage benefits for the treatment of mental illness.

A group policy, contract, or plan covered under this section shall at a minimum allow for 30 inpatient days and 52 outpatient visits annually (Sec. 514C.22, as added by H. 420, L. 2005).

This section applies to third-party payment provider policies or contracts and to plans established pursuant to Ch. 509A that are delivered, issued for delivery, continued, or renewed in Iowa on or after January 1, 2006 (Sec. 514C.22, as added by H. 420, L. 2005).

Coordination of benefits.- An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government through Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of benefit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, health maintenance organizations, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they will coordinate benefit payments with other plans.

Group contracts must specify how benefits will be coordinated (Iowa Administrative Code, Ch. 38, Secs. 38.1-38.11).

Order of benefits.- The following priority applies when coordinating health benefit payments (Iowa Administrative Code, Chapter 38, Sec. 38.4(4)):

1. Employee/Dependent: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that covers the individual as a dependent;

2. Dependent Child/Birthday Rule: For a dependent child whose parents are not separated or divorced and who is covered by two health benefit plans, health maintenance organizations, or health insurance policies, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time. If only one plan specifies the birthday rule and the other plan specifies priority based on the gender of the parent, benefits will be paid first according to the order of benefits specified in the plan without the birthday rule;

3. Dependent Child/Divorced or Separated Parents: For a dependent child whose parents are separated or divorced and who is covered by two health benefit plans, health maintenance organizations, or health insurance policies, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent;

4. Active/Inactive Employee: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored;

5. Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longer period of time before a plan or policy that covered the individual for a shorter period of time; and

6. Excess Benefits: A complying plan may coordinate its benefits with a plan that is “excess” or “always secondary” or that uses an order of benefit determination provision that is inconsistent with that contained in this rule, (called a noncomplying plan) on the following basis: if the complying plan is the primary plan, it must pay or provide its benefits on a primary basis. If the complying plan is the secondary plan, it must still pay or provide its benefits first, as the secondary plan. In such a situation, such payment is the limit of the complying plan's liability, except if the noncomplying plan does not provide the information needed by the complying plan to determine its benefits within a reasonable time after it is requested to do so, the complying plan may assume that the benefits of the noncomplying plan are identical to its own and pay its benefits accordingly. The complying plan must adjust any payments it makes based on such assumption when information becomes available about the actual benefits of the noncomplying plan. If the noncomplying plan pays less in benefits than it would have if the noncomplying plan paid or provided its benefits as the primary plan, the complying plan must advance an amount equal to such difference.

Maintenance of benefits.- A plan that pays benefits on a secondary basis may reduce benefits payable so that total benefits paid do not exceed allowable expenses (Iowa Administrative Code, Chapter 38, Secs. 38.4(4) and 38.6).

Medicare coordination.- A group contract may not reduce benefits if a person is or could be covered under another plan, except for Part B of Medicare (Iowa Administrative Code, Chapter 38, Sec. 38.4(4)).

Providers: Optometrists.- A provision must be made available to policyholders under group accident or health insurance policies covering vision care services or procedures for payment of necessary medical or surgical care and treatment provided by a licensed optometrist if the care and treatment are provided within the scope of the optometrist's license and if the policy would pay for the care and treatment if the care and treatment were provided by a person engaged in the practice of medicine or surgery. This provision does not apply to blanket, short-term travel, accident only, limited or specified disease, or individual or group conversion policies, or policies designed only for issuance to persons for coverage under Title XVIII of the federal Social Security Act, or any other similar coverage under a state or federal government plan (Sec. 509.3(5), as amended by H. 701, L. 1997).

Similarly, the health care services available to enrollees under prepaid group plans covering vision care services or procedures must include a provision for payment of necessary medical or surgical care and treatment provided by a licensed optometrist if performed within the scope of the optometrist's license, and the plan would pay for the care and treatment if provided by a person engaged in the practice of medicine or surgery. This provision does not apply to enrollees eligible for coverage under Title XVIII of the federal Social Security Act or any other similar coverage under a state or federal government plan (Sec. 514B.1, as amended by S. 8, L. 1999).

Chiropractors.- A provision must be made available to policyholders under group accident or health insurance policies covering diagnosis and treatment of human ailments for payment or reimbursement for necessary diagnosis or treatment provided by a licensed chiropractor, if the diagnosis or treatment is provided within the scope of the chiropractor's license and if the policy would pay or reimburse for the diagnosis or treatment by a physician of the human ailment, irrespective of and disregarding variances in terminology employed by the various licensed professions in describing the human ailment or its diagnosis or its treatment. This provision does not apply to blanket, short-term travel, accident-only, limited or specified disease, or individual or group conversion policies, or policies under Title XVIII of the federal Social Security Act, or any other similar coverage under a state or federal government plan (Sec. 509.3(7), as amended by H. 701, L. 1997).

Similarly, the health care services available to enrollees under prepaid group plans covering diagnosis and treatment of human ailments must include a provision for payment of necessary diagnosis or treatment provided by a licensed chiropractor if the diagnosis or treatment is provided within the scope of the chiropractor's license and if the plan would pay or reimburse for the diagnosis or treatment of human ailment, irrespective of and disregarding variances in terminology employed by the various licensed professions in describing the human ailment or its diagnosis or its treatment, if it were provided by a physician. This provision does not apply to enrollees eligible for coverage under Title XVIII of the federal Social Security Act, or any other similar coverage under a state or federal government plan (Sec. 514B.1, as amended by S. 8, L. 1999).

Nurses/physician assistants.- A provision must be made available to policyholders under group accident or health insurance policies covering hospital, medical, or surgical expenses for payment of covered services determined to be medically necessary and provided by registered nurses certified by a national certifying organization identified by the Iowa Board of Nursing, if the services are within the practice of the profession of a registered nurse, under terms and conditions agreed upon between the insurer and the policyholder, subject to utilization controls. This provision does not require payment for nursing services provided by a certified nurse practicing in a hospital, nursing facility, health care institution, physician's office, or other noninstitutional setting if the certified nurse is an employee of the hospital, nursing facility, health care institution, physician, or other health care facility or health care provider. Also, this provision does not apply to blanket, short-term travel, accident only, limited or specified disease, or individual or group conversion policies, policies rated on a community basis, or policies designed only for issuance to persons for eligible coverage under Title XVIII of the federal Social Security Act, or any other similar coverage under a state or federal government plan (Sec. 509.3(8), as amended by H. 701, L. 1997).

A policy or contract delivered, issued for delivery, continued or renewed in Iowa on or after July 1, 1996, and providing for third-party payment or prepayment of health or medical expenses must include a provision for the payment of necessary medical or surgical care and treatment provided by a licensed physician assistant or advanced registered nurse practitioner within the scope of the individual's license if the policy or contract would pay for the care and treatment if it were provided by a person engaged in the practice of medicine and surgery or osteopathic medicine and surgery (Sec. 514C.11, as added by H. 2144, L. 1995).

Dentists.- A policy of accident and sickness insurance issued in Iowa that provides payment or reimbursement for any service within the lawful scope of practice of a licensed dentist must provide benefits for the service whether the service is performed by a licensed physician or a licensed dentist (Sec. 514C.3).

Podiatrists.- Medical or surgical services or procedures constituting the practice of podiatry, also known as chiropody, and covered by the terms of any individual, group, blanket, or franchise policy providing accident or health benefits delivered or issued for delivery in Iowa and covering an Iowa risk may be performed by any practitioner selected by the insured who is licensed as a podiatrist to perform such medical or surgical services or procedures (Sec. 514.18, as amended by S.F. 152, L. 1995).

Prescription drugs.-Contraceptives.- A group policy or contract providing for third-party payment or prepayment of health or medical expenses must not do either of the following (Sec. 514C.19):

1. exclude or restrict benefits for prescription contraceptive drugs or prescription contraceptive devices that prevent conception and that are approved by the U.S. FDA, or generic equivalents approved as substitutable by the FDA, if such policy or contract provides benefits for other outpatient prescription drugs or devices.

2. exclude or restrict benefits for outpatient contraceptive services that are provided for the purpose of preventing conception if such policy or contract provides benefits for other outpatient services provided by a health care professional.

HPV vaccine.- A policy, contract or plan providing for third-party payment or prepayment of health or medical expenses that provides coverage benefits for any vaccination or immunization shall provide coverage benefits for a vaccination for human papilloma virus (HPV), including but not limited to the following classes of third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in the state on or after January 1, 2009: (1) group accident and sickness insurance providing coverage on an expense-incurred basis; (2) group hospital or medical service contracts issued pursuant to Ch. 509, 514, or 514A; and (3) group HMO contracts regulated under Ch. 514B (Sec. 514C.23, as added by H. 2145, L. 2007, enacted April 18, 2008).

Prosthetics.- A policy, contract or plan providing for third-party payment or prepayment of health or medical expenses must provide benefits for medically necessary prosthetic devices when prescribed by a licensed physician. At a minimum, benefits must equal the coverage and payment provided under federal health insurance laws for the aged and disabled. The requirement applies to plans issued for delivery, continued or renewed in the state on or after July 1, 2009, including: (1) group accident and sickness insurance providing coverage on an expense-incurred basis; (2) group hospital or medical service contracts issued pursuant to Ch. 509, 514, or 514A; and (3) group HMO contracts regulated under Ch. 514B. Plans issued in connection with health savings accounts may impose the same deductibles and out-of-pocket limits on prosthetic benefits that apply to substantially all health, medical and surgical benefits under the plan (Sec. 514C.24, as added by H. 311, L. 2009, enacted April 24, 2009).

Preexisting conditions: Small employers.- A carrier or organized delivery system offering group health insurance coverage, with respect to a participant or beneficiary, may impose a preexisting condition exclusion only as follows (Sec. 513B.10(4), as amended by H. 701, L. 1997):

1. The exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date. However, genetic information must not be treated as a condition under this provision in the absence of a diagnosis of the condition related to such information.

2. The exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date.

3. The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.

A carrier or organized delivery system offering group health insurance coverage may not impose any preexisting condition as follows (Sec. 513B.10(4), as amended by H. 701, L. 1997):

1. In the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage.

2. In the case of an individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage.

3. Relating to pregnancy as a preexisting condition.

A carrier or organized delivery system must waive any waiting period applicable to a preexisting condition exclusion or limitation period with respect to particular services under health insurance coverage for the period of time an individual was covered by creditable coverage, provided that the creditable coverage was continuous to a date not more than 63 days prior to the effective date of the new coverage. An HMO that does not use preexisting condition limitations in any of its health insurance coverage may impose an “affiliation period” of not to exceed 60 days for new entrants and 90 days for late enrollees during which no premium will be collected and coverage issued is not effective, as long as the period is applied uniformly, without regard to any health status-related factors. This provision does not preclude application of a waiting period applicable to all new enrollees under the health insurance coverage, provided that any carrier or organized delivery system-imposed waiting period is no longer than 60 days and is used in lieu of a preexisting condition exclusion (Sec. 513B.10(4), as amended by H. 701, L. 1997).

Health insurance coverage may exclude coverage for late enrollees for preexisting conditions for a period not to exceed 18 months (Sec. 513B.10(4), as amended by H. 701, L. 1997).

Mammograms.- A policy or contract providing for third-party payment or prepayment of health or medical expenses must provide minimum mammography examination coverage, including, but not limited to, the following classes of third-party payment provider contracts or policies delivered, issued for delivery, continued, or renewed in Iowa on or after July 1, 1989 (Sec. 514C.4):

1. individual or group accident and sickness insurance providing coverage on an expense-incurred basis;

2. individual or group hospital or medical service contracts;

3. individual or group health maintenance organization contracts;

4. individual or group Medicare supplemental policies, unless coverage pursuant to such policies is preempted by federal law.

Minimum mammography examination coverage means benefits that are better than or equal to the following minimum requirements (Sec. 514C.4):

1. one baseline mammogram for any woman who is 35 through 39 years of age;

2. a mammogram every two years for any woman who is 40 through 49 years of age, or more frequently if recommended by the woman's physician;

3. a mammogram every year for any woman who is 50 years of age or older.

Maternity benefits: Minimum maternity stays. Insurers that provide maternity benefits must provide coverage for a minimum of 48 hours of inpatient care following a vaginal delivery and a minimum of 96 hours of inpatient care following a cesarean section for the insured mother and newly born child in a licensed hospital (Sec. 514C.11(1), as added by H. 2369, L. 1995).

A mother and her newly born child may only be discharged prior to the minimum inpatient length of care prescribed above if the attending provider determines that the minimum inpatient stay is not necessary, following consultation with the mother (Sec. 514C.11(2), as added by H. 2369, L. 1995).

If the mother and newly born child are discharged prior to the required minimum inpatient length of care, the entity providing inpatient services coverage must provide coverage for two postdischarge visits for the mother and newly born child (Sec. 514C.11(2), as added by H. 2369, L. 1995).

Diabetes: Diabetic outpatient self-management education programs.- A policy or contract providing for third-party payment or prepayment of health or medical expenses delivered, issued for delivery, continued or renewed in Iowa on or after July 1, 1999, must provide coverage benefits for the cost associated with equipment, supplies and self-management training and education for the treatment of all types of diabetes mellitus when prescribed by a licensed physician (Sec. 514C.14, as added by S. 8, L. 1999).

Dental care.- A policy or contract providing for third-party payment or prepayment of health or medical expenses must provide coverage for the administration of general anesthesia and hospital or ambulatory surgical center charges related to the provision of dental care services provided to any of the following covered individuals (Sec. 514C.19, as added by H. 754, L. 1999, effective July 1, 2000):

1. a child under five upon a determination by a licensed dentist and the child's treating physician, that such child requires necessary dental treatment in a hospital or ambulatory surgical center due to a dental condition or a developmental disability for which patient management in the dental office has proved to be ineffective.

2. any individual upon a determination by a licensed dentist and the individual's treating physician that such individual has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center.

Skilled nursing care.- An insurer, a hospital service corporation, or a medical service corporation that covers the costs of skilled nursing care under an individual or group policy of accident and health insurance, a nonprofit hospital or medical and surgical service plan, or a health care service contract must also cover the costs of skilled nursing care in a hospital if the level of care needed by the insured or subscriber has been reclassified from acute care to skilled nursing care and no designated skilled nursing care beds or swing beds are available in the hospital or in another hospital or health care facility within a 30-mile radius of the hospital (Sec. 514C.2, as amended by H.F. 247, L. 1995).

Utilization review.- A utilization review program must be established for purposes of health care cost control, according to usual and customary third-party insurance payment or reimbursement procedures, by a corporation and by physician providers and registered nurse providers. This utilization review program must not be used directly or indirectly to circumvent the provisions for payment or reimbursement to providers of health care services. The boards of examiners must establish utilization and cost control review committees of licensees or must accredit and designate other utilization and cost control organizations as utilization and cost control committees to review the appropriateness of levels of treatment and give opinions as to the reasonableness of charges for diagnostic or treatment services of licensees (Secs. 514f.1 and 514.21).

WHO TO CONTACT

Contact the Insurance Division of the Commerce Department at 1918 SE Hulsizer Avenue, Ankeny, IA 50021. Telephone: (515) 281-7400. Fax: (515) 281-7372.

<p>Contact the Insurance Division of the Commerce Department at 1918 SE Hulsizer Avenue, Ankeny, IA 50021. Telephone: (515) 281-7400. Fax: (515) 281-7372.</p>

Iowa, Health Insurance Benefit Coverage Law Summaries

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