2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514B - HEALTH MAINTENANCE ORGANIZATIONS
514B.1 - DEFINITIONS -- SERVICES REQUIRED OR AVAILABLE.

        514B.1  DEFINITIONS -- SERVICES REQUIRED OR
      AVAILABLE.
         As provided in this chapter, unless the context otherwise
      requires:
         1.  "Basic health care services" means services which an
      enrollee might reasonably require 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 and treatment when the care and treatment
      were provided by a person engaged in the practice 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 of the applicable
      collective bargaining contract, if any, whichever is the later.  This
      paragraph does not apply to enrollees eligible for coverage under
      Title 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
      Title 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
      Title 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.
         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.  

         Section History: Early Form

         [C75, 77, 79, 81, § 514B.1] 

         Section History: Recent Form

         83 Acts, ch 166, § 3; 84 Acts, ch 1290, § 3; 86 Acts, ch 1180, §
      7; 89 Acts, ch 164, § 5; 99 Acts, ch 75, §4; 2008 Acts, ch 1088, §128

         Referred to in § 135.61, 514.4, 514.23