§ 513C.3 — Definitions

Iowa § 513C.3

• Jurisdiction: Iowa
• Title XIII: COMMERCE
• Ch. 513C: INDIVIDUAL HEALTH INSURANCE MARKET REFORM

Text

As used in this chapter, unless the context otherwise requires:
1. “Actuarial certification” means a written statement by a member of the American
academy of actuaries or other individual acceptable to the commissioner that an individual
carrier is in compliance with the provisions of section 513C.5 which is based upon the
actuary’s or individual’s examination, including a review of the appropriate records and the
actuarial assumptions and methods used by the carrier in establishing premium rates for
applicable individual health benefit plans.
2. “Affiliate” or “affiliated” means any entity or person who directly or indirectly through
one or more intermediaries, controls or is controlled by, or is under common control with, a
specified entity or person.
3. “Basic or standard health benefit plan” means the core group of health benefits
developed pursuant to section 513C.8.
4. “Block of business” means all the individuals insured under the same individual health
benefit plan.
5. “Carrier”meansanyentitythatprovidesindividualhealthbenefitplansinthisstate. For
purposes of this chapter, carrier includes an insurance company, a group hospital or medical
service corporation, a fraternal benefit society, a health maintenance organization, and any
otherentityprovidinganindividualplanofhealthinsuranceorhealthbenefitssubjecttostate
insurance regulation.
6. “Commissioner” means the commissioner of insurance.
7. “Eligible individual” means an individual who is a resident of this state and who
either has qualifying existing coverage or has had qualifying existing coverage within the
immediately preceding thirty days, or an individual who has had a qualifying event occur
within the immediately preceding thirty days.
8. “Established service area” means a geographic area, as approved by the commissioner
and based upon the carrier’s certificate of authority to transact business in this state, within
which the carrier is authorized to provide coverage.
§513C.3, INDIVIDUAL HEALTH INSURANCE MARKET REFORM 2
9. “Filedrate”means,foraratingperiodrelatedtoeachblockofbusiness,theratecharged
to all individuals with similar rating characteristics for individual health benefit plans.
10. “Individual health benefit plan” means any hospital or medical expense incurred
policy or certificate, hospital or medical service plan, or health maintenance organization
subscriber contract sold to an individual, or any discretionary group trust or association
policy, whether issued within or outside of the state, providing hospital or medical expense
incurred coverage to individuals residing within this state. Individual health benefit plan
does not include a self-insured group health plan, a self-insured multiple employer group
health plan, a group conversion plan, an insured group health plan, accident-only, specified
disease, short-term hospital or medical, hospital confinement indemnity, credit, dental,
vision, Medicare supplement, long-term care, or disability income insurance coverage,
coverage issued as a supplement to liability insurance, workers’ compensation or similar
insurance, or automobile medical payment insurance.
11. “Premium” means all moneys paid by an individual and eligible dependents as a
condition of receiving coverage from a carrier or an organized delivery system, including
any fees or other contributions associated with an individual health benefit plan.
12. “Qualifying event” means any of the following:
a. Lossofeligibilityformedicalassistanceprovidedpursuanttochapter249AorMedicare
coverage provided pursuant to Tit. XVIII of the federal Social Security Act.
b. Loss or change of dependent status under qualifying previous coverage.
c. The attainment by an individual of the age of majority.
d. Loss of eligibility for the Hawki program authorized in chapter 514I.
13. a. “Qualifying existing coverage” or “qualifying previous coverage” means benefits or
coverage provided under any of the following:
(1) Any group health insurance that provides benefits similar to or exceeding benefits
provided under the standard health benefit plan, provided that such policy has been in effect
for a period of at least one year.
(2) An individual health insurance benefit plan, including coverage provided under a
health maintenance organization contract, a hospital or medical service plan contract, or a
fraternal benefit society contract, that provides benefits similar to or exceeding the benefits
provided under the standard health benefit plan, provided that such policy has been in effect
for a period of at least one year.
b. For purposes of this subsection, an association policy under chapter 514E is not
considered “qualifying existing coverage” or “qualifying previous coverage”.
14. “Rating characteristics” means demographic characteristics of individuals which are
considered by the carrier in the determination of premium rates for the individuals and which
are approved by the commissioner.
15. “Rating period” means the period for which premium rates established by a carrier
are in effect.
16. “Restricted network provision” means a provision of an individual health benefit plan
thatconditionsthepaymentofbenefits,inwholeorinpart,ontheuseofhealthcareproviders
that have entered into a contractual arrangement with the carrier to provide health care
services to covered individuals.