Iowa Health Law

Grace period

weekly- 7 days monthly- 10 days any other- 31 days

Time Payment of claim provision

Claims must be paid immediately upon the receipt of a written proof of loss Disability must be paid monthly

LTC policy cannot

be canceled or non-renewed on grounds of age or mental deterioration Contain a new probationary period if policy replaced Provide coverage for solely skilled nursing Contain a probationary period greater than 6 months both sides Limit benefits by: 1. requiring insured need skilled care 2. limiting eligible services provided by registered nurse or LPNs 3. requiring an acute condition 4. limiting benefits to service provided by medicare certified provicer

Policies without chiropractic care (group and individual)

Accident only Specified disease Short-term hospital or medical Credit Dental Vision Medicare Supplement Long-term care Basic hospital or surgical Disability income Workers Compensation Automobile medical payments

Group Required provisions

All group accident or health shall contain: Copy of the application shall be attached to policy issue All statements are representations Each person insured shall receive a certificate of insurance Covered persons who leave have option to: 1. continue through COBRA or 2. convert to an individual policy

Mandatory individual coverages

All polices must cover physician appointed costs for self-managed diabetes (supplies/ equipment) Baseline mammography 1 for 35-39 year old women One every 2 years for40-49 one every year for 50+ Any complications of pregnancy (handled like a sickness)

Nursing care

1. skilled nursing care- one or more daily professional services required 2. Intermediate nursing care- less often than daily 3. Custodial care- Level of care required to assist in daily living activities

medicare suplement pre-existing conditions

A 6 month on either side for preexisting

Medicare Supplement Cancelation

Cannot be canceled or non-renewed on the grounds of health status

Pre-Existing Conditions

Cannot deny, or limit benefits for a covered individual for losses more than 12 months following the effective date of coverage. "A condition for which medical advice, diagnosis, care, or treatment was recommended or received during 12 months preceding effective date of coverage." 10 day probationary period upon reinstatement

Medicare Supplement Exclusions

Cannot exclude any health issue event occurred in last 6 months (would be considered preexisting)

Medicare Supplement Required provisions

Cannot use waiver to exclude coverage for specific conditions Cannot duplicate benefits provided by medicare Must be guaranteed renewable Require producer to deliver 1. guide to health insurance for people with medicare 2. outline of coverage AT TIME OF APPLICATION Must have 30 day free look 6 month open enrollment that starts when applicant 1. is 65 2. enrolls in part b (ins company cannot reject during this period)

Optional Provisions

Change of occupation Provision- insurer may reduce benefits if the insured changes to a more dangerous job If less, insurer must make a pro rata refund of premium

Small Employer Group

Defined as one who: on at least 50% of the working days employed at least 2 but no more than 50 eligible employees (Work at least 30 hours) Must be guaranteed renewable and only canceled for fraud or non-payment of premium New enrollees may be on probation for a max 12 months for preexisting conditions 6 month prior Late enrollees may be on for up to 18 months (pregnancy isn't preexisting condition)

LTC outline of coverage

Description of principal benefits and coverage provided statement of the principal exclusions etc Statement of the renewal provisions Stametnet that it is a summary only

LTC partnership Program

Designed to shield additional assets and apply for medicaid To qualify: resident of Iowa at policy beginning for qualified LTC

Mandatory Group Coverages

Diabetes Mammography: 1 for 35-39, one per 2 years 40-49, 1 a year 50+ Prescription contraceptive drugs Coverage for newborns Adopted Children (from effective date of adoption) Pregnancy complications must be covered

Required Provisions- required by law to protect Insured

Entire contract provision Time limit on certain defenses Grace Period Reinstatement Provision notice of claim provision claims forms provision proof of loss provision time payment of claim provision Payment of claims provision Physical exam provision Change of beneficiary Legal actions provision

Dependent Children

Family coverage will not be discontinued at limiting age if: Incapable of sustaining full time employment due to mental retardation or physical handicap Continues to be dependent upon the person for support Insurer may require proof of such within 31 days of limiting age

Special Iowa Programs

HAWK-I: for kids under 19 in Iowa whose family income doesn't exceed 200% poverty level, not in prison or metal institution HIPIOWA: non-profit coverage available by application Only if reject in last 9 months for similar insurance coverage terminates at age 19 (25 if dependent in college) or longer for retardation or handicap 6 month window on either side for pre-existing Only pay after deductible and coinsurance Max 3 million lifetime

Medicare Supplement Replacement of coverage

If medi-gap replaces another policy, replacing insurer must waive any time period applicable to preexisting conditions to the extent that it was original satisfied Producers must give applicants a signed "notice regarding replacement" AT TIME OF APPLICATION

Chiropractic care

Individual and group health insurance (including HMOs) must provide. Subject to same co-pay or co-insurance imposed for services provided by a person in medicine or surgery

Renewablity

Individual health ins policies are renewable at the option of the individual except: Non-payment of premium Fraud Decision by the insurer to discontinue offering that type of policy Decision by the insurer to discontinue offering in that state (must stay out for 5 years)

Physical exam provision

Insurer may request physical exam or autopsy

Claims and Premium Disclosure

Insurers who issue large group policies must provide to the policy holder upon their request on an annual basis: 1. total amount of actual claims paid 2. total amount of premiums paid

Home health care

Medical and nonmedical services provided at persons's residency

LTC Policy Provisions

Must provide coverage for at least 12 months Must include 1 or more medically necessary diagnostic, preventative etc service other than acute care unit (hsptl) Must be guaranteed renewable or noncancelable If guaranteed renewable Premiums can only change by class If also noncancelable can't change premium or rate 30 day free look at delivery No coverage limit for type of illness No riders or changes after issue date Must offer inflation protection 31 days to convert to individual (no insurability proof) Tax qualified? must contain nonforfeiture (premiums tax deductible) Spousal survivor rider may be added (waiver of premium when first spouse dies) Bed reservation rider may be added Pays on an "expense incurred" basis May include "respite" care Often 30,60,90 day elimination period by calendar-day (day of services) or service-day (service days)

LTC marketing

Must provide shoppers guide (time of application) and Outline of Coverage (before they purchase)

Medicare Supplement Minimum Benefits

NAIC says only 10 plans may be offered: ABCDFGKLMN EHI&J are no longer available as of June 1 2010 hospice care became a Part A benefit June 1 2010 (K covers 50% L covers 75%) ABC are all the same no matter the company Ins companies offering Medicare Supplement must offer Part A Medicare has two main parts A-hospital B-doctor Medicare part C? no supplement plans needed

Reinstatement Provision

Policy (after lapse) may be reinstated upon the insurer's request. (10 day probationary period for sickness) If application and premium is submitted to the insurer and the insurer gives the insured a conditional receipt, if the insurer does not reject the reinstatement application is is considered reinstated on the 45th day following the date of conditional receipt

Nursing facility

Primary engaged in providing accommodations and skilled or intermediate nursing Provide assistance through an RN Maintain daily medial record NOT Home primary for rest Rehab Home for mental diseases or disorders

Payment of claims provision

Statement saying who claims go to

Medicare Supplement Insurance

Supplement insurance is regulated in order to: Provide for standardization of coverage and simplification Help the insurance buying public understand options eliminate misleading provisions Provide for full disclosure

Assisted living

health related care, personal care, assistance with instruental activities of living

20, 15, 90, 60, up to 3 years

notice of claim provision- 20 days after loss claims forms provision- 15 days after receiving NofC proof of loss provision- 90 days to present proof Legal actions provision- file suit after 60 days with no payment, up to 3 years