As provided in this chapter, unless the context otherwise requires:
1.“Basichealthcareservices”meansserviceswhichanenrolleemightreasonablyrequire
in order to be maintained in good health, including as a minimum, emergency care, inpatient
hospital and physician care, and outpatient medical services rendered within or outside of a
hospital.
2.“Commissioner” means the commissioner of insurance.
3.“Enrollee” means an individual who is enrolled in a health maintenance organization.
4.“Evidence of coverage” means any certificate, agreement or contract issued to an
enrollee setting out the coverage to which the enrollee is entitled.
5.
a.“Health care services” means services included in the furnishing to any individual
of medical or dental care, or hospitalization, or incident to the furnish
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As provided in this chapter, unless the context otherwise requires:
1. “Basichealthcareservices”meansserviceswhichanenrolleemightreasonablyrequire
in order to be maintained in good health, including as a minimum, emergency care, inpatient
hospital and physician care, and outpatient medical services rendered within or outside of a
hospital.
2. “Commissioner” means the commissioner of insurance.
3. “Enrollee” means an individual who is enrolled in a health maintenance organization.
4. “Evidence of coverage” means any certificate, agreement or contract issued to an
enrollee setting out the coverage to which the enrollee is entitled.
5. a. “Health care services” means services included in the furnishing to any individual
of medical or dental care, or hospitalization, or incident to the furnishing of such care or
hospitalization, as well as the furnishing to any person of all other services for the purposes
of preventing, alleviating, curing, or healing human illness, injury, or physical disability.
b. The health care services available to enrollees under prepaid group plans covering
vision care services or procedures shall include a provision for payment of necessary medical
or surgical care and treatment provided by an optometrist licensed under chapter 154, if
performed within the scope of the optometrist’s license, and the plan would pay for the care
andtreatmentwhenthecareandtreatmentwereprovidedbyapersonengagedinthepractice
of medicine or surgery as licensed under chapter 148. The plan shall provide that the plan
enrollees may reject the coverage for services which may be provided by an optometrist if the
coverage is rejected for all providers of similar vision care services as licensed under chapter
148 or 154. This paragraph applies to services provided under plans made after July 1, 1983,
and to existing group plans on their next anniversary or renewal date, or upon the expiration
§514B.1, HEALTH MAINTENANCE ORGANIZATIONS 2
of the applicable collective bargaining contract, if any, whichever is the later. This paragraph
does not apply to enrollees eligible for coverage under Tit. XVIII of the Social Security Act or
any other similar coverage under a state or federal government plan.
c. The health care services available to enrollees under prepaid group plans covering
diagnosis and treatment of human ailments shall include a provision for payment of
necessary diagnosis or treatment provided by a chiropractor licensed under chapter 151
if the diagnosis or treatment is provided within the scope of the chiropractor’s license
and if the plan would pay or reimburse for the diagnosis or treatment of human ailment,
irrespective of and disregarding variances in terminology employed by the various licensed
professions in describing the human ailment or its diagnosis or its treatment, if it were
provided by a person licensed under chapter 148. The plan shall also provide that the
plan enrollees may reject the coverage for diagnosis or treatment of a human ailment by a
chiropractor if the coverage is rejected for all providers of diagnosis or treatment for similar
human ailments licensed under chapter 148 or 151. A prepaid group plan of health care
services may limit or make optional the payment or reimbursement for lawful diagnostic or
treatment service by all licensees under chapters 148 and 151 on any rational basis which
is not solely related to the license under or the practices authorized by chapter 151 or is
not dependent upon a method of classification, categorization, or description based upon
differences in terminology used by different licensees in describing human ailments or their
diagnosis or treatment. This paragraph applies to services provided under plans made after
July 1, 1986, and to existing group plans on their next anniversary or renewal date, or upon
the expiration of the applicable collective bargaining contract, if any, whichever is the later.
This paragraph does not apply to enrollees eligible for coverage under Tit. XVIII of the
Social Security Act, or any other similar coverage under a state or federal government plan.
d. The health care services available to enrollees under prepaid group plans covering
hospital, medical, or surgical expenses, may include, at the option of the employer
purchaser, a provision for payment of covered services determined to be medically necessary
provided by a certified registered nurse certified by a national certifying organization, which
organization shall be identified by the Iowa board of nursing pursuant to rules adopted by
the board, if the services are within the practice of the profession of a registered nurse as
that practice is defined in section 152.1, under terms and conditions agreed upon between
the employer purchaser and the health maintenance organization, subject to utilization
controls. This paragraph shall not require payment for nursing services provided by a
certified registered nurse practicing in a hospital, nursing facility, health care institution,
a physician’s office, or other noninstitutional setting if the certified registered nurse is an
employee of the hospital, nursing facility, health care institution, physician, or other health
care facility or health care provider. This paragraph applies to services provided under plans
within this state made on or after July 1, 1989, and to existing group plans on their next
anniversary or renewal date, or upon the expiration of the applicable collective bargaining
contract, if any, whichever is later. This paragraph does not apply to enrollees eligible for
coverage under an individual contract or coverage designed only for issuance to enrollees
eligible for coverage under Tit. XVIII of the federal Social Security Act, or under coverage
which is rated on a community basis, or any other similar coverage under a state or federal
government plan.
6. “Health maintenance organization” means any person, who:
a. Provides either directly or through arrangements with others, health care services to
enrollees on a fixed prepayment basis;
b. Provides either directly or through arrangements with other persons for basic health
care services; and,
c. Is responsible for the availability, accessibility and quality of the health care services
provided or arranged.
3 HEALTH MAINTENANCE ORGANIZATIONS, §514B.3
7. “Provider” means any physician, hospital, or person as defined in chapter 4 which is
licensed or otherwise authorized in this state to furnish health care services.