Insurance- Iowa laws, rules, regulations Health only

Nonrenew

terminate an insurance policy at its expiration date

individual mandate

Requirement that individuals get health insurance or pay a tax penalty to the federal government.

Exempt

not subject to an obligation

Mandatory Coverage for Individual Health Plans

-Diabetes -Mammography: women 35-39 need a baseline, 40-49 need one every 2 years(biennial), above 50 need annually -Coverage for newborns and Adopted Children: Newborn immediately insured under parents insurance, must give notification of birth and payment of premium within 60 days. Adopted children receive same benefits as biological children -Complications of pregnancy

Group Health Insurance Eligibility

-Employee Group... 2 employees at date of issue -Labor Union Group -Debtor Group -Trustee Group- 2 must cover 100 at date of issue -Nonprofit industrial Associations: incorporated for 10 yrs, and cover 1,000 at date of issue

Group Health Plan Required Provisions and Coverages

-Employee must request continuation of coverage within 10 days of termination -Continuation of coverage: convert to individual coverage within 31 days after termination of employment -Prescription contraceptive coverage

Affordable Care Act- Insurance Exchanges (Marketplace)

-Federally facilitated marketplace -State exchange -SHOP (small business health options plan) -Help applicants -Compare private health plans -Obtain information about health coverage options and eligibility or tax credit -Enroll in an appropriate health plan

Iowa Comprehensive Health Insurance Association (HIPIOWA)

-Funded by the State of Iowa and the federal government -Nonprofit organization to ensure health insurance is available to eligible Iowa residents who are unable to obtain individual health coverage -subject to examination by the Commissioner and Legislative Council no later than April 30 each year

Individual Health Plan Claims

-insurers are required to accept and pay, or deny a clean claim within 30 days of receipt -If payment is late, the insurer is required to pay interest of 10% on the claim annually

Expense incurred contract

pays health policy benefits as a reimbursement of actual expenses

indemnity contract

pays health policy benefits to the insured based on a predetermined, fixed rate, regardless of the actual expense incurred

Eligible Employee

An employee who works on a full time basis with a normal work week of 30 hours per week Includes -Sole proprietors -Partners of a partnership -Independent contractors

Small employer

a business that employed between 2 and 50 full time employees during at least 50% of the preceding year's working days

Suitability

a requirement to determine if an insurance product is appropriate for a customer

Individual Health Insurance Reform Act

enacted to promote the availability of health insurance to individuals, to ensure fair access to health plans, and to improve fairness and efficiency of the health insurance market

Long Term Care

-Any policy or rider designed to provide coverage for at least 12 consecutive months -Coverage must be guaranteed renewable -Pre existing condition exclusion: no longer than 6 months -Type of care: home health care, nursing home, and assisted living -Long Term Care Partnership Program: partnership between the state government, private long term care insurance companies, and state residents who wish to purchase long term care policies.. MEDICAID recipients... -insurers must provide a statement of benefits to the insured monthly

Medicare Supplement Plans

-Cannot duplicate Medicare benefits -30 day free look period -Coverage must be guaranteed renewable -Pre existing condition exclusion: no longer than 6 months

Healthy and Well Kids in Iowa Program (HAWK-I)

-Designed to improve healthcare of children ELIGIBILITY -Must be younger than 19 -Be a member of a family whose adjusted gross income does not exceed 300% of the federal poverty line -Be a resident of Iowa -Not eligible for medical assistance -Not be currently covered, or covered in the last 6 months under a group health plan, or other health benefit plan, unless the coverage was involuntarily dropped or dropping the coverage was allowed by the rule of the board -Not be a member of a family that is eligible for health benefits coverage under a state health benefit plan -Not be an inmate of a public institution or a patient in an institution for mental disease

Iowa Individual Health Benefit Reinsurance Association

-Members are all insurers that provide health, accident, and sickness policies in Iowa -makes health insurance available to everyone regardless of health status or claims history -prevents abusive rating practices

Affordable Care Act- Eligibility

-Must be a U.S. citizen or national or be lawfully present in the U.S. -Must live in the U.S. -Cannot be currently incarcerated -Coverage for children of members until age 26 -no limits apply for essential benefits

Affordable Care Act- Essential Health Benefits

1. Ambulatory(outpatient) patient services 2. Emergency services 3. Hospitalization 4. Pregnancy, maternity, and newborn care 5. Mental health and substance use 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventative and wellness services and chronic disease management 10. Pediatric services, including oral and vision care

Affordable Care Act- Plan categories for coinsurance

1. Bronze 60/40 2. Silver 75/25 3. Gold 80/20 4. Platinum 90/10

Affordable Care Act- Appeals Rights

1. Internal appeal -no cost within 180 days of claim denial -insurer reviews within 30 days of preservice claims, 60 days if the insured received a service -insurer provides written final internal adverse benefit determination if claim is still denied -insured gets information on requesting external review 2. External appeal -filed within 60 days of written final internal adverse benefit determination if claim is still denied -may be filed concurrently, with internal appeal if persons health is at stake -expedited reviews may be verbal, but written within 48 hours -whatever decision is, it is final decision

Individual Health Insurance Eligibility

Eligible Individual -Resident of Iowa -has qualifying existing coverage or has had it in the past 30 days

Individual Health Plan Renewability

Individual health plans are renewable unless: -Nonpayment of premiums -Fraud or misrepresentation -The insured becomes eligible for Medicare -The insurer elects not to renew all of its individual health benefits plans for the state -The Commissioner finds that continuation would not be in the policyholders best interests, or would impair the insurer's ability to meet its contractual obligations. -If the insurer elects not to renew all plans, they must give the Commissioner a notice at least 3 days prior and notice to all affected individuals at least 90 days prior -An insurer that elects not to renew all health benefit plans is prohibited from writing new health insurance plans for 5 years in Iowa

Provisions for Individual Health

MANDATORY 1. Entire Contract provision 2. time limit on certain defenses provision- 2 years 3. grace period provide- 7 days for weekly, 10 days for monthly and 31 days for all other 4. notice of claim provision- 20 days after loss 5. claim forms provision- 15 days give forms to insured 6. proof of loss provision- complete claim within 90 day 7. time payment of claims provision- immediate payment 8. payment of claims provision 9. physical examination and autopsy provision 10. change of beneficiary provision 11. legal actions provision- no sooner than 60 days, no later than 3 years 12. 10 day free look provision OPTIONAL 1. Misstatement of age 2. Change of occupation 3. other insurance in this company 4. insurance with other companies 5. unpaid premium 6. Relation of earning to insurance 7. illegal occupation 8. intoxicants and narcotics 9. conformity with state statues

Dependent

someone relying on the insured for support