Iowa Admin. Code r. 191-36.6 - Accident and sickness minimum standards for benefits
The following minimum standards for benefits are prescribed
for the categories of coverage noted in the following subrules. No individual
policy of
Nothing in this rule shall preclude the issuance of any policy or contract combining two or more categories of coverage set forth in this chapter.
Nonprofit
(1)
General
rules.
a. A "noncancelable,"
"guaranteed renewable," or "noncancelable and guaranteed renewable" policy
shall not provide for termination of coverage of the spouse solely because of
the occurrence of an event specified for termination of coverage of the
insured, other than nonpayment of premium. The policy shall provide that in the
event of the insured's death, the spouse of the insured, if covered under the
policy, shall become the insured.
b. The terms "noncancelable," "guaranteed
renewable," or "noncancelable and guaranteed renewable" shall not be used
without further explanatory language in accordance with the disclosure
requirements of 36.7(1)"a. " The terms "noncancelable" or
"noncancelable and guaranteed renewable" may be used only in a policy which the
insured has the right to continue in force by the timely payment of premiums
set forth in the policy until the age of 65 or to eligibility for Medicare ,
during which period the insurer has no right to make unilaterally any change in
any provision of the policy while the policy is in force: Provided, however,
any accident and health or accident only policy which provides for periodic
payments, weekly or monthly, for a specified period during the continuance of
disability resulting from accident or sickness may provide that the insured has
the right to continue the policy only to age 60 if, at age 60 the insured has
the right to continue the policy in force at least to age 65 while actively or
regularly employed. Except as provided above, the term "guaranteed renewable"
may be used only in a policy which the insured has the right to continue in
force by the timely payment of premiums until the age of 65 or to eligibility
for Medicare , during which period the insurer has no right to make unilaterally
any change in any provision of the policy while the policy is in force, except
that the insurer may make changes in premium rates by classes: Provided,
however, any accident and health or accident only policy which provides for
periodic payments, weekly or monthly, for a specified period during the
continuance of disability resulting from accident or sickness may provide that
the insured has the right to continue the policy only to age 60 if, at age 60,
the insured has the right to continue the policy in force at least to age 65
while actively and regularly employed.
c. In a family policy covering both husband
and wife, the age of the younger spouse must be used as the basis for meeting
the age and durational requirements of the definitions of "noncancelable" or
"guaranteed renewable." However, this requirement shall not prevent termination
of coverage of the older spouse upon attainment of the stated age limit (e.g.,
age 65) so long as the policy may be continued in force as to the younger
spouse, to the age or for the durational period as specified in said
definition.
d. When accidental
death and dismemberment coverage is part of the insurance coverage offered
under the contract, the insured shall have the option to include all insureds
under the coverage and not just the principal insured.
e. If a policy contains a status type
military service exclusion or a provision which suspends coverage during
military service, the policy shall provide, upon receipt of written request,
for refund of premiums as applicable to the person on a pro-rata
basis.
f. In the event the insurer
cancels or refuses to renew, policies providing pregnancy benefits shall
provide for an extension of benefits as to pregnancy commencing while the
policy is in force and for which benefits would have been payable had the
policy remained in force.
g.
Policies providing skilled, or convalescent, or extended care benefits
following hospitalization shall not condition the benefits upon admission to
the nursing facility within a period of less than 14 days after discharge from
the hospital .
h. Family coverage
shall continue for any dependent child who is incapable of self-sustaining
employment due to mental retardation or physical handicap on the date that the
child's coverage would otherwise terminate under the policy due to the
attainment of a specified age limit for children and is chiefly dependent on
the insured for support and maintenance. The policy may require that within 31
days of the date, the company receive due proof of such incapacity in order for
the insured to elect to continue the policy in force with respect to the child,
or that a separate converted policy be issued at the option of the insured or
policyholder.
i. Any policy
providing coverage for the recipient in a transplant operation shall also
provide reimbursement of any medical expenses of a live donor to the extent
that benefits remain and are available under the recipient's policy, after
benefits for the recipient's own expenses have been paid.
j. A policy may contain a provision relating
to recurrent disabilities; provided, however, that no provision shall specify
that a recurrent disability be separated by a period greater than six
months.
k. Accidental death and
dismemberment benefits shall be payable if the loss occurs within 90 days from
the date of the accident , irrespective of total disability . Disability income
benefits, if provided, shall not require the loss to commence less than 30 days
after the date of accident , nor shall any policy which the insurer cancels or
refuses to renew require that it be in force at the time disability commences
if the accident occurred while the policy was in force.
l. Specific dismemberment benefits shall not
be in lieu of other benefits unless the specific benefit equals or exceeds the
other benefits.
m. Any accident
only policy providing benefits which vary according to the type of accidental
cause shall prominently set forth in the outline of coverage the circumstances
under which benefits are payable which are lesser than the maximum amount
payable under the policy.
n.
Termination of the policy shall be without prejudice to coverage for any
continuous loss which commenced while the policy was in force, but the
extension of benefits beyond the period the policy was in force may be
predicated upon the continuous total disability of the insured, limited to the
duration of the policy benefit period, or payment of the maximum
benefits.
o. Rescinded IAB
11/27/91, effective 1/1/92.
(2)
"Basic hospital expense
coverage" is a policy of accident and sickness insurance which
provides coverage for a period of not less than 31 days during any continuous
hospital confinement for each person insured under the policy, for expense
incurred for necessary treatment and services rendered as a result of accident
or sickness for at least the following:
a.
Daily hospital room and board in an amount not less than the lesser of 80
percent of the charges for the semiprivate room accommodations or $100 per
day;
b. Miscellaneous hospital
services for expenses incurred for the charges made by the hospital for
services and supplies which are customarily rendered by the hospital and
provided for use only during any one period of confinement in an amount not
less than either 80 percent of the charges incurred up to at least $3,000 or
ten times the daily hospital room and board benefits;
c. Hospital outpatient services consisting of
(1) hospital services on the day surgery is performed, and (2) hospital
services rendered within 72 hours after accidental injury , in an amount not
less than $150, and (3) X-ray and laboratory tests, to the extent that benefits
for such services would have been provided if rendered to an inpatient of the
hospital in an amount not less than $100.
Benefits provided under"a" and"b" above may be provided subject to a combined deductible amount not in excess of $100.
(3)
"Basic medical-surgical expense
coverage" is a policy of accident and sickness insurance which
provides coverage for each person insured under the policy for the expenses
incurred for the necessary services rendered by a physician for treatment of an
injury or sickness for at least the following:
a. Surgical services:
(1) In amounts not less than those provided
in a fee schedule based on the relative values contained in the state of New
York certified surgical fee schedule, or the 1964 California Relative Value
Schedule or other acceptable relative value scale of surgical procedures, up to
a maximum of at least $1,000 for any one procedure; or
(2) Not less than 80 percent of the
reasonable charges.
b.
Anesthesia services, consisting of administration of necessary general
anesthesia and related procedures in connection with covered surgical service
rendered by a physician other than the physician (or assistant) performing the
surgical services:
(1) In an amount not less
than 80 percent of the reasonable charges; or
(2) Fifteen percent of the surgical service
benefit.
c. In-hospital
medical services, consisting of physician services other than surgical care,
rendered to a person who is a bed patient in a hospital for treatment of
sickness or injury in an amount not less than 80 percent of the reasonable
charges or $50 per day for not less than 21 days during one period of
confinement .
(4)
"Hospital confinement indemnity coverage" is a policy of
accident and sickness insurance which provides daily benefits for hospital
confinement on an indemnity basis in an amount not less than $40 per day and
not less than 31 days during any one period of confinement for each person
insured under the policy.
a. Coverage shall
not be excluded due to a preexisting condition for a period greater than 12
months following the effective date of coverage of an insured person unless the
preexisting condition is specifically and expressly excluded.
b. Except as provided in 191-Chapter 38,
division II, benefits shall be paid regardless of other coverage.
(5)
Individual major
medical expense coverage.
a.
"Individual major medical expense coverage" is an accident and sickness
insurance policy which provides hospital , medical and surgical expense
coverage, to an aggregate maximum of not less than $500,000; coinsurance
percentage per year per covered person not to exceed 50 percent of covered
charges, provided that the coinsurance out-of-pocket maximum after any
deductibles does not exceed $10,000 per year; a deductible stated on a per
person, per family, per illness, per benefit period, or per year basis, or a
combination of these bases not to exceed 5 percent of the aggregate maximum
limit under the policy for each covered person for at least:
(1) Daily hospital room and board expenses
subject only to limitations based on average daily cost of the semiprivate room
rate in the area where the insured resides;
(2) Miscellaneous hospital
services;
(3) Surgical
services;
(4) Anesthesia
services;
(5) In-hospital medical
services;
(6) Out-of-hospital care,
consisting of physicians' services rendered on an ambulatory basis where
coverage is not provided elsewhere in the policy for diagnosis and treatment of
sickness or injury, diagnostic X-ray, laboratory services, radiation therapy,
and hemodialysis ordered by a physician ; and
(7) Not fewer than three of the following
additional benefits:
1. In-hospital private
duty registered nurse services.
2.
Convalescent nursing care.
3.
Diagnosis and treatment by a radiologist or physiotherapist.
4. Rental of special medical equipment, as
defined by the insurer in the policy.
5. Artificial limbs or eyes, casts, splints,
trusses or braces.
6. Treatment for
functional nervous disorders , and mental and emotional disorders.
7. Out-of-hospital prescription drugs and
medications.
b. If the policy is written to complement
underlying basic hospital expense coverage and basic medical-surgical expense
coverage, the deductible may be increased by the amount of the benefits
provided by the underlying coverage.
c. The minimum benefits required by paragraph
36.6(5)"a" may be subject to all applicable deductibles,
coinsurance and general policy exceptions and limitations. An individual major
medical expense policy may also have special or internal limitations for
prescription drugs, nursing facilities, intensive care facilities, mental
health treatment, alcohol or substance abuse treatment, transplants,
experimental treatments, mandated benefits required by law and those services
covered under subparagraph 36.6(5)"a"(7) and other such
special or internal limitations as are authorized or approved by the
commissioner. Except as authorized by this subrule through the application of
special or internal limitations, an individual major medical expense policy
must be designed to cover, after any deductibles or coinsurance provisions are
met, the usual, customary and reasonable charges, as determined consistently by
the carrier and as subject to approval by the commissioner, or another rate
agreed to between the insurer and provider , for covered services up to the
lifetime policy maximum.
(6)
Individual basic medical expense
coverage.
a. "Individual basic
medical expense coverage" is an accident and sickness insurance policy that
provides hospital , medical and surgical expense coverage, to an aggregate
maximum of not less than $250,000; coinsurance percentage per year per covered
person not to exceed 50 percent of covered charges, provided that the
coinsurance out-of-pocket maximum after any deductibles does not exceed $25,000
per year; a deductible stated on a per person, per family, per illness, per
benefit period, or per year basis, or a combination of these bases not to
exceed 10 percent of the aggregate maximum limit under the policy for each
covered person for at least:
(1) Daily
hospital room and board expenses subject only to limitations based on average
daily cost of the semiprivate room rate in the area where the insured resides
or such other rate agreed upon by the insurer and provider for a period of not
less than 31 days during continuous hospital confinement;
(2) Miscellaneous hospital
services;
(3) Surgical
services;
(4) Anesthesia
services;
(5) In-hospital medical
services;
(6) Out-of-hospital care,
consisting of physicians' services rendered on an ambulatory basis where
coverage is not provided elsewhere in the policy for diagnosis and treatment of
sickness or injury, diagnostic X-ray, laboratory services, radiation therapy
and hemodialysis ordered by a physician ; and
(7) Not fewer than three days of the
following additional benefits:
1. In-hospital
private duty registered nurse services;
2. Convalescent nursing home care;
3. Diagnosis and treatment by a radiologist
or physiotherapist;
4. Rental of
special medical equipment, as defined by the insurer in the policy;
5. Artificial limbs or eyes, casts, splints,
trusses or braces;
6. Treatment for
functional nervous disorders , and mental and emotional disorders; or
7. Out-of-hospital prescription drugs and
medications.
b. If the policy is written to complement
underlying basic hospital expense coverage and basic medical-surgical expense
coverage, the deductible may be increased by the amount of the benefits
provided by the underlying coverage.
c. The minimum benefits required by paragraph
36.6(6)"a" may be subject to all applicable deductibles,
coinsurance and general policy exceptions and limitations. An individual basic
medical expense policy may also have special or internal limitations for
prescription drugs, nursing facilities, intensive care facilities, mental
health treatment, alcohol or substance abuse treatment, transplants,
experimental treatments, mandated benefits required by law and those services
covered under subparagraph 36.6(6)"a"(7) and other such
special or internal limitations as are authorized or approved by the
commissioner. Except as authorized by this subrule through the application of
special or internal limitations, an individual basic medical expense policy
must be designed to cover, after any deductibles or coinsurance provisions are
met, the usual customary and reasonable charges, as determined consistently by
the carrier and as subject to approval by the commissioner, or another rate
agreed upon by the insurer and provider , for covered services up to the
lifetime policy maximum.
(7)
"Disability income protection
coverage" is a policy which provides for periodic payments, weekly or
monthly, for a specified period during the continuance of disability resulting
from either sickness or injury or a combination of them which:
a. Provides that periodic payments which are
payable at ages after 62 and reduced solely on the basis of age are at least 50
percent of amounts payable immediately prior to 62;
b. Contains an elimination period no greater
than:
(1) Ninety days in the case of a
coverage providing a benefit of one year or less;
(2) One hundred eighty days in the case of
coverage providing a benefit of more than one year but not greater than two
years; or
(3) Three hundred
sixty-five days in all other cases during the continuance of disability
resulting from sickness or injury; and
c. Has a maximum period of time for which it
is payable during disability of at least six months except in the case of a
policy covering disability arising out of pregnancy or childbirth in which case
the period for disability may be one month. No reduction in benefits shall be
put into effect because of an increase in social security or similar benefits
during a benefit period.
If a policy provides
Subrule 36.6(7) does not apply to those policies providing business buy-out coverage.
(8)
"Accident only coverage"
is a policy of accident insurance which provides coverage, singly or in
combination, for death, dismemberment, disability, or hospital and medical care
caused by accident . Accidental death and double dismemberment amounts under
such a policy shall be at least $1,000 and a single dismemberment amount shall
be at least $500.
(9)
Specified disease and specified accident coverage.
a. "Specified disease coverage" is a policy
which meets one of the following definitions:
(1) A policy which provides coverage for each
person insured under the policy for a specifically named disease (or diseases)
with a deductible amount, if any, not in excess of $250 and an overall
aggregate benefit limit of not less than $5,000 and a benefit period of not
less than two years for at least the following incurred expenses:
1. Hospital room and board and any other
hospital -furnished medical services or supplies;
2. Treatment by a legally qualified physician
or surgeon;
3. Private duty
services of a registered nurse (R.N.);
4. X-ray, radium and other therapy procedures
used in diagnosis and treatment;
5.
Professional ambulance for local service to or from a local hospital ;
6. Blood transfusions, including expense
incurred for blood donors;
7. Drugs
and medicines prescribed by a physician ;
8. The rental of a respirator or similar
mechanical apparatus;
9. Braces,
crutches and wheelchairs as are deemed necessary by the attending physician for
the treatment of the disease;
10.
Emergency transportation if in the opinion of the attending physician it is
necessary to transport the insured to another locality for treatment of the
disease; and
11. May include
coverage of any other expenses necessarily incurred in the treatment of the
disease.
(2) A policy
which provides coverage for each person insured under the policy for a
specifically named disease (or diseases) with no deductible amount, and an
overall aggregate benefit limit of not less than $25,000 payable at the rate of
not less than $50 a day while confined in a hospital and a benefit period of
not less than 500 days.
b. "Specified accident coverage" is an
accident insurance policy which provides coverage for a specifically identified
kind of accident (or accidents) for each person insured under the policy for
accidental death or accidental death and dismemberment, combined with a benefit
amount not less than $5,000 for accidental death, $5,000 for double
dismemberment, and $2,500 for single dismemberment.
(10)
"Limited benefit health
insurance coverage" is any policy or contract which provides benefits
that are less than the minimum standards for benefits required under 36.6(2) to
36.6(8). Limited benefit policies or contracts may be delivered or issued for
delivery in this state only if the outline of coverage required by 36.7(12) is
completed and delivered as required by 36.7(2). A policy covering a specified
disease or combination of diseases shall meet the requirements of 36.6(9) and
shall not be offered for sale as a "limited coverage." A policy which is
designed to supplement Medicare shall meet the requirements of 191-Chapter 37
and shall not be offered for sale as a "limited coverage."
(11)
Short-term limited-duration
insurance coverage.
a. "Short-term
limited-duration insurance coverage" provides coverage up to an aggregate
maximum of not less than $500,000 for each initial or renewal policy term and
shall include a minimum of all of the following services subject to the
approved policy terms, limitations and exclusions:
(1) Daily hospital room and board expenses
subject only to limitations based on average daily cost of the semiprivate room
rate in the area where the insured resides;
(2) Miscellaneous hospital services,
including emergency room services;
(3) Surgical services;
(4) Anesthesia services;
(5) In-hospital medical services;
(6) Out-of-hospital care consisting of
physicians' services rendered on an ambulatory basis, and through telemedicine
by remote diagnosis and treatment of patients by means of telecommunications
technology, where coverage is not provided elsewhere in the policy for
diagnosis and treatment of sickness or injury, diagnostic X-ray, laboratory
services, radiation therapy, and hemodialysis ordered by a physician ;
(7) In-hospital registered nurse
services;
(8) Convalescent nursing
care;
(9) Diagnosis and treatment
by a radiologist or physiotherapist;
(10) Rental of special medical equipment, as
defined by the insurer in the policy;
(11) Artificial limbs or eyes, casts,
splints, trusses or braces;
(12)
Treatment for functional nervous disorders , mental and emotional disorders and
substance use disorders; and
(13)
Out-of-hospital prescription drugs and medications.
b. If the short-term limited-duration
insurance coverage establishes a separate out-of-pocket maximum for the
prescription drug benefit, the short-term limited-duration insurance coverage
shall contain a deductible, coinsurance and copayment out-of-pocket maximum for
all benefits for each covered person, excluding prescription drug services,
that shall not exceed $5,000 multiplied by the number of months of coverage and
not in excess of $20,000 for the full policy term of any duration, and the
separate prescription drug benefit shall have a deductible, coinsurance and
copayment out-of-pocket maximum separate from the other required services that
shall not exceed $2,500 multiplied by the number of months of coverage and not
in excess of $ 10,000 for the full policy term of any duration.
c. If the short-term limited-duration
insurance coverage integrates a prescription drug benefit into the plan design,
the deductible, coinsurance and copayment out-of-pocket maximum for each
covered person for all medical and prescription drug coverage shall not exceed
$7,500 multiplied by the number of months of coverage and not in excess of
$30,000 for the full policy term of any duration.
d. After 180 days of coverage, short-term
limited-duration insurance coverage that has an initial policy term or has been
renewed or extended beyond 180 days in duration shall also provide preventative
and wellness services subject to deductibles, coinsurance and copayments,
including annual routine office visits, immunizations, mammography
examinations, prostate-specific antigen blood tests and Papanicolaou
tests.
e. Short-term
limited-duration insurance shall not contain preexisting condition exclusions
that exceed the initial policy term. Any renewable short-term limited-duration
insurance shall be guaranteed renewable.
f. Short-term limited-duration insurance
shall have an expiration date specified in the policy.
g. All short-term limited-duration policies
shall contain the notices required of short-term limited-duration insurance as
set forth in the Public Health Service Act ,
45
CFR Section 144103 ..
h. All short-term limited-duration insurance
shall contain a free-look period of not less than ten days after the insured
receives the policy during which the insured may cancel the insurance. If the
insurance is so canceled, all fees and premiums paid shall be promptly refunded
and the insurance shall be voided as if the policy had not been issued. Notice
of the free-look period shall be prominently displayed on the first page of the
policy.
(1) For the purposes of this
paragraph, the policy shall be determined to be received by the insured as
follows:
1. Pursuant to Iowa Code section
554D117.
if received electronically; and
2.
Four days after the policy is postmarked for delivery if sent in the
mail.
(2) For the
purposes of this paragraph, the insured may cancel the insurance by giving
notice to the insurance company, agent, broker or other representative in any
manner, including but not limited to via electronic notice or by
telephone.
i. All
applications for short-term limited-duration insurance shall contain clear and
unambiguous questions designed to ascertain the health condition of the
applicant and identify any preexisting conditions.
This rule is intended to implement Iowa Code section 514D.4.
Notes
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