As used in this chapter:
"ACA " means, collectively, the Patient
Protection and Affordable Care Act (Pub. L. 111-148) and Health Care and
Education Reconciliation Act (Pub. L. 111-152).
"Applicant" means an individual or entity
applying or intending to apply for a navigator license.
"Business entity" means a corporation,
association, partnership, limited liability company, limited liability
partnership or other legal entity.
"Commissioner " means the Iowa commissioner
of insurance.
"Credit" means continuing education credit.
One credit is 50 minutes of instruction or reading material in an acceptable
topic.
"Division " means the Iowa insurance
division.
"Health insurance " means insurance that is
primarily for the diagnosis, cure, mitigation, treatment, or prevention of
disease or amounts paid for the purpose of affecting any structure of the body,
including transportation that is essential to obtaining medical care, but
excluding:
1. Coverage only for
accident or disability income insurance, or any combination thereof;
2. Coverage issued as a supplement to
liability insurance;
3. Liability
insurance, including general liability insurance and automobile liability
insurance;
4. Workers' compensation
or similar insurance;
5. Automobile
medical payment insurance;
6.
Credit-only insurance;
7. Coverage
for on-site medical clinics;
8.
Coverage only for limited-scope vision benefits;
9. Benefits for long-term care, nursing home
care, home health care, community-based care, or any combination
thereof;
10. Coverage for specified
disease or critical illness;
11.
Hospital indemnity or other fixed indemnity insurance;
12. Medicare supplement policies;
13. Medicare, Medicaid, or the Federal
Employee Health Benefit Program, 5 U.S.C. §§
8901 -
8914, as it
existed on January 1, 2013;
14.
Coverage only for medical and surgical outpatient benefits;
15. Excess or stop-loss insurance;
and
16. Other similar insurance
coverage under which benefits for health insurance are secondary or incidental
to other insurance benefits.
"Individual" means a private or natural
person, as distinguished from a partnership, corporation or association.
"License " means the authorization by the
commissioner for a person to act as a navigator in the state of Iowa.
"Market place " means any health benefit
exchange authorized under the ACA and established or operating in this state,
including any exchange established or operated by the U.S. Department of Health
and Human Services.
"Navigator" means the individual or business
entity that is granted the title, duties, and responsibilities under 45 CFR §
155.210 of a navigator by the granting or appointing authority. A
navigator would engage in the activities and meet the standards described in 45 CFR §
155.210, including:
1.
Maintaining expertise in eligibility, enrollment, and program
specification;
2. Conducting public
education activities to raise awareness about the marketplace;
3. Providing information and services in a
fair, accurate, and impartial manner, including information that acknowledges
other health programs such as Medicaid and the healthy and well kids in Iowa
program;
4. Facilitating selection
of a qualified health plan;
5.
Providing referrals for consumers with questions, complaints, or grievances to
any applicable office of health insurance consumer assistance or health
insurance ombudsman established under Section 2793 of the Public Health Service
Act, or other appropriate state agency or agencies;
6. Providing information in a culturally and
linguistically appropriate manner, including to persons with limited English
proficiency; and
7. Ensuring
accessibility and usability of navigator tools and functions for persons with
disabilities.
"Navigator renewal notice" means a written
or electronic communication issued by the division to inform a navigator about
license renewal.
"Negotiate" means the act of advising a
purchaser or prospective purchaser of a particular contract of insurance
concerning any of the substantive benefits, terms or conditions of the contract
provided that the person engaged in that act either sells insurance or obtains
insurance for purchasers. The definition of "negotiate" shall not
include:
1. Impartially informing a
purchaser or prospective purchaser about substantive benefits, terms or
conditions of a contract while facilitating the enrollment in a qualified
health plan by providing fair, impartial, and accurate information that assists
a purchaser or prospective purchaser with submitting an eligibility
application;
2. Clarifying the
distinctions among qualified health plans; and
3. Helping qualified individuals make
informed decisions during a health plan selection process.
"Person" means an individual or
entity.
"Producer" means a person required to be
licensed in this state to sell, solicit or negotiate insurance.
"Qualified health plan" means a health
benefit plan that has in effect a certification that the plan meets the
criteria for certification described in Section 1311(c) of the ACA.
"Sell" means to exchange a contract of
insurance by any means, for money or its equivalent, on behalf of an
insurer.
"Solicit" means attempting to sell insurance
or asking or urging a person to apply for a particular kind of insurance from a
particular company.
"U.S. Department of Health and Human
Services" means the United States Department of Health and Human
Services and any of its subsidiaries.
