1. a. An individual who is and continues to be a resident is eligible for plan coverage if
evidence is provided of any of the following:
(1)A notice of rejection or refusal to issue substantially similar insurance for health
reasons by one carrier.
(2)A refusal by a carrier to issue insurance except at a rate exceeding the plan rate.
(3)That the individual is a federally defined eligible individual.
(4)Thattheindividualhasahealthconditionthatisestablishedbytheassociation’sboard
of directors, with the approval of the commissioner, to be eligible for plan coverage.
(5)That the individual has coverage under a basic or standard health benefit plan under
chapter 513C.
b. A rejection or refusal by a carrier offering only stoploss, excess of loss, or reinsurance
coverage with respect to an a
Free access — add to your briefcase to read the full text and ask questions with AI
1. a. An individual who is and continues to be a resident is eligible for plan coverage if
evidence is provided of any of the following:
(1) A notice of rejection or refusal to issue substantially similar insurance for health
reasons by one carrier.
(2) A refusal by a carrier to issue insurance except at a rate exceeding the plan rate.
(3) That the individual is a federally defined eligible individual.
(4) Thattheindividualhasahealthconditionthatisestablishedbytheassociation’sboard
of directors, with the approval of the commissioner, to be eligible for plan coverage.
(5) That the individual has coverage under a basic or standard health benefit plan under
chapter 513C.
b. A rejection or refusal by a carrier offering only stoploss, excess of loss, or reinsurance
coverage with respect to an applicant under paragraph “a”, subparagraphs (1) and (2), is not
sufficient evidence for purposes of this subsection.
c. The association shall rescind coverage for an individual who no longer resides in the
state.
2. a. An association policy shall provide that coverage of a dependent unmarried person
terminates when the person becomes nineteen years of age or, if the person is enrolled full
time in an accredited educational institution, terminates at twenty-five years of age. The
policy shall also provide in substance that attainment of the limiting age does not operate to
terminate coverage when the person is and continues to be both of the following:
(1) Incapable of self-sustaining employment by reason of an intellectual disability or
physical disability.
(2) Primarily dependent for support and maintenance upon the person in whose name the
contract is issued.
b. Proof of incapacity and dependency must be furnished to the carrier within one
hundred twenty days of the person’s attainment of the limiting age, and subsequently as
may be required by the carrier, but not more frequently than annually after the two-year
period following the person’s attainment of the limiting age.
3. An association policy that provides coverage for a family member of the person in
whose name the contract is issued shall also provide, as to the family member’s coverage,
thatthehealthinsurancebenefitsapplicableforchildrenincludethecoveragerequiredunder
section 514C.1.
4. a. A preexisting condition exclusion shall not apply to a federally defined eligible
individual.
b. Plan coverage shall not impose any preexisting condition exclusion as follows:
(1) In the case of a child who is adopted or placed for adoption before attaining eighteen
years of age and who, as of the last day of the thirty-day period beginning on the date of the
adoptionorplacementforadoption,iscoveredundercreditablecoverage. Thissubparagraph
shall not apply to coverage before the date of such adoption or placement for adoption.
(2) In the case of an individual who, as of the last day of the thirty-day period beginning
with the date of birth, is covered under creditable coverage.
(3) Relating to pregnancy as a preexisting condition.
(4) In the case of an individual transferring to an association policy from a basic or
standard health benefit plan under chapter 513C beginning on or after January 1, 2005.
c. Plan coverage shall exclude charges or expenses incurred during the first six months
followingtheeffectivedateofcoverageforpreexistingconditions. Suchpreexistingcondition
exclusions shall be waived to the extent that similar exclusions, if any, have been satisfied
underanypriorhealthinsurancecoveragewhichwasinvoluntarilyterminated,providedboth
of the following apply:
(1) Application for association coverage is made no later than sixty-three days following
such involuntary termination and, in such case, coverage under the plan is effective from the
date on which such prior coverage was terminated.
§514E.7, IOWA COMPREHENSIVE HEALTH INSURANCE ASSOCIATION 8
(2) The applicant is not eligible for continuation rights that would provide coverage
substantially similar to plan coverage.
d. This subsection does not prohibit preexisting conditions coverage in an association
policy that is more favorable to the insured than that specified in this subsection.
e. Iftheassociationpolicycontainsawaitingperiodforpreexistingconditions, aninsured
may retain any existing coverage the insured has under an insurance plan that has coverage
equivalent to the association policy for the duration of the waiting period only.
5. Anindividualisnoteligibleforcoveragebytheassociationifanyofthefollowingapply:
a. Theindividualisatthetimeofapplicationeligibleforhealthcarebenefitsunderchapter
249A.
b. The individual has terminated coverage by the association within the past twelve
months, except that this paragraph does not apply to an applicant who is a federally eligible
individual.
c. The individual is an inmate of a public institution, except that this paragraph does not
apply to an applicant who is a federally defined eligible individual.
d. The individual premiums are paid for or reimbursed under any government sponsored
program or by any government agency or health care provider, except as an otherwise
qualifying full-time employee, or dependent of the employee, of a government agency or
health care provider.
e. The individual, on the effective date of the coverage applied for, has not been rejected
for, already has, or will have coverage similar to an association policy as an insured or
covered dependent. This paragraph does not apply to an applicant who is a federally eligible
individual.
f. The individual is eligible for Medicare based upon age.
6. The association is not required to make plan coverage available to an individual who is
covered or is eligible for any continued group coverage under Internal Revenue Code §4980B,
the federal Employee Retirement Income Security Act of 1974, codified at 29 U.S.C. §1001 et
seq., the federal Public Health Service Act of July 1, 1944, codified at 42 U.S.C. §201 et seq.,
or any continued group coverage required by the state. For purposes of this subsection, an
individual who would have been eligible for such continuation of group coverage, but is not
eligible solely because the individual or other responsible party failed to make the required
election of coverage during the applicable time period, or terminated such coverage prior to
the end of such applicable time period, shall be deemed to be eligible for such group coverage
until the date on which the individual’s continuing group coverage would have expired had
an election been made or a termination not occurred.