Iowa Laws, Rules, and Regulations Pertinent to Health Only
Unpaid premium
when a claim is paid, any premium due and not yet paid may be deducted from the claim payment
Clean claim
a properly completed paper or electronic bill containing all reasonably necessary information -If payment is late, the insurer is required to automatically pay interest on the claim at the rate of 10% per annum.
intoxicants and narcotics
The insurers is not liable for loss resulting from the insured's being intoxicated or under the influence of a narcotic, unless the narcotic is taken on the advice of a physician
Coverage for Newborns
- the health insurance benefits applicable for children are payable for a newborn child of the insured from the moment of birth -If a premium is required to provide coverage for a newly born child, the policy may require notification of birth of new born child to the insurer within 60 days after the date of birth
Mandatory Coverages
-Diabetes -Mammography -Coverage for Newborns -Adopted Children -Complications of Pregnancy
Group Health Insurance - eligibility
-Group life insurance policies may be issued in Iowa insuring lives of more than one individual if they comply with the requirements 1. employee group 2. Labor union grou 3. debtor grou 4. trustee grou 5. nonprofit industrial associations
Pre-Existing Conditions
-In Iowa, a pre-existing condition cannot be defined more restrictively than to mean the existence of symptoms that would cause an ordinarily prudent person to seek diagnosis, care or treatment 12 months before the effective date of coverage. -In iowa, basic plans cannot deny, exclude, or limit benefits for losses incurred more than 12 months following the effective date of coverage due to a pre-existing condition
Eligible Individual
-an Iowa residente who has qualifying existing coverage or has had qualifying existing coverage within the last 30 days. -individual who has and an event occur in the last 30 days that qualifies them for coverage.
Eligibility
Iowa residents rejected for health insurance coverage or for health care services, or those who could only obtain health insurance at a rate higher than that of the Association are eligible for cover under the Association -unmarried persons under the age of 19 -unmarred full-time students under the age of 25
Debtor Groups
Policies issued to a creditor to insure its debtors are subject to the following requirements -insurance must be payable to the policyholder for the purpose of reducing the debtor's unpaid indebtedness -the amount of insurance cannot exceed the amount of unpaid indebtedness to the creditor -The group of eligible debtors must receive (or expect to receive) new entrants at a rate of at least 100 persons annually
Medicare Supplement Insurance
Purpose: -provide for reasonable standardization of coverage and simplification of terms and benefits -help the public understand and compare policies -Eliminate misleading or confusing provisions -provide full disclosure in the sale of such coverages
Required Provisions for Medicare Supplement policy
The first page of Medicare Supplement policy must include provisions for renewal, continuation, or non renewal of the policy -state and explain any reservation by the issuer or the right to change premiums and any automatic renewal premium increases that are based on age. -must have notice prominently printed on the first page statin that the policyholder has the right to return the policy within 30 days.
Nursing Home
coverage usually pays a specified amount for the time the insured spends in a nursing home, or for medical services received in a setting bother than a hospital -skilled nursing care, intermediate nursing care, custodial care
Iowa Comprehensive Health Insurance Association (HIPIOWA)
nonprofit organization established to assure that health insurance is available to eligible Iowa residents who are unable to obtain individual health coverage. -all carriers and any relevant delivery system in Iowa must be a member of the Association.
Payment of Claims provision
stating that indemnity for loss of life is payable according to beneficiary designation
Claims
-health insurers are required to either accept and pay or deny a clean claim within 30 days of receipt of such claim
Renewability cont.
If the insurer elects not to renew all plans, the insurer must give notice to the commissioner no less than 3 days prior, and notice to all affected individuals at least 90 days prior. -an insurer that elects not to renew all of its individual health benefit plans is prohibited from writing new individual health benefit plan in Iowa for 5 years.
mammography
minimum mammography examination coverage: -One baseline mammogram for every woman of ages 35-39, or more frequently if recommend by the woman's physician -A mammogram every 2 years for any woman of ages 40-49 -An annual mammogram for women above age 50
Nonprofit Industrial Associations
that have been incorporated for at least 10 years and organized for purposes other than obtaining insurance -at least 2 members of eh association must elect to insure their employees or any class of employees determined by conditions pertaining to employment -at least 1000 employees must be insured, at least 75% of whom must be employees of members wo have at least 20 insured employees each, and no more than 10% can be employees of members with less than 10 insured employees each -premiums must be paid by members -at least 75% of the eligible employees nut be insured
Prescription Contraceptives.
the following are PROHIBITED: -excluding or restricting services and benefits if the policy provides benefits for other outpatient prescription drugs -denying to an individual eligibility to enroll for a coverage b/c of the individual's use or potent ion use of contraceptives -providing a monetary compensation or rebating to a covered individual to encourage the individual to accept less than minimum benefits -Penalizing or reducing reimbursement of health care professions due to the prescription of contraceptive drugs and services.
Illegal Occupation
the insurer is not liable for loss resulting from the insured's committing or attempting to commit a felon or engaging in an illegal occupation.
Complications of Pregnancy
-conditions requiring a hospital stay which are distinct from pregnancy, but are affected or caused by it -non-elective Caesarean section, ectopic pregnancy which is terminated, or spontaneous termination of pregnancy, which occurs during a period of gestation during which a viable birth is not possible
Converted policy issued
-in iowa, a group health insurance policy that insures employees or members on an expense-incurred or service basis, must provide that a coverdd person whose coverage under the group policy is terminated is entitled to have a "converted policy issued" without evidence of insurability. -if proper notice of the conversion right is given, written application and first premium payment for the converted policy must be made to the insurer within 31 days.
Requirement for a policy to meet the standards of a partnership
-insured must be a resident of iowa at the time of issuance -policy must be issued after January 1, 2010 -policy must meet the requirement set forth in the S.S. act and federal regulations -policy must provide inflation protection for policyholders who are below 61 years old at the time of policy purchase.
Medicare Supplement Replacement
-insurer must give the applicant a notice regarding replacement of Medicare Supplement coverage. -applicant receives on copy of this notice signed by the agent and the applicant at the time of application
Renewability: renewable at the individual's options except:
-nonpayment of premium -fraud or misrepresentation -the insured becomes eligible for Medicare coverage -The insurer elects not to renew all of its individual health benefit plans in the state -The commissioner finds that continuation would not be in the policyholder's best interest, or would impair the insurer's ability to meet its contractual obligation
Labor Union Groups
-only accident and health policies may require the insured to pay the entire premium -at least 65% of the eligible, insurable members must elect to make the required contributions -policy must cover at least 10 members at the date of issue -
Other insurance in this company
-provision limits the coverage the insurer may underwrite for any one person and provides for the return of premiums paid for coverage in excess to this limit
Two addition coverages exclusive to a group health insurance
1. prescription contraceptives 2. Chiropractic coverage
Medicare Supplement exclusions
CANNOT -Duplicate benefits provided by Medicare -use waivers to exclude, limit or reduce coverage for benefits specifically named or described pre-existing disease or physical conditions. -contain limitations or exclusions that are more restrictive than those imposed by Medicare.
Long-term care (LTC) insurance
any policy, certificate, or rider designed to provide coverage for at least 12 consecutive months for each covered person on an expense-incurred, indemnity, prepaid or other basis. -protect applicants from unfair and deceptive practices and such regulations
Conformity with state statutes
any revision of the policy that on its effective date, conflicts with the laws of the state in which the insured resides on that date will be amended to conform to the minimum requirements of the laws.
Home Health Care
care provided in the insured's home, usually on a part-time basis. It can be skilled care or unskilled care -
Adopted Children
coverage for adopted children must be the same for the biological children of the insured in both individual and group health plans
Long-term care partnership program
creates a partnership between the state government, private LT care insurance companies and state residents who wish to purchase LT care policies -Purpose:create incentives for individuals to insure against the cost of LT care needs -allow individuals to qualify for Mediaidby disregarding certain assets when determining eligibility. -reduce the financial burden on the state's medicaid program by providing initiatives for using qualified LT care policies.
"Individual Health Insurance Reform Act"
enacted to promote the availability of health insurance to individuals, to assure fair access to health plans, and to improve the overall fairness and efficiency of the individual health insurance market. -members include all insurers that provide health, accident and sickness insurance policies in Iowa -prevents abusive rating practices compels insurers to disclose their rating practices to consumers, sets rules for renewing coverage and sets limits on the exclusions or pre-existing conditions
Grace Period Provision
granting a grace period of at least 7 days for weekly premium policies -10 days for monthly premium policies -31 days for all other policies, for payment of each premium after the first.
Misstatement of Age (optional)
he or she will receive the benefits that the premium paid would have been purchased at the correct age
Optional Provisions
health insurance company can include any one or more of the following optional provisions providing the wording is just as beneficial to the insured and beneficiary
Change of Occupation
if moving to a more hazardous job then the insurer will pay benefits that the same premium would have purchased for more hazardous occupation -if moving to a less hazardous job then a reduction in premium will happen
Relation of earnings to insurance
if the total monthly loss-of-time benefits promised for the same loss under all loss-of-time coverage on the insured exceeds the insured's monthly earnings, the insurer is liable only for a proportionate amount of benefits under the policy as the insured monthly earnings relative to the total monthly benefits
Health and Well Kids in Iowa Program (HAWK-1)
joint federal-state funded program that provides health insurance to certain children. -younger than 19 -member of a family whose adjusted gross income that does not exceed 300% of the federal poverty level -Resident of Iowa -Not eligible for medical assistance -Not currently covered or was not covered within the prior six months under a group health plan -not a a member of a family that is eligible for health benefits coverage under a state health benefit plan on the basis of family member employment -not an inmate of a public institution or a patient in an institution for mental diseases.
Required Provisions
mandated provisions which must be included in all individual accident and health insurance policies issued in the state.
Medicare Supplement Cancellation
must be issued "guaranteed renewable" so that they cannot be cancelled or non renewed by the insurer for any reason other than nonpayment of premium
10 day free look Provision
must be provided -If a policy is returned under this provision, it will be considered to have been void from the beginning and a full refund of any premium paid must be returned.
Diabetes
must provide coverage for benefits for the cost associated with equipment, supplies, and self-management training and education for the treatment of types of diabetes mellitus when prescribed by a licensed physician.
Assisted Living
offers help with non medical aspects of daily activities in an atmosphere of separate, private living units. Provides meals, transportation, laundry service, assistance with dressing and bathroom, reminders to take medication, assistance with eating
Employee Group
policies issued to an employer to insure employees are subject to the following requirements -if part of the premium is paid from funds contributed by the insured employees, at least 75% of the eligible, insurable employees must elect to make the required contributions
Trustee Group
policies issued to the trustees of a fund established by 2 or more employers or by one or more labor unions are subject to the following: -premium must be paid by the trustees from funds established by the insureds' employers -policy must cover at least 100 person at the date of issue -policies may include dependents of the insured, including spouse.
Insurance with other companies
provides for prorating of benefits payable for expenses incurred in cases where the insurer accepted the risk without being notified of other existing coverage for the same risk. -where premiums paid exceed the amount needed to cover what the insurer determines it will pay, the excess premium must be refunded to the insured.
Continuation Right
refers to the right of an employee, group member, spouse and dependent children whose coverage under a group policy would otherwise end due to termination divorce, death etc. to continue their health insurance coverage under the group policy for the period -must request continuation in writing within 10 days after the termination or the date the employee is given notice of the right of continuation -must pay a monthly contribution in advance to the employer or group policyholder
Notice of Claim Provision
requiring that a written notice of claim must be given to the insurer within 20 days after the occurrence of any loss covered by the policy
time limit on certain defenses Provision
stating that 2 years after the date of issue no misstatements on the application can be used to void the policy or deny a claim unless the statements were fraudulent
A Time Payment of Claims Provision
stating that claims must be paid immediately upon receipt of written proof of a loss, unless provided by periodic payments
Legal Actions Provision
stating that legal actions to recover on a policy can begin no sooner than 60 days or later than 3 years after written proof of loss is furnished
Change of Beneficiary Provision
stating that the insured has the right to change the beneficiary, unless an irrevocable beneficiary designation has been made
A proof of Loss Provision
stating that the insured must furnish a completed claim form to the insurer within 90 days of the date of loss
A Claim Forms Provision
stating that the insurer, no later than 15 days after receiving notice of the claim must furnish the claimant with the forms required for filing proof of loss
Entire Contract Provision
stating that the policy, including endorsements and attached papers, constitutes the entire contract.
Physical Examination and Autopsy Provision
stating the insurer, at its own expense, has the right to requires a physical examination or autopsy of the insured while a claim is pending (where it is not forbidden by law)
