514C.1 SUPPLEMENTAL COVERAGE FOR ADOPTED OR NEWLY
BORN CHILDREN.
1. 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 issued
pursuant to chapters 509, 514, and 514A, which provide coverage for a
family member of the insured or subscriber shall also provide that
the health insurance benefits applicable for children shall, subject
to the enrollment requirements of this section, be payable with
respect to a newly born child of the insured or subscriber from the
moment of birth, or, in the situation of a newly adopted child of a
covered person, such child shall be covered from the earlier of any
of the following:
a. The date of placement of the child for the purpose of
adoption and continuing in the same manner as for other dependents of
the covered person, unless the placement is disrupted prior to legal
adoption and the child is removed from placement.
b. The date of entry of an order granting the covered person
custody of the child for purposes of adoption.
c. The effective date of adoption.
2. The coverage for adopted or newly born children shall consist
of coverage for injury or sickness including the necessary care and
treatment of medically diagnosed congenital defects and birth
abnormalities and is not subject to any preexisting condition
exclusion.
3. If payment of a specific premium or subscription fee is
required to provide coverage for a newly born child, the policy or
contract may require that notification of birth of a newly born child
and payment of the required premium or fees must be furnished to the
insurer or nonprofit service or indemnity corporation within sixty
days after the date of birth.
4. If payment of a specific premium or subscription fee is not
required to provide coverage for a newly born child, the policy or
contract may require that notification of birth of a newly born child
must be furnished to the insurer or nonprofit service or indemnity
corporation within sixty days after the date of birth in order for
coverage to be provided for the child from the date of birth.
5. a. If payment of a specific premium or subscription fee is
required to provide coverage for a newly adopted child or child
placed for adoption, the policy or contract may require that
notification of the adoption or placement for adoption and payment of
the required premium or fees must be furnished to the insurer or
nonprofit service or indemnity corporation within sixty days after
the coverage is required to begin under this section.
b. If payment of a specific premium or subscription fee is
not required to provide coverage for a newly adopted child or child
placed for adoption, the policy or contract may require that
notification of the adoption or placement for adoption must be
furnished to the insurer or nonprofit service or indemnity
corporation within sixty days after the coverage is required to begin
under this section.
c. If a covered person fails to provide the required notice
or to make payment of premium or subscription fees within the
sixty-day period required in this subsection, the newly adopted child
or child placed for adoption shall be treated no less favorably by a
health carrier than other dependents of the covered person, other
than newly born children, who seek coverage under a policy or
contract at a time other than the time when the dependent is first
eligible to apply for coverage. Section History: Early Form
[C75, 77, 79, 81, § 514C.1] Section History: Recent Form
2006 Acts, ch 1117, §62
Referred to in § 514E.7
514C.2 SKILLED NURSING CARE COVERED IN HOSPITALS.
An insurer, a hospital service corporation, or a medical service
corporation, which covers the costs of skilled nursing care under an
individual or group policy of accident and health insurance regulated
under chapter 509 or 514A, a nonprofit hospital or medical and
surgical service plan regulated under chapter 514, or a health care
service contract regulated under chapter 514B, shall 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 thirty-mile radius of the
hospital. The insurer or corporation shall reimburse the insured or
subscriber based on the skilled nursing care rate. Section History: Recent Form
84 Acts, ch 1034, § 1; 95 Acts, ch 185, §12
514C.3 DENTIST'S SERVICES UNDER ACCIDENT AND SICKNESS
INSURANCE POLICIES.
A policy of accident and sickness insurance issued in this state
which provides payment or reimbursement for any service which is
within the lawful scope of practice of a licensed dentist shall
provide benefits for the service whether the service is performed by
a licensed physician or a licensed dentist. As used in this section,
"licensed physician" includes persons licensed under chapter 148,
and "policy of accident and sickness insurance" includes
individual policies or contracts issued pursuant to chapter 514,
514A, or 514B, and group policies as defined in section 509B.1,
subsection 3. Section History: Recent Form
88 Acts, ch 1127, § 1; 2006 Acts, ch 1117, §63; 2008 Acts, ch
1088, §129
514C.3A DISCLOSURES RELATING TO DENTAL COVERAGE
REIMBURSEMENT RATES.
1. An individual or group policy of accident or health insurance
or individual or group hospital or health care service contract
issued pursuant to chapter 509, 514, or 514A, and delivered, amended,
or renewed on or after July 1, 1995, that provides dental care
benefits with a base payment for those benefits determined upon a
usual and customary fee charged by licensed dentists, shall disclose
all of the following:
a. The frequency of the determination of the usual and
customary fee.
b. A general description of the methodology used to determine
usual and customary fees, including geographic considerations.
c. The percentile that determines the maximum benefit that
the insurer or nonprofit health service corporation will pay for any
dental procedure, if the usual and customary fee is determined by
taking a sample of fees submitted on actual claims from licensed
dentists and then determining the benefit by selecting a percentile
of those fees.
2. The disclosure shall be provided upon request to all group and
individual policyholders and subscribers. All proposals for dental
care benefits shall inform the prospective policyholder or subscriber
that information regarding usual and customary fee determinations is
available from the insurer or nonprofit health service corporation.
All employee benefit descriptions or supplemental documents shall
notify the employee that information regarding reimbursement rates is
available from the employer. Section History: Recent Form
95 Acts, ch 78, §1; 95 Acts, ch 209, §26
514C.4 MANDATED COVERAGE FOR MAMMOGRAPHY.
1. A policy or contract providing for third-party payment or
prepayment of health or medical expenses shall 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
this state.
a. Individual or group accident and sickness insurance
providing coverage on an expense-incurred basis.
b. An individual or group hospital or medical service
contract issued pursuant to chapter 509, 514, or 514A.
c. An individual or group health maintenance organization
contract regulated under chapter 514B.
d. An individual or group Medicare supplemental policy,
unless coverage pursuant to such policy is preempted by federal law.
A long-term care policy or contract is specifically excluded from
regulation under this section.
2. As used in this section, "minimum mammography examination
coverage" means benefits which are better than or equal to the
following minimum requirements:
a. One baseline mammogram for any woman who is thirty-five
through thirty-nine years of age, or more frequent mammograms if
recommended by the woman's physician.
b. A mammogram every two years for any woman who is forty
through forty-nine years of age, or more frequently if recommended by
the woman's physician.
c. A mammogram every year for any woman who is fifty years of
age or older, or more frequently if recommended by the woman's
physician.
3. Mammogram benefits may be subject to any policy or contract
provisions which apply generally to other services covered by the
policy or contract.
4. The commissioner of insurance shall adopt rules under chapter
17A necessary to implement this section. Section History: Recent Form
89 Acts, ch 289, § 1; 92 Acts, ch 1162, §32, 33; 2003 Acts, ch
135, §1--3
514C.5 PRESCRIPTION DRUG BENEFIT RESTRICTIONS.
1. A group policy or contract providing for third-party payment
or prepayment for prescription drugs shall not require a person
covered under the policy or contract to obtain prescription drugs
from a mail order pharmacy as a condition of obtaining benefits for
prescription drugs if the pharmacy selected by the covered person
agrees to provide pharmaceutical services under the same terms and
conditions as those provided by the mail order pharmacy.
2. Group third-party payor policies or contracts delivered,
issued for delivery, continued, or renewed in this state on or after
July 1, 1990, are subject to this section, including but not limited
to the following classes:
a. A group accident and sickness insurance policy.
b. A group hospital or medical service contract.
c. A group health maintenance organization contract.
d. A group Medicare supplemental policy. Sectionstory: Recent Form
90 Acts, ch 1130, §1
514C.6 UNIFORMITY OF TREATMENT -- EMPLOYEE WELFARE
BENEFIT PLANS.
1. A statutory provision to mandate a health care coverage or
service, or to mandate the offering of a health care coverage or
service, applies to all state-regulated third- party payors and to
employee welfare benefit plans described in 29 U.S.C. § 1001 et seq.
However, if an employee welfare benefit plan subject to federal
regulation is not subject to a substantially similar requirement, the
statutory provision does not apply to a state-regulated third-party
payor until the employee welfare benefit plans are subject to a
substantially similar standard under federal regulations as
determined by the commissioner.
2. For purposes of this section unless the context otherwise
requires, a third-party payor means:
a. An accident and sickness insurer, subject to chapter 509
or 514A.
b. A nonprofit health service corporation, subject to chapter
514.
c. A health maintenance organization, subject to chapter
514B.
d. Any other entity engaged in the business of insurance,
risk transfer, or risk retention, which is subject to the
jurisdiction of the commissioner. Section History: Recent Form
91 Acts, ch 213, §20
Referred to in § 514C.7, 514C.11, 514C.12, 514C.18, 514C.19,
514C.20, 514C.22, 514C.23, 514C.24, 514C.25
514C.7 PROHIBITION ON RESTRICTING COVERAGE IN CERTAIN
INSTANCES INVOLVING A DIAGNOSIS OF A FIBROCYSTIC CONDITION.
Notwithstanding the uniformity of treatment requirements of
section 514C.6, a third-party payor as defined in that section shall
not deny or fail to renew, or include an exception to or exclusion of
benefits in, a policy or contract of individual or group accident and
sickness insurance solely based upon an insured being diagnosed as
having a fibrocystic condition. Section History: Recent Form
92 Acts, ch 1046, § 1
514C.8 COORDINATION OF HEALTH CARE BENEFITS WITH
STATE MEDICAL ASSISTANCE.
1. An insurer, health maintenance organization, or hospital and
medical service plan providing health care coverage to individuals in
this state shall not consider the availability of or eligibility for
medical assistance under Title XIX of the federal Social Security Act
and chapter 249A, when determining eligibility of the individual for
coverage or calculating payments to the individual under the health
care coverage plan.
2. The state acquires the rights of an individual to payment from
an insurer, health maintenance organization, or hospital or medical
service plan to the extent payment for covered expenses is made
pursuant to chapter 249A for health care items or services provided
to the individual. Upon presentation of proof that payment was made
pursuant to chapter 249A for covered expenses, the insurer, health
maintenance organization, or hospital or medical service plan shall
make payment to the state medical assistance program to the extent of
the coverage provided in the policy or contract.
3. An insurer shall not impose requirements on the state with
respect to the assignment of rights pursuant to this section that are
different from the requirements applicable to an agent or assignee of
a covered individual.
4. For purposes of this section, "insurer" means an entity
which offers a health benefit plan, including a group health plan
under the federal Employee Retirement Income Security Act of 1974.
Section History: Recent Form
95 Acts, ch 185, §13
514C.9 MEDICAL SUPPORT -- INSURANCE REQUIREMENTS.
1. An insurer shall not deny coverage or enrollment of a child
under the health plan of the obligor upon any of the following
grounds:
a. The child is born out of wedlock.
b. The child is not claimed as a dependent on the obligor's
federal income tax return.
c. The child does not reside with the obligor or in the
insurer's service area. This section shall not be construed to
require a health maintenance organization regulated under chapter
514B to provide any services or benefits for treatment outside of the
geographic area described in its certificate of authority which would
not be provided to a member outside of that geographic area pursuant
to the terms of the health maintenance organization's contract.
2. An insurer of an obligor providing health care coverage to the
child for which the obligor is legally responsible to provide support
shall do all of the following:
a. Provide information to the obligee or other legal
custodian of the child as necessary for the child to obtain benefits
through the coverage of the insurer.
b. Allow the obligee or other legal custodian of the child,
or the provider with the approval of the obligee or other legal
custodian of the child, to submit claims for covered services without
the approval of the obligor.
c. Make payment on a claim submitted in paragraph "b"
directly to the obligee or other legal custodian of the child, the
provider, or the state medical assistance agency for claims submitted
by the obligee or other legal custodian of the child, by the provider
with the approval of the obligee or other legal custodian of the
child, or by the state medical assistance agency.
3. If an obligor is required by a court order or administrative
order to provide health coverage for a child and the obligor is
eligible for dependent health coverage, the insurer shall do all of
the following:
a. Allow the obligor to enroll under dependent coverage a
child who is eligible for coverage pursuant to the applicable terms
and conditions of the health benefit plan and the standard enrollment
guidelines of the insurer without regard to an enrollment season
restriction.
b. Enroll a child who is eligible for coverage under the
applicable terms and conditions of the health benefit plan and the
standard enrollment guidelines of the insurer, without regard to any
time of enrollment restriction, under dependent coverage upon
application by the obligee or other legal custodian of the child or
by the department of human services in the event an obligor required
by a court order or administrative order fails to apply for coverage
for the child.
c. Maintain coverage and not cancel the child's enrollment
unless the insurer obtains satisfactory written evidence of any of
the following:
(1) The court order or administrative order is no longer in
effect.
(2) The child is eligible for or will enroll in comparable health
coverage through an insurer which shall take effect not later than
the effective date of the cancellation of enrollment of the original
coverage.
(3) The employer has eliminated dependent health coverage for its
employees.
(4) The obligor is no longer paying the required premium because
the employer no longer owes the obligor compensation, or because the
obligor's employment has terminated and the obligor has not elected
to continue coverage.
4. A group health plan shall establish reasonable procedures to
determine whether a child is covered under a qualified medical child
support order issued pursuant to chapter 252E. The procedures shall
be in writing, provide for prompt notice of each person specified in
the medical child support order as eligible to receive benefits under
the group health plan upon receipt by the plan of the medical child
support order, and allow an obligee or other legal custodian of the
child under chapter 252E to designate a representative for receipt of
copies of notices in regard to the medical child support order that
are sent to the obligee or other legal custodian of the child and the
department of human services' child support recovery unit.
5. For purposes of this section, unless the context otherwise
requires:
a. "Child" means a person, other than an obligee's spouse or
former spouse, who is recognized under a qualified medical child
support order as having a right to enrollment under a group health
plan as the obligor's dependent.
b. "Court order" or "administrative order" means a ruling
by a court or administrative agency in regard to the support an
obligor shall provide to the obligor's child.
c. "Insurer" means an entity which offers a health benefit
plan.
d. "Obligee" means an obligee as defined in section 252E.1.
e. "Obligor" means an obligor as defined in section 252E.1.
f. "Qualified medical child support order" means a child
support order which creates or recognizes a child's right to receive
health benefits for which the child is eligible under a group health
benefit plan, describes or determines the type of coverage to be
provided, specifies the length of time for which the order applies,
and specifies the plan to which the order applies. Section History: Recent Form
95 Acts, ch 185, §14
514C.10 COVERAGE FOR ADOPTED CHILD.
1. Definitions. For purposes of this section, unless the
context otherwise requires:
a. "Child" means, with respect to an adoption or a placement
for adoption of a child, an individual who has not attained age
eighteen as of the date of the issuance of a final adoption decree,
or upon an interlocutory adoption decree becoming a final adoption
decree, as provided in chapter 600, or as of the date of the
placement for adoption.
b. "Placement for adoption" means the assumption and
retention of a legal obligation for the total or partial support of
the child in anticipation of the adoption of the child. The child's
placement with a person terminates upon the termination of such legal
obligation.
2. Coverage required. A policy or contract providing for
third-party payment or prepayment of health or medical expenses shall
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. The issuer of the policy or contract shall not restrict
coverage under the policy or contract for a dependent child adopted
by, or placed for adoption with, the insured or enrollee solely on
the basis of a preexisting condition of such dependent child at the
time that the child would otherwise become eligible for coverage
under the plan, if the adoption or placement occurs while the insured
or enrollee is eligible for coverage under the policy or contract.
This section applies to the following classes of third-party payment
provider contracts or policies delivered, issued for delivery,
continued, or renewed in this state on or after July 1, 1995:
a. Individual or group accident and sickness insurance
providing coverage on an expense-incurred basis.
b. An individual or group hospital or medical service
contract issued pursuant to chapter 509, 514, or 514A.
c. An individual or group health maintenance organization
contract regulated under chapter 514B.
d. An individual or group Medicare supplemental policy,
unless coverage pursuant to such policy is preempted by federal law.
e. An organized delivery system licensed by the director of
public health. Section History: Recent Form
95 Acts, ch 185, §15
514C.11 SERVICES PROVIDED BY LICENSED PHYSICIAN
ASSISTANTS AND LICENSED ADVANCED REGISTERED NURSE PRACTITIONERS.
Notwithstanding section 514C.6, a policy or contract providing for
third-party payment or prepayment of health or medical expenses shall
include a provision for the payment of necessary medical or surgical
care and treatment provided by a physician assistant licensed
pursuant to chapter 148C, or provided by an advanced registered nurse
practitioner licensed pursuant to chapter 152 and performed within
the scope of the license of the licensed physician assistant or the
licensed advanced registered nurse practitioner if the policy or
contract would pay for the care and treatment if the care and
treatment were provided by a person engaged in the practice of
medicine and surgery or osteopathic medicine and surgery under
chapter 148. The policy or contract shall provide that policyholders
and subscribers under the policy or contract may reject the coverage
for services which may be provided by a licensed physician assistant
or licensed advanced registered nurse practitioner if the coverage is
rejected for all providers of similar services. A policy or contract
subject to this section shall not impose a practice or supervision
restriction which is inconsistent with or more restrictive than the
restriction already imposed by law. This section applies to services
provided under a policy or contract delivered, issued for delivery,
continued, or renewed in this state on or after July 1, 1996, and to
an existing policy or contract, on the policy's or contract's
anniversary or renewal date, or upon the expiration of the applicable
collective bargaining contract, if any, whichever is later. This
section does not apply to policyholders or subscribers eligible for
coverage under Title XVIII of the federal Social Security Act or any
similar coverage under a state or federal government plan. For the
purposes of this section, third-party payment or prepayment includes
an individual or group policy of accident or health insurance or
individual or group hospital or health care service contract issued
pursuant to chapter 509, 514, or 514A, an individual or group health
maintenance organization contract issued and regulated under chapter
514B, an organized delivery system contract regulated under rules
adopted by the director of public health, or a preferred provider
organization contract regulated pursuant to chapter 514F. Nothing in
this section shall be interpreted to require an individual or group
health maintenance organization, an organized delivery system, or a
preferred provider organization or arrangement to provide payment or
prepayment for services provided by a licensed physician assistant or
licensed advanced registered nurse practitioner unless the physician
assistant's supervising physician, the physician-physician assistant
team, the advanced registered nurse practitioner, or the advanced
registered nurse practitioner's collaborating physician has entered
into a contract or other agreement to provide services with the
individual or group health maintenance organization, the organized
delivery system, or the preferred provider organization or
arrangement. Section History: Recent Form
96 Acts, ch 1169, §1; 2008 Acts, ch 1088, §130
514C.12 POSTDELIVERY BENEFITS AND CARE.
1. Notwithstanding section 514C.6, a person who provides an
individual or group policy of accident or health insurance or
individual or group hospital or health care service contract issued
pursuant to chapter 509, 509A, 514, or 514A or an individual or group
health maintenance organization contract issued and regulated under
chapter 514B, which is delivered, amended, or renewed on or after
July 1, 1996, and which provides maternity benefits, which are not
limited to complications of pregnancy, or newborn care benefits,
shall not terminate inpatient benefits or require discharge of a
mother or the newborn from a hospital following delivery earlier than
determined to be medically appropriate by the attending physician
after consultation with the mother and in accordance with guidelines
adopted by rule by the commissioner. The guidelines adopted by rule
shall be consistent with or may adopt by reference the guidelines for
perinatal care established by the American academy of pediatrics and
the American college of obstetricians and gynecologists which provide
that when complications are not present, the postpartum hospital stay
ranges from a minimum of forty-eight hours for a vaginal delivery to
a minimum of ninety-six hours for a cesarean birth, excluding the day
of delivery. The guidelines adopted by rule by the commissioner
shall also provide that in the event of a discharge from the hospital
prior to the minimum stay established in the guidelines, a
postdischarge follow-up visit shall be provided to the mother and
newborn by providers competent in postpartum care and newborn
assessment if determined medically appropriate as directed by the
attending physician, in accordance with the guidelines.
2. When performing utilization review of inpatient hospital
services related to maternity and newborn care, including but not
limited to length of postdelivery stay and postdischarge follow-up
care, any person who provides an individual or group policy of
accident or health insurance or individual or group hospital or
health care service contract issued pursuant to chapter 509, 509A,
514, or 514A, or an individual or group health maintenance
organization contract issued and regulated under chapter 514B, shall
use the guidelines adopted by rule by the commissioner, and shall not
deselect, require additional documentation, require additional
utilization review, terminate services to, reduce payment to, or in
any manner provide a disincentive to an attending physician solely on
the basis that the attending physician provided or directed the
provision of services in compliance with the guidelines adopted by
rule.
3. Preauthorization or precertification for a hospital stay or
for a postdischarge follow-up visit in accordance with the guidelines
adopted by rule by the commissioner shall not be required. Section History: Recent Form
96 Acts, ch 1202, §1
514C.13 GROUP MANAGED CARE HEALTH PLANS --
REQUIREMENTS ATTACHED TO LIMITED PROVIDER NETWORK PLAN OFFERS.
1. As used in this section, unless the context otherwise
requires:
a. "Carrier" means an entity that provides health benefit
plans in this state. "Carrier" includes an insurance company,
group hospital or medical service corporation, health maintenance
organization, multiple employer welfare arrangement, and any other
person providing health benefit plans in this state subject to
regulation by the commissioner of insurance.
b. "Health benefit plan" means a policy, certificate, or
contract providing hospital or medical coverage, benefits, or
services rendered by a health care provider. "Health benefit
plan" does not include a group conversion plan, accident-only,
specific-disease, short-term hospital or medical hospital confinement
indemnity, credit, dental, vision, Medicare supplement, long-term
care, or disability income insurance, coverage issued as a supplement
to liability insurance, workers' compensation or similar insurance,
or automobile medical payment insurance.
c. "Health care provider" means a hospital licensed pursuant
to chapter 135B, a person licensed under chapter 148, 148C, 149, 151,
or 154, or a person licensed as an advanced registered nurse
practitioner under chapter 152.
d. "Indemnity plan" means a hospital or medical
expense-incurred policy, certificate, or contract, major medical
expense insurance, or hospital or medical service plan contract.
e. "Large employer" means a person actively engaged in
business who, during at least fifty percent of the employer's working
days during the preceding calendar year, employed more than fifty
full-time equivalent employees.
f. "Limited provider network plan" means a managed care
health plan which limits access to or coverage for services to
selected health care providers who are under contract with the
managed care health plan.
g. "Managed care health plan" means a health benefit plan
that selects and contracts with health care providers; manages and
coordinates health care delivery; monitors necessity,
appropriateness, and quality of health care delivered by health care
providers; and performs utilization review and cost control.
h. "Organized delivery system" means an organized delivery
system as defined in section 513C.3.
i. "Point of service plan option" means a provision in a
managed care health plan that permits insureds, enrollees, or
subscribers access to health care from health care providers who have
not contracted with the managed care health plan.
j. "Small employer" means a person actively engaged in
business who, during at least fifty percent of the employer's working
days during the preceding calendar year, employed not less than two
and not more than fifty full-time equivalent employees.
2. A carrier or organized delivery system which offers to a small
employer a limited provider network plan to provide health care
services or benefits to the small employer's employees shall also
offer to the small employer a point of service option to the limited
provider network plan.
3. A carrier or organized delivery system which offers to a large
employer a limited provider network plan to provide health care
services or benefits to the large employer's employees shall also
offer to the large employer one or more of the following:
a. A point of service plan option to the limited provider
network plan. The price of the point of service plan option shall be
actuarially determined.
b. A managed care health plan that is not a limited provider
network plan.
c. An indemnity plan.
4. A large employer that offers a limited provider network plan
to its employees shall also offer to its employees one or more of the
following:
a. A point of service plan option to the limited provider
network plan.
b. A managed care health plan that is not a limited provider
network plan.
c. An indemnity plan. Section History: Recent Fo/b>
97 Acts, ch 88, §1; 2008 Acts, ch 1088, §131
Referred to in § 505.25
514C.14 CONTINUITY OF CARE -- PREGNANCY.
1. Except as provided under subsection 2 or 3, a carrier, as
defined in section 513B.2, an organized delivery system authorized
under 1993 Iowa Acts, ch. 158, or a plan established pursuant to
chapter 509A for public employees, which terminates its contract with
a participating health care provider, shall continue to provide
coverage under the contract to a covered person in the second or
third trimester of pregnancy for continued care from such health care
provider. Such persons may continue to receive such treatment or
care through postpartum care related to the child birth and delivery.
Payment for covered benefits and benefit levels shall be according to
the terms and conditions of the contract.
2. A covered person who makes an involuntary change in health
plans may request that the new health plan cover the services of the
covered person's physician specialist who is not a participating
health care provider under the new health plan, if the covered person
is in the second or third trimester of pregnancy. Continuation of
such coverage shall continue through postpartum care related to the
child birth and delivery. Payment for covered benefits and benefit
levels shall be according to the terms and conditions of the new
health plan contract.
3. A carrier, organized delivery system, or plan established
under chapter 509A, which terminates the contract of a participating
health care provider for cause shall not be liable to pay for health
care services provided by the health care provider to a covered
person following the date of termination. Section History: Recent Form
99 Acts, ch 41, §1
514C.15 TREATMENT OPTIONS.
A carrier, as defined in section 513B.2; an organized delivery
system authorized under 1993 Iowa Acts, ch. 158, and licensed by the
director of public health; or a plan established pursuant to chapter
509A for public employees, shall not prohibit a participating
provider from, or penalize a participating provider for, doing either
of the following:
1. Discussing treatment options with a covered individual,
notwithstanding the carrier's, organized delivery system's, or plan's
position on such treatment option.
2. Advocating on behalf of a covered individual within a review
or grievance process established by the carrier, organized delivery
system, or chapter 509A plan, or established by a person contracting
with the carrier, organized delivery system, or chapter 509A plan.
Section History: Recent Form
99 Acts, ch 41, §2
514C.16 EMERGENCY ROOM SERVICES.
1. A carrier, as defined in section 513B.2; an organized delivery
system authorized under 1993 Iowa Acts, ch. 158, and licensed by the
director of public health; or a plan established pursuant to chapter
509A for public employees, which provides coverage for emergency
services, is responsible for charges for emergency services provided
to a covered individual, including services furnished outside any
contractual provider network or preferred provider network. Coverage
for emergency services is subject to the terms and conditions of the
health benefit plan or contract.
2. Prior authorization for emergency services shall not be
required. All services necessary to evaluate and stabilize an
emergency medical condition shall be considered covered emergency
services.
3. For purposes of this section, unless the context otherwise
requires:
a. "Emergency medical condition" means a medical condition
that manifests itself by symptoms of sufficient severity, including
but not limited to severe pain, that an ordinarily prudent person,
possessing average knowledge of medicine and health, could reasonably
expect the absence of immediate medical attention to result in one of
the following:
(1) Placing the health of the individual, or with respect to a
pregnant woman, the health of the woman or her unborn child, in
serious jeopardy.
(2) Serious impairment to bodily function.
(3) Serious dysfunction of a bodily organ or part.
b. "Emergency services" means covered inpatient and
outpatient health care services that are furnished by a health care
provider who is qualified to provide the services that are needed to
evaluate or stabilize an emergency medical condition. Section History: Recent Form
99 Acts, ch 41, §3
514C.17 CONTINUITY OF CARE -- TERMINAL ILLNESS.
1. Except as provided under subsection 2 or 3, if a carrier, as
defined in section 513B.2, an organized delivery system authorized
under 1993 Iowa Acts, ch. 158, or a plan established pursuant to
chapter 509A for public employees, terminates its contract with a
participating health care provider, a covered individual who is
undergoing a specified course of treatment for a terminal illness or
a related condition, with the recommendation of the covered
individual's treating physician licensed under chapter 148 may
continue to receive coverage for treatment received from the covered
individual's physician for the terminal illness or a related
condition, for a period of up to ninety days. Payment for covered
benefits and benefit levels shall be according to the terms and
conditions of the contract.
2. A covered person who makes a change in health plans
involuntarily may request that the new health plan cover services of
the covered person's treating physician licensed under chapter 148
who is not a participating health care provider under the new health
plan, if the covered person is undergoing a specified course of
treatment for a terminal illness or a related condition.
Continuation of such coverage shall continue for up to ninety days.
Payment for covered benefits and benefit levels shall be according to
the terms and conditions of the contract.
3. Notwithstanding subsections 1 and 2, a carrier, organized
delivery system, or plan established under chapter 509A which
terminates the contract of a participating health care provider for
cause shall not be required to cover health care services provided by
the health care provider to a covered person following the date of
termination. Section History: Recent Form
99 Acts, ch 41, §4; 2008 Acts, ch 1088, §132
514C.18 DIABETES COVERAGE.
1. Notwithstanding the uniformity of treatment requirements of
section 514C.6, a policy or contract providing for third-party
payment or prepayment of health or medical expenses shall 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 physician licensed
under chapter 148. Coverage benefits shall include coverage for the
cost associated with all of the following:
a. Blood glucose meter and glucose strips for home
monitoring.
b. Payment for diabetes self-management training and
education only under all of the following conditions:
(1) The physician managing the individual's diabetic condition
certifies that such services are needed under a comprehensive plan of
care related to the individual's diabetic condition to ensure therapy
compliance or to provide the individual with necessary skills and
knowledge to participate in the management of the individual's
condition.
(2) The diabetes self-management training and education program
is certified by the Iowa department of public health. The department
shall consult with the American diabetes association, Iowa affiliate,
in developing the standards for certification of diabetes education
programs that cover at least ten hours of initial outpatient diabetes
self-management training within a continuous twelve-month period and
up to two hours of follow-up training for each subsequent year for
each individual diagnosed by a physician with any type of diabetes
mellitus.
2. a. This section applies to the following classes of
third-party payment provider contracts or policies delivered, issued
for delivery, continued, or renewed in this state on or after July 1,
1999:
(1) Individual or group accident and sickness insurance providing
coverage on an expense-incurred basis.
(2) An individual or group hospital or medical service contract
issued pursuant to chapter 509, 514, or 514A.
(3) An individual or group health maintenance organization
contract regulated under chapter 514B.
(4) Any other entity engaged in the business of insurance, risk
transfer, or risk retention, which is subject to the jurisdiction of
the commissioner.
(5) A plan established pursuant to chapter 509A for public
employees.
(6) An organized delivery system licensed by the director of
public health.
b. This section shall not apply to accident-only, specified
disease, short-term hospital or medical, hospital confinement
indemnity, credit, dental, vision, Medicare supplement, long-term
care, basic hospital and medical-surgical expense coverage as defined
by the commissioner, disability income insurance coverage, coverage
issued as a supplement to liability insurance, workers' compensation
or similar insurance, or automobile medical payment insurance. Section History: Recent Form
99 Acts, ch 75, §1; 99 Acts, ch 208, §58; 2008 Acts, ch 1088,
§133; 2009 Acts, ch 139, §1, 2 Footnotes
2009 amendment takes effect May 22, 2009, and applies to the
classes of third-party payment provider contracts or policies that
are delivered, issued for delivery, continued, or renewed on or after
July 1, 2009; 2009 Acts, ch 139, §2
514C.19 PRESCRIPTION CONTRACEPTIVE COVERAGE.
1. Notwithstanding the uniformity of treatment requirements of
section 514C.6, a group policy or contract providing for third-party
payment or prepayment of health or medical expenses shall not do
either of the following:
a. Exclude or restrict benefits for prescription
contraceptive drugs or prescription contraceptive devices which
prevent conception and which are approved by the United States food
and drug administration, or generic equivalents approved as
substitutable by the United States food and drug administration, if
such policy or contract provides benefits for other outpatient
prescription drugs or devices.
b. Exclude or restrict benefits for outpatient contraceptive
services which 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.
2. A person who provides a group policy or contract providing for
third-party payment or prepayment of health or medical expenses which
is subject to subsection 1 shall not do any of the following:
a. Deny to an individual eligibility, or continued
eligibility, to enroll in or to renew coverage under the terms of the
policy or contract because of the individual's use or potential use
of such prescription contraceptive drugs or devices, or use or
potential use of outpatient contraceptive services.
b. Provide a monetary payment or rebate to a covered
individual to encourage such individual to accept less than the
minimum benefits provided for under subsection 1.
c. Penalize or otherwise reduce or limit the reimbursement of
a health care professional because such professional prescribes
contraceptive drugs or devices, or provides contraceptive services.
d. Provide incentives, monetary or otherwise, to a health
care professional to induce such professional to withhold from a
covered individual contraceptive drugs or devices, or contraceptive
services.
3. This section shall not be construed to prevent a third-party
payor from including deductibles, coinsurance, or copayments under
the policy or contract, as follows:
a. A deductible, coinsurance, or copayment for benefits for
prescription contraceptive drugs shall not be greater than such
deductible, coinsurance, or copayment for any outpatient prescription
drug for which coverage under the policy or contract is provided.
b. A deductible, coinsurance, or copayment for benefits for
prescription contraceptive devices shall not be greater than such
deductible, coinsurance, or copayment for any outpatient prescription
device for which coverage under the policy or contract is provided.
c. A deductible, coinsurance, or copayment for benefits for
outpatient contraceptive services shall not be greater than such
deductible, coinsurance, or copayment for any outpatient health care
services for which coverage under the policy or contract is provided.
4. This section shall not be construed to require a third-party
payor under a policy or contract to provide benefits for experimental
or investigational contraceptive drugs or devices, or experimental or
investigational contraceptive services, except to the extent that
such policy or contract provides coverage for other experimental or
investigational outpatient prescription drugs or devices, or
experimental or investigational outpatient health care services.
5. This section shall not be construed to limit or otherwise
discourage the use of generic equivalent drugs approved by the United
States food and drug administration, whenever available and
appropriate. This section, when a brand name drug is requested by a
covered individual and a suitable generic equivalent is available and
appropriate, shall not be construed to prohibit a third-party payor
from requiring the covered individual to pay a deductible,
coinsurance, or copayment consistent with subsection 3, in addition
to the difference of the cost of the brand name drug less the maximum
covered amount for a generic equivalent.
6. A person who provides an individual policy or contract
providing for third-party payment or prepayment of health or medical
expenses shall make available a coverage provision that satisfies the
requirements in subsections 1 through 5 in the same manner as such
requirements are applicable to a group policy or contract under those
subsections. The policy or contract shall provide that the
individual policyholder may reject the coverage provision at the
option of the policyholder.
7. a. This section applies to the following classes of
third-party payment provider contracts or policies delivered, issued
for delivery, continued, or renewed in this state on or after July 1,
2000:
(1) Individual or group accident and sickness insurance providing
coverage on an expense-incurred basis.
(2) An individual or group hospital or medical service contract
issued pursuant to chapter 509, 514, or 514A.
(3) An individual or group health maintenance organization
contract regulated under chapter 514B.
(4) Any other entity engaged in the business of insurance, risk
transfer, or risk retention, which is subject to the jurisdiction of
the commissioner.
(5) A plan established pursuant to chapter 509A for public
employees.
(6) An organized delivery system licensed by the director of
public health.
b. This section shall not apply to accident-only, specified
disease, short-term hospital or medical, hospital confinement
indemnity, credit, dental, vision, Medicare supplement, long-term
care, basic hospital and medical-surgical expense coverage as defined
by the commissioner, disability income insurance coverage, coverage
issued as a supplement to liability insurance, workers' compensation
or similar insurance, or automobile medical payment insurance. Section History: Recent Form
2000 Acts, ch 1120, §1
514C.20 MANDATED COVERAGE FOR DENTAL CARE --
ANESTHESIA AND CERTAIN HOSPITAL CHARGES.
1. Notwithstanding section 514C.6, and subject to the terms and
conditions of the policy or contract, a policy or contract providing
for third-party payment or prepayment of health or medical expenses
shall 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:
a. A child under five years of age upon a determination by a
licensed dentist and the child's treating physician licensed pursuant
to chapter 148, 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.
b. Any individual upon a determination by a licensed dentist
and the individual's treating physician licensed pursuant to chapter
148, 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.
2. Prior authorization of hospitalization or ambulatory surgical
center for dental care procedures may be required in the same manner
that prior authorization is required for hospitalization for other
coverages under the contract or policy.
3. This section applies to the following classes of third-party
payment provider contracts or policies delivered, issued for
delivery, continued, or renewed in this state on or after July 1,
2000:
a. Individual or group accident and sickness insurance
providing coverage on an expense-incurred basis.
b. An individual or group hospital or medical service
contract issued pursuant to chapter 509, 514, or 514A.
c. An individual or group health maintenance organization
contract regulated under chapter 514B.
d. Any other entity engaged in the business of insurance,
risk transfer, or risk retention, which is subject to the
jurisdiction of the commissioner.
e. A plan established pursuant to chapter 509A for public
employees.
f. An organized delivery system licensed by the director of
public health.
4. This section shall not apply to accident-only, specified
disease, short-term hospital or medical, hospital confinement
indemnity, credit, dental, vision, Medicare supplement, long-term
care, basic hospital and medical-surgical expense coverage as defined
by the commissioner, disability income insurance coverage, coverage
issued as a supplement to liability insurance, workers' compensation
or similar insurance, or automobile medical payment insurance. Section History: Recent Form
2000 Acts, ch 1193, §1; 2008 Acts, ch 1088, §134
514C.21 COVERAGE FOR IMMUNIZATIONS -- MERCURY.
1. Third-party payment provider contracts or policies delivered,
issued for delivery, continued, or renewed in this state on or after
January 1, 2006, that provide reimbursement for immunizations shall
provide reimbursement for immunizations containing no more than trace
amounts of mercury at the acquisition cost rate for immunizations
containing no more than trace amounts of mercury. For the purposes
of this section, "trace amounts" means trace amounts as defined
by the United States food and drug administration.
2. For the purposes of this section, "third-party payment
provider contracts or policies" includes:
a. Individual or group accident and sickness insurance
providing coverage on an expense-incurred basis.
b. An individual or group hospital or medical service
contract issued pursuant to chapter 509, 514, or 514A.
c. An individual or group health maintenance organization
contract regulated under chapter 514B.
d. An organized delivery system licensed by the director of
public health. Section History: Recent Form
2004 Acts, ch 1159, §2
Organized delivery systems authorized; see 93 Acts, ch 158, §3
514C.22 BIOLOGICALLY BASED MENTAL ILLNESS COVERAGE.
1. Notwithstanding the uniformity of treatment requirements of
section 514C.6, a group policy, contract, or plan providing for
third-party payment or prepayment of health, medical, and surgical
coverage benefits issued by a carrier, as defined in section 513B.2,
or by an organized delivery system authorized under 1993 Iowa Acts,
ch. 158, shall provide coverage benefits for treatment of a
biologically based mental illness if either of the following is
satisfied:
a. The policy, contract, or plan is issued to an employer who
on at least fifty percent of the employer's working days during the
preceding calendar year employed more than fifty full-time equivalent
employees. In determining the number of full-time equivalent
employees of an employer, employers who are affiliated or who are
able to file a consolidated tax return for purposes of state taxation
shall be considered one employer.
b. The policy, contract, or plan is issued to a small
employer as defined in section 513B.2, and such policy, contract, or
plan provides coverage benefits for the treatment of mental illness.
2. Notwithstanding the uniformity of treatment requirements of
section 514C.6, a plan established pursuant to chapter 509A for
public employees shall provide coverage benefits for treatment of a
biologically based mental illness.
3. For purposes of this section, "biologically based mental
illness" means the following psychiatric illnesses:
a. Schizophrenia.
b. Bipolar disorders.
c. Major depressive disorders.
d. Schizo-affective disorders.
e. Obsessive-compulsive disorders.
f. Pervasive developmental disorders.
g. Autistic disorders.
4. The commissioner, by rule, shall define the biologically based
mental illnesses identified in subsection 3. Definitions established
by the commissioner shall be consistent with definitions provided in
the most recent edition of the American psychiatric association's
diagnostic and statistical manual of mental disorders, as such
definitions may be amended from time to time. The commissioner may
adopt the definitions provided in such manual by reference.
5. This section shall not apply to accident-only, specified
disease, short-term hospital or medical, hospital confinement
indemnity, credit, dental, vision, Medicare supplement, long-term
care, basic hospital and medical-surgical expense coverage as defined
by the commissioner, disability income insurance coverage, coverage
issued as a supplement to liability insurance, workers' compensation
or similar insurance, or automobile medical payment insurance, or
individual accident and sickness policies issued to individuals or to
individual members of a member association.
6. A carrier, organized delivery system, or plan established
pursuant to chapter 509A may manage the benefits provided through
common methods including, but not limited to, providing payment of
benefits or providing care and treatment under a capitated payment
system, prospective reimbursement rate system, utilization control
system, incentive system for the use of least restrictive and least
costly levels of care, a preferred provider contract limiting choice
of specific providers, or any other system, method, or organization
designed to assure services are medically necessary and clinically
appropriate.
7. a. A group policy, contract, or plan covered under this
section shall not impose an aggregate annual or lifetime limit on
biologically based mental illness coverage benefits unless the
policy, contract, or plan imposes an aggregate annual or lifetime
limit on substantially all health, medical, and surgical coverage
benefits.
b. A group policy, contract, or plan covered under this
section that imposes an aggregate annual or lifetime limit on
substantially all health, medical, and surgical coverage benefits
shall not impose an aggregate annual or lifetime limit on
biologically based mental illness coverage benefits that is less than
the aggregate annual or lifetime limit imposed on substantially all
health, medical, and surgical coverage benefits.
8. A group policy, contract, or plan covered under this section
shall at a minimum allow for thirty inpatient days and fifty-two
outpatient visits annually. The policy, contract, or plan may also
include deductibles, coinsurance, or copayments, provided the amounts
and extent of such deductibles, coinsurance, or copayments applicable
to other health, medical, or surgical services coverage under the
policy, contract, or plan are the same. It is not a violation of
this section if the policy, contract, or plan excludes entirely from
coverage benefits for the cost of providing the following:
a. Marital, family, educational, developmental, or training
services.
b. Care that is substantially custodial in nature.
c. Services and supplies that are not medically necessary or
clinically appropriate.
d. Experimental treatments.
9. This section applies to third-party payment provider policies
or contracts and to plans established pursuant to chapter 509A that
are delivered, issued for delivery, continued, or renewed in this
state on or after January 1, 2006. Section History: Recent Form
2005 Acts, ch 91, §1
Referred to in § 135H.3
514C.23 HUMAN PAPILLOMA VIRUS VACCINATIONS --
COVERAGE.
1. Notwithstanding the uniformity of treatment requirements of
section 514C.6, a contract, policy, 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,
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 this state on or after January 1,
2009:
a. Individual or group accident and sickness insurance
providing coverage on an expense-incurred basis.
b. An individual or group hospital or medical service
contract issued pursuant to chapter 509, 514, or 514A.
c. An individual or group health maintenance organization
contract regulated under chapter 514B.
d. An individual or group Medicare supplemental policy,
unless coverage pursuant to such policy is preempted by federal law.
e. A plan established pursuant to chapter 509A for public
employees.
2. This section shall not apply to accident-only, specified
disease, short-term hospital or medical, hospital confinement
indemnity, credit, dental, vision, long-term care, basic hospital and
medical-surgical expense coverage as defined by the commissioner,
disability income insurance coverage, coverage issued as a supplement
to liability insurance, workers' compensation or similar insurance,
or automobile medical payment insurance.
3. As used in this section, "human papilloma virus" means the
human papilloma virus as defined by the centers for disease control
and prevention of the United States department of health and human
services.
4. The commissioner of insurance shall adopt rules pursuant to
chapter 17A as necessary to administer this section. Section History: Recent Form
2008 Acts, ch 1108, §1
514C.24 CANCER TREATMENT -- COVERAGE.
1. Notwithstanding the uniformity of treatment requirements of
section 514C.6, a contract, policy, or plan providing for third-party
payment or prepayment for cancer treatment shall not discriminate
between coverage benefits for prescribed, orally administered
anticancer medication used to kill or slow the growth of cancerous
cells and intravenously administered or injected cancer medications
that are covered, regardless of formulation or benefit category
determination by the contract, policy, or plan.
2. The provisions of this section shall apply to all of the
following classes of third-party payment provider contracts,
policies, or plans delivered, issued for delivery, continued, or
renewed in this state on or after July 1, 2009:
a. Individual or group accident and sickness insurance
providing coverage on an expense-incurred basis.
b. An individual or group hospital or medical service
contract issued pursuant to chapter 509, 514, or 514A.
c. An individual or group health maintenance organization
contract regulated under chapter 514B.
d. An individual or group Medicare supplemental policy,
unless coverage pursuant to such policy is preempted by federal law.
e. A plan established pursuant to chapter 509A for public
employees.
3. This section shall not apply to accident-only, specified
disease, short-term hospital or medical, hospital confinement
indemnity, credit, dental, vision, long-term care, basic hospital,
and medical-surgical expense coverage as defined by the commissioner,
disability income insurance coverage, coverage issued as a supplement
to liability insurance, workers' compensation or similar insurance,
or automobile medical payment insurance.
4. The commissioner of insurance shall adopt rules pursuant to
chapter 17A as necessary to administer this section. Section History: Recent Form
2009 Acts, ch 179, §183
514C.25 COVERAGE FOR PROSTHETIC DEVICES.
1. a. Notwithstanding the uniformity of treatment
requirements of section 514C.6, a policy, contract, or plan providing
for third-party payment or prepayment of health or medical expenses
shall provide coverage benefits for medically necessary prosthetic
devices when prescribed by a physician licensed under chapter 148.
Such coverage benefits for medically necessary prosthetic devices
shall provide coverage for medically necessary prosthetic devices
that, at a minimum, equals the coverage and payment for medically
necessary prosthetic devices provided under the most recent federal
laws for health insurance for the aged and disabled pursuant to 42
U.S.C. § 1395k, 13951, and 1395m, and 42 C.F.R. § 410.100, 414.202,
414.210, and 414.228, as applicable.
b. For the purposes of this section, "prosthetic device"
means an artificial limb device to replace, in whole or in part, an
arm or leg.
2. a. This section applies to the following classes of
third-party payment provider policies, contracts, or plans delivered,
issued for delivery, continued, or renewed in this state on or after
July 1, 2009:
(1) Individual or group accident and sickness insurance providing
coverage on an expense-incurred basis.
(2) An individual or group hospital or medical service contract
issued pursuant to chapter 509, 514, or 514A.
(3) An individual or group health maintenance organization
contract regulated under chapter 514B.
(4) A plan established pursuant to chapter 509A for public
employees.
(5) An organized delivery system licensed by the director of
public health.
b. This section shall not apply to accident-only, specified
disease, short-term hospital or medical, hospital confinement
indemnity, credit, dental, vision, Medicare supplement, long-term
care, basic hospital and medical-surgical expense coverage as defined
by the commissioner, disability income insurance coverage, coverage
issued as a supplement to liability insurance, workers' compensation
or similar insurance, or automobile medical payment insurance.
3. Notwithstanding subsection 1, paragraph "a", a policy,
contract, or plan providing for third-party payment or prepayment of
health or medical expenses that is issued for use in connection with
a health savings account as authorized under Tit. XII of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003, Pub.
L. No. 108-173, may impose the same deductibles and out-of-pocket
limits on the prosthetics coverage benefits required in this section
that apply to substantially all health, medical, and surgical
coverage benefits under the policy, contract, or plan. Section History: Recent Form
2009 Acts, ch 89, §1